Every finding on record at Mount Vernon Countryside Manor

Based on observation, interview and record review the facility failed to ensure a medication cart was kept locked when out of staffs visual control. This has the potential to affect all 83 residents living at the facility. The findings include: On 03/25/2026 at 8:16 AM, V6 (Licensed Practical Nurse) prepped medications, left the cart unlocked and went down the hallway to room [ROOM NUMBER] leaving the unlocked cart out of her visual control. On 03/25/2026 at 8:22 A.M. V6 returned to the medication cart which remained unlocked. On 03/25/2026 at 12:02 P.M. V6 was observed at the end of 300 hall by the nurse's station talking with a resident. V6's medication cart for 300 hall was observed to be in the middle of the hallway unlocked. On 03/25/2026 at 12:05 P.M. V1 (Administrator) was observed walking down 300 hall, stopping at the medication cart and locking it.On 03/25/2026 at 12:11 PM, V6 stated she realized she left the cart unlocked after we had walked away and entered the resident's room. V6 stated she knows the policy and the cart is supposed to be locked when she walks away.On 03/26/2025 at 3:08 P.M. V1 (Administrator) stated medication carts should be locked when the nurse is not at the cart.The facility Medication Administration policy with no date documented, 16. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.The facility census dated 03/24/2026 documented a total of 83 residents living at the facility.

Based on observation, interview and record review the facility failed to ensure the kitchen was clean and sanitary. This has the potential to affect all 83 residents residing in the facility. The Findings Include:During the lunch meal service on 3/24/26 at 11:30 AM the following observations were made: the cart that holds the clean plates for meal service was full of crumbs/old food debris, open shelves under preparation tables were dusty with food crumbs/dried drink spills, the top of the convection oven was dirty with food debris and grease buildup, the stationary cabinets underneath were littered with dropped dishes/paper trash/dirt, gnats were seen throughout the kitchen, underneath the juice machine was spilled dried juice, the floor appeared to be sticky and appeared to not have been mopped under the carts and stationary tables. On 3/24/26 corn meal was left open to air in the dry storage area from 9:00 AM until 2:00 PM. On 3/24/26 boxes were found in the dry storage area; some were empty stacked up and some were full sitting on the ground at 9:00 AM and still remained at 2:00 PM after the first shift had gone home. On 3/24/2026 at 2:10 PM, V1 (Administrator) walked through kitchen with surveyor due to dietary manager being gone for the day and acknowledged areas needed to be cleaned more thoroughly. V1 stated that she will get the cleaning issues taken care of this evening by calling in an extra employee to do take care of this immediately. The Long Term Care Facility Application for Medicare and Medicaid dated 3/24/26, documents that 83 residents reside in the facility.

Based on observation, interview and record review the facility failed to treat residents with dignity during mealtimes for 1 of 1 resident (R34) reviewed for dignity in a sample of 34. Findings included:R34's admission Record documented an admission date of 2/13/24 with diagnoses including nontraumatic chronic subdural hemorrhage, Alzheimer's disease, major depressive disorder, cognitive communication deficit, and dysphagia, unspecified. R34's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 01, showing R34 had severe cognitive impairment. R34's Care Plan documented a focus area of sometimes feels lonely or isolated from others with interventions that included to observe for changes in appetite, signs of withdrawal, crying, and tearfulness, decrease in social interaction and encourage resident to keep involvement of choice. R34's Progress Note by V19 (Social Service Director/SSD) dated 2/13/2026 documented quarterly social service assessment completed, R34 alert but unable to answer some questions without confusion. Mood and communication remain the same. States she sometimes feels lonely or isolated from others. Plans are to remain in this facility for long-term care. R34's Progress Note by V19 (SSD) dated 3/6/2026 documented quarterly social service assessment completed, R34 confused and unable to answer most questions. Communication and mood remain the same. States she sometimes feels lonely or isolated from others. Plans are to remain in this facility for long-term care. On 03/24/2026 at 11:41 AM, V12 (Family) stated she hired V18 (Personal Sitter) to come to the facility to sit with R34 on Tuesdays and Thursdays from 830 am-1130am to sit with her and take her to activities. V12 stated, R34 sits at the nurse station for meals because the facility said she is too loud and disrupts other residents. V12 stated, R34 likes socialization and wants attention. On 03/24/2026 at 11:45 PM, R34 was observed sitting by the nurses station in her wheelchair, facing the corner at time R35 had been served her lunch meal which consisted of a mechanical soft diet of baked zitti, broccoli, apple crisp and bread and butter. On 03/25/2026 at 12:05 PM, V13 (Family) stated she is not happy about R34 eating meals by the nurses station. V13 stated, she did notify the facility during a care plan meeting about 3 months ago that the family does not like that she cannot eat in the dining room. V13 stated, during the care plan meeting she had been told that it was because R34 gets overstimulated when she is in the dining room and hollers out. On 3/25/2026 at 12:00 PM, observed R34 sitting in her wheelchair at the table next to the nurses station facing the wall. On 03/25/2026 at 1:05 PM, V19 stated R34 does eat most of her meals by the nurses station related to her behaviors in the dining room. V19 stated, V12 had been willing to try letting R34 sit elsewhere during mealtimes for behaviors as a trial. V19 stated, V13 never told her she had not been happy with R34 sitting at the table by the nurses station. V19 stated, R34 had been sitting at the nurses station to eat for a few months. V19 stated, she does not feel the R34 documentation of feeling isolated dated 2/13/26 and 3/06/2026 had been about her not eating in the dining room. On 03/25/2026 at 2:15 PM, V1 (Administrator) stated it is her expectation that staff treat all residents with dignity and respect. V1 stated, she could see how R34 sitting at the table by the nurses station while facing the wall may not be the best option. V1 stated the facility had attempted multiple interventions, including resident sitting with another resident during lunch time and watching television that the family requested not to continue, however there is no documentation provided. On 03/26/2026 at 8:53 AM, V18 (Personal Sitter) stated she started coming to sit with R34 the last 3 weeks on Tuesdays and Thursdays from 8:30 AM -11:30 AM. V18 stated, she was hired by V12 to come in and socialize with R34 because the family felt R34 was not getting any socialization at the facility. V18 stated, every Tuesday and Thursday that she had come in the facility the last few weeks, R34 was sitting up at the nurses station table facing the wall and no staff was sitting with her while she was eating. V18 stated, today is the first day that R34 had been sitting in the hallway with a staff member since she started sitting with her a few weeks ago. On 03/26/2026 at 2:30 PM, V20 (Activity Aide) stated, R34 had been eating in her room until the facility came and told her that they were going to have R34 sit at the table by the nurses station. V20 stated, R34 had been eating her meals at the table by the nurses station facing the wall. The facility policy Quality of Life-Dignity (revision February 2012) documented under Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.

Based on interview and record review, the facility failed to maintain a functional status of mobility for 1 (R34) of 1 residents reviewed for ADL (Activities of Daily Living) in the sample of 34. Findings included:R34's admission Record documented an admission date of 2/13/24 with diagnoses including muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness (generalized), other abnormalities of gait and mobility, nontraumatic chronic subdural hemorrhage, and Alzheimer's disease. R34's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 01, showing R34 had severe cognitive impairment. This same document under Section GG0115: Functional Limitation in Range of Motion (ROM) documented an impairment to both sides of the lower extremities and Section O0500 Restorative Nursing Programs of 0 days completed for walking. R34's Care Plan documented a focus area of needing verbal cues and substantial to dependent staff assist for activities of daily living and mobility. R34 demonstrates impaired cognition, poor safety awareness, impulsiveness, delayed processing, decreased ROM (range of motion)/mobility, muscle weakness, unsteadiness on feet. I am easily distracted. History of right hip periprosthetic fracture, nonsurgical, history of right humerus fracture. I will transfer with 2 person assist with a goal to maintain present level of functioning through next review.R34's Physical Therapy (PT) Discharge summary dated [DATE] documented under Patient Progress to Treatment: PT recommended RNP (Restorative Nursing Program) and walking program for pt (patient) to prevent functional decline, maintain gains achieved from therapy and maintain strength / flexibility. Overall, R34 demonstrated good progress and had improvements as to sitting and standing balance, activity tolerance, endurance, AROM (Active Range of Motion) and BLE (Bilateral Lower Extremities) strength / flexibility which lead to safer and better level of independence with mobility skills as compared to SOC (Standard of Care). R34 can also walk 100-200ft using follow with wheelchair with minimal /CGA (Contact Guard Assist) and cues using walker and with close wheelchair follow. This same document under Discharge Recommendations documented in part: Restorative Program Established/Trained = Other Restorative Program (Please refer to completed RNP and walking program documentation). On 03/24/2026 at 11:34 AM, V12 (Family) stated the nursing staff is supposed to walk R34 to the dining room, but they have not been doing that. On 03/25/2026 at 12:05 PM, V13 (Family) stated R34 is supposed to be walked to the dining room with her walker for restorative care and does not think that is happening. On 03/25/2026 at 12:23 PM, V3 (Restorative Aide) stated she is the restorative aide for the facility. V3 stated, restorative therapy is completed by all staff, but she does complete restorative care as well that includes walking, activities daily living, showering, repositioning, etc. V3 stated, all restorative care is documented in the resident's electronic health record (EHR). V3 stated, R34 does not get assistance in walking because she is unable to complete the task safely, she has behaviors V3 stated, it is not walking if 3 people must help you. On 03/26/2026 at 8:33 AM, V14 (Certified Nurse Assistant/CNA) stated, R34 cannot walk and is not walked by staff. On 03/26/2026 at 9:05 AM, V1(Administrator) stated R34 had never had a walking program while in the facility. V1 stated, R34 only has the activities of daily living documentation located in the electronic health record. On 03/26/2026 at 10:40 AM, V15 (PT) stated he did actively work with R34 on ambulating distance by himself with assistance by using a wheelchair and walker. V15 stated, R34 had been discharged from PT in 12/2024 with recommendations of the restorative nursing program. V15 stated, R34 should have been referred to therapy for an evaluation if she was not maintaining her mobility function. V15 stated, the nursing staff could have used a second person behind R34 when walking with a wheelchair for safety. On 03/26/2026 at 1:20 PM, V16 (MDS/Minimum Data Set Coordinator) reviewed MDS documentation for 4/6/2025 through 8/2025 for R34. V16 stated, during the look back period for 4/6/2025 and 5/2025 there was documentation R34 had been being walked by nursing staff. V16 stated, the 7/2025 look back period documented no walking related to safety concerns. On 03/26/2026 at 1:28 PM, V17 (Director of Rehab) stated there was no notification that R34 had not been ambulated, so the therapy department had not been aware of any other issues. PT's recommendation was to implement a walking program in 12/2024 and there has been no notification of ambulation decline to their department. V17 stated, If R34 had not been staying at the level of function from her therapy discharge then she should have been referred to therapy for evaluation. On 03/26/2026 at 1:42 PM, V3 (Restorative Aide) stated she does communicate with the therapy team daily in the morning meetings and this is when she would communicate if a resident were having trouble transferring, eating, mobility, etc. V3 stated, R34 had more behaviors related to ambulation. V3 stated, R34 is hard to redirect, and therapy had been aware. On 03/27/2026 at 9:28 AM, V8 (Regional Clinical Reimbursement) stated R34 did not have a walking program in place even though it had been the recommendation from physical therapy. R34's MDS dated [DATE] Section GG0170. Mobility documented under: Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If performance in the last 7 days is coded 07, 09, 10, or 88 Skip to GG0170Q5, Does the resident use a wheelchair and/or scooter? J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns as able to with partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. This same document under Section O documented O0500 Restorative Care: Training and Skill Practice In: F. Walking with 0 days. R34's MDS dated [DATE] Section GG0170. Mobility documented under: Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If performance in the last 7 days is coded 07, 09, 10, or 88 Skip to GG0170Q5, documented 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. This same document under Section O documented O0500 Restorative Care: Training and Skill Practice In: F. Walking with 0 days. R34's Point of Care History report document dated 3/31/2025 - 4/6/2025 documented under Functional Abilities Walk 10 Feet with dates of 4/1/2025 at 11:54 with partial/moderate assistance, 4/2/2025 with partial/moderate assistance, 4/3/2025 with supervision or touching assistance, 4/4/2025 with partial/moderate assistance and 4/5/2025 with partial/moderate assistance. Walk 50 feet with two turns documented dates of 4/4/2025 with partial/moderate assistance and 4/5/2025 with partial/moderate assistance. Walk 150 feet documented dates of 4/4/25 with partial/moderate assistance and 4/5/2025 with partial/moderate assistance. R34's Point of Care History report document dated 7/3/2025 - 7/9/2025 documented under Functional Abilities Walk 10 Feet with dates of 7/4/2025 with partial/moderate assistance, 7/5/2025 with partial/moderate assistance, 7/6/2025 with substantial/maximal assistance. Walk 50 feet with two turns documented not applicable. Walk 150 feet documented not applicable. The facility Resident Mobility and Range of Motion (revised October 20, 2025) documented Policy Statement: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation: 1. As part of the resident's comprehensive assessment, the nurse will identify the resident's: a. Current range of motion of his or her joints; b. Current mobility status (per current MDS assessment tool), including his or her ability to:(1) Move to and from the lying position; (2) Turn and move side-to-side in bed; (3) Change body positions; (4) Transfer to and from bed or chair; and (5) Walk.

Based on interview, observation, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (R46) of 18 residents reviewed for position and mobility in the sample of 34. The Findings Include: R46's face sheet documents R46 was recently readmitted to the facility on [DATE]. The diagnoses listed include displaced intertrochanteric fracture of left femur, dementia, conversion disorder with seizures, hypertensive chronic kidney disease, mixed hyperlipidemia, hypothyroidism, chronic obstructive pulmonary disease, and Parkinson's Disease. R46's current orders document on 09/03/2025 an order for restorative active range of motion to be completed 6-7 times a week every shift. R46's MDS (Minimum Data Set) dated 02/06/2026 coded as quarterly documents section C0500 BIMS (Brief Interview for Mental Status) as 03 - severe cognitive impairment. Section GG of the same MDS documents Functional Limitation in Range of Motion impairment on both sides of the lower extremities. Section O of the MDS documents 0 days for passive range of motion and 7 days of active range of motion for the look back period. R46's care plan documents a problem area of ADL's (Activities of Daily Living) Functional Status / Rehabilitation Potential. I require verbal cues and substantial staff assistance for ADL's and mobility. I am dependent on staff for safety, mealtimes, and activities. I am alert to self with confusion to situation, place and time. I am able to answer simple yes / no questions. The goal listed I will be able to maintain present level of functioning through next review as evidenced by. Interventions listed include verbal cues and substantial staff assistance with adl's and mobility, mechanical lift transfers with two assists, and active / passive range of motion with care as tolerance. R46's therapy progress note, dated 09/30/3035 documented physical therapy recommended Restorative nursing program to prevent functional decline and to maintain strength / flexibility. R46's referral to restorative report dated 09/30/2025 documents the recommended restorative nursing programs are passive range of motion, active range of motion, and bed mobility. R46's Point of care history report with a date range of 03/21/2026-03/27/2026 documents R46 receives 15 minutes of active range of motion each shift. On 03/26/2026 at 2:28 P.M. V3 (Restorative Certified Nurse Assistant) stated R46 is active assist range of motion. V3 stated she is not sure why the order in the chart is for active range of motion but stated there is no place to chart it. V3 stated R46 doesn't need passive range of motion because he can participate with the program. On 03/26/2026 at 3:08 P.M. V1 (Administrator) stated when a resident is discharged off therapy, V5 (Registered Nurse) is responsible for writing the program and assigning it in the electronic medical record. On 03/26/2026 at 3:53 P.M. V5 (Registered Nurse / Assistant Director of Nursing) stated all residents on admission get placed on an active range of motion and bed mobility program. V5 stated, I would assume that each program is for all extremities unless a resident is observed to have a contracture. V5 stated if she had seen the referral for restorative on R46, she would have just written the active range of motion not the passive range of motion. On 03/27/2026 at 8:30 A.M. V4 (Family Member) stated that R46 has a hard time following commands and that is why R46 doesn't do exercises. V4 stated R46 does get agitated and is easily distracted. On 03/27/2026 at 10:03 A.M. V3 (Restorative Certified Nurse Assistant) explained to R46 what she was going to do. V3 then washed her hands and sat next to R46's recliner. V3 asked R46 to raise and lower his arm. R46 looked at V3 and smiled. V3 attempted again to get R46 to raise and lower his arm. R46 was unable to follow the commands from V3. V3 then raised and lowered her arms and asked R46 to do the same thing. R46 did not raise or lower his arm. V3 then attempted to assist R46 in raising and lowering his arms, but R46 did not participate. V3 stated she would attempt again later. Facility policy titled Resident Mobility and Range Motion dated October 20,2025 documented residents with limited range of motion will receive treatment and services to increase and or prevent a further decrease in range of motion.

Based on interview and record review, the facility failed to obtain daily weights per physicians orders for a resident with a history of weight loss for 1 of 4 residents (R5) reviewed for weight loss in the sample of 34.Findings include:R5's Face Sheet documented an admission Date of 3/10/23 with diagnoses to include Dementia, Epilepsy, and Chronic Kidney Disease. R5's Minimum Data Set, dated [DATE] documented R5 has moderate deficits in cognition.R5's Care Plan dated 2/12/26 documented a problem area, Resident has had a weight loss of 14% (percent) in 6 months and 2.7% in 1 month. R5's March 2026 Physicians Orders documented an order for daily weights with a start date of 3/19/26.R5's March 3/1/26-3/27/26 Vital Report documented that R5 weighed 156 pounds on 3/2/26 and 169.4 pounds on 3/27/26. These were the only 2 weights charted.On 03/26/2026 at 1:57 PM, V11 (Registered Dietician) stated R5's oral intake has improved within the past month and her weight is picking up and has stabilized. V11 stated the facility should have carried out orders for R5's daily weights.On 03/27/2026 at 10:46 AM, V1 (Administrator) stated the issue with failing to obtain daily weights as ordered for R5 will be discussed in Quality Assurance.The facility's Weight Management Program Policy dated February 2024 documented, It is the policy of (Name of the facility) to manage resident weight through prevention, assessment, and implementation and evaluation of interventions.An Obtaining and Following Physicians Orders Policy dated July 2017 documented, It is the policy of (the facility) that physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgment think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified. If the failure to follow physician orders is more than just one instance, such as not passing medications to the residents assigned to him/her, then a quality monitoring process should be implemented to prevent reoccurrence. For example, medication carts would be audited to determine the extent of the problem. Then the Director of Nursing or designee would monitor medication passed weekly for four weeks, then every other week for four weeks, then monthly thereafter.

