Every finding on record at Moorings of Arlington Heights

Based on interview and record review, the facility failed to have sufficient evidence to confirm that a thorough investigation was conducted after a physical altercation occurred between two residents. This failure applied to two (R1 and R2) of four residents reviewed for abuse investigations. Record review of Resident R1's electronic health record revealed R1 was a cognitively impaired [AGE] year-old female with diagnoses including Alzheimer's Disease, Osteoarthritis, and Major Depressive Disorder.Record review of R1's clinical record and facility Incident Reports revealed an incident note dated 04/24/2026 at 18:33 (6:33 PM) documenting that R2 struck R1 on the left shoulder during an interaction in the activity and dining area. The note indicated that staff members were present in the immediate area but were unable to reach the residents in time to prevent the physical strike.Record review of Resident R2's electronic health record revealed R2 was a cognitively impaired [AGE] year-old male with diagnoses including atrial fibrillation, heart disease, dementia with other behavioral disturbances, and depression. R2's Comprehensive Care Plan identified a focus area for behavioral problems including restlessness, agitation, irritability, anger, and a documented history of aggressive behavior directed toward staff.Record review of R2's progress notes revealed a Behavior Note written by V7 RN/registered nurse on 04/30/2026 at 2:49 PM documenting that R2 was uncooperative with care, yelling, and verbally aggressive. The note further documented that R2 refused an Accu-Chek, refused to eat until seeing his wife, took Ensure at breakfast and lunch, took morning medications, and required 1:1 care for safety.Record review of R2's progress notes revealed a subsequent Behavior Note written by V8 RN on 05/01/2026 at 7:23 AM documenting that during a skin assessment, R2 started yelling, attempted to kick staff, and verbalized, Leave me alone. The note documented that R2 was uncooperative and unable to be redirected, after which he was kept comfortable in bed and offered fluids.Record review of the facility's investigative file for the 04/24/2026 incident revealed no written interview statements from the staff members present in the dining area, nor any documented interviews, cognitive screenings, or behavioral safety assessments of other residents residing on the unit or present in the dining area during the altercation.On 08/18/2026 at 12:30 PM, an interview was conducted with V3 CNA/certified nursing assistant. V3 stated he was present in the corner of the dining area watching the hallway when the incident occurred. V3 stated R2 was attempting to propel himself in his wheelchair and got stuck trying to squeeze through a narrow space between two female residents (R1 seated on the left and another female resident seated on the right). V3 stated that when R2 got stuck, he became mad and aggressive, lashed out, and struck R1 on the shoulder with his fist. V3 stated R1 screamed once, stating he hit me, and V3 ran over immediately to assist her and reported the physical assault to V6 RN.On 08/18/2026 at 12:45 PM, an interview was conducted with V6 RN. V6 stated her back was turned to the incident from the nurse's station in the dining area, but she heard a commotion from a moving chair before V3 CNA called her attention to the altercation. V6 stated V3 informed her that R2 was attempting to get into a space between residents, got mad when he could not fit, and struck R1. V6 confirmed that V3 was the only witness present in the area and acknowledged that V3 rotates monitoring duties every 20 minutes in the dining area.On 08/18/2026 at 11:15 AM, an interview was conducted with V1 Administrator. V1 acknowledged awareness of R2's documented history of agitation, irritability, and past aggressive behaviors. V1 stated he verbally interviewed the staff members present in the dining area following the altercation between R1 and R2 but confirmed he neglected to keep or maintain any written notes or interview statements from those staff members. Record review of the facility's investigative file lacked written documentation of a thorough investigation.

Based on interview and record review, the facility failed to provide adequate supervision during staff-assisted wheelchair transport and failed to ensure staff were informed of a resident's known fall risks and resident-specific safety precautions prior to providing care for a resident. This failure applied to one (R3) of four residents reviewed for accidents and supervision. Record review of R3's electronic health record revealed R3 was an [AGE] year-old female admitted to the facility on [DATE] for rehabilitation following a fall at home caused by leaning forward, which resulted in a closed head injury and a stable odontoid fracture. The odontoid fracture was managed conservatively with an Aspen cervical collar, and her diuretics were discontinued due to orthostatic hypotension concerns. R3's diagnoses included Parkinson's disease, history of falls, and urostomy, for which she experienced difficulty managing independently due to the Aspen collar. She was actively receiving anticoagulant therapy, specifically Eliquis. A Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 15, reflecting intact cognitive functioning. R3's current Care Plan identified her as a high fall risk, requiring staff assistance for all mobility, transfers, and care due to impaired balance, Parkinson's disease, and the presence of the Aspen cervical collar. Review of facility Incident Reports, Progress Notes, and Hospital Records revealed that on 06/01/2026 at approximately 6:45 PM, CNA V5 was transporting R3 via wheelchair inside her room toward the bathroom. During transport, R3 leaned forward, lost balance, and fell forward out of the wheelchair, striking her face on the floor. R3 sustained a right forehead hematoma, and due to her baseline usage of Eliquis, emergency medical services were dispatched. R3 was emergently transferred to the hospital Emergency Department on 06/01/2026. Hospital documentation dated 06/01/2026 confirmed a right forehead hematoma and noted CT scans of the head and cervical spine were unremarkable for acute intracranial injury, after which R3 was discharged back to the facility. On 08/18/2026 at 12:15 PM, an interview was conducted with V4 RN. V4 stated she was the nurse on duty on the night of the incident. V4 stated V5 CNA came to get her after the fall to perform an assessment. V4 stated that R3 was initially assessed as okay to go back to bed, but because R3 was on blood thinners and hit her head, she was sent to the emergency room later that evening between 11:00 PM and 12:00 midnight. V4 acknowledged that R3 was wearing a neck brace, had a history of falls, was a known fall risk, and was doing okay with one-person assistance, but leaned over too much during the transfer and fell.On 08/18/2026 at 1:55 PM, an interview was conducted with V5 CNA. V5 stated she was working as PRN staff and had only worked with R3 a few times previously. V5 stated that the licensed nurse assigned to R3 did not inform her of R3's fall risk status, care plan safety interventions, or specific clinical precautions prior to the shift. V5 stated that while pushing R3 in the wheelchair toward the bathroom, R3 suddenly bent and leaned forward without warning, causing the fall. V5 acknowledged she was unaware of R3's high fall risk status or care plan precautions when initiating the transfer. On 08/18/2026 at 2:10 PM, an interview was conducted with V2 Director of Nursing. V2 confirmed that R3 was a known high risk for falls with a history of leaning forward, wore an Aspen collar for a prior odontoid fracture, and was on Eliquis. V2 verified that direct care staff, including PRN agency and temporary staff, must be informed of resident care plans and fall precautions prior to providing care, and that staff should provide adequate supervision and transport precautions necessary to prevent R3's fall. Review of facility Policy Number HCC4, titled Assessment, Documentation and Care Planning for Residents at Risk for Falls or Who Have Fallen, revised 01/05/2025, revealed that the facility's purpose is to ensure appropriate risk assessment, documentation, and care planning are completed for residents at risk for falls or who have fallen. The policy mandates that in the event of a fall, staff must assess, develop interventions, and revise the plan of care, ascertain injuries, address factors for the fall, and complete appropriate documentation. The policy further requires staff to complete a post-fall analysis with the resident and unit staff working at the time of the incident to determine the root cause and obtain staff input on risks and prevention, as well as initiate neuro checks if there is any indication the resident hit their head.

Based on observation, interview, and record review the facility failed to ensure a resident was transferred safely and, in a manner, to prevent resident injury. These failures resulted in a resident (R1) sustaining a leg laceration during a resident transfer. The resident was sent to a local hospital where she required fourteen sutures to repair her leg laceration. These failures apply to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: A facility incident report and progress notes dated 1/20/25 showed R1 was found by staff to have a large, bleeding laceration to her right lateral lower leg, immediately after being transferred from her wheelchair to bed by V5 Certified Nursing Assistant (CNA). The incident report showed, Per CNA (V5) when transferring resident, her right leg scraped on the enabler piece of the resident's bed frame. The progress notes showed R1 was assessed by V4 Registered Nurse (RN) and found to have a 10 cm (centimeter) x 1 cm laceration to her leg. 911 was called. R1 was transported emergently to a local hospital for an evaluation and treatment. R1's hospital discharge notes dated 1/20/25 showed R1 was treated for a large laceration to her right lower leg that required fourteen sutures to repair. R1 was discharged back to the facility on [DATE]. R1's progress note dated 1/21/25 showed R1 was provided with a new bed. R1's progress note dated 1/23/25 showed R1 was started on antibiotics due to developing redness to the wound on her right lower leg. R1's admission record showed R1 was admission care plan dated 1/13/25 showed R1 was admitted to the facility with diagnoses of spinal stenosis, history of falling, muscle weakness, unsteadiness on feet, and dementia. R1 was cognitively impaired. R1's transfer assessment dated [DATE] showed R1 required the assistance of 1-2 staff members for transfers. On 1/29/25 at 9:38 AM, R1 was seated in a wheelchair with a large gauze dressing noted to her right lower leg. R1 stated she didn't remember what happened to her right leg, but she remembers her leg was bleeding. R1 was unable to state when the incident happened or who was with her at the time of the incident. This surveyor's interview with R1 was limited due to R1's impaired cognition. On 1/29/25 at 10:24 AM, V5 CNA stated, on 1/20/25, she (V5) had wheeled R1 in her wheelchair into her room to provide cares. V5 stated she transferred R1 from her wheelchair to the toilet (by herself), using a gait belt. While R1 was seated on the toilet, V5 placed R1 in a nightgown for bed. V5 stated R1 had no bleeding from her right leg at that time. V5 then transferred R1 back into her wheelchair (using a gait belt) and wheeled R1 over next to her bed. V5 transferred R1 from her wheelchair to her bed with a gait belt. V5 stated, Once I got her on the bed, I noticed her right leg was bleeding. I got the nurse and that's when we saw that she cut her leg on a screw that was sticking out of the bed. Her leg must have scraped against the screw when I put her on the bed. V5 stated, She never fell . That night, (R1) was tired. She seemed confused. This was my first-time taking care of (R1). I didn't know how she was supposed to be transferred. I asked her if she could stand, and she said yes. (R1) kept saying I'm ok so I transferred (R1) myself. I didn't realize she had hit her leg. On 1/29/25 at 12:04 PM, V4 RN stated she was called into R1's room, by V5 CNA, on 1/20/25. V4 stated she found R1 seated on the side of the bed with a bleeding wound to her right leg. V4 stated, It appeared that when (V5 CNA) was getting (R1) into bed, her leg brushed against her bed frame where a small (metal) projection was sticking out . On 1/29/25 at 12:33 PM, V2 Director of Nursing stated R1's bed was exchanged for another bed on 1/21/25 because she felt it's what caused her injury. We wanted to prevent further injury. On 1/29/25 at 1:30 PM, V8 (R1's Physician) stated he had been R1's physician for the past twenty years. V8 stated R1 was recently transferred from assisted living to skilled care due to a physical and mental decline in condition. V8 stated, She (R1) is definitely declining. She has become more confused. She (R1) can't stand up without assistance. She (R1) has severe spinal stenosis and chronic pain. V8 stated, Yes, I would expect she be transferred in a way that she does not get hurt. When she was in assisted living, she required one assist for transfers. Since being admitted to skilled care, she is bordering on needing a (mechanical) lift for transfers. She (R1) would need at least a two person assist now .

Based on observation, interview, and record review the facility failed to ensure the dishwasher final rinse sanitizer solution concentration was at the required level. This has the potential to affect all 51 resident's residing in the facility. The findings include: The CMS-671 dated 4/15/2024 lists total residents at 51. On 4/15/2024 at 10:15AM, a test strip was run by V8 Dietary with V9 Food Service Director present. Color of the test strip was a light pink/purple color correlating with the 10 result color on the color chart being used by staff. On 4/15/2024 at 10:15AM, V9 said the result should be 10-50 and thinks the log might be the wrong one. On 4/15/2024 at 11:03AM, V9 said the dishwasher isn't delivering the chemical and unsure why. V9 said the machine washing in that area is stopped for now and a company has been called to come look at the machine. V9 said that dishwasher is used for resident dishes in the building. V9 said the larger pots and pans are sent to the other kitchen. On 4/15/2024 at 11:55AM, V8 said she normally works in a different area. V8 said she just received some additional education today regarding the dishwasher and 10 is too low for that machine. V8 said she thought it was the wrong log for the machine. V8 said she didn't check the dishwasher in the morning, but [V7 Dietary] did. On 4/15/2024 11:59AM, V7 said she checked the machine in the morning, and it was low. V7 said sometimes the machine comes back low and sometimes high. V7 said it was low this time. On 4/17/2024 at 9:38AM, V9 said the machine was inspected and there was a crack in the line that pulls the chemical in. The facility provided Dish machine Temperature Record (Low Temperature Machine) shows chlorine rinse reference range as (50-99ppm). The facility's Dish machine Temperatures policy revised 1/24, states Low Temperature Machine Wash Temperature 120F, Final Rinse Sanitizer Solution Concentration 50-100ppm (parts per million) sodium hypochlorite (chlorine) on dish surface in final rinse (minimum of 100F).

Based on observation, interview, and record review the facility failed to protect R7 from being verbally abused by a staff member for 1 of 16 residents (R7) reviewed for abuse in the sample of 16. The findings include: On 04/15/2024 at 10:44AM, R7 was sitting in a wheelchair in her room. V15 CNA-Certified Nursing Assistant was not in the facility. On 04/15/24 at 10:44 AM, R7 said, when the V15 first came into my room, she was fine, then she (V15) got irate about something that was said or done. She (V15) started pacing back and forth saying something. After she (V15) left the room, I turned on the call light so I could get help to use the bathroom. Then she (V15) came back in. She (V15) said, I do not have time to help you; I put adult briefs on you, use it. I told her (V15), that is not how things work here. She (V15) then left the room. Then came back in and said, I like you. Then she (V15) started pacing back and forth. I told her (V15) to go, just go. I will use the adult brief. She (V15) then got irate, put me in the chair, pushed me into the wall in the bathroom, then got me back into bed very roughly. She (V15) was like two different people. My roommate described her (V15) as sometimes a bumble bee other times a hornet's nest. When she pushed me into the bathroom, I was scared, petrified. I was not hurt physically but I was frightened. R7's Abuse Investigation by V1 Administrator dated 03/29/24 at 8:20AM, shows, Verbal Abuse Substantiated-The allegation was verified by evidence collected during the investigation. The evidence does support that V15 CNA was verbally abusive toward R7. R7's Physical Therapy assessment dated [DATE] at 4:38PM, shows, R7 needs substantial/maximal assistance for toilet transfers. R7's Occupational Therapy assessment dated [DATE] at 3:00PM, shows, R7 needs substantial/maximal assistance for toilet transfers. R7's current Care Plan on 04/15/24 shows, Incontinence/Bladder: R7 is at risk for complication associated with incontinence such as skin breakdown, infection, and need for extensive assist with her toileting needs. The facility Abuse Policy revised 01/16/24 shows, abuse the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing.

