Every finding on record at Hillview Senior Living & Rehab

Based on interview, record review, and observation, the facility failed to prevent, assess, and monitor a pressure ulcer for 1 of 6 (R13) residents reviewed for pressure injuries in a sample of 26. This failure resulted in R13's non-assessed small open area to her right buttock, which was document 6/16/26, to develop into a stage 3 pressure ulcer identified on 7/25/26.Findings included:R13's Transfer/Discharge Report documents an admission date of 6/20/2018 with diagnoses of abnormal posture, anxiety disorder, congestive heart failure, need for assistance with personal care, muscle weakness and stage 3 chronic kidney disease among others. R13's MDS (Minimum Data Set) dated 4/24/2026 documents R13 with a BIMS (Brief Interview for Mental Status) score of 99 which indicates R13 has severe cognitive impairment and could not participate in the BIMS testing due to cognitive impairment. This same MDS documents R13 is dependent on staff for all bed mobility including turning and repositioning, dependent on staff for toileting, showering and transferring and is incontinent of bowel and bladder. This same MDS also documents that R13 is at risk for developing pressure ulcers/ injuries and has no unhealed pressure ulcers/injuries. Under Skin Ulcer/Injury Treatments documents a pressure reducing device for chair and bed, turning/repositioning program, and applications of ointment/medications other than to feet.On 7/29/2026 at 1:00pm, V12 (Registered Nurse) said previously on 6/16/2026 she noticed R13 had a small open area to her right buttock. V12 said she notified the doctor and received orders for: small open area to right buttock, 1) cleanse with dermal wound cleanser, 2.) apply skin prep to peri wound edges, 3.) apply zinc ointment every shift and as needed. V12 said on 7/25/26 she was the nurse providing care for R13. V12 said she was surprised to discover R13's right buttock wound had gotten so much worse than when she had seen it previously on 7/18/26 when she worked, so she notified V14 (Minimum Data Set Coordinator/Care Plan Coordinator) of the wound changes and sent V14 a picture of the wound via cell phone. V12 said they notified R13's doctor and received orders. V12 said the wound was bigger and was bleeding, which it had not done before when she had seen it. V12 said she did not measure the wound and did not document the wound in R13's medical record.R13's Order Summary Report documents the following active order with an order date of 7/27/26: DTI (Deep Tissue Injury) R (right) buttock, 1.) cleanse open area with dermal wound cleanser and allow to dry, 2.) apply skin prep to peri wound, 3.) apply cut-to -fit honey-soaked dressing and cover with silicone dry dressing.On 7/29/2026 at 11:45am, V14 (MDS Coordinator/Care Plan Coordinator) said she does the weekly wound rounds with V13 (Wound Care Nurse Practitioner) and is responsible for completing weekly wound care assessments. V14 said she does not provide daily wound care to the residents on a regular basis. V14 said she first was notified of R13's right buttocks wound on 7/25/26 when V12 sent her a text message and included a picture of R13's wound. When V14 was asked about R13's June TAR (Treatment Administration Record) which documented a small open area to R13's right buttocks, V14 said that specific wound was a different wound and had already healed up. V14 said she did not document any weekly wound assessments for the wound and did not document any wound measurements and could not find any other documentation about the wound except for the treatment order documented on R13's June TAR. V14 said V13 sees all residents with wounds every week at this facility, but V13 never saw R13 for a right buttock wound until 7/29/26. V14 said it's their facility's policy that all wounds are to be assessed weekly with measurements taken, progression of wound to be documented in the resident's medical record and a picture taken weekly of all wounds.On 7/29/2026 at 10:00am, V13, V14, and V15 (Certified Nursing Assistant) performed a wound assessment on R13. R13's wound is located on the right buttock. The wound is covered in yellowish slough with small amount of bleeding noted to the wound edge. V13 measured the wound with measurements documented as 0.9cm (centimeters) by 1.6cm and is 0.1cm deep.On 7/29/2026 at 10:10am, V13 said today was the first time assessing R13's right buttock wound. V13 said the wound is a pressure injury and has progressed to a stage 3 pressure ulcer. V13 said she could tell R13's wound was older than 5 days old due to the amount of slough formation on the wound and feels it could not have first developed on 7/25/26. V13 said frequent repositioning and keeping R13's skin clean and dry would have prevented R13 from developing any pressure injuries. V13 said R13's wound was reported to her as a blood blister, but she did not feel the wound was a blood blister but could see where the wound had been previously bleeding. V13 said the wound did not have any signs of infection and felt it would take 9 to 12 months to heal the wound.On 7/29/2026 at 11:35am, V9 (Licensed Practical Nurse) said she was the nurse providing care to R13 on dayshift on 7/5/26, 7/6/26, 7/8/26, 7/24/2026 and 7/27/2026. V9 said V13 doesn't do daily wound care for the residents, the floor nurse assigned to the hall does the daily wound care. V9 said R13 has only had one open area on her right buttock. V9 said R13 did not have multiple open areas on her buttocks and only had the one wound and it has never healed. V9 said it is the same wound and not a different wound. V9 said she has provided R13 with wound care but said she has never measured the wound or documented any progress about R13's wound in R13's medical record. R13's Progress Notes for June and July 2026 do not document any wounds to R13's skin until 7/27/26. R13's Progress Note dated 7/27/26 at 11:10am documented the following: New skin issue, location right gluteal fold, pressure injury, new wound. Pressure ulcer staging-unstageable pressure injuries presenting as deep tissue injury, wound acquired in house on date of 7/25/26.R13's June TAR documented the following treatment orders: start date 6/16/26, small open area to R (Right) lower buttock-cleanse with dermal wound cleanser and allow to dry. Apply skin-prep to area and allow to dry, apply zinc ointment Q (every) shift and PRN (as needed) with a D/C (discontinue) date of 7/28/2026.R13's Care Plan does not address R13's wound documented on 6/16/26 on R13's TAR. R13's Care Plan documented the following Focus Area: actual alteration in skin integrity d/t (due to) deep tissue injury to right buttock with an initiation date of 7/27/2026. Interventions documented with initiation date of 7/27/26 were: treatment per MD (medical doctor) orders, educate resident and family on skin conditions and prevention of skin breakdown, float heals while in bed, incontinence care, apply barrier cream, notify dietary, pressure reducing cushion to wheelchair, provide supplements as ordered, record labs that can affect skin, turn and reposition every 2 hours. The same Care Plan documents the following Focus Area: ADL's (Activities of Daily Living) R13 has a performance deficit. Under interventions documents bed mobility: the resident is able to T/P (Turn and Position) self in bed with an initiation date of 7/11/24.On 7/29/2026 at 10:25am, V14 said she thought R13 was independent with bed mobility but would have to check R13's MDS to see for certain.On 7/29/2026 at 10:30am, V15 (Certified Nursing Assistant) said R13 is cooperative with care and is independent with turning and repositioning herself while in bed. V15 said R13 gets up for all meals but after eating R13 likes to go back to bed to rest. V15 said she knew R13 had a wound on her right buttock, but they have not been doing anything different to R13's care.R13's Wound Care Visit note dated 7/29/2026 documents R13's right buttock wound is caused by pressure, is a stage 3, is covered with 70% slough and measures 0.9cm (centimeters) by 1.6cm and is 0.1cm deep. The visit note documents estimated time to heal is 9-12 months.The facility's policy titled Prevention of Pressure Ulcers/Injuries (revised July 2017) documents the following: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific factors. Under Risk Assessment documents 1. Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Under Monitoring documents 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 3. Update the provider as needed.Weekly skin assessments in R13's medical record titled Skin Check Weekly and PRN (as needed) dated 6/1/26, 6/2/26, 6/12/26, 6/14/26, 6/16/26, 6/19/26, 6/21/26, 6/22/26, 7/5/26, 7/6/26, 7/2/26, 7/14/26, 7/19/26, 7/21/26 and 7/27/26 all document the same information- under the section titled Changes This Week: No new changes this week. Under the section titled Skin Impairment Documentation: are there any new areas of skin impairment? No.

Based on Interview, record review, and observation, the facility failed to follow infection control practices during resident care for 5 of 12 residents (R13, R43, R39, R31, R5) reviewed for infection control in a sample of 26.Findings included: 1.) R13's Transfer/Discharge Report documents an admission date of 6/20/2018 with diagnoses of abnormal posture, anxiety disorder, congestive heart failure, need for assistance with personal care, muscle weakness and stage 3 chronic kidney disease among others. R13's MDS (Minimum Data Set) dated 4/24/2026 documents R13 with a BIMS (Brief Interview for Mental Status) score of 99 which indicates R13 has severe cognitive impairment and could not participate in the BIMS testing due to cognitive impairment. This same MDS documents R13 is dependent on staff for all bed mobility including turning and repositioning, dependent on staff for toileting, showering and transferring and is incontinent of bowel and bladder. R13's Care Plan documents that R13 has a alteration in skin integrity related to a deep tissue injury to the right buttock. The same Care Plan documents a Focus area of EBP (Enhanced Barrier Precautions) are indicated for residents with any of the following: Infection or colonization with a CDC (Centers for Disease Control)-targeted MDRO (Multi-drug Resistant Organism) when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO during high-contact resident care activities regardless of their multidrug-resistant organism status dated 7/27/26. Under Goal documents .EBP are used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment) to donning of gown and gloves during high contact resident care activities. On 7/29/2026 at 10:00am, V13 (Wound Care Nurse Practitioner), V14 (MDS Coordinator/Care Plan Coordinator), and V15 (Certified Nursing Assistant) entered R13's room to perform a wound assessment and wound measurements on R13's right buttock wound. V13, V14 and V15 performed hand hygiene and applied clean gloves but did not apply a protective gown before entering R13's room and performing the wound care assessment and measuring. V2 (Director of Nursing) and V10 (Corporate Nurse) were present in the room to observe the wound assessment also. R13's wound is located on the right buttocks. The wound is covered in yellowish slough with small amount of bleeding noted to the wound edge and measured 0.9cm (centimeters) by 1.6cm and 0.1cm deep. On 7/29/2026 at 10:15am, V2 said as part of Enhanced Barrier Precautions and the facility's infection control program, V13, V14 and V15 should have applied a clean protective gown before entering R13's room and performing the wound care assessment. V2 said R13 is on Enhanced Barrier Precautions. 2.) R43's admission Record documents an admission date of 7/6/26 with diagnoses including pressure induced deep tissue damage of right heel and pressure ulcer of left heel, stage 2. R43's Order Summary Report dated 7/29/26 documents orders for left heel blister treatment: cleanse with wound cleanser, pat dry, cover with abdominal pad, and wrap with gauze wrap and secure with tape daily and as needed until healed with an order date of 7/8/26. R43's Order Summary Report documents another order for right heel blood blister treatment: cleanse with wound cleanser, pat dry, cover with abdominal pad, wrap with gauze wrap and secure with tape daily and as needed with a start date of 7/8/26. R43's most recent Care Plan documents a Focus area of actual alteration in skin integrity due to a fluid filled blister on left heel and blood blister on right heel with an initiated date of 7/6/26. Interventions for this focus area include following physician's treatment orders on physician's order tab in electronic health record. The same Care Plan documents another focus area stating EBP are indicated for residents with any of the following including wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO: fluid filled blister left heel and blood blister right heel with an initiation date of 7/6/26. Interventions for this focus area include the facility must establish teaching to staff of residents for whom EBP are indicated. EBP is employed when performing the following high-contact resident care activities including device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and/or wound care for any skin opening requiring a dressing with an initiation date of 7/6/26. R43's MDS dated [DATE] documents R43 has a pressure ulcer/injury over a bony prominence. The same MDS documents R43 has one unhealed stage 2 pressure ulcer (left heel) and 1 unstageable pressure ulcer (right heel). On 7/28/26 at 3:31 PM, V12 (Registered Nurse/RN) was observed performing wound care to R43's heels. V2 (Director of Nurses/DON) was also present during this observation. V12 performed hand hygiene and donned disposable gloves, but V12 did not don a disposable gown. R43's right heel was open and had a flap of calloused skin hanging from what appeared to be a broken blister with tissue below that was moist and stuck to R43's sock with scant amount of drainage with a mixture of what appeared to be bruised skin and a covering of eschar present over approximately 2-3 centimeters of the wound. There was EBP signage on R43's door that documented gloves and gowns for the following high contact care areas: dressing, bathing, showering, device care, and wound care. On 7/29/26 at 2:03 PM, V12, when asked if she should have worn a disposable gown yesterday when providing wound care to R43 she stated, I didn't think I had to because the wounds were closed. I think (V2, DON) told me that. We're supposed to wear EBP when a person has an indwelling medical device or if they have open wounds. On 7/29/26 at 2:09 PM, V2 stated yes, V12 should have donned EBP including a disposable gown before providing wound care to R43's heel wounds due to the right heel wound being open. The facility's Enhanced Barrier Policy dated 3/28/24 documents, Enhanced Barrier Precautions will be instituted for those residents deemed to be at high risk for MDROs (multi-drug resistant organisms) with any of the following: infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g. (example) Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. EBP should be used for any resident who meets the above criteria, wherever they reside in the facility. 3.) On 7/28/26 at 8:07 AM, while preparing medication to be administered for R39, V12 (Registered Nurse/RN) picked up an extended release 50 milligram (mg) Seroquel tablet prescribed for R39 with her bare hand out of the cup so she could crush the other tablets in the tablet crusher. V2 (Director of Nursing) was present during this observation. On 7/28/26 at 8:12 AM, while preparing medication to be administered for R31, V12 picked up a delayed release tablet of aspirin 81mg prescribed for R31 using her bare hand out of the cup so she could crush the other tablets in the tablet crusher. V2 was present during this observation. On 7/28/26 at 1:22PM, while preparing medication to be administered for R5, V12 picked up a Xanax 1mg tablet and hydrocodone/acetaminophen 7.5/325mg tablet prescribed for R5 using her bare hand and placed them in the pill crush pouch at this time. V2 was present during this observation. On 7/29/26 at 2:03 PM, V12, when asked if she should have handled medication for residents R5, R31 and R39 using her bare hands, stated no she should not have, but had gotten nervous and forgotten. On 7/29/26 at 2:09 PM, V2 stated yes, V12 should have not handled medication for residents R5, R31 and R39 with only her bare hands. V2 stated V12 could have used a spoon or a glove to handle the medications if she needed to. The facility's Administering Medications Policy (revised April 2019) documents staff should follow established facility infection control procedures for the administration of medications as applicable.

Based on interview, observation and record review, the facility failed to provide nutritional supplements as ordered for 1 of 3 residents (R8) reviewed for nutrition in the sample of 26.The findings include:R8's admission Record documents an admission date of 11/22/24 with diagnoses including dysphagia, type II diabetes, and dementia.R8's Order Summary Report dated 7/29/26 documents a physician order for fortified pudding to be given one time per day with an order date of 7/13/26 and start date of 7/14/26.R8's most recent Care Plan documents a Focus area for R8 being at risk for fluid imbalance and weight loss dated 11/23/24. Interventions for this focus area include follow diet orders found on Physician's Order Summary with a date initiated of 11/23/24.R8's Minimum Data Set (MDS) dated [DATE] documents R8 had a weight loss of 5% or more in the last month and was not on a physician prescribed weight loss program.R8's meal tickets for breakfast, lunch, and supper dated 7/29/26 did not show R8 has a supplement of fortified pudding to be served at any of the three meals.R8's Progress Noted dated 7/13/26 documented by V2 (Director of Nurses/DON) documents a new order received for fortified pudding supplement to be added to lunch meal due to a 6.8-pound weight loss R8 recently had.R8's Progress Note documented by V1 (Administrator) dated 7/17/26 documents a physician's order for supplement of fortified pudding added to R8's daily lunch menu.On 7/27/26 at 12:40 PM, there was no observation of fortified pudding on R8's lunch tray when the tray was served to R8.On 7/28/26 at 12:30 PM, there was no observation of fortified pudding on R8's lunch tray when the tray was served to R8. R8's meal ticket placed with R8's tray did not document fortified pudding as a supplement to be served to R8.On 7/29/26 at 12:27 PM, there was no observation of fortified pudding on R8's lunch tray when the tray was served to R8. R8's meal ticket placed with R8's tray on the table did not document fortified pudding as a supplement to be served to R8. On 7/29/26 at 1:05 PM, V5 (Certified Nurse Aide/CNA) stated she was not sure what supplements R8 was supposed to have. When asked if she remembered if R8 had a supplement of fortified pudding ordered, V5 stated she saw him last week with pudding but not sure if it was fortified because there were several residents who had pudding. On 7/29/26 at 1:07 PM, V15 (CNA) stated she did remember that R8 did have fortified pudding as a supplement, but she was not sure what meal R8 gets that supplement with.On 7/29/26 at 1:12 PM, V6 (CNA) stated she was not sure if fortified pudding was an ordered supplement for R8.On 7/29/26 at 1:15 PM, V2 (Director of Nurses/DON) stated yes, R8 did get fortified pudding as a supplement, but she was not sure which meal it was administered at. On 7/29/26 at 2:59 PM, V1 (Administrator) and V10 (Corporate Nurse) stated they reviewed why R8 was not getting his fortified pudding supplement and discovered V2 had put the new order in for the fortified pudding as she was supposed to, but for some reason the order did not cross over from the electronic health record to be printed out on R8's meal ticket. V1 and V10 both agreed if a supplement is ordered it should be given to the residents as ordered.On 7/30/26 at 10:34 AM, V2 stated if a resident has physician's order for any supplement, then it should be given to the resident as ordered. The facility policy titled Food and Nutrition Services Policy (revised October 2017) documents meals and/or nutritional supplements will be provided per provider order.