Based on interview and record review, the facility failed to weigh a dialysis resident daily per physicians orders and to maintain regular communication with the dialysis center about post dialysis weights for one resident of one resident (R3) reviewed for dialysis in the sample of 34.Findings include:R3's Face Sheet documented an admission Date of 12/6/24 and listed Diagnoses including End Stage Renal Failure, Cirrhosis of the Liver, and Diabetes Type 2.R3's Minimum Data Set, dated [DATE] documented that R3 has no deficits in cognition and receives hemodialysis. R3's Care Plan dated 2/24/26 documented a problem area, I am at risk for complications due to End Stage Renal Disease & Hemodialysis therapy. I go to (company name) Dialysis on Tuesday, Thursday, and Saturday. I have history of right nephrectomy. I frequently refuse Lactulose. I am not receptive to education.R3's March 2026 Physicians Orders documented an order for daily weights with a start date of 12/6/24, and an order to obtain post dialysis weights from the dialysis provider on dialysis days, which are Tuesdays, Thursdays, and Saturdays, with a start date of 2/8/26.R3's Vital Report for 3/1/26-3/27/26 documented that R3 was not weighed on 3/13/26, 3/14/26, 3/15/26, 3/16/26, or 3/19/26 through 3/25/26. The only weights listed were for 3/2/26 and 3/27/26.There was no documentation in R3's chart to indicate that the dialysis center had been in communication with the facility about the resident's post dialysis weights from 2/8/26 through 3/27/26.On 3/26/25 at 9:20am, V2, (Director of Nurses/DON), stated the facility does not have a dialysis communication book, but that the facility talks on the phone at times with dialysis about (R3).On 03/26/2026 at 1:16 PM, V8 (Dialysis Center Registered Nurse) stated R3 gets weighed after every dialysis session and it is documented at their facility. V8 stated she has told the facility numerous times they need to maintain a dialysis communication book to be sent with R3 to dialysis to be completed by dialysis staff, which would include the post dialysis weights.On 03/27/2026 at 10:58 AM, V2 stated she was in contact with V8 on 3/26/26 about getting a dialysis communication book started.A Care of a Resident with End Stage Renal Disease (ESRD) Policy dated November 2017 documented, Residents with ESRD will be cared for according to currently recognized standards of care. Agreements between this facility and the contracted ESRD facility will include all aspects of how the residents care will be managed, including: A. How the care plan will be implemented; B. How information will be exchanged between the facilities; and C. Responsibility for waste handling, sterilization and disinfection of equipment.

Based on observation, interview, and record review the facility failed to follow infection control practices for 2 (R10 and R96) of 6 residents reviewed for infection control in the sample of 34. The findings include:1. R96's face sheet documented that R96 was admitted to the facility on [DATE]. Diagnoses listed include metabolic encephalopathy, type 2 diabetes mellitus, acute kidney failure, chronic kidney disease stage 4, non-pressure chronic ulcer of other part of left foot, atherosclerotic heart disease, depression, essential hypertension, and hyperlipidemia. R96's Physicians order for blood glucose dated 01/22/2026, documents an order for blood glucose to be taken prior to giving sliding scale insulin before meals. On 03/25/2026 at 7:46 AM, V10 (Licensed Practical Nurse) opened the medication cart and removed the blood glucose monitor device placing it on top of the medication cart. V10 then put gloves on, walked over to R96. V10 then cleaned R96's left first finger with an alcohol prep pad. V10 then used the lancet and stuck R96's finger. V10 obtained a blood sample in the blood glucose machine. V10 recorded the result and placed the strip in the trash. V10 then placed the blood glucose machine on the medication cart and prepared the insulin for R96. It was noted that V10 did not clean the glucose monitor with any type of cleaning pad or wipe. Several minutes later V10 opened the medication cart and placed the blood glucose machine inside. On 03/25/2026 at 8:38 A.M. V10 stated she cleaned the blood glucose machine with an alcohol prep pad. On 03/26/2026 at 3:08 P.M. V1 (Administrator) stated she expects the staff to follow the policy on cleaning glucometers. V1 stated an alcohol prep pad is not what the nurse should have used to clean the machine. Facility policy titled Obtaining a Fingerstick Blood Glucose Level dated March 2023 documented 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The EvenCare Proview meter cleaning and disinfecting procedure documents the meter must be disinfected between patient uses by wiping with a CaviWipe towelette or EPA registered disinfecting wipe in between tests and be cleaned prior to disinfecting. 2. R10's admission Record documented an admission date of 4/12/25 with diagnoses including type 2 diabetes mellitus without complications, moderate protein-calorie, malnutrition, vascular dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety. R10's Minimum Data Set (MDS) Brief Interview dated 3/25/26 documented a Mental Status (BIMS) score of 10, showing R10 had moderate cognitive impairment. This same document under Section M Skin Conditions: M0150. Risk of Pressure Ulcers/Injuries, Is this resident at risk of developing pressure ulcers/injuries with yes. R10's Physician Order Sheet (POS) documented on 2/11/2026 an order apply Silver Silvadene cream 1% amount: 1 treatment: topical. Special Instructions: Apply silvadene/collagen powder to wound bed in intergluteal cleft, cover with calcium alginate and bordered gauze dressing daily and PRN. 03/26/2026 2:01 PM Observed R10's dressing change to right intergluteal cleft completed by V6 (Licensed Practical Nurse/LPN). R10 observed standing with assist by V7 (Certified Nurse Assistant/CNA). V6 removed old dressing, duffed gloves and used hand sanitizer prior to donning clean gloves. Observed V6 (LPN) picking up spray bottle of wound cleanser, sprayed twice with using her right index finger, and wiped the wound off with one piece of gauze. V6 did not [NAME] gloves after cleaning the wound and continued with the same dirty gloves applying Silvadene cream with her right index finger and applied collagen powder to wound bed. V6 continue with the same gloves to apply the calcium alginate and bordered gauze. V6 duffed her gloves, picked up a marker to write date and initials on dressing then used hand sanitizer. 03/26/2026 2:20PM V6 (LPN) stated, she should have duffed her gloves and completed hand hygiene after cleaning the wound bed with the wound cleaner because she did pick up the wound cleaner bottle. V6 stated, however, if she changed her gloves every time she touched something she would have to change her gloves 7 times. V6 stated, she is not sure what the facility policy stated, but she thinks it would document donning and duffing gloves after cleaning the wound. 03/26/2026 3:11 PM V1 (Administrator) stated, it is her expectations that staff follow the policy and procedure for dressing changes including infection control practices. The facility Infection Prevention and Control Program Policies and Procedures (revised August 2018) documented under Policy: The organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidenced based approaches to infection prevention.

Based on interview, observation, and record review, the facility failed to properly secure a resident's wheelchair into the facility van for 1 of 3 residents (R1) reviewed for accidents in the sample of 3.This past non-compliance occurred between 9/19/25 and 9/20/25.The findings include:R1's Face Sheet documented an admission Date of 3/1/25 and listed Diagnoses including COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation, Rheumatoid Arthritis, and Hypertension. A Minimum Data Set, dated [DATE] documented that R1 has moderate deficits in cognition, has impaired range of motion to both lower extremities, and requires the use of a wheelchair. R1's Care Plan with a start date of 4/15/25 and a review date of 9/23/25 documented a problem area, I am prescribed anticoagulant medication.R1's Event Report documents an event date and time of 9/19/25 at 1:27pm, description of fall, and a location of facility vehicle. Under Conclusion of root cause documents Resident's wheelchair tipped to the right side but remained in the air and buckled in the van. Resident is unsure if she hit her head but believed she did and acquired skin tear to the left arm. Sent to (local hospital) ER (Emergency Room) for further evaluation and treatment. Under Notes documents Resident returned from hospital at (5:40pm.) Started on neuros (neurological checks) at (5:45pm) pupils equal, responsive to light and accommodation. Equal grasp strength bilaterally, ROM (Range of Motion) WNL (Within Normal Limits) in all extremities. Significant bruising scattered throughout body. On right posterior calf bruises measuring 3x3.5cm (centimeter) and 2x1cm. On outer lateral right calf bruises measuring 3x3.5cm, 1x1cm, 2x0.75cm, 0.5x0.5cm and 0.5x0.5cm. On inner lateral right calf bruise measuring 3x3.5cm. On left posterior calf bruises measuring 6.5x4cm and 0.75x0.75cm. Bruise behind knee 6.5x2.5. All bruises previously mentioned were dark red in color upon assessment. On lateral outer left calf greenish-yellow bruise 5x2 (cm), then more red bruises measuring 1x1.5cm, 2.5x2.5cm,1.5x1cm. [NAME] bruise on knee assessed at 1.5x1cm. Right upper arm pinpoint bruising measuring 11x7.5 cm, resident states was from BP (Blood Pressure) cuff at hospital. Bruise on right upper forearm measuring 5.5x2.5cm. Bruise on left hand measuring 3x5cm. Bruise behind left upper arm 5.5x3.5cm. Skin tear on anterior left forearm measuring 3x1 cm, bruise surrounding it 4.5x3cm. Skin tears below that one measuring 5x2cm and 1.5x1cm with bruise surrounding them measuring 10x3.5cm.R1's 9/19/25 ED (Emergency Department) Provider Note documented, (R1) is an [AGE] year-old female with a past history of COPD, Hypertension, A Fib (Atrial Fibrillation), Rheumatoid Arthritis and is on Eliquis who presents to the ED with complaints of hitting the back of her head and has a left forearm skin avulsion. Patient stated that she was in the wheelchair van when her wheelchair tipped backwards, and she hit the back of her head. She denies experiencing loss of consciousness, dizziness, blurry or double vision, chest pain, shortness of breath, and denies any other injury. Patient has a skin avulsion on her left forearm, bleeding is controlled, patient is neurologically intact, patient denies cervical tenderness, no spinal step offs noted, no obvious injury or deformity noted on physical exam. Clinical Impressions: Fall, initial encounter. Avulsion of skin of left forearm, initial encounter. Disposition: Discharge. Condition: Stable.On 9/30/25 at 10:35am, R1 was alert and oriented to person, place, and time. R1 stated she might be somewhat fuzzy on the details, but on 9/19/25 she was riding in the facility van when V4, Transport Staff, turned right, and R1's wheelchair tipped over to the left, but not all the way over. R1 stated she somehow sustained a skin tear to her left forearm, which was observed to be covered with a clean dry dressing dated 9/30/25. R1 stated she also thinks she hit the back of her head on something, but she is not sure what. R1 stated she has had some back pain after the incident which she thinks was from being in a sitting position on the floor of the van afterwards, but nothing requiring intervention with narcotic pain medications. R1 stated V4 was not driving fast or not in an unsafe manner. R1 stated examination and imaging at the ER showed the only injury was the skin tear. R1 stated following the incident her memory and level of functioning are baseline. R1 stated all transport staff have always been extremely safe and careful with her. When asked her if there was any issue with any of the straps not being attached properly to the wheelchair, R1 stated she had no idea if this was a factor. When asked about the Incident Report stating there was bruising to the body, R1 stated she was not sure if she sustained bruises, but it was no big deal and it was probably gone by now. When asked by the Surveyor if she would allow observation of a nursing skin assessment, she stated not today as she was tired and wanted to rest.On 9/30/25 at 11:10am, V4 stated on 9/19/25 she had taken R1 to the bank. V4 stated she had gotten R1 out of the van and into the building to do her banking, then they came back out, and she strapped in R1's wheelchair into the van in what she thought was a secure manner. V4 stated she made a right turn, which was not a sharp turn, and she was not speeding, and heard R1 yell out and V4 looked around to see the wheelchair was tipping over toward the left side of the van. V4 stated she quickly made a right turn into a parking lot to pull over, at which time the wheelchair tipped over toward the left even more. V4 stated R1's body was not making contact with anything inside of the van. V4 stated she unhooked R1's lap belt and carefully lowered R1 into a sitting position on the floor of the van. V4 stated R1's left arm was bleeding, and V4 assumed in being jostled around the arm had made contact with the arm of the wheelchair. V4 stated R1 was alert and oriented. V4 stated she asked R1 if she had hit her head and R1 stated she didn't think so. V4 stated R1 initially was not panicking or in pain but was somewhat upset about her arm injury. V4 stated she had not needed to put pressure on the skin tear as it was not profusely bleeding. V4 stated she called V1, Administrator, who called 911. V4 stated it took about 12-15 minutes for the ambulance to arrive, and when questioned by paramedics, R1 stated she thought maybe she had hit her head but wasn't sure, and she complained of back pain from sitting on the floor of the van. V4 stated upon her return to the facility, V1 wrote V4 up for not double checking if the wheelchair was securely strapped in. V4 stated she and other transport staff were reeducated on proper use of the restraint belts in the van. V4 stated the proper procedure is to buckle the lap belt, and there are 2 back and 2 front restraint straps which attach to the wheelchair frame. V4 stated she recalled attaching the back and front straps by weaving then through the wheels, which she later learned was not proper procedure. V4 stated she does not think she was initially properly trained about securing the wheelchair straps.The facility's undated Van Usage Policy and Procedure documented, Policy: When employees operate a facility owned van, they have inherent responsibilities to care for the vehicle and the residents, obey all state and local traffic laws, and abide by established driver operating procedures. This policy is designed to ensure that employees authorized to operate vehicles for the purpose of conducting business and transporting residents for the company will comply with certain conditions. Procedure: To ensure proper van usage: 3. Employees must practice safe driving procedures and obey the rules of the road when operating a facility owned van. C. Ensure all residents and wheelchairs are safely secured.On 9/30/25 at 1:50pm, V5, Maintenance Staff, stated on 9/19/25 after the above referenced incident, all Transport Staff were reeducated on securing wheelchairs in the van, with return demonstration given. V5 stated all were required to pass a safe driving test he administered and all passed. V5 stated when V4 demonstrated how she secured R1's wheelchair, she failed to properly secure the chair, but upon return demonstration, did so appropriately. V5 stated he did not think V4 had been properly trained initially.On 9/30/25 at 2:25pm, V2, Director of Nurses, stated when R1 was readmitted from ER, there was a skin tear to the left forearm and significant bruising to body in several areas, most likely due to anticoagulant therapy. V2 stated R1 was now at baseline in all areas including level of functioning and cognition. V2 stated R1 has had some occasional complaints of back pain which have been effectively controlled with analgesics.On 9/30/25 at 2:00pm, V1, Administrator, produced a 9/19/25 document titled Ad Hoc QAPI (Quality Assurance Improvement Plan). V1 stated the quarterly QA (Quality Assurance) meeting is scheduled for October 2025. V1 stated by 9/20/25, prior to the Surveyors entrance to the facility on 9/30/25, the facility implemented all the below referenced steps as stated in the QAPI Ad Hoc.Prior to the survey date, the facility took the following actions to correct the non-compliance:1. On 9/19/25, (V4) received disciplinary action regarding the appropriate procedure for securing a wheelchair during transport.2. On 9/19/25, a safety inspection was conducted on all vehicles.3. On 9/20/25, all drivers were educated on the proper procedure for securing wheelchairs during transport.4. On 9/20/25, all drivers were evaluated for competency by conducting a road test with (V5, Maintenance Staff).5. The Administrator or designee will audit resident transportation twice weekly for 4 weeks to ensure wheelchairs are secured for transport.6. The Administrator will report the findings of the audit to the QA Committee.

Based on observation, interview, and record review, the facility failed to utilize PPE (Personal Protective Equipment) per CDC (Centers for Disease Control) guidelines when coming in contact with Covid positive residents. This has the potential to affect all 74 residents living at the facility. Findings include: On 2/18/25 at 1:00pm, signage to the facility's front entrance read, Community respiratory illness activity is high. Masks are strongly recommended to protect our residents. Notice per IDPH (Illinois Department of Public Health) regulations notice is hereby given that a positive Covid test result has been confirmed (in a) resident. R3's Face sheet documented an admitted [DATE] and listed diagnoses including Left Fibula Fracture and Hypertension. R3's Physicians Orders for February 2025 documented a 2/13/25 order for droplet/contact isolation due to a positive Covid test result. R12's Face Sheet documented an admitted [DATE] and listed diagnoses including Parkinson's Disease and Dementia. R12's February 2025 Physicians Orders documented a 2/13/25 order for droplet/contact isolation due to a positive Covid test result. R13's Face Sheet documented an admitted [DATE] and listed diagnoses including Alzheimer's Dementia and Parkinson's Disease. R13's Physicians Orders for February 2025 documented a 2/13/25 order for droplet/contact isolation due to a positive Covid test result. On 2/19/25 at 8:20am, a sign on R12's door read, Transmission-based droplet contact (isolation) precautions: Respirator (N95) (required) when entering room. V13, Certified Nursing Assistant (CNA) was observed entering the room wearing a gown, gloves, and a surgical mask. On 2/19/25 at 11:05am, V2, Director of Nurses, stated she is the staff member designated as Infection Control Preventionist. V2 stated the facility currently has 5 residents positive for Covid. V2 stated staff should wear a gown, gloves, and an N95 mask into Covid rooms. On 2/19/25 at 1:05pm, V7, family member of R12, stated she is at the facility several hours daily. V7 stated R12 is currently Covid positive. V7 stated when staff provide R12's care, they always wear gloves and a surgical mask but no gown. On 2/19/25 at 1:10pm, a sign on R3's door read, Transmission-based droplet contact (isolation) precautions: Respirator (N95) (required) when entering room. V8, Housekeeper, was observed inside the room removing trash from an isolation barrel. V8 was wearing gloves and a surgical mask but no gown. On 2/19/25 at 1:15pm, a sign on R13's door read, Transmission-based droplet contact (isolation) precautions: Respirator (N95) (required) when entering room. V5, Patient Aid, was observed entering the room with R13's lunch tray. V5 donned a gown and gloves and was wearing a surgical mask. On 2/19/25 at 1:30pm, R3 was alert and oriented to person, place, time, and purpose. R3 stated she is on isolation for Covid. R3 stated when staff provide care, they wear masks and gloves, she is not sure what kind of mask, and sometimes gowns. A Respiratory Illness Policy dated 1/7/25 stated, Infection Prevention and Control: Health care personnel and visitors should adhere to the appropriate precautions when in the presence of a resident with suspected or confirmed respiratory illness. Until the cause of an ARI (Acute Respiratory Illness) outbreak is determined, facilities should use the most protective level of precautions. Transmission based precautions, such as droplet, airborne, and/or contact precautions may be recommended, depending on the type of respiratory virus detected. The table, Recommended precautions for common respiratory viruses, provides a pragmatic approach to transmission based precautions recommended by IDPH (The Illinois Department of Public Health). At a minimum, facilities should follow CDC (Centers for Disease Control) guidelines for the specific type and duration of precautions. Guidance at https://www.cdc.gov/covid/hcp/infection-control/index.html#cdc_infection_control_comm_que-frequently-asked-questions documented, Why does CDC continue to recommend respiratory protection with a NIOSH (National Institute for Occupational Safety and Health) -approved particulate respirator with N95 filters or higher for care of patients with known or suspected COVID-19? CDC ' s guidance to use NIOSH-approved particulate respirators with N95 filters or higher when providing care for patients with suspected or confirmed SARS-CoV-2 (Covid) infection is based on the current understanding of SARS-CoV-2 and related respiratory viruses. Facemasks commonly used during surgical procedures will provide barrier protection against droplet sprays contacting mucous membranes of the nose and mouth, but they are not designed to protect wearers from inhaling small particles. NIOSH-approved particulate respirators with N95 filters or higher, such as other disposable filtering facepiece respirators, powered air-purifying respirators (PAPRs), and elastomeric respirators, provide both barrier and respiratory protection because of their fit and filtration characteristics. The facility's Matrix dated 2/18/25 documented there are 74 residents living at the facility.