Based on observation, interview, and record review the facility failed to follow their policy to investigate a bruise/injury of unknown origin for 1 of 16 residents (R33) reviewed for injuries of unknown origin/abuse in the sample of 16. The findings include: R33's care plan dated 3/2/24 showed R33 was cognitively impaired related to her diagnosis of dementia. The plan showed R33 was legally blind, hard of hearing, and required staff assistance for all activities of daily living. On 4/15/24 at 9:30 AM, R33 was asleep in a high-back wheelchair located in the doorway of her room. A nickel-sized, light purple bruise was noted to R33's right temple/forehead area. On 4/15/24 at 9:30 AM, V4 Registered Nurse (RN) was asked about R33's bruise. V4 stated, I noticed the bruise sometime last week. The CNA (certified nursing assistant) brought it to my attention because he said the bruise wasn't there the day before. She hasn't had any falls. I am not sure what happened. She can't tell us what happened. Her skin is really thin, so I just thought she hit her head on something or rubbed her head. V4 stated she did not report R33's bruise to V2 Director of Nursing/DON or V1 Administrator. V4 stated she did not document R33's bruise/change in skin condition. On 4/15/24 at 11:35 AM, V5 Family of R33 stated she was notified of R33's bruise one day last week when I was visiting. V5 stated she did observe a bruise to R33's right forehead/temple area last week. On 4/16/24 at 8:17 AM, V6 CNA stated, I noticed (R33's) bruise one day last week. It was much darker initially. I don't exactly remember what day but she didn't have the bruise the day before, so I reported it to (V4 RN). If we notice a new bruise on a resident, we are to report it to a nurse right away so they can do an investigation. (R33) can't tell us how it happened. V6 stated he did not document R33's bruise/change in skin condition. On 4/16/24 at 8:47 AM, V2 DON stated R33 did have a discoloration to her head but she bruises easily. V2 DON stated R33 could not explain what caused the bruise due to her impaired cognition. V2 stated V4 RN did not report R33's bruise to her when it was found by V4. V2 DON stated bruises or injuries of unknown origin should be investigated. V2 DON stated no investigation had been done in regard to R33's new bruise. The facility's Prevention of Abuse, Neglect, and Exploitation policy dated 1/16/24 showed, Injuries of unknown origin may be indicators of abuse which may include, but are not limited to bruising, swelling, increased pain, changes in behaviors or physical indications that are different than the resident's baseline. Nursing staff is responsible for reporting unusual occurrences, including the appearance of bruises, lacerations, or other abnormalities observed. Upon report of such occurrence, a registered nurse is responsible for assessing the resident, reviewing the documentation, and immediately reporting the occurrence to the Abuse Coordinator (Healthcare Administrator) .

Based on observation, interview, and record review the facility failed to provide ADL (activities of daily living) assistance to residents that required staff assistance for toileting/incontinence care for 2 of 16 residents (R218, R31) reviewed for activities of daily living in the sample of 16. The findings include: 1. R218's care plan dated 4/12/24 showed R218 required the extensive assistance of staff for toileting. The care plan showed R218 had a history of urinary incontinence. On 4/15/24 at 9:36 AM, R218 was seated in a wheelchair in his room. A strong odor of urine was noted in the room. A circular, wet area was noted to the groin area of R218's sweatpants. R218 stated, I'm wet. I called someone to help clean me up. R218 stated he had been up in the wheelchair since 6:00 AM. R218 stated he was last toileted around 6:00 AM. At 9:40 AM, V3 Certified Nursing Assistant (CNA) entered R218's room. R218 stated to V3 CNA, I'm wet. V3 CNA stated to this surveyor, He was up in the wheelchair when I started my shift this morning at 7:00 AM. I haven't toileted him yet today. V3 CNA propelled R218, in his wheelchair, into the bathroom and assisted him onto the toilet. 2. R31's care plan dated 3/29/24 showed R31 required extensive to limited assistance of staff for transferring and toileting. The care plan showed R31 had a history of urinary incontinence. On 4/15/24 at 9:45 AM, R31 was seated on the side of her bed, dressed in pajamas. A strong odor of urine and stool was noted in R31's room. When R31 was asked when she was last toileted and/or had her incontinence brief changed, R31 stated, Sometime last night. At 9:47 AM, V3 CNA entered R31's room. V3 CNA took R31 into the bathroom. As V3 pulled back the adhesive clasp on the left side of R31's brief, R31's brief immediately dropped to R31's ankles due to the heaviness of R31's brief. R31's brief was saturated with dark yellow urine and stool. R31's buttocks were pink in color. V3 CNA stated this was the first time she had toileted or changed R31 since she started her shift at 7:00 AM. On 4/16/24 at 10:20 AM, V3 CNA stated staff are to toilet or change residents every two hours. The facility's Activities of Daily Living policy dated 6/30/23 showed every resident in the facility will maintain their abilities in Activities of Daily Living which included bathing, dressing, toileting, transferring, and eating. The policy showed, Resident who is unable to carry out Activities of Daily Living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure a resident with an extensive need for assistance was repositioned for one of two residents (R16) reviewed for ADLs (activities of daily living) in the sample of 19. The findings include: On 3/14/23 at 11:30 AM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/14/23 at 12:30 PM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/14/23 at 2:00 PM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 8:30 AM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 11:30 AM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 12:55 PM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 1:35 PM, V3 (Nurse Manager) stated that the residents who need extensive assist for ADLs are turned at least every two hours. V3 stated that the CNAs (certified nursing assistants) document it on the kiosks that are stationed near the resident's rooms on the unit, after a task is done. On 3/15/23 at 2:00 PM, this surveyor reviewed the documentation, with V3, on the kiosks. The following was documented for R16: Bladder care on 3/14/23 at 6:19 AM, Bowel care on 3/14/23 at 9:56 PM, Morning care at 6:36 AM on 3/15/23. No other documentation for R16's repositioning was documented on 3/14/23 or 3/15/23. On 3/15/23 at 2:15 PM, V3 stated that the care plan is developed by the inter-disciplinary team and the family and, that is the actual care that is carried out for that resident. V3 also stated that to ensure that an order is carried out, the staff documents it after it is done or signs off on it. V3 stated that if it's not documented, it is considered as not done. On 3/16/23 at 1:17 PM, V7 (certified nursing assistant) stated that he repositions R16 every couple hour. V7 stated that if R16 is not repositioned, she would get a bedsore. R16's face sheet, printed on 3/16/23, showed her date of admission to the facility was on 2/18/2020 with diagnoses to include pressure ulcer of heel stage 3, Alzheimer's disease, muscle weakness, unspecified dementia, and severe protein-calorie malnutrition. R16's facility assessment printed on 3/16/23, showed R16 had severe cognitive impairment and required extensive assistance of two staff for Activities of Daily Living (ADLs). R16's POS (Physician Order Sheet) showed an order, dated 8/11/22, to reposition frequently. R16's Care Plan, initiated on 3/3/23, showed a problem of fragile skin and poor skin turgor. The interventions included, encourage to turn and reposition while in bed and in wheelchair. The facility policy number FT686, revised on 8/15/22, showed, Statement of Policy Promote the prevention of pressure injury development B. Plan/Intervention Redistribute pressure (repositioning, protecting heels etc.).

Based on observation, interview, and record review the facility failed to ensure PPE (personal protective equipment) was worn in a manner to prevent cross contamination for one of two residents (R48) reviewed for infection control in the sample of 19. The findings include: On 3/14/23 at 11:33 AM, R48 was observed with a large sign on the door of his room that said, STOP Enhanced Barrier Precautions. The signage had illustrations to show gloves and gowns must be worn when inside the room. The sign clearly stated gloves and gowns to be worn when high-contact resident care activities were performed. The care activities included, but were not limited to transferring, providing hygiene, changing briefs or assisting with toileting, and when a urinary catheter was in use. On 3/15/23 at 10:14 AM, the enhanced barrier sign was still on R48's door. This surveyor entered the resident's room and observed V4 (CNA-Certified Nurse Aide) standing next to R48 at the toilet. R48 had a urinary drainage bag attached to his right, upper thigh. V4 was assisting R48 to transfer from the toilet to the wheelchair. V4 wore gloves but was not wearing a gown. On 3/15/23 at 1:08 PM, V4 (CNA) was questioned regarding the enhanced barrier precautions for R48 and stated, I guess it is because he has a foley catheter. My understanding is a gown is only necessary in a COVID positive room. I am a travel aide and honestly the whole thing wasn't explained very well to me. This is my first time working in this facility and I am still learning the ways here. I don't wear gowns in the enhanced barrier rooms. I just wear gloves and use hand sanitizer before and after care. At 1:54 PM, V4 approached this surveyor and stated, I did go get clarification on that sign. The nurse told me the special precautions are for any resident with a foley catheter, wounds, feeding tube, and stuff like that. We do have to wear the gown and gloves when giving care. It is an extra form of protection against spreading germs. I probably should have had a gown on earlier. On 3/15/23 at 2:03 PM, V4 donned gloves and a gown then entered R48's room. V4 explained to R48 she was going to empty the urinary drainage bag attached to his thigh. V4 opened the drainage nozzle on the collection bag and drained the urine into a beaker. V4 was touching the tip of the nozzle with her gloves, resting the nozzle on the side of the beaker, and allowing the nozzle to float in the urine container. V4 closed the nozzle with her gloves and reinserted the nozzle into the bag holder. V4 did not alcohol off the nozzle before or after emptying the urinary bag. V4 went to the bathroom and dumped the urine into the toilet. V4 noticed R48's pants were wet and decided to change the leg bag into his nighttime, full collection bag. V4 continued wearing the same gloves and got the nighttime bag from the bathroom, which she laid on the floor next to the bed. V4 disconnected the leg bag tubing and connected the nighttime bag tubing. V4 did not alcohol any tubing during the process. R48's nighttime bag quickly filled with urine. V4 opened that bag and drained the urine into the collection beaker. V4 closed the nozzle and reinserted it into the bag. Again, V4 did not alcohol off the nozzle before or after emptying the nighttime bag. R48's nighttime bag remained lying on the floor during the entire bag exchange. V4 dumped the second beaker of urine into the toilet. Returned to the bedside and touched the wheelchair, bed linens, and assisted R48 to a lying down position. V4 finally removed her contaminated gloves that she had first donned upon entrance to the room and had continued to wear during the entire catheter care process. On 3/16/23 at 11:26 AM, V2 (Director of Nurses/Infection Control Preventionist) stated gowns are to be worn inside any enhanced barrier precaution room if there is prolonged resident contact. It is important for infection control. The gowns stop the spread of any secretion or fluids. Gowns protect staff so they don't become infected with an organism that a resident may have. It is important to stop the spread of germs to other residents and/or staff members. V2 said aides should be sanitizing catheter tubing with an alcohol swab before reinserting the drainage tubing back into the collection bags. Tubing should be sanitized before connecting to a different collection bag. Gloves should always be changed between dirty and clean areas. Fresh gloves are needed before touching anything. It is important to prevent the spread of contaminates to other surfaces. Catheter bags should not be placed on the floor. It is not a clean surface. There is the potential for the spread of organisms and infections, like UTIs (urinary tract infections). R48's March 2023 Physician Order Sheet showed the indwelling catheter was ordered on 2/28/23 and the Enhanced Barrier Precautions implemented the next day on 3/1/23. The facility's Enhanced Barrier Precautions policy dated 11/1/22 states under the procedure section: EBP will be implemented for all residents with any of the following- .indwelling medical devices (e.g. central line, urinary catheter, feeding tube, .) . The policy further states: 11. PPE, gloves and gowns, will be required for all staff providing high-contact care activities which include: .changing briefs or assisting with toileting, indwelling device care or use .urinary catheter . The facility's Standard Precautions policy last review dated 9/14/22 states: Gloves should be changed during care of residents to prevent cross contamination from one body site to another. The facility was unable to provide a policy related to changing urinary catheter collection bags.

