Every finding on record at Grove Health & Rehab CTR, The

Based on observation, interview and record review, the facility failed to ensure that a newly identified injury was fully assessed, documented, and investigated for one of three residents (R2) reviewed for injuries in the sample list of 20.R2's Face Sheet documented a re-admission date of 4/30/26 with diagnoses that included Alzheimer's Disease, Neurocognitive Disorder with Lewy Bodies, Type 2 Diabetes Mellitus, Aphagia and Unspecified Protein Calorie Malnutrition.R2's Minimum Data Set (MDS) dated [DATE] does not document a Brief Interview for Mental Status (BIMS) score due to R2 being rarely/never understood.On 4/3/2026 at 2:00PM, Nursing progress note documents R2 being sent to the local emergency department for evaluation related to foul smelling and dark colored gastric residual.On 4/5/2026 at 12:38 PM, re-admission Nursing Assessment completed by V24 Licensed Practical Nurse (LPN) documents R2 returned from the hospital. The re-admission Nursing Assessment goes on to document under the Skin section of assessment, that R2's skin is clear, intact-no skin issues. No further progress notes noted in R2's chart regarding return from the hospital.On 4/6/2026 at 4:16PM, order placed in R2's chart by V25 Wound Nurse to cleanse right arm blisters with wound cleanser apply (sterile, non-adherent gauze impregnated with petrolatum and bismuth) gauze, apply gauze and wrap qd (every day) and prn (as needed). R2's Nurses Note dated 4/30/26 documents measurements of a wound on the right inner forearm as 1.8 cm (centimeters) x (by) 4.3 cm x 0.2 cm. This note documents this is a new wound acquired in house. No correlating progress notes or skin assessment regarding blister to R2's right arm noted in R2's chart.On 7/27/26 at 10:23AM, V4 R2's family stated R2 had an area on R2's wrist that appeared to be a burn.On 7/28/26 at 10:39 AM, R2 had a scar on the right wrist that was bright pink with a small, scabbed area in the center. On 7/28/2026 at 11:20 AM, V3 Assistant Director of Nursing confirmed that an incident report or investigation was not conducted for R2's injury of unknown origin.On 7/28/2026 at 2:00PM, V2 Director of Nursing confirmed that an incident report or investigation was not conducted for R2's injury of unknown origin.On 7/28/2026 between 1:54PM and 2:26PM, three separate attempts were made to contact V24 with no contact made.On 7/28/2026 between 2:26 PM and 3:00PM, two separate attempts were made to contact V25 with no contact made.The Facilities Accidents and Incidents policy initiated on 07/01/2023 states All accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions

Based on observation, interview, and record review, the facility failed to prevent an accident during a full mechanical lift transfer in 1 of 5 residents (R3) reviewed for accident hazards in the sample of 9. This failure resulted in R3 sustaining fractures to the left distal fibula, right distal tibia, and right distal fibula.Findings Include:On 4/1/26 at 9:45 AM, R3 was observed in her wheelchair with bilateral ankle contractures and a right knee contracture. A full mechanical lift transfer was observed with V16, CNA (Certified Nursing Assistant), and V17, CNA, without incident. R3's Face Sheet, undated, documents R3 has the following diagnoses, in part: Dementia, Contractures of the Right Knee, Left Knee, Right Ankle and Left Ankle, Fracture of the Right Tibia and Left Fibula, History of Falling, and Disorders of Bone Density and Structure.R3's MDS (Minimum Data Set), dated 3/4/25, documents R3 has severe cognitive impairment and is dependent on staff for ADLs (Activities of Daily Living). R3's Care Plan, dated 6/23/24, documents R3 has an ADL self-care performance deficit and requires a full mechanical lift with two staff for transfers. R3's Care Plan, dated 5/27/25, documents R3 has an alteration in musculoskeletal status related to a fracture of the right distal tibia, the left distal fibula, and osteopenia.R3's Progress Note, dated 5/23/25 at 9:29 PM, documents the following: Resident's leg caught on the (full mechanical lift) during transfer causing 3 skin tears and [NAME] scratches to right shin, area cleansed, and TAO (Triple Antibiotic Ointment) applied, MD (Medical Doctor) updated per fax, husband updated per phone call, on-call updated.R3's Progress Note, dated 5/26/25 4:09 AM, documents the following: CNA reported when changing resident's socks, light blue bruising near resident's ankle but more on top of foot with bruising scattered down to right great toe, slight swelling in this area, tender to touch, noted leg was caught on (full mechanical lift) causing skin tears on same leg, orders to obtain 3 view x-ray of foot to rule out injury, (portable x-ray company) called, message to POA (Power of Attorney), (V18, R3's Physician) agreed.R3's Progress Note, dated 5/27/25 at 10:15 AM, documents the following: X-ray results received, Impression: Distal tibial fracture. Results sent to (V18) for review.R3's Progress Note, dated 5/27/25 at 10:38 AM, documents the following: Orders received from (V18) to send to ER (Emergency Room) for evaluation and treatment. Call placed to POA, made aware of orders and portable x-ray results showing distal tibial fracture.R3's Progress Note, dated 5/27/25 at 3:39 PM, documents the following: Resident returned to facility at this time from (local) ER. Was evaluated by (V19, Orthopedic Surgeon). Orders for soft splints to BLE (Bilateral Lower Extremities), (Acetaminophen or Motrin) for pain, and follow up with (V19) in 10-14 days. Dx (Diagnosis): Left distal fibula fracture, and right distal tibia fibula fracture.R3's Hospital Records, dated 5/27/25, documents, in part, the following: R3 presents with an injury to the right distal tibia, non-ambulatory, requires a full mechanical lift in the nursing home and is on comfort care. Nursing home reportedly hit her leg while using the lift recently. X-ray results showed a distal tibial fracture. She presents for further treatment. 5/27/25 - X-ray of the right ankle - mildly displaced transverse fractures through the distal tibial and fibular shafts. There is adjacent soft tissue swelling. Bones are osteopenic. X-Ray 5/27/26 - Tibia/Fibula - acute left distal fibular shaft fracture, possible acute right distal tibial shaft fracture, consider right ankle work up for further workup. Impression and Plan: Left distal fibula fracture, right distal tibial/fibula fracture, soft splints to bilateral lower legs, follow up with orthopedic physician in 10-14 days. The Facility Fall Investigation Final Report, undated, documents the following, in part: Date and time of incident 5/23/25 at 8:00 PM, transfer with injury, left distal fibular shaft fracture and right distal tibial shaft fracture. After comprehensive clinical investigation, staff was transferring resident via full body lift, when resident was raising from w/c wheelchair), resident's leg noted to hit the motor of the (full mechanical lift) machine, resident lowered back into chair, repositioned then lifted back into bed. Nurse assessed, did have small abrasions noted, no signs of pain at this time. X-ray ordered when swelling and bruising noted. Orthopedic appointment scheduled. Soft splints applied. In servicing initiated, and direct supervision and teaching given to CNA that was involved.The Facility Fall Investigation, undated, documents the following: V6, Former Licensed Practical Nurse (LPN), CNAs were transferring resident with full mechanical lift, resident hit shin on machine, CNA got resident to bed and notified of new skin tears. V7, CNA, transferring resident with full mechanical lift, when raising resident up, residents' legs were crossed, how they always are, hit shin on machine because the foot board was not in place, and machine was closer than normal. They lowered her back into her chair, repositioned the wheelchair and then using the full mechanical lift, placed her in bed and notified V6,. Former LPN. The Agency Aide (Unnamed) was unreachable. In-servicing on proper transfers started. There is a picture included showing R3's legs without the foot board on, R3's right lower leg lying on top of the left lower leg due to contractures and being too close to the enclosed motor of the lift, that when the lift was raised would have caused R3's lower legs to hit the motor. On 4/1/26 at 11:05 AM, V7, CNA, stated she was the CNA that transferred R3 in May 2025, during the transfer she accidentally hit R3's shin on the lift causing a skin tear. V7 stated she reported it to V6, Former LPN, who assessed R3 and treated the skin tear. V7 stated she did not work with R3 again until 2 days later, when she noticed R3's leg was bruised and she reported it to the nurse on duty, R3 was sent to the hospital and had a fracture in her leg. V7 stated an agency CNA, unable to recall her name, was in the room with her during the transfer. V7 stated the former DON (Director of Nurses), had her show him how she transferred R3 to try and find out how it happened. On 3/31/26 at 8:15 AM, V1, Administrator, stated he was not the Administrator at the time R3's fractures occurred and was unable to provide any details of the event. On 4/2/26 at 9:10 AM, R18's Physician stated he remembers there was an incident with R3 and the full mechanical lift but is unable to recall any details. V18 stated he would expect the facility staff to position the residents accordingly to prevent accidents or injuries while utilizing the mechanical lifts.The Transfer Policy, dated 7/1/23, documents the following, in part: The purpose of the policy is to promote safe transfer for the residents, as well as the staff. Gait belts, Hoyer lifts, and/or sit to stand lifts will be used, unless otherwise specified. It is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident.

Based on interview and record review, the facility failed to ensure CPR (cardiopulmonary resuscitation) was initiated per physician's orders and resident's wishes for 1 of 3 (R16) residents reviewed for death. This failure resulted in an Immediate Jeopardy on [DATE] at 8:20 AM when R16 was found without a pulse nor respirations by a CNA (Certified Nurse Assistant). CPR was not attempted per R16's wishes. This failure has the potential to affect all 138 residents of the facility.The Immediate Jeopardy began on [DATE] at 8:20 AM when R16 was found without a pulse or respirations by V30 CNA. V30 notified R16's nurse V19 LPN (Licensed Practical Nurse) of R16's condition and V19 failed to initiate CPR per R16's wishes. R16 expired at the facility on [DATE]. On [DATE] at 10:26 AM V1 Administrator, V2 DON (Director of Nursing), V3 ADON (Assistant Director of Nursing), and V4 Regional Nurse were notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE], but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training.Findings Include:R16's admission Record with a print date of [DATE] documents R16 had diagnoses including hypokalemia, type 2 diabetes mellitus, emphysema, cerebellar stroke syndrome, and congestive heart failure.R16's MDS (Minimum Data Set) dated [DATE] documents R16 was cognitively intact.R16's Order Summary Report print date of [DATE] documents R16 had a Physician's order to be a full code.R16's IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated [DATE] documents attempt resuscitation/CPR, and medical interventions of full treatment with primary goal of sustaining life by medically indicated means. In addition to treatment described in selective treatment, use intubation, mechanical ventilation and cardioversion as indicated.R16's undated Care Plan documents (R16) desires CPR to be initiated in the event of cardiac arrest. Care Plan Goal: Resident wishes will be honored. In the event of cardiac arrest, CPR will be initiated and continue until EMS (Emergency Medical Services) arrival to take over compressions and/or Physician gives order to stop compressions, if not effective.R16's progress note dated [DATE] at 9:00 AM documents notified Dr. (V15) and (V13) daughter of R16 that resident had expired this AM. Writer was notified by CNA (Certified Nurse Assistant) around 8:20 AM that resident was no longer breathing or had a pulse. Verified with North-South Nurse that there was indeed no pulse/heartbeat and no breathing activity.On [DATE] at 11:44 AM V13 (R16's daughter) stated she was her mom's POA (Power of Attorney) although her mom was completely alert and oriented until she passed away. V13 stated her mom (R16) still wanted to be a full code. V13 stated she discussed her mom's code status within the last year, and her mom (R16) reiterated she still wanted to be a full code.On [DATE] at 12:46 PM V2 DON looked at R16's progress notes along with Surveyor and V2 stated I do not see where CPR was initiated. V2 stated she was not the DON at the time R16 passed away.On [DATE] at 2:31 PM V18 LPN (Licensed Practical Nurse) stated V19 LPN called her to come down to R16's room and verify her death. V18 stated as she was going to R16's room she asked V19 if R16 needs CPR, and she thought V19 went to check R16's medical records to see if she was to receive CPR or not. V18 stated V19 came back in the room, did not say anything about R16 being a full code, so she informed V19 that R16 did not have any heart sounds nor respirations. V18 stated about 2 hours after R16 passed away she overheard V19 speaking on the phone to V15 (R16's Physician) and she heard V19 say R16 was a full code. V18 stated she then looked at R16's Physician orders and saw R16 was a full code, then she went and reported the issue to the DON. V19 stated R16 did not have any signs of rigor mortis nor any signs she had been deceased for a long period of time.On [DATE] at 8:58 AM V15 Physician of R16 stated he would have expected R16's nurse to honor R16's wishes and initiate CPR.On [DATE] at 1:42 PM V19 LPN was asked by Surveyor what he did when he was alerted of R16's condition on [DATE] and V19 stated he did not follow protocol, someone said she (R16) took her last breath, so he went in there to check, and she wasn't breathing. V19 stated he was not aware there was an issue with R16's death until today ([DATE]). V19 stated he assumed R16 was a no code (no CPR) by the way she looked. Survey team asked V19 what R16 looked like and V19 replied she looked like she took her last breath. V19 then stated, I only received 2 days of orientation, I did not look at her (R16's) paperwork to see if she was a code.On [DATE] at 10:38 AM V30 CNA stated she found R16 unresponsive on [DATE] and she went to get the nurse (V19), and he (V19) told her to get the other nurse (V18). V30 stated V19 informed her R16 was a DNR (Do Not Resuscitate).On [DATE] at 1:55 PM V2 DON stated she expects the facility nurses to follow facility protocols.On [DATE] at 11:26 AM V1 Administrator stated he would have expected the nurses to administer CPR.The facility's CPR Policy dated [DATE] documents Emergency Procedure - Cardiopulmonary Resuscitation. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. Instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator (if applicable). Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:Immediate re-education of all licensed and direct care staff on CPR requirement, including initiation unless a valid DNR order is present [DATE] prior to working the floor.Facility staff educated in-serviced all staff on the code status of facility residents and where to check for code status of resident on [DATE] or prior to working the floor on their next scheduled shift.All agency staff will be checked off on knowledge of CPR and knowledge of code status prior to working the floor on their next scheduled shift.Verification of all residents' code status to ensure accuracy and accessibility [DATE].Removal of any staff involved from resident care pending re-education and competency validation [DATE].Hands-on CPR return demonstrations completed for all staff [DATE] and prior to working the floor.Emergency equipment (crash cart, oxygen) checked and confirmed functional [DATE].Policy reviewed that it clearly requires initiation of CPR unless a valid DNR order is verified [DATE].Code status verification added to shift report and electronic medical record review [DATE].HR (Human Resource) assigned responsibility for CPR compliance and education [DATE].Routine mock code drills scheduled weekly for 4 weeks then monthly x 3 months [DATE] and ongoing.CPR requirements incorporated into orientation for all new hires [DATE].This alleged deficient practice has potential to affect all residents in the facility.R16 no longer resides in the facility.Monitoring:All staff will complete CPR competency validation immediately on [DATE] and ongoing.Weekly audits of code status starting on [DATE] and ongoing verification x4 weeks, new admissions verified upon admission.Monthly mock code drills with documentation starting on [DATE].Quarterly audits of emergency response documentation starting on [DATE].Results will be reviewed in QAPI meetings. The facility's Census Room Roster dated [DATE] documents there are 138 residents residing at the facility.

Based on interview and record review, the facility failed to prevent misappropriation of resident's medication for 5 of 8 residents (R4, R5, R6, R7, and R13) reviewed for misappropriation of personal property in the sample of 19.Findings include:1. The facility's document Report Form/IDPH (Illinois Department of Public Health) Notification dated 2/26/2025 documents alleged abuse/misappropriation of personal property and identifies the names of the residents involved as R4, R5, R6, and R7. This report identifies a brief description of the incident/event as, On 2/26/2025 a facility nurse alleged that the residents' Morphine is miscolored and not correct. The report's Summary of Investigative Findings documents, A comprehensive investigation was initiated. Results of investigation concluded that the morphine in seven bottles were clear where morphine should have been pink in color. Narcotic counts were immediately conducted on remaining narcotic with no discrepancies noted. It was verified with V2 RN (Registered Nurse) that morphine that she administered on 2/24/2025 was pink in color. V2 had counted with on coming nurse V23 RN at shift change. V23 verified color of morphine was pink when she administered on 2nd shift. At the end of shift V23 counted with on coming nurse V22 LPN (License Practical Nurse); no discrepancies noted. Approximate 8:30 am V2 was going to administer morphine (liquid) when she noted the color of the morphine was clear not pink. She notified V21, DON. Conclusion of investigation is that the morphine liquid had been switched for clear liquid sometime after count on 3rd shift. Police report case number 2025-003839 dated 2/26/2025 at 9:29 AM documents On Wednesday, February 26th, 2025, at approximately 9:29 a.m., I was dispatched to (facility) for a Theft of medication report. Once on scene, I activated my Body Worn Camera and spoke with employee, V24 (Social Service Director). V24 explained she suspected LPN (V22) of stealing 100 milligrams (mg) of liquid Morphine. V24 explained that V22 worked last night and was in charge of giving four residents their Morphine, however, when the day time nurse went to give the residents their next round of Morphine, she discovered the Morphine bottles had been filled with water. V24 said the business was going to cover the cost to replace the medication, but she was not sure of the total cost. I asked V24 if she wanted to pursue charges, to which she said she did not and only wanted the information.R4's physician order dated 9/16/2024 documents R4 was taking Morphine Sulfate (Concentrate) oral solution 20mg/mL (milliliter), give 0.25 mL by mouth every 1 hour as needed for pain or shortness of breath.R4's face sheet dated 3/23/26 documents a diagnosis of polyneuropathy.R5's physician orders dated 8/7/2024 documents R5 was taking Morphine Sulfate oral solution 10 mg/5mL, give 0.25 mL every 2 hours as needed for pain or shortness of breath. R5's face sheet dated 3/25/26 documents a diagnosis of partial intestinal obstruction and palliative care.R6's physician orders dated 9/11/2024 document R6 was taking Morphine Sulfate oral solution 20mg/5mL, give 0.25 mL by mouth every two hours as needed for severe pain or air hunger. R6's face sheet dated 3/23/26 documents a diagnosis of compression fracture of thoracic vertebra.R7's physician orders dated 2/29/2024 documents R7 was taking Morphine Sulfate (Concentrate) Oral Solution 100mg/5mL, give 0.25 mL by mouth every 1 hours as needed for pain. R7's face sheet dated 3/23/26 documents a diagnosis of diabetic neuropathy and history of healed traumatic fracture.2. On 3/23/26 at 11:09 AM R13 stated she has chronic back pain and she takes scheduled pain medication for pain relief. R13's physician orders dated 8/29/2025 show R13 is taking Hydrocodone-Acetaminophen oral tablet 10-325 mg, give one tablet by mouth three times daily for pain not to exceed 4g (gram)/day. R13's care plan dated 11/1/2023 states R13 is at risk for pain related to Chronic Physical Disability, on hospice for diagnosis of heart failure and dysphagia.On 3/23/2026 at 10:19 am, V8 RN states more than six months ago V2, Director of Nursing (DON), who at that time was a floor nurse, noticed that a resident's liquid morphine was lighter in color than normal and that it had been tampered with. V8 states that all medication carts in the facility were checked and that the consistency and color of all liquid morphine bottles were different, stating the morphine was not bright pink in color as it usually is. V8 states they were able to identify the nurse who did it and since that nurse has been gone there have been no further issues.On 3/23/2026 at 2:52 pm, V1 Administrator provided a document titled Profile Scan by (facility's contracted pharmacy) dated 3/23/2026 which includes R4's, R5's, R6's, and R7's names. V1 stated all these residents were involved with the misappropriation of their morphine. V1 stated they drug tested all the nurses and were unable to determine who had altered the morphine.On 3/24/2026 at 10:40 am V2 states she was working the night that the morphine was discovered as having a different color and consistency than usual. V2 states that the morphine was usually more viscous and this morphine was watery and the color of the morphine was off. V2 states she reported the incident to the nurse on call and an audit of three or four medication carts was done by management and additional bottles of morphine were noted to have been tampered with. V2 states she was drug tested for the morphine incident and had also been drug tested for an incident that happened in June 2025. V2 states in June of 2025, V2 noted an entire card of R13's Norco had went missing. V2 states she reported this, was then drug tested and suspended upon further investigation.On 3/24/2026 at 10:40 am, V3, Assistant Director of Nursing (ADON) confirmed that she was aware of an entire card of R13's Norco going missing in 6/2025 and doesn't think that the card of medication was ever found or that the person responsible was identified. V3 stated she was the Quality Assurance nurse at the time and assisted in the investigation of R13's missing medication.The facility's document Report Form- IDPH Notification dated 6/5/2025 at 3:00 PM documents an allegation of missing medication for R13. The report documents a brief description of the incident/event as On 6/5/2025 a facility nurse alleged that the resident's card of hydrocodone was missing. A summary of this report documents A comprehensive investigation was initiated. Results of investigation concluded that hydrocodone card of 60 tablets was unable to be located. Narcotic counts were immediately conducted on remaining narcotics in the building with no discrepancies noted. It was verified with V2 that during count on evening of 6/3/2025, card was present in narcotic locked box and during count on morning of 6/5/2025, card was not present. She notified V26 (DON at the time of incident) and immediate count of narcotics throughout entire building was conducted. V26 LPN states that during count on morning of 6/4/2025, card was still present and during count on evening shift of 6/4/2025, card was not present. V23 states card was not present during count in the morning of 6/4/2025. Investigation as completed on 6/6/2025, unable to determine who or where the card of hydrocodone went.The facility's policy, Abuse Policy, revised 12/2025 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents and in correspondence with the Elder Justice Act of 2010 that strengthens elder abuse protections and the Illinois Administrative Code.

Based on interview and record review the facility failed to prepare food at an appetizing temperature. This failure affects 2 of 2 (R1 and R3) residents reviewed for dietary services. Findings include:Facility's Resident Council Minutes dated 1/20/26 at 2:00 PM documents Concerns with food being cold at mealtimes.Facility's Resident Council Minutes dated 2/17/26 at 2:00 PM documents Concerns with food being cold at mealtimes.Facility's Resident Council Minutes dated 3/16/26 at 2:05 PM documents Food is not hot enough during mealtimes.Facility's Grievance dated 1/22/26 documents Concerns with food being cold at mealtimes. Addressed during resident council, dietary manager aware will in-service staff.Facility's Grievance dated 2/18/26 documents Food is not hot enough at mealtimes. FSD (Food Safety Director) continues to monitor temperatures in dining room and hall trays. All temperatures were about 150 degrees for hot food and under 40 for cold food. FSD has and will continue to monitor temperatures on all floors. Tracking of temperatures will continue.Facility's Grievance dated 3/16/26 documents Concerns with food being cold at mealtimes. Checked random plates during service on different floors. All food was within proper range. Will continue to monitor. Checked and verified all temperatures were within range.On 3/18/26 at 10:49 AM, R1 stated that the food is sometimes cold, especially vegetables.On 3/18/26 at 10:56 AM, R3 stated that the food is cold.Facility's Food Palatability dated 9/1/21 documents Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs.CMS form 671 dated 3/19/26 documents a censure of 143 residents.

Based on interview and record review the Facility failed to provide a safe transfer for 1 of 3 residents (R1) reviewed for transfers in the sample of 10. This failure resulted in R1 being left unattended as staff left the room and R1 fell out of the bed and sustained an Intracranial hemorrhage (head injury).Findings include:R1's Physician Order Sheet (POS) for November 2025 documents a diagnosis of unspecified sequelae of unspecified cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side; dementia in other diseases classified elsewhere; unspecified severity without behavioral disturbances, psychotic disturbance, and insomnia. R1's Minimum Data Set (MDS) dated [DATE] document R1 was moderately impaired for cognition for activities of daily living. Under Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed- R1 was documented as Dependent. Dependent documents the Helper does ALL of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity.R1's Care Plan with the date initiated of 11/19/2021 documents, Fall Risk: (R1) is at risk for falls due to confusion, gait/balance problems. He has history of syncope, seizure disorder, stroke with right-sided weakness, history of falls. He has weakness/unsteady, incontinent of bowel/bladder. He leans in his wheelchair when he is tired.R1's Fall Risk assessment dated [DATE] documents R1 was high risk for falls.R1's Health Status Note dated 11/8/2025 at 9:45 PM, Note Text: CNA (Certified Nursing Assistant) reported she had resident on bed and resident had extra large bm (bowel movement), she walked away to get toilet paper from bathroom and observed resident falling off bed, resident did not become unconscious, alert and responding appropriately with clear speech, CNA states resident was on right side and rolled himself over to his left side, states he is not in pain, no abnormalities noted to head, skin intact, resident remained in position this writer first observed him in, resident contracted and has limited ability to move limbs, order to send resident for evaluation to rule out injury, echo transport notified, residents POA (Power of Attorney) updated on incident per phone call and agrees to bed hold policy at this time.R1's Health Status Note dated 11/9/2025 at 1:09 PM, Note Text: called ER (Emergency Room) for follow up, resident being transferred, call placed to POA (Power of Attorney) and he is aware of transfer, and dx (diagnosis of) right frontal lobe hemorrhage.On 11/13/2025 at 2:05 PM, V12, CNA stated, I am familiar with (R1). He is not able to turn himself. I was performing incontinent care on him, and he had a large BM and I went to get toilet paper. (R2) usually does not move but when I left his bed he rolled over and fell off the bed. I have been trained and I never should have left him unattended, and I feel bad. I know they sent him out to the hospital. We are not supposed to ever leave resident unattended while providing incontinence care. On 11/13/2025 at 3:15 PM, V14, CNA stated If we are providing incontinent care, we are never to leave the resident even for a minute unless we put the bed down all the way, put resident back on their back and give them the call light. (R1) is not able to turn himself over.On 11/13/2025 at 3:24 PM, V15, CNA stated when we are providing incontinent care, we are never ever supposed to leave the resident unattended ever, even for a second. If we need help, we are supposed to push the call light and/or put the resident's call light on and wait for help. If we can't wait, we are supposed to put the bed down all the way down to the floor, position the resident on their back, and give them their call light before we ever leave the room. (R1) is not able to turn himself.On 11/13/2025 at 3:27 PM, V16, CNA stated, We are never to leave a resident unattended while providing incontinent care. If we need supplies and I did not bring them, then I would put the call light on and wait for help. If nobody came, then I would put the resident on their back, cover them up, lower the bed all the way to the floor and hand them the call light.On 11/13/2025 at 4:18 PM, V17, Corporate Nurse stated, (V12) should have put on the call light and waited for help. She should have never left the resident unattended.R1's emergency room Visit date reviewed 11/10/2025 document hospital problem, (Principal) Intracranial hemorrhage. [AGE] year old male presents to the emergency department as a trauma transfer. The patient fell at the nursing home CAT scan obtained in outlying facility was suspicious for a frontal confusion. Patient was transferred here to be seen by neurosurgery. History mainly EMS patient has dementia. Minor head injury.On 11/20/2025 at 8:39 AM, V26, Nurse Practitioner stated, During incontinent care if a staff member raised the bed, then I would expect the staff to lower the bed and place the resident on their back and or call for assistance before leaving the room. The resident should never be left with the bed raised unattended. I would not expect staff to leave the room with the bed up because it puts the resident at risk for falling out of the bed and they could sustain any injury from the fall.The Facility Fall Policy with a date initiated of 7/1/2023 documents, To provide staff with guidelines for investigating, reporting, and recording Accidents and Incidents. An accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve injury or damage to property. It may involve residents, visitors, or volunteers.