Based on interview and record review the facility failed to implement dietary supplements as ordered for 4 (R39, R44, R45 and R63) of 8 residents reviewed for nutrition in a sample of 36. This failure resulted in R63 experiencing a 7.88 percent weight loss within one month. Findings include: 1. R63's Resident Face Sheet documented an admitted [DATE] with diagnoses including: dementia, underweight, mild protein-calorie malnutrition, muscle wasting and atrophy. R63's 12/13/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 1, indicating R63 had severe cognitive impairment. R63's Progress Note dated 12/19/24 from V3 (Dietician) documents, Note r/t (related to) wound. Resident has skin tear to R (right) hip/buttock. Wt (Weight) 104# (pounds), usual for resident and stable. Diet order: regular, regular texture, thin liquids. Health shake one daily. Dietary intake is poor to fair. Recommend health shake BID (twice daily) and vit C 1000mg (milligrams) r/t wound healing. R63's Active Physician Orders sheet document Vitamin C 1000 mg once a day with a start date of 1/23/25 and Health shakes twice a day, morning and evening with a start date of 1/23/25. R63's Care Plan documented in part .Problem Start Date: 8/23/23 .Category: Nutritional Status . I am risk for impaired nutrition and hydration related to underweight, poor appetite, vitamin deficiencies, protein calorie malnutrition, electrolyte imbalance, impaired cognition . January 2025: weight loss 7.8% one month and 7.8% loss 3 months . with a approaches documenting in part . Approach Start Date: 8/23/23 . Nutritional supplements/ vitamins as ordered and monitor for side effects . Approach Start Date, 8/29/23 Health Shake daily for nutritional supplement (related to) underweight/ poor intake . R63's Weight Log from 3/13/24 to 1/24/25 documents R63's weight on 12/3/24 as 104 pounds with a BMI (Body Mass Index) of 18.42 and a weight on 1/3/25 as 95.8 pounds with a BMI of 16.97. This weight loss represents a 7.88 percent (severe) weight loss in one month. On 1/23/25 at 9:31 AM, V7 (Dietary Manager) said when a resident has a diet or supplement change, nursing staff will bring the order to dietary staff. V7 said she was unsure how often the V3 (Dietitian) came to the facility to review residents. V7 said V1 (Administrator) was meeting with V3 while V7 was still learning the duties of the Dietary Manager. V7 said she did not receive V3's reports and Nutritional Recommendations, V1 was the staff that would receive them. On 1/23/25 at 9:46 AM, V1 said V3 would send her the Nutritional Recommendations and she would then give them to V7 and V2 (Director of Nursing/ DON). V1 said V2 would print out the Nutritional Recommendations and give them to the resident's medical provider and when they were signed nursing staff would put the order in the Physician Order Set and notify dietary via a diet communication slip. On 1/24/25 at 11:17 AM, V9 (Nurse Practitioner) said a resident with weight loss was at risk to develop significant weight loss if not provided with ordered supplements. On 1/23/25 attempts were made to reach V3 via phone. A voicemail was left and not returned. On 1/24/25 an email was sent to V3 which again resulted in no contact back from V3. 2. R45's face sheet documents an admitted [DATE] and included the following diagnosis: Unspecified severe protein-calorie malnutrition. R45's Nutritional Recommendation dated 12/12/24 by V3 documents, recommended Health shake twice a day related to weight loss. R45's current physician order sheet includes an order with a start date of 1/24/25 for Health Shakes twice daily. R45's care plan has a problem area of: Problem I am risk for impaired nutrition and hydration related to electrolyte imbalances, vitamin deficiencies. An approach to this problem area is a health shake twice a day with a start date of 1/23/24. On 1/22/25 at 2:30 PM, V1 (Administrator) stated that V7 (Dietary Manager) is a new employee and had not been given the list of residents who had dietary recommendations from the December dietary recommendations made by V3. On 1/23/25 at 9:31 AM, V7 (Dietary Manager) provided a list of residents receiving supplements and R39, and R45 were not on the list. On 1/24/25 at 11:28 AM, V9 stated she expected the facility to follow the orders written for dietary supplements and provide them as ordered with meals and/or snacks. 3. R39's face sheet documents an admitted [DATE]. This same document include the following diagnosis: unspecified severe protein-calorie malnutrition. R39's Nutrition Recommendation dated 12/12/24 by V3 documents health shake snack daily related to weight loss. R39's current Physician orders include an order for sugar free health shake daily, once a day- day shift starting 10/22/24 with no end date and a second order for sugar free health shakes twice a day, morning and evening starting 1/23/25. Review of R39's care plan problem: I am risk for impaired nutrition and hydration related to vitamin deficiencies, weakness/fatigue, acid reflux, decreased cardiac function, hypo/hyperglycemia, or poor intake. My appetite is fair to good. The goal for this problem area is: I will be nutritionally stable as evidenced by no significant weight changes through the next review. An approach to this problem area with a start date of 1/24/24 is to provide a sugar free health shake twice a day. 4. R44's Resident Face Sheet documented an admitted [DATE] and listed diagnoses including Dementia, Hypertension, and Anxiety Disorder. R44's Minimum Data Set, dated dated dated [DATE] documented that R44 is severely cognitively impaired, requires partial or moderate assistance for eating, and requires a mechanically altered diet, R44's Care Plan dated 12/20/24 documented a problem area, I am at risk for impaired nutrition and hydration related to poor intake, tearful behavior, decreased activity tolerance, vitamin deficiency, and electrolyte imbalance. R44's January 2025 Physicians Order Sheet documented an order for a regular mechanical soft with thin liquids, and a 1/23/24 order for health shakes three times daily. R44's 12/12/24 Registered Dietician Progress Notes, authored by V3, Registered Dietician, documented, Note related to weight loss, wound. Weight 123lb., significant loss in the past 1 month. Resident's condition has declined, and she was put on palliative care with comfort measures on 11/22/24. Weight loss is related to change in condition and decrease in oral intake. Resident has an open area to right ischium which is being treated. Recommend offer health shake three times daily if resident does not eat meals. There was no documentation in the record to indicate R44 received health shakes from 12/12/24 through 1/23/25. On 1/21/25 at 1:26pm, R44 was alert only to herself. R44 was sitting up in bed with a lunch tray on the overbed table in front of her. R44's plate contained a whole boneless chicken breast which had not been cut up. There was no health shake on the tray. When R44 was asked why she didn't eat the chicken, R44 stated it was too tough. On 1/22/25 at 11:16am, V4, Family Member, stated R44 is weak at times, with a generally poor appetite. V4 stated she has been to visit during meals several times in the past few months and has not witnessed anybody offering a R44 health shake nor has she seen one on her tray. On 1/23/25 at 10:01 AM, V5, Certified Nursing Assistant (CNA) working on the 200 hall, stated R44 was transferred there from the 300 hall yesterday. V5 stated R44 had fed herself breakfast that morning and ate about 50 percent of the meal. V5 stated she did not offer R44 a health shake and was not aware she should have had one. On 01/23/25 at 10:09 AM, V6, CNA working on the 300 hall, stated some days R44 will feed herself, and some days she needs assistance. V6 stated R44 is on a mechanical soft diet. V6 stated she has never given R44 any supplements and doesn't think any were ordered. On 01/23/25 at 11:08 AM, V7, Dietary Manager, stated she was not sure if R44 was supposed to be getting a health shake. V7 stated if R44 was to be offered a health shake due to poor meal intake, the CNAs should notify the kitchen and they would send it along with a snack. On 01/23/25 at 02:31 PM, V1, Administrator, stated there is no documentation of R44 receiving health shakes as V3's 12/12/24 order was overlooked and not implemented. V1 stated on 1/23/25, R44's Primary Care Provider ordered health shakes to be given three times daily regardless of meal intake. On 1/23/25 at 2:31 PM, V1 said none of the Nutritional Recommendations from December of 2024 had been completed. The facility's revised February 2024 Weight Management Program documented in part . 10. The DON or his/her designee will list all residents who have had a weight loss or gain greater than five pounds, poor intake . results will be given to the register dietician (sic) for assessment and recommendations. 11. The DON will then distribute the R.D. (Registered Dietitian) recommendations per wing to the charge nurse. 12. The charge nurse will notify the attending physician of the current resident's condition and of the R.D.'s recommendations and document the physician's order on the physician order sheet and the 24 hour report sheet. 13. The charge nurse will then initiate a Diet Order & Communication form to the Dietary Manager who will chart the change in the dietary progress note and to the MDS Coordinator to update the care plan . A (Trade Name) Supplementation Policy dated November 2017 stated, It is the policy of (the facility) to provide each resident with additional supplementation as ordered by the Physician to promote weight maintenance or gain, to promote skin integrity, or to maintain nutritional status if meal intake is inadequate to meet needs.

Based on observation, interview, and record review, the facility failed to provide the correct physician's ordered diet and dietary recommendations for 3 of 12 residents (R5, R26, R44) reviewed for therapeutic diets in the sample of 36. Findings include: 1. R44's Resident Face Sheet documented an admitted [DATE] and listed diagnoses including Dementia, Hypertension, and Anxiety Disorder. R44's Minimum Data Set, dated dated dated [DATE] documented that R44 is severely cognitively impaired, requires partial or moderate assistance for eating, and requires a mechanically altered diet, R44's Care Plan dated 12/20/24 documented a problem area, I am at risk for impaired nutrition and hydration related to poor intake, tearful behavior, decreased activity tolerance, vitamin deficiency, and electrolyte imbalance. R44's January 2025 Physicians Order Sheet documented an order for a regular mechanical soft with thin liquids. R44's Physician Order sheet documents in part, Diet: Regular consistency: mechanical soft. Start date of 11/18/24. On 1/21/25 at 1:26pm, R44 was alert only to herself. R44 was sitting up in bed with a lunch tray on the overbed table in front of her. R44's plate contained a whole boneless chicken breast which had not been cut up. When R44 was asked why she didn't eat the chicken, R44 stated it was too tough. On 1/22/25 at 11:16am, V4, Family Member, stated R44 is weak at times, with a generally poor appetite. V4 stated R44 is to have ground meat. On 01/23/25 at 10:09 AM, V6, CNA working on the 300 hall, stated some days R44 will feed herself, and some days she needs assistance. V6 stated R44 is on a mechanical soft diet. On 01/23/25 at 11:08 AM, V7, Dietary Manager, stated R44 is on a mechanical soft diet and confirmed the meat served to R44 should be ground. A December 2024 Consistency Modified Diets Policy documented, Mechanical soft: This diet is used for patients with limited chewing ability. Food menus include ground moist poultry and meat without bones. 49714 2. R5's face sheet documents an admitted [DATE]. This same document includes the following diagnosis: Diabetes Mellitus, End Stage Renal Disease, and Muscle wasting and atrophy. R5's current month physician orders documents an order with a start date of 1/23/25 of Prostat 30 milliliters (ml) once a day for wound healing. R5's progress note documents on 12/19/2024 V3 (Dietitian) documented weight fluctuates related to fluid status on dialysis. No significant sustained weight loss is noted at this time. Recommend Pro Stat 30 ml daily and zinc sulfate 220 mg daily related to wound healing. R5's care plan documents a problem area of: Problem: I am risk for impaired nutrition and hydration related to poor intake, electrolyte imbalance, vitamin deficiencies, wounds, edema, hyper/hyperglycemia, weakness. The goal for this problem area is: I will be nutritionally stable as evidenced by no significant weight changes through the next review. An approach for this problem area dated 1/24/25 is: ProStat 30mL a day. 3. R26's face sheet documents an admitted [DATE] with the following diagnosis: moderate protein calorie malnutrition. R26's Nutrition Recommendation by V3 dated 12/12/24 documents at Pro Stat 30 ml daily, Vit C 1000 mg daily and zinc sulfate 220 mg daily for multiple wounds/pressure ulcers. R26's care plan documents a problem area of risk for impaired nutrition and hydration related to poor intake. An approach to this problem area dated 1/10/25 to provide nutritional supplements as ordered. R26's current physician order sheet has an order for health shake daily twice daily with a start date of 1/23/25. On 1/22/25 at 2:30 PM, V1 (Administrator) stated that V7 (Dietary Manager) is a new employee and had not been given the list of residents who had dietary recommendations from the December dietary recommendations made by V3 (Dietician). On 1/23/25 at 2:31 PM, V1 said none of the Nutritional Recommendations from December of 2024 had been completed.

Based on interview and record review the facility failed to maintain range of motion for 1 (R25) of 1 resident reviewed for decreased range of motion in the sample of 36. The findings Include: R25's Face Sheet documented R25 as a [AGE] year-old with an admitted [DATE] to the facility. Diagnoses listed are chronic respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, chronic obstructive pulmonary disease, venous insufficiency, chronic systolic congestive heart failure, obstructive sleep apnea, major depressive disorder, essential hypertension, non - pressure chronic ulcer of other part of right lower leg, and atherosclerosis of native arteries of right leg with ulceration of other part of lower leg. R25's Physician's orders with no print date document an order for AROM (Active Range of Motion) 6-7 times per week and Bed Mobility 6-7 times per week. Both orders were discontinued on 01/22/2025. On 01/22/2025 there was a new order for PROM (Passive Range of Motion) to right lower extremity 6-7 times a week. R25's Admission MDS (Minimum Data Set) with a date of 08/12/2024 noted that R25 has a BIMS (Brief Interview of Mental Status) of 15 which indicates R25 is cognitively intact. Section GG documents for functional limitation in range of motion that R25 has an impairment on both sides for lower extremity. Section GG for self-care documents that R25 is dependent on toileting, putting on / taking off footwear, lower body dressing, upper body dressing and shower/bathe. Section O of the same MDS documents R25 received 1 day of active range of motion and 0 days of passive range of motion (with a look back period of 7 days). R25's Quarterly MDS dated [DATE], documented in section GG, documents for functional limitation in range of motion that R25 has an impairment on both sides for lower extremity. Section GG for self-care documents that R25 is dependent on toileting, putting on / taking off footwear, lower body dressing, upper body dressing and shower/bathe. Section O of the same MDS documents R25 received 0 days of passive / active range of motion (with a look back period of 7 days). R25's Care Plan with a start date of 10/16/2024 documents a focus area activities of daily living / functional status / rehabilitation potential, I am alert and oriented times 4, I am able to make all my needs / wants known appropriately. I utilize my call light. I have a BIMS of 15. I prefer to remain in bed, I am non-ambulatory and transfer with two assists utilizing a mechanical lift. I am frequently incontinent, and I keep a urinal at bedside. I require substantial to dependent staff assist with bed mobility, dressing, toileting hygiene, and bathing. I have decreased range of motion, mobility, bilateral lower extremity venous insufficiency, chronic pain and respiratory deficits. Interventions listed are active / passive range of motion with care as tolerance, assist with activities of daily living, assist as needed with toileting with start date of 10/16/2024. R25's Behavior Analysis Report with a date range of 08/02/2024 -01/22/2025 documented range of motion was completed on the following dates: 08/12/2024, 08/13/2024, 08/22/2024, 08/26/2024, 10/16-10/19/2024, 10/24/2024, 10/26/2024, 10/31/2024 and 01/14/2025. On 01/22/2025 at 1:37 PM, R25 stated he does not receive range of motion from the facility staff. On 01/22/2025 at 2:20 PM, V13 (Restorative Certified Nurse Aide) stated that R25 does not like to participate in restorative therapy. V13 stated that R25 refuses care. On 01/22/2025 at 2:22 PM, R25 stated that no staff members offer to do range of motion on him. On 01/24/2025 at 1:00 PM, V2 (DON) stated that she changed the order on R25's range of motion from active too passive because the resident needs passive range of motion. Review of facility policy titled Restorative Nursing with a date of August 2023 documented It is the policy of company name to provide restorative nursing which promotes the resident's ability to live as independently and safely as possible. Restorative nursing focuses on achieving and maintaining the optimum level of physical, mental, and psychological function of the resident. 4. Restorative treatments are recorded in the electronic health record.6. Services which are provided at least 15 minutes per day in a 24-hour period are also recorded on the MDS if in the MDS observation period.8. The restorative nurse documents the resident's progress and indicates if the current plan should continue or if the resident should be referred back to therapy for a screen / evaluation.