Based on observation, interview and record review the facility failed to dispose of vials of multi dose medications after open date had expired for greater than 30 days. This has the potential to affect all 39 residents living in the facility. Findings include: R21's admission Record documents admission date of [DATE], and includes diagnoses of Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Hypo magnesium, Left Hip Prosthesis, and Thiamine Deficiency. R21's MDS (Minimum Data Set) dated for [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15 indicating R21 is cognitively intact. R21's Care plan documents R21 has Diabetes Mellitus with goal of R21 will have no complications related to diabetes through review date (no date documented). Interventions include monitoring hyperglycemia, hypoglycemia and educate regarding medications and importance of compliance. R21's Physician current order sheet contains orders for Trulicity 0.75mg/0.5ml subcutaneous every Friday for Diabetes Mellitus, Novolin Flex Pen for sliding scale accu checks for Diabetes Mellitus, and Lantus 15 units twice a day for Diabetes Mellitus. On [DATE] at 12:30PM, V2 DON (Director of Nursing) and V6 LPN (Licensed Practical Nurse) were present for the inspection of the medication room. During the inspection of medications in the refrigerator, there was a vial of Lantus Insulin with R21's listed on it with an open date of [DATE]. The open date was validated by V2 and V6. Also, at that time there was a vial of Tubersol, Facility Stock with open date of [DATE]. On [DATE] at 1:15PM, V2 was asked how long they use a refrigerated vial of medication after the marked open date, V2 stated no longer that 30 days. V2 stated she expects staff to discard the medication after the 30 days and not use the medication. V2 stated the Tubersol is used for all new staff, all new admissions, if physician orders one or a resident has symptoms, and those are 2 step TB (Tuberculosis) screens. On [DATE] at 3:40PM, V10 RN (Registered Nurse) stated when a new vial (multidose) is opened the date of which it was opened must be put on the bottle. The medication is only safe to use for either 28 or 30 days, according to medications. V10 stated then the bottle must be discarded to avoid being used and medication must be replaced if needed. V10 stated she would not use a medication that had been opened for more than the days allowed. On [DATE] at 3:45PM, V6 LPN (Licensed Practical Nurse) stated she marks the vials with a sharpie with the date when she opens the bottles. V6 stated the reason for dating the bottles is to let everyone know when the bottle was opened and not to use after either 28 or 30 days. On [DATE] at 8:10AM, V11 LPN stated when she opens a new multidose vial of medication she always dates the bottle. The reason she dates the bottle is because some medications are only good for 28-30 days after the vial has been opened. V11 stated they have a list to go by on the safe length of use of the medication after the bottle has been opened. On [DATE] at 8: 15AM, V5 RN (Registered Nurse) stated all multidose vials are dated with the date the bottle was opened. V5 stated the purpose of dating the bottles is because the medication in the vials is only good for 30 days (most meds) to be used. V5 stated after the allotted time the vial should be discarded and replaced with a new vial if it is necessary. Document titled Insulin Expiration Date, was provided by V2, which is kept in the medication room as a reference for the medication nurses. The document reads Lantus Vial & Solostar Pen, 28-day expiration date after opening or removing from refrigerator, whichever comes first. On the Tubersol package insert under Storage documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. The Department of Health and Human Services Center for Medicare and Medicaid Services form CMS-20089, dated 2/2017, documents multi-dose vials which have ben opened or accessed (e.g. needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Policy titled Storage of Medications #4 stated The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Revision date of [DATE]. Long Term Care Facility application for Medicare and Medicaid (CMS-671) signed and dated [DATE] documents a total of 39 residents residing in the facility.

Based on observation and interview, the facility failed to provide dietary supplements to prevent weight loss and follow fluid restriction orders to prevent fluid overload for 2 (R9, R144) of 4 residents reviewed for nutrition in the sample of 22. The findings include: 1. R9's admission record documents she was admitted to the facility on [DATE]. The same admission record notes R9's diagnoses in part as heart failure, dysphagia, oral phase, unspecified dementia, moderate with other behavioral disturbances. R9's MDS (Minimum Data Set) dated 4/4/25 documents R9 has a BIMS (Brief Interview of Mental Status) of 02 which indicates R9 has severe cognitive impairment. The same MDS documents that R9 has no impairment of her upper or lower extremities, requires supervision or touching assistance for eating, has weight loss and not on a prescribed weight loss program and is on a therapeutic diet. R9's current Care Plan documents R9 has potential nutritional problem and at risk for weight loss R/T (related to) Dysphagia, Dementia with Behavioral Disturbance, Pseudobulbar Affect, Cognitive Communication Deficit, decline in ADLs Self Performance abilities, Weakness, decreased Mobility. Res (Resident) on Therapeutic Diet for Heart Health. Some of the interventions listed are: Provide, serve, and encourage supplements as ordered per physicians orders, Monitor/record/report to MD (Medical Doctor) PRN (As needed) s/sx (signs or symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. R9's Physician's orders document the following orders under Dietary- Supplements: ice cream in evening with supper- start date 5/31/25, Fortified Pudding one time a day- start date 11/13/24, whole milk one time day with breakfast- start date 3/14/25. R9 is also listed to have a snack three times a day between meals and at bedtime with an order date of 5/16/25. The same Physician's orders note R9 is on a NAS (no added salt) Regular texture, regular liquid consistency diet. On 6/11/25 at 8:45am, V9 was observed to have her glass of milk poured over her fruit loops. On 6/10/25 at 12:20pm, there was no fortified pudding on R9's lunch tray. On 6/11/25 at 12:30pm, there was no fortified pudding on R9's lunch tray. R9's lunch meal tickets dated 6/10/25 and 6/11/25 document R9 is to receive fortified pudding. On 6/12/25 at 8:40am, V9 was observed to have her glass of milk poured over her fruit loops. On 6/13/25 at 8:28am, V2 (DON/Director of Nurses) said it was her expectation that R9's milk not be poured on her cereal because you wouldn't really know how much she drank and that the supplements be given as they should. V12 also said it is her expectation that residents be given the supplements as ordered. On 6/12/25 at 2:00pm, V12 (Dietary Aide) said they get orders for supplements from the dietary manager but they currently do not have one. V12 said that V2 tells them of new orders. V12 said that supercereal and milk is given at breakfast, pudding and ice cream is usually at lunch. V12 said it was probably okay to pour the milk over the cereal and that they currently have no one on whole milk. On 6/13/25 at 8:35am, V13 (CNA/Certified Nurse Assistant) said that before today, she always poured R9's milk on her cereal and R9 didn't drink the milk left in the bowl. On 6/13/25 at 9:45am, V14 (RD/Registered Dietician) said that R9 had a significant weight loss of 10.8% over 3 months. V14 said she would expect that R9 get her fortified pudding at lunch. V13 also said technically by the order she did get the whole milk at breakfast. V13 then said she would have staff give her 2- 4 oz (ounce) cups of milk, 1 for the cereal and 1 to drink. Facility document labeled Food and Nutrition Services (revised October 2017) notes that meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the Resident's medication requirements. 2. R144's admission record documents she was admitted to the facility on [DATE]. The same admission Record lists some of R144's diagnoses as ventricular tachycardia, long term use of anticoagulants, Type 2 Diabetes Mellitus without complications, malignant neoplasm of unspecified site of left female breast. R144's Physician's Order Summary document on 5/30/25 an order for 1800 ml (milliliter) Fluid Restriction-Dietary 360 ml per meal, Nursing 630 ml a day. R144's diet card documents an 1800 ml/24hr Fld (Fluid) Restriction for each meal. R144's care plan document initiated 6/2/25 that R144 is at risk for fluid imbalance/weight fluctuations R/T CHF(Congestive Heart Failure) , 1800ml/24hr Fld Restriction, recent hospitalization after fall at home, Weakness, Decreased Mobility, Decline in ADLs Self Performance Abilities, Previous R) Rotator Cuff Injury. Some of the interventions listed are, Diet as ordered per physician's order, 1800ml/24hf Fld Restriction. (Date Initiated: 06/02/2025), Encourage oral intake (Date Initiated: 06/02/2025), Establish food preference. An undated cup list provided by the facility documents: juice cup: 4oz/120cc, water cup: 8oz/240cc, coffee cup: 8oz/240cc, milk cup: 12oz/360cc, sweet tea cup: 12oz/360cc, unsweet tea cup: 12oz/360cc. On 6/12/25 at 12:15pm, R144 was observed to have a glass of tea, small glass of water, cup of milk with only about 1/4 left in cup. According to the cup list provided R144 was given 960cc of liquids. On 6/12/25 at 12:15pm, R144 who was alert to person, place and time said she just does not drink the extra fluids they give her. On 6/13/25 at 8:10am, R144 was observed to have cup of coffee, glass of milk and small cup of juice. According to the cup list provided R144 was given 720 cc of liquids. On 6/12/25 at 1:30pm, V3 (Cook) said she didn't know anything about the fluid restrictions and does not know if anyone is on one. On 6/13/25 at 8:28am, V2 (DON) said that R144 is on a fluid restriction and she told dietary the amount R144 gets with meals. V2 said her expectation would be that residents get there fluid restrictions as ordered. V2 also said she does random checks to make sure residents are getting them. On 6/13/25 at 9:45am, V14 (RD) said the order in the chart does not specify the amount for dietary. After informing V14 that the order was in there yesterday, she said that she got the order changed last night and she is going to calculate the amount for dietary and nursing. V14 also said she is going to speak with R144 to get her preferences and set up the restriction on that. V14 said she also will inservice the dietary staff on fluid restrictions. Document labeled Encouraging and Restricting Fluids (Revised October 2010) document the The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluid. The same document also notes Follow specific instructions concerning fluid intake or restrictions.

Based on observation, interview and record review the facility failed to allow freedom of visitation at any time. This has the potential to affect all 22 residents residing at the facility. Findings include: On 08/14/23 sign posted on the entrance door stating, visiting hours 8:00 AM - 5:00 PM with no visitation during lunch 12:00 -1:00 PM. The resident admission packet includes a document titled, Resident Rules and Regulations documents: Visiting Hours: Regular visiting hours for the facility have been established and posted. The facility reserves the right to limit any or all visitors. Relatives or guardians and clergy, if requested by the resident or family, will be allowed to see critically ill residents at any time in keeping with the orders of the physician. Visitation outside of posted visiting hours may be arranged with prior notification to the facility administrator or Social Services Designee. On 08/17/23 at 11:20 AM, V9 (Registered Nurse/RN) stated they discourage visitation during lunch (12:00 PM - 1:00 PM) and dinner (at 5:30 PM). V9 stated, there is a sign on the door that states the visiting hours. If the visitor really wanted to visit during those hours, she guesses arrangements could be made. On 08/17/23 at 11:23 AM, V11 (Certified Nurse Aide) stated there is a sign on the door that states the visiting hours are between 8:00 AM and 5:00 PM with no visitation between 12:00 PM and 1:00 PM. On 08/15/23 at 11:20 AM during the resident council meeting, R1, R9, R15, R27, and R29 stated, visitors are not supposed to come in and eat with them, there is a sign on the door that states the visiting hours are between 8:00 AM and 5:00 PM with no visitation between 12:00 PM and 1:00 PM. On 08/17/23 at 2:10 PM, V1 (Administrator) stated people are allowed to visit whenever the sign on the front door with visiting hours says on it. The nurses put the sign back up after the new Covid-19 protocol V1 didn't notice it. V1 does not know why the nurse stated they discourage visitation during lunch or meals. The Resident Census and Conditions of Residents Form dated 08/14/23 documents there are currently 22 residents residing at the facility.

Based on interview and record review, the facility failed to notify the physician of changes in a resident's weight for one resident of 4 residents (R31) reviewed for physician notification in a sample of 22. Findings Include: R31's Face Sheet documents R31 is an [AGE] year-old female resident with an admittance date of 10/10/17. R31's Face Sheet documents diagnosis including: Cerebrovascular disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic neuropathy, Edema, Arthropathy, Essential hypertension, Dysphagia, Acute upper respiratory infection, Iron Deficiency anemia, and Barrett's esophagus without dysplasia. R31's Physician Order Sheet documents an order for Metformin tablet 1000 mg (milligrams) twice a day with a start date of 04/04/2021 and a discontinued date of 04/26/23. R31's Physician Order Sheet documents an order for Torsemide tablet 10 mg, for a diagnosis of fluid retention, one time per day with a start date of 12/29/2021 and a discontinued date of 04/26/23. R31's Physician Order Sheet documents an order for Torsemide tablet 20 mg, for a diagnosis of fluid retention, one time per day with a start date of 12/29/2021 and a discontinued date of 04/26/23. R31's progress notes document on 04/27/23 at 11:08 AM, V8 (Medical Director) was at the facility doing rounds on 04/26/23, V8 discontinued R31's order for Metformin, Torsemide and Colace and initiated daily weights for 5 days to monitor fluid retention, no swelling noted at this time. The facility document dated 04/27/23 - 08/16/23 titled, Vitals Report documents: on 04/27/23 at 6:59 PM R31's weight was 113.8 pounds and on 04/28/23 at 1:48 PM 116.6 pounds. On 05/01/23 at 1:37 PM R31 had a weight of 115.6 pounds. On 05/08/23 at 9:36 AM R31 had a weight of 120.4 pounds. On 08/16/23 at 1:12 PM, V2 (Director of Nursing/DON) stated the order from V8 (Medical Director) was to monitor R31's weight for 5 days. V2 stated he would have no expectation to monitor any longer than what V8 ordered. When V2 was asked if V8 was notified of the weight gain R31 had between 4/27 and 4/28 V2 stated, no. V2 said the order stated to only monitor. When V2 was asked if V8 was notified of the 7 pound weight gain in the week of 5/1 to 5/8 V2 stated they (the facility) did not notify the doctor because that would be outside the parameters V8 specified. On 08/17/23 at 1:45 PM, V8 (Medical Director) stated, he discontinued R31's metformin and Torsemide because she was dehydrated and was not eating well. He was wanting her to gain some weight. He ask for them to monitor her weight for 5 days for fluid retention, but did not set any parameters because R31 was a smaller lady. V8 would not state whether he would expect them to notify him or not of the 2.8-pound weight gain the next day or the 7 pound weight gain 11 days later.