Based on observation, interview and record review the facility failed to ensure a resident was free from abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: 1. R1's Final Report Investigation dated 7/22/22 documents on 7/19/22 at 12:15 PM, V4 (CNA-Certified Nursing Assistant) observed R1 sitting in her wheelchair with a gait belt fastened to her wheelchair and wrapped around her abdomen. This appeared to be a safety precaution to keep R1 from falling. V5 (RN- Registered Nurse) asked (R1's) private caregiver (V8) why this occurred. V8 admitted to using the gait belt in this fashion because she needed a personal break to use the washroom and she was concerned for R1's safety V8 admitted she used the gait belt inappropriately . The allegation of abuse was substantiated. V8 admitted to using the gait belt to keep her within her wheelchair. V8 is not allowed back in the facility. The agency has assigned a new care giver with education about resident abuse and restraints. R1's face sheet show's she is an [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired and has physical and verbal behaviors towards others. R1's nurses note dated 7/19/22 documents (R1) with caregiver (V8). CNA notified nurse (V5) about V8 using the gait belt wrapped around the wheelchair to R1's abdomen. V5 talked to V8 about the restraint and how it is illegal and a form of abuse. V8 stated it's the hospice person who told her to do that when (R1) gets agitated and was trying to stand up unassisted. On 9/6/22 at 9:00 AM, R1 was observed in the dining room. V8 (Perpetrator) was observed sitting next to R1 assisting her during the breakfast meal. On 9/6/22 at 1:35, V1 (Administrator) stated V8 (caregiver/perpetrator) was prohibited from coming into the facility because the allegation of abuse was substantiated. This surveyor notified V1 of R1's assigned private care giver is V8 (caregiver/perpetrator) at this present time. V1 was visibly shocked and did not know V8 (caregiver/perpetrator) was in the facility caring for R1. On 9/6/22 at 10:27 AM, V7 (CNA) stated on 7/19/22 she was called to assist R1 to the bathroom. V4 stated when she entered R1's room, she was in her wheelchair with the gait belt wrapped around her abdomen and the belt tied to the wheelchair arm handle. V7 stated she reported this to V5 (RN). On 9/6/22 at 1:00 PM, V4 (Social Services) stated she interviewed V8 (caregiver/perpetrator) regarding the incident. V4 stated V8 said she confined R1 to the wheelchair using the gait belt because she had to use the bathroom. V4 stated she notified the private caregiver agency and told them V8 was not allowed to come back in the building. On 9/6/22 at 11:47 AM, V10 (R1's POA- Power of Attorney) stated she was notified of a private care giver using a gait belt incorrectly. V10 stated she was informed the private care giver was no longer permitted to work with R1. V10 said she was not informed who the private caregiver was. On 9/6/22 at 12:30 PM, V11 (Manager for Agency) stated she was notified regarding the incident with R1 and V8. It was reported to her V8 secured the gait belt to R1's wheelchair. V11 stated the facility reported they did not want V8 back in the building and we notified V12 (Staff Manager for Agency). On 9/6/22 at 1:33 PM, V12 (Staff Manager Agency) stated V8 reported to her she had worked a 12-hour day and the facility was understaffed and she had to use the bathroom. V12 stated V8 reported to her securing R1 to her wheelchair with the gait belt. V12 explained to V8 that is something we don't do and V8 stated, I know. V12 said anytime there is an incident we remove the caregiver right away. V12 stated she spoke with V10 (R1's POA) and she requested V8 to continue to care for R1. V12 said she spoke with V3 (Interim DON) regarding V10's request for V8 to continue to care for R1 and she was okay with V8 returning to the facility. V12 stated V8 returned to the facility on [DATE] and has been caring for R1 two days a week. V12 stated R1 does not remember who V8 is, but she gets along with her. 2. The facility's Final Incident Report dated 7/22/22 documents resident's family shared a picture of (R1) with a sheet tied to her bed apparently confined to her bed. The picture was taken by a private caregiver .The facility staff member assigned to R1 the evening was V9 (Terminated CNA). V9 confirmed she tied the bedsheet to the bed to prevent (R1) from getting up. The allegation of abuse is substantiated. V9 admitted to tying a sheet to the bed. V9 was terminated by the facility. On 9/6/22 at 10:15 AM, V1 (Administrator) stated V9 was terminated over the incident. V1 stated V9 confirmed to tying the bedsheet to R1's bed rail. At 12:05 PM V1 stated residents should not be restrained because that would be abuse. A copy of the printed image was provided by the facility of R1 lying in bed with her eyes closed and the bedsheets tied to both siderails. The facility's Abuse Policy revised 2/2021 states, To ensure the safety and welfare of the residents and to ensure appropriate investigation, follow up and correction action is taken if abuse, neglect, misappropriation, of resident property or exploitation, including punishment and involuntary seclusion is suspected .All residents have the right to be protected from abuse, neglect, misappropriation of residents property, including corporal punishment and involuntary seclusion .The facility maintains a no tolerance philosophy for abuse persons to have engaged in such conduct will be terminated from employment and/or barred from access to the community as required . k. Misuse of restraints- chemical or physical control of the individual receiving services beyond physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to change and disinfect eye protection and face masks after caring for a COVID positive resident and before caring for COVID negative residents. The facility also failed to have signage for droplet precautions outside a COVID positive resident's room during a COVID-19 outbreak for seven of seven residents (R1, R10, R14, R30, R43, R46, R301) reviewed for infection control in the sample of 16. The findings include: On 1/4/22 at 11:11 AM, V6 Certified Nursing Assistant (CNA) entered R43's room to assist R43 with care. R43 did not have a face mask on. V6 was within six feet on R43. R43 was in a wheelchair next to the bed. V6 exited R43's room and did not remove, change, or disinfect her goggles and N95 mask. V6 walked around the unit caring for other residents and talking with staff. R43's room is located on the second floor in a locked dementia rehab unit. The unit had seven residents residing in rooms on the unit. On 1/4/22, R43's room door had two contact isolation signs and no droplet isolation sign during observations by two surveyors. On 1/4/22 at12:40 PM, R1, R10, R30, R46 and R301 were served lunch in the second-floor rehab unit and assisted by V6 and another CNA. R14 was in bed in R14's room. V6 brought lunch into R43's room. R43's face mask was under R43's chin. V6 cut up R43's food. After exiting R43's room, V6 did not remove, change or disinfect her face shield and N95 mask. V6 was asked why she now had a face shield on (instead of the goggles she had on earlier). V6 said they (goggles) didn't fit right. V6 then pulled two pairs of goggles out of her uniform pocket to show this surveyor. They were too small. V6 said she is the main person caring for R43 but assists with other resident care as well. V6 said R14 needs two people to help R14 so she helps the other CNA turn (R14) and stuff. V6 then returned to the dining area to assist the other residents as needed. On 1/5/22 at 9:42 AM, V2 Director of Nursing (DON) said on 1/1/22, R43 complained of watery eyes and congestion. R43 tested positive and told us then R43's brother who visited R43 (did not remember the date) had since tested positive for COVID-19. R43 couldn't remember the date. That's why R43 is on our dementia rehab unit. R43 is the only known COVID positive resident on the unit and the only resident on isolation. The facility's visitor log showed R43's brother last visited on 12/12/21. On 1/5/22 at 1:25 PM, V2 said (for COVID positive residents) full PPE is required goggles or a face shield and a N95 face mask when caring for the resident. A sign outside the door is posted to tell you the resident is on precautions and what PPE to wear. Placing isolations signs is important because we have an obligation to let anyone entering the room know what PPE (personal protective equipment) is recommended to prevent transmission. Contact isolation doesn't require eye protection. Droplet isolation requires an N95 mask and eye protection. Staff keep the same mask and eye protection on while caring for all residents. They don't disinfect or change them after caring for a COVID positive resident. I am not sure if that's per facility but that is what they are doing. V2 confirmed she is the facility's Infection Preventionist. On 1/5/22 at 2:22 PM, V4 Central Supply said she does not have trouble ordering PPE and receiving what is ordered. V4 said she had worked at the facility for over [AGE] years and the facility's current supply of N95's, goggles and face shields would not be considered contingency or crisis levels. We have about three weeks of PPE in stock and that was their norm. On 1/6/22 at 09:56 AM, V2 DON said V5 Licensed Practical Nurse developed symptoms while working on the subacute dementia unit (R43's unit) tested positive for COVID-19 and was sent home some time before lunch that day. V2 said V5 is a floater and works all areas of the facility. V2 said on 12/23/21, V5 worked in the assisted living area and was unsure where V5 worked prior to 12/23/21. On 1/6/22 at 10:32 AM, V2 said the facility declared an outbreak (COVID) on 12/22/21. The following second floor rehab unit staff tested positive for COVID: On 12/24/21, V5 LPN; on 12/26/21 V6 CNA; on 12/29/21 V13 social worker; and on 12/29/21 V14 maintenance worker for the health center. On 1/6/22 at 11:00 AM, V2 said it's not appropriate to wear same eye protection and N95 while caring for COVID positive and COVID negative residents. We now changed our practice to double masking (surgical mask over N95) and disinfecting eye protection. The other practice was in place before I came (four months ago). We learn from each other so thank you for pointing this out. The facility's rapid COVID testing log showed R43 tested positive for COVID on 1/1/22. R43's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's vaccination log showed R1, R10, R14, R30, R43, R46, R301, V5, V6, and V14 were fully vaccinated for COVID-19. The facility's 1/5/22 PPE supply log showed 10,080 KN95 face masks, 14,000 surgical masks, 1200 goggles, and 950 face shields. The log did not indicate the number of N95 face masks. The facility's 11/24/21 Interim PPE use and Extended/Re-use of PPE during COVID-19 showed the intent of the optimization strategies is to use these options as PPE becomes stressed, running low or if facility is out. As the supply of PPE returns to normal, standard practices should be resumed. Place TBP (Transmission Based Precautions) signage outside each resident's room. Facemasks should not be reused. Reuse of face mask is not recommended unless there used as a crisis capacity strategy in limited situations with extended use. Extended wear is considered contingency use. Reuse is considered crisis use. Disposable respirators should be removed and discarded after exiting the resident's room. Extended use refers to the practice of wearing the same PPE for repeated [NAME] contact encounters with individual or multiple residents without removing the PPE between resident encounters. Extended use may be implemented when multiple residents are infected with the same respiratory pathogen and residents are placed together in dedicated units/areas. When to discard respirators/facemasks: There are times that it becomes important to discard the mask due to significant chance of contamination. These circumstances should be cause to discard a respirator/facemask and to secure a new unused respirator/facemask. Discard following close contact with, or exit from, the care area of any resident co-infected with an infectious disease requiring contact precautions. The facility's 12/30/21 Interim Policy for Suspected or Confirmed Coronavirus showed healthcare facilities should not be using crisis capacity strategies at this time. Place signage on the use of specific PPE.

Based on observation, interview, and record review the facility failed to identify a pressure ulcer prior to becoming unstageable and failed to ensure preventative measures were in place for 1 of 6 residents (R12) reviewed for pressure ulcers in the sample of 16. The findings include: On 1/05/22 at 10:00 AM, R12 was sitting up in bed wearing a hospital type gown. R12 had an air mattress in place and stated, I have a sore to my backside. I got it here. I didn't have it when I came in. There is a nurse that looks at it once a week; she was here yesterday. R12 stated staff do not come in and turn R12 every couple of hours. R12 stated, Occasionally someone will come in and put a pillow behind my back. I try to turn myself in bed so it will heal. It would be nice if they did come in and help turn me. R12's Nurses Notes showed R12 was admitted to the facility on [DATE]. On 10/11/21 a CNA (certified Nursing Assistant) noted a blister to the right buttock. It was shown to the nurse practitioner during rounds, and she gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R12's Wound Skin Care Assessment Tools showed: On 10/13/21 she had a stage 2 pressure ulcer to R12's right buttock that was identified by the facility on 10/11/21 and healed on 11/8/21. On 11/4/21 R12 had a facility acquired, unstageable pressure ulcer to the coccygeal area that was identified on 11/4/21. The Wound Care Physicians Note dated 1/4/22 showed, Patient presents with a wound to (R12's) coccyx. (R12) has an unstageable (due to necrosis) to (R12's) coccyx for at least 53 days duration. There is moderate serous exudate. Past Medical History: Muscle Weakness, [CONDITION(S)], Diabetes Mellitus, [CONDITION(S)], and [CONDITION(S)]. Off-load wound; reposition per facility protocol; Turn side to side and front to back every 1-2 hours if able. R12's Care Plan dated 10/19/21 showed, R12 is at risk for skin breakdown. Coccygeal pressure injury will heal by next review. Turn and reposition R12 in bed and in wheelchair. On 1/05/22 at 2:10 PM, V8 RN (Registered Nurse/ Wound Care Nurse) stated, On 10/8/21 is when I first saw (R12) at 9:00 AM. I put a note in the computer. V8 reviewed the Wound Care Skin Assessment Tools for R12 dated 10/13/21 that showed 10/11/21 as the date the resident's wound was assessed. V8 stated, I didn't have a chance to put in the assessment right away. I documented it on 10/13/21. The right buttock wound healed on 11/8/21. A new wound that was facility acquired was identified to (R12's) coccyx on 11/4/21. It was unstageable when it was identified because there was slough in the wound so you cannot see the base of the wound. Staff are supposed to identify the pressure at any stage that they find it. Of course, ideally, they should find pressure at a stage I. R12 only has one wound to (R12's) coccyx now. The latest assessment was done yesterday on 1/4/21 and (R12) has an unstageable wound with daily dressing changes. The facility's Prevention and healing of pressure injuries and non-pressure related injuries policy (5/19/21) showed, Residents at the facility will not develop clinically avoidable pressure injuries. Residents admitted with pressure injuries will receive care and services to promote healing and prevent further injuries. Plan/Intervention: Implement individualized interventions to attempt to stabilize, reduce or remove each underlying risk factor. Prevention - redistribute pressure (repositioning, protecting heels.) Monitor/Evaluate: monitor and evaluate the resident's response to preventative efforts. Revise approaches as necessary. Nursing assistant observes and reports alteration in skin integrity. Notify the nurse of any change in skin condition. Nurse evaluates skin condition weekly or more often if indicated.

Based on interview and record review the facility failed to ensure bedtime snacks were offered to 1 of 1 resident (R11) reviewed for bedtimes snacks in the sample of 16. The findings include: On 1/5/21 at 11:00 AM, R11 stated, I am supposed to have crackers and cheese at bedtime because my doctor didn't want me to have low blood sugars during the night. It is on my meal ticket that I am supposed to have a bedtime snack, but they still didn't provide that. The Face Sheet dated 1/6/22 for R11 showed diagnoses including Type I Diabetes Mellitus with Ketoacidosis, Diabetic Autonomic [CONDITION(S)], Acute Kidney Failure, Obesity, [CONDITION(S)], Chronic Kidney Disease, Hypertension, and [CONDITION(S)] Disease. The MDS (Minimum Data Set) dated 10/13/21 showed no impairment of memory and cognition. The Physician's Note dated 12/20/21 for R11 showed, History of present illness: Is a resident of the health center due to diabetic management needs. History of labile Diabetes Mellitus and recurrent Diabetic Ketoacidosis. Bedtime snack: crackers and cheese ordered per patient choice of snack when reviewed by me. R11's Physician Order Sheet for January 2022 showed to offer a bedtime snack and stated, Patient should get cheese and crackers every night at 8:30 PM or 9:00 PM. R11's Physician Order Sheet for January 2022 showed R11 receives the following: [MEDICATION(S)] insulin 18 units in the morning and 8 units at bedtime; Novalog insulin 8 units at 8:00 AM, 12:00 PM and 5:00 PM. On 1/5/21 at 11:00 AM, during the group interview they stated, You can ask for bedtime snacks it is not a voluntary offering. They don't come around and ask if you want one. The residents in the group interview stated they would like bedtime snacks offered. On 1/06/22 at 8:50 AM, V2 DON (Director of Nursing) stated they have bedtime snacks available in the pantry and the residents have to request them. V2 stated bedtime snacks are not offered. V2 stated the residents on the first floor are alert and oriented and can ask for them. V2 stated it is different upstairs because those residents have memory problems. On 1/06/22 at 9:17 AM, V3 Director of Food Service stated, For bedtime snacks we assign a stocking sheet to a dietary aide. Then they gather what they need and deliver it to the units. We only have one resident that gets a snack all the time at bedtime because (R11) is diabetic and that is R11. (R11) is supposed to get a bedtime snack and it's delivered on (R11's) dinner tray because it is on the meal ticket. If nursing checks (R11's) blood sugar and its low nursing can grab additional snacks. Residents have to request snacks. The facility's HS (bedtime) Snacks policy (11/17/15) showed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. If necessary, in between nourishments are provided for residents as deemed necessary by the physician, registered dietician (RD) or designee, and/or at a resident's request. Bedtime snacks are in addition to three meals served daily, with no more than 14 hours between the start of dinner and breakfast.

