Every finding on record at Helia Healthcare of Olney

Based on observation, interview and record review the facility failed to ensure the planned menu was provided to residents. This has the potential to affect all 71 residents residing in the facility. The Findings Include: 1.On 5/19/26 the meal planned for lunch for the week 'at a glance' menu was chicken breast supreme, carrots, green beans and peach slump cake. On 5/19/2026 at 11:30 AM the meal provided to the residents was a chicken patty or beef patty, corn, green beans and cake with whipped topping. V4 (Culinary Assistant) was asked why the chicken breast supreme was not served as planned. V4 stated that someone forgot to get the chicken thighs out of the freezer the night before and she did not have enough time to get them thawed and cooked for lunch today. V4 stated she had to look and see what she could use in place of the planned meal and chicken patty, and beef patties were the best option. V4 went stated the dessert was supposed to be a peach slump cake, so she just added some crushed canned peaches to the cake mix. 2.On 5/20/26 at 11:15 AM the meal that was planned for lunch per the week 'at a glance' menu was meatballs with a sweet and savory sauce, rice and green peas. The meal that residents were receiving was meatballs with no sauce, white rice and green beans mixed with green peas. V5 (Culinary Assistant) stated she had to make the sauce for the meatballs with teriyaki sauce and orange marmalade because that was all she had to work with and had to add green beans to the peas because she would of ran out of vegetables. On 5/20/26 at 11:45 AM, V3 (Culinary Manager) stated the truck came later than usual today. V3 stated usually the food is delivered first thing in the morning and that they would have the food items needed for lunch on it, but the last few weeks it has been coming after lunch. V3 stated she guesses she needs to start adjusting her order. V3 stated they had to buy meatballs from the local grocery store today and peas but realized that they did not purchase enough peas, so they added green beans to make them go further and feed the entire census. V3 stated she is new and she is still trying to learn the ordering process. 3.On 5/21/26 at 11:30 AM, the meal planned for lunch per the week 'at a glance' menu was savory baked chicken, company potatoes, garden seasoned carrots, and chef's choice of dessert. The meal being served to the residents was baked chicken thighs, rosemary potatoes and seasoned carrots with cake. V3 stated they did not make the company potatoes, which is a casserole, due to not having enough fresh baking potatoes for today's meal and Friday's meal to make the recipe so she substituted for rosemary potatoes. V3 stated the next truck delivery would not be here until next week, so they just used what they had available. During the resident council meeting on 5/20/26 at 1:00 PM, R14 who was alert to person, place and time stated during resident council meetings they complained about the facility not always following the menu and not knowing what was going to be served. The Long Term Care Facility Application for Medicare and Medicaid dated 5/19/26 documents 71 residents reside in the facility.

Based on observation, interview and record review the facility failed to offer meal substitutions that were appealing and of similar nutritive value to residents. This has the potential to affect all 71 residents residing in the facility. The Findings Include: On 5/19/26 during the lunch meal service at 11:00 AM a chicken patty, green beans, carrots and peach cake was served to all residents. The planned menu for 5/19/26 was chicken supreme, carrots, peach slump cake, and green beans. V4 (Culinary Assistant) stated she did have a beef patty for those who do not want chicken but no alternative to the vegetable and the meal was not served with any type of bread. On 5/19/26 during the lunch meal service at 11:30 AM, R19 who was alert to person, place and time stated they always get carrots or green beans it seems served at lunch and dinner, and there are never alternate meal selections available to choose from. R19 stated it is a chicken salad sandwich or leftovers from the previous meal as an alternative if there is any left, and most of the time she didn't like that meal either. On 5/20/26 at 11:15 AM during the lunch meal service meatballs, white rice, green peas mixed with green beans and apple pie were served for lunch. No other food items were available on the steam table. V5 (Culinary Assistant) stated she did not make any alternative food choices but if a resident does not like the meatballs, she could make a chicken salad sandwich. On 5/20/26 at 1:00 PM, during the resident council meeting R8, R14, R19, R44 and R63, who were all alert and oriented to person, place and time confirmed that they do not have alternate meal options for the main choice or the vegetable on a regular basis. The same residents all confirmed the food is generally not good, and they don't eat a lot off their plate. They are only offered a cold cut or chicken salad sandwich. On 5/21/26 at 11:30AM during the lunch meal service the steam table was observed to have baked chicken thighs, rosemary potatoes, and seasoned carrots. V5 confirmed there were no substitutions available other than the chicken salad sandwiches she could make when tray line was complete. On 5/22/26 at 11:00 AM during the lunch meal service the steam table was observed to have fish, baked potato, and green beans. There were no other hot meal options on the steam table. The Long Term Care Facility Application for Medicare and Medicaid dated 5/19/26 documents 71 residents reside in the facility. The Meal Substitutions Policy dated 12/2016 documented: an appealing alternate option of similar nutritive value should be available for all meals for residents who choose not to eat food that is initially served or who request a different meal choice Procedures: 1. Alternates shall be prepared and made available at all meals. At breakfast an alternate entree shall be prepared. At lunch and dinner an alternate entree and vegetable shall be prepared. 2. The dietary manager, cook or aide shall inform nursing of the alternates available. 3. Residents who refuse menu items, based on preference, shall be offered an alternate. 4. The dietary manager shall monitor meal service to ensure alternates are available.

Based on observation, interview and record review the facility failed to ensure that proper sanitation of dishes and cleanliness of equipment was maintained to prevent cross contamination. This failure has the potential to affect all 71 residents residing in the facility. The Findings Include:On 05/19/2026 at 9:55 AM during the initial kitchen walk through the following observations were made:Dirt and debris were observed under the floor mounted stainless-steel tables. The oven/stove had a layer of grease/dust build up on the top shelf over the stove, the back splash/sides/oven doors and oven top were full of old food splatters and dried spills. The dish machine had no sanitizer registering on the chlorine test strips. On 5/19/26 at 10:00 AM, V4 (Culinary Assistant) stated she is unsure when the machine is tested for sanitizer other than once a month when some guy comes in and services the machine. On 5/19/26 at 10:05 AM, V15 (Culinary Assistant) stated he is the main dish washer but is not sure when the sanitizer is checked. V15 stated he does not regularly test the sanitizer level in the dish machine and was not aware that he should be doing this. On 5/19/26 at 10:10 AM, V4 (Culinary Assistant) stated she determined the chlorine test strips were outdated/past expiration and maybe the reason no sanitizer level was detected and would contact the maintenance man to see if he had any in his stock. On 5/19/26 at 10:20 AM, V10 (Maintenance Director) entered the kitchen with pool and spa test strips and stated that he tested the water in the dish machine, and it all comes out testing as it should. V10 stated those are the strips he was told to use when testing the water. V10 stated he would attempt to work on the machine and prime the line to see if that would help get the sanitizer to flow through the tubing and the administrator went to find/borrow test strips from a sister facility. On 5/19/26 at 10:20 AM the dish machine was not in use due to sanitizer level not being within manufacturer recommended range. On 5/19/26 at 11:00 AM, V3 (Director of Human Resources/Culinary Manager) stated she is unsure how to test the sanitizer level and is unsure who services the dish machine but will speak with the administrator. V3 stated that the kitchen appliances should all be cleaned and the floors swept daily but confirmed that the stove/oven combination has clearly not been wiped down for quite some time. On 5/19/26 at 11:20 AM, V1 (Administrator) stated she was unsure who services the dish machine or where the correct strips are that should be used to test the chlorine level. V1 stated she will contact the corporate office and get the appropriate strips ordered if the pool and spa test strips were inadequate. On 5/19/26 at 11:45 AM, V15 ran the dish machine a full cycle and used the new test strips that were obtained from sister facility, and the test strip measured a concentration level of chlorine to be within 50-100ppm (parts per million). The Long Term Care Facility Application for Medicare and Medicaid dated 5/19/26 documents that 71 residents reside in the facility. The Cleaning and Sanitation-General Policy with a revision date of 01/2012 documents that the kitchen will be maintained in a clean and sanitary condition. The State and/or Federal Food Code will be maintained on file within the food service department and will be the basis of all sanitation and food safety practices 15. Food Service workers will receive training on the following subjects: .principals of cross contamination , proper techniques for cleaning and sanitizing utensils, equipment, and surfaces

Based on observation, interview and record review the facility failed to ensure that resident meals were delivered at appetizing/preferred temperatures for 5 of 5 (R8, R14, R19, R44 and R73) residents reviewed for cold food complaints in a sample of 49. The Findings Include:During the resident council meeting on 5/20/26 at 1:00 PM, R8, who was alert and oriented, stated the food is cold when it is delivered to her room. R8 stated she eats most meals in her room by choice but most of the time if she is hungry, she has to eat cold food. R14 , R19 and R44 who are alert and oriented to person place and time, stated they have complained about the food temperatures in the resident council meetings. On 5/21/26 at 9:00 AM, R8 stated by the time her breakfast tray was delivered this morning it had cold eggs and French Toast on it, so she did not eat very much of it. On 5/21/26 during lunch meal delivery the Arch unit trays were loaded on a non-insulated open to air cart. The trays had a plastic dome over the non-insulated plates. The cart left the serving window at 11:13 AM and the test tray was not delivered to the room until 11:40 AM. On 5/21/26 at 11:30am a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. The temperatures were taken immediately at 11:40AM for the food items and were as follows: chicken 109.4 degrees Fahrenheit, potatoes 94.2 degrees Fahrenheit and carrots 88.5 degrees Fahrenheit. 5/21/2026 at 11:48 AM, R73 who was alert and oriented to person, place and time stated, her lunch served today was cold. R73 was observed sitting in her recliner in her room while eating lunch. On 5/21/26 at 3:00 PM, V7 (Activities) stated the residents do complain about the food temperature in the resident council meetings and thought she had filled out a grievance for this issue in the last couple months. Upon review of the last 12 months of grievances and resident council minutes nothing was found on cold food complaints. On 5/22/26 at 9:00 AM, R8 stated her breakfast tray had barely warm food on it when it was delivered this morning as usual. R8 stated that she feels the staff try their best, but the food just gets cold fast.

Based on observation, interview and record review the facility failed to ensure residents receive food items in accordance with physician orders for safe swallowing/therapeutic diets for 18 of 18 residents (R4, R6, R13, R14, R16, R21, R22, R26, R27, R29, R34, R35, R45, R47, R52, R53, R64 and R65) reviewed for therapeutic diets in a sample of 49. Findings include: 1. On 5/19/26 at 11:00 AM the lunch meal service was observed to be serving ground chicken patty to the residents that receive a mechanical soft diet with no gravy on top. The steam table was observed to see options available for residents to eat for lunch and no gravy was seen. V4 (Culinary Assistant) confirmed that no gravy was made for this meal. No menu was available to review for this meal due to serving an item that was not planned and no recipe available. 2. The recipe for Meatballs sweet and savory ground for 5/20/26 documents the following serving instructions: 1. Prepare regular recipe as directed. 2. Remove the appropriate number of cooked meatballs and place in a food processor. Grind to desired texture. 3. Serve in a #6 scoop of meatballs with 2 fluid ounces of sweet and savory sauce. Additional sauce may be needed to moisten meat. During the lunch meal tray preparation on 5/21/26 at 11:15 AM, V5 (Culinary Assistant) was observed scooping the 2 ounces of meatballs in a slotted spoon and letting the thin sauce drain out of the spoon prior to placing on the plates. V5 stated that her meatballs were moist and tender. 3. R53's admission Record documented an admission date of 4/10/2026 with diagnoses including cerebral ischemia, adult failure to thrive, chronic pulmonary edema, pulmonary fibrosis, unspecified, heart failure, paroxysmal atrial fibrillation, and dysphagia, oral phase. R53's Minimum Data Set (MDS) dated [DATE] documented under Section K-Swallowing/Nutritional Status: R53 complaints of difficulty or pain with swallowing and mechanically altered diet R53's Physician Order dated 4/13/2026 documented a diet: Regular, Consistency: Mechanical Soft and gravy with meat. R53's Dietary Card documented a diet of mechanical soft and gravy with meat. On 05/19/2026 at 11:19 AM, R53 was served a mechanical soft diet of chicken patty, green beans and peas mixed and cooked carrots. There was no gravy on the chicken patty. On 05/20/2026 at 11:37 AM, V14 (Certified Nurse Assistant/CNA) served R53 a mechanical soft diet that included sweet and savory meatballs, green beans and peas, rice and apple pie. There was no sweet and savory sauce noted on 53's meatballs. On 05/20/2026 at 11:39 AM, V14 (CNA) stated R53 should have gravy/sauce on her meat for each meal because of swallowing issues. V14 stated there was no sauce on R53's meatballs. On 05/20/2026 at 11:43 AM, V6 (Minimum Data Set/MDS Coordinator) stated R53 is supposed to have gravy on her meats at each meal because she had been choking on her food while at the hospital prior to coming to the facility. On 05/20/2026 at 11:55 AM, V1 (Administrator) stated her expectation is for staff follow dietary orders. On 05/20/2026 at 12:02 PM, V5 (Cook) stated she does not serve gravy over meats if the meat is moist that day. V5 stated R53 did not get any gravy on her meatballs today and the sauce with the meatballs is too thin to use as well. On 5/21/2026 at 10:39 AM, V12 (Speech Pathologist) stated, R53 does have an order for a mechanical soft diet with gravy on meats to aid in swallowing. V12 stated, all other facility's do add gravy or some type of sauce to the mechanical soft meats to aid in swallowing, but this facility does not do that and is not consistent with adding gravy to mechanical soft diets. V12 stated, in her opinion all meat on a mechanical diet should include gravy or sauce to aid in swallowing. On 5/21/26 at 12:30 PM, V13 (Registered Dietitian) stated it is the policy that all mechanical soft meats should have gravy on them to aide in swallowing and reduce chance of choking due to swallowing difficulties. On 5/22/26 at 2:00 PM, V1 (Administrator) provided a diet type report of all residents residing in the facility. This report documents that R4, R6, R13, R14, R16, R21, R22, R26, R27, R29, R34, R35, R45, R47, R52, R53, R64 and R65 are to receive Mechanical Soft diets.

Based on observation, interview and record review the facility failed to ensure resident equipment was maintained in a state of good repair for 1 (R58) of 18 residents reviewed for environment in the sample of 49. Findings included:R58's admission Record documented an admission date of 9/21/2010 with diagnoses including rheumatoid arthritis, unspecified, mild intermittent asthma, uncomplicated heart failure, unspecified, essential primary hypertension, and type 2 diabetes mellitus without complications.R58's Minimum Data Set (MDS) dated [DATE] documented under BIMS (Brief Interview of Mental Status) score of 15 indicating R58 is cognitively intact.On 05/19/2026 at 10:46 AM, R58 stated she had an issue with her shower in her bathroom. R58 stated her shower is not working and continues to run water. R58 stated she had spoken to V10 (Maintenance) about her shower room, but it had been a while ago and V10 said he is still waiting for parts. At the time R58's shower head was continuously running water at a medium flow into the shower with black substance noted to shower floor in front of the drain.On 5/20/2026 at 10:15 AM, R58's shower head was continuously running water at a medium flow into the shower. There was a scattered black substance on the shower floor in front of and around the drain. On 05/20/2026 at 1:17 PM, V9 (Licensed Practical Nurse/LPN) stated the staff fill out a work order for items that are not working properly and turn it in to V10 (Maintenance). V9 stated, R58's shower did get a ticket filled out for maintenance and thinks it had been about 2 weeks ago.On 05/20/2026 at 1:19 PM, V10 (Maintenance) stated staff will complete a work order for broken items for him to fix. When this surveyor asked to look at work the order for R58's shower, V10 stated that he is moving offices, and he does not know where the work order is. V10 stated, he believes it was about 2 months ago when he first received the work order for R58's shower. V10 stated he is aware that R58's shower continuously runs water out of the shower head. V10 stated, he did notify V1 (Administration) about 2 months ago the parts he needed, which included a new cartridge for R58's shower. V10 stated, he will need to follow up with V1 on parts today.On 05/20/2026 at 1:27PM, V11 (Certified Nurse Assistant/CNA) stated, she does have direct patient care with R58. V11 stated, at first R58's shower head had just a trickle of water, but in the last 3-4 months the shower does constantly run a moderate amount of water in the tub. V11 stated, there had been a work order turned in about 3-4 months ago for the shower and they have been waiting on the parts. V11 stated, she had noticed the black substance on the shower floor.On 05/20/2026 at 1:31 PM, V1 (Administration) stated staff will fill out a work order form for broken items and give to V10. V1 stated, she had not been aware of R58's shower issues until today. V1 stated, V10 should have gotten parts from the local hardware store where they have a charge account, and she would not have ordered anything special. V1 stated, V10 should have fixed the shower in a timely manner. The facility's Quality of Life-Homelike Environment policy (revised February 2012) documented under Policy: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview, observation and record review the facility failed to provide range of motion program per COTA (Certified Occupational Therapy Assistant) recommendations to a resident with limited range of motion to prevent further reduction of range of motion (ROM) for 1 (R40) of 18 residents reviewed for range of motion in the sample of 49. The Findings Include: R40's Face Sheet documents an admission date to the facility of 01/23/2025. The diagnoses listed include cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right side, speech and language deficits following cerebral infarction, chronic kidney disease, and insomnia.R40's current care plan does not document any problem areas related to R40's hemiplegia and hemiparesis of the right arm / hand requiring restorative nursing.R40's MDS (Minimum Data Sheet) dated 03/26/2026 coded as Quarterly documents in Section GG0115, Functional limitation in Range of Motion, impairment in upper extremity coded 1 indicating that R40 has impairment. The same MDS, under Section O0500 Restorative Nursing Program, Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 days (enter 0 if none or less than 15 minutes daily) answered 0 indicating R40 does not receive restorative nursing.R40's Occupational Therapy Discharge summary dated [DATE] documents under section titled Discharge recommendations and status, restorative programs, restorative range of motion program upper extremity.On 05/20/2026 at 9:35 AM, R40 was observed sitting in a wheelchair in her room. R40 stated she does not receive any type of exercises on her arms or legs. R40's right arm was observed to be lying in her lap, with her fingers curled in. On 05/21/2026 at 9:44 AM, V8 (Certified Occupational Therapy Assistant) stated not all residents will be placed on a restorative program. It depends on their cognitive and physical abilities. V8 stated that R40 was discharged with a program for range of motion for the upper extremity. V8 stated she would expect the facility to put a program into place if a resident is discharged with a recommendation for a restorative program.On 05/21/2026 at 9:44 AM, V2 (Director of Nursing) stated range of motion is not a program the facility usually places for residents. V2 stated most residents are on bed mobility and transfer programs. V2 stated she thought range of motion was incorporated. V2 stated she was not aware when occupational therapy discharged R40 there was a recommendation for range of motion restorative program.On 05/21/2026 at 9:46 AM. V1 (Administrator) stated it is her expectation when a resident is discharged from therapy and a restorative program is recommended; the nursing department put the program in place. A Resident Mobility and Range of Motion Policy dated 10/20/25 documented, Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 7. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives.

