Every finding on record at La Salle County Nursing Home

Based on interview, and record review the facility failed to follow their emergency menu. This applies to 4 of 6 (R1, R4, R5, R6) in the sample of 6. The findings include: On 2/10/2025 at 9:26AM and 10:15AM, R1 said on Wednesday 1/29/2025 the kitchen wasn't working. R1 said he was served graham crackers and peanut butter for breakfast. R1 said he received two packages of crackers for breakfast. R1 said he was still hungry, and breakfast didn't have enough food to fill him up. On 2/10/2025 at 10:44AM, R4 said he remembers Wednesday 1/29/2025 being served 2 packages (4 crackers) for breakfast that day. R4 said he doesn't recall being hungry after breakfast. On 2/10/2025 at 9:47AM, V5 (Kitchen Manager) said on Monday 1/27/2025 through Wednesday 1/29/2025 said the kitchen had electrical issues and the facility was on emergency meals for three days. V5 said the breakfast while on the emergency meal plan included graham crackers and the residents should have received six graham crackers or three packages of graham crackers each. On 2/10/2025 at 10:05AM and 1:02PM, V7 (Certified Nursing Assistant/CNA) said she was working Wednesday 1/29/2025. V7 said residents were served a smaller amount of food that day. V7 said R4 and R5 were only served 1-2 packets of graham crackers that day. On 2/10/2025 at 10:08AM and 1:10PM, V8 (CNA) said she worked on Wednesday 1/29/2025. V8 said residents received 1 packet of crackers that day. V8 said R1 was complaining of being hungry after breakfast. V8 said R6 received a couple of crackers not six that day. On 2/10/2025 at 12:02PM, V1 (Administrator) she gets a test tray every day from the kitchen. V1 said she was only served two packages of crackers on that day (Wednesday 1/29/2025) on the test tray. On 2/10/2025 at 11:16AM, V9 (Registered Dietician/RD) said if the menu says the residents should receive six graham crackers, then they should receive six. V9 said it throws off the amount of carbs the resident gets if they don't receive the right amount of graham crackers. V9 said the menu should be followed. The facility provided Emergency Menu Guide for No Electricity, No Gas shows day 3 (1/29/2025) breakfast 4 ounces of juice, 3/4 cup of cheerios, 6 crackers, 2 tablespoons of peanut butter, 1 ounce of jelly, and 8 ounces of milk.

Based on observation, interview, and record review the facility failed to identify a severe weight loss and put interventions in place for one (R33) of one resident reviewed for nutrition in the sample of 27. This failure resulted in R33 having a continued severe weight loss of 10.2% in one month and 12.9% loss in six months. Findings include: The facility's Resident Weight policy, dated 7/1/18, documents Any significant weight discrepancy from the previous weight is to be investigated at that time to rule out errors in weighing the resident (scale errors, incorrect procedure.) The nurse will report significant weight gains or losses to the physician and to the dietary department. (Significant weight gains or losses are defined as 5% in one month, 7.5% in 3 months, or 10% in 6 months. The Monthly Weight Summary for R33, documents the following weights: 8/15/24 at 128.0 pounds; 8/6/24 at 132.0 pounds; 7/3/24 at 147.0 pounds; 6/4/24 at 144.4 pounds; 5/2/24 at 148.0 pounds; 4/8/24 at 146.0 pounds; 3/12/24 at 145.0 pounds; and 2/12/24 at 147.0 pounds. This weight record documents a significant weight loss of 10.2% in one month (7/3/24 to 8/6/24) and 12.9% loss in six months. The Electronic Health Record for R33, does not document that V4 (Dietary Manager) or V17 (R33's Physician) was notified of R33's significant weight loss. The current Physician Order Sheet for R33, documents R33 is on a regular diet with no other dietary orders and to ensure R33 was offered snack three times a day. On 8/12/24 through 8/14/25, between 8:30 am through 3:00 pm, R33 paced the facility, circling one hallway to the next, and refused to rest frequently. On 8/13/24, 8/14/24, and 8/15/24, R33 was not seen in the dining room during mealtimes and was walking the hallways during those times. Meal trays were delivered to R33's room and R33 did not eat the meal provided. On 8/14/24 at 9:11 am, V2 (Director of Nursing) stated, We all encourage (R33) to rest and take breaks and she will at times. Sometimes (R33) with say no and keep on walking. We have to encourage her frequently. On 8/14/23 at 10:00 am, V10 (Certified Nursing Assistant/CNA), V11 (CNA), and V12 (CNA) stated R33 walks around the facility all day long. R33 used to be given finger foods and she would eat while walking but R33 won't eat now. R33 won't eat in the dining room most of the time and will say she is not hungry. On 8/15/24 at 9:45 am, V15 (Restorative CNA) stated she does all the monthly weights for the facility. V15 stated the last weight she got for R33 was 120 something (pounds), so she reweighed R33 and that is when she got the weight of 132 (pounds) and put the weight in R33's medical record. I did notice (R33) had a weight loss. V15 stated R33 walks even more now, it is harder to get her to stay focused, and her attention span is shorter than it used to be. On 8/15/24 at 12:58 pm, V2 stated she does all the monthly weight meetings and is unaware of R33 having any recent weight loss. V2 stated, No one has reported anything to me.

Based on observation, interview, and record review the facility failed to date opened food items, use items within the opened date timeframe, and failed to implement the cleaning schedule of equipment. This has the potential to affect all 59 residents residing in the facility. Findings include: The facility's Food Storage: Cold Foods, revised 04/2018, documents that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's Equipment policy, revised 09/2017, documents that all food service equipment will be clean, sanitary, and in proper working order. This form also documents that all food contact equipment will be cleaned and sanitized after every use. This form documents that all non-foods contact equipment will be clean and free of debris. On 8/12/24 at 9:00am there were four plastic containers of open, undated cereal on the counter. V4 (Dietary Manager) stated that the cereal is supposed to be dated when it is opened and put into the containers. V4 stated that it is only good for seven days after opened. V4 opened the drink refrigerator and there were two containers of thickened water, one apple and one cranberry thickened liquid containers open and undated. V4 stated that the containers of thickened liquids are to be dated when opened and kept for only seven days. A container of whole liquid eggs was dated as opened on 7/1/24. V4 verified that the eggs are only kept for seven days after opened. The two basket deep fryer baskets were covered in a dark brown greasy substance. The oil in the deep fryer was dark brown with burnt foods and crumbs on the bottom and on the shelf of the fryer. V4 stated that the deep fryer oil is to be changed weekly. V4 also stated that the debris is to be filtered out of the oil every night. V4 stated that is does not appear that it was done last night. The convection oven had a spilled brownish liquid on the floor. V4 stated that the chicken leaked over this morning the oven will be cleaned today. On 8/13/24 at 1:30pm, the convection oven had a dark brown dry crusty area on the floor. V4 verified that the oven was not cleaned yesterday (8/12/24). On 8/15/24 at 9:30am, V5 (District Dietary Manager) verified that all opened foods are to be covered and dated when opened. V5 stated that opened items are only kept for seven days. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 8/12/24, documents 59 residents residing in the facility.

Based on interview and record review, the facility failed to ensure all required staff attended the facility's Quality Assurance Meetings. This has the potential to affect all 59 residents residing in the facility. Findings include: The facility's policy Quality Assurance and Performance Improvement (QAPI) last modified 6-20-18, documents Procedures: 1) The facility will maintain, at all times including staff transitions, a Quality Assurance and Performance Improvement (QAPI) committee which will meet at least quarterly and more frequently according to the facility's needs. The committee will consist of at least the following: 1. The QAPI officer. 2. The Medical Director of this facility. 3. The Administrator of this facility. 4. The Director of Nursing. 5. The Restorative RN (Registered Nurse). 6. The Admissions Coordinator. 7. The Dietary Service Coordinator. 8. The Director of Social Services. 9. The Pharmaceutical Representative. 10. The Infection Control/Preventionist Coordinator. 11. Activities Coordinator. 12. MDS (Minimum Data Set) Coordinator. 13. Administrative Assistant/HR (Human Resources) Coordinator. The facility's Quality Assessment and Assurance Committee Meeting, dated 4/18/24, documents Absent for this meeting: (V16 Previous Administrator). The facility's Quarterly Quality Assurance Meeting Attendance Record, dated 4/18/24, does not include a signature by V16. On 8/15/24, at 9:29am, V2 (Director of Nursing) confirmed that (V16) the previous Administrator was not at the April 18, 2024, meeting. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 8/12/24, documents a census of 59 residents residing in the facility.