Based on observation, interview and record review the facility failed to ensure a dependent resident was toileted, and failed to ensure incontinence care was provided for 1 of 13 residents (R21) reviewed for Activities of Daily Living / ADL's in the sample of 13. The findings include: On 2/23/2021 at 8:35 AM, R21 was observed sitting in a reclining wheelchair in her room. At 10:30 AM and 12:16 PM, R21's reclining wheelchair was in the same place in her room and did not appear to have been moved. On 2/23/2021 at 12:13 PM, this surveyor asked V3 (Licensed Practical Nurse) when R21 was last toileted and changed. V3 said that R21 is not typically changed for 4 hours or so. She said she is usually gotten up before breakfast and remains up throughout lunch time. V3 said she believes that R21 has not been changed or toileted yet. On 2/23/2021 at 12:16 PM, V6 (Certified Nursing Assistant/CNA) said she got R21 up at 7:30 AM and she had not been changed or toileted since. On 2/23/2021 at 12:20 PM, V5 (CNA) said he will be the one to provide incontinence care and toilet R21 after lunch. V5 verified she had not been changed or toileted by him since she got up. On 2/23/2021 at 1:31 PM, V4 and V5 both (CNA's) took R21 into her room to toilet her. Her incontinence brief was saturated with urine. V5 said that R21 is usually incontinent of urine and is not always able to communicate her toileting needs. V5 said R21 is dependent on staff for her ADL needs. He also said that incontinent residents should be checked and or toileted every 2 hours. R21's face sheet shows she is legally blind and has a [DIAGNOSES REDACTED]. R21's 12/17/2020 facility assessment, shows that she is cognitively impaired, is frequently incontinent of bowel and bladder, she is unable to walk, and requires extensive assistance of 2 staff for toileting and transfers. R21's care plan shows that she is incontinent of bowel and bladder and needs assistance from staff for toileting. The same care plan stated she should be checked for incontinence and changed if wet or soiled, and be toileted before and/or after meals and as needed. The facilities Activities of Daily living policy revised on 7/8/2020 states .Resident who is unable to carry out Activities of Daily Living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on interview and record review the facility failed to have an Infection Preventionist responsible for the facility's Infection Prevention Control Program. This applies to all 35 residents residing in the facility. The findings include: The facility's Resident Census and Conditions of Residents Form (CMS Form 672) shows there were 35 residents residing at the facility on 2/23/21. On 2/22/21 at 9:00 AM, V1 (Administrator) said that V2 (Director of Nursing) is the Infection Control Nurse. On 2/23/21 at 11:50 AM, V2 said that she started working at the facility on 12/29/20. V2 said that she is still working on getting the infection preventionist training done. V2 said that there is no one else in the facility that has done the Infection Preventionist training. On 2/23/21 at 2:21 PM, V1 (Administrator) said that there is a corporate person that has the training but she does not meet the criteria for the facility. The facility's Infection Control Policy revised on 6/22/20 shows, Infection Preventionist or his/her designee performs ongoing surveillance to prevent, as feasible, the onset and spead of infection. Follows policies set forth for suspected or confirmed pandemic infections.

Based on observation, interview, and record review, the facility failed to ensure resident rooms were cleaned and disinfected following treatment for [REDACTED]. The findings include: On (MONTH) 20, 2019 at 8:30 AM, signs were posted on the doors at the facility alerting visitors of a skin infection, and encouraging people to refrain from visiting, and to see a nurse if they must visit. Additional signs were posted throughout the facility including at the secretary's desk, on entry to the 1st floor, nurse's station and the elevator doors to the second floor. On (MONTH) 20, 2019 at 10:00 AM, R2 was observed on the second floor scratching her left side/back area. V5 (Registered Nurse) said R2 has a rash and was scratching when she took care of her on three days ago. V5 wheeled R2 to her room to do a skin check. R2's room had an isolation cart outside of room with sign enhanced precautions. V5 said staff have to wear gowns and gloves when providing direct care to all residents. V5 pulled up R2's shirt, she had multiple scattered round red areas to her right and left side of her back. R2 also had red round areas to her abdomen and bilateral breasts. On (MONTH) 20, 2019 at 10:30 AM, V8 (Certified Nursing Assistant) said residents were being treated for [REDACTED]. V8 said the 1st shift staff would shower resident in the morning after the treatment. On (MONTH) 20, 2019 at 9:07 AM, V2 (Director of Nursing) said when a resident is getting treatment for [REDACTED]. Residents should not return back to their room until their room is disinfected. The medicated cream remains on their body for 8- 14 hours then the resident receives another shower. On (MONTH) 20, 2019 at 1:15 PM, V4 (Housekeeping Manager) said nursing staff would notify housekeeping when a room needed to be disinfected following their day of treatment for [REDACTED]. V4 said disinfecting a resident's room following treatment for [REDACTED]. All items should be bagged for 14 days if they could not be laundered. There are no housekeeping staff after 3:30 PM. On (MONTH) 20, 2019 at 1:45 PM, V7 (RN) said I don't know how housekeeping kept track of which rooms needed to be disinfected following the day of treatment for [REDACTED]. On (MONTH) 20, 2019 at 2:13 PM, V3 (Cook County Health Department) said the day of treatment for [REDACTED]. This includes removing/bagging lines, disinfection of all surfaces including mattress and pillows. The facility should have tracking in place to show what time the resident received the medication and to coordinate cleaning of the resident's room. R2's nurse's note, dated (MONTH) 6, 2019 (8:41 PM), showed she received a shower with oral and topical treatment for [REDACTED]. R2's nurse's notes, dated (MONTH) 13, 2019 (9:39PM), showed R2 received his shower and topical treatment for [REDACTED]. On (MONTH) 20, 2019 at 2:00 PM, V2 said all showers are given during the day shift because housekeeping staff leaves at 3:30 PM. V2 said she did not track when a resident received treatment for [REDACTED]. V2 said she consulted with V3 regarding recommendations. 2. On (MONTH) 20, 2019 at 10:19 AM, R1 was observed in the common area with a fading rash to his upper arms and three small scabs to the top of his head. On (MONTH) 20, 2019 at 9:07 AM, V2 (DON) said R1 tested positive for scabies on (MONTH) 7, 2019. The nurse's notes, dated (MONTH) 6, 2019, shows R1 received a shower and [MEDICATION NAME] (topical medicated treatment for [REDACTED]. The nurse's notes, dated (MONTH) 12, 2019, documents received instructions from DON to reschedule R1's oral and topical treatment for [REDACTED]. R1's shower report shows R1 received a shower on (MONTH) 13, 2019 at 9:46 PM. The Physician order [REDACTED]. The facilities Scabies Elimination Checklist, dated (MONTH) 5, 2019, shows to Contact Laundry Service to remove and launder/dry clean all clothes .Call Housekeeping/schedule cleaning . 3. On (MONTH) 20, 2019 at 9:47 AM, R3 was in the hallway self-propelling in his wheelchair. He had a visible red rash to his arms. On (MONTH) 20, 2019 at 9:07 AM, V2 said R3 resides on the first floor and tested positive for Scabies on (MONTH) 5, 2019. We have been dealing with scabies since (MONTH) 2019. The nurse's notes, dated (MONTH) 28, 2019 (6:16PM), shows R3 received [MEDICATION NAME] treatment for [REDACTED]. R3's shower report showed he received his shower at 10:33 PM that evening. The Scabies Abatement Plan: Typical or Atypical report, dated (MONTH) 29, 2019, shows Housekeeping called:/schedule cleaning/remove cloth chairs .Clean the environment: remove stuff from drawers/clean items and clean drawer with disinfectant, scrub down bed/change sheets/blankets/pillows/towels vacuum THROUGHLY All with a completion date of (MONTH) 29, 2019 (1 day after R1's treatment). R3's Laboratory report dated (MONTH) 5, 2019 shows he tested positive for Scabies. The nurse's notes, dated (MONTH) 8, 2019 (9:58 PM), shows R3 is on contact isolation for scabies and the CNA gave R3 a shower, then topical medicated cream applied for scabies. R3's shower report shows he received a shower on (MONTH) 8, 2019 and (MONTH) 16, 2019, following the day of treatment for [REDACTED]. The facilities Scabies control policy revised policy (MONTH) 2019 states, III Procedure 6. Nursing staff-Follows treatment procedure for typical scabies infestation: Notifies Environmental Services to clean the room and launder clothing. Showers resident, clips and cleans finger and nails .applies topical treatment based on manufacturer's guideline. Applies [MEDICATION NAME] cream on skin leaves elmite cream on for 8-12 hours then showers resident again to remove cream

Based on interview and record review, the facility failed to identify a significant change in a resident's condition, which required emergency transportation to the hospital, for 1 of 3 residents (R1) reviewed for quality of care in the sample of 6, resulting in a delay of care. R1 is the subject of the complaint. The findings include: R1's facesheet shows he was admitted to the facility on (MONTH) 22, 2019, with a long medical history including high blood pressure, dementia, [MEDICAL CONDITION]. According to R1's Registered Nurse (RN), V6, on (MONTH) 16, 2019, R1 was very fatigued and had low blood pressure (BP). His wife, V11, was concerned that R1 wasn't acting right and needed to go to the emergency department. V6 charted R1's BP had been 89/50 on the facility's transfer form, dated 8/16/19. On (MONTH) 28, 2019 at 12:42 PM, V6 said she could not remember what R1's BP had been on the day she transferred him to the hospital, (8/16/19) but she would NOT consider a BP of 89/50 to be stable. R1's BP taken one day prior at 10:20 PM was 150/70. V6 also said nothing about R1's physical condition alarmed her that his condition was an emergency. After urging by R1's wife and consultation with the Nurse Practitioner, V6 called the non-emergency ambulance service to transport R1 to the emergency department. On (MONTH) 28, 2019 at 3:10 PM, V9, Operational Manager at Elite Ambulance Company, said a Basic Life Support (BLS) crew was sent to transport R1 to the local emergency department on (MONTH) 16, 2019. When his crew arrived, R1 was extremely lethargic and his BP was too low for their level of skill. After being advised by the ambulance company's medical control, V9's crew called 911 to have an Advanced Life Support (ALS) crew respond and transport R1. On (MONTH) 28, 2019 at 1:30 PM, V11 said R1 didn't look right on (MONTH) 16, 2019. V11 said R1 was very pale. V11 said the non-emergency ambulance crew came into R1's room and took his BP and told her it was too low and they could not take him to the hospital. She said someone called 911 to transport R1 to the emergency department. On (MONTH) 28, 2019 at 2:48 PM, V4, RN, said it is nursing judgement on whether to call a non-emergency transport or the emergency ambulance for an ill resident. She said, We can tell when someone needs an emergency ambulance. On (MONTH) 29, 2019 at 9:38 AM, V2, Director of Nursing (DON), said the nurse caring for the resident is the best person to evaluate a resident's condition. V2 said a prudent nurse would look at the resident's normal BP to compare to the current findings when there is any concern or change in their condition. V2 said nursing is always going to err on the side of caution; we would call an emergency ambulance if there is an ill resident who needs emergency care. V2 said they don't have a written guide for their nurses to evaluate a resident's change in condition. It depends on the nurse's judgement to assess the situation. The Elite Ambulance run sheet for R1, dated 8/16/19, shows R1's initial BP was 80/60 and he was diaphoretic (sweating profusely). The BLS crew reached R1 at 12:35 PM and they transferred care to the ALS crew at 1:26 PM. R1's medical record was reviewed and his average BP for (MONTH) 2019 was 130/71. The facility's transfer form for R1, dated 8/16/19, shows his BP was 89/50. BP on 8/16/19 deviated by 41 points systolic (top number of BP) and 21 points diastolic (bottom number of BP). The facility's Change in Condition Policy, revised 8/21/17, defines a clinically important change in condition as a deviation that, without intervention, may result in complications or death. V6's documentation in R1's clinical notes from 3:25 PM on 8/16/19 shows R1 departed the facility on a stretcher with the ALS crew at 1:24.