Based on interview and record review the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 (R25) of 5 residents reviewed for unnecessary medications in the sample of 36. The Findings Include: R25's Face Sheet documented R25 as a [AGE] year old with an admitted [DATE] to the facility. Diagnoses listed are chronic respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, chronic obstructive pulmonary disease, venous insufficiency, chronic systolic congestive heart failure, obstructive sleep apnea, major depressive disorder, essential hypertension, non - pressure chronic ulcer of other part of right lower leg, and atherosclerosis of native arteries of right leg with ulceration of other part of lower leg. R25's MDS (Minimum Data Set) with a date of 12/03/2024 noted that R25 has a BIMS (Brief Interview of Mental Status) of 15 which indicates R25 is cognitively intact. R25's Orders printed 01/24/2025 documented an order for bupropion 100 mg by mouth daily with a start date of 12/12/2024, and duloxetine 120 mg by mouth daily related to increased depression with a start date of 08/16/2024. R25's Care Plan has a focus area of: I receive an antidepressant medication for diagnosis of depression with an initial date of 08/19/2024. Documented interventions are given bupropion 100mg by mouth daily with a start date of 12/12/2024, duloxetine 120 mg by mouth daily with a start date of 08/19/2024, monitor residents' mood and response to medication with a date of 08/19/2024. Care Plan has a focus area of I am at risk for adverse side effects due to the use of medications with a black box warning with a start date of 10/16/2024. Documented interventions are monitor patient at the start and throughout therapy for any signs of clinical worsening, suicidal ideations, or unusual change in behaviors, behavior tracking per policy with a date of 10/16/2024. R25's Behavior Analysis Report from 08/02/2024 - 01/22/2025 shows no behaviors occurred for the dates listed. R25's document titled Psychotropic Medication Tracking/ GDR Tracking with an initiation date of 08/02/2024 documented on 12/12/2024 to increase bupropion to 100 mg by mouth daily for depression. R25's Progress Note dated 12/12/2024 authored by V11 (Registered Nurse) documented, V12 (Nurse Practitioner) in facility to see resident on 12/11/24. Received the following recommendations: Increase bupropion to 100mg po daily related to increase in irritability over the last 30 days. Resident agreeable. Will monitor x30 days. On 01/24/2025 at 10:23 AM, V1 (Administrator) stated that if the staff do not chart any behaviors, then the report will show no behaviors tracked. V1 stated that the behavior tracking for R25 has no behaviors charted. On 01/24/2025 at 10:27 AM, V5 (Certified Nurse Assistant) stated the behaviors that R25 has is refusing care, peeing in a water cup instead of a urinal, and will urinate in a towel then throw it in the floor. V5 stated she has not seen any crying, irritability, or sadness from R25. On 01/24/2025 at 10:30 AM, V10 (Certified Nurse Assistant) stated that R25 refuses care from staff but she has not seen any signs or symptoms of crying, irritability, or sadness. The facility policy titled Psychotropic Medication Use with a date of December 2018 documented It is the policy of company name that all residents receiving psychotropic medications, be monitored to ensure the least amount of medication is given to treat the diagnosis. This is accomplished through tracking behaviors and effectiveness of interventions.

Based on interview and record review the facility failed to use the appropriate size shower chair for 1 (R1) of 4 residents reviewed for accidents in the sample of 4. This failure resulted in R1 sliding down in the chair into the open part, causing an acute impacted fracture of the left femoral neck. This past non-compliance occurred between 07/10/2024 and 07/16/2024. The findings include: R1 ' s Resident Face Sheet documents an initial admitted to the facility of 05/07/2022 with diagnoses including unspecified dementia, anorexia, hypokalemia, chronic obstructive pulmonary disease, anxiety, major depressive disorder, arthritis, restlessness, agitation, and pseudobulbar affect. Additional diagnoses include acute impacted fracture of the left femoral neck dated 07/10/2024. R1 ' s MDS (Minimum Data Set) section C, dated 06/21/2024, documents that R1 has a BIMS (Brief Interview of Mental Status) of 05 indicating R1 has severe cognitive impairment. The same MDS section GG documents that R1 has impairment in both sides of lower extremities (hip, knee, ankle, foot) and uses a wheelchair as a mobility device. The same section, GG0130 documented Shower/bathe self: as a 01 indicating R1 is dependent for care (helper does all of the effort). Section GG0170 documented Tub/Shower transfer as a 01 indicating R1 was dependent for transfers (helper does all of the effort). R1's electronic medical record vital sign tab documented R1 has a height of 5 foot 2 inches and a July 2024 weight of 110 pounds. R1 ' s Care Plan with a date of 01/17/2024 documented a focus area of I am cognitively impaired due to disease progression of Dementia. I demonstrate poor short- and long-term memory, disorganized thought process, delayed processing, inability problem solves, and impaired safety awareness. My appetite is poor. I require verbal cues and substantial to dependent staff assistance for ADL ' s (Activities of Daily Living) and mobility. I am usually able to answer yes/no questions appropriately with a goal of Will remain safe. Documented interventions include verbal cues as needed, simple yes/no questions and commands and observe whereabouts - encourage to stay in common areas when out of room for staff supervision. Undated facility final investigation report for R1 documents in part, On 7/9/24 .It was noted that resident had a bruise to posterior left upper left. An Xray was ordered and completed on 7/10/24. 7/10/24 2 view left femur Xray result: acute impacted left femoral neck/intertrochanteric fracture . Following facility investigation this resident had slid through the opening of the shower chair and required 2 assist out of the opening. She had a bruise that was observed on the back of her leg following shower under the fractured hip. Staff education was initiated to give showers in appropriate fitting shower chair. R1 ' s progress note, authored by V10 (Licensed Practical Nurse/LPN) dated 07/08/2024 with a time of 2:21 p.m., documented CNA (Certified Nursing Assistant) alerted this nurse that resident has a bruise on the back of her left leg above her knee. Resident is not complaining of any pain at this time. The bruise is black-purplish color, it is 8cm (centimeter) x 5cm. CNA and this nurse believes that the bruise came from when night shift got her up this morning, they put the bed rail down and when they set her up on the side of the bed the back of her leg hit the side rail. We replaced the hard side rail with a soft side rail. POA (Power of Attorney) and V4 (Nurse Practitioner) notified. R1 ' s progress note, authored by V11 (Registered Nurse/RN) dated 07/09/2024 with a time of 7:30 A.M., documented CNA notified this nurse that resident has a large purple bruise on inside of left thigh that goes from groin to knee. Resident is crying and complaining of pain. This nurse will notify V4 this am when she comes to this facility to make rounds. R1 ' s progress note dated 07/09/2024 authored by V11 (RN) with a time of 8:30 A.M. documented V4 here making rounds. This nurse informed her of the bruising to resident's inner left thigh. V4 stated that she was aware of the bruising to posterior left knee, as it had been reported yesterday. V4 said she would look at it when she saw the resident. R1 ' s progress note dated 07/09/2024 authored by V11 with a time of 10:30 A.M. documented Received order from V4 to obtain x-ray of L (left) hip, pelvis, and L femur related to bruising and pain. R1 ' s progress note dated 07/10/2024 authored by V12 (RN) with a time of 2:12 P.M., documented X-ray obtained this afternoon of resident's Lt (left) femur/pelvis. Results from X-ray reveal acute impacted left femoral neck/intertrochanteric fracture. V4 notified, resident to be sent to local hospital ER (emergency room ). POA notified of break and of resident going to ER. Local Ambulance company in facility to transfer resident. R1 ' s progress note dated 07/10/2024 authored by V2 (RN/Director of Nursing) with a time of 6:29 P.M. documented Resident is admitted to hospital. Room number not available at this time. Dx (diagnosis): left hip fracture. R1's X-ray report with a date of 07/10/2024 documented the procedure as Left hip, unilateral w/Pelvis. Results are as follows: as an acute impacted fracture of the left femoral neck. There is a 3mm (millimeter) offset of fracture fragments and impaction of the fracture site. There is multiple screws involving proximal right femur. On 08/22/2024 at 10:34 AM, V5 (LPN/Minimum Data Set/Care Plan Coordinator) stated she was working the floor on the Saturday that R1 received her shower. V5 stated she was walking up the hall and noticed the call light was on in the shower room. V5 stated she entered the shower room and saw R1 in the shower chair and two staff providing care. V3 and V9 stated they did not need anything so V5 went out of the shower room to continue doing what she was. V5 stated that R1 was not straight in the shower chair but the shower chair wasn't positioned straight with R1. V5 stated that later that week when she was at work, she heard V2 talking about R1 having a bruise and that they were investigating it. V5 stated the next day it was discussed that the bruise was worse, so she went to talk to V2 about it. V5 told V2 that staff were giving R1 a shower in a bariatric chair and the chair was way too big for R1. V5 stated that she told V2 that R1's positioning in the chair was off. V5 stated that when she entered the shower room, R1 was not in any distress and the staff did not look like there were any problems which is why she left the shower room. V5 stated that R1 was very impulsive at times and had cognitive issues. On 08/21/2024 at 3:34 PM, V2 (RN/Director of Nursing) stated that she was not aware of any incident with R1. V2 stated it was reported to V10 (LPN) from a CNA that R1 had a bruise to the back of her left leg. The following day the bruise was worse. V4 (Nurse Practitioner) was in the facility and saw R1. V4 ordered x-rays on R1. The x-rays came back with a fracture. V2 stated that she immediately started investigating the cause. V2 stated at first, they were looking for a transfer that did not go how it should or a fall that was not reported. V2 stated she interviewed staff about R1 having a fall, if they knew how R1 obtained the bruise, and if any staff had been a part of or witnessed an unsafe transfer. V2 stated that R1 would often throw her legs over the side of her wheelchair and did ask staff if they had ever seen R1 have any body part stuck in the side rail. V2 stated that when she was interviewing V5, V5 told her to look into the shower that R1 was given on 07/04/2024. V5 told V2 that when she went into the shower room to answer the call light, R1 did not look right in the shower chair and the V9 reported that she had slid down multiple times during the shower. V2 stated she looked at the shower chair that staff had used on R1 on 07/04/2024 because it was reported to V2 by V5 that the shower chair was too big. V2 stated V9 had used a bariatric shower to give R1 a shower. V2 stated that R1 was a little resident, and the shower chair was too big for her. V2 stated that after review of shower chair and bruises, that the bruise lined up with the front area of the shower chair that was open. V2 stated that during the investigation staff reported that R1 was difficult to give a shower to as she would constantly move and slid around in the shower chair. V2 stated that R1 had sun downing and her behaviors were worse in the afternoon. On 08/21/2024 at 4:14 PM, V1 (Administrator) stated that R1 had bruising that staff noticed. V1 stated that V2 investigated the cause of the bruising. V1 stated that R1 had more pain and V4 ordered x-rays. V1 stated that the x-ray results came back with a fracture. V1 stated that staff were having difficulty keeping R1 in the shower chair to complete her shower. R1 was noted to be sliding down and having to be repositioned. V1 stated that R1 did not have any falls or prior injuries that she is aware of. V1 stated that the R1 was sent to a local hospital for evaluation of the fracture. R1 went to another facility after the hospitalization . V1 stated that R1 did not have full range of motion and was constantly having to be repositioned in her wheelchair prior to this incident. V1 stated that she always leaned to one side and had a kyphotic posture. V1 stated that the facility reviewed shower chairs and what size resident best fit each one. The facility then ordered a pediatric chair for smaller sized residents. V1 stated the facility did education regarding the shower chairs and have color coated the shower schedule to alert staff of what chair to use for each resident. V1 stated that V2 has completed audits regarding shower chair use. On 08/22/2024 at 8:23 AM, V3 (CNA) stated she was not the CNA giving the shower the day in question. V3 stated she helped transfer R1 to the shower chair and told V9 to use the call light when she needed help transferring R1 back to her chair. V3 stated that she saw the call light on and went back into the shower room. V9 told V3 that R1 had tried to jump out of the shower chair. V3 stated she helped transfer R1 and then left the room to go provide care for other residents. V3 stated that R1 was hard to shower because she would constantly be sliding down in the chair. V3 stated she is not aware of R1 ever having a fall in the facility. On 08/22/2024 at 9:22 AM, V4 (Nurse Practitioner) stated she did provide care for R1. V4 stated that she had seen R1 on 06/13/2024 and 07/03/2024 prior to seeing her on 07/09/2024. V4 stated on the prior visit she was complaining of pain and was noted to have an abscessed tooth. V4 stated on 07/09/2024 R1 was saying it hurt but could not specify what exactly hurt. V4 stated since there was bruising, she ordered x-rays to be completed. V4 stated that R1 had a bone density test in 2018 that had documented borderline osteopenia. V4 stated that before R1 was admitted she had had numerous falls at home but was not aware of R1 having any falls in the facility. Attempts were made to contact V9 (CNA) via phone on 08/22/2024 at 11:48 A.M. and 2:05 P.M. A handwritten statement that was included with the investigation titled Regarding R1 documents, V9 (CNA) documented she did not see R1 sitting on her foot pedals, and she did not feel the shower chair was the appropriate size for R1. V9 ' s written statement documented, Gave shower on the 4th of July, V3 assisted me in transferring her to and from the shower. I did not observe a bruise on her thigh at the time of shower or after. Her butt slides forward and you have to pick her up and straighten her up. She was very agitated. Kept saying she was going to jump in the floor. So, I stood in front of her while drying her off. She tried to scoot herself forward out of the chair multiple times after that. I just held on to her and hit the call light for assist. Document titled Local Hospital R1 Progress Note dated 07/13/2024 documented R1 had a left intertrochanteric femur fracture with no plan for surgery at this time. On 08/21/2022, V1 provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form from at QAPI meeting on 7/10/24 outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: Immediate Corrective Action for those affected by the deficient practice: Sent R1 to ER for further evaluation and treatment. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents could be affected. Measures put into place/systemic changes to ensure the deficient practice does not recur: Staff education on using proper fitting wheelchairs for small residents. Completed on 07/16/2024. Shower sheets coded for residents who should use small / pediatric shower chair (who weigh under 120 pounds) Completed 07/16/2024. Verbal / written warning for CNA who completed the shower. Completed 07/11/2024. Plan to monitor performance to ensure solutions are sustained: Code new admits (under 120 pounds) on shower sheets upon admission. Audit 2 times weekly x 4 weeks, staff are using correct / appropriate fitting chair.

Based on interview and record review, the facility failed to report an allegation of abuse to the Illinois Department of Public Health (IDPH) for 1 of 4 residents (R1) reviewed for abuse in the sample of 6. The findings include: R1's face sheet documents she was admitted to the facility on [DATE]. The same face sheet documents R1's diagnoses to include Unspecified dementia, severe, with agitation, urinary tract infection, site not specified, restlessness and agitation, nutritional deficiency, unspecified, other symptoms and signs concerning food and fluid intake. R1's MDS (Minimum Data Set) dated 5/14/24 documents R1 has a BIMS (Brief Interview of Mental Status) of 04 which indicates R1 has severe cognitive impairment. On 6/11/24 at 10:00am, V1 (Administrator) stated that last night V13 (MDS (Minimum Data Set) coordinator/Care plan coordinator) called her and said she had a CNA (Certified Nurse Assistant) (V3) with her. V13 told V1 that V12 (family member) had came to her and said that a housekeeper had shoved her mom out of her room in her wheelchair and yelled at her. V1 said V3 had told her that (R1) had hit the housekeeper. V3 told V1 that is not what she had told V12 and that she had told her that the housekeeper came out of the room yelling she hit me, she hit me. V1 said she did not do an investigation or report it to IDPH since that is not what happened. On 6/12/24 at 1:30pm, V1 stated she felt the incident with R1, and the housekeeper was not to the level of abuse, and it was handled within minutes, not days apart. V1 said she felt the situation was handled and V12 was satisfied with the outcome. V1 said she did not do an investigation or report it. Facility document labeled Abuse Prevention Program, revision date 9/29/22 documents on page 8 that the allegation shall either be called or faxed into the Regional Public Health Office. Public Health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated and the report shall contain the following information: 1. Name, age, diagnosis and mental status of the resident allegedly abused or neglected. 2. Type of abuse reported (physical, sexual, misappropriation, neglect, verbal or mental abuse). 3. Date, time, location and circumstances of the alleged incident. 4. Any obvious injuries or complaints of injury. 5. Steps the facility has taken to protect the resident. .

Based on interview and record review, the facility failed to initiate and conduct a thorough investigation of an allegation of abuse for 1 of 4 residents (R1) reviewed for abuse in a sample 6. The findings include: R1's face sheet documents she was admitted to the facility on [DATE]. The same face sheet documents R1's diagnoses to include unspecified dementia, severe, with agitation, urinary tract infection, site not specified, restlessness and agitation, nutritional deficiency, unspecified, other symptoms and signs concerning food and fluid intake. R1's MDS (Minimum Data Set) dated 5/14/24 documents R1 has a BIMS (Brief Interview of Mental Status) of 04 which indicates R1 has severe cognitive impairment. On 6/11/24 at 10:00am, V1 (Administrator) stated that last night V13 (MDS (Minimum Data Set) coordinator/Care plan coordinator) called her and said she had a CNA (Certified Nurse Assistant) (V3) with her. V13 told V1 that V12 (family member) had came to her and said that a housekeeper had shoved her mom out of her room in her wheelchair and yelled at her. V1 said V3 had told her that (R1) had hit the housekeeper. V3 told V1 that is not what she had told V12 and that she had told her that the housekeeper came out of the room yelling she hit me, she hit me. V1 said she did not do an investigation or report it to since that is not what happened. When V1 was asked to provide any documented information on the incident between R1 and the housekeeper V1 provided a document provided written by V1 dated 6/12/24 that documented in part, Timeline for Monday, June 10th, 2024 .5:50 p.m.- V12 approached V13 and reported that (V3) told her that the housekeeper shoved her mother out her room after the resident hit her .This was treated as a grievance and not a reportable matter because it was secondhand information/gossip from the daughter and there was no willful intent . During this investigation V1 could not provide a grievance regarding the incident from June 2024 between R1 and a housekeeper. Facility document labeled Abuse Prevention Program, revised 9/29/22 documents in part, 5. Internal Reporting Requirements and Identification of Allegations .Supervisors shall immediately inform the administrator of all reports of incidents, allegation, or suspicion of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation .7. Internal investigation of abuse, neglect or misappropriation allegations and response. a. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. b. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation .

