Every finding on record at Greenup Rehab and Nursing

Based on interview and record review the facility failed to complete post fall neurological assessments for 72 hours as directed by the facility's policy for three of three residents (R1, R2, R3) reviewed for accidents in the sample list of eight. Findings include:1.) R3's Nursing Notes document: On 2/20/2026 at 7:16 PM R3 was found on the floor in the day room leaning up against the wall near a wheelchair. On 2/20/2026 at 7:51 PM after prior fall, R3 fell again while V17 Certified Nursing Assistant (CNA) was walking ahead of R3 as R3 would not let V17 guide R3 into the dining room. R3 obtained an 8 centimeter (cm) by 7 1/2 cm hematoma (bump) to the back of her head. On 2/23/2026 at 11:03 AM V14 Licensed Practical Nurse (LPN) was in the living area with another resident and saw R3 stand up with R3's blanket at her feet causing her to fall backwards and hit her head on the ground. R3 had a scalp hematoma on the right side/back of her head. On 3/13/2026 at 3:00 AM V5 and V29 CNAs heard a thud from R3's room and found R3 lying on her back on the floor of her room near the sink and R3 had a small hematoma on the back of her head. R3's Incident Audit Report dated 3/16/26 documents R3 had an unwitnessed fall at 7:15 AM. R3 was found crawling on the floor of her room as V5 walked past to the dining room. R3 had an open area to the left/back side of her head that measured 0.3 cm by 0.2 cm. R3's Neurological Assessment Flow Sheets dated 2/20/26, 2/23/26, 3/13/26 and 3/16/26 document to assess every 15 minutes x4, then hourly x4, then every 4 hours x19 hours (a total of 24 hours). There is no documentation that R3's post fall neurological assessments were continued for a total of 72 hours after each fall. R3's Hospital Discharge summary dated [DATE] documents R3 was hospitalized on [DATE] following a recent fall with multiple rib fractures, tiny right anterior pneumothorax (collapsed lung), subdural hematoma (collection of blood between the brain and outer covering), and skull fracture. R3's head CT dated 3/7/26 documents small acute to subacute appearing left cerebral convexity subdural hematoma without midline shift and non-displaced right occipital skull fracture suggested. On 4/1/26 at 12:00 PM V18 LPN stated V18 completed post fall neurological assessments for R3, which are completed for 24 hours. On 4/1/26 at 1:18 PM V14 LPN completed post fall neurological assessments for R3, which are documented on the neurological assessment form. 2.) R1's Nursing Note dated 2/16/26 at 7:37 PM documents R1 was heard yelling for help and was found sitting on the floor, an unwitnessed fall, and neurological assessments were initiated. R1's February 2026 Medication Administration Record documents R1 received Eliquis (blood thinner) 2.5 milligrams (mg) twice daily. R1's Neurological Assessment Flow Sheet dated 2/16/26 documents to complete for 24 hours post fall. There is no documentation that these assessments were continued for 72 hours after R1's fall.3.) R2's Physician Order dated 1/14/26 document Eliquis 2.5 mg twice daily. R2's Nursing Notes document the following: On 2/21/2026 at 10:56 PM documents R2 had an unwitnessed fall while walking independently in her room when she tipped forward with her walker. On 2/22/2026 at 8:38 PM documents small hematoma and bruising continue to back of R2's head. On 3/3/2026 at 5:36 AM R2's spouse turned call light on to report R2 sat down on the floor but denied hitting R2's head. Neurological checks were initiated. R2's Neurological Assessment Flow Sheets dated 3/3/26 and 2/21/26 indicate to complete neurological assessments for 24 hours. There is no documentation that these assessments were continued for 72 hours after each fall. On 4/1/26 at 2:55 PM V3 Regional Administrator stated the facility's policy is for post fall neurological assessments to be completed for 72 hours and when the facility change ownership in January 2026, they did not change the forms from 24 hour monitoring to 72 hours to match the policy. On 4/2/26 at 10:08 AM V1 Administrator stated V1 was unable to find documentation that neurological assessments are completed besides the 24-hour neurological forms. The facility's Fall Reduction Policy dated 10/30/25 documents initiate neurological assessments based on the schedule on the neurological status evaluation if the fall was not witnessed, or the resident hit their head. The facility's Neurological Assessment policy dated 11/5/19 documents the following time frames for assessments: every 15 minutes x4, then every 30 minutes x2, then hourly x4, then every 4 hours x2, then every shift x7.

Based on interview and record review the facility failed to report an injury of unknown origin to the state survey agency for one of three residents (R1) reviewed for accidents/injuries in the sample list of eight. Findings include: R1's Minimum Data Set, dated [DATE] documents R1 has moderate cognitive impairment and is dependent on staff for transfers. R1's February 2026 Medication Administration Record documents R1 received Eliquis (blood thinner) 2.5 milligrams by mouth twice daily.R1's Nursing Note dated 2/25/2026 at 8:25 PM documents V29 Certified Nursing Assistant (CNA) alerted nurse to bruising to R1's side. The bruising was dark purple and extended from left mid-breast over nipple to underneath R1's left armpit measuring 7.5 centimeters (cm) by 27 cm. R1 was unable to state what happened due to cognition but displayed signs of pain when area was touched. The physician, family and Administrator were notified. R1's interdisciplinary team note dated 2/26/2026 at 11:47 AM documents root cause of R1's bruising as R1 is a two person transfer with gait belt, R1 is combative with transfers, and likely due to the gait belt and transfer. Intervention to in-service staff on proper gait belt placement. There is no documentation that the facility reported this injury of unknown source to the state survey agency. On 3/31/26 at 10:45 AM V1 Administrator stated R1's bruising was identified to be due to use of gait belt. V1 stated we investigated the bruising and identified the cause within two hours, therefor it wasn't considered an injury of unknown origin and was not reported as such. On 4/2/26 at 11:25 AM V29 CNA stated V29 was assisting R21 to bed and changing R1's clothes, when R1 complained of pain. V29 found bruising on R1's left side that extended from R1's breast to her side. V29 assisted R1 the morning prior and the bruising was not there. V29 reported the bruising to V15 Licensed Practical Nurse, who said there were no reported bruising or incidents. V29 stated nothing had been reported prior and nothing had happened during V29's shift that would have caused the injury and R1 had not had any recent falls or bumping into anything. V29 stated R1 and V15 were also not sure what caused the bruising. V29 stated it did align with gait belt or also R1 leaned over the side of her wheelchair armrests at times. On 4/2/26 at 11:30 AM V2 Director of Nursing stated V2 assisted with the investigation of R1's injury, believed to be caused by gait belt. V2 stated per V1, V2 thought the facility had two hours to investigate injuries to determine the cause and since the cause was identified there was no need to report this injury. On 4/2/26 at 12:45 PM V15 stated V29 reported R1's bruising which was immediately reported to V1. V15 stated V29 said the bruising wasn't there the prior night and we weren't sure what caused the injury. V15 stated R1 was confused and didn't know the cause either. V15 stated the bruising was purple in color and was over 20 cm long stretching from armpit to across breast on left side. The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents policy dated 10/1/23 documents an injury of unknown source criteria as the source of the injury was not observed by any person, the source of injury could not be explained by the resident, and the injury is suspicious due to the extent of the injury or the location such as an area not generally vulnerable to trauma. This policy documents injuries of unknown source as an example of crimes that are required by state and federal law to be reported to the state survey agency.

Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one of three residents (R1) reviewed for accidents/injuries in the sample list of eight. Findings include:R1's Minimum Data Set, dated [DATE] documents R1 has moderate cognitive impairment and is dependent on staff for transfers. R1's February 2026 Medication Administration Record documents R1 received Eliquis (blood thinner) 2.5 milligrams by mouth twice daily.R1's Nursing Note dated 2/25/2026 at 8:25 PM documents V29 Certified Nursing Assistant (CNA) alerted nurse to bruising to R1's side. The bruising was dark purple and extended from left mid-breast over nipple to underneath R1's left armpit measuring 7.5 centimeters (cm) by 27 cm. R1 was unable to state what happened due to cognition but displayed signs of pain when area was touched. The physician, family and Administrator were notified. R1's interdisciplinary team note dated 2/26/2026 at 11:47 AM documents root cause of R1's bruising as R1 is a two person transfer with gait belt, R1 is combative with transfers, and likely due to the gait belt and transfer. Intervention to in-service staff on proper gait belt placement. There is no documentation for this investigation or staff interviews/statements to determine the cause of the injury. On 3/31/26 at 10:45 AM V1 Administrator stated R1's bruising was identified to be due to use of gait belt. V1 stated we investigated the bruising and identified the cause within two hours, therefor it wasn't considered an injury of unknown origin and was not reported as such. On 4/2/26 at 11:25 AM V29 CNA stated V29 was assisting R21 to bed and changing R1's clothes, when R1 complained of pain. V29 found bruising on R1's left side that extended from R1's breast to her side. V29 assisted R1 the morning prior and the bruising was not there. V29 reported the bruising to V15 Licensed Practical Nurse, who said there were no reported bruising or incidents. V29 stated nothing had been reported prior and nothing had happened during V29's shift that would have caused the injury and R1 had not had any recent falls or bumping into anything. V29 stated R1 and V15 were also not sure what caused the bruising. V29 stated it did align with gait belt or also R1 leaned over the side of her wheelchair armrests at times. On 4/2/26 at 12:45 PM V15 stated V29 reported R1's bruising which was immediately reported to V1. V15 stated V29 said the bruising wasn't there the prior night and we weren't sure what caused the injury. V15 stated R1 was confused and didn't know the cause either. V15 stated the bruising was purple in color and was over 20 cm long stretching from armpit to across breast on left side.On 4/2/26 at 11:30 AM V2 Director of Nursing stated V2 assisted with the investigation of R1's injury, believed to be caused from gait belt. On 4/2/26 at 12:00 PM V1 Administrator stated V15 reported R1's bruising that evening and V1 and V2 conducted the investigation that evening. V1 stated phone calls were made to V19 Physical Therapy Assistant, V5 CNA, and V29 CNA. V1 stated R1 has dementia and will sometimes stop while walking and gets combative. V19 reported that V19 was transferring R1 from the couch to the wheelchair and R1's legs gave out like R1 was going to sit and the gait belt caused the bruising. At 1:55 PM V1 stated V1 had no documentation to provide for R1's investigation including staff interviews or statements. The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents policy dated 10/1/23 documents an injury of unknown source criteria as the source of the injury was not observed by any person, the source of injury could not be explained by the resident, and the injury is suspicious due to the extent of the injury or the location such as an area not generally vulnerable to trauma. This policy documents the facility must send in an investigative report to the state survey agency within five days of the incident for injuries of unknown source and maintain evidence of a thorough investigation.