Based on observation, interview, and record review the facility failed to ensure restorative programs were implemented for 1 of 8 (R25) residents reviewed for restorative care in the sample of 22. Findings Include: R25's Face Sheet with a print date of 8/17/23 documents R25 was admitted to the facility on [DATE] with diagnoses that include Stage 3 pressure ulcer left hip, spondylosis, osteoarthrosis of spine, dementia, mood disturbance, and cognitive communication deficit. R25's Minimum Data Set (MDS) dated [DATE] documents R25 has a severe cognitive impairment. This same MDS documents under Section G, R25 is totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. R25's Care Plan dated 6/28/23 documents a problem area with a start date of 4/8/23, Category: ADL's (activities of daily living) Functional Status/Rehabilitation Potential Res (resident) needs PROM (passive range of motion) Restorative Program r/t (related to) at risk for developing an impairment in functional joint ability R/T recent decline in ADL's self-performance abilities, weakness, Decreased Mobility, Cognitive Communication Deficit, Dementia, Contracture BUE/BLE (bilateral upper extremity/bilateral lower extremity). The interventions with approach dates of 4/8/23, documented for this same problem area include, .Assist to move through tol (tolerated) range, supporting joints above et (and) below all major joints BID (twice daily) x (times) 7 days per week Evaluate and tx (treat) discomfort as needed . Gradually decrease assistance as tol to encourage progress to AAROM (active assisted range of motion) .Refer res (R25) to therapy as needed Report any declines in ROM abilities Reposition res (R25) for comfort at end of session . R25's Physician Order Report dated 8/1/23 to 8/17/23, documents the following physician order with a start date of 4/8/23, PROM (passive range of motion) to all major joints BID (twice daily) 7 days/wk (week) as tolerated . R25's Point of Care Restorative Nursing Category Report dated 8/17/23 documents no restorative programs were documented as administered for the following dates, 7/11-7/15, 7/17- 7/24, 7/26, 7/28- 7/30, 8/2-8/16/23. The report documents passive range of motion was provided for five minutes on 7/16, 7/25, 7/27, and 8/1/23 and for 15 minutes on 7/31/23. On 8/16/23 at 4:23 PM, R25 was observed while V5 (Licensed Practical Nurse/LPN) was administering treatments to the pressure ulcer located on R25's left hip. During this observation, R25 did not independently move his lower extremities. R25's legs were contracted at the knees with approximately a few inches of movement. V2 (Director of Nurses) who was present for this observation stated, R25 had the contractures when he was admitted to the facility. On 08/17/23 at 9:43 AM, V11 (Certified Nursing Assistant/CNA) was observed assisting R25 with passive range of motion. V2 (DON) was present during this observation. V11 was assisting R25 with upper extremity passive range of motion when V2 asked this surveyor if there was anything specific I was wanting to see. This surveyor explained I needed to see the restorative programs but also needed to see the restorative programs for R25's lower extremities. V2 stated R25 has been that way since he was admitted to the facility and R25 grimaces when they do lower extremity restoratives so they don't really do them. This surveyor asked V11 (CNA) if she did any restoratives with R25's lower extremities during activities of daily living. V11 stated she did with R25's upper extremities but R25 didn't really move his lower extremities. When asked how she assisted R25 with putting his pants on, V11 stated she was able to get R25's legs apart far enough to slide his pants on. Throughout this observation, R25 was lying in bed with his legs partially drawn up, with the left leg on top of the right leg. This is the same position R25 was observed in during the observation on 8/16/23 at 4:23 PM. The facility Restorative Nursing Programs policy dated 2021 documents, Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level 2. Nursing personnel are trained on basic, or maintenance nursing care that does not requires the use of a qualified therapist or licensed nurse oversight. This training may include but is not limited to: a. Maintaining proper positioning and body alignment. b. Encouraging and assisting residents, as needed, in turning and position changes. c. Encouraging residents to remain active and assisting with any exercises according to the plan of care .f. Assisting residents with range of motion exercises, performing passive range of motion for residents who lack active range of motion ability .4. All residents will receive maintenance nursing services as described above, as needed, by certified nursing assistants. 5. The Restorative Nurse and restorative aides receive additional training on restorative nursing program activities upon hire and as needed .

Based on interview, record review, and observation the facility failed to ensure staff provided urinary catheter care and performed hand hygiene per current standards of practice for 2 of 3 (R23 and R28) residents reviewed for catheter care in the sample of 22. Findings Include: 1. R23's Face Sheet with a print date of 08/17/23 documents R23 was admitted to the facility on [DATE] with diagnoses that include orchiectomy, congestive heart failure, acute kidney failure, benign prostatic hyperplasia (BPH), urinary retention, obstructive and reflux uropathy, and history of urinary tract infection. R23's MDS (Minimum Data Set) dated 6/9/23 documents a BIMS (Brief Interview for Mental Status) score of 09, which indicates R23 has a moderate cognitive deficit. R23's current Care Plan dated 4/18/23 documents a problem area with a start date of 12/10/2019 of, Category: Indwelling Catheter, (R23) requires an indwelling urinary catheter R/T (related to) DX (diagnosis) of Urinary Retention, Neurogenic Bladder, Bladder Spasms, Obstructive Uropathy, et (and) BPH. The interventions (Approaches) documented for this problem area include; provide catheter care every shift and as needed, report urinary tract infection signs/symptoms, administer medications as ordered, store collection bag inside protective dignity pouch, and use a catheter strap. On 08/16/23 at 2:52 PM, V10 (CNA/Certified Nursing Assistant) was observed providing catheter care to R23, with V2 (Director of Nurses/DON) present for the observation. V10 donned gloves and used a no rinse wipe to clean R23's groin area. V10 used a clean wipe to wipe around the tip of R25's penis near the catheter insertion site. V10 did not pull R25's foreskin back and clean under/around the foreskin. V10 used a clean wipe to wipe down the catheter tube from the insertion site. V10 wiped up and down the catheter tubing three to four times, wiping to and from the insertion site. V10 doffed her gloves and donned clean gloves and used a dry washcloth to dry the areas. V10 doffed her gloves and donned clean gloves and covered V10 up with a clean sheet. V10 did not hand sanitize between glove changes. At 2:58 PM on this same date, V10 stated she normally would use hand sanitizer between glove changes but she was nervous and forgot. On 08/16/23 at 2:59 PM, when asked if he observed V10 cleaning the catheter tube to and from the insertion site, V2 (DON) stated, Well, you are supposed to go from the insertion site down, but she cleaned the tube so that is all I have to say. 2. R28's Resident Face Sheet with a print date of 8/17/23 documents R28 was admitted to the facility on [DATE] with diagnoses that include Parkinson's disease, heart disease, diabetes, chronic kidney disease, benign prostatic hyperplasia, and obstructive and reflux uropathy. R28's MDS dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 07, which indicates R28 has a severe cognitive deficit. R28's Care Plan dated 6/27/23 documents a Problem area with a start date of 6/8/23 of, Res (R28) admitted from hospital with an indwelling urinary catheter R/T (related to) Hospice Care, decline in health condition et (and) ADL's (activities of daily living) self-performance, weakness, decreased mobility. This problem area documents interventions that include avoid lying (R28) on top of tubing, avoid obstructions in the drainage, change catheter bag every week and as needed, change catheter every month and as needed, position bag below the level of the bladder, report signs/symptoms of UTI (urinary tract infection), and provide catheter care every shift and as needed. On 08/16/23 at 3:50 PM, V7 (CNA) was observed providing catheter care to R28 with V2 (DON) present. V7 used no rinse wipes to clean down both sides of R28's groin then used a clean wipe to wipe around the foreskin that was covering the head of the penis, without pulling the foreskin back to clean the head of the penis. V7 then used a clean wipe to wipe down the catheter tubing. When asked if that was the way she would normally clean the penis, V7 didn't respond. When asked if she should have pulled the foreskin back and cleaned the head of the penis, V7 stated she should have done that. V7 then pulled the foreskin back and cleaned the head of the penis with a clean wipe. The facility Hand Hygiene policy dated 2022 documents, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility Additional Considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves The facility Catheter Care policy dated 2021 documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel Male: 14. Gently grasp penis, draw foreskin back if applicable. 15. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap)/non-rinse cleansing cloth. 16. With a new cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. 17. With a new cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. 18. Dry area with towel