Based on observation, interview and record review the failed to identify and contain the spread of a communicable skin rash for 16 of 16 resident's (R1-R16) reviewed for infection control in the sample of 16. The findings include: The facility's Scabies Outbreak list dated (MONTH) 30, 2019 showed that on (MONTH) 26, 2019, the facility treated 16 residents (R1-R16) with a topical cream for scabies. The list showed as of (MONTH) 23, 2019, 12 residents (R1-R12) had developed a rash in the facility and of those 12 residents, 11 residents (R1, R3-R12) resided in the secured memory care unit on the second floor of the facility. The list showed R1 developed a symptomatic rash on (MONTH) 11, 2019 but did not receive treatment for [REDACTED]. The list showed R2 and R3 did not receive treatments for scabies until (MONTH) 26, 2019 despite R2 developing a symptomatic rash on (MONTH) 23, 2019 and R3 developing a rash on (MONTH) 12, 2019. On (MONTH) 29, 2019 at 11:20 AM, R1 and R3 were seated in the dining room on the second floor, in a group activity with 17 residents. R1 and R3 were observed with red rashes to their arms with notable itching to their arms during the group activity. On (MONTH) 29, 2019 at 11:15 AM, R2 was seated in the first floor activity room with 14 residents. R2 was observed with a red rash and notable itching. On (MONTH) 29, 2019 at 11:10 AM, V4 Medical Director stated during the months of (MONTH) and (MONTH) 2019, he treated multiple residents with a red rash in the facility including R1-R3. V4 stated, I didn't suspect scabies. I treated the residents for [MEDICAL CONDITION] so I didn't order for any of the residents to be put on contact isolation. On Friday (July 26, 2019), when (R1's) skin biopsy came back positive for scabies we began treating every resident with a rash and every resident on the second floor for scabies. When V4 was asked if he wrote orders for the residents, with rashes, to be on contact isolation for 24 hours after the first scabies treatment, V4 stated, I never wrote orders for anyone to be isolated anytime before or after the scabies treatment. I am not sure isolation would have made a difference. On (MONTH) 29, 2019 at 11:30 AM, V3 Nursing Supervisor stated none of the residents with rashes had ever been placed on contact isolation while having active rashes and were not placed on contact isolation after their initial treatment for [REDACTED]. V3 stated 2 CNA's (Certified Nursing Assistants), V14 and V15 had developed rashes within past week and received scabies treatment. V3 also stated she believed the facility was in the middle of an outbreak due to the number of residents with rashes. When V3 was asked if the facility had notified the local health department of the outbreak, V3 stated she was unsure if the health department had been contacted. On (MONTH) 30, 2019 at 1:35 PM, V2 Director of Nursing (DON) stated she felt that the facility did not sustain an outbreak of a communicable skin rash despite having 16 residents with rashes and one resident positive for scabies. V2 stated she did not declare an outbreak or isolate the residents with rashes because we didn't know what we were working with so we didn't consider it an outbreak. The rashes didn't all look the same V2 stated, The residents with rashes were seen by (V4 Medical Director) and treated but were not getting any better despite different treatments so we met last week and decided to just treat everyone with rashes for scabies because we didn't know what else to do. V2 stated none of the residents with rashes had ever been placed on contact isolation while having active rashes and were not placed on contact isolation after their initial treatment for [REDACTED]. On (MONTH) 31, 2019 at 9:16 AM, when V2 DON was asked how the facility identified an outbreak, V2 stated, I don't really have a good answer for that. I am newer here. I would have to refer to the policy. We would look to see if a group of residents developed the same infection but in the case of the rashes we didn't really know what we were dealing with. On (MONTH) 29, 2019 at 12:45 PM, V6 Vice President of Clinical Services stated she called the local health department on Friday, (MONTH) 26, 2019, when R1's biopsy results came back positive for scabies but they told me it wasn't an outbreak. V6 stated she did not report the rashes and R1's positive scabies result to the state agency. On (MONTH) 29, 2019 at 12:10 PM, V7 Epidemiologist for the local health department stated, Someone from the facility did call to tell us on Friday (July 26) they had a resident that was positive for scabies but they did not tell us about the 15 other residents and 2 CNA's that have rashes. They have an outbreak. An outbreak is defined as 2 or more symptomatic residents in a confined space or unit. They should have called us on (MONTH) 28, 2019, when (R1's) rash wasn't getting any better. Any resident that developed a rash should have been put on contact isolation immediately especially after a cluster of residents had also developed a rash. All residents treated for [REDACTED]. The facility's Infection Control Policy dated (MONTH) 6, (YEAR) showed, Outbreak- is the occurrence of more cases of a particular infection that is normally expected . The policy also showed, 2. Monitor residents for outbreaks or clusters of infections to institute precautions advantageously to prevent and control further outbreak of infections. Report infections or conditions to Illinois Department of Public Health (IDPH) and local health departments per IDPH guidelines and CDC (Centers for Disease Control) recommendations . The facility's Scabies Control policy dated (MONTH) 22, (YEAR) showed, 3. Isolates resident in a private room as able utilizing contact precautions . The Management of Scabies in Illinois Healthcare and Residential Facilities guide downloaded from the CDC website on (MONTH) 30, 2019 showed, 1) Healthcare workers and other employees should be suspicious of scabies in persons with a rash or pruritus (itching) that has gradually gotten worse . 4) Healthcare and residential facilities should place patients with signs and symptoms suggestive of scabies in contact isolation until the infestation has been ruled out or appropriately treated . Patients who have symptoms or have positive skin scrapings need to be placed in contact isolation and then for only 24 hours following appropriate treatment .

Based on observation, interview, and record review, the facility failed to ensure the dishwasher properly sanitized, and failed to ensure correct food time and temperatures were mainintained to prevent food born illiness. This applies to all the residents in the facility. The findings include: 1. The facility's CMS-672 dated 5/13/2019, shows, Census: 53 residents in the certified beds. On 05/13/19 at 9:45 AM, the dish washer control screen was red, and showed error call for service. A one gallon bottle marked sanitizer was on top of the dishwasher, with a plastic tube coming out of it into the dishwasher. A cap on the bottle that held the tube in the bottle, was loosely taped to the top of the bottle. V6, Food Service Director, tested the dishwasher sanitizer solution three times. The test strip showed zero parts per million on all three tests. On 5/13/19 at 9:45AM, V6 said, The test strip should read 100 parts per million to properly sanitize. I will call the service technician to fix the dishwasher. On 5/13/19 at 10:43 AM, two dietary workers were at the dishwasher. One of the staff members was on the left side of the machine, and the other on the right side of the machine. The staff member on the left removed a tray filled with plates from the dish washer after the cycle ended. The dish washer control screen was red and showed, error call for service. The cap on the sanitizer bottle was loosely taped to the bottle. A tray of silverware was then placed in the dishwasher by the staff member on right side of the dishwasher. The dishwasher cycle was started. The staff member on the left side of the dishwasher then removed the silverware after the cycle ended. The dish washer control screen was red and showed, error call for service. On 5/13/19 at 10:43AM, as one of the dietary staff placed a tray of silverware into the dishwasher, she said, I am washing the dishes with soap and then I put them in the dishwasher. We called the service person. We cannot fix it. We do not know what is wrong. On 5/13/19 at 1:15 PM, V18, Dishwasher Maintenance Vendor, said, I am going to look at the machine. The cap on the sanitizer bottle is broken. On 5/13/19 at 1:15PM, V6 said, I put a sign on the dishwasher that says do not use. 2. On 5/13/19 at 9:15AM, three pans with meat in the refrigerator were not covered. A sticker on the pans showed, Roast 5/12/19. The roasts were positioned directly under a fan that was blowing air directly on them. There was no cooling times located on the stickers. The cooling log for the food preparation area was not filled out. The page was blank. On 5/13/2019 at 9:15AM, V5, Dietician, said, The roasts were left uncovered to allow them to cool. If they are covered it will hold the heat in. On 5/13/19 at 9:24AM, V19, Health Care Cook, said, The roast is for the roast beef sandwiches to be served tomorrow (5/14/19). I did not fill out the cooling log. I will fill it out now. Let's see it, was around . On 5/14/19 at 12:20 PM, V5, Dietician, said, They are going to use the meat. I think they do a good job. I think they cooled the meat properly. They did not document the temperature and times. The food should be covered. On 05/14/19 at 12:27 PM, V19, Health Care Cook, said, I cooked the roasts Sunday early afternoon around 12:00PM, maybe between 11:30AM to 1:30PM; there were 3 roasts. They reached 70 degrees Fahrenheit at about 3:30PM, then 40 degrees Fahrenheit around 4:30PM, maybe .one hour after. I logged the cooling times and temperatures in front of you (5/13/19) the best I could remember from the day before (5/12/19). Cooling is done to eliminate bacteria growing. On 5/14/19 at 12:40PM, V17, Cook, said, The roasts were cooked the day before. They need to be cooled. This is done to ensure the food does not stay in the temperature danger zone. The sous-chef was pulled to do dishes and did not have time to wrap the roasts. On 5/14/19 at the Noon meal, all residents in the facility were offered the roast beef prepared on 5/12/2019. The (YEAR) FOOD CODE Unites States Public Health Services, United States Food and Drug Administration shows, Duties 2-103.11 Person in Charge. A primary responsibility of the person in charge is to ensure compliance with Code requirements. Any individual present in areas of a food establishment where food and food-contact items are exposed presents a potential contamination risk. By controlling who is allowed in those areas and when visits are scheduled and by assuring that all authorized persons in the establishment, such as delivery, maintenance and service personnel, and pest control operators, comply with the Code requirements, the person in charge establishes an important barrier to food contamination. An important duty of the Person in Charge is to make sure that any required temperatures are achieved or maintained when foods are cooked, cooled or held in a food establishment. By making it a duty of the Person in Charge to ensure that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced. This includes oversight of temperature monitoring to ensure: 1) that animal foods are being cooked to the required minimum temperatures to prevent the survival of pathogens that may be present (2-103.11(G)); 2) that cooked foods are being cooled rapidly to ensure that the growth of bacterial pathogens and toxin production is prevented (2-103.11(H)); and 3) that foods that require temperature control for safety are being held at temperatures that adequately prevent pathogen growth and toxin production (new 2-103.11(I)).

Based on observation, interview, and record review, the facility failed to ensure a resident was supervised during medication administration, and failed to ensure safe transfers. This applies to 4 of 16 (R8, R16, R24, R50) residents in the sample of 16 reviewed for safety. The findings include: 1. The Physician order [REDACTED].S.) dated through (MONTH) (YEAR), shows R16 has a [DIAGNOSES REDACTED]. R16's Speech Therapy Discharge Summary dated (MONTH) 3, 2019, shows R16's swallowing strategies include: pills one at a time in applesauce with liquid wash, one bite or sip at a time, alternate liquids and solids, upright posture during meals, and requires supervision with oral intake. The Minimum Data Set assessment dated (MONTH) 6, 2019, shows R16's cognition is intact, and requires extensive assist with transfers. On (MONTH) 14, 2019 at 10:07 AM, R16 was in R16's room, with 3 pills (1 large pill and 2 small pills) in R16's medicine cup, and a cup of [MEDICATION NAME] and applesauce on R16's bedside table. R16 stated, I'm having trouble taking my pills. R16 said the nurse said I couldn't take my morning medications at breakfast because state was here. R16 said the nurse came in, gave R16 10 pills in R16's medicine cup, and left the room. On (MONTH) 14, 2019 at 10:20 AM, V7, (Registered Nurse), said she gave R16 medications, and left the room. V7 said R16 takes medications with applesauce. V7 stated, I'll go back and make sure (R16) took them. On (MONTH) 14, 2019 at 11:46 AM, V3, (Assistant Director of Nursing), stated staff should not leave medications at the bedside table. Staff should make sure the residents take their medications before leaving the room. The facilities on Medication Administration Guideline Policy states, Do not leave meds at the bedside; be sure resident finishes all meds . 2. The Minimum Data Set assessment dated (MONTH) 6, 2019, shows R16's cognition is intact and requires extensive assist with transfers. On (MONTH) 13, 2019 at 10:23 AM, V15, (Certified Nursing Assistant), transferred R16 off the toilet without using a gait belt. 3. The Physician order [REDACTED]. The Minimum Data Set assessment dated (MONTH) 27, 2019, shows R24's requires extensive two person assist with transfers and toileting. The Fall Risk assessment dated (MONTH) 26, 2019, shows R24 is at risk for falls. On (MONTH) 13, 2019 at 2:15 PM, V8, (Certified Nursing Assistant), assisted R24 to the bathroom. V8 pulled R24 up from the back of R24's pants to a standing position, without using a gait belt. R24's gait was slow and unsteady. V8 then transferred R24 from the toilet to wheelchair, without using a gait belt. On (MONTH) 14, 2019 at 1:23 PM, V14, (CNA), said R24 is a extensive assist with transfers. R24 has problems moving R24's legs. Staff should use a gait belt with transfers. 4. The Physician order [REDACTED]. The Minimum Data Set assessment dated (MONTH) 2, 2019, shows R50 requires extensive two person assist with transfers and toileting. On (MONTH) 13, 2019 at 10:08 AM, V15, (CNA), assisted R50 to the bathroom. V15 pulled R50 from the back of R50's pants to a standing position, without using a gait belt. R50 was unable to stand in a full upright position, R50's gait was slow and unsteady, and R50 was holding onto the grab bar for balance. On (MONTH) 14, 2019 at 1:25 PM, V14 said R50 had surgery on R50's right hip. R50 is an extensive assist for transfers, and staff should use a gait belt with all transfers. 5. ) R8's current facesheet shows R8 has [DIAGNOSES REDACTED]. R8's minimum data set (MDS) (date field left blank), shows that R8 is cognitively intact and requires extensive assistance of 2 staff for toileting and transferring. R8's active care plan shows that R8 requires the use of a mechanical lift for transfers with the assistance of 2 staff. The same care plan shows that R8 has a self-care deficit requiring assistance to complete activities of daily living including toileting and transferring, due to limited range of motion to R8's left upper extremity from a [MEDICAL CONDITION]. On (MONTH) 13, 2019 at 10:10 AM, R8 was sitting in R8's wheelchair in room waiting for assistance to use the bathroom. R8 was observed to have limited use of R8's left arm and left leg. V8, (CNA), came into the room, applied a mechanical lift, and transferred R8 from R8's wheelchair to the toilet. During the transfer, R8 used only R8's right hand to hold onto the bar to stand in the mechanical lift. R8's left arm dangled to the side. V8 was the only CNA present in the room, and this surveyor asked V8 if R8 was okay to transfer with only one staff. V8 said that R8 can be transferred with one staff. On (MONTH) 14, 2019 at 10:00 AM, V4, (Restorative Coordinator), said that R8 requires the use of a mechanical lift, and should have 2 staff present during the transfer; it is the facility's policy. V4 said that R8 is not able to stand or walk alone due to weakness in R8's extremities. The facility's suggested mode of transfer list updated on (MONTH) 13, 2019, shows that R8 is an extensive assist of 2 staff requiring a medstand lift due to left sided weakness. The facility's Safe Resident Handling/Use of Mechanical Lifts policy with a revision date of (MONTH) 30, (YEAR), states, 5. Uses mechanical lift equipment/ aids in accordance with instructions and training (NOTE: TWO STAFF MEMBERS ARE REQUIRED TO BE IN ATTENDANCE TO PERFORM A LIFT TRANSFER) .