Based on observation, interview and record review the facility failed to report and thoroughly investigate falls and serious injuries and failed to develop/implement fall interventions for two of three residents (R1, R3) reviewed for falls in the sample list of eight. Findings include:1.) R3's admission Minimum Data Set (MDS) dated [DATE] documents the following: R3's diagnoses include Dementia and Osteoporosis. R3 has severe cognitive impairment, is dependent on staff for toileting, is independent with walking and chair/bed transfers, and requires partial/moderate staff assistance with toilet transfers. R3 is always incontinent of bowel and bladder, is dependent on staff assist for toileting hygiene, and a toileting program has not been attempted. R3 has a history of falls within the last month prior to admitting to the facility. R3's Fall Risk Assessments dated 2/23/26, 3/12/26 and 3/13/26 document R3 had three or more falls within the last three months, R3 has balance problems while standing and walking, R3 has changes in gait when walking through a doorway, and R3's gait pattern as jerking movements or unstable when making turns. R3's active Care Plan documents: R3 as high risk for falls and R3 is unaware of safety needs, and surroundings. Fall interventions include self-15-minute checks (2/18/26) and anticipate toileting needs (2/19/26). R3's Hospital Discharge summary dated [DATE] documents R3 was hospitalized on [DATE] following a recent fall, R3 had multiple rib fractures, tiny right anterior pneumothorax (collapsed lung), subdural hematoma (collection of blood between the brain and outer covering), and skull fracture. R3's head CT dated 3/7/26 documents small acute to subacute appearing left cerebral convexity subdural hematoma without midline shift and non-displaced right occipital skull fracture suggested. R3's prior head CTs dated 12/3/25, 12/26/25, and 12/30/25 do not document a subdural hematoma. R3's Investigative file for R3's rib fractures and pneumothorax, provided by V1 Administrator, included documentation these injuries were reported to the state survey agency and investigated but did not include R3's subdural hematoma or skull fracture. There was no documentation that these injuries were identified, reported and investigated. There is no documentation that R3's 15 minute checks/monitoring continued after R3 returned to the facility on 3/12/26. As of 4/1/26 the Certified Nursing Assistant (CNA) task for 15 minute checks is inactive. R3's Nursing Notes document: On 3/13/2026 at 3:00 AM V5 and V29 CNAs heard a thud from R3's room and found R3 lying on her back on the floor of her room near the sink. There was urine on the floor leading from R3's bed and R3's incontinence brief was on the floor. R3 had a small hematoma on the back of her head. R3 was assisted with toileting needs and back to bed. On 3/13/2026 at 12:59 the IDT identified the root cause of this fall as R3 getting up to use the bathroom in the middle of the night while carrying incontinence brief and intervention was to wake R3 at least once to toilet during the night.R3's Incident Audit Report dated 3/16/26 documents R3 had an unwitnessed fall at 7:15 AM. R3 was found crawling on the floor of her room as V5 walked past to the dining room. R3 had an open area to the left/back side of her head that measured 0.3 cm by 0.2 cm. V5's Statement dated 3/17/26 documents prior to the fall R3 was last toileted at approximately 2:30 AM - 3:00 AM. There is no documentation if R3 was checked on after this, prior to her fall. There is no documentation that a post fall intervention was developed/implemented and care planned for this fall. R3's fall investigations for the above falls, provided by V2 Director of Nursing (DON), do not contain staff interviews or statements that identified the last time R3 was checked on or toileted prior to these falls or R3's activity when last observed. On 3/31/26 at 1:52 PM V5 CNA stated V5 came in at 2:00 AM on 3/13/26 and R3 was last seen around that time in bed sleeping prior to her fall. On 4/2/26 at 12:20 PM in regard to R3's 3/16/26 7:15 AM fall, V5 CNA stated V5 walked past R3's room and saw R3 on her hands and knees near a dining room chair that was in her room and R3 was heading towards her bed. On 4/2/26 at 12:45 PM V15 LPN confirmed R3's unwitnessed fall as documented on 3/13/26. V15 stated there was urine on the floor and thinks R3 was trying to get to the toilet. V15 stated R3 is checked/changed every two hours during the night and usually the last time checked on or changed is documented on the fall investigation forms, as V15 did not specifically remember for this fall. V15 stated the CNAs document 15 minute checks, R3 would stay in bed usually but sometimes she would get restless which would indicate need for toileting. On 4/1/26 at 10:52 AM V2 confirmed R3's 3/13/26 fall investigation does not identify the last time staff observed or toileted R3 prior to the falls. V2 stated R3 was on a standard every two hour toileting schedule prior to adding specific toileting times post falls. V2 stated R3's 15 minute CNA task documentation was not resumed after R3 readmitted to the facility from the hospital, but should have been. V2 stated the cause of R3's rib fractures was determined to be R3 bumping into her sink. V1 Administrator and V2 stated they found out about R3's subdural hematoma and skull fracture upon return from the hospital and thought this was related to a prior fall when R3 had hit her head. V1 stated V1 thought the subdural hematoma was the same one that was previously noted in August 2025. V1 confirmed these injuries were not included in the facility's report to the survey agency or investigated. On 4/1/26 at 2:55 PM V1 confirmed all investigation documentation was provided for R3's injuries/falls.On 4/1/26 at 4:00 PM V2 provided R3's 3/16/26 7:15 AM fall investigation and staff statement. V2 confirmed no documented post fall intervention. V2 stated the intervention was to remove the stationary chair from R3's room. At this time V2 was taken to R3's room where a stationary dining room chair was in R3's room. V2 stated R3's family must have brought the chair into R3's room today when they visited. On 4/2/26 at 10:00 AM V2 confirmed R3's care plan had not been updated with a post fall intervention for this fall. 2.) R1's MDS dated [DATE] documents R1 has moderate cognitive impairment and is dependent on staff for transfers and toileting. R1's Nursing Note dated 2/16/26 at 7:37 PM documents R1 was heard yelling for help and was found sitting on the floor, an unwitnessed fall. On 4/2/26 at 10:13 AM V2 provided R1's fall investigation and confirmed it does not include staff statements/interviews to determine when R1 was last checked on or toileted prior to the fall. V2 stated R1's fall was unwitnessed, R1 was found on the floor by nursing staff and call don't fall signs and encourage use of call light were the post fall interventions. The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents policy dated 10/1/23 documents crimes such as serious bodily injury must be reported to the state survey agency and investigated. The facility's Fall Reduction policy dated 10/30/25 documents the following: The purpose of the policy includes providing an environment that remains as free of accident hazards as possible, identifying residents at risk for falls, developing appropriate interventions, and providing supervision and assistive devices to prevent or minimize fall related injuries. The care plan will indicate for caregivers residents who are high risk for falls and fall interventions, and the care plan will be reviewed and updated after each fall. Falls will be reviewed during the weekly risk management meetings to identify root cause, effectiveness of interventions, and to revise the are plan. The Director of Nursing (DON) or designee shall review the event log on a weekly basis with review of the Quality Assurance Committee to assure the objectives of this policy are being met.

Based on interview and record review the facility failed to protect resident's right to be free from resident-to-resident physical abuse. This failure affected four of five residents (R1, R30, R31, R37) reviewed for resident rights on the sample list of 24 residents.Findings include:R4's Medical Diagnoses List dated August 2025 documents R4 is diagnosed with Severe Dementia with Behavioral Disturbance, Anxiety Disorder, Personality Disorder, Hallucinations, and Major Depressive Disorder.R4's Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. The same MDS documents R4 exhibited physical behavioral symptoms directed toward others such as hitting and kicking. R4's Social Services Quarterly assessment dated [DATE] documents R4 gets agitated and is non-compliant with safety interventions. R4 is verbally aggressive towards residents and staff. R4's Care Plan dated 6/11/25 documents R4 exhibits behaviors of verbal and physical aggression towards other residents. Staff are to provide one on one supervision until aggression has ceased, make sure all her needs are met, and allow phone calls to family. 1.The Incident Report dated 9/28/25 documents R4 kicked R37 on the shin. The incident was witnessed by a cognitively intact resident (R16). R16 reported R4 kicked R37 on R37's leg and R37 yelled ouch. R37 developed a hematoma on her corresponding shin. On 12/5/25 at 1:09 PM, R16 confirmed R16 had witnessed R4 kick R37' shin. R37 stated R4 often gets upset with other residents for no reason and is easily agitated. R16 stated when R4 kicked R37, R37 yelled ouch and made an upset facial expression. 2. The Incident Report dated 10/9/25 documents R4 hit R1. The incident occurred during a group activity. V6 Activity Director witnessed the incident. R4 missed catching the ball in balloon toss and R1 chuckled. In response, R4 reached back and hit R1 on the shoulder. On 12/5/25 at 1:15 PM, V6 Activity Director confirmed V6 was running a game of balloon toss with a group of residents and R4 missed the balloon. R1 laughed but V6 does not believe it was regarding R4, however R4 seemed offended and reached back and hit R1 on the shoulder. 3. The Incident Report dated 11/14/25 documents R4 hit R30. V16 Registered Nurse witnessed the incident. Unprovoked, R1 became upset with R30 and yelled out at R30 and slapped R30 on his arm three times. On 12/5/25 at 12:45 PM, V16 Registered Nurse stated V16 was at the nurses' station and R4 was on the phone with a family member. R30 was sitting near R4 in his wheelchair. Suddenly R4 got upset and R4 turned to R30 and yelled at R30 and slapped him on the arm three times. V16 RN stated R4 often gets upset with others easily and for no reason at all. R4 is agitated and will curse and become aggressive with others- both residents and staff. 4. The Incident Report dated 11/17/25 documents R4 kicked R31. V18 Certified Nurse's Assistant witnessed the incident. R31 accidently laid in R4's bed. R4 retrieved V18 CNA to help get her out and as she wheeled up to the bed, R4 kicked R31's leg that was hanging off the bed. On 12/5/25 at 12:40 PM, V18 CNA confirmed R4 had come down the hall to get help getting V31 out of her bed. V18 CNA followed R4 into her room and saw R31 in R4's bed. R31 was asleep with her legs hanging over the side of R4's bed. Before V18 could do anything, R4 kicked R31's right shin. On 12/5/25 at 12:30 PM, V1 Administrator confirmed R4 has a problem with becoming physically aggressive with other residents. V1 confirmed R4 has hit or kicked R1, R30, R31, and R37 and confirmed these are examples of physical abuse. V1 confirmed R1, R30, R31, and R37 are all cognitively impaired residents and do not recall the incidents. The facility's Abuse, Prevention, and Prohibition Policy dated December 2024 documents each resident has the right to be free from abuse. Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking. Resident to resident abuse includes the term willful which means that the individual's actions were deliberate (not accidental) regardless of whether the individual intended to inflict injury or harm.

Based on interview and record review the facility failed to submit a final investigation report regarding allegations of abuse to the state surveying agency. This failure has the potential to affect three of five residents (R1, R30, R31) reviewed for abuse on the sample list of 24 residents. Findings include: The facility's Abuse, Prevention, and Prohibition Policy dated December 2024 documents the facility administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. The facility will conduct an investigation within five business days and will submit a final report to the required state agency. 1. The Initial Incident Report dated 11/14/25 documents R4 hit R30. V16 Registered Nurse witnessed the incident. Unprovoked, R1 became upset with R30 and yelled out at him and slapped him on his arm three times. 2. The Initial Incident Report dated 11/17/25 documents R4 kicked R31. V18 Certified Nurse Assistant witnessed the incident. R31 accidently laid in R4's bed. R4 retrieved V18 CNA to help get R31 out of R4's bed and as R4 wheeled up to the bed, R4 kicked R31's leg that was hanging off the bed. On 12/5/25 at 12:30 PM V1 Administrator confirmed R4 is physically aggressive with other residents, and it is considered physical abuse. V1 stated V1 completed the initial abuse report and investigation on these incidents, however, did not have time to compile the investigations into a final report and did not submit a final abuse investigation report to the state surveying agency for either of these incidents. 3. R1's admission Record dated 12/4/25 documents original admission date of 9/3/19. Documents R1's active medical diagnoses to include Muscle Weakness, Recurrent Depressive Disorder, Major Depressive Disorder, Osteoarthritis, Diabetes Mellitus Type 2, Unsteady on Feet, Lack of Coordination, Dementia with Behavioral Disturbances, History of Falls, and Displaced Fracture of the Sixth Cervical Vertebra. R1's Minimum Data Sheet (MDS) dated [DATE] documents R1 has moderate cognitive impairment with inattention and disorganized thinking. R1's Progress Notes dated 11/22/25 document R1 had a change in condition related to physical altercation. On 12/4/25 at 10:00 AM, V1 stated that on 11/22/25, R1 had kicked R4 because R4 was in his way to get to kitchen door. V1 stated R1 most likely kicked her wheelchair. V1 stated no investigation had been done related to the 11/22/25 incident and no final report had been sent.