Based on interview and record review the facility failed to protect a resident from neglect when they failed to recognize a significant decline in condition and accurately assess, treat, and seek progressive emergent treatment in a timely manner for 1 (R1) of 6 residents reviewed for neglect in a sample of 6. These failures resulted in R1 being transferred to a local hospital on [DATE], and R1's subsequent death from cardiopulmonary arrest due to or as a consequence of probable gastrointestinal hemorrhage. These failures resulted in an Immediate Jeopardy, which was identified to have begun on [DATE], when the facility failed to recognize a significant decline in condition and seek timely emergent medical treatment. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 12:35 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet documented an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure (CHF), hypertensive heart disease, dementia, weakness, ataxic gait, muscle weakness, cellulitis of right lower limb, Vitamin D deficiency, and chronic kidney disease stage 3. R1's [DATE] Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact. R1's Care Plan dated [DATE] includes - Problem Start Date: [DATE]. Category: Psychosocial Well-Being. Resident chooses to be a Do Not Resuscitate. Long Term Goal Target Date: [DATE]. Resident will inform staff of changes to advance directive. Approach Start Date: [DATE]. Code status available for facility staff members. Will follow resident wish and will not attempt to resuscitate. Will review quarterly, annually or with significant change MDS's. Problem Start Date: [DATE]. Category: ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential. Res (resident) has Dx (diagnoses) of COPD, CHF, et HTN (and hypertension). Long Term Goal Target Date: [DATE]. Resident will maintain vital signs within normal limits, perform activities of daily living, and participate in desired activities without evidence of fatigue and/or weakness, breath sounds clear, vital signs within acceptable range, stable weight, no edema. Approach Start Date of [DATE] includes: Maintain a sitting/semi-fowler positioning, 1:1 (one on one) relaxation techniques, breathing exercises, redirection, O2 (oxygen) , Nebs (nebulizer), Inhalers etc. (other similar things) .as needed during episodes of severe shortness of breath .Monitor and report signs of respiratory distress: (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds) .Monitor for tachycardia, dyspnea, sweating, pale skin color with activity, E.g. (example given); walking, dressing, bathing .Obtain Diagnostic Tests/Labs per MD (medical doctor) orders et (and) notify of abnormalities . R1's record includes a progress note dated [DATE] at 6:36 PM by V10 (Registered Nurse - RN) that documents, Resident noted to have 104 temp (temperature) axillary. PRN (as needed) Tylenol given suppository. NP (V2 - Advanced Practice Registered Nurse/APRN and Director of Nursing/DON) notified. Awaiting further orders. R1's Progress Note dated [DATE] at 9:17 PM by V7 (Licensed Practical Nurse - LPN) documents, Resident resting per recliner. Temp is now 101.2. LCTA Resp E/U (lungs clear to auscultation respirations even/ unlabored). Resident is very slow to respond when spoken to, she keeps her head down while sitting in recliner. Resp are at 32. SPO2 94% (oxygen saturation, percent). R1's record under Vital Signs on [DATE] at 9:26 PM/9:27 PM by V14 (Certified Nursing Assistant/CNA) are recorded as: Blood pressure: ,d+[DATE], Respirations: 32 (alert triangle with exclamation mark noted), Pulse: 77, and O2 Sat (oxygen saturation): 94%. R1's Progress Note dated [DATE] at 2:31 AM by V7 documents, Resident (R1) had a large loose stool in recliner, on the floor and on resident from head to toe. Both hands coated slathered on fronts of thighs and in her hair. Resident was transferred to w/c (wheelchair) and to shower. Residents temp 100.9, Resp 20, Pulse 64 and regular and SPO2 94%. WCTM (will continue to monitor). Right leg remains bright red and warm to touch. R1's Progress Note dated [DATE] at 6:59 AM by V7 documents, When resident had large loose BM at 2:30 AM [DATE] the stool was thin with undigested food particles noted. Color was an orange, brown color with no noted [NAME] or occult blood. R1's Progress Note dated [DATE] at 2:40 AM by V7 documents, Resident did not speak to staff but could follow staff with eyes. Held onto w/c (wheelchair) and shower chair during transfers. Required max (maximum) assist x 2 (2 staff) with gait belt for transfer. R1's record under Vital Signs, on [DATE] at 8:24 AM and recorded by V2, document her pain is assessed as 6 out of 10 and at 11:14 AM, her temperature is 100.1. R1's Progress Note dated [DATE] at 9:39 AM by V2 (APRN/DON) documents, Resident in recliner when passing medications that resident was stupor in recliner and labored breathing. Temp of 102.9. Resident is unresponsive to verbal stimuli however is responsive to painful stimuli of sternal rubs and deep nail press. SPO2 88% on RA (room air). LCTA. Unable to arouse to eat breakfast or take medications PO (by mouth). O2 (oxygen) applied at 3L/min PNC (liters/minute per nasal cannula), Tylenol supp (suppository) given for fever. Cool wash cloths applied to forehead and groin region to decrease temp. Resident was moved to bed out of recliner to perform assessment and treatment. Resident noted with redness, swelling and warmth to RLE (right lower extremity). Cellulitis indicated and resident was given 1-gram Rocephin IM (intramuscularly) x 1 now and then will start Keflex 500 mg (milligram) po tid (three times daily) x 10 days. An Event Report Infection Control Tracker form completed by V2 documents the finding of R1's RLE cellulitis and includes Event Date: [DATE] 9:26 AM . Classification: Infection Type: Cellulitis/Soft Tissue/Wound. Surveillance Definition Met? McGreers Criteria obv (observation) performed? Yes. Reportable Infection? No. History: Symptoms: Fever, RLE erythema and swelling. Onset Date: [DATE]. Device Type: No device .Diagnostics (microbiology, other labs, radiology): Diagnostics Performed: No . Treatment: Select which provider ordered testing and treatment: (V2). Order Origin: Nursing Home. Indicate Antibiotic used. If no Antibiotic used, type N/A (not applicable): [DATE]: Rocephin 1 gram (IM) x 1 now. [DATE]: Keflex 500 mg po tid x 10 days .Other Information: Was an Event/Observation performed for the related infection? If no, reason needs explained: Yes. Transmission-based Precautions? None. Re-cultured/Assessment Date (if applicable). If yes, indicate date re-tested . NA. Any new orders from re-assessment/culture? If so, indicate new order. NA. Select which provider ordered testing and treatment. (V2) .Additional Information: RLE Cellulitis. Notifications: Attending Faxed: No. Physician Notified: No. Resident Representative Notified: No. Care Plan Reviewed: No. Vitals: Blank. The remainder of this form contains the orders and notes as documented above. R1's record under Vital Signs, on [DATE] at 11:14 AM, recorded by V2, documents R1's temperature is 100.1. There were no further recordings of vital signs or documentation of an assessment of R1 in R1's medical record until [DATE] at 3:26 PM as documented below. R1's Progress Note dated [DATE] at 3:26 PM by V2 (APRN/DON) documents POA (Power of Attorney/ V3) came to visit resident. Updated POA on current medical condition of resident. Assessed resident while POA in room and noted that resident was in acute respiratory distress. Resident currently on 3L/min PNC, temp is 102.6 prn (as needed). Tylenol supp given at this time. O2 increase to 4L/min. RLE noted to have erythema and swelling and warm to touch, anterior portion erythema has decreased slightly, posterior area unchanged. Mottling noted up to mid-thigh on BLE (bilateral lower extremities). Spoke to POA about changes in condition and explained that sepsis or AKI (acute kidney injury) could be the cause. Resident remains unresponsive to verbal stimuli only has mild responsiveness to sternal rubs. POA states that she would like resident to be evaluated at (name of hospital) however if she has a major issue that she more than likely will not want to do anything. POA chose (name of hospital) to be sent to for evaluation. (Ambulance company) notified and arrived and transferred resident to (hospital). Report was given to V12 (Physician) in the ER (emergency room ). R1's Prehospital Care Report Summary form from the ambulance company dated [DATE] documents that Emergency Medical Services (EMS) arrived at the facility at 2:57 PM after a 911 call from the facility and that R1 was found unresponsive lying-in bed guppy breathing. Staff stated PT (patient/ R1) respirations had been this way all day and they also noticed that PT has cellulitis to the right leg from the ankle to the knee . and Skin looked normal but on the back side of arms and both legs noticed PT looked like her blood was pooling. The form further states Upon arrival at ED (Emergency Department), PT respirations became worse and while cot into room PT went apneic. Ventilations initiated per ED staff. On [DATE] at 12:24 PM, V6 (Paramedic) stated he arrived at the facility on [DATE] and found R1 to be lying in bed guppy breathing and unresponsive. V6 said facility staff told him R1 had been guppy breathing like this on and off all day. V6 stated just by the way (R1) was breathing I knew she was not going to last long. V6 said the back side of R1's arms and legs had dark discoloration which looked like blood was pooling, like how blood pools in the skin at the lowest point after a person expires. V6 said R1 stopped breathing as they were going through the ED doors. R1's progress note dated [DATE] at 6:05 PM by V2 documents, Received phone call from V12 (Physician) at (hospital ER). MD (Medical Doctor) states that resident arrived at ER and coded. Attempted to intubate and noticed resident had aspirated on blood. MD states that resident had a massive GI (gastrointestinal) bleed and was DNI (do not intubate) and DNR (do not resuscitate) and resident expired in ER. V4 (Medical Director), V1 (Administrator) aware. V3 at facility when resident expired. R1's hospital ED Physician Documentation dated [DATE] at 3:38 PM by V12 documents Patient (R1) was brought in by (ambulance company) with no spontaneous respirations, but an irregular heartbeat. (R1) is DNR/ DNI. (R1) was evidencing black emesis from the mouth and she was full in both lungs of black fluid that appeared to be from a GI bleed. R1 expired fully at 3:49 PM today ([DATE]). R1's Death Certificate documents date of death was [DATE]. The Cause of Death documents: a. Cardiopulmonary Arrest, due to (or as a consequence of) b. Probable Gastrointestinal Hemorrhage. On [DATE] at 9:26 AM, V3 (POA) confirmed R1 was not receiving services of hospice or comfort care measures. V3 said she had never told the facility she did not want R1 sent to the hospital if it was medically needed. V3 said R1 was a 'Do Not Resuscitate' but V3 still expected the facility to treat R1. V3 said R1 was alert and oriented on [DATE]. R1's State of Illinois, Illinois Department of Public Health - IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form documents in Section A Cardiopulmonary Resuscitation (CPR), If patient has no pulse and is not breathing, the option of Do Not Attempt Resuscitation (DNR) is selected. Section B Medical Interventions, if patient is found with a pulse and/or is breathing the option of Comfort-Focused Treatment is selected and defined as follows: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. V3 signed R1's POLST form as her Legal Representative and V2 (APRN/DON) signed as the Authorized Practitioner and both dated [DATE]. On [DATE] at 10:31 AM, V2 (APRN/DON) said he assessed R1 on [DATE] in the morning and found R1 was unresponsive and was transferred from the recliner to bed. V2 said R1 was febrile and V2 ordered a Tylenol suppository, Rocephin, and Keflex. V2 said R1 was mainly unresponsive most of the day. V2 said R1's oxygen saturation dropping was not normal for R1 and oxygen was applied. V2 said he did not contact V3 (POA) because V3 had the facility number blocked so R1 could not call V3 during the night. V2 said the facility would text V3 if they needed to report any change in condition. V2 said he did not attempt to contact V3 in any way because V2 did not think R1's change in condition was serious enough to contact V3. V2 said when V3 arrived at the facility, V2 updated V3 on R1's change in condition. V2 said he asked V3 if they wanted R1 to be transferred to the hospital or if they wanted R1 to stay in the facility and keep R1 comfortable. V2 said V3 chose to send R1 to the hospital. V2 said R1 was not under hospice services and was not on comfort care. When V2 was asked if R1 being so unresponsive that R1 could not take medications by mouth and had to have a Tylenol suppository was concerning, V2 said the fever was concerning, that is why I was treating her. On [DATE] at 10:25 AM, a follow-up interview was conducted with V3 (POA). V3 was asked to recount and confirm the events on [DATE] regarding R1. V3 stated she was there that day because the grandkids had sent some pictures and she wanted to put them in frames and do some decorating in R1's room. V3 added that the whole family had just been in the facility on Easter Sunday ([DATE]) and ate dinner together with R1. V3 stated, My brother and everyone got to see her, so everyone saw her in great condition and she was able to visit. She was perfectly cognitive that Sunday. V3 continued that when she arrived in the facility on the afternoon of [DATE], V2 caught her up on what had been happening with R1 from the night before and wanted to prepare her. When this surveyor asked what that meant, V3 stated she was not sure exactly what he meant. V3 stated V2 told her it had been a couple of hours since he had last checked on R1 so they both had gone to her room at that time. V3 stated she felt blindsided. V3 said that R1 was not in her regular room, but in another room across the hall. V3 stated she observed R1 lying flat in a bed with no oxygen on her nose, nor did she observe any oxygen in the room. V3 stated, I don't know how long (R1) had been lying in bed, but (V2) just said the night before she had run a fever, was still running a fever that day, and had been given a shot and antibiotic. (R1) did not have a bed in her regular room because she sleeps in a recliner because of her COPD. She had slept in a chair forever. (R1) was observed to be non-responsive, so V2 tried doing a sternal rub. (R1) did not respond. V2 looked at R1's legs and he saw the mottling in her lower legs and told me 'that concerned him'. V3 stated that V2 told her, It just has me baffled. I don't know what more to do because most of her vital signs were good. V3 stated that it was not clear to V2 what he was dealing with, and at that point V3 said, I think we need to send her to the hospital and that maybe it was something an IV could take care of. If it was not something the ER could stabilize, I would have gone from there and discussed comfort care if nothing else would have worked at that time. When asked if she had spoken to the hospital yet, she (V3) stated, Not really, I was told she had passed in the ambulance. She had thrown up some black tarry vomit and had a major gastric bleed. The ER doctor did tell me that. A few years ago, she (R1) was in another hospital for a gastric bleed. That was another thing that raised questions for me because she had COPD and a history of gastric bleed, and I didn't receive a phone call from anyone in the facility prior to me walking in on [DATE]. When asked if V3 had any of her phone numbers blocked so the facility would be unable to contact her, V3 stated, I did not have my phone off and my phone number is not blocked to receive calls from the facility. A lot of times I may not hear the ringer or may not have my phone on me but if I had missed a call, I'd have seen that and would have called back immediately. I have missed calls before and I always return their call. I have phone records to show there were no missed calls from the facility on [DATE] or [DATE]. When asked about receiving texts, V3 stated she had received texts in the past from V2. On [DATE] at 9:50 AM, V4 (Medical Director/Physician) said if a resident was found to be febrile, unresponsive to verbal stimuli, and have labored breathing with an oxygen saturation in the 80's he expected the facility would contact V4. V4 said if it is a serious problem the resident should be transferred to the hospital. V4 said he expected the facility to notify a resident's POA with any change in condition. V4 said it is possible if R1 was transferred to the hospital six hours earlier, when symptom onset began, R1 may not have expired. On [DATE] at 3:24 PM, V4 was contacted for a second interview. V4 stated that a resident's condition certainly changes, and they should be taken care of appropriately. Sometimes the patient and the family change their mind or direction they are going when they sign the POLST originally, but there should be a clear understanding from the patient and family of what treatment they want. When asked if DNR meant do not treat, V4 confirmed it means, Do Not Resuscitate, adding the patient should always be taken care of regarding their symptoms or whatever is happening. When asked if on [DATE], the emergency room could have provided any further or different treatment than R1 had already been provided at the facility, V4 stated when you go to the hospital, they do everything so they can find out what is going on. An additional document with the State of Illinois, Illinois Department of Public Health seal titled Illinois Statutory Short Form Power of Attorney for Health Care documents that R1 wants (V3) to be her health care agent. The form further documents, I authorize my agent to with the box checked Make decisions for me starting now and continue after I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to. Under Life-Sustaining Treatments documents, in part . In general, in making decisions concerning life-sustaining treatment, your agent is instructed to consider the relief of suffering, the quality as well as the possible extension of your life, and your previously expressed wishes. Your agent will weigh the burdens versus benefits of proposed treatments in making decisions on your behalf. On [DATE] at 3:05 PM, V2 (APRN/DON), V9 (Chief Executive Officer/CEO), and V1 (Administrator) entered the conference room where this surveyor was working. V2 again stated he had not been given the chance to report the events that transpired throughout the day on [DATE] regarding R1's condition. V2 was asked if he had any new information he would like to provide at this time. V2 stated when he got to R1's room on [DATE] to pass medication at approximately 7:30 AM, she was sitting up in her recliner with her chin down to her chest. V2 stated he did notice she looked uncomfortable at that time stating R1 was stupor and not as alert. V2 stated, I did a sternal rub on her. She did wake up and look at me. Then, I asked her if she was hurting. She did not respond to that. At that point, we moved her from the recliner to the bed in a room across the hall. V2 stated once R1 was in bed her vital signs were checked. R1's oxygen saturation was about ,d+[DATE]%, so she was placed on oxygen via nasal cannula at 2 liters and the head of her bed was elevated to 45 degrees. V2 stated, While I was in there, I assessed her by listening to her lungs which were clear and I checked her skin. I did see that her right lower extremity had some redness, swelling, and was warm to the touch and she had a fever of 102 degrees. V2 stated at that point he gave R1 a Tylenol suppository and an injection of Rocephin. V2 stated he placed cool wash clothes on her forehead, armpits, and groin and from there made the decision not to give her any oral intake due to the risk of aspiration. V2 stated R1 was peaceful and comfortable at this time. V2 stated that after R1 was settled, he went to the nursing station and continued with nursing duties. He did attempt to call R1's POA (V3) but it only rang once and the call was disconnected. V2 stated normally if she saw we called, she would call back or come in. V2 stated, It could be minutes, hours, or days before you would get a response. V2 stated at 9:30 AM, he checked on R1 again, removed the wash cloths, but did not check her temperature because it would not have given a correct reading. V2 stated R1 had no rapid breathing, nothing appeared abnormal, and R1 displayed no signs or symptoms of pain. V2 stated he did not attempt to wake R1 at that time opting to let her rest. V2 stated that he went back at 11:00 AM, rechecked her temperature and it was 101 degrees. He did try to wake her by speaking to her but she did not wake up. V2 stated he did another sternal rub and R1 did wake up, open her eyes, and groaned slightly. V2 stated R1's lungs were still clear at that time, she had no symptoms of respiratory distress, and her color was good. V2 stated he asked the CNAs if they would attempt to feed her at lunch and they reported back to him that R1 did not eat lunch. V2 stated the CNAs checked on R1 around noon, then V2 went back down around 2:30 PM when V3 showed up to visit R1. V2 stated he assessed R1 with V3 present, and her fever was 102 degrees. V2 stated he administered another Tylenol suppository and explained that R1 had cellulitis that could be causing the fever. V2 stated V3 tried to wake R1 up herself by repeating her name and when she did that, R1 started breathing heavier and more labored than what she had been previously. V2 stated he explained the options of keeping R1 in the facility would be to keep her comfortable, pain free, and without respiratory distress or they could send her to the ER and see if there was anything else that was going on they might be able to fix. V2 stated, V3 asked him what he thought, and he told V3 it was her decision, and that V2 could do either. V2 stated, I could start her on Morphine/Ativan or send her to the hospital. V3 then asked which hospital she should go to. V2 again told V3 that was her decision. V2 stated R1 did not appear critical at that time, so it was up to V3. V2 stated that V3 opted to send R1 to the hospital, claiming that the family would be mad at her if she didn't send R1 to the hospital. V2 stated V3 then said if they find anything serious, she was not going to do anything. V2 then told V3 he would call EMS and have her sent. V2 stated V3 asked him if she had to be there and he again told V3 that it was up to her but he would give report to the ER. V2 stated V3 left at that time, EMS arrived and did not do an in-room assessment - just got report from him. V2 stated, R1 was loaded on the stretcher and was in their hands after that. V2 stated he gave report to V12 in the ER. V12 called back about an hour later and explained to V2 that R1 had passed .that she coded when she came through the ER doors, (V12) attempted to intubate but saw what appeared to be aspiration of blood and assumed she had a massive GI bleed. They witnessed the POLST form DNR and did not proceed with intubation nor any further treatment. On [DATE] at 3:30 PM, V9 (Chief Executive Officer/CEO/Social Services) stated V3 came by the next day to get R1's belongings and praised the facility for the care of R1. V9 had with him the IDPH printout titled, Guidance Document for Illinois Health Care Professionals and Providers - Illinois Department of Public Health (IDPH) Uniform Practitioner Orders for Life-Sustaining Treatment and stated he wanted to go over the parts he highlighted. V9 then read from Page 2 of this document - healthcare professionals and institutional providers are legally protected from liability if, in good faith they honor the instructions contained in the POLST form . V9 stated, Which is exactly what we did. V9 stated R1's POLST indicated she was comfort focused treatment. V9 stated, This is the big one, and read the following from the document - Transfer to hospital only if comfort cannot be achieved in the comfort setting . V9 stated, We were going by what was on her POLST .I think we were within our guidelines and it's cut and dry we were following the resident's wishes. V9 read, POLST portable medical orders form, signed by the patient's qualified healthcare practitioner and either the patient or their legal representative, converts the patient's care choices into an actionable medical order that all other physicians, nurse practitioners, physicians assistants, long-term care facilities, hospices, home health agencies, emergency medical services, hospital staff, and other provider staff are required by law to honor . V9 also read, .the POLST model allows individuals to specify the intensity of medical interventions when they experience a life-threatening emergency where they still have a pulse. On [DATE] at 3:45 PM, V2 stated he believes the facility did everything as they should have and provided the care and comfort to R1 she required prior to her being transferred to theER on [DATE]. When asked if V2 had anything else he would like to add to his interview, he stated, I stand beside the treatment R1 received in the facility on [DATE] and [DATE]. If I had to do it over, I would do the same thing. I wouldn't change anything. An email correspondence from V1 (Administrator) dated [DATE] at 1:43pm documents that (V2) is a full practice NP (Nurse Practitioner) in response to the question if V2 has a collaborating agreement with a physician or if V2 has a full practice authority license. This email also contained V2's license that documents Full Practice Authority APRN. The facility's [DATE] Notification of Changes in Condition policy documented in part . The facility must inform . the resident's family member or legal representative when there is a change requiring such notification. Circumstance requiring notification include: 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . 3. Circumstances that require a need to alter treatment . According to https://www.polstil.org/resources-for-healthcare-providers/, the Guidance Document for Healthcare Professionals documents the following in part . POLST stands for 'Practitioner Orders for Life-Sustaining Treatment.' A POLST form is a signed medical order that travels with the patient to assure that a patient's treatment preferences are honored across settings of care. The POLST form is designed to ensure that seriously ill or frail patients can choose the treatments they want or do not want and that their wishes are documented and honored Use of the POLST form is voluntary. This form contains orders that can be revoked or changed at any time by patients or their legal representative When a patient's condition changes significantly, prior decisions about treatment should be revisited and consideration should be given to completing a new, updated POLST form. On [DATE] at 8:23 AM, V15 (LPN) stated prior to R1's fever the evening of [DATE], she did not appear to have anything going on. V15 stated, It seemed like it came out of nowhere. It seemed like it happened very quickly. V15 stated R1 would propel through the facility in her wheelchair but did stay in her room quite a bit. She was not able to ambulate or stand/transfer on her own but once she was in the wheelchair she could propel independently where she wanted to go. On [DATE] at 9:07 AM, V16 (CNA) and V8 (CNA) both stated normally R1 was awake and alert but sometimes she would get sleepy and tell us she just wanted to sleep. She had a habit of staying up at night sometimes and going through the drawers/packing her things to go home. V16 stated they would have to check the schedule but the last time they worked, R1 was fine. V8 stated the last time she worked and saw R1 was on [DATE] between 6:30 AM and 3:00 PM. V8 stated R1 had a shower that day and was tired after and wanted to sleep. V8 stated R1 slept in her recliner. V8 stated she did work the same shift on [DATE] but was not really involved with R1's care that day. However, there was nothing observed that would have given an indication R1 needed to be sent out to the hospital. She just knows she was sent out to the hospital and was surprised to hear she passed away. On [DATE] at 11:03 AM, V10 (RN) stated she did work on [DATE] from 2:30 PM to 7:00 PM. V10 was asked about R1's condition that day. V10 stated, I remember she started running a fever when I was getting ready to leave between 6:15 PM and 6:30 PM that evening. I gave her a Tylenol suppository and called (V2/APRN) to report the fever and lethargy and he said he would follow-up with (R1) the next morning. V10 stated R1 had episodes of lethargy in the past where she would look at you but would not speak. V10 reported they sent R1 to the hospital for a similar episode in the past and R1 told the hospital staff she just didn't want to talk to us and wanted to be left alone so she could sleep. V10 confirmed on [DATE], R1 did have redness to her legs, however, R1 had intermittent edema/cellulitis in her legs in the past that had been treated with steroid creams and wraps/socks. At times, it was cellulitis, but R1 did have chronic dermatitis. V10 stated, It was not too alarming at that point. I gave the night nurse the report and asked her to monitor R1. At that point, she just had a fever and was not verbalizing, so I thought it was like her past behavior. On [DATE] at 11:27 AM, V7 (LPN) stated it was normal for R1 to be incontinent. When asked about the events of her shift on [DATE], V7 stated, On [DATE], she did not want to get up and get in the shower, but she had been incontinent and had feces everywhere. She would not talk to us; she would glare at us and hold on for dear life to anything she could get a hold of. She would do the same thing to the CNAs in the past when they tried to get her up if she had been incontinent in her recliner through the night. V7 stated that R1 had been running a fever earlier in the day on [DATE] and received report it was coming down. V7 stated she kept checking R1's temperature and it was going down. V7 stated there was really no change in R1's condition from when she arrived to when her shift ended on [DATE], and there was nothing to make her think R1 should expire the next day. V7 stated that other than R1's leg being red, there was nothing different at all. R1 sat in her recliner with her head on her chest like she did every night. V2 was treating the redness to the leg with the Rocephin injection and antibiotic. V7 stated, I had been in contact with (V2) through the night regarding (R1's) condition and temperature. V7 stated V2 continued to monitor R1's temperature as it was coming down. V7 stated R1's biggest issue was the high temperature while V10 (RN) was there. On [DATE] at 11: [TRUNCATED]

