Every finding on record at Goldwater Care Spring Valley

Based on observation, interview, and record review the facility failed to offer substitutes/alternatives for meals of equal nutritional value. This applies to 3 of 3 residents (R9, R10, R11) reviewed for substitutes in the sample 11. The findings include: On 7/10/26 the facility menu shows the noon meal to be served as Herb Baked Fish, Red beans and Rice, and Spinach. The facility Always Available Menu posted on the wall in the dining room shows the following choices: Beef or Chicken Broth/Crackers, Hot Tea/Toast, Grilled Cheese Sandwich and Peanut Butter and Jelly Sandwich. On 7/10/26 at 12:30PM R9, R10 and R11 all stated they did not want to eat the fish that was prepared for them for lunch. All three residents requested a grilled cheese sandwich off of the Always Available Menu. There was no other entree available from the kitchen for them to choose from. On 7/10/26 at 1:15PM V2 (Dietary Manager) stated, As far as the Alternative list, food costs are up and I have been told I have to watch my budget. I have been questioned by Corporate at times when our census is up as to why my food costs are so high. That is one area I will not skimp. I have to make sure I have enough food to feed my residents. I buy what we need based on the menu and our census. We buy bulk hamburger, not patties so we can't make burgers on demand. We also don't have the storage space for a lot of food. On 7/10/26 at 2:15PM V4(Cook) stated, On the grilled cheese there are 2 pieces of yellow or white American cheese and on the peanut butter and jelly there is 2 tablespoons of peanut butter. They are made on whatever bread we have based on what will expire first- white or wheat. I don't know how much protein is in the fish or the grilled cheese or the Peanut butter and Jelly. If they don't get the fish, they can get the sandwich with the sides too if they want. The facility spread sheet shows that each resident should get 3 oz of Herb Baked Fish. A Google search shows this is approximately 21 grams of protein vs. 10 grams of protein in the grilled cheese sandwich. (Or 8 grams of protein in the peanut butter and jelly sandwich that is offered) The facility does not have a policy regarding their Always Available (Alternate) Menu however their undated policy entitled Menu Substitutions or Changes and Approval states, When making s one-time substitution or permanent menu change, the replacement food item is of the same nutritional equivalency as the item being substituted, for example .three ounces of protein is substituted with another three ounces of protein equivalency .

Based on interview and record review the facility failed to ensure resident's records were complete and accurate for1 of 3 residents (R1) reviewed for accuracy of medical records in the sample of 8.The findings include R1 was admitted to the facility last 12/23/25 with diagnoses that include alcoholism and diabetes.On 2/13/25 at 9:38 AM, V7 (Social Services) said R1 was at the facility for approximately two days. R1 left the facility last 12/25/25. R1 did not sign the form of AMA (Against medical advice.)R1's medical record did not include R1's AMA unsigned form.On 2/13/26 at 10:43 AM, V9 (Registered Nurse-RN) said she was the PM Nurse last 12/25/26. V9 said she received report from V11 (RN Day Nurse) that R1 went out on pass (OOP) for the holidays this morning. As the day went on, and it was getting late, R1 did not come back. V9 said she checked in the sign in and out sheet binder at the front desk. There was no sign out done for R1, or who was the responsible party that took R1 out of the facility. V9 said she called V2 (Director of Nursing) who directed her to call R1's family. R1's family said R1 refused to go back to the facility. V9 confirmed she did not document any of these occurrences in R1's progress notes.R1's progress notes by V11 only documented accu checks before meals and at bedtime due to type 2 diabetes mellitus without complications. V11 said she did not document that she could not locate R1 during the lunch time Accu-Check.On 2/13/26 at 10:05 AM, V11 (RN) said she was the day Nurse on 12/25/26. Around breakfast, R1 said his daughter might come to bring him out for the holidays. V11 said at noon, she went to R1's room to check R1's blood sugar. R1 was not in his room. V11 said she assumed R1's daughter took R1 OOP. On 2/13/26 at 11:22 AM, V13 (CNA) said on 12/25/26 around lunch time, she saw V10 (R1's daughter) taking R1 out on pass. V13 said she reported this to V11. (Again, V11 did not document this.) On 2/13/26 at 12PM, V2 (Director of Nursing) said it was important to document accurately in the resident's record especially when a resident was out of the facility so there was proper follow up and monitoring for the residents' safetyThe Facility's Policy (undated) entitled Medical Record Policy states, it is the policy of this facility that organized, accurate and complete written records will be maintained for each resident in accordance with applicable State and Federal guidelines and laws

Based on interview and record review the facility failed to identify, monitor, and review prophylactic antibiotic use for five (R1, R2, R33, R54, and R67) of five residents reviewed for antibiotic stewardship in the sample of 36. Findings include: The facility's Infection Surveillance, Tracking and QA (Quality Assurance) Reporting policy and procedure, dated 2/14/18 documents infection tracking includes: Completing Infection Tracking Log for all residents with an infection and/or treated with antibiotics. Review documentation of clinical signs and symptoms to determine if McGeer's criteria for infection were met and antibiotic use is appropriate. The facility's Antibiotic/Antimicrobial Stewardship Program policy, dated 11/28/17, documents This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections, and reduce healthcare costs. The Medical Director will set standards for antibiotic prescribing practices for all physicians providing care in the facility, review antibiotic use data gathered by tracking and monitoring, and provide feedback and recommendation to ensure that best practices are followed in the medical care of residents in the facility. The Director of Nursing and/or in conjunction with the Infection Control Officer will be responsible for setting the standards for assessing, monitoring and communicating changes in a resident's condition by the nursing staff providing direct care. Data gathered each month related to antibiotic use and treatment of infections will be submitted and reviewed by the QA Committee, and action plans developed as identified and recommended. Data will be compared month to month to identify trends and improvements made to work toward a long-term goal. On 2/4/25 at 12:00 pm, V3 ADON (Assistant Director of Nursing) stated she is the ICP (Infection Control Preventionist) for the facility and tracks all the residents antibiotic use, date started, the organism and stop dates. V3 stated she does not keep track or review the residents who are currently on prophylactic antibiotics and is unsure who is currently receiving prophylactic antibiotics, does not get a list of those antibiotics from the pharmacy and they are not discussed in the facility's monthly QA (Quality Assurance) Meetings. On 2/4/25 at 2:10 pm, V3 ADON/ICP stated she found that (R2), (R67), and (R1) are currently on prophylactic antibiotics. V3 stated she called the facility pharmacy and is waiting to hear back to find out how to find out if there are currently any other residents on prophylactic antibiotics. V3 stated she only reviews and monitors residents on prophylactic antibiotics when they are first initiated and then does not do anything else with them. On 2/4/25 at 2:30 pm, V3 ADON/ICP provided an Order Listing Report, dated 2/4/25, for Residents currently on antibiotics. This report documents R1, R2, R33, R54, and R67 are currently receiving prophylactic antibiotics. The January 2025 Monthly Infection Log Report does not include R1, R2, R33, R54, and R67 as receiving any antibiotics. 1. The Order Summary Report for R1, dated 2/4/25 documents a 2/24/22 physician order for the antibiotic Nitrofurantoin 50 mg (milligrams), one capsule by mouth daily related to Long Term (current) use of antibiotics. There is no documented stop date or diagnosis for this antibiotic. 2. On 2/3/25 at 9:00 am, R2's bedroom door held a Contact Precautions sign giving instructions to staff and visitors prior to entering R2's bedroom. The Order Summary Report for R2, dated 2/4/25 documents a 11/11/24 physician order for the antibiotic Nitrofurantoin 100 mg, one capsule daily related to Personal History of Urinary Tract Infections. There is no documented stop date. 3. The Order Summary Report for R33, dated 2/4/25 documents the following dated antibiotic orders for DMAC (Disseminated Mycobacterium Avium-Intracellular Complex) as: 7/20/21 physician order for the antibiotic Azithromycin 500 mg one tablet daily; 10/01/21 physician order for the antibiotic Ethambutol 100 mg three tablets in the morning; 10/02/21 physician order for the antibiotic Ethambutol 400 mg two tablets in the morning; and 10/01/21 physician order for the antibiotic Rifampin 300 mg two capsules in the morning. There are no documented stop dates. 4. The Order Summary Report for R54, dated 2/4/25 documents a physician order for the antibiotic Macrodantin 50 mg one capsule at bedtime for UTI (urinary tract infection) Suppression. There is no documented stop date. 5. The Order Summary Report for R67, dated 2/4/25 documents the following dated antibiotic orders as: 11/15/24 Ciprofloxacin 500 mg one tablet daily for Spontaneous Bacterial Peritonitis prophylaxis and 11/15/24 Rifaximin 550 mg one tablet two times daily for Liver Disease. There are no documented stop dates. On 2/4/25 at 2:31pm V3 ADON/ICP stated (R33) has been here for a long time and I had no clue R33 was on all the antibiotics. V3 also confirmed she was unaware that R54 and R1 were also on prophylactic antibiotics.

Based on observation, interview and record review, the facility failed to assess a resident's range of motion quarterly, and failed to implement and follow through ROM (Range of Motion) exercises for one of two residents (R2), a resident with functional limited range of motion, in the sample of 36. FINDINGS INCLUDE: The (undated) facility policy, Passive Range of Motion Exercises (PROM) directs staff, Residents will be assessed for their need of passive range of motion per the Functional Limitation in Range of Motion assessment. If the resident is recommended for a PROM program, trained nursing staff will provide the range of motion exercises. Range of Motion exercise will assist to prevent changes in the structure of the joints. Improve circulation of the involved part of the body. Aid in preventing pressure areas. Maintain normal range of motion. Increase joint motion to the maximum possible range. Increase or return power in muscles. Retain muscle strength. Develop control and coordination. Prevent deformities. Promote deformities. Promote a sense of well- being. Assist in the rehabilitation of the resident. R2's current Physician Order Sheet, dated February 2025 includes the following diagnoses: Multiple Sclerosis, Contracture Left Shoulder; Contracture Right Knee; Contracture Left knee. R2's current Minimum Data Set assessment, dated 11/29/2024 documents, BIMS (Brief Interview for Mental Status) as 15:15 (Cognitively Intact) and (Section C) GG0115. Functional Limitation in Range of Motion as Upper Extremities: Impairment on one side and Lower Extremities: Impairment on both sides. R2's current Care Plan includes the following Focus Area: CONTRACTURES: The resident has contractures of the right knee, left knee, left shoulder. This same document includes the following Interventions/Tasks: Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use call light for assistance. Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. On 02/02/2025 at 8:22 A.M., R2 was sleeping in bed. R2's bilateral legs were bent at the knees. On 02/02/205 at 11:30 A.M., R2 was seated in a reclining back wheelchair in her room, feeding self the noon meal. R2's left arm was resting on the wheel chair tray table. At that time R2 stated she was unable to use her left arm/hand due to contractures. On 02/04/25 at 8:56 A.M., V3/Assistant Director Of Nurses stated, We don't have a restorative nurse or any restorative aides. I guess the CNAs (Certified Nursing Assistants) do restorative stuff and document it. On 02/04/25 at 9:07 A.M., V7/Care Plan Coordinator stated, We don't have a restorative nurse or restorative aides. I don't think we have any restorative programs (including Range of Motion). I don't add any programs to the care plan. On 02/04/25 at 9:11 A.M., V10/Director of Rehab (Rehabilitation) stated, We don't have a restorative nurse or restorative aides. When a resident comes off of skilled therapy we fill out a Therapy to Nursing Recommendations form and give it to the nursing staff. It isn't a formal program, it's a restorative recommendation, meaning we recommend that a restorative program be implemented and performed by staff. I do a quarterly screens, but it's not a contracture screen. On 02/04/25 at 9:21 A.M., V2/Director Of Nurses verified that R2 did not have a restorative Passive Range of Motion program to address R2's multiple contractures. On 02/04/25 at 9:25 A.M., R2 stated, No one does range of motion (exercises) with me.

Based on observation, interview and record review, the facility failed to implement fall precautions for one of five residents (R43), reviewed for falls in a sample of 36. The facility policy, Fall Prevention Program, dated (revised) 11/21/17 directs staff, 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. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The fall prevention program includes the following components: Methods to identify residents at risk, communication with direct staff members. Safety interventions will be implemented for each resident identified at risk. Fall/safety interventions may include, but are not limited to: Nursing personnel will be informed of residents who are at risk for falling. R43's current Physician Order Sheet, dated February 2025 includes the following diagnoses: Dementia, Depression, Anxiety and Chronic Pain. R43's Nursing Progress Note dated 9/6/2024 documents, Summary of the fall: (R43) with gait imbalance due to dementia with behavioral disturbance, MDD (Major Depressive Disorder), Anxiety, HTN, and protein calorie malnutrition had an unwitnessed fall in (the) dining room. (R43) was ambulating with cane for assist, to her normal dining room chair. Activities employee was present but turned to help another resident. (R43's) mobility status was able to walk with cane unassisted. (R43) fell backwards hitting her head on the floor. Back of head assessed per nurse, no bleeding noted but closed injury occurred as hematoma was palpable. EMS (Emergency Medical Services) contacted and transported resident to hospital. Visual signs placed in room to call for help and (R43) described as increased fall risk. R43's Nursing Progress Notes, dated 9/11/2024 at 09:20 A.M .document, Summary of the fall: On rounds, (R43) observed lying on her left side on the floor next to her bed alert and talking. Resident had placed a pillow under her head. Call light was on bed within reach and proper footwear on. (R43) stated I don't know what happened just call the ambulance and call my son. Do not touch me, don't move me just call the ambulance. The nurse was able to obtain her vitals which were stable. No bruising or injury noted. Resident had a previous fall on 9/5/24 in which she did hit her head. (R43) was made comfortable on floor with blankets and pillows and EMS notified. (R43) remained alert and talking. (R43) had ER (emergency room ) visit only. Repeat CT (Computerized Tomography) of head negative. No new orders. R43s Nursing Progress Notes, dated 1/22/2025 document, Summary of the fall: (R43) was heard by the nurse from the hallway asking for some help. When the nurse entered the room, (R43) was observed sitting on her buttocks on the floor next to her bed. Bed was in the lowest position, call light in reach but not activated, and regular socks on. Her pants were down around her thighs. Resident states she was trying to get out of the bed. (R43) assessed, no injuries present, ROM (Range of Motion) and neuro's (neurological) at baseline. On 2/2/2025 at 9:13 A.M., (R43) was asleep in bed. No Falling Leaf to designate resident as at risk for falls, was present on (R43's) door. On 2/2/2025 at 11:03 A.M., V11/Licensed Practical Nurse stated, When a resident is at risk for falls, we place a leaf on the resident's door so staff will know the resident is at risk and to check on them more often. At that time, V11/Licensed Practical Nurse verified that R43 was at risk for falls and a leaf was not present on R43's door. On 2/3/2025 at 2:27 P.M., V2/Director Of Nurses stated she was responsible for the facility Fall Program. V2/DON verified that when a resident is at risk for falls or has a history of falls, a leaf symbol is placed on the resident's room door, next to their name, to designate that resident as high risk for falls and to alert staff to provide increased observations. At that time, V2/DON also verified that R43 did not have a leaf symbol outside her room door, despite the fact that she had a recent fall and has a history of falls.

Based on observation, interview and record review, the facility failed to perform urinary catheter care to reduce the risk of infection for one of two residents (R221) reviewed for urinary catheters, in a sample of 36. FINDINGS INCLUDE: The facility policy, Urinary Catheter Care, dated (revised) 2-14-19 directs staff, To establish guidelines to reduce the risk of or prevent infections with an indwelling catheter. The following should be discouraged: Use of antiseptic/antimicrobial solutions for cleansing during catheter care. Routine hygiene (cleansing of the meatal surface during daily bathing or showering) is appropriate. Encrustations on the foley catheter should be removed from the meatus outward with a clean wash cloth, rinsed with clean water on an as needed basis. R221's current Physician Order Sheet, dated February 2025 includes the following diagnoses: Traumatic Amputation Below the Left Knee, Stage 3 Pressure Ulcer Right Buttock, Stage 4 Pressure Ulcer Left Buttock, History of Urinary Tract Infection. This same form includes the following physician orders: (Indwelling Urinary) Catheter 18 FR (French) 30 CC (Cubic Centimeters) Change monthly and as needed. (Urinary Catheter) Cares every shift. On 02/02/25 at 10:36 A.M., V3/Infection Preventionist Nurse and V11/Licensed Practical Nurse (LPN) prepared to perform urinary catheter care for R221. V11/Licensed Practical Nurse squirted a 3 CC vial of normal saline onto a 4 X 4 gauze pad and wiped down the middle of R221's peri area. At that time, V3/Infection Preventionist handed V11/Licensed Practical Nurse a package of moisturizing peri wipes. V11/Licensed Practical Nurse took a handful of wipes and wiped the left side of R221's peri area, grabbed another handful of wipes and wiped the right side of R221's peri area. V11/LPN removed her gloves and assisted in repositioning R221 and left the room. On 02/04/25 at 11:08 A.M., V2/Director Of Nurses stated, Our policy for catheter care is to cleanse (the peri area and meatal surface) with soap and water. We don't use peri wipes as a cleanser. They can be very irritating and irritated skin can lead to urinary tract infections.

Based on interview and record review, the facility failed to document a rationale for the continued use of an antibiotic for one of two residents (R2), reviewed for unnecessary medications in a sample of 36. Findings Include: The facility policy, Antibiotic/Antimicrobial Stewardship Program, dated 11/28/2017 directs staff, This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program will help ensure that our residents get the right antibiotics at the right time for the right duration, and can help improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections and reduce healthcare costs. This facility utilizes the McGeer's Criteria for determining if an infection meets criteria for treatment with an antibiotic. R2's current Physician Order Sheet, dated February 2025 documents, 11/11/2024 Nitrofurantoin 100 MG (Milligrams) one capsule by mouth one time a day related to Personal History of Urinary Tract Infections. No stop date is included for the antibiotic usage. On 2/4/23 at 9:09 A.M., V2/Infection Preventionist stated, (R2) is on continuous antibiotics due to a history of urinary tract infections. I didn't realize the antibiotic was started that long ago. There is no stop date for the medication.

Based on observation, interview and record review, the facility failed to perform hand hygiene during medication administration for one of two residents (R48) reviewed for medication administration, in a sample of 36. FINDINGS INCLUDE: The (undated) facility policy, Medication Administration General Guidelines, directs staff, Medications are administered as prescribed in accordance with good nursing principals and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Examination gloves are worn when necessary. R48's current Physician Order Sheet, dated February 2025 includes the following medications: Aspirin 81 MG (Milligrams) one tablet by mouth in the morning; Calcium 600 MG with Vitamin D3 10 MG one tablet by mouth one time a day; Cetirizine 10 MG one tablet by mouth one time a day; Docusate Sodium 100 MG one capsule by mouth one time a day; Multivitamin one tablet by mouth one time a day; Omeprazole 20 MG one capsule by mouth one time a day; Simethicone 80 MG one tablet by mouth two times a day. On 02/03/2025 at 7:49 A.M., V14/Registered Nurse prepared to administer medications for R48. V14/Registered Nurse opened the top drawer of the mobile medication cart and withdrew community, stock medications bottles, opened each bottle and poured one tablet each of Aspirin, Calcium/Vitamin D, Docusate Sodium, Multivitamin, Simethicone and one capsule of Omeprazole into her ungloved hand and placed each pill in a small, plastic medication cup. V14/Registered Nurse placed the medication cup in front of R48 with a glass of water and R48 took each pill. Upon return to the medication cart, V14/Registered Nurse confirmed she she touched each of R48's pills with ungloved hands. On 02/04/2025 at 2:53 P.M., V2/Director of Nurses stated, Nurses should not touch medications, they are preparing for administration, with their ungloved hands.