Based on interview and record review, the facility failed to safely transfer and reposition 1 of 5 residents (R1) reviewed for safe resident handling in the sample of 13.This failure resulted in R1sustaining a fractured left humerus on [DATE] when the staff failed to use a gait belt to reposition R1.Findings include: R1's Face Sheet documented an admission Date of [DATE], a discharge date of [DATE], and listed diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Type 2, Congestive Heart Failure, Small Cell B Lymphoma, and Hypertension. R1's [DATE] Physicians Orders documented orders for restorative nursing services daily for bed mobility and transfers.R1's Transfer assessment dated [DATE] completed by V6, Registered Nurse, documented, Is the resident Independent in transfers and ambulation? No. Is resident predictable, cooperative, and able to follow directions? No. Is resident able to bear weight well during transfers, do they have history of being able to bear weight? No. Does resident only need minimal assistance (up to 25 # (pounds))? No. Is resident able to put both feet on the base of the Stand Assist Lift and bear some weight? No. Is resident able to lean back into the lifting belt at least a little? No. Is resident cooperative, and able to follow simple directions? No. Can resident bear weight on at least 1 leg well or bear weight moderately well on both legs (up to 5# assistance, or 25# per staff member)? Does resident have history of being able to bear weight and is resident predictable, cooperative, and able to follow directions? No. Use full body (mechanical) lift for all transfer. Consult physical/occupational therapy and Director of Nursing.R1's Functional Abilities assessment dated [DATE], completed by V6, documented, Sit to stand: admission Performance: Not attempted due to medical condition or safety concerns. Lying to sitting on side of bed - admission Performance: Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.R1's Nursing Progress Note dated [DATE] at 12:23pm, authored by V5, Registered Nurse (RN), documented, This nurse took report from a nurse at the hospital. Resident is a [AGE] year-old full code with a history of Prostate Cancer and Atrial Fibrillation. He is here for rehab so he can go back home to live with his wife. Hospital treated him with Intravenous fluid, Continuous Bladder Irrigation, and 1 unit of blood. At time of this report, resident hemoglobin is 9.7. Resident is alert and oriented times 4, very weak, appears pale, is three times a day (glucose check), incontinent of bowels, has a (indwelling urinary catheter) that was changed on the [DATE]. Resident has a stage 2 pressure sore that they have been treating with zinc. He is a heavy 2 assist, takes pills whole, regular diet, thin liquids. R1's Nursing Progress Note dated [DATE] at 7:51pm, authored by V6, RN, documented, (V3, Certified Nursing Assistant/CNA) reported to me that this resident was being pulled up in his chair around dinner time and as V3 and other aide (V4) went to hook one of their arms under residents arms, and their other hands were used to grab ahold of resident's waist/pants. As resident was being lifted and pulled back up into his chair, (V3) heard 3 'pops' and resident then stated, 'Ow ow ow my arm is broke.' Resident left arm movement is minimal below elbow, and is unable to move above the elbow, especially without serious pain. Resident requested Tylenol for pain. Family was in the room during the entire occurrence and witnessed what had happened. I asked the family about options, such as getting an x-ray or being sent back to the hospital; I also stated that we currently had (portable x-ray provider) on their way for another resident, and I could see about getting this resident added on to the workload. Family requested resident be seen by x-ray as they 'just left (local hospital) today around 2 and we don't want to go back.' I called (V9, On Call Physician/Medical Director) as he is on call and explained the situation. I stated what the family had requested and asked if it would be okay to add resident to current x-ray trip. (V9) stated that he thought that would be okay and to go ahead with adding them to current workload. I called (x-ray provider) and added this resident to the list, (provider) stated that they would be here between 8:20-8:30 (pm) to do both x-rays.R1's Nursing Progress Note dated [DATE] at 8:33am, authored by V8 RN documented, Called (V10, Primary Care Physician) on his cell. Reported resident pain level of 10 this morning and Tylenol given but family requested something stronger for pain control. Order received for Hydrocodone 5/325 four times daily as needed for pain. Clarification regarding Eliquis needed as family thought MD stopped it. (V10) stated it depends on if family is wanting to pursue palliative care or full treatment, and he will speak with them and then update this nurse. Order to hold Eliquis for now. R1's Nursing Progress Note dated [DATE] at 12:02pm authored by V8 stated, Telephone order received from (V10) at 1056 am to send to ER for evaluation instead of going the referral route. Called (local Emergency Room) report to (name of hospital staff) at 12:00. Called EMS (Emergency Management Systems) at 11:02am, EMS arrived at 11:15 am.R1's Event Report authored by V6 dated [DATE] at 7:48pm documented the event as per the [DATE] 7:52pm Nursing Progress Note as stated above.A Long Term Care Facility Serious Injury Incident Report Initial and Final report for R1 submitted by V1, Administrator, Initial dated [DATE] and Final dated[DATE] documented, Detailed Incident Summary: Resident was being pulled up in his chair around dinner time and as (V3 and V4) went to hook one of their arms under residents arm and their other hands were used to grab ahold of residents waist/pants. As resident was being lifted and pulled back up into his chair, (V3) heard 3 pops and resident then stated, 'ow ow ow, my arm is broke.' X-ray was performed by (portable x-ray provider) and came back as a pathological fracture due to Osteoporosis.R1's X-ray Patient Report dated [DATE] documented, Left shoulder: Findings: There is an acute fracture at the proximal shaft of the left Humerus which is suspected to be pathological fracture. R1's [DATE] Hospital Discharge Summary documented, Patient is a [AGE] year-old male who presents to the Emergency Department via Emergency Management Systems from a local nursing facility for left shoulder pain. Last night he was being moved up in bed when he heard a pop. An X-ray of the left shoulder discovered a pathological fracture of the left humerus. Patient is alert and oriented upon presentation. Per wife and daughter, patient has a history of colon cancer 2003 status post bowel resection, prostate cancer 2016, status post radiation, leukemia 2023, status post chemotherapy - currently in remission. Patient was hospitalized last week for blood in his catheter. He was too weak to work with physical therapy while he was hospitalized so he was discharged to a local nursing facility. Spoke with family about discharge planning. Family wants to take patient home and will not be returning to the nursing facility. They are trying to set up home hospice care at this time. Contacted case management to talk to family. Clinical Impression: Closed nondisplaced fracture of surgical neck of left humerus, unspecified fracture morphology, initial encounter. Disposition: Discharge.R1's Death Certificate documents a date of death of [DATE] and a Cause of Death: Coronary Artery Disease. On [DATE] at 8:55 am, V11, Family Member, stated on [DATE] around supper time before 5pm, she asked staff to pull R1 up in his recliner as he was sliding down. V11 stated V3 and another unknown CNA stood on either side of R1, hooked their arms under R1's armpits and lifted, without using a gait belt, and a loud crack was heard from R1's left arm, and R1 stated, You broke my arm. V11 stated V3 immediately left the room to inform the nurse what had happened. V11 stated at that time R1 did not complain of pain unless he moved his arm. V11 stated V3 came in and looked at the arm every 10 minutes or so in between time and said she was checking for swelling and bruising. V11 stated V6, Registered Nurse, came into the room to evaluate the arm at around 7pm. V11 stated V6 then called the on-call physician and got an order to have the arm x-rayed, which showed that it was fractured. V11 stated V3 stated the on-call physician recommended not sending R1 to the local emergency room (ER) as no Orthopedic services were available there but waiting until the next morning so an emergent appointment could be made with an Orthopedic Surgeon. V11 stated that V11 and V12 were in agreement with that plan as R1 had just gotten out of the hospital on [DATE] and they felt it would be hard on him to have to go back unless it was needed. V11 stated as time wore on in the evening, R1 was in, Horrible pain, moaning, and screamed out when they repositioned him to change him. V11 stated sometime around 9pm, V6 gave R1 two Tylenol and stated that was the only thing R1 had ordered for pain. V11 stated she asked V6 if R1 could have some stronger pain medication, and V6 stated trying to get an order for narcotic pain medication at that time of the day was, A whole big thing. V11 stated R1 did get some relief from the Tylenol and was able to sleep. V11 stated by the next morning, R1 was in severe pain. V11 stated V8, RN, contacted V10, R1's Physician, about getting stronger pain medication but it was not administered until after 10:30am on [DATE]. V11 stated staff were also trying to get R1 an orthopedic appointment that morning. V11 stated by that time she and R1 were tired of waiting on the referral and tired of seeing R1 in pain and asked V8 that R1 be sent to the local ER to make sure he would have access to needed pain medication. V11 stated R1 was discharged to home from the hospital on [DATE] on hospice care and died on [DATE]. V11 stated it is her belief that the fracture and resulting pain caused R1 to, Give up, and this contributed to his death.On [DATE] at 10:50am, V3 stated on [DATE] she worked 2pm-10pm. V3 stated R1 was a new admission who arrived about the same time as when she started her shift. V3 stated V11, V12, and V13, Family Members, were in the room with R1. V3 stated R1 was alert but somewhat confused, calling out for V12 although she was in the room. V3 stated around 4:30pm, V11 put on the call light and said R1 needed moved up in the recliner. V3 stated she and V4 got on either side of the recliner, put their arms under R1's armpits, and lifted. V3 stated a gait belt was not used. V3 stated, They all heard 3 loud pops, and (R1) said oh I think you broke my left arm. V3 stated she immediately left the room and told V5, RN, what had happened. V3 stated V5 asked if the arm was swelling and V3 said no. V3 stated V5 said she would be down there as soon as she got finished with what she was doing. V3 stated as V5 did not go assess R1, V3 was checking in and looking at his arm every 10 minutes or so. V3 stated R1 stated he had no arm pain as long as his arm was immobilized but had significant pain if it was moved. V3 stated V5 left the facility when her shift ended at 6pm without having assessed R1. V3 stated at about 6:30pm she told the oncoming nurse, V6, RN, what had happened and V6 then went and assessed R1.On [DATE] at 12:40pm, V4 corroborated V3's account of the incident, with V4 stating she stood on the right side of the recliner with V3 on the left side. V4 stated after a pop was heard, V3 left the room to tell the nurse working that night, identity unknown, what had happened. V4 stated she was engaged in caring for other residents for the remainder of her shift and was not sure what happened with R1 the remainder of the evening.On [DATE] at 1:10pm, V13, Family Member, stated on [DATE] when she was visiting R1, V3 needed to get R1 into bed using a mechanical lift. V13 stated V3 left the room to get help from other staff, but nobody was available. V13 stated she offered to help with the lift and V3 accepted, with V3 using the controls and V13 helping with positioning in the bed. V13 stated the transfer was uneventful. On [DATE] at 2:15pm, V3 corroborated V13's account of the mechanical lift transfer as stated above. V3 stated two staff are to do mechanical lift transfers, but other staff were busy and V13 offered to help. On [DATE] at 2:20pm, V6 stated she worked 6pm-10pm on [DATE]. V6 stated shortly after arriving, V3 stated to V6, There was a popping noise from (R1's) arm when they pulled him up in the chair around supper and asked if I could go down to see him ASAP (As Soon As Possible) as he was in pain. V6 stated V3 told V6 that she had told V5 about it earlier, but V3 thought V5 forgot. V6 stated V11, V12, and V13 were present in R1's room when she went in. V6 stated the arm wasn't bruised or swollen and was not painful if immobile but there was pain with movement as well as decreased range of motion. V6 stated she did not recall asking R1 what his pain was on a ten scale but did ask if he wanted anything for pain and he said yes, Tylenol, for which he had an order. V6 stated she called V9, who ordered an x-ray. V6 stated she administered the Tylenol she thinks at about 7pm and recalls later the resident felt it had been effective. V6 stated the x-ray result came back toward end of her shift showing a pathological fracture of the left humerus. V6 stated she notified V9 of the result, who stated he did not feel R1 needed to be sent to the local ER, as they had no orthopedic services, but to wait until the next day and get him an appointment with an orthopedic surgeon. V6 stated she notified V11, who was in agreement with this plan. V6 stated V11 stated R1 had just gotten out of the hospital and didn't want him to return if it wasn't necessary. V6 stated the rest of her shift, in regard to R1, was uneventful.On [DATE] at 8:30am, V7, RN, stated she worked 10pm to 6am on [DATE]. V7 stated she had been informed of R1's condition during shift report. V7 stated she did not recall doing a pain scale on R1 or the specific severity of his pain. V7 stated she recalled R1 was guarding the arm and didn't want it moved. V7 stated she was not sure if she administered Tylenol, but upon checking R1 he was sleeping soundly, and she assumed he was not having severe pain. V7 stated she asked V11 if V11 felt R1 needed to go to the ER and V11 said no. V7 stated V11 nor R1 asked for stronger pain medication at any time during the shift. V7 stated she regularly works the night shift and obtaining narcotic pain medication can be difficult. V7 stated it is difficult to get the on-call physicians to prescribe opiates for residents that are not their patients, and they expect primary care physicians to address this during daytime hours. V7 stated a written prescription is required and a verbal order can't be used. V7 stated if there is a written order sent to the pharmacy, the facility can call the pharmacy and get a code for which to obtain the medication from the Emergency Medication Kit (E-Kit).On [DATE] at 9:15am, V5 stated she thinks she worked 2pm-6pm on [DATE]. V5 stated R1 had just been admitted , and she recalled going into the room with consents for him to sign and V11 was also present. V5 stated R1 was able to appropriately answer questions but was not talkative and V11 did most of the talking. V5 stated she had no further contact with R1 that shift. V5 stated about 30 minutes before time to leave for the day, she was passing medications on A Hall when V3 came to her and said, They had attempted to pick (R1) up, and he felt something pop. V5 stated she told V3 she would assess R1 after she finished medication pass. V5 stated she forgot about it, did not assess R1, and did not tell the oncoming nurse about it in report. V5 stated, Only about 30 minutes elapsed from when (V3) told her about it until her shift was over and she left. V5 stated V3 did not express to her that the arm might be broken, and if she had she would have locked up the medication cart and went down there immediately.On [DATE] at 11:05am, V9 stated staff called him (time unknown) on the evening of [DATE] to report that when R1 was being repositioned in a chair, a pop was heard. V9 stated he ordered a portable x-ray which showed a pathological transverse fracture of the left humerus. V9 stated such fractures are generally treated with external stabilization, such as sling, rather than surgical intervention. V9 stated based on this, as well as a lack of availability of orthopedic services at the nearby ER, he felt there was no indication to send R1 out but to instead obtain an appointment with an orthopedic surgeon the next day. V9 stated staff told him the family agreed with this plan as they wanted to avoid rehospitalization if possible. V9 stated had the family wanted R1 sent out, he would have done so immediately. V9 stated staff did not say that R1 was in severe pain and needed narcotic pain medication or he would have provided it. V9 stated an e-script (electronic prescription) could have been sent to the pharmacy and a code given for the e-kit. On [DATE] at 11:55am, V8, RN, stated she came in to work at 6am on [DATE] and was given report by V7, who stated R1 had a left arm fracture which occurred after CNAs lifted him up by arms to reposition him in the chair. V8 stated V7 said the family and V9 had planned to get R1 an orthopedic referral that morning. V8 stated within about 30 minutes after report she went to check on R1 and found he was in severe pain, at a 10 on a 10 scale. R1 and V11 were unable to say how long the pain had been going on. V8 checked R1's orders and found there was only Tylenol ordered, so she went ahead and gave it about 6:30am, and upon checking back, found it had been mostly ineffective. V8 stated she did not recall what R1's pain was on a ten scale at that point or if she asked. V8 stated she called V10, R1's Primary Care Physician, who ordered Norco for R1's pain. V8 stated since V10 was not in his office with the ability to send an e-script, she could not get a code from the pharmacy to get into the e-kit until after 10am. V8 stated by that time, V11 and R1 were very upset and wanted R1 sent out. V8 stated she got an order to send R1 out from V10 at about 11am and the ambulance arrived about 11:15am. V8 stated with their current pharmacy services, getting medications, especially narcotics is often difficult.On [DATE] at 12:35pm, V10 stated he last saw R1 on [DATE] as he was discharging R1 from the hospital. V10 stated R1 had multiple serious chronic health problems including Prostate Cancer and Lymphoma. V10 stated to his knowledge there was no metastasis to the bones nor did R1 have osteoporosis. V10 stated the plan was for R1 to receive rehab services at the facility and return home with V11. V10 stated R1 was weak but stable and was on a lot of medications. V10 stated he was surprised to learn of the arm fracture. V10 stated in his weakened state, R1 would not have been able to assist staff with repositioning and with a gait belt not being used, it most likely caused the fracture. V10 stated when R1 returned to the ER on [DATE], he deteriorated and was sent home on hospice later that same day. V10 said he was surprised to learn that R1 died on [DATE]. V10 stated the cause of death per the death certificate was coronary artery disease. V10 stated when the incident was reported to V5, R1 should have been immediately assessed for injury and pain V10 stated the facility, Could have done a better job of taking care of this patient. V10 stated he was not aware of any ongoing issues with resident's medications being available, including opiates. V10 stated V8 called him the morning of [DATE] saying R1 was in severe pain and got a verbal order for Norco for R1. V10 stated he cannot e-script from his phone, so he was able to do that from his office at 10:20am. V10 stated it was his understanding that opiates could be obtained from the e-kit with a verbal order.On [DATE] at 2pm, V14, Certified Occupational Therapy Assistant/Therapy Services Director, stated she did not evaluate R1 and could not speak directly as to his care, but current recommendations for a similar resident would be repositioning with a gait belt, not by lifting under the arms.On [DATE] at 8:30am, V2, Director of Nurses, stated it is the facility's policy that repositioning a resident in a situation such as R1 requires the use of a gait belt. V2 stated it was her understanding that V6 assessed R1 instead of V5 as the incident occurred at shift change around 6pm. V2 stated it was her understanding that V3 did not relay to V5 how serious R1's situation potentially was and that he most likely had a fracture. V2 stated had the family wanted R1 sent out, V9 would have given the order to do so, but they had stated they wanted to avoid rehospitalization if possible. V2 acknowledged getting narcotics and medication for new residents with their current pharmacy is at times problematic.The facility's Safe Patient Handling Policy dated [DATE] stated, Policy: All resident care will be provided in a safe appropriate and timely manner in accordance with the individual resident's care plan. Manual lifting of all residents who are unable to bear weight will be minimized. Residents identified as totally dependent or extensive assistance, for example will be transferred by means of lift equipment and/or other resident assist devices instead of by manual lift. Gait/transfer belts, including two handled gait/transfer belts where deemed appropriate, will be used where manual assistance is required for ambulation and transfer activities.The facility's Repositioning of Resident Policy dated [DATE] documented, Repositioning a resident in a chair: 6. Prevent skin to skin contact with use of sheets, pillows, or positioning devices.The facility's Mechanical Lift Policy dated [DATE] documented, Two staff members are required when transferring a resident with a mechanical lift.The facility's Resident Examination and Assessment Policy dated February 2014 documented, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical Exam: Musculoskeletal: A. Gait. B. Mobility and range of motion of extremities. C. Joint deformity. D. Fractures.The facility's Gait Belt Use Policy dated [DATE] documented, Policy: It is the policy of (the facility) that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident and the employee. Procedure: 5. When transferring the resident use good body mechanics, bend knees, not back, reach under the residents' arms and hold the gait belt behind his/her back.

Based on interview and record review, the facility failed to promptly assess and treat a resident with severe pain for 1 of 10 Residents (R1) reviewed for pain in the sample of 13. This failure resulting in R1 experience severe pain for a period of approximately 4 hours after sustaining a fractured left humerus.Findings include: R1's Face Sheet documented an admission Date of 11/11/25, a discharge date of 11/12/25, and listed diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Type 2, Congestive Heart Failure, Small Cell B Lymphoma, and Hypertension. R1's November 2025 Physicians Orders documented an 11/11/25 order for Tylenol 500 milligrams two tablets four times daily as needed for pain, and an 11/12/25 order for hydrocodone acetaminophen 5-325 milligrams take one tablet four times daily as needed for pain. R1's November 2025 Medication Administration Record (MAR)documented an order for Tylenol 500 milligrams two tablets as needed four times daily start date 11/11/25. This MAR documented that the Tylenol was given on 11/11/25 at 9:29pm for 'Pain and was effective. There was no numeric value documented to rate this pain. The MAR documented the Tylenol was again given on 11/12/25 at 6:35am for Pain and was slightly effective. There was no numeric value documented to rate this pain. The MAR documented an order for hydrocodone-acetaminophen 5-325 milligrams take one tablet as needed four times daily with a start date 11/12/25. The MAR documented this medication was given on 11/12/25 at 10:36am and was not effective. There was no numeric value documented to rate this pain. The MAR documented an order for Pain assessment every shift. This documented that on evening shift (2pm-10pm) and night shift (10pm-6am) on 11/11/25, R1's pain was zero. On 11/12/25 on the day shift (6am-2pm) R1's pain was 10. R1's Minimum Data Set Pain assessment dated [DATE] at 8:09pm, authored by V6, Registered Nurse (RN), documented Purpose of assessment: Admission. Complete for all residents, regardless of current pain level. At any time in the last 5 days, has the resident received scheduled pain medication regimen? No. Complete for all residents, regardless of current pain level. At any time in the last 5 days, has the resident received PRN pain medications OR was offered and declined? Yes. Ask resident: 'How much of the time have you experienced pain or hurting over the last 5 days?' Rarely or not at all. Numeric Rating Scale (00-10). Ask resident: 'Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine.' (Show resident 0-10 pain scale). 4.R1's Nursing Progress Note dated 11/11/25 at 7:51pm, authored by V6 Registered Nurse (RN), documented, (V3, Certified Nursing Assistant/CNA) reported to me that this resident was being pulled up in his chair around dinner time and as (V3) and other aide (V4) went to hook one of their arms under residents arms, and their other hands were used to grab ahold of resident's waist/pants. As resident was being lifted and pulled back up into his chair, (V3) heard 3 'pops' and resident then stated, 'Ow ow ow my arm is broke.' Resident left arm movement is minimal below elbow, and is unable to move above the elbow, especially without serious pain. Resident requested Tylenol for pain. Family was in the room during the entire occurrence and witnessed what had happened. I asked the family about options, such as getting an x-ray or being sent back to the hospital; I also stated that we currently had (portable x-ray provider) on their way for another resident, and I could see about getting this resident added on to the workload. Family requested resident be seen by x-ray as they 'just left (local hospital) today around 2 and we don't want to go back.' I called (V9, On Call Physician/Medical Director) as he is on call and explained the situation. I stated what the family had requested and asked if it would be okay to add resident to current x-ray trip. (V9) stated that he thought that would be okay and to go ahead with adding them to current workload. I called (x-ray provider) and added this resident to the list, (provider) stated that they would be here between 8:20-8:30 (pm) to do both x-rays.R1's Nursing Progress Note dated 11/12/25 at 833am, authored by V8, RN, documented, Called (V10, Medical Doctor/Primary Care Provider) on his cell. Reported resident pain level of 10 this morning and Tylenol given but family requested something stronger for pain control. Order received for Hydrocodone 5/325 four times daily as needed for pain. Clarification regarding Eliquis needed as family thought V10 stopped it. V10 stated it depends on if family is wanting to pursue palliative care or full treatment, and he will speak with them and then update this nurse. Order to hold Eliquis for now.R1's Event Report authored by V6 dated 11/11/25 at 7:48pm documented the event as per the Nursing Progress Note as stated above.A Long Term Care Facility Serious Injury Incident Initial and Final Report for R1 submitted by V1, Administrator, dated 11/11/25 and 12/3/25 documented, Detailed Incident Summary: Resident was being pulled up in his chair around dinner time and as (V3 and V4) went to hook one of their arms under residents arm and their other hands were used to grab ahold of residents waist/pants. As resident was being lifted and pulled back up into his chair, (V3) heard 3 pops and resident then stated, 'ow ow ow, my arm is broke.' X-ray was performed by (portable x-ray provider) and came back as a pathological fracture due to Osteoporosis.R1's X-ray Patient Report dated 11/11/25 documented, Left shoulder: Findings: There is an acute fracture at the proximal shaft of the left Humerus which is suspected to be pathological fracture.On 12/31/25 at 855am, V11, Family Member, stated on 11/11/25 around supper time before 5pm, she asked staff to pull R1 up in his recliner as he was sliding down. V11 stated V3 and another unknown CNA stood on either side of R1, hooked their arms under R1 and lifted, without using a gait belt, and a loud crack was heard from R1's left arm, and R1 stated, You broke my arm. V11 stated V3 immediately left the room to inform the nurse what had happened. V11 stated at that time R1 did not complain of pain unless he moved his arm. V12 stated V6, Registered Nurse, came into the room to evaluate the arm at around 7pm. V12 stated V6 then called the on-call physician and got an order to have the arm x-rayed, which showed that it was fractured. V11 stated as time wore on in the evening, R1 was in, Horrible pain, moaning, and screamed out when they repositioned him to change him. V11 stated sometime around 9pm, V6 gave R1 two Tylenol and stated that was the only thing R1 had ordered for pain. V11 stated she asked V6 if R1 could have some stronger pain medication, and V6 stated trying to get an order for narcotic pain medication at that time of the day was, A whole big thing. V11 stated R1 did get some relief from the Tylenol and was able to sleep. V11 stated by the next morning by 6am, R1 was in severe pain. V11 stated V8, RN, administered Tylenol and contacted V10, R1's Physician, about getting stronger pain medication, but it was not administered until after 10:30am. V11 stated staff were also trying to get R1 an orthopedic appointment that morning. V11 stated by that time she and R1 were tired of waiting on the referral and tired of seeing R1 in pain and asked V8 that R1 be sent to the local ER to make sure he would have access to needed pain medication. On 12/31/25 at10:50am, V3 stated on 11/11/25 she worked 2pm-10pm. V3 stated R1 was a new admission who arrived about the same time as when she started her shift. V3 stated V11, V12, and V13, Family Members, were in the room with R1. V3 stated R1 was alert but somewhat confused, calling out for V12 although she was in the room. V3 stated around 4:30pm, V11 put on the call light and said R1 needed moved up in the recliner. V3 stated she and V4 got on either side of the recliner, put their arms under R1's armpits, and lifted. V3 stated a gait belt was not used. V3 stated, They all heard 3 loud pops, and (R1) said oh I think you broke my left arm. V3 stated she immediately left the room and told V5, RN, what had happened. V3 stated V5 asked if the arm was swelling and V3 said no. V3 stated V5 said she would be down there as soon as she got finished with what she was doing. V3 stated R1 stated he had no arm pain as long as his arm was immobilized but had significant pain if it was moved. V3 stated V5 left the facility when her shift ended at 6pm without having assessed R1. V3 stated at about 6:30pm she told the oncoming nurse, V6, RN, what had happened and V6 then went and assessed R1.On 12/31/25 at 2:20pm, V6 stated she worked 6pm-10pm on 11/11/25. V6 stated shortly after arriving, V3 stated to V6, There was a popping noise from (R1's) arm when they pulled him up in the chair around supper and asked if I could go down to see him ASAP (As Soon As Possible) as he was in pain. V6 stated V3 told V6 that she had told V5 about it earlier, but V3 thought V5 forgot. V6 stated V11, V12, and V13 were present in R1's room. V6 stated the arm wasn't bruised or swollen and was not painful if immobile but had significant pain with movement as well as decreased range of motion. V6 stated she did not recall asking R1 what his pain was on a ten scale but did ask if he wanted anything for pain and he said yes, Tylenol, for which he had an order. V6 stated she called V9, who ordered an x-ray. V6 stated she administered the Tylenol at about 7pm and recalls later the resident felt it had been effective. V6 stated the x-ray result came back toward end of her shift showing a pathological fracture of the left humerus. V6 stated the rest of her shift in regard to R1 was uneventful.On 1/7/26 at 8:30am, V7, RN, stated she worked 10pm to 6am on 11/11/25. V7 stated she had been informed of R1's condition during shift report. V7 stated she did not recall doing a pain scale on R1 or the specific severity of his pain. V7 stated she recalled R1 was guarding the arm and didn't want it moved. V7 stated she was not sure if she administered tylenol during her shift. V7 stated she asked V11 if V11 felt R1 needed to go to the ER and V11 said no. V7 stated she went back to check on R1 and he was sleeping soundly which led her to believe he was not having severe pain. V7 stated V11 nor R1 asked for stronger pain medication at any time during the shift. V7 stated she regularly works the night shift and obtaining narcotic pain medication can be difficult. V7 stated it is difficult to get the on-call physicians to prescribe opiates for residents that are not their patients, and they expect primary care physicians to address this during daytime hours. V7 stated a written prescription is required and a verbal order can't be used. V7 stated if there is a written order or escript sent to the pharmacy, the facility can call the pharmacy and get a code for which to obtain the medication from the Emergency Medication Kit. (E-Kit).On 1/7/26 at 9:15am, V5 stated she thinks she worked 2pm-6pm on 11/11/25. V5 stated R1 had just been admitted , and she recalled going into the room with consents for him to sign and V11 was also present. V5 stated R1 was able to appropriately answer questions but was not talkative and V11 did most of the talking. V5 stated she had no further contact with R1 that shift. V5 stated about 30 minutes before time to leave for the day, she was passing medications on A Hall when V3 came to her and said, They had attempted to pick (R1) up, and he felt something pop. V5 stated she told V3 she would assess R1 after she finished medication pass. V5 stated she forgot about it, did not assess R1, and did not tell the oncoming nurse about it in report. V5 stated, Only about 30 minutes elapsed from when (V3) told her about it until her shift was over and she left. V5 stated V3 did not express to her that the arm might be broken, and if she had she would have locked up the medication cart and went down there immediately.On 1/7/26 at 11:05am, V9 stated staff called him the evening of 11/11/25 to report that when R1 was being repositioned in a chair, a pop was heard. V9 stated he ordered a portable x-ray which showed a pathological transverse fracture of the left humerus. V9 stated such fractures are generally treated with external stabilization, such as sling, rather than surgical intervention. V9 stated based on this, as well as a lack of availability of orthopedic services at the nearby ER (Emergency Room), he felt there was no indication to send R1 out but to instead obtain an appointment with an orthopedic surgeon the next day. V9 stated staff told him the family agreed with this plan as they wanted to avoid rehospitalization if possible. V9 stated had the family wanted R1 sent out, he would have done so immediately. V9 stated staff did not say that R1 was in severe pain and needed narcotic pain medication or he would have provided it. V9 stated an e-script (electronic prescription) could have been sent to the pharmacy and a code given for the e-kit. On 1/7/26 at 11:55am, V8, RN, stated she came in to work at 6am on 11/12/25 and was given report by V7, who stated R1 had a left arm fracture which occurred after CNAs lifted him up by arms to reposition him in the chair. V8 stated V7 said the family and V9 had planned to get R1 an orthopedic referral that morning. V8 stated within about 30 minutes after report she went to check on R1 and found he was in severe pain, at a 10 on a 10 scale. R1 and V11 were unable to say how long the pain had been going on. V8 checked R1's orders and found there was only Tylenol ordered, so she went ahead and gave it about 6:30am, and upon checking back, found it had little effect. V8 stated she called V10, R1's Primary Care Physician, who ordered Norco for R1's pain. V8 stated since V10 was not in his office with the ability to send an e-script, she could not get a code from the pharmacy to get into the e-kit until after 10am. V8 stated by that time, V11 and R1 were very upset and wanted R1 sent out. V8 stated she got an order to send R1 out from V10 at about 11am and the ambulance arrived about 11:15am. V8 stated with their current pharmacy services, getting medications, especially narcotics is often difficult.On 1/7/26 at 12:35pm, V10 stated he last saw R1 on 11/11/25 as he was discharging R1 from the hospital. V10 stated R1 had multiple serious chronic health problems including Prostate Cancer and Lymphoma. V10 stated to his knowledge there was no metastasis to the bones nor did R1 have osteoporosis. V10 stated the plan was for R1 to receive rehab services at the facility and return home with V11. V10 stated R1 was weak but stable and was on a lot of medications. V10 stated he was surprised to learn of the arm fracture. V10 stated when the incident was reported to the nurse, R1 should have been immediately assessed for injury and pain. V10 stated the facility, Could have done a better job of taking care of this patient. V10 stated he was not aware of any ongoing issues with resident's medications being available, including opiates. V10 stated V8 called him the morning of 11/12/25 and got an order for Norco for R1. V10 stated he cannot e-script from his phone, so he was able to do that from his office at 10:20am. V10 stated it was his understanding that opiates could also be obtained from the e-kit with a verbal order.On 1/8/26 at 8:30am, V2, Director of Nurses, stated pain is to be rated and documented at any time during the 8-hour shift. V2 stated it was her understanding that V6 assessed R1 instead of V5 as the incident occurred at shift change around 6pm. V2 stated it was her understanding that V3 did not relay to V5 how serious R1's situation potentially was and that he most likely had a fracture. V2 acknowledged getting narcotics and medication for new residents with their current pharmacy is at times problematic.The facility's Pain Prevention and Treatment Policy dated 10/10/23 documented, Certain medical conditions may be painful, including: Musculoskeletal conditions: Fractures. Procedure: Each resident will be assessed for pain including an appropriate pain rating scale upon admission and at least quarterly. A. Residents capable of answering yes/no questions will be assessed using Wong-Baker, Numeric Scale, or similar form in the Electronic Health Record. After completion of the assessment, the resident will receive interventions to reduce or alleviate the pain. These interventions may be non-pharmacological or pharmacological (with physician's order).