Based on interview and record review, the facility failed to answer call lights in a timely manner in 2 of 3 residents (R109, R131) when reviewed for accommodation of needs in the sample of 32. Findings Include:On 08/26/2025 at 10:50 AM, R109 was observed in her room, in the wheelchair, clean, dry, without odors, and call light within reach. R109 stated sometimes she will have to press her call light 2-4 times to get someone to come in. R109 stated it has taken over 2 hours for the staff to provide care. R109 stated she has a bed sore on her bottom from not being cleaned up timely. R109 stated she goes to dialysis 3 days per week and has to sit up for the 3 hours she is there, so when she gets back to the facility, she's ready to lay down and it takes a long time.R109's Face Sheet, undated, documents R109 has the following diagnoses: Osteomyelitis of the Vertebrae, Type 2 Diabetes, End Stage Renal Disease, Dependence on Renal Dialysis, Urinary Retention, Back Pain, and Disc Degeneration.R109's MDS (Minimum Data Set), dated 7/22/25, documents R109 has modified independence with daily decision making, is dependent with toileting, is frequently incontinent of bowel & bladder, and has a stage 2 pressure ulcer that was present upon admission.R109's Care Plan, dated 5/14/25, documents R109 requires assistance with ADLs (Activities of Daily Living). On 08/26/2025 at 11:10 AM, R131 was observed in her room in recliner, clean, dry, without odors, walker beside recliner, and call light within reach. R131 stated it takes 1-2 hours sometimes to get her call light answered. R131 stated she fell recently and hurt her tailbone and hip because she was waiting so long for the staff to take her to the bathroom, so she got up by herself and tripped over her oxygen tubing causing her to fall. R131 stated she is mostly continent but when she has an accident it will take 1-2 hours for someone to help her because they don't answer the call light. R131's Face Sheet, undated, documents R131 has a diagnosis of Hemiplegia/Hemiparesis following a Cerebral Infarction affecting the Left Side.R131's MDS, dated [DATE], documents R131 has a BIMS (Brief Interview of Mental Status score of 12, indicating R131 has moderate cognitive impairment, utilizes a walker and wheelchair, requires substantial/maximal assist with toileting, requires partial/moderate assist with transfers, and is occasionally incontinent of urine.R131's Care Plan: dated 10/25/24, documents R131 has a Self-Care Deficit related to weakness, terminal condition, is under hospice care, and has a history of stroke with left sided hemiparesis.R131's Progress Note, dated 8/16/2025 at 5:45 AM, documents the following: Resident found sitting on floor on her buttocks between her butt and bed. Resident assisted to w/c (wheelchair), neuros initiated, ROM (Range of Motion) and VS (Vital Signs) are all WNL (Within Normal Limits) for this resident. Management, family and on call aware of fall with no injury. Resident denies pain.R131's Progress Note, dated 8/18/2025 at 4:09 PM IDT (Interdisciplinary Team) met to discuss recent fall. RCA (Root Cause Analysis): Resident noted to have been attempting to transfer self, and lost balance. Intervention: call don't fall sign hung, and resident educated.The Resident Council Minutes, dated 6/17/24, document under nursing concerns: call lights are not being answered in a timely manner. Call lights being turned off and not returning to assist resident.The Resident Council Minutes, dated 7/15/25, document under nursing concerns: call light wait time is too long.The Resident Council Minutes, dated 8/19/25, document under nursing concerns: call light wait time is too long. Concerns with people walking by when call lights are on. On 8/29/25 at 11:47AM, V1, Administrator, stated she has not had anyone specifically complain to her about the call light response time, but there have been complaints made in resident council. V1 stated when that happens, V2, DON (Director of Nurses), will do call light audits and will educate management, ancillary staff, and the nursing staff, not to walk by a call light, anyone can answer the light. The Call Light Guidance Policy, dated 7/1/23, document resident call lights shall be responded to within a reasonable amount of time.

Based on Interview, and Record Review the facility failed to ensure physical abuse did not occur for 1 of 2 (R88) residents reviewed for abuse in the sample of 32. Findings Include: R112's Face sheet documents an admission date of 10/10/2023. Diagnosis include Heart failure, Dementia, Anemia, Dysphagia, and Hypertension. R112's Minimum Data Set, MDS, updated 6/25/2025 documents R112 is moderately cognitively impaired. R112's Care Plan updated 7/10/2025 documents R112 has a behavior problem of hitting others related to: Cognitive Impairment/Dementia. Interventions include: If reasonable/appropriate, discuss R112's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to R112. Monitor for behavior of hitting. Praise R112 for appropriate behavior. R88's Face sheet documents an admission date of 5/12/2023. Diagnosis include Dementia, Type 2 Diabetes, Osteoarthritis, Dysphagia, Hearing Loss, R88's MDS updated 8/1/2025 documents R88 is severely cognitively impaired. R88's Care Plan updated 8/1/2025 documents R88 has a behavior problem of hollering out related to Alzheimer's or related Dementia. Interventions include monitor for behavior of hollering out. Ensure physical safety of resident and others when behavior is seen. Facility's Verification of Incident Investigation/Administrative Summary dated 7/6/2025 documents A comprehensive investigation was initiated on 7/6/2025 and showed that staff reported that one resident (R112) with a BIMS of 8 had a hold of a puzzle book which made contact with fellow resident (R88) with a BIMS of 5 on the right side of her head. Upon interview R88 could not recall the incident stating 'No' when asked if she was hit by another resident. R112 could not recall the incident stating 'I never hit her and would never hit anyone.' Neither resident shows any signs of Psychosocial/mental anguish. Other staff were interviewed with no negative findings of anyone willfully striking another resident. The allegation of willful physical abuse is unsubstantiated. The facility finds the allegation of willful abuse unsubstantiated. All appropriate parties have been notified of the outcome.On 8/28/2025 at 11:35AM when R112 was asked if she had an altercation with another resident R112 stated No nothing has happened.On 8/28/2025 at 11:45AM V21, Certified Nursing Assistant, CNA, unable to contact. Facility incident report undated signed interview documents I walked around the corner, and the aids were asking R112 to move so she can get other residents through for lunch on East Hall. She yelled No and hit another resident with her book twice. She then began to yell and hit the aids (both of them) and calling everyone b#####s. Then she pulled her pants down and said see my p#### b######. Interview signed by V21. On 8/28/2025 at 12:30PM V19, Registered Nurse, RN, stated I was working the floor that day, but I don't exactly remember what happened. R112 has behaviors all the time so I don't remember this one in particular. On 8/28/2025 at 12:50PM V20, CNA, stated the day R112 hit R88 I was pushing a resident down the hall when R88 bumped into R112. R112 took her book and hit R88 in the shoulder area with it. V22 and I separated the 2 residents and got the nurse. On 8/28/2025 at 12:53PM V22, CNA, stated the day R112 hit R88 I was in the hall and saw R88 self-propelling her wheelchair up the hallway. R88 bumped R112's wheelchair and that set R112 off. I saw R112 hit R88 with her book. R112 hit R88 in the shoulder. We then separated them and got the nurse.Facility abuse policy with a revision date of 1/9/2024 states This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivations of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including but not limited to facility, staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual family members or legal guardian friends or another other individual.

Based on interview, observation, record review, the facility failed to attach mechanical lift sling in the appropriate manner to prevent 1 resident (R12) of 8 residents from experiencing a fall from the mechanical lift out of a sample of 32. Findings include:R12's undated Face Sheet documents an initial admittance dated of 03/01/2025 with pertinent medical diagnoses Other Acute Osteomyelitis Right Humerus, Arthritis due to other bacteria right elbow, Unspecified fracture of Upper end of Right Humerus, Subsequent encounter for fracture with Routine Healing, low back painR12's Minimum Data Set (MDS) dated [DATE] documents R12 is cognitively intact, she does not exhibit any behaviors that reject care, R12 is on as needed pain medication, R12 is dependent on staff for toileting, showering, lower body dressing, rolling left and right, and transferring from chair/bed to chair and is frequently incontinent of urine and always incontinent with bowels.On 8/28/25 at 9:15 AM R12 stated she was afraid of transferring with the mechanical lift. R12 stated she had fallen because the loops on the sling were rotten. and she fell to the floor. Talk to my daughter she can explain every thing On 8/28/25 2:00 P V27 daughter of R12 stated that her mother (R12) actually fell from the mechanical lift sometime last year. She (V27) was told by nursing home staff (R12) was lowered to the floor when the sling straps came loose. (R12) was not taken to the hospital (R12) has always complained of pain so it was difficult to tell if she (R12) was actually injured.R12's Nurse Progress notes dated 10/23/24 document a late entry of staff transferring (R12) using a mechanical lift did not ensure the loops to the sling were attached properly. Staff were educated.On 8/29/25 at 9:17 AM V1 Administrator stated the staff involved in the incident are no longer with the facility. all staff were educated on the proper use of any transferring of resident.The facility's Transfer Policy dated 07/01/2023 documents , It is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident. When using a mechanical lift, pay close attention to be sure that the mechanical lift sling is properly positioned and the straps are securely in the strap holder.

Based on interview and record review, the facility failed to prevent physical abuse for 2 of 7 residents (R1, R2) reviewed for abuse in the sample of 7. Findings include: 1. On 5/15/25 at 1:22 PM, R2 is lying in bed. R2 does not speak much. R2 was asked if anyone has ever hurt her, R2 shook her head yes. R2 was questioned if her roommate hit her, R2 shook her head yes. R2 was questioned as to where she was hit, R2 pointed to her face. R2's Verification of Incident Investigation / Administration Summary, dated 5/7/25, documents, A comprehensive investigation was initiated and showed that staff reported that one resident (R2) with a BIMS (Brief Interview of Mental Status) of 9 (moderately cognitively impaired) was heard alleging that she got into an altercation with resident (R3) BIMS of 4 (severely cognitively impaired). It continues, (R2) could recall the incident stating I would like a new roommate she came over and smacked my arm. Neither resident shows signs of psychosocial / mental anguish. V3 Certified Nurses Aide witness statement, dated 4/30/25, documents, I (V3) walked into (R2's and R3's) room, because (R2) was yelling and seen (R3) hitting (R2) in the face with her hand telling her to shut up. R2's Admission Record, print date of 5/15/25, documents R2 was admitted on [DATE] and has a diagnosis of Cerebal Palsy and Developmental Disorder. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is moderately cognitively impaired. R2's Health Status Note, dated 4/30/25, documents, This resident alleged abuse from another resident. Admin/DON/ (Administrator, Director of Nursing) on call NM(Nurse Manager)/OSG (Office of State Guardian)/LPD(local police department)/IDPH notified. Investigation pending. R3's Face Sheet, print date of 5/15/25, documents, R3 was admitted on [DATE] and has a diagnosis of Anemia. R3's MDS, dated [DATE], documents, R3 is severely cognitively impaired. R3's Occurrence Note, dated 4/30/2025, documents, Another resident states this resident smacked her in the face. Investigation pending. 2. R1's Verification of Incident Investigation / Administration Summary, dated 4/24/25, documents, A comprehensive investigation was initiated and showed that staff reported that one resident (R4) with a BIMS of 6 (severely cognitively impaired) was seen smacking fell ow resident (R1) BIMS of 6. on top of head. Upon interview R1 did not recall the incident. It continues, R4 stated, I did not hit her, we may have bumped wheelchairs in the hall way, but I did not hit her.Neither resident shows signs of psychosocial / mental anguish. R1's Admission Record, print date of 5/15/25, documents, R1 was admitted on [DATE] and has a diagnoses of Dementia. R1's MDS, dated [DATE] documents R1 is severely cognitively impaired. R1's Care Plan, dated 4/21/25, documents, (R1) has been involved in an alleged resident to resident physical altercation .Allow resident to verbalize feelings and thoughts. Notifications to necessary parties. Social services to provide one to one visits as needed to discuss feelings and thoughts. Trauma assessment, as appropriate. R4's Admission Record, print date of 5/15/25, documents, R4 was admitted on [DATE] and has a diagnoses of Dementia. R4's MDS, dated [DATE], documents R4 is severely cognitively impaired. R4's Health Status Note, dated 4/19/2025, documents, Residents was preparing to get up and get prepared for supper. Resident was seen hitting another resident in the head and then pushed her wheelchair out the way. Advised resident not to hit another resident and she began to hit writer. Advised resident not to hit the nurse and resident began to swear at the nurse and then started to say racial slurs at the nurse. Advised resident not to speak in that manner and escorted resident to her room. Made the house supervisor on duty of the incident. On 5/15/25 at 2:00 PM, V1, Administrator, stated R3 did hit R2. They are no longer roommates. R3 does have a history of hitting but she has not hit anyone in a very long time. R4 did hit R1 they were in the hallway. In both cases, they were immediately separated, no one was hurt, and I was notified immediately. The Abuse Policy, dated 1/9/24, documents, Purpose to provide guidance and Procedure to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. .

Based on interview and record review, the facility failed to notify a resident's guardian of a change in medications in 1 of 5 residents (R2) reviewed for notification of changes in the sample of 6. Findings include: On 11/20/24 at 8:38 AM, V6, RN (Registered Nurse) stated (R2) has had some changes with her Gabapentin because it was causing her to be sleepy, so the physician lowered the dosage. V6 stated she did not notify (V15), (R2's) Daughter/Guardian, of the order for Gabapentin, but should've. On 11/20/24 at 8:50 AM, R2 stated (V15) went through the court and got custody of her because at that time, she needed someone to make decisions for her, but now she is improving and doesn't necessarily need both she and (V15) to be notified of everything. R2 stated if there has been an addition of a medication or change in a medication, she would like to consent from her and (V15). On 11/20/24 at 9:40 AM, V15, stated she was not notified of (R2's) order for Gabapentin. R2's Face Sheet, undated, documents V15 as R2's Daughter and legal guardian. R2's Order for Appointment of Guardian, dated 9/25/23, documents V15 was appointed as R2's legal guardian by the Seventh Court of the Seventh Judicial Circuit of the county where R2 resides. R2's MDS (Minimum Data Set) dated, 9/5/24, documents R2 has a BIMS (Brief Interview of Mental Status) score of 11, which indicates R2 moderate cognitive impairment. R2's Care Plan, dated 9/6/24, documents R2 has impaired cognitive function or thought processes related to impaired decision making. R2's POS (Physician Order Sheet) documents an order, dated 10/17/24, for Gabapentin 100 mg three times per day for Neuropathy. R2's Progress Note, dated 10/15/24 at 2:10 PM by V18, R2's Physician, documents in part Back pain with leg pain - likely neuropathy related pain- start Neurontin (Gabapentin) 100 mg TID (Three Times Daily) - monitor mentation closely. There is no documentation in R2's progress notes that V15 was notified of the addition of the Neurontin. The Charting & Documentation Policy, dated 7/1/24, documents All services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Documentation of procedures and treatments will include care-specific details, including: notification of family and physician.

Based on interview and record review the facility failed to verify medications for accuracy and number of dose of each medication being sent home on discharge for 1 of 3 residents (R4) reviewed for discharge medications in the sample of 10. Finding include: 1. On 9/16/2024 9:58 am V8, Clinical Manager stated when R4 seen physician for follow up appointment. R4 care giver brought R4's medication cards from discharge from the facility V8 stated R4 did have all required medications and 7 different medication cards with meds that belonged to R5. V8 stated that R4's care giver had not given R4 any of R5's medications. On 9/16/2024 at 1:10PM V2 Director of Nursing (DON) stated when R4 went to her physician office and took her medications from discharge form the facility she also had some of R5's medication cards with medication. V2 stated this was 3 days after discharge. V2 stated the facility sent a driver out to get the medications and R5 did not miss any medication. V2 stated the nurse that discharged R4 must have accidentally grabbed some of R5's med cards. V2 stated when a resident is discharged their medications are sent with them. V2 stated she spoke to the nurse and informed her to pay more attention with discharge medications. On 9/17/2024 at 10:48AM V6, Registered Nurse (RN) stated when a resident is discharged to make sure there is discharge order in place, review medications, complete discharge sheet and resident takes all of their meds with them. V6 stated it appears she sent some of R5's medications home with R4 R4's discharge plan and instructions dated 9/3/2024 documents follow up/recommendations; follow up with primary regarding medications. R4's discharge plan documents Medication Education/Reconciliation (Has a medication reconciliation been completed? (compare pre-discharge and post-discharge medications to include both prescription and over the counter medication) R4's discharge plan documents yes. R4's discharge plan or clinical record fails to document the number of doses of each medication discharged to R4 or R4's responsible party. R4's clinical record documents in part that R4 has altered mental status. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has severe cognitive impairment. On 9/17/2024 at 11:45AM V2, DON stated when a resident is discharged a discharge packet is sent , the medication cards for resident, V2 stated the nurse is to make a copy of MAR or physician orders and let resident/ caregiver know when the next dose is due. V2 stated the facility does not record the number of doses for each med resident being discharged with. V2 agreed this is a problem as the facility does not know how much medication is being sent with resident. The facility [NAME] Tree Pharmacy policy Discharge with Medications dated, last revision dated 2/15/2024 documents the labels on discharge medications are verified for completeness and accuracy by reconciling them against the most recent physician's orders. The policy documents directions for use are reviewed with the resident and/or responsible party. The policy documents the nurse should document the number of doses of each medication discharged to the patient or responsible party.

Based on interview, observation and record review, the facility failed to ensure personal use items were within reach and provide an environment free of clutter to prevent falls and injury for 1 of 6 residents (R12) reviewed for accidents in the sample of 61. This failure resulted in R12 sustaining a cervical fracture, wearing a neck brace from 4/8/24 until 6/18/24, and requiring 9 sutures to his forehead. Findings include: R12's Admission Record, print date of 9/11/24, documents that R12 was admitted on [DATE] with diagnoses of Repeated Falls, Mild Cognitive Impairment, and Pallative Care. R12's Minimum Data Set, dated dated [DATE], documents R12 is cognitively intact, requires partial to moderate assistance from staff with sitting to standing position and standing and walking, and occasionally incontinent of bowel and bladder. R12's Health Status Note, dated 4/8/24 at 9:31 PM, documents, Heard noise down the hall. Resident observed laying on floor on right side with head on bathroom floor. Resident states he was going to use urinal at bedside and lost balance and fell . Laceration noted to right eyebrow area and forehead. VS (vital signs): temp (temperature) 98.7, pulse 64, resp.(respirations) 18 B/P (blood pressure) 130/60, SPO2 (oxygen saturation level) 96. Resident denies discomfort except for head Towels placed to bleeding areas. Ambulance called for transport to ER (emergency room ) for Evauation (sic). Hospice notified resident needs to go to ER and okay given. POA (Power of Attorney) notified. RN (Registered Nurse) on call notified. R12's Health Status Note, dated 4/9/24 at 4:09 AM, documents, Resident returned to facility per POA. Staff assisted resident to room and to bed. Alert and oriented x3. Neck Brace in place. Message left with Appt. (appointment) Scheduler to f/u (follow up) with Spine specialist. PRN (as needed) Morphine given. R12's Fall Investigation, undated, documents, Heard noise down hall. Resident observed laying ion floor in room on right side with head laying on bathroom floor. Laceration noted to right eyebrow area and forehead. Resident states stood up out of bed to use urinal and lost balance and fell . Appears resident grabbed hold of bedside table since bedside table upside down and under resident and urinal on bathroom floor. Resident stats he has gotten up out of bed to use urinal. Resident noted urinal was on the bedside table 2 feet from him, so he got up to grab urinal on his own. Resident then stated that he tried to pull the table to him and it got farther from him instead, causing him to fall forward towards bathroom. It continues, Staff state the CNA (Certified Nurse Assistant) had put resident to bed at approximately 8:30 PM, an hour prior to fall, and thinks she forgot to put bedside table closer to the bed. It continues, resident states he does use his urinal at night with no assistance, and staff agree with this statement. R12's ED (Emergency Department) Physician Notes, dated 4/8/24, documents, Associated Diagnoses: C5 cervical fracture; laceration of forehead. It continues, Laceration: 3 cm (centimeters) in length R (right) forehead. Skin closure: 9 sutures. R12's Cervical Spine 2 views, dated 4/9/24, documents, Impression: Interval improved anatomic alignment of the anterior superior corner fracture fragment of C5 vertebral body since prior CT (computed tomography scan) study. R12's Health Status Note, dated 5/28/24, documents, Resident returned from MD (Medical Doctor) with progress note stating he must wear his cervical collar at all times for another 4 weeks. follow up appt (appointment) in 1 month. R12's Health Status Note, dated 6/18/24, documents, orders received per hospice to d\c (discontinue) neck brace. On 9/12/24 at 12:05, V3, Assistant Director of Nurses (ADON), stated the aides should place the bed side table next to the resident so they can reach their items. On 9/10/24 at 10:18 AM. R12's room was entered, by the bathroom door the is are 2 larger oxygen cylinders in a cart and 4 smaller oxygen cylinders not in a cart sitting on the floor. The 4 smaller cylinders have a thin metal tube that extends upward approximately 2 1/2 inches from the top of the cylinder. There is no cap on these metal tubes to prevent injury if someone fell on to them. These 4 oxygen cylinders also are not secured to prevent being knocked over and causing injury. ON 9/10/24 at 10:25 AM, V14 Licensed Practical Nurse, was questioned why the oxygen cylinders were in R12's room, V14 stated, Those are from hospice. I am not sure why they are here. On 9/10/24 at 10:30 AM, V2 , Director of Nurses, (DON), was questioned about the oxygen tanks in R12's room, V2 stated, Those are still there? (The hospice) company delivered them for (R12). This (hospice) brings them for their patients. I had sent an email to them to come and pick them up. R12's Health Status Note, dated 9/9/24 at 6:35 AM, documents, Writer called to (R12's) room at 630 AM. (R12) was laying on the floor head leaning on O2 (oxygen) tanks that were against the wall by the bathroom door. Small dresser next to bathroom door knocked over. (R12) stated he had to go to the bathroom and lost his balance. He grabbed the dresser knocking it and the belongings on top of it over. (R12) stated he didn't fall that hard due to grabbing dresser. He denies any pain or discomfort. ROM WNL (range of motion within normal limits). No bruising noted at this time. VS WNL (vital signs within normal limits). PCP (primary care provider) made aware. Neuro (neurology) checks initiated. R12's Health Status Note, dated 9/9/24, documents, IDT (intradisciplanary team) met to discuss recent fall. RCA (root cause analysis): Resident is often noncompliant and transfers on his own, even though he is an assist of 1. Resident got up on his own to use restroom and fell . Resident needs cues to remind him to not get up unassisted. Intervention: 'Call don't fall' sign posted Care plan updated. R12's Health Status Note, dated 9/10/24, documents, Continues on FVS/Neuros (follow up vital signs / neurology checks). Resident is a/o (alert and oriented) x 4 per norm (normal). Denies pain or discomfort. Bruising to right shoulder, left hand and right foot/ankle r/t (related to) fall reported by Hospice CNA (Certified Nurse Assistant) during resident shower. R12's Care Plan documents, Fall risk, weakness, terminal condition, under hospice care, has been having multiple falls at home, prior to admission, history of TIA (trans ischemial attack) with some memory deficits, may be incont (incontinent), (R12) is non-compliant at times will try to get up without help Date Initiated: 01/21/2024. Intervention: Keep environment free from clutter. Date Initiated: 01/21/2024 Revision on: 01/21/2024. Keep personal belongings within reach Date Initiated: 01/21/2024. The policy Accidents & Incidents, dated 7/1/23, documents, 4. Investigate and follow up action: A. The charge Nurse must conduct an immediate investigation of the accident / incident and implement immediate appropriate interventions to affected parties.

Based on interviews, observations, and record reviews the facility failed to assess, monitor, and implement interventions to prevent weight loss in 1 out of 5 residents, R323, reviewed for nutrition in a sample of 61. This failure resulted in R323 acquiring a 9.09% weight loss in less than 3 months. Findings include: R323 was admitted to the facility on [DATE] with diagnosis of, in part, fracture of unspecified part of neck of left femur, unspecified fall, unspecified dementia. R323's MDS dated [DATE] documents R323 is severely cognitively impaired with a brief interview of mental status score of 3. R323's MDS further documents R323 requires supervision or touching assistance with eating. R323's Care Plan dated 7/19/24 documents R323 has a self-care deficit as evidenced by needing assistance with activities of daily living (ADLs) with an intervention for eating to provide set-up and assist as needed. R323's weight documentation on 7/03/2024, documents R323 weighed 125.4 lbs. On 09/01/2024, R323 weighed 116.2 pounds which is a -7.34% loss. On 9/11/24 at 8:55 AM, V7, certified nursing assistant, CNA, took R323 to the scale and R323 weighed 114 pounds making her total a 9.09% weight loss since 7/3/2024. On 9/11/2024 at 9:10 AM, V21, CNA, stated she has noticed R323 has not been eating much but not aware of any weight loss and R323 does get nutrition shakes but not sure on anything else they are doing for her. On 9/11/2024 at 12:10 PM, V3, assistant director of nursing, ADON, stated the dietician is notified of all weights, including weight loss every month and has access to all the resident's charts. V3 stated R323's appetite decreased when she was diagnosed with Covid about three weeks ago. V3 stated he was not aware the R323 continued to lose weight, he thought she was doing better. V3 stated he would have expected to be notified of R323's weight loss. V3 stated the staff had tried to move R323 to the assisted feeding table not too long ago to help but her daughter did not want her to be moved. On 9/11/2024 at 12:26 PM, V18, dietician, stated she was not aware of R323's continued weight loss. V18 stated the facility sends her a report at the beginning of each month and will often start interventions that she will review but no new interventions were started for this month that she knew of on R323. V18 stated R323 was started on nutritional shakes and Med Pass for supplementations on 8/29/24. V18 stated she was not notified of the further weight-loss since 9/1/24 but she would have expected to be notified of any. V18 stated she would recommend R323 to be re-evaluated and to be provided more assistance while eating. The facility's Weight Assessment and Intervention policy dated 7/1/23 documents, The dietician will review the Weight Record at least monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. It further documents, The threshold for significant unplanned and undesired weight loss will be based on the following criteria .3 months - 7.5% weight loss is significant; greater than 7.5% is severe.