Based on observation, interview, and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. This failure has the potential to affect all 36 residents in the facility. Findings Include: The September 2024 Nurse Schedule documents no Registered Nurse coverage on 9/7/24, 9/8/24, 9/21/24, and 9/22/24. On 9/22/24 at 7:55 AM, upon the entrance of the facility's Annual Certification Survey there was no Registered Nurse on duty. On 9/24/24 at 3:18 PM V2 Director of Nurses confirmed the facility only employs two Registered Nurses. V2 stated there are some weekends that the facility does not have eight hours of consecutive Registered Nurse coverage. The facility's Facility assessment dated [DATE] documents the facility will be staffed according to resident's needs and in order to provide competent support and care. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents that there are 36 residents who reside in the facility.

Based on interview and record review, the facility failed to employ a qualified Director of Food and Nutrition Services. This failure has the potential to affect all 36 residents residing in the facility. Findings include: On 9/23/24 at 8:40 am V9, (Dietary Manager) was actively supervising dietary operations with residents' food preparation in the facility kitchen. V9 stated she does not have dietary management certification. V9 also stated she has a high school diploma but no further education. On 9/23/24 at 11:45 am V1, Administrator confirmed V9, Dietary Manager has not taken Dietary Manager classes to qualify V9 as a qualified Director of Food Services. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents 36 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to employ dietary support/staff with the appropriate competencies to carry out the functions of the food and nutrition service. This failure has the potential to affect all 36 residents residing in the facility. Findings include: On 9/23/24 at 8:40 am V9, (uncertified Dietary Manager) was actively supervising dietary operations in the facility kitchen. V9 stated she does not have a Food Handlers certification nor Food Sanitation certification. On 9/23/24 at 11:45 am V1, Administrator stated V9, (uncertified Dietary Manager) does not have a Food Handlers certification or Dietary Sanitization certification. On 9/24/24 at 8:10 am V23, [NAME] was actively plating residents' food in the facility kitchen. V23 stated V23 does not have a Food Handlers certification. On 9/24/24 at 8:16 am V1, Administrator stated (V23) does not have a food handlers' card either. The Illinois Public Act [PHONE NUMBER] documents, Anyone working with unpackaged food, food equipment, utensils, or food contact surfaces is defined as a food handler. Food handlers working in non-restaurants (nursing homes and long-term care facilities) must have the training completed, with enforcement to begin January 1, 2017. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents 36 residents reside in the facility.

Based on observations, interviews, and record review the facility failed to provide a substitute menu, honor resident's preferences, and provide appropriate condiments. These failures have the potential to affect all 36 residents residing in the facility. Findings include: 1.) On 09/22/24 at 10:15 am, R30 stated last night the facility served beef and noodles that had a one-inch-thick layer of grease on top. The only substitute available was a bologna sandwich. Sometimes they have turkey sandwiches as a substitute but those and peanut butter and jelly, are their only substitutes. On 9/22/24 at 12:35 pm V1, Administrator stated We don't have a substitute menu. (new facility company) does have an always available menu, but that has not been an option in this facility yet. The residents can have peanut butter and jelly or lunch meat sandwiches. They can have leftovers from the previous day, but that is all we do right now. 2.) On 9/23/24 at 8:11 am R30 was eating biscuits and gravy. R30 had a glass of milk, glass of orange juice and a glass of water. R30 stated My diet card says no orange juice, no peas, no carrots and no sweet potatoes. They serve me these things all the time. They don't even look at the cards. Everybody gets the same thing. R30's undated Diet Card documents: Breakfast: Dislikes OJ (orange juice). On 9/23/24 at 9:00 am V9, Dietary Manager stated, The dietary staff are supposed to read the residents preferences and honor them. V15, Dietary Assistant added We were out of apple juice, so I substituted. I did not read her diet card. 3.) On 9/23/24 at 11:35 am R30 was served Salisbury steak, potatoes and peas, diet Pepsi and water. R30's diet card documents R30 dislikes peas. R30 sent her plate back to the kitchen. An unidentified Certified Nursing Assistant stated R30 wants a new plate without peas. V5, cook stated We (dietary staff) should have honored (R30's) preferences (documented) on the (R30's) diet card. R30's undated Diet Card documents: Lunch: Dislikes peas, cooked carrots and sweet potatoes. The facility policy, undated General Dining Experience documents the following: Guidelines: Residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes. 35380 4.) On 9/23/24 at 9:28 AM, during the Resident Council Meeting, R9 and R30 stated condiments are not being served with the meals and not coming on trays (R9) in rooms, the residents have to ask for it and then wait on it. The Residents' Rights for Persons Residing in Supportive Living Facilities dated Revision 11/06, documents the facility must make available services to promote health and wellness. The facility's Long-Term Care Facility Application For Medicare and Medicaid dated 9/22/24 documents 36 residents reside in the facility.

Based on observation, interview, and record review the facility failed to provide residents breakfast meal in a timely manner. This failure affected all 36 residents residing in the facility. Findings include: On 9/24/24 at 8:05 am the main dining room of the facility was full of residents waiting for their breakfast meal to be served. Each resident had beverages, but none of the residents had been served food. R30 stated The facility has not served anybody. We have no idea what is going on. We have been out here for over an hour waiting. Breakfast is supposed to be served at 7:15 am. It is often late, but today its extremely late. On 9/24/24 at 8:10 am V23, [NAME] stated she overslept so the food is just being cooked. On 9/24/24 at 8:16 am V1, Administrator stated V1 realizes the meal is late this morning. V1 stated the expectation is that breakfast is to be served between 7:15 am and 7:30 am. On 9/24/24 at 8:50 am V9, Dietary Manager stated I (V9) came in at 5:00 am this morning but did not cook resident meals. V9 stated she had a food delivery coming in and cleaned until they arrived. (V23, Cook) came in late. I don't know for sure of the time, but that is why breakfast was late. I will get her timecard. V23's Timecard documents that on 9/24/24 V23 clocked into the facility at 6:52 am (23 minutes before resident breakfast meal is scheduled to be served). The facility Long-Term Care Facility Application For Medicare and Medicaid dated 9/22/24 documents 36 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain sanitization of a commercial table top can opener, free of grease-like substance, metal fragments, rust and exposed metal, failed to maintain food surface areas in a clean sanitary manner, failed to clean grease build-up on kitchen and food storage room floors, failed to adequately clean grease build- up off the flat top grill, failed to clean commercial ovens and failed to air dry dishware. These failures have the potential to affect all 36 residents residing in the facility. Findings include: 1.) On 9/22/24 at 8:15 am on initial tour of the facility kitchen the floors had a build-up of sticky, dark black and brown grease-like debris throughout the kitchen, dishwashing station, dry storage, and cooks' food service line. This surveyors' feet stuck to the floor with every step throughout the heavily soiled areas of the kitchen. There was an accumulation of dust and debris under all the shelving and next to the walls. V4, Dietary Assistant was in the cooks' service area plating a resident food. V4, confirmed the floors had a build-up of sticky, dark black and brown grease like debris throughout the kitchen, dish washer station and dry storage and cooks' line but was not sure who was supposed to clean the kitchen floor areas. On 9/23/24 at 8:40 am - 8:55 am on the follow-up tour of the facility kitchen with V9, (uncertified) Dietary Manager (DM), the soiled floors noted above, continued unchanged. During the walk through of the kitchen the surveyor and V9's feet stuck to the grease-like build-up on floor tiles with ever step. V9, DM confirmed the floors are not being cleaned according to the cleaning schedule. The facility Dining RD (Registered Dietician) Kitchen Inspection report dated 8/12/24 and signed by V11, Consultant Registered Dietician documents: Both the kitchen and food storage room floors are in need of in-depth mopping. Needs Correction. 2.) The same follow up tour of the kitchen with V9, DM, there was a stainless steel, approximately six-foot-wide food preparation table. The food preparation table had three refrigerators below. Above the preparation table, there was steel brackets attached to the wall and that held four wooden shelves. Two of the brackets were rusted. The two lowest shelves had a build-up of brown grease-like substance and strings of dust that dangled from under the shelves and directly over the food preparation table. V9 stated That is real sticky and dirty. It needs cleaned better. The facility Dining RD (Registered Dietician) Kitchen Inspection report dated 8/12/24 and signed by V11, Consultant Registered Dietician documents: Debris was noted on shelves Needs Correction. 3.) During the same tour, the facility's commercial table-top can opener was soiled with a build-up of a brown and black grease - like substance, rust and metal fragments embedded in the gears. The shaft sleeve and tabletop can opener mount bracket, also had a build-up of brown and black grease-like substance. The can opener blade tip was also missing approximately one inch of the silver veneer exposed bare metal. V9, DM stated I can see the stuff in the gears. I didn't know we needed to do anything but wipe the outer part off. The facility Dining RD (Registered Dietician) Kitchen Inspection report dated 8/12/24 and signed by V11, Consultant Registered Dietician documents: The can opener has a build-up of food debris, and needs cleaned and sanitized after each use. Needs Correction. A second facility Dining RD Kitchen Inspection report the following month, dated 9/11/24, and signed by V11, Consultant Registered Dietician documents: The can opener has a build-up of food debris, and the blade has evidence of metal shavings. Needs Correction. The undated facility policy Cleaning Procedure - Can Opener documents: Guidelines: The can opener is maintained in a sanitary condition. Procedure: After each use: Wipe the blade clean with a cloth saturated in sanitizer solution. Allow to air dry. Daily: 1. Remove the opener by lifting the shank out of the base. 2. Scrub the opener with a small wire brush, especially around the cutting edge. 3. Wash/rinse can opener shank in dishwashing machine and allow to air dry. 4. Scrub base with warm water and detergent and rinse with clean, warm water. 5. Return shank to base. 6. Check the blade to assure that it is sharp. Note: Metal shavings and shredding can result from a dull cutting blade or a worn-out cogwheel. 4.) During the same tour, there were two commercial ovens, under the range burners and flat-top grill. Both oven floors were soiled with approximately one - inch deep, wide-spread, build-up of charcoal-like food debris. V9 stated it does not look like the ovens have been clean for a long time. 5.) During the same kitchen tour, the commercial range burners and flat-top grill had a copious amount of brown and black grease like build-up. The flat -top grill of the range had a large shoe print in the heavily soiled grease. V9 stated The footprint is from the vent cleaning company guy, that came this morning. V9 acknowledged a like-new abrasive grill brick for cleaning was on a stainless-steel shelf above the flat-top grill. V9 stated she did not know the abrasive block was for cleaning the grill, so she used a wet cloth to clean the flat-top grill. V9 stated The footprint did not come off because of the grease build-up. The facility Dining RD (Registered Dietician) Kitchen Inspection report dated 9/11/24 and signed by V11, Consultant Registered Dietician documents: The cooking stove, has evidence of food debris or grease. Needs Correction 6.) During the same kitchen tour, there were 27 various sized, steam table pans stacked cradled style together with water between each pan. There were 30 small, glass five-inch plates stacked in a cradled style together with water between each plate. There were seven dinner sized plates stacked cradle fashion with water between each plate. V9 acknowledged the wet pans, and dishes were not being air dried in a single layer. V9 stated The kitchen does not have enough shelves for that. The facility Long-Term Care Facility Application For Medicare and Medicaid dated 9/22/24 documents 36 residents reside in the facility.