Based on interview and record review, the facility failed to ensure that the Antibiotic Stewardship Program was complete, accurate and done monthly for residents who are receiving antibiotics or have any type of infection. This failure has the potential to affect all 59 residents residing in the facility. Findings Include: The facility policy, named Antibiotic Stewardship-Infection Control Program, no date, documents the following: It is the policy of the facility is to monitor and maintain an Antibiotic Stewardship Program that monitors the use of antibiotics and their order specifics to decrease the amount antibiotic resistant organisms following the procedure: A.) Utilize the antibiotic tracking form to monitor reason for antibiotics and; B.) Identify the use of antibiotics and the appropriateness of the situation. C.) Analyze if antibiotic meets the appropriate criteria for infection using the algorithm for treatment of specific infections if available. D.) Track whether the patient is colonized and/or if they are clinically infected. Only treat if warranted. E.) Monitor for appropriateness of prophylaxis. F.) Physician compliance tracking and education. Procedure 4.) Infection Prevention Program Coordinator has the key expertise and data to inform strategies to improve antibiotic use. The Infection Preventionist tracks antibiotics, monitors adherence to evidence-based published criteria, reviews antibiotic resistance patterns in the facility. In coordinating using education and training, dedicated time, and resources to collect and analyze surveillance data, this will be used to support the antibiotic stewardship program. The facility's Monthly Infection Control Log dated May 1st through May 31st 2024, documents only the following information: Residents name, body site, and antibiotic with start date. The Infection Control Log for May is blank for the following pertinent information: Date of onset of infection, a culture when applicable, organism, antibiotic resistant, and classification of the infection, type of antibiotic, how long the antibiotic is for and symptoms to support the use of the antibiotic. The facility's Monthly Infection Control Log dated June 1st through June 31st 2024, documents only the following information: Residents name, body site, the antibiotic with start date and what the resident is being treated for. June's Infection Control Log does not document the following pertinent information: Date of the onset of the infection, a culture when applicable, antibiotic resistant, the classification of the infection, the organism that is being treated, any symptoms to support the use of the antibiotic, and stop date for the antibiotic. On 8/14/2024 at 11:32 AM V3 (Infection Preventionist), stated, I have not started the Infection Control Log for July or August yet. Typically, it should be started at the beginning of each month to accurately track, monitor infections or any trends, and to ensure that the resident is being treated appropriately for the infection. The logs are not complete. The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 8/12/2024, documents 59 residents currently reside within the facility.

Based on observation, interview, and record review the facility failed to ensure resident call devices were in reach for one (R8) of 15 reviewed for call devices in a sample of 27. Findings include: The undated facility's Call Light, Use Of policy documents Procedure: 11. Be sure call lights are placed within resident reach at all times, never on the floor or bedside stand. On 8/12/24, at 10:05am, R8 sat in a recliner in her room. R8 stated that she uses the call light for help to get to the bathroom. I am on a water pill, so I go a lot. At this time R8's call device is on the floor beside her and out of R8's reach. On 8/12/24, at 10:10am, V18 (Unit Attendant), stated the following: As a Unit Attendant I answer call lights and also when in a room I check to make sure the residents have their call light. On 8/12/24, at 10:16am, V18 confirmed R8's call device was on the floor and stated, It must have fallen when she got up in the chair earlier and I didn't see it. R8's current Care Plan includes a focus of The resident is at moderate risk for falls related to incontinence, hemiplegia, history of CVA (Cerebral Vascular Accident), on antidepressant, diuretics, anti-seizure, antihypertensive with an intervention of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.

Based on interview and record review the facility failed to perform a PASRR (Pre-Admission Screening & Resident Review) rescreen after a severe mental illness diagnosis was added for one (R22) one resident reviewed for PASRRs in a sample of 27. Findings include: The facility's undated PASRR policy documents a Project Introductions including but not limited to PASRR. Level I screen identifies known/suspected PASRR conditions: MI (Mental Illness)/ID (Intellectual Disability)/RC (related condition). Level II assessment - individualized to determine presence of MI/ID/RC and needed services and supports. Determination & Needs - (NFs) Nursing Facility's must incorporate PASRR findings in the person's plan of care. Refer for Level II - Has/suspected PASRR condition; Requires a Level II. R22's Face Sheet documents R22 admitted to the facility on [DATE] and includes a diagnosis of Unspecified Psychosis not due to a Substance or known Physiological Condition with a revised date of 4/20/23. R22's PASARR Level I, review date 3/28/23, documents PASRR Level I Determination: No Level II Required - Situational symptoms; Mental Health Diagnoses - Anxiety Disorder, current. R22's Minimum Data Set/MDS assessment, dated 6/20/23, documents 'Psychiatric/Mood Disorder: Diagnoses include: Psychotic disorder (other than schizophrenia) and Anxiety Disorder; Yes - Antipsychotics were received on a routine basis only. On 8/13/24, at 2:25pm, V22 (Admissions Coordinator) stated, On admission I request a Level I or whatever they required .V9 (Social Service Director/SSD) coordinates with V6 (Minimum Data Set/MDS and Care plan Coordinator) regarding changes like behaviors or medications. V9 would get a Level II if needed. If she is not here, then I would intervene and do it. On 8/14/24, at 11:55am, V6 (MDS/Care plan Coordinator) confirmed R22's Face Sheet includes a diagnosis of Unspecified Psychosis. V6 stated the following: (R22) came in with that diagnosis and was on Seroquel. I did not mark psychosis on (R22's) admission MDS because I did not have the psychotic diagnosis until 4/20/24 when we got verification from the doctor. V6 confirmed that R22 should have had another PASRR Level I Screening done when we saw that diagnosis. On 8/15/24, at 8:37am, V9 (SSD) stated the following: I did not realize that (R22) had the psychotic disorder diagnosis. If I had known, I would have put in for another Level 1 Screening then they would have determined if a Level II was needed. V9 confirmed that R22 should have been referred for another Level I Screening.

Based on observation, interview, and record review, the facility failed to ensure a respiratory assessment was completed pre and post nebulizer treatment for one (R5) of one resident reviewed for nebulizer treatments in a sample of 27. Findings include: The facility's undated Nebulizer policy documents Purpose: 1. To administer bronchial medications and humidifying agents into the lungs. 2. To assist in loosening lung secretions .Procedure: 6. Note pre-treatment data such as pulse and breath sounds .14. Note post treatment data (pulse, breath sounds and any side effects) and record in the medical record. (If pulse is increased more than 20 beats per minute over baseline, notify Physician.). R5's current Physician Order Sheet/POS documents R5 has an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligrams)/3ml (millimeters) (Ipratropium-Albuterol) 1 vial inhale orally via nebulizer four times a day related to Chronic Obstructive Pulmonary Disease, Unspecified. On 8/14/24, from 9:45am - 10:00am, R5 sat in her room. V8 (Licensed Practical Nurse/LPN) administered an Ipratropium Bromide & Albuterol nebulizer treatment to R5. V8 did not auscultate R5's lungs or take any vital signs before or after the treatment. On 8/14/24 at 1:43pm, V8 (LPN) confirmed that V8 did not auscultate R5's lungs or take R5's vital signs before or after giving R5 a nebulizer treatment. V8 stated, I don't auscultate lungs or take vitals unless the doctor ordered it specifically or it is a prn (as needed) dose for someone having breathing issues. (R5) gets nebulizer treatments regularly. I don't do that for scheduled maintenance nebulizer treatments but would for prn. On 8/14/24, at 2:30pm, V2 (Director of Nursing) confirmed that their policy states they are to auscultate lungs and take vital signs before and after a nebulizer treatment. V2 stated We will have to change our policy since that is not what we are doing for residents with scheduled nebulizer treatments.

Based on interview and record review, the facility failed to ensure a rationale was documented by the physician for a pharmacy recommendation for one (R53) of five residents reviewed for Medication Regimen Review in a sample of 27. Findings include: The facility's Psychotropic Medication Use policy, revised 10/24/22, documents Definition - Psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental processes and behavior .14.1 Physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. R53's Physician Order Sheet/POS includes orders for Trazadone HCl (Hydrochloride) 100mg (milligrams) by mouth at bedtime for insomnia related to Primary Insomnia and Melatonin 5 mg by mouth at bedtime for insomnia related to Primary Insomnia. R53's Consultation Report, dated on 7/24/24 and signed by V23 (R53's Nurse Practitioner), documents Comment: (R53) has orders for duplicate therapy. Trazodone 100mg (milligrams) q hs (every bedtime) and Melatonin 5mg q hs. Recommendation: Please discontinue one agent. If dual therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. The Rationale is blank. On 8/14/24, at 4:05pm, V2 (Director of Nursing) confirmed that V23 (R53's Nurse Practitioner) signed the Consultation Report but did not give a rationale and should have.

Based on record review and interview the facility failed to document the rational for the continued use of an antibiotic for two of three residents (R16 and R51) reviewed for unnecessary medications in a sample of 27. Findings Include: The facility's Antibiotic Stewardship-Infection Control policy, undated, documents the following: Procedure of Core Elements, D.) Action-Implementing at least one policy or practice to improve antibiotic use this facility will implement a stricter policy (s) on antibiotic order specifics including, but not limited to identifying clinical situations in which inappropriate antibiotics are used such as asymptomatic urinary tract infections, treating a colonized asymptomatic resident, prophylaxis, and guidelines for treating infections. The key element involved is control over antibiotic use which will reduce the threat of antibiotic resistance. The goal is to add one or two activities to start the program and over time as the program evolves implement more strategies to improve antibiotic use. Procedure 3.) The nurse shall document any signs and symptoms of infection following the criteria for clinical infecting on the infection Report form as well as in the nurses' notes. 4.) Floor nurse shall update the physician with a change in condition. if infection criteria met, inform physician of antibiotic algorithm as well as any culture and sensitivity results, and the strict standards our antibiotic stewardship program follows. 5.) If orders are received for antibiotics, double check the algorithm and or sensitivity report before administrating. If a conflict is noted, update physician and request replacement. R16's Physician Order Sheet, dated 8/14/2024, documents the following: Macrobid Oral Capsule 100 MG (milligram) (Nitrofurantoin Monohydric Macro Anti-bacterial) give one capsule by mouth one time a day every other day for UTI (urinary tract infection) prophylactic related to personal history of urinary tract infection. Order date 6/13/2024- (admitted ). Start date 6/14/2024. R16's Progress Notes, dated 7/24/2024, documents the following: (R16) remains on prophylactic antibiotics. No signs of adverse effect or complaints. R16's Care Plan, dated 6/26/2024, documents the following: R16's urinary tract infection is related to chronic history of UTI. Intervention: Obtain and monitor lab/diagnostic work as ordered. Report results to V17 (R16's Physician) and follow-up as indicated. On 8/14/2024 at 11:10 AM V2 (Director of Nurses) stated, R16 was admitted to us with this antibiotic in place. R16 is hospice, so we just left her on the Macrobid (antibiotic). No labs or urinalysis have been done for (R16) to indicate that (R16) has a UTI. 30678 2. On 8/12/24 at 10:54 am, R51 stated she is on an antibiotic for a UTI (urinary tract infection) and has not had any problems with it. R51 stated Today is the last day. The urine laboratory results for R51, dated 7/29/24, documents a urine culture was obtained for R51. This laboratory result does not document R51 with a current urinary tract infection. This form has a handwritten physician order to administer the Antibiotic Macrobid, even though the colony count for R51 was not indicating infection due to symptomatic. The current Physician Orders for R51, document a Physician Order dated 8/5/24 for R51 to start Macrobid 100 mg (milligrams) bid (twice daily) for seven days for symptomatic urinary with no infection noted. The Progress Notes for R51 documents the following: 8/5/24 Received new order for Macrobid despite no infection noted for symptomatic urinary issues and 8/6/24 Remains on Macrobid for urinary issues but has no active infection at this time, temperature 97.9 degrees. On 8/15/24 at 8:40 am, V3 (Infection Control Preventionist) stated she believes that R51 had a urinary tract infection. V3 confirmed R51's urine culture did not indicate R51 with a urinary tract infection due to the colony count not being high enough but R51's Physician decided to treat her anyway.