Based on interview and record review, the facility failed to provide Physician prescribed medication for 1 of 4 residents (R223) reviewed for medication. This failure resulted in R223 missing 28 doses of oxcarbazepine (seizure medication) and having 10 seizures between 8/2/24 and discharge to the hospital on 8/11/24. Findings include: R223 was admitted on [DATE] with diagnoses of metabolic encephalopathy, convulsions, schizophrenia. R223 Minimum Data Set, MDS, dated [DATE], documents that R223 is cognitively intact. R223's Health Status Note, dated 7/19/2024 4:45 PM, documents, (V30, R223's Neurologist) called gave order to start Trileptal 300 mg (milligram) i bid (twice a week) x i (one) week then increase to Trileptal 600 mg i bid for break through seizures. Dr said next time he sees res (resident) in clinic he will probably start the D/C (discontinue) process of Keppra. (V30) said he sent order to pharmacy for res (resident). R223's Health Status Note, dated 8/2/2024 12:50 PM, documents, Resident continue with seizures back to back resident appears very tired and weak NP (Nurse Practitioner) here present in the facility witness these episode want resident to recieve (sic)I V (Intravenous) Ativan obtain order to tranfer (sic) to hospital POA (Power of Attorney) updated. R223's Health Status Note, dated 8/2/2024 20:30, returned from ER (emergency room ) per facility staff, was having seizure in facility van, lasted 3 minutes, remained alert and responded correctly when seizure subsided, returned to with (hall) staff x 2, bp (blood pressure)100/66 p (pulse)100 r (respiration) 20 t (temperature) 97.4, resident rec'd (received) labs and cts (computed tomography scan) while in er, new order for cefdinin (sic) for uti (urinary tract infection)/pneumonia starting 8/3 with titrating doses of prednisone, resident had poor appetite but did intake fluids, full body lift to bed, recid (sic) iv ativan and iohexol (sic) and ceftriaxone while in er R223's Health Status Note, dated 8/3/2024 6:45 PM, documents, Resident continue with seizures x3 updated MD (Medical Doctor).Remain on ABT (antibiotic) for UTI no adverse reaction encouraging fluids and POA R223's Health Status Note, dated 8/10/2024 6:30 PM, documents, resident yelled out in dining room that she was going to have seizure, had small seizure for 30 seconds, remained with eyes open during seizure, was quiet and able to respond after, R223's Health Status Note, dated 8/11/2024 09:35 AM, documents, Resident in the Dining room eating breakfast staff noted resident seizuring (sic) writer went to resident to observe and give support seizure lasted about 2 minutes .Resident was easy to arouse offer meds (medications) due to resident alertness request meds to be crushed . Took meds with no problems .assist to bed per resident request. Updated POA of this incident and called (V31, R223's neurologist) on call MD was (V32, neurologist) update on resident reviewed med list MD stated she will call back today R223's Health Status Note, dated 8/11/2024 4:39 PM, documents, (V32) on call for (V31) return call with new orders for seizure .Updated POA with new orders and medication. (new order was for oxcarbazepine 600 mg bid) R223's Health Status Note, dated 8/11/2024 5:17 PM, documents, Resident experienced seizure during dinner and was sent to (local hospital) via EMS (Emergency Medical Services) MD and POA notified R223's Health Status Note, dated 8/11/2024 11:01 PM, documents, called (local hospital) for update, resident will be transferring to (Regional Hospital) when bed available due to resident has not returned to baseline R223's Health Status Note, dated 8/12/2024 1:16 PM, documents, notified by (Regional Hospital) that resident will be going to another facility at daughter request to be closer to spfld ([NAME]). R223's Medication Administration Record (MAR), documents, Trileptal Oral Tablet (Oxcarbazepine) Give 300 mg by mouth two times a day for Seizures for 7 Days -Start Date07/20/2024 0600 -D/C Date07/28/2024 0942. R223's MAR, documents, Trileptal Oral Tablet (Oxcarbazepine) Give 600 mg by mouth two times a day for seizures -Start Date07/27/2024 4:00 PM -D/C Date07/28/2024 0942. R223's MAR, documents, OXcarbazepine Oral Tablet 300 MG (Oxcarbazepine) Give 300 mg orally two times a day related to EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS (G40.909) until 08/18/2024 11:59 PM -Start Date08/12/2024 0800 -Hold Date from 08/12/2024 0031 to 08/14/2024 0030. R223's Hospital Record, signed date of 8/12/24, documents, Assessment ? Plan (R223) is a [AGE] year old female, with history of bitemporal seizures, who presents with breakthrough seizures. (Hospital) Neurology consulted for medical management to breakthrough seizures. It appears that her seizures were likely due to sub optimal management of her medications while she was in the nursing home. At this time I will resume the medication she was on in the nursing home with the addition of oxcarbazepine which she was prescribed by (V31). R223's Hospital Record, print date of 8/13/24, documents, (Hospital Neurology Consult Note, documents, Reason for Admission: Seizure. HPI (History of Present Illness) She is has been having seizures at the nursing home for the past few weeks which have been increasing in frequency. Upon interview with the nursing home it appears that she was on a different dose of medications than those that were recommended when she last saw (V31) in the clinic. it continues, It is unclear why she was not taking the oxcarbazepine 600 mg bid prescribed to her. On 9/12/24 at 11:28 AM, V2, Director of Nurses, stated, I have looked into how the oxcarbazepine was discontinued. I reached out to pharmacy and when (V33, Licensed Practical Nurse) looked at the order she only read the first part of 300 mg for seven days and went into the computer and discontinued the medication. On 9/12/24 at 11:39 AM, (V34, Medical Director) stated, Any medication ordered should be given as ordered. (R223) is a very complicated case not getting the oxcarbazepine did not help her but I am unable to say if it harmed her because she was such a complicated case. On 9/12/24 at 12:01 PM, V1, Administrator, stated that he does not know what policy would work for this medication error but he does expect that medications should be given as they are prescribed by the Physician.

Based on observation, interview and record review the facility failed to provided assistance during feeding in a dignified manner for 5 of 32 residents (R26, R39. R50, R54 and R91) reviewed for dignity in the sample of 61. Findings include: 1. On 09/09/24 at 11:54 AM during the the noon meal at the first floor dining room the first tray was served at 11:36 AM. The meal consisted of beef stroganoff, Brussels sprouts or green beans, roll, white confetti cake with white frosting. V5, Certified nursing Assistant (CNA) standing in the middle of assisted feeding tables that form a circle. V5 standing up feeds resident a bite off of a spoon , sanitizes hands then feds another resident bite of food with a spoon. This includes R26 and R39. On 9/9/2024 at 12:14PM V6, CNA enters the circle and starts feeding R26 while standing up and when providing drink has to reach to get cup to R26's mouth. R26's Physician order (PO) dated 9/2024 document s regular diet mechanical soft texture, thin consistency. R26's care plan dated 6/10/2024, documents self care deficit as evidenced, need assistance with Activity of Daily Living (ADL)'s , intervention dated 6/10/2024 eating - one person physical assist required; occasionally feeds self finger foods or takes a drink but usually dependent on staff to feed. R26's Minimum Data Set (MDS) dated [DATE] documents R26 is rarely/never understood 2. R39's PO dated 9/2024 documents regular diet pureed texture, nectar consistency. R39's care plan dated 6/9/2024 documents self care deficit needs assistance with ADL's related to dementia, impaired decision making and weakness. R39's care plan documents intervention for eating; dated 8/27/2024 one person physical assist required. R39's MDS dated [DATE] documents R39 is severely cognitively impaired. 40650 3. On 09/09/2024 at 12:20 PM, V9, CNA, was standing up feeding R54 at lunch time. On 09/10/2024 at 1:30 PM, R54 stated that they feed him and sometimes they don't sit down. R54's Physician's order sheet, dated 09/2024, documented a diagnosis of Metabolic Encephalopathy and Type 2 Diabetes. R54's MDS, dated [DATE], documented that his cognition was intact and that he was dependent upon staff for eating. R54's Care Plan, dated 8/27/2024, documented, Eating - One person physical assist required as an intervention. 4. On 09/09/2024 at 12:25 pm, V8, CNA, was standing up feeding R50 her lunch. R50's Physician's order sheet, dated 09/2024, documented diagnoses of Alzheimer's and Dementia. R50's MDS, dated [DATE], documented that her cognition was severely impaired and that she was dependent upon staff for eating. R50's Care Plan, dated 7/3/2024, documented, Eating - One person physical assist required. as an intervention. 5. On 09/09/2024 at 12:25 pm, V8, CNA, was standing up feeding R91 her lunch. R91's Physician's order sheet, dated 09/2024, documented a diagnosis of dementia. R91's MDS, dated [DATE], documented that her cognition was severely impaired and that she was dependent upon staff for eating. R91's Care Plan, dated 8/12/2024, documented, Eating - Provide set up, encourage self feeding, assist to finish most times. On 9/12/2024 at 9:25 AM, V28, CNA, stated that when she is feeding a resident in the dining room, she always sits down. On 9/12/2024 at 9:27 AM, V9, CNA, stated that when they are feeding residents they are to sit down. On 9/12/2024 at 9:30 AM, V11, CNA stated that they are to be sitting down while feeding a resident during a meal. The facility's policy, Providing Assistance with Meals, issue date 9/12/2024, documented, 1. Not standing over residents while assisting them with meals. The pamphlet, Residents' Right for People in Long-term Care Facilities, dated 3/2017, documented, Your facility must provide services to keep you physical and mental health, and sense of satisfaction. It continues, Your facility must make reasonable arrangements to meet your needs and choices.

Based on observation, interview and record review, the facility failed to perform complete incontinent and peri care for 4 of 4, (R4, R29, R232, R273) residents, reviewed for incontinence, in a sample of 61. Findings include: 1. On 09/10/2024 at 10:00 AM, V9, Certified Nurse Assistant (CNA), with gloved hands, pulled back R273, incontinent brief, and cleansed her right groin, then left groin and then down the center of R273's labia with rinse free peri wash and a wet washcloth. These areas were not dried and R273 was then rolled on to her right side. V9, CNA, then took a wet washcloth, that had the rinse free peri wash on it and cleansed R273's right hip and then cleansed, R273's rectal area from back to front. There were soapy suds of the rinse free wash on R273's left hip and left buttocks when V9 placed a new incontinent brief under her. R273 was then rolled on to her left side, and V9 cleansed R273's right hip with the no rinse peri wash and then fastened the clean incontinent brief without drying the right hip. R273's physicians order sheet, dated 9/1/24, documented diagnoses of Urinary tract infection and Hemiplegia and Hemiparesis following cerebral infraction affecting the right dominate side. It also documented that R273 was admitted to the facility on [DATE]. R273 Baseline care plan, dated 9/1/2024, documented, Assist with peri-care if incontinent, to help keep resident clean dry & odor free. R273's Minimum Data Set, dated dated [DATE], was incomplete, during this investigation. On 9/12/2024 at 9:25 AM, V28, CNA, stated that the peri wash should be rinsed off and that all areas should be dried after incontinent care. V28 also stated that when doing incontinent care, she would cleanse from front to back and not back to front. On 9/12/2024 at 9:27 AM, V9, CNA, stated that when they do incontinent care, that they should rinse off the peri wash and dry all areas that were cleaned and that when incontinent care is done from front to back. On 9/12/2024 at 9:30 AM, V11, CNA stated that when incontinent care is done, that she would clean from front to back and that she dries all areas that were washed. 50908 2) R323 was admitted to the facility on [DATE] with diagnosis of, in part, fracture of unspecified part of neck of left femur, unspecified fall, unspecified dementia. R323's MDS dated [DATE] documents R323 requires substantial/maximal assistance with toileting hygiene. R323's Care Plan dated 7/19/24 documents R323 is at skin risk for weakness with decreased mobility related to medical condition and may be incontinent with an intervention to assist with peri-care if incontinent, to help keep resident clean dry and odor free. On 09/11/24 at 9:10 AM, V7, certified nursing assistant, CNA, provided peri-care to R323 after having a bowel movement on the toilet. V7 stood R323 up to walker with a gait belt. V7 did not change her gloves, nor did she perform hand hygiene after wiping R323. V7 proceeded to pull R323's brief and pants up with the same dirty gloves. V7 did not dry R323's peri region off after wiping her with a wet towel. 32874 3. On 9/11/2024 at 11:30AM during incontinent care V21, Certified Nursing assistant (CNA) with disposable washcloths cleansed R4's R groin, l groin, inner thighs , then turned to left side. V21 did not separate or cleanse the labia. V21 did not dry R4's peri area prior to turning R4. V21 CNA then swiped disposable washcloth from front to back with R4 on left side. V 21 then cleanse inner thighs and buttocks , V21 did not dry R4 prior to putting adult diaper on R4. R4's care plan dated 8/15/2024 documents R4 is at risk of urinary tract infection due to history of (UTI). R4's care plan dated /15/2024 documents incontinent of bowel/bladder. R4's care plan documents the following intervention: encourage and assist to toilet routinely and provide peri-care when incontinent. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is always incontinent The facility Incontinence Care policy dated 7/1/2023 documents all incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/odor. Incontinence care will be provided as required. The policy documents wash all soiled skin areas and dry very well. 4. On 9/11/2024 at 10:44AM during incontinent care V19, CNA filled basin with warm. V19 then squirted body cleanser in the basin and placed on bedside table .V19 removed adult diaper which was wet as verified by v19, CNA. After cleansing R29 front including peri area and inner thighs V19 CNA did not rinse or dry R29 . V19 than assisted R29 to roll on right side . R19 took clean towel and placed in basin then cleanse R29. V19 started cleansing from the back to the front starting at rectal area . V19 then dried R29 rectal area and buttocks with dry towel going from the rectal area to the vaginal area. V19 did not rinse R29 prior to drying back are with towel R29's care plan dated 6/22/2022 documents R29 is incontinent of bowel and bladder, and needs staff assistance with toileting. R29's care plan documents the intervention to encourage and assist to toilet routinely and provide peri-care when incontinent. R29's MDS dated [DATE] documents R29 is frequently incontinent of urine The facility bottle label DermaVera documents body cleanser is suitable for skin and moisture the label documents apply a small amount , massage into a rich full lather . Rinse. 880- After providing incontinent care V19. do with same gloves provided incontinent care touched curtain and barrier V19 provided incontinent cream packet with unclean gloves and applied barrier cream to R29's buttocks and rectal area with the same gloves used to provide incontinent care to R29. On 9/12/2024 at 7:52AM V21, CNA stated when doing incontinent care on a female she was trained to clean peri area including to separate and cleanse the labia.

Based on interview, observation, and record review, the facility failed to discard expired blood glucose monitor control solutions for 4 of 4 (R10, R14, R48, R84) reviewed for medication storage in the sample of 61. Findings include: On [DATE] at 10:53 AM, the North South medication cart was reviewed with V14 Registered Nurse, The blood glucose machine High Control Solution expired on [DATE]. The, undated, facility provided list of residents that receive blood glucose monitoring on the north south hall documents R14, R10, R84 and R48 all receive blood glucose monitoring. 1. R84's Physician Order, dated [DATE], documents, Accu check (blood glucose check) four times a day relate to type 2 diabetes mellitus without complications. 2. R14's Physician Order, dated [DATE], documents, Accu check at bedtime for DM (Diabetes Mellitus). 3. R10's Physician Order, dated [DATE], documents that (R10) will have her blood sugar checked three times a day due to Diabetes Mellitus. 4. R48's Physician Order, dated [DATE], documents, accucheck in the morning for Diabetes. On [DATE] at 11:08 AM, V1, Administrator, stated that the nurse doing the callibration should make sure the controls are not expired. The policy Obtaining a blood glucose level procedure, undated, documents, 4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacture or this facility.

Based on observation interview and record review, the facility failed to perform hand hygiene before donning and after doffing gloves, prior to donning personal protective equipment (PPE), failing to prevent cross contamination during care and donning PPE prior to entering a enhance barrier precaution labeled resident room, for 4 of 4 (R29, R58, R273 and R323) residents reviewed for infection control, in a sample of 61. Findings include: 1. On 09/10/2024 at 10:00 AM, After R273 was transferred into her bed by V9 and V22, both Certified Nurse Assistants (CNA's). V22 doffed her gloves and reapplied a new pair of gloves without benefit of hand hygiene and removed the cover and the sling from underneath R273. V9, CNA, with gloved hands, performed perineal care and once completed, both V9 and V22, doffed gloves and without benefit of hand hygiene, both donned a new pair of gloves. V9, CNA, then continued to provide perineal care. R273's physicians order sheet, dated 9/1/24, documented diagnoses of Urinary tract infection and Hemiplegia and Hemiparesis following cerebral infraction affecting the right dominate side. On 9/12/2024 at 9:25 AM, V28, CNA, stated that hand hygiene is done when you take off your gloves and before you put them on. On 9/12/2024 at 9:27 AM, V9, CNA, stated that hand hygiene is done before you put on gloves and after they are taken off. On 9/12/2024 at 9:30 AM, V11, CNA stated that hand hygiene is done between glove changes and before you put on gloves. 32874 2. On 9/11/1014 at 10:42AM V20, Certified Nursing Assistant (CNA) donned gloves and did not sanitize hands prior to donning gloves, V20 donned gown and did not secure the gown by fastening the ties on the gown. V20 entered R58's room and pulled back adult brief during the process V20's gown is falling forward exposing V20's top and the gown is touching R58's bed. V20 stated i forgot to tie my gown. There is a sign posted outside R58's room, the facility sequence for putting on Personal Protective Device (PPE) undated documents gown fully cover torso from neck to knees, area to end of wrists , and wrap around the back. R58's record documents R58 is on Enhanced barrier precaution related to Colostomy. 3. On 9/11/2024 at 10:44AM during incontinent care V19, CNA with same gloves provided incontinent care did not change gloves and touched the curtain and barrier cream packet. V19 CNA then applied barrier cream to R29's buttocks and rectal area with the same gloves used to provide incontinent care to R29. 50908 4) R323 was admitted to the facility on [DATE] with diagnosis of, in part, fracture of unspecified part of neck of left femur, unspecified fall, unspecified dementia. R323's MDS (Minimum Data Set) dated 8/26/24 documents R323 requires substantial/maximal assistance with toileting hygiene. R323's Care Plan dated 7/19/24 documents R323 is at skin risk for weakness with decreased mobility related to medical condition and may be incontinent with an intervention to assist with peri-care if incontinent, to help keep resident clean dry and odor free. On 09/11/24 at 9:10 AM, V7, certified nursing assistant, CNA, provided peri-care to R323 after having a bowel movement on the toilet. V7 stood R323 up to walker with a gait belt. V7 did not change her gloves, nor did she perform hand hygiene after wiping R323. V7 proceeded to pull R323's brief and pants up with the same dirty gloves. R323 is on enhanced barrier precautions requiring staff to glove and gown up when providing hygiene care as documented on the enhanced barrier sign. V7 did not put a gown on while providing peri-care to R323. The facility's Hand Washing Policy dated 7/1/23 documents, If hands are not visibly soiled, use hand sanitizer: Before moving from contaminated body site to a clean body site during resident care. The facility's Incontinence Care Policy dated 7/1/23 documents, Wash all soiled skin areas and dry very well .changing gloves and performing hand hygiene as required to prevent cross-contamination. The facility's Isolation Equipment and Supplies policy dated 7/1/23 documents, Personal protective equipment (gloves, gowns) are worn when handling or transporting resident-care equipment and supplies that are visibly soiled or have been in contact with blood or body fluids.

Based on interviews, observations, and record reviews the facility failed to provide eating assistance for 1 out of 8 residents (R323), reviewed for feeding assistance in a sample of 61. Findings include: R323 was admitted to the facility on [DATE] with diagnosis of, in part, fracture of unspecified part of neck of left femur, unspecified fall, unspecified dementia. R323's Minimum Data Set (MDS) dated [DATE] documents R323 is severely cognitively impaired with a brief interview of mental status score of 3. R323's MDS further documents R323 requires supervision or touching assistance with eating. R323's Care Plan dated 7/19/24 documents R323 has a self-care deficit as evidenced by needing assistance with activities of daily living (ADLs) with an intervention for eating to provide set-up and assist as needed. On 9/9/2024 at 11:48 AM, R323 was not touching the meal and received no prompting by staff to eat, beef stroganoff on noodle, brussel sprouts, roll and white confetti cake with frosting. On 9/9/2024 at 12:00PM, R323's table mate prompted R323 to eat. At 12:18 PM, table mate placed cake in front of R323 and put a fork in cake for her. On 9/09/2024 at 12:30 PM, R323 was not prompted by any staff member to eat her food. R323 ate a couple bites of cake. R323 ' s weight documentation on 7/03/2024, documents the resident weighed 125.4 lbs. On 09/01/2024, the resident weighed 116.2 pounds which is a -7.34% loss. On 9/11/24 at 8:55 AM, V7, certified nursing assistant, CNA, took R323 to the scale and R323 weighed 114 pounds making her total a 9.09% weight loss since 7/3/2024. On 9/11/2024 at 9:10 AM V21, Certified Nurse Assistant (CNA), stated she has noticed R323 has not been eating much but not aware of any weight loss and R323 does get nutrition shakes but not sure on anything else they are doing for her. On 9/11/2024 at 12:10 PM, V3, assistant director of nursing, ADON, stated the dietician is notified of all weights, including weight loss every month. V3 stated R323's appetite decreased when she was diagnosed with Covid about three weeks ago. V3 stated he was not aware that R323 continued to lose weight, he thought she was doing better. V3 stated he would have expected to be notified of R323's weight loss. V3 stated the staff had tried to move R323 to the assisted feeding table not too long ago to help her but her daughter did not want her to be moved. On 9/11/2024 at 12:26 PM, V18, dietician, stated she was not aware of R323's increased weight loss. V18 stated the facility sends her a report at the beginning of each month and will often start interventions that she will review but no new interventions were started for this month that she knew of. V18 stated she would recommend R323 to be re-evaluated and have more assistance while eating. The facility's policy on Providing Assistance with Meals printed 9/12/24 documents, All residents will be encouraged to eat in the dining room. Nursing staff and/or Feeding Assistants will serve resident trays and will help residents who require assistance with eating.