Based on interview and record review the facility failed to establish a water management program, failed to develop a risk assessment ensuring that interventions to monitor control limits are met, develop a method to audit the program to prevent the growth of Legionella and other water borne pathogens in the building's water systems. This failure has the potential to affect all 36 residents that reside in the facility. Findings Include: The facility Long-Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents that there are 36 residents who reside in the facility. The facility Legionella Policy and Procedure dated 4/20/20 documents that each facility will complete a risk assessment to identify if the entire building or parts of the building are at risk for Legionella growth and spread. Additionally, the facility will implement control measures to reduce spread, ensure that the program remains operational, and monitor the program's effectiveness. The facility could not provide documentation of a Legionella risk assessment to identify if the building is at risk for Legionella growth and spread, a way to monitor the measures they have in place including testing protocols and acceptable ranges, an assessment of redundant or dead-end pipe work in the building and plan to remove it, and ways to intervene when control limits are not met in the building's water systems. On 9/25/24 at 12:12 PM V16 Maintenance Director stated he has worked in the facility for six years and just recently completed water testing for Legionella risk for the first time in six years. V16 stated he has never identified areas of pipe where water could stagnate (dead-ends) and just today (9/25/24) he identified 17 dead end pipes. V16 denied ever flushing the system and denied cleaning and disinfecting the shower heads. V16 denied following the facility's Legionella Policy regarding water born pathogen prevention. V16 was unaware of any risk assessment and was not familiar with any monitoring or testing protocols.

Based on observations, interview, and record review the facility failed to maintain kitchen equipment in a safe operable and functional manner. This failure affected all 36 residents in the facility. Findings include: 1.) R30's Minimum Data Set, dated dated dated [DATE] documents R30's Brief Interview of Mental Status score as 15 out of a possible 15 indicating no cognitive impairment. On 9/24/24 at 8:05 am the facility foyer, resident lounge, and resident shared dining room had a distinct, foul gas-like odor. The resident dining room was filled with residents. R30 stated There is a strong odor of gas coming from the kitchen. I am not sure what that is all about, either. On 9/24/24 at 8:10 am V23, [NAME] and V16, Maintenance Director were in the facility kitchen. V23, [NAME] stated the gas was turned off to the stove and flat-top grill the night before and V23 is not sure why it was turned off. V16, Maintenance Director was present in the kitchen and had already assessed the kitchen for a gas leak. V16 stated there was no gas leak but the problem may be the range hood not ventilating properly. On 9/25/24 at 11:40 am V16, Maintenance Director stated The gas company came out and could not find any leaks. It was determined that the exhaust fan, above the stove had a capacitor (electronic component) out, that caused the exhaust not to work properly. It was burnt gas that caused the smell yesterday. Last May (2024) we had a similar situation with the exhaust fan. We could smell the burnt gas outside then. I called (private company name), yesterday and they will be out sometime this week (later determined to be 9/26/24). 2.) On 9/23/24 at 10:50 am On the counter of the food preparation table was a large commercial-sized food processor and a small home-sized food processor. V5, cook attempted to puree meals for six residents (unidentified). V5 stated The (brand name, commercial-sized food processor) has not worked for weeks, so we use this little one (home- sized food processor). It is hard to get meats to the right consistency with this. Meats are always grainy (not smooth) It is all we have right now, until the (name brand commercial sized food processor) gets fixed. V5 followed the recipe to puree six portions of Salisbury steak. After approximately five minutes, V5 poured the pureed Salisbury steak into a steam table pan, covered the pan with foil and stated the pureed Salisbury steak was ready to serve. At surveyor request, V5 removed the foil to confirm the texture was smooth. Both surveyor and V5 used a plastic spoon to taste to assess the texture of the Salisbury steak. The Salisbury steak had a chunky appearance with shredded-coconut-sized pieces of meat and fat throughout. V5 stated the Salisbury steak looks like all the other meat she prepares with the small home-sized food processor, and the meat is not a smooth consistency. V5 repeated the food processor activation five additional times, over 45 minutes, until the consistency of the Salisbury steak was smooth. V1, Administrator confirmed the commercial-sized food processor did not work to puree residents food well, and the new home-size food processor doesn't either. V1 stated I called (private company kitchen equipment company) yesterday, for a quote (estimated cost) on a commercial (sized food processor) one. They know we need it as soon as possible. 3.) On 9/23/24 at 11:20 am, V9, Dietary Manager filled the compartments of the kitchen three-well with water to be used for washing pots and pans. The first well contained water with pre-mixed cleaning detergent from a wall mount. The second well contained clear rinse water. V9 stated she will fill the third well of the sink and add the chlorine based pre-mixed sanitizer solution from the wall mount in order to measure the concentration of chlorine is at the adequate level to sanitize the kitchenware washed in the sink. V9, stated I have worked her six weeks. I was told the third well (sanitization sink) does not hold water. V9 ran water in the sanitizer well of the sink. Water poured out from plastic pipes under the sink. The water flow was a constant moderate stream that covered a six-foot area of the tiled floor. There were large circles of water- like stains on the tile. The tiles had peeled up corners on the edges. V9 shut off the water and stated she would have to get a bath blanket to soak up the water. V9 stated she does not know why Maintenance has not fixed the sink. V9 stated We have to run the pots and pans through the dishwasher, repeatedly to get them cleaned and sanitized. V15 Dietary Assistant stated That sink has not held water for a long time. Long before (V9, DM), started last month. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents 36 residents reside in the facility.

Based on observation, interview, and record review the facility failed to honor residents' right to a clean and comfortable homelike environment by failing to repair and maintain the cleanliness of the only two resident-shared shower rooms in the facility. These failures affect all 36 residents residing in the facility. Findings include: On 09/22/24 at 10:10 am R30 stated Both shower rooms have black areas, maybe mold that they (the facility) can't seem to clean off. R30 also stated The housekeeper are great, so I think it (black mold-like substance) is coming from inside the wall. On 9/22/23 at 1:55 am during a tour with V1, Administrator, the resident shared shower room, closest to the nursing station, and adjacent to the resident common lounge was a dark shower room with one shower stall and one toilet. The shower had a strong, musty odor. There was a small, sole ceiling vent above the toilet alcove that measured approximately six inches by eight inches. The ceiling vent was corroded with a thick gray dust-like substance and had no air movement when tested with one, four by four-inch square piece of tissue. The inside of the toilet bowl had a build-up of a black crusted-looking substance that the rimmed the top of the water. The shower stall alcove measured approximately four and a half feet wide, by four and a half feet deep. The slope of concrete that led into the shower stall alcove was cracked and chipped the full width of the entrance. The tile floor in the shower stall, had black mold-like substance in most the mortar-like one eight-inch spaces between each tile. The tile extended up the baseboard of the shower stall. The tiles on the baseboard had a brown and black build-up adhering to the entire surface. The three walls, above the baseboard had the same built- up of the black and brown substance over the entire surface that extended up the wall approximately four feet. The shower faucet handle had a white plastic-coated metal hanging soap shelf. The soap shelf had patches of missing white coating, with visible rust on the bare metal. V1, Administrator stated the new company, taking over the management of the facility did a walk through and saw the poor condition of both the two resident shared showers. The previous company knew the same but would not allocate money to repair the shared shower rooms. 2.) On the same tour noted above, V1, Administrator walked over to the only other resident shared shower room of the facility. The shower room was the furthest from the nurse's station, and also adjacent to the resident common lounge. There was foul odor present outside the door that permeated the entry way/ lounge area to the shower room. The foul odor became stronger as the shower door opened. V1, Administrator confirmed the strong-foul odor and stated the ventilation is worse in this second shared resident shower room. There was one six inches by eight-inch vent on the ceiling above the toilet stall. The ceiling vent was corroded in thick gray dust-like substance and had no air movement when tested with one four inch by four inch tissue. There was a light fixture with no functioning light bulb in the toilet alcove stall. The shower stall had a fluorescent fixture that held three fluorescent lights bulbs, two of which were not functioning at all and the third was dim and flickering off and on. The resident shared shower stall had slope of concrete that lead into the shower. The concrete slope was cracked and chipped the entire four-foot width of the shower entry way. The tile floor of the shower had black mold-like substance in most the mortar-like one eight-inch tile junctions. The base board tile continued with brown and black build-up adhering to the surface. The three walls had the same built- up black and brown corrosion that extended up approximately four feet. The painted ceiling of the shower stall had paint strips that had pulled off the wall and hung down two and three inches from the shower ceiling. V1, Administrator stated (the new company) knows about the shower rooms and needs to address them. They are not clean comfortable and homelike, like the rest of the facility is. On 9/22/24 at 2:15 pm V16, Maintenance Director stated We got tagged (citations of non-compliance) for this before, nothing has been done. We had plans, I drew up. They were beautiful plans but (previous company) would not approve them. V16 also stated I have been here six years. The shower rooms have needed new tiles and ventilation the whole time I have been here. The housekeepers are supposed to be taking care of cleaning in there (the shower rooms) daily. Obviously, that is not happening like it should. The Resident's Right for People in Long-Term Care booklet dated November 2018 documents residents have the right to a clean and comfortable home-like environment. The facility Long-Term Care Facility Application For Medicare and Medicaid dated 9/22/24 documents 36 residents reside in the facility.

Based on observation, interview, and record review the facility failed to serve palatable resident preferred temperature, and pleasant looking food. This failure affected four of four residents (R9, R19, R30, and R32) reviewed for palatability of food on the sample list of 28. Findings include: 1.) R30's Minimum Data Set, dated dated dated [DATE] documents R30's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. On 09/22/24 at 10:15 am R30 stated last night the facility served beef and noodles that had an inch thick layer of grease on top. 2.) On 9/23/24 at 8:11 am R30 was eating biscuits and gravy. R30 stated The meal was served hot, except the oatmeal. R30 had a full bowl of oatmeal, that floated in water. R30 stated the oatmeal was soupy and she will not eat soupy oatmeal. 35380 3. On 9/22/24 at 8:30 AM, R9 stated the food at the facility is terrible, it's cold. R9 also stated when they had beef and noodles, there was so much grease on the top of it, you could spoon it off. On 9/23/24 at 9:28 AM, during the Resident Council Meeting, R19, R30, and R32, also stated the grease on the beef and noodles was a lot and made it terrible. R19, R30, and R32, also stated the food was cold a lot and looked like a bunch of crap. The facility policy, undated General Dining Experience documents the following: Guidelines: Residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care and dining wishes. The same policy documents: Meals will be nourishing, attractive and palatable. The same policy documents: Meals will be served at the appropriate texture and consistency to meet the individuals plan of care, but not limiting the right to make personal choices.