Based on interview and record review the facility failed to assess and evaluate a resident with a condition change, failed to arrange for emergency transport to the hospital. These failures resulted in a delay in treatment. R2 expired on (MONTH) 2, (YEAR). This applies to 1 (R2) of 3 residents reviewed for quality of life in the sample of 8. The findings include: The ambulance report dated (MONTH) 2, (YEAR) showed a call was received from the facility at 9:27 AM. The ambulance arrived to R(2) at 9:55 AM. The report documents a crew was dispatched to the facility for vomiting. Nurse states the (R2) has been vomiting since last night around five times. Nurse states the vomit was brown in color. (R2) vomited in front of the crew one time. Crew noted (R2's) vomit was bright red blood. Nurse insisted on changing (R2's) shirt and did. At 9:59 AM R2's blood pressure ,[DATE] and pulse 120. (R2) became unresponsive at 10:26 AM and did not have a pulse, CPR was started. Crew called 911 at 10:27 AM for assistance as crew consisted of two members. The physician's orders [REDACTED]. The P.O.S. showed he was receiving [MEDICATION NAME] (anticoagulant) and an antibiotic at the same time. The Minimum Data Set assessment dated (MONTH) 9, (YEAR) showed R2's cognition is impaired and requires extensive assist with activities of daily living. The nursing home to hospital transfer form dated (MONTH) 2, (YEAR) (without a time documented) by V15 (Registered Nurse) documents R2's reason for transfer he is having coffee ground emesis four to five times. Informed resident was having emesis during the night shift. Appears brown in color, R2 did not have his medications or his breakfast this morning. The same report showed R2 [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus Aureus) in his urine and completed his antibiotic. The nurses notes dated (MONTH) 2, (YEAR) by V15 documents shown by V17 (Certified Nursing Assistant-CNA) (R2's) clothing protector appears to have dark brown emesis. (R2) continuing to spit/vomit brown/red colored liquid. No medications or breakfast given. V23 (Physician) notified and orders received to send to the local hospital (R2) continues to spit up orange/red liquid . (R2) is a full code . resident left the facility at 10:00 AM. On (MONTH) 19, 2019 at 12:40 PM, V17 (CNA) said he was R2's CNA on (MONTH) 2, (YEAR). V17 said he worked a double shift that day and came in on the evening shift of (MONTH) 1, (YEAR) at 11:00 PM. V17 said during the night shift he had to change R2's bedding because his bedding was stained with dark mucous. V17 said R6 threw up blood in the morning around 8:00 AM. V17 said he reported this to his nurse V15. V17 said R6 seemed weak that morning. On (MONTH) 18, 2019 at 9:26 AM V15 (RN) said if a resident is having coffee ground emesis it could indicate they are having [MEDICAL CONDITION]. Residents should get sent out by 911. Any nurse knows coffee ground emesis is abnormal and should be sent out right away. On (MONTH) 18, 2019 at 2:34 PM, V5 (RN) said if a resident has coffee ground emesis they should be sent out by 911. 911 is more equipped to handle this type of situation. On (MONTH) 19, 2019 at 12:30 PM, V15 said she was R2's nurse on (MONTH) 2, (YEAR) when he was throwing up. V15 said she did not think she should have called 911 for R2. V15 stated, I guess at the time I must have felt was not an emergency type of situation. On (MONTH) 20, 2019 at 9:45 AM, V23 (Physician) said if a resident is on an anticoagulant (blood thinner) and an antibiotic they are at increased risk for severe thinning of the blood. V23 confirmed R2 was receiving both of these type of medications. V23 said if a resident is throwing up blood they should be sent out by 911 this is an emergency situation indicating they are actively bleeding. R2's Medical Certificate of Death dated (MONTH) 2, (YEAR) showed his cause of death was septic shock, aspiration pneumonia, and acute [MEDICAL CONDITION]. The facility's Medical Emergencies policy dated revised on (MONTH) (YEAR) states, To prevent complications or deterioration if the residents status. All residents will receive timely assessment of care in the event of a medical emergency .

Based on observation, interview and record review the facility failed to modify a resident's diet (R1) after showing signs and symptoms of aspiration. The facility failed to ensure staff supervised a resident (R3) at risk for aspiration during a meal. The facility failed to ensure staff could identify residents at risk for aspiration. These failures contributed to R1 choking on (MONTH) 31, 2019, requiring CPR (cardiopulmonary resuscitation), and hospitalization . R1 subsequently expired. This applies to 3 of 3 residents (R1, R3, R4) reviewed for safety and supervision in the sample of 8. The findings include: During this survey, R1 was unavailable for observation and interview as R1 was discharged from the facility on (MONTH) 31, 2019. R1's Physician order [REDACTED]. R1's Minimum Data Set, dated dated dated (MONTH) 6, 2019 showed R1 required supervision with one person assistance when eating. R1's Nursing Home to Hospital Transfer Form dated (MONTH) 31, 2019 at 7:00 PM showed, Resident having dinner in dining room. Husband was yelling for help .Resident choking, tried [MEDICATION NAME] maneuver but not effective and she lost consciousness .Called 911 .started chest compressions. Able to take some meat out of her mouth . R1's Hospital Medical Admit Note dated (MONTH) 31, 2019, showed, Chief Complaint: Aspiration event .Today, while in dining hall eating dinner she started to choke on her food, had L[NAME] (loss of consciousness) and lost pulse momentarily . On (MONTH) 19, 2019 at 11:45 AM, V3 Assistant Director of Nursing (ADON) stated R1 was transferred to the hospital on (MONTH) 31, 2019 and expired while hospitalized . R1's hospital Discharge Summary dated (MONTH) 7, 2019 showed R1 expired on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. On (MONTH) 19, 2019 at 9:02 AM, V4 COTA stated, On (MONTH) 31, 2019 around 10:00 AM, I was working with (R1) when she started coughing while drinking water. (R1) said she felt like the water went down the wrong pipe. I was concerned (R1) was aspirating so I reported it to the speech therapist (V10) and a nurse. I don't remember the nurse I talked too. I told (V10) about it but she (V10) stated she was leaving for the day and she would order a speech evaluation on (R1) the next day when she was back at work. On (MONTH) 18, 2019 at 2:00 PM, V10 (speech therapist) stated, If there is concern that a resident is aspirating their food, the staff will notify me. I will fill out a telephone order for a speech evaluation and immediately downgrade the resident's diet until I can do the evaluation. On (MONTH) 31, 2019, (V4/COTA) came to me and told me (R1) was coughing when drinking fluids. I was done for the day. (R1) was on my list to see and evaluate the next day . V10 SLP stated she did not modify or downgrade R1's diet or write an order for [REDACTED]. concerns prior to leaving work on (MONTH) 31, 2019. On (MONTH) 19, 2019 at 10:00 AM, V10 SLP stated, After (R1's) episode on (MONTH) 31, we should have downgraded (R1's) diet immediately and we didn't. We should have potentially modified her liquids too. I thought (V4 COTA) had reported her concerns to R1's nurse too. I should have made sure (R1's) diet had been downgraded before leaving work that day . V10 also stated, I have never been allowed to make a list of residents, at risk for aspiration, to put up in the nurse's station to help keep staff informed. There is no system in place here to inform staff of who is at risk for aspiration other than word-of-mouth communication. Each resident's meal ticket shows what type of diet they are on but doesn't show who is at high risk for aspiration or what swallowing strategies should be used for each resident. I can't communicate this information verbally to every staff member. On (MONTH) 19, 2019 at 10:53 AM, V13 Certified Nursing Assistant (CNA) stated, I noticed that the week before (R1) went to the hospital, she was having coughing episodes and trouble swallowing. I told the nurses about it . On (MONTH) 18, 2019 at 10:30 AM, V9 CNA stated, I was in the dining room on (MONTH) 31, 2019, when (R1) choked. I was the only staff member in the small dining room. I turned around and was looking at the tray cart. I had my back to (R1) when I heard (R5) yell out. I turned around and (R1) was blue and not breathing. I yelled for help .The small dining room is where residents that need assistance or supervision while eating are placed in .I was the only staff in the dining room when this happened with (R1) . (R1) didn't need help eating or supervision. On (MONTH) 18, 2019 at R5 stated, I'm (R1's) husband. I was seated next to her in the dining room when she choked. She started spitting up meatball and her lips were blue. She couldn't talk. I yelled for help .She never came back from the hospital. On (MONTH) 18, 2019, V5 Registered Nurse (RN), V6 RN, and V7 CNA each stated they were working the night of R1's choking episode on (MONTH) 31, 2019 but each stated they were not in the small dining room when the incident occurred. At 10:55 AM, V7 stated R1 had no history of choking that I know of. At 10:52 AM, V6 RN stated, (R1) did not need help eating or supervision. At 2:30 PM, V5 RN stated, I didn't know (R1) very well. She had no history of choking that I know of. R3's (MONTH) 2019 Physician order [REDACTED]. R3's Order sheet showed R3 was prescribed a pureed diet with honey thickened liquids. R3's Minimum Data Set, dated dated dated (MONTH) 9, 2019 showed R3 required limited assistance of one staff member when eating. On (MONTH) 18, 2019 at 8:18 AM, R3 was seated at a table in the small dining room, feeding himself pureed foods from his breakfast tray. No staff were noted in the small dining room. On (MONTH) 18, 2019 at 2:00 PM, V10 SLP stated, (R3) had a swallow study done and is at high risk for aspiration .He needs supervision while eating and on bad days, he needs assistance to eat . R4's Speech Therapy Plan of Care dated (MONTH) 6, 2019 showed R4 had [DIAGNOSES REDACTED]. R4's Speech Therapy Plan of Care showed, Pt choking incident observed by nursing and SLP on Saturday, [DATE] on hard toast .Recommended continue thin liquids and mech soft/ground solids at this time with standard aspiration precautions . On (MONTH) 18, 2019 at 12:55 PM, R4 was seated in the large dining room, eating a mechanical soft lunch. Two CNA's were in the dining room assisting other residents, with no staff providing swallowing cues or reminders to R4. At 12:59 PM, as V9 CNA was standing by R4's table, V9 stated, I don't know if (R4) has swallowing difficulty or is at risk for choking. I'm not normally in the big dining room. On (MONTH) 18, 2019 at 2:00 PM, V10 SLP stated, (R4) had a near choking episode on a Saturday at breakfast so she had a swallow study done. She has dementia related dysphagia which causes a delay in swallowing and poor control of food in her mouth. (R4) needs supervision when eating with reminders to slow down and take more drinks . On (MONTH) 19, 2019, V2 Director of Nursing (DON), V3 Assistant Director of Nursing (ADON), V8 RN, V11 CNA, and V12 CNA each stated the facility did not have a consistent documented process in place to identify residents at risk for aspiration. At 9:00 AM, V8 RN stated, We have no way of knowing who is at increased risk of aspiration unless symptomatic in our facility . At 10:50 AM, V12 CNA stated, I would depend on the nurse to tell me who is at risk for aspiration. We don't have a list to identify residents at risk for aspiration or what swallowing strategies are needed . At 11:25 AM, V2 DON stated, We don't have a list or quick reference to identify which residents are at increased risk for aspiration. Staff would have to get verbal report .

Based on interview and record review, the facility failed to ensure that a resident was safely positioned and supported during process of transfer from recliner chair to bed. This affected one of three residents (R3) reviewed for falls in a sample of 9 which subsequently resulted to R3 sustaining a fracture. Findings include: R3's incident report documented: -On 1/26/18, around 10:45 am, (V6 - Certified Nursing Assistant/CNA) who was assigned to (R3) asked (V5- CNA) to help transfer R3 from the (tilt recliner chair) to the bed. As V6 was trying to straighten the bed of R3 before transfer, V5 was trying to prepare R3 on (tilt recliner chair), positioned the (tilt recliner chair) in an upright position. (R3's) poor trunk control caused R3 to fall forward, and out of chair. - (R3) sustained a bump on forehead, and was showing signs of pain on the right hip area. R3 was sent to emergency room for further evaluation. - (R3) returned to facility on 1/26/18, at around 6:15 pm, with negative finding on computed tomography scan of head and [DIAGNOSES REDACTED]. Interviews were conducted with facility staff. On 2/27/18 at 11:01 am, V5 was interviewed in the conference room. V5 stated that during that day, V6 had asked V5 for assistance to transfer R3. V5 stated that R3 transfers using a mechanical lift, with 2 staff assistance. V5 stated that while V6 was fixing bed, V5 lifted R3's (tilt recliner chair), from a 45 degree tilt to an upright 90 degree position. V5 stated that V5 was at the back of the (tilt recliner chair), since the only way the chair can be reclined pressing a lever located at the back of the chair. V5 stated that R3 fell forward, with all of R3's body falling off the chair. V5 stated that V6 was in front of the chair but could not react enough to stop R3 from falling. On 2/27/18 at 11:43 am, V6 was interviewed in the conference room. V6 stated that V6 has been assigned to care for R3 for about 3 years. V6 stated that R3 is alert, would rarely respond, confused and not able to follow requests. V6 stated that R3 had been slowly declining and needed total assistance with all ADLs (Activities of Daily Living) including bed mobility and transfers. V6 stated that R3 needed two-person assistance and that a mechanical lift was used to transfer R3. V6 stated that R3 sat in the (tilt recliner chair) because R3 had the tendency to slide down, slump, was unable to sit upright for long periods of time and also because R3 has involuntary jerks. V6 stated that after breakfast, R3 looked tired that R3 needed to be transferred to bed. V6 stated that V6 had asked V5, who was at that time standing by the nurses' station, to assist with transferring R3 back to bed. V6 stated that V5 has assisted V6 in transferring R3 in the past. V6 stated that V6 was fixing the bed and that V5 was at the back of R3's chair. V6 stated that V6 didn't see V5 adjusting the chair, as it happened so fast. V6 stated that V5 felt R3's head on V6's feet. V6 stated, R3 screamed but V6 had asked if R3 was ok and R3 replied that R3 was. V5 stated that V4 was called to the room. On 2/27/18 at 11:47 am, V4 (Registered Nurse) was interviewed in the conference room. V4 stated that R3 had been declining over last few months and was under hospice care. V4 stated that R3 was dependent on staff for all ADLs (Activities of Daily Living) and used (tilt recliner chair) when out of bed. V4 stated that R3 didn't have any trunk control, had recently lost weight and unable to maneuver chair and that the (tilt recliner chair) was appropriate for R3. V4 stated that R3's (tilt recliner chair) was usually reclined to a 45 degree angle. V4 stated that every week, there is an updated list regarding what kind of assist need, how to transfer, what equipment to use for transfer and how many person assistance would each resident needs. V4 stated that this is where staff would get information about transfers and equipment and it is communicated through report by both nurses and CNAs. V4 stated that R3 was transferred via mechanical lift with two person assistance. V4 stated that V4 was not at the room at the time of the incident but V5 had called V4. V4 stated that as soon as V4 entered the room, V4 found R3 was on the floor and the (tilt recliner chair) was parallel to the bed. V4 stated that V6 was at the head of the bed and when V4 asked V6 about the incident, V6 had told V4 that V6 didn't see what happened because V6 was fixing the pillows by the head of R3's bed and then just felt R3 at V6's feet. V4 stated that V5 said that V5 tilted the (tilt recliner chair) to an upright position and R3 fell forward. V4 stated that V4 observed R3's entire body lying on the floor on the right side .V4 stated that R3 was sent to the hospital and returned the same day with [DIAGNOSES REDACTED]. On 2/27/18 at 2:59 pm, V29 (RN/Restorative Manager) was interviewed in the conference room. V29 stated that before a resident could use the (tilt recliner chair), an assessment to determine appropriateness is conducted by (skilled) therapy department and then re-assessed by restorative department during quarterly assessments. V29 stated that R3 needed total assistance with ADLs and did not follow instructions. V29 also confirmed in a statement that R3 used a (tilt recliner chair) due to poor body trunk control, being unable to sit without support, needing to be positioned and needing total care from staff. V29 stated that R3 was unable to sit upright without support. V29 stated that each resident's needs related to ADL care, support and equipment are communicated via a list that is being updated weekly. V29 also stated that staff is educated on transfers and use of (tilt recliner chairs) annually. On 2/27/18 at 4:00 pm, V3 (Assistant Director of Nursing) was interviewed in the conference room. V3 stated that R3 had poor trunk control, needs total assistance in all transfers and mobility, needs assist in turning and repositioning on bed and chair, has episodes of involuntary jerking movements, not able to follow instructions and has poor strength and balance. V3 stated that V3 conducted the investigation of the fall and concluded that the root cause was (staff) attentiveness and focus during this transfer which caused the fall. R3's 2/2018 Physician order [REDACTED].>May use reclining wheelchair Notes: (MONTH) use a recliner wheelchair to accommodate height and get more trunk support R3's current care plan documents: Therapeutic use of enabling device, recliner wheelchair (tilt recliner chair) - poor trunk control R3's 12/15 Functional needs assessment as documented by V29, Rehabilitation potential: Poor. (R3) continues to be dependent on staff with all areas of ADL functions .R3 uses a recliner wheelchair for better sitting positioning. R3's 1/26/18 (acute hospital) emergency department record documented: Seen by V30 (Hospital Physician) Reason for visit: Fall Diagnosis: [REDACTED].>Read attached information: [MEDICAL CONDITION]