Based on interview and record review, the facility failed to provide supervision and assistance, do a thorough fall investigation including a root cause analysis, and implement progressive intervention to prevent falls for 3 of 4 residents (R1, R4, R5) reviewed for falls. This failure resulted in R4 falling and sustaining a left sided subdural hematoma, subarachnoid hemorrhage with intraventricular hemorrhage which was the cause of her death. Findings include: 1. R4's Electronic Admission Profile documents that R4 was admitted on [DATE] and has diagnoses of Traumatic Subarachnoid Hemorrhage without loss of consciousness [DATE] and Palliative Care on [DATE] with previous diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure and Atrial Fibrillation. R4's Minimum Data Set (MDS), dated [DATE], documents that R4 is severely cognitively impaired and required supervision and physical assistance of 1 staff member for bed mobility, transfers, walking in the room and on the corridor, locomotion on the unit, dressings, toileting, and personal hygiene. This MDS also documents that during transition and walking R4 is not steady but is able to stabilize self without staff assistance. R4's Fall Scale, dated [DATE], documents that R4 is a high fall risk. R4's Care Plan, documents, Focus: Date Initiated: [DATE]. Revised [DATE]. FALL RISK: (R4) is at risk for falls due to advanced age, unsteady at times, weakness, COPD (Chronic Obstructive Pulmonary Disease) may cause shortness of breath. She is very hard of hearing and may need questions/information written down for her to understand. [DATE] sustained a left side subdural subarachnoid and intraventricular hemorrhage. Date Initiated: [DATE]. Goal: Minimize risk of falls / injury through the review date. Interventions: Date initiated: [DATE]. Therapy to evaluate; assess footwear; notify MD for SpO2. Date initiated: [DATE]. Allow rest breaks as needed to minimize shortness of breath, place head of bed up to minimize shortness of breath lying flat. Date Initiated: [DATE] Call light with reach while in bed and at bedside. Keep pathway clear. R4's Care Plan, initiated [DATE], documents ADL (Activity of Daily Living) Self care Performance Deficit r/t (related to) Impaired balance, diagnosis of CHF (congestive Heart Failure) & COPD (Chronic Obstructive Pulmonary Disease), which can impact level of ADL abilities. Goal: Sate Initiated [DATE]. Maintain Current level of function through the review date. dressing: Will perform upper body dressing, putting arms in sleeve and pulling garment over head by next review. Interventions: Date Initiated: [DATE]. Bathing 1 assist. Dressing: Supervision. Toileting: Supervision. Bed Mobility: Supervision. R4's Care Plan, initiated on [DATE], documents, INCONTINENCE RISK: (R4) is occasionally incontinent of bowel/bladder, needs staff assist at times with toileting. Goal: Date Initiated: [DATE]. Minimize risks of incontinence through the review date. Interventions: Date Initiated: [DATE]. Encourage and assist to toilet routinely and provide peri-care when incontinent. R4's Activity of Daily Living (ADL) Plan of Care flow sheet, dated [DATE] - [DATE], documents that R4 was observed walking in her room [ROOM NUMBER] times, 11 times she was independent, 3 times she needed supervision and 6 times she needed one staff member physical assistance, 13 times toileting, 4 times she needed supervision, 7 times she need physical help from 1 staff member, 1 time she needed limited assistance from 1 staff member and 1 time she was independent. On [DATE] R4 was totally dependent on one staff member for toileting. R4's Health Status Note, dated [DATE] at 2:30 PM, documents, Note Text: CNA (Certified Nurse Aide) came out of another room found resident sitting on buttocks in front of B/R (bathroom) door was closed walker at residents feet resident lying partially on floor, when staff asked her what happened stated I got dizzy and lost my balance resident assessed resident c/o (complaint of) pain unable to lay back on floor resident started yelling out in pain, unable to do AROM (active range of motion) c/o pain in right hip and leg, no other injuries noted . CNA and Administrator with resident for duration of time. R4's Health Status Note, dated [DATE] 3:05 PM, documents, Note Text: Ambulance here. resident transported to hospital at this time. R4's Health Status Note, dated [DATE] 10:30 PM, documents, Note Text: Resident returned to facility with facility driver from ER (emergency room ), new order received for Oxygen at 2 liters per NC (nasal canula). Resident is refusing to wear the oxygen, she absolutely refuses. resident educated on the need for the oxygen, but she will not put it on. Call light is in reach, will continue to monitor. R4's Local Hospital emergency room Report, dated [DATE], documents, Rational: This is a [AGE] year-old African American female who presents per EMS (Emergency Medical Services) to the ED (Emergency Department) for evaluation. Patient is extremely hard of hearing, and it is more successful to write notes. Patient is alert oriented x 2. This is her baseline. History is given that she was up walking to the bathroom became dizzy and fell . She reports that she fell on to her right hip. She denies any loss of consciousness. She denies striking her head. She denies neck or back pain. Patient denies any chest pain or increasing shortness of breath. Reports right hip pain. CT (Computed Tomography Scan) head and neck negative for bleed or fracture. It continues, Patient reports shortness of breath when she is up to the bathroom with assistance. Pulse ox (oxygen) will dropped down into the 80s. 2 L (liters) of oxygen applied. Plan is to return patient to the nursing home with oxygen. Discharge Information: Oxygen at 2 liters per nc (nasal canula) especially during activity. The Facility Incident Report, dated [DATE], documents, Resident is independent was found sitting in front of her bathroom door sitting on buttocks with feet extended in front of her walker at her feet by a CNA, assessment was done resident c/o of buttocks per writing board and resident stated she was coming out of the bathroom and got dizzy and lost her balance. Immediate Action Taken: Assessment done vitals obtained SPo2 (oxygen saturation) 92 RA (room air) P (pulse) 76 R (respirations) 20 temp (temperature) 98.1 B/P (blood pressure) ,d+[DATE] staff started to have resident lay down to put full body lift under her when she yelled out oh my hip resident left on floor with staff at side monitoring. Notes: Fall risk meeting completed. Continue to encourage O2 (oxygen) compliance, notified (V19 Physician) of resident non - compliance with N.O (new order) for O2, re-evaluate resident transfer, assess appropriate footwear. R4's Care Plan Intervention, initiation date of [DATE], documented Therapy to evaluate; assess footwear; notify MD (medical doctor) for SpO2. R4's ADL Plan of Care flow sheet, dated [DATE] - [DATE], documents that R4 was observed walking in her room [ROOM NUMBER] times, 1 time she was independent, 6 times she needed supervision and 7 times she needed one staff member physical assistance, 20 times toileting, 4 times she needed supervision, 7 times she need physical help from 1 staff member and 8 times she was independent. On [DATE] R4 was totally dependent on one staff member for toileting. The Facility Fall Interventions Sheet, dated [DATE], documents, [DATE] (R4) Intervention: Re eval (re-evaluate) transfer, assess app (appropriate) footwear, notify MD (medical doctor) regarding need for O2. R4's Health Status Note, dated [DATE] 10:58 AM, documents, Note Text: Resident O2 sat reading 78% on RA this morning due to resident refusing to wear O2, writer notified poa (Power of Attorney) by phone to see if able to encourage resident to wear O2 but was unsuccessful. (V19, Physician) faxed info, will continue to monitor. R4's Health Status Note, dated [DATE] 9:49 PM, documents, Note Text: continues to have low SPO2 below 80%, refuses to allow O2 to be applied, continues to refuse assistance to toilet, remains up in recliner and getting up without assistance, as not complained of pain, refused lung assessment. R4's Health Status Note, dated [DATE] 1:38 AM, documents, Note Text: Resident continues to refuse O2 at this time. Resting in recliner at this time watching tv with no distress noted. Will not allow pulse ox (oxygen saturation) to be read 'I don't need that. No. No thank you.' R4's [DATE] Physician Orders documents, Order Date [DATE] 7:42 AM. PT/ OT (Physical Therapy / Occupational Therapy) to eval (evaluate) and treat as indicated. R4's PT (Physical Therapy) Evaluation & Plan of Treatment, dated [DATE], documents that R4 had a prior level of functioning of independent for Sit to lying, Sit to stand, Chair/bed to chair transfer, toilet transfer, ambulating safely with a 2 wheeled walker and on [DATE] R4 required Partial to moderate assistance with these tasks except for Sit to lying which R4 required Supervision or touching assistance. R4's PT Evaluation & Plan of Treatment, dated [DATE], documents, Reason for Referral / Current Illness: Moderate Complexity Evaluation: Pt (Patient) is a 98 y/o female who was referred to PT for strengthening, balance and functional training following a fall on ,d+[DATE]. Pt cannot recall the circumstances of the fall but stated that the (R) (right) knee is bothering her. Medical Factors: Precautions: Falls, Pain on (R) knee. Reason for therapy: Patient presents with balance deficits, strength impairments, safety awareness deficits, proximal instability, postural alignment / control and gross motor coordination deficits and in consideration of history, personal factors, and functional limitations documented in the eval summary, patient requires skilled PT services to minimize falls, increase LE ROM (lower extremity range of motion) and strength, increase functional activity tolerance, facilitate motor control and facilitate independence with all functional mobility. R4's Restorative Note, dated [DATE] at 5:56 PM, documents, Per Therapy recommendation, transfer status changed to one assist with walker, and walking program initiated at this time. On [DATE] at 8:23 AM, V12, Physical Therapist stated, I evaluated her (R4) in the morning right before she fell ( [DATE]). She was weak, having pain in her right knee and slightly confused. I think the fall on the 23rd was a result of these factors. She was needing help with transfers and ambulation. V12 was questioned if nursing staff could tell that R4 needed help with ambulation, V12 stated, It was obvious that she needed help. She had a hard time standing from her recliner, turning, and walking to the bathroom. She needed minimal assistance. She was limping at this time because of the right knee. I think I even worked with her to put more weight on her arms to take pressure off the knee while using the walker. I think I saw her not even an hour before her fall. She was sitting in her recliner when I left her. I did not speak to the nurse about my therapy evaluation that I had done. I don't know why it was 5 days after her first fall for my evaluation. I don't know if it was a weekend or when they got the order from the doctor for a therapy evaluation. There was no documentation in R4's Medical Record documenting that V12 talked to any nursing staff regarding R4 requiring assistance with transfers and ambulation. R4's Health Status Note, dated [DATE] 10:43AM, documents Note Text: CNA went to resident room during fire alarm to close doors went across hallway to close their door when she was closing other door heard a thump went to check on resident CNA yelled another CNA and writer because unable to get resident door open but was able to see resident lying on floor but unable to get between doors writer ran to check resident unable to get doors open noted bathroom door pushing against outer room door staff unable to get between doors, 911 called immediately by maintenance for assistance. staff continue to try different staff members to get between doors, 1 CNA was able to get between doors and reposition resident so other staff ADON (Assistant Director of Nurses) and another CNA was able to get in and help and assess resident, resident noted to be laying on abdomen face down with blood noted on floor vitals obtained B/P (blood pressure) ,d+[DATE] P(pulse) 77 R (respirations) 24 T (temperatures 97.7 SPO2 78 ROOM AIR resident started on O2 at 5L per n/c at this time. R4's Health Status Note, dated [DATE] 11:00, documents, Note Text: Ambulance here resident out of facility at this time resident is alert with O2 on SPO2 now 95%. R4's Health Status Note, dated [DATE] 2:21 PM, documents, Note Text: Writer called (local) ER to check if any updates post fall 3 brain bleeds, being transfers to (Regional Hospital), can't see, confused. R4's Regional Hospital Report, dated [DATE], documents, Impression Plan, dated [DATE], (R4) is a [AGE] year-old female with PMH (Primary Medical History) atrial fibrillation / flutter not on AC (anticoagulants), aortic stenosis, HTN (hypertension), COPD (Chronic Obstructive Pulmonary Disease) who presents as trauma transfer from (Local Hospital) after sustaining an unwitnessed fall at her nursing home, sustaining subdural, subarachnoid, and intraventricular hemorrhages. Patient admitted to Hospital NCC (Neurological Critical Care). Active Problems: 1. Left sided subdural hematoma, subarachnoid hemorrhage with intraventricular hemorrhage, traumatic. R4's Fall Investigation, dated [DATE], documents, Mobility: Ambulatory with assistance. Mental Status: Oriented to Person Oriented to Place. Predisposing Physiological Factors: Gait imbalance. Impaired Memory. Other Info (information) Independent with transfers. R4's Health Status Note, dated [DATE] 4:47 PM , Health Status Note, documents, Note Text: Resident was admitted to the facility via facility transport. She was admitted into room (room # of R4). She was accompanied by family. She arrived in a wheelchair with (mechanical lift) sling under her. Resident was assisted into bed via (mechanical lift) lift. She has her helmet in place. Skin assessment done. Resident has a bruise to her right eye that measures 10x10xutd (unable to be determined). She has a small skin tear to her right cheek that is cover by steri strips. No other skin issue noted. Resident has a fall mat in her room. Resident is with family at this time. R4's Health Status Note, dated [DATE] 11:18 AM, documents, Note Text: Resident sent to ER this morning per POA wishes due to resident O2 sat reading 83% with 3L of O2 N/C (nasal cannula), (local) ambulance called, transported resident to (local hospital) around 10:00 am. R4's (Local Hospital) Patient Insurance and Demographics, dated [DATE], documents, Contrast induced nephropathy with acute kidney injury, acute liver injury, dehydration, lactic acido [sic]. R4's (Local Hospital) History and Physical, dated [DATE], documents, In the ED, she was afebrile with stable blood pressures with no SBP (systolic blood pressure) greater than 100. HR was in the 40's with RR (respiration rate) up to 20. BUN/ Cr (blood urea nitrogen/ creatine) were elevated to ,d+[DATE].32 from baseline of ,d+[DATE].4 on ,d+[DATE] at (Regional Hospital). (V20, Hospital Doctor) discussed with POA, (Power of Attorney, V21), again at 7 pm regarding and she stated the family has discussed the situation and requested comfort measures with no hemodialysis. Per his note, 'She will be admitted to the floor with comfort measures.' R4's Health Status Note, dated [DATE] 12:30 PM, documents, Note Text: Resident returned to facility per ambulance. R4's Health Status Note, dated [DATE] 4:17 PM, documents, Note Text: Hospice nurse here today interviewed resident obtain new orders family at bedside updated on medication. R4's Hospice Note, dated [DATE] 16:06, documents, Note Text: Writer was notified by other floor nurse that the resident has expired. Writer and other floor nurse verified and called TOD (time of death) at 4:06 PM. R4's Death Certificate documents R4's date of death : [DATE]. Cause of Death: 1. Intraventricular Hemorrhage 2. Fall. On [DATE] at 2:42 PM V3, Certified Nurse's Aide (CNA), stated, She (R4) was on the 100- hall. I was actually working on the 200 Hall that day ([DATE]) and someone came and got me. I don't remember who. Her (R4's) room door was closed, and her bathroom door was open so when she fell , she was blocking the entry to the room. You could not open the door all the way. I squeezed through. Her head was lying on the left side of the door and her legs were facing into the room. I pulled her back a bit so the door could be opened and then I saw the blood. She was independent with her walker. She was alert not confused. On [DATE] at 3:00 PM, V4 LPN (Licensed Practical Nurse), stated, I wasn't here when she (R4) fell . She was independent. She would take herself to the bathroom. She used a walker. She ate in her room. She was alert and orientated times three. She was not a big talker. She would piddle around her room. She always sat in her recliner. She slept in her bed. She would dress herself and take herself to the bathroom. After the big fall when she came back, she was completely different. Her eyes where open but she was not there. She was a (full mechanical lift) complete and total care after that fall. On [DATE] at 3:05 PM, V5 CNA, stated, Before her (R4) big fall she was very quiet, always smiling. I helped her a few times. I would walk in her room to check on her and she would be taking herself to the bathroom so I would watch her and make sure she was ok and help her if she needed. She walked with a walker. She was alert and orientated times 2. On [DATE] at 3:15 PM, V7, CNA stated, Before the fall ([DATE]) she (R4) would get up by herself. She didn't ask for help or let you help her. She was safe to transfer herself with a walker. She would stay in her room. On [DATE] at 1:05 PM, V8, CNA stated, She (R4) was up and mobile. She would do things on her own. She didn't like for people to assist her. I would toilet her at meal times. She would wear her oxygen. She didn't have a problem with the long oxygen tubing. I was not here the day she had the bad fall. When she came back from that she was totally different. She was totally dependent on staff. She was non responsive, and she wouldn't use her communication board anymore. On [DATE] at 2:23 PM, V9, LPN stated, I work the night shift. (R4) was independent. She slept in her recliner. She took all her meals in her room. She walked with a walker. She didn't like help. She could use her call light. For me all she ever wanted was Laxatives. She didn't have any night time medications. When she came back from the hospital ([DATE]) she had oxygen, but she would always take it off. I would put it on her and then she would take it back off. I did SpO2 (oxygen saturation) checks on her. She would let you do that. I usually would check her once a shift. She was pretty alert. She could hold a conversation with you. On [DATE] at 3:12 PM, V11, LPN stated, Before (R4) fell on [DATE] she took care of herself. She took herself to the bathroom. When she came back from the ER (emergency room ) she did have an order for oxygen. The ER told me good luck with it she won't keep it on. She refused to keep it on. We would go in and try to get her to wear it, but she wouldn't. I did let the doctor know via fax and I spoke with (V10 Nurse Practitioner) about it. I checked her pulse ox (oxygen saturation) every morning because that really was the only way you knew if she was having difficulty. Before the fall ([DATE]) she normally ran between 93% and 95%. After the fall it was 88% to 91%- 92% that is as high as she would get. In between the 2 falls she was weak. She was bound and determined to keep doing things the way she wanted. We were encouraging her to let us help her. She needed assist of 1. We were doing increased monitoring checking on her. The second fall ([DATE]) it was during a fire drill. I had a CNA come and tell me she couldn't get the (R4's) door open and she thought someone is in there. I went and tried to get the door open, and I couldn't either. I did get it open a little and I saw feet. I was calling maintenance and managers because we had to get that door open to find out who it was and help them. At one point they thought they might have to call the fire department to come in through the window. I told them do whatever but we gotta get in there. I then remember we have (V3) she is tiny. She was working that day, so she came, and she was able to squeeze through. (V3) pulled her enough so the door would open. She was found face first on the floor. Her oxygen level was low. The paramedics came and took over. I remember it was a new CNA , I don't remember who, that was taking care of her that day and she did tell me that she had seen (R4) earlier. On [DATE] at 10:40 AM, V13, LPN stated, (R4) stayed in her room. She was independent. She would go to the bathroom by herself. She sat in her recliner. She took her meals in her room. I don't remember her using the call light that often. She didn't ask for a lot. She was in the first room on the left so she couldn't have gotten any closer to the nurses station. On [DATE] at 10:47 AM, V14, CNA stated, Before the bad fall the shower aide would give (R4) her showers. She was able to walk by herself. She would use the light to call for things like hot chocolate or tissues. I don't remember her needing more help between the falls. On [DATE] at 10:50 AM, V15, CNA stated, I was here the day she fell but she wasn't on my set. She refused for anyone to help her. She refused her oxygen. She did everything by herself. You would ask her if she needed to go to the bathroom and she would tell you no then you would catch her taking herself. She wasn't any different after the first fall she was just the same. On [DATE] during separate interviews, between 12:40 - 12:45 PM, V11, V14 and V15 all stated that they did not notice R4 having a limp. V11 stated, I only saw R4 walk maybe twice. On [DATE] at 2:23 PM, V18, RN (Registered Nurse) / MDS / Restorative Nurse, stated that when someone falls, we downgrade their transfer status until Therapy can evaluate them and all interventions can be put into place that way staff are just not continuing to let them do what they were doing when they fell so they don't fall again. V18 also stated that she is unsure why R4 did not get downgraded for her transfer status or why it took 5 days to get an order for Physical Therapy for R4. On [DATE] at 2:46 PM, V1, Administrator, stated that his expectation is that a therapy order should have been written before [DATE] so she could have been assessed sooner. V1 also stated that he is unable to locate the root cause analysis for R4's fall on [DATE]. On [DATE] at 3:05 PM, V22, Director of Operations, stated that it is unknown if R4's shoes were ever assessed. 2. R1's Admission Profile documents that R1 was admitted on [DATE] and has diagnosis of Lung cancer, Alzheimer's, hemiplegia, and Hemiparesis following a stroke affecting the right dominant side. R1's MDS, dated [DATE], documents that R1 is severely cognitively impaired and requires supervision with physical assistance from 1 staff member for transfers, walking in room and in the corridor, locomotion on and off the unit, toileting, hygiene, and dressing. R1's MDS, dated [DATE], documents that R1 is severely cognitively impaired and requires extensive physical assistance from 1 staff member for bed mobility, transfers, walking in room and in the corridor, locomotion on and off the unit, toileting, hygiene, and dressing. R1's Health Status Note , dated [DATE] at 12:10, Note Text: Writer was notified by staff that the resident was on her knees in her room. Writer observed the resident in a praying position in front of her recliner with her hands fold and head in seat of chair like she was praying. Writer asked resident how she got like that. The resident stated that she did not fall, she was walking to push her tray/bedside table to the foot of her bed and when she turned back around to walk to her recliner, she felt weak/dizzy. She stated she lowered herself to the floor that she didn't fall. Writer and another staff member assisted her off the floor and into her recliner. No injuries were noted but she had carpet imprints on her knees that were starting to fade. Resident denies any pain of discomforts. She is able to move all extremities without difficulties. She takes scheduled pain medication. Resident denies any new pain just the previous discomforts we are treating. MD notified. All parties notified. Will continue to monitor. R1's Fall Investigation, dated [DATE], documents, IDT (Intradisciplinary Team) meeting held with DON (Director Of Nurses) ADMIN (Administrator), MDS (Minimum Data Set) therapy and nurse managers. Root cause identified as residents noted to be dizzy and having increased confusion. Intervention: change transfer status to 1 - assist, MD (Medical Doctor) to review medications possibly rule out UTI (urinary tract infection) r/t (related to) increased confusion. R1's Fall Investigation, dated [DATE], documents, resident noted to have UTI , Hospice MD aware and treating with ATB (antibiotics) at this time. R1's Health Status Note, dated [DATE] 18:15, documents, Note Text: Writer was notified that the resident was on the floor in her room. The resident was observed on the floor in front of her bathroom with her back up against the door frame and her legs extended out in front of her towards the door. Resident was incontinent no shoes on but had socks on. Resident is c/o pain and discomforts when we attempt to move her. She states she is unaware if she is injured or not. Writer spoke with DON and about sending her to the hospital. Writer also spoke with the residents POA, and she stated she would like for her to be seen as well. Writer called and informed hospice of the occurrences and that we are sending her to the ER for evaluation and treat. Ambulance is en route to the facility to pick up resident. R1's Health Status Note, dated [DATE] 22:37 Health Status Note, documents, Note Text: resident returned to facility per transport and staff assist of one, rec'd (received) ct (computed tomography) and numbers x-rays of all extremities, results of questionable fractures of the tuft of the distal third digit, returned with sling resident can wear as per request, does not want on at this time, states is not hurting at this time, able to move, swollen as prior to fall no bruising noted at this time, neuro checks restarted, wnl (within normal limits) possible avulsion fracture, mild degenerative changes. R1's Fall Investigation, dated [DATE], documents, Intervention: reassess toileting plan, encourage to assist to recliner after meals. R1's Health Status Note, dated [DATE] 08:29, documents, Note Text: Resident found per CNA sitting on floor in front of her recliner. She couldn't verbalize how she ended up there. VSS. (vital signs stable) Denies pain. ROM WNL (range of motion within normal limits). No apparent injuries. Call light in reach. POA (power of attorney) sister notified. R1's Fall Investigation, dated [DATE], documents, IDT meeting held with DON, ADMIN, and clinical nurse, Root cause identified as resident increased confusion BIMS (Brief Interview of Mental Status) of 5 and all needs were met at that time. Intervention: bed alarm, chair alarm, and w/c (wheelchair) alarm. R1's Health Status Note, dated [DATE] 08:59, documents, Note Text: CNA came to get me to notify resident was on the floor. Observed resident sitting on buttock, feet out in front of her and it appeared she slid out of recliner. Assessed resident for any injuries, none noted and no c/o pain. Vitals obtained, ROM w/o any pain observed. Transferred resident back to recliner via (mechanical lift). MD/POA notified. R1's Health Status Note, dated [DATE] 12:28, documents, Note Text: Resident noted to have increase in falls. Intervention for bed, chair, and w/c alarms. POA gave verbal consent and is aware of plan of care. MD aware. R1's Health Status Note, dated [DATE] 20:45, documents, Note Text: CNA (V23) was walking past the resident's room and noted her sitting on the floor in front of her recliner. This writer was notified, and resident assessed. No injury noted and has FROM (full range of motion) to extremities. She did not hit her head. Alarm in place and alarming. (R1) is attempting to get up and is sliding to the floor. Educated again on using her call light for help. She remains non-compliant. Isolation precautions continue due to ESBL (Extended Spectrum Beta-Lactamase) of the urine. No AR (adverse reactions) from ABT (antibiotic). Intervention is to ensure legs are elevated when in recliner and ensure alarm in place and active. Assist toileting at least every 2 hours and frequent checks. ,d+[DATE]-[DATE].9, SAO2 (oxygen saturation) 95% on RA (room air). R1's Fall Investigation, dated [DATE], documents, IDT meeting held with ADMIN, MDS, DON, and Therapy. Resident continues to get up despite intervention. Intervention: 15-minute checks. R1's Fall Investigation, dated [DATE], documents, Went to (R1's) room and noted her on the floor behind her recliner. IDT meeting held with ADMIN, MDS, DON, and Therapy. Resident continues to get up despite redirecting. Intervention: 15-minute checks. R1's Fall Investigation, dated [DATE], documents, Nursing Description: resident observed on floor in front of recliner. IDT meeting held with DON, ADMIN, therapy, and MDS. Root cause: resident continues to get up w/o (without) assistance. Resident stated at time of fall she had no pain but has c/o (complaint of) stomach pain and has had difficulty the past few weeks regarding ambulation and overall decline. Intervention: Hospice to review medication and evaluate for increase pain. R1's Care Plan, dated [DATE] and revised on [DATE], documents, Fall risk, history of stroke, COPD & other medical conditions that may cause weakness. Under hospice care, incont (incontinent) of urine at times, may try to get up without help. Interventions: [DATE] transfer status changed to one assist. [DATE] Evaluate for toileting plan. [DATE] MD to review medications. [DATE] Encourage to assist to recliner after meals. [DATE] Bed, recliner, and w/c alarms on at all times. [DATE] Hospice to assess r/t decline. [DATE] initiate 15 minute checks. [DATE] hospice to review medication. [DATE] Call light within resident's reach when in bed & at bedside. [DATE] Encourage and assist resident to toilet routinely and assist with peri care after incontinent episodes to help keep resident clean dry and odor free. [DATE] Keep pathway clear. 3. R5's Admission Profile, with print date of [DATE], documents that R5 was admitted on [DATE] and has diagnoses of Parkinson's Disease with Dyskinesia and repeated falls. R5's MDS, dated [DATE], documents that R5 is cognitively intact and requires extensive assistance from 2 staff members for bed mobility, transfer, locomotion on unit, dressing, toileting, and personal hygiene. R5's Health Status Note, dated [DATE] at 2:21 AM, documents, Note Text: Resident found face down near the foot of his bed. Resident has advanced Parkinson's and has difficulty with speak, unable to understand what resident was attempting to state happened. Residents VS as follows 97.8, 95% RA, 108, 22, unable to obtain BP. Resident shook his head yes when asked if he was having pain. (V19) called and order received to send to (local hospital) for eval and treat. (ambulance) called and arrived at 0220. Sister called and message left to update on incident. On call notified at 0232. R5's Health Status Note, dated [DATE] at 6:00 AM, documents, Resident returned from (local hospital) post fall. No new orders. No c/ [TRUNCATED]