Based on interview and record review, the facility failed to provide routine and emergency medications and failed to correctly document medications not administered as ordered for 1 of 10 residents (R1) reviewed for pharmacy services in the sample of 13. Findings include:R1's Face Sheet documented an admission Date of 11/11/25, a discharge date of 11/12/25, and listed diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Type 2, Congestive Heart Failure, Small Cell B Lymphoma, and Hypertension.R1's November 2025 Physicians Orders Sheet (POS) documented an 11/11/25 order for Tylenol 500 milligrams two tablets four times daily as needed for pain, and an 11/12/25 order for hydrocodone acetaminophen 5-325 milligrams take one tablet four times daily as needed for pain. The same POS documented 11/11/25 orders for Eliquis 2.5mg. (milligrams) one tablet twice daily at 6am to 10am and 7pm to 10pm, fluticasone propionate spray, 50 micrograms, two sprays in each nostril daily at 6am, folic acid 1mg one tablet at 6am, formoterol fumarate nebulizer 20 micrograms per 2 milliliters inhalation twice daily, 6am to 10am and 3pm to 7pm, magnesium oxide 400mg one tablet twice daily 6am to 10am and 7pm, metoprolol 100mg. one tablet twice daily, allopurinol 300mg one tablet at 6am, azelastine 137 micrograms 1 spray at 6am, budesonide 0.5mg per 2 milliliters per inhalation twice daily from 6am to 10am and 3pm to 7pm, cholecalciferol 125 micrograms one tablet at 6am, Lasix 20mg. one tablet at 6am to 10am and one tablet from 7pm to 10pm, and potassium chloride 20 milliequivalents one tablet at 6am.R1's November 2025 Medication Administration Record (MAR) documented an order for Tylenol 500 milligrams two tablets as needed four times daily start date 11/11/25. This MAR documented that the Tylenol was given on 11/11/25 at 9:29pm for 'Pain and was effective. The MAR documented the Tylenol was again given on 11/12/25 at 6:35am for Pain and was slightly effective. The MAR documented an order for hydrocodone-acetaminophen 5-325 milligrams take one tablet as needed four times daily start date 11/12/25. The MAR documented this medication was given on 11/12/25 at 10:36am and was not effective. The MAR documents that on 11/11/25, no scheduled evening medications were given as they were unavailable. This MAR documented the following medications scheduled at 6am were given on 11/12/25 by V8: potassium chloride, magnesium oxide, metoprolol, cholecalciferol, budesonide nebulizer, allopurinol, azelastine nasal spray, Eliquis, fluticasone spray, and formoterol per nebulizer. R1's Nursing Progress Note dated 11/11/25 at 7:51pm, authored by V6 Registered Nurse (RN), documented, (V3 Certified Nursing Assistant/CNA) reported to me that this resident was being pulled up in his chair around dinner time and as (V3) and other aide (V4) went to hook one of their arms under residents arms, and their other hands were used to grab ahold of resident's waist/pants. As resident was being lifted and pulled back up into his chair, (V3) heard 3 'pops' and resident then stated, 'Ow ow ow my arm is broke.' Resident left arm movement is minimal below elbow, and is unable to move above the elbow, especially without serious pain. Resident requested Tylenol for pain. Family was in the room during the entire occurrence and witnessed what had happened. I asked the family about options, such as getting an x-ray or being sent back to the hospital; I also stated that we currently had (portable x-ray provider) on their way for another resident, and I could see about getting this resident added on to the workload. Family requested resident be seen by x-ray as they 'just left (local hospital) today around 2 and we don't want to go back.' I called (V9, On Call Physician/Medical Director) as he is on call and explained the situation. I stated what the family had requested and asked if it would be okay to add resident to current x-ray trip. (V9) stated that he thought that would be okay and to go ahead with adding them to current workload. I called (x-ray provider) and added this resident to the list, (provider) stated that they would be here between 8:20-8:30(pm) to do both x-rays.R1's Nursing Progress Note dated 11/12/25 at 8:33am, authored by V8, RN, documented, Called (V10, Medical Doctor/Primary Care Provider) on his cell. Reported resident pain level of 10 this morning and Tylenol given but family requested something stronger for pain control. Order received for Hydrocodone 5/325 four times daily as needed for pain. Clarification regarding Eliquis needed as family thought V10 stopped it. V10 stated it depends on if family is wanting to pursue palliative care or full treatment, and he will speak with them and then update this nurse. Order to hold Eliquis for now.R1's Nursing Progress Note authored by V8, dated 11/12/25 at 1:11pm documented, (Morning) Meds charted as given at 08:13 were not administered due to family questions about meds. Clarification received from (V10) on Eliquis 2.5mg to hold for now but is documented given. Was not given. Other meds not given but charted as so are as follows: Magnesium oxide 400mg tab, Vitamin D3 5,000 international unit tablet, Folic acid 1mg. tablet, and Furosemide (Lasix) 40 mg tablet not given. The rest of his morning meds had not yet come from pharmacy as they had complications with the delivery. Pharmacy did not arrive until after resident was sent out to hospital.On 12/31/25 at 855am, V11, Family Member, stated on 11/11/25 around supper time before 5pm, she asked staff to pull R1 up in his recliner as he was sliding down. V11 stated V3 and another unknown CNA stood on either side of R1, hooked their arms under R1 and lifted, without using a gait belt, and a loud crack was heard from R1's left arm, and R1 stated, You broke my arm. V11 stated V3 immediately left the room to inform the nurse what had happened. V11 stated at that time R1 did not complain of pain unless he moved his arm. V12 stated V6, Registered Nurse, came into the room to evaluate the arm at around 7pm. V12 stated V6 then called the on-call physician and got an order to have the arm x-rayed, which showed that it was fractured. V11 stated as time wore on in the evening, R1 was in, Horrible pain, moaning, and screamed out when they repositioned him to change him. V11 stated sometime around 9pm, V6 gave R1 two Tylenol and stated that was the only thing R1 had ordered for pain. V11 stated she asked V6 if R1 could have some stronger pain medication, and V6 stated trying to get an order for narcotic pain medication at that time of the day was, A whole big thing. V11 stated R1 did not get his evening medications as the pharmacy had not yet delivered them. V11 stated R1 did get some relief from the Tylenol and was able to sleep. V11 stated by the next morning by 6am, R1 was in severe pain. V11 stated V8 administered Tylenol and contacted V10 about getting stronger pain medication, but it was not administered until after 10:30am. V11 stated she did not recall if R1 got any of his morning medications on 11/12/25 but recalls thinking that the nurse came in with Eliquis, which V11 thought had been discontinued by the hospital. V11 stated by that time she and R1 were tired of waiting on the referral and tired of seeing R1 in pain and asked V8 that R1 be sent to the local ER to make sure he would have access to needed pain medication. On 12/31/25 at 2:20pm, V6 stated she worked 6pm-10pm on 11/11/25. V6 stated shortly after arriving, V3 stated to V6, There was a popping noise from (R1's) arm when they pulled him up in the chair around supper and asked if I could go down to see him ASAP (As Soon As Possible) as he was in pain. V6 stated V3 told V6 that she had told V5 about it earlier, but V3 thought V5 forgot. V6 stated V11, V12, and V13 were present in R1's room. V6 stated the arm wasn't bruised or swollen and was not painful if immobile but had significant pain with movement as well as decreased range of motion. V6 stated she did not recall asking R1 what his pain was on a ten scale but did ask if he wanted anything for pain and he said yes, Tylenol, for which he had an order. On 1/7/26 at 8:30am, V7, RN, stated she worked 10pm to 6am on 11/11/25. V7 stated she regularly works the night shift and obtaining narcotic pain medication can be difficult. V7 stated it is difficult to get the on-call physicians to prescribe opiates for residents that are not their patients, and they expect primary care physicians to address this during daytime hours. V7 stated a written prescription is required and a verbal order can't be used. V7 stated if there is a written order or e-script sent to the pharmacy, the facility can call the pharmacy and get a code for which to obtain the medication from the Emergency Medication Kit (E-Kit).On 1/7/26 at 11:05am, V9 stated staff called him the evening of 11/11/25 to report that when R1 was being repositioned in a chair, a pop was heard. V9 stated he ordered a portable x-ray which showed a pathological transverse fracture of the left humerus. V9 stated staff did not say that R1 was in severe pain and needed narcotic pain medication or he would have provided it. V9 stated an e-script (electronic prescription) could have been sent to the pharmacy and a code given for the e-kit. On 1/7/26 at 11:55am, V8, RN, stated she came in to work at 6am on 11/12/25 and was given report by V7, who stated R1 had a left arm fracture which occurred after CNAs lifted him up by arms to reposition him in the chair. V8 stated V7 said the family and V9 had planned to get R1 an orthopedic referral that morning. V8 stated within about 30 minutes after report she went to check on R1 and found he was in severe pain, at a 10 on a 10 scale. V8 did not recall if R1 and V11 said how long the severe pain had been going on. V8 checked R1's orders and found there was only Tylenol ordered, so she went ahead and gave it about 6:30am, and upon checking back, found it had little effect. V8 stated she recalled that R1's morning medications had not arrived from the pharmacy but recalled perhaps giving some which were available as stock medications and/or in the e-kit. V8 stated while documenting in the electronic record, she had gone ahead and checked off some of the medication as given, and when she realized they were not in the cart, there was no way to uncheck them. V8 stated she later called V10 who ordered Norco for R1's pain. V8 stated since V10 was not in his office with the ability to send an e-script, she could not get a code from the pharmacy to get into the e-kit until after 10am. V8 stated by that time, V11 and R1 were very upset and wanted R1 sent out. V8 stated she got an order to send R1 out from V10 at about 11am and the ambulance arrived about 11:15am. V8 stated with their current pharmacy services, getting medications, especially narcotics is often difficult.On 1/7/26 at 12:35pm, V10 stated he last saw R1 on 11/11/25 as he was discharging R1 from the hospital. V10 stated the facility, Could have done a better job of taking care of this patient. V10 stated he was not aware of any ongoing issues with resident's medications including opiates. V10 stated V8 called him the morning of 11/12/25 and got an order for Norco for R1. V10 stated he cannot e-script from his phone, so he was able to do that from his office at 10:20am. V10 stated it was his understanding that opiates could be obtained from the e-kit with a verbal order.On 1/8/26 at 8:30am, V2, Director of Nurses, acknowledged getting narcotics and medications for new residents with their current pharmacy is at times problematic.On 1/9/26 at 11:10am, V2 stated there is not a place in the MAR to document a pain scale when as needed pain medications are given. V2 stated the nurse could write an accompanying progress note or the facility might consider adding it to the MAR. V2 stated once medications are checked off on the electronic MAR there is no way in which to go back and uncheck them if they were not administered.On 1/13/26 at 815am, V16, Pharmacist, stated all R1's daily medications were delivered to the facility at 11:10am on 11/12/25. V16 stated the medications left the pharmacy at midnight 11/12/25 and should have got there between 2am-5am but two of their drivers were involved in accidents so R1's evening and morning medications were not there, but most all commonly taken medications are available in the e-kit and the facility could have called and gotten codes for them which they did not do or possibly given stock medications. V16 stated had the facility asked for a STAT (emergency) delivery when R1 was admitted on [DATE], the pharmacy guarantees delivery within 4 hours, but the facility did not ask. V16 stated a code was given for the Norco and it was taken out of the e-kit at 10:29am on 11/12/25. V16 stated they can take an emergency verbal order from the physician over the phone and give a code for an emergency up to 3 day supply of narcotics to be taken out of the e-kit, which the facility did not do.The facility's undated Medications Administration Policy documented, Policy: The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Administration: 2. Medications are administered in accordance with written orders of the prescriber. 6. Medications are administered without unnecessary interruptions. D. Documentation: 1. The individual who administers the medication dose records the administration on the residents MAR directly after the medication is given.The facility's undated Emergency Pharmacy Service and Emergency Kits Policy documented, Emergency pharmacy service is available on a 24 hour basis. Emergency needs for medication are met by using the facility's approved emergency medication kit/box or by special order from (out of state corporate contractual pharmacy). (Said pharmacy) supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the residents. Procedures: G. To access medication from the emergency kit secondary to a new order, or when medication for which there is not readily available, the nurse should not take a medication from the e-box without checking allergies on the medical record and possible drug-drug interactions with the pharmacist. 1. The nurse confers with the prescriber to determine whether the order is a true emergency, (example) order cannot be delayed until the scheduled pharmacy delivery. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to verify that it meets the criteria of an emergency situation. 2. Only after verifying that the above communication has occurred, the pharmacy has received a complete prescription, and drug allergies, interactions, and other contraindications have been checked, the nurse unlocks the container/cabinet/breaks the container seal and removes the required medication.

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 3 (R1) residents reviewed for abuse in the sample of 18.This past non-compliance occurred between [DATE] and [DATE]. Findings Include:R1's undated Resident Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses that include dementia with mood disturbances, heart failure, anxiety disorder, Parkinsonism, and localized edema. R1's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status score of 07, indicating a moderate cognitive deficit. R1's Care Plan documents a Problem area with a start date of [DATE] of, Category: Behavioral Symptoms, Resident is alert and able to let his needs be known most of the time. He has dx (diagnoses) of depression and anxiety. He has made inappropriate comments to the young staff members, false accusations against staff.likes to get some of the residents stirred up.he will make a fist and threaten them.he also likes to call female resident his girlfriend. 12/3 altercation with another resident. The interventions documented for this Problem area include, Approach start date: [DATE] try to keep this resident away from other resident. R5's undated Resident Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses that include neuroleptic induced parkinsonism, bipolar disorder, and schizophrenia. R5's MDS dated [DATE] documents a BIMS score of 13, indicating R5 is cognitively intact. R5's Care Plan documents a Problem with a start date of [DATE] of, Category: Behavioral Symptoms, she is alert and able to let her needs known.she has the dx of anxiety, depression.schizophrenia, bipolar, and insomnia.12/3 manic and hit another resident Klonopin started 12/4 delusions and hallucinations. Labs ordered. This Problem area includes interventions of, Approach Start Date: [DATE] see MAR (Medication Administration Record) for Klonopin assess for effectiveness. A facility Long-Term Care Facility and IID (Individuals with Intellectual Disability)-Serious Injury Incident Report dated [DATE] documents, (R5) (perpetrator) female who is [AGE] years old was in her wheelchair going down the hall when (R1) (victim) 81 was walking back to her (sic) room. (R5) reach out with fist making contact with (R1) side and arm. (R1) then took his fist at (R5) making contact with her arm. Both patients were separated by staff and assessed for any injuries. Skin assessment was performed with no signs of bursing (sic) or red marks. Patient had no other interaction with one another. POA (Power of Attorney), MD (Medical Doctor), and police notified. Care plans updated. No further altercations have occurred with either patient. R1's Progress Notes document on [DATE] at 9:28 AM, CNA (Certified Nursing Assistant) reported to this nurse that resident was hit with a closed fist 4 times by another resident in the torso and arm. CNA stated that resident then grabbed the other resident's arm. Residents assessed for injury and separated. Administrator notified of situation. Called and notified (name of physician). Attempted to notify resident's wife (V4) of situation, no answer, voicemail left to call back. R5's Progress Notes document on [DATE] at 9:13 AM, This nurse was notified by CNA that resident closed fist hit another resident 4 times in the torso and arm. CNA stated that the other resident grabbed her left arm. Both residents were immediately assessed and separated. Administrator notified. Resident is also having hallucinations and made the statement, I wish I could die. Devil come and get me. Called and notified (name of physician). Attempted to notified (sic) POA/daughter (name of POA), no answer. Left voicemail to call back. [DATE] 4:30 PM, (name of physician) office called back with N.O. (new order) Klonopin 0.5 mg (milligrams) BID (twice daily). Called POA/daughter (name of POA) and received verbal consent for medications. [DATE] 12:43 PM, Resident very calm and relaxed today. No behaviors or hallucinations. 15 minute checks continue. R1 is deceased so this surveyor was unable to obtain an interview. This surveyor attempted to interview R5 on [DATE] at 1:25 PM, R5 was unable to recall details of the incident. On [DATE] at 1:56 PM, V4 (Family Member) stated R1 was involved in an altercation with another resident and was hit in the stomach 2-3 times.On [DATE] at 1:39 PM, V3 (Licensed Practical Nurse/LPN) stated the altercation between R1 and R5 was reported to her by V7 (CNA). V3 stated she reported it to V1 (Administrator) and documented it in the residents' medical records. On [DATE] at 2:08 PM, V7 (CNA) stated she reported an altercation she witnessed between R1 and R5 to V3 (LPN). V7 stated after she reported it, she resumed providing care to other residents. On [DATE] at 1:34 PM, V2 (Director of Nurses) stated V7 (CNA) reported an altercation between R1 and R5 to her. V2 stated V7 told her V1 (Administrator) was with the residents. V2 stated she confirmed V1 was with the residents and did not have any direct knowledge of the events after that. On [DATE] at 1:58 PM, V1 (Administrator) stated she didn't witness the altercation between R1 and R5, but it was reported to her. V1 stated V7 (CNA) told her R5 said something to R1 and made a punching/tapping motion to R1's arm and R1 did it back to R5. V1 stated R5 was very upset and agreed to a psychiatric evaluation so they contacted R5's psychiatrist. V1 stated both residents were assessed with no injury and their care plans were reviewed and updated. V1 stated she reported the incident to the physician, local police and state survey agency. The facility Abuse Prevention Program dated [DATE] documents, Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Prior to the survey date, the facility took the following actions to correct the deficient practice according to the QAPI (Quality Assurance Performance Improvement) Ad Hoc Form with meeting date of [DATE]:1. Immediate Corrective Action for those affected by the deficient practice:Both residents were immediately separated upon discovery of the incident.(R5) was assessed by nursing staff following the incident. No marks, bruising or redness noted. Resident remains stable.(R1) was assessed by nursing staff following the incident. No marks, bruising, or redness notes. Resident remains stable.Comprehensive skin check performed on both residents [DATE].Increased supervision implemented pending investigation.Staff interviews initiated on [DATE] Resident interviews initiated on [DATE].Police, POA, MD notified [DATE].2. Process/Steps to identify others having the potential to be impacted by the same deficient practice:All other residents could be affected by the deficient practice.3. Measures put into place/systematic changes to ensure the deficient practice does not recur.Behavioral care plans for involved and at-risk residents were reviewed and updated to Include triggers, redirection techniques, and supervision interventions. Initiated staff educated abuse policy on [DATE]. Initiated staff educated on resident rights on [DATE]. Customer service training/in service scheduled [DATE]. Resident Council meeting held to review resident rights and abuse prevention.4. Plan to monitor performance to ensure solutions are sustained.DON (Director of Nurses)/designee will audit 1 resident 3x (times) a wk. (week) for 2 weeks, and monthly for 2 months to ensure no concerns with resident's right/abuse. Any non-compliance will be addressed immediately.Administrator to review audits to ensure compliance.Trends will be reported to the QA (Quality Assurance) Committee for review with any identified deficiencies to have further corrective action implemented as needed.

Based on observation, interview, and record review, the facility failed to ensure a medication cart was locked and its keys were not accessible to 4 (R31, R42, R58 and R66) of 4 confused ambulatory residents reviewed for safe and secure storage of medications in the sample of 34. On 04/09/25 at 08:05 AM, V5 (Registered Nurse/RN) was observed passing medications on B Hall. V5 prepared medications for a resident and entered the residents room, leaving the medication cart unlocked and the cart keys on top of the cart, and out of V5's visual control. On 04/09/25 at 08:13 AM, V5 prepared medications for another resident and left the cart keys on top of the cart and out of V5's visual control. During these observations, there were residents or staff near the cart. On 04/10/25 at 03:01 PM, V2 (Director of Nurses/DON) confirmed the medication cart is to be kept locked and its keys in possession of the nurse passing medications. The facility's Storage of Medications Policy dated 5/1/18 documented Medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (are) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. An undated policy for Personnel Authorized to Handle Medications in the Facility stated, Licensed nursing personnel who administer medications have authorized access to medication storage areas in the facility. Consistent with their scope of practice, licensed nurses may transcribe and transmit orders to the pharmacy(ies), receive and store medications, and have possession of the keys to all drug storage areas in the facility. Keys to medication storage areas are under the control of licensed personnel only. The facility provided a list dated 4/11/25 which documented R31, R42, R58, and R66 as being confused, ambulatory residents living at the facility.

Based on interview and record review, the facility failed to review and implement gradual dose reductions (GDR's) as recommended by the pharmacist and/or document a rationale for contraindication for 1 (R13) of 5 residents reviewed for unnecessary psychotropic medications in the sample of 34. Findings Include: R13's Face Sheet documented R13 was admitted to the facility on [DATE] and included the following diagnoses: acute and chronic respiratory failure, undifferentiated schizophrenia, type 2 diabetes mellitus, convulsions, hepatic failure, depressive disorders, chronic obstructive pulmonary disease, essential hypertension, sleep apnea, heart failure, atrial flutter, generalized anxiety disorder, and gastro esophageal reflux disease. R13's MDS (Minimum Data Set) dated 03/03/2025 documented R13 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R13 is cognitively intact. R13's Physician Order Report with a print date of 04/10/2025 documented an order for Effexor XR (extended release) 150 milligrams (mg) by mouth daily for depressive symptoms with a start date of 07/30/2023, clozapine 100mg by mouth every night for schizophrenia with a start date of 03/22/2023, and buspirone 10 mg by mouth daily for generalized anxiety with a start date of 09/23/2023. R13's Care Plan has a focus are of: Cognitive Loss / Dementia: Problem: R13 currently goes to senior renewal. R13 has the dx of schizophrenia, dependent personality disorders, depression and anxiety. R13 is currently taking anti-psychotic, antidepressant and antianxiety. R13 does not take criticism will [sic]. R13 lacks self-confidence. when a problem comes up, she likes to look for support to make a decision. R13 is independent with her activities of daily living. For the most part R13 is alert and oriented and able to let needs known. Documented interventions are R13 goes to senior renewal program weekly, take medications and record effectiveness, allow resident to express feelings, do not confront, argue against, or deny residents thoughts, and do not judge resident in any way. R13's Point of Care History with a print date of 04/10/2025 documented behaviors monitored are verbal expressions of distress, sleep cycle issues, apathetic, anxious, or sad appearance, mood, or loss of interest with a date range of 3/11/25 - 4/10/25, and documented behaviors did not occur for these dates. The consultant pharmacist's Note to Attending Physician/Prescriber documented a Medication Regimen Review (MRR) dated 10/28/24 and stated, This resident's order noted below is due for review and dose reduction attempt. Please document current mental and behavior status; review the new dose recommended below or provide detailed reason(s) that a dose reduction is not indicated .Current order: Clozaril (clozapine) 100 mg at bedtime for schizophrenia .Date started: 12-6-2016 .Recommend to change to: 75 mg at bedtime. Under the section titled, Physician/Prescriber Response, the boxes for agree, disagree, and other are left blank, along with the space to explain the rationale, the physician/prescriber's signature, and date. Progress Notes in R13's medical record authored by V2 (Director of Nursing/DON) documented the following: 10/14/24: GDR (gradual dose reduction) requests for buspirone, clozapine and Effexor sent to psych NP (Nurse Practitioner). 10/17/24: GDR requests from 10-14 forwarded to V14 (NP) per request of V16 (NP). 12/16/24: GDR request for Clozaril emailed to (V14) psych NP, per request of V16 (NP). 02/27/25: GDR requests sent to V16 (NP) for buspirone, clozapine, and Effexor xr. 03/11/25: GDR requests for buspirone, Clozaril, and Effexor ER emailed to (V14) psych NP, per request of V16. 04/09/25: Reached back out to (V14) regarding GDR requests for Buspar, clozapine, and Effexor. Last correspondence was 3/11/25, where she stated she would review them. Email communications between V2 (DON) and V14 (NP) document the following: 10/17/24 documented V2 emailing R13's gradual dose reductions to V14. 12/16/24 documented V2 again emailing R13's GDR requests to V14. 03/11/25 documented another request from V2 for V14 to review R13's GDR requests. Return correspondence from V14 on that same day documented V14 replied Yes . 04/09/25 documented V2 emailing V14 to follow up on R13's GDR's, noting, We have state in for annual survey this week, so I was trying to get everything in order. Have you had a chance to review them yet? with V14 replying she would attempt to stop by on 04/09/25. On 04/10/2025 at 9:20 AM, V2 (DON) stated she does not know why it takes V14 (NP) so long to respond to the gradual dose reductions. V2 stated that V14 has been contacted multiple times regarding R13's gradual dose reduction. V2 stated that she has tried to stress the importance of V14 responding to the gradual dose reductions and that V14 has replied that she will review them, but she never does. V2 stated that R13 has no behaviors, and she feels that a gradual dose reduction is appropriate. On 04/11/2025 at 9:36 AM, V15 (Registered Nurse) stated R13 does not have any behaviors. V15 stated she is pleasant and gets along well with staff and other residents. On 04/11/2025 at 10:00 AM, V2 stated that V14 has not responded to any of the gradual dose reductions that have been emailed to her. V2 stated V14 has never responded to any of the requests. V1 (Administrator) was also present and stated that V1 emailed V14 on 04/09/25 at 6:00 PM trying to correspond with V14 about the gradual dose reductions. V1 stated that V14 has not responded. According to WebMD's drug interaction checker at https://www.webmd.com/interaction-checker/default.htm, there is a potential for serious interaction between venlafaxine (Effexor XR) and buspirone (Buspar) and regular monitoring by your doctor is required or alternate medication may be needed. Venlafaxine and buspirone both increase affecting serotonin levels in the blood. Too much serotonin is a potentially life-threatening situation. Severe signs and symptoms include high blood pressure and increased heart rate that led to shock. In addition, Venlafaxine and Clozapine document a significant interaction possible and close monitoring by your doctor is required. Facility policy titled Psychotropic Medication Use with a date of December 2018 documented It is the policy of (company name) that all residents receiving psychotropic medications, be monitored to ensure the least amount of medication is given to treat the diagnosis. This is accomplished through tracking behaviors and effectiveness of interventions, monitoring for side effects, reviewing data at least quarterly and dosage reduction attempt at least one quarter annually 2. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .8. The Psychoactive Medication Review (Quarterly) will be completed at least quarterly to combine the data on one form for review 9. The physician/psychiatrist will order a reduction in medication, as indicated, or document the need for continuing the current dosage, at least quarterly.