Based on observation, interviews and record review the facility failed to adequately supervise and protect 3 (R1, R2 and R3) of 3 sampled residents from serious injuries and hospitalization . This failure resulted in; R1 sustained second degree burn to both thighs from hot coffee, R3 sustained a 5X7cm (centimeter) first degree burn to right knee from hot coffee and R2 fell , sustaining a broken tail bone. Findings Include: 1. R1 has [DIAGNOSES REDACTED]. R1 is alert but confused and disoriented. R1's care plan states that R1 needs assistance in all activities of daily living (ADL's). R1's assistance varies from cueing to maximum assistance depending on mood and behavior. Cognitive status: R1 is frequently forgetful and confused. Resident has no awareness to safety. August 2, 2013 at 1:20 pm., E5 (Restorative Aide) with E6, E7 and E10 (CNA's/Certified Nursing Assistants) were passing lunch trays on the memory care unit. The CNA's picked the trays up from the table as the dietary staff pulled the trays from the cart and placed hot beverages such as coffee and tea into the open cups with no lids. The trays were then taken to the residents with the hot liquids on them and left in front of the unattended residents . E5, E6, E7 and E10 continued to get in line and pass one tray after another until all of the thirty residents received their lunch trays. No one was watching the residents when the trays were placed in front of them. The nurse (E3) was in the medication room. August 6, 2013 at 12:05 pm, E11 (Dietary Manager) and E12 (Dietary aide), brewed a fresh pot of hot coffee in the main kitchen. Writer asked E11 to obtain a temperature on the fresh coffee after it was completely brewed. The temperature measured at 170 degrees Fahrenheit. The coffee was then transferred into three Ivory carafe containers and placed in the holding unit to be transported to the memory care unit. August 6, 2013 at 1:00 pm. Surveyor and E11 followed food carts/coffee containers to the memory care unit. The carts were placed in the kitchenette. E11 was asked to obtain coffee temperatures again, the temperature measured at 145 degrees in Fahrenheit. August 6, 2013 at 1:12 pm, E12 poured the first cup of coffee from the carafe into a cup with no cream or sugar. The temperature was taken and measured at 136 degrees in Fahrenheit. The coffee was placed on a tray and set in front of R4 by E5. E7 placed food trays with open hot beverages in front of R5 and R1. August 2, 2013 at 2:00 pm, E5 (Restorative Aide) stated that on July 30, 2013 at 9:30 am, R1 was in the dining room having breakfast. (E5) was sitting next to R1 providing supervision with meals. R1 called out to staff that her coffee was cold. E5 took the coffee from R1's tray and went into the kitchenette to warm the coffee up in the microwave. E5 stated she changed her mind and did not use the microwave. E5 stated she got a fresh cup of coffee out of the kitchenette. E5 stated the coffee was hot because she could see the steam from the cup. E5 stated she placed the hot cup of coffee on the table in front of R1. E5 stated I told R1 that the coffee was hot, to be careful; I left the table of R1 to attend to another resident at a different table. E5 stated she was taking care of another resident when she heard R1 screaming. E5 stated she turned around to see that the coffee was spilled all over R1. E5 stated she tried to help R1 when CNA's E6 and E10 assisted by getting more clothing protectors to place under R1's chest area. August 2, 2013 at 12:50 pm, E6 stated she was passing trays when E5 started screaming at her that she passed cold coffee to residents. E6 stated she saw E5 go towards the kitchenette to warm up the coffee. E6 stated she continued to pass her lunch trays when she heard R1 screaming "I am burning, I am burning." E6 stated E10 came to the table and took R1 into her room to change her clothes. E6 stated R10 brought R1 back to the table to finish the rest of her lunch. August 2, 2013 at 2:00 pm, E10 stated he was in the dining room when he heard a loud scream coming from R1. E10 said he asked E5 what is going on, E10 said E5 was sitting on the left side of R1 placing clothing protectors under her clothes trying to separate the clothing from R1's skin. E10 said he grabbed some more clothing protectors to give to E5 to place under R1's chest. E10 stated he looked down and saw that R1 was soaked on her lap as well and decided to rush R1 quickly to the room to change her clothes. E10 stated he told E7 another CNA he was leaving the dining room to change R1's clothes. E10 stated he passed the nurse while taking R1 to her room, the nurse was passing medications; when he told her that R1 had spilled hot coffee all over lap and chest area. E10 stated that E3 (RN/Registered Nurse) told him to put some skin barrier cream on the burned areas. E10 stated he can tell that R1 was burning so he grabbed top off right away. E10 stated he struggled to get the pants off R1, because R1 was moving all around and screaming "HOT, HOT." E10 placed the skin barrier cream that is used for incontinent care on R1's chest and thighs. E10 stated after he changed R1's clothes, he immediately took R1 back to the dining room for E5 to finish breakfast. E10 was asked if E3 (RN) came into the room with him to assess R1's burns. E10 stated No, E3 did not come into the room with him while he was changing and putting skin barrier cream on R1. E10 stated he dressed R1 and put R1 back in wheel chair and rolled R1 into the dining room to finish breakfast. August 2, 2013 at 3:10 pm, E7 stated she was not there to witness the incident. E7 stated she was taking care of another resident when she heard R1 screaming. E7 said she asked E5 and E10 what happened to my resident. E7 said E10 told her that R1 spilled coffee. At about 2:30 pm, I was told by E3 to check R1's thighs and I saw the blisters on the right thigh and I went and told E3. August 2, 2013 at 3:40 pm, E3 (RN) stated she was passing the morning medications. I heard R1 screaming and I was told that R1 dropped coffee in lap. "E10 was using clothing protectors to blot under clothing and on top." E3 stated, she followed E10 to the room and helped remove the clothes quickly. E3 stated she and E10 placed R1 in the bed and covered R1 with a sheet. E3 was asked if R1 returned to the dining room to finish breakfast. E3 responded No, we put R1 in bed and that is where R1 stayed. E3 was asked if she assessed R1's wounds and told E10 to place skin barrier cream on the wound. E3 did not answer and kept changing her information of the incident. E3 was asked if she called the physician and E3 stated yes I did twice but was not able to recall what times she called the physician. E3 stated she left the supervisor (E2, Assistant Director of Nursing/ADON) a voice message earlier in the day and that E2 was in a meeting all day. E3 stated she was waiting for E3 to call her back to let her know that R1 had burned herself. August 2, 2013 at 11:45 am, E2 (ADON) stated, R1 is alert but disoriented for the most part. R1 is not able to make her own decisions. E2 stated R1 is care planned for poor safety and depends on staff to make all safety awareness decisions. E2 stated that on July 30, 2013 at about 1:45pm-2:15 pm, not certain of time; E3 asked if I got her voice message that R1 spilled coffee on lap and there are blisters. I told E3 I was in a meeting all day and had not checked my voice mail messages. E2 stated when E3 said blisters she did not allow E3 to finish the telephone conversation; that she rushed upstairs to check on R1's condition. E2 was asked if E3 notified the physician and if any orders were carried out by any nurses for R1 prior to E2 coming up to assess R1's thermal burns. E2 responded I was not aware of any orders being implemented by the nurse per the physician. E2 stated she immediately told E3 to call the physician for special foam to help heal blisters and drainage of the blisters. E2 stated she asked R1 if there is any pain but that she is also aware that R1 is not able to respond appropriately to that question. Facility's Policy for Medical Emergencies: 2. All residents will receive timely assessment and care in the event of a medical emergency. Emergency situations include, but are not limited to: cardiac arrest, acute seizures, Shock, Trauma, such as burns, fractures, lacerations, poisoning, etc. In all emergency situations the immediate needs of the resident(s) will be assessed and treated, and the on-call and/or attending physician will be notified as soon as possible for further orders. D. Acute Trauma (e.g., burns, severe lacerations, fractures or other trauma), Nurse's duties are to: 1. Assess results of trauma and maintain patent airway. 2. Administer routine first aid as necessary; cover wounds with dressing; apply wet compresses to burns, applies splits and flushes chemical burns with water, etc.) 8. Notify the attending physician, physician on call, or Medical Director as indicated. Physician Statement: August 6, 2013 at 9:30 am, Z1 (Physician) was asked what time he was made aware of R1's injury. Z1 stated around 2:45pm, because he was in his vehicle headed to his other facility. Z1 stated he was left a voice message without a number or any general information as to the urgency of the call. Z1 stated he had to wait until he arrived to his facility and then he googled the facility phone number and called to find out that R1 had spilled coffee on her. Z1 stated he visited R1 at the facility on August 5, 2013 and was asked by the facility why he did not come to see R1 related to the incident. Z1 stated "no one asked me to come out to the facility or told me the severity of the phone call or about any blisters on my patient." Wound Assessment Detail Report: July 30, 2013 at 2:18 pm, report ordered by E2 and completed by E3 documents R1's wounds as active thermal-burn with partial thickness. Wound report pictures show different views of formed blisters and redness of the right groin area. The documentation and the wound certified nurse indicated the burn to be a second degree burn. Physician order [REDACTED]. July 30, 2013 at 9:30 pm., order to the pharmacy for R1's wound treatment to the burn area was not carried out until 9:30 pm for a special silver cream to the burn site. R1 went the entire day without any treatment or pain medication for the second degree burn. E2 was asked if she was aware that R1 was not treated for [REDACTED]. Nursing Notes and Medication Administration Record: July 30, 2013 at 3:44 pm E3 documented that R1 sustained three 2nd degree burns to her right groin and one 1st degree burn to her left groin area. July 31, 2013 at 4:30 am, R1 was awake and calling out "mother " with facial grimacing, R1 was medicated with Norco 5/325 mg. (milligrams) for comfort. 2. R3 has a [DIAGNOSES REDACTED]. R3 is care planned for generalized weakness due to limited mobility. Incident Report: February 20, 2013 at 8:40 am, R3 was eating breakfast in the dining room when hot coffee was spilled onto right leg. R3 sustained a chemical burn with pinkish discoloration on the right knee. Skin Detail Report: R3 sustained a 1st degree burn to the right knee. Nursing Notes Feb. 20, 2013 at 3:56 pm, R3's right knee noted to be pink and measured site at 5cm x 7 cm (centimeters). Resident states 6/10 pain of burning sensation. No blisters noted and ice pack applied. Physician and family made aware of incident. 3. R2 has a [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS) scores R2 as alert but confused, not able to make own decisions. R2 is care planned for previous injuries and lack of safety awareness for self. R2 requires total assistance of ADL's from staff and does exhibit moods and behaviors. Admission Report: R2 was admitted to the facility on [DATE] at 4:30 pm. R2 was received via paramedics after being discharged from the local hospital where R2 had a total hip replacement as a result of a fall on July 25, 2013. R2 fell while outside and broke the left hip. admitting [DIAGNOSES REDACTED]. R2 's care plan does not have any type of alarm device intervention to alert staff of attempts to get out of chair. Admission Nursing Assessment/Nursing Notes: July 28.2013 at 4:30pm, E13 (nurse) documented R2 was received from the local hospital via stretcher and paramedics with spouse. R2 was transferred to bed with a three person extensive assist. R2 was in significant pain but was unable to describe the pain. Patient is alert to name only, spouse answers all questions. R2 is unaware of the year, season or President. July 29, 2013 at 8:45 am, (E14) nurse documented R2 as alert but confused to her surroundings. R2 was very fidgety in bed and continually tried to sit on edge of bed. R2 had torn off left hip dressing from left hip surgical site. August 6, 2013, at 11:00 am, E2 (Assistant Director of Nursing) was asked why R2 did not have an alarm attached since the facility was aware that R2 had fallen a few days ago and just had a new hip replacement. (E2) stated the alarms startle our residents on the Dementia unit so we just decided sometime in June or July of 2013 not to use the alarms. We use them in the facility but not on the Dementia unit. Fall Risk Screen Assessment: July 28, 2013 in the section of Mobility when rising from chair: E13 stated that R2 made multiple attempts and was successful in rising from the chair. The risk factor increase tool documented by E13 states that R2 is (4 times more likely to fall than if R2 stands with a single movement). R2 is unable to rise without assist. Incident/Occurrence Report: Type = Falls August 2, 2013 at 6:50 pm, R2 was noted to be sitting at the very edge of her wheelchair, the seat cushion was sliding off the chair. R2 was trying to reposition self. The wheel chair was unlocked which made it difficult for R2 to get back in the chair. R2 has impaired balance and coordination with generalized weakness and poor safety awareness. R2 is on psychotropic drug use, related to [DIAGNOSES REDACTED]. R2 was found on the floor by E17 (CNA). August 4, 2013 at 7:45 pm, R2 was found on the floor, lying on left side complaining of left hip pain and headache, unable to move left leg. Transfer to Acute Care Hospital Report: August 4, 2013 at 7:50 pm, E18 (nurse) completed transfer papers to hospital for R2. E18 documented reason for transfer to hospital as followed: "patient got up to walk, un-witnessed, fell to ground "I feel like I cracked my head open" patient unable to extend left leg. emergency room Report: Visit Date August 4, 2013 at 10:35 pm, R2 was diagnosed by a physician as a having a coccyx fracture (Tail bone fracture). Fall Care Plan: July 28, 2013 R2 has impaired cognition, is status [REDACTED]. Impaired/decreased physical activity and mobility related to left total hip replacement. Minimum Data Set (MDS): Admission R2 is scored as a 2 for moderately impaired and decision making skills. R2 requires cues and supervision.