Based on interview, observation and record review, the facility failed to provide pain medication to control pain for 1 of 2 residents (R202) reviewed for pain control in the sample of 43. The failure resulted in R202 being in severe pain from 8:00 AM until 4:40 PM on 8/8/23. Findings include: R202's Admission Record, dated 8/14/23, documents, that R202 was admitted on [DATE] and has diagnosis of Diverticulitis of Large Intestine with Perforation and Abscess without Bleeding, Encounter for Palliative Care, Neoplasm of the Parotid Salivary Glands, Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Anxiety and Depression. R202's, Medication Administration Record, (MAR), for August 2023 beginning 8/7/23 documents, Morphine Sulfate (Concentrate) Oral Solution 10 MG (milligram) / 0.5 ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain moderate. Start date 8/7/2023 8:15 PM. D/C, (discontinue), date of 08/08/23 at 1:38 PM. This MAR documents, that this dosage of morphine was not given. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.5 ml by mouth every 2 hours as needed for severe pain (7-10). Start date of 08/08/23 at 12:30 AM D/C date of 8/14/23 at 1:04 PM. This MAR documents, that this dosage of morphine was not given until 8/8/23 at 4:40 PM for a pain level of 7. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML give 0.25 ml by mouth every 2 hours as needed for moderate pain (4 -7)/SOB, (shortness of breath). Start date of 08/08/23 at 12:15 AM D/C date of 8/14/23 at 1:03 PM. This MAR documents, that this dosage of morphine was not given until 8/9/23 at 11:00 AM. R202's Health Status, Note, dated 8/7/2023 at 4:57 PM, documents, pt, (patient), arrived at 4:40 PM, via facility transport. pt is (local) hospice. pt is friendly and clean in appearance. BP, (blood pressure), 116//59, pulse, 82, O2, (oxygen), 96%, temp, (temperature), 97.1. R202's Health Status Note, dated 8/7/23 at 8:32 PM, documents, Hospice RN, (Registered Nurse), here to evaluate resident. New orders received, to admit to (local) Hospice, new med, (medication), orders received. Family at bedside and spoke with RN regarding orders. R202's Hospice Note, dated 8/8/2023 at 8:15 AM, documents, Writer spoke with Hospice Nurse who came in to evaluate resident, about her narcotic scripts and us needing them from the Physician. She stated that she had spoken with the MD, (Medical Director), and was just waiting for the Doctor to sign the scripts, (prescription), and then they would send them to Pharmacy as well as us. She stated that it shouldn't be long. Writer explained the importance of having those scripts for the resident was in discomfort. Resident was given PRN, (as needed), Tylenol at her 08:00AM Med, (Medication), pass, will continue to monitor. R202's Health Status Note, dated 8/8/2023 1:43 PM, documents, Spoke with (local) Hospice to clarify orders. Able to d/c some morphine and Ativan orders from hospital and d/c hydrocodone. (V20 RN) stated, she would be sending the scripts over to the Pharmacy to get filled. Awaiting Pharmacy at this time. R202's Health Status Note, dated 8/8/23 at 3:46 PM, documents, Writer spoke with nurse from hospice about the residents Narcotic scripts. Hospice nurse stated that she is waiting for the doctor to sign the script and send to pharmacy. She asked if I could call (pharmacy) at 4:30 PM to see if pharmacy has the scripts yet. Writer stated she would. R202's Health Status Note, dated 8/8/23 at 4:13 PM, documents, Called pharmacy to ask if hospice has sent over scripts. Pharmacist stated that they had them and this writer could get them out of the Pyxis. Writer and second nurse went to get medication from Pyxis. Once given access code, writer obtained morphine and administered residents PRN dose at 4:40 PM. R202's Health Status Note, dated 8/8/23 at 6:42 PM, documents, Administrator assisted with getting clarification from (Pharmacy) regarding fentanyl scripts. This writer was able to access Pyxis with second nurse to obtain fentanyl patch. Placed onto residents left chest after removing old patch from right side of chest with (V18 RN) to verify placement. On 8/8/23 at 3:40 PM, this surveyor is standing at the nurse's station speaking with V18, Registered Nurse. V20, Hospice Nurse, came up to the nurse's station and starts talking with V18 regarding a hospice patient that she is caring for. V17, R202's Power of Attorney, came up to the nurse's station and asked to speak with V18 regarding R202. V17 asked, V18 if R202 can have some Morphine, because she is in pain. V18 stated, that she did not have any pain medication available to give to R202 because, it had not been delivered to the facility yet. V18 stated, that when she was discharged from the hospital yesterday, the hospital did not send R202 with a written Prescription for the Morphine. V18 explained that a narcotic requires a written Prescription, or an electronic prescription sent directly to the Pharmacy from the Doctor. V17 asked, Well what do I need to do to get her some Morphine? V18 stated, that R202 is going to have to wait and that the Hospice Nurse has been here and V6, Assistant Director of Nurses, is aware of the issue and is working on it. V17 asked, Well can I go to the hospital and get a Prescription from them, she is in pain? V18 stated, that the hospital would not give her a Prescription for medications for R202. V17 asked again if she could go to the hospital. V18 told her that would not work, she knows R202 is in pain and that she did give R202 a Tylenol this morning for pain. V17 stated, that R202 does have a Fentanyl patch on that is dated 8/5/23 and it is only good for 3 days, so it needs to be changed. V18 told V17 that none of R202's pain or anxiety medications had been delivered yet. V18 stated, that Hospice was here last night and admitted R202 and wrote orders for R202 but then none of the medications were available and then the hospice nurse was here again this morning and wrote orders for her but none of the medications are available yet and that V6 has been working on getting the problem solved. V7, Licensed Practical Nurse Unit Manager, came to the nurse's station and spoke with V17 about V17's concerns and then they both walked down to R202's room. V20 spoke up and said to V18 let me try and figure out what is going on because I know that V19, Hospice Nurse assigned to R202, was here and should have had those orders completed. V20 then called V19 on the phone while standing at the nurse's station. V20's phone conversation was overheard. V20 said to V19 why is R202's medications not available. There was a pause. V20 then said V19 you need stop what you're doing and put those orders in right now so that the Hospice Doctor can sign off on them and the Prescription can be sent to the Pharmacy. V20 then hung up the phone. V20 told V18 that V19 was going to put the orders in and to call the Pharmacy at 4:30 PM to see if they have the Prescription. V20 then walked down to R202's room. V19 then told this surveyor that she was not sure what happened, but the Hospice Nurses have been here twice and that V6 was working on it. V19 said R202 is in pain because, she is full of cancer and that she did give her a Tylenol this morning for her pain. V7 returned to the nurse's station and told V18 to call the Pharmacy at 4:30 PM to see if the Prescription has been sent. On 8/8/23 at 3:55 PM, R202's room was entered. R202 is lying in bed on her back with her face turned toward the wall. R202 is very pale. V17 is sitting in the room. V17 stated, that R202 is a lot of pain and she doesn't understand why if she was admitted yesterday afternoon none of her medications are available to her. R202 was asked if she was having pain, R202 slowly moved her head and nodded yes. R202 was asked where her pain was, R202 very softly said, stomach. R202's face was grimacing, and she then very slowly turned her head back to the wall. V17 then showed this surveyor R202's Fentanyl patch that was on her chest and the Fentanyl patch was dated 8/5/23. V17 stated that it needs to be changed but the facility does not have one of those for her either. On 8/8/23 at 4:02 PM, V6 and V1, Administrator were interviewed. V6 was questioned regarding R202's medications, V6 stated, that she spoke with the hospice nurse around 1:30 PM and that she was told that R202's medications would be available. V6 was informed that R202 still did not have any pain medication available to her. V6 stated that she was not aware of that. V6 stated, that when R202 was admitted her medications were never reconciled and she worked on them from home that night and then the Hospice Nurse, (V19) had come again this morning and wrote orders and that she said she was going to send them to the Pharmacy. V6 and V1 were told of this surveyor's observation of R202 that just happened was of a Hospice resident lying in bed in pain. V6 stated, that R202 is full of cancer, and she has a perforated intestine. V1 and V6 both stated that R202 not having her pain medication is ridiculous and that they would figure out what exactly is going on and get to the bottom of the problem. V1 and V6 both agreed that the whole point of hospice is to die with dignity and to not be in pain. On 8/9/23 at 8:30 AM, V1, stated, I am going to take responsibility for this, but we are not the only ones that failed. I think it was an all-around failure including hospice and the pharmacy. I did talk to hospice and with the help of V20 we were able to get (R202) her morphine at 4:40 PM and then we were able to get her Fentanyl Patch put on around 6:00 PM. (V6) and I stayed until R202's pain medications were given to her, and everything was straightened out. On 8/15/23 at 10:00 AM, V23, Hospice Executive Director Specialist, stated, that R202's medication orders were sent to Pharmacy on the evening of admission. When a facility uses their own Pharmacy, I have no control over when the medications will be delivered. Our responsibility is to ensure that the order is sent to the Pharmacy which we did. It is the facilities responsibility to let the off-hour Pharmacy know that orders have been sent and access them. The facility always has the ability to notify their Medical Director and get orders if they need something right away or if there are problems. On 8/15/23 at 11:39 AM, V22, Pharmacist, stated, that R202's Hyoscyamine, Morphine, Lorazepam and second Morphine order was entered into e-scripts (electronic prescription) on 8/7/23 at 5:42 PM and the order was sent by V25, Hospice Doctor. V22 stated, that the Pharmacy closes at 5:30 PM and after that we have an after hour Pharmacist that is available to enter orders. Since the orders came in after hours, the facility should have called and talked to the off-hour Pharmacist and then let them know that Prescriptions were sent. The off-hour Pharmacist then would review the Prescriptions and make sure, and all the needed information is there. If the Nurse needs to get the medication, all the Nurse needs to do is call the off-hour Pharmacist and he will give them an access code and they can then get the medication for the Pyxis machine. At this time, I do not see any notes where the night Nurse called to get an access code. These medications were valid in the Pyxis machine on 8/7/23 and 8/8/23 all that needed to happen was a Nurse to call and get an access code for the Pyxis machine. On 8/15/23 at 12:34 PM, V18, Registered Nurse 8/8/23 Day Shift, stated, When I came in, I was told that the Hospice Nurse came in the night before and admitted R202 and wrote orders on her. I was told that she did not have Prescriptions for the Narcotics and when she gets the Prescriptions, she will send them to the Pharmacy. A Hospice Nurse came in in the morning and I showed her how the medications were changed. The day Hospice Nurse told me that she was trying to get the Prescriptions from the Doctor. I let V6 know that I just got this piece of paper from the night Nurse and that we don't have any of her Narcotics. V18 was questioned if she thought of calling V27, Medical Director, for pain medication, V18 stated, No I didn't. I thought it was being taken care of plus he is not the Hospice Doctor. On 8/15/2023 at 12:48 PM, V24, Hospice RN, stated, that she saw R202 at approximately 5:45 PM on 8/7/23 and signed papers with the family. I then went and assessed R202 then I went and talked with the family again. I then went over the orders with the Nurse. I then called the (our electronic Pharmacy) and gave them her profile which is her basic information and entered her orders. I write the Prescription electronically and send them to (our electronic Pharmacy). The Doctor then signs it, and it is sent electronically to the Pharmacy. I spoke to the night Nurse (did not remember name) and explained the orders and that the orders were sent to (facility Pharmacy) so if she needed to access any of the medications, she would need to call the Pharmacy and let them know and they can give her access to the Emergency Kit. On 8/15/2023 at 12:56 PM, V25, Licensed Practical Nurse, (LPN), stated, that she came in at 6:00 PM on 8/7/23. The Hospice Nurse was there late around 9 or 10. She wrote orders for R202. She told me she had sent them to the Pharmacy and if I needed them to call the Pharmacy and then I could pull them from the pyxis machine. I did not need any because R202 slept all night. She had a good Fentanyl Patch on. In the morning in report, I told the day Nurse (V18) the Hospice had been in and had written orders and sent them to the Pharmacy. I told her I did not need to access the Pyxis machine because R202 slept all night, but if she needed the pain medication or the Ativan just to call the Pharmacy and get an access code. The facility Management of Pain policy dated 5/16/22, documents, Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Using pain medication judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences. The Pharmacy Pharmacist On-Call Procedure, undated, documents, During regular Pharmacy business hours: 9:00 AM - 5:30 PM Monday - Friday 9:00 AM - 2:00 PM Saturday. After Pharmacy is closed: 1. call Pharmacy as you would during our business hours. 2. You can leave a message as before if something isn't needed until the business day by pressing 1 and then the appropriate extension. 3. Or, you can follow the message prompt and press 2 to be transferred directly to the pharmacist on call. 4. The on-call pharmacist will arrange to obtain the needed medications from the back-up Pharmacy. 5. The on-call Pharmacist will also arrange delivery.

A. Based on observation, interview and record review, the facility failed to provide supervision while eating for residents with potential choking hazards for 5 of 5 residents (R41, R46, R57, R216, R217) reviewed for supervision to prevent choking in the sample of 56. This failure has resulted in R57, R216, and R217 choking that resulted in death related to the incidents of choking. This failure resulted in an Immediate Jeopardy (IJ) which began on [DATE] when R217, a resident with dysphagia (difficulty swallowing), was left unattended to consume a liquid dietary supplement and choked. R217 expired on [DATE]. The Immediate Jeopardy was identified on [DATE]. On [DATE], V1, Administrator, was notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1. R57's Health Status Note, dated [DATE] at 1:21 PM, documents, housekeeper yelled out 'hey i think she needs some help in here'. Writer ran to resident room noted resident sitting in bed, head of bed up meal tray in front of her. When staff asked what she needed writer noted res (resident) unable to talk food running out of her mouth and down her clothing writer asked again if she was choking unable to respond verbally just looked at nurse. Mouth sweep done small amount of food obtained, writer gave several back thrusts continued with nonverbal. Writer yelled at housekeeper to get help, another nursing staff member, and emergency equipment. CNA (Certified Nurse Aide) arrived assisted resident with abdominal thrusts from in bed resident became unresponsive lips turning and fingertips turning blue, pulse obtained at this time. resident assisted to floor per 2 CNAs DON (Director of Nurses) arrived writer went to call 911 and get confirmed code status. DON AND CNA's remained with resident. R57's Health Status Note, dated [DATE] at 1:25 PM, documents, This writer entered the room and observed resident minimally responsive with her eyes open and gasping for air. Two staff are present in the room attending to resident. Pulse present to radial pulse upon palpation. Elevated head and suctioned resident. Performed [MEDICATION(S)] Maneuver performed. HR (heart rate) 32, SPO2 (oxygen saturation) at 85%. Applied Oxygen via non rebreather mask at 10L (liters). Remain with resident until paramedics arrived. R57's Health Status Note, dated [DATE] at 1:25 PM, documents, 911 called at this time. R57's Health Status Note, dated [DATE] at 1:27 PM, documents, Ambulance/paramedics here in facility. R57's Health Status Note, dated [DATE] at 1:30 PM, documents, Writer called (V48, R57's Power of Attorney- POA) informed of current status and res choking paramedic with resident now. R57's Health Status Note, dated [DATE] at 1:37 PM, documents, Paramedics working with resident unable to obtain vitals called passing at this time. R57's Health Status Note, dated [DATE] at 1:50 PM, documents, Writer called to have (V49, Coroner) paged regarding passing of resident at this time. R57's Health Status Note, dated [DATE] at 2:04 PM, documents, (V49) returned call informed res had passed called by paramedics/informed of circumstances following up to death. (V49) informed that staff may return resident to bed hold body until had a chance to talk with family. R57's Face Sheet, print date of [DATE], documents R57 was admitted on [DATE] and has medical diagnoses of [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction, Dysphagia (difficulty swallowing) following Cerebral Infarction affecting right dominant side, Dysarthria (difficulty with speech) and Anarthria (inability to articulate speech in the absence of any deficit both of auditory comprehension and of written language. R57's Minimum Data Set (MDS), dated [DATE], documents that R57 was cognitively intact, requires extensive assist of two staff members for bed mobility and is totally dependent on 2 staff members for transfers. This MDS further documents that R57 requires supervision and one person physical assist with eating and R57 has range of motion limitation of one side on both the upper and lower extremities. R57's Order Summary Report, Active Orders as of: [DATE], documents, REGULAR diet, Easy to Chew (Mech) (EC7) texture, Moderately Thick (Honey) consistency and DNR (Do Not Resuscitate). R57's Care Plan, dated [DATE], documents, (R57) is at risk for wt (weight) fluctuations. dx (diagnoses) dysphagia, diabetes type 2, history of stroke, with [CONDITION(S)] and [CONDITION(S)] rt (right) dominant side. [DATE], dietician requested due to gradual weight loss, a diet change from low concentrated sweets to regular. Interventions: Provide divided plate/wt (with) built up utensils. Provide, serve diet as ordered by MD (Medical Doctor). Sit upright for all meals and provide supervision. R57's Care Plan, dated [DATE], documents, ADL (Activities of Daily Living) r/t (related to) [CONDITION(S)] (Cerebral Vascular Accident) with right sided weakness, cognition deficits/poor safety awareness and poor balance, DX of [CONDITION(S)]. Res has RT sided [CONDITION(S)]/flaccidity from stroke, dysphagia, RT wrist/hand decreased ROM (range of motion)/contracted. Interventions: Eating, feeds self with set up, sit upright for all meals and supervision, may need assist at times. The Facility's Dietary Spread Sheet, dated week 3 Wednesday, documents, Easy to Chew / Mech (EC7) 4 oz (ounces) Chop meatloaf w (with) / 2 oz. gravy, #8 scp (scoop) mashed potatoes, 2 oz L (ladle) gravy, 4 oz S (scoop) Brussels Sprouts, 1 each bread/ Marg (margarine), 4 oz watermelon, no seeds, 8 fl (fluid) oz milk. R57's Care Plan, dated [DATE], documents, Advanced Directives. I have formulated advanced directives. No code. R57's Health Status Note, dated [DATE] at 2:25 PM, documents, (V49) returned called informed writer that (V48) has no concerns with what happened with death had no issue due to resident had frequent issues with swallowing since stroke. POA is very happy with the care she has received during her stay here and is ok with going ahead to release the body to the funeral home. (V49) informed writer she has no issues at this time happy with POA response order May release body to Funeral Home when ready. On [DATE] at 1:25 PM, V31, Licensed Practical Nurse (LPN), stated, (R57) was choking. The housekeeper said that (R57) needed help. I ran down there. I got there and she couldn't talk and she was just staring. I was trying to do the [MEDICATION(S)] on her, but she was like dead weight. She had a pulse. I tried to do a finger sweep, but I couldn't get anything. I yelled to get the crash cart and call 911. She had a pulse, but they lost it about a minute ago. The paramedics are working on her now there are so many people in there now. On [DATE] at 2:00 PM, V36, Housekeeping, stated, I just finished cleaning that room (pointing to R57's neighbor's room) and was coming up this way. I always look in the rooms as I walk by. I noticed she (R57) was in bed and having trouble. I thought she was choking so I went up and told the nurse that I thought R57 was choking, and she (V31) ran down the hall to her. When asked if anyone was in the room helping (R57) eat, (V36) stated, No, she (R57) was alone. On [DATE] at 4:45 PM, V35, LPN, stated, During my medication pass, (V39, CNA) came and told me (R57) would not wake up to eat. I told her to cover up her tray and try again later. I told both her and (V28, CNA) that we would try later to get her up and feed her. Everyone knew that she was supposed to be supervised during meals because she was thickened liquids. I was at break. I just got my food and they told me (V31) needed me because of (R57). When I got to the room, (R57) was on the board on the floor and (V2, Director of Nurses-DON) was suctioning her at the time. She (R57) told me about a month and a half ago that she was [AGE] years old, and she didn't want to get out of bed anymore and she wanted to eat in bed. They told me yesterday she went out to the dining room for lunch. I don't know how they got her out there. On [DATE] at 4:52 PM, V28, CNA, stated, (V50, CNA) called me in there and I put the bedside rail down and I was able to position her (R57) where I could stand on the floor and get behind her and I did the [MEDICATION(S)]. She did throw up a little bit and some food was visible in her mouth, so I cleaned that out of her mouth. During this process, (V31) told (V50) to get the back board and then we got her on the ground. This is my first time working with her, but I do know that she ate in the dining room at a regular table. I really don't know how she got her tray today. On [DATE] at 4:55 PM, V31, LPN, stated, I was at the nurse's station and (V6, Dietary Manager) came up and said (V36) needs you. I ran down the hall yelling. She (V36) yelled I am in (R57's) room. I went in she (R57) was sitting up in bed. It looked like she threw up some green stuff on her, her tray was in front of her, and it looked like she pushed it away a little. She had whole brussel sprouts on her tray. I don't know about the rest. I just saw the brussel sprouts because of the green. I asked her if she was choking. She couldn't answer. She was just staring at me. I leaned her forward and hit her on her back a few times. It didn't help. I couldn't get behind her or move her by myself. (V28) came in and we were able to move her enough for (V28) to get behind her and do the [MEDICATION(S)]. (R57) lips and the tips of her fingers started turning blue, so I knew I needed someone to get me the back board and suction machine. By the time we got her on the floor, (V2, DON) came in and told me 'I am here, you go call 911 and check her code status'. On [DATE] at 5:15 PM, (V39, CNA) stated, I sat her (R57) up and tried to wake her up and I gave her her tray. She had a whole meatloaf piece and mashed potatoes. I don't know if the brussel sprouts were whole or not. She had three thickened drinks. I went and told the nurse (V35) that she was sleepy, and she said we will try again later. She would eat in her room all by herself all the time. I guess she woke up and started to eat. On [DATE] at 12:47 PM, V44, Dietary Field Supervisor for the Heritage Corporation, stated, EC7 is an easy to chew diet it is the International Dysphagia Diet Standardization Initiative. When if brussel sprouts are on an easy to chew mechanical diet, V44 stated, Yes they are. On [DATE] at 1:45 PM, V2 stated, So I was in the hallway, they said, someone said someone is choking so I started running to where all the people were. I said get the suction machine to (V51, Admission Coordinator). She grabbed the crash cart it has suction on it. I got to the room (R57) is already on the floor on a back board. 2 CNA's are in the room, (V28) is at her head and (V34) is at her chest. (V34) had her hands on her chest, I didn't see her doing CPR (cardiopulmonary resuscitation), but she told me she did. There was not a nurse in the room. I do know that (V31) had been in the room maybe she was calling 911. When asked if she told (V31) to leave the room that you were there and go and call 911, V2 stated, I don't remember that. V2 stated, Her eyes were open she had a pulse. You could tell she was gasping for air. I raised her head and put it in my chest and suctioned her. I was able to get some food out. It was brown. I assume it was meatloaf. Once I was done suctioning, (V28) did the [MEDICATION(S)]. At this time, her heart rate was 32, her O2 (oxygen saturation) was 85%. I applied 10 liters of oxygen on a nonrebreather mask. The medics came and took over at this time she still had a pulse. At 1:37 PM, she no longer had a heart rate. The medics cannot call time of death. Myself and another nurse (V16, Registered Nurse- RN) called the time of death. (R57) was a DNR (Do Not Resuscitate). (R57) needed supervision while she ate because she had dysphagia which is difficulty swallowing. She should not have been in the room eating alone. When asked how this happened, V2 stated, I have not finished my investigation yet. When asked, if she saw R57's food tray, V2 stated, I told them to save it for me but by the time it was all over someone had gotten rid of it. On [DATE] at 1:45 PM, V6, Dietary Manager, stated, I did not deliver (R57's) tray. I was walking down the hall and (V36) said she need help. I yelled at (V31). (V31) ran past me. I stood in the doorway and got (V31) gloves. (R57) was sitting at a 90 degree angle maybe even more in bed. I remember seeing meatloaf and mashed potatoes and gravy on her tray. I cannot tell you how the meatloaf was. I want to say it was cut up but not sure. With her diet, she should of had a piece of meatloaf that is broken up with a fork then gravy is put over it to give it liquid and that is done in the kitchen. Whoever set (R57) up should have cut her brussel sprouts in half. On [DATE] at 10:46 AM, V51, Admission Coordinator, stated, The dietary manager called me on my phone and said she couldn't reach (V2) DON, and we have someone choking down here. Can you get the crash cart? I went that way and passed (V2) in in the hall. I went to the dining room to get it (the crash cart) and a dietary aide said they already got it. I went down to the room, and it wasn't there. I went back and (V35) was bringing it out. I took the cart to the room. She (R57) was already on the floor, (V2) started to suction her. It was me, (V2, V31, V35 and 2 CNA's and V16) was right behind us. (V2) to able to suction a couple of wads of meatloaf that was in her jowls and some mucous. (V2) thought she felt a pulse, so I put a pulse oximetry meter on her, and we were able to get a pulse. (V2) placed (R57) on oxygen on a nonrebreather mask, then the paramedics came and took over. On [DATE] at 10:57 AM, V34, CNA, stated, I was bringing my resident out of the dining room, and I saw (V50) CNA running down the hall with the back board. I got my resident out of the way and followed (V50). When I got to (R57's) room, (V50) was pulling (R57) out of the bed, she put her on the floor on top of the back board. (V28) was holding her head. I heard someone, I think (V31), but I haven't worked here that long to know all the voices, said to start CPR. I started CPR, I probably got 15 compressions in. Then (V2) entered and said do you have a pulse, I said I don't know I just started CPR, (V2) checked and got a pulse and told me to stop. We got the suction machine all hooked up and (V2) was behind (R57) suctioning her and doing the [MEDICATION(S)]. I also did suction because I was in front, and I could see in her mouth. I was able to get some food chunks out but not all some of the pieces were too big for the suction machine. Some of the pieces were the size of pebbles and even nickels. It looked like she hadn't chewed her food at all. Then the paramedics came and took over. On [DATE] at 11:20 AM, V16, RN, stated that she was made aware of (R57's) choking. V16 stated, I started going that way when I got to the nurse's station someone yelled call 911. I stopped and did. I was on the phone with them for a few moments. I hung up when done and I went to see if I could help. (V2) was at her head suctioning her and working with her. I was trying to get the room clear of the CNA's that did not need to be in there. I told the maintenance man to go met the paramedics at the door and make sure the hallway was clear. The paramedics showed up and were talking to (V2). They put their electrodes on her, and they did get a heart rate. It was in the 30's. Then her heart rate stopped. One of the ambulance guys came out of the room and called the coroner. I asked what time they were going to call the death for charting and one of the paramedics said that they don't do that. (V2) and I called the time of death. I did not see (R57's) tray. When asked if R57 should have been in her room eating unsupervised, V16 stated, No (R57) should not have been eating by herself. On [DATE] at 2:53 PM, V55, Firefighter/Paramedic, stated, We were the first on the scene. The ambulance pulled up behind us. We were told that CPR had been initiated but it had not been. She (R57) was on the floor with her head in someone's chest. She had oxygen on. Her mouth was wide open, she was not breathing, and I could not see any airway obstruction in her throat. The facility had been suctioning her and there was what looked like meatloaf and mucous in the suction container. We did not suction her because the facility already had, and I did not see an obstruction. We felt for a pulse and thought we got one radially, so we checked it on the carotid, and we did not get one. She had no rise and fall of the chest and did not respond to painful stimuli. Her pupils were fixed and dilated. We put the monitor on her, and we were getting an initial pulse of 35 which dropped to 10. The monitor was indicating PEA (pulseless electrical activity). The hospital was called for medical directive since she was a DNR, and they said to stop treatment. The local Fire Department Incident Report, dated [DATE], documents, Primary Impression: [CONDITION(S)]. Initial Patient Acuity: Dead without Resuscitation Efforts. Final Patient Acuity: Dead without Resuscitation Efforts. Vital Signs: 1:25 PM Unresponsive, Pulse 35 R (regular), RR (Respiration Rate) 0. 1:29 PM Unresponsive, Pulse 25. ECG (electrocardiogram): 1:25 PM PEA (pulseless electrical activity). 1:29 PM PEA. Assessment: Mental Status: Unresponsive. Skin: Cyanotic Pale. Eyes: Left 6 mm (millimeters). Non-Reactive. Narrative: Rescue (1:51 PM) dispatched to above address for a pt. choking that has gone unresponsive and stopped breathing. Upon arrival staff member stated they believed CPR was being performed on pt. Upon arrival to pt. room. CPR was not being performed and pt. was unresponsive and apneic. NH (nursing home) staff had suctioned food from pt's mouth and cleared pt's airway and then placed pt on O2 via non rebreather. When asked how long pt. has been choking prior to arrival NH staff stated that they did not know and that pt. was found in her room. (1:51 PM) checked pt's radial pulse and believed a weak and thready pulse may have been felt. Pt's carotid pulse then checked and was absent. NH staff then present (1:51 PM) with DNR paperwork. (1:51 PM) then placed pt. on cardiac monitor showing 35 bpm (beats per minute), and pt's pulse rechecked at both radial and carotid locations and confirmed by two members from 1351 (1:51PM) to be absent. Pt in PEA. Local ALS (Advanced Life Support) ambulance then arrived on scene. (Local ambulance) then contacted medical control and informed them of the situation. Medical control then advised (ambulance) to not perform resuscitation efforts. (1:51 PM) cleared from the scene. Specialty Patient - CPR: [CONDITION(S)]: Yes, prior to EMS (Emergency Medical Services) arrival. [CONDITION(S)] Etiology: Respiratory/ Asphyxia. On [DATE] at 10:45 PM, V54, Fire Chief, stated that PEA is the heart is dying but it does show some electrical activity still. R57's Death Certificate, dated [DATE], documents that R57's date of death was [DATE] and the cause of death was choking due to food. On [DATE] at 9:45 AM, V49, Coroner, stated, (R57's) cause of death was choking. I did speak with (R57's) family about (R57's) death. I explained to the family that to prove a choking death I would have to do an autopsy and they did not want a autopsy done on her. The family said that she had problems with swallowing and they were very happy with the care (R57) received while at the facility. The primary cause of death is choking and the secondary cause will be all of her comorbidities. I did speak with the fire department and the hospital. The hospital did tell the fire department to stop treatment because she was a DNR. 2. R217's Health Status Note, dated [DATE] at 7:57 PM, documents, Called to resident room she was choking her color was blue and no air exchange. Was able to lift her up in w/c (wheelchair) lean forward and she cleared enough [MEDICATION(S)] to get air. Attempted to suction with little success due to congestion very deep. Contacted POA (Power of Attorney V56) she does not want resident transferred to hospital under no circumstances. Neb (nebulizer) treatment started. Talked with her son who was visiting he had fed her 1 glass of blue berry juice/2 sm. candy bars/1 sm. mint candy bar then water where she started coughing and after she stopped for few min (minutes) he gave her boost supplement that is when cough got worse he called staff. Currently no further problems in dining room for supper drank her orange juice without issue. R217's Health Status Note, dated [DATE] at 6:10 PM, documents, Called to dining room after drinking med pass resident started coughing up phlegm. Color pale/blue. Taken to room to bed, resp. (respirations) faint, back compression/rub chest with no change. 02 (oxygen) started at 2L. (liters) no change. 6:15 PM called family. family on her way to facility. Resp. about 2 per min (minute) pulse faint. Coroner notified. Body mottled. R217's Health Status Note, dated [DATE] at 6:11 PM, documents, Family aware of current condition verbalize wished not to send resident to hospital. Keep resident in facility to keep comfortable. R217's Health Status Note, dated [DATE] at 7:36 PM, documents, Resident expired in facility at 6:25 PM in her room per dayshift nurse. R217's Illinois Department of Public Health Final Report, dated [DATE], documents, On [DATE] at 6:10 PM, resident observed coughing out frothy phlegm in the dining room. Resident was minimally alert upon nurse initial assessment and observed pale in color. No visual obstructions observed to oral cavity. There was no food in front of the resident. Per staff, resident has consumed her supplement drink (med pass) that was in front of her. Resident was the only one at the table and had not yet been served food. Per dietary staff who was present in the dining room stated that she visually observed resident sleeping when she entered the dining room. Around 6:00 PM she observed resident was awake and smiled at her. Few minutes later she heard a faint coughed and resident started to change in skin color asked for staff help. POA was notified and verbalized wishes not to send resident to ER (emergency room ) and just keep her comfortable in the facility. Resident was transferred back to her room to continue to assess and provide intervention. Nurse provided back thrust and chest rub. Resident is DNR - comfort focus treatment per her advanced directives. Nurse applied oxygen from 2 liters to 4 liters with no improvement. Administered nebulizer treatment to help with respiratory distress. Head of bed elevated to 45 degrees. Assigned nurse and staff stayed with resident to provide interventions for comfort while waiting for family members until she passed a 6:25 PM. MD (Medical Doctor) notified. Family was aware of all interventions provided and honored POA's wishes. Resident has diagnosis of Dysphagia, Diabetes type 2, [CONDITION(S)] ([CONDITION(S)]), Hypertension, and Coronary artery disease. Resident is on pureed diet with thin liquid related to dysphagia. It continues, Re-education provided to all staff on handling possible aspiration. The Facility In-Service Attendance Sign in Sheet, dated [DATE], documents, Topic: Med Pass. Content of Program: Nurses to be present until Med Pass is consumed by resident do not leave resident unattended. The Facility In-Service Attendance Sign in Sheet, dated [DATE], documents, Topic: Suctioning. Content of Program: All dining rooms have suctioning machines. Reeducation of Oral suctioning with Policy and Procedure attached. On [DATE] at 2:45 PM, when asked if staff ever did the [MEDICATION(S)], suctioned or called 911 for R217, V2 stated, That is why I did the education to teach the staff how to handle a choking situation. Then a few days later I actually did a mock drill on choking with a real person and I wanted to see how the staff reacted and educate them if they did need more education. The Facility In-Service Attendance Sign in Sheet, dated [DATE], documents, Content of Program: All staff re-education on oral suctioning to clear airway if resident having aspiration or choking episodes. Performed [MEDICATION(S)] maneuver or resuscitate if necessary and call 911 immediately. The policy Oral Suctioning, dated [DATE], documents, Objective: To maintain a patent airway. To maintain good oral hygiene. On [DATE] at 2:38 PM, V35 LPN, stated, When I went in the dining room to give her (R217) her med pass, she was asleep, so I left it on the table in front of her. Then a little while later the dining room called for me, I went in, and she R217 was coughing. I got her back to her room; I did do a finger sweep of her mouth, but nothing was there. I went to call the family and left her with (V46, LPN) the other nurse. The family said they did not want her sent out. They said let nature take its course. The other nurse said he did the [MEDICATION(S)], but I did not see that. When asked if R217 was ever suctioned, V35 stated, We had the equipment in the room. On [DATE] at 8:50 AM, V2 stated, If I was in this situation, I would have suctioned, [MEDICATION(S)] and called 911 just like I did for (R57). On [DATE] at 11:40 AM, V35 stated, (V46, LPN) did do the [MEDICATION(S)]. We did not call 911 because the family did not want her sent out. If 911 would have showed up they would have taken her and that is not what the family would have wanted. She had choked a few months before. (At that time) The son was present, and he was feeding her things she shouldn't have had. He called me and said she was choking. He wanted me to send her out but his sister the POA said no, don't send her anywhere. On [DATE] at 1:27 PM, V46 stated, I was not present the second time she choked but I was the first time. (V35) came and got me and said R217 is not breathing. I went and got the crash cart, did the [MEDICATION(S)], and started suctioning. During one of the [MEDICATION(S)]'s, she coughed up a popcorn kernel. She then took a breath and started breathing again. R217's son was present, and he wanted R217 sent out but V35 talked to the POA and the POA did not want her sent out. I thought that was crazy, so I even called the Assistant Director of Nurses and (V16) to confirm this. On [DATE] at 4:30 PM, V2 stated, I did not know about (R217's) choking incident on [DATE]. I was on vacation that week and I was not notified. I think (V35) is confused because from my investigation of [DATE] (V46) had nothing to do with it. R217's Face Sheet, print date of [DATE], documents R21 was admitted on [DATE] and has diagnoses of Dementia and Dysphagia. R217's MDS, dated [DATE], documents that R217 is severely cognitively impaired and requires extensive assistance of 1 staff member for eating. R217's Care Plan, dated [DATE], does not address the need for eating assistance. R217's Physician Orders, dated [DATE], documents, REGULAR diet, Pureed (PU4) texture, Thin consistency and DNR-comfort focused treatment. On [DATE] at 9:45 AM, V49, Coroner, stated, (R217's) death was reported to me as a comfort care resident that had multiple comorbidities and that she died a peaceful death. I had no idea that she had a choking incident and did not receive any treatment or assistance for it because she was a DNR. If I had known that I would have made this a coroner case and ruled it an accidental death by choking. Even if I call something a coroner case, I don't have to do an autopsy because it is not going to change the outcome. I can go back a year and change a death certificate. 3. R216's Face Sheet, print date of [DATE], documents that R216 was admitted on [DATE] with diagnoses of Stroke, Pneumonitis due to inhalation of food and vomit and Dementia. R216's Hospital Record, dated [DATE], documents, that R216 was admitted to regional hospital on [DATE] and that his wife stated he had been having trouble with choking for the last week. R216's Hospital Summary Visit, dated [DATE], documents, Diet Carb Controlled. Fluid consistency: Nectar thick Fluids. R216's Physician Order, dated [DATE], documents, LCS (low concentrated sweets) diet Reg RG7 texture mildly thick nectar consistency for nutrition. R216's Health Status Note, dated [DATE] at 11:55 PM, documents, Res (resident) had his thickened liquids spilled all over him, his covers and the bed. Noted res tongue and mucous membranes in his mouth where dry and res nodded head yes when asked if he was thirsty. Gave res 250 ml's of nectar thick water. He needs to be fed and given drinks as he will not follow commands. R216's Health Status Note, dated [DATE] at 1:20 PM, documents, Writer summoned to room per wife stated resident choking and coughed up thick meat airway cleared Wheezing noted to right lungs updated (V47, Physician) Received order to down grade diet to mechanical soft till Monday so speech therapy may eval (evaluation) and chest Xray T (temp) started q (every) 4 hours at this time Xray ordered. R216's Health Status Note, dated [DATE] at 4:00 PM, documents, Writer went to room to check on resident and found wife lying bedside resident saying he is ok he is sleeping writer observed deep breathing walked over to bed calling his name gently no response Massaging chest no response. Pulse and respiration present 97.3 ,d+[DATE] 103 36 spo2 (oxygen saturation) and 92% RA (room air). writer left staff with resident to monitor for changes. R216's Health Status Note, dated [DATE] at 4:12 PM, documents, Ambulance called per H1 nurse while writer remained with resident performing safety measures. R216's Health Status Note, dated [DATE] at 4:46 PM, documents, Returning to room blood sugar 289 coverage given spo2 dropped to 82% RA Rebreather in place periods of apnea (no respirations) noted After elevating HOB (head of bed) with stimulation resident vomited a moderate of brown substance no odor noted unable to clear mouth suction resident blood tinge color in tubing and mouth. Ambulance arrived to facility for transport resident arousing more upon departure Spoke with (V47, Physician) update on resident okay to transport Wife followed in private vehicle. R216's Health Status Note, dated [DATE] at 11:07 PM, Writer called to check status on resident. Writer was informed that resident was admitted with a dx of [CONDITION(S)] with subquertal herniation and aspiration pneumonia. POA is at bedside. The facility nurse interview written by V45, LPN, dated [DATE], documents, Writer at nurses station when resident wife approached alone with nurse manager. Wife stated, I think my husband choked on his food. Writer immediately traveled to resident room with wife behind me. Entered room found resident almost laying flat on his back. Immediately elevated head of bed 45 degrees. No evidence of any choking found on bed, floor or around resident mouth. At that point wheezing noted complete assessment and notified (V47 Physician). The local hospital report, dated [DATE], documents, Around noon today, patient choked and aspirated while eating. Patient became non responsive afterwards. He was in respiratory failure on arrival to ED (Emergency Department). Patient was placed on non-rebreather oxygen and saturating in the low 90's. It continues. Glascow coma scale (clinical scale used to reliably measure a person's level of consciousness) of a 4 on admission. ED physician discussed transfer to higher level of care with family for neurosurgery evaluation. However, wife who is surrogate decision maker refused transfer to higher level of care. she stated that husband doesn't want any extraordinary measures if in a coma. It continues, He was hypoxic from aspiration pneumonia. It continues, Patient expired at 2:15 AM on [DATE]. R216's Report to Illinois Department of Public Health, dated [DATE], documents, Final Report; O[TRUNCATED]