Based on observation, interview, and record review, the facility failed to ensure proper diagnoses and targeted behaviors were in place for psychotropic medications for two residents (R53 and R49) of three residents reviewed for psychotropic medications in a sample of 27. Findings include: The facility's Psychotropic Medication Use policy, revised 10/24/22, documents Definition - Psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental processes and behavior. Procedure - 1. Psychotropic medication is prescribed for a diagnosed condition and not being used for convenience or discipline .2.1 The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors .2.1.3 Staff should become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for a specific behavior type .5. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms .13. When Physician/Prescriber orders a psychotropic medication for a resident, facility should ensure that Physician/Prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. 14. If Physician/Prescriber orders a psychotropic medication in the absence of a diagnosis Facility should ensure that the ordering Physician/Prescriber reviews the medication plan and considers a gradual dose reduction (GDR) of psychotropic medications for the purpose of finding the lowest effective dose unless a GDR is clinically contraindicated. 14.1 Physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. 1. On 8/12/24, at 12:32pm, R53 sat quietly in the Dining Room eating with assistance. On 8/13/24, at 1:25pm, R53 sat quietly in the lounge area eating a cookie. On 8/15/24, at 10:20am, R53 sat quietly in the Activity room smiling while watching the game being played. R53's current Physician Order Sheet/POS documents diagnoses including but not limited to Unspecified Dementia without Behavior Disturbance, Restlessness and Agitation, and Insomnia; there are no diagnoses for Anxiety or Depression. R53's Medication Administration Records/MARs for July and August 2024 includes orders for Lorazepam Oral Tablet 0.5 mg (milligrams) (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days and Trazadone HCl (Hydrochloride) Oral Tablet 100mg Give 100 mg by mouth at bedtime for insomnia related to Primary Insomnia. R53's July MAR documents R53 received Trazadone every evening and Lorazepam on 7/1, 7/3, and 7/31/24. There is no documentation of any behavior on this MAR or in R53's Nursing Progress Notes. R53's August MAR documents R53 received Trazadone every evening and Lorazepam on 8/5, 8/10, and 8/11/24. There is no documentation of any behavior on this MAR or in R53's Nursing Progress Notes. R53's Behavior Summary Reports for 7/1/24 - 8/15/24, do not include specific targeted behaviors. On 8/14/24, at 12:05pm, V6 (Minimum Data Set/Care Plan Coordinator) stated that R53's indication for use of Ativan is anxiety and the indication for use of Trazadone is insomnia. V6 stated that the diagnosis for R53's Ativan is restlessness and agitation. V6 confirmed that restlessness and agitation are symptoms and was unable to locate a diagnosis of Anxiety from R53's clinical record. V6 stated that Trazadone is an Anti-depressant, but the diagnosis for Trazadone is insomnia. V6 was unable to locate a diagnosis of Depression from R53's clinical record. On 8/15/24, at 10:15am V2 (Director of Nursing) stated there are no individualized targeted behaviors documented for (R53) or (R49). V2 confirmed that they go by the generic behaviors that the CNAs (Certified Nursing Assistants) track. V2 also confirmed that R53's list of diagnoses do not include Anxiety or Depression and should. On 8/15/24, at 1:47pm, V19-V21 (CNAs) stated that R53 gets antsy at times, but does not have any aggressive or harmful behaviors. 30678 2. The current Physician Orders for R49 document R49 is currently receiving the following psychotropic medications: Duloxetine 60 mg/milligrams daily, Mirtazapine 7.5 mg in the evening and Ativan 0.5 mg three times daily. On 8/12/24 at 9:45 am, 8/13/24 at 9:38 am, 12:03 pm, and on 8/14/24 at 8:40 am and 12:00 pm, R49 was alert and oriented, up in a wheelchair in his room, in the dining room, or lying in bed with eyes closed and without behaviors. On 8/14/24 at 9:20 am, V2 (Director of Nursing) stated R49 came to the facility as a Hospice patient, is alert and oriented with periods of confusion and is currently receiving psychotropic medications for Anxiety and Depression. V2 stated R49 has not had any behaviors related to his Depression or Anxiety but generally does well. V2 stated, We have not had any behaviors from him. On 8/14/24 at 10:00 am, 10:07 am, and 10:12 am, V10, V11, and V12 CNAs stated R49 is alert and oriented with periods of confusion, able to make needs known and has not had any behaviors, other than refusing cares at times and will reproach at later time with no problems. On 8/15/24 at 10:15 am, V2 stated the staff just chart any behaviors that R49 might have in the progress notes and on the Behavior Tracking sheets. V2 confirmed there are no specific targeted behaviors for R49.

Based on interview and record review the facility failed to implement fall interventions for a resident at risk for falls for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 experiencing an unwitnessed fall, subsequently sustaining a left hip fracture requiring surgical repair. Findings include: R1's Admission Fall Risk Assessment, dated 2/2/24 documents that R1 is at risk for falls. R1's Baseline Care Plan, dated 2/2/24, documents that R1 requires one-person physical assist for locomotion on the unit. This form documents that R1 is cognitively impaired. R1's baseline care plan does not have fall or safety interventions in place. R1's Restorative/Rehabilitation Evaluation, dated 2/2/24, documents that R1 requires extensive assist of one person for transfers. R1's Progress Notes, dated 2/11/24 at 6:45am, documents that R1 was awake at 4:15am. R1 was assisted to bed, but got out of bed. R1 was taken to the bathroom and fluids were offered, will continue to monitor. R1's Progress Notes, dated 2/12/24, documents that at 8:30pm, V4 (Licensed Practical Nurse/LPN) kept R1 by her side, due to R1 repeatedly trying to walk. R1 was given a stuffed animal to hold. V4 documented that she came out of a room after giving a medication and heard R1 say AH! R1 was rubbing her left knee. V4 documented that R1's knees were checked for injuries, but none were noted. R1 was asked if she could move her legs, which she did. R1 was assisted up to her wheelchair. R1 progress notes document that R1 was rubbing above her knees. V6 (R1's Primary Care Physician) gave orders for hip and knee x-rays. R1's Progress Notes, dated 2/13/24 at 12:45am, documents that R1 was crying out with facial grimacing and grabbing her left leg and hip area. R1 was sent to the emergency room for suspected hip fracture. At 4:14am, V3 (Registered Nurse) documented that R1 was being admitted to the hospital for a left hip fracture. V9's (Certified Nursing Assistant) signed Witness Interview Form, dated 2/12/24, documents that Resident (R1) frequently stands, self-transfers, walks around unsupervised. This form documents that R1 was one on one with the nurse while passing medications. On 3/13/24 at 10:30am, V7 (Registered Nurse/Minimum Data Set Nurse) stated that R1's base line care plan did not have fall interventions put into place. V7 verified that R1 should have had a completed care plan at the time of her fall. On 3/13/24 at 2:20pm, V1 (Administrator) stated that R1 had a history of falls prior to admission to the facility. V1 stated that the facility does not have the staff to do one on one care. On 3/13/24 at 2:50pm, V4 (LPN) stated that R1 was anxious and kept trying to stand up. V4 stated that the staff could not get their jobs done, so she took R1 with her during medication pass. V4 stated that she entered a room to give medicine then heard a Ah. V4 stated she went to check on R1 and she was on the floor. V4 stated that R1 was rubbing her knees but did not show signs or symptoms of pain. V4 verified that R1 had adverse behaviors often. V4 verified that R1 was out of sight for only a minute and fell . V4 stated that R1 did not get out of bed after returning from the hospital. The facility's Care Plans policy, reviewed 03/13/24, documents that the resident care plan is initiated at the time of admission. This form documents that the care plan will include the following information but not limited: needs, concerns or problems identified during initial assessment of the resident. The facility's Falls and Incident Reporting policy, modified 10/31/23, documents that a Fall risk Assessment 2.0 Form is to be completed as soon as possible and practicable, within 24-48 hours as practicable, when a resident has sustained a fall. This form also documents that the resident's care plan is reviewed and revised as indicated. Approaches will be implemented for ongoing evaluation of interventions will be done on a resident individualized basis.