Based on observation, interview, and record review the facility failed to ensure resident safety during transfer, failed to use a gait belt during resident transfer, and failed to follow the facility policy and procedure for mechanical lift slings for one (R4) of three residents reviewed for falls in a sample of four. Findings include: The facility's Fall Prevention Program policy, revised 11/21/17, documents 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. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service. The facility's Transfers - Manual Gait Belt and Mechanical Lifts policy, revised 1/19/18, documents: Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for lifting and movement of Residents .Guidelines: 4. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure that equipment remains in good working order .9. Use of gait belt for all physical assist transfers is mandatory. 1. On 8/16/24, at 12:50 pm, V6 Certified Nursing Assistant/CNA wheeled R4 into his room. V7 CNA arrived to assist in transferring R4 from his wheelchair to the bed. They wheeled R4 next to his bed and while V7 stood beside the wheelchair, V6 had R4 stand and pivot then sit on the bed; no gait belt was used. On 8/16/24, at 2:18 pm, V6 CNA confirmed she did not place a gait belt on R4. V6 stated they do not use a gait belt on (R4) because it bothers his suprapubic catheter if they put it down too low and he says it hurts his abdomen if we put it up higher. We just have him reach and use the bedrail to get into bed and that's why we use two staff. R4's Minimum Data Set/MDS assessment, dated 7/18/24, documents R4 requires partial/moderate assistance for chair/bed-to-chair transfer. R4's current Care Plan documents R4 is at risk for fall/injury from weakness and tiredness. On 8/16/24, between 2:35 pm - 2:45 pm, V5, V8, and V9 CNAs denied ever having a problem using a gait belt on R4 because of his suprapubic catheter or any other reason. On 8/16/24, at 3:41 pm V3 Assistant Director of Nursing/ADON confirmed that if a resident is a one or two person assist staff should always use a gait belt. 2. R4's Un-witnessed fall investigation, dated 6/27/24, documents CNA (V5) answered resident's light. Resident was observed sitting on the floor with his back resting against the bed. Resident states he sat on the edge of the bed himself to transfer to the wheelchair but slid to the ground. Resident denied hitting his head, any injury, or pain. Oriented x 3, ROM (Range of Motion) intact. Resident being (mechanically lifted) from the floor to the bed per (V4 Registered Nurse/RN and V5 CNA. The (mechanical lift) sling tore apart from left upper fabric strap where it attaches to sling. Resident was approximately 6 inches off the ground and nurse held the end up preventing resident falling to the ground and then lowered him gently. No injury occurred. On 8/16/24, at 2:26 pm, V3 Assistant Director of Nursing/ADON stated the following: I got called to (R4's) room and he was on the floor and the strap to the mechanical lift sling was broke, the top one on his right side. Not sure of when the sling was last examined. Laundry does that .V3 confirmed that staff should look them over first to be sure they are in good condition and stated, That is common knowledge. On 8/16/24, at 2:35 pm, V5 CNA stated the following: When I walked by, I saw (R4) on the floor. (R4) said he slid out of bed and said that he had wanted to get into the chair. I had the nurse (V4 Registered Nurse/RN) come down to his room. We got the (mechanical lift) and (V4 RN) assessed him and he didn't have any pain he just wanted to go back to bed. We hooked (R4) up to the sling and proceeded to use the (mechanical lift) and the sling busted into two pieces. We lowered (R4) down and he hadn't cleared the bed yet, so he wasn't up very high. (V4) hooked the top parts and I hooked the bottom parts for his legs. The sling was the one in his room, so it had been used already. I didn't really inspect it before using it. On 8/16/24, at 2:58 pm, V4 RN stated the following: The CNA (V5) came and got me cause (R4) slid out of bed. We went and put a (mechanical lift) sling on. (R4) was only few inches off the floor when one of the slings had broken so we lowered him back to the floor. I held onto it while (V5 CNA) lowered him back to the floor. We hooked it up like we always do. I don't recall if (V5) looked the sling over first, I didn't. On 8/20/24 at 9:50 am, V2 Director of Nursing/ DON stated laundry staff is responsible for checking all the mechanical lift slings when they are laundered, and the CNAs should be checking prior to each use. On 8/20/24 at 9:57 am, V11 Housekeeping/Laundry Supervisor stated the mechanical lift slings are all checked by whoever is in charge of laundry that day. On 8/20/24 at 11:14 am, V13 Maintenance Director stated he does not check the mechanical lift sling and has nothing to do with them. V13 stated laundry staff checks all the slings. On 8/21/24 at 9:12 am, V2 DON stated the broken sling was brought to her and she bagged it up and it sat in sat in her office for a few days. V2 stated she asked V1 Administrator what to do with it and took it to laundry for them to log and throw out. V2 confirmed the facility's Mechanical Lift policy documents the slings are to be assessed by Maintenance and Nursing Staff.

Based on observation, interview, and record review, the facility failed to ensure the ice scoop, for the ice machine, was stored on the outside of the ice machine. This failure has the potential to affect all 79 residents residing in the facility. Findings include: Facility Policy, entitled Cleaning Instructions: Ice Machine and Equipment, dated 2010, document, 10. Store the ice scoop outside the machine in a separate, sanitized container that allows the water to drain and not collect around the scoop. On 03/26/2024, at 9:35 a.m., during the initial kitchen tour, with V6/Dietary Manager, the ice scoop, for the ice machine, was inside of the ice machine and full of ice. V6 confirmed the ice scoop should not be left inside the ice machine, but rather in a container outside of the ice machine. The Centers for Medicare and Medicaid Services form, entitled Long-Term Care Facility Application for Medicare and Medicaid, dated 3/26/2024, signed by V1/Administrator, document, 79 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure the lids, to the trash receptacle, were closed and the area surrounding the trash receptacle was free of litter. This failure has the potential to affect all 79 residents residing in the facility. Findings include: Facility Policy, entitled Garbage and Rubbish Removal, dated 2020, document, 8. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. Trash receptacles will be placed a pad that is cleanable and non-porous. On 03/26/2024, at 9:30 a.m., during the initial kitchen tour, with V6/Dietary Manager, the lid, to the steel trash receptacle, located outside, was left opened. Additionally, the area surrounding the trash receptacle was littered with cigarette butts. V6 confirmed the lid, to the trash receptacle, should have been closed and area free of debris. The Centers for Medicare and Medicaid Services form, entitled Long-Term Care Facility Application for Medicare and Medicaid, dated 3/26/2024, signed by V1/Administrator, document, 79 residents reside in the facility.

Based on record review and interview, the facility failed to develop a Comprehensive Care Plan for three residents (R8, R24, and R35) of 29 residents reviewed for Care Plans in a sample of 29. Findings includes: The facility's Comprehensive Care Plan dated 11/17/17 documents: To develop a Comprehensive Care Plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. A) Facility's Smoking Safety Policy dated 10/24/22 documents: Smoking includes the use of electronic cigarettes and vaping devices. Resident's plan of care and smoking compliance will be reviewed quarterly. Facility's Smoking Safety Risk Assessment Policy dated 8/9/19, documents: The purpose of the Smoking Safety Risk assessment is to determine the individual's ability and willingness to comply with facility rules and regulations governing smoking. Additionally, the assessment helps to determine the extent of the individual's smoking habit and his/her interest in smoking cessations. R35's current Smoking Safety Risk assessment dated [DATE] documents: 1. Does the resident currently smoke or use electronic smoking device? No--resident does not smoke. R35's current Care Plan does not document R35's vaping/smoking and/or non-compliance with vaping/smoking. Facility's Resident Smokers and Smoke Time List Updated 3/20/24, does not document R35 as a smoker or vaper. R35's Progress Note dated 3/18/24 documents: As this Registered Nurse/RN was giving (R35's) night medications, saw a vape pen on her bed. Unsure if it's a regular or THC vape pen. Refused to surrender it to staff. Refused to disclose on how she obtained vape pen. Explained facility protocol. (R35) got upset and stated, Give it back to me! I am so tired of losing my pens! (R35) does have history of being caught with THC vape pen at bedside. She used to have a pattern of developing respiratory and gastrointestinal/GI symptoms whenever she uses THC vape pen before. (THC/Tetrahydrocannabinol-organic chemical found in cannabis, per Internet Definition dated 3/28/24.) R35's Progress Note dated 3/13/24 documents: It was discussed with the patient today her current pain management and the use of marijuana vape pens. (R35) did not confirm or deny that she has been using marijuana vape pens recently. R35's Progress Note dated 12/15/23 documents: (R35) assessed. (R35) angry because she cannot use her marijuana vape pen. (R35) counseled and educated. Support given. On 3/27/24 at 1:45pm, V12 Activity Director stated: I do not keep vaping or marijuana paraphernalia for (R35); (R35's) paraphernalia was taken from (R35) and was locked in safe in (V1 Administrator's) office. On 3/28/24 at 10:55am, V11 Registered Nurse/RN stated that she had taken vaping pens from (R35) on two occasions, that the first pen contained THC, but not sure if the second pen contained THC or not. On 3/27/24 at 1:47pm, V13 Social Services Director/SSD stated that R35 does vaping without supervision; stated that intervention was done of taking (R35's) paraphernalia away and educating (R35); stated that no one had actually seen (R35) smoking or vaping. On 3/28/24 at 9:20am, V13 SSD, stated that R35's issues relating to smoking or vaping were not included on R35's Care Plan. V13 SSD stated, (R35) denies smoking; the smoking assessments will say 'No'; no one actually saw (R35) smoke. On 3/28/24 at 9:30am, V3 Minimum Data Set/MDS/Care Plan Coordinator stated that she did not include smoking focus or interventions on R35's Care Plan. On 3/27/24 at 1:50pm, R35 stated that she uses a vape pen for marijuana once in a while, that this settles her down. R35 stated, None of your business who brings it. I will keep it; don't want to let Activity have it; it does not affect my breathing; I can breathe better after using it. On 3/28/24 at 9:40am, V2 Director of Nursing/DON stated: (R35's) continued non-compliance with smoking and use of marijuana paraphernalia should have been included in R35's Care Plan along with interventions and education. 30678 B) The facility's Weight Assessment and Intervention policy and procedure, dated 2020, documents: If the weight change is planned or related to fluid management and is determined to be desirable, it will be documented and no change in the care plan will be necessary. Care planning for undesirable weight loss or impaired nutrition shall be a multidisciplinary effort and will include the physician, nursing staff, Registered Dietitian, a member for the Food and Nutrition Department, consultant pharmacist, and the resident or the resident's legal surrogate. Care plans will consider the wishes of the resident and right to choose their treatment plan. Individualized care plans shall address the following to whatever extent possible: Identified of the problem that is causing the weight loss; Goals with measurable time frame for improvement; Interventions/approaches; A weight loss regimen shall not be initiated for a cognitively capable resident without his or her involvement and approval; and If a resident declines to participate in weight loss goal, the Registered Dietitian shall document the resident's wishes and respect them. The annual MDS (Minimum Data Set) assessment for R8, dated 1/17/24, documents R8 with significant weight loss and not on a physician-prescribed weight loss regimen. This MDS does not include a diagnosis of Obesity and is without difficulty swallowing. The current Order Summary Report for R8 includes the following physician orders: 4/21/23 General diet, Regular texture, Regular consistency for diet; 7/12/23 House Nutrition Supplement two times a day for unplanned weight loss, 120cc (cubic centimeters) 1/2 cup BID (twice daily); 4/26/23 Divided plate at all meals: cut up food as needed every shift; 9/18/23 Mirtazapine 7.5 mg (milligrams) by mouth at bedtime for appetite stimulant. This Order Summary Report does not document a physician order for a weight loss program for R8. The current Care Plan for R8 does not include a nutritional plan of care for R8 or address R8's significant weight loss. This Care Plan does not document R8 with planned weight loss program and does not include supplements or medications for weight loss. On 3/26/24 at 9:59 AM, R8 stated he lost weight the first five or six months after admitting to the facility. R8 stated, I lost 90 pounds. I have gained some of it back, but not all of it. R8 stated he does not eat breakfast and never has but usually goes down for lunch and dinner. On 3/28/24 at 10:01 AM, R8 stated he is not trying to lose weight, and no one has talked to him about a weight loss program or he would have told them no. The facility EHR (electronic health record) documents R8's admission weight on 2/27/23 as 278.0 lbs. (pounds) with the following monthly weights as: 3/2/24 at 266.0 lbs.; 4/21/23 at 254.0 lbs.; 5/3/24 at 240.0 lbs.; 6/1/23 at 224.0; 7/2/23 at 219.0 lbs.; 8/2/23 at 223.0 lbs.; 9/5/23 at 212.0 lbs.; 10/2/23 at 210.0 lbs.; 11/3/23 at 213.0 lbs.; 12/1/23 at 208.0 lbs.; 1/1/23 at 206.0 lbs.; 2/7/24 at 212.0 lbs.; and 3/1/24 at 205.0 lbs. This EHR documents R8 with a weight loss of 73 pounds since 2/27/23 admission and total loss of 49 pounds since last survey date of 4/10/23. On 3/27/24 at 2:15 PM, V6 DM (Dietary Manager) provided the RD lists of residents seen monthly. This list documents V16 RD reviewed and assessed R8's weights and overall nutritional assessment in August, September, October, and December 2023 for planned weight loss. The RD monthly, quarterly, and annual assessments, dated 5/12/23, 6/12/23, 7/12/23, 8/7/23, 9/11/23, 10/12/23, 12/11/23, and 1/30/24 document R8 with favorable and planned significant weight loss, and refusing breakfast at times. On 3/28/24 at 2:30 PM, V3 MDS (Minimum Data Set)/CPC (Care Plan Coordinator) stated we only do planned weight loss programs if there is a physician's orders which R8 does not have. V3 MDS/CPC confirmed R8's Care Plan does not include a nutritional plan of care or address R8's significant weight loss and stated she will make sure the Care Plan is developed. 30722 C) A Physician Order, dated 09/28/23, documents to change R24's Indwelling Urinary Catheter every 28 days and as needed to prevent further breakdown of Stage Four Pressure Ulcers on R24's Right and Left Buttocks. R24's Care Plan, dated 12/21/23, does not address R24's Indwelling Urinary Catheter or include measurable objectives and timeframes to meet R24's needs. On 03/28/24 at 10:49 am, V3 (Care Plan Coordinator) confirmed R24's current Care Plan does not include an Indwelling Urinary Catheter or objectives for an Indwelling Urinary Catheter. V3 stated R24's Indwelling Urinary Catheter was removed on 07/21/23 and reinserted in 8/23, at which time it was not added back into R24's current Care Plan.

Based on observation, interview, and record review the facility failed to revise a plan of care for two (R27 and R49) of 29 residents reviewed for care planning in the sample of 29. Findings include: The facility's Comprehensive Care Plan policy and procedure, revised 11/17/17, documents the care plan is to be Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments; and The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. On 3/28/24 at 2:30 PM, V3 MDS (Minimum Data Set)/CPC (Care Plan Coordinator) confirmed resident Care Plans are to be revised as needed. 1. The current Care Plan for R27, documents the following focus areas for R27: Potential nutritional problem related to swallowing disorder, dependent on nutrition by PEG (percutaneous endoscopic gastrostomy) tube; Swallowing problem related to dysphasia; and unplanned/unexpected weight loss related to poor food intake. The following interventions for the focus areas include: Bolus feedings, NPO (nothing by mouth), G-tube for nutrition, and add pudding to lunch and supper meals. The current Order Summary Report for R27, documents the following dated physician orders as: 7/23/21 General diet, Mechanical Soft texture, thin consistency, may have small meals d/t (due to) TF (tube feeding) at HS (hour of sleep) for diet; and 12/20/21 Resident to sit upright 90 degrees during meals. There is currently no physician order for Bolus feedings, NPO status, or adding pudding to lunch and supper meals. The EHR (electronic health record) for R27, documents R27's weight on 3/4/24 as 125.0 pounds indicating an 8.09% (percent) weight loss in last five months between 10/2/23 and 3/4/24. There are no documented interventions for this gradual weight loss for R27. On 3/26/24 at 11:11 AM, R27 was lying in bed with eyes closed. A G-tube pump was next to R27's bed without feeding hanging and was turned off. On 3/27/24 at 11:53 AM, R27 was lying in bed. On this same date at 12:25 PM, staff entered R27's room with a meal tray and then exited the room with the same meal tray. On 3/27/24 at 12:49 PM, R27 was lying in bed on his back and stated he was not going to eat today and I'm not hungry. On 3/27/24 at 12:50 PM, V18 CNA (Certified Nursing Assistant) stated she took R27 his lunch and (R27) refused to eat today. He sometimes does that. On 3/28/24 at 10:00 AM, V9 CNA stated R27 eats pretty good but does refuse to eat at times. On 3/28/24 at 2:30 PM, V3 MDS (Minimum Data Set)/CPC (Care Plan Coordinator) confirmed R27 is no longer dependent by PEG tube feedings, no longer gets bolus G-tube feedings, is no longer NPO, and the pudding was discontinued. V3 MDS/CPC stated she would update R27's Care Plan. 2. The current Care Plan for R49, documents the following focus areas for R49 as: COPD (Chronic Obstructive Pulmonary Disease) related to smoking with intervention for Oxygen at 5L (liters) via nasal cannula; On Antibiotic therapy related to pneumonia infection; and Indwelling urinary catheter. The current Order Summary Report for R49, documents the following dated physician orders as: 3/5/24 Oxygen at 5L continuously via nasal cannula, SpO2 (blood oxygen level) above 90% every shift and change oxygen tubing every Sunday on night shift; 3/5/24 Change urinary catheter 18 Fr (french) 10 cc (cubic centimeter) balloon every 28 days on night shift, Urinary catheter care every shift and as needed, and monitor urinary catheter output three times daily. There is no physician ordered antibiotic on R49's current Order Summary Report. On 3/26/24 at 10:11 AM, R49 was sitting upright in his bed without oxygen on. An oxygen concentrator was resting on floor next to (R49's) bed and not being used at this time. R49 also had visible urinary catheter tubing connected to a urinary drainage bag attached to his bed frame. R49 stated he uses the oxygen three or four times a day when he is short of breath, puts the oxygen tubing on, turns the machine on himself, and adjusts the oxygen to what he needs, when he needs it. R49 also stated, I clean it myself. They don't do it. They empty it for me if I haven't already. On 3/26/24 at 11:34 AM, R49 stated he was admitted to the facility with Pneumonia and was on an antibiotic and finished it shortly after coming to the facility. On 3/27/24 at 11:55 AM, R49 was lying in bed on his back with oxygen on at 4.5 L (liters) via nasal cannula. On 3/27/24 at 12:30 PM, R49 was sitting up on the side of his bed eating lunch with oxygen on or infusing at this time. On 3/27/24 at 1:30 PM, R49 was lying in bed without oxygen on and refused to allow catheter care and stated I already did that this morning. I do it first thing in the morning, every time I go to the bathroom and before I go to bed. On 3/28/24 at 10:06 AM, V10 RN (Registered Nurse) stated R49 is independent with his oxygen and will put it on and remove it himself. V10 RN stated R49 takes care of his own catheter at times as well. On 3/28/24 at 2:30 PM, V3 MDS (Minimum Data Set)/CPC (Care Plan Coordinator) confirmed R49 is no longer on the antibiotic and stated she was unaware that R49 was not using his oxygen continuously, was managing his own oxygen and performing his own urinary catheter care and would make sure to revise R49's Care Plan.