Based on interview, and record review the facility failed to monitor temperatures of coffee to prevent burns for 1 (R1) of 3 residents reviewed for accidents in the sample of 4. The findings include: An incident description report sent to the Illinois Department of Public Health document that on 1/29/25 R1 was in the dining room getting coffee from container when she spilled a small amount of coffee on her inner thigh causing .5cm (centimeter) blister to right inner thigh. A final incident description documented, After a thorough investigation the patient was with a nurse manager when she pushed back in her chair to talk to another resident while holding her coffee cup. The coffee spilled on resident's inner thigh causing a red mark that later turned into a blister. Doctor notified of resident burn area is now open. Orders to cleanse with wound cleaner and apply dry dressing. Resident is now using a coffee cup with a lid to prevent other incidents from happening. Care plan has been updated and coffee temperature logs kept and an audit of all coffee/hot beverage drinkers preventing all residents who could be affected. R1's Resident Face Sheet documents an initial admitted the facility of 06/03/2021 with diagnosis including neuroleptic induced parkinsonism, bipolar disorder, schizophrenia, chronic obstructive pulmonary disease, major depressive disorder, peripheral vascular disease, polyosteoarthritis, restless leg syndrome, gastro - esophageal reflux disease, other anxiety disorders, urinary incontinence, anemia, constipation, dementia, presence of intraocular lens, insomnia, delusional disorder, and hyperlipidemia. R1's MDS (Minimum Data Set) section C, dated 01/10/2025, documents that R1 has a BIMS (Brief Interview of Mental Status) of 10 indicating that R1 has moderate cognitively impairment. R1's Care Plan with a date of 06/16/2021 documented a focus area of Pressure Ulcer / Injury. She is at risk for breakdown. She has a history of breakdown; she will scratch self until she bleeds. Factors that may affect the breakdown: diabetes with insulin, chronic obstructive pulmonary disease, overactive bladder, peripheral vascular disease with stent in legs, psychotic symptoms, anxiety/depression, schizophrenia, Bipolar, dementia, hypertension, neuroleptic induce Parkinson, anemia, clopidogrel, and age. 1/29/2025 dropped coffee on right inner thigh. 01/29/2025 ordered spill proof lids for cups. 01/30/2025 lids arrived and in service done. Documented interventions include cleanse right inner thigh with wound cleanser and apply dry dressing, make sure spill proof silicone lids are on the cup that contains hot liquids. R1's Progress Note authored by V6 (Registered Nurse) dated 01/29/2025 with a time of 1:57 P.M., documented V7 (Medical Doctor) was notified of 0.5 centimeter blister to right inner thigh obtained from resident spilling coffee on herself today at meal time. R1's Progress Note authored by V5 (Registered Nurse) dated 01/31/2025 with a time of 10:22 A.M. documented V7 was notified of resident burn area is now open. New order to cleanse with wound cleanser and apply a dry dressing daily. R1's Event Report dated 01/29/2025 documented R1 received a burn to right inner thigh measuring 0.5 centimeters. Intervention listed new lid has been ordered to help reduce spills and burns. R1's Wound Management Detail Report with a print date of 02/25/2025 documented the date the area was identified as 01/29/2025 and measurements of 0.5 centimeters by 0.5 centimeters. On 02/21/2025 the wound to the right inner thigh measured 0.3 centimeters by 0.3 centimeters. In the comment section it is noted the area has no signs and symptoms of infection, continue the treatment per the medical doctor. Facility Coffee Temperature Log documented temperatures were obtained on 01/31/2025 - 02/06/2025 and 02/15/2025 - 02/25/2025. There were no temperatures documented for 02/07/2025 - 02/14/2025. The temperatures that were documented ranged from 185 - 130 degrees Fahrenheit. On 02/25/2025 at 10:02 A.M. R1 stated she dumped a whole cup of coffee on her leg. R1 stated she was at the table, and she just dropped the cup. R1 stated that my leg is healing. R1 stated that since the incident the facility has placed lids on the coffee cups to prevent spilling. R1 stated she was ok with the lid on her coffee cup. On 02/25/2025 at 10:09 A.M. V3 (Dietary Manager) stated when the coffee comes out of the machine it is 205 degrees Fahrenheit. V3 stated it then goes in the carafe. At that time coffee was poured out of the carafe V3 temped it at 122 degrees Fahrenheit. V3 stated that after the incident with R1 spilling coffee and burning her leg, the dietary staff are now temping coffee three times a day. V3 stated that the log has extra temps on it because someone wasn't paying attention and just wrote them down. On 02/25/2025 at 10:38 A.M. V3 stated he is not sure why there are no temps documented from 02/07-02/14. V3 stated there was some confusion when we started doing the temps. V3 stated that the coffee is made roughly around 530-545 am and is allowed to cool for at least 30 minutes before capping it. V3 stated they do this to ensure it is not over the temperature it is supposed to be. On 02/25/2025 at 10:43 A.M. V3 stated after reviewing his schedule, he realized the week that there were no temperatures checked, he had 3 staff members out with various illnesses. V3 stated the staff who covered the shifts were not aware to check the coffee temperatures. On 02/25/2025 at 10:26 A.M. V5 (Registered Nurse / MDS) stated she was passing out coffee like she normally does for breakfast and lunch. V5 stated she gave R1 coffee and was giving other residents coffee when she heard R1 yell, Ouch. V5 stated R1 explained to her that she just dropped her coffee cup. V5 stated she has done observations of all residents who drink coffee to ensure that they are safe to do so. V5 stated there are a few residents who refuse to use coffee lids on their coffee. V5 stated she is not sure how long the coffee had been placed on the carafe. V5 stated she educated the residents who refuse to use lids and documented it. On 02/25/2025 at 10:30 A.M. V2 (Director of Nursing) stated that once the incident was discovered, the kitchen staff were educated on keeping temperatures of the coffee. V2 stated V5 did an audit of all residents who drink coffee to ensure they are safe to do so or if they need any assistive devices. V2 stated no one else has had a burn related to coffee being spilled on themselves. V2 stated the staff have been educated about R1 using lids on her coffee. On 02/25/2025 at 11:00 A.M. V1 (Administrator) stated prior to this incident they believed that R1 was on too much medication for her psych diagnoses. V1 stated R1 was noted to be sleeping more than normal. V1 stated R1 is either manic or sleeping and adjusting her medications to get the right dose for her is tricky. V1 stated R1's Klonopin had been reduced after the incident. V1 stated V5 was in the dining room giving out coffee. V1 was told that R1 was kind of drowsy but pushed herself back in her wheelchair to talk to another resident and spilled the coffee on her leg at that point. V1 stated the doctor was notified and treatment orders were obtained. V1 stated the facility completed a new BIMS (Brief Interview for Mental Status) and R1's went up from a 10 to a 14 with the medication reduction. V1 stated in order to prevent another occurrence, the facility removed the coffee carafes from the common areas and replaced them with Keurig's. V1 stated they ordered a silicone cover for R1's coffee cup. V1 stated that R1 was ok with the silicone cover going over the cup. V1 stated the facility has completed an audit of all residents who drink coffee to see if they are at risk for a similar event. V1 stated she did not speak to any of the dietary staff the day of the incident to see if they had a temperature on the coffee prior to the incident.

Based on interview, observation and record review, the facility failed to ensure dishware was sanitized appropriately. This has the potential to affect all 66 residents residing at the facility. Findings include: On 05/05/24 at 11:00 AM, V11 (Dietary Aide) showed the test strips he uses to check the dish machine sanitizer. The test strips indicated they were for testing swimming pool water. V11 was finishing washing the breakfast dishes and tested the dish machine sanitizer with the pool test strips, which read very high. On 05/05/24 at 11:10 AM, V10 (Dietary Manager) stated the strips have been in the kitchen since before he started. V10 stated he has been the dietary manager for about 2 months. V10 acknowledged the pool test strips were not the correct strips and said he would try to find the correct strips to use. On 05/05/24 at 11:15 AM, V10 (Dietary Manager) found the appropriate chlorine test strips and tested the dish machine sanitizer with them. The test strip read approximately 10 ppm (parts per million). V10 stated, That is too low, it should be at least 50 ppm. V10 stated he would get rid of the pool test strips now. On 05/05/24 at 12:30 PM, none of the previous dishware was sanitized appropriately before use and more dishes were washed and put away without appropriate sanitization. On 05/05/24 at 1:10 PM V10 (Dietary Manager) stated, he didn't think about sanitizing the dishes another way, he is still new to this position and figuring it out. On 05/06/24 at 10:30 AM, V10 checked the dish machine sanitizer, and the chlorine test strip indicated an appropriate range of 100 ppm chlorine sanitizer. On 05/06/24 at 10:30 AM, V10 (Dietary Manager) stated, the dish machine works appropriately, and he was able to test it with the correct test strips now. The Daily Census report dated 05/05/24 documents 66 residents residing at the facility. The facility policy dated 01/2012 titled, Machine Ware Washing documents: 1. Employees that use the ware washing machine will be responsible for knowing how to use the machine, document its use, and properly maintain it after use. Steps include: Check sanitizer concentration using appropriate test strips.

Based on observation, interview and record review, the facility failed to provide food portions as directed by the approved menu for 4 (R42, R45, R58, R168) of 12 residents reviewed for nutrition in a sample of 40. Findings include: 1. R45's face sheet documents an admitted [DATE] and diagnoses that included: Cerebral ischemia, Dementia, Repeated falls, Essential hypertension, Diaphragmatic hernia without obstruction or gangrene, Type 2 diabetes mellitus without complications, Unsteadiness on feet, Gastro-esophageal reflux disease without esophagitis, chronic kidney disease, stage 3, iron deficiency anemias, Vitamin D deficiency and Hypothyroidism. R45's Physician order sheet documents a diet order of: mechanical diet with double desserts with a start date of 03/10/24 and an end date documented as: open ended. 2. R58's face sheet documents an admitted [DATE] and diagnoses that included: Other specified disorders of brain, protein-calorie malnutrition, Muscle weakness (generalized), Other disorders of lung, Unsteadiness on feet, Abnormal posture, Hypokalemia, Mixed hyperlipidemia, Atherosclerosis of aorta, Unspecified convulsions, Cardiac murmur, Essential (primary) hypertension, Rhabdomyolysis, and Abnormal weight loss. R58's Physician Order Sheet documents an order of: mechanical soft diet with a start date of 11/27/23 and an end date of: open ended. 3. R42's face sheet documents an admitted [DATE] with diagnosis including: Nontraumatic intracranial hemorrhage, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Essential (primary) hypertension, Type 2 diabetes mellitus with unspecified complications, Gastro-esophageal reflux disease without esophagitis, Chronic obstructive pulmonary disease, Atherosclerotic heart disease of native coronary artery without angina pectoris, Occlusion and stenosis of unspecified carotid artery, Dysarthria following cerebral infarction, Hypo-osmolality and hyponatremia, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. R42's Physician Order Sheet documents an order stating: Diet Clarification: Mechanical Soft Consistency diet with a start date of 06/13/23 and an end date of: open ended. On 05/05/24 during lunch service, at approximately 11:30 AM, V13 (Cook) served R45, R58, and R42 a #12 scoop (2.875 ounces) of ground chicken tenders and a #30 scoop (1.125 ounces) of mashed potatoes. The recipe #1171 titled, Chicken Tenders grnd (ground) documents: serve a #6 (4.75 ounces) of ground chicken tenders. The production recipe titled, Potatoes Mashed documents: 2. serve using a #8 (3.75 ounces) scoop. On 05/06/24 during lunch service, at approximately 11:30 AM V13 (Cook) served R45, R58, and R42 approximately 1.5 scoops of the # 30 scoop (1.125 ounce) of ground Swedish meatballs. The facility document titled, cycle Day: 16, Monday 11/06/23 documents: lunch: Swedish meatballs: Mech (mechanical) soft: #6 (4.75 ounce) scp (scoop). 4. R168's face sheet documents an admitted [DATE] and diagnoses including: Nontraumatic subarachnoid hemorrhage, Other cerebral infarction due to occlusion or stenosis of small artery, Chronic obstructive pulmonary disease, Acute pulmonary edema, Pulmonary fibrosis, Dysphagia, oropharyngeal phase, atrial fibrillation, disorders of brain, Anemia, Essential (primary) hypertension, Atherosclerotic heart disease of native coronary artery without angina pectoris, Cardiomegaly, Atherosclerosis of aorta, Synovitis and tenosynovitis and Gastro-esophageal reflux disease without esophagitis. R168's Physician order sheet documents an order of: Diet: regular, consistency: pureed with a start date of 05/01/24 and an end date documented as: open ended. On 05/05/24 during lunch service at approximately 11:30 AM V13 (Cook) served R168 a #16 scoop (2 ounces) of pureed chicken and a #30 scoop (1.125 ounces) of mashed potatoes, and no pureed bread. The production recipe titled, Chicken tenders pureed thick documents: 6. serve 3 heaping #16 (2 ounce) scoops per serving. The production recipe titled, Potatoes Mashed documents: 2. serve using a #8 (3.75 ounces) scoop. The recipe #779 titled, bread pureed documents: 6. serve 1 slice = 2/3 thick, 0.415 cup or 6.6 Tbsp. (tablespoon). On 05/06/24 during lunch service at approximately 11:30 AM V13 (Cook) served R168 a #30 scoop (1.125 ounces) of pureed meat, a #30 scoop (1.125 ounces) of pureed egg noodles and no pureed bread. The facility document titled, cycle Day: 16, Monday 11/06/23 documents: lunch: Swedish meatballs: Pur (pureed): #10 (3.25 ounce) scp (scoop), egg noodles: #8 (3.75 ounces) scoop pureed, buttered breadstick 2/3 slice pureed bread. On 05/08/24 at 1:30 PM, V10 (Dietary Manager) stated, all residents should receive the portion size listed on the menu or recipe unless otherwise directed by the registered dietician or the physician. All residents should receive the supplements they are ordered to have or any other dietary order including double protein, double desserts or double portions. The facility policy titled, Menus and Food Preparation dated 12/2016 documents in part: Policy: Meals shall be prepared according to the facility approved menu. The menu shall be approved by the Registered Dietitian licensed in the state of practice. Corresponding recipes shall be used in conjunction with meal service.

Based on interview, observation and record review, the facility failed to provide nutritional supplements as ordered for 2 (R56, R58) of 12 residents reviewed for nutrition in a sample of 40. Findings include: 1. R45's face sheet documents an admitted [DATE] and diagnoses including: Cerebral ischemia, Dementia, Polyarthritis, Repeated falls, scoliosis, lumbar region, Essential hypertension, Spinal stenosis, lumbar region without neurogenic claudication, Other specified disorders of bone density and structure, multiple sites, Osteophyte, left hip, Diaphragmatic hernia without obstruction or gangrene, Type 2 diabetes mellitus without complications, Trochanteric bursitis, right hip, Unsteadiness on feet, Gastro-esophageal reflux disease without esophagitis, Chronic kidney disease, stage 3, iron deficiency anemias, History of falling, Anxiety disorders, Insomnia, Pain in unspecified joint, Vitamin D deficiency, Hypothyroidism, Restless legs syndrome, and Dysuria. R45's Physician order sheet documents a diet order of mechanical diet with double desserts and nutritional shakes with meals with a start date of 03/10/24 and an end date documented as: open ended. On 05/07/24 at 11:45 AM, R45 was served the lunch meal and did not receive her nutritional shake, nor any substitute for the nutritional shake. On 05/07/24 at 1:30 PM, V10 (Dietary Manager) stated, the facility did run out of nutritional shakes today. V10 stated they should have provided nutritional ice creams as a substitute. V10 stated he has been trying to educate his staff on situations like this. The facility policy dated 02/2024 titled, Weight Management Program documents in part: Policy: It is the policy of (this facility) to manage resident weight through prevention, assessment, and implementation and evaluation of interventions. 12. The charge nurse will notify the attending physician of the current resident's condition and of the RD's (Registered Dietician) recommendations and document the physician's order on the physician's order sheet and the 24 hour report sheet. 48356 2. R56's Face Sheet dated 05/08/24, documents an admitted [DATE] with diagnoses in part, of unspecified severe protein-calorie malnutrition, hypertension, dysphagia, oropharyngeal phase, hypo-osmolality and hyponatremia, hyperlipidemia, and abnormal weight loss. R56's Minimum Data Set (MDS) Section GG dated 03/04/24, under eating documents that R56 requires supervision or touching assistance. R56'S Current Care Plan documents a Category of Nutritional Status, noting a problem of Resident (R56) is at risk for wt. (weight) changes. She (R56) is currently on puree diet with supplements. She is not a big eater. She has severe protein calorie malnutrition. She is currently on antidepressant for appetite, other factors that may affect the wt.: Tylenol, digoxin, diltiazem, Dulcolax (dulc) Suppository (supp), Norco, Remeron, Zofran, telmisartan, hypertension (HTN), dysphagia, chronic pain, diastolic dysfunctional, Chronic Kidney Disease (CKD), neuropathy, lumbar stenosis, cardiac arrhythmia, constipation, History (hx) of Multiple (multi) Fractures( fx) and age, with interventions in part of Provide supplements: milk (health) shakes with meals, fortified food with meals. R56's Physician Orders documents an order for Nutritional health shake q (every) meal with a start date of 08/08/23. On 05/07/24 at 11:50 AM, R56 was observed to be cognitively impaired and was not interviewable at this time. R56 was served her lunch meal of pureed diet with a glass of water and glass of flavored drink mix. No nutritional shake was served to R56. R56 ate around 25-50% of her meal and then was taken out of the dining room with no nutritional shake ever given during meal, nor any substitute for the nutritional shake. On 05/07/24 at 12:05 PM, V13 (Cook) stated that the facility ran out of nutritional health shake and didn't have enough to serve everyone that was ordered nutritional health shakes.

Based on interview, observation, and record review, the facility failed to provide sufficient nursing staff to ensure resident's care needs were being met in a timely manner. This failure has the potential to affect all 70 residents living in the facility. On 02/26/23 at 10:20am, R40 was alert and oriented to person, place, and time. R40 stated call lights can take up to two hours to be answered, and evening shift is the worst for this issue. On 02/26/23 at 10:25am, R19 was alert and oriented to person, place, and time. R19 stated she is not getting twice weekly showers and bed linen changes. On 02/26/23 at 10:35am, R17 was alert and oriented to person, place, and time. R15 stated it is rarely less than 30 minutes for his call light to be answered. On 02/26/23 at 10:50am, R125 was alert and oriented to person, place, and time. R125 stated call light wait times can be up to two hours. On 02/26/23 at 12:16pm, R57 was alert and oriented to person, place, and time. R57 stated she is not getting twice weekly showers and linen changes' bed linens were observed to be streaked with feces. R57 stated she has not had a shower in a week. R57 stated she regularly waits up to an hour for her call light to be answered. R57 stated the facility does not have enough staff on any shift. On 02/28/23 at 11:01am, R1 was observed receiving range of motion exercises. R1 stated he is not getting range of motion done regularly. R1 stated, When would these girls (staff) have time to do it? They don't have enough help around here. On 12/28/23 at 12:40pm, V3 (Director of Nurses) stated she does not believe residents are not getting range of motion regularly as she believes there is an issue with staff not documenting it. Resident Council Meeting Minutes documented the following issues: 10/27/22: Waiting too long for call lights. (Staff) hurrying in and hurrying out of the room (without meeting the resident's needs). 1/26/23: Taking too long to answer call lights. 2/23/23: Call lights take too long to answer. On 03/01/23 at 8:34am, V16, (Certified Nursing Assistant/CNA), stated getting all the showers and linen changes done can be very difficult, especially when she is assigned as the only CNA on A Hall. On 03/02/23 at 10:10am, V3, stated the facility is meeting the State of Illinois' minimum staffing requirements. V3 stated she did not believe it takes up to two hours for call lights to be answered. V3 stated it was probably the residents perception that it was taking that long. The facility's Staffing Policy dated November 2017 documented, Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met. The facility's Answering the Call Light Policy dated July 2014 stated, Purpose: The purpose of this procedure is to respond to the residents needs and requests .8. Answer the residents call light as soon as possible. The facility Resident Census and Conditions Form dated 02/26/23 documented a total of 70 residents living at the facility.

Based on observation, interview and record review the facility failed to provide food to residents that was palatable and at a preferred temperature. This has the potential to affect all 70 residents residing at the facility. Findings include: 1. On 02/26/23 at 11:05 AM, R125 who was alert to person, place and time stated the food is frequently cold, it does not matter if he eats in his room or the dining room. On 02/27/23 at 11:35 AM, R4 stated sometimes the food is cold, especially breakfast. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 12 (moderately impaired). On 02/26/23 at 12:40 PM, R19 stated the food is cold and that it is frequently a problem. R19's MDS dated [DATE] documents a BIMS of 15 (cognitively intact). On 02/27/23 at 12:12 PM, R7 stated the food is cold, he does not like the scrambled eggs, the sausage was cold this morning, especially this far down the hall. R7's MDS dated [DATE] documents a BIMS of 14 (cognitively intact). On 02/27/23 at 12:45 PM, R49 who was alert to person, place and time stated the food can be cold and it makes it taste not so great. On 02/27/23 at 11:29 AM, R65 stated the food is not hot, sometimes even cold, it is not very good and sometimes she cannot even eat it. R65's MDS dated [DATE] documents a BIMS of 15 (cognitively intact). On 02/27/23 at 12:17 PM, R72 stated the food is cold, but it is ok, usually breakfast is the coldest. R72's MDS dated [DATE] documents a BIMS of 09 (moderately impaired). 2. On 03/01/23 at 8:15 AM Breakfast menu documents: Wednesday 03/01/23 choice of cereal, choice eggs 1 egg, biscuits, and gravy 1 biscuit and 1 ounce gravy, margarine 1 each, juice of choice 6 ounces, 2% milk 8 ounces, coffee or tea 6 ounces. On 03/01/23 at 8:15 AM a metal stemmed thermometer was calibrated using the ice point method. On 03/01/23 at 8:15 AM a test tray from the food cart for the D hall was observed and had the temperature measured of the hot item on the tray, the breakfast consisted of cereal, biscuits and gravy, orange juice 6 ounces, milk 6 ounces and coffee. The biscuits and gravy were 109 degrees Fahrenheit using a calibrated metal stemmed thermometer. At that time the biscuits and gravy tasted bland with a cool temperature. On 03/02/23 at 11:20 AM, V8 (Dietary Manager) stated she does not know why the food was cold and that she was sure the food was at least at the holding temperature on the steam table. 3. Resident Council minutes dated 01/26/23 and 02/23/23 document: the food tasting awful and food being cold. The facility policy dated 12/2016 titled menus and food preparation documents: Food shall be prepared by methods that conserve nutritive value, flavor and appearance and in a form designed to meet individual needs. Food shall accommodate resident allergies, intolerances, and preferences. Food and drinks served shall be palatable, attractive and at a safe and appetizing temperature. The Resident Census and Conditions of Residents dated 02/26/23 documents 70 residents residing at the facility.

Based on interview and record review the facility failed to provide snacks to the residents. This has the potential to affect all 70 residents residing at the facility. Findings include: 1. On 02/26/23 at 2:40 PM, R70 stated, they do not receive evening snacks. R70's MDS dated [DATE] documents a BIMS of 12 (moderately impaired). R70's Progress Note dated 01/25/23 at 4:11 PM by V25 (RD) documents: R70's current body weight is 142 pounds; her body mass index is 21.5 (Underweight). She intakes a regular diet along with an evening snack. She is at risk for weight loss as evidenced by the acute disease stress and the inflammatory nature of the diagnoses. 2. On 02/26/23 at 3:00 PM R7 stated, they do not receive evening snacks. R7's MDS dated [DATE] documents a BIMS of 14 (cognitively intact). R7's Progress Note dated 02/27/2023 at 5:58 AM by V25 (RD) documents: R7's current body weight is 178.2 pounds and body mass index is 23.8 (within normal limits). He intakes a mechanical soft diet including diet condiments/beverages along with an evening snack, double protein with breakfast and lunch and he is offered a magic cup with lunch and supper. He is at risk for weight loss as evidenced by the acute disease stress, and the inflammatory nature of the diagnoses. 3. On 02/26/23 at 1:30 PM R54 shook his head no when asked if receives a snack in the evening. R54's progress note dated 02/27/2023 at 6:32 AM by V25 (RD) documents R54's current body weight is 146.6 pounds-down 6% x1 month; 9% since admission. R54's body mass index is 23.66 (within normal limits). He is in facility for rehab from surgery. He intakes a regular diet including prostat@30cc's two times a day, and an evening snack. He is at risk for weight loss as evidenced by the acute stress of disease and the inflammatory nature of the diagnoses. 4. On 02/26/23 at 2:20 PM R4, stated they do not bring them snacks, especially evening snacks. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 12 (moderately impaired). 5. On 02/27/23 at 12:10 PM, R72 stated they do not receive evening snacks. R72's MDS dated [DATE] documents a BIMS of 09 (moderately impaired). R72's progress note dated 02/03/23 at 3:38 PM by V25 (Registered Dietician) documents: R72 's current body weight is 171 pounds and his body mass index is 23.19 (within normal limits). R72 intakes a regular diet along with an evening snack. Continue R72's current diet and encourage intake. 6. On 02/27/23 at 11:30 AM, R58 who was alert to person, place and time stated they do not get evening snacks. On 02/27/23 at 12:35 PM. R65 stated they do not get evening snacks and she thought they were supposed to if it was more than 14 hours between evening meal and breakfast. R65's MDS dated [DATE] documents a BIMS of 15 (cognitively intact). On 02/26/23 at 12:00 PM, V8 (Dietary Manager) stated, that breakfast was at 7:30 AM, lunch is around 11:30 AM and dinner is 4:30 - 5:00 PM. On 03/02/23 at 11:15 AM, V20 (Licensed Practical Nurse) stated she does not know why they are not given snacks to deliver to the residents in the evening, sometimes she will be given some peanut butter and jelly sandwiches for some of the diabetic residents. She would have to guess that they would come from the kitchen. On 03/02/23 at 4:20 PM, V25 (Registered Dietician/ RD) stated she expects the residents to receive an evening snack. She has the evening snack written into her dietary recommendation for several residents due to their potential for weight loss. On 03/02/23 at 11:20 AM, V8 stated they are supposed to get evening snacks, she does not know why they are not taking them to them. Resident Council Minutes dated 01/26/23 and 02/23/23 document, no evening snacks are being given to residents. The untitled undated facility Policy documents: Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. An H.S. (evening) snack shall be provided by Dietary and offered to the residents by nursing. Additional snacks shall be provided between meals as ordered by the physician or per resident's request. Dietary shall be responsible for all food preparation including snacks and shall deliver meals (with assigned assistance) to the residents or to the nursing units. Snacks shall be delivered to the nursing units by dietary personnel. Nursing shall be responsible for distributing snacks to the residents. 5. Dietary shall deliver nourishments to the nursing units. Nursing shall be responsible for distribution of snacks. The Resident Census and Conditions of Residents dated 02/26/23 documents 70 residents residing in the facility.