Based on interview and record review, the facility failed to recognize a significant decline in condition and accurately assess, treat, and seek progressive emergent treatment in a timely manner for 1 (R1) of 6 residents reviewed for change in condition in a sample of 6. These failures resulted in R1 being transferred to a local hospital on [DATE], and R1's subsequent death from cardiopulmonary arrest due to or as a consequence of a probable gastrointestinal hemorrhage. These failures resulted in an Immediate Jeopardy, which was identified to have begun on [DATE], when the facility failed to recognize a significant decline in condition and seek timely emergent medical treatment. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 12:35 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet documented an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure (CHF), hypertensive heart disease, dementia, weakness, ataxic gait, muscle weakness, cellulitis of right lower limb, Vitamin D deficiency, and chronic kidney disease stage 3. R1's [DATE] Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact. R1's Care Plan dated [DATE] includes - Problem Start Date: [DATE]. Category: Psychosocial Well-Being. Resident chooses to be a Do Not Resuscitate. Long Term Goal Target Date: [DATE]. Resident will inform staff of changes to advance directive. Approach Start Date: [DATE]. Code status available for facility staff members. Will follow resident wish and will not attempt to resuscitate. Will review quarterly, annually or with significant change MDS's. Problem Start Date: [DATE]. Category: ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential. Res (resident) has Dx (diagnoses) of COPD, CHF, et HTN (and hypertension). Long Term Goal Target Date: [DATE]. Resident will maintain vital signs within normal limits, perform activities of daily living, and participate in desired activities without evidence of fatigue and/or weakness, breath sounds clear, vital signs within acceptable range, stable weight, no edema. Approach Start Date of [DATE] includes: Maintain a sitting/semi-fowler positioning, 1:1 (one on one) relaxation techniques, breathing exercises, redirection, O2 (oxygen) , Nebs (nebulizer), Inhalers etc. (other similar things) .as needed during episodes of severe shortness of breath .Monitor and report signs of respiratory distress: (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds) .Monitor for tachycardia, dyspnea, sweating, pale skin color with activity, E.g. (example given); walking, dressing, bathing .Obtain Diagnostic Tests/Labs per MD (medical doctor) orders et (and) notify of abnormalities . R1's record includes a progress note dated [DATE] at 6:36 PM by V10 (Registered Nurse - RN) that documents, Resident noted to have 104 temp (temperature) axillary. PRN (as needed) Tylenol given suppository. NP (V2 - Advanced Practice Registered Nurse/APRN and Director of Nursing/DON) notified. Awaiting further orders. R1's Progress Note dated [DATE] at 9:17 PM by V7 (Licensed Practical Nurse - LPN) documents, Resident resting per recliner. Temp is now 101.2. LCTA Resp E/U (lungs clear to auscultation respirations even/ unlabored). Resident is very slow to respond when spoken to, she keeps her head down while sitting in recliner. Resp are at 32. SPO2 94% (oxygen saturation, percent). R1's record under Vital Signs on [DATE] at 9:26 PM/9:27 PM by V14 (Certified Nursing Assistant/CNA) are recorded as: Blood pressure: ,d+[DATE], Respirations: 32 (alert triangle with exclamation mark noted), Pulse: 77, and O2 Sat (oxygen saturation): 94%. R1's Progress Note dated [DATE] at 2:31 AM by V7 documents, Resident (R1) had a large loose stool in recliner, on the floor and on resident from head to toe. Both hands coated slathered on fronts of thighs and in her hair. Resident was transferred to w/c (wheelchair) and to shower. Residents temp 100.9, Resp 20, Pulse 64 and regular and SPO2 94%. WCTM (will continue to monitor). Right leg remains bright red and warm to touch. R1's Progress Note dated [DATE] at 6:59 AM by V7 documents, When resident had large loose BM at 2:30 AM [DATE] the stool was thin with undigested food particles noted. Color was an orange, brown color with no noted [NAME] or occult blood. R1's Progress Note dated [DATE] at 2:40 AM by V7 documents, Resident did not speak to staff but could follow staff with eyes. Held onto w/c (wheelchair) and shower chair during transfers. Required max (maximum) assist x 2 (2 staff) with gait belt for transfer. R1's record under Vital Signs, on [DATE] at 8:24 AM and recorded by V2, document her pain is assessed as 6 out of 10 and at 11:14 AM, her temperature is 100.1. R1's Progress Note dated [DATE] at 9:39 AM by V2 (APRN/DON) documents, Resident in recliner when passing medications that resident was stupor in recliner and labored breathing. Temp of 102.9. Resident is unresponsive to verbal stimuli however is responsive to painful stimuli of sternal rubs and deep nail press. SPO2 88% on RA (room air). LCTA. Unable to arouse to eat breakfast or take medications PO (by mouth). O2 (oxygen) applied at 3L/min PNC (liters/minute per nasal cannula), Tylenol supp (suppository) given for fever. Cool wash cloths applied to forehead and groin region to decrease temp. Resident was moved to bed out of recliner to perform assessment and treatment. Resident noted with redness, swelling and warmth to RLE (right lower extremity). Cellulitis indicated and resident was given 1-gram Rocephin IM (intramuscularly) x 1 now and then will start Keflex 500 mg (milligram) po tid (three times daily) x 10 days. An Event Report Infection Control Tracker form completed by V2 documents the finding of R1's RLE cellulitis and includes Event Date: [DATE] 9:26 AM . Classification: Infection Type: Cellulitis/Soft Tissue/Wound. Surveillance Definition Met? McGreers Criteria obv (observation) performed? Yes. Reportable Infection? No. History: Symptoms: Fever, RLE erythema and swelling. Onset Date: [DATE]. Device Type: No device .Diagnostics (microbiology, other labs, radiology): Diagnostics Performed: No . Treatment: Select which provider ordered testing and treatment: (V2). Order Origin: Nursing Home. Indicate Antibiotic used. If no Antibiotic used, type N/A (not applicable): [DATE]: Rocephin 1 gram (IM) x 1 now. [DATE]: Keflex 500 mg po tid x 10 days .Other Information: Was an Event/Observation performed for the related infection? If no, reason needs explained: Yes. Transmission-based Precautions? None. Re-cultured/Assessment Date (if applicable). If yes, indicate date re-tested . NA. Any new orders from re-assessment/culture? If so, indicate new order. NA. Select which provider ordered testing and treatment. (V2) .Additional Information: RLE Cellulitis. Notifications: Attending Faxed: No. Physician Notified: No. Resident Representative Notified: No. Care Plan Reviewed: No. Vitals: Blank. The remainder of this form contains the orders and notes as documented above. R1's record under Vital Signs, on [DATE] at 11:14 AM, recorded by V2, documents R1's temperature is 100.1. There were no further recordings of vital signs or documentation of an assessment of R1 in R1's medical record until [DATE] at 3:26 PM as documented below. R1's Progress Note dated [DATE] at 3:26 PM by V2 (APRN/DON) documents POA (Power of Attorney/ V3) came to visit resident. Updated POA on current medical condition of resident. Assessed resident while POA in room and noted that resident was in acute respiratory distress. Resident currently on 3L/min PNC, temp is 102.6 prn (as needed). Tylenol supp given at this time. O2 increase to 4L/min. RLE noted to have erythema and swelling and warm to touch, anterior portion erythema has decreased slightly, posterior area unchanged. Mottling noted up to mid-thigh on BLE (bilateral lower extremities). Spoke to POA about changes in condition and explained that sepsis or AKI (acute kidney injury) could be the cause. Resident remains unresponsive to verbal stimuli only has mild responsiveness to sternal rubs. POA states that she would like resident to be evaluated at (name of hospital) however if she has a major issue that she more than likely will not want to do anything. POA chose (name of hospital) to be sent to for evaluation. (Ambulance company) notified and arrived and transferred resident to (hospital). Report was given to V12 (Physician) in the ER (emergency room ). R1's Prehospital Care Report Summary form from the ambulance company dated [DATE] documents that Emergency Medical Services (EMS) arrived at the facility at 2:57 PM after a 911 call from the facility and that R1 was found unresponsive lying-in bed guppy breathing. Staff stated PT (patient/ R1) respirations had been this way all day and they also noticed that PT has cellulitis to the right leg from the ankle to the knee . and Skin looked normal but on the back side of arms and both legs noticed PT looked like her blood was pooling. The form further states Upon arrival at ED (Emergency Department), PT respirations became worse and while cot into room PT went apneic. Ventilations initiated per ED staff. On [DATE] at 12:24 PM, V6 (Paramedic) stated he arrived at the facility on [DATE] and found R1 to be lying in bed guppy breathing and unresponsive. V6 said facility staff told him R1 had been guppy breathing like this on and off all day. V6 stated just by the way (R1) was breathing I knew she was not going to last long. V6 said the back side of R1's arms and legs had dark discoloration which looked like blood was pooling, like how blood pools in the skin at the lowest point after a person expires. V6 said R1 stopped breathing as they were going through the ED doors. R1's progress note dated [DATE] at 6:05 PM by V2 documents, Received phone call from V12 (Physician) at (hospital ER). MD (Medical Doctor) states that resident arrived at ER and coded. Attempted to intubate and noticed resident had aspirated on blood. MD states that resident had a massive GI (gastrointestinal) bleed and was DNI (do not intubate) and DNR (do not resuscitate) and resident expired in ER. V4 (Medical Director), V1 (Administrator) aware. V3 at facility when resident expired. R1's hospital ED Physician Documentation dated [DATE] at 3:38 PM by V12 documents Patient (R1) was brought in by (ambulance company) with no spontaneous respirations, but an irregular heartbeat. (R1) is DNR/ DNI. (R1) was evidencing black emesis from the mouth and she was full in both lungs of black fluid that appeared to be from a GI bleed. R1 expired fully at 3:49 PM today ([DATE]). R1's Death Certificate documents date of death was [DATE]. The Cause of Death documents: a. Cardiopulmonary Arrest, due to (or as a consequence of) b. Probable Gastrointestinal Hemorrhage. On [DATE] at 9:26 AM, V3 (POA) confirmed R1 was not receiving services of hospice or comfort care measures. V3 said she had never told the facility she did not want R1 sent to the hospital if it was medically needed. V3 said R1 was a 'Do Not Resuscitate' but V3 still expected the facility to treat R1. V3 said R1 was alert and oriented on [DATE]. R1's State of Illinois, Illinois Department of Public Health - IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form documents in Section A Cardiopulmonary Resuscitation (CPR), If patient has no pulse and is not breathing, the option of Do Not Attempt Resuscitation (DNR) is selected. Section B Medical Interventions, if patient is found with a pulse and/or is breathing the option of Comfort-Focused Treatment is selected and defined as follows: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. V3 signed R1's POLST form as her Legal Representative and V2 (APRN/DON) signed as the Authorized Practitioner and both dated [DATE]. On [DATE] at 10:31 AM, V2 (APRN/DON) said he assessed R1 on [DATE] in the morning and found R1 was unresponsive and was transferred from the recliner to bed. V2 said R1 was febrile and V2 ordered a Tylenol suppository, Rocephin, and Keflex. V2 said R1 was mainly unresponsive most of the day. V2 said R1's oxygen saturation dropping was not normal for R1 and oxygen was applied. V2 said he did not contact V3 (POA) because V3 had the facility number blocked so R1 could not call V3 during the night. V2 said the facility would text V3 if they needed to report any change in condition. V2 said he did not attempt to contact V3 in any way because V2 did not think R1's change in condition was serious enough to contact V3. V2 said when V3 arrived at the facility, V2 updated V3 on R1's change in condition. V2 said he asked V3 if they wanted R1 to be transferred to the hospital or if they wanted R1 to stay in the facility and keep R1 comfortable. V2 said V3 chose to send R1 to the hospital. V2 said R1 was not under hospice services and was not on comfort care. When V2 was asked if R1 being so unresponsive that R1 could not take medications by mouth and had to have a Tylenol suppository was concerning, V2 said the fever was concerning, that is why I was treating her. On [DATE] at 10:25 AM, a follow-up interview was conducted with V3 (POA). V3 was asked to recount and confirm the events on [DATE] regarding R1. V3 stated she was there that day because the grandkids had sent some pictures and she wanted to put them in frames and do some decorating in R1's room. V3 added that the whole family had just been in the facility on Easter Sunday ([DATE]) and ate dinner together with R1. V3 stated, My brother and everyone got to see her, so everyone saw her in great condition and she was able to visit. She was perfectly cognitive that Sunday. V3 continued that when she arrived in the facility on the afternoon of [DATE], V2 caught her up on what had been happening with R1 from the night before and wanted to prepare her. When this surveyor asked what that meant, V3 stated she was not sure exactly what he meant. V3 stated V2 told her it had been a couple of hours since he had last checked on R1 so they both had gone to her room at that time. V3 stated she felt blindsided. V3 said that R1 was not in her regular room, but in another room across the hall. V3 stated she observed R1 lying flat in a bed with no oxygen on her nose, nor did she observe any oxygen in the room. V3 stated, I don't know how long (R1) had been lying in bed, but (V2) just said the night before she had run a fever, was still running a fever that day, and had been given a shot and antibiotic. (R1) did not have a bed in her regular room because she sleeps in a recliner because of her COPD. She had slept in a chair forever. (R1) was observed to be non-responsive, so V2 tried doing a sternal rub. (R1) did not respond. V2 looked at R1's legs and he saw the mottling in her lower legs and told me 'that concerned him'. V3 stated that V2 told her, It just has me baffled. I don't know what more to do because most of her vital signs were good. V3 stated that it was not clear to V2 what he was dealing with, and at that point V3 said, I think we need to send her to the hospital and that maybe it was something an IV could take care of. If it was not something the ER could stabilize, I would have gone from there and discussed comfort care if nothing else would have worked at that time. When asked if she had spoken to the hospital yet, she (V3) stated, Not really, I was told she had passed in the ambulance. She had thrown up some black tarry vomit and had a major gastric bleed. The ER doctor did tell me that. A few years ago, she (R1) was in another hospital for a gastric bleed. That was another thing that raised questions for me because she had COPD and a history of gastric bleed, and I didn't receive a phone call from anyone in the facility prior to me walking in on [DATE]. When asked if V3 had any of her phone numbers blocked so the facility would be unable to contact her, V3 stated, I did not have my phone off and my phone number is not blocked to receive calls from the facility. A lot of times I may not hear the ringer or may not have my phone on me but if I had missed a call, I'd have seen that and would have called back immediately. I have missed calls before and I always return their call. I have phone records to show there were no missed calls from the facility on [DATE] or [DATE]. When asked about receiving texts, V3 stated she had received texts in the past from V2. On [DATE] at 9:50 AM, V4 (Medical Director/Physician) said if a resident was found to be febrile, unresponsive to verbal stimuli, and have labored breathing with an oxygen saturation in the 80's he expected the facility would contact V4. V4 said if it is a serious problem the resident should be transferred to the hospital. V4 said he expected the facility to notify a resident's POA with any change in condition. V4 said it is possible if R1 was transferred to the hospital six hours earlier, when symptom onset began, R1 may not have expired. On [DATE] at 3:24 PM, V4 was contacted for a second interview. V4 stated that a resident's condition certainly changes, and they should be taken care of appropriately. Sometimes the patient and the family change their mind or direction they are going when they sign the POLST originally, but there should be a clear understanding from the patient and family of what treatment they want. When asked if DNR meant do not treat, V4 confirmed it means, Do Not Resuscitate, adding the patient should always be taken care of regarding their symptoms or whatever is happening. When asked if on [DATE], the emergency room could have provided any further or different treatment than R1 had already been provided at the facility, V4 stated when you go to the hospital, they do everything so they can find out what is going on. An additional document with the State of Illinois, Illinois Department of Public Health seal titled Illinois Statutory Short Form Power of Attorney for Health Care documents that R1 wants (V3) to be her health care agent. The form further documents, I authorize my agent to with the box checked Make decisions for me starting now and continue after I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to. Under Life-Sustaining Treatments documents, in part . In general, in making decisions concerning life-sustaining treatment, your agent is instructed to consider the relief of suffering, the quality as well as the possible extension of your life, and your previously expressed wishes. Your agent will weigh the burdens versus benefits of proposed treatments in making decisions on your behalf. On [DATE] at 3:05 PM, V2 (APRN/DON), V9 (Chief Executive Officer/CEO), and V1 (Administrator) entered the conference room where this surveyor was working. V2 again stated he had not been given the chance to report the events that transpired throughout the day on [DATE] regarding R1's condition. V2 was asked if he had any new information he would like to provide at this time. V2 stated when he got to R1's room on [DATE] to pass medication at approximately 7:30 AM, she was sitting up in her recliner with her chin down to her chest. V2 stated he did notice she looked uncomfortable at that time stating R1 was stupor and not as alert. V2 stated, I did a sternal rub on her. She did wake up and look at me. Then, I asked her if she was hurting. She did not respond to that. At that point, we moved her from the recliner to the bed in a room across the hall. V2 stated once R1 was in bed her vital signs were checked. R1's oxygen saturation was about ,d+[DATE]%, so she was placed on oxygen via nasal cannula at 2 liters and the head of her bed was elevated to 45 degrees. V2 stated, While I was in there, I assessed her by listening to her lungs which were clear and I checked her skin. I did see that her right lower extremity had some redness, swelling, and was warm to the touch and she had a fever of 102 degrees. V2 stated at that point he gave R1 a Tylenol suppository and an injection of Rocephin. V2 stated he placed cool wash clothes on her forehead, armpits, and groin and from there made the decision not to give her any oral intake due to the risk of aspiration. V2 stated R1 was peaceful and comfortable at this time. V2 stated that after R1 was settled, he went to the nursing station and continued with nursing duties. He did attempt to call R1's POA (V3) but it only rang once and the call was disconnected. V2 stated normally if she saw we called, she would call back or come in. V2 stated, It could be minutes, hours, or days before you would get a response. V2 stated at 9:30 AM, he checked on R1 again, removed the wash cloths, but did not check her temperature because it would not have given a correct reading. V2 stated R1 had no rapid breathing, nothing appeared abnormal, and R1 displayed no signs or symptoms of pain. V2 stated he did not attempt to wake R1 at that time opting to let her rest. V2 stated that he went back at 11:00 AM, rechecked her temperature and it was 101 degrees. He did try to wake her by speaking to her but she did not wake up. V2 stated he did another sternal rub and R1 did wake up, open her eyes, and groaned slightly. V2 stated R1's lungs were still clear at that time, she had no symptoms of respiratory distress, and her color was good. V2 stated he asked the CNAs if they would attempt to feed her at lunch and they reported back to him that R1 did not eat lunch. V2 stated the CNAs checked on R1 around noon, then V2 went back down around 2:30 PM when V3 showed up to visit R1. V2 stated he assessed R1 with V3 present, and her fever was 102 degrees. V2 stated he administered another Tylenol suppository and explained that R1 had cellulitis that could be causing the fever. V2 stated V3 tried to wake R1 up herself by repeating her name and when she did that, R1 started breathing heavier and more labored than what she had been previously. V2 stated he explained the options of keeping R1 in the facility would be to keep her comfortable, pain free, and without respiratory distress or they could send her to the ER and see if there was anything else that was going on they might be able to fix. V2 stated, V3 asked him what he thought, and he told V3 it was her decision, and that V2 could do either. V2 stated, I could start her on Morphine/Ativan or send her to the hospital. V3 then asked which hospital she should go to. V2 again told V3 that was her decision. V2 stated R1 did not appear critical at that time, so it was up to V3. V2 stated that V3 opted to send R1 to the hospital, claiming that the family would be mad at her if she didn't send R1 to the hospital. V2 stated V3 then said if they find anything serious, she was not going to do anything. V2 then told V3 he would call EMS and have her sent. V2 stated V3 asked him if she had to be there and he again told V3 that it was up to her but he would give report to the ER. V2 stated V3 left at that time, EMS arrived and did not do an in-room assessment - just got report from him. V2 stated, R1 was loaded on the stretcher and was in their hands after that. V2 stated he gave report to V12 in the ER. V12 called back about an hour later and explained to V2 that R1 had passed .that she coded when she came through the ER doors, (V12) attempted to intubate but saw what appeared to be aspiration of blood and assumed she had a massive GI bleed. They witnessed the POLST form DNR and did not proceed with intubation nor any further treatment. On [DATE] at 3:30 PM, V9 (Chief Executive Officer/CEO/Social Services) stated V3 came by the next day to get R1's belongings and praised the facility for the care of R1. V9 had with him the IDPH printout titled, Guidance Document for Illinois Health Care Professionals and Providers - Illinois Department of Public Health (IDPH) Uniform Practitioner Orders for Life-Sustaining Treatment and stated he wanted to go over the parts he highlighted. V9 then read from Page 2 of this document - healthcare professionals and institutional providers are legally protected from liability if, in good faith they honor the instructions contained in the POLST form . V9 stated, Which is exactly what we did. V9 stated R1's POLST indicated she was comfort focused treatment. V9 stated, This is the big one, and read the following from the document - Transfer to hospital only if comfort cannot be achieved in the comfort setting . V9 stated, We were going by what was on her POLST .I think we were within our guidelines and it's cut and dry we were following the resident's wishes. V9 read, POLST portable medical orders form, signed by the patient's qualified healthcare practitioner and either the patient or their legal representative, converts the patient's care choices into an actionable medical order that all other physicians, nurse practitioners, physicians assistants, long-term care facilities, hospices, home health agencies, emergency medical services, hospital staff, and other provider staff are required by law to honor . V9 also read, .the POLST model allows individuals to specify the intensity of medical interventions when they experience a life-threatening emergency where they still have a pulse. On [DATE] at 3:45 PM, V2 stated he believes the facility did everything as they should have and provided the care and comfort to R1 she required prior to her being transferred to theER on [DATE]. When asked if V2 had anything else he would like to add to his interview, he stated, I stand beside the treatment R1 received in the facility on [DATE] and [DATE]. If I had to do it over, I would do the same thing. I wouldn't change anything. The facility's [DATE] Notification of Changes in Condition policy documented in part . The facility must inform . the resident's family member or legal representative when there is a change requiring such notification. Circumstance requiring notification include: 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . 3. Circumstances that require a need to alter treatment . According to https://www.polstil.org/resources-for-healthcare-providers/, the Guidance Document for Healthcare Professionals documents the following in part . POLST stands for 'Practitioner Orders for Life-Sustaining Treatment.' A POLST form is a signed medical order that travels with the patient to assure that a patient's treatment preferences are honored across settings of care. The POLST form is designed to ensure that seriously ill or frail patients can choose the treatments they want or do not want and that their wishes are documented and honored Use of the POLST form is voluntary. This form contains orders that can be revoked or changed at any time by patients or their legal representative When a patient's condition changes significantly, prior decisions about treatment should be revisited and consideration should be given to completing a new, updated POLST form. On [DATE] at 8:23 AM, V15 (LPN) stated prior to R1's fever the evening of [DATE], she did not appear to have anything going on. V15 stated, It seemed like it came out of nowhere. It seemed like it happened very quickly. V15 stated R1 would propel through the facility in her wheelchair but did stay in her room quite a bit. She was not able to ambulate or stand/transfer on her own but once she was in the wheelchair she could propel independently where she wanted to go. On [DATE] at 9:07 AM, V16 (CNA) and V8 (CNA) both stated normally R1 was awake and alert but sometimes she would get sleepy and tell us she just wanted to sleep. She had a habit of staying up at night sometimes and going through the drawers/packing her things to go home. V16 stated they would have to check the schedule but the last time they worked, R1 was fine. V8 stated the last time she worked and saw R1 was on [DATE] between 6:30 AM and 3:00 PM. V8 stated R1 had a shower that day and was tired after and wanted to sleep. V8 stated R1 slept in her recliner. V8 stated she did work the same shift on [DATE] but was not really involved with R1's care that day. However, there was nothing observed that would have given an indication R1 needed to be sent out to the hospital. She just knows she was sent out to the hospital and was surprised to hear she passed away. On [DATE] at 11:03 AM, V10 (RN) stated she did work on [DATE] from 2:30 PM to 7:00 PM. V10 was asked about R1's condition that day. V10 stated, I remember she started running a fever when I was getting ready to leave between 6:15 PM and 6:30 PM that evening. I gave her a Tylenol suppository and called (V2/APRN) to report the fever and lethargy and he said he would follow-up with (R1) the next morning. V10 stated R1 had episodes of lethargy in the past where she would look at you but would not speak. V10 reported they sent R1 to the hospital for a similar episode in the past and R1 told the hospital staff she just didn't want to talk to us and wanted to be left alone so she could sleep. V10 confirmed on [DATE], R1 did have redness to her legs, however, R1 had intermittent edema/cellulitis in her legs in the past that had been treated with steroid creams and wraps/socks. At times, it was cellulitis, but R1 did have chronic dermatitis. V10 stated, It was not too alarming at that point. I gave the night nurse the report and asked her to monitor R1. At that point, she just had a fever and was not verbalizing, so I thought it was like her past behavior. On [DATE] at 11:27 AM, V7 (LPN) stated it was normal for R1 to be incontinent. When asked about the events of her shift on [DATE], V7 stated, On [DATE], she did not want to get up and get in the shower, but she had been incontinent and had feces everywhere. She would not talk to us; she would glare at us and hold on for dear life to anything she could get a hold of. She would do the same thing to the CNAs in the past when they tried to get her up if she had been incontinent in her recliner through the night. V7 stated that R1 had been running a fever earlier in the day on [DATE] and received report it was coming down. V7 stated she kept checking R1's temperature and it was going down. V7 stated there was really no change in R1's condition from when she arrived to when her shift ended on [DATE], and there was nothing to make her think R1 should expire the next day. V7 stated that other than R1's leg being red, there was nothing different at all. R1 sat in her recliner with her head on her chest like she did every night. V2 was treating the redness to the leg with the Rocephin injection and antibiotic. V7 stated, I had been in contact with (V2) through the night regarding (R1's) condition and temperature. V7 stated V2 continued to monitor R1's temperature as it was coming down. V7 stated R1's biggest issue was the high temperature while V10 (RN) was there. On [DATE] at 11:19 AM, V14 (CNA) was called for an interview. V14's phone went straight to voicemail. V14's mailbox was full and a message was not able to be left. On [DATE] at 11:37 AM, V5 (LPN) stated when she came to work on [DATE], V7 had been the nurse the previous shift and gave her report that R1 had a large bowel movement through the night requiring R1 to take to shower. V5 stated she w [TRUNCATED]