Based on interview and record review, the facility failed to provide timely physician notification of symptoms of a urinary infection and timely collection of specimens for 1 (R22) of 1 resident reviewed for Urinary Tract Infections in the sample of 60. This failure resulted in R22 experiencing untimely treatment of a Urinary Tract Infections with symptoms of pain and burning expressed by R22 beginning on 2/15/24, with antibiotic treatment not initiated until 2/28/24. Findings Include: R22's face sheet documents an admitted [DATE] to the facility and includes the following diagnoses: major depressive disorder, need for assistance with personal care, and disorder of kidney and ureter. R22's most recent completed MDS (Minimum Data Set) dated 11/7/23 Section C documents a BIMS (Brief Interview of Mental Status) score of 15, indicating that R22 is cognitively intact. Section GG for toileting hygiene, shower/bathe self and personal hygiene are coded as needing substantial/maximal assist. In this same Section GG is coded as being dependent for toilet transfers. On 2/27/24 at 9:00 AM, R22 stated that she has been hurting when she urinates for weeks, and she doesn't understand why they are taking so long to get her medication. R22 stated that they have had to collect two or three samples of her urine in the meantime, and she doesn't know if they are losing it or what but would like this urinary tract infection taken care of. R22 states that she gets infections kind of regularly. R22's progress note entry on 2/15/24 at 6:12 PM, documents that R22 c/o (complained of) pain, burning upon urination and a message was sent to V13 (Nurse Practitioner) and awaiting return orders. The progress note further documents that the POA (Power of Attorney) was aware of c/o (complaints of) and was ok with whatever V13 orders. A progress note dated 2/22/24 documents (R22) c/o pain /discomfort when urinating. Urine obtained for UA (urinalysis) C & S (culture and sensitivity). A Progress note dated 2/27/24 made by V15 (Licensed Practical Nurse)(LPN) documents Received new order to start resident on ceftriaxone 1 gm (gram) daily x 5 days r/t (related to) UTI (Urinary Tract Infection). Resident and POA made aware of new order. A progress note dated 2/28/24 made by V16 (Registered Nurse) documents First dose of ceftriaxone was administered to rt (right) buttock, resident tolerated well. Ceftriaxone was diluted in 2.1 mL (milliliters) of lidocaine per pharmacy direction. (Local Hospital) lab was contacted several times to send over UA results, UA results were never sent x3. On 2/29/24 at 3:00 PM, V2 (Director of Nursing) stated that the initial urine sample was not labeled properly so it had to be redrawn. When they got the culture back, they waited for the sensitivity prior to notify the doctor to get an antibiotic ordered. V2 confirmed at this time no broad spectrum antibiotic was started while waiting for the sensitivity to come back. R22's current physician order sheet for March 2024 has an order with a start date of 2/29/24 for Ceftriaxone 1 gram injection with an end date of 3/4/24. On 3/1/24 at 9:15 AM, V2 stated that R22 had no complaints when V13 (Nurse Practitioner) rounded on her on 2/15/24. R22 must have became symptomatic after seeing V13. The order was obtained on 2/18/24 to collect the urine for a urinalysis and was sent off on 2/19/24. It was determined on 2/19/24 that the collection was not properly labeled and needed to be recollected. The next sample collected was on 2/22/24 and an antibiotic order Ceftriaxone 1 gram daily for 5 days was started on 2/28/24. V2 stated that the nurse did not get the order into the system until after midnight, so the order shows a start date of 2/29/24. V2 went on to state that the lab picks up samples early in the morning prior to 8:00 AM Monday-Friday. V2 stated that the second collection fell on a weekend and if the provider does not order a stat lab they will wait until Monday morning to collect the sample. V2 stated that is what happened with R22 and why the delay occurred with obtaining the second sample and getting the results. V2 provided 24 hour report sheets with the following information for R22. On 2/15/24 R22 has documentation on the 6AM-6PM shift that she is complaining of burning upon urination and that a message was sent for a urinalysis. On 2/16/24 the 6PM-6AM shift documents that faxed communication to (V13) related to burning with urination. Awaiting new orders. On 2/17/24 the 6PM-6AM shift documents burning with urination, awaiting orders. On 2/18/24 the 6PM-6AM shift documents burning with urination, awaiting orders and the 6AM-6PM shift reports new order for urinalysis. On 2/20/24 the 6AM-6PM shift documented urinalysis not labeled and need to redo. On 2/21/24 the 6PM-6AM shift reported need urinalysis. On 2/22/24 6PM-6AM reported need urine, and the 6AM-6PM reported ok urinalysis in fridge. On 2/23/24 6PM-6AM reported the urinalysis in fridge. On 2/24/24 the 6PM-6AM shift reported faxed urinalysis results, awaiting results. A lab report provided documents that the specimen was collected on 2/19/24 and was not labeled. The report advised the facility to collect a new specimen properly labeled with full name, date of birth, and date/time of collection. A patient report from local hospital dated 2/23/24 documents a positive nitrite in the urinalysis and a culture and sensitivity to follow. A lab report dated 2/27/24 documents the culture and sensitivity results of >(greater than) 100,000 CFU (colony forming unit)/ML(milliliters) of Escherichia Coli. On 3/1/24 at 9:05 AM, V13 (Nurse Practitioner) stated that in reviewing documentation, she does not see where she was notified of R22 experiencing burning with urination until 2/18/24, when at that time she gave the order for a Urinalysis with Culture and Sensitivity if indicated. V13 also stated she was never notified of a specimen not being labeled correctly, which resulted in a prolonged collection time with urinary infection symptoms present. V13 stated that it is her expectations that if the facility is not receiving a response via fax, that they should call her for orders and communicate any concerns. V13 acknowledges the untimely collection for the facility obtaining the culture, resulted in delayed treatment to R22. V13 agreed that it is fair to say R22 would have experienced prolonged discomfort with the lack of timely treatment provided. V13 stated her expectations are that if a resident is experiencing symptoms of infection, such as burning with urination, the lab would be ordered to be completed immediately and not that a routine culture would be obtained at just the next available pickup date. An undated antibiotic stewardship policy documents .Procedure: 1. When the nurse suspects that the resident has an infection, the nurse will perform an evaluation of the resident that includes: a. resident signs and symptoms. i. complete set of vital signs ii. interview of resident for symptoms iii. assessment. 2. The nurse will utilize the McGeer Contitutional Criteria infection criteria protocol to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made. 3. Notify the physician/practitioner of resident change of condition and evaluation information. The nurse to communicate to physician of infection criteria protocol to treat the respective infection. 4. When diagnostics are ordered by the practitioner, the nurse will contact the lab/radiology to notify of physician order. a. Physician will be notified of results of diagnostics to ensure resident is taking the appropriate antibiotic or if antibiotic needs to be discontinued or changed. 5. If indicated, based upon (identified) criteria, an antibiotic is ordered, the practitioner will identify the diagnosis/indication, the appropriate antibiotic, proper dose, duration and route. a. In the event the prescribing physician orders an antibiotic without identification of infection criteria, the physician will be requested to identify rationale for ordered antibiotic .

Based interview and record review the facility failed to ensure the Activity Director had the appropriate qualification to conduct the activity program of the facility. This has the potential to affect all 87 residents living in the facility. Findings include: On 2/28/2024 at 9:25 AM, V4 (Activity Director) stated that she has been in the role as Activity Director for 10 months and is not certified at this time. V4's Activity Director's personnel file, revealed a hire date of 2/28/2023 as the Activity Director. There was no evidence in the personnel file to show that V4 was qualified to be the Activity Director. On 2/29/2024 at 2:20 PM, V1 (Administrator) confirmed that V4 does not have Certification in Activities. V1 acknowledged that the Activity Director should be certified or enrolled in the certification classes. V1 stated that V4 is currently signed up for the on-line certification classes as of 2/28/2024. An email provided by V1 dated 2/28/24 documents that V4 was now registered for the Outcome Services (OSI) of Illinois Activity Director Correspondence Course, attached was a copy of the registration form and course description. The Facility's Activity Director Job Description documents in part .Education and experience requirements . The activity director must have the following: Activities Certification preferred; must be eligible and willing to become certified in Illinois if not. The Long Term Care Facility Application for Medicare and Medicaid (CMS Form 671) signed and dated 2/27/24, documents 87 residents reside in the facility.

Based on observation, interview and record review the facility failed to properly store and label food items, failed to maintain the ice machine in a safe and sanitary manner and failed to prevent potential cross contamination of food and food contact areas by staff not wearing hair restraints. This has the potential to affect all 87 residents that reside in the facility. The Findings Include: During the initial tour of kitchen on 2/27/24 at 8:30 AM the following concerns were observed: 1. A package of waffles were found in the walk in cooler not dated and open to air not sealed back up. 2. Margarine spread buckets were open/partially used and not dated or labeled. 3. Yellow shredded cheese was open, and half used not dated or labeled. 4. Lunch meat and cheese slices were wrapped in plastic wrap in smaller packages not in original packaging not dated and not labeled. 5. Styrofoam cups without a handle were found in the bulk sugar, corn meal, bulk thickener. There was also a container of white powder not dated and not labeled. At this time V3 (Dietary Supervisor) stated that all of these items found at initial tour of the kitchen will be discarded. On 2/28/24 at 11:24AM, V5 (Cook) and V6 (Dietary Aide) were observed in the kitchen without hair restraints. At this time V1 (Administrator) stated that the expectation is that hair restraints are to be worn at all times in the kitchen and she instructed them to get a hair restraint on. On 2/29/24 at 11:30 AM, the ice machine in the service hall by the kitchen was found to have a white hard water build up accumulated on the outside of the ice machine and also dripping water down the front causing a rust colored water to be building up on the door that opens to the ice machine. Inside the ice machine black and pink spots were found on the plastic shield where the ice drops down into the holding bin to be then scooped out for use. The Food and Supply Storage policy with a revision date of January 2012 documents in part 4. Prepared foods stored in the refrigerator until service will be covered, labeled and dated with an expiration date 6. All foods will be covered, labeled and dated The Personal Hygiene and Uniform Appearance policy with a revision date of January 2012 states that staff shall report to work in clean uniforms according to the facility uniform policy. Hair nets or hair covering shall be worn while in the kitchen or storage units. The Long Term Care Facility Application for Medicare and Medicaid (CMS Form 671) signed and dated 2/27/24, documents 87 residents reside in the facility.

Based on interview and record review the facility failed to ensure residents who are transferred with a patient whole body lift machine are transferred safely and in accordance with the facility's lift machine policy for 1 of 3 (R1) residents reviewed for accidents in a sample of 9. This failure resulted in R1 falling while being transferred with the patient lift machine and sustaining moderate to large volume left scalp hematoma, acute minimally displaced fracture of C7 vertebral body, acute mildly displaced fracture of T1 vertebral body, and non-displaced fracture of the right posterior first rib. This past non-compliance occurred from 12/16/2023 to 12/18/2023. Findings include: R1's EHR (Electronic Health Record) documents an admission to this facility on 12/8/2021 with diagnoses of Chronic Respiratory Failure, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Chronic Venous Hypertension, Lymphedema, Morbid Obesity, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hearing Loss among others. R1's MDS (Minimum Data Set) dated 12/4/2023 under section GG (Functional Abilities and Goals) documented R1 is dependent on staff for showers, shower transfers, dressing lower body, personal hygiene, toilet transferring and toilet hygiene, and chair/bed-to-chair transfers. This same MDS under section C (Cognitive Patterns) documented R1's mental function was assessed with the BIMS (Brief Interview for Mental Status) in which R1 scored 14 out of 15 total. A BIMS score of 14 out of 15 indicates R1 is cognitively intact. On 1/31/2024 at 9:30am, V1 (Administrator) said on 12/16/2023 at 1:00pm, she was notified of R1 falling from the mechanical lift machine while being transferred from her wheelchair to her bed and was sent to the emergency room to be evaluated for injuries. V1 said she and V2 (Director of Nursing) immediately came to the facility and began investigating R1's fall. V1 said while at the emergency room , R1 was diagnosed with scalp hematoma, neck sprain and bruised left shoulder/chest and sent back to the nursing home. V1 said while investigating, she determined V5 (Certified Nursing Assistant/CNA) had transferred R1 with the whole body mechanical lift by herself and not in accordance with the facility's policy. V1 said two staff must be present when transferring a resident with the mechanical lift. V1 said on 12/16/2023, she and V2 retrained all nursing staff and inspected all lift slings and lift machines. V1 said after V5 was retrained and disciplined for her actions. V1 said a few days later, R1 continued to have pain and was sent back to the emergency room for further evaluation where it was determined R1 had fractured a rib and two vertebrae. On 1/30/2024 at 3:30pm, V5 (Certified Nursing Assistant/CNA) said she and V6 (CNA) were the assigned CNA's working on the 200 hall on 12/16/2023. V5 said right after the residents finished their noon meal, she began assisting residents to the toilet while V6 went on her 30 minute lunch break. V5 said she noticed R1 was really wet and wanted to get out of her wheelchair and lay down. V5 said R1 does not stand and is transferred using a whole body mechanical lift machine. V5 said it's the facility's policy for two staff to be present when using the lift machine to transfer patients. V5 said she decided to go against policy and transfer R1 with the mechanical lift without a second staff member present. V5 said they were not short of staff that day and she could have asked for another staff to come assist her, but she didn't. V5 said she hooked all four of the corner lift straps to the lift machine and lifted R1 up into the air about shoulder level. V5 said suddenly one of the lift straps slipped off and R1 flipped out of the lift sling and fell to the floor. R1 said she yelled for help and the nurses came to help R1. V5 said she was re-trained on whole body mechanical lift machine policy and procedure and given discipline. On 1/30/2024 at 12:15pm, R1 said she can't walk or stand and must be transferred with a whole body mechanical lift machine to move her body from one place to another. R1 said the staff place a mechanical lift sling underneath her body and hook the four corner straps of the sling to the lift machine. The staff uses the mechanical lift machine to raise and lower her into and out of her bed or into and out of her wheelchair. R1 said on 12/16/2023 after she ate lunch, she was wet, needed changed and wanted to lay down in her bed for a rest period. R1 said V5 (Certified Nursing Assistant/CNA) took her to her room to provide her care and put her to bed. R1 said V5 hooked R1's mechanical lift sling to the mechanical lift machine and began to lift R1 out of her wheelchair. R1 said next thing she knew, one of the corner straps of the mechanical lift sling came off causing her to flip over and fall out of the lift sling. R1 said she hit her head on the floor when she fell and had pain all over her body. R1 said she was sent to the emergency room and was diagnosed with a big knot on her head and a sprained neck, but that was wrong. R1 said a few days after her fall, she still had severe pain and was sent back to the emergency room and was diagnosed with a two fractured vertebrae and a broken rib. R1 said she spent a few days in the local hospital and now must wear a neck brace and back brace for them to heal. Hospital admission records dated 12/20/2023 document R1 was admitted due to injuries sustained from a fall from a patient lift machine on 12/16/2023 while a the nursing home. These same records document on 12/20/2023, R1 was given CT (Computed Tomography) Scans of the head, neck and spine. The results of the CT Scans documented R1's injuries from her fall as: moderate to large volume left scalp hematoma, acute minimally displaced fracture of C7 vertebral body, acute mildly displaced fracture of T1 vertebral body and non-displaced fracture of the right posterior first rib. R1's fall event and fall investigation report dated 12/16/2023 under the section titled Conclusion with root cause documented: Mechanical lift was in use with resident in mid-air with 1 strap not attached to arm of (mechanical lift). All CNA staff educated on policy of the facility of hoyer lift usage. This same report under section titled Additional Information documented: Upon investigation, resident was put in mechanical lift by one CNA and then was in mid transfer from wheelchair to bed when hoyer sling was not hooked properly and caused resident to fall out of (lift sling). Hematoma noted to back of head. Sent to ER (emergency room ) for further evaluation and treatment. Head and Spine CT clear and returned to facility. Staff in-serviced on mechanical lift policy. All hoyer pads checked for no frayed or ripped areas. IDT (Interdisciplinary Team) met and reviewed investigation, continue current interventions. On 12/19/2023, resident returned to (local emergency room ) for altered mental status. Radiology impressions report acute fracture of right rib, C7, and T1. IDT met and reviewed current interventions, continue current and CNA's checked off on mechanical lift transfers. A facility policy titled Mechanical Lift with a revision date of September 8, 2023 documented in part: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety for residents and nursing personnel, The mechanical lift must be able to accommodate the weight of the resident and two staff members are required when transferring a resident with a mechanical lift. On 2/6/2024 at 11:00am, V18 (Maintenance Director) verified he had performed inspections on both of the facility's mechanical lift machines on 12/18/2023 and again on 1/17/2024. V18 said the next check will be performed on 2/16/2024. On 2/6/2024 at 11:30pm, V19 (Laundry Aide) said the laundry staff inspect each mechanical lift sling every week and document the finding of the inspection. On 1/31/24, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: A meeting was held on 12/16/2023 in which V1 (Administrator) and V2 (Director of Nursing) were in attendance and identified an Opportunity for Improvement/Deficient Practice: 1.) Immediate Corrective Actions for those affected by the deficient practice: Sent to ER (emergency room ) related to fall. Returned with hematoma to scalp and a sprained neck. 2.) Process/Steps to Identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3.) Measures put into place/systematic changes to ensure the deficient practice does not recur: Education provided to all nurses and Certified Nursing Assistants on the policy and procedures for using a mechanical lift, completed on 12/16/2023. All mechanical lifts slings inspected, completed on 12/16/2023. Maintenance inspected mechanical lifts, completed on 12/18/2023. 4.) Plan to monitor performance to ensure solutions are sustained: Audit to use of mechanical lifts by observing staff twice a week for 60 days, Laundry to perform inspection of mechanical lift slings, Maintenance to perform monthly Mechanical Lift Inspections.