Based on observation, interview and record review the facility failed to develop behavior care plans for four residents (R1, R3, R5, R6) of six residents reviewed for care plans. Findings include: Social Service Director Job Description, Essential Duties and Responsibilities dated 6/5/17 documents: Complete MDS (Minimum Data Set) assessments (Cognitive, Mood, Behavior, Hearing, Vision, Speech, and Discharge) and identify problems, concerns, goals, and interventions through developing and updating the Plan of Care according to Federal and State Regulations. 1.) Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses of Dementia with Agitation, Alzheimer's Disease and Anxiety Disorder. R1's care plan did not include a developed focus area to address R1's multiple altercations with other residents or interventions to prevent further incidence. Current Physician Order Summary Report indicates R2 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Cognitive Communication Deficit and Anxiety Disorder. Incident Investigation Summary (undated) indicates on 10/13/23 R1 wheeled up (in her wheelchair) to R2 and was cursing at R2. Summary indicates R2 then grabbed R1's arm and tapped R1 three times. 2.) Incident Investigation Summary (undated) indicates on 10/16/23 R1 struck out at R3 because R1 thought R3 was in her room (R1 was in R3's room). Summary indicates a Stop Sign was applied to the doorway of R3's room to prevent other residents from entering. R3's care plan did not include focus area to include R3 as recipient of R1's behaviors or interventions to prevent future incidents. 3.) Incident Investigation Summary (undated) also indicates on 10/19/23 R1 wheeled up to R4 and slapped at/pushed R4's shoulder. 4.) Incident Investigation Summary (undated) indicates on 10/14/23 R1 slapped at R5 while sitting behind R5 in the dining room making light contact. Summary indicates R1 was moved immediately. R5's care plan did not include focus area to include R5 as recipient of R1's behaviors or interventions to prevent future incidents. On 11/2/23 at 2:30pm V3, SSD (Social Service Director) stated she is responsible for behavior care planning and R1, R2, R3, R4 and R5's care plans should have been either updated or developed after each incident. 5.) Email dated 6/23/23 at 12:05pm (from facility to Ombudsman) indicates R6 was having safety issues with her electric wheelchair. Email indicates R6 pinned a staff member against a soda machine, got the wheelchair footrests stuck under her bed - requiring assistance to get unstuck and (on 6/23/23) rammed her feet under her bed causing a gash on top of her foot requiring stitches. Email indicates R6 was very upset when told she must use a manual wheelchair until an electric wheelchair evaluation could be done. Email indicates the facility is also concerned about the safety of other residents. Nurse Note dated 8/10/23 at 10:15am indicates that when given a new manual wheelchair to use, R6 stated her plan was to move to another facility where she would be able to use her motorized chair. Note indicates at that time, R6 was advised that once insurance is submitted for a custom chair - her electric chair would no longer be covered. Note indicates R6 was adamant that she did not want a custom manual chair and wanted to keep her electric chair covered. Nurse Note dated 8/11/23 at 10:30am indicates staff told R6 the reason she is not allowed to use her electric wheelchair is because R6 cannot safely operate the chair. Note indicates R6 became agitated and yelling that it was the facility's fault. Nurse Note dated 9/12/23 at 2:00pm indicates R6 wanted to know when she would be getting her electric wheelchair returned. Note indicates R6 stated that her independence is being taken away. Nurse Note dated 10/4/23 at 10:30am indicates R6 upset and tearful over electric wheelchair - upset that she is not able to use motorized wheelchair in the facility. Nurse Note dated 10/5/23 at 10:06pm indicates R6 became very tearful in the dining room and was upset that she is not able to use her motorized chair. Note indicates R6 feels she is not able to do the things she would like to do because her chair is not comfortable. Note indicates R6 was worried about her warranty being voided on her motorized chair. Email dated 10/10/23 at 10:59am (Ombudsman to facility) indicates R6 is asking about her electric wheelchair Insisting it be returned to her. On 11/2/23 at 9:45am V1 (Administrator) stated (R6) is just not safe in the electric wheelchair. She is still upset, obsessed with losing her chair. Not rational when staff try to explain the reasons, she can't use it in the facility. On 11/2/23 at 1pm R6 was in her room in a large reclining wheelchair. At that time R6 stated I have to wait now for staff to take me wherever I want to go. I have no life now. I'm actively looking for a group home I can go to. I'm not happy here. R6's current care plan does not address R6's unsafe behavior or incidence as related to R6's electric wheelchair and does not address the resulting psycho-social impact on R6's wellbeing. On 11/2/23 at 3:00pm V1 (Administrator) stated she was unaware a care plan had not been developed to address the issues with R6's electric wheelchair or R6's difficulty adjusting to its loss. V1 stated V3 should have added these areas to R6's care plan.

Based on observation, interview and record review the facility failed to revise the comprehensive care plan for two residents (R2, R4) of six residents reviewed for resident-to-resident altercations. Findings include: Social Service Director Job Description, Essential Duties and Responsibilities dated 6/5/17 documents: Complete MDS (Minimum Data Set) assessments (Cognitive, Mood, Behavior, Hearing, Vision, Speech, and Discharge) and identify problems, concerns, goals, and interventions through developing and updating the Plan of Care according to Federal and State Regulations. Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses of Dementia with Agitation, Alzheimer's Disease and Anxiety Disorder. Current Physician Order Summary Report indicates R2 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Cognitive Communication Deficit and Anxiety Disorder. Incident Investigation Summary (undated) indicates on 10/13/23 R1 wheeled up (in her wheelchair) to R2 and was cursing at R2. Summary indicates R2 then grabbed R1's arm and tapped R1 three times. Summary indicates R2 stated that R1 had hit her first. R2's current care plan indicates R2 had a recent incident (10/13/23) of hitting another resident on the arm and R2 can become verbal with other confused residents and engage in yelling or arguments. R2's care plan was not revised to include any specific interventions to prevent further resident to resident altercations. 2) Current Physician Order Summary Report indicates R4 was admitted to the facility on [DATE] with diagnoses of Dementia without Behavioral Disturbance, Other Psychotic Disorder and Anxiety Disorder. Incident Investigation Summary (undated) indicates on 10/19/23 R1 wheeled up (in her wheelchair) to R4 and pushed/slapped at R4's shoulder. R4's current care plan indicates R4 wanders aimlessly and significantly intrudes on the privacy (of others) and/or activities. R4's care plan was not revised to include incident with R1 and did not include interventions to prevent further resident to resident altercation. On 11/2/23 at 2:30pm V3 (Social Service Director) stated she is responsible for behavior care planning and R2 and R4's care plans should have been either updated or developed after each incident.

Based on observation, interview, and record review the facility failed to monitor refrigerated medication storage temperatures. This failure has the potential to affect all 59 residents in the facility. The facility also failed to ensure refrigerated controlled medications were double locked for four residents (R27, R29, R40, R45) during review for medication storage. Findings include: 1.) Facility Policy/Storage and Expiration Dating of medications and Biologicals dated/revised 8/7/23 documents: Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Refrigeration: 36 degrees Fahrenheit (F) to 46 degrees (F). Facility should monitor the temperature of medication storage areas at least once a day. Facility Policy/Refrigerator Cleaning dated 7/23 documents: Midnight Licensed staff monitors the temperatures of all refrigerators on the nursing unit nightly and documents on the form provided. Report temperatures over 40 degrees (F) to maintenance as soon as possible. Resident Census and Condition Report indicates 59 total residents in the facility on 8/15/23. Refrigerator/Freezer Temperature Logs dated July and August 2023 document: Standard: 41 degrees (F) or colder - Refrigerator July 2023 Log - Temperatures documented only for July 19, 20 and 26 - 31. July 19 and 20 were documented at 30 degrees (F) and July 26 to July 30 were documented at 32 degrees (F). August 2023 Log - Temperatures only documented for August 1, 4, 6 - 8 and 11-16. On 8/17/23 at 11:35am V5 (Registered Nurse) stated night shift checks and records the temperature of the medication refrigerator. V5 confirmed there is only one medication room/medication refrigerator in the facility which receives medications for all facility residents. 2.) Facility Policy/Storage and Expiration Dating of Medications, Biologicals dated/revised 8/7/23 documents: Controlled Substances Storage: Controlled Substances stored in the refrigerator must be in a separate container and double locked. On 8/17/23 at 11:30am facility medication storage room contained one refrigerator with a latch that was unlocked with a padlock sitting next to the latch directly on top of the refrigerator. The medication room refrigerator contained unopened controlled medications for the following residents: Liquid Morphine (opiate/narcotic) - R27, R29, R40, R45 Liquid Lorazepam (benzodiazepine) - R45 V5 (Registered Nurse) stated I really don't know, but I'm assuming since there are narcotics in the refrigerator it should be locked. The narcotics in the medication cart need to be double locked.