Based on interview and record review, the facility failed to notify a resident's family member/Power of Attorney (POA) in accordance with facility policy when there was a significant change in the resident's condition for 1 (R1) of 6 residents reviewed for resident representative notification in a sample of 6. Findings Include: R1's face sheet documented an admitted [DATE] with diagnoses including: chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure (CHF), hypertensive heart disease, dementia, weakness, ataxic gait, muscle weakness, cellulitis of right lower limb, Vitamin D deficiency, chronic kidney disease stage 3. R1's [DATE] Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact. R1's face sheet, under Contacts documents that V3 (Family Member/POA-Power of Attorney) is listed as R1's Emergency Contact/Responsible Party and lists a primary phone number, a cell phone number and an email address. V13 (Family Member) is listed as a second Emergency Contact, however the face sheet does not have a phone number listed. A third family member (V18) is listed with a phone number as well, although not listed as an Emergency Contact. The face sheet designates a call order as V3 (first), V13 (second), and V18 (third). R1's record includes the following progress notes in part - On [DATE] at 6:36 PM, V10 (Registered Nurse - RN) documented - Resident (R1) noted to have 104 temp axillary. PRN (as needed) Tylenol given suppository. NP (V2 - Advanced Practice Registered Nurse/APRN - Director of Nursing/DON) notified. Awaiting further orders. On [DATE] at 9:17 PM, V7 (Licensed Practical Nurse - LPN) documented - Resident (R1) resting per recliner. Temp is now 101.2. LCTA Resp E/U (lungs clear to auscultation respirations even and unlabored). Resident is very slow to respond when spoken too, she keeps her head down while sitting in recliner. Respirations are at 32. SPO2 94% (oxygen saturation). R1's record under Vital Signs on [DATE] at 9:26 PM/9:27 PM documented by V14 (Certified Nursing Assistant - CNA) are recorded as - Blood pressure: ,d+[DATE], Respirations: 32 (alert triangle with exclamation mark noted), Pulse: 77, and 02 Sat: 94%. On [DATE] at 2:31 AM, V7 (LPN) continues to document - Resident (R1) had a large loose stool in recliner, on the floor and on resident from head to toe. Both hands coated slathered on fronts of thighs and in her hair. Resident was transferred to w/c (wheelchair) and to shower. Residents temp 100.9, Resp 20, Pulse 64 and regular and SPO2 94%. WCTM (will continue to monitor). Right leg remains bright red and warm to touch. On [DATE] at 2:40 AM, V7 also noted - Resident (R1) did not speak to staff but could follow staff with eyes. Held onto w/c and shower chair during transfers. Required max (maximum) assist x 2 with gait belt for transfer. R1's record under Vital Signs on [DATE] by V2 (APRN/DON) at 8:24 AM, document R1's pain is assessed as 6 out of 10, and at 11:14 AM, her temperature is 100.1. On [DATE] at 9:39 AM V2 (APRN/DON) documented - Noted Resident in recliner when passing medications that resident was stupor in recliner and labored breathing. Temp of 102.9. Resident is unresponsive to verbal stimuli however is responsive to painful stimuli of sternal rubs and deep nail press. SPO2 88% on RA (room air). LCTA (lungs clear to auscultation). Unable to arouse to eat breakfast or take medications PO (by mouth). O2 (oxygen) applied at 3L/min (liters per minute) PNC (per nasal cannula), Tylenol supp (suppository) given for fever. Cool wash cloths applied to forehead and groin region to decrease temp. Resident was moved to bed out of recliner to perform assessment and treatment. Resident noted with redness, swelling and warmth to RLE (right lower extremity). Cellulitis indicated and resident was given 1-gram Rocephin IM (intramuscularly) x 1 now and then will start Keflex 500 mg (milligram) po tid (three times daily) x 10 days. The facility was unable to provide documentation or reproducible evidence that the V3 (POA) or any other family members had been notified of R1's change in condition. V2 (APRN/DON) completed an Event Report Infection Control Tracker form related to the finding of R1's RLE cellulitis and includes - Event Date: [DATE] 9:26 AM . Classification: Infection Type: Cellulitis/Soft Tissue/Wound. Surveillance Definition Met? McGreer's Criteria obv (observation) performed? Yes. Reportable Infection? No. History: Symptoms: Fever, RLE erythema and swelling. Onset Date: [DATE]. Device Type: No device . Diagnostics (microbiology, other labs, radiology): Diagnostics Performed: No . Treatment: Select which provider ordered testing and treatment: (V2). Order Origin: Nursing Home. Indicate Antibiotic used. If no Antibiotic used, type N/A (not applicable): [DATE]: Rocephin 1 gram (IM) x 1 now. [DATE]: Keflex 500 mg po tid x 10 days .Other Information: Was an Event/Observation performed for the related infection. If no, reason needs explained: Yes. Transmission-based Precautions? None. Re-cultured/Assessment Date (if applicable). If yes, indicate date re-tested . NA. Any new orders from re-assessment/culture? If so, indicate new order. NA. Select which provider ordered testing and treatment. (V2) .Additional Information: RLE Cellulitis. Notifications: Attending Faxed: No. Physician Notified: No. Resident Representative Notified: No. Care Plan Reviewed: No. Vitals: Blank. The remainder of this form contains the orders and notes as documented above. R1's record under Vital Signs on [DATE] by V2 at 11:14 AM records her temperature is 100.1. It should be noted this is the last vital sign the facility was able to confirm until 3:26 PM later this same day. R1's record continues to document in progress notes the events that led up to R1 being sent out for emergent treatment - On [DATE] at 3:26 PM, V3 (Family Member/POA) came to visit (R1). Updated POA on current medical condition of resident. Assessed resident while POA in room and noted that resident was in acute respiratory distress. Resident currently on 3L/min PNC, temp is 102.6 prn (as needed). Tylenol supp given at this time. O2 increase to 4L/min. RLE noted to have erythema and swelling and warm to touch, anterior portion erythema has decreased slightly, posterior area unchanged. Mottling noted up to mid-thigh on BLE (bilateral extremities). Spoke to POA about changes in condition and explained that sepsis or AKI (acute kidney injury) could be the cause. Resident remains unresponsive to verbal stimuli only has mild responsiveness to sternal rubs. POA states that she would like resident to be evaluated at (hospital) however if she has a major issue that she more than likely will not want to do anything. POA chose (name of hospital) to be sent to for evaluation. (Ambulance) notified and arrived and transferred resident to (name of hospital). Report was given to V12 (Physician) in the ER. On [DATE] at 10:31 AM, V2 said he assessed R1 on [DATE] in the morning and found R1 was unresponsive and was transferred from the recliner to bed. V2 said R1 was febrile and V2 ordered a Tylenol suppository, Rocephin, and Keflex. V2 said R1 was mainly unresponsive most of the day. V2 said R1's oxygen saturation dropping was not normal for R1 and oxygen was applied. V2 said he did not contact V3 (POA) because V3 had the facility number blocked so R1 could not call V3 during the night. V2 said the facility would text V3 if they needed to report any change in condition. V2 said he did not attempt to contact V3 in any way because V2 did not think R1's change in condition was serious enough to contact V3. V2 said when V3 arrived at the facility, V2 updated V3 on R1's change in condition. V2 said he asked V3 if they wanted R1 to be transferred to the hospital or if they wanted R1 to stay in the facility and keep R1 comfortable. V2 said V3 chose to send R1 to the hospital. V2 said R1 was not under hospice services and was not on comfort care. When V2 was asked if R1 being so unresponsive that R1 could not take medications by mouth and had to have a Tylenol suppository was concerning, V2 said, The fever was concerning, that is why I was treating her. On [DATE] at 9:26 AM, V3 (POA) confirmed R1 was not receiving services of hospice or comfort care measures. V3 said she had never told the facility she did not want R1 sent to the hospital if it was medically needed. V3 said R1 was a Do Not Resuscitate but V3 still expected the facility to treat R1. V3 said R1 was alert and oriented on [DATE]. R1's State of Illinois, Illinois Department of Public Health - IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form documents in Section A Cardiopulmonary Resuscitation (CPR), If patient has not pulse and is not breathing, the option of Do Not Attempt Resuscitation (DNR) is selected. Section B Medical Interventions, if patient is found with a pulse and/or is breathing the option of Comfort-Focused Treatment is selected and defined as follows: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. V3 signed R1's POLST form as her Legal Representative and V2 (APRN/DON) signed as the Authorized Practitioner and both dated [DATE]. On [DATE] at 10:25 AM, a follow-up interview was conducted with V3 (POA). V3 was asked to recount and confirm the events on [DATE] regarding R1. V3 stated she was there that day because the grandkids had sent some pictures and she wanted to put them in frames and do some decorating in R1's room. V3 added that the whole family had just been in the facility on Easter Sunday ([DATE]) and ate dinner together with R1. V3 stated, My brother and everyone got to see her, so everyone saw her in great condition and she was able to visit. She was perfectly cognitive that Sunday. V3 continued that when she arrived in the facility on the afternoon of [DATE], V2 caught her up on what had been happening with R1 from the night before and wanted to prepare her. When this surveyor asked what that meant, V3 stated she was not sure exactly what he meant. V3 stated V2 told her it had been a couple of hours since he had last checked on R1 so they both had gone to her room at that time. V3 stated she felt blindsided. V3 said that R1 was not in her regular room, but in another room across the hall. V3 stated she observed R1 lying flat in a bed with no oxygen on her nose, nor did she observe any oxygen in the room. V3 stated, I don't know how long (R1) had been lying in bed, but (V2) just said the night before she had run a fever, was still running a fever that day, and had been given a shot and antibiotic. (R1) did not have a bed in her regular room because she sleeps in a recliner because of her COPD. She had slept in a chair forever. (R1) was observed to be non-responsive, so V2 tried doing a sternal rub. (R1) did not respond. V2 looked at R1's legs and he saw the mottling in her lower legs and told me 'that concerned him'. V3 stated that V2 told her, It just has me baffled. I don't know what more to do because most of her vital signs were good. V3 stated that it was not clear to V2 what he was dealing with, and at that point V3 said, I think we need to send her to the hospital and that maybe it was something an IV could take care of. If it was not something the ER could stabilize, I would have gone from there and discussed comfort care if nothing else would have worked at that time. When asked if she had spoken to the hospital yet, she (V3) stated, Not really, I was told she had passed in the ambulance. She had thrown up some black tarry vomit and had a major gastric bleed. The ER doctor did tell me that a few years ago, she was in another hospital for a gastric bleed. That was another thing that raised questions for me because she had COPD and a history of gastric bleed, and I didn't receive a phone call from anyone in the facility prior to me walking in on [DATE]. When asked if V3 had any of her phone numbers blocked so the facility would be unable to contact her, V3 stated, I did not have my phone off and my phone number is not blocked to receive calls from the facility. A lot of times I may not hear the ringer or may not have my phone on me but if I had missed a call, I'd have seen that and would have called back immediately. I have missed calls before and I always return their call. I have phone records to show there were no missed calls from the facility on [DATE] or [DATE]. When asked about receiving texts, V3 stated she had received texts in the past from V2. On [DATE] at 9:50 AM, V4 (Medical Director/Physician) said if a resident was found to be febrile, unresponsive to verbal stimuli, and have labored breathing with an oxygen saturation in the 80's he expected the facility would contact V4. V4 said if it is a serious problem the resident should be transferred to the hospital. V4 said he expected the facility to notify a resident's POA with any change in condition. V4 said it is possible if R1 was transferred to the hospital six hours earlier, when symptom onset began, R1 may not have expired. On [DATE] at 3:24 PM, V4 was contacted for a second interview. V4 stated that a resident's condition certainly changes and they should be taken care of appropriately. Sometimes the patient and the family change their mind or direction they are going when they sign the POLST originally, but there should be a clear understanding from the patient and family of what treatment they want. An additional document with the State of Illinois, Illinois Department of Public Health seal titled Illinois Statutory Short Form Power of Attorney for Health Care documents that R1 wants (V3) to be her health care agent. The form further documents I authorize my agent to with the box checked Make decisions for me starting now and continue after I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to. Under Life-Sustaining Treatments documents, in part . In general, in making decisions concerning life-sustaining treatment, your agent is instructed to consider the relief of suffering, the quality as well as the possible extension of your life, and your previously expressed wishes. Your agent will weigh the burdens versus benefits of proposed treatments in making decisions on your behalf. The facility's [DATE] Notification of Changes in Condition policy documented in part .The facility must inform .the resident's family member or legal representative when there is a change requiring such notification. Circumstance requiring notification include: 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . 3. Circumstances that require a need to alter treatment .