Based on observation, interview, and record review the facility failed obtain a physician order for a weight loss program and to ensure a resident with significant weight loss was monitored and followed by a physician for one (R8) of three residents reviewed for weight loss in the sample of 29. Findings include: The facility's Weight Assessment and Intervention policy and procedure, dated 2020, documents The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Any weight change of 5% (percent) or more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietician, Dining Services Manager, or other members of the interdisciplinary team within 24 hours. Verbal notification must be confirmed in writing. The threshold for significant unplanned and undesired weight loss shall be based on the following criteria: 1-month significant loss - 5% and severe loss greater than 5%; 3 months significant loss - 7.5% and severe loss greater than 7.5%; and 6-month significant loss - 10% and severe loss greater than 10%. If weight change is planned or related to fluid management and is determined to be desirable, it will be documented and no change in the care plan will be necessary. The physician along with the interdisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or an increased risk of weight loss. A weight loss regiment shall not be initiated for a cognitively capable resident without his or her involvement and approval. If a resident declines to participate in a weight loss goal, the Registered Dietitian shall document the resident's wishes and respect them. The Face Sheet for R8 includes the following diagnoses: Cerebrovascular Disease, Hemiplegia affecting left non-dominant side, Type 2 Diabetes Mellitus, and GERD (Gastro-esophageal Reflux Disease) and does not include a diagnosis of obesity. The current Order Summary Report for R8 includes the following physician orders: 4/21/23 General diet, Regular texture, Regular consistency for diet; 7/12/23 House Nutrition Supplement two times a day for unplanned weight loss, 120cc (cubic centimeters) 1/2 cup BID (twice daily); 4/26/23 Divided plate at all meals: cut up food as needed every shift; 9/18/23 Mirtazapine 7.5 mg (milligrams) by mouth at bedtime for appetite stimulant. This Order Summary Report does not document a physician order for a weight loss program for R8. The annual MDS (Minimum Data Set) assessment for R8, dated 1/17/24, documents R8 with significant weight loss and not on a physician prescribed weight loss program. On 3/26/24 at 9:59 AM, R8 stated he lost weight the first five or six months after admitting to the facility and wasn't trying to. R8 stated, I lost 90 pounds. I have gained some of it back, but not all of it. R8 stated he does not eat breakfast and never has but usually goes down for lunch and dinner. On 3/28/24 at 10:01 AM, R8 stated no one has talked to him about weight loss or about a weight loss program or he would have told them no. The facility EHR (electronic health record) documents R8's admission weight on 2/27/23 as 278.0 lbs. (pounds) with the following monthly weights as: 3/2/24 at 266.0 lbs.; 4/21/23 at 254.0 lbs.; 5/3/24 at 240.0 lbs.; 6/1/23 at 224.0; 7/2/23 at 219.0 lbs.; 8/2/23 at 223.0 lbs.; 9/5/23 at 212.0 lbs.; 10/2/23 at 210.0 lbs.; 11/3/23 at 213.0 lbs.; 12/1/23 at 208.0 lbs.; 1/1/23 at 206.0 lbs.; 2/7/24 at 212.0 lbs.; and 3/1/24 at 205.0 lbs. This EHR documents R8 with a weight loss of 73 pounds since 2/27/23 admission and total loss of 49 pounds since last survey date of 4/10/23. On 3/27/24 at 2:15 PM, V6 DM (Dietary Manager) stated V16 RD (Registered Dietician) comes to the facility monthly or as needed. V16 RD provides a list of who she sees when she is here. V6 DM provided the RD lists of residents seen monthly. This list documents V16 RD reviewed and assessed R8's weights and overall nutritional assessment in August, September, October, and December 2023 for planned weight loss. The RD quarterly Nutrition Assessment for R8, dated 5/12/23 documents R8 weight at 239.0 lbs., requires supervision for eating, and eats 26-75% (percent) of estimated needs. Recently had a sig (significant) wt. (weight) loss of 5.9% x (times) 1 mo (month), and 14% x 3 mo down to 239# (pounds). Recommend continuing the current diet and monitor. No recommendations. The RD Nutrition Progress Note for R8, dated 6/12/23, documents Recently had a sig. wt. loss of 7.1% x 1 mo, to 223# on 6/10/23. Recommend continuing the current diet and monitor. No recommendations. The RD Nutrition Progress Note for R8, dated 7/12/23, documents R8 with significant weight loss of 8% x 2 mo, 13.8% x 3 mo, and 21.2% x 6 mo. down to 219# for July. House supplement recommended - 120 cc BID for extra kcal (kilocalories). The RD Nutrition Progress Note for R8, dated 8/7/23, documents R8 presents at nutritional risk rt (related to) favorable significant weight loss 19.8% x 6 months. R8's August 2023 weight: 223 # and occasionally refuses meals. No Recommendations. The RD Nutrition Progress Note for R8, dated 9/11/23, documents significant weight loss 10.9% x 3 months down to 212#. Continue plan of care. RD available prn (as needed) via nutritional risk referral. No Recommendations. The RD Nutrition Progress Note for R8, dated 10/12/23, documents significant weight loss 17.3% x 6 months, down to 210# for October. Some weight loss is planned. Continue plan of care. No Recommendations. The RD Nutrition Progress Note for R8, dated 12/11/23, documents significant weight loss 12.6% x 6 months down to 208# for December. Some weight loss is planned. General, regular appetite is fair to good, but occasionally refuses meals-dislikes eating breakfast most days. He has a divided plate and meat is cut up for him. Receiving house supplement 120cc BID for extra kcal. Continue plan of care. No Recommendation. The RD annual Nutrition Assessment for R8, dated 1/30/24, documents R8's current weight at 206.0 pounds, requires supervision when eating, eats 76-100% of estimated needs. Annual review: (R8) has had a sig (significant) planned wt (weight) loss of 72# (pounds) from admit weight in Feb of 2023. Admit weight may have been in error. He eats fair to good - at times refuses breakfast. Will continue the current diet and monitor. No recommendations. The Physician Progress Notes for R8 since admission to the facility, dated 3/2/23, 3/9/23, 3/16/23, 3/21/23, 2/23/23, 4/1/23, 4/25/23, 4/27/23, 5/2/23, 5/23/23, 6/13/23, 6/27/23, 6/29/23, 7/13/23, 7/18/23, 8/17/23, 8/24/23, 9/21/23, 1/5/24, 2/21/24, and 3/11/24 do not document R8 being on weight loss program or address R8's significant weight loss. On 3/28/24 at 12:54 PM, V6 DM stated she is not aware of R8 being on a planned weight loss program. V6 DM stated (R8) comes out for some meals and we try to get him out more often. Sometimes he does and sometimes he doesn't. On 3/28/24 at 1:08 PM, V16 RD stated she sees all the residents with weight loss monthly. V16 RD confirmed (R8) was on a planned weight loss program and stated R8 was admitted to the facility in the obese range, has had significant weight loss since admission, and V16 RD added the supplement due to gradual decline in R8's weight; and wanted to slow R8's weight loss down. V16 RD also stated since V6 DM hired on, the food is better, and the staff try to get R8 to come out for meals more frequently as R8 will refuse as times. On 3/28/24 at 2:30 PM, V3 MDS (Minimum Data Set)/CPC (Care Plan Coordinator) stated We only do planned weight loss programs if there is a physician's orders which (R8) does not have.

Based on observation, interview, and record review the facility failed to ensure a PEG (percutaneous endoscopic gastrostomy) tube dressing change was completed as physician ordered for one (R27) of one resident reviewed for tube feeding in the sample of 29. Findings include: The facility's Gastrostomy Tube - Feeding and Care policy and procedure revised 8/3/20, documents Stoma Site Care: Inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent drainage, or gastric leakage: immediately report skin irritation or infection and provide treatment. Clean skin with soap and water or antiseptic of choice - begin next to stoma site, using a spiral pattern and moving outward; clean under skin disk with cotton swab. Dry thoroughly; leave area open to air to minimize dampness, skin irritation, and maceration; use a dressing only if ordered. The current Order Summary Report for R27 documents physician treatment order dated 5/9/23: Tx (treatment) to g-tube (gastrostomy tube): Cleanse with soap and water, pat dry, apply bacitracin (antibiotic ointment), cover with (split drain sponge) every night shift and every 24 hours as needed. The current Care Plan for R27 includes intervention for the care of R27's g-tube as: Provide local care to G-tube site as ordered and monitor for s/sx (signs and symptoms) of infection every shift. On 3/27/24 at 11:53 AM, R27 was lying in bed on his back. G-tube dressing to abdomen was noted with the date of 3/24/24 with visible yellow/tan discoloration to the outside of the dressing. When asked R27 when the dressing was changed last R27 stated I don't know. Sometimes they do sometimes they don't. On 3/27/24 at 12:49 PM, R27 remained in bed on his back with g-tube dressing unchanged. On 3/27/24 at 1:30 PM, requested V8 LPN (Licensed Practical Nurse) to accompany this writer to R27's room to verify the date on R27's dressing. V8 LPN stated she was finishing up something first. On 3/27/24 at 2:54 PM, R27's g-tube dressing remained unchanged, dated 3/24/24. V2 DON (Director of Nursing) stated V8 LPN left early due to being ill. V2 DON confirmed R27's g-tube dressing should have been changed by the night nurse. On 3/27/24 at 2:57 PM, V14 RN (Registered Nurse) stated R27's dressing is changed on the night shift and was signed out on the TAR (Treatment Administration Record) on 3/24/24 and 3/25/24 as having been done.

Based on observation, interview and record review the Facility failed to clean, maintain and change disposable Respiratory supplies for two of three Residents (R52 and R71) reviewed for Respiratory Care in a sample of 29. Findings include: The Facility Oxygen and Respiratory Equipment (Changing and Cleaning) Policy, revised 1/7/19, documents: to provide guidelines to employees for changing all disposable respiratory supplies; ensure the safety of Residents by providing maintenance of all disposable respiratory supplies; minimize the risk of infection; Nasal Cannulas are to be changed once a week and as needed; a clean plastic bag with a zip lock/draw string will be provided to store the cannula when not in use and will be dated with the date the tubing was changed; and oxygen humidifiers should be changed weekly or as needed and will be dated when changed. The Facility Continuous Positive Airway Pressure/CPAP Therapy Policy, undated, documents: the goal of this therapy is therapy include ventilation, improve sleep, decrease hospitalization s, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing and improve lung compliance; equipment includes CPAP machine, tubing, oxygen tubing, adapter, mask and humidifier; cleaning and maintenance include wash hands, remove headgear from mask/pillow shell, with a soft cloth, wash the mask/pillow with a solution of warm water and a mild clear liquid detergent, rinse, allow mask/pillow to air dry, clean and inspect all components regularly (mask, tubing and headgear should last approximately six to 12 months, but can vary greatly; clean the CPAP unit as necessary with a damp cloth, wipe the outside of the unit and use a dry cloth to wipe dry; filter maintenance includes replacing disposable filters and reusable filters should be rinsed of dust and allowed to air dry. A) R52's Physician Order Sheet/POS, dated 3/27/24, documents diagnoses including Chronic Obstructive Pulmonary Disease/COPD, Emphysema, [NAME] Disorder, Chronic Respiratory Failure, Type Two Diabetes and Morbid Obesity. The POS also documents Physician Orders for a Bi-level Positive Airway Pressure Machine (Bi-Pap) via full mask with 1:65/E/:5, at bedtime for Sleep Apnea and an order for Oxygen at two to four liters via Nasal Cannula continuous every shift related to COPD and a oxygen tank portable two to four liters by Nasal Cannula related to COPD. The POS does not document orders for cleaning, changing or maintaining respiratory (Oxygen and CPAP) supplies. R52's current Care Plan documents R52's Oxygen therapy. The Care Plan does not document a Physician's Order for cleaning, changing or maintaining R52's Respiratory (Oxygen and CPAP) supplies. R52's Treatment Administration Record, dated 3/1/24 through 3/27/24, does not document a Physician's Order for cleaning, changing or maintaining R52's Respiratory (Oxygen and CPAP) supplies. On 3/26/24 at 10:13 am, R52 was sitting in wheelchair in room and R52's oxygen concentrator was running at two liters, and the tubing and cannula were laying on the floor next to R52's bed. R52 stated, My tubing is not long enough to reach, I need longer tubing. R52 picked up the oxygen tubing off of the floor and placed it on R52's face. The tubing was not dated or in a plastic storage bag. R52's humidification bottle was not dated. R52's CPAP tubing and face mask/pillow were hanging/dangling on the side of R52's nightstand, unbagged and undated. R52's face mask/pillow were moderately soiled with a white substance. On 3/27/24 at 1:00 pm, R52, was sitting in R52's wheelchair at the entrance of V1's (Administrator) office doorway, with oxygen setting at two liters, and R52's portable oxygen tank tubing was not dated. On 3/28/24 at 10:39 am, R52's was sitting in bed wearing oxygen tubing and R52's oxygen concentrator was running at two liters. R52's oxygen tubing and humidification bottle were not dated, and a plastic storage bag was not in R52's room. R52's CPAP mask/pillow was in a storage bag, dated 3/28/24. R52's CPAP mask/pillow had a moderate amount of white substance on the inside of the mask/pillow. R52's CPAP supplies could not be located. On 3/28/24 at 10:39 am, V7 (Licensed Practical Nurse/LPN) stated, I cannot find any CPAP supplies. I am not sure who is responsible for changing and cleaning the filters, tubing and mask/pillow. It may be third shift's responsibility, I am not sure. V7 confirmed that there is no documentation for changing or cleaning, the Oxygen and CPAP filters, tubing or mask/pillow on R52's Physician Order Sheet, Treatment Administration Record or Medication Administration Record. On 3/28/24 at , V2 (Director of Nursing) stated, I have posted the Oxygen Policy at the Nurse's Station because we have been having problems and we have lacking with the oxygen cares. The nurses should be dating and changing oxygen and CPAP supplies. On 3/28/24 at 2:10 pm, V1 (Administrator) stated, We just talked to nursing about this because we have been having issues with this. They should be changing, dating and bagging the oxygen and CPAP supplies. 30722 B) A physician order dated 12/2/23 for R71 reads to change out, date and label all oxygen tubing/bags and to clean the filter and wipe the machine down every Sunday. On 03/27/24 at 2:11 PM, R71 was laying in bed with oxygen via nasal prong and a concentrator. R71's tubing had no date visible and R71's humidity bottle was dated 02/07/24. On 03/27/24 at 2:17 PM, V14 observed R71's oxygen equipment and confirmed R71's tubing had no date stating, The tape may have been torn off. V14 also stated the date on R71's humidity bottle was, either 02/07 or 02/09/24. V14 stated she was unsure how often humidity bottles should be changed and that she would have to check.

Based on interview and record review, the facility failed to follow a physician treatment order for one resident (R1) reviewed for wound treatment orders in a sample of three. Findings Include: The facility's Pressure Injury and Skin Condition Assessment Policy, dated 1/17/18, documents: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries, and other ulcers and assuring interventions are implemented. 18. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. R1's diagnoses include: Personal history of other malignant neoplasm of skin, varicose veins of right and left lower extremities, non-pressure ulcer of right and left lower extremities, excoriation (skin picking) disorder, end stage renal disease. R1's Treatment Administration Record/TAR dated 10/2023 documents: Treatment to bilateral lower extremities/BLE: Cleanse wounds to BLE with wound cleanser, pat dry, apply calcium alginate to open areas, cover with unna boots and wrap with kerlix and ace wraps. Every day shift every Wednesday, Saturday for wound care per (V6 Wound Care Physician) related to Encounter for change or removal of nonsurgical wound dressing. (Internet definition for unna boot, dated 2/2024 documents: An Unna boot is a compression dressing made by wrapping layers of gauze around your leg and foot. It is often used to protect an ulcer or open wound. The compression of the dressing helps improve blood flow in your lower leg.) Review of R1's 10/2023 TAR indicated there were no staff signage for treatment care for R1 on Wednesday 10/18/23 or on Saturday 10/21/23 to indicate wound care had been done for R1's left foot wound. On 2/16/24 at 12:25pm, V3 Assistant Director of Nursing/ADON/Infection Control Preventionist stated that in October 2023, R1 had scheduled wound treatments; (noted treatments scheduled for Wednesdays and Saturdays); stated that R1 had a wound on his left foot between great toe and second toe; and stated that R1 liked to pick at his lower extremities. On 2/28/24 at 11:10am, V4 Minimum Data Set/MDS/Care Plan Coordinator, confirmed that R1's Treatment Administration Record/TAR for October 2023 indicated no treatment sign offs by staff for 10/18/23 or 10/21/23 prior to 10/25/23 when maggots were noted in R1's left foot wound and stated I notified the appropriate staff and documented about (R1's) infection and about the foul odor on 10/18/23. Not sure why I did not sign the TAR and forgot to mark the treatment off as being done for 10/18; but there was a change in (R1's) wound and we got a new order.

Based on observation, interview and record review, the facility failed to ensure residents were informed they could choose their own physician for three residents (R1, R3, and R4) of four residents reviewed for Resident Rights in a sample of four. This failure has the potential to affect all 75 residents in the facility. Findings include: The facility's Residents' Rights for People in Long-Term Care Facilities, undated, documents, You have the right to choose your own doctor. 1. R1's clinical record documents R1 admitted on [DATE] under the care of V3 Medical Director. On 8-25-23, at 1:04pm, R1 was lying in bed. R1 stated that on admission, They did not ask about choosing my own doctor. They said they had one here. He's not my first choice. 2. R3's clinical record documents R3 admitted on [DATE] under the care of V3 Medical Director. On 8/25/23, at 1:11pm, R3 stated the following, When I was admitted they never asked who I wanted for a doctor. They didn't tell me that I could choose. I would have chosen (V8 Medical Doctor). They have (V3 Medical Director) and that is who I have. 3. R4's clinical record documents R4 admitted on [DATE] under the care of V3 Medical Director. On 8/29/23, at 10:10am, R4 stated that no one asked R4 what doctor R4 wanted. On 8/25/23, at 12:20pm, V1 stated the following, On admission, residents are told that we have a house doctor (V3 Medical Director) with his own nurse or they can have one of their own choices .I am not the one who tells them; I believe it would be our Admissions person (V4) and she is not here today. On 8/29/23, at 8:35am, V4 Business Office Director/BOM/Admissions stated that once a resident comes through the door, V4 does the initial admission contract with them. V4 denied talking to residents about their right to choose their own doctor. V4 stated that prior to residents coming to the door, (V5 Marketer) does the initial admission packet which goes over resident rights. On 8/29/23, at 9:08am, V5 Director of Business Development (Marketer) denied reviewing any resident rights with the residents including what doctor they want. V5 stated, I believe you would need to refer to (V1 Administrator) for that. On 8/29/23, at 9:18am, V2 former Director of Nursing/DON stated the following, (V2's) last day was 8-18-23 and V2 was here a little over a year. (V3) is the Medical Director. (V3) has the whole facility right now .Upon admission we have to put (V3) down to be able to get their medications. If another doctor is named for a follow up appointment (V7 Transporter) will ask them prior to their appointment who they want to follow up with - the named doctor or (V3) our Medical Director. Those who are here for therapy usually will go see their Primary Care Physician/PCP and we provide their transportation. The ones who are here long term are (V3's) since (V3) is the Medical Director. It's a convenience to (V3) to follow them and know them. I have never asked them if they want someone else .I don't think anyone asks them what doctor they want. On 8/29/23, at 9:57am, V6 Social Security Director/SSD stated V6 does not ask residents who they want for a doctor. V6 is unsure if it is the nurses or admissions who ask them. When V6 does their initial assessments V6 goes over resident rights in general. It does not include what doctor they want. On 8/29/23, at 10:04am, V7 Transporter/CNA stated V3 (former Director of Nursing/DON) told V7 there is no reason for them to see an outside doctor as their Primary Care Physician/PCP if they are inside the facility and we have a doctor here who sees them. Usually when they come in, they see our facility doctor (V3) automatically. The facility's Resident Roster, dated 8-25-23, documents there are 75 residents currently residing in the facility.

Based on interview and record review, the facility failed to ensure a physician personally conducted the required face to face visits for four of four (R1-R4) residents reviewed for physician visits in a sample of four. This failure has the potential to affect all 75 residents in the facility. Findings include: The facility's Admission Agreement, undated, documents, Contract Between Resident and Facility. C. Residents' Rights and Obligations. 15. Selection of Health Care Professionals. Resident may select, or have selected on his/her behalf, qualified health care professionals who conforms to the Facility's policies, rules, applicable laws, and regulations. Resident must have, select, or have chosen on his/her behalf a personal physician who will be available, or whose agent will be available, at all times for notification of significant changes in the Resident's clinical condition. On 8/25/23, at 10:50am, V1 Administrator, who stated V1 just spoke with V3 Medical Director, stated the following: (V3) is the primary doctor who sees residents. (V3) does telehealth on Tuesdays and Thursdays. V3 said that because they are rural hospital, they are allowed to do telemedicine. (V3) does telehealth once every 60 days for all long-term residents. For Medicare at least once a week up to three times a week. Our last Covid outbreak was March 2023. V1 confirmed at this time that V3 does not do face to face visits - only telemedicine. V1 is unaware of the last time V3 came into the facility to see residents. On 8/25/23, at 10:55am, V1 was unable to produce a list of residents seen personally by V3 and stated they do not keep a log of (V3's) in-person visits. 1. R1's clinical record documents R1 admitted on [DATE] under the care of V3 Medical Director. R1's current Physician Progress notes document R1 had telemedicine doctor visits on 7/25, 8/1, 8/8, and 8/22/23. These physician notes all begin with the statement, Telemedicine visit performed in lieu of face to face visit during unprecedented COVID-19 national crisis. R1's clinical record documents R1 as cognitively intact and does not document any face-to-face visits with V3 or any other physician. On 8-25-23, at 1:04pm, R1 denied every being physically seen by a doctor and stated, It is always on the computer. 2. R2's clinical record documents R2 admitted on [DATE] under the care of V3 Medical Director. R2's current Physician Progress notes document R2 had telemedicine doctor visits on 7/11, 7/13, 7/18, 7/20, 7/25, 8/1, 8/8, 8/17, 8/22, and 8/24/23. These physician notes all begin with the statement, Telemedicine visit performed in lieu of face to face visit during unprecedented COVID-19 national crisis. R2's clinical record documents R2 as cognitively intact and does not document any face-to-face visits with V3 or any other physician. On 8/25/23, at 12:54 pm R2 self-propelled in a wheelchair into R2's room. At this time R2 denied ever seeing V3 personally for a visit. 3. R3's clinical record documents R3 admitted on [DATE] under the care of V3 Medical Director. R3's current Physician Progress notes document R3 had telemedicine doctor on 6/8, 6/13, 6/20, 6/22, 6/27, 6/29, 7/11, 7/20, 8/8, 8/15, and 8/22/23. These physician notes all begin with the statement, Telemedicine visit performed in lieu of face to face visit during unprecedented COVID-19 national crisis. R3's clinical record documents R3 as cognitively intact and does not document any face-to-face visits with V3 or any other physician, On 8/25/23, at 1:11pm, R3 denied ever seeing V3 physically and stated, Only on the computer. R3 stated, I would definitely have remembered if I saw him in person. 4. R4's clinical record documents R4 admitted on [DATE] under the care of V3 Medical Director. R4's current Physician Progress notes document R4 had telemedicine doctor on 3/21, 3/23, 3/28, 3/30, 4/4, 4/6, 4/13, 5/18, 5/25, 5/30, 6/15, 6/27, 6/29, 7/18, and 8/15/23. These physician notes all begin with the statement, Telemedicine visit performed in lieu of face to face visit during unprecedented COVID-19 national crisis. R4's clinical record documents R3 as moderately cognitively impaired and does not document any face-to-face visits with V3 or any other physician, On 8/29/23, at 10:10am, R4 was lying in bed and stated that R4 has never physically seen (V3). (V3) talks to R4 over the computer. R4 stated it makes R4 feel terrible that (V3) doesn't come in to see R4. R4 stated, I would like to see him in person. The facility's Medical Professionals report, dated 8-25-23, documents 75 residents currently residing in the facility have V3 Medical Director listed as their attending physician. The facility's Resident Roster, dated 8-25-23, documents there are 75 residents currently residing in the facility.