Based on interview, observation and record review, the facility failed to assess, monitor and provide pressure ulcer treatments as ordered for 2 of 2 residents (R1, R3) reviewed for pressure ulcers in the sample of 5. This failure resulted further skin breakdown and larger pressure ulcers for R3. Findings include: 1. R3's Order Summary, print date of 4/28/22, documents R3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS), dated [DATE] documents R3 is severely cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and is totally dependent on 2 staff members for transfers. R3's HH (Health History) Ulcer / Wound documentation, dated 2/28/22, documents that R3 has a newly identified unstageable pressure ulcer on the right side of right toe measuring 1.5 (Centimeter) (cm) (Length) (L)) x 1.3 cm (Width) (W), the wound bed tissue is necrotic and has no drainage. R3's HH Ulcer / Wound documentation, dated 2/28/22, documents that R3 has a newly identified unstageable pressure ulcer on the right side of right foot measuring 1.4 cm L x 1.6 cm W, the wound bed tissue is necrotic and has no drainage. R3's Treatment Administration Record (TAR), dated 2/28/22, documents, Right foot lat (lateral) prox (proximal) and distal: cleanse with area with NS (normal saline), apply xeroform cover with dry dressing every day shift for skin integrity. This TAR documents that the wound treatment was done on 2/28/22. R3's TAR, dated 3/1/22 - 3/30/22, documents, Right foot lat (lateral) prox (proximal) and distal: cleanse with area with NS, apply xeroform cover with dry dressing. every day shift for skin integrity. This TAR documents that the wound treatment was done daily. R3's TAR, dated 3/31/22 - 4/20/22, documents, Right foot lat prox and distal: cleanse with area with NS, apply cal alginate with silver cover with dry dressing. every day shift for skin integrity. This TAR documents that the wound treatment was done daily. R3 has no other HH / Wound documentation on these 2 wounds identified on 2/28/22 for review. However on 4/20/22, R3 does have HH / Wound documentation for her right foot in similar areas just described using different verbiage. R3's HH Ulcer / Wound documentation, dated 4/20/22, documents that R3 has a newly identified unstageable pressure ulcer on the right lateral foot distal measuring 4.5 cm L x 1.0 cm W x 0.1 D (depth), the wound bed tissue is necrotic and has moderate drainage. R3's HH Ulcer / Wound documentation, dated 4/20/22, documents that R3 has a newly identified unstageable pressure ulcer on the right lateral foot proximal measuring 1.5 cm L x 1.2 cm W x 0.3 D, the wound bed tissue is granulation tissue and has moderate drainage. R3's Nurses Note, dated 4/20/22, documents, (V3, Assistant Director Of Nurses- ADON) looked at an open area on right foot outer area - changed treatment order - order faxed to (V12, Physician). R3's Nurses Notes have no other documentation on the condition of R3's right foot from 2/28/22 to 4/20/22 for review. On 4/26/22 at 2:00 PM, V3, ADON, stated that the wound doctor wants to get the areas very moist with the xeroform and then he will debride the areas next week when he sees her. V3 also stated that he believes that R3 got the wound from crossing her feet but he is not sure. On 4/28/22 at 11:50 AM, V7, Licensed Practical Nurse (LPN), stated, (R3's) lateral foot has been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . It originally started out as blisters and turned into this. On 4/28/22 at 3:20 PM, V11, Nurse Practitioner, stated, I would expect the facility to be measuring and monitoring wounds on a weekly basis and notify us if the wound worsens or is not healing with the current treatment. Unfortunately in R3's case, the lack of monitoring caused her to have further skin breakdown and resulting in a larger wound. 2. R1's Order Summary Report, print date of 4/28/22, documents R1 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS, dated [DATE], documents R1 is moderately impaired cognitively, requires extensive assistance of 2 staff members for bed mobility, transfers, hygiene and toileting and in frequently incontinent of her bladder and always incontinent of her bowel. R1's Specialized Wound Doctor Report, dated 4/4/22, documents, Shear wound of the left buttocks. Dressing Treatment Plan. Primary. Add Alginate Calcium. Discontinue Alginate Calcium w/ (with) Silver. Secondary. Dressing. Gauze Island w/ brd (border) once daily. R1's Treatment Administration Record (TAR), dated April 2022 through March 26/2022, documents, Calcium Alginate - Silver Pad 4. Apply to sacrum topically every day shift. These TAR's document R1 has received this treatment everyday. R1's HH Ulcer / Wound documentation, dated 4/25/22, documents that R1 has pressure ulcer to the sacrum initially found 3/21/22 measuring 1.0 cm L x 2.0 cm w x 0.2 cm D. This wound was staged as a Stage II wound. This document also documents that the wound is now a cluster wound and the peri wound was intact and the wound had moderate sanguineous drainage. At this time, R1 rated the pain from the wound a 5 on the 1 to 10 pain scale. On 4/26/22 at 11:04 AM, V4, Licensed Practical Nurse (LPN), entered R1's room to change R1's sacrum dressing. V4 stated that she was going to cleanse the wound with wound cleanser, dry the wound, apply calcium alginate with silver and cover the wound with an [MEDICATION(S)] dressing. V4 removed the old dressing. The right side of the sacrum had one pressure ulcer. The wound bed was red. The edges of the wound were white. On the left side of the sacrum, there were 3 smaller areas of pressure that was noted to be open. The wound beds were red on all three wounds. V4 cleansed all 4 wounds, applied the calcium alginate with silver to the larger wound, nothing to the 3 smaller wounds and covered the sacrum with a foam dressing. On 4/27/22 at 3:30 PM, V3, ADON, stated that he charts wounds as cluster wounds if there are more than one wound in an area and he just measures and assesses the area not the individual wounds / ulcers. V3 stated that all the wounds are measured every week. V3 stated that he will manage the wounds if he can with the primary doctor and if the wounds get worse he will get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/22 at 11:25 AM, V1, Administrator, stated that wounds should be assessed and measured every week and charted on more if the wound deteriorates. V1 further stated that the nursing staff should be following the Physician prescribed wound treatment. On 4/27/22 at 4:00 PM, V1, Administrator, stated that all of the areas of the wound should be treated during a dressing change. The facility policy and procedure, dated 1/10/2018, documents, When a resident is found to have a wound a licensed nurse will complete ulcer, either on admission or during their stay, the following Document assessment of the wound / ulcer in the medical record. Initiate the treatment protocol appropriate for the stage of ulcer or for the wound assessed. It continues, Assessment of progress toward healing is completed at least weekly and the physician is notified at least monthly. If there is regression, the physician is notified of the condition change. Treatment continues per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to remove transdermal pain patch for 1 of 3 residents (R2) reviewed for pain management with transdermal pain patches in the sample of 7. This failure resulted in R2's overdose of [MEDICATION(S)] requiring emergency interventions and sent to the hospital. Findings include: R2's hospital emergency room (ER) assessment dated [DATE] documents that R2 presented to emergency department for altered mental status. R2's ER assessment documents that R2 had 3 [MEDICATION(S)] patches in place, and paramedic administered 2 milligrams (mg) of [MEDICATION(S)] and R2 became more arousable. R2's assessment documents a [MEDICATION(S)] patches removed in ER. R2's assessment documents a discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility Risk Watch Classic dated 1/12/2022 at 6:00 PM documents medication error that R2 was sent to the hospital due to decreased level of consciousness, observed [MEDICATION(S)] patch to left chest was intact and new patch intact to Right chest. R2's January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2' Face sheet dated 3/13/ documents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/24/2021 at 3:45PM, V3, Corporate Nurse, stated R2 did have 2 [MEDICATION(S)] patches on prior to leaving for the hospital. V2 stated the nursing staff did not remove the old patch prior to applying a new patch.V3 stated, Of course, I would expect them to remove the old patch prior to placing a new patch. On 1/25/2022 at 1:55 PM, V2, Director of Nursing (DON), stated she did remember that R2 had 2 transdermal pain patches is place and that R2 received [MEDICATION(S)] by ambulance personnel before going to the hospital. V2 stated that she checked the order to make sure it was documented to remove, and V2 stated the order was in place. V2 stated that she did a medication error report for risk management. The facility policy Medication Administration dated 1/11/10 documents it is the policy of the facility to accurately administer medication following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, observation and record review the facility failed to provide supervision and follow interventions put in place for 1 of 4 residents (R1, R2, R3, R4) reviewed for falls in a sample of 4. This failure resulted in R1 having 11 falls from June 16 to September 7, 2020. The September 7, 2020 fall resulted in R1 [DIAGNOSES REDACTED]. R1's Care Plan, dated 5/12/2020, documents, in part, Risk for falls due to impaired balance and gait secondary [MEDICAL CONDITION](stroke) with left sided weakness. Resident frequently chooses to get up and ambulate without asking for staff assist despite frequent teaching and reminders. Interventions: 6/1/2020 Bed/WC alarm applied, on at all times to notify staff that resident has gotten up without asking for assist. 6/19/20 Resident and POA agreeable to sign placed in bathroom stating do not leave resident unattended in bathroom. 6/29/20; bed alarm removed and floor mat alarm applied. 6/29/2020 Transfer status assessed; resident requires assist of 2. R1's Minimum Data Set, dated dated [DATE], documents extensive assist of 1 person for transfers and toileting. Not steady, only able to stabilize with staff assistance with moving on and off the toilet. Arm and leg impairment on one side. R1's Health Status note, dated 8/22/2020 at 3:06 PM, documents Observed res sitting on the floor in front of the toilet. Res (resident's) aide verbalized res had an extra large BM (bowel movement). While res aide stepped away from the toilet to grab more wash cloths res fell . Aide verbalized to writer that the aide observed res lying on left side in front of the toilet in between the toilet and her wheel chair. Noted a 1cm X 0.6cm skin tear to the bridge of res nose from res eye glasses being pushed to the right side of res face. Noted 4cm X 1.5cm, 6cm X 1cm, and 9cm X 1 cm red abrasion like area to res left thigh, 8cm X 1cm red abrasion like area to the middle of res back. Res assisted into her w/c (wheelchair). Full ROM (range of motion) noted to all extremities WNL (with in normal limits) for resident. Res denies hitting her head with no s/s of res hitting her head observed. Res denies pains and discomforts. R1's C.N.A. and Nurse Post fall Investigation, dated 8/22/2020, documents Fall Description Details (R1) had an incontinent BM, I went to the next room to get more washcloths when I came back she was on the floor. R1's Health Status Note, dated 9/6/2020 at 11:10 PM, documents Writer was sitting at desk when writer observed resident walking down the hall after just being put to bed. Resident had been toileted just a few minutes earlier as she was put to bed. CNA states alarm was on when she left room but resident turned alarm off and proceeded to get up from bed being in lowest possible position. Resident lacks the dexterity to turn off the alarm. Resident was observed during this fall and did not hit head. MD and poa (power of attorney) notified. R1's Health Status Note, dated 9/7/2020 at 4:55 PM, documents, Writer summoned to res room. Upon entering room observed res sitting on her left hip with upper left side of body lying on the floor, right leg extended out with left leg bent in a sitting position, and back against her recliner. Res stated I have to go to the bathroom. Noted a 1.5cm X 0.5cm abrasion to the bridge of nose, 4cm X 4.5cm Red abrasion with a scratch in the center to left knee, 0.6cm scratch/abrasion to left knee, 5.5cm X 1.5cm red area with a 3cm X 0.6cm abrasion in the middle above right eye, 4cm X 3cm light blue raised area to the center of forehead. Full ROM noted to all extremities. Res denies pains and discomforts with ROM. Denies nausea, verbalizes she does have a headache at this time. Neuro checks initiated per protocol. VS: 140/74, 102, 18, 98.4, 98% RA (room air) R1's C.N.A. and Nurse Post Fall Investigation, dated 9/7/2020, documents Fall Description Details documents, Alarm sounded directly after aide heard res fall. Alarm being used. Alarm not working correctly. On 9/9/2020 at 11:00AM observed R1 sitting, on an alarm pad, in her recliner with feet elevated. She was awake and playing a game. Observed large discoloration, ranging in color from black to green, to both eyes. Discoloration covered from the inner corner, lower socket and outer corner of the both eyes and cheeks. Black bruise and abrasion to right eyebrow ridge. Green and black bruising to ridge of nose with dressing in place. Dressing in place to left hand. R1's Health Status Note, dated 9/9/2020 at 1457, documents Aid approached writer today stating she was having a difficult time getting resident to stand up; that it took two of them to stand resident. Writer did an assessment and noticed that the speech was slower than normal and that resident was completely unable to follow finger with eyes. Resident had a fall 2 days ago and hit her head. All neuro checks have been good, however, resident is just not acting right. Dr. Vargas gave the order to send her to ER (emergency room ) for eval (evaluation). Dr. Vargas also gave order for Hospice to evaluate. POA was informed of all and stated he would meet resident at hospital. R1's CT (computed tomography) results from an area hospital, dated 9/9/2020, documents There is [MEDICAL CONDITION] the right nasal bone and probable acute of the tips of the nasal bones. On 9/9/2020 at 1050 AM V9, CNA, stated (R1) was alert and oriented. She has been different since she has been falling. She won't stay still. Forgetful. Forgets what she needs. She needs more help now. She has always needed some help but now it takes 2 people. Before it only took 1. On 9/9/2020 at 1105 AM V10, CNA, stated She had a stroke and her processing is slow. She has delayed speech. Her balance is bad. She has had a lot of falls. She needs 2 people now to transfer her. She has fallen from her chair. Her balance is horrible. She tries to stand but she has the weakness on her left side and when she steps down her foot turns in and she falls. She doesn't protect her face when she falls as you can see with all the bruising. She has a floor mat alarm and a chair alarm. The one (chair alarm) she is sitting on doesn't work. I didn't want to wake her up to put the new one on her. The new one is sitting on her bed. I just didn't want to wake her. On 9/9/2020 at 1215 PM V12, Licensed Practical Nurse, stated (R1) has left sided weakness. I just sent her out. She had increased confusion. Multiple falls. She is a fall risk. She does have a UTI (urinary tract infection). And when she has an UTI her fall risk is even higher. She had loss of balance and her speech was slower. She couldn't follow my finger when I was assessing her. She just wasn't acting right. I knew something was wrong. I am really not sure what causes her falls. She doesn't fall on days. Evenings doesn't have as much staff as days do. On 9/10/2020 at 217 PM V13, CNA, stated (R1) said she needed to go to the bathroom. I took her to the bathroom and sat her on the toilet. Noticed she had a bowel movement. Didn't have enough towels. Left the room and went next door to get some more. When I came back she was on the floor. I saw blood on the floor that was coming from her nose. She was not supposed to be left in the bathroom unattended. I knew that. Her balance is pretty bad and I shouldn't have left her. She is very unsteady. On 9/10/2020 at 242 PM V14, Medical Doctor, stated Became familiar with patient in 2014 she had multiple falls and had a compression fracture to her spine. She is a high fall risk and has had multiple falls. I would expect the facility to provide her with more supervision. I would expect them to follow the care plan. If the staff would have increased (R1's) supervision and followed the care plan by not leaving her in the bathroom unattended, using the appropriate staff for transfers, assuring the chair alarm is in place and working it is possible she would not have had as many falls. And if she didn't have the falls she wouldn't have had the injuries and the fracture. On 9/10/2020 at 302 pm V1, Interim Administrator, stated If the staff are aware of a chair alarm not working properly, I would expect them to replace it immediately. I would expect the staff to follow the care plan. If the C.N.A. would have followed the care plan the fall (8/22/2020) would not have occurred. The policy and procedure titled, Fall Assessment & Management, revised 4/2019 was reviewed. It documented under, Policy: It is the policy of this facility to assess each resident's fall risk on admission, quarterly and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce risk. Factors related to the risk will be addressed and care planned. Under Procedure: F. Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall.