Based on observation, interview and record review the facility failed to provide meals according to the menu. This failure has the potential to affect all 59 residents in the facility who receive meals from the kitchen. Findings include: Facility Policy/Menus dated/revised 2017 documents: Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. Resident Census and Condition Report indicates 59 total residents in the facility on 8/15/23. On 8/18/23 at 12:45pm V1 (Administrator) stated that all 59 residents in the facility receive meals from the kitchen. Facility Week at a Glance Menu, dated 8/8/23, documents that the scheduled Lunch Meal for 8/15/23 at 12:00 pm was Marinated Chicken Thighs, Sugar Snap Peas, Oven [NAME] potatoes, Dinner Roll and Chocolate Chip cookies. On 8/15/23, at 12:30pm, V4 (Dietary Manager) stated, Our menu is wrong. We prepared the wrong week's food on our Week at a Glance. The meal today should have been chicken thighs, peas, and potatoes, but my staff prepared ham, sweet potatoes, and spinach instead. We have new workers in the kitchen, and they messed up the weeks on our menu. On 8/16/23 at 11:15am All nine residents (R5, R8, R11, R12, R23, R28, R42, R46, R50) attending a group meeting at that time stated that meals were not following the menus posted and all nine agreed the meal served not matching the meal posted had been going on for a while and believed it was due to constantly changing dietary staff. Food Committee Meeting notes dated June 15, 2023 indicate Residents complained when meal tickets are made with changes, they don't always get what they have chosen. Food Committee Meeting notes dated July 20, 2023 indicate Residents are upset with menus being changed. They would like to know when menu is being changed.

Based on interview and record review the facility failed to provide/offer bedtime snacks to nine residents (R5, R8, R11, R12, R23, R28, R42, R46, R50) of nine residents who attended a group meeting in the sample of 27. Findings include: Facility Policy/Snacks dated/revised 9/2017 documents: Bedtime snacks will be provided for all residents. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. On 8/16/23 at 11:10 am, all nine residents attending a group meeting at that time stated that bedtime snacks were offered sporadically. We might get them, or we might not. Food Committee Meeting notes dated June 15, 2023 indicate Residents reported that the snacks aren't available or being passed out. On 8/16/23 at 2:53pm V4 (Dietary Manager) stated All CCD (diabetic) snacks are labeled. The bucket containing snacks is on the snack cart which is left at the nurse's station. CNAs (Certified Nurse Assistants) are supposed to go around and offer snacks at night. Sometimes the snack cart comes back in the morning and nothing has been touched including the CCD snacks.

Based on observation, interview, and record review, the facility failed to administer medications without touching with bare hands, cleanse a glucometer, perform handwashing between glove changes, cleanse a bedside table to prevent cross contamination, and change gloves with cares for five (R11, R29, R40, R42, R45) out of 24 residents reviewed for infection control in a sample of 27. Findings include: Facility Infection Control Glove Technique, dated 3/14, documents Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other resident or environments. Remove gloves, dispose of gloves in the regular trash, and wash hands or Facility Infection Control program policy and procedures, undated, documents Preventing the spread of infection procedures must be followed to prevent cross-contamination; including handwashing and/or changing gloves after performing personal care, or when performing tasks that provide the opportunity for cross-contamination to occur (i.e., facility equipment). 1.) On 8/17/23 at 10:37am, V7 (Registered Nurse/RN) went into R40's room to perform cares. V7 grabbed R256's overbed table to perform cares for R40. After cares for R40, V7 did not cleanse R256's overbed table. V7 then placed R256's overbed table back on R256's side of the room and left the room. On 8/17/23 at 10:37am, V7 (RN) stated I usually use a cleanser with 70 percent alcohol on the bedside table after I do cares for (R40). I did not have the cleanser on my cart, so I did not clean (R256's) table after I used it for (R40). 2.) On 8/17/23 at 9:21, R45 was in bed in her room. On 8/17/23 at 10:10am, V7 (RN) was performing wound cares with R45 when R45 became incontinent of stool. V7 grabbed R45's incontinence brief and pushed R45's incontinence brief full of stool together and down under R45's buttocks, and without changing V7's gloves, V7 used the same gloves to put on R45's new dressing. V7 then snapped R45's stool filled brief back on over R45's new dressing. On 8/17/23 at 11:55am, V7 RN stated, I should have changed (R45) when she was incontinent of stool and changed my gloves before doing the dressing change. 3.) On 8/17/23 at 1:15pm, R29 was lying in bed. At that same time, V10 (Certified Nurse Assistant/CNA) performed personal cares for R29. After performing personal cares for R29, V10 did not wash her hands or use waterless hand antiseptic between glove changes. V10 put on new gloves and put on R29's new brief. V10 did not wash her hands or use waterless hand antiseptic after changing her gloves and grabbed R29's two blankets and put on R29. On 8/17/23 at 1:20pm, V10 stated I should have washed my hands between glove changes. 4) Facility Policy/Glucometer Decontamination dated 2012 documents: The glucometer will be decontaminated with the facility approved wipes following use on each resident. After performing the glucometer testing, the nurse shall perform hand hygiene, don gloves, and use the disinfectant wipe to clean all external parts of the glucometer. A specific amount of contact time is not required for cleaning. A second wipe shall be used to disinfect the glucometer, allowing the meter to remain wet for the contact time required by the disinfectant label. The clean glucometer will be placed on a paper towel. On 8/17/23 at 11:30am V8 (RN) performed a blood glucose test for R11 which required extracting a drop of blood from R11's finger. After completing the blood glucose test, V8 administered insulin to R11, returned to the medication cart and put the glucometer back into the top drawer of the medication cart and closed the drawer. On 8/17/23 at 11:35am V8 stated I forgot to clean the glucometer, I usually clean after I used it. V8 then proceeded to remove the glucometer from the drawer, removed bleach wipes from the bottom drawer of the medication cart and wiped the glucometer for approximately 20 seconds and placed the glucometer on top of the medication cart. V8 stated she preferred to use bleach wipes, but product can change and All of them have different contact and cleaning times. Bleach wipe instruction for use indicate to clean/wipe surfaces of non-porous materials and to keep wet for three minutes. 5) Facility Policy/General Dose Preparation and Medication Administration dated/revised 1/1/13 documents: Facility staff should not touch the medication when opening a bottle or unit dose package. On 8/17/23 at 11:50am V5 (RN) dispensed one tablet of Reglan (antiemetic) 5mg (milligrams) into a medication cup. As V5 pushed the tablet through the foil seal, the tablet split into two halves. While preparing to administer the Reglan tablet to R42, the medication cup tipped over and both halves of the tablet spilled out onto the top of the medication cart. V5 then picked up both halves of the tablet with her bare hands, placed the halves back into their medication cup and administered the medication to R42. On 8/17/23 at 1:45pm V5 acknowledged she should have used gloves to pick up the Reglan from the cart before administering to R42. 34131

Based on interview and record review the facility failed to provide consents for influenza vaccinations and provide documentation of vaccination education/potential side effects for five residents (R10, R16, R40, R45, R50) of five residents reviewed for immunizations in the sample of 27. Findings include: Facility Policy/Infection Control Resident Immunizations and Vaccinations dated 7/31/17 documents: The resident's medical record shall include documentation that indicates, at a minimum, the following: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. On 8/17/23 at 11:00 am a request was made to V7 (Registered Nurse/RN) and V9 (RN/Infection Preventionist) for influenza and pneumococcal vaccination documentation including consents for five residents (R10, R16, R40, R45, R50). On 8/17/23 at 12:00pm a handwritten list of dates of vaccination for influenza (flu) and pneumatically vaccinations were presented for R10, R16, R40, R45 and R50. At that time V9 stated that she only verbally received consent for the flu vaccinations given to R10, R16 and R40 in October 2022. V9 stated that R45's flu vaccination was historical and R50 had no record of flu immunization although was admitted in February of 2023. V9 stated that there is no written consent or education on benefits or side effects in the medical records. The handwritten list of dates of vaccinations for R10, R16, R40, R45 and R50 indicates I called the families. They gave verbal consent, but it's not charted.

Based on observation, interview, and record review, the facility failed to have a bedside table for one (R49) of 24 residents reviewed for room furnishings in a sample of 27. Findings include: Facility Resident Room Furnishings Policy, reviewed 6/23, documents Each resident shall have a sufficient number of tables that can be either rolled over the resident's bed or that can be placed next to the bed to serve every resident. On 8/15, 8/16, and 8/17/23, R40 did not have a bedside table in her room. On 8/17/23 at 10:37am V7 (Registered Nurse) was unable to find R40's bedside table. At that same time, V7 stated I don't know where (R40's) bedside table went, and she should have one. Everyone has to have one for use.