Facility Failures resulted in two deficient practice statements. A. Based on observation, interview and record review, the facility failed to serve hot cereal at a safe temperature to prevent a resident's second-degree burn (R1) and failed to notify the facility Administration so an investigation could be conducted, which resulted in another resident (R2) suffering a second-degree scalding burn after facility kitchen staff served a scalding hot beverage without performing the required safe temperature check prior to serving. R1 sustained a 4.0 CM (centimeter) X 1.4 CM X 0.1 CM second degree, blistered, painful wound to the left anterior thigh on 11/29/22 when she was served a bowl of hot cereal. After R1 had suffered a second-degree burn, facility staff did not document the accident in R1's Nurse's notes, did not notify facility administrative staff and therefore no subsequent evaluation of the situation or implementation of further safety interventions were developed. On 4/17/23, R2 was served a scalding hot cup of tea and sustained a 4.05 CM X 2.72 CM second degree, blistering burn to her abdomen after she spilled the beverage. Facility kitchen staff served the hot beverage from the hot beverage machine without checking the required temperature prior to serving. Nursing staff again did not notify facility Administrative Staff and no evaluation of the incident nor implementation of further safety interventions were developed prior to discovery on 5/16/23. These failures have the potential to affect 73 of the 74 residents currently residing the facility. These failures resulted in an Immediate Jeopardy. The immediacy was removed on 5/22/2023. FINDINGS INCLUDE: The (undated) facility policy, Precautions for Handling Hot Beverages directs staff, Staff will monitor, serve and hold hot beverages in a safe manner to prevent potential burns. The temperature for brewing and serving hot beverages will be based on the manufacture recommendations for the beverage equipment utilized in the (facility). Although the recommended settings for proper brewing may vary based on the equipment, it is recommended that the temperature of the equipment be set at the lowest possible temperature for adequate brewing; anticipated to be in the range of 160- 170 degrees Fahrenheit. The serving temperature should be approximately 10 -15 degrees less than the brewing temperature. It is suggested that brewing and serving temperatures of hot beverages are monitored on a monthly or quarterly basis to assure proper functioning of equipment. Additional precautions may be implemented: Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. Ensuring staff monitor the identified high- risk resident(S) during mealtimes and/or when hot beverages are served. Utilizing specialized spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning. The (undated) facility policy, Serving Temperatures for Hot and Cold Foods directs staff, Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods. Hot foods served at higher temperatures, based on resident preference, must be done cautiously because foods served too hot may potentially decrease food quality and possibly contribute to resident burns. Hot cereal: 135 degrees Fahrenheit to 170 degrees Fahrenheit. Hot beverages: Follow facility guidelines. The Cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. The manufacture guidelines for the facility hot beverage machine (NG C300 Black) documents, The liquid dispenser (NG C300) is a dispenser for the delivery of coffee, tea and only hot water in commercial sectors. Warning: The liquids delivered by the dispenser are hot. Avoid scalding. The hot beverage machine Work Order dated 5/16/23 documents, (Facility) wants to know the temperature setting on their machine and would like the machine checked. Last check on 5/13/21. Solution: Replaced filter. Replaced temperature probe. Adjusted temperature from 194 degrees to 185 degrees, per customer (request). The (facility) Food Temperature Log Sheet, provided by V9/Cook directs staff to check food temperatures for Breakfast for eggs, scrambled eggs, oats, super cereal, and pureed eggs. No direction for checking temperatures of hot beverages is given. The facility Food Temperature Chart dated 4/30/23 through 5/15/23 documents the food temperature of the hot cereal served to facility residents during that time period ranging from 200 degrees Fahrenheit on 5/7/23 to 178 degrees on 5/8/23. No recorded temperatures of hot beverages are documented during this time frame. The current State Operations Manual, documents the following concerning burns: Table 1. Time and Temperature Relationship to Serious Burns Water Temperature Time Required for a 3rd Degree Burn to Occur 155 F 68 C 1 sec 148 F 64 C 2 sec 140 F 60 C 5 sec 133 F 56 C 15 sec 127 F 52 C 1 min 124 F 51 C 3 min 120 F 48 C 5 min 100 F 37 C Safe Temperatures for Bathing (see Note) NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. A. 1. R1's (facility) Admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Dementia with Behavioral Disturbance, Conversion Disorder with Seizures, Anxiety Disorder and Age- Related Cognitive Decline. R1's May 2023 Physician Order Sheet includes the following physician orders: General diet, add Super Cereal (hot cereal) at breakfast. R1's (facility) Skin and Wound Evaluation form, dated 11/29/22 documents, Burn, Second Degree, Front of Left Thigh, In- House Acquired on 11/29/22, Measures 4.0 CM (Centimeters) X 1.4 CM X 0.1 CM with surrounding tissue: erythema: redness of the skin, Pain at dressing change. R1's (facility) Wound Evaluation with photographs, dated 11/29/22 documents a reddened wound with currently blisters present, measured as 4.01 CM X 1.37 CM X 0.1 CM. The wound is described as painful at dressing change with a daily treatment in place. R1's Initial Wound Evaluation and Management Summary, dated 12/7/22 by V15/Wound Doctor documents, (R1) presents with a wound on her left thigh. (R1) has a burn wound of the left thigh for least 1 day's duration. There is moderate serous exudate. Burn wound measures 4.5 CM X 1 CM X 0.1 CM with moderate, serous exudate. 15% slough and 35% granulation tissue. Procedure Note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.1 CM and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 15 percent to 5 percent. Hemostasis was achieved and a clean dressing was applied. Dressing Treatment Plan: Silver sulfadiazine apply three times per week for 30 days. Alginate calcium apply three times per week for 30 days. Foam silicone border dressing. Skin prep to the peri wound. R1's Wound Evaluation and Management Summary, dated 12/14/22 documents, (R1) presents with a wound to her left thigh. (R1) spilled hot oatmeal on her leg, causing a burn wound. Current wound size: 3 CM X 1 CM X 0.1 CM. Procedure Note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.1 CM and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 15 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied. R1's (facility) Wound Evaluation, dated 12/28/22 documents, Burn wound to left thigh measures 1.1 CM X 0.71 CM X 0.1 CM. Wound bed is 100% epithelial tissue. Progress: Healed. On 5/15/2023 at 1:45 P.M., V5/Registered Nurse verified she did fill out the wound information sheet for R1's leg wound. V5 also verified that R1 feeds herself after staff prepared her food and R1 dropped a bowl of hot cereal on her leg, causing injury. V5/RN verified she did not tell V1/Administrator or V2/DON about (R1's) injury but did obtain a wound treatment for the injury. V5 stated that R1 complained of much pain when wound treatment was being done and stated R1 saw the facility Wound Doctor about a week after the injury happened. On 5/16/23 at 9:39 A.M., V9/Cook stated, We don't currently have a Dietary Manager. We haven't had one for about a month. Dietary Managers from other facilities take turns coming here and looking things over. The Cook is responsible for temping each food offered prior to the start of the meal. At that time, V9 was only able to produce the facility Food Temperature Logs from 4/30/23 through 5/15/23. V9/Cook verified temperature checks of the cooked cereal were between 178 degrees and 200 degrees. At 9:57 A.M., V9/Cook stated, We don't check the temperature of hot beverages (prior to serving). I suppose we could start doing that. At that time, V9/Cook verified the temperature of a cup of hot water/coffee from the facility hot beverage machine was 190 degrees. V9/Cook also verified all 73 facility residents receive meals and beverages form the facility kitchen, except one resident who receives gastrostomy tube feedings. On 5/16/23 at 10:00 A.M., V10/Dietary Manager of sister facility who was over-seeing the facility kitchen stated, Kitchen staff should always check the temperature of hot beverages prior to serving. We always check hot beverage temperatures at the facility I have worked at for the past [AGE] years. Hot food/hot beverages can cause severe burns in elderly residents. 190 degrees is too hot. 2. R2's (facility) Admission Record documents that R2 was admitted to the facility on [DATE] with the following diagnoses: Lack of Coordination, Abnormal Posture, Weakness and Anxiety. R2's May 2023 Physician Order Sheet includes the following physician orders: General, Regular Diet. R2's Nursing Progress Notes, dated 4/17/23 at 7:09 A.M. document, (R2) spilled tea on abdomen causing a second-degree burn. Area cleansed with soap and water. Bacitracin applied to wound bed and covered with Border Foam dressing. R2's Wound Evaluation, dated 4/18/23 documents, Second degree burn to lower left abdomen, measures 4.05 CM X 2.72 CM, acquired in- house on 4/17/23. 90% granulation tissue present with light serous drainage. Treatment in place. R2's Wound Evaluation, dated 5/9/23 documents, Second degree burn to lower abdomen, measures 3.79 CM X 2.76 CM X 0.1 CM. 100% granulation tissue present with light serous drainage. Progress: Healing. On 5/16/23 at 1:17 P.M., R2 stated she likes hot tea at each meal and usually the temperature is warm when she receives it. However, on that day (4/17/23), her tea was extremely hot and when she spilled it, it caused a painful burn. R2 stated the area was painful, especially when dressing was changed. Observation of area at that time shows an 8 CM X 4 CM healing burn to (R2's) lower left abdomen. The facility Room Roster dated 5/15/23 documents 74 residents currently reside in the facility. The Immediate Jeopardy began on 11/29/22 at 1:29 P.M. when R1 was served a bowl of hot cereal. After R1 had suffered a second-degree burn, facility staff did not document the accident in R1's Nurse's Notes, did not notify facility Administrative Staff and therefore no subsequent evaluation of the situation or implementation of further safety interventions were developed. V1/Administrator was notified of the Immediate Jeopardy on 5/22/23 at 1:35 P.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 and R2 incidents were both reported to IDPH (State Agency) on 5/16/2023. 2. The dietary assistant manager has been in-service on the safe temperature range for serving hot food and beverages. Training completed on 5/22/23 by Administrator. 3. All dietary staff have been in-serviced on performing hot beverage and food temps prior to each meal. They have also been in-serviced on interventions/measures required if hot food and beverages are not within an acceptable range. Staff's knowledge was evaluated based on a quiz. Any staff that do not have sufficient knowledge base will be re-trained and retested . Training initiated on 5/22/23 by Administrator and anyone on FMLA (Family Medical Leave Act) or vacation will be educated via phone and again before next scheduled shift. 4. The Director of Nursing has been educated on what constitutes an Incidents/Accidents and the timely reporting criteria for all unexplained bruises and abrasions, incidents and accidents with injury or the potential to result in injury. Training was completed on 5/22/23 by RNC (Regional Nurse Consultant). 5. The facility will check temperatures of hot foods and beverages at every meal to ensure hot food and beverages are at appropriate serving temperature. A QA (Quality Assurance) tool was completed to verify this practice has occurred. The QA tool will be completed by the dietary assistant manager or designee, for 6 weeks. There will be oversight of the QA tool by Administrator. 6. All nursing staff have been educated on what constitutes an incident/accident and the timely reporting on incidents/accidents for all unexplained bruises or abrasions, and all accidents or incidents where there is an injury. Staff's knowledge competencies will be based on a written quiz. Any staff that do not have sufficient knowledge base will be re-trained and retested . Training initiated on 5/22/23 by RNC or DON (Director of Nurses) anyone on PRN (as needed) status, FMLA or vacation will be educated via phone and again before next scheduled shift. 7. An impromptu QAPI (Quality Assurance and Performance Improvement) meeting was held with the (facility) Medical Director and staff IDT (Intra Disciplinary Team) team to discuss deficiency and facility action plan on 5/22/23. 8. The facility will read the progress notes daily to ensure a potential incidents/accidents have been captured as such and have appropriate follow up. A QA tool will be completed to verify this practice has occurred. The QA tool will be completed by DON or designee, daily for 6 weeks. There will be oversight of the QA tool by RNC or DON on 5/22/23 and on-going. 9. The coffee machine has been serviced by technician on 5/16/2023 resulting in adjusted dispensing temperature of 150-170 degrees as per policy. Completion Date: This plan was completed on May 22, 2023. B. Based on interview and record review, the facility failed to provide increased supervision after administration of two (as needed) psychotropic medications within a two-hour time span, resulting in a resident falling from a bed, sustaining a laceration and a head injury for one resident (R1) of three residents reviewed, in a sample of 6. The facility policy, Fall Prevention Program, dated 11/28/2012 directs staff, 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. The Fall Prevention Program includes the following components: Use and implementation of professional standards of practice. In addition to the use of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk: The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care. R1's (facility) Admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Dementia with Behavioral Disturbance, Conversion Disorder with Seizures, Anxiety Disorder, Age- Related Cognitive Decline, Insomnia, Lack of Coordination, Abnormal Posture and Weakness. R1's current Physician Order Sheet, dated May 2023 includes the following medications: Risperidone (antipsychotic) 1 MG (Milligram) by mouth in the morning and 0.5 MG by mouth at bedtime; Mirtazapine (antidepressant) 30 MG by mouth at bedtime; Ativan (antianxiety) 0.5 MG by mouth every 6 hours as needed; and Ativan Injection 2 MG/ML (Milliliters) Inject 1 ML intramuscularly every 12 hours as needed for agitation and anxiety. R1's Fall Risk Assessment, dated 01/31/2023 documents R1 is at high risk for falls (Score 21) (High Risk is 10 or greater). R1's current Care Plan, dated 2/9/22 includes the following Focus Area: (R1) is at risk for falls related to weakness due to self-care deficit. R1's Care Plan documents R1 had falls on: 2/20/22, 7/14/22, 7/18/22, 9/16/22, 9/24/22, 10/1/22, 10/28/22, 12/22/22 and 4/18/22. This same Care Plan includes another Focus Area, (R1) uses an anti-anxiety medication related to anxiety disorder. Interventions include, Administer anti-anxiety medication as ordered by physician. Monitor for side effects and effectiveness. Monitor/document/report any adverse reactions: Drowsiness, lack of energy, clumsiness, slow reflexes, confusion and disorientation, dizziness, impaired thinking and judgement, blurred or double vision. R1's April 2023 Medication Administration Record documents that R1 received the following medications on 4/17/2023: Ativan 2 MG/ML (1 MG) intramuscularly at 2:11 P.M. due to behaviors; Ativan 0.5 MG PO at 8:14 P.M. for agitation and anxiety; and Ativan 2 MG/ML (1 MG) intramuscularly at 10:53 P.M. for agitation. R1's (facility) Fall-Initial Occurrence Report, dated 4/18/23 at 1:25 A.M. and signed by V12/Registered Nurse, documents, Unwitnessed fall at (R1's) bedside, (R1) observed laying on floor next to her bed, face down, in a pool of blood, moaning and groaning. Contributing Factors: Confused, forgets to use call light, Recent room change. Other factors: Was given IM Ativan at (10:53) P.M. for behaviors. Injuries: Left lower lip laceration. New interventions initiated immediately: Floor mat, Nonskid footwear, Safety checks every 15 minutes. Sent to ER (emergency room ). R1's emergency room Report, dated 4/18/23 documents, (R1) resides at (facility) and presents to ER for evaluation of head injury and lip laceration after a fall out of bed. The (facility) gave (R1) some Ativan because of agitation at bedtime. (R1) then rolled out of bed and struck her head. Exam: Evidence of contusion to the face with lip laceration. Diagnosis: Head Injury, Head Contusion, Lip Laceration. On 5/16/23 at 11:13 A.M., V12/Registered Nurse denied providing increased supervision for R1 after facility staff had administered three additional doses of Ativan to R1, within a 10-hour period. V12/Registered Nurse stated, I was the nurse the night that (R1) fell from bed. I work 6 P.M. to 6 A.M. and R1 was having behaviors all night. (R1) wouldn't take her medications; (R1) was very anxious and combative. I gave her an extra dose of (oral) Ativan at 8:14 (P.M.) and (R1) was still having behaviors, so I called (R1's) doctor and got an order for I.M. (Intramuscularly) Ativan. It took three additional staff members help for me to give (R1) the shot. I gave it around 10:53 P.M. Around 11 (o'clock P.M.) I noticed (R1) was falling asleep in her wheelchair. A couple of hours later I heard a movement and a sound like something fell . I found (R1) lying face down in a pool of blood. I sent (R1) to the ER. We didn't do anything special for (R1) after I gave (R1) the shot. We just put (R1) to bed, like normal.