Based on observation, interview, and record review the facility failed repeatedly to change oxygen tubing and nasal cannula, store oxygen tubing off the floor, and maintain nebulizer breathing treatment equipment and Continuous Positive Airway Pressure (CPAP) equipment in a sanitary fashion. These failures affected two of two residents (R24, R30) reviewed for oxygen in the sample list of 36. Findings Include: 1.) R24's Medical Diagnoses Sheet dated September 2024 document R24 is diagnosed with Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. R24's Physician Order Sheet (POS) dated September 2024 documents R24 is prescribed oxygen at three liters per nasal cannula. The nasal cannula is ordered to be changed every Thursday night. R24's Treatment Administration Record (TAR) dated September 2024 documents staff are to change R24's oxygen tubing every Thursday on night shift. On 9/12/24 the TAR documents the tubing was not changed because R24 was asleep. On 9/19/24 R24's TAR documents R24's tubing was changed however when observed on 9/22/24 the date of the tubing was still 9/6/24. On 9/22/24 at 9:30 AM R24's oxygen tubing was connected to an oxygen concentrator and coiled on the floor. The date on the tubing was 9/6/24. On 9/24/24 at 10:47 AM R24's oxygen tubing was again coiled on the floor. 31642 2.) R30's Diagnosis Sheets dated 9/24/24 documents the following: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, and 'Malignant Neoplasm of Upper Left Bronchus or Lung. R30's Physician Order Sheet dated 9/24/24 documents the following: Oxygen three liters per nasal cannula each shift (continuous), Oxygen - tubing and humidifier change every night shift every Thursday, and CPAP, (machine to keep the airway open) per home settings- do not add distilled water to CPAP per resident. The same POS documents: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) vial inhale orally every 6 hours as needed for Prophylaxis related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation. R30's Minimum Data Set, dated dated dated [DATE] documents R30's Brief Interview of Mental Status score as 15 out of a possible 15 indicating no cognitive impairment. R30's Treatment Administration Record (TAR) dated September 2024 documents staff are to change R30'ss oxygen tubing every Thursday on night shift. On 9/05/24, R30's TAR documents R30's oxygen tubing was changed, though when observed (documented below) on 9/22/24 and 9/23/24 the date on R30's oxygen tubing was 8/01/24. On R30's TAR dated 9/12/24 documents R30's oxygen tubing was not changed because R30 was asleep. On 9/19/24 R30's TAR documents R30's oxygen tubing was changed though when observed (documented below) on 9/22/24 and 9/23/24 the date of the tubing was 8/01/24. R30's same TAR does not document R30 has been administered a nebulizer treatment over the course of September 2024. The observation documented below reflects R30's soiled nebulizer medication administration apparatus which indicates R30's nebulizer equipment has not been used, cleaned, or replaced (undated equipment) in September. On 09/22/24 at 10:20 am R30 was seated in bedside chair. R30 had oxygen per nasal cannula actively dispensing three litter from a bedside concentrator. R30's oxygen nasal cannula prongs in nares are discolored a light gray instead of the clear plastic color of the attached oxygen tubing. The opposite end of R30's oxygen tubing is attached to the bedside concentrator. The oxygen tubing dated 8/01/24. R30 stated The nurses are great but don't change the tubing like they should. R30 had a CPAP mask laid on R30's bed attached to tubing that connected CPAP mask to the respiratory machine on the bedside table. The CPAP mask is a discolored gray instead of clear. R30 stated The CPAP mask does not get cleaned, ever. R30 also stated When it (CPAP mask) gets really bad, I order some (CPAP mask) off the Internet and give them to the nurse to change it out. R30 also has a nebulizer machine covered with dust. The nebulizer tubing and medication cup apparatus is undated and soiled. On 9/23/24 at 8:55 am R30's CPAP mask was soiled and laid on R30's unmade bed. R30's nebulizer medication cup/apparatus and tubing were laid on R30s bedside table. Both remain soiled and undated. The oxygen nasal cannula and tubing were attached to R30's bedside oxygen concentrator and remain soiled and dated 8/1/24. V6, Licensed Practical Nurse confirmed the observation and stated The nurses are supposed to wash (R30's) mask every week I think. The neb (nebulizer) treatment cup (medication for inhalation delivery) and tubing are supposed to be changed weekly on nights and dated. I am not sure why that did not happen. On 9/25/24 at 8:50 am V1, Administrator stated I was not able to find the oxygen policy for changing O2 (oxygen) tubing or the policy for nebulizer equipment. Both are supposed to be changed weekly and prn. Neb (nebulizer) equipment is supposed to be wash after each treatment and left to air dry on a paper towel. Everything should be dated when its changed. V1 also stated The CPAP policy says that it is supposed to be washed every day. I don't know why the nurses aren't doing this. On 9/25/24 at 11:45 am V1, Administrator confirm the oxygen policy does not document the care f the oxygen equipment only directs the administration of oxygen. V1 stated there is supposed to be a plastic bag attached to the oxygen concentrator to keep the oxygen tubing off the floor. The facility policy CPAP/BiPAP Support dated January 2017 directs staff as follows: Masks, nasal pillows and tubing: a. Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses.

Based on observation, interview, and record review the facility repeatedly failed to provide dignity while dining for four of four residents (R15, R17, R27, and R87) reviewed for dignity on the sample list of 28. Findings include: 1.) R15's Minimum Data Set (MDS) dated [DATE] documents R15 has a Brief Interview of Mental Status (BIMS) score of five out of a possible 15, indicating R15 has severe cognitive impairment. R15's same MDS documents R15 requires substantial/maximum assistance for eating. R17's MDS dated [DATE] documents R17 has severe cognitive impairment and requires supervision/touching/and or verbal assistance for eating. R27's MDS dated [DATE] documents R27 has severe cognitive impairment and requires substantial/maximum assistance for eating. R87's MDS dated [DATE] documents R87 has a BIMS score of five out of a possible 15, indicating R87 has severe cognitive impairment. R87's same MDS documents R87 is totally dependent on staff assistance for eating. On 9/23/24 at 7:35 am R27 was seated in a straight back dining room chair. V24, Certified Nursing Assistant (CNA) was feeding R17, V26, CNA was feeding R15. V13 was assisting R87. At the same table, R27 was eating pureed biscuits and gravy, apple sauce and pureed scrambled eggs. R27 was eating on her own and had food smeared on herself and completely over her place at the table. V13, CNA was seated beside R27, but was not feeding R27, and did not attempt to clean R27 or R27's table area. R15, R17 and R87 continued to eat at the same soiled table, that was smeared with food and beverages. On 9/22/24 at 8:10 am R27 left the dining room table via wheelchair. Three unidentified staff were feeding, R15, R17, R87 and pureed food and beverages were smeared all over the table where R27 had been eating. There was no attempt by unidentified staff to clean the table while R15, R17, and R87 remained at the table for the duration of their meal. On 9/23/24 at 8:17 am V8, Registered Nurse (RN) was passing medications to the residents. V8, RN confirmed R27 had smeared food and beverage all over R27's area at the table and the smeared food and beverages encroached the center of the shared resident dining table. R15, R17 and R87 were seated at the same soiled table. V8, RN stated (R15, R17 and R87) all have Dementia, so the mess probably doesn't bother them. It would bother me. I wouldn't want to sit and eat with that mess at my table. I would say yes, it is a dignity issue. On 9/24/24 at 8:40 am V24, CNA was seated next to R27, who was eating pureed food on her own. R27's milk and water were spilt and mixed with the unidentified pureed food and spread over R27's side of the dining table. R27's dining table, from the center forward and onto R27's chest, was covered in spilt food. R17, and R15, were seated in wheelchairs at the same table. V24, Certified Nursing Assistance confirmed the lack of R27's cleanliness, and the smeared food and beverages on the table while R15, and R17 were eating, is a dignity issues. The Resident's Right for People in Long-Term Care booklet dated November 2018 documents facility residents have the right to dignity and respect. Residents have the right to a clean and comfortable home-like environment. 32172 2.) R27's Medical Diagnoses List dated September 2024 documents R27 is diagnosed with Cerebral Palsy, Cerebral Infarction, Convulsions, Severe Intellectual Disabilities, and Dysphagia. R27's Physician Order Set dated September 2024 documents R27 is on a Regular Diet with Pureed Texture and Thin Liquids. R27's Minimum Data Set, dated dated dated [DATE] documents R27 is severely cognitively impaired and requires substantial/max assistance for eating. R27 loses liquid or solids from her mouth when eating or drinking. On 9/22/24 at 8:10 AM, during dining observation R27 was propelling her own wheelchair out of the dining room with her feet. R27' s face, shirt and pants had copious amounts of dried food-like substance adhering to all areas. On 9/23/24 at 12:20 PM R27 was eating lunch in the dining room. She was sitting at a table right in the middle of the dining room, facing all other residents and visitors. R27 was feeding herself. R27 had copious amounts of food on her chin and falling onto her clothing protector and shirt with each bite. Staff were walking around and serving and assisting other residents however no one offered to assist R27 in cleaning her mouth or changing out her heavily soiled clothing protector over the fifteen-minute period that it took for R27 to finish eating. R27 had food on her face the entire time.

Based on interview and record review, the facility failed to provide a resident with an Advance Beneficiary Notice (ABN), at the termination of a Medicare Part A covered stay, thereby nullifying the resident's right to continue therapy services at their own expense or decline therapy services. This failure affects one resident (R187) out of a sample of three reviewed for Beneficiary Notices on the sample of 28. Findings include: R187's Beneficiary Protection Notification Review (undated) documents R187 began a Medicare Part A covered stay at the facility on 11/14/23, with a last covered date of 3/17/24. There was no evidence that R187 had received and Advance Beneficiary Notice of her options to decline to receive further therapy, or to continue therapy services at R187's own expense. On 9/25/24 at 11:06 AM, V1, Administrator stated, We did not give (R187) an ABN notice but I'm not sure why because we gave them to other residents. The form entitled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) (2018), documents the SNFABN provides information to the beneficiary so that the resident can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. The Residents' Rights for Persons Residing in Supportive Living Facilities Pamphlet dated Revised 11/06, documents You can arrange and receive non-Medicaid covered services at your own expense.

Based on record review and interview, the facility failed to issue a written bed hold notice to a resident's family member when the resident was transferred to the hospital. This failure affects one of one resident (R2) reviewed for hospitalization on the sample list of 28. Findings include: 1. R2's Health Status Note 8/1/2024 11:59 pm documents the following: Note Text: Contacted 911 for emergency transfer at 2235 (11:35 pm) D/T (due to) c/o (complaint of) chest pain with SOB (shortness of breath), tachycardia (very fast heart rate) and low BP (blood pressure) noted. Res. (resident R2) left facility at this time via (local) EMS (emergency medical service) for (distant hospital) ER (emergency room ), all paperwork sent. On 9/25/24 at 9:10 am V1, Administrator stated V1 was the staff member responsible to send out the written bed hold notice to R2's family representatives. V1, confirmed she did not send a written bed hold notice to R2's family member in regard to R2's 8/1/24 hospital transfer. The facility BED HOLD GUARANTEE POLICY dated 8/1/17 (sic) documents the following: The resident and resident family or legal representative will be given the appropriate Notice of Bed Hold Policy at the time of discharge or therapeutic leave if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave.