Based on observation, interview, and record review, the facility failed to timely identify, assess, monitor and treat pressure ulcers for 3 of 6 residents (R23, R33, R39), reviewed for pressure ulcers in a sample of 42. This failure resulted in the deterioration of ulcers for R39. Findings include: 1. On 6/24/19 at 2:30 PM, V9 Licensed Practical Nurse, (LPN), removed the dressing to R39's left heel, not dated. V9 stated, My order is skin prep, but it's not going to be the answer today. It's too open, we need to get a new treatment order. R39's wound, had a foul odor and the left heel was black with red drainage. V9 cleansed the wound and performed wound care. R39's left heel was not off loaded, when V9, left the room. On 6/25/19 at 11:55 AM, R39's heels not off loaded. R39's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders written on 5/16/19, documents, May see facility wound MD to evaluate and treat any wounds as needed. R39's Minimum Data Set (MDS) dated [DATE] documents, Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. The MDS further documents, Functional Status 3/3 needs extensive assist of 2 for Activities of Daily Living (ADLs). R39's Braden scale dated 6/20/19 documents Braden Score is 12 (High Risk). R39's Ulcer Care Plan-Treatment Plan documents R39 developed an in-house deep tissue injury (DTI) discovered on 6/14/19 with measurements of 4 X 4.5 centimeters (cm). Treatment orders are Calcium Alginate, ABD, (High Absorbency Pad) and kling. On 6/20/19 R39's Ulcer Care Plan-Treatment Plan documents, wound measurements 3.7 X 3.7 cm color black. Keep heel off loaded, use skin prep every day. On 6/26/19 R39's Ulcer Care Plan-Treatment Plan documents R39's wound measurements are 5.9 X 5.9 cm with serosanguinous drainage, odor present, color of wound is black/yellow. R39's Care Plan dated 4/19/19 documents-Focus: Risk for skin integrity related to need for assist with repositioning, frequent incontinence and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: (include) Treatments as ordered. R39's nurses notes, dated 6/24/19, documents, foul odor to left outer heel. [MEDICATION(S)] dressing had dark red drainage when removed. V9, LPN, cleansed area with wound wash, area black in center with open edges. Nurses notes dated 6/25/19 document, Dressings were changed as ordered. Scabs/DTI's intact to toes. Left heel blister has burst, some loose skin remains. Black/dark purple unstageable tissue under. Slight odor with moderate amount of serosanguinous drainage. Denies pain to area, right posterior calf wound edges, red in color, wound bed is yellow, moderate amount serous drainage, he states it tender to touch. Pressure relief boot in place, offloading heels/legs. V24's, (wound doctor), Initial Wound Evaluation and Management Summary documents, V24, began seeing R39 on 5/22/19, for multiple arterial wounds and wounds due to [CONDITION(S)]. V24, saw R39 in the facility on 6/19/19, documentation of 6/19/19 visit includes treatments to arterial wound of right lower leg, arterial wound of the left distal first toe, arterial wound of the left, distal third toe, arterial wound of the left, distal, fourth toe, arterial wound of the right distal second toe, arterial wound of the left second toe. No documentation that V24 saw R39's left heel. On 6/25/19 at 12:10 PM, V3 Assistant Director of Nurses (ADON), stated, (R39's) wound was a deep tissue injury, but is now an unstageable pressure sore, I didn't make rounds with (V24) last week, so I did not tell her about the new wound. On 6/25/19 at 3:55 PM V2, Director of Nurses, (DON), stated, The nurse should notify the wound doctor of a new wound or a change in a wound. On 6/26/19 at 9:00 AM V30, Registered Nurse, (RN), stated, When I made rounds with (V24) on 6/19/19 I did not tell (V24) about (R39's) wound on the left heel, because I was not aware of it, (R39's), form was not placed in the right file. On 6/27/19 at 11:30 AM, V3 stated, I expect (R39's) heels to be offloaded, I know they have not been and I talked to the nurses about that today. 2. On 6/25/19 at 9:02 AM, V14, CNA, rolled R23 onto his left side and there was pink tinged drainage noted on the gauze coming from R23's right ischium (Stage 4 pressure ulcer) and onto the incontinent brief. There was no border dressing noted in R23's incontinent brief nor on his body. R23's right and left knees were noted bent toward his chest and no positioning devices were noted between his legs. Deep white creases were observed when V14 attempted to open R23's legs to perform incontinent care. On 6/26/19 at 11:02 AM R23 was lying in bed on his back with his knees pressed together bent towards his chest with no positioning devices between his knees. On R23's right inner knee were red creases extending up to his right inner thigh. As V15, CNA, rolled R23 onto his right side, a red Stage 1 pressure ulcer was noted to his left trochanter. V15, CNA stated she would inform the nurse of the red area, and V11, CNA, said, He gets red areas all the time. On 6/27/19, V3, ADON, stated that R23's pressure ulcer to his right ischium was previously classified as a Stage 4 because it was in the exact same area before, but it was healed. V3 further stated that because the area broke back open, and because it is in the same area, she staged it again at a Stage 4 pressure ulcer. V3 also stated the Stage 4 pressure ulcer was acquired at the facility and that he sees the wound doctor weekly, but that the wound doctor didn't come this week. V3, ADON, also stated she would expect for R23 to have positioning devices between his legs given his contractures and because he is such a high risk for pressure ulcers. On 6/26/19 at 11:19 AM after V20, RN, performed a pressure ulcer dressing change to R23's right ischium. When R23 was rolled onto his right side, a reddened area was noted to his left trochanter. V20, RN, stated in part, When I look at his left ischium I am going to call the doctor and notify the family and get a treatment. V20, RN, measured the area and stated, Measures 9 centimeters long by 2 centimeters wide and not open. So, a Stage 1, is not open and doesn't blanche. Treatment Administration Record (TAR) dated 6/1/19 through 6/30/19, documents the following treatments for R23, LIGHTLY PACK one 4x(by)4 gauze, dampened with Dakins solution (quarter strength) into pressure injury right ischium BID (twice daily) every day and night shift for Wound Healing for 30 days. -Start Date - 05/15/2019 TAR documents no dressing changes were performed on the day shift for 6/6/19 and 6/8/19. The TAR further documents in part, check dressing to right dressing to right ischium every shift if missing or soiled change per tx (treatment) order every shift for Wound Healing. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Plan initiated on 4/11/19 and revised on 6/26/19, documents in part R23 having a history of bilateral lower extremities [CONDITION(S)], requiring assistance with bed mobility, being frequently incontinent of urine, and having a Stage 4 pressure ulcer to his right ischium. The Care Plan further documents in part, 6/26/19 (R23) has a reddened area {9cm x 2cm} on his left trochanter. {Pressure Ulcer Stage 1}. MDS dated [DATE], documents R23 requiring total dependence for his ADL's, including bed mobility. Wound Evaluation & Management Summary dated 6/19/19, documents in part R23 having a Stage 4 pressure ulcer to his right ischium. 3. On 6/26/19 at 2:00 PM, R33 was observed with a circular open area with depth on her right ischium. On 6/26/19 at 2:15 PM, R33's floor nurse, V29, Registered Nurse, (RN), stated, I saw it a couple weeks ago and they healed it out, it had a small opening then. I haven't seen it since. On 6/26/19 at 2:26 PM, V3, ADON, stated, It's gotten worse, I saw it a couple weeks ago and it was the size of the tip of a sharp pencil. I healed it out and I ordered skin prep daily for 1 week. I made that order, it's what the wound doctor usually prescribes. I don't know who's been monitoring it, I guess it's the CNA's and the nurses, there is no wound nurse here, I just do rounds with the wound doctor, (V24), and (R33) hasn't been her patient for a while. Nobody's said anything to me about (R33's) pressure ulcer. V3 then took a cotton tipped applicator and inserted the end into the open area for a measurement. On 6/27/19 at 11:15 AM, V3, ADON, stated, I called the doctor and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses are signing off on the TAR (Treatment Administration Record) that they are looking at that area. Some of the nurse are documenting the area is open and some are documenting the area is closed. If the area is open they are supposed to call the doctor and then let me know, I haven't been told anything. On 6/27/19 at 1:40 PM, V3 stated she has always marked (R33's) pressure ulcer as unstageable because she thought unstageable was the worst stage it can get. On 6/27/19 at 12:10 PM, V2, DON, stated she did not agree with (V3's) unstageable description of R33's wound. V2 stated, If (V24), Wound Doctor, documented it was a Stage 4, then we go with what the doctor says. Braden skin risk assessments dated 1/16/19, 4/18/19, and 6/20/19 documents R33 having a score of 12, indicating high risk for pressure ulcers. Ulcer Care Plan-Treatment Plan for R33, dated 6/29/19, V3, ADON, documents in part, length: 0.2 width: 0.2 Depth 0.1 Unstageable. Review of V3's Ulcer Care Plan for R33 from 8/17/18 to present, V3 documents R33's Right Ischium Pressure Ulcer as Unstageable. Wound Doctor, (V24) documents on 11/07/19 through 12/18/19 R33 having a Right Ischium Pressure Ulcer, Stage 4. TAR for R33, dated June 2019, nurses documented Skin assessment: every day shift I=intact, R=red, B=Broken B on 6/1, 3-7,10-13, 24-26, and I on 6/2,14-15, 1719-23. POS for R33, dated 6/27/19, documents, Cleanse pressure area to right ischium with normal saline or wound wash; apply [MEDICATION(S)] gel to wound bed; and cover with bordered dressing. as needed for wound healing AND every day shift for wound healing. Facility Policy entitled Wound & Ulcer Policy and Procedure revised on 1/10/2018, documents in part It is the policy to provide nursing standards for assessment, prevention, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. All residents will be assessed to determine the risk of developing a pressure ulcer using the Ulcer Risk Assessment. The resident will be assessed upon admission, once a week for four weeks, and monthly thereafter. The Policy also documents in part, High Risk Protocol: Residents with existing ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment Score. Daily skin check-completed by direct care staff. Specialty mattress (low air loss, alternating pressure, etc.) with enhanced pressure reducing/relieving properties may be placed on the resident's bed and chair. Skin contact surfaces may be padded to protect bony prominence. The Policy further documents in part, Pressure Ulcer: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure. STAGE IV (4) - Full Thickness Tissue Loss - Full thickness tissue loss with exposed bone, tendon, or muscle. Exposed bone/tendon is visible or directly palpable. The policy also states for a Stage 4 Pressure Ulcer having moderate to heavy drainage, Treat: lightly pack the ulcer, cover with foam dressing. Skin Risk assessment dated [DATE], documents R23 scoring a 12, indicating a high risk of developing a pressure ulcer. The Assessment further documents R23 having limited sensory perception, being chairfast, and with very limited mobility.

Based on record review, interview and observation, the facility failed to provide safe handling during transfer to prevent falls for 1 of 3 residents (R2) reviewed for falls in the sample of 7. This failure resulted in R2 sustaining a right femoral neck fracture and right frontotemporal scalp contusion. Finding includes: R2's Minimum Data Set (MDS), Brief Interview of Mental Status (BIMS), dated 12/13/18, documents a score of 10, documents moderately impaired cognition, also to include limited assistance with Transfers and Balance to not be steady, requiring assistance from staff. The same MDS, documents an active [DIAGNOSES REDACTED]. R2's Care Plan, last completed review dated 12/24/18, documents the Focus: (R2) is at risk for falls related to gait/balance problems and medications that may cause dizziness and a history of falls with no indication of the use of a Postural Positioning Chair ordered on [DATE]. The same Care Plan continues to document the Intervention initially dated 1/18/19 as previously reviewed on 3/6/19 and as of 3/7/19 documents a date of 3/7/19 due to facility printing error when presented to state reviewer, Intervention: To ensure that the Postural Positioning Chair is leaned back and pedals are on when assisting resident with locomotion. R2's Fall Risk Assessment, dated 12/13/18, indicates Ambulatory Aide, as the use of crutches, cane or walker, the same assessment continues to document a score of 90, indicating High Risk for Falling. R2's Occurrence Report, dated 1/15/19 at 7:45 PM, documents, V7, Certified Nurses Aide (CNA), was pushing the Postural Positioning Chair from out of the bathroom when R2 leaned forward at the waist causing her to exit from the chair to the floor resulting in a 5cm (centimeter) x (by) 5cm bump on right side of forehead. R2's Local Hospital discharge [DIAGNOSES REDACTED]. R2's Illinois Health Care Facility report on Resident Death, dated 1/17/19 at 10:30 AM, documents Existing conditions at time of death: Dehydration, Fractures/broken bones, Head Injury and Accidental. The Operating Manual Specifications for Basic Models: 30VT Semi-Recliner and/or 80V Tilt Chair , undated, and utilized by R2, documents in part, Safety Requirements: Position of Chair-Danger of Falling, Immediately after a resident is transferred into a chair, the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. On 3/06/19 at 8:45 AM, V2, Director of Nursing (DON), stated that V7 was pushing (R2) out from the bathroom back to bed, when (R2) leaned forward from the chair and fell forward. On 3/07/19 at 10:15 AM, V8, Assisting Director of Nursing (ADON), stated there are no residents currently in the facility using a Postural Positioning Chair. On 3/06/19 at 3:30 PM, V7 stated she was providing evening care to R2 while sitting in her Postural Positioning Chair, then transferred R2 out from the bathroom when R2 leaned forward with one arm extended out from her body and fell forward out of the chair hitting her head on the corner of the dresser. V7 continued to state that she did not have the Postural Positioning Chair in the tilt back position during transfer. V7 continued to state, she has not been in-serviced on the operation and/or safe handling of the Postural Positioning Chair since employed at this facility. On 3/07/19 at 3:10 PM, V8 stated since the facility does not utilize Postural Positioning Chairs as often, and staff is not in serviced on the use of safe handling/operation, she would expect that staff be in serviced at the time of staff orientation and as needed. On 3/11/19 at 8:30 AM, R4 and R5 were sitting in a Postural Positioning Chair. On 3/11/19, V2 stated the facility does not have a Policy and/or Procedure for residents requiring the use of a Postural Positioning Chair.

Based on observation, record review and interview, the facility failed to follow their Policy and Procedure for choking by not initiating Cardiopulmonary Resuscitation and/or the [MEDICATION NAME] Maneuver for 1 of 3 residents (R1) reviewed for choking in the sample of 3. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE] the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their policy for choking. Findings include: 1. R1's Physician order [REDACTED]. The POS documents an order for [REDACTED]. R1's UNIFORM D0-NOT RESUSCITATE (DNR) ORDER FORM documents Do Not Attempt Cardiopulmonary Resuscitation (CPR) (Measures to promote patient comfort and dignity will be provided).This was marked for both Full Cardiopulmonary Arrest (When both breathing and heartbeat stop) and for Pre-Arrest Emergency (When breathing is labored or stopped, and heart is still beating). The DNR was signed by Z5, R1's Power of Attorney/Daughter. R1's Minimum Data Set (MDS) of [DATE] documents R1 required supervision - oversight, encouragement or cueing and setup help only with eating. MDS documents no swallowing disorder. R1's Care Plan of [DATE] shows there is no documentation of chewing or swallowing problems. R1's MONTHLY SUMMARY of [DATE] documents R1 is alert and oriented x 1 and has short term memory loss and memory recall. R1 needs assistance with eating, has a good appetite and is on a general diet. R1's Nurse's Notes dated [DATE] by E4, Licensed Practical Nurse (LPN) documented: 6PM, R1 is in the dining room for evening meal. R1 had a coughing episode with phlegm and large food particles. R1 answered questions when talked to and breathing well. E4 asked E7, Speech Therapist, to stay with R1. 6:15PM, Z6's , R1's Physician office was called. 6:20PM, Z7, Physician on call for Z6, gave new orders to change diet to pureed and honey thick liquids, place on aspiration precautions, start [MEDICATION NAME] 500 mg tid (three times a day) x 10 days and have Speech Therapy evaluate and treat. 6:30PM, R1 continues with coughing episodes with phlegm and large food particles. R1 able to respond to question. R1 stated, "Don't know why I keep coughing can't stop!" R1 reached for a drink and E4 took it away and gave R1 a glass that was honey thick liquids. R1 coughed again phlegm and food particles came out of nasal passage. R1 slumped over in chair. R1 became unresponsive. 911 was called. 6:42PM, suction R1 with no food particles or phlegm retrieved. 6:45PM, Paramedics arrived at this time. Placed R1 on floor from chair. Paramedics checked airway with Laryngoscope and found nothing in airway. 7:00PM, Paramedics hooked R1 to monitor. no respirations, no pulse, no blood pressure. 7:20PM, Z5, R1's Power of Attorney/Daughter, was called. 8:15PM, R1's remains were released to Z2, coroner. In an interview with Z4, Paramedic, on [DATE] at 8:10AM, Z4 stated R1 was sitting in a chair and slumped over when he arrived. Z4 stated they put R1 on the floor. Staff stated they had tried to suction R1. When Z4 arrived, R1 was not breathing and was cyanotic and had no pulse. Z4 stated staff said R1 was a DNR. It's a tough situation. They may think they don't do anything. [MEDICATION NAME] would have been in order and chest compressions. Even if a DNR would have tried [MEDICATION NAME], abdominal thrusts and if couldn't get results then stop. Not do nothing. In an interview with E5, LPN, on [DATE] at 10:45PM, E5 stated R1 was coughing up a large amount of food and phlegm and was talking to them during the coughing. E7, Speech Therapist, said to get a suctioning machine. E5 stated she went to get the suctioning machine in the corner of the Dining Room and there was no tubing or water. E5 went to the Medication Room and found the tubing and water and went back and suctioned R1. E5 stated R1 was still responsive when she started to suction and during suctioning R1 became nonresponsive so she stopped. (This conflicts with E4's Nurses Notes that documented R1 was suctioned after she slumped over in chair.) E5 stated no one did [MEDICATION NAME] once R1 became unresponsive because R1 was a DNR and no one attempted CPR because R1 was a DNR. E5 stated shortly after R1's choking incident, E2, Director of Nursing, gave an inservice that instructed staff to do CPR. In an interview with E7, on [DATE] at 11:10AM, E7 confirmed no one did [MEDICATION NAME] or CPR on R1. E7 stated there was a delay in getting suction because all the parts weren't there. E7 stated in hind site they could have called 911 sooner. On [DATE] at 2:05PM, E7 stated she could not remember which Nurse started suctioning R1. E7 stated the Nurse started suctioning before R1 became unresponsive and slumped over in her chair. In an interview with E4, LPN, on [DATE] at 12:45PM, E4 stated R1 was coughing but still talking. R1 stated she could not stop coughing and then became limp and unresponsive. E5 did the suctioning. E4 stated no one did the [MEDICATION NAME] after R1 became unresponsive. No CPR was done because R1 was a DNR. E2 did an inservice on suctioning, [MEDICATION NAME] and choking ,[DATE] days after the incident. E4 was told someone needs to do [MEDICATION NAME] if the resident becomes unresponsive. "Someone should have done the [MEDICATION NAME]." In an interview with E9, Certified Nurse Aide (CNA), on [DATE] at 1:25PM, E9 stated she did not see anyone do the [MEDICATION NAME] on R1. E9 heard E4 and E5 state this is not going to work and they needed to do something else. E9 asked them if they were going to do CPR and they said no because R1 was a DNR. In an interview with E6, Registered Nurse (RN) on [DATE], E6 stated E4 called down stairs because she needed tubing for the suctioning machine. E6 stated when she got up to the second floor, R1 was sitting in the chair and was already gone. E6 stated she did a finger sweep and looked in R1's mouth and nothing was visible. R1 had no heart beat, no pulse. E5 had already called 911 and they arrived within 1 minute of E6 being on the floor and pronounce R1 dead. E6 stated she didn't due [MEDICATION NAME] and didn't know if the other Nurses did or not. E6 stated R1 was already dead when she got to the floor. In an interview with E3, Assistant Director of Nursing (ADON) on [DATE], at 12:57PM, E3 stated the next day E1, Administrator, E2 and E3 met with the staff who were working in the Dining Room when R1 choked. They asked why no one did the [MEDICATION NAME] and staff stated she was still talking and breathing.. E3 stated she was told that E5 did the suctioning. E3 stated after the incident, they put a policy and procedure in place to have Nurses Check the emergency equipment on a daily basis. In an interview with E2, Director of Nursing, on [DATE] at 11:20AM, E2 stated she would not have expected staff to do the [MEDICATION NAME] if R1 was still breathing and talking. When asked would she expect the staff to do the [MEDICATION NAME] after R1 became unresponsive, E2 stated that would be a Nursing judgement and she wasn't there. On [DATE] at 10:00AM, E2 was asked for the facility Policy and Procedure on choking and E2 stated the Surveyor already had it. It's the Policy and Procedure for the [MEDICATION NAME]. The Policy and Procedure for [MEDICATION NAME] MANEUVER dated [DATE] documents, "OBJECTIVE: 1. To expel food or foreign body lodged in the throat, creating a blockage of the airway. CLINICAL SIGNS: 1. unable to speak or breathe 2. Turning blue 3. [MEDICATION NAME] sign: Hand to neck signals: "I am choking!" 4. Collapses PROCEDURE: 1. If a person is choking on food or a foreign body, act immediately - call [DATE]." The procedure continues to document the technique for preforming the [MEDICATION NAME]. On [DATE] at 10AM, E2, stated they have posters on Choking posted in all Dining Rooms and that is part of their policy. The CHOKING poster was observed to be on the Dining Room wall. The Poster documents, "Emergency for choking...If victim can breathe, cough or speak - DO NOT INTERFERE. If victim cannot breathe, cough or speak - Give quick upward thrusts (grip above waist but below ribs)...Repeat thrust steps until effective or until victim becomes UNCONSCIOUS. UNCONSCIOUS VICTIM Clear airway with finger...begin mouth to mouth breathing. Seal victim's mouth with your mouth. Pinch nose closed with thumb and index finger. Five victim 2 slow breaths. Give up to 5 upward abdominal thrusts. Continue ventilation. If victim still has no pulse, perform CPR and call for help." On [DATE] the following staff were interviewed concerning procedure of choking resident: 1:30PM, E13, LPN, stated if a resident is choking and responding would encourage them to get it up. If the resident became unresponsive would do the [MEDICATION NAME] and call for another Nurse. If the Resident is a DNR would not do CPR. If Resident was a full code would do CPR and call 911. 1:35PM, E15, LPN, stated if a resident is choking she would check to see if the resident is breathing, do finger sweep and do [MEDICATION NAME]. If that didn't work would get oxygen and then take vitals. E15 stated she would not do CPR if resident is a DNR. 1:40PM, E16, RN, stated if resident has airway let them cough it up. If not do [MEDICATION NAME] and if unresponsive do CPR. If the Resident has a DNR, then do not resuscitate. Call 911. Do not do CPR with a DNR order. 1:42PM, E17, CNA, stated if choking resident is non responsive and not a DNR, call for a Nurse and if sitting up get out of the chair and give CPR. If the resident is a DNR you can't do anything. No CPR. 1:55PM, E18, LPN, stated she would look in the residents mouth, try to pull item out if not able do [MEDICATION NAME]. If the resident becomes unresponsive try to develop an air way. Do CPR. If the resident has a DNR, would not do CPR but would still try the [MEDICATION NAME]. 2:15PM, E2 was asked what she would expect staff to do if a resident is choking. E2 stated to do the [MEDICATION NAME]. E2 was asked what to do if the [MEDICATION NAME] did not work and resident became unresponsive and was a DNR. E2 stated she knew the poster stated abdominal thrust. "Yes I guess CPR and abdominal thrust." Nursing staff inservices from [DATE] to [DATE] show no inservices on Choking. An inservice sheet dated [DATE] documents an inservice on Adult/Child Choking. The handout given to staff documents, When a victim is choking and suddenly cannot breathe, talk, or make any sounds, give abdominal thrusts. These thrusts are sometimes called [MEDICATION NAME] maneuver...Give thrust until the object is forced out and he can breathe, cough, or talk or until he stops responding...When the victim stops responding, follow these steps: 1. Yell for help. If someone comes, send that person to phone your emergency response number (or 911) and get the AED (Automated External Defibrillator) if available. 2. Lower the victim to the ground, face up....start the steps of CPR...." Interview with Z5, on [DATE], at 8:55AM, Z5, stated she felt R1 was neglected. Z5 stated she did not feel a DNR was for choking. It would be when a resident is terminal, had a [MEDICAL CONDITION] or dying of pneumonia. If having a declining condition due to illness don't do heroic measures, machines or tube feeding. It wouldn't be for a choking accident. "Choking is different. I would expect [MEDICATION NAME] and CPR. Should they just sit and watch her. No that's not right. I think it's ridiculous they didn't do [MEDICATION NAME] or CPR. My mother would recognize when I visited. Knew I was her daughter. She was walking. She had a walker. She was in good health other than Arthritis, Alzheimer's and normal aging." R1's CERTIFICATE OF DEATH WORKSHEET dated [DATE] documents R1 choked on food. Cause of Death, "Aspiration of food [MEDICATION NAME], with food abundantly within the larynx, trachea and into bronchi of proximal lungs." The Immediate Jeopardy was identified to have begun on [DATE] when staff failed initiate CPR and /or the [MEDICATION NAME] Maneuver for a resident that was choking. On [DATE] at 9:25AM, E1, Administrator, was informed of the Immediate Jeopardy. Based on observation, interview and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE] all department managers were educated as to Emergency Care for Choking They will immediately begin to education staff. Inservices for cardiopulmonary resuscitation (CPR) regardless of Do-Not-Resuscitate (DNR) status were completed [DATE]. 2. On [DATE], appropriate policies were sent to corporate Medical Director for review and they were approved. . . .