Based on observation, interview and record review, the facility failed to conduct COVID-19 testing on residents that displayed COVID-19 like symptoms for five residents (R2, R7, R15, R16 and R17) out of 16 residents reviewed for COVID-19 testing in a sample of 24. The facility also failed to perform COVID-19 testing on employees that displayed COVID-19 like symptoms prior to providing direct care and services to residents in the facility. This failure has the potential to cause COVID-19 infection to all 80 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/6/23 when the facility failed to conduct COVID-19 testing on R16 after R16 started displaying COVID-19 like symptoms. V15, Regional [NAME] President of Operations (RVP) was notified of the Immediate Jeopardy on 3/23/23 at 3:20 PM. While the immediacy was removed on 3/23/23, the facility remains out of compliance at Severity Level two due to the facility's ongoing monitoring of their plan of correction, completion of in-service training, and Quality Assurance (QA) team meetings to identify residents at risk for communicable diseases during the QA process. The abatement plan was received from the facility on 3/23/23 at 4:28 PM. The abatement plan was returned to the facility on [DATE] at 9:03 AM to be updated with additional information needed. The facility returned the updated abatement plan on 3/24/23 at 9:27 AM. The abatement plan was accepted on 3/24/23 at 10:42 AM and the facility was notified of accepted abatement plan at 10:43 AM. Findings include: The facility's Infection Control - Interim COVID-19 policy revised 10/31/22 documents Screening of Visitors, Staff and Residents: Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive viral test for SARS-CoV-2 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or higher risk exposure (for healthcare personnel (HCP)). Staff: Instruct HCP to report any of the three above criteria to occupational health or another point designated by the facility so these HCP can be properly managed. The facility's Interim COVID-19 Testing - Residents and Staff policy revised 10/21/22 documents Testing of Staff and Residents: Testing Trigger - Symptomatic individual identified. Staff, regardless of vaccination status, with signs or symptoms must be tested . Residents, regardless of vaccination status, with signs or symptoms must be tested . Testing of Symptomatic Individuals: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Symptoms include: 1) Temperature greater than 100.0 Fahrenheit. 2) Significant decrease in oxygen saturation from baseline or oxygen saturation less than 92%, cough. 3) Cough, cold symptoms. 4) Sore throat. 5) New loss of smell/taste. 6) Headache. 7) Chills. 8) Muscle pain. 9) GI (Gastrointestinal) symptoms (nausea, vomiting, diarrhea). If using an antigen test, a negative result should be confirmed be either a negative NAAT (molecular PCR The polymerase chain reaction (PCR) test for COVID-19 is a molecular test that analyzes your upper respiratory specimen, looking for genetic material (ribonucleic acid or RNA) of SARS-CoV-2, the virus that causes COVID-19.) or a second negative antigen test taken 48 hours after the first negative test and maintain transmission-based precautions until results are confirmed. Staff with symptoms or signs of COVID-19 must be tested and are expected to be restricted from the facility pending results of COVID-19 testing. The facility's census report dated 3/21/23 documents 80 residents residing in the facility. 1. On 3/21/23 at 8:14 AM, during an observation of medication administration, R2 noted to have cough and mucus hanging down from his nose. V3, Registered Nurse (RN), stated, You don't look to good. You feeling ok? R2 replied, I don't feel well. I haven't felt well in days. V3 turned to surveyor and stated, He's been like this for a couple of weeks. I'm going to give him a breathing treatment. On 3/21/23 at 9:03 AM, V2, Director of Nursing/Infection Preventionist (DON/IP) was asked for all infection control tracking documentation to include employee and resident symptoms tracking and screening along with employee and resident COVID-19 testing for the last month. V2, DON/IP, stated, We haven't screened anyone in months. Our policy says we don't have to because our community transmission level is green. We just started wearing masks today. We haven't tested resident for COVID in months because we haven't had an outbreak or a positive employee. When asked about symptom tracking and COVID-19 testing for resident given R2's observed COVID-19 like symptoms, V2, DON/IP, stated, (R2) didn't have to be tested for COVID because our community transmission is green. (R2) has another respiratory issue. We didn't test him. R2's medical record dated 3/14/23 documents, Per report, resident had low-grade fever last night. Assessed resident this morning. Oxygen saturation is 91-92% on room air. Diminished breath sounds throughout lungs. Noted increased wet cough. Daughter at bedside. Primary care physician in facility and saw resident. Received order for stat chest X-ray and as needed Tylenol for fever. R2's medical record dated 3/14/23 documents, Physician progress note. Patient with fever yesterday, had mild cough. Poor appetite last couple of days, sore throat per family member. Plan: 1. Reviewed therapy notes and discussed any issues with the patient. Continue current therapy regimen. 2. Patient with fever and cough since yesterday. Chest X-ray is pending. Has poor appetite, recommend COVID-19 swab. R7's medical record dated 3/8/23 documents, Resident has a coarse, non-productive cough. Crackles auscultated to bilateral lower lobes. Oxygen saturation 93 % on room air. Medical doctor (MD) notified and order for Chest X-ray received. R7's medical record dated 3/8/23 documents, Chest X-ray results are within normal limits. MD notified. No new order. The facility's monthly infection control log dated March 2023 documents that on 3/6/23 R16 had an onset of fever, cough, and shortness of breath, on 3/7/23 R15 had an onset of a cough and on 3/12/23 R17 had an onset of increased coughing, lowered oxygen saturation and colored phlegm. On 3/21/23 at 3:20 PM, V2, Director of Nursing/Infection Preventionist, (DON/IP), stated You asked for the resident COVID symptom tracking and testing, that COVID resident line list I gave is it. (R19) was the last resident we had and (V5, Dietary Housekeeping Supervisor) was the last employee we had that tested positive. We tested (R2) today around 11:00 am. I did see in the progress notes that the doctor wanted a COVID test on him (R2) last week, but he never wrote an order for it so we missed it. I'll be honest with you, the only reason we tested him today was because you're here in the building. The facility's COVID-19 Resident line listing and symptom tracking log documents the last resident to have symptoms and tested for COVID-19 was R19 on 11/20/22. The facility's COVID-19 Resident line listing and COVID-19 symptom tracking log does not include R2, R7, R15, R16, and R17. R2, R7, R15, R16 and R17's medical record does not document a COVID-19 test was performed. R7's medical record documents R7 tested positive for COVID-19 on 3/22/23. On 3/22/23 at 11:42 AM, V15, Regional [NAME] President of Operations (RVP), stated, We don't need an order to test residents for COVID. If they have any of the symptoms identified by the CDC (Center for Disease Control) as COVID symptoms, then we should be testing. On 3/23/23 at 9:50 AM, V15, RVP, stated, I looked into those residents you asked me about. (R15, R16 and R17) were not tested for COVID prior to the outbreak. Yes, they should have been tested given their symptoms. (R2) should have been tested when staff identified his symptoms. Any resident that has COVID like symptoms should be tested immediately. 2. The facility's COVID-19 outbreak testing results dated 3/22/23, documents six of the nine residents, R9 through R14, that reside on C Hall tested positive for COVID-19. The facility's COVID-19 Staff line listing and symptom tracking log documents V5, Housekeeping/Dietary Supervisor (HDS), tested positive for community acquired COVID-19 on 3/16/23 with her last day of work on 3/13/23. On 3/21/23, at 1:45 PM V2, DON/IP, stated, The last positive COVID we had was (V5, HDS). She tested positive on 3/16/23, but the last day she worked was 3/13/23. Therefore, it was community acquired. She wasn't here in the building to expose the residents. V2, DON/IP, was asked if there were any employees over the last month that have come to work with COVID like symptoms or that had an illness and went home due to illness. V2, DON/IP, replied No, we haven't had any employees sick while here at work that went home or had to be sent home due to illness. On 3/21/23 at 2:55 PM, V5, HDS, confirmed a COVID-19 test was not conducted prior to her working on 3/16/23 and stated, I came into work last Thursday (3/16/23) and I was sick. I went straight to my office around 6:30 AM. I called the doctor to get some medicine for my symptoms, but they wouldn't call any in. So, I left work around 11:30 AM, went home and did an at home COVID test. It was positive. I called (V2, DON/IP) the same day to let her know I tested positive and that I was at work. On 3/22/23 at 8:24 AM, V9, CNA, stated, There's been a few CNAs that have worked while sick over the last few weeks. I don't know their names. On 3/22/23 at 8:25 AM, V10, CNA stated, There's been a couple of employees that worked while sick, but I can't tell you their names. On 3/22/23 at 8:28 AM, V11, CNA, stated, There were two employees who had to go home due to illness over the last couple of weeks. (V8, CNA) left her shift early sometime last week because she was sick and the other was (V7, CNA). She went home yesterday because she was sick. Those are the only two that I know of. On 3/22/23 at 8:31 AM, V2, DON/IP, stated, (V7, CNA) went home yesterday (3/21/2023) due to respiratory symptoms, but her rapid test was negative. She was supposed to do a COVID PCR test before she left, but I forgot to collect it. When the employee has symptoms and tests negative on a rapid test, we must do a PCR test and send it to the lab. (V8, CNA) went home sick (3/15/2023) on her own accord. She wasn't sent home. I didn't find out until after she went home that she left because she was sick. I found out around 3:00 PM that day. I tried calling her the next morning to have her test, but she didn't answer her phone so I left her a message. This morning she came to work and when we told her she had to test due to an outbreak, she refused and left so we never did get her tested . On 3/22/23 at 8:44 AM, V7, CNA, stated, I came to work sick yesterday. I didn't screen or test because I thought we didn't have to do that anymore. I got to work at 6:00 AM and around 11:00 AM (V2, DON/IP) tested me and sent me home. I showed up to work with a cough and congestion, but it got worse. V7's, Certified Nursing Assistant (CNA), timecard report documents V7 worked on 3/21/23 from 6:09 AM to 11:03 AM and worked on C Hall. V7's Point of Care COVID-19 testing sheet dated 3/21/23 and signed by V2, DON/IP, documents, Is this person exhibiting any symptoms consistent with COVID-19? Yes. On 3/22/23 at 9:51 AM, V8, CNA, stated, Last Wednesday (3/15/23) I got to work around 6:00 AM and wound up having to leave at about 10:00 AM because I was vomiting and had diarrhea. My symptoms actually started a few days prior to that. I was having a headache and body aches for a few days, but they stopped the day I went to work. The day I went to work, I only had the nausea and diarrhea, but I wound up vomiting, so I told the scheduler I was sick, and I went home. (V2, DON/IP) called me the next morning and told me that I needed to let her know if I left work. I never tested for COVID. I thought I would be ok. V8's, CNA, timecard report documents V8 worked on 3/15/23 from 6:00 AM to 10:13 AM and worked on C Hall. On 3/23/23 at 9:24 AM, V14, Housekeeping, observed in the hallway going into resident rooms and cleaning. During the interview with V14, her voice sounded hoarse. V14 stated Yeah, I've been sick over a week now. It started last week. I came to work (3/15/23) with a headache, sore throat, and stiff neck. After a couple of days of working, it started getting worse, so I went to the nurses' station and asked for a rapid test. It was negative, so I went back to work. I didn't tell anyone I was sick until I did the test. I'm housekeeping, so I go all over the facility. On 3/23/23 at 9:50 AM, V1, Administrator, and V15, RVP, were informed of V14, Housekeeping, and requested V14's COVID-19 testing record. V14's, Housekeeping, timecard report documents V14 worked 7.5 hours on 3/15/23, 3/16/23, 3/17/23, 3/20/23, 3/21/23 and 3/22/23. The time report also documents V14 punched in to work on 3/23/23 at 6:28 AM, with no time punch out. On 3/23/23 at 11:53 AM, V15, RVP, stated, I just wanted to let you know that (V14, Housekeeping) tested negative on the rapid test when we did the whole facility, but because she's symptomatic, she has to do a PCR test. We did collect the PCR and sent her home, immediately after you informed us, and told her that she can't return to work until we get the PCR test results back. The employees have been in-serviced about not coming to work with COVID symptoms. If they're having symptoms, they have to notify management and get a rapid COVID test. If the rapid test is negative, and they're symptomatic, then they have to do a PCR test and can't return to work until we get the results. If the PCR is negative, they can return to work. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3/22/23 throughout the day from 8:24 AM to 3:30 PM, observations of employee and resident COVID-19 testing observed. 2. On 3/24/23 at 10:40 AM, review of the resident roster and resident COVID-19 testing dated 3/22/23 verified all residents to include R2, R7, R15, R16 and R17 were tested by V17, Nurse Manager on 3/22/23. 3. On 3/24/23 at 12:18 PM, The facility's employee COVID-19 in-servicing and staff COVID-19 testing sheets dated 3/22/23 and 3/23/23 were reviewed and reconciled against the facility staffing schedule dated 3/22/23 and 3/23/23 and verified the facility tested and educated all employees working on 3/22/23 and 3/23/23 on COVID-19 testing residents and staff and COVID-19 Infection Control Guidelines by V1, Administrator, and V15, RVP. Staff on vacation or FMLA (Family Medical Leave Act) will be in-serviced before returning to work by the Administrator. New hires will be in-serviced before beginning work by the Administrator. The facility's surveillance plan also reviewed and verified the Facility is tracking all resident and employee symptoms along with COVID-19 tracking. 4. All residents displaying any of the COVID-19 like symptoms as identified by the CDC will be tested immediately by Nurse Management or floor nurse. The Nurse Management or floor nurse will test all symptomatic employees prior to working. 5. The Administrator or designee will audit testing of symptomatic staff and residents for twelve weeks. The findings of the audit tools will be reviewed in the QA meeting. If the Administrator is not available, the Administrator will appoint the designee to review with QA Committee.