Based on observation, interview and record review, the facility failed to monitor for and prevent an elopement for 1 of 4 residents (R2) reviewed for elopement risk in the sample of 8. These failures resulted in an Immediate Jeopardy which was identified to have begun on 10/18/21 at 2:05 AM when the facility failed to monitor and prevent an elopement that resulted in R2 being outside for 1 hour, falling, and sustaining serious injuries, such as several abrasions, skull/facial/orbital fractures, rib fractures, vertebral [MEDICATION(S)] compression fractures, subdural hematomas and adjacent subarachnoid hemorrhage, for the hour that R2 was outside the building. V1 (Administrator) was notified of the Immediate Jeopardy on 10/26/21 at 1:25 PM. The surveyor confirmed through observations, record review, and interview, that the Immediate Jeopardy was removed on 10/19/21, the facility remains out of compliance at a severity Level Two as the facility evaluates the implementation and effectiveness of their interventions put in place with their removal plan. Findings include: R2's face sheet documents that she is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)] Disorder, [CONDITION(S)], Abnormalities of Gait and Mobility; Lack of Coordination and History of repeated falls. R2's Minimum Data Set (MDS) documents a Brief Interview for Mental Status score of 99, indicating R2 has a severe cognitive impairment. R2's MDS documents R2 is limited assistance of 1 person for ambulation. R2's Elopement Risk assessment dated [DATE] documents under Cognitive Skills for Daily Decision-Making documents: Moderately impaired-decisions poor, cues/supervision required. R2's Progress Note dated 10/17/21 at 11:57 AM, documents that R2 had exit seeking behavior on the day shift. R2 was walking the halls attempting to exit out the hall D door and she kept pushing the staff away when they tried to help R2. R2 is to be assisted during transfers and ambulation. R2's Physician's Orders document that R2 has orders for Pressure Alarms at all times related to R2 having a safety awareness deficit. R2's Progress Note dated 10/18/21 at 3:56 AM documents the following: while walking down the hallway and past R2's room, staff noticed resident (R2) was not in her room. R2's bed pad alarm was in place and intact in resident's room but failed to alarm. Staff began attempting to locate resident. Once staff checked indoor the building staff member began looking outside the facility for resident. Resident was located in arch parking lot sitting next to the facility vehicle. Injuries noted to the left ankle, right eye and right shoulder. On call doctor called and resident was sent to E.R. (emergency room ) for evaluation. POA (Power of Attorney) notified, DON (Director of Nursing) notified administrator attempted to be notified. Resident is currently in the hospital. On 10/19/21 at 3:55 AM, V3 (Certified Nurse's Aide) demonstrated to this surveyor where R2 exited the facility. V3 walked out of the hall D exit door, walked to a wooden fence that had an open gate, turned to the right toward the end of the Arch wing, walked around the Arch wing toward the middle of the parking lot near the Arch entrance. On 10/26/21 at 8:30 AM, V9 (Maintenance) measured the distance from the hall D exit door, toward the wooden fence, around the end of the Arch wing, to the middle of the parking lot was 92 yards. The temperature registered 46 degrees Fahrenheit at 2:00 AM on 10/18/21, according to the local weather reports. On 10/27/21 at 8:45 AM, at the local police station, the video from the park across the street, dated 10/18/21 at 2:10 AM, was observed and it shows a small framed figure at the exit door outside the hall D exit. The figure was then seen on the ground, crawling, and there was no one else seen on the video. At 3:25 AM the staff were seen outside searching for R2, then the ambulance was seen arriving at 3:55 AM. The facility's Event Report dated 10/18/21 documents under Safety Events-Fall and Investigation that R2 had an unwitnessed fall outside the facility on facility grounds at 3:54 AM. Prior to the elopement and fall R2 was lying in bed at last bed check. Once R2 was found, she had swelling and an abrasion to her left ankle, a laceration on right side of her forehead, swelling to her right eye and R2's nose was bleeding. R2 also had an abrasion to the front and back of R2's right shoulder and both lower legs. R2 was alert and responded appropriately to stimuli, both right and left pupils were equal and responsive. The Fall and Investigation documents that R2 has a history of falls and her last fall was on 8/8/21. The contributing factors for R2's elopement and fall were the use of antipsychotics, anxiolytics, recent room change and a history of falls in the past 31-180 days. R2's vital signs at the time of the fall were: Pulse 122, Temperature 97.3, Respirations 20, Blood Pressure 89/60, O2 Saturation 98%. There is no description of R2's exit from the facility or how she ended up in the parking lot near the Arch entrance. The local hospital Emergency Department report dated 10/18/21, documents under HPI (History of Present Illness): 44 yF (year old female) with [CONDITION(S)] presents from nursing home via EMS after being found outside. Patient has unsteady gait at baseline but is ambulatory. Per NH (nursing home) she was in bed at last bed check but was found outside an hour later. Patient is verbal, per daughter who is POA (Power of Attorney), she fed herself yesterday, will answer yes and no questions and sometimes communicates needs with sentences. Under Past Medical History: R2 has a diagnosis of Asthma, History of [CONDITION(S)], Gastroesophageal Reflux Disease, History of headaches, History of [CONDITION(S)], [CONDITION(S)], Retinitis. Under Review of Systems: Physical Exam: She is not in acute distress; Extraocular movements intact. Pupils are equal, round, and reactive to light. Abrasion over right shoulder and abrasion over left ankle. Abrasion and ecchymosis over right side of head/face/eye. Skin cool to touch. Patient will not follow commands but resists movements and will move freely in the bed. Under Medical Decision Making: During the evaluation of this patient, other medical conditions were considered as possible causes of this patient's medical complaint including but not limited to Intracerebral brain hemorrhage (ICH), Subarachnoid hemorrhage (SAH), acute worsening of [CONDITION(S)]. Chest Xray Impression: 1. No evident displaced fracture. 2. No evidence for acute cardiopulmonary pathology. Xray of right and left ankle Impression: No evidence of acute skeletal injury. CT (Computed Tomography) Brain without Contrast Impression: Trace left frontotemporal subdural hematoma with adjacent subarachnoid hemorrhage in the sylvian fissure and a combination of subarachnoid hemorrhage and contusion of the posterior left temporal lobe with surrounding vasogenic [CONDITION(S)]. R2's History and Physical from the larger hospital she was transferred to dated 10/18/21, documents under CT Facial Bones without Contrast; Bones/Joints: There are mildly displaced and comminuted fractures involving the right sphenoid bone with extension along the right posterior orbital roof and right lateral orbital wall. There is a fracture of the right posterior lamina papyracea. Fracture involves the left sphenoid roof and anterior wall of the left sphenoid [MEDICATION(S)]. There is a nondisplaced right zygoma fracture. CT Chest/Abdomen/Pelvis with Contrast; under findings; Bones: Acute fractures of the anterior right fifth, sixth, seventh ribs and the lateral ninth and tenth ribs. Healing fracture of the left sixth rib. Acute, mild compression fractures of the T1, T2, T3 and T4 vertebral bodies. CT Brain without Contrast; Stable, moderate size: intraparenchymal hematoma within the left temporal lobe measuring up to 3.5 X 2.5 centimeters in the axial plane with surrounding vasogenic [CONDITION(S)]. There is a new subdural hematoma coursing along the falx that measures 4 millimeters in thickness. Stable subdural hematoma coursing along the left frontal temporal convexity. There is a new subdural hematoma coursing along the right frontal convexity measuring 3.2-millimeter thickness. On 10/18/21 at 12:22 PM, V8 (Registered Nurse, emergency room ) stated she spoke with V11 (Family) and V11 reported to her that the morning of 10/18/21 around 3:15 AM, R2 walked past 2 Nurses stations and out of the building which doesn't make sense because R2 can't walk very far without falling. V8 stated R2 has a diagnosis of [CONDITION(S)] and she has severe [CONDITION(S)]. V8 stated V11 also reported that R2 went out of the exit door without an alarm sounding and R2's bed alarm also didn't sound when she got out of bed. V8 stated the facility staff reported that R2 got out of the facility and she was found in the front parking lot. V8 stated they brought R2 back into the building instead of calling the Emergency Medical Service (EMS) right away. V8 stated she didn't talk to the facility staff about the incident involving R2 and stated she got the information from the EMS report. V8 stated the facility's explanation regarding R2's injuries wasn't consistent with the injuries she sustained, and this information came from V14 (emergency room Physician) and V15 (emergency room Physician). V8 stated V14 and V15 thought the injuries were from an assault. V8 stated the report documents that R2 had abrasions on her right shoulder, a laceration to the right side of her head, bruising and swelling to R2's right eye, abrasions to both shins, and an intracranial subdural hematoma on the left side of her head. V8 also stated R2 had bruises on her ribs that appeared to be handprints. On 10/19/21 at 5:00 AM, V1 (Administrator) stated V4 (Licensed Practical Nurse) called him and V2 (Director of Nursing) on 10/18/21 around 4:00 AM, the morning R2 got out of the D hall exit door and R2 was found in the front parking lot near the Arch entrance. V1 stated the keypad for the alarm on the D hall exit door wasn't working, and they had a back-up alarm system on that door. V1 stated the back-up alarm has a key to turn the alarm on or off, and the alarm was turned off. V1 stated the key was kept on top of the red alarm box and anyone who could reach it could turn off the alarm. V1 stated someone turned off that alarm. V1 stated he had looked into who had potentially done it and no one had confessed to it at that time. V1 stated R2 also had a bed alarm on her bed that R2 managed to scoot away from, and it didn't sound either. V1 stated he didn't know how R2 got that far because he had never seen R2 walk. On 10/19/21 at 11:29 AM, V1 stated he reviewed their camera's recording and it showed all of the night shift staff at the nurse's station located between hall A and hall B. V1 stated the Arch door was partially open, blocking the view of the B hall. V1 also stated the video recorded R2 walking down B hall toward D hall and turning toward the exit door on D hall at 2:04 AM. On 10/19/21 at 4:00 AM, V4 (Licensed Practical Nurse/LPN) stated on 10/18/21 at 3:10 AM, she and V3 (Certified Nurse Aide/CNA) had just came back into the facility from outside, because they were taking a break. V4 stated that all of the night staff were at the nurse's station discussing their plan for getting the residents up for the day. V4 stated V3 (CNA) saw R2 in her bed at the 2:00 AM bed check. V4 stated V5 (LPN) noticed that R2 wasn't in her bed at 3:15 AM, and they started searching the facility to find R2. V5 stated they couldn't find R2 in the building so everyone took an exit door and went searching outside the building. V4 stated at 3:30 AM, V7 (CNA) found R2 in the parking lot on the Arch side. V4 stated it was very dark and cold and they couldn't really assess R2 very well, so they carried R2 inside the front door and sat her on a couch, and she went to get R2's wheelchair. V4 stated R2's nose was red and bleeding, she had abrasions on the front and back of her right shoulder, abrasions on both of her shins, abrasion on her left ankle. R2 had a cut on the right side of her head near the scalp and her right eye was swollen and red. V4 stated when they got R2 into the building to put her in the wheelchair, she stood up without any problems. V4 stated they immediately put blankets around R2 and cleaned the blood from her nose and wound on her head and then the ambulance arrived. V4 stated the door alarm didn't sound because if it had, they would have heard it because they were right next to the alarm box. V4 stated R2 had a bed alarm, and it didn't sound either. V4 stated R2 is so small that sometimes the alarm scoots away from her from her constant moving and because she is so small and doesn't weigh very much the alarm doesn't sound. V4 also stated V3 usually sits at the other nurse's station on D hall, but she and V3 just came in from outside after having a break and she wasn't at the nurse's station desk. V4 stated R2 never attempts to go outside of her room and the most she's ever seen R2 attempt anything was go to the bathroom by herself. V4 stated R2 usually sleeps through the night. On 10/19/21 at 3:45 AM, V3 (CNA) stated at 3:15 AM on 10/18/21, V5 was doing the 3:00 AM bed check and noticed that R2 wasn't in her bed and the bed alarm was at the head of the bed and it didn't sound. V3 stated R2 is so light that she scoots the alarm without it sounding. V3 stated once they searched inside the building and couldn't find R2, they started their search outside. V3 stated one reason R2 may have been more confused was because she got moved to another room on a different hall because of needing her room for an isolation. V3 stated R2 doesn't ambulate well, and she usually just goes to the bathroom, and R2 sleeps most nights. V3 said R2 somehow walked to the D hall and went out the D hall exit door. V3 stated the D hall keypad for the exit door alarm hadn't been working and V1 had the keypad for the alarm fixed 10/18/21 and the back-up door alarm was turned off. V3 stated R2 walked around the end of the building and ended up in the parking lot facing North, near the Arch entrance. V3 also stated it was cold outside and they carried R2 in the front door and V4 went to get R2's wheelchair. V3 stated they brought her inside and wrapped her in blankets and took her vital signs, and the ambulance came and took her to the hospital. V3 stated R2 was alert and scared, but she doesn't talk, so she couldn't tell them how she got hurt. V3 stated she didn't hear an alarm sound when R2 eloped, and she also stated she wasn't aware of a key to turn the red box alarm off and on. V3 stated she wasn't aware that the key was on top of the red alarm box. On 10/20/21 at 2:55 PM, V5 (LPN) stated on 10/18/21 around 3:15 AM when she went to answer R5's call light, she noticed that R2 wasn't in her bed. V5 stated she saw the bathroom light on and thought she was in there, but when she looked, R2 wasn't there. V5 stated that R2 could ambulate, but she was very wobbly and had poor balance. V5 stated she yelled at the staff that they needed to look for R2 and V7 (CNA) came off of the Arch unit and checked the rooms on A hall and B hall, V3 and V4 searched D hall and went out the exit door on D hall to look outside. V6 (CNA) searched A hall and the Arch hall, and once they discovered that R2 wasn't inside the building, they went outside. V5 stated she headed for the park, V4 searched the church parking lot and V7 went to the parking lot and she saw R2 in the front parking lot in a parking space near V7's vehicle. V5 stated R2 was sitting on her knees. V5 stated it was dark and cold and she and V3 carried her to the front door and sat her on the couch while V4 went to get a wheelchair. V5 stated R2's socks were soaked so she took them off and R2's toes were very cold, and her left ankle was bruised and swollen. V5 also stated R2 had a nosebleed from both nostrils, and she got tissues and cleaned the blood and put pressure on her nose to stop the bleeding. V5 said they heated some blankets in the warmer and put them around R2 and they got R2's paperwork ready, called an ambulance, R2's doctor, R2's Power of Attorney, the Administrator and Director of Nursing. V5 stated when R2 eloped, V5 was on the Arch unit and was giving residents pain medication. V5 stated she didn't hear an alarm and she wasn't aware of a key to turn off/on the red alarm box at the D hall exit door. On 10/20/21 at 3:05 PM, V13 (CNA) stated she and V3 did a bed check around 1:00 AM. V13 stated she saw R2 at 1:30 AM, and she was awake fidgeting with her blanket. V13 stated R2's bed alarm was on and under her at that time. V13 stated she wasn't aware that there was a key to turn the red exit door alarm on and off. V13 said she had no idea there was a key on top of the alarm. On 10/20/21 at 3:10 PM, V7 stated on 10/18/21 at 3:15 AM, V5 went to answer R5's call light and she noticed that R2 wasn't in her bed or in the bathroom and V5 yelled for everyone to start looking for R2. V7 stated when they had searched inside the building, they all went outside to look for R2. V7 stated she and V5 went out the front doors and she went to the front parking lot where she found R2 sitting in a parking space next to her truck. V7 stated she noticed that R2's nose was bleeding and her right shoulder had been scrapped. V7 stated when they tried to have R2 stand, R2 couldn't bear weight on her left foot. V7 stated V3 and V5 carried R2 to the front door and sat her on a couch in the living room and V4 and V5 started doing First Aide on R2. V7 stated she didn't ever hear a door alarm sound and she also wasn't aware that there was a key on top of the red door alarm located on the D hall exit door. On 10/20/21 at 3:15 PM, V6 (CNA) stated she heard V5 hollering that R2 wasn't in her bed or in her bathroom and that they all needed to search for her. V6 stated she had just finished bed check and was taking the linen barrel to the laundry room and was at the nurse's station. V6 stated that V3 and V4 had just came back in from being on break and they were all at the nurse's station when they heard V5 yell that they needed to search for R2. V6 stated she searched the A hall rooms and she stayed inside while everyone else went outside to search for R2. V6 stated she didn't hear an alarm sound and she also wasn't aware of a key on top of the red alarm box on the D hall that turns the alarm on or off. On 10/19/21 at 5:45 AM, V9 (Maintenance) stated he checks the exit door alarms daily throughout the week. V9 stated the D hall door alarm works, but the door alarm was turned off. V9 stated they were having C.N.A. classes near that door and they may have been going in and out of that door. V9 also stated someone in that class must have left it off. V9 said he checks the alarms every week and the back-up alarm was working and has been working each time he has checked it. On 10/26/21 at 8:30 AM, V9 stated he measured the distance that R2 walked, and it was 92 yards from the hall D exit door to the middle of the parking lot near the Arch entrance. On 10/19/21 at 11:50 AM, V10 (Physician) stated R2 is very unstable and has very poor coordination due to [CONDITION(S)] from diagnosis of [CONDITION(S)] Chorea. V10 stated R2 is very unstable with walking and usually when he sees R2, she is lying in bed or sitting in her wheelchair. V10 stated R2's movements are very spastic, and she can't control the jerking and constant moving. V10 stated the injuries are probably a result of falling several times while R2 was outside. V10 stated the pictures he saw of R2's injuries after her elopement are more than likely due to R2 falling. V10 also stated a lot of the areas are older bruises from repeated falls and hitting her extremities on bed rails or other objects due to R2's condition. V10 stated R2 is very fragile, has no fat pads, is very thin and boney and she bruises easily and could fracture easily. V10 stated that her injuries do not look suspicious and aren't due to someone treating her badly or assaulting her. V10 stated the swollen eye could have been due to hitting it on a vehicle since she was near the cars. V12 (Police Officer) stated he hasn't been able to obtain R2's medical records from the larger hospital so he can finish his investigation. V12 stated he is of the opinion that R2 eloped and fell , maybe multiple times in order to sustain the injuries she had. V12 stated the camera located across the street at the park shows a small framed figure leaving the facility at the hall D exit door, then a dark shadow is seen crawling on the ground. V12 also stated he reviewed the camera recording from the facility, and it shows R2 at the end of hall B going around the corner onto hall D, then out the exit door. V12 stated he has also asked for the Rape Kit results and hasn't received them at this time. On 10/28/21 at 8:50AM, V19 (Administrator at a different LTC facility) states R2 was admitted to their facility on Tuesday, 10/26/21 and she was admitted on Hospice. V19 states R2 was extremely restless the day she was admitted but is not responding at all now. V19 also stated R2 has old abrasions on her legs, left ankle, and her shoulders, and several old bruises. The facility's Missing Resident Policy dated November 17, 2017 documents under Policy: It is the policy of this facility that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to: door alarms, personal door activation devices, staff intervention, staff education regarding response to door alarms, and individual resident intervention. It is the policy of the facility to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the event a resident is deemed missing. The Immediate Jeopardy that began on 10/18/21 was removed on 10/19/21 when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: The facility has determined that all staff in the facility are identified as responsible for resident's safety. Immediate changes to the facility systems include the following: 1.) V9 contacted local door alarm company and the technician was onsite the morning of 10/18/21 and repairs were made to the door alarm system and work was completed on 10/18/21 at 12:00 PM. 2.) V9 checked all doors to ensure they were working properly and that alarms sounded as designed on 10/18/21 at 1:00 PM. 3.) Keys to the red fire box door alarm were located, collected, and placed in the Administrator's office on 10/18/21 at 3:00 PM. 4.) V9 will continue to check door alarms per facility policy daily, initiated 10-18-21. 5.) Nurses will check door alarms at the beginning of every shift, initiated 10-18-21. 6.) All resident records were audited by 10-19-21 V2 (Director of Nursing), V16 (Assistant Director of Nursing), V17 (Director of Arch), V18 (Minimum Data Set/Care Plan Coordinator) to identify residents who are at risk for elopement including exit seeking behaviors. 7.) Assessments were completed for all residents who have been identified with these behaviors, and based on the completed assessments, revision to all identified resident's care plans to implement progress person-centered interventions to address these behaviors was done by V2, V16, V17 and V18, completed 10-19-21. 8.) All policies were reviewed regarding residents at risk for elopement and what staff are to do if residents display exit seeking behavior, completed 10-19-21. 9.) At 4:30 PM on 10/18/21 all staff working in the facility were in-serviced on Safety and Supervision of residents, code yellow/missing resident, work order process, elopement and door alarm checks by V2 and V16. All other staff were in serviced on these policies by V2 and V16, completed on 10/19/21 by 6:00 PM. 10.) All staff will be trained during their orientation and quarterly for 1 year regarding the Missing Resident policy and door alarm response procedure; Ensure all staff are trained on the new policies and procedure.