Based on interview, observation and record review, the facility failed to ensure a resident's bed was maintained in a stabilized, locked position for 1 (R3) of 7 residents reviewed for falls. This failure resulted in R3 leaning against the bed, falling, and sustaining a right femoral fracture. This past non-compliance occurred between 10/13/22 and 10/20/22. The Findings Include: R3's Face Sheet documents he was admitted to this facility on 09/27/22 with admission diagnoses to include - Displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, pulmonary embolism without acute cor pulmonale, systolic (congestive) heart failure, essential (primary) hypertension, chronic [CONDITION(S)], [CONDITION(S)] with lower urinary tract symptoms, presence of urogenital implants, [CONDITION(S)], personal history of [CONDITION(S)] (TIA), and cerebral infarction without residual deficits, constipation, unsteadiness on feet, cognitive communication deficit, repeated falls, weakness, abnormalities of gait and mobility, need for assistance with personal care, history of falling, other symptoms and signs involving cognitive functions and awareness, muscle wasting and atrophy. Additional diagnoses include - Covid-19 - 10/09/22, [CONDITION(S)] pneumonia- 10/13/22, acute respiratory failure with [CONDITION(S)] - 10/13/22, hypo-osmolality and [CONDITION(S)] - 10/13/22, urinary tract infection - 10/13/22, proteus (mirabilis) (morganii) as the cause of diseases - 10/13/22; fracture of unspecified pubis, subsequent encounter for fracture with routine healing - 10/14/22. R3's admission MDS (Minimum Data Set) dated 10/05/22, section C (cognitive patterns) documents a BIMS (Brief Interview for Mental Status) of 9, indicating R3 was moderately cognitively impaired. Section G (Functional Status) documents R3 required extensive two+ person assist for transfers. R3's admission Fall Risk assessment dated [DATE] documents a score of 22, indicating R3 is at high risk for falls. R3's post Fall Risk assessment dated [DATE] documents a score of 19, indicating R3 remains at high risk for falls. R3's Initial Care Plan dated 09/29/22, updated on 10/13/22 includes - Problem: Problem Start Date: 09/29/2022. Category: Falls - I am at risk for falls due to cognitive impairments, poor safety awareness, unsteadiness on feet, muscle atrophy, repeated falls prior to facility admission, abnormalities of gait and mobility. I have a foley catheter. I may experience symptoms of [CONDITION(S)]. I am s/p ORIF (status post open reduction internal fixation) due to right femoral neck fracture. I require verbal cues/reminders and staff assistance with mealtimes, ADL's (activities of daily living) and mobility. I attempted to self-transfer unassisted out of my wheelchair. The bed rolled due to bed not locked. I was sent to ER (emergency room ) for eval and treat. On 10-13-22, all beds in facility were checked for locked position and there was a staff in-service to ensure beds are locked after care provided .Goal: Long Term Goal Target Date: 12/29/2022. Resident will remain free from injury .Approach: Approach Start Date: 09/29/22: Give resident verbal reminders not to ambulate/transfer without assistance. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Observe frequently and place in supervised area when out of bed. Place resident in a fall prevention program. Provide toileting assistance. R3's hospital discharge summary dated 09/27/22 includes - Discharge Instruction Sheets Provided: . Hip Fracture Treated with ORIF, Care After . Patient Instructions: Discharge to (skilled nursing facility), weight bearing as tolerated . PT/OT (physical therapy/occupational therapy) eval and treat . R3's progress note dated 09/29/22 at 5:31 PM, documents in part that R3 sustained a fall at home resulting in a right femoral neck fracture with subsequent repair, and admission to this facility for rehab and care on 09/27/22. On 11/01/22 at 12:37 PM, V4 and V7 (Certified Nursing Assistants/CNA's) were working the hall where R3 previously resided. V7 stated she works PRN (as needed) and did not work with R3 on 10/13/22, but knew he had a fall that day. V4 relayed that R3 had just returned to the facility on the afternoon of 10/13/22 from a hospitalization due to other issues including Covid-19, and a bed had been moved to the room he would be in while quarantined. V4 stated she was clocking in for her shift on 10/13/22 when she was informed R3 had fallen in his room. V4 stated R3 reported to staff he had gotten up from his wheelchair and leaned on the bed which rolled, causing him to fall. V4 stated R3 did refuse to go back to the hospital that day but ended up going the next day for evaluation and treatment. V4 and V7 stated R3's fall resulted in a broken femur, which they were also aware he refused surgical repair. V4 and V7 do not know who moved the bed or who failed to double check if the bed was locked after the resident entered the room. V4 and V7 stated the facility did an investigation and V4 made a statement along with other staff working with R3 that day. When asked if R3's bed was still where it was when R3 fell on [DATE], they stated it had been moved one room over. At this time, this surveyor observed the bed which had been stripped down to the wire frame. It had quarter side rails and step-on brake pedals at the foot of the bed just above floor level. There was a green pedal to unlock the brakes and a red pedal to lock the brakes. V4 and V7 confirmed management conducted an in-service regarding locking the beds for resident safety in which they both participated. R3's progress note dated 10/09/2022 at 6:00 PM documents in part - CNA staff alerted nurse that patient did not feel well and was shaking. Upon arrival to patient's room, this nurse noted patient was indeed shaking, stated he felt sick, and that he filled my britches. Patient had . runny diarrhea, patient then began projectile vomiting multiple times. Set of vitals were obtained and patient was hypertensive with systolic in the 160s and diastolic >100 (greater than). This nurse contacted (V11 - Nurse Practitioner) who gave order to send resident to the ER. Upon waiting for EMS (emergency medical services), rapid COVID test was done by this nurse and resulted positive. Patient was sent to (local) hospital for eval and treatment . R3's progress notes dated 10/13/22 by V3 (Agency Licensed Practical Nurse - LPN) are as follows: 3:37 PM - Res readmitted to facility. Transported via ambulance; 5:20 PM - Res report he attempted to walk over to nightstand to put mail up and used bed for support. The bed rolled away from him causing him to fall. V/S (vital signs) 133/68 70-20 temp 98. res c/o (complaints of) right hip pain which he fractured last month but refused to be sent for x-ray at this time; 7:15 PM - (V11 - Nurse Practitioner - NP) called regarding resident increased pain from prior fall new orders received to obtain a stat (immediate) 3 view in-house x-ray of right hip; 10:25 PM by V25 (Registered Nurse/RN) - x-ray results received showing periprosthetic fracture of the greater trochanter. V11 notified. New orders to send to ER for Eval. This nurse went to tell resident the x-ray results and to inform him of the new orders to send to ER for eval. He said absolutely not. I am staying here. I might go tomorrow morning but not tonight. This nurse tried to explain the need to go out, but resident continued to say no not tonight. V11 notified that resident would not go out for eval. She stated to make sure that ortho was notified in the AM. R3's in-house mobile x-ray report of the right hip dated 10/13/22 confirms R3 sustained a periprosthetic fracture of the greater trochanter. On 11/01/22 at 3:15 PM, V23 (Housekeeping) stated she and another staff member (she cannot recall who) were notified a resident was on their way back to the facility and were asked to move a bed. V23 stated R3 was returning from the hospital on 10/13/22 and was to be placed in a different room for quarantine. V23 stated she moved the bed to the room she was asked to move it to, then continued with her other duties. V23 confirmed R3 had yet not arrived, and she was not present when he was brought to his room. When asked what circumstance would require staff to lock or unlock a resident's bed, she stated, I would lock/unlock a bed if the room is empty and I'm cleaning it. This would be if there was no resident assigned to that room. If a resident is assigned to a bed, I do not touch the locks, I just clean around and sweep under the bed. She stated management gave everyone in-service training on locking the beds and resident safety. R3's Initial Fall and Investigation Event Report dated 10/13/22 at 5:18 PM by V3 documents - Description: Unwitnessed fall. Event Details: Resident room. What was resident doing just prior to fall? Ambulating. Was fall witnessed? No. Pain Observation: Does resident exhibit or complain of pain related to fall? If so, described location: Yes, right hip. On a scale of 0-10, how does resident rate intensity or indicate based on observation? 6 (moderate pain - distressing, miserable) .Note any injury to the head, extremities, or trunk: No injury noted. Range of Motion (ROM): ROM painful/limited in lower extremity. Position of Extremities: No rotation/deformity/shortening noted. Level of Consciousness: Alert wakefulness - perceives the environment clearly and responds appropriately to stimuli. Facial Muscle Movement: Strong. Upper Left Extremity Movement/Grasps: Strong. Upper Right Extremity Movement/Grasps: Strong. Lower Left Extremity Movement: Strong. Lower Right Extremity Movement: Strong. Left Eye - Pupil Size/Pupil Response/Shape: 2 mm (millimeter), round/brisk. Right Eye - Pupil Size/Pupil Response/Shape: 2 mm, round/brisk .Does resident respond to the following? Name, pain, environment. Does resident exhibit or complain of any of the following since the fall? None of the above. Mental Status: No changes. Possible Contributing Factors: Cardiac/respiratory disease. Were restraints/adaptive equipment in use at the time of the fall? None of the above. Did resident complain or experience any of the following PRIOR to the fall? None of the above. Drug Review - Does resident use any of the following types of medications? Antihypertensives, narcotics. Accidents: c. Hip fracture in the last 180 days. Interventions - Immediate measures taken: Rest .Outcome of Interventions: No interventions used .Investigation: History of Falls? Yes .Is the resident diabetic? No. Was [CONDITION(S)] present in extremities? No. Any recent change of condition? Yes. Describe changes noted: Covid positive/pneumonia. Has therapy evaluation been completed? No. Are any of the following in use? Wheelchair. Does resident have vision problems? Adequate .Has resident experience or complained of dizziness? No. Does resident require assistance with transfers? Yes. Is resident continent? Yes. Was resident incontinent at time of fall? No. What equipment was in use at time of fall? Wheelchair. What footwear was in use at time of fall? Rubber sole shoes. Environmental issues identified? Room change recently .Assessed for orthostatic hypertension. Sitting/standing BP (blood pressure): Not attempted. Conclusion with root cause: Used bed to aid in ambulation and bed rolled away from res. Additional Information: Upon further investigation and elders' statement that bed rolled away immediate action taken to verify that all beds in facility are in locked position and in-service completed with staff to ensure that beds are always in the locked position when care is not being provided: Physician notified .Resident is his own POA (Power of Attorney). Vitals taken .Orders to obtain a stat (immediate) 3 view x-ray of the right hip r/t (related to) fall and increased pain. Notes: 10/13/2022 5:20 PM: Res report he attempted to walk over to nightstand to put mail up and used bed for support. The bed rolled away from him causing him to fall. V/S (vital signs) 133/68 (BP) 70-20 (pulse/respirations), temp 98, res c/o right hip pain which he fractured last month but refused to be sent for x-ray at this time. Evaluation Notes: Elder initially refused to go to ED (emergency department) and after eventually going to ED, refused surgical intervention/repair . R3's progress note dated 10/14/22 at 8:30 AM documents - Patient reporting R (right) knee and hip pain post fall yesterday. Patient requesting to be sent to the hospital. It was reported . patient had refused to go to hospital prior to this nurse's shift. Patient will be sent to (local ER) r/t (related to) his surgeon being (at this hospital) . R3's progress note dated 10/17/22 at 2:33 PM reads - Elder readmitted at this time from (local hospital) via ambulance on stretcher. Diagnosis for pelvic fracture and elder now comfort care. Pharmacy and provider notified of readmission. Reoriented to room and call light. Elder denies much pain at this time, stated I am comfortable at the moment. On 11/01/22 at 3:00 PM, V2 (Director of Nursing - DON) and this surveyor went to the room where R3's bed currently sits. V2 pressed the green foot pedal to unlock the bed. This surveyor placed fingers on the frame and exerted light pressure at which time the bed rolled without force or resistance. V2 stated they have no facility policy regarding locking or unlocking resident beds. When asked what she would expect staff to do regarding ensuring resident beds are stable, V2 stated her expectation would be that staff would always check to make sure the resident's bed was locked and stable for safety. On 11/02/22 at 8:44 AM, V3 (Agency LPN) stated she worked in the facility on 10/13/22 and R3 was one of the residents in her care. V3 recalled that day one of the CNA's reported to her the unwitnessed fall of R3. V3 stated at the time of his fall his bed was in the unlocked position. V3 stated they locked the wheels, and placed R3 in his bed so she could do his assessment. V3 stated R3 did refuse to go the ER at that time. V3 confirmed she has not worked in the facility since 10/13/22. V3 stated in her experience, resident beds are to be locked at all times unless you are actively transporting the resident in the bed for medical purposes. V3 also stated management gave in-service training on locking the beds for resident safety. On 11/02/22 8:54 AM, V4 also stated resident beds are always locked and R3's incident on 10/13/22 was a terrible oversight. V4 stated R3 was able to get up on his own and do things, but he was assessed, and it was recommended by therapy he receive assist of 2, due to his fracture from a fall at home when he admitted , which we were doing. Again, V4 stated he was doing pretty well. R3 just leaned on the bed for support, and it rolled away from him that day. V4 stated the resident beds should always be locked unless you are transporting them somewhere in the bed. R3's Long-Term Care Facility and IID (Individuals with Intellectual Disabilities) - Serious Injury Incident Report dated 10/21/22 at 9:00 PM by V2 (Director of Nursing - DON) includes - General Information: Final .Incident Category: Fall with physical harm or injury. Resident #1 Involved in Incident: R3. Date of Birth: 03/04/26 .Male, victim, ambulatory, wheelchair, transfer with 2. Interviewable: No. Informed Decisions: No. Alert and Oriented x 2. Capable of Communication: Yes .Assessment by V3 (LPN) on 10/13/22 at 5:30 PM. Hospital ER (emergency room ): Yes, on 10/14/22 at 8:30 AM. admitted : Yes. Diagnosis: Femur fracture. Final Report Summary - On 10/13/22 elder was picked up from (local) hospital after an acute stay for hypertension. He returned on droplet precautions for Covid-19 relating to testing positive previously on 10/10/22, so he returned in a different room. He was sitting in his wheelchair with call light within reach when he self-transferred and leaned on the bed for support when he lost his balance. Initial biotech x-ray reported fracture of right hip prosthesis. Denied going to ER at that time .the following day he complained to the nurse that he thought his knee was broke. Agreed to go to ER for further evaluation. Hospital x-ray report of the pelvis and right hip impression: There is a fracture involving the proximal femur just proximal to the stem of the femoral component of the hip replacement. There is 1.9 cm (centimeter) of medial angulation of the distal fracture fragment. 6 mm [CONDITION(S)] change involves the right knee. Minimal [CONDITION(S)] changes involve the knee. IDT (Interdisciplinary Team) met and reviewed investigation. Housekeeping and nursing departments in-service completed on 10/20/22 on ensuring beds are locked before exiting any room. R3's facility incident investigative file included - V4's written statement dated 10/13/22 as follows - I, (V4) arrived at work around 4:40 PM. I was told (room) had fallen on the floor. I went and got a fall mat, place it by the bed, made sure his bed was locked and lowered as low as it would go. I made sure his call light was clipped to him in reach. V5's (Agency CNA) written statement dated 10/13/22 as follows - On 10/13/22 around 4:30 PM (room) fell on the floor. I, (V5) seen (room) on the floor by the window, the bed was not locked, he was trying to transfer to the bed from chair, he did have his w/c (wheelchair) locked. When I seen him on the floor, I asked him if he was o.k. and told him to stay put, I have to go find the nurse. Myself, the nurse and the other aide helped him back to the bed. We got vitals and made sure he was set in the bed. (unwitnessed fall) Resident had non-slick socks on. At the time we were passing hall trays (resident did not push call light for help, he self-transferred). V6's (PRN CNA) written statement dated 10/13/22 as follows - Around 4:30 PM, I, (V6) came of (different room) after helping therapy with .I walked by R3's room and saw the nurse and (V5) getting him off the floor. I ran into help, and we found the bed wasn't locked. I locked the bed before we transferred him from the floor. He had non-slick socks on. After we transferred him from the floor, we got vitals on him. He did not put call light on for help. He self-transferred. On 11/02/22 at 11:25 AM, V14 (Restorative CNA) stated she was tasked with conducting audits once a week for 4 weeks and signing the resident roster as completed as part of the corrective action taken. She stated the audits consisted of physically checking every residents bed in the facility to ensure it was properly locked and secured so as not to roll. The last audit was completed on 10/31/22. V14 stated she continues to do bed lock checks at least once a week and verbally reminds CNAs to always check the beds to make sure they are locked before exiting the resident's room. V14 stated there are at least 3 types of beds with different lock mechanisms located on different areas of the beds in the facility. V14 stated there are foot pedal locks, tire wheel locks, and manual crank locks that lower and raise the legs of the bed. Education in-service training with return demonstration observation was given to all staff by V2 (DON - Director of Nursing) and V15 (Assistant DON). R3's facility incident file also included four facility resident roster sheets dated 10/14/22, 10/21/22, 10/26/22, and 10/31/22. Each roster was signed by V14 with a handwritten note at the bottom of the sheet documenting, All beds locked. On 11/02/22, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 10/14/22. In attendance - V1, V2, V15, V16 (LPN/MDSC - Minimum Data Set Coordinator), and V17 (LPN/CCD - Care Plan Director). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V3 and V15 (ADON) provided in-service to nursing staff and housekeeping regarding - ensure beds are locked prior to exiting the room. Completed on 10/20/22. All beds checked and ensured they are locked. 4. Plan to monitor performance to ensure solutions are sustained: Bed lock audits to be conducted weekly x 4 weeks by V14. The first complete facility audit was completed on 10/14/22.