Based on interview and record review, the facility failed to directly supervise a resident (R1) who required supervision and assistance while eating. This failure resulted in R1, who has a history of dysphagia, is on a mechanically altered diet, is impulsive with eating and needs verbal cuing to eat slowly and take small bites, being served a lunch meal tray within R1's reach without staff members directly present. R1 subsequently choked on food items from R1's lunch tray. R1 required the [MEDICATION(S)] Maneuver, Cardiopulmonary Resuscitation efforts and transfer to the local area hospital where R1 expired. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity level II while the facility continues to: monitor the effectiveness of education and training on supervising residents who require assistance with eating and on Emergency Procedures, develops a Quality Improvement and Performance Improvement (QAPI) plan after a QAPI meeting is held, and continue to provide ongoing education and training on Assisted Dining policy and procedures. Findings include: The facility's Dining Experience: Staff Roles policy, 2020, states, Staff members will strive to enhance the resident's quality of life while serving meals that meet nutritional needs, offers choice, is served with dignity and considers the person-centered care plan. Staff will offer personal attention to each resident and monitor the resident's satisfaction and food intake. Procedure: 4. Staff members serving in the dining room will offer personal attention to each resident, giving consideration to the resident's plan of care, their preferences, intolerances and allergies. The facility's Feeding and Assisting Residents to Eat policy, undated, documents nursing personnel assisting should be positioned/seated at eye level with the resident to provide a relaxed and comfortable environment and documents that chewing and swallowing should be encouraged. The facility's Dental Soft/Mechanical Soft Diet policy, dated 2017, states, The Dental Soft/Mechanical Soft Diet is for individuals with limited or difficulty in chewing regular consistency foods. If a mechanical soft diet is ordered, the Dental Soft/Mechanical Soft Diet would be appropriate if there is a chewing/dentition problem. This diet may also be used by a Speech Language Pathologist/SLP in the treatment of dysphagia with individualization per recommendations by the SLP. For individuals that have any swallowing problems or dysphagia, it is recommended that a SLP be consulted and one of the Dysphagia Level Diets may need to be implemented. R1's Facesheet documents R1 with diagnoses to include but not limited to: Dysphagia; Epilepsy; Unspecified Dementia; [CONDITION(S)]; [CONDITION(S)] Disorder; Unspecified Intellectual Disability and Postural Kyphosis. The Facesheet documents R1 with an original admitted [DATE]. R1's Minimum Data Set Assessment, dated [DATE], documents the following: R1 can comprehend most conversation; requires extensive assistance of one person physical assist for eating; and R1 is on a mechanically altered diet. R1's current Care Plan documents R1 has an Activity of Daily Living/ADL self-care performance deficit and needs assistance to complete ADL care related to Postural Kyphosis, Lack of Coordination and Weakness. Interventions/Tasks are stated as Eating: Requires hands on assist, extensive assist of one. This same Care Plan documents R1 with short and long term memory impairments and impaired decision making. R1's Physician Order Sheet, dated [DATE] at 1:30 PM status post video swallow study, states, Recommend mechanical soft solids, thin liquids. No more than one ounce to be presented to the patient (R1) at a time, due to impulsivity. (R1) to be seated upright, 90 degrees during all meals. (R1) to take small bites of food, small sips of liquids and eat slowly. Recommend cough/throat clear periodically during meals as well. R1's Dietary Initial/Quarterly Evaluation, dated [DATE], documents R1 requires extensive assistance for eating. R1's Speech Therapy Plan of Care notes on [DATE] documents R1 required speech therapy services for evaluation and treatment of swallowing dysfunction and documents R1 required prompting for safe intake patterns. R1's Speech Therapy Discharge Summary, dated [DATE], documents R1 at risk for aspiration of liquids and R1 was discharged from therapy services on a mechanical soft diet with nectar thick liquids and supervision during meals. This form states, Pt (patient/R1) training on safe swallowing strategies. Constant supervision with verbal prompting for consistent use. R1's Physician Progress Note on [DATE] at 10:29 AM documents R1 was evaluated by V3 (R1's Physician). This same note states, 15. History of dysphagia: status post video swallow. (R1) is followed by speech therapy. We will continue to monitor their recommendations and monitor the patient clinically on his current diet. R1's current Physician Order Sheet/POS documents the following orders: General diet, mechanical soft texture, nectar consistency; Give no more than one ounce of fluid at a time d/t (due to) impulsivity. Take small bites of food and small sips of liquids for oral dysphagia with a start date of [DATE]; Have (R1) drink liquids after ,d+[DATE] (two to three) bites of food with a start date of [DATE]; Please have resident stay upright for ,d+[DATE] hours after meals with a start date of [DATE]. R1's Meal Card documents R1 was on a mechanical soft diet with nectar thick liquids. The facility's Diet Spreadsheet week two, day 13-Friday documents the dental/mechanical soft menu as Ground Beef Stew, Biscuit, Soft Cooked Vegetable, Apple Streusel Cake and Beverage. R1's Nursing Note on [DATE] at 12:10 PM, signed and dated by V2 (Director of Nursing/Registered Nurse/RN), states, This RN (V2) was notified by RN and CNA (Certified Nursing Assistant) that (R1) was choking. (V2) proceeded to do the [MEDICATION(S)] Maneuver on (R1) while in his chair. This RN (V2) could not get behind (R1) to do the proper maneuver. (V2) instructed for 911 to be called. (V2) proceeded to place (R1) on the floor on his left side. This RN (V2) did a mouth sweep and noticed some food that was obstructing (R1's) airway. This RN (V2) instructed for another RN to get the suction off the crash cart. Suction hooked up and was initiated by this RN. EMS (Emergency Medical Services) took over residents care. EMS started compressions and called (local area hospital) ED (Emergency Department) doctor due to resident was a DNR (Do Not Resuscitate) code. Doctor instructed for EMS to bring (R1) in and to continue to code (R1). (R1) left with EMS via ambulance (to local area hospital). R1's Code Blue Event note, signed and dated by V2 on [DATE], documents R1 was brought to V2 by another staff member after R1 was found to have choked on R1's lunch. This form documents Code Blue was called on [DATE] at 12:10 PM, 911 was called on [DATE] at 12:20 PM, and CPR was initiated on [DATE] at 12:28 PM. This same form documents suctioning, and the [MEDICATION(S)] Maneuver were performed on R1. Paramedics are documented to have arrived at 12:28 PM on [DATE] and R1 was transported to the nearest emergency room . R1's condition at the time of transfer is documented as unresponsive and cool. This same form states, Time of Death: [DATE] at 12:40 PM. R1's Emergency Medical Service/EMS Report documents on [DATE], EMS was dispatched to the facility for R1 who was choking and not breathing. This same report states, (R1) was found on the ground and not breathing but (R1) still had a pulse present. The known downtime was five minutes prior to our arrival. (R1) is visible cyanotic. There were CNAs and Nurses around the patient suctioning the patients airway trying to dislodge the food. Medic15 had continued to suction (R1's) airway and was able to get more food out of (R1's) airway. At this time, Medic24 had checked for a pulse and there was none present. This report documents that CPR and lifesaving measures were continued the entire time en route to the local area hospital. R1 remained in Asystole with no pulse regained. The emergency room doctor ceased all efforts at this time and presented (R1) as deceased . R1's Emergency Department note dated [DATE] at 12:34 PM, states, Chief Complaint: Respiratory Arrest. Stated Complaint: Unresponsive. Initial Comments: (R1) brought in from the nursing home as a full arrest. (R1) was reportedly eating, then choked on food. Paramedics called and by the time they arrived, (R1) had suffered a cardiac and respiratory arrest. On scene, paramedics removed the visible food from (R1's) oropharynx and ultimately intubated (R1), performed CPR and transported (R1) to the Emergency Department. This same note documents R1 with a medical history of Cognitive Impairment, [CONDITION(S)], [CONDITION(S)] Disorder and that R1 is wheelchair bound. Physical Exam: (R1) is asystolic with no blood pressure and no spontaneous respirations. Intubated. Unresponsive to verbal or painful stimuli. Pupils fixed and dilated. Progress/Clinical Impression: (R1) asystole on the monitor. (R1) has a history of DNR (Do Not Resuscitate) order. Since there is no readily identifiable reversible cause of patient's arrest, resuscitation efforts were discontinued and (R1) was pronounced dead at 12:40 PM. The facility's Initial Report to the local state agency documents that on [DATE] at 12:10 PM, R1 choked in the dining room; 911 was called, [MEDICATION(S)] and suctioning were performed. EMS arrived and transported R1 to the local area hospital. V7s (Certified Nursing Assistant) written statement, dated [DATE], states, (V4/R2's Family Member) yelled, 'He's choking.' I got up and yelled for a nurse and started pushing (R1) towards the Nurse's Station. I was at the table next to (R1) but (my) back was towards (R1). I was feeding (R7 and R8). After (V4) yelled when I looked at (R1) he was turning blue. I saw V5 (Licensed Practical Nurse/LPN and she took (R1). I moved residents out of the way. I helped get (R1) on the ground and held his head while (V2) was trying to suction. V5's (Licensed Practical Nurse) written statement, dated [DATE], states, I pulled (V11/CNA) out of the dining room because (R4) was threatening to throw herself down. (V12/CNA) was in with (R4) and she asked me to go get one of the girls. (V11) came to help her. Then as I was walking towards the dining room with some pills, (V7) hollered that (R1) was turning blue. I grabbed (R1) and pulled him towards the nurse's station and yelled for (V2). (V2) then started giving (R1) the [MEDICATION(S)]. (V2) tried suctioning him and the paramedics came. V13's (CNA) written statement, dated [DATE], states, I was feeding (R6) and (R1) was at another table. I could see the back of (R1). (V4) yelled (R1) was choking. We stood up and (R1) was turning purple. (V7) grabbed (R1) and started moving him towards the nurse's desk. Then (V5) was coming, so she took him. I stayed in the dining room with the other residents. V6's (LPN) written statement, dated [DATE], states, I was standing at the nurse's station. I heard (V7/CNA) yell at (V5/LPN). I saw him turning blue. I called 911. I pulled up (R1's) chart for code status and printed out his paperwork. I tried to help (V2) with suctioning before the paramedics came. V11's (CNA) written statement, dated [DATE], states, I was sitting in between (R1) and (R3). (V5) came to get me because (V5) needed help with (R4). I got up to help (V12/CNA) with (R4). (R1) wasn't eating when I walked away. (R1) had just finished a bite of coleslaw. (R1) did have a biscuit on his plate but I hadn't given it to (R1). (V9/CNA), (V13/CNA), and (V7/CNA) were in the dining room. When I was walking back towards the dining room, I saw (V5/LPN) pushing (R1) towards the nurse's station. V14's (Dietary Manager) written statement, dated [DATE], documents R1 is a mechanical soft diet, and that stew, biscuit cabbage and dessert were served for lunch on [DATE]. V9's (CNA) written statement, dated [DATE], states, I was in the dining room. I was sitting with (R5). I had my back towards (R1). (V4) yelled, 'I think he's choking.' (V7/CNA) got up and started pushing him towards the nurse's desk and (V5/LPN) took (R1). I stayed in the dining room with the other residents. V12's written statement, dated [DATE], states, I was on C Hall in R4's room. (R4) was threatening to throw herself on the floor and trying to climb out of her bed. I asked (V5) to help me because I couldn't leave (R4). (V11) came to help me. (V11 and V12) got (R4) in her chair. I think it was a little after noon. As we were coming out of (R4's) room, we saw everyone in the hallway with (R1). V4's (R2's Family Member) written statement, dated [DATE], states, I was sitting with (R2) and (R1) picked up a roll. The girl (V11) at the table had left. I saw (R1) was choking. A girl (V7) behind him got up. It seemed like forever. (V7) immediately wheeled him back by the nurse's station. (R1) was turning blue. On [DATE] at 7:08 PM, V2 (Director of Nursing) stated, On [DATE], in the main dining room, at lunch time, the CNA (V11) was called away from (R1) due to another resident (R4) threatening to put herself on the floor. (V11) left the table. (V4) was sitting with (R2) at the table. (R1) was at the table in (R1's) wheelchair and (V4) was next to (R1). (V4) told (V7) that (R1) was choking. (V7) took (R1) out of the dining room and wheeled (R1) to the nurse's station. I was at the nurse's station at that time. I tried to do the [MEDICATION(S)] Maneuver. I didn't have enough strength to do it right. We lowered R1 to the floor and I told (V6) to call 911. R1's body is curved (contracted) to the side and he has Kyphosis, so he can't lay flat very well. I was laying on the floor with him doing the [MEDICATION(S)]. I could see something in (R1's) mouth so I did a finger sweep. I got a fingertip worth of mushy biscuit. I got the (suction catheter) and started sucking. (R1's) lips were turning blue. (R1) was not able to talk but he had a pulse. EMS came and started CPR. EMS pulled two large forceps full of mushy biscuit out of (R1's) mouth. They continued CPR and left with (R1). The coroner called me and said that (R1) passed away at 12:40 PM. V2 stated that R1 sat at the assisted dining table and that R1 needed small bite cues V2 stated, (R1) likes to shove food in his mouth at times. (R1) needs reminded to take sips (of liquids) after bites and to slow down. V2 stated V11 should not have left R1 while R1 was eating. If (V11) was called away, she should have told someone to come over and sit with (R1) or push (R1's) plate away from him. There is enough room on that table to move the plate away and it is not near another resident or within (R1's) reach. V2 stated two residents sit with one CNA for assisted dining. At this time, V2 verified that no staff members were sitting at R1's table monitoring R1 with R1's tray of food. On [DATE] at 9:48 AM, V4 (R2's Family Member) stated that on [DATE], V4 was eating lunch with R2 at the same assisted dining table as R1. V4 stated there was not any staff members present at the table at all. V4 stated, I saw (R1) pick something up and put it in his mouth. (R1) started gagging. I yelled out 'He's choking.' (R1) was turning blue. I had to yell three times before any of the staff responded and then they immediately wheeled him to the nursing station and closed the doors. This should not have happened, no one was watching him (R1) eat. On [DATE] at 7:41 PM, V15 (LPN) stated that residents who require supervision/assistance with dining should never be left alone while eating. V15 stated, They don't even start delivering trays until staff is present with the residents. On [DATE] at 7:53 PM, V8 (CNA) stated that assisted dining table residents should never be left unattended while eating. On [DATE] at 7:55 PM, V10 (CNA) stated, (R1) sat at the assisted dining table because (R1) would eat too quickly and shove everything in too fast and shove too much food in. (R1) needs cues to slow down. (R1) should never be left alone with his meal tray. On [DATE] at 7:59 PM, V16 (Registered Nurse) stated that R1 sat at the assisted dining table and that R1 was a high risk for choking. V16 stated, Oh, of course not. (R1) should not be left alone with (R1's) meal tray. On [DATE] at 8:05 PM, V17 (CNA) stated that R1 sat at the assisted dining table and that R1 was able to feed himself at times. V17 stated R1 would eat too fast and that staff sat with R1 to remind R1 to slow down and take small bites. V17 stated, No one at that table (assisted dining table) should ever be left alone. They don't even deliver the trays until a staff member is present. On [DATE] at 8:21 PM, V11 stated, I was sitting at the lunch table with (R1). (V5) came and told me that (V12) needed help. I left (R1) to help her because the other resident (R4) was trying to get out of bed. (R1) had his tray in front of him when I left him. When we walked out of (R4's) room, I saw (R1) in the area by the nurse's station. I was probably gone five to ten minutes. We dressed (R4), got the (mechanical lift) sling underneath her and got her up with the (mechanical lift). V11 stated R1 sat at the assisted dining table because R1 would need physical assistance with certain food items. V11 stated R1 could hold toast but holding a spoon would be hard for R1. V11 stated R1 would need physical assistance with eating and R1 would also need cues to take drinks in between bites and that sometimes R1 would eat too fast. V11 stated, I checked (R1's) plate after everything happened, his coleslaw and biscuit were gone. At this time, V11 verified the following: V11 did not push R1's tray out of R1's reach before leaving R1's table, did not say anything to R1 before leaving the table; and did not ask anyone else to watch R1 while V11 was gone. V11 stated, I should not have left (R1) unattended. I left when the nurse (V5) came and got me. (V5) didn't stay with (R1) either, she was doing med pass. There were three staff members at the other feeding table, but they were feeding (residents) too. No one was directly laying eyes on (R1). On [DATE] at 8:41 PM, V1 (Administrator) stated, (On [DATE]) I was in my office, I heard V6 (Licensed Practical Nurse) page maintenance (V18/Maintenance Director) to the nurses' desk immediately. I went back there to see what was going on. I saw (V2) trying to give (R1) the [MEDICATION(S)] in his chair. She was trying to get up underneath him. He was real floppy. He was awake but blue. (V2) said, 'Let's get him out of the chair.' (R1) had the (mechanical lift sling) under him so a bunch of staff lowered him to the floor. (V2) said to get suction. Once (R1) was on the ground, (V5) ran and got suction and we rolled (R1) on his side. The suction plug was too far away from where he was lying, so I ran to get an extension cord. When I came back, they already had the suction working and (V2) was suctioning (R1). (V2) said, 'Come on (R1), let's get it out.' It looked like they were suctioning wet cracker out of his mouth. They kept checking a pulse and said that he still had one. EMT (Emergency Medical Technician) got there and used a device to open his throat and look down. They pulled up what looked like chewed up cracker. Then they said he didn't have a pulse. EMT started compressions. (V6) said he was a DNR. The paramedics then called the ER (emergency room ) doctor and the doctor said that if something was obstructing his airway, to bring him in so they took him to the ER. EMT was doing CPR the whole time. No one here did CPR. (V2) said he had a pulse and was suctioning him. V1 stated, We couldn't get a grip around him, He couldn't sit up on his own. V2 was trying. V1 stated that R1 should not have been left alone with R1's food tray at the assisted dining table. V1 stated, There were three other CNAs in the dining room helping feed but from where they were sitting, they didn't see (R1) was choking until (V4) yelled out and (V7) ran over. On [DATE] at 11:57 AM, V5 (LPN) stated, (On [DATE]), I had to pull one of the CNAs from the dining room to help with a behavior down the hall. I go back out to the dining room and was notified by another CNA that (R1) was turning blue. (R1) was still in his wheelchair, we were able to get (R1) over to the side to get behind him enough to do the [MEDICATION(S)] Maneuver. We then used the (mechanical lift) sling that was under (R1) to lower him to the floor. V5 stated that R1 sat at the assisted dining table because R1 required assistance with eating. V5 stated that R1 should not have been left alone with his food tray. On [DATE] at 12:14 PM, V9 (CNA) stated, (On [DATE]), I was sitting at the other feeder table. No one was observing (R1) directly. My back was towards (R1). (R1) sits at the assisted dining table because he is a choke risk. (V4) yelled, 'I think he is choking' and then they took (R1) through the doors. At this time, V9 verified no staff was present at R1's table when R1 was eating. On [DATE] at 12:28 PM, V13 stated, (On [DATE]), I was feeding (R6). (R1's) back was to me at the other table. No staff was at the table with (R1) and (R1) had his food tray. (R1) sits at the assisted dining table because he has problems swallowing. His liquids are thickened, and he uses (adaptive cups). (V4) started yelling, 'I think he's choking.' There was a CNA (V7) behind him. (V7) took (R1) to (V5) and (V5) took him out of the main dining room. (R1's) face was purple. No staff was at (R1's) table. (V11) was supposed to be at that table. I didn't see when she left. There was an empty chair between (R1) and (R3). That's the chair for us to use to feed them. I know that (R1) eats fast and grabs large amounts of food with his hands and puts it in his mouth. On [DATE] at 12:36 PM, V12 stated, (On [DATE]), I was in (R4's) room. I asked (V5) to get me help. (V11) came to help me. (R1) should not be left alone with food. (R1) is on nectar thickened liquids, he has a hard time swallowing. He was choking on the thin liquids. We have to sit with (R1) to watch him and make sure he's ok. Sometimes he can feed himself and sometimes he needs help. On [DATE] at 12:43 PM, V6 (LPN) stated, (On [DATE]), I was standing behind (V2) at the nurse's station. (V5 and V7) brought (R1) to the nurse's desk. He was cyanotic. (V2) was attempting the [MEDICATION(S)] Maneuver. I'm nine months pregnant so I was no help with lifting. They lowered him to the floor and was suctioning food out of his mouth. The (catheter tube) clogged so I ran to get water to help clear the tubing. V6 continued to say that R1 sat at the assisted dining table because (R1) got impulsive with eating and would not take appropriate size bites. V6 stated, (R1) should not have been left alone with his food tray. No feeder should be left alone with a food tray. It's not a good idea, it's unsafe. On [DATE] at 10:09 AM, V7 (CNA) stated, (On [DATE]), I was in the dining room feeding (R7 and R8). (V4) got my attention that (R1) was choking. I could see that (R1's) face had turned blue. I yelled for another CNA to get the nurse. (V5) then took (R1) from me and they were trying to suction the food out of his mouth, but they couldn't. We (V7 and R1) were sitting with our backs to each other in the main dining room at the time of the incident. (R1) was not in my direct line of vision. No one was at the table with (R1). Another CNA (V11) was originally sitting with R1. She did not say anything to me that she was getting up from the table with (R1). (R1) needs assistance with feeding and has thickened liquids. (R1) has difficulty handling silverware but can feed himself finger foods. (R1) should not have been left unsupervised with his tray. I did not attempt [MEDICATION(S)] Maneuver, I wanted to wait for the supervisors and get him out of the dining room. (V2 and V5) immediately took over. Once he was on the floor, I helped hold his head while they were suctioning him. I couldn't see anything in his mouth directly. I think this could have been prevented if staff was with (R1) while he was eating, or we could have at least got to him quicker. (R1) looked like he had been choking for a while before anyone noticed. Had I known the staff was leaving (R1), I would have sat with him. On [DATE] at 4:13 PM, V3 (R1's Physician) verified that R1 has chronic dysphagia and requires assistance with eating. R1's Death Certificate, signed and dated [DATE] by V19 (Medical Examiner/Coroner) documents R1's date of death as [DATE]. The cause of death is documented as Choking and Food Aspiration. This same certificate states, Describe how injury occurred: (R1) was seated at the dining table when he put a whole biscuit into his mouth and then started choking on it. (R1) was transported to the hospital and soon pronounced dead. The manner of death is documented as Accidental. The Immediate Jeopardy began on [DATE] when R1 was left unsupervised with R1's lunch meal tray, eating food off the tray without staff supervising or assisting R1. R1 choked on food items on the tray and required [MEDICATION(S)] Maneuver and CPR efforts. R1 was transferred to the local area hospital where R1 expired. On [DATE] at 2:17 PM, V1 (Administrator) was notified of the Immediate Jeopardy. On [DATE] and [DATE], the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. Staff will be in-serviced on dysphagia and residents that are at risk for choking. All staff members re-educated on facility policy and procedures for residents who require feeding assistance/supervision. Education will be ongoing. Staff on vacation or FMLA/Family Medical Leave Act will be in-serviced before returning to work by V2 (Director of Nursing) and V1 (Administrator). On [DATE], all interviewed staff state they were in-serviced on Emergency Procedures: CPR and [MEDICATION(S)] Maneuver and Assisted Dining Residents/Protocols. All interviewed staff state they could not start their shift without this re-education. Staff members were seen entering V1's office to receive this face-to-face re-education. In-servicing sign in sheets provided by V1 document the training was initiated on [DATE] to Nursing and CNAs and is ongoing. [MEDICATION(S)] in-servicing sign in sheets document training began on [DATE] and is ongoing. 2. New hires will be trained on choking risk, policy and procedure of dining room supervision. Training will be conducted by V1 (Administrator). 3. Dining room and residents have been re-arranged to ensure all residents who need assistance are always in direct view of staff. On [DATE], V1 and V2 confirmed that V1 and V2 rearranged the assisted dining tables so that all residents are facing out into the dining room. On [DATE], during the dinner meal service, all residents who sit at the assisted dining table were facing outward to the dining room. Staff members were seated between all residents who require assistance with eating. 4. All residents who require assistance will not have meal trays without direct staff supervision. On [DATE], dinner meal observations noted that assisted dining residents were not served their meal tray until a staff member was directly present. Interviewed staff state they were re-educated on this policy prior to their shift beginning. 5. QAPI (Quality Assurance and Performance Improvement) review with V3/Medical Director to review identified residents who require assistance and/or altered diets. Action plan will be reviewed monthly at QAPI meeting. On [DATE], V1 stated this meeting is scheduled to occur on [DATE]. 6. All residents with a diagnosis of dysphagia and/or require assistance with meals will have care plan reviewed and updated appropriately, staff will be educated on specific needs. On [DATE], Assisted Dining Resident List provided by V29 (Regional [NAME] President of Operations). All reviewed charts documented care plan updated. 7. Resident charts reviewed to ensure appropriate diets, supervision during meals, tray card and diet orders- audit completed by V27 (RN Clinical Risk Management Consultant) and V28 (Regional Nurse Consultant). All charts were updated. 8. Policy and procedure for resident dining and seating to address when/if staff must leave a resident they are assisting. Policy will include that staff must either have staff replace them prior to leaving or remove all food and drink items from residents reach prior to leaving. On [DATE], Policy provided by V29 (Regional [NAME] President of Operations) documents updated dining policy and procedures as stated.

Based on interview, and record review, the facility failed to routinely assess a pressure wound and failed to follow physician's orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in the disruption of surgical skin grafts, resulting in a delay of healing to R1's wounds. FINDINGS INCLUDE: The facility policy, Skin Condition Assessment and Monitoring- Pressure and Non-Pressure, dated (revised) 6/8/2018 directs staff, To establish guidelines for assessing, monitoring and documenting the presents of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Pressure and other ulcers will be assessed and measured at least weekly by licensed nurses and documented in the resident's clinical record. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. A wound assessment will be initiated and documented in the resident's chart when pressure and/or other skin conditions are identified by the licensed nurse. Adherent or semipermeable membranous dressings used for [MEDICATION(S)] or healing purposes will be removed at least weekly or more often in accordance to physician's orders. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. R1's (hospital) History and Physical, date 1/28/22 documents, (R1) was admitted for gangrene of the bilateral feet (heels) with [CONDITION(S)]. Start IV (Intravascular) antibiotics. Podiatry was consulted. (R1) has received debridement and surgical intervention. Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician Order Sheet, dated 1/31/22 documents that R1 was admitted to the facility on [DATE] with the following physician orders: Wound Vac (Vacuum-Assisted Wound Closure) at 125 mmHg (millimeters of mercury) to bilateral heels; Change Wound Vac every day shift, every three days; Non-weight bearing. R1's Admission Minimum Data Set Assessment documents, Section C: Cognitive Patterns-15:15 (Cognitively Intact). R1's Admission Care Plan includes the following Focus Areas: (R1) is non weigh bearing due to bilateral heel wounds. R1's Admission Observation Assessment, dated 1/31/22 at 11:35 A.M. documents, Section D: Skin Integrity (interruption of skin integrity) to Right heel and Left heel. No description or details (assessment) are given. The facility report: Resident Abuse Investigation Form, dated 2/1/2022 documents, (R1) is alert and oriented, with a BIMS (Brief Interview for Mental Status of 15. (Range 1-15). (R1) was interviewed and states that at approximately 4:20 A.M. her bedroom door opened, and two CNAs (V4 and V5) said they were taking (R1) to the bathroom. (R1) states she told (V4 and V5) that she was not supposed to put any weight on her feet. (R1) states the two CNAs (V4 and V5) put yellow socks on her and assisted her to the bathroom. When (R1) sat down on the toilet she noticed blood on the floor. V3/Registered Nurse sent her to the hospital for treatment. R1's Skin Condition report, dated 2/1/22 and signed by V3/Registered Nurse documents, Right heel skin graft dehiscence. Assessed (R1's) right heel. Bleeding present. Dressing changed. Physician and (V2) Director of Nurses notified. Sent to ER (emergency room ) for further evaluation. R1's emergency room report, dated 2/1/22 documents, (R1) is a [AGE] year-old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1) on January 28, 2022, was seen at (local hospital) and had bilateral heels operated on with skin grafts. (R1) was getting treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1) had incision and drainage and a procedure done by (V6/Doctor of Podiatry Medicine). According to (R1) she was awoken at 4 AM this morning and was trying to go to the restroom. (R1) is not supposed to be weight bearing. According to (R1) she was forced to put weight onto her right foot. Upon putting weight onto the right foot (R1) felt tearing of the staples. (R1) had bleeding. Wounds were dressed and (R1) was brought to the emergency department. Right heel examined and heel graft present with staples. At heel and distal area patient has dehiscence from staples with oozing of blood. More at the heel, versus distal. Wound was visualized by myself and undressed. Images were taken. (V6/DPM) was contacted from the emergency department and images and videos were reviewed via secure medium. (V6/DPM) recommended that the patient should do well with continued negative pressure wound therapy and dressed the wound with an adaptive base layer and compression. (Facility) recommendations are (R1) should be 100% non-weigh bearing for 1-week, bedside commode only. Two-person lift. In the emergency department wound has been redressed. (R1) will be discharged back to the (facility) with instructions of non-weight bearing once again. R1's Electronic Medical Record, date 1/31/22 (Admission) does not document that a Wound Assessment was initiated or documented on, despite R1 being admitted to the facility with open pressure wounds to the bilateral feet. Nor does R1's Medical Record include any Weekly Wound Assessment from 1/31/22 through 2/15/22. On 2/15/22 at 8:15 A.M., R1 stated, I was at (local hospital) after a long bout with Covid. I had been on bed rest and both of my heels developed wounds. I was admitted (to the facility) on 1/31/22 with a doctor's order for no weigh bearing because of my recent skin graft surgery. On 2/1/22, before breakfast, 2 CNAs (V4 and V5/Certified Nursing Assistants) entered my room and without asking me, put yellow socks on my feet and set me on the side of the bed. I kept telling I was not supposed to bear weight on my feet, but they (V4 and V5/CNAs) stood me up and walked me to the bathroom. As soon as I put weight on my heels, I felt the staples in my right heel tear and saw blood saturate the bandages and on the floor. They (V4 and V5/CNAs) got the nurse. They sent me to the local ER (emergency room ), where they took pictures of the injury, dressed my heel and sent me back to the facility. I just want to go home now. On 2/15/22 at 10:45 A.M., V2/Director of Nurses (DON) stated, (R1) was admitted to our facility on 1/31/22 from (a local hospital). (R1) was admitted as no weight bearing on admission (1/31/22). That information was placed on R1's CNA Kardex. I expect staff to consult a resident's Kardex for ambulation status and new information status, prior to ambulating a resident for the first time. V2/DON also stated, It is the facility policy to assess all wounds upon admission and weekly thereafter. At that time, V2/DON verified no wound assessments were performed on R1's bilateral heels wounds on admission or weekly thereafter, as required. On 2/16/22 at 8:33 A.M., V3/Registered Nurse (RN) stated, (R1) was no weight bearing on her bilateral heels, due to recent skin grafts (on admission). The previous nurse passed along that information in Report. Around midnight or 1:00 A.M. (on 2/1/22), (V5/CNA) asked me what (R1's) weight bearing status was and I told (V5/CNA) that (R1) was no weight bearing. Around 5:00 A.M., I was summoned to (R1's) room due to (R1) bleeding from the right foot. (R1) was lying in bed and there was active bleeding from her right heel. When I asked what happened, both CNAs (V4 and V5) stated they had ambulated (R1) to the bathroom and back. I undressed only the right heel and noted the bottom of the wound had dehisced and the area was bleeding, profusely. I applied a dressing to staunch the blood, called (R1's) physician and the (V2/Director of Nurses) and requested (R1) be sent to the ER for an evaluation. On 2/16/22 at 10:59 A.M., V4/Certified Nursing Assistant (CNA) stated, I was told in Report that (R1) was not ambulatory due to wounds on her bilateral heels. I guess I didn't think about it later when me and (V5/CNA) went into (R1's) room around 5:00 AM (on 2/1/22), to take her to the bathroom. I don't recall if (R1) said she wasn't supposed to be on her feet. Once (R1) ambulated to bathroom, we (V4 and V5/CNAs) noticed bright red blood from (R1's) right heel and alerted the nurse (V3/RN). On 2/16/22 at 10:21 A.M., V6/DPM (Doctor of Podiatry Medicine) stated, I am the physician that has been following (R1), since performing bilateral skin grafts on her heels. (R1) developed the bilateral wounds and presented to the hospital after developing gas gangrene, back in December of 2021. The disruption of the skin grafts, due to weight from ambulation, would cause a delay in healing of (R1's) wounds.