Based on Interview and Record Review the facility failed to a) identify and implement preventative treatment and services for Pressure Ulcer risk, and b) timely identity an area of compromised skin and Pressure Ulcer for 1 of 3 residents (R2) reviewed for Pressure Ulcers in the sample of 4. This failure resulted in R2 developing an unstageable pressure ulcer, resulting in hospitalization and comfort care measures. This past noncompliance occurred from 2/15/18 to 3/12/18. The Findings Include: R2's Daily Skilled Nurse's Notes dated 2/15/18 showed admission to the Long Term Care (LTC) facility on 2/15/18. R2's History and Physical from the local hospital showed an admission date of [DATE], and under Impression included the following Diagnoses: [REDACTED]. The Discharge Summary from the local hospital lists a discharge date of [DATE] to the LTC facility, and under Assessment, documents a [DIAGNOSES REDACTED]. upon hospital admission on 2/12/18 was 123 lbs (pounds), and height was 70 inches. R2's Clinical Health Status form, Section N- Braden Scale for Prediction Pressure Sore Risk, dated 2/15/18, documented a Braden Scale score of 18, indicating R2 was at risk for pressure sores. R2's Baseline Care Plan dated 2/15/18, documented that R2 was on a regular diet. The dietary risks section, specifically risk for weight loss was blank/not checked, and the dietary goal was marked as prevent weight loss. The document further shows that R2 was continent of bowel and bladder. Under Skin Concerns, skin intact was checked. Skin break risk was blank/not checked, and Resident's skin integrity goal was blank/not checked. Under Skin break interventions, a specialty mattress was checked, but other skin break interventions such as turn and reposition, cushion for chair and wheelchair, and skin and wound treatments were left blank. This same document has four blank areas that could be used to document or write in any Other Conditions with possible documentation of Risk, Goal, and Interventions. These areas were also left blank. R2's available Daily Skilled Nurse's Notes dated 2/16/18 through 3/6/18 have boxes for nursing staff to check underneath the heading Skin for Day and Evening shifts. Under that section, each daily note available for review were all either marked Skin WNL (within normal limits) for both Day and Evening shifts, or were left blank/unchecked. In the same section, these notes also have boxes for nursing staff to check underneath Skin Concerns that include Pressure Ulcer and Bruise. The boxes for Pressure Ulcer were never marked for any of the dates previously listed, and the box for Bruise was only marked on the Day Shift note for 3/2/18. In addition, these same notes have a section to document GI (Gastrointestinal) Concerns, with options to check for Poor Appetite and Poor or restricted fluid intake. R2's available Daily Skilled Nurses notes for 2/16/18 through 3/6/18 show Poor Appetite was marked on both Day and Evening shifts on 2/18/18, 2/19/18, 2/20/18, 2/24/18, 2/26/18, 2/27/18, 2/28/18, 3/1/18, 3/3/18, 3/4/18, and 3/5/18. Other nurses notes marked with Poor Appetite for R2 included: 2/22/18 (Day Shift), 2/23/18 (Evening Shift) 2/25/18 (Day Shift), 3/2/18 (Day Shift), and 3/6/18 (Day Shift). The dates and shifts in which R2 was marked for poor fluid intake include the following: 2/19/18, 2/20/18, 2/22/18, 2/24/18, 2/26/18, 2/27/18, 2/28/18, 3/1/18, 3/3/18, 3/4/18, 3/5/18 (both Day and Evening Shifts marked), and 2/18/18 (Evening Shift), 2/23/18 (Evening Shift), 2/25/18 (Day Shift), and 3/2/18 (Day Shift). R2's Daily Skilled Nurse's Note dated 3/2/18, documented a small bruise to R2's coccyx. There was no documentation found in the Nurse's Note regarding a description of the bruise, such as color or size of the injury. R2's Daily Skilled Nurse's Note dated 3/3/18, documented that R2 was incontinent of bladder on evening shift, with no mention of a bruise as noted the day prior on 3/2/18. R2's Daily Skilled Nurse's Note, dated 3/4/18, documented the Physician was notified of nasal drainage, again with no mention of a bruise to R2's coccyx. R2's Occupational Daily Treatment Note dated 3/1/18, documented CNAs report pt (R2) has area of skin compromise to buttock/sacral area Collaboration with nurse on duty who reports was just informed of skin compromise. A Physical Therapy Daily Treatment Note dated 3/1/18, included a recommendation to place a pressure relieving cushion in both wheelchair and/or recliner when R2 is up. R2's Significant Change Care Area Assessment Summary dated 3/1/18, documented the following change in conditions: Decrease in his Cognitive Status, He is sleeping more, Resident is at risk for pressure ulcers. He relies on the staff for ADL help, He has decline in condition and continence too, He has a poor appetite, He was on a regular diet and now is on a pureed diet, He has poor appetite versus what he was when he first came in, he will occasionally pocket food and let food run out of the mouth. He is gradually losing weight. R2's Nurse's Notes dated 3/6/18, documented the following: Noted area to resident's coccyx. Noted unstageable 5 centimeters x 2 centimeters area. Area open and draining moderate amount of serosanguinous drainage. Area reddened open [MEDICATION NAME] tissue with area of necrosis in center. MD notified with treatment request per facility treatment protocol. Order obtained and treatment applied. Physician order [REDACTED]. The Prescription for the Calcium Alginate Order contained the following: Dated 3/6/18, for the Calcium Alginate Dressing to area. On 3/28/18 at 2:45 PM, V4 (Certified Nurse Aide/CNA) stated she worked 3/3/18 and 3/4/18 and toileted R2 one of those days and noted a sore area to R2's coccyx that was smaller than a quarter, very red, and V4 thought it was starting to open. V4 stated she wrote it on the CNA Report Sheet, but did not report it to the nurse. On 3/29/18 at 9:15 AM, V5 (Registered Nurse/RN) stated that R2 was admitted for Dementia, Wandering, and declined by sleeping more and more. A medication adjustment was done and R2 did improve some, he ate better when the staff fed him. V5 stated the area to R2's coccyx was noted on 3/2/18 during a shower and was 1 centimeter (cm) in circumference. V5 went on to say that when she returned to work on 3/6/18, the area was 5 cm x 2 cm, and was black/brown in color. V5 stated that there was no assessment of the wound except for the 3/2/18 and 3/6/18 Daily Skilled Nurse's Note, and the 3/6/18 Wound Log. When questioned regarding the assessment of the area and palpation, V5 had no answer. Further, no documentation of a wound assessment could be found in the Nurses Notes or on the Wound Log for 3/2/18. R2's care plan documented a problem start date of 3/4/18 for the problem of Resident is at risk for pressure ulcers. He relies on staff to adls. He has decline in condition and continence too. He has a poor appetite and sleeps more. Other factors that may affect the risk for breakdown: dementia, [MEDICAL CONDITION], depression, [MEDICAL CONDITIONS], [MEDICATION NAME], Trazadone, HCTZ (hydrochlorathiazide), changes in alertness and age. The goal was listed as Resident's skin will remain intact. Approaches also had a start date of 3/4/18 and included: conduct a systematic skin inspection nursing weekly, CNA daily with care pay particular attention to the bony prominence's, diet as ordered, encourage resident to have a good fluid and food intake, pressure reduction when resident is in chair and bed . Further, R2's care plan documented problem areas of decline in condition and at risk for weight changes that were also not initiated until 3/4/18, approximately 2-1/2 weeks after his admission. The Wound Management Program Policy, revised (YEAR), listed the following: #3 Residents identified at risk on the Braden scale will have this addressed on their care plan and will have interventions put in place for preventative measure. Interventions: pressure reducing mattress and/or cushion, be reviewed by a dietician and lab values as needed. Residents identified with wounds will have a care plan initiated regarding impaired skin integrity. #4 The facility will assess residents weekly for current skin conditions. #4 c. If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it . d. The new area should also be noted on the 24 Hour Report. g. The nurse will measure the area; call physician to obtain appropriate treatment order, call the guardian/family member to inform him/her, document the area on the TAR (Treatment Administration Record) and initiate the treatment. On 4/2/18 at 3:30 PM, V12 (Dietary Manager) stated that the Dietician is the person responsible for completing the Dietary History and Initial Screening assessment. V12 stated the Dietician comes monthly, and clarified that the Dietician was not called when R2 was admitted . On 3/29/18 at 9:31 AM, V2 (Director of Nursing/DON) stated R2 was not seen by the dietician because of his admit and discharge being between her visits. R2's Resident Transfer Form with date of transfer noted as 3/6/18, documented that R2 was discharged from the LTC facility to a local Assisted Living Memory Care facility in the same town. On 3/29/18 at 10:30 AM, V7 (Director of local Assisted Living Memory Care Facility) stated that she went to assess R2 at the LTC facility on 2/28/18 for admission to the memory care facility where she is employed. V7 stated that R2 was a planned admission to the memory care facility for 3/6/18. V7 said that during her assessment, R2 had been discontinued from physical therapy, but was still on speech therapy for swallowing. V7 stated that R2 was observed in a wheelchair, but he was able to get up and back in on his own. V7 said that on 3/6/18, a nurse from the LTC skilled care unit called to give report to the admitting nurse at the memory care facility, and said the LTC facility had just noticed R2 had an open area to his buttock, but had not dressed it yet. V7 stated that the LTC nurse told the admitting memory care nurse that R2's open area was about dime size. V7 stated that R2 arrived at the memory care facility by facility van around 4:00 PM on 3/6/18, and upon arrival, V7 definitely noticed a decline since seeing R2 on 2/28/18. V7 stated that R2 appeared to have lost weight, cheeks drawn, was extremely exhausted, and was in a wheelchair for mobility. V7 stated that the only document they received from the LTC facility were R2's physicians orders dated 3/1/18 through 3/31/18, adding that a discharge summary or plan of care was not received. V7 stated the memory care facility normally does skin checks at admission, but R2 acted so exhausted they let him go to his room and rest before supper. V7 then stated that on the morning of 3/7/18, memory care staff were assisting R2 to toilet to get him ready for the day, and noted a foul smell. V7 said the staff thought R2 had a bowel movement, and soon realized it was R2's skin breakdown. V7 stated she called R2's wife and physician to see if R2 could get an appointment since the open area was so bad. V7 stated R2's wife was unable to go on 3/7/18, so the appointment was made for 3/8/18. V7 stated while they were waiting for the ordered dressing to arrive, the memory care nurse received an order for [REDACTED]. On 3/28/18 at 3:30 PM, V8 (Licensed Practical Nurse-LPN/Assisted Living Memory Care Facility) said she sent R2 to the physician's office on 3/8/18, and it was reported to her that R2 was going to be a direct admit to the hospital from the physician's office. R2's hospital History and Physical (H & P) dated 3/8/18, documented that R2 was admitted due to weakness and large decub ulcer. Further, under History of Present Illness, the H & P documented Apparently he was just discharged from the nursing home skilled care unit and was brought to the assisted living facility for demented people but he was noted to be really weak with difficulty walking and had a large lesion in the buttocks that was foul smelling. In the clinic he was very weak and had a large decubitus ulcer in the coccygeal area. The document further noted by Back Exam: He has an approximately 2 x 4 cm at least stage III decubitus ulcer with slightly blackish eschar with surrounding mild [DIAGNOSES REDACTED] that extends to the buttocks, and by Impression: Acute Dehydration, [MEDICAL CONDITION] Stage IV, Advanced Dementia, Decubitus Ulcer in Buttocks with possible Infection. R2's hospital Consultation dated 3/8/18 listed the reason for consultation as Sacral decubitus and documents that the area is a full fledged necrotic area. Patient has a large sacral coccyx decubitus it is unstageable is a large area of eschar measures 7-1/2 cm by 5-1/2 cm in size. Culture and sensitivity was obtained deep to the eschar. Patient also has a lot of inflammation on the surrounding buttocks particularly the right side. This is exceptionally tender tone. The Impression noted: Large unstageable sacral coccyx decubitus in need of surgical debridement in the operating room under mask anesthesia. This may likely involve the bone. The hospital H & P dated 3/8/18 also listed an Addendum that included: Discussed with his daughter, wife and brother about his medical condition and his overall poor prognosis. They have decided to do comfort measures only. Will cancel surgical consult. Will stop everything and will start IV (intravenous) [MEDICATION NAME] and [MEDICATION NAME] and oxygen. Will do in house comfort care. On 4/2/18 at 2:10 PM, V11 (Physician) stated that R2 had an unexpected decline due to the formation of his Pressure Ulcer, and that the Pressure Ulcer contributed to R2's death. V11 stated the facility should have done better pressure ulcer prevention measures on admission, as well as assessing for nutrition and hydration needs. On 4/5/18 at 2:25 PM, V11 (Physician) stated that R2 was highly prone to a pressure ulcer and yes this was preventable. V11 stated that R2 was at risk to develop a Pressure Ulcer because of his mental state, physical state, and being malnourished. However, V11 also clarified that if the facility would have put hydration, nutritional and preventative measures in place for pressure ulcers, R2 would have been alive for a few weeks to a few months more, but not long term. The Certificate of Death Worksheet dated 3/13/18, documents R2's cause of death as Acute [MEDICAL CONDITION] and the significant condition contributing to the death as Advanced Dementia and Decub Ulcer on Buttocks. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on 3/9/18 with V1 (Administrator), V2 (DON), V3 (Assistant DON), and V14 (Registered Nurse) in attendance. The QAPI Ad Hoc form notes under #1 Immediate corrective action for those affected by the deficient practice: Full Chart Review. Under #2 Process/Steps to identify others having the potential to be impacted by the same deficient practice the form states Braden Assessments update for entire facility. Under #3 Measures put in to place/systematic changes to ensure the deficient practice does not recur lists that Education to staff for Stop and Watch, SBAR (Situation, Background, Assessment, & Recommendation), skin assessment, Bradens, change in condition, process for reporting new wounds. Under #4 Plan to monitor performance to ensure solutions are sustained lists -DON will perform daily rounds with nurses x 2 wks (times 2 weeks), -DON will perform weekly rounds with nurses to monitor change in condition and wounds x 1 month, and -DON will perform monthly rounds thereafter. 2. Documentation of Braden assessments show they were completed on 3/9/18, and documentation of skin checks show they were completed on 3/12/18 for every resident in the facility. 3. CNA education/in-service documentation shows that all facility CNA's were educated on using the stop and watch tool to inform nursing of change in condition, which includes eating or drinking less, or skin issues. In addition, education on using the facility shower sheet as part of the skin assessment process was completed. These in-services were completed on 3/9/18. 4. Inservice documentation for nursing (RN and LPN) shows that all nursing staff were educated on 3/9/18 on the following policies and procedures: Wounds, Charting, Medicare 24 hour Skilled Nursing Documentation, Falls Management, Weekly Skin Assessment, and Change in Resident's Condition or Status. 5. Daily Monitoring for Director of Nursing documentation was completed beginning 3/9/18 and was ongoing through survey exit date of 4/5/18, and included ensuring completion of 24 hour reporting, Medicare A charting, showers, weekly skin checks, consumption and elimination book, monthly summaries and quarterly assessments, MAR (Medication Administration Record) and TAR (Treatment Administration Record), etc.

Based on record review and interview, the facility failed to assess and address a resident's nutritional status and hydration needs on admission, and to implement preventative services and interventions based on such assessment for 1 of 1 resident (R2) reviewed for nutrition/hydration needs in the sample of 4. These failures resulted in a significant weight loss and a rehospitalization for dehydration. Findings include: R2's Daily Skilled Nurses Note, dated 2/15/18, documented an admission date of [DATE] to the Long Term Care (LTC) facility. The Patient Transfer Form from the local hospital dated 2/15/18, documented that prior to admission to the LTC facility, R2 was a patient at the hospital from 2/12/18 through 2/15/18. This same form listed R2's date of birth as 3/23/48, R2's height as 70 inches, showed R2 was on a regular diet, and documented a weight of 123 lbs (pounds) that was obtained at the hospital on [DATE]. The Graphic I & O (intake and output) form showed this weight was obtained via bed scale. R2's admission history and physical from the hospital dated 2/12/18, documented that R2 was having increased confusion and his appetite was poor lately. Under Impression, the following were listed: Altered mental status, could be multifactorial in etiology, Mild worsening of [MEDICAL CONDITION] most likely from dehydration, [MEDICAL CONDITION] Stage III to IV, History of diastolic heart failure, and [MEDICAL CONDITIONS]. This same document included the plan for R2 to admit to the Medical Floor and cautiously hydrate with IV fluids. R2's Assessment section of the hospital progress note dated 2/13/18 documented worsening mental status, dehydration, acute on [MEDICAL CONDITION] from dehydration, dementia, and ataxia. R2's Assessment section of the hospital progress note dated 2/14/18 documented worsening mental status, acute kidney disease from dehydration improving, dementia, ataxia, and microscopic hematuria which is chronic. R2's Hospital Course section of the hospital Discharge Summary dated 2/15/18, documented His renal function improved. His BUN was 43 with creatinine of 2.3 and it went down to 22 and 1.6 respectively. The Assessment section of this same document included the following: 1) acute on [MEDICAL CONDITION] secondary to dehydration, 2) Advanced Dementia, 3) Hypertension, 4) Chronic microscopic hematuria, and 5) [MEDICAL CONDITION] stage 3. The Disposition section of the Discharge Summary further documented R2 would be transferred to the LTC facility, activity as tolerated, Physical Therapy to follow, and diet of low salt. R2's Baseline Care Plan from the LTC facility dated 2/15/18, documented that R2 was on a regular diet. The dietary risks section, specifically risk for weight loss was blank/not checked, and the dietary goal was marked as prevent weight loss. This same document has four blank areas that could be used to document or write in any Other Conditions with possible documentation of Risk, Goal, and Interventions. These areas were also left blank. R2's admission Dietary History and Initial Screening assessment dated [DATE] is lacking R2's height, weight, usual or goal weight, prior weight loss, weight history in the last 12 months, BMI (Body Mass Index), and meal consumption reported or observed. This assessment was also blank in the section to document potential risk factors/referral criteria for new admission, such as observed intake of less than 50% 2 of 3 meals, BMI less than 19, or [DIAGNOSES REDACTED]. Other sections not completed include the estimate of calorie, nutrient and fluid needs, and whether intake is adequate to meet those needs. On 4/2/18 at 3:30 PM, V12 (Dietary Manager) stated the Dietary History and Initial Screening assessment is completed by the dietician, however clarified that V12 completes the chewing/swallowing, dining needs, and likes and dislikes section of the document within 72 hours of admission. V12 added that the Certified Nurse Aides (CNA's) provide her with the admission height and weights and sometimes the height comes from the admission record. V12 stated the dietician comes monthly and the dietician was not called when R2 was admitted . R2's available Daily Skilled Nurse's Notes dated 2/16/18 through 3/6/18 have boxes for nursing staff to check underneath the heading GI (Gastrointestinal) Concerns, with options to check for Poor Appetite and Poor or restricted fluid intake. R2's available Daily Skilled Nurses notes for 2/16/18 through 3/6/18 show Poor Appetite was marked on both Day and Evening shifts on 2/18/18, 2/19/18, 2/20/18, 2/24/18, 2/26/18, 2/27/18, 2/28/18, 3/1/18, 3/3/18, 3/4/18, and 3/5/18. Other nurse's notes marked with Poor Appetite for R2 included: 2/22/18 (Day Shift), 2/23/18 (Evening Shift) 2/25/18 (Day Shift), 3/2/18 (Day Shift), and 3/6/18 (Day Shift). The dates and shifts in which R2 was marked for poor fluid intake include the following: 2/19/18, 2/20/18, 2/22/18, 2/24/18, 2/26/18, 2/27/18, 2/28/18, 3/1/18, 3/3/18, 3/4/18, 3/5/18 (both Day and Evening Shifts marked), and 2/18/18 (Evening Shift), 2/23/18 (Evening Shift), 2/25/18 (Day Shift), and 3/2/18 (Day Shift). None of these notes mentioned notification of R2's Physician or the Dietician for poor appetite or poor fluid intake. R2's Daily Skilled Nurse's Notes for day shift dated 2/26/18, documented nursing staff notified MD (Medical Doctor) of increased sleep, however there was no mention of notifying the MD or Dietician of poor appetite or poor fluid intake. R2's Nurse's Notes dated 3/1/18, documented that resident is very sleepy and following one step request. Transfers with one assist. R2's Daily Skilled Nurse's Note, dated 3/4/18, documented the Physician was notified of nasal drainage, again with no mention of poor appetite or poor fluid intake being reported to the Physician or to the Dietician. The Speech Therapy Daily Treatment Note dated 2/28/18 documented The pt (R2) demonstrated severe impairments with regular solids as ordered. Downgraded diet consistency to puree with thin liquids with recommendation for 1:1 feed and to check for pocketing. Notified nursing and dietary of recommendation to change. The Weekly Weights form documented two weights recorded for R2. The first showed 126.7 lbs on 2/19/18 and the second showed 129.1 lbs on 2/26/18. On 4/3/18 at 9:10 AM, V1 (Administrator) stated fluid intake is not recorded unless the physician orders [REDACTED]. V1 stated R2 did not have an order for [REDACTED]. V1 stated R2's admission height and weight was not completed because he resisted care at times per his admission sheet dated 2/15/18. V1 stated ideally staff would try again or try a different staff member. V1 stated that R2 weighed 126 pounds on 2/19/18. V1 also stated that R2 was reviewed in the facility's internal review program on 2/21/18, and since R2 showed a weight increase from the 2/12/18 hospital weight, it was agreed that R2 was stable, and to wait until the dietician came. V1 added that R2's weight was 129 on 2/26/18, and R2 was again reviewed in the facility's internal review program on 2/28/18. V1 stated at that time, speech therapy was seeing R2 for pocketing food and he was downgraded from a regular diet to a pureed diet, but the internal review program continued to agree the dietician did not need to see R2 until 3/13/18. When asked about tracking of snacks, V1 stated the CNA's chart bedtime snacks on the CNA sheets and on (R2's unit) HS (bedtime) snack record sheets. V1 added that dietary staff also goes around with a cart to every resident at 10:00 AM and 2:00 PM, and accepted snacks are not recorded. V1 provided an undated Per Menu/recipes standard for fluid/snacks that showed a total of 20 ounces is offered at breakfast, a total of 14 ounces is offered at lunch, a total of 20 ounces is offered at dinner, and unidentified amounts of ounces at snack time. Side two of R2's CNA-ADL tracking forms, (which were undated, but verified by V1 they were for the months of (MONTH) and (MONTH) (YEAR)) under Eating showed spaces for staff to document codes for how the resident eats and drinks regardless of skill (such as independent, supervision, total dependence, no help from staff, setup help only, one person physical assist, etc.), and another space to document the percentage of each meal consumed for breakfast, lunch, and dinner. These forms for 2/16/18 - 3/6/18 were filled out for each meal with regard to R2's self-performance and support provided, however there were no percentages of consumption documented for dinner the entire time period except for 50% documented on 3/5/18. In the section for snacks, there are spaces for staff to document Day, Evening, and Night shift snack tracking with codes of 0 - Not offered, 1 - Offered, or R - Refused. These are also all blank, with the exception of 2/22/18 and 2/27/18, in which 1's were entered in the Day Shift slot to indicate snacks were offered, and 3/3/18 and 3/4 18, in which R was entered in the Day Shift slot to indicate snacks were refused. The sections for Dietary Substitute Offered (Indicate Number Offered and % taken) and Fluids Offered (Indicate Number offered and mL's (milliliters) Consumed are also all blank for the entire time period. On these same forms, only 7 out of 41 documented meals were recorded with greater than 50% consumption of the meal. On 3/3/18 breakfast consumption was recorded as 10% of the meal, lunch and supper were recorded as refused; 3/4/18 breakfast and lunch were recorded as refused (4 meals refused and 1 meal 10%), with no documentation that an alternative was offered. On 4/5/18 at 11:30 AM, V4 (CNA) stated she fed R2 during his stay at facility. V4 stated R2 was a picky eater and he was hard to get to eat. V4 stated R2 had to be assisted to sit up sometimes. V4 also stated she used ice one night on his lips to encourage him to eat and drink. On 3/29/18 at 9:31 AM, V2 (Director of Nurses/DON) verified that R2 was not seen by the dietician during his stay and stated this was because of R2's admit and discharge date s being between her visits. On 4/3/18 at 2:10 PM, V2 stated that (R2's unit) HS snack record sheets were initiated on 4/3/18, and that prior to that, the CNA's documented snacks on the CNA Activities of Daily Living (ADL) tracking form. R2's Care Plan with a Problem Start date of 3/4/18 documented the following: Resident has risk of wt. (weight) changes. He has had a decline in condition. He was on a regular diet now he is on the puree diet. He has poor appetite vs (versus) what he was when he first came in. He will occasionally pocket food and let food run out of the mouth. He was able to feed self some before and now he is total. He is gradually losing wt . This care plan listed a goal of Resident will have no significant wt changes from current wt of 127 and approaches that included: Assure dentures are in place before meals and assure a proper fit, check resident often with meals for pocketing, diet puree with thin liquids, encourage oral intake of food and fluids, labs as ordered, monitor and record intake of food, monitor/record weight, notify MD and family of significant weight change, provide setup help, cueing, physical help assistance for meals, provide a selective diet menu, and therapies as ordered. R2's Discharge Instructions for Care form documents that R2 was discharged from the LTC nursing facility to an Assisted Living Memory Care facility in the same town on 3/6/18. On 3/29/18 at 10:30 AM, V7 (Director of the Assisted Living Memory Care facility) stated that she went to assess R2 at the LTC facility on 2/28/18 for admission to the assisted living memory care facility where she is employed. V7 stated that R2 was a planned admission for 3/6/18. V7 said that during her assessment, R2 had been discontinued from physical therapy but was still on speech therapy for swallowing. V7 stated that R2 arrived at the memory care facility by facility van around 4:00 PM on 3/6/18, and upon arrival, V7 definitely noticed a decline since seeing R2 on 2/28/18. V7 stated that R2 appeared to have lost weight, cheeks drawn, R2 was extremely exhausted, and was in a wheelchair for mobility. On 3/28/18 at 3:30 PM, V8 (Licensed Practical Nurse-LPN/Assisted Living Memory Care Facility) said she sent R2 to the physician's office for an appointment on 3/8/18 due to a pressure ulcer, and it was reported to her that R2 was going to be a direct admit to the hospital from the physician's office. R2's Impression section of the History and Physical dated 3/8/18 from the hospital, documented Acute dehydration, [MEDICAL CONDITION] stage IV, Advanced dementia, decubitus ulcer in buttocks with possible infection. R2's patient progress note from the hospital admission date of [DATE], documented R2's recorded weight as 111 pounds obtained by a bed scale. As stated earlier, R2's weight from the previous hospital admission on 2/12/18 (just prior to admission to the LTC facility on 2/15/18) was 123 lbs per bed scale at the same hospital. This showed a 12 lb. weight loss (or 9.75% loss) in 24 days. R2's comparative laboratory report dated 2/15/18 from the previous hospital stay documented R2's [MEDICATION NAME] level as 3.8 grams per deciLiter (G/DL) on 2/12/18, and R2's blood urea nitrogen (BUN) level as 22 milligrams per deciLiter (MG/DL) and creatinine level as 1.6 MG/DL on 2/15/18. R2's laboratory report for the second hospital admitted d 3/8/18, documents R2's [MEDICATION NAME] level as 3.0 G/DL, BUN level as 82 MG/DL and creatinine level as 2.5 MG/DL. This same document provides reference ranges for BUN level as 7-20 MG/DL; creatinine level as 0.6-1.4 MG/DL; and [MEDICATION NAME] level as 3.4-5 G/DL. On 4/2/18 at 2:10 PM, V11 (Physician) stated that the facility should have done better assessing for nutrition and hydration needs. The Nutritional policy dated (MONTH) 2012 documents that all residents who experience significant or undesirable weight loss shall be assessed for nutritional status and required intervention by the registered, licensed dietitian. A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for improvement of medical status. Under Procedures #1 states residents shall be weighed and weights reported monthly to the RDLD (Registered/Licensed Dietician). If significant weight loss is identified or low body weight is identified, a request for supplementation for once daily, twice daily, or three times daily shall be made by the consultant dietician to the physician through the Director of Nursing or his/her designee. This document does not identify or address any procedure to follow for assessment of new admissions, such as identifying low body weight upon admission, or a procedure for contacting or making a referral to the dietician in between the dietician's monthly visits for new admissions identified with low body weight or at risk for weight loss. The Hydration policy dated (MONTH) (YEAR), documents to provide residents with adequate fluids, including water and other liquids that are consistent with resident needs and preferences and sufficient to maintain resident hydration. Procedures listed state that fluids and snacks will be offered to each resident in accordance with the Dietary Snack times or based on individual needs or preferences, staff will offer fluids on a routine basis, in addition to the fluids offered on the meal tray, all residents will be encouraged to drink the fluids offered, and snacks will be offered at HS to all residents. This document does not identify or address any procedure for assessing new admissions to identify residents at risk for dehydration.