Based on record review and interview, the facility failed to supervise a resident (R1) while toileting. This failure resulted in R1 falling off the toilet and sustaining a brain bleed with scalp laceration. R1 is one of three residents reviewed for falls. Findings include: The Cumulative [DIAGNOSES REDACTED]. R1's Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documents R1 as being moderately cognitively impaired and needing extensive assistance with transfers and toileting. This same MDS documents R1 needing staff assistance for stabilizing when moving from a seated to standing position, and from surface to surface. R1's Care Plan dated (current), documents R1 needing supervision for care, and has fall risk factors that require monitoring, and interventions to reduce potential for self-injury. Nursing Notes dated 9/26/18, document R1 being a new admit, and a returning admit after falling at home, and being a permanent resident in the facility. Fall Risk assessments from 9/26/18 to 1/3/19 document R1 being high risk for falls. A facility Situation Background Assessment Recommendation (SBAR) dated 2/19/19 at 6:10 pm, documents a fall with abrasion to left shoulder, contusion, and laceration to left side of scalp above ear, and a skin tear to elbow. The pain evaluation (above same report) documents R1 complaining of left hip, rib, and shoulder pain. The left leg is documented as being turned outward. The SBAR summary is documented as, R1 was lying on left side, bleeding from laceration to left side of scalp with hematoma forming, skin tears to left elbow, left hip and abrasion to left shoulder. Response from V3, Primary Care Physician, was an order to send R1 to the emergency room per ambulance. Local emergency room (ER) records dated 2/19/19 at 7:05 pm, document the following: (R1) presents to ER from (facility) w/co (with complaints of) fall. EMS (Emergency Medical Service) states (R1) was using the toilet and fell , hitting head, landing on left shoulder and hip. Computerized Tomography Brain/Head - Impression: Bilateral cerebral convexity acute subdural hemorrhages, 7 millimeters (mm) on the left and 4 mm on the right and 2.3 mm acute subdural hemorrhage at the anterior left falx. LET ([MEDICATION NAME]-[MEDICATION NAME]-tertracaine) was applied to the 2 centimeter laceration to the occipital area and staples were applied. This same record documents R1 being transferred to an area trauma hospital due to R1's subdural hemorrhages and use of Xarelto (blood thinner) for follow-up. On 3/7/19 at 11:05 am, V1(Administrator) stated R1 was sent to the local emergency room where a CT scan was done, and a brain bleed was diagnosed . R1 was then sent to the trauma hospital for follow-up. R1 was admitted with a brain bleed on 2/19/19 at the trauma hospital and readmitted to the facility on [DATE]. V1 stated previous to the fall, V4, Certified Nursing Assistant, had sat R1 on the toilet that had a riser on it. V4's glove had gotten soiled, and the sink and gloves are outside the bathroom in the residents' room. V4 left R1 on the toilet unattended and retrieved fresh gloves. V4 then heard R1 fall. V1 acknowledged V4 could have used the call light for assistance, but didn't. On 3/7/19 at 10:40 am, V3 Primary Care Physician stated R1's head injury was caused by the fall from the toilet, and R1 should not have been left unattended on the toilet by V4. V3 acknowledged V4 should have used the call light, or placed gloves in the bathroom prior to toileting. V3 stated had V4 been in the bathroom with R1, V4 could have prevented or lessened the fall, thereby preventing R1's major injury.

Based on record review, observation and interview, the facility delayed physician notification of chest pain for one of one resident (R1). This failure resulted in R1 sustaining a completed acute [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]), resulting in heart damage. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/1/16, the facility remains out of compliance at severity level two. The facility is in the process of evaluating the effectiveness of staff re-education on Pain Management, Physician Notification of Resident Change in Condition. In addition to monitoring the use of Care Paths (including Chest Pain and Shortness of Breath), Pain Flow Sheets, Shift Report Sheets, Nurses Notes, and ensuring proper nursing assessments with physician notification for are completed accurately and in a timely manner. Findings include: The Physician order [REDACTED]. The facility Admission Nursing Assessment for R1, dated 8/19/16 at 5:30 pm documents that R1 is alert and oriented, to person, place and time. The facility policy titled Notification for Change in Resident Condition or Status dated 7/1/12 directs facility staff to perform the following: The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etc) of changes in the resident's medical/mental condition and/or status .any symptom, sign or apparent discomfort that is: sudden in onset, a marked change unrelieved by measures already prescribed .A significant change in the resident's physical/emotional/mental condition. A need to alter a resident's medical treatment significantly abnormal complaints of pain The nurse supervisor/charge nurse will notify the DON (Director of Nursing), Physician and unless otherwise instructed by the resident, the resident's next of kin .when the resident has any of the afore mentioned situations . Facility Nurses Notes for R1 documents the following over a 21.5 hour time span: 08/19/16 at 9:00PM by E12 LPN (Licensed Practical Nurse: Patient complaint of chest pain HRRR (heart Rate and Rhythm Regular). Then states ' I just want to go back to the hospital. ' Reminded (R1) that (R1) could not just go back to hospital because she wanted to. On 08/20/16 at 3:00Am E3 LPN: has been awake most of shift. On 08/20/16 at 11:00 AM E13 RN (Registered Nurse): Patient complains of shortness of breath, patient very upset. On 08/20/16 at 3:30PM E14 RN: Complains of pain (upper abdomen) and chest. Resident vague when describing pain (stating) ' It just hurts. ' Will contact pharmacy for code to get (pain medication) out of narcotic box. On 08/20/16 at 3:55PM E14 RN: Resident stated pain still there. Gave two [MEDICATION NAME] 7.5milligram/325 milligram. On 08/20/16 at 6:20PM E14 RN documents that R1 is sitting up in bed alert and oriented times three, stating pain is not as bad but it ' it's still there (pointing to chest). E14 then documents the following: Upon more direct questioning resident finally stated ' when the pain comes it ' s like a squeezing pain that goes to both shoulders down both arms and into my back. ' On 08/20/16 at 6:30PM, 21.5 hours after R1 first complained of chest pain, E14 documents that Z2 (physician on call) was contacted and a new order was received to call 911 and send R1 to the emergency room for evaluation and treatment. On 8/24/16 at 1:55 pm E12 LPN (Licensed Practical Nurse), the employee responsible for R1's care the evening of 8/19/16, stated R1 did complain of chest pain, but R1 was vague about it and wasn't showing any facial grimacing. E12 stated that E12 did not ask the resident to rate the chest pain or at least I don't remember if I did. E12 stated that E12 did not give any pain medication because E12 did not have the code to get into the narcotic convenience box. E12 stated the pharmacy has the code and did not answer when E12 had called. E12 stated that R1 arrived from the hospital at approximately 5:30 pm. It was dinner time. E12 stated that E12 did not remember that after hours pharmacy needed to be called for the narcotic box code. E12 stated I had all these other residents to deal with. E12 acknowledged that R1's physician had not been called. On 8/24/16 at 11:15 am E3 LPN, the employee responsible for R1's care on the night shift of 8/19/16 (10:00 pm to 6:00 am), stated that E3 received report from E12 and E12 stated that R1 had complained of chest pain but R1 was a complainer. E3 stated that R1 also complained of chest pain to E3, but E3 did not have a code to get into the narcotic box for pain medication. E3 stated she did not know to call the after-hours pharmacy for the code. E3 acknowledged that R1's complaints of chest pain had not been charted and did not know why E3 didn't chart the chest pain. E3 stated she had passed on in report to the day nurse, E15 Registered Nurse about R1's chest pain. E3 acknowledged that R1's physician had not been notified of the chest pain or the unavailable pain medication. On 8/25/16 at 1:35 pm E13 RN, the employee responsible for R1's care the day of 8/20/16, acknowledged that report about R1's chest pain through the shifts had been reported to E13. E13 stated that R1 had complained of chest pain and shortness of breath. E13 stated (R1) was very upset and anxious. E13 stated that E13 was told there were no pain medications in the building for R1. E13 stated I didn't look in the narcotic box. E13 stated that report of R1's chest pain and shortness of breath was passed on in report to the evening Registered Nurse, E14. E13 acknowledged that R1's chest pain and the unavailability of pain medication had not been reported to R1's physician. On 8/25/16 at 2:55 pm E14 RN, the employee responsible for R1's care the evening of 8/20/16, stated that report was received from E13 about R1's chest pain and anxiousness and agitation. E14 stated that R1 was assessed after report and narcotic count was finished. E14 stated on assessment R1 looked exhausted. R1 was asked about pain and R1 stated I hurt and pointed to R1's chest. R1 stated again I hurt. E14 stated that the physician was not called because E14 thought it was referred pain from R1's right hip. E14 stated R1 was given pain medication after calling pharmacy for code access. E14 stated later E14 checked on R1 and R1 was able to better describe the chest pain and the physician (Z2) was notified and R1 was sent to the emergency room A facility report titled Nursing Transfer/Discharge assessment dated [DATE] at 6:35 pm documents that R1 was transferred to the local hospital. R1 ' s Hospital emergency room records dated 8/20/16 at 7:11 pm documents the following: History of Present Illness .The patient (R1)reports onset of symptoms 30 hours prior to arrival .the patient reports that she received pain medication but was not evaluated while she was having chest pain. emergency room Course Notes document that R1's tests are consistent with an Acute [MEDICAL CONDITION] Infarction. The Notes continue (R1) remained pain-free through numerous evaluations and (R1's) symptoms are consistent unfortunately with a completed [MEDICAL CONDITION] infarction. The same Hospital Records dated 8/21/16 document that R1 developed onset of chest pain again and was sent to a specialized hospital per ambulance. Specialized Hospital Reports dated 8/21/16 document a procedure of a Cardiac Catheterization and findings are documented as R1 having a 100% blockage of the Right Coronary Artery with stent placement. On 8/24/16 at 1:35 pm Z1, Primary Care Physician for R1, stated that the expectation of facility staff would be to notify Z1 if a resident is having chest pain or discomfort. Z1 stated Absolutely I should have been notified immediately of (R1's) chest pain. On 8/25/16 at 8:00 am R1 was sitting up supine in the hospital bed. R1 was alert and oriented to person, place and time. R1 was aware of R1's surroundings and was able to discuss the sequence of events that led to hospitalization . R1 stated that R1 had started having chest pain just after arriving at the long term care facility around 5:30 pm. R1 stated the nurses were told about it and R1 felt like they were ignoring R1. R1 stated my call light wasn't even working and I had to yell for help. I was hot and sweaty and wanted to go to the hospital. The nurse E12 told me very hatefully that just because I wanted to go to the hospital did not mean I could go. R1 stated that E12 told R1 that E12 had other residents to take care of. R1 stated that E12 shut the door and came back later and fixed the call light. R1 stated that R1 did not receive any pain medication until the next day in the afternoon. R1 stated that R1 did not sleep all night and was up up praying that R1 would get out of the facility alive. R1 was tearful at this time and stated I was scared for my life. It was a nightmare to me. I knew something was going on with my heart but no one would listen. They made me feel like I was crazy and didn't know what I was talking about. Like I had dementia and I don't. I'm just glad to be out of there and alive. On 8/25/16 at 9:40 am Z3, emergency room Physician stated that when R1 arrived in the emergency room R1's tests were consistent with a completed acute [MEDICAL CONDITION] infarction (MI) over a 24 hour period. Z3 stated that the delay in transport from the facility certainly caused a delay in intervention and morbidity (death) could have been a result. Z3 stated R1 certainly has heart muscle damage from the completed MI. Z3 stated I believe (R1) had a horrific experience at that facility. On 8/31/16 an Immediate Jeopardy was identified. The immediate jeopardy situation began on 8/19/16 when the facility delayed physician notification of chest pain for R1 resulting in R1 sustaining heart damage. E1 was notified of the Immediate Jeopardy on 8/31/16 at 1:25pm. The surveyor was able to confirm through record review and interview that the facility took the following actions to remove the immediacy: 1. Nurses will or have been in-serviced by a Corporate Administrator, the Director of Nursing, and the Administrator of the facility on: Pain Prevention Policy (including assessment and prevention), obtaining controlled pain medication and medications after hours from the contingency box, notification to physician when medications are not readily accessible; Physician Notification Policy of a resident's change in condition; Care Cards and Care Paths including chest pain and shortness of breath; Physician order [REDACTED]. Corporate Administrator completed on 8/31/16.