Based on interview and record review, the facility failed to monitor/supervise an altered diet with swallowing deficits that required staff supervision for one (R1) of three residents reviewed for dietary supervision in a sample of three. This failure resulted in R1 experiencing a choking episode leading to the death of R1. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: R1's State of Illinois Certificate of Death Certificate, dated [DATE], documents R1's [DATE] cause of death, as Asphyxiation and choking on a sandwich. On [DATE] at 1:27 pm, an Immediate Jeopardy was identified to have begun on [DATE] when staff failed to follow care plan interventions for supervising and monitoring R1 while eating a peanut butter sandwich. On [DATE] at 1:27 pm, V1 (Administrator) and V2 (Director of Nurses/DON) were notified of the Immediate Jeopardy. Facility Job Description for Certified Nursing Assistant/CNA, undated, documents: that the primary purpose of the job description is to provide residents with nursing and personal care under the supervision of a Charge Nurse to safeguard the health, safety and welfare of all residents of the facility, in accordance with the directions of supervisors, including Administrator, Director of Nursing, Charge Nurse and Rehabilitation Director, in order to assure the highest degree of quality care is maintained at all times. As a CNA, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties; to carry out assignments for resident care including feeding; be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty; and to follow established safety precautions when performing tasks. Facility COVID 19 Communal Dining Guidelines, documents that the Facility Guidelines for Phase One (1) are that communal dining is not recommended but may be considered on a limited and modified basis and that dining services should be served in resident rooms. On [DATE], at 2:26 pm, V3 (Dietary Manager) stated, We are in Phase One with dining. On [DATE], at 3:25 pm, V2 (Director of Nursing/DON) stated, We cannot go to Phase Two until the County COVID numbers fall below ten percent for two consecutive weeks, so all residents eat in their rooms. Some residents that require supervision for altered diets will eat in their doorway, or if they require feeding, then a Certified Nursing Assistant/CNA will go to their room and feed them. R1's Dietary Initial/Quarterly/Annual Notes, dated [DATE], document that R1 readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Notes also document that R1 was on a Mechanical Soft diet and required Supervision Assistance with eating. The Notes also document that R1 was to receive a pudding snack at 2:00 pm. R1's Dietary Assessment, dated [DATE], documents a swallowing issue of Holding food in mouth/cheeks or residual food in mouth after meals. R1's Speech Therapy Plan of Care, dated [DATE], documents that R1's current level of swallow function as Patient utilizes swallow strategies/precautions in fifty percent of the trials. and that R1 was receiving Speech Therapy for swallowing dysfunction and/or oral feeding. R1's Speech Therapy Note, dated [DATE], documents that V6 (Speech Therapist) reviewed aspiration precautions with R1 and R1 Did not follow strategies for small bites and slow pace given maximum prompting in any trials. R1's Speech Therapy Note, dated [DATE], documents that Certified Nursing Assistant (CNA) reported to (V6) that (R1) had been 'chugging' drinks during lunch and that (V6) noted occasional coughing from down the hall while patient was eating lunch. Patient independently recalled swallowing strategies during review but becomes impulsive at times and will not use. R1's Speech Therapy Note, dated [DATE], documents that Nurse expressed concerns about increased coughing during meals and coughing up phlegm. Nurse notes that patient eats and drinks with quick pace outside of therapy sessions and that R1 was inconsistent with implementation. R1's Speech Therapy Note, dated [DATE], documents that concerns were reported About increased coughing and wet quality of coughing to nurse. R1's current Care Plan documents: to place R1 in common area for snacks due to potential behavior with Dementia; to cue, reorient and supervise as needed for cognitive function related to Dementia; to provide and serve diet as ordered and that snacks will be consumed safely; and to monitor and report signs of Dysphagia, pocketing, choking, coughing, holding food in mouth and several attempts at swallowing. On [DATE], at 3:15 pm, V12 (Resident Assistant) stated, The resident's get snacks from the kitchen at 10:00 am, 2:00 pm and 7:00 pm. They usually come out with their names on them. On [DATE] at 3:18 pm, V11 (Certified Nursing Assistant) stated, Whoever is the float, hands the snacks out. The snacks come out with assigned stickers and the resident room number. If someone is a special diet and they do not want their snack, we have to ask the nurse before giving an alternate. On [DATE], at 2:15 pm, V4 (Certified Nursing Assistant/CNA) stated, I came onto shift on [DATE] at 2:00 pm and immediately started handing out the 2:00 pm snacks to the residents on (R1's) hall. R1 got a peanut butter and jelly sandwich about 2:50 pm or 2:55 pm. She did not have a snack with a dietary label on it, so I gave her the peanut butter and jelly sandwich as she requested. I continued to pass snacks down the hallway, to the other residents, and at about 3:05 pm, (V7/Physical Therapy Assistant) came to me and told me to get a nurse because R1 was choking. I ran and got V8 (Licensed Practical Nurse/LPN). About 10 to 15 minutes went by from the time I gave her the sandwich until the time she she was observed choking. I did not see her choking until (V7) came and got me and was not aware that she had been experiencing any swallowing issues. On [DATE], at 2:00 pm, V7 (Physical Therapy Assistant/PTA) stated, I was doing therapy with another resident right across the hallway from (R1). On [DATE], at about 3:05 pm, I happened to look out the doorway and (R1) did not look right at all, I could tell something was wrong. I ran across the hallway to check on (R1) and asked if (R1) was okay, and (R1) told me, in a whisper, 'I am choking.' I kind of panicked and set her forward and pounded on (R1's) back. I then got (V4/CNA) and told (V4) that (R1) was choking and (V4) went and got (V8). Then the nurses took over. On [DATE], at 2:24 pm, V8 (Licensed Practical Nurse/LPN) stated, On [DATE], at about 3:05 pm or 3:10 pm, I was alerted by (V4) that (R1) was choking. We immediately started the [MEDICATION NAME] Maneuver. It was very difficult to do because (R1) was a large lady. I did scoop (R1's) mouth and throat and had a small amount of bread and peanut butter on my glove afterwards. Then (R1's) skin became discolored, (R1) went unconscious and I did not feel a pulse, so we laid (R1) on the floor and began Cardio [MEDICAL CONDITION] Resuscitation/CPR and suctioning to try and expel the debris and establish an airway until the paramedics came. It was unsuccessful and the paramedics declared her expired at 3:36 pm. On [DATE], at 1:50 pm, V13 (Registered Nurse/RN) stated, On [DATE], a little after 3:00 pm, I was in my office on C Hall and overheard something going on down the hall. I came out of my office and saw the crash cart and a couple nurses down the hallway by (R1's) room. They were performing the [MEDICATION NAME] and then (R1) went unresponsive and they lowered (R1) to the floor and started CPR. (R1) was on speech therapy for swallowing issues. (R1) did not sit in the supervised dining room because of COVID, we sat (R1) in the doorway of (R1's) room for meals and snack time. On [DATE], at 3:30 pm, V13 (RN/Minimum Data Set/MDS Nurse) stated, (R1) was supervision for meals according to the documentation from staff for the MDS. There are two CNA's down the hallway and sometimes a float but not all resident's can be supervised at all times during meals and snacks. On [DATE], at 2:26 pm, V3 (Dietary Manager) stated, Resident that are feeders or supervision are not sitting in the dining room due to COVID. I know (R1) was working with (V6/Speech Therapy). She was working on getting on a regular diet and back on thin liquids. (R1) needed reminded to slow down because she was a fast eater. We individually label the snacks with resident names and also send out extra for alternatives. We base who gets a snack on if that resident tells me they are hungry between meals, or if I have orders or recommendations from Dietician, Speech Therapy or the Doctor. The CNA's should know the resident's diets. On [DATE], at 2:07 pm, V8 (Speech Therapist) stated, (R1) was a readmission after multiple hospitalization s for Aspiration Pneumonia, Urinary Tract Infections and [MEDICAL CONDITION]. (R1) has been mechanical soft diet through all of those admissions and we trialed thin liquids. (R1) was always in the Supervised Dining Room prior to COVID restrictions because (R1) needed supervision. I believe (R1) was to be receiving a pudding snack at 2:00 pm and not a peanut butter sandwich. (R1) still had recommendations for supervision with swallowing, (R1) was impulsive and needed reminders to slow down. I observed (R1) eating in the doorway to (R1's) room multiple times and even saw (R1) coughing. R1's Nursing Note, dated [DATE] and [DATE], does not document notification or monitoring of R1's swallowing and coughing issues per V6's (Speech Therapist) notes. R1's Medical Record dated [DATE] through [DATE], does not document coughing or choking monitoring of R1 per V6's recommendation. On [DATE], at 3:12 pm, V2 (DON) stated, We always gave (R1's) food in the doorway of the room because she was impulsive with her eating. (R1) did not always need supervision because she would sometimes do alright by herself. We always had two CNAs on the floor. The CNAs did pass snacks and did have to care for other residents, so they could not continually monitor (R1) but were still on the hallway. When the snacks were being passed, the nurse was always on the floor doing medication pass. On [DATE], at 10:55 am, V5 (Medical Director) stated, (R1) has been in and out of the hospital multiple times over the last few months for Dysphagia, Aspiration Pneumonia, [MEDICAL CONDITION] and other infections. When (R1) is sick (R1) gets weaker and requires more supervision with cares. I would think that if a resident is supervision for meals and on a mechanical soft diet that a peanut butter and jelly would require supervision with staff watching (R1) eat. Supervision technically means that a staff member should be right there with the resident or it can be a major problem. The surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. All residents's diets were reviewed by V2 (DON) and V3 (Dietary Manager) and residents with altered diets were identified. Completion date [DATE]. 2. All staff were immediately in-serviced on altered diets and proper supervision according to the facility's Policy and Procedure. Completed by V2 (DON) and V3 (Dietary Manager). Completion date [DATE] and ongoing. 3. Direct Care Staff will be in-serviced on supervision for all dining and snacks of altered diet residents. Completed by by V2 (DON) and V3 (Dietary Manager). Completion date [DATE] and ongoing. 4. Staffing will be monitored and reviewed daily by V2 (DON) or designee in morning meeting to ensure there is adequate staffing for supervision during meal and snack times. Completion date [DATE] and ongoing. 5. All snacks will be labeled to identify appropriate diet restrictions. V3 (Dietary Manager) will be responsible for labeling. Completion date [DATE] and ongoing. 6. Random auditing of altered diets will be completed by V2 (DON) or designee weekly or as needed for three months. Completion date is ongoing for three months. 7. Random auditing of staffing levels will be completed weekly or as needed by V1 (Administrator) for three months. Completion date is ongoing for three months. 8. Observations noted during monitoring will be discussed with the Quality Assurance (QA) Committee. Concerns will be discussed among the members, a plan of action is devised and past plan of actions evaluated by QA Committee for three months or as needed. Completion date is ongoing for three months or as needed.

Based on interview and record review, the facility failed to provide supervision during toileting for one of three residents (R2), reviewed for falls, in a sample of seven. This failure resulted in R2 sustaining a fatal closed head injury, after a fall in the bathroom. FINDINGS INCLUDE: The facility policy, Fall Prevention Program, dated (revised) [DATE] directs staff, 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. Residents who require staff assistance will not be left alone after being assisted to bathe, shower or toilet. R2's Admission Record documents that R2 was admitted to the facility on [DATE]. This same document includes R2's Diagnoses: [REDACTED]. R2's Fall Risk Assessment, dated [DATE] documents that R2 has a history of falls, has balance problems while standing and walking, has decreased muscular coordination and has predisposing disease that place her at high risk for falls. R2's Care Plan, dated [DATE] includes the following Focus/Interventions, I am at risk for fall/injury from weakness and tiredness related to recent hip replacement. Follow facility fall protocol. R2's Minimum Data Set Assessment, dated [DATE] documents under Section G0110 (Activities of Daily Living Assistance), Requires extensive assist of two plus staff for transfers, walking in room and toileting. This same document includes under Section G0300 (Balance During Transitions and Walking), Not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfers. R2's Progress Notes, dated [DATE] at 7:17 P.M. document, (R2) had an unwitnessed fall at 7:00 P.M., in resident's bathroom. Notified by (V22/Certified Nursing Assistant) (CNA) that (R2) had fallen in bathroom and hit head on floor. (R2) bleeding from small laceration to right eyebrow. (R2) said, I went to reach for the door handle of the bathroom door, lost my balance and fell . I hit my head on the floor. Steristrips applied. Bleeding continued so (R2) sent to ER (emergency room ). The facility form, Incident Witness, dated [DATE], from V22/CNA documents, I assisted (R2) to the bathroom with (R2's) walker, positioned (R2) in front of the toilet with the walker in front of (R2). I left the bathroom to give (R2) some privacy and as I was removing (R2's) roommate's dinner tray, I turned around and (R2) was on the floor. It happened in a few seconds. (R2) sat up and I noticed a laceration to (R2's) eyebrow and it was bleeding so I called (V21/Registered Nurse) (RN). R2's ED (Emergency Department) Note, dated [DATE] documents, ED arrival time 1940 (7:40 P.M.) (R2) brought in from nursing home. States (R2) was using walker and went to bathroom and turned to the right side trying to grab doorknob. The doorknob was too far away and (R2) fell on to the floor hitting the right side of (R2's) face on the ground. This same document includes, Physician Exam: Right supraorbital, right temporal localized swelling, about 2 CM (centimeters) in diameter each with small laceration above the right eyebrow. Skin: 2 CM lac (laceration) above right eyebrow. Right periorbial ecchymosis with bruising at the right temporal region. This document concludes with, (R2) presents with mechanical fall at the nursing home. Normal neurological exam. Has bruising to the right temporal region and right suproribital region. There is a small laceration at the right eyebrow. (R2) is experiencing some facial pain but not in acute distress at this time. Takes Aspirin. CT (Computerized Tomography) of head reveals large right subdural hematoma. Contacting (Regional Trauma Center) for stat (immediate) transfer. R2's hospital Facial Bones CT, dated [DATE] at 8:36 P.M. document, Impression: Right-sided facial trauma involving zygomatic arch, maxillary sinus and orbital wall and rim. Maxillary sinus fracture involves gas outside the lumen of the sinus indicating an open fracture due to its involvement with sinuses. [MEDICAL CONDITION]. R2's hospital Brain/Head CT, dated [DATE] at 8:36 P.M. document, Ventricles: mass effect upon the right lateral ventricle related to the acute hemorrhage. [MEDICAL CONDITION]: There are several regions of acute hemorrhage. The acute hemorrhage has significant mass effect with dimensions of 7.5 CM AP (anterior to posterior) X 2.4 CM medial to lateral and extending nearly 8.7 CM craniocaudally. Midline shift: 5 MM (millimeters) right to left. Impression: Acute on chronic right subderal hemorrhage resulting in right-to-left midline shift. Additional acute blood within the sylvian fissure on the left with the inferior posterior left anterior fosa. Multiple facial fractures. R2's (Regional Trauma Center) Discharge Summary, dated [DATE] documents, (R2) was transferred after suffering a ground level fall at her nursing home. (R2) had been taking dual anti-platelet therapy. (R2's) imaging at the first hospital demonstrated a large subdural hematoma and subarachnoid hemorrhage as well as several orbital fractures. (R2's) mental status markedly declined prior to transport, so (R2) was intubated prior to arrival to (Regional Trauma Center). On arrival to (Regional Trauma Center), (R2's) sedation and paralytic was reversed. (R2's) exam did not improve with reversal or Mannitol. (R2's) POA (Power of Attorney) was consulted. (R2) apparently would never have wanted heroic measures to keep (R2's) self alive. Neurosurgery offered that surgery for [REDACTED]. (R2's) POA elected for comfort measures to be initiated. (R2) was extubated. (R2) expired at 0400 (4:00 A.M.) on [DATE]. R2's Certificate of Death documents, Cause of Death: Subdural Hematoma, Subarachnoid Hemorrhage and Ground Level Fall (from injury on [DATE] at 7:00 P.M.). On [DATE] at 9:50 A.M., V21/Registered Nurse (RN) stated, I was working on [DATE] (2020). It was around 7:00 (P.M.) and (V22/Certified Nursing Assistant) came and got me and said (R2) had fallen in the bathroom and hit (R2's) head. I went into the bathroom and (R2) was sitting up, on the floor. (R2) had a small laceration above (R2's) right eyebrow. (R2) said was alone in the bathroom and had reached to try and shut the door and fell and bumped head on the sink. I did ROM (range of Motion) on (R2). We helped (R2) up and set resident on the toilet. I put steri strips on the wound. I sent (R2) to the ER (emergency room ) because the wound kept bleeding. On [DATE] at 10:04 A.M., V22/Certified Nursing Assistant (CNA) stated, I had came into work at 6:00 (P.M.) that night ([DATE]). I got bumped to that hall. I usually work A Hall. I remember it was the first call light of the night. (R2) wanted to use the bathroom. I walked beside (R2) and (R2) used walker. (R2) said she felt unsteady. When we got to the bathroom, (R2) said was fine from here. When I left, (R2) was standing in front of the toilet. I stepped out of the bathroom, but was still in the room. I was cleaning up (R2's) roommate's dinner tray and I heard a loud thud. I found (R2) in the bathroom, on the floor. (R2) was bleeding from face. (R2) said had reached for the door and fell , tripping on walker. (R2) said thought hit head on the sink. I told (R2) not to move and I ran and got the nurse (V21). We helped (R2) back up. (R2) had a bump protruding above right eye and a cut above eyebrow. I didn't know (R2) couldn't be left alone in the bathroom. I feel so bad about all of this.