Based on observation, interview and record review, the facility failed to utilize a gait belt to safely transfer 1 of 3 residents (R3) reviewed for falls in the sample of 3. This failure resulted in R3 falling and sustaining a fractured arm. Findings include: 1. R3's 9/29/17 Physician order [REDACTED]. R3's Care Plan dated 9/07/17, documents the following: Make sure there is always 2 assist with the use of a gait belt for all transfers and ambulation. R3's Nurse's Note dated 9/11/17 at 9:00 PM, documents, Reporting nurse responded to resident yelling and screaming at Nurses station saying, It hurts. Reporting nurse asked (E5), (Certified Nurse Aid/CNA), what was going on . (E5), CNA stated, We put (R3) to bed and I heard (R3's) arm pop. (R3) stated that she was dropped in the BR (bedroom) and CNA grabbed her L (left) arm. (E7), (Registered Nurse/RN), touched and moved (R3's) arm and (R3) yelled out in pain. Reporting nurse called, (Z3) (on call Physician), N.O. (new orders) rec'd (received) to send to ER, (emergency room ), for evaluation. R3's Nurse's Note dated 9/11/17 at 11:34 PM documents in part,(R3) is coming back to the facility. Xray, (radiograph), showed (R3's) got a L humeral head, (upper arm), impacted fracture. (Z2), (Orthopedic Physician), consulted in ER and stated to leave in a sling and call his office in the morning. (R3) had Norco 5/325 (1) po, (by mouth), at 2300 (11:00 PM) in ER. Rx, (Prescription), for Norco 5/325, (1) po Q6 (every 6 hours) #18. Facility's Incident Report, dated 9/11/17 at 8:55 PM, documents that E5 and E6, (CNAs), transferred (R3) from recliner to bed, per (E5), Resident's arm popped and she started screaming. Resident states that CNAs almost dropped her when taking to bedroom and grabbed left arm. The Incident Report also contains a Pain Evaluation completed by E8 (Licensed Practical Nurse/LPN), that reads, On the initial evaluation, describe the behavior of the resident when in pain. E8 documented, Resident was lying in bed screaming/crying that left arm hurt, and yelled out in pain when left arm was touched or moved. Resident sent to ER for evaluation related to complaint of pain and decreased ROM, (Range OF Motion), to LUE, (Left Upper Extremity). SBAR, (Situation, Background, Assessment, Recommendation), progress note, dated 9/11/17 for R3 and completed by E8, documents, (R3) states when CNAs went to put (R3) to bed, they almost dropped me and grabbed me by my arm. (R3) is screaming out in pain when left arm/shoulder is moved or touched. CNA, (E5), stated that they were putting (R3) to bed and she heard (R3's) arm pop. Employee Disciplinary Action forms, dated 9/12/17, for each CNA, (E5, E6), and signed by E5, E6, and E3, (Assistant Director of Nursing/ADON), document: Transferring a 2 assist resident without a gait belt, which resulted in injury to the resident. Disciplinary Action Taken: Suspension (3 days). The Emergency Department Record for E3, dated 9/11/17 at 10:01 PM, describes Chief Complaint: Shoulder/arm problem, pain rated 8/10. History Of Present Illness: The severity of the pain was moderate. Note: Patient was held up by lifting left arm during transfer. Now complains of pain in left shoulder and arm. Physical Examination: Shoulder: Positive for left side tenderness and limited range of motion. Arm: Positive for left side proximal humeral swelling. There was moderate arm tenderness. Xrays were obtained of the left arm and shoulder region. Impression: Mildly impacted fracture at the humeral neck junction. Fracture of the greater tuberosity with no significant displacement. The facility's Occupational Therapy Plan Of Care, dated 9/15/17, documents, The patient has shown a significant decline in ADLs, (Activities of Daily Living), and associated functional mobility tasks over past few weeks due to medically complex conditions resulting from N/V, (nausea/vomiting), hx CVA, (history of Cerebral Vascular Accident), and with recent humerus fx, (fracture). On 10/02/17 at 3:00 PM, E4, (Social Services Director), described R3 as interviewable. On 10/03/17 at 12:50 PM, R3 stated that only 1 CNA, (Certified Nurse Aid), attempted to transfer (R3) from the recliner to the bed on 9/11/17. R3 also stated that a second CNA was busy with another resident. R3 said that she does not recall the names of either CNA, but the CNA that assisted, was in a hurry, did not use a gait belt, and She dropped me and I broke my arm. On 10/03/17 at 12:50 PM, R3 had a sling intact to the left arm. On 10/03/17 at 9:25 AM, E2, (Director Of Nursing/DON), stated that R3 transfers with the assistance of 2 staff and a gait belt. E2 said that the facility's investigation of the 9/11/17 incident found that the 2 CNAs involved, (E5, E6), failed to use a gait belt. E2 said that the resident fell , was sent to the ER, (emergency room ), and xrays showed a left humerus fracture. E2 said that both CNAs had recently received training on Transfers, on 8/02/17. E2 said that both CNAs were given a write up on 9/12/17, suspended from work for 3 days, and all staff were reeducated on Transfers.

Based on observation, interview and record review the facility neglected to: a) Implement policies and procedures ensuring therapeutic diets are served as ordered by the Physician to prohibit neglect of one resident b) Follow the menu as planned for a resident on a Mechanical Soft Diet at the supper meal on [DATE] resulting in choking of food [MEDICATION NAME]. The resident's face and lips turned blue. The [MEDICATION NAME] Maneuver was performed without success and the resident expired in the facility from the choking occurrence. c) Employ a qualified Dietary Manager to educate, train, and supervise dietary staff in proper food preparation in accordance with the facility's Diet Manual planned menu approved by the Registered Dietitian. This is for one (R1) of three residents reviewed requiring a mechanically altered diet to minimize the risk of choking in the sample of three. These failures resulted in R1 choking at the supper meal requiring the [MEDICATION NAME] Maneuver. The facility staff was unable to dislodge [MEDICATION NAME] food resulting in R1's death. These failures resulted in an Immediate Jeopardy. On [DATE] the facility identified on an undated and untitled paper the facility has 16 residents with a physician's orders [REDACTED]. While the immediacy was removed on [DATE] at 8PM, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of their interventions to ensure resident dietary tolerances are being met. Findings include: 1. The face sheet in R1's medical record notes a [AGE] year old male admitted to this facility on [DATE]. The [DIAGNOSES REDACTED].He was also Edentulous, he had dentures but refused to use them. The Physicians Order Sheet for [DATE], signed by Z1 (medical Doctor) includes an order for [REDACTED]. E9, (Cook), stated at 1:15PM on [DATE], she mistakenly served R1 a whole skinless hot dog on a bun. E9 noted all other mechanical soft diets were served a skinless hot dog that was sliced lengthwise and then cut diagonally in the bun. E9 noted she did not have a menu to follow and served the hot dog as trained. E9 stated R1 choked on the hot dog in the dining room and had fallen to the floor when residents hollered R1 needed help. E9 stated she did not know to grind the hot dog and had always served a skinless hot dog before this day. E9 noted when she was hired in [DATE] and two staff cooks showed her the job and what to do during two days of training. E10, (Dietary Aide), stated at 1:35PM on [DATE], she delivered R1's supper tray to his table on [DATE] and it contained a whole hot dog on bun. E10 noted we missed it and it did not get cut up. E10 stated at the time of the incident she and E6, (Certified Nurse Aide, (CNA), were in the dining room serving supper trays to residents. During an interview with E3, (Dietary Manager), at 10:15AM on [DATE], E3 stated he determined skinless hot dogs for Mechanical Soft Diets was okay and informed the cook of this. At 12:45PM when questioned about a menu spreadsheet, E3 stated he did not know they existed. Further review of dietary services determined the facility utilizes their Food Vendor's system for menu planning, purchasing and preparation. This was confirmed by interview with E4, (Registered Dietitian Consultant, (RD), at 8:10PM on [DATE]. At this interview, E4 noted E3 had been inserviced [DATE] on menus, recipes and diets. E3 noted he has not completed a Dietary Manager's Course but his background is in culinary arts. E3 noted he has not received training in therapeutic diets and just told the cooks what he thought they should serve. Observation at lunch and supper on [DATE] indicated there was no posting of a menu guideline for dietary staff to follow for regular or therapeutic diets. E3 also noted he occasionally planned meals and served his menu in place of the menu approved by E4. E3 did not keep a record of dated menus as served to determine which meals were substituted with his menu plan. The supper menu for Friday of week 3 on the undated Spring/Summer 2013 Menu System Guide (signed by E4 available in the kitchen), indicated Bratwurst on Bun, German Potato Salad, and Mandarin Oranges be served. E3 confirmed during the 10:15AM interview, this was the menu he was serving for supper on [DATE] when R1 choked. The undated Therapeutic Spreadsheet for this meal (signed by E4) states to serve 3 ounces of ground Bratwurst and bun. E3 stated he decided and instructed staff to have staff serve skinless hot dogs for the mechanical soft diets because the Bratwurst has casein. The facility's Diet Manual labeled by Healthcare Services Group, Inc., Second Edition 2005, was provided to this surveyor by E3 on [DATE]. This manual lacks an approval signature by either staff, consultant or physician. The meal planning guidelines for a Mechanical Soft Diet states to follow the Regular Diet with changes to include but not limited to meats are ground to the consistency of ground meat and the Dietitian/Speech Therapist will customize foods based on individual tolerance. The instruction further states if dysphagia is suspected, a swallowing evaluation should be performed and the diet individualized based on swallowing alterations. The facility's undated policy for Modified Diets states The Dietitian/Consultant shall monitor the planning and serving of all modified diet menus. The purpose is to assure that diets are planned and served to all residents according to their medical and psychological needs. The procedure indicates: 1. Diets ordered which are not found on the modified spread sheets should either be added to the spread sheets or have posted instructions in the serving area, as well as on the tray card. Extremely restricted diets such as renal diets are explained to dietary personnel via an inservice. 2. Dietary modifications will adhere to the latest state of facility diet manual, with deviations from the manual placed in writing in each diet manual in the facility. 3. Tray cards for residents receiving modified diets are checked periodically by the Dietitian and Food Service Supervisor for appropriate information. Tray cards are periodically checked against the written diet order form as well as against the written order in the medical record. Tray cards can be checked during quarterly care plan meeting to ensure routine monitoring. E8, (Speech Therapist), stated in an interview at 2:25PM on [DATE], R1 received dysphagia treatment in the facility. A Therapy Discharge Note by E8 on [DATE] in R1's medical record indicates a Mechanical Soft Diet with thin liquids was recommended at that time. E8 noted R1 was non compliant with treatment for [REDACTED]. Therefore, no reevaluation was conducted. E8 noted R1 preferred to eat in the dining room alone and if she had noticed he was given a whole hot dog she would have taken it away. E8 is in the facility full time and in the dining room at least one meal per day. E7, (Licensed Practical Nurse, LPN), stated at 4:05PM on [DATE], she had finished the medication pass on A Hall and was at the nurse's desk the evening of [DATE] when she heard a person say R1 is on the floor. E7 noted she went to the dining room and E10, (Dietary Aide) stated he is not breathing so she ran over to R1 where E8 was also present and E8 started the [MEDICATION NAME] Maneuver while E7 and E11, (Certified Occupational Assistant), assisted. E7 noted R1's face was turning blue and not breathing. E7 stated she switched with E8 and began abdominal thrusts to try and dislodge food. E8 noted during interview at 2:25PM on [DATE], R1 did take 4 to 5 breaths while she performed the abdominal thrusts. E9, (Cook), called 911 while E7 and E8 continued the [MEDICATION NAME] Maneuver. E8 noted E11 performed a mouth sweep and removed a few pieces of hot dog. When the Emergency Medical Technicians, (EMT's) arrived they attempted to suction with no success. They connected an electrocardiogram which indicated no rhythm. The facility's incident report dated [DATE] for R1 completed by E7, documents arrived to the dining room and resident by alternating staff. 911 called and arrived on scene. It is noted the incident occurred on 17:15 P.M.on [DATE] Ambulance Service Patient Care Report documents the call was received at 17:10 and they arrived at scene 17:13 and departed scene at 17:41. The report notes patient unresponsive and not breathing. Skin bluish purple from neck up. Report was given the resident choked on hot dog and staff was able to get pieces of it up. Staff attempted abdominal thrusts without suction. Cardiac monitor showing asystole. At 9AM on [DATE], E2, (Director of Nursing), stated the facility had one suction machine on the Arch Unit and one on Whisper Grove the evening of [DATE]. E2 also noted E8 told her R1 was taking breaths up to when the EMT's arrived. At 10:40AM, E2 further stated she talked with Z4, (EMT) to verify their actions and Z4 told her R1 was suctioned with no results. R1 was not intubated. A written report by E2, dated [DATE] notes E6, (Certified Nurse Aide, (CNA), was the first staff to find R1 on the floor and she called for a nurse and E13, (Licensed Practical Nurse, LPN) responded with E7, (LPN), close behind her. E13 began abdominal thrusts when she arrived to R1 and then rotated to E7. By this time therapy staff arrived (E8 and E11) and both attempted abdominal thrusts as well. R1 became unconscious about the time they arrived. E8, (Speech Therapist), reported hearing R1 taking breaths, she stated they were not good breaths, but he did take some breaths. By this time Emergency Medical Service, (EMS) arrived and R1 was unconscious and not breathing. EMS attempted suctioning and retrieved nothing. They attached R1 to the cardiac monitor and by then had flat lined. They called for paddles to shock him and the nurses stopped them informing them of R1's Do Not Resuscitate status. Review of facility records indicate E2, E7, E8, E11, and E13 are current with completed objectives and skills in accordance with the curriculum of the American Heart Association Heartsaver Cardiopulmonary Resuscitation (CPR) Automated External Defibrillator (AED) Program. E2 noted at 4:25PM on [DATE] this training includes the [MEDICATION NAME] Maneuver. E2 stated at 4:25PM on [DATE], after the choking incident she checked R1's plate of uneaten food. E2 stated she noted ,[DATE] inch of the hot dog and one inch of the bun was gone. None of the other food items appeared to have been eaten. The Death Certificate dated [DATE] notes the immediate medical cause of death as choking on food [MEDICATION NAME]. Manner of Death accidental. Conclusions noted from Necropsy by Z2, (Pathologist), 1) Choking on food [MEDICATION NAME] (hot dog), witnessed, 2) Large food [MEDICATION NAME] in cervical esophagus, 3) Blood and urine test pending, 4) History of dysphagia and [DIAGNOSES REDACTED] s/p partial esophagectomy with [MEDICAL CONDITION] anastomosis, 5) Small right forehead ecchymosis (2) consistent with terminal collapse. E1, (Administrator), was notified of the Immediate Jeopardy on [DATE] at 4:55PM. The Immediate Jeopardy was determined to have begun on [DATE] at 17:15 when R1 choked, fell to the ground and their face started turning blue. At that time, R1 had consumed part of a whole hot dog that should have been ground due to the fact the resident was on a mechanical soft diet The surveyor confirmed by observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: A. All dietary staff, nursing deparment heads and the Administrator were inserviced by E5, (Licensed Dietitian), at 7PM to 8 PM. on [DATE] regarding following the planned menu and guidelines for all diets and food ordering. B. An Inservice Attendance Record dated [DATE] notes an inservice was held by E1 from 1:30PM to 1:45PM regarding skinless hot dogs will no longer be considered as appropriate for Mechanical Soft Diets. Noting the hot dog must be ground. Directions noted Regular Diets will have hot dogs sliced in two. E3, E9 and E12, (Dietary Aide), attended. C. Another inservice was held, at 2PM on [DATE], for all staff by E1 also addressing all hot dogs must be ground up if served to Mechanical Soft Diets. All ot dogs will be sliced down the middle for Regular Diets. D. Starting [DATE] a suction machine was placed in the long term care dining room for immediate availability. E. On [DATE], E4, arrived at 8PM to begin a full review of dietary processes and procedures and to conduct an evaluation of manager's fitness for duty. F. On [DATE], E4 was in the facility to review and monitor the Dietary Department and their activities. G. E3 was terminated at 10:40AM, [DATE] on the recommendation of E4. H. The facility is actively recruiting a Certified Dietary Manager. I. E4, (Registered Dietitian Consultant, (RD), will consult the facility 8 hours each week until a manager is recruited and trained. J. E4 verified that menus, recipe book and dietary cards are available to dietary employees. Completed on [DATE]. K. E4 will verify diet orders by [DATE]. L. Dietary staff trained on the use of the menus, recipe book and diet cards. To be completed by [DATE]. M. E1 and E2 and E13 will monitor appropriate use of diet cards. To be reported to Quality Assurance on a quarterly basis. N. All action will be reviewed at the next Quarterly Quality Assurance meeting and updated quarterly.

Based on record review, observation and interview the facility failed to: 1) Ensure therapeutic diets are served as ordered by the physician. 2)a) Ensure the menu is followed as planned by the Registered Dietitian for a Mechanical Soft Diet at supper on 7-26-13 resulting in choking of food. b) Ensure the menu is followed as planned for Mechanical Soft Diets at supper on 7-30-13. 3) Employ a qualified Dietary Manager to educate, train, and supervise dietary staff in proper food preparation in accordance with the facility's Diet Manual. This is for one (R1) of three residents reviewed requiring a Mechanical Soft Diet to minimize the risk of choking and 16 residents (R3, R5, R6, R7, R8, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20) in the supplemental sample. These failures resulted in R1 choking at the supper meal requiring the [MEDICATION NAME] Maneuver. The facility staff was unable to dislodge [MEDICATION NAME] food resulting in R1's death. These failures resulted in an Immediate Jeopardy. On 7-31-13 the facility identified on an undated and untitled paper the facility has 16 residents with a physician's orders [REDACTED]. While the immediacy was removed on 7-30-13 at 8PM, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of their interventions to ensure resident dietary tolerances are being met. Findings include: 1. The face sheet in R1's medical record notes a [AGE] year old male admitted to this facility 7-3-08. The [DIAGNOSES REDACTED]. He was also Edentulous, he had dentures but refused to ues them.The physician's orders [REDACTED]. The menu planned and approved by E4, (Registered Dietitian Consultant), for supper 7-30-13 (Tuesday, Week 1) states Hot Dog on Bun, Potato Salad and Pineapple. This menu was changed by E3, (Dietary Manager), to state Grilled 3 Cheese, or Grilled Ham and Cheese, Three Bean Salad or Penne with Spinach Tomato Salad and Fresh Fruit. No Therapeutic Diets were planned or posted for this change in menu. Observation at supper on 7-30-13 indicated Mechanical Soft Diets received canned Three Bean Salad that included large red kidney beans, whole wax beans and whole green beans. This was acknowledged per interview with E12, (Dietary Aide) at 5:10PM on 7-30-13. Planned menu review indicated Three Bean Salad is written on the Spring/Summer 2013 menu cycle for Monday of Week One. The Therapeutic Spread Sheet (approved by E4) for this day indicates the Three Bean Salad is to be served chopped fine. The Three Bean Salad served at supper on 7-30-13 was not chopped presenting a risk to residents on Mechanical Soft Diets. (R3, R5, R6, R7, R8, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20) Regarding the choking incident involving R1 at supper on 7-26-13, E9, (Cook), stated at 1:15PM on 7-30-13, she mistakenly served R1 a whole skinless hot dog on a bun. E9 noted all other mechanical soft diets were served a skinless hot dog that was sliced lengthwise and then cut diagonally in the bun. E9 noted she did not have a menu to follow and served the hot dog as trained. E9 stated R1 choked on the hot dog in the dining room and had fallen to the floor when residents hollered R1 needed help. E9 stated she did not know to grind the hot dog and had always served a skinless hot dog before this day. E9 noted when she was hired in April 2013 and two staff cooks showed her the job and what to do during two days of training. E10, (Dietary Aide), stated at 1:35PM on 7-30-13, she delivered R1's supper tray to his table on 7-26-13 and it contained a whole hot dog on bun. E10 noted we missed it and it did not get cut up. E10 stated at the time of the incident she and E6, (Certified Nurse Aide, (CNA), were in the dining room serving supper trays to residents. During an interview with E3, (Dietary Manager), at 10:15AM on 7-30-13, E3 stated he determined skinless hot dogs for Mechanical Soft Diets was okay and informed the cook of this. At 12:45PM when questioned about a menu spreadsheet, E3 stated he did not know they existed. Further review of dietary services determined the facility utilizes their Food Vendor's system for menu planning, purchasing and preparation. This was confirmed by interview with E4, (Registered Dietitian Consultant, (RD), at 8:10PM on 7-30-13. At this interview, E4 noted E3 had been inserviced 6-17-13 on menus, recipes and diets. E3 noted he has not completed a Dietary Manager's Course but his background is in culinary arts. E3 noted he has not received training in therapeutic diets and just told the cooks what he thought they should serve. Observation at lunch and supper on 7-30-13 indicated there was no posting of a menu guideline for dietary staff to follow for regular or therapeutic diets. E3 also noted he occasionally planned meals and served his menu in place of the menu approved by E4. E3 did not keep a record of dated menus as served to determine which meals were substituted with his menu plan. The supper menu for Friday of week 3 on the undated Spring/Summer 2013 Menu System Guide (signed by E4 available in the kitchen), indicated Bratwurst on Bun, German Potato Salad, and Mandarin Oranges be served. E3 confirmed during the 10:15AM interview, this was the menu he was serving for supper on 7-26-13 when R1 choked. The undated Therapeutic Spreadsheet for this meal (signed by E4) states to serve 3 ounces of ground Bratwurst and bun. E3 stated he decided and instructed staff to have staff serve skinless hot dogs for the mechanical soft diets because the Bratwurst has casein. The facility's Diet Manual labeled by Healthcare Services Group, Inc., Second Edition 2005, was provided to this surveyor by E3 on 7-30-13. This manual lacks an approval signature by either staff, consultant or physician. The meal planning guidelines for a Mechanical Soft Diet states to follow the Regular Diet with changes to include but not limited to meats are ground to the consistency of ground meat and the Dietitian/Speech Therapist will customize foods based on individual tolerance. The instruction further states if dysphagia is suspected, a swallowing evaluation should be performed and the diet individualized based on swallowing alterations. The facility's undated policy for Modified Diets states The Dietitian/Consultant shall monitor the planning and serving of all modified diet menus. The purpose is to assure that diets are planned and served to all residents according to their medical and psychological needs. The procedure indicates: 1. Diets ordered which are not found on the modified spread sheets should either be added to the spread sheets or have posted instructions in the serving area, as well as on the tray card. Extremely restricted diets such as renal diets are explained to dietary personnel via an inservice. 2. Dietary modifications will adhere to the latest state of facility diet manual, with deviations from the manual placed in writing in each diet manual in the facility. 3. Tray cards for residents receiving modified diets are checked periodically by the Dietitian and Food Service Supervisor for appropriate information. Tray cards are periodically checked against the written diet order form as well as against the written order in the medical record. Tray cards can be checked during quarterly care plan meeting to ensure routine monitoring. E8, (Speech Therapist), stated in an interview at 2:25PM on 7-30-13, R1 received dysphagia treatment in the facility. A Therapy Discharge Note by E8 on 5-31-11 in R1's medical record indicates a Mechanical Soft Diet with thin liquids was recommended at that time. E8 noted R1 was non compliant with treatment for [REDACTED]. Therefore, no reevaluation was conducted. E8 noted R1 preferred to eat in the dining room alone and if she had noticed he was given a whole hot dog she would have taken it away. E8 is in the facility full time and in the dining room at least one meal per day. E7, (Licensed Practical Nurse, LPN), stated at 4:05PM on 7-30-13, she had finished the medication pass on A Hall and was at the nurse's desk the evening of 7-26-13 when she heard a person say R1 is on the floor. E7 noted she went to the dining room and E10, (Dietary Aide) stated he is not breathing so she ran over to R1 where E8, (Speech Therapist) was also present and E8 started the [MEDICATION NAME] Maneuver while E7 and E11, (Certified Occupational Therapist), assisted. E7 noted R1's face was turning blue and not breathing. E7 stated she switched with E8 and began abdominal thrusts to try and dislodge food. E8 noted during interview at 2:25PM on 7-3-13, R1 did take 4 to 5 breaths while she performed the abdominal thrusts. E9, (Cook), called 911 while E7 and E8 continued the [MEDICATION NAME] Maneuver. E8 noted E 11 performed a mouth sweep and removed a few pieces of hot dog. When the Emergency Medical Technicians, (EMT's) arrived they intubated R1 and attempted to suction with no success. They connected an electrocardiogram which indicated no rhythm. The Death Certificate dated 7-27-13 for R1 notes the immediate medical cause of death as choking on food [MEDICATION NAME]. E1, (Administrator), was notified of the Immediate Jeopardy on 7-30-13 at 4:55PM. The Immediate Jeopardy was determined to have begun on 7-26-13 at 17:15 when R1 choked, fell to the ground and their face started turning blue. At that time, R1 had consumed part of a whole hot dog that should have been ground due to the fact the resident was on a mechanical soft diet The surveyor confirmed by observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: A. All dietary staff, nursing deparment heads and the Administrator were inserviced by E5, (Licensed Dietitian), at 7PM to 8 PM. on 7-30-13 regarding following the planned menu and guidelines for all diets and food ordering. B. An Inservice Attendance Record dated 7-29-13 notes an inservice was held by E1 from 1:30PM to 1:45PM regarding skinless hot dogs will no longer be considered as appropriate for Mechanical Soft Diets. Noting the hot dog must be ground. Directions noted Regular Diets will have hot dogs sliced in two. E3, E9 and E12, (Dietary Aide), attended. C. Another inservice was held, at 2PM on 7-30-13, for all staff by E1 also addressing all hot dogs must be ground up if served to Mechanical Soft Diets. All ot dogs will be sliced down the middle for Regular Diets. D. Starting July 29, 2013 a suction machine was placed in the long term care dining room for immediate availability. E. On July 30, 2013, E4, arrived at 8PM to begin a full review of dietary processes and procedures and to conduct an evaluation of manager's fitness for duty. F. On July 31, 2013, E4 was in the facility to review and monitor the Dietary Department and their activities. G. E3 was terminated at 10:40AM, July 31, 2013 on the recommendation of E4. H. The facility is actively recruiting a Certified Dietary Manager. I. E4, (Registered Dietitian Consultant, (RD), will consult the facility 8 hours each week until a manager is recruited and trained. J. E4 verified that menus, recipe book and dietary cards are available to dietary employees. Completed on 7-31-13. K. E4 will verify diet orders by 8-2-13. L. Dietary staff trained on the use of the menus, recipe book and diet cards. To be completed by 8-2-13. M. E1 and E2 and E13 will monitor appropriate use of diet cards. To be reported to Quality Assurance on a quarterly basis. N. All action will be reviewed at the next Quarterly Quality Assurance meeting and updated quarterly.