Based on observation, interview and record review the facility failed to ensure one resident (R3) was safe to operate a motorized wheelchair of three residents reviewed for accidents. This failure resulted in R3 sustaining a foot laceration requiring stitches at the hospital. Findings include: Facility policy/Falls and Incident Reporting documents: Each incident involving a resident shall be documented on a standard Incident Report Form. All incidents are treated in that same manner. Incidents are identified as any event or occurrence out of the ordinary process of care including such events, but not limited to, the following: 2. Wheelchair accidents Current Physician Order Summary indicates R3 has diagnoses that include Cerebral Palsy, Quadriplegia, Anxiety and Bipolar Disorders. On 7/5/23 at 10:30am R3 was sitting in an electric wheelchair in the dining room during an activity. On 7/5/23 at 1:30pm R3 was in bed resting with her electric wheelchair at her bedside. R3's left foot had several layers of gauze and stretch bandages around her left foot and ankle. R3 became irritated and argumentative when questioned about her accident with her motorized wheelchair. R3 stated there was nothing wrong with the speed of the chair and no one was going to slow it down. Employee Incident Report of Injury/Incident dated 6/17/23 indicates V8 (Activity Aide) was helping R3 with the pop machine and when R3 moved closer she hit V8 with her power chair and pushed V8 into the wall and pinned V8 against the wall. Report indicates V8 reported (R3) couldn't stop (the chair). R3's medical record did not include any documentation or investigation of R3 pinning V8 against a wall or being unable to stop the wheelchair. Investigative Summary Report dated 6/23/23 at 7:15am indicates staff responded to R3 room due to R3 screaming. R3's electric wheelchair, which was occupied by R3 at the time, was facing R3's bed with the foot portion of the wheelchair being under R3's bed with R3's foot being trapped between the bed and the wheelchair. An injury was noted to R3's left foot with a 4.4 cm (centimeter) in length laceration to the upper portion of left foot with drainage and underlying exposed tissue. Summary indicates R3 stated she got her foot stuck under the bed. R3 was sent to the hospital for treatment and returned with six sutures. Nurse Note dated 6/23/23 at 7:37am indicates staff were called to R3's room, Large gash to top of left foot 4.4 inches long, fatty layer exposed. Note indicates efforts were made by staff to close wound and gauze wrapped to control bleeding; top of foot starting to bruise. Note indicates physician notified with orders to send to hospital via 911. Note indicates R3 stated her foot became stuck under bed while in electric wheelchair and obtained laceration to top of left foot. Nurse Note dated 6/23/23 at 11:14am indicates R3 returned from the hospital via ambulance with stitches to left foot and wrapped with supportive bandages. Nurse Note dated 6/23/23/at 11:52am indicates R3's Family/POA (Power of Attorney) was notified of incident of R3 running into her bed with her electric wheelchair causing injury to left foot. Note indicates this incident follows the incident regarding (R3) pinning a staff member against the vending machine causing her to be off work. Note also indicates Staff have had to get her electric wheelchair unstuck from her bed before. Note indicates This causes a safety concern regarding her and other residents. POA was notified of safety concerns and need for a wheelchair evaluation. A regular wheelchair will be used until the evaluations completed. Ombudsman updated with our concern with electric wheelchair and safety concerns. Nurse Note dated 6/26/23 at 4:03pm indicates staff spoke with motorized wheelchair company regarding R3 electric wheelchair, appointment made for them to come out and assess electric wheelchair and speeds, scheduled for 7/18/2023. Motorized Wheelchair Evaluation Form dated 2/6/23 (admission) and 5/3/23 (quarterly) both indicate R3: Does have a physical limitation that prevents R3 from accomplishing mobility-related activities of daily living. Does not have the mental capacity sufficient for safe operation of mobility-related functions with the use of a motorized wheelchair. Is unable to be trained for safe operation of a motorized wheelchair. Wheelchair Clinic Form dated 6/26/23 for Electric wheelchair indicates (R3) was assessed for her ability to operate her wheelchair in several environments. In close conditions within resident room during which (R3) had light contact with several objects due to delayed reactions with a possible solution being to reduce the top speed of the propulsion of her wheelchair in which (R3) was highly resistant to the idea. Wheelchair Clinic Form dated 6/26/23 for Standard wheelchair indicates (R3) evaluated for fit in a standard wheelchair following difficulties encountered in operation of her electric wheelchair with two accidents involved. On 7/5/23 at 2:30pm V7 (Restorative Registered Nurse) stated I do believe (R3) is a little at risk for accidents - a safety issue. I believe the speed needs to be reduced on the chair, but (R3) won't even hear of it. V7 stated he became aware of R3's accident with the employee through the nurse note later documented on 6/26/23. No one told me about the incident when it happened. I should have been told and I didn't know of any other incidents with her feet or footrests getting stuck under her bed until now. V7 stated R3's motorized chair was taken away after she injured her foot, but the other chairs didn't fit her right, so they had to put R3 back in her motorized chair. V7 stated they are unable to adjust the speeds so the company will come out to adjust. V7 further stated he didn't know why he documented that R3 did not have mental capacity to operate the motorized chair and couldn't be trained in the admission and quarterly assessments. Care Plan dated 2/17/23 indicates R3 has an electric wheelchair which R3 uses on a consistent basis with intervention to assess speed setting quarterly and as needed. Care Plan was not updated/revised to include R3 pinning staff against the wall, any incidents with R3's feet or footrests becoming stuck under her bed or the incident causing injury to R3's foot. On 7/6/23 V1 (Administrator) stated that the facility did not have a Motorized Wheelchair Policy or Consent until 7/6/23.

Based on observation, interview, and record review, the facility failed to ensure bed brakes were locked while providing care, failed to ensure two staff assist for bed mobility, dressing for two residents, and failed to provide the appropriate size bed for safe bed mobility for two (R1, R2) of three residents reviewed for falls. This failure resulted in R1 sustaining a scalp laceration with sutures, shoulder, and scalp contusions and an 18-centimeter skin tear. Findings include: R1 was admitted to the facility on [DATE] and has current diagnoses that include Lung/Brain Cancer, [CONDITION(S)] status post Stroke and Obesity. Current Comprehensive assessment dated [DATE] indicates R1 is severely cognitively impaired and is two (plus) person total assists with bed mobility, transfers, and dressing. Weight and Vital Signs record dated 8/4/21 indicates R1 weighs 189 pounds. Progress Note dated 8/2/21 at 6:16am indicates During cares at 5:25am, (R1) rolled out of bed and hit the floor face first. Note indicates R1 sustained lacerations to her head, large hematoma on right side (of head) and large skin tear from elbow to wrist on right arm. Note indicates ambulance was called and R1 was transferred to the hospital at 5:40am. Progress Note dated 8/2/21 at 9:20am indicates R1 returned from the hospital and is noted to have four sutures to top middle of head and one suture to right upper outer forehead; right posterior shoulder with approximate 2cm (centimeter) bruise, right forehead bruising and swelling; 3cm open area to right arm, 4cm wide by 18cm in length. Hospital Records dated 8/2/21 at 8:08am indicate R1 was seen on that date due to a fall and was diagnosed with a scalp laceration with sutures, scalp contusion, contusion of right shoulder and a skin tear of right forearm. Investigative Summary (Incident) Report dated 8/2/21 indicates that (V7, CNA/Certified Nurse Assistant) was providing cares to R1 in bed. Report indicates as V7 began to turn R1, the bed shifted forward away from V7 with R1 falling and landing front down and R1's head having contact with a bedside chest during the descent. Report indicates R1 is alert, and oriented to person only, non-ambulatory and dependent for all transfers. Report indicates Root Cause of fall: Bed moved as R1 was being turned for cares. Report indicates brakes on bed are functional. On 8/4/21 at 11:47am V7, CNA stated that R1 is total care - unable to move arms or legs, can't assist with any movement and that R1 is dead weight. V7 stated that she was almost done with care, pulled R1 toward her to get her pants on and the bed shot back and R1 rolled to the floor. V7 stated that the lock on the bottom of the bed unlocked, popped up and the bed shot over. V7 stated that she can provide care for R1 by herself including turning, dressing, and incontinent care. V7 stated there is nothing specific in their charting that tells them if a resident should be one assist or two. V7 stated that beds can be moved by housekeeping, maintenance, or other nursing staff and sometimes don't get re-locked. On 8/4/21 at 12:15pm V2, DON (Director of Nursing) stated that the staff providing the care to a resident is ultimately responsible to ensure the brakes are locked on a bed or a wheelchair. Facility Policy/Strategies for Managing Falls dated 2007 documents: Make sure bed is locked and in lowest position related to toileting needs. On 8/4/21 at 12:30pm V5 and V6 CNA's were transferring R1 from a chair into bed. At that time both V5 and V6 stated that they always have two CNA's to transfer R1 because she is a mechanical lift transfer. Both V5 and V6 stated that R1 only requires one staff to assist with bed mobility, dressing and incontinent care. V5 stated that the CNA's use an information sheet that's kept at the nurse's station to know how many staff are required to transfer a resident but the flow sheet does not identify how many staff should assist with bed mobility. On 8/4/21 at 1:45pm V3, Restorative Nurse stated, If I could get two CNA's to provide care for these heavy residents - I would. On 8/5/21 at 2:00pm V3, RN stated that the Bed should be locked for all care, not just toileting. Our policy needs to be updated and revised. V3 acknowledged that it is harder for both the CNA and on the resident to change, dress, and turn a totally dependent resident with only one person. V3 stated there is no assessment for bed mobility, CNA's just know how many it takes to care for the resident. V3 agreed if there had been two CNA's taking care of R1 before she fell , one of the CNA's may have been able to prevent the bed from moving and possibly prevented R1 from rolling out of the bed. Facility Policy/Positioning the Resident dated 2008 documents: To move a resident up in bed/When a resident is helpless: Two-person lift - two staff members may stand on the same side or on one side. Both staff members lift resident into desired position. To use a pull sheet under the resident - have a staff member on each side of the bed. 2) R2 was admitted to the facility on [DATE] and has current diagnoses that include Morbid/Severe Obesity, Diabetes Mellitus and Pseudobulbar Affect. Weight and Vitals Record indicates on 8/4/21 R2 weighed 346 pounds. Dietary Note dated 7/12/21 at 1:31 indicates R2 has a BMI (Body Mass Index) of 48.8/Class lll Obesity. Comprehensive assessment dated [DATE] indicates R2 is extensive assist of two staff for bed mobility and total assist of two staff for dressing. On 8/5/21 8:45am R2 was observed sleeping in bed on his right side. R2's body took up the entire width of the bed with his stomach/abdomen hanging off the right side of the bed. The bed was not wide enough to contain the entire width of R2's body. On 8/5/21 at 11:04am R2 was receiving care (incontinent, dressing) in bed by V8, CNA. No other staff was assisting V8 with R2's care. R2 could only minimally turn from side to side in the bed and had to hold on to the trapeze above the bed to assist in turning. Despite using the trapeze, R2 could not fully turn in the bed due to the small size of the mattress/bed. R2 refused to answer questions at that time. On 8/5/21 at 2:00pm V3, Restorative Nurse stated that he agrees R2 needs a bigger bed and that R2 has a bariatric reclining chair and should have a bariatric bed. V3 acknowledged that both R2's bed size and only one staff providing care could be a potential fall risk for R2. Current Care Plan indicates R2 had an actual fall on 6/3/21 with no injuries due to R2 leaning out of bed and R2's noncompliance with maintaining a safe bed position. Care plan also indicates R2 had an actual fall on 6/12/21 with injuries to right forehead, facial abrasions and foot injuries related to poor resident safety awareness and poor awareness of position in bed. Care Plan intervention dated 6/9/21 was to place a floor mat on the floor next to R2's bed. Care plan intervention dated 6/14/21 was to fit R2 for a reclining chair. No interventions were initiated to address R2's poor safety awareness or poor awareness of position in bed. Restorative Progress Note dated 6/7/21 at 4:20pm indicates V3, Restorative Nurse spoke to R2 Concerning safety in relation to R2's recent fall - specifically the height of the resident's bed to promote resident safety. Note indicates R2 was able to operate the controls for raising/lowering the bed and R2 was educated on the bed control keypad. This problem and intervention were not found on R2's current care plan. On 8/5/21 at 2:00pm V3, RN stated R2's poor bed positioning and interventions should have been implemented on R2's care plan. Current Care Plan indicates to use a draw sheet or lifting device to move R2 (in bed). Facility Policy/Positioning the Resident dated 2008 documents: To use a pull sheet under the resident: Have a staff member on each side of the bed.