Based on observation, interview, and record review the facility failed to mitigate the risk for infection by allowing foley catheter tubing and collection bags to touch the ground and failed to perform hand hygiene per current standards of practice while administering treatments for 4 of 4 (R10, R11, R15, and R31) residents reviewed for infection control out of a sample of 26. Findings include: 1. R10's face sheet documented an initial admitted [DATE]. R10's face sheet documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/22 at 11:10 AM, on 9/21/22 at 10:03 AM, and on 9/21/22 at 3:19 PM, R10 was observed sitting in a recliner in R10's room. R10's foley catheter was hanging from the footrest bar with the foley catheter collection bag was touching the floor. On 9/21/22 at 11:34 AM, R10 was observed sitting in the dining room. R10's foley catheter tubing was coming out of the bottom of R10's pant leg and was lying on the floor. On 9/21/22 at 1:04 PM R10 was sitting in the dining room with R10's foley catheter tubing on the floor with R10's shoe on top of it. 2. R31's face sheet documented an admitted [DATE]. R31's face sheet documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/22 at 11:30 AM and on 9/21/22 at 10:02 AM, R31 was lying in bed with R31's foley catheter collection bag hanging from the bed frame with the bottom of the bag touching the floor. On 9/23/22 at 10:31 AM, V2 Director of Nursing (DON)/ Family Nurse Practitioner (FNP) said catheter tubing and collection bags should never be touching the floor for infection control purposes. V2 said the facility did not have a policy stating catheter tubing and collection bags should not touch the ground. 3. R11's Resident Face Sheet dated 9/23/22 documents R11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's MDS (Minimum Data Set) dated 7/22/22 documents a BIMS (Brief Interview for Mental Status) score of 09, which indicates R11 has a moderate cognitive impairment. R11's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . clean left knee abrasion with soap and water, apply triple antibiotic ointment and leave open to air, 2. clean abrasion to left shin with soap and water, rinse, pat dry, apply very thin layer of triple antibiotic ointment, then collagen powder, cover with dry dressing daily and as needed, 3. clean shearing left hip with soap and water, rinse, pat dry, apply very thin layer of triple antibiotic ointment, then collagen powder, cover with dry dressing, change daily and as needed, 4. clean left palm with soap and water, rinse, pat dry, apply sure prep and let dry, then apply palm roll for maintenance. On 9/22/22 at 11:00 AM, V3 (Licensed Practical Nurse/LPN) was observed, with V2 (DON) present, administering treatments to R11. V3 administered the treatment to R1's left palm, left hip, left knee, and left shin as ordered by the physician. V3 changed her gloves per current standards of practice while administering the treatments. V3 did not perform hand hygiene between glove changes. 4. R15's Resident Face Sheet dated 9/23/22 documents R15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's MDS dated [DATE] documents R15 has a BIMS score of 00, which indicates R15 has a severe cognitive impairment. R15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/22 at 11:30 AM, V3 (LPN) was observed, with V2 (DON) present, administering treatment to R15's left hip. V3 changed her gloves per current standards of practice but did not perform hand hygiene between glove changes. On 9/22/22 at 11:30 AM, V3 (LPN) stated she had not hand sanitized or washed her hands between glove changes. V3 stated she normally does but forgot to take it with her. On this same day at this same time, V2 (DON) stated he would expect staff to hand sanitize between glove changes.

Based on interview and record review the facility failed to ensure a resident was ambulated to the bathroom for toileting per the resident's preference for to 1 of 6 residents (R22) reviewed for resident rights in a sample of 26. Findings include: R22's face sheet documented R22 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's 8/19/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, which indicates R22 is moderately cognitively impaired. The same MDS documents under section G that R22 requires supervision and setup for toilet use. On 9/20/22 at 11:27 AM, R22 was observed sitting in her room in a wheelchair. R22 was alert to person, place and time. R22's room had a rolling walker present. R22 said she needed to have assistance to ambulate to the bathroom. R22 said facility staff did not assist her quick enough to ambulate to the bathroom to void and she would be incontinent on herself. R22 said if facility staff would assist her to the toilet regularly, she would not have to wear an incontinent brief. On 9/23/22 at 10:31 AM, V2 Director of Nursing (DON)/ Family Nurse Practitioner (FNP) said R22 can wheel herself to the bathroom and alerts staff to when she needs assistant toileting. V2 denied R22 being on a toileting program. The facility's 2022 Promoting/ Maintaining Resident Dignity policy documented in part . It is the practice of this facility to protect and promote resident right and treat each resident with respect and dignity as well as care for each resident in a manner . that maintains or enhances resident's quality of life 2. The resident's . personal choices will be considered when providing care and services to meet the resident's needs and preferences . 4. Respond to requests for assistance in a timely manner .

Based on observation, interview, and record review the facility failed to accurately code restorative therapy days for 1 of 6 residents (R22) reviewed for MDS (Minimum Data Set) accuracy in a sample of 26. Findings include: R22's face sheet documented R22 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's 8/19/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, which indicates R22 is moderately cognitively impaired. The same MDS documents under section G that R22 requires limited assistance of one when walking in room and walking in corridor. The same MDS documents under section O: Restorative Nursing Programs walking 7 days per week. R22's Care Plan with initial start date 4/15/20, last revised 8/19/22 documented in part .needs Walk to Dine Restorative Program as tol (tolerated) r/t (related to) decline in ability to walk . with interventions including . cue res (resident) as needed using task segmentation . Provide only the amount of assist necessary to ensure walking task is completed safely . Report any declines in activities . Use adaptive equipment: rollator et (and) gait belt . Walk to Dine Program TID (three times a day) c (with) rollator et CGA (contact guard assist) x7 days per week as tol . On 9/20/22 at 11:27 AM, R22 was observed sitting in her room in a wheelchair. R22 was interviewable. R22's room had a rolling walker present. R22 stated I only get assisted to walk one day a week when therapy is here. The rest of the time I'm in my wheelchair. R22 said if the facility staff would assist her to get strong enough to walk, she believed she could go home. On 9/21/22 at 1:05 PM, R22 was sitting in the dining room after eating the noon time meal. R22 was not asked or encouraged by staff to ambulate with assistance back to her room. R22 was observed wheeling herself back to her room. On 9/21/22 at 3:21 PM, R22 was sitting in her room in her wheelchair. R22 denied any facility staff asking or encouraging her to walk to or from the dining room with assistance. R22 said no facility staff has assisted her to walk to or from the dining room in ages. On 9/22/22 at 1:43 PM, V7 Certified Nurse's Assistant (CNA) said she had been working in the facility since March of 2022. V7 said R22 had not been able to walk since V7 has been employed in the facility. V7 said R22 was not on a restorative walking program to her knowledge. V7 said resident restorative programs could be found in the Electronic Medical Record (EMR). V7 then opened R22's EMR and verified R22 was on a restorative walking program. V7 said restorative therapy should be documented every day if the resident participated or refused. V7 said she did not know who to tell if a resident was unable to participate in a restorative therapy program. On 9/22/22 at 2:47 PM, V2 Director of Nursing (DON)/ Family Nurse Practitioner (FNP) said the Certified Nurse's Assistant (CNA) should be completing any restorative therapy activities. V2 said CNAs should be documenting in the EMR if a resident is participating or refused. On 9/23/22 at 10:31 AM V2 said he was aware R22 usually refused to participate in restorative therapy. V2 said R22's 8/19/22 MDS had been coded with at least 15 minutes of participation of walking restorative therapy daily, between the dates of 8/12/22 and 8/19/22, as seven because R22 was offered restorative therapy. V2 said V2 was aware R22 did not participate in walking restorative therapy for at least 15 minutes per day in the seven days look back period for R22's 8/19/22 MDS. V2 said the time spent working with residents on restorative therapy programs would be found on the Nursing Rehab Time log. R22's Nursing Rehab Time Log documented nine entries for the month of August 2022: (8/5/22, 8/14/22, 8/22/22 could not assess), (8/6/22, 8/11/22, 8/20/22, 8/31/22 deferred due to condition), (8/13/22, 8/19/22 refused).

Based on observation, interview, and record review the facility failed to provide restorative services to maintain a resident's mobility for 1 of 2 residents (R22) reviewed for restorative therapy in a sample of 26. Findings include: R22's face sheet documented R22 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's 8/19/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, which indicates R22 is moderately cognitively impaired. The same MDS documents under section G that R22 requires limited assistance of one when walking in room and walking in corridor. The same MDS documents under section O Restorative Nursing Programs walking 7 days per week. R22's Care Plan with initial start date 4/15/20, last revised 8/19/22 documented in part .needs Walk to Dine Restorative Program as tol (tolerated) r/t (related to) decline in ability to walk . with interventions including . cue res (resident) as needed using task segmentation . Provide only the amount of assist necessary to ensure walking task is completed safely . Report any declines in activities . Use adaptive equipment: rollator et (and) gait belt . Walk to Dine Program TID (three times a day) c (with) rollator et CGA (contact guard assist) x7 days per week as tol . On 9/20/22 at 11:27 AM, R22 was observed sitting in her room in a wheelchair. R22 was alert to person, place and time. R22's room had a rolling walker present. R22 stated I only get assisted to walk one day a week when therapy is here. The rest of the time I'm in my wheelchair. R22 said if the facility staff would assist her to get strong enough to walk, she believed she could go home. On 9/21/22 at 1:05 PM, R22 was sitting in the dining room after eating the noon time meal. R22 was not asked or encouraged by staff to ambulate with assistance back to her room. R22 was observed wheeling herself back to her room. On 9/21/22 at 3:21 PM, R22 was sitting in her room in her wheelchair. R22 denied any facility staff asking or encouraging her to walk to or from the dining room with assistance. R22 said no facility staff has assisted her to walk to or from the dining room in ages. On 9/23/22 at 9:50 AM, V6 Physical Therapy Assistant (PTA) said R22 was receiving physical therapy in February and March of 2022. V6 said one of R22's physical therapy goals were to safely ambulate 75 feet and that goal was met 2/18/22. V6 said when a resident meets their goal in therapy, they should be placed on a restorative therapy program to maintain the level of physical ability achieved during physical therapy. V6 said if R22 had a decline in functional abilities R22 should have been reevaluated by physical therapy. R22's Physical Therapy Discharge Summary dated 2/1/22-3/9/22 documents in part, d/c (discharge) reason- Patient refuses treatment .discharge date [DATE] . Summary Since Eval/SOC- Patient response- Progress & Response to Tx (treatment): Pt (patient) progress w/transfers & gait, however pt decided she wanted to be done w/therapy . Discharge recommendations: con't with transfers assist with nursing. R22's 2/1/22- 3/16/22 Physical Therapy Treatment Encounter Notes documented in part . 2/7/22 . Pt amb c 4 wheeled rollator CGA/[NAME] up to 125' c cueing (patient ambulated with four wheeled rollator contact guard assist/ minimum assist up to 125 feet with cueing) . 2/25/22 . the pt (patient) ambulated with rollator in the halls 80'x2 (80 feet times two) with rest breaks after 80 (80 feet) . On 9/22/22 at 1:43 PM, V7 Certified Nurse's Assistant (CNA) said she had been working in the facility since March of 2022. V7 said R22 had not been able to walk since V7 has been employed in the facility. V7 said R22 was not on a restorative walking program to her knowledge. V7 said resident restorative programs could be found in the Electronic Medical Record (EMR). V7 then open R22's EMR and verified R22 was on a restorative walking program. V7 said restorative therapy should be documented every day if the resident participated or refused. V7 said she did not know who to tell if a resident was unable to participate in a restorative therapy program. On 9/22/22 at 2:47 PM, V2 Director of Nursing (DON)/ Family Nurse Practitioner (FNP) said the Certified Nurse's Assistant (CNA) should be completing any restorative therapy activities. V2 said CNAs should be documenting in the EMR if a resident is participating or refused. V2 said the time spent working with residents on restorative therapy programs would be found on the Nursing Rehab Time log. On 9/23/22 at 10:31 AM, V2 said residents should be assessed for restorative therapy programs quarterly. V2 said if a resident is regularly refusing to participate in a restorative therapy program they should be reassessed. R22's Nursing Rehab Time Log Number of Minutes for Walking, documents from 3/9/22 to 9/14/22, R22 was walked in sessions of 5-10 minutes on 11 of those days. During those days R22 walked between 25-125 feet with either using wheelchair or walker with 1 person assist. All other days were either not listed, marked as refused, could not assess or deferred due to condition. The facility's April 2006 Range of Motion policy documented in part . Purpose . 2. To improve or maintain joint mobility and muscle strength . 4. To increase strength and activity tolerance . Special considerations . 1. When the resident's activity level or joint function is at risk or decreased, range of motion should be started as soon as possible. Joints may begin to stiffen within 24 hours or disuse . 2. Encourage the resident to participate in the exercise .