Based on observation, interview and record review, the facility failed to assure adequate supervision and to implement effective injury prevention strategies for five residents (R2, R4, R9, R10, R12) in the sample of 15. These failures resulted in R9's fall on 3/6/2013 causing a left hip fracture. In addition, the facility failed to properly manage hazardous and potentially biohazardous sharps and blood specimens. This had the potential to affect any resident moving past the supply cart, including two residents (R1, R9) in the sample of 15 and one supplemental resident (R16). Findings include: The facility ' s Policy Number FT 323, titled " Accidents and Supervision " with an effective date of 12/17/12, includes the following relevant parts: " III. Definitions - Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident ' s assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. " " Resident Vulnerabilities - Falls: Assess, develop interventions, and/or revise the plan of care for a resident who has experienced falls, or who is identified as having risk factors for falling; Determine what may have caused or contributed to the fall; Address the factors of the fall; Revise the resident's plan of care and/or facility practices, as needed, to reduce the likelihood of another fall. " 1. As of 2/6/13, the quarterly Minimum Data Set (MDS) for R9 reflected a history of one recent fall on 12/30/12, coded R9 as needing the limited assistance of one person for transfers and reflected [DIAGNOSES REDACTED]. A " Fall Risk Screen " dated 2/5/13 listed one additional fall for R9 that occurred on 10/28/12. The risk screen further indicated that R9 rises from a chair with " multiple attempts but successful. " Fall follow-up reports for both events indicate R9 fell in the bathroom having failed to call for assistance. On 10/28/12, R9 stated " I lost my balance. " On 12/30/12, R9 stated " I don ' t know what happened, I just got weak while I was at the sink. " The " Fall Occurrence Report " for 12/30/12 recommends a " stand-by assist in ADLs " and concludes " Gait unsteady. " Nurses Notes for R9 dated 2/12/13 include an entry that " Z4 (Attending Physician) ... ordered orthostatic blood pressures daily and to follow-up with neurologist because family is concerned of syncope and unresponsive episodes. Per physician states Parkinson ' s Disease medications can cause hypotension. " The Medication Administration Record (MAR) reflects the implementation of new orders to check orthostatic blood pressures daily, which began 2/13/13. Nurses Notes for R9 dated 2/19/13 (time of charting 2:18 PM, time of observation unclear) documents, " Noted by Activity staff to walk without walker in dine room to obtain cloth protector in the closet. Had unsteady gait. " Nurses Notes for R9 dated 2/20/13 as late entry documents, " Noted at 12:15 PM in television room by Activity staff that R9 was unresponsive. Nurse and Certified Nurse Aide assessed. Unresponsive to verbal and painful stimuli. " The period of unresponsiveness was listed as lasting approximately 3-5 minutes. physician progress notes [REDACTED]. Nursing Notes for R9 dated 3/1/13 at 2:15 PM indicate the appointment for a Neurology consultation had not yet been made by the family. R9 ' s Falls care plan dated 2/12/13 includes in the Problem list a history of syncope and " unsteady gait at times with decreased strength and endurance. " Care plan interventions do not include any mention of monitoring blood pressure or monitoring for signs and symptoms of hypotension or precursors to syncopal episodes. Care plan interventions state " Instruct R9 to seek assistance as needed " but do not include interventions to instruct the resident about reporting symptoms or about causes of syncope to improve resident compliance with safety measures. The intervention for " Stand by assist with all his ADLs " is crossed out with no date or explanation. No update to R9 ' s Falls care plan was made noting the episode of unresponsiveness on 2/20/13. The Fall Occurrence Report of 3/6/13, indicates R9 fell while standing from the dining table. The Post Fall Occurrence Follow-up dated 3/6/13 indicates R9, " lost balance when attempting to sit at table. Resident is in habit of leaving walker aside instead of keeping it in hand all the way to the chair. " Nursing Notes document that R9 was transported to the hospital on [DATE] at 6:40 PM and was admitted with a [DIAGNOSES REDACTED]. The Fall Occurrence Report dated 3/7/13 and the Post fall investigation summary report dated 3/8/13 describe R9 as sometimes forgetful, with poor safety awareness and poor judgment, yet care plans at the time of the R9's fall did not mention any ongoing or episodic lack of understanding, nor include strategies to safeguard R9 for such deficits. On 6/30/13 at 1:00 PM, E3 (Assistant Director of Nursing) reviewed R9 ' s physician orders [REDACTED]. E3 stated " Nurse should call the physician when readings drop. " A review of blood pressure readings from 2/13/13 to 5/31/13 included episodes when either the systolic blood pressure was below 90 millimeters of mercury or the diastolic blood pressure was below 60 millimeters of mercury. Eleven episodes of blood pressures below those levels were recorded in the Medication Administration Record. Nursing Notes indicate the physician was contacted about the low blood pressures on two occasions, 3/21/13 ad 4/14/13. On 6/3/13 at 1:45 PM, Z4 (Attending Physician) stated " Maybe I'll give parameters and better directions about reporting symptoms " with regard to monitoring and reporting periodic low blood pressure readings. Falls care plans dated 3/19/13 following the fall event of 3/6/13 that resulted in a hip fracture were not updated to address R9 ' s change in weight bearing status or changes in transfer needs related to hip precautions ordered upon readmission. Per orthopedic progress notes, as of 3/25/13, R9 was still limited to toe-touch weight bearing on the left leg and progressed to 25 percent weight bearing as of 4/8/13. Nursing Notes dated 3/20/13 indicate R9 required a two-person assist for transfer. 2. R10 had six falls in 2012 and one fall in 2013. Incident reports, nursing notes, care plans, and post fall occurrence follow-up sheets were reviewed. On 4/8/12, R10 walked back to the nurse's desk after supper and fell to the floor when she opened her chocolate candy. R10 had sustained slight redness in her left knee. No intervention was listed on the care plan. On 4/12/12, R10 slipped on floor while trying to get up. No injuries were noted. No personalized interventions were put in the care plan for this fall. Only pre-typed interventions were checked off on the care plan. On 6/7/12, R10 fell to the floor next to her bed. R10 sustained a skin tear over shin area 2x1.5x0.1cm (centimeter) in her right lower leg and also sustained a red bruise surrounding skin tear on shin 8x4 cm. The only intervention on the care plan was to add floor mats when R10 is in bed. On 7/14/12, R10 fell to the floor and was found sitting by her recliner. No injuries were noted. The only intervention on the care plan was to increase nursing rounds. On 9/8/12, R10 fell while she was in the bathroom. No injuries were noted. The interventions on the care plan were to keep R10 close to the nursing station, anticipate resident needs, and assist with ADLs (Activities of Daily Living). On 11/20/12, R10 fell to the floor and was found sitting on her floor mat, next to the bed with her legs extended out in front of her, facing her bedside table. R10 sustained a skin tear 1.5cm x 1cm on her left lateral shin. The intervention on the care plan was to get resident up in wheel chair when awake. On 4/20/13, R10 fell out of bed and was found sitting on the floor mattress with both lower extremities extended forward. No injuries were noted. The interventions were to reposition frequently so that R10 will lie in the middle of the bed and do hourly monitoring. 3. R12 had two falls in 2013. On 4/10/13, R12 went to the toilet with her walker, fell to the floor and landed on her left hip and shoulder. R12 complained of pain to the left shoulder and hip. R12 sustained a 100% red superficial open area, skin tear. R12 sent to local community hospital. Left arm was put in a sling due to sprain. X-ray was negative. No individualized intervention was written on the care plan for this fall. Only the pre-typed interventions were checked off. On 4/13/13, R12 fell in her room. R12 was found to be sitting on her buttocks with her legs extended forward. No injuries noted. The only intervention on the care plan was to round every hour. 4. On 5/28/13, as R4 wrapping his stump and slid from his cart. R4 sustained a skin tear on his right upper arm that measured 4.5cm x 5.5cm. R4 sustained another skin tear on his right forearm that measured 2cm x 1.5cm. No individualized intervention was listed on the care plan. Only the pre-interventions were checked off. On 6/3/13 at 2:45pm, E4 (Rehabilitation Care Unit Manager) stated, " I'm sorry. I didn't get a chance to carry over the intervention that I wrote on the incident report to the care plan. " 5. Record review documents that R2 was admitted to the facility on [DATE] and re-admitted on [DATE]. R2 has osteoporosis, esophageal reflux, history of falls, gastrostomy, gastro-paresis and multi system atrophy. Facility Occurrence Report dated 6/27/12 documents a fall in the treatment room while R2 was ambulating. Physician and Power of Attorney (POA) were notified. R2 ' s cognition prior and after the occurrence was oriented X3. No injuries noted, no pain when range of motion (ROM) performed. R2 was placed in a chair. Registered nurse (RN) was notified and an assessment was done, then R2 was assisted to a standing position and to a chair. Nursing notes dated 6/28/12 at 11:54 documents that R2 " was ambulating, with her rollator walker, across the therapy department and began turning to sit in armchair. R2 appeared to have caught her foot on back wheel of rollator and fell to the floor. " Witness statement documents " OT observe R2 with one hand holding rollator and the other hand/arm extended to the left, toward the floor. The fall was slow and gradual. " R2 was sitting when found and wearing well-fitting shoes. Under general procedures the following were marked: (X)= factor was present. -Root cause- no fault -Factual description of accident added to nurse note-X -Report and investigation completed in full-X -Notifications completed and documented in nurse note-X -Care plan updated-X Staff interviews: no staff interviews available. Recommendation: Therapy will continue to address safe turns using rollator. On 6/3/13 at 2:45pm, E3 Assistant Director of Nursing (ADON) stated " R2 ' s care plan was not updated or new interventions addressed " because R2 fell in therapy room. " Facility Occurrence Report dated 7/29/12 documents a fall in R2 ' s room while transferring R2. Physician and Power of Attorney (POA) were notified. R2 ' s cognition prior and after the occurrence was oriented X3.R2 complained of upper left back pain of 10/10. " Neuro checks were initiated, R2 had pain when ROM performed, placed in wheel chair, toileted per demand, Physician made aware with orders received, noted and carried out. " Nurse ' s notes at 12:01am documents " R2 alert, oriented and forgetful, stable gait with walker earlier. "R2 stated " do not know what happened earlier. " No witness. Fall Details Report document under: Fall Type: visually observed on floor, sitting upright on the foot side of the bed on the right side.R2 was in a quiet environment and barefoot. Conclusion: " R2 tries to be independent but not able to do it safely, with poor balance and decreased strength, with unsteady gait , poor safety awareness. " Staff Interviews: no staff interviews available Recommendation: " Remind R2 to call for assist. " Illinois Department of Public Health was notified. Updated Care Plan dated 7/29/12 documents under: Problem: Potential for falls due to: -Previous history of falls -Recent fall Goals: -will not fall -will not sustain injury The only new intervention for 7/29/12 after the fall was " increase nursing rounds. " R2 had history of falls on admission and a prior fall on 6/27/13. Facility Occurrence Report dated 2/7/13 documents a fall in R2 ' s room. Physician and Power of Attorney (POA) were notified. R2 ' s cognition prior and after the occurrence was oriented times three. No injuries noted no pain when range of motion (ROM) performed. R2 was placed in bed. Call light within reach and encouraged to use it. Nurses ' notes on 2/7/13 at 8:27pm document " Noted R2 is sitting on the floor facing her bed. R2 is AAOx3. R2 denies pain or discomfort. Able to move both upper and lower extremities. Assisted to bed, Assessment done, No apparent injury noted. " R2 stated that, "she was trying to reach for the waste can to vomit and fell on her knees. Kidney basin is by her side and verbalized that she wanted to use it to vomit. " They were no witness during the fall. Fall Details Report dated 2/7/13 documents the fall type as R2 visually observed. R2 was found sitting on the floor facing her bed. The environment was quiet, R2 was wearing socks only. Conclusion: " R2 with complaint of nausea, with some weakness, needs assist with activites of daily living, poor safety awareness, with unsteady gait, and poor balance. With poor judgment." Staff interventions: None available Recommendation: Increase nursing rounds for R2. Illinois Department of public Health was notified. Updated Care Plan dated 2/7/13 documents under: Problem: Potential for falls due to: -Previous history of falls *same Goals: -will not fall *same The only new intervention for2/ 7/13 after the fall was " Remind R2 to call for assistance before attempting independent activity. " R2 had history of falls on admission and two (2) prior falls on 6/27/12 and 7/29/12. There was no implementation of other interventions consistent with R2 needs in order to reduce the risk of more falls. R2 ' s care plan did not reflect R2 ' s current conditions and other risk factors that have changed since the previous assessment. 6. On 06/03/13 from 8:25am to 8:30am Z5 (Laboratory technician) was in Room 104 on the first floor east doing laboratory services. During this time laboratory cart was outside in the hallway. The door was closed and Z5 was in the room. The laboratory supply cart was not covered or supervised, and all supplies and blood products on the cart were easily accessible to any resident. R1, R9 and R16 have rooms near Room 104 and are able to move independently in the hallway. The laboratory cart had 17 containers of blood specimen, one open box full of clean needles, two closed boxes of clean needles, one open biohazard container for sharps and blood products, one open box of tourniquet, one closed box of tourniquets, 4 box of open, clean specimen containers, one open box of clean alcohol swabs and two closed boxes of alcohol swabs. On 06/03/13 at 8:30 am Z5 indicated that she worked for contracted laboratory company and was not sure about leaving supplies out and that was how she usually did it (left in hallway uncovered). Facility ' s agreement titled " Laboratory Service Agreement " under Article V Supplies, Equipment and Services, 5.1 Responsibilities. states " all supplies and equipment essential to Lab ' s execution of its duties under this Agreement shall be responsibility of Lab. " Under Supplies: states " Lab shall furnish specimen collection supplies to Client for the sole purpose of specimen collection for samples sent to Lab for testing. Client agrees to follow test-specific collection protocol when collecting laboratory specimens. "