Based on observation, interview, and record review, the facility failed to assess an assistive device and implement recommended safety precautions for the prevention of wheelchair slips and falls for one of 5 residents (R7) reviewed for falls, in a sample of 26. This facility failure resulted in R7 sustaining a closed [MEDICAL CONDITION] elbow and right hip. FINDINGS INCLUDE: The facility policy, Wheelchair Movement and Positioning Assessment, dated 5/31/19 directs staff, To promote pro action in maintaining resident safety, functionality and comfort for (facility) residents who use wheelchairs. A resident wheelchair movement and positioning assessment will be developed and incorporated. The wheelchair movement and positioning assessment will be completed for all residents who use wheelchairs on at least an occasional basis. The wheelchair movement and positioning assessment will be completed by the Restorative Nurse on the following basis: On admission or readmission to the facility. Quarterly in conjunction with resident ARD (Assessment Reference Date). Significant change of resident's condition and as needed or indicated by (the) resident's condition. The facility policy, Support Surface and Heel Lift Guidelines (2007) directs staff, The overall goal of any support surface is to evenly distribute pressure over a large area, allowing for blood flow to the skin and its supporting structures. Overall Recommendations: Assess products periodically to ensure they are being utilized per manufacturer's directions and are in good working condition. The manufacturer's Operations Manual for Dry Flotation Cushioning Products documents (Pg. 3), Precautions. Product use: This product is designed to be used as a cushioning device (wheel chair) to conform to a user's seated shape to protect skin tissue and aid in the prevention of tissue breakdown. Do not use on top (of) or in conjunction with another cushioning product. A cover is included with every standard cushion to help protect the cushion cells from protruding beyond the wheelchair seat. Because the cover is made with non-skid material, the cushion does not move in the chair. If properly fitted, the cushion will sit flat on the chair (non-skid material on the bottom). Make sure cushioning product is not too big or too small for the chair. Make sure non-skid bottom of the cushion cover is facing down. R7's current Physician order [REDACTED]. R7's current Minimum Data Set Assessment, dated (MONTH) 6, (YEAR) documents under Section G0300 (Functional Status) Balance During Transfers and Walking R7 is unable to move from a seat position to a standing potion, move on and off the toilet or transfer from surface to surface without staff assistance. On 06/17/19 at 9:34 A.M., R7 was lying on the floor in (R7's) room, yelling for help. At that time, R7 stated, The cushion and blanket in my wheel chair shifted when I leaned forward, when I was brushing my teeth. I slipped out of my chair No anti-slip cover was present over the cushion in R7's wheel chair. R7 was complaining of pain in the right elbow and right hip. R7 was unable to straighten (R7's) right leg or arm. At that time, V3/Registered Nurse/Quality Assurance Performance Improvement Nurse verified there was no anti-slip cover over R7's wheel chair cushion, to prevent R7' from slipping from (R7's) chair. On 6/17/19 at 10:00 A.M., V2/Director of Nurses stated, There should always be non-slip material under a wheel chair cushion. On 6/19/19 at 9:30 A.M., V5/Restorative Nurse stated, (R7's) family brought in that cushion, awhile back. We have not assessed that cushion for placement in R7's wheel chair. On 6/19/19 at 11:00 A.M., V3/Registered Nurse/Quality Assurance Performance Improvement Nurse stated, My understanding is (R7's) family brought that cushion in for (R7). It hasn't been assessed for (R7's) wheel chair. That specific cushion comes with a non-slip cover that encases the cushion to prevent slips from a wheelchair. All cushions that are added to a wheel chair are to be evaluated by the therapy department. I don't know why (R7's) cushion was not assessed by therapy. On 6/19/19 at 1:55 P.M., V6/Daughter/Power of Attorney stated, The facility has never informed us that the cushion in (R7's) wheelchair required a cover with a non-slip backing to help prevent (R7) from falling out of (R7's) wheelchair. If they had, we would have insisted on having that non-slip cover. (R7) has a broken right elbow and a broken right hip and (R7) is [AGE] years old. The doctor told us it is doubtful (R7) will ever fully recover from those injuries. R7's emergency room report, dated 6/17/19 documents,(R7) is a [AGE] year-old, who resides at (facility) who fell from (R7's) wheelchair today. (R7) was found to have an impacted femoral neck [MEDICAL CONDITION] hip and a complex right elbow fracture with lateral and medial epicondyle fractures and radial head fracture.

Based on record review and interview, the facility failed to perform timely cardiopulmonary resuscitative measures for one of four residents sampled with full code status in a sample of 11. This failure has the potential to affect the other thirteen residents in the facility whose status is Full Code (R3, R4, R5, R7, R9, R12, R13, R14, R15, R16, R17, R18, and R19). These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE] the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of newly implemented policies/procedures as well as to complete training for staff in emergency response. Findings include: The POS (Physicians Order Sheet) for R1 dated [DATE] documents the following Diagnoses: [REDACTED]. The same POS for R1 documents that R1 has full code status. Facility Policy on Cardiopulmonary Resuscitation (undated) received on [DATE] from E4 (ADON/Assistant Director of Nursing) documents the following: "Cardiopulmonary Resuscitation (CPR) will be initiated on all patients for whom this intervention is indicated. CPR will be initiated by any member of the Nursing Department who has been trained in this procedure. Determine unresponsiveness by tapping or gently shaking resident and shouting, 'Are you okay?' Call out for help. Early access to 911 is critical to the survival of the adult victim." Facility Policy on Automated External Defibrillator (AED) (undated) received on [DATE] from E4 (ADON/Assistant Director of Nursing) documents the following: "Initiate CPR according to center procedure and bring the AED to the location." The facility nurses notes for R1 dated [DATE] at 10:45AM document the following: "Apical pulse 60 beats per minute, Respirations 24 per minute, blood pressure ,[DATE], and oxygen saturation 51 percent on 2 liters of oxygen by nasal cannula. Lung sounds audibly congested, more than earlier this morning. Son in room and states he feels (R1's) condition has declined considerably in the past hour. Paged doctor at 10:55AM. Orders received to send to the emergency room . Called 911. Son here and informed." Facility nurses notes for R1 dated [DATE] at 11:01AM documents the following: "At nurses station getting transfer papers ready. (R1's) son came to the desk and said, 'I think we lost him.' Went to (R1's) room. Unable to detect pulse. No breathing. No verbal response. Left son in room and went down to the lobby to get LPN (Licensed Practical Nurse). Told LPN I needed help. As we were running back to (R1's) room EMS (Emergency Medical Response) team arrived. CPR (Cardiopulmonary Resuscitation) started after returning to room. Attempts were unsuccessful. Resident was transferred to hospital emergency room and was pronounced dead upon arrival." On [DATE] at 9:15AM E3 (DON/Director of Nursing) stated, "I received conflicting stories. The nurse in charge of (R1) left the resident knowing this resident had no pulse. She came to the desk for help and took the other nurse back to the room with her. EMS (Emergency Medical Response) had already been called. The two facility nurses and EMS got to (R1's) room at the same time. CPR was initiated at that time and not before as it should have been. (R1) was transferred to the hospital and never regained a pulse. In investigation of this, I felt the nurse should have stayed with (R1) and initiated emergency care, yelled for help rather than leave (R1) to go get help. I terminated this nurse. In her initial story, the nurse told me she did not leave (R1); however, in talking to the other nurse that assisted her, she came to the nurses station for help. I don't know why she did not use the AED. It was appropriate to be used in situations like these. I have been here for 4 months now. We have not had any inservices on emergency care since I started here." On [DATE] at 2:00PM E12 (RN/Registered Nurse) stated, "I was doing the paperwork for (R1's) transfer. I had called the doctor earlier about (R1's) declining condition. As I was working on paperwork for (R1's) transfer the son came to the nurses station and told me 'I think (R1) is gone.' I ran down the hall and checked for signs of life. There was no pulse or respirations. I left the son in (R1's) room and went down to the lobby to get help. I saw E13 (LPN/Licensed Practical Nurse) and told her I needed help. (E13/LPN) said 'okay' and I said, no I need help now. We both went back to (R1's) room and arrived at the same time as EMS. I've only been a nurse for 2 years and have never had anyone code on me. You can't start CPR alone so I ran and grabbed (E13/LPN). I am certified in CPR and AED use. I was aware the facility had an AED but had no idea where it was kept. I have not seen the facility policy on CPR or AED use. I was not aware of (R1's) heart condition. I didn't get a very good report on (R1) when I came on duty and spent a lot of time clarifying orders for (R1). This all happened near the end of working a 24 hour shift at the facility, and I was not thinking clearly. I stayed over my shift to do the documentation." On [DATE] at 2:25PM E13 (LPN) stated, "I was passing medications. (E12/RN) was at the nurses station. (R1's) son was standing near the nurses station and had a sad look on his face. (E12/RN) was going through some papers. I looked at (E12/RN) and asked if she needed me. I then saw the look on (R1's) son's face and took off down to the end of the hall to (R1's) room. (E12) followed me. I found (R1) unresponsive and just as I started to do CPR the EMS team arrived and took over. I am certified in CPR and in the use of the AED. It would have been appropriate to use the AED on (R1). I don't know why (E12/RN) didn't grab it." On [DATE] at 2:20PM Z4 (R1's attending Physician) stated, "Any delay in CPR can have a negative outcome on a persons survival chances. Whether one minute or ten minutes had elapsed I cannot say whether this patient would have survived. I felt (R1) was discharged from the hospital before (R1) was well enough to go to the nursing home. I had been (R1's) doctor for over two years and knew (R1) wanted to be a full code. (R1) still had a wife at home and was worried about leaving her without any help. I explained to (R1) what CPR might do but those remained (R1's) wishes." On [DATE], E4 (ADON) provided a facility roster and a list with resident names highlighted in yellow. E4 stated the names on the facility roster highlighted in yellow are residents who have Full Code status. The names highlighted were R3, R4, R5, R7, R9, R12, R13, R14, R15, R16, R17, R18, and R19. On [DATE] at 3:30PM an Immediate Jeopardy was identified to have begun on [DATE] when the nurse on duty failed to begin CPR for R1 who was a Full Code. On [DATE] at 3:40PM E1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. [DATE]-The Medical Director, Administrator, and DON (Director of Nursing) developed and implemented a policy requiring quarterly CPR and AED inservices for all nursing personnel. 2. [DATE]-The Medical Director, Administrator, and DON developed and implemented a policy requiring a color-coded identification system for residents with a physician's orders [REDACTED]. 3. [DATE]- The Director of Nursing and Assistant Director of Nursing conducted mandatory cardiopulmonary resuscitation (CPR) inservices including the color-coded system. The appropriate use of an AED was discussed in detail. This inservice was provided to all nursing staff both licensed and unlicensed. 4. [DATE]-Residents with a valid order for a DNR are designated on the resident roster. A list of residents with a DNR is posted at the nurse's station and on the medical cart.