Based on interview and record review, the facility failed to provide the correct textured diet to a resident (R2) with an order for a mechanical soft diet. This failure resulted in R2's choking and death. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to provide a mechanical soft texture diet as ordered for R2. This was identified as past non-compliance that occurred from [DATE] to [DATE]. V1 (Regional Director) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 9:10 AM. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE]. Findings include: The Resident Face Sheet of R2's Electronic Health Record (EHR) documents that R2 was admitted to the facility on [DATE] and documents diagnoses including a fracture of unspecified part of the neck of the left femur, acute posthemorrhagic [CONDITION(S)], gastrointestinal hemorrhage, type 2 diabetes mellitus with [CONDITION(S)] and diabetic [CONDITION(S)], Alzheimer's Disease, cognitive communication deficit, and dysphagia (oropharyngeal phase). The Resident Face Sheet also documents that R2 has an allergy to beef containing products. R2's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documents in section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 10, indicating that R2 has moderate cognitive impairment. Section G- Functional Status documents that R2 requires supervision with oversight, encouragement, and cueing when eating and set-up help only. R2's Physician's Order Report dated [DATE] to [DATE] documents an order dated [DATE] for Diet: no added salt (NAS), low concentrated sweets (LCS). Consistency: Mechanical Soft. R2's Care Plan (dated [DATE]) documents under Focus that R2 chooses not wear my dentures frequently and I am able to have proper nutrition with the mechanical soft diet. Interventions documented include: NAS/ LCS mechanical soft diet, I am able to feed myself with supervision and I am receiving speech therapy (ST) as outlined. R2's Speech-Language Pathology (SLP) Evaluation and Plan of Care dated [DATE] documents a reason for referral of referred to skilled ST due to concerns of a decline in cognitive and swallowing function following a recent hospitalization . A Speech Therapy Treatment Encounter Note completed by V11 (Speech-Language Pathologist) dated [DATE] documents that R2 presents with moderate oropharyngeal dysphagia and is at mild risk for aspiration. The recommended diet is puree and thin liquids. Standard aspiration precautions. A note by V11 dated [DATE] documents diet was upgraded to mechanical soft and thin liquids. An Interdisciplinary Resident Data Collection Form dated [DATE] by V11 documents that R2 is still tolerating mechanical soft and no further skilled ST recommended at this time. R2's Progress Note dated [DATE] at 5:25 PM by V10 (Licensed Practical Nurse/LPN) documents that CNA (Certified Nursing Aide) stated resident (R2) was choking. This nurse (V10) immediately assessed resident and started [MEDICATION(S)]. A pecan sized piece of meat came up, but resident continued to gasp for air and lips were blue. 911 was called. The note further documents, Resident (R2) was taken out of dining room and moved to living room area. [MEDICATION(S)] was continued, but nothing came up. Resident (R2) was then moved to the ground per 911 and CPR (Cardiopulmonary Resuscitation) was started. The note also documents, Emergency Medical Services (EMS) then arrived and took over at 1732 (5:32 PM). Do Not Resuscitate (DNR) was found and Cardiopulmonary Resuscitation (CPR) was stopped. EMS was able to get another piece of meat out. After 5 min EMS stated there were no signs of life. On [DATE] at 3:15 PM, V10 said that she was called to the dining room by V7 (CNA) because R2 was choking. V10 said that she immediately began to do the [MEDICATION(S)] and a piece of food that looked like lunchmeat was removed. V10 said that R2 was still unable to breath and was turning blue. A Progress Note in R2's EHR dated [DATE] at 2:21 PM, documented as a late entry from [DATE] at 5:25 PM, by V3 (MDS Coordinator/ Licensed Practical Nurse) documents, This nurse heard Certified Nurse's Aide (CNA) say someone was choking in the dining room (D/R) when this nurse got to D/R noted resident (R2) choking and gasping for air. The note further documents that V10 (Licensed Practical Nurse) was doing the [MEDICATION(S)] maneuver and V3 did a finger sweep and pulled a pecan size piece of food from mouth and that R2 continued to gasp for air and [MEDICATION(S)] continued. On [DATE] at 12:20 PM, V3 said that when she did the finger sweep after the [MEDICATION(S)] was performed, a hunk of bread and ham came out of R2's mouth but R2 continued to gasp for air. On [DATE] at 2:40 PM, V7 (CNA) said that she was in the dining room when R2 began to choke. V7 said that she ran and got V3, and they did the [MEDICATION(S)], and a chunk of food came out. V7 said that R2 had a ham and cheese sandwich that evening but could not recall if the meat was ground up or not. On [DATE] at 2:50 PM, V8 (Dietary Manager) said that V8 was at the facility on [DATE] when trays were served but left prior to R2 choking. V8 said that R2 could feed self and received diced tomato salad, chicken noodle soup, and a ham sandwich that evening. V8 said that R2 was allergic to beef and could not eat the bologna being served so V9 (Dietary Cook) gave R2 a ham sandwich. V8 said that the ham was not chopped up. V8 said that R2 was on a mechanical soft diet. V8 said that they normally give ham salad that is chopped up to residents that are on a mechanical soft diet. V8 said that they had given R2 regular ham sandwiches before and she did ok. On [DATE] at 3:05 PM, V9 said that they were serving beef on [DATE] so R2 was given a ham sandwich because R2 cannot eat beef. V9 said that the sandwich contained sliced ham and cheese. V9 said that R2 did not like the mechanical soft diet and would often refuse it. V9 said that V8 would tell V9 to go ahead and give R2 the sandwich anyway and V8 would get some kind of waiver for R2 to eat ham sandwiches. V9 said that R2 got choked on the ham that evening and had eaten all but the crust of the ham sandwich. On [DATE] at 1:25 PM, V12 (Dietary Aide/ Cook) said that V12 was not at the facility when R2 choked. V12 said that R2 was on a mechanical soft diet and would eat regular lunchmeat sandwiches. V12 said that V8 said that R2 had a waiver and was able to eat regular ham and cheese sandwiches. On [DATE] at 2:40 PM, V8 said that there is no waiver in place and V8 knew that R2 had received ham sandwiches. V8 said that R2 would refuse the mechanical soft diet and would be given a sandwich instead. V8 said that R2 did not use dentures and only had a few teeth. On [DATE] at 11:10 AM, V11 said that she saw R2 in March and April after a hospitalization . V11 said that R2 returned from the hospital in March on a pureed diet and was having swallowing difficulty. V11 said that R2's swallowing improved, R2 was able to feed self without difficulty, and R2 was upgraded to a mechanical soft diet. V11 said that R2 had more difficulty with chewing rather than swallowing and felt that it was not safe for R2 to be on a regular diet. V11 said that R2 was screened again in June and felt that the mechanical soft diet was still appropriate for R2. V11 said that R2 did not have any teeth, did not wear dentures, and had difficulty chewing. V11 said that no one had reached out to her to change R2's diet. V11 said with R2's chewing difficulties, R2 would have difficulty with eating a ham sandwich. V11 said that a regular ham sandwich is definitely not appropriate for R2 unless it was minced, moist, or chopped. On [DATE] at 3:05 PM, V13 (Nurse Practitioner) said that R2 was on a mechanical soft diet per the recommendation of the Speech Therapist. V13 said that she signs the order for the diet that the speech therapist or dietician recommends. On [DATE] at 11:20 AM, V14 (Registered Dietitian) said that R2 was on a mechanical soft diet and was able to feed self. V14 said that R2's ham should be minced or chopped. V14 said that per the standards of a mechanical soft diet, all meat should be minced or chopped. The facility Diet Spreadsheet for cycle day: 4 documents the mechanical soft diet served for dinner on [DATE] was cream of broccoli soup, a ground deli sandwich, stewed tomatoes, and spiced peaches. An EMS report dated [DATE] documents that the ambulance company was dispatched to an EMS call of a patient (pt) choking and the pt is pulseless and apneic. (Local fire department) placed their cardiac monitor on the pt and the pt strip showed asystole. (Local fire department) used a set of forceps to clear (R2's) airway of food debris. Some food was removed from (R2's) throat, but with no improvement from the pt. The EMS report documents the disposition of R2 as dead at scene. R2's Certificate of Death Worksheet documents a date of death of [DATE]. The cause of death documented is Acute Hypoxic Respiratory Failure and Choking on Food Bolus. The facility policy titled Menus (revision date 2016) documents that Menus shall be followed which have been written, reviewed for nutritional adequacy and approved by a Registered, Licensed Dietician in compliance with Federal and State Regulations and consistent with Standards of Practice on nutritional care. The surveyor confirmed through interview and record review the facility took the following actions, which were initiated on [DATE] and completed on [DATE], to remove the Immediate Jeopardy: 1. On [DATE], the Quality Assurance (QA) team members initiated a Quality Assurance Performance Improvement (QAPI) plan to ensure the residents are served the appropriate meal based on their diet restrictions. 2. On [DATE], all physician's orders were reviewed on all residents to ensure physician's orders for diets matched dietary information. 3. On [DATE], education was provided to evening shift nursing staff including Certified Nurse's Aides, Licensed Practical Nurses, and Registered Nurses were educated on providing emergency care/ [MEDICATION(S)] by watching the video titled Mayo Clinic Minute: A Quick Guide to the [MEDICATION(S)] Maneuver. Education session continued with each shift working on [DATE] and [DATE]. All remaining staff, including staff that work as needed (PRN), will be educated prior to the next working shift. 4. On [DATE], V8 (Dietary Manager) was educated on following proper food preparation guidelines and ensuring proper diet consistency is served. 5. On [DATE], dietary staff were educated on following proper food preparation guidelines and ensuring proper diet consistency is served. All remaining dietary staff (part time or PRN) will be educated prior to working next scheduled shift. 6. On [DATE], staff, including anyone who delivers food trays to residents, were educated on ensuring proper diet consistency is served and appropriate set up is provided. All remaining staff (part time and PRN) will be educated prior to working the next scheduled shift. All staff will be trained during orientation and quarterly for 1 year on providing emergency care including the [MEDICATION(S)] by watching the video and serving proper diet consistencies by reviewing a power point presentation by the Director of Quality Assurance. Administrator or designee will conduct random meal audits 3 times a week for 4 weeks and will report findings to the QA committee.

Based on interview and record review the facility failed to notify the primary care physician of a change in condition for 1 (R166) of 8 residents reviewed for physician notification in the sample of 34. This failure resulted in R166 experiencing prolonged restlessness, increased confusion, anxiety, shortness of breath, diaphoresis, an abnormal oxygen saturation level, and death on [DATE]. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] at 11:00 PM, when the facility failed to notify the primary care physician R3 was experiencing a change in baseline status which included restlessness, increased confusion, anxiety, shortness of breath, pulling at foley catheter, and diaphoresis resulting in R166's expiration at the facility at 1:37 AM on [DATE]. This past noncompliance occurred from [DATE] to [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 12:54 PM. The immediacy was removed on [DATE]. Findings Include: R166's Admission Record documents an original admitted to the facility as [DATE]. This document lists V4 (physician) as R166's primary physician and the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R166's most recent comprehensive Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 7, indicating cognitive impairment. Review of section G0110 in this same assessment documents R166 requires limited assistance of one-person physical assist with bed mobility, transfer, walking in room and the corridor, and toilet use. Section G0300 documents R166 is not steady, and only able to stabilize with staff assistance for all positional changes. V4's(Physician) physician note dated [DATE] documents R166 was in the local hospital for several days due to a TIA ([CONDITION(S)]). V4 documents, Due to prolonged hospitalization and multiple medical issues, the patient gained significant weakness that worsened, constant, and persisted and radiated throughout the rest of the body. Patient was transferred to the nursing home for therapy in order to improve strength. R166's Progress Notes documents an entry made by V7 (Registered Nurse/RN) at [DATE] at 8:57 AM stating the following, Elder was very restless in his bed during the nighttime hours. He was confused off and on, trying to climb out of his bed and walk on his own in his room unsafely, and was attempting to pull out his Foley catheter tubing from his penis. When asked what he was trying to do, he stated that he 'had to go pee.' Explained to Elder that he did not have to take the Foley out to 'go pee.' Attempted to explain the usage of Foley catheter in simple terms to help him understand to not pull on the tubing. He did stop for a short time and lay back down on the bed. Attempted to educate Elder to not get out of bed without assistance due to his falling earlier in the day and he was not steady at this time on his feet and walking. He laid down for a short period of time, indicated by nodding his head that he understood what was being told to him. Elder continued this behavior off and on during the evening time et his vital signs were stable early in the shift through the middle of shift et then noticed that Elder seemed out of breath, so Oxygen placed on Elder at 2 L (liters) per nasal cannula. This seemed to help relax him and he closed his eyes et rested a short time. Meanwhile, while checking Elder's vital signs, it was noted by this nurse that Elder's SP02 (Pulse Oximeter Oxygen Saturation) was just above 88% to beginning 90's some of the time, et at another time, was found at 82% with 2 L oxygen per nasal cannula. Elder would not always leave oxygen tubing on his face. In his at times confused state of waking up after dozing off, he would pull it off. He was checked on by this nurse et CNA's (Certified Nurse Assistant) very frequently. He was found most of times attempting to get out of bed. At 0130 on the early morning of [DATE], Elder's vital signs were taken by this nurse et assessment made to call his doctor, due to the confusion et restlessness. VS were: ,d+[DATE], (Right wrist, lying down), Pulse 112, with Pulse oximeter showing 52 for Pulse while his SP02 was found to be 88% on 2 L per nasal cannula. His respirations were rapid and shallow at 42 per minute, et temp of 96.8 F. Blood sugar reading was 223. This nurse went to the desk to look over diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon arriving to room, Elder's coloring in his face was dusky in areas et very white in others, he was staring off straight ahead et he took about 3 shallow breaths et all vital signs ceased at 0137 AM. Elder was headfirst at the foot of his bed, et he was laid down et all vital signs assessed by this nurse. There were no further heartbeats or breaths. CNA ran to determine if Elder was a Code et was found to be a DNR with Selective Treatment. The ambulance and fire department was immediately dispatched by a second nurse, (name) V16 (Licensed Practical Nurse, LPN). The ambulance service arrived at 0152 et they assessed Elder et also deemed cessation of vital signs. They left the building at 0200. Called V4's phone service at 0205. He returned call immediately. Called the nurse on call at the facility, V12 (Minimum Data Set Coordinator) et let her know all that had happened. Called Elder's daughter, (name) V17 (Family Member) at 0230 et let her know that Elder had passed away. She requested to speak to her mother et tell her, which was the second person on his call list. From this time to after 0630, Elder's family arrived et left, with daughter bringing Elder's wife to visit. Daughter just said to call (name) local funeral home to set up arrangements. Called funeral home at 0730 et they arrived at 0820 to take Elder to the Mortician. Paperwork was signed et sent with patient. On [DATE] at 03:16 PM, V5 (CNA) stated she was working with V6 (CNA) the night R166 expired, along with V7 (RN). V5 stated she works 3rd shift (11 PM - 7 AM), and 2nd shift had reported at shift change that R166 had tried getting out of bed unassisted a few times that day. V5 stated R166's normal status is slightly confused, but super mild, R166 didn't normally try to get out of bed, almost always slept through the night, and she had never witnessed him pull at his catheter before. V5 stated on [DATE], from the start of the shift, R166 was very confused, continuously trying to get out of bed on his own, pulling at his catheter, anxious, and sweaty. R166 stated that herself and V6 had attempted to toilet R166 in case he needed to use the restroom but stated that didn't seem to help. V5 stated they (she and V6) reported R166's change in baseline status to V7 numerous times and even encouraged she call the physician to send R166 out for evaluation because she was worried about him and could tell something was wrong. V5 stated V7 continued her medication administration pass and never gave her any further instruction on anything special to do with R166. V5 stated that she and V6 had taken R166's vital signs which were all normal at the time they checked them, except his pulse which was a little elevated at 110. V5 stated this too was also reported to V7 with nothing done that she was aware of. V5 stated R166's abnormal status continued as the shift went on, and she would definitely describe (name) R166 as appearing in distress. V5 stated herself and V6 had checked on R166 every ,d+[DATE] minutes throughout the night to try and keep him from falling and because he wasn't acting right. V5 stated herself and V6 entered R166's room around 1:30 AM on [DATE] and observed R166's head at the foot of the bed with no respirations noted and no pulse noted. V5 stated V6 ran to get V7 who came to assess, rolled R166 on his side she said in case he had a [CONDITION(S)], and left to check R166's resuscitation status, which was Do Not Resuscitate. V5 stated V7 called the ambulance to confirm death, in which they responded and confirmed. V5 stated herself and V6 repositioned and cleaned up R166 to prepare for his family and funeral home to arrive. On [DATE] at 11:17 AM, V6 stated herself and V5 were the aides working with R166 the night he expired, and V7 as the nurse for that wing. V6 stated she works 11 PM - 7 AM. V6 stated in report received from the off going shift that day, they had passed on that R166 kept trying to get out of bed on his own, which he wasn't supposed to do and was not steady on his feet. V6 stated it would have been about 11:30 PM on [DATE] when she had first gone to check on R166 in his room and observed him as being very sweaty and trying to get out of bed. V6 stated he was sweating to the point that if you touched him, your hand was wet. V6 stated she immediately reported the observation to V7. V6 stated she knows R166 is diabetic so she was worried something may have been wrong. V6 stated V7 did go check R166's blood glucose at that time, and she couldn't remember the exact number but thought it was one hundred and some and V7 said it was ok. V6 stated as the night went on both she and V5 expressed multiple times to V7 that something wasn't right with R166, and they thought he needed sent to the emergency room for evaluation. V6 stated R166 was restless, anxious, pulling on his catheter, requiring oxygen, and would not stay in bed, all of which she stated are very abnormal for R166. V6 stated R166 normal status is mildly confused, but easily redirectable, normally slept all through the night, and she had never seen him require oxygen or pull on his catheter. V6 stated at one point she specifically recalls telling V7 that R166 was not ok. V6 stated this specific incident was when V7 was doing her medication pass and V7 had told V6 she would see about calling R166's doctor later. V6 stated herself and V5 checked on R166 about every 15 minutes due to R166's abnormal status, fear of something was wrong, and fear R166 would fall getting out of bed on his own. V6 stated around 1:30 AM on [DATE] she had entered in R166's room and observed him lying in his bed with his head at the foot of the bed and oxygen off, breathing at this time. V6 stated she left the room to get V5 to help her get R166 turned back around in the bed. V6 stated when herself and V5 returned to the room, R166 took a couple of gasping breaths and quit breathing. V6 stated she hollered for V7 who came and observed R166 status, then checking his resuscitation code, noting he was a DNR. V6 stated the ambulance responded to confirm expiration and V7 instructed V5 and V6 to get R166 cleaned up for family to see him and the funeral home. V6 stated R166 displayed a definite change in his baseline status from the start of her shift until his expiration. On [DATE] at 10:42 AM, V7 stated she had previously worked with R166 prior to [DATE]. V7 stated she works the 6PM - 6 AM shift. V7 stated on [DATE], the only thing she can recall being conveyed from the day shift report was that R166 had experienced a fall earlier in the day and had been trying to get out of bed. V7 stated that R166 would frequently try to ambulate on his own and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V7 stated from her understanding R166 was at the facility short term for therapy services and planned to discharge back home. V7 stated R166 had not been at the facility long before he expired and describes R166's expiration as being unexpected. V7 stated she cannot recall if CNA staff reported to her any abnormal concerns regarding R166 the night he expired, as she's cared for a lot of people since then. V7 stated she does recall that R166 was abnormally restless that night, but just wrote if off as that R166 had a fall earlier in the day and was out of sorts. V7 stated she does not feel it was abnormal for R166 to be restless as he previously had attempted to get out of bed during the night occasionally on his own, although she acknowledges he is usually easily re-directable and was not on this night. V7 stated while she did document an oxygen saturation level of 82%, she applied oxygen and would talk to R166, which seemed to help calm him down and improve R166's oxygen level. V7 stated R166 would doze off for short periods of time, only to re-awaken and again attempt to get out of bed and take the oxygen off. V7 stated she had occasionally applied oxygen per nasal cannula for R166 in the past. V7 stated had R166's oxygen saturation level not improved with the oxygen application she would have notified the physician. V7 acknowledges in some cases restlessness can be a sign of distress for some residents. V7 confirmed R166 did appear short of breath at times. V7 stated that R166 was unable to ambulate alone and used a walker and wheelchair for longer distances she believes. V7 stated another abnormal occurrence R166 was exhibiting on [DATE] was that he was continuously pulling at his catheter and stating he had to pee. V7 stated she provided R166 education that he needed to leave his catheter alone, and that he didn't need to pee and had a catheter. V7 stated she never notified V4 (physician) at any point on [DATE] or [DATE] prior to R166's exhibiting severe distress of respirations ceasing and expiration. V7 again stated she cannot specifically recall the timeline of events leading to R166's expiration as she's cared for many people since then. V7 stated an aide whom she cannot recall came to notify her R166 was in distress. V7 stated she believed V6 was working but cannot remember the other staff member. V7 stated when she arrived to R166's room, R166's head was at the foot of his bed, with his oxygen off. V7 stated R166 took a couple shallow breaths and respirations ceased. V7 stated R166 was dusky in color and after confirming his do not resuscitate status, she verified via auscultation and palpation that there were no respirations or a pulse. V7 stated she notified V4 (Physician) and the local ambulance company to confirm death. V7 stated the ambulance arrived, and an asystole cardiac rhythm was confirmed. V7 stated R166's family was notified of the expiration. V7 stated the expectation is for staff to notify the physician if resident's experience a problem or change in their baseline status. V7 confirms V4 responds quickly and appropriately to resident needs when notified. On [DATE] at 2:49 PM, V2 (Director of Nursing) stated that it is the expectation that facility staff notify the physician immediately in the event a resident is experiencing a change in their baseline condition. V2 confirmed that documentation completed by V7 that describes R166 as having increased restlessness, pulling on his catheter, attempting to repeatedly climb out of bed, not sleeping, experiencing an oxygen saturation rate of 82% would all be instances in which the physician should have been immediately notified. V2 stated that on [DATE], R166 had experienced a witnessed fall with no injury, and later that same day also an emesis. V2 states hindsight it seems R166 had several small occurring problems leading up to his distress and expiration. V2 stated V4 had been notified of the fall, due to facility policy, but not the emesis due to relief with no further concerns after the emesis. V2 describes R166 as being mildly confused stating he was oriented to person, time, and recognized he was in a nursing home for therapy but would be unable to give the specific name of the facility. V2 stated R166 propelled himself in a wheelchair around the facility and was planned to be in the facility for short term therapy needs, then return home. V2 stated she was notified of the death by V12 (Minimum Data Set Coordinator) who was the nurse manager on call. V2 stated on [DATE] the facility's Interdisciplinary Team which consists of herself, V13 (Assistant Director of Nursing/ADON), V12, V14 (Care Plan Coordinator), and V1 (Administrator) began an investigation into R166's death due to the unexpected nature. V2 stated it was determined the notable significant decline of R166 began during 3rd shift, which is 11 PM-7 AM on [DATE] in which V7 failed to notify the physician of R166's change in status. V2 stated beginning [DATE] and completed [DATE], the facility completed in-service training with all nursing staff on the facility change in condition policy and the computer program Interact Pathway-Change in Condition which is described as a program in which information is entered and will lead you to notifications and referrals needing made. V2 stated V5 and V6 were determined to have acted appropriately, evaluating and reporting concerns observed with R166 to V7. On [DATE] at 08:25 AM, V12 stated she recalls receiving a call from V7 during the night of [DATE], as she was the nursing staff on call that weekend. V12 stated V7 seemed a bit shook up due to the unexpected nature, and when asked what happened, V7 stated she didn't know, that R166 had been restless, anxious, and up and down all night. V12 stated she went through the notifications needed to ensure V7 contacted everyone she needed to. V12 stated she believes she text V2 to notify her of R166's death. V12 stated the facility completed and investigation and implemented a quality assurance performance improvement plan re-training nursing staff on the facility Change in Condition policy and the Interact Pathway-Change in Condition computer program. On [DATE] at 8:43 AM, V1 (Administrator) stated that she did not have much interaction with R166 during his short admission at the facility, so cannot specifically speak on his baseline status. V1 stated R166 was admitted to the facility for short term rehabilitation services after a hospitalization . V1 stated prior to R166's hospitalization , he resided at home with his wife, and his plans were to complete rehab and return home. On [DATE] at 7:55 PM, V4 (Physician) stated he recalls (name) R166. V4 confirmed that should a resident be experiencing a deviation from their baseline status; he would expect to be notified immediately. V4 stated he was never notified that R166 was experiencing any concerns on [DATE] or [DATE] including increased confusion, anxiousness, diaphoresis, pulling at catheter, restlessness, etc. On [DATE] at 11:13 AM, V4 confirmed the cause of death listed as diabetes on R166's death certificate was due to the weakening effects Diabetes has on the immune system. V4 said that it's fair to say should he have been notified of R166's change in condition, R166 could have been treated. V4 stated, while the outcome may not have changed, the option of attempted treatment was possible. Review of the local ambulance report dated [DATE] documents at 1:44 AM, an ambulance was dispatched to the facility for report of a male not breathing. Emergency Service Personnel verified R166's DNR status and observed R166 lying in his bed, with his head at the foot of the bed. R166 is documented as being pulseless, apneic, cyanotic, pupils fixed and dilated, and cold to touch. A cardiac monitor is documented as being applied showing asystole, confirming death. Review of the document titled Certificate of Death Worksheet documents R166 expired at the facility on [DATE] at1:37 AM, at the age of [AGE] years old. The manner of death is listed as being natural with the cause listed as Diabetes. The facility policy titled Change in a Resident's Condition or Status with a revision date of [DATE] documents, A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is (e.g., changes in level of care, resident rights, etc.). The same policy documents the resident's attending physician or on-call physician will be notified then there is a. An accident or incident involving the resident, which results in injury and has potential for requiring physician intervention d. A significant change in the resident's physical/emotional/mental condition psychosocial status to either life-threatening conditions or clinical complications .g. A need to transfer the resident to a hospital/treatment center. The same policy also goes on to state a resident's physician should be notified in the event of a significant change which is defined as a decline or improvement in the resident's status that, a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. b. Impacts more than one area of the resident's health status. Review of the facility policy titled, Making an Emergency Transfer or Discharge with a revision date of [DATE] documents, Residents will be transferred from the facility to the hospital and ensured of timely admission to the hospital when transfer is medically appropriate as determined by the attending physician or in an emergency situation, by another practitioner in accordance with facility policy and consistent with state law. This document states, 1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician of the change in condition and request immediate orders to transfer the resident to the hospital. In an emergency situation, another practitioner may order the hospital transfer and notification of the transfer will be made to the attending physician. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 12:54 PM. The immediacy was removed on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE], prior to the survey date. Prior to the survey date, the facility took the following actions to remove the immediacy and correct the non-compliance as confirmed through observation, interview, and record review: 1. On [DATE], the facility initiated an internal review regarding R166's unexpected death. 2. The investigation concluded an identified opportunity for improvement/deficient practice regarding R166 experiencing emesis, low SPO2, and timely notification of the physician. It is documented the facility concluded potentially all residents were at risk. 3. On [DATE] the facility initiated a quality assurance performance improvement plan (QAPI) in service training with all nursing staff on the facility Change in Condition policy and the Interact Pathway-Change in Condition computer program. All nursing staff are documented as having completed the training on [DATE]. 4. The facility will in-service quarterly on the Interact Change in Condition form and monitor the 24-hour report summary weekly for 4 weeks.