Based on observation, interview and record review, the facility failed to monitor a resident for bleeding and failed to notify the physician of a potential life threatening condition for one of one resident (R29), reviewed for medication side effects, in the sample of 43. This failure resulted in R29 developing diffuse, scattered bruising throughout and a large hematoma to the left lower leg. FINDINGS INCLUDE: R29's facility Admission Record, documents that R29 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R29's Admission Physician order [REDACTED]. R29's Weekly Skin Observation form, dated 12/17/19 documents R29's skin as, Skin intact. No concerns. R29's Progress Notes, dated 12/18/2019 at 7:28 P.M. document, Resident returned from appt (appointment) with V6/Neurologist. N.O. (New Order) received to increase Aspirin 81 mg to BID (two times daily). Start [MEDICATION NAME] (anticoagulant) 75 mg PO (by mouth) daily. Monitor for bleeding. PT/OT/ST (Physical Therapy, Occupational Therapy and Speech Therapy) to evaluate and treat. Return 4/24/20 at 11:30. Will need husband or family member to go with to discuss memory due to at risk for [MEDICAL CONDITION]. Call placed out to (spouse). He was notified of new orders and his presence needed at upcoming appointment He also stated he will attend. R29's Progress Notes, dated 12/18/2019 document, The order you have entered, [MEDICATION NAME] Tablet 75 MG give 1 tablet by mouth in the morning has triggered the following drug protocol alerts/warning(s):Drug to Drug Interaction Aspirin Tablet 81 MG give 1 tablet by mouth one time a day. Severity: Moderate Interaction: The risk of life-threatening bleeding such as intracranial or gastrointestinal hemorrhage may be increased in patients receiving [MEDICATION NAME] Tablet 75 MG with Aspirin Tablet 81 MG, especially among patients following a recent [MEDICAL CONDITION], ischemic or lacunar stroke. R29's facility Physician order [REDACTED]. R29's Medication Administration Records, dated (MONTH) 2019 and (MONTH) 2020 do not include the standard facility practice of facility nurse's monitoring R29 each shift for abnormal bruising or bleeding. On 01/13/2020 at 9:58 [NAME]M., V4 and V5/Certified Nursing Assistant (CNA) prepared to assist R29 from the wheel chair to the bed. After assisting R29 into bed, V5/CNA removed R29's jeans. Multiple, diffuse bruises, mainly purple in color were scattered over R29's bilateral legs, hips and arms and a large, prominent, deep purple hematoma to R29's left shin was present. At that same time, R29 stated she was unaware of when or how the injuries occurred. On 1/13/2020 at 9:58 [NAME]M., V3/Licensed Practical Nurse (LPN) stated,I don't know when all these bruises occurred. I don't know anything about watching (R29) for bleeding. I just started on day shift, two weeks ago. R29's Weekly Skin Observations, dated 1/14/2020 document the following bruises, 22.5 CM X 6.9 CM X 4.7 CM bruise to face; 13.3 CM X 6.3 CM X 3.3 CM bruise to right medial malleolus; 3.2 CM X 2.7 CM X 1.7 CM bruise to left intercostal rib area; 0.5 CM X 0.9 CM X 0.8 CM bruise to outer, upper left arm; 3.1 CM X 2.9 CM X 1.5 CM bruise to left buttock; 4.9 CM X 3.7 CM X 2.1 CM bruise to right lateral thigh; 1.1 CM X 1.3 CM X 1.2 CM bruise to right lateral calf; 22.4 CM X 7.2 CM X 5.1 CM bruise to left dorsum; 4.2 CM X 3.2 CM X 1.9 CM bruise to front left thigh; 25.4 X 10 CM X 4.5 CM hematoma to left lateral thigh; 11.6 CM X 8.7 CM X 3.6 CM hematoma to left shin and 18.4 CM X 16 CM X 2.3 CM hematoma to right lateral calf. On 1/14/2020 at 3:30 P.M., V2/Director of Nurses (DON) stated, The staff are supposed to monitor (R29) for bleeding and bruising. Our facility practice is for staff to monitor her skin each shift and document they did, on the MAR (Medication Administration Record). I don't know why (R29)'s (MONTH) and (MONTH) MAR indicated [REDACTED]. On 1/15/2020 at 10:27 [NAME]M., V6/Physician stated, I was not aware of any bruising on (R29). If I had been made aware of all those bruises, I would have altered the treatment that (R29) receives. I gave an order for [REDACTED].

Based on interview and record review, the facility failed to administer oxygen as prescribed for one (R1) of three residents reviewed for receiving oxygen therapy in a sample of three. This failure resulted in R1 retaining CO2 (carbon [MEDICATION NAME]) and needing hospitalization with [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) for four days. Findings include: R1's medical record documents R1 was a new admission from the hospital, admitted to the facility on [DATE], went to the hospital on [DATE], and returned to the facility on [DATE]. R1's admission orders [REDACTED]. R1's Medication List orders, dated 7/7/19, documents Continuous Oxygen 3L (liters). R1's Admission Observation note, dated 7/7/19 at 3:45pm, documents R1 was receiving oxygen via nasal cannula at a rate of 6. R1's nurses notes, dated 7/7/19 at 3:45pm, documents O2 (oxygen) at 6Lpm (liters per minute) nc (nasal cannula). R1's nurses notes, dated 7/7/19 at 9:15pm, documents The resident's (R1) facial color was ashen, her head was tilted back and she had pursed lipped breathing, (respiratory) rate 32 per minute. V18 MD (Medical Doctor) contacted and received an order to send to the ER (emergency room ). R1's nurses notes, dated 7/7/19 at 10:00pm, documents EMS (Emergency Medical Service) here to transfer (R1) to (local hospital). R1's (local hospital) ED (Emergency Department) progress notes, dated 7/7/19 at 10:23pm by V19 MD, documents Lungs with decreased air exchange throughout and subcostal retractions noted. She presented to the emergency department with hypercarbic (too much carbon [MEDICATION NAME] in your blood) [MEDICAL CONDITION]. After a trial of [MEDICAL CONDITION] as well as a [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) her air exchange improved significantly. Repeat blood gasses performed demonstrates good pH (acidity or alkalinity of a solution) with improved CO2 blow off. R1's (local hospital) Arterial Blood Gases (ABG's) pCO2, dated 7/7/19 at 10:30pm, documents 64.2 (high) and (normal pCO2- 23 to 29 mEq/L (milliequivalents/liter). R1's (local hospital) clinical resume, dated 7/8/19 at 3:48pm by V3 MD, documents Acute unresponsive episode secondary to acute hypoxic hypercarbic [MEDICAL CONDITION] with increased sedation from CO2 narcosis. There was some concern that she was getting too much oxygen. She is adequate getting 2-3 liters of oxygen and this should cut down on the possibility and probability of CO2 narcosis. R1's Discharge Instructions, dated 7/11/19, documents Reason for Visit: Hypercarbic [MEDICAL CONDITION]. On 7/23/19 at 11:03am, V9 CNA (Certified Nurses Aid) stated (R1) came in around 2:30-3pm (7/7/19) and I saw R1 in bed on 6 liters of oxygen, her daughter was in the room. I worked (7/7/19) from 6am to 6pm. On 7/23/19 at 11:55am, V4- R1's family member stated I was (at the facility) when mom was admitted (7/7/19) and they had R1on 6 liters of oxygen and she should have been on 3 liters of oxygen at home and I told the nurse that. On 7/24/19 at 7:13 AM, V7 QA (Quality Assurance) LPN (Licensed Practical Nurse) stated The oxygen order should have been clarified by (V10-LPN). At that same time, V7 verified R1's orders was for 3 liters of oxygen not 6 liters. On 7/24/19 at 10:41am, V3 MD (Medical Doctor) stated Six liters of oxygen would have contributed to her (R1) hypercapnia, I don't know why she (R1) was on 6 liters of oxygen because she doesn't need that much. She has [MEDICAL CONDITION], chronic [MEDICAL CONDITION], and has a tendency to retain CO2.

Based on interview and record review, the facility failed to administer medications at the times prescribed by the physician for one (R1) of three residents reviewed for medication timing in the sample of three. This failure resulted in R1 experiencing [MEDICAL CONDITION] and sedatory effects from her medications which resulted in R1 being hospitalized for [REDACTED]. Findings include: Facility policy Medication Pass: Process and Procedure, revised 1/1/15, documents Administration of Medication: Administer medication in accordance with frequency prescribed by physician, i.e, within 60 minutes before or after prescribed dose time. Facility Med Pass Times paper, undated, documents 5am, 8am, noon, 4pm, and 8pm. V10's employment details documents V10 started working at (facility) on 5/28/19 and terminated 7/8/19 R1's medical record documents R1 was a new admission from the hospital who was admitted to the facility on [DATE], went to the hospital on [DATE], and returned to the facility on [DATE]. R1's admission orders [REDACTED]. R1's Medication List orders, dated 7/7/19, documents [MEDICATION NAME] ([MEDICATION NAME]) 5mg (milligram) take one tab by mouth nightly as needed for muscle spasms; Lorazapam ([MEDICATION NAME]) 0.5mg take one tab by mouth nightly as needed for sleep; [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 7.5mg-325mg take one tab by mouth every four hours as needed for moderate or more severe pain; and Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) 50mg take one tab by mouth nightly. R1's nurses notes, dated 7/7/19 at 6:30pm by V10 LPN (Licensed Practical Nurse), documents Resident complained of pain 10/10 to both hips and her back spasms. This nurse offered [MEDICATION NAME] for the hip pain and [MEDICATION NAME] for the back spasms. Lorazapam offered to aid in sleep and labored respirations. (R1) took the medications. Medications also given at this time were Tylenol 650 mg, [MEDICATION NAME] 200mg, [MEDICATION NAME] 300mg, Quetiapine [MEDICATION NAME] 50mg, Rivaroxaban 20mg, Senna-[MEDICATION NAME] 8.6-50mg, and [MEDICATION NAME] 100mg. R1's nurses notes, dated 7/7/19 at 9:15pm by V10 LPN, documents The resident's (R1) facial color was ashen, her head was tilted back and she was pursed lipped breathing, (respiratory) rate 32 per minute. V18 MD (Medical Doctor) contacted and received orders to sent to the ER (emergency room ). R1's nurses notes, dated 7/7/19 at 10:00pm by V10 LPN, documents EMS (Emergency Medical Service) here to transfer (R1) to (local hospital). R1's (local hospital) ED (Emergency Department) progress notes, dated 7/7/19 at 10:23pm by V19 MD, documents Patient (R1) presents to the emergency department (ED) from the nursing home after she reportedly became unresponsive. Patient is unable to contribute to the medical history due to her current mental status. Reportedly at 6:30pm she received [MEDICATION NAME], Lorazapam, [MEDICATION NAME], and [MEDICATION NAME] at the same time. Approximately 1-2 hours following she became unresponsive. Patient is stuporous and nonreponsive on arrival, lungs coarse with scattered rhonchi, decreased air exchange throughout and subcostal retractions noted. She presented to the emergency department with hypercarbic (too much carbon [MEDICATION NAME] in your blood) [MEDICAL CONDITION]. She also likely had sedative effects of medication she received at 6:30pm. R1's (local hospital) clinical resume, dated 7/8/19 at 3:48pm by V3 MD, documents Acute unresponsive episode secondary to acute hypoxic hypercarbic [MEDICAL CONDITION] with increased sedation from CO2 narcosis coupled with home medications. She did receive Lorazapam, [MEDICATION NAME], and [MEDICATION NAME] all at once. There was some concern that she got all four pills at once. On 7/23/19 at 11:55am, V4- R1's family member stated I was (at the facility) when mom was admitted (7/7/19), I am not sure why they gave her bedtime medications at 6:30pm because she had not even eaten supper yet. On 7/24/19 at 10:41am, V3 MD (Medical Doctor) stated (R1) took [MEDICATION NAME], and [MEDICATION NAME] all at the same time and that didn't help with her respiratory status. We recommend that you do not give Lorazapam and [MEDICATION NAME] within two hours of one another because of the sedation. On 7/24/19 at 7:13am, V7 QA (Quality Assurance) LPN (Licensed Practical Nurse) stated I am not sure why (R1) got all her medications at once, The [MEDICATION NAME] was ordered for sleep and the [MEDICATION NAME] was ordered for nightly. We usually don't give nightly medications at 6:30pm, especially [MEDICATION NAME]. On 7/24/19 at 11:00am, V8 Registered Nurse stated We pass medications at 8am, 12pm, 2-4pm, 8pm, or there could be an 4am med pass. Nightly meds depends on the resident sleep schedule for how medication should be taken, but most nightly medications are taken around 8pm unless a resident wants later because they stay up late.

Based on record review and interviews the facility failed to supervise and prevent a fall of one of three residents (R1) reviewed for falls in a sample of three. R1 fell from wheelchair, causing a laceration to crown of head which required two staples to close. Findings include: R1's care plan dated 11/27/17 notes that R1 was admitted to the facility on [DATE] and that R1's is at a high risk for falls. Care plan notes that R1 has had multiple falls at home prior to admission. R1's care plan notes that R1 had her left leg amputated just above the knee on 11/19/17. R1's Minimum (MDS) data set [DATE] noted R1 to have a Brief Interview for Mental Status (BIMS) score of 8 out of 15. BIMS interview notes R1 to have problems with short term memory and recall. R1's incident report and fall investigation dated 12/7/17 noted that R1 was observed just before 9:00 A.M. on 12/7/17 by V14 (Certified Nurse's Aide) in her room leaning forward in her wheelchair for unknown reason. On 7/27/18 at 11:45 A.M, V14 stated that she was pushing another resident down the hall when she noticed R1 leaned forward in her wheelchair in her room as if R1 was trying to get something. V14 said she told R1 to sit back and that V14 would come back to help R1. V14 said she did not call for someone to help R1 right then and did not go into R1's room at that time. V14 stated that she proceeded to take the other resident to their room, while leaving R1 unattended. V14 stated that by the time V14 got back to R1's room, R1 was on the floor and was bleeding from her head. Local hospital Emergency Department records dated 12/7/17 note that R1 had a laceration to the crown of her head that required two staples to close.

Based on interview and record review, the facility failed to provide supervision for seven of eleven residents (R3, R4, R8, R10, R17, R18) reviewed for falls in a sample of 17 and one resident (R24) reviewed for falls on the supplemental sample. This failure resulted in R18 sustaining a femur fracture after a fall and R15 sustaining a head laceration after a fall which required 5 sutures at the local area emergency department. Findings Include: 1. The facility Incident Report for R18 dated 8/1/13 at 7:20 P.M. states "...In shower room, just had shower. Aide states stepped away to get towels. (R18) leaned forward on shower chair to see what aide doing, lost balance and fell to floor landing in a sitting position in front of shower chair...". The facility Witness Interview report for R18, dated 8/15/13 from E15 CNA (Certified Nursing Assistant) states, "...I was giving (R18) a shower in the shower chair. I went to go grab some towels and (R18) leaned forward to see what I was doing and (R18) slipped out of the chair and landed on (R18)'s right leg..." R18's care plan, dated 4/15/13 states, "Requires extensive assist with ADL's (Activities of Daily Living) due to dementia, generalized weakness, CVA history and the side effects". And directs staff to "...Stay with resident in shower..." On 2/6/14 at 2:50 P.M., E2 (Director of Nurses) stated, "(E15) CNA was giving (R18) a shower. (E15) stepped away to get some towels. (R18) toppled over and broke her hip...". R18's History and Physical from the local hospital dated 8/3/13 states "... (R18) was in the shower room yesterday and left unattended for a brief period of time so caregiver could get a towel. (R18) leaned forward to see where the caregiver was...and fell forward out of the chair...ASSESSMENT: Acute distal right femur fracture...". 2. R15's Physician order [REDACTED]. R15's entire medical record was reviewed and did not contain an assessment for fall risk. Facility Incident Reports document R15 fell on [DATE], 8/27/2013, 10/19/2013, 11/14/2013, 11/27/2013, and 1/9/2014. R15's Incident Report, dated 7/3/2013, documents, "Resident lying on floor in front of his wheelchair...When put back in chair, resident attempted to slip back out of chair. Resident put in bed for safety measures...Actions taken to prevent recurrence: Resident to continue to be monitored. R15's Incident Report, dated 8/27/2013, documents, "Resident observed lying on floor on left side by his bed and side chair. Personal alarm going off. Stated he was trying to get in his chair...Actions taken to prevent recurrence: Resident reminded to wait for help before transferring." R15's Incident Report, dated 10/19/2013, documents, "Resident incontinent of stool at 11:55PM. Was cleaned up and left to go back to sleep. Five minutes later he was found sitting on floor near bed wrapped in bed linens with stool on floor...Actions taken to prevent recurrence: Offer bed pan even after incontinent episodes." R15's Incident Report, dated 11/14/2013, documents, "Resident observed sitting on buttocks next to bed...Actions taken to prevent recurrence: (left blank)." R15's Incident Report, dated 11/27/2013, documents, "Aide stated she heard (R15's) alarm going off and walked in to find resident on floor on right side...Actions taken to prevent recurrence: (left blank)." Incident Report for R15's fall on 1/9/2014 documents, "Observed on floor in room. Patients chair was all the way up to a standing position. Laceration right forehead-sent to emergency room ...was resident injured: yes." Local area hospital Patient Summary Report, dated 1/9/2014, documents, "5 stitches to forehead laceration 1centimeter in length." R15's care plan, dated 12/26/2013, has not been updated after each fall to address new interventions on 7/3/2013, 8/27/2013, 10/19/2013, 11/14/2013, 11/27/2013, and 1/9/2014. Facility's Falls, Post-Fall Protocol policy, dated January 2013, documents, " The incident report and the nurses notes must include the following information: New fall intervention implemented to prevent recurrence of falls. " This same policy also documents, "The Restorative Nurse will: Complete a Fall Risk Assessment which includes a full medication review, add new interventions to the resident ' s fall risk care plan, and inform the Unit Nurse of the new interventions. " On 02/05/13 at 11:02 a.m., E4 Restorative Nurse, verified that R15 ' s current care plan has not been updated with new interventions and no new interventions were created after R15 ' s falls. E4 then stated the facility does not complete fall risk assessments on their residents, " 3. Fall Incident Reports document R3 fell at the facility on 08/10/2013. R4 ' s Fall Incident Reports document R4 fell at the facility on 06/18/13, 06/27/2013, 07/01/2013, 08/18/2013, and 10/06/13. R8's Fall Incident Report documents a fall on 07/07/2013. R10 's Fall Incident Reports document R10 fell on [DATE], 07/23/2013, 08/06/2013, and 01/26/2014. Fall Incident Reports document R17 fell on [DATE], 10/07/2013, and 11/18/2013. R24's Fall Incident Reports document R24 fell on [DATE], 12/26/2013, and 01/20/2014. R3's, R4's, R8's, R10's, R17's, and R24's current medical record does not contain a fall assessment. R3's current care plan, dated 1/16/2014 does not address R3's fall on 8/10/2013. R4 ' s current care plan dated 01/23/14 does not address R4 ' s falls 06/18/13, 06/27/13, 07/01/13, 08/18/13, and 10/06/13. R8's current care plan, dated 12/31/2013, has not been updated with a new fall intervention for R8's fall on 07/07/2013. R10's current care plan, dated 01/21/2014 does not address R10's falls on 07/17/2013, 07/23/2013, 08/06/2013, and 01/26/2014. R17's current care plan, dated 01/07/2014, has not been updated with new fall interventions for falls occurring on 04/19/2013, 10/07/2013, and 11/18/2013. R24's current care plan, dated 12/20/2013, does not address R24's falls on 12/13/2013, 12/26/2013, and 01/20/2014. Facility ' s Falls, Post-Fall Protocol policy dated January 2013 documents, " The incident report and the nurse ' s notes must include the following information: New fall intervention implemented to prevent recurrence of falls. " This same policy also documents, " The Restorative Nurse will: Complete a Fall Risk Assessment which includes a full medication review, add new interventions to the resident ' s fall risk care plan, and inform the Unit Nurse of the new interventions. " Between the days of 02/04/2014 at 12:00 p.m. until 02/07/2014 at 12:40 p.m., E8, Care Plan Coordinator, verified that for R3, R4, R8, R10, R17, and R22 current and past care plans were/are not updated with new interventions after these residents fell . On 02/04/2014 at 12:00 p.m. and again on 02/07/2014 at 12:40 p.m., E4, Restorative Nurse, confirmed the facility has not completed fall risk assessments for R3, R4, R8, R10, R17, and R22. E4 stated, "(The facility) does not completed fall assessment on any of our residents."