Based on record review and interview, facility staff failed to accommodate a resident's need to avoid foods with bananas due to an allergy for one of two residents (R3) with identified food allergies in a sample of 11 residents. R3 had a reaction to the bananas in the dessert served requiring hospitalization for treatment of [REDACTED]. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 09/07/10, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of policies/procedures and to complete training for staff. Findings include: The POS (Physicians Order Sheet) for R3 dated 08/01/10 documents the following Diagnosis: [REDACTED]. The care plan for R3 dated 06/24/10 documents the following: Problem- Is allergic to Latex, [MEDICATION NAME], Sulfa, Iodine, Banana, and Nuts; Intervention- Notify kitchen of food allergies; check food trays for food that will cause reaction as needed. The dietary card for R3 received from the facility dietary manager on 08/31/10 documents that R3 has allergies to nuts, bananas, and grape jelly. The nurses notes for R3 dated 08/10/10 at 5:45PM documents the following: "Resident approached nurse at the desk and stated (R3) ate banana cake before realizing it contained bananas. Kitchen employee confirmed real bananas were used in the cake. Resident complained of being light headed, extremely cold and was having difficulty breathing. Oxygen was started at 2 liters by nasal cannula. 911 was called to transport to emergency room ." Hospital emergency room record for R3 dated 08/10/10 documents the following: "Patient complained of having eaten food product containing bananas then shortly after feeling cold and drowsy. Patient has a history of severe allergic reaction. Patient was given [MEDICATION NAME] by ambulance staff on route to hospital emergency room ." Same record for R3 documents that at 6:35PM R3 was given [MEDICATION NAME] 125mg (milligrams) IVP (Intravenous Push) and [MEDICATION NAME] 50mg IVP. R3 was discharged back to the facility at 11PM. Hospital Record for R3 dated 08/10/10 documents the following: "Diagnosis: [REDACTED]. Return if worsens. Follow up with physician in 1 month." On 09/02/10 at 3:40PM Z2 (Attending Physician) for R3 stated, "(R3) has had this happen twice. It takes a pretty severe reaction to need the medications (R3) was given to offset this reaction. I don't remember the reaction (R3) had a year ago but this recent one caused a rapid reaction." Nurses notes for R3 dated 08/10/10 at 11:00PM document the following: "Returned to facility with new order for [MEDICATION NAME] for 4 days which is to start on 08/11/10. Resident states he is still having some difficulty breathing. Lungs are clear." On 08/31/10 at 2:35PM E7 (RN/Registered Nurse) stated, "I worked that night. After (R3) came to me with complaints of shortness of breath and said what (R3) had eaten, I went to the kitchen and asked if there was bananas in the banana cake (R3) was served. The dietary supervisor said yes, there were real bananas in the cake. I immediately called 911. I also called (R3's) medical doctor. Facility dietary spreadsheet for 08/10/10 documents that banana cake was the dessert for the evening meal. On 08/31/10 at 2:58PM E6 (Evening Dietary Supervisor) stated, " I was serving the main meal that night and (E9/Dietary Aide) was serving desserts. We usually just take the desserts out on a tray and pass them out. (E9/Dietary Aide) gave (R3) a piece of cake. It was banana cake. Later, one of the nurses came to me and asked me if there was real bananas in the cake that (R3) was served. I called (E5/Cook), who had made the cake earlier that day, to verify that there was. (E5/Cook) told me that she had put real bananas in the cake for dessert that evening. I called (E8/Dietary Manager) after that, but I don't know what she did about it." On 08/31/10 at 1:35PM E5 (Cook) stated, " I got a call from the kitchen at home the evening of 08/10/10. (E6/Evening Dietary Supervisor) asked me if there were bananas in the banana cake I had made earlier that day. I told (E6/Evening Dietary Supervisor) yes and I laughed to myself. What else would be in banana cake? (E9/Dietary Aide) has been here long enough to know better." On 08/31/10 at 3:15 E8 (Dietary Manager) stated, "I heard about that problem. (E6/Evening Dietary Supervisor) called me upset because (E9/Dietary Aide) had served banana cake to (R3). (E9/Dietary Aide) was unaware it was banana cake even though it was on the menu and on (R3's) dietary card. When desserts are passed out to residents, the Dietary Aide is supposed to check the dietary card where the resident sits to make sure they get the appropriate dessert. This was serious. I followed up with (E9/Dietary Aide). (E9) did not realize she had done it. I told (E9) to be more careful. I have not inserviced the staff about dietary allergies as of yet. I'm still new to this position." On 08/31/10 at 4:30PM E9 (Dietary Aide) stated, " I though it was spice cake. I have worked here for 4 years and am usually pretty good on that and don't give (R3) things like that. I didn't know banana cake was on the menu. I didn't check the menu out that evening. No one has talked to me since this happened." On 08/31/10 at 2:10PM R3 stated, " I was told it was spice cake. The people in the kitchen did not know it had bananas in it. I didn't taste bananas in it, more spice and there was a lot of frosting on it. I had not eaten bananas in over [AGE] years. I tasted mostly spice. As I left the dining room I stopped and read the menu posted there and saw that banana cake was the dessert. I started to feel light headed, dizzy, cold with chills, and real sleepy. Then I started to get short of breath. The nurse checked me out and called 911. In the emergency room they gave me some medications through my vein and watched me for awhile then sent me back here. I stayed in bed for 2 days after I got back. I just didn't feel good. This happened to me here also about a year ago. I was served a muffin with nuts in it and had to go to the hospital then also." The nurses notes for R3 dated 07/06/09 at 7:47AM documents the following: (R3) had allergic reaction to banana nut muffin. Shortness of breath noted. Anxiety noted and difficulty breathing. Epi-pen ([MEDICATION NAME]) given in right thigh. Oxygen administered by nasal cannula at 2 liters. Blood pressure 149/93. Respiration 40 in one minute. Called 911 at 7:48AM and sent to hospital." On 09/03/10 at 9AM an Immediate Jeopardy was identified to have begun on 08/10/10 when R3 was served the banana cake and experienced an allergic reaction. On 09/03/10 at 9:15AM E1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. 09/07/10- Facility Nursing Home developed and implemented a new policy on food allergy awareness. Licensed personnel will notify the FSD (Food Service Director) and FSS (Food Service Supervisor) on identifying, documenting and monitoring food allergies. 2. 09/07/10- The Consultant Dietician inserviced the FSD and FSS on identifying, documenting and monitoring food allergies. 3. 09/07/10- The FSD reviewed the charts of all residents with identified food allergies and ensured the diet cards accurately reflected the residents' diet. A list of residents with food allergies was posted in the kitchen where the trays are prepared. The list will be revised by the FSD monthly (and as residents' needs change). 4. 09/07/10-The Consultant Dietician inserviced dietary aides and CNA's (Certified Nurse Aides) on the importance of reviewing the resident's diet card before serving and feeding residents.