Based on observation, interview and record review, the facility failed to consistently and accurately assess, monitor and implement new treatments for pressure sores to prevent decline for 3 of 5 residents (R2, R3 and R14) reviewed for pressure sores in a sample of 26. This failure resulted in R2 having a decline and increase in size in her pressure sore from purple non-blanchable area on her heel to an unstageable pressure sore with full thickness loss with drainage. This failure resulted in R3 developing an avoidable pressure sore on her right trochanter that facility did not identify, assess and treat until it was unstageable. Findings include: 1. Record review of R2's Admission Sheet of 8-15-11 shows documentation that R2 was readmitted to the facility from the hospital with purple non-blanchable area on her left heel. Record review of R2's ULCER Care Plan - Treatment Plan of 8-15-11 documents a pressure sore on R2's left heel with an "X" next to stage 1 "Non-blancheable [DIAGNOSES REDACTED], discolor dark skin or warmth/[MEDICAL CONDITION]/induration. Skin intact. Size: length; 3 width:2.5 Drainage: none" An undated note under Initial Entry Note: had documentation, "DTI (deep tissue injury) to L (left heel, waffles to feet, et (and) floated, area dark brown, boggy et intact. Dr (Doctor) updated for skin prep order." On 9-16-11 at 11AM, E13 (Treatment Nurse) stated she had written the note concerning DTI on 8-18-11. (R2's Treatment Administration Record (TAR) show the facility did not start treatment until 8-22-11 when order was obtained for skin prep and cover with Allevyn heel dressing and Kling. This was 7 days after a stage 1 was identified and 4 days after DTI was assessed.) The next assessment of 8-25-11 on the ULCER - Treatment Plan, shows pressure sore measured 3.2 x 3.1 cm with <0.1 cm depth with scant Serosanguinous drainage and is red in color. A note is written with documentation: "Necrotic tissue off, 100% red dermis, 0 undermining, 0 tunneling cont (continue) current TX" The next assessment of 9-1-11 documents pressure sore is 3 x 3 cm with superficial depth and no drainage and red in color. Note "100% red dermis heel protector in place cont current tx." The next assessment of 9-8-11 shows documentation that the pressure sore is 3.2 x 3 cm unstageable 0.1 black. Note states to continue same treatment. The next assessment of 9-15-11 shows documentation that pressure sore is 3 x 3 cm with <0.1 depth with scant serosanguinous drainage ane 0.8 x 0.5 red dermis and .4 x .6 black. Note documents Physician was notified on 9-15-11. R2 was observed on 9-14-11 at 10:10AM to be in bed and had an Allevyn heel and Kirlex on her left heel. E14, Licensed Practical Nurse (LPN) removed the dressing from R2's heel. The Allevyn heel was stuck to the wound and there was dark brown drainage. The pressure sore was beefy red with edges that were black in some areas. The beefy red area was a full thickness wound. E14 cleansed the wound with wound cleanser and gauze and then put R2's heel down on the pillow at the foot of her bed. E14 then opened a Sureprep wipe and wiped around and over the pressure sore. E14 fanned R2's heel until Sureprep dried and then placed a gauze pad in the same soiled Allevyn heel and placed the dressing on R2's heel. E14 was asked if she was using the same dressing that she just took off and E14 confirmed she had used the same Allevyn heel. E14 then stated maybe she shouldn't and took the dressing off R2's heel, took out the gauze pad and confirmed the Allevyn was soiled with brown drainage. E14 then placed R2's ankle on the pillow and told her not to let the pillow touch her heel. E14 left the room to get supplies and when she came back, R2 had rearranged her foot and the pressure sore was touching the pillow. E14 put a new gauze pad into a new Allevyn heel, put the dressing on R2's heel and dressed with kling without re cleansing the pressure sore. On 9-15-11 at 10:25AM, E13 stated R2's heel was red when first admitted and then identified as DTI. E13 confirmed R2 has not had a treatment change. E13 stated she had just today, sent information to the Doctor to see if they could change the treatment order. At 1:40PM, E13 stated the pressure sore was a full thickness skin loss with partial brown edges and had been like that for about a week. According to the manufacturer's information for Sureprep, provided by the facility on 9-15-11, Sureprep is for management of healing wounds to provide an additional barrier to the delicate skin around a wound during the healing process. During an interview on 9-15-11 at 9:45AM, with Z3, Certified Wound Specialist/Nurse for Sureprep, Z3 stated the only time Sureprep is to be used is to protect intact skin. It should not be used on full thickness loss. It's contraindicated for full thickness loss wounds. Record review of Nurses Notes from 8-15-11 through 9-14-11 shows no documentation that R2's Physician was contacted of decline in the pressure sore. Physician order [REDACTED]. Nutrition Assessment of 8-24-11 shows R2 was admitted on [DATE] with a weight of 130 lbs and a DWR (desired weight range) of 97-138 lbs. The Assessment shows history of poor intake and estimated intake < 25%. Assessment documents general mechanical diet is adequate to meet nutritional needs, area on left heel DTI; poor intake with recommendation for supplement due to weight loss and open area. R2's TAR shows R2 weighed 118 lbs on 9-1-11 and 9-7-11 yet there in no Nutritional Assessment address the significant weight loss or the decline in pressure sore. The Facility was informed of concern on 9-14-11 and had the Dietitian assess on 9-15-11 with recommendation for increased nutritional supplement. R2's laboratory test of 9-7-11 show total protein and [MEDICATION NAME] are within normal limits. During interview with E19, LPN, on 9-15-11 at 3:45PM, E19 stated she does treatments to R2's heel. E19 stated when she first saw R2's left heel it was a blister. E19 states its now real beefy red with brown dried edges. She said she changes the dressing every night when she works. Last week the blister broke and they were still using skin prep (Sureprep) to the heel. The heel didn't seem to be improving over the weekend. E19 stated she felt the skin prep was not working and the pressure sore was getting worse. E19 felt the treatment needed to be changed and on Sunday, September 11, 2011, she let the night Nurse so the Physician could be notified. Nurses Notes of 9-14-11 at 2325 document R2's Physician was faxed update with regards to treatment to left heel - no improvement. Fax provided by E21, Corporate Nurse, showed Fax Communication form dated 9-15-11 at 0730 sent to R2's Physician documenting R2 "has current order for skin prep L heel. Area now open can we DC (discontinue) current order et change to cleanse dly (daily with normal saline or wound wash, apply [MEDICATION NAME] gel to open area Cover with foam pad et wrap with kerlix?" Fax was signed with OK and sent back to the facility on [DATE] at 1431. 2. According to Minimum Data Set ((MDS) dated [DATE], R3 requires extensive assist of staff for transfers and bed mobility and is frequently incontinent of bladder. The Braden Scale dated 8/31/11 identifies R3 as a "moderate risk" for pressure ulcer development. Labs dated 4/13/11 indicate [MEDICATION NAME] is 2.6 (normal 2.4 - 4.3) and Total Protein 5.7 (Normal 5.1 - 7.2) are both normal. The Registered Dietician identified a weight gain of 5 pounds on 8/18/11. The physician's orders [REDACTED]. The care plan dated 7/14/11 identifies R3 at risk for skin breakdown. The Pressure Ulcer weekly report identifies R3 as developing an in-house acquired ulcer on her right trochanter on 8/21/11. The nurses notes also reflect the pressure sore and indicates it measured 1.6cm x 1.4cm with a necrotic area in the center measuring 0.5cm x 0.2cm, stage III. There is no justification for the development of this ulcer and no explanation as to why the area was not identified prior to the development of the necrotic area. The "Weekly Ulcer Report" dated 9/1/11 reflects the initial ulcer on the right trochanter and an additional ulcer developing in the same area which measured 1.0cm x 0.2 staged at a II which began as a blister. On 9/16/11 at 10:30am, E2 Director of Nursing (DON) identified R3 as being on Hospice and the pressure ulcers being "unavoidable" offering documentation, Clinically unavoidable pressure sore guide tool", that lists R3 as having [MEDICAL CONDITION] and chronic urinary incontinence and having labs that indicate R3 may be at risk for [MEDICAL CONDITION] and/or dehydration/poor healing. The tool also includes interventions implemented at the time the ulcer were identified but don't include any reference to her right side. Interview with E15, Certified Nurses Aide, said on 9/16/11 at 12:45pm, that R3 has declined in the past couple months and always insists on laying on her right side when in bed so she can face the wall. R3 was observed to sit in her chair at bedside and/or in the dining room throughout the survey except for toileting. The ULCER POLICY & PROCEDURE indicates all residents will be assessed upon admission, quarterly and as changes occur. The policy includes protocol for low, moderate and high risk residents. Moderate risk indicates "Daily skin checks are completed, as well as weekly skin checks by CNA (Certified Nurses Aide) on bath day using the "skin observation worksheet." The policy continues under HIGH RISK to document that "residents with existing ulcers will be scored at high risk automatically." There is no documentation that R3 was reassessed for risk following the development of the stage III pressure ulcer. 3. The Facility Care Plan with the target date of 10/28/11 documents that R14 has [DIAGNOSES REDACTED]. Review of the care plan problem area of skin, dated 8/30/11 documents a stage one pressure ulcer to the right heel and stage two pressure area to the left heel. Under the area of goals is documented "right heel discontinued on 9/7/11 and 9/8/11." Review of the current MDS dated [DATE] documents that R 14 requires extensive assistance with all activities of daily living, is non- ambulatory and uses a wheelchair. She is also assessed as being at risk for pressure ulcers and requires pressure relieving devices in bed and in the chair. Review of the Facility "Weekly Ulcer Report" for the week of 9/1/11 documents that R14 has a Stage one pressure ulcer to the right heel measuring 2.5 by 1.7 centimeters, and a stage two pressure ulcer to the left heel measuring 0.5 by 0.3. The Weekly Ulcer Report dated 9/8/11 documents that R14's Right heel wound is resolved and the left heel measures 2.1 by 2.5 centimeters. There is no documentation of any dressing to R 14's coccyx area. A skin check done with E20 Registered Nurse, on 9/14/11 at 4:30PM. Observed that Right heel has a darkened area, firm to the touch, and non-blanching. E20 stated, " there is still something there so we should be tracking that until it is gone." Skin check with E16 on 9/14 /11 at 4:00PM. R 14 was observed to have an occlusive dressing area applied to her coccyx. When the dressing was removed, the entire coccyx was reddened and towards the center were several open areas with skin peeling back in small sections. E 16 stated, "well I asked the wound care nurse about this dressing because we didn't have any for (R14), and she stated, hospice has been putting that on because of irritation due to incontinence. No we have not been tracking or measuring that area."

Based on interviews, observations and record review, the facility failed to ensure residents receive adequate supervision and proper assistance to prevent falls and skin tears for 6 residents R7, R17, R19, R21, R22 and R25 of 15 residents reviewed for falls and bruises/abrasions in the sample of 26. The failure resulted in R19 obtaining a left hip fracture. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R19 as having short/long term memory deficits with moderate cognitive impairment and requires assist of one staff for mobility. The Fall assessment dated [DATE] identifies R19 at a moderate risk for falls. The Care Plan dated [DATE] identifies R19 as needing assistance of one with a gaitbelt and wheeled walker with transfers, ambulation to/from bathroom and walking in corridor. The Occurrence Report dated [DATE] at 8:55 AM, documented R19 was "observed sitting on floor in the resident's room." The report further documented cognitive level of "oriented x 2" and "no injuries noted." On [DATE] at 8:00 PM, additional information was documented as "skin tear 3.5 x 2.5 x 0" and a resident statement was given as "I was reaching for my coffee cup earlier today and there was stuff in the way and I must of hit my arm then." Treatment documented as "Steri strips applied." Interventions documented on the report as "Will look at room to arrange area for resident to put coffee and other items within easy reach. Will continue to monitor area until resolved. Will have maintenance look at room for any sharp edges to help prevent future skin tears." Another Occurrence Report dated [DATE] at 7:31 PM, documented R19 was "observed on floor in dining room." The report further documented cognitive level of "oriented x 1" and "pain when ROM performed, resident complained of left hip/leg pain, outside services required." Documentation indicated that R19 was transported via ambulance to the hospital. Hospital documentation indicated that R19 sustained a Left Hip Femoral Neck Fracture and underwent Left Hip Hemiarthroplasty. Nurses Notes indicated that R19 was repeatedly walking without assist of staff and/or walker days and the evening approaching the fall on [DATE]. On [DATE], R19 was readmitted to the Facility. On [DATE], the Care Plan indicated "personal alarm" was added as an intervention. On [DATE] at 10:30 AM, E24, LPN, stated the Facility attributed the fracture to a fall on [DATE]. On [DATE] at 11:50 PM, an Occurrence Report documented that R19 was "observed on floor in resident's room, laying along side of bed on back." The report documented prevention measures at the time of fall "Alarm: None." R19's cognitive level was documented as "oriented x 1." The report documented "Immediate Actions Taken:...Alarm applied." There was no further changes made to the Care Plan at this time. On [DATE], the "Endurance/Functional Ability Assessment" documented R19 "transfers with extensive assist of ,[DATE] using gait belt and wheeled walker...Extensive assist for toileting, bed mobility, dressing and personal hygiene also..." On [DATE] at 12:30 AM, an Occurrence Report documented that R19 was "observed on floor on his back with his head near closet in resident's room." The prevention measures at the time of fall "Alarm: none." The report documented resident statement "I don't know for sure but I think that I lost my balance and fell . It made my bad hip start hurting again." Documentation indicated that R19 was transferred via ambulance to the hospital for treatment and returned later the same day. On [DATE], after many complaints of pain of the left hip/leg by R19, R19 was transferred to the hospital and admitted with the [DIAGNOSES REDACTED]. 2. Per the admissions face sheet R17 has current [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] documents that R 17 is severely cognitively impaired, with both short and long term memory problems. The Facility Fall assessment dated [DATE] documents that R 17 is at high risk for falls. The Plan of Care with the Target date of [DATE] under the problem area of Mobility deficits does not include any connection to R17's Urinary Tract Infections (UTI) or UTI symptoms that warrant interventions or the need to increase supervision for R17 during these times. Facility Occurrence reports dated [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE] and [DATE] document that R17 had repeated falls. The Facility Occurrence report dated [DATE] states, " fell out of Broda Chair while at the nurses station, no witnesses." The intervention recommendation for this incident states, "Current Broda Chair to be replaced with drop seat wheelchair and self releasing seat belt." The [DATE] Occurrence Report states, "fell on floor next to Broda chair out in common area, no witnesses, head trauma noted...abrasion." No changes in care interventions were provided by the facility between the ,[DATE] fall and the ,[DATE] fall. The Facility occurrence report dated [DATE] documents R17 fell out of her bed on to the mat at the bedside. Facility Recommendations were to, "continue current safety measure and re-evaluate effectiveness." R 17 fell again on [DATE] from her bed to the mat on the floor. This fall per the report resulted in a head injury. No changes in care interventions had been made between the ,[DATE] and [DATE] fall. Facility follow up written by E3,RN, on [DATE], notes that R 17 "had an elevated temperature and increased restlessness with frequent attempts to toilet herself. Recommendations state, continue current safety measure which are effective when (R17) does not have a Urinary Tract infection." There are no interventions/recommendations given on the occurrence report or on the current care plan for increased supervision when R 17 states to display signs/symptoms of a Urinary Tract Infection. E17, LPN, stated during the facility tour on [DATE] at 10:30 AM that the bruise was a result of R17's most recent fall dated [DATE]. On [DATE] at 11:30AM, E3 stated "yes she got the bruise as a result of that fall, we know she has these falls when she gets a urinary tract infection. She gets more restless and agitated, and crawls out of bed or out of her chair." On [DATE] at 11:30am, R17 was observed in her Broda chair in the dining room at the table. R17's left side of her face was black/blue/purple extending from her hairline to her upper neck. 3. R25 nurses notes indicate he sustained a skin tear on [DATE] and on [DATE]. The Care plan fails to include fragile skin/skin tears and a prevention plan addressing this. R25's nurses notes written on [DATE] at 11:53pm documents that "(Certified Nurses Aide, CNA) reports repositioning in bed - pulling resident up in bed c (with) his assist - grabbed right upper arm to pull up in bed - received skin tear" measuring 4cm x 2cm in half moon shape. The area was cleansed and steri-striped after the physician was notified. The report fails to identify lifting a resident by the upper arm as harmful and fails to include a plan to prevent further skin tears. According to the nurses notes, R25 expired on [DATE]. Pictures of R25's body received on [DATE] from Z4, funeral director, show him to have the skin tear on the upper right arm but also have an open skin tear on his left elbow along with his right great toe which also had a skin tear on. This was confirmed by Z4. The nurses notes contained no information on the right great toe and/or the left elbow. E2, Director of Nursing provided wound care sheets showing that R25 had a left second toe wound but was unable to provide any documentation as to why his right great toe would have been steri striped or that he sustained an additional skin tear on his left elbow which went undocumented. 4. R22's Occurrence Report, dated [DATE] at 02:00, documented "staff (E28, CNA)) had resident in sit to stand was moving her into the bathroom to use toilet when her right upper arm bump the frame of doorway into the bathroom and caused skin tear." It was also noted that her right upper arms was bruised with a skin tear of 1cm. In an interview of E3, RN, on [DATE] at 1:45p.m., E3 stated R22's door frame was checked for sharp edges, R22 was provided a wider high back wheel chair and E15 (CNA) would mentor staff concerning R22's new wheel chair. Interview of E15, on [DATE] at 1:56p.m., E15 stated R22 had been provided a new wheel chair, did not inservice concerning the new wheel chair and that E26, Restorative LPN, would address transfers. Interview of E26, on [DATE] at 2:01p.m., E26 stated E27, Restorative Aide, inserviced E28 on transfers. Interview of E27, on [DATE] at 2:06p.m., stated E28 went on light duty after R22's [DATE] transfer and that she did not inservice E28 on transferring. Interview of E26, on [DATE] at 2:01p.m., E26 stated R22's "last assessment of R22's sit to stand transfer was [DATE]" when asked if R22 had been assessed for the appropriateness of sit to stand transfer after the [DATE] incident. 5. R7's MD, dated [DATE], documented sever cognitive impairment and extensive assistance of one to two plus persons physical assistance with mobility, transfer and ambulation. R7's Care Plan, target date [DATE], documented potential for injury related to falls due to impaired cognition physical limitation and lack of safety awareness. It was also noted "clip belt with an alarm while in wheelchair". R7's Care Plan, target date [DATE], documented potential for impaired skin integrity. It was also noted "(arm protectors) to be work bilateral upper extremities" and "padded arms of wheelchair for protection." R7's Occurrence Reports, dated from [DATE] to [DATE], documented: [DATE], 1 cm xc 2cm skin tear on right hand with an intervention to "continue with (arm protectors)"; [DATE], 2cm x 2cm skin tear on left thumb with an intervention to "continue with (arm protectors) "; [DATE], right hand skin tear with an intervention to "continue with (arm protectors)"; [DATE], fall after R7 released her "clip belt" with an intervention to discontinue her "clip belt"; [DATE], right elbow bruise with interventions to "place protective (arm protectors) on resident's arms"; and, [DATE], right wrist bruise with an interview to provide "long sleeves or (arm protectors).": R7 was observed, on [DATE] and [DATE], with her wheel chair "clip belt" in place, the right arm of her wheel chair torn and pieces of torn plastic type material rubbing against her right arm and R7 did not have bilateral "(arm protectors)" or consistently wear long sleeves. 6. R21's MDS, dated [DATE], documented an diagnosis, in part, of Alzheimer's and extensive to total dependence of one to two person persons physical assistance with mobility, transfer and ambulation. R21's Occurrence Report, dated [DATE] at 15:40, documented "R21 sundowns in evenings and wants to pack up and go home." Per her statement she was looking for her suitcase under her bed and fell . An alarmed mat is at bedside and there is a sensor paid on her bed." It was also noted her alarm was not sounding at time of fall. R21's Occurrence reports, dated [DATE] to [DATE], documented: [DATE], at 17:00, R21 fell during unassisted toileting, [DATE], at 22:20, R21 was found lying on her back in the middle of the floor and her alarm was not sounding; [DATE], at 18:50, left knee abrasion from a fall during unassisted ambulation and her alarm was not sounding; [DATE], at 20:55, R21 bumped her head on a dining room chair during unassisted transfer, [DATE], at 20:25, R21's roommate informed staff at the nursing station that R21 had fallen after she attempted unassisted ambulation, [DATE], at 22:00, R21 fell after an attempted self transfer, [DATE], at 22:30, fell from bed and her alarm was not sounding; and, [DATE], at 22:10, R21 received a right and left knee abrasion after she was found laying on a mat by her bed. R21's Care Plan, target date [DATE], documented potential for injury related to falls due to impaired cognition, limited physical, mobility and lack of safety awareness. It was also noted personal alarm in chair while in room and motion sensor alarm for use while in bed. R21's Care Plan did not document R21's sundowning or interventions related evening activities and fall history.. R21's chart did not document an assessment of the effectiveness of the alarm to prevent falls. Interview of E8, on [DATE] at 10:00a.m., E8 stated when R21 would stand up her alarm would go off immediately and staff were not able to assist her in time. E8 did not provide an alarm assessment.

Based on interviews, observations and record review, the facility failed to adequately monitor for accusatory behaviors; resisting care; the effectiveness including side effects of the [MEDICATION NAME] and the possible link to an overall decline including eating, activities and hygeine/bathing for 2 of 15 residents reviewed for Antipsychotic mecidations in a sample of 26. This failure resulted in R3 showing a decline in condition as documented on her Minimum Data Set (MDS). Findings include: 1. According to the physician's orders [REDACTED]." The Minimum Data Set (MDS) Section E BEHAVIORS (5/31/11) identifies R3 as having no hallucinations or [MEDICAL CONDITION] and no behavioral symptoms being present. The nurses notes from 4/26/11 through 6/23/11 document only one behavior as occurring on 4/28/11 when R3 was documented as asking for a scissors so she could "cut herself loose." On 6/21/11, R3 was seen by her primary physician for the monthly visit and documents "according to nursing staff, the patient apparently has been fairly stable." On 6/23/11, the Psychiatrist is documented as seeing her and writes R3 "for an increasing paranoid persecutory bizarre grandiose delusional system, becoming increasingly agitated and accusatory of male staff to the point of having a police investigation when she claimed that staff had raped her." The Psychiatrist ordered [MEDICATION NAME] 1mg daily and increased her [MEDICATION NAME] to 40mg daily and added [MEDICATION NAME] 20mg and [MEDICATION NAME] 10mg daily. There is no justification for the use of the [MEDICATION NAME] as the clinical record including behavioral tracking shows no evidence of continuing behaviors related to staff care. According to the facility's investigation, the accusation appeared as a one time event in which the facility determined to be R3 misunderstanding and confusion with staff during incontinent care at night. On 9/16/11 at 11:45am, E3 Registered Nurse (RN) said R3 has had an increase in behaviors that including resisting care, accusatory behaviors, and increased agitation which resulted in the addition of the [MEDICATION NAME] following the incident of 6/23/11. E3 stated she realized yesterday (9/15/11) that she did not have behavioral tracking sheets out for the right behaviors and has since added those in. Tracking sheets dated 9/16/11 identify R3 as having resisting care issues and making false accusations about people (staff and family). On 9/16/11 at 10am, R3's family member (Z2) stated R3 had no behaviors that she was aware but did have some adjustments problems on admission which had been over a year ago. Z2 stated she visited R3 often at the facility and was aware that they had started R3 on medication for Alzheimers recently but did not know that the [MEDICATION NAME] was an antipsychotic medication. On 9/16/11 at 12:40pm, E16, Licensed Practical Nurse (LPN) said R3 "used to have behaviors" but doesn't anymore and provided behavioral tracking sheets from the medication administration records and aides books. On 9/16/11 at 12:45pm, R15 CNA stated R3 had an incident a couple months ago where she accused the staff but has not had any additional incidents. E15 said "Actually, R3 has had a decline in the past couple months" adding that she used to talk all the time and attend activities and no longer does either. E15 stated she will sit at bedside in her wheelchair with her eyes shut. E15 said R3 will respond when spoken to but doesn't talk like she used to. On 9/13/11 from 12:55pm until 4pm, R3 was observed to sit at bedside with her eyes shut at bedside. R3 was fed the majority of her lunch meal after taking a couple bites by herself with intake being < 25%. R3 was toileted on 9/13/11 at 12:55pm with no resisting behaviors noted and did respond to the CNA's when spoken to. On 9/15/11, from 9am until 11:25am, R3 was again noted to be sitting at bedside in her wheelchair with her eyes closed. R3 was not observed to attend and/or participate in any activities during the survey process. The MDS dated [DATE] fails to identify any behaviors for R3 but reflects a decline in eating from the MDS dated [DATE] as setup/supervision to extensive assist, hygiene from minimal to extensive assist and bathing to total dependency on staff. The Admission sheet for R3 identifies her to be a [AGE] year old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. R10's POS shows an order of 2-28-11 for .5 mg of [MEDICATION NAME]. R10's MDS of 8-6-11 shows no behaviors. Record review of R10's PSYCHOACTIVE MEDICATION MONTHLY FLOW RECORDS for June, July and August 2011 show R10 receives [MEDICATION NAME] .5 mg for [MEDICAL CONDITION]. Flow records show documentation of no [MEDICAL CONDITION]. During interview with E3, on 9-15-11 at 3:45PM, E3 confirmed R10 is not having [MEDICAL CONDITION] and stated they had just decreased R10's [MEDICATION NAME] not too long ago. In the morning of 9-16-11, E2, Director of Nursing, provided a Consultant Pharmacist Communication to Physician form dated 9-4-11 with recommendation to reduce the [MEDICATION NAME] with an order dated 9-16-11 from R10's Physician to lower the [MEDICATION NAME] to .25 mg.