Based on observation, record review and interviews the facility failed to provide adequate pain medication management, failed to provide the correct treatment, and failed to document and monitor the status of wounds for 1 of 7 residents (R2) reviewed for pain management and or wound care in the sample of 15. These failures caused R2 to have to have an increase in pain during a treatment observation. Findings include: 1. R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to R2's Significant Change Minimum Data Set Assessment ((MDS) dated [DATE] (compared to MDS dated [DATE]), R2 had a decline in all Activities of Daily Living and is now totally dependent on 2 staff persons for transfers, dressing, eating and bathing. R2 is transferred by mechanical lift and is nonambulatory. R2 now has a indwelling urinary catheter and is totally incontinent of bowel. R2 developed two stage 2 Pressure sores since the MDS dated [DATE]. According to R2's weight log, R2 has had a weight loss of 9.13% in one month (weight from 03-01-12 #104 to 03-31-12 #94). R2 fractured her right hip and returned to the facility on [DATE], with a physician's orders [REDACTED]. This was documented given through February and March 19, 2012 when R2 reentered the hospital for a Acute bowel distention and probable ileus bowel obstruction. According to R2's March physician's orders [REDACTED]. R2's "Pain Management Assessment" dated 03-17-12 states "no complaints of pain voiced". No [MEDICATION NAME] was given to R2 from March 17 to present (04-04-12), confirmed by interview with E2 (Director of Nursing) on 04-05-12 at 11 AM. During observation of treatments to R2's legs and feet of multiple skin tears and pressure ulcers on 04-04-12 at 10:05 AM by E3 (Registered Nurse) and assisted by E4 (Certified Nurse Aide), R2 voiced numerous complaints of pain. Treatments were done to 2 skin tears on R2's right outer and inner leg (all stage II) , a large 7 cm x 2.4 cm skin tear to the left calf (progressing to a stage III with [MEDICAL CONDITION] Resistive Staphylococcus Aureus from a hospital lab culture - dated 03-13-12). Additional treatments were done on R2's pressure ulcer of the right heel (stage II), and left lateral foot (stage II). During the treatments performed by E3, R2 repeatedly stated "that hurts" , "that hurts my leg", "help, help help", "quit fooling with my knee" , "ouch, ouch, ouch", "that's enough", "don't do that" and "hurry up". When R2 was questioned on 04- 05-12 at 2:15 PM regarding pain during treatment/bandage changes R2 stated "of course it hurts". Interview with E3 on 04-04-12 at 10:05 AM regarding pain management for R2, E3 stated R2 did not receive any pain medication prior to the treatment. E3 was unsure if R2 had any routine pain medications ordered or given. E3 did not stop the treatment or ask if R2 needed pain meds during the treatment. Interview with E4 (Certified Nurse Aide) on 04-04-12 at 10:45 AM, E4 stated R2 complains of pain when her legs are moved during care since her [MEDICAL CONDITION] in January. E4 states she was not aware if R2 receives pain medication. R2's physician's orders [REDACTED]. During the treatment observation on 04-04-12 at 10:04 AM, E3 cleansed all wounds with wound cleanser, applied [MEDICATION NAME] ointment to a foam dressing (no silver) and covered with a clear occlusive dressing. The physician's orders [REDACTED]. Documentation of skin tear wounds and pressure ulcers are done weekly but it is not clear which areas are treated and when they originated. All areas were facility acquired according to the facility's "Skin Integrity Reports". For example R2's left calf skin tear acquired on the incident dated 03-05-12 was listed as "foreleg". On the "Non-pressure Skin Condition Report" dated 03-18-12 identifies the left shin as the area treated. No documentation if the left foreleg and the left shin were the same areas. On 03-28-12 documentation on the "Non-pressure Skin Condition Report" states the area on the left shin is 5.7 cm x .3 cm, per observation on 04-04-12 at 10:32 AM the area measured 7 cm x 2.4 cm with a moderate amount of brown bloody drainage (worsening of the area).

Based on record review, observations, and interviews the facility staff failed to provide adequate supervision to prevent the elopement of 1 of 4 residents (R3) reviewed for elopement in the sample of 4. The facility identified 8 residents (R1-R8)at risk for elopement. R3's [DIAGNOSES REDACTED]. R3 left the faciity on [DATE] between 6:30 - 6:48AM without staff knowledge. R3 was found by the local police in a ditch face down with her wheelchair on top of her. R3 required treatment at the hospital for a closed head injury. This elopement resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 08-22-11 when staff had been inserviced, residents had been reevaluated and alarms had been adjusted to assure staff would be alerted to a resident leaving at all exits, the facility remained out of compliance at a level that is not actual harm with the potential for more than minimal harm. The deficient practice remains uncorrected due to the facility needing time to assure that the new systems are functioning correctly. Findings include: 1. R3's medical record face sheet indicates R3 is a [AGE] year old female admitted to this facility on 07-09-10. R3's [DIAGNOSES REDACTED]. The most current Annual Minimum Data Set Assessment (MDS) is dated 06-17-11 provided by E3 (MDS/Care Plan Coordinator). This assessment noted in Section C0700 and C0800 that R3 has a long and short term memory problem. Section C1000 codes R3's cognitive skills for decision making as severely impaired-never/rarely made decisions. R3's mode of transportation was identified as a wheelchair and is self-sufficient once in the chair according to Section G0110. The Functional Status Section of the MDS (G0110) indicates that R3 was dependent for transfers and unable to ambulate. R3 was coded with functional limits in range of motion noted with impairments on both sides of the upper extremities and one side of the lower extremity (Section G0400). R3 was observed on 08-18-11 at 9AM on the secure unit (D Wing) with a self release waist belt and saddle type cushion in a wheelchair propelling herself with her feet. Anti-tip devices were observed on the back of R3's wheelchair. R3 was observed to have purple bruise under the right eye and yellow/green bruise across the bridge of the nose and across the forehead. E1 (Director of Nursing) stated on 08-18-11 at 8:30AM, that R3 is alert with confusion, oriented to person but not place or time. E1 stated R3 was on the secure unit (D Wing) from admission 07-09-10 until 03-28-11 when she returned from the hospital with a [DIAGNOSES REDACTED]. According to R3's nursing notes while R3 was on C Wing dated 07-16-11 at 4PM, R3 had some aggression toward another resident and had also attempted to exit the facility four times. Nursing note on 07-20-11 at 5:30PM, R3 again tried to kick another resident's wheelchair and to exit the facility multiple times. E1 stated R3's medical condition had improved and she was more mobile in the wheelchair but remained on C Wing. No reassessment was done to determine if R3 was at risk for elopement when her condition improved in July, confirmed by interview with E1 on 08-29-11 at 8:57AM. R3 was assessed on 08-09-11 in the clinical record on the facility's "Elopement Assessment" form to be at high risk. No changes to R3's care plan were noted related to the high risk assessment or the exit seeking behaviors noted in the nurses notes on 7/16/11 and 7/20/11, confirmed by interview with E1 on 08-29-11 at 3:30PM. The facility's initial incident report ,dated 8/14/11,to Illinois Department of Public Health by E1, documents R3 left the facility unattended between 6:30AM - 6:45AM on 08-14-11. Z2 (Police Officer) found R3 in a ditch across the road from the facility at 6:48AM. R3 was transported by ambulance to the emergency room for evaluation and treatment. R3 returned to the facility the same day, with a [DIAGNOSES REDACTED]. The facility incident report dated 08-14-11 at 6:48AM, states R3 had swelling of the nose and bruising of the bilateral bridge of nose. The hospital emergency department form dated 08-14-11 at 8:41AM documents R3 had tenderness in the right lateral hip area and dried blood in the right nares. The report also states an X-ray of the right hip was done at 08-14-11 and was negative for a fracture. R3 was discharged back to the nursing home in good condition with head injury instructions, according to the hospital emergency department form Disposition/Plan dated 8/14/11. No diagnostic tests were conducted at the hospital to determine the nature of R3's head injury, confirmed by interview with Z1 (Physician) on 08-18-11 at 1PM. According to the facility's "Incident Investigation" dated 08-16-11 completed by E1. On 08-14-11 between 6:30AM and 6:45AM, R3 exited the facility in her wheelchair. It was documented R3 was last seen by E14 (Certified Nursing Assistant) on 08-14-11 at 6:30AM. R3 crossed the road in front of the facility and fell in a ditch. When R3 fell the wheel chair fell with her and she remained in the wheel chair (attached by the self release seat belt) at the time of the fall. Z2 (police officer) was driving by the facility on 08-14-11 at 6:48AM and noted R3 in the ditch and stopped to assess the situation. At 6:49AM, Z2 called for an ambulance and motioned for E6 (Licensed Practical Nurse), E4 (Certified Nursing Assistant - CNA) and E10 (CNA) to come to the scene. (These individuals were outside the facility in the smoking area to the West of the building and were seen by Z2.) R3's self release seat belt was released by E6 after assessing her. R3 was noted to have blood on her face and was taken by ambulance to the hospital for evaluation and treatment. R3 returned to the facility on [DATE] at 9:15AM with a [DIAGNOSES REDACTED]. Upon her return to the facility, R3 was assessed, neuro checks were continued and she was placed on 15 minute checks according to the written investigation dated 08-18-11 by E1. As of 08-18-11 the 15 minute checks are ongoing. R3's elopement risk status dated 08-14-11 and care plan dated 08-14-11 were updated after the incident. After consulting with R3's family, R3 was transferred to the secure Alzheimer's unit for additional safety. The facility's "Incident investigation" - timeline dated 08-16-11 was began immediately on 08-14-11 upon identifying R3 had eloped from the facility and a "Code Yellow" was initiated by the charge nurses to identify all residents were accounted for at 7AM on 08-14-11. The report indicated all staff on duty were interviewed regarding their knowledge of R3's whereabouts prior to the incident. E1 identified 2 staff members (E5 and E11-CNAs) that came in the West door at 6:30 or 6:33AM. Residents that smoke were taken out the West door to smoke by E6 (LPN) at approximately 6:45AM, according to interview with E6 on 08-18-11 at 12:55PM. E1 identified in the report that all door alarms all have approximately a 1 minute delay on them. If two door alarms sound at the same time and one is silenced that they are both silenced without the second alarm sounding. E2 stated R3 could have went out the East dining room exit door when the residents who smoke, went out the West dining room exit door. Staff may have silenced the West door and did not identify there were two alarms sounding at one time, according to E1 per interview on 08-18-11 at 1:45PM, but E1 was unable to determine if this occurred in her investigation or which door E3 exited.. R3 was interviewed at 9:02AM on 08-18-11. R3 did not recall leaving the facility or falling in a ditch across the road on 08-14-11. R3 was confused to her current location and date/time. R3 speech rambled and did not stay focused on a topic of discussion. When questioned what happened to cause the bruises on her face she stated "a guy knocked her out along the highway and brought me to the hospital the next day". R3 states she goes outside when she wants to. R3 stated she would put her jacket on before crossing the road and if cars were present she would stop and watch them go by. When R3 was asked about crossing a ditch she stated she would cross the ditch if the water was not too deep. R3 was unable to remove the lap seat belt on her wheelchair upon request. According to interview with Z1 on 08-18-11 at 1PM, R3 does not have safety awareness and is unaware of possible dangers. Observation of the path R3 may have traveled indicates she may have exited from the front door of the facility, East or West dining room exits. R3 traveled in her wheelchair propelling through the parking lot then making a right (going West) on Mack Avenue. R3's wheelchair went off in a ditch on the north side of Mack Ave by a electrical pole next to an entrance to a business. The wheelchair turned over in a ditch approximately 200 feet from the front entrance of the nursing home facility. Mack Avenue is a busy street with heavy local traffic. The ditch is approximately 3 feet deep. According to interview with Z2 on 08-18-11 at 11:45AM per phone, R3 was found in the ditch head down with the wheelchair on top of her. R3 was still fastened in the wheel chair with a seat belt. R3 was observed to have a scuff on her face and a bloody nose, according to Z2. Z2 called the ambulance for R3 at 6:49AM on 08-14-11. Z2 confirmed with E6 (LPN) at that time that the facility staff were not aware R3 had left the facility. The weather for 08-14-11 at 7AM was 67 degrees sunny and clear, according to the facility's "Illinois Department of Public Health" reporting form dated 8/14/11. According to interview with E5 (CNA) on 08-18-11 at 11:30AM, R3 was dressed in a short sleeve knit shirt, sweat pants, shoes and socks. Observation of East Dining Room door alarms with E1 on 08-18-11 at 3:35PM, noted the door alarm had a 60 second delay after the door code was entered on the key pad when entering or exiting before the alarm resets itself. Other exit doors (front door, West Dining Room exit, Wings A, C and D exit doors) in the facility have a 30 second delay before the door alarm resets, confirmed by interview with E9 (Maintenance Supervisor) on 08-29-11 at 2PM. E1 (Director of Nursing).was notified of the Immediate Jeopardy situation regarding R3 at 2:45 P.M.on 8/18/11. The Immediate jeopardy was determined to have begun on 08-14-11 between 6:30AM and 6:48AM when R3 eloped from the facility without staff knowledge. The Immediate Jeopardy was determined to have been removed on 08-14-11 at 9:15AM when R3 returned to the facility from the hospital, was reassessed and transferred to the secure unit. The facility implemented the following steps to remove the Immediate Jeopardy which reduced the severity to no actual harm with potential for more than minimal harm and the scope isolated. 1. Staff inservice education began by E1 on 08-14-11 after R3 eloped. Education included Door Alarms, Code Yellow, Motion Detectors and Elopement Policy and Procedures. All staff were inserviced by 10AM on 08-15-11, confirmed by interview with E1 on 08-29-11 at 3PM. 2. The facility staff evaluated R3 for elopement risk and she was placed on the secure unit with 15 minute checks on 08-14-11. R1's wandering assessment and care plan were updated on 8/14/11 to include high risk for elopement. 3. The door alarm system (10 exit doors) were assessed for proper functioning by E9 (Maintenance Director) on 08-14-11. There is a 60 second delay after the East Dining Room door alarm is deactivated before the alarm resets and if two alarms are tripped simultaneously there was no evidence 2 alarms were activated. Z4 (Contracted Alarm Inspector) was in the facility on 08-17-11 and reset the door alarms for less than one minute delay except for the East Dining Room exit door. Z4 coded individual exit doors so the facility staff could identify which doors had been exited from the facility when 2 alarms are tripped at the same time. The East Dining Room door was designated as a emergency exit and a 2nd shrill alarm was placed on this door on 8/22/11 (to be only turned off at the door). 4. On 8/15/11 staff reevaluated all in house residents. According to the facility's "Elopement Risk" form revised 8/2011, 2 residents(R2 R3) were identified as high risk for elopement , and 6 residents were identified as "at risk" for elopement (R1, R4, R5, R6, R7 and R8). Information to better identify at risk residents was added to the facility's elopement program book. 5. On 8/22/11, E1 developed an Interdisciplinary assessment tool to use for residents being moved off the secure Alzheimer's unit . A quality assurance tool has also been developed to monitor a residents move to the secure unit.

Based on observation, interviews and records reviewed, the facility failed to provide safe wheel chair transportation by not properly securing the wheel chair with proper shoulder and lap belts.for one of four residents (R9) reviewed for safety measures from the sample of four. These failures resulted in R9 falling from the wheel chair to the van floor .This fall resulted in an injury requiring an emergecy room visit to treat the right knee avulsion requiring staples, numerous skin tears on the arms and legs,a head contusion and avulsion of the left elbow. Findings include: On 10/5/11, at 9:30am, E1 (Administrator) and E2 (Assistant Administrator) stated that E4 (CNA) was driving R9 to a physician's appointment with the facility's van. E4 stated a semi-trailer crossed into her lane of traffic. E4 said she turned into the concrete shoulder to prevent a collision with the semi. Then E4 said the van went over the concrete shoulder and back onto the highway. When this occurred, R1 fell out of the wheel chair onto the van floor. E4 stated she stopped the van in a parking lot and assessed R9. E4 stated the wheel chair was still locked to the van floor. E4 stated R9 insisted she was ok and did not want to go to the hospital. E4 called the facility to report the incident. E1 and E2 drove to meet E4 and R9 to assess R9. E1 and E2 stated upon assessment of R9, she was transported to the local hospital emergency room . The nurses notes dated 10/5/11 indicated R9 was not admitted to the hospital. The consultation report dated 10/4/11 addresses the following injuries: Struck head, multiple lacerations on the arms and legs, a 25 centimeter length laceration on the right thigh above the knee and this is an avulsion type injury going down through the subcutaneous fat but not violating the fascia or muscle layer; this is a curvilinear in nature: left forearm is another deep tissue avulsion but the skin has been completely avulsed and there is no overlying tissue that is amenable to primary closure. The report indicated the right thigh wound was closed primarily with a complex repair of the laceration. The report indicated R9 did not have any broken bones. On 10/6/11 at 1:30pm, R9's treatment to the right leg was observed. R9 was noted to have several dressings on both hand, and left forehead. R9 stated her left shoulder is sore. R9 said she can still hear the sound of the van driving over the curve. R9 said it was awful. On 10/6/11at 9:30 A.M. E1 and E2 stated E4 has received no formal training in the use of the restraints for the wheelchair in the van. On 10/6/11, at 2:00pm, E2 stated upon checking with their insurance carrier for the employees cleared to drive the transportation van E4 was not included.

Based on record reviews, observations, facility policy review, incident report reviews and interviews the facility staff failed to provide adequate supervision to prevent the elopement of one resident (R1) out of three sampled residents reviewed. The facility has identified 27 residents at high risk for elopement. R1's [DIAGNOSES REDACTED]. R1 left the facility after dark without staff knowledge on 2-24-11. R1 required treatment for [REDACTED]. This elopement resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 2-25-11, the facility remained out of compliance at a level that is not actual harm with the potential for more the minimal harm. The deficient practice remains uncorrected due to the facility's failure to develop an active quality assessment and assurance committee to assist staff with determining and maintaining compliance with Federal Regulations. Findings include: 1. The medical record face sheet indicates R1 is a [AGE] year old male who was admitted to this facility on 3-11-10. The [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) is dated 2-18-11 as a re entry assessment. (From the hospital.) This assessment notes R1's communication abilities as understands and is understood by others. R1's mode of locomotion was identified as a wheel chair. The Functional Status Section of the MDS (G0110) indicates at this time R1 was dependent for transfers, unable to ambulate and required staff performance for locomotion in the wheel chair. Limits in range of motion were noted with impairments on both sides of upper and lower extremities. (Section G0400) Interview with E3, (Registered Nurse), on 3-2-11 at 10:15AM indicated R1 had been very ill upon hospital return and was placed in a Hopsice bed. E3 commented she observed R1's health improve on 2-23-11 and 2-24-11 for he was out of bed and propelling himself in his wheel chair in the halls of the facility. The facility's initial incident report by E1, (Administrator) documents R1 was seen at 8PM in the facility on 2-24-11. The front door alarm sounded at 8:10PM. A caller called the facility at 8:20PM to report a resident had fallen out of a wheel chair near the facility. The resident (R1) was transported to the hospital by ambulance and treated for [REDACTED]. The unsigned 7 day follow-up report dated 3-1-11 notes R1 is an alert and oriented resident and left the building at approximately 8:10PM to go to Hardees to get something to eat. He was discovered a half block away by a passerby at 8:20PM where he had fallen out of his wheel chair and down a slope onto the ground. He was seen in his pajamas at 8PM but had went to his room and put on his coat and boots (loafer shoes of which R1 refers to as boots) and left. According to R1 in this report, R1 noted he was startled by traffic and stood out of his wheel chair and fell and his wheel chair toppled on him down a slope which prevented him from getting back up. The passerby called an ambulance and R1 was taken to the hospital for observation for Hypothermia. He was readmitted to this facility the following day. R1 was interviewed by this surveyor at 11:25AM and 3:40PM on 3-2-11. R1 stated he recalled leaving the facility on the evening of 2-24-11. R1 noted he wheeled himself out the front door and was going to get something to eat at Hardees. R1 noted it was dark outside, raining and cold. R1 commented he tried to get out of the way of a car and couldn't see where he was going, and didn't see the ditch where the wheel chair landed. He indicated the wheel chair turned over in the ditch and landed on his legs. He stated the water in the ditch was up to his shoulders. R1 said he was not scared but was cold. R1 stated he was going to Hardees because he wanted regular food. (Not pureed.) He did note when he pushed the front door open he heard the alarm sound. The Hospital Emergency Department Report states the ambulance arrived at 2043. R1's temperature at the scene was 91 degrees Fahrenheit. R1 was transported by ambulance with warming en route. Treatment at the emergency room included continued warming, oxygen, warmed Normal Saline IV, Complete Blood Count, Complete Metabolic Panel, and Cardiac Profile. The report notes patient is presently too tremulous to obtain an Electrocardiogram. Body temperature was 97.6 degrees F by 2230. R1 was admitted to the hospital for observation and returned to the Nursing Home on 2-25-11 at 1500. Upon return to the facility R1 was placed on the secured unit (D Hall) with 15 minute checks on his location. As of 3-7-11, the 15 minute checks are ongoing. Observation of the the path R1 traveled indicates he left the facility's front entrance in his wheel chair and propelled through the parking lot then made a right (going West) onto Mack Avenue. His wheel chair went off of this Avenue into a ditch at the corner of the next road. (Silver Street) The wheel chair turned over in a ditch approximately 86 yards from the front entrance of the facility. This Avenue is a well traveled street by local traffic. This ditch is approximately 3 feet deep. A security light was noted in the parking lot area and a street light was observed on the South side of the Avenue where R1 was found in the ditch. According to an interview with Z3, (Emergency Medical Technician), at 11:20AM on 3-1-11, the ditch contained 2 to 3 feet of water. Z3 noted R1 was partially submerged up to his chest in water. The wheelchair was turned over and the resident's foot was caught in the wheel chair. The weather was rainy and cold. Z3 noted R1 was wearing a hospital gown, pajama bottoms, house slippers and a coat was beside him in the water. An interview with E3, (Registered Nurse in charge of caring for R1 on the evening shift of 2-24-11) at 10:15AM on 3-2-11 indicated they heard the alarm go off at approximately 8:10PM and she went to the panel at the nurses station to see what area had set off the alarm. The panel indicated the front door and E3 stated she immediately went to this door and stepped outside approximately five feet but did not see any one. E3 noted it was dark and raining. E3 noted she yelled to E5, (Certified Nursing Assistant), who was in his car for break approximately 20 yards from the front door and asked him if he saw anyone leave. He noted he had just got back from getting coffee but had not seen anyone. E3 noted E5 got out of his car and said he would walk around the building. E3 came back into the facility and had a feeling that it could have been R1 because he was not in his room at 8PM when she parked her med cart by his room. (E3 noted she had seen R1 at approximately 7:50PM.) E3 noted she asked staff if they had seen R1 and no one could find him. While staff was searching in the facility for R1, a call came in to the facility asking if they were missing a resident. E3 stated an unidentified male said there was a man in the ditch between Mack and Silver Streets and did he belong to the facility. E3 stated she said probably because they were looking for a resident. E5 stated in an interview at 3PM on 3-2-11 he had returned to the facility entering the East side of the parking lot from Mack Avenue when he saw E3 out the door of the front of the facility. E5 noted E3 asked him if he had seen anyone come out. E5 stated it was rainy with poor visibility and had not seen anyone. E5 noted he then checked both sides of the facility but did not check the road in front of the facility. The weather channel web site notes at 8:25PM on 2-24-11 the facility city had light rain and was windy. The temperature was 39 degrees F with conditions feeling like 29 degrees. Winds were East North East at 20 miles per hour. The facility failed to follow their undated Door Alarm Policy and Procedure. Staff did not announce a "Code Yellow Unknown Resident" when the exit alarm sounded. E10, (CNA) stated on 3-7-11 at 9:15AM she turned off the alarm without acknowledging a code status. i.e. Code Yellow Unknown Resident or Code Yellow All clear. E9 noted at 2:00PM on 3-3-11, she saw E10 shut the alarm off at the nurses station on 2-24-11 around 8PM. She noted she asked E10 what door alarmed and E10 did not respond. E9 stated she checked the two dining room exits and then went back into the break room to finish break time. Staff failed to follow their Elopement 1/2004 Policy and Procedure regarding searching the facility surrounding grounds. The Immediate Jeopardy was identified on 3-2-11 at 1:03PM to E1, (Administrator). The Immediate Jeopardy was determined to have begun on 2-24-11at 8:10PM when the facility alarm sounded and R1 eloped the facility without staff knowledge. The Immediate Jeopardy was determined to have been removed on 2-25-11 at 1500 when R1 was returned to the facility from the hospital and placed on the secured unit. The facility implemented the following to remove the Immediate Jeopardy which reduced the severity to no actual harm with potential for more than minimal harm and the scope to isolated. 1. Staff inservice education began by E2, (Interim Director of Nursing), the evening of 2-24-11 after R1 eloped. Education included door alarms and elopement policy and procedures. All staff were inserviced by 1:30PM on 2-26-11. 2. Motion detectors were installed near to the 5 facility exits. The alarms are to be activated from 7PM to 7AM to add extra security when a resident nears the exit. 3. The facility staff evaluated R1 for elopement risk and he was placed on the secured unit with 15 minute checks for his location. R1's wandering assessment and care plan were updated to include high risk for elopement. 4. Staff evaluated all residents and determined 27 residents are at risk for elopement. A binder with resident pictures and personal data is maintained to identify these residents.