Based on record review and interview, the facility neglected to follow facility policy on Pain Management/administration and Notification of a Resident's Change in Condition. The facility also neglected to follow their policy on physician notification and notify the physician of a resident's (R1) change of condition for one of one resident (R1) reviewed for pain in the sample of three. This failure resulted in R1 going over 21 hours without pain intervention and delayed physician notification of chest pain resulting in R1 suffering a [MEDICAL CONDITION] infarction with heart damage. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/1/16, the facility remains out of compliance at severity level two. The facility is in the process of evaluating the effectiveness of staff re-education on Pain Management, Physician Notification of Resident Change in Condition. In addition to monitoring the use of Care Paths (including Chest Pain and Shortness of Breath), Pain Flow Sheets, Shift Report Sheets, Nurses Notes, and ensuring proper nursing assessments with physician notification for are completed accurately and in a timely manner. Findings include: The facility policy titled Pain Prevention and Treatment dated January 2010 directs facility staff to perform the following: To assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems . Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nursing notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The facility policy titled Notification for Change in Resident Condition or Status dated 7/1/12 directs facility staff to perform the following: The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etc) of changes in the resident's medical/mental condition and/or status .any symptom, sign or apparent discomfort that is: sudden in onset, a marked change unrelieved by measures already prescribed .A significant change in the resident's physical/emotional/mental condition. A need to alter a resident's medical treatment significantly abnormal complaints of pain The nurse supervisor/charge nurse will notify the DON (Director of Nursing), Physician and unless otherwise instructed by the resident, the resident's next of kin .when the resident has any of the afore mentioned situations . R1's Hospital transfer orders dated 8/19/16 direct facility staff to notify the physician of unrelieved chest pain. The Physician order [REDACTED]. The facility Admission Nursing Assessment for R1, dated 8/19/16 at 5:30 pm documents that R1 is alert and oriented, to person, place and time. R1's nurses notes document the following: On 08/19/16 R1 complained of chest pain to E12 LPN. No pain interventions/medications were documented. On 08/20/16 at 3:00AM E3 LPN documented that R1 had been awake most of the night. There was no documentation of any pain assessment. On 08/20/16 at 11:00 E13 documented that R1 complained of being short of breath and was very upset. R1 ' s clinical record contains no documentation of any intervention. On 08/20/16 at 3:30PM E14 RN documented that R1 complained of pain in the upper abdomen and chest stating it just hurts. At 3:55PM E14 documents R1 was given [MEDICATION NAME]. At 6:20PM E14 documents that R1 was sitting up in bed and stated the pain was still there. At 6:30PM E14 notified the physician who gave orders to call 911 and transfer R1 to the emergency room . A facility report titled Nursing Transfer/Discharge assessment dated [DATE] at 6:35 pm documents that R1 was transferred to the local hospital. On 8/24/16 at 1:55 pm E12 LPN (Licensed Practical Nurse), the employee responsible for R1's care the evening of 8/19/16, stated R1 did complain of chest pain, but R1 was vague about it and wasn't showing any facial grimacing. E12 stated that E12 did not ask the resident to rate the chest pain or at least I don't remember if I did. E12 stated that E12 did not give any pain medication because E12 did not have the code to get into the narcotic convenience box. E12 stated the pharmacy has the code and did not answer when E12 had called. E12 stated that R1 arrived from the hospital at approximately 5:30 pm. It was dinner time. E12 stated that E12 did not remember that after hours pharmacy needed to be called for the narcotic box code. E12 stated I had all these other residents to deal with. E12 acknowledged that facility policy had not been followed and that E12 had knowledge of the policy on pain and physician notification. On 8/24/16 at 11:15 am E3 LPN, the employee responsible for R1's care on the night shift of 8/19/16 (10:00 pm to 6:00 am), stated that E3 had knowledge of R1's complaints of chest pain from the previous nurse (E12) but E12 had also told E3 that R1 was a complainer. E3 stated that R1 did complain to E3 about chest pain during the night but did not have access to the narcotic box. E3 acknowledged awareness of the facility policies on pain and physician notification. E3 acknowledged that R1's complaints of chest pain had not been treated with pain medication or charted in the Medical Record. E3 stated R1's physician had not been notified. On 8/25/16 at 1:35 pm E13 RN, the employee responsible for R1's care the day of 8/20/16, acknowledged that R1 had complained of chest pain and shortness of breath. E13 stated (R1) was very upset and anxious. E13 stated that E13 was told there were no pain medications in the building for R1. E13 stated I didn't look in the narcotic box. E13 stated that report of R1's chest pain and shortness of breath was passed on in report to the evening E14 RN. E13 acknowledged that R1's physician had not been notified of R1's chest pain or pain medication. On 8/25/16 at 2:55 pm E14 RN, the employee responsible for R1's care the evening of 8/20/16, stated that E14 had received in report R1's complaints of chest pain, agitation and anxiousness. E14 stated R1 was assessed after report and narcotics were counted. E14 stated that on assessment R1 looked exhausted. R1 was asked about pain and R1 stated that R1's chest hurt. E14 stated R1 was given pain medication after calling pharmacy for code access. E14 stated that R1 was checked on later and after prompting, was able to describe the pain better. (Z2) was notified and R1 was sent to the emergency room . R1's emergency room hospital records dated 8/20/16 at 7:11 pm documents the following: History of Present Illness .The patient (R1)reports onset of symptoms 30 hours prior to arrival .the patient reports that she received pain medication but was not evaluated while she was having chest pain. emergency room reports document that R1's tests results are consistent with an Acute [MEDICAL CONDITION] Infarction. Z3, Hospital Physician documents R1 remained pain-free through numerous evaluations and her symptoms are consistent, unfortunately with a completed [MEDICAL CONDITION] infarction. Hospital Records dated 8/21/16 document that R1 developed onset of chest pain again and was sent to a specialized hospital per ambulance. Specialized Hospital Reports dated 8/21/16 document that R1 underwent a Cardiac Catheterization and was found to have 100% blockage in the Right Coronary Artery. On 8/24/16 at 1:35 pm Z1, Primary Care Physician stated that the expectation of facility staff would be to notify Z1 if a resident is having chest pain or discomfort. Z1 stated Absolutely I should have been notified immediately of (R1's) chest pain. On 8/2/5/16 at 9:40 am Z3, emergency room Physician stated that when R1 arrived in the emergency room , R1's tests showed indication of a completed [MEDICAL CONDITION] infarction (MI) over a 24 hour period. Z3 stated that the delay in transport from the facility certainly caused a delay in intervention and morbidity (death) could have been a result. Z3 stated R1 certainly has heart muscle damage from the completed MI. Z3 stated I believe (R1) had a horrific experience at that facility. On 8/25/16 at 8:00 am R1 was sitting up supine in the hospital bed. R1 was alert and oriented to person, place and time. R1 was aware of R1's surroundings and was able to discuss the sequence of events that led to R1's hospitalization . R1 stated that R1 had started having chest pain just after arriving at the facility. R1 stated the nurses were told about it and R1 felt like they were ignoring R1. R1 stated my call light wasn't even working and I had to yell for help. I was hot and sweaty and wanted to go to the hospital. The nurse E12 told me very hatefully that just because I wanted to go to the hospital did not mean I could go. R1 stated that E12 told R1 that E12 had other residents to take care of. R1 stated that E12 shut the door and came back later and fixed the call light. R1 stated that R1 did not receive any pain medication until the next day in the afternoon. R1 stated that R1 did not sleep all night and was up up praying that R1 would get out of the facility alive. R1 was tearful at this time and stated I was scared for my life. It was a nightmare to me. I knew something was going on with my heart but no one would listen. They made me feel like I was crazy and didn't know what I was talking about. Like I had dementia and I don't. I'm just glad to be out of there and alive. On 8/31/16 an Immediate Jeopardy was identified. The immediate jeopardy situation began on 8/19/16 when the facility neglected to follow facility policy on Pain Management/administration and Notification of a Resident's Change in Condition resulting in R1 going over 21 hours without pain intervention and delayed physician notification of chest pain resulting in R1 suffering a [MEDICAL CONDITION] infarction with heart damage. E1 was notified of the Immediate Jeopardy on 8/31/16 at 1:25pm. The surveyor was able to confirm through record review and interview that the facility took the following actions to remove the immediacy: 1. Nurses will or have been in-serviced by a Corporate Administrator, the Director of Nursing, and the Administrator of the facility on: Pain Prevention Policy (including assessment and prevention), obtaining controlled pain medication and medications after hours from the contingency box, notification to physician when medications are not readily accessible; Physician Notification Policy of a resident's change in condition; Care Cards and Care Paths including chest pain and shortness of breath; Physician order [REDACTED]. Corporate Administrator completed on 8/31/16.