Based on interview and record review the facility failed to identify organisms by conducting culture and sensitivities to ensure appropriate antibiotic use for 2 of 3 (R10 and R15) residents reviewed for antibiotic stewardship in the sample of 26. Findings Include: 1. R15's Resident Face Sheet dated 9/23/22 documents R15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's MDS (Minimum Data Set) dated 7/15/22 documents R15 has a BIMS (Brief Interview for Mental Status) score of 00, which indicates a severe cognitive impairment. R15's Event Report dated 1/14/22 documents under progress note, 1/17/22 2:55 PM [MEDICATION(S)] 1 gm (gram) IM (intramuscular) x (times) 1 dose given 1/14/21 et (and) [MEDICATION(S)] po (by mouth) BID (twice daily) x 10 days cont (continue) as ordered with no ADR's (Adverse Reactions) noted for URI (upper respiratory infection) et [CONDITION(S)] (urinary tract infection). Moist nonproductive cough cont, Lungs diminished bilat, (bilaterally), resp E/U (respirations even and unlabored). O2 @ 1 L per NC (oxygen at 1 liter per nasal cannula) as res tol/allows (resident tolerates) PO flds (fluids) encouraged. Res is more alert et talking this AM. Res easily agitated per res norm. The event report continues to document on 1/18/22 3:07 PM [MEDICATION(S)] po BID x 10 days cont as ordered with no ADR's noted for URI et [CONDITION(S)]. Moist nonproductive cough cont, Lungs diminished bilat, Resp E/U. Ox Sats (saturations) WNL (within normal limits) RA (room air). PO flds encouraged. Res is more alert et talkative this am. Res easily agitated per res norm. The facility provided an untitled piece of paper with R15's name and date of 1/14/22 written at the top with a typed urinalysis report documented at the bottom of the paper that includes 2 plus leukocytes, and 3 plus ketones. R15's urinalysis dated 1/14/22 from the local lab documents negative for leukocytes, nitrites, ketones, and normal protein. This same urinalysis documents 1-5 white blood count, squamous cells, epithelial cells, and hyaline cast. Hand written at the bottom of the urinalysis is documented, Recently given [MEDICATION(S)] and started on [MEDICATION(S)] 875mg/125 mg (milligrams) PO BID x 10 days. On 9/21/22 at 3:00 PM, V2 (Director of Nurses) stated, on 1/14/22, R15 had an elevated temperature of 102.0 degrees Fahrenheit. V2 stated they did an in-house urinalysis that documented 2 plus leukocytes. When asked what the culture and sensitivity documented, V2 stated the urine was not sent for a sensitivity. When asked how they knew which antibiotic would be effective if no culture and sensitivity was done, V2 stated he goes by most up to date recommendations. V2 stated if someone has a positive urinalysis, he starts them on an antibiotic they are not allergic to. V2 stated the lab only comes to the facility weekly and he isn't going to make the residents wait a whole week for treatment. When asked about the culture for the urinalysis that was done at the local lab V2 stated I don't know why it's not on there. The facility was not able to provide reproducible evidence a culture and sensitivity was done for R15. 2. R10's face sheet documented an initial admitted [DATE]. R10's face sheet documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Resolved Infection by Infection Type log documented in part R10 was diagnosed with a Urinary Tract Infection ([CONDITION(S)]) on 9/2/22. R10's 9/2/22 Event Report documented in part R10 was started on oral [MEDICATION(S)] twice a day for seven days. The facility was able to produce documentation a urinalysis had been completed on 9/2/22 but a culture and sensitivity was not completed. On 9/23/22 at 10:31 AM, V2 Director of Nursing (DON)/ Family Nurse Practitioner (FNP) said no culture and sensitivity was completed for R10's 9/2/22 [CONDITION(S)]. V2 said R10's urine was milky with sediment and dark. V2 said V2 prescribed R10 [MEDICATION(S)] on 9/2/22 and if they don't get better then we would send the urine out for culture to see if there would be a better antibiotic choice. The facility undated Antibiotic Stewardship Program documents, It is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff shall assess residents who are suspected to have an infection and complete an antibiotic need form prior to notifying the physician. Laboratory testing shall be in accordance with current standards of practice. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. Reassessment of empiric antibiotics is conducted after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changed in the clinical status of the resident. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized if physician prescribes . The research article titled Urinary Tract Infections in Older Adults Resident in Long-Term Care Facilities found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 48/ and dated 2/15/2013 documents the following, Urinary tract infections (UTIs) are commonly suspected in residents of long-term care (LTC) facilities, and it has been common practice to prescribe antibiotics to these patients, even when they are asymptomatic. This approach, however, often does more harm than good, leading to increased rates of adverse drug effects and more recurrent infections with drug-resistant bacteria. It also does not improve [CONDITION(S)] symptoms (eg, polyuria or malodorous urine) or lead to improved mortality rates; thus, distinguishing UTIs from asymptomatic bacteriuria is imperative in the LTC setting. This article provides a comprehensive overview of [CONDITION(S)] in the LTC setting, outlining the epidemiology, risk factors and pathophysiology, microbiology, diagnosis, laboratory assessment, and management of symptomatic [CONDITION(S)] .Unlike the case for [CONDITION(S)] in community-dwelling older adults, a urine specimen with bacteriuria and pyuria in LTC residents is insufficient to confirm a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Both conditions will be present in approximately half of patients without a catheter and in almost all patients with an IUC. Dipstick testing for urine is a fast method for ruling out [CONDITION(S)] as the cause of the residents' symptoms. Juthani-Mehta and colleagues32 demonstrated a negative predictive value of 100% but a positive predictive value of 45% with this method; thus, a positive leukocyte esterase and/or [MEDICATION(S)] result is not synonymous with infection, but if both results are negative, the clinician can be certain that there is no [CONDITION(S)] The choice of antibiotic to treat [CONDITION(S)] in LTC facilities should be individualized on the basis of the patient's allergy history and renal clearance, local practice patterns, prevalence of resistance at the patient's LTC facility, availability and cost of the antibiotic, and the threshold for noncompliance. In addition, treatment requires microbiological confirmation and should be tailored toward bacterial susceptibility; empiric treatment can be based on prior urine cultures, if available.

Based on interview, and record review the facility failed to provide the services of a Registered Nurse for 8 consecutive hours per day 7 days a week . This failure has the potential to affect all 39 residents in this facility. Findings include: On 6/28/2021 at 10:30am, V4 (Licensed Practical Nurse/Care Plan Coordinator) said all administrative staff were out of the state on vacation together and she was the acting person in charge until the administrative staff returned on 07/05/2021. V4 verified the facility's current census was 39 residents. On 6/30/2021, the facility's nursing schedule for 05/30/2021 through 07/03/2021 for all shifts were reviewed for registered nurse coverage. This schedule showed the facility did not provide 8 continuous hours of registered nurse services on 06/28/2021 and 6/30/2021 and does not have a Registered Nurse scheduled to be on duty at all on 7/2/2021. On 6/30/2021 at 10:15am, V4 was asked if the facility had the required 8 hours of consecutive registered nurse coverage for 6/28/2021 and 6/30/2021. V4 declined to answer and did not provide the requested documentation to show the facility did have the required registered nurse coverage for the days requested. On 06/30/2021 at approximately 12:30pm, V5 (Business Office Manager) provided time clock reports for all nursing staff who worked on 5/30/2021 and 6/28/2021. The time clock reports showed on 6/28/2021, the facility did not provide any registered nurse services for these days. A time clock report for 6/30/2021 and 7/2/2021 were not yet available for review, however no Registered Nurse was scheduled to work on either day according to the facility's nursing schedule provided by V4 (Licensed Practical Nurse/Care Plan Coordinator) and V5 (Business Office Manager). The facility's time clock report for 24 hours on 6/28/2021 showed the following nursing staff were on duty: V4, V7 and V12 (all Licensed Practical Nurses) and V13, V18, V19, V20, V21, and V22 (all Certified Nursing Assistants) A facility document titled Resident Census and Conditions of Residents, dated 06/28/2021, shows the facility current census is 39.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for a [CONDITION(S)] medication for 1 of 5 (R22) residents reviewed for gradual dose reductions in a sample of 31. Findings include: R22's Current Electronic Health Record Resident Face Sheet documents, R22 was admitted to the facility on [DATE] with an admitting diagnosis of unspecified dementia with behavioral disturbance and generalized anxiety disorder. R22's Physician's Order Report dated 5/30/2021- 6/30/2021 documents an order for an antipsychotic medication, ([MEDICATION(S)] 2.5mg), to be used daily every evening starting on his admitted [DATE]. A document titled Note to Attending Physician/ Prescriber dated 9/4/20 documents a request to decrease [MEDICATION(S)] to 2.5 mg every other day. The physician's response is marked as disagree noting the resident is too stable. On 7/6/21 at 1:15 PM, V2 (Director of Nursing) said that there were no previous GDR attempts prior to 9/4/20 for R22. V2 said that he should have had 2 attempts since his admission and they were not done. V2 stated there is a currently a request for a GDR for [MEDICATION(S)] that was sent to the prescriber on 6/29/21 and they are currently waiting on a response. R22's care plan (last revision date of 5/09/2021), documents that R22 is at risk for adverse reactions related to receiving antipsychotic medication for the treatment of dementia with behaviors and [CONDITION(S)]. Interventions include attempting to give the lowest dose possible of antipsychotic medication and to attempt a gradual dose reduction. The facility policy titled Use of [CONDITION(S)] Drugs (dated 06/18/2019) section 5 states Residents who use [CONDITION(S)] drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. The facility policy titled Gradual Dose Reduction of [CONDITION(S)] Drugs (dated 01/04/ ) section 2 states within the first year in which a resident is admitted on a [CONDITION(S)] medication or after the prescribing practitioner has initiated a [CONDITION(S)] medication, the facility will attempt a GDR (gradual dose reduction) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. Section 3 states After the first year, a GDR will be attempted annually, unless clinically contraindicated. There is no documentation in R22's medical record stating that a GDR is clinically contraindicated.

Based on record review, and interview the facility failed to provide 80 square feet of space per resident for 10 residents (R1, R3, R6, R8, R17, R19, R25, R35, R36, R89 ) reviewed for room size in the sample of 31. Findings Include: On 06/28/2021 at 10:15 AM, V5 (Business Office Manager/BOM) stated that rooms 15, 22, 23, 25, 26, 27, 30 and 32 are all covered under the room waiver. All the rooms have been measured and do not provide the required 80 square feet per resident bed. V5 also stated that at this time, the waivered rooms are dually certified for Medicare and Medicaid. These rooms (15, 22, 23, 25, 26, 27, 30 and 32) all have the potential to be double occupancy rooms. Inquiries regarding these rooms throughout the survey from 06/28/2021 to 07/01/2021 found no negative interviews from residents who reside in these rooms. Observations of the rooms found there was adequate space to meet the medical and personal needs of the residents living in the waivered rooms. On 06/28/2021 at 11:15 AM, V5 verified that the waivered rooms are occupied by R3, R7, R12, R17, R20, R21, R22, R30, R33, R34, R37, and R39.

Based on interview, and record review, the facility failed to assess, analyze, develop interventions, and initiate steps to minimize the risks for the recurrence of falls with injuries for 2 of 8 residents (R1 & R7) reviewed for falls in the sample of 10. As a result of this failure, R1 sustained a left hip fracture which required surgical repair after falling twice within 30 days. Findings include: 1. R1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R1's Care Plan was updated on 07-28-11 on with the problem "At risk for falls, had falls before entering facility..." One of the approaches added to address this problem was "personal body alarm on at all times." A facility Fall Report dated 08-25-11 at 3:07 pm states that R1 was found on the floor in her room next to the roommate's bed and night stand. According to the report, R1 stated she was trying to get up for popcorn and hit her head. This report also states that R1 sustained a small knot and reddened area to the back of her head from the fall. R1's Care Plan problem for being at risk for falls was updated on 08-25-11 to include "Attempt self transfer and fell . Res (resident) is aware of how to turn off the PBA (personal body alarm) and does." A facility Fall Report dated 09-24-11 at 12:50 am documents that R1 was found on the floor of her room with a small amount of blood on the floor under her head. According to the report, R1 said she was trying to walk to the bathroom and fell . The report states that R1 complained of slight pain to the left hip but was found to be within normal limits for range of motion and did not cry out or have facial grimacing during the assessment. A statement written by E2, Director of Nurses, is attached to the 09-24-11 Fall Report. It states, "(R1) has had some falls in recent weeks. (R1) wears a personal body alarm but frequently either removes/unclips it or turns it off. This has been witnessed by myself and (E4, Physical Therapy Assistant). When she is up without assistance her body alarm is usually found to be off or unclipped." This statement was verified by E2 on 09-28-11 at 11:05 am. The Narrative Notes for 9-24-11 at 9:00 am document that R1 was up in the dining room for breakfast and did not indicate any pain or discomfort. The Narrative Notes for 12:00 p.m. on 9-24-11 state that R1 was complaining of pain to the left groin area and an order was obtained for Z2, Physician, to send R1 to the emergency room for evaluation and treatment. The Diagnostic Imaging Report dated 09-24-11 documents an "impression" of "Minimally-displaced left femoral neck fracture involving the intertrochanteric region." R1's Care Plan problem of being at risk for falls was again updated on 09-24-11 to include "Fall which resulted in a left hip fracture. PBA (Person Body Alarm) in place did not sound." The new intervention of the same date is to verbally remind R1 not to turn off the personal body alarm. 2. According to the facility Incident/Accident Report dated 6-11-11 at 3:15 am, R7 was heard yelling and was found lying in his bed with his right leg over the top of the side rail, his lower right leg positioned back through the bars of the side rail, and his right foot twisted down and lodged against the rail. R7 was assisted to a sitting position and the right foot and lower leg were gently removed from the side rail. The Incident/Accident Report indicates that R7 sustained bruising to the right lower leg just below the knee. R7's Care Plan was updated on 09-19-11 to include a problem of "Bruising noted to R (right) ear with some edema." The nurses notes dated 9-18-11 at 7:00 am document that R7 "has right ear red/swollen/dry crusted blood. This was not noted last night at 7 pm when writer of this note left facility. When asked resident what happened. Resident stated, 'I hit it last night on bed rail in my room when turning myself in bed.' Resident denies pain..." On 9-29-11 at 8:30 am, R7 stated that he has 2 full side rails on his bed that are up when he is in bed. R7 also said that he can use the side rails to turn himself. R7 stated he did not know if he could use small hand hold type side rails but indicated that his arms were strong from lifting his body up while sitting in his wheel chair. The facility Side Rail Assessment Form dated 5-2-11 documents that R7 requested the side rails at the time of the initial assessment. There are no risks or benefits listed for R7. In the margin next to the risks and benefits area on the form is a symbol that indicates there are no risks or benefits. The form also indicates that the benefits do not outweigh the risks/hazards of the side rails. There were no changes in the side rails or Care Plan to keep R7 from having injuries related to the side rails.