Based on record review, observation and interview, the facility failed to address complaints of chest pain for one (R1) of three residents reviewed for pain in the sample of three. This failure resulted in R1's chest pain going untreated for [REDACTED]. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/1/16, the facility remains out of compliance at severity level two. The facility is in the process of evaluating the effectiveness of staff re-education on Pain Management, Physician Notification of Resident Change in Condition. In addition to monitoring the use of Care Paths (including Chest Pain and Shortness of Breath), Pain Flow Sheets, Shift Report Sheets, Nurses Notes, and ensuring proper nursing assessments with physician notification for are completed accurately and in a timely manner. Findings include: Discharge Orders dated 8/19/16 at 1:37 pm from the local hospital document that R1 is status [REDACTED]. The facility Physician order [REDACTED]. The facility policy titled Pain Prevention and Treatment dated January 2010 directs facility staff to perform the following: To assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems . Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nursing notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The facility policy titled Notification for Change in Resident Condition or Status dated 7/1/12 directs facility staff to perform the following: The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etc) of changes in the resident's medical/mental condition and/or status .any symptom, sign or apparent discomfort that is: sudden in onset, a marked change unrelieved by measures already prescribed abnormal complaints of pain .when the resident has any of the afore mentioned situations . The facility Admission Nursing Assessment for R1, dated 8/19/16 documents that R1 is alert and oriented, to person, place and time. The Nursing Note dated 8/19/16 at 9:00 pm by E12 Licensed Practical Nurse documents . complaints of Chest pain, HRRR (Heart Rate and Rhythm Regular). Then states I just want to go back to the hospital. Reminded (R1), (R1) could not just go back to hospital because she wanted to. R1's Pain assessment dated [DATE] (no time documented), documents that R1 has no pain. R1's Pain Management Flow Sheet has no documentation during R1's time at the facility. At 3:00 am on 8/20/16 Licensed Practical Nurse, E3 documents in the Nursing Notes has been awake most of shift. Nursing Notes 8/20/16 at 11:00 am by E13, Registered Nurse documents Patient complains of shortness of breath, patient very upset Nursing Notes dated 8/20/16 at 3:30 pm by E14, Registered Nurse documents Complains of pain (upper abdomen) and chest. Resident vague when describing pain 'It just hurts' will contact pharmacy for code to get (pain medication) out of locked (narcotic) box. E14 documents at 3:55 pm in the Nursing Notes Resident stated pain still there gave two 7.5 mg /325 mg ([MEDICATION NAME] with [MEDICATION NAME]). E14 documents in the Nursing Notes at 6:20 pm that R1 is sitting up in bed alert and oriented times three, stating pain not as bad but it is still there (pointing to R1's chest). E14 documents .Upon more direct questioning resident (R1) finally stated 'when the pain comes it's like a squeezing pain that goes to both shoulders down both arms and into my back.' Nursing Notes document that at 6:30 pm E14 contacted Z2, on call physician for Z1, Primary care Physician. A new order was received to call 911 and send (R1) to the emergency room for evaluation and treatment. On 8/24/16 at 1:55 pm E12 LPN (Licensed Practical Nurse), the employee responsible for R1's care the evening of 8/19/16, stated R1 did complain of chest pain, but R1 was vague about it and wasn't showing any facial grimacing. E12 stated that E12 did not ask the resident to rate the chest pain or at least I don't remember if I did. E12 stated that E12 did not give any pain medication because E12 did not have the code to get into the narcotic convenience box. E12 stated the pharmacy has the code and did not answer when E12 had called. E12 stated that R1 arrived from the hospital at approximately 5:30 pm. It was dinner time. E12 stated that E12 did not remember that after hours pharmacy needed to be called for the narcotic box code. E12 stated I had all these other residents to deal with. E12 acknowledged that R1's physician had not been called about the chest pain or lack of medication. On 8/24/16 at 11:15 am E3 LPN, the employee responsible for R1's care on the night shift of 8/19/16 (10:00 pm to 6:00 am), stated that E3 received report from E12 and E12 stated that R1 had complained of chest pain but R1 was a complainer. E3 stated that R1 also complained of chest pain to E3, but E3 did not have a code to get into the narcotic box for pain medication. E3 stated she did not know to call the after hours pharmacy for the code. E3 acknowledged that R1's complaints of chest pain had not been charted and did not know why E3 didn't chart the chest pain. E3 stated she had passed on in report to the day nurse, E13 Registered Nurse about R1's chest pain. E3 acknowledged that R1's physician had not been notified about the chest pain or the lack of pain medication availability. On 8/25/16 at 1:35 pm E13 RN, the employee responsible for R1's care the day of 8/20/16, acknowledged that report about R1's chest pain through the shifts had been reported to E13. E13 stated that R1 had complained of chest pain and shortness of breath. E13 stated (R1) was very upset and anxious. E13 stated that E13 was told there were no pain medications in the building for R1. E13 stated I didn't look in the narcotic box. E13 stated that report of R1's chest pain and shortness of breath was passed on in report to the evening nurse, E14 Registered Nurse. E13 acknowledged that R1's physician had not been called about R1's chest pain or pain medication. On 8/25/16 at 2:55 pm E14 RN, the employee responsible for R1's care the evening of 8/20/16, stated that report was given from E13 about R1's chest pain and anxiousness and agitation. E14 stated that R1 was assessed after report and narcotic count was finished. E14 stated on assessment R1 looked exhausted. R1 was asked about pain and R1 stated I hurt and pointed to R1's chest. R1 stated again I hurt. E14 stated that the physician was not called because E14 thought it was referred pain from R1's right hip. E14 stated R1 was given pain medication after calling pharmacy for code access. E14 stated later E14 checked on R1 and R1 was able to better describe the chest pain and the physician (Z2) was notified and R1 was sent to the emergency room . A facility report titled Nursing Transfer/Discharge assessment dated [DATE] at 6:35 pm documents that R1 was transferred to the local hospital. R1's emergency room hospital records dated 8/20/16 at 7:11 pm documents the following: History of Present Illness .The patient (R1)reports onset of symptoms 30 hours prior to arrival .the patient reports that she received pain medication but was not evaluated while she was having chest pain . emergency room Course .The patient's (R1) 12-Lead (EKG) Electrical Cardiogram demonstrates .This is consistent with ST elevation Acute [MEDICAL CONDITION] Infarction (STEMI). The patient (R1) was started on a [MEDICATION NAME] drip, was medicated with 4 (four) 81 milligrams chewable aspirins. Troponin was elevated .the patient (R1) remained pain-free through numerous evaluations and her symptoms are consistent unfortunately with a completed [MEDICAL CONDITION] infarction. Hospital Records dated 8/21/16 document that R1 developed onset of chest pain again and was sent to a specialized hospital per ambulance. Specialized Hospital Reports dated 8/21/16 document Cardiac Catherization: Left Heart Cath and Coronary [MEDICATION NAME], Left Ventriculography, Temporary Pacemaker with findings of Right Coronary Artery Blockage of 100%, stents to mid and distal. On 8/24/16 at 1:35 pm Z1, Primary Care Physician stated that the expectation of facility staff would be to notify Z1 if a resident is having chest pain or discomfort. Z1 stated Absolutely I should have been notified immediately of (R1's) chest pain. On 8/25/16 at 9:40 am Z3, emergency room Physician stated that when R1 arrived in the emergency room , R1's Troponin levels were high and R1 had ST elevation on the EKG an indication of a completed [MEDICAL CONDITION] infarction (MI) over a 24 hour period. Z3 stated that the delay in transport from the facility certainly caused a delay in intervention and morbidity (death) could have been a result. Z3 stated R1 certainly has heart muscle damage from the completed MI. Z3 stated I believe (R1) had a horrific experience at that facility. On 8/25/16 at 8:00 am R1 was sitting up supine in the hospital bed. R1 was alert and oriented to person, place and time. R1 was aware of R1's surroundings and was able to discuss the sequence of events that led to hospitalization . R1 stated that R1 had started having chest pain just after arriving at the long term care facility. R1 stated the nurses were told about it and R1 felt like they were ignoring R1. R1 stated my call light wasn't even working and I had to yell for help. I was hot and sweaty and wanted to go to the hospital. The nurse E12 told me very hatefully that just because I wanted to go to the hospital did not mean I could go. R1 stated that E12 told R1 that E12 had other residents to take care of. R1 stated that E12 shut the door and came back later and fixed the call light. R1 stated that R1 did not receive any pain medication until the next day in the afternoon. R1 stated that R1 did not sleep all night and was up up praying that R1 would get out of the facility alive. R1 was tearful at this time and stated I was scared for my life. It was a nightmare to me. I knew something was going on with my heart but no one would listen. They made me feel like I was crazy and didn't know what I was talking about. Like I had dementia and I don't. I'm just glad to be out of there and alive. On 8/31/16 an Immediate Jeopardy was identified. The immediate jeopardy situation began on 8/19/16 when the facility failed to assess and treat R1 ' s complaints of chest pain for over 21 hours resulting in a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]) with heart damage. E1 was notified of the Immediate Jeopardy on 8/31/16 at 1:25pm. The surveyor was able to confirm through record review and interview that the facility took the following actions to remove the immediacy: 1. Nurses will or have been in-serviced by a Corporate Administrator, the Director of Nursing, and the Administrator of the facility on: Pain Prevention Policy (including assessment and prevention), obtaining controlled pain medication and medications after hours from the contingency box, notification to physician when medications are not readily accessible; Physician Notification Policy of a resident's change in condition; Care Cards and Care Paths including chest pain and shortness of breath; Physician order [REDACTED]. Corporate Administrator completed on 8/31/16.

Based on observation,interview and record review, the facility failed to implement pressure relieving interventions for one of three residents (R1) reviewed for pressure ulcers in a sample of 10. These failures have resulted in R1, known to be at high skin risk, developing an avoidable pressure ulcer on his left heel. Findings include: The Physician order [REDACTED]. The facility's document titled "Braden Scale" skin assessment tool and pressure risk assessment, dated 10/26/12 shows a score of 16 for R1. The legend on the Braden Scale for scores of 16 and higher states resident is at high risk for skin breakdown and pressure ulcers. The facility form titled "Weekly Wound Tracking" and dated 11/8/12 documents a pressure ulcer on R1's left heel as a stage II and measuring 8 centimeters by 4 centimeters and a pressure ulcer located on R1's right lower buttocks, measuring 1.3 centimeters by 0.5 centimeters as a stage II, with both pressure ulcers documented as being acquired in the facility. This same titled form dated 12/17/12, documents the left heel ulcer still present and right lower buttocks ulcer still present. R1's Care Plan dated 11/26/12 states to "offload pressure to areas of concern." The facility's document titled "Quality Reporting Form" and dated 11/9/12 documents under summary of event and any recommendations taken - "blister area on left heel - heel protectors, skin prep every shift, float heels when in bed; check fit of shoes." On 12/18/12 R1 was in his bed with his shoes off and his feet did not have heel protectors on and his feet were not floated at the following times: 1:30 pm, 2:30 pm and 3:30 pm. On 12/19/12 R1 was lying in bed without heel protection and his heels were not floated at the following times: 10:35 am, 11:30 am, 1:30 pm and 2:30 pm. On 12/20 at 10:30 am R1 was lying in bed without heel protection and his heels were not floated. On each occasion R1's heels were in direct contact with the surface of the standard scoop style mattress. On 12/20/12 at 10:33 am E2 stated "that was my fault, I put him (R1) to bed and I forgot to float his heels."

A. Based on record review and interview the facility failed to provide the supervision and stand by assistance required for R2, one resident reviewed for falls in a total sample of four. Failure to provide stand by assistance for R2 resulted in R2 falling and sustaining a laceration requiring 14 sutures. Findings include: The physician's orders [REDACTED]. The Minimum Data Set (MDS) dated ,[DATE]/ 2011 states R2 is severely impaired in cognitive skills for daily decision making and is totally dependent on staff for all activities of daily living to include toileting and transfers. R2 requires two plus persons physical assist for all needs. The MDS states that R2's balance is not steady and R2 is only able to stabilize with human assistance, and has upper and lower extremities impairment on both sides. The Nurses Notes dated 3/29/11 for R2 at 6:45 AM states, R2 had been transferred to the bedside commode when E6, CNA (Certified Nurse Assistant) turned to grab clothes off the wheelchair and E6 heard a noise and found R2 on the floor laying on R2's right side. E6 noticed blood on the floor near R2's head. The Nurses Notes continues to state R2 had a laceration on the right side of the forehead that measured 7 cm (centimeter) by 5 cm. R2 was transferred by ambulance to the emergency room for evaluation. The Nurses Notes dated 3/29/11 at 8:30 AM states that R2 returned to the facility and had 14 sutures from mid forehead to right side of the forehead. The Hospital report form titled "Patient Visit Information" dated 3/29/11 under the section titled Diagnosis: [REDACTED]. Closed Head Injury. Complex Forehead Laceration..... Follow up with physician for suture removal." R2's care plan dated 9/17/10 under the section titled "Falls" states as an intervention for R2 "...... provide stand by or balance support as needed." E1,Administrator confirmed on 9/28/11 at 3:45 PM that E6 turned away from R2 and R2 fell from the bedside commode, and received sutures for the laceration. B. Based on observation, interview, and record review the facility failed to ensure that electro-mechanical medical devices were not powered by power strips and extension cords . Medical devices including electric beds, oxygen concentrators, nebulizers and C-pap (continuous positive airway pressure) machines were plugged into the extension cord power strip in R9's bedroom. Extension cords were found to power an electro-mechanical medical device in R10's bedroom. Extension cords inappropriately used in series was found in R11's bedroom. R9, R10, and R11 are 3 supplemental residents. This failure has the potential to affect all 36 residents residing in the 25 rooms of the facility. Findings include: The Facility tour on 9/27/11at 10:15 AM showed the usage of electrical extension cords and power strips in multiple resident rooms. Each room had the use of a power strip with several electrical items being plugged into the strip. The strip was then plugged into the electrical outlet in the wall. On 9-27-11 at 10:25 a.m. R9 had the following items plugged into the power strip that was located at the head of the first bed upon entering the room: Oxygen concentrator, electric bed, floatation mattress and C-pap machine. On 9-27-11 at 10:20 a.m. R10 had an electric medication nebulizer breathing machine plugged into an extension cord power strip. On 9-27-11 at 10:40 AM R11 had two extension cords being used . One extension cord was plugged into another extension cord (serially) and was stretched across the wall and plugged into the electrical outlet. E1, Administrator on 9/27/11 at 12:50 PM stated she was not aware that power strips and electrical extension cords could not be used and requested where this information could be found. E1 stated she was not aware of any facility policies addressing the use of extension cords . E1 was directed to review the State Operation Manual Appendix PP dated 1/7/11 under F323 section titled "Resident Risks and Environmental Hazards" Section titled "Electrical Safety" which states "...Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for computer, monitor, and a printer. Power strips are not designed to be used with medical devices in patient care areas..." E1, Administrator on 9/27/11 at 12:50 PM confirmed power strips were being used in the resident rooms, and R9 did have the medical devices plugged into a power strip.