Based on interview and record review, the facility failed to thoroughly assess a resident reported to be in distress and recognize the need to call the physician for additional guidance after a change in condition to seek medical treatment for 1 (R166) of 8 residents reviewed for a change in condition in the sample of 34. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] at 11:00 PM, when the facility failed to notify the primary care physician R166 was experiencing a change in his baseline status which included: restlessness, increased confusion, anxiety, shortness of breath, pulling at foley catheter, abnormal oxygen saturation level, and diaphoresis which resulted in R166's expiration at the facility at 1:37 AM on [DATE]. This past noncompliance occurred from [DATE] to [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 12:54 PM. The immediacy was removed on [DATE]. Findings Include: R166's Admission Record documents an original admitted to the facility as [DATE]. This document lists V4 (physician) as R166's primary physician and the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R166's most recent comprehensive Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 7, indicating cognitive impairment. Review of section G0110 in this same assessment documents R166 requires limited assistance of one-person physical assist with bed mobility, transfer, walking in room and the corridor, and toilet use. Section G0300 documents R166 is not steady, and only able to stabilize with staff assistance for all positional changes. V4's (Physician) physician note dated [DATE] documents R166 was in the local hospital for several days due to a TIA ([CONDITION(S)]). V4 documents, Due to prolonged hospitalization and multiple medical issues, the patient gained significant weakness that worsened, constant, and persisted and radiated throughout the rest of the body. Patient was transferred to the nursing home for therapy in order to improve strength. R166's Progress Notes documents an entry made by V7 (Registered Nurse/RN) at [DATE] at 8:57 AM stating the following, Elder was very restless in his bed during the night time hours. He was confused off and on, trying to climb out of his bed and walk on his own in his room unsafely, and was attempting to pull out his Foley catheter tubing from his penis. When asked what he was trying to do, he stated that he 'had to go pee.' Explained to Elder that he did not have to take the Foley out to 'go pee.' Attempted to explain the usage of Foley catheter in simple terms to help him understand to not pull on the tubing. He did stop for a short time and lay back down on the bed. Attempted to educate Elder to not get out of bed without assistance due to his falling earlier in the day and he was not steady at this time on his feet and walking. He laid down for a short period of time, indicated by nodding his head that he understood what was being told to him. Elder continued this behavior off and on during the evening time et his vital signs were stable early in the shift through the middle of shift et then noticed that Elder seemed out of breath, so Oxygen placed on Elder at 2 L (liters) per nasal cannula. This seemed to help relax him and he closed his eyes et rested a short time. Meanwhile, while checking Elder's vital signs, it was noted by this nurse that Elder's SP02 (Pulse Oximeter Oxygen Saturation) was just above 88% to beginning 90's some of the time, et at another time, was found at 82% with 2 L oxygen per nasal cannula. Elder would not always leave oxygen tubing on his face. In his at times confused state of waking up after dozing off, he would pull it off. He was checked on by this nurse et CNA's (Certified Nurse Assistant) very frequently. He was found most of times attempting to get out of bed. At 0130 on the early morning of [DATE], Elder's vital signs were taken by this nurse et assessment made to call his doctor, due to the confusion et restlessness. VS were: ,d+[DATE], (Right wrist, lying down), Pulse 112, with Pulse oximeter showing 52 for Pulse while his SP02 was found to be 88% on 2 L per nasal cannula. His respirations were rapid and shallow at 42 per minute, et temp of 96.8 F. Blood sugar reading was 223. This nurse went to the desk to look over diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon arriving to room, Elder's coloring in his face was dusky in areas et very white in others, he was staring off straight ahead et he took about 3 shallow breaths et all vital signs ceased at 0137 AM. Elder was head first at the foot of his bed, et he was laid down et all vital signs assessed by this nurse. There were no further heartbeats or breaths. CNA ran to determine if Elder was a Code et was found to be a DNR with Selective Treatment. The ambulance and fire department was immediately dispatched by a second nurse, (name) V16 (Licensed Practical Nurse, LPN). The ambulance service arrived at 0152 et they assessed Elder et also deemed cessation of vital signs. They left the building at 0200. Called V4's phone service at 0205. He returned call immediately. Called the nurse on call at the facility, V12 (Minimum Data Set Coordinator) et let her know all that had happened. Called Elder's daughter, (name) V17 (Family Member) at 0230 et let her know that Elder had passed away. She requested to speak to her mother et tell her, which was the second person on his call list. From this time to after 0630, Elder's family arrived et left, with daughter bringing Elder's wife to visit. Daughter just said to call (name) local funeral home to set up arrangements. Called funeral home at 0730 et they arrived at 0820 to take Elder to the Mortician. Paperwork was signed et sent with patient. On [DATE] at 03:16 PM, V5 (CNA) stated she was working with V6 (CNA) the night R166 expired, along with V7 (RN). V5 stated she works 3rd shift (11 PM - 7 AM), and 2nd shift had reported at shift change that R166 had tried getting out of bed unassisted a few times that day. V5 stated R166's normal status is slightly confused, but super mild, R166 didn't normally try to get out of bed, almost always slept through the night, and she had never witnessed him pull at his catheter before. V5 stated on [DATE], from the start of the shift, R166 was very confused, continuously trying to get out of bed on his own, pulling at his catheter, anxious, and sweaty. R166 stated that she and V6 had attempted to toilet R166 in case he needed to use the restroom but stated that didn't seem to help. V5 stated they reported R166's change in baseline status to V7 (RN) numerous times and even encouraged she call the physician to send R166 out for evaluation because she was worried about him and could tell something was wrong. V5 stated V7 continued her medication administration pass and never gave her any further instruction on anything special to do with R166. V5 stated herself and V6 had taken R166's vital signs which were all normal at the time they checked them, except his pulse which was a little elevated at 110. V5 stated this too was also reported that to V7 with nothing done that she was aware of. V5 stated R166's abnormal status continued as the shift went on, and she would definitely describe (name) R166 as appearing in distress. V5 stated herself and V6 had checked on R166 every ,d+[DATE] minutes throughout the night to try and keep him from falling and because he wasn't acting right. V5 stated herself and V6 entered R166's room around 1:30 AM on [DATE] and observed R166's head at the foot of the bed with no respirations noted and no pulse noted. V5 stated V6 ran to get V7 who came to assess, rolled R166 on his side she said in case he had a [CONDITION(S)], and left to check R166's resuscitation status, which was Do Not Resuscitate (DNR). V5 stated V7 called the ambulance to confirm death, in which they responded and confirmed. V5 stated herself and V6 repositioned and cleaned up R166 to prepare for his family and funeral home to arrive. On [DATE] at 7:55 PM, V4 (Physician) stated he recalls (name) R166. V4 confirmed that should a resident be experiencing a deviation from their baseline status; he would expect to be notified immediately. V4 stated he was never notified that R166 was experiencing any concerns on [DATE] or [DATE] including increased confusion, anxiousness, diaphoresis, pulling at catheter, restlessness, etc. On [DATE] at 8:43 AM, V1 (Administrator) stated that she did not have much interaction with R166 during his short admission here, so cannot specifically speak on his baseline status. V1 stated R166 was admitted to the facility for short term rehabilitation services after a hospitalization . V1 stated prior to R166's hospitalization , he resided at home with his wife, and his plans were to complete rehab and return home. V1 stated that she has received complaints from other nurses regarding V7 that she is slow, but no complaints from residents. V1 stated nurses work 12-hour shifts, with V7 working 6 PM - 6 AM. V1 stated CNA staff work 7 AM - 3 PM, 3 PM - 11 PM, and 11 PM - 7 AM. V1 stated that the shift that V5 and V6 work are 11 PM - 7 AM. On [DATE] at 10:42 AM, V7 (Registered Nurse) stated that she has worked at the facility for about 3 months. V7 stated she had previously worked with R166 prior to [DATE]. V7 stated she works the 6PM - 6 AM shift. V7 stated that on [DATE], the only thing she can recall being given from the day shift report was that R166 had experienced a fall earlier in the day and had been trying to get out of bed. V7 stated R166 had not been at the facility long before he expired and describes R166's expiration as being unexpected. V7 stated she cannot recall if staff reported to her any abnormal concerns with R166 the night of his expiration, as she's cared for a lot of people since then. V7 stated she does recall that R166 was abnormally restless that night, but just wrote it off that R166 had a fall earlier in the day and was out of sorts. V7 stated she does not feel it was abnormal for R166 to be restless as he previously had attempted to get out of bed during the night occasionally on his own, although she acknowledges he is usually easily re-directable and was not on this night. V7 stated while she did document an oxygen saturation level of 82%, she applied oxygen and would talk to R166, which seemed to help calm him down and improve R166's oxygen level, allowing him to doze off for short periods of time. V7 stated R1 would re-awaken and attempt to get out of bed and take the oxygen off. V7 stated she had occasionally applied oxygen per nasal cannula for R166 in the past. V7 stated had R166's oxygen saturation level not improved with the application; she would have notified the physician. V7 acknowledges in some cases restlessness can be a sign of distress for some residents. V7 confirmed R166 did appear short of breath at times. V7 stated another abnormal occurrence R166 was exhibiting on [DATE] was that he was continuously pulling at his catheter and stating he had to pee. V7 stated she provided R166 education that he needed to leave his catheter alone, and that he didn't need to pee and had a catheter. V7 stated she never notified V4 (Physician) at any point on [DATE] or [DATE] prior to R166's exhibiting severe distress of respirations ceasing and expiration. V7 stated looking back the only thing she feels she could have done better, although it was not an option with staffing would be to provide R166 a 1:1 staff member to ensure he stayed in bed. V7 again stated she cannot specifically recall the timeline of events leading to R166's expiration as she's cared for many people since then. V7 stated an aide whom she cannot recall came to notify her R166 was in distress. V7 stated she believed V6 was working but cannot remember the other staff member. V7 stated when she arrived to R166's room, R166's head was at the foot of his bed, with his oxygen off. V7 stated R166 took a couple shallow breaths and respirations ceased. V7 stated R166 was dusky in color and after confirming his do not resuscitate status, she verified via auscultation and palpation that there were no respirations or a pulse. V7 stated she notified V4 of R166's passing and the local ambulance company to confirm death. V7 stated the ambulance and fire department arrived, and an asystole cardiac rhythm was confirmed. V7 stated R166's family was notified of the expiration. V7 stated the expectation is for staff to notify the physician if resident's experience a problem or change in their baseline status. V7 confirmed that V4 responds quickly and appropriately to resident needs when notified. On [DATE] at 11:13 AM, V4 confirmed the cause of death listed as diabetes on R166's death certificate was due to the weakening effects Diabetes has on the immune system. V4 said it's fair to say that should he have been notified of the change in condition, R166 could have been treated. V4 stated, while the outcome may not have changed, the option of attempted treatment was possible. On [DATE] at 11:17 AM, V6 stated she and V5 were the aides working with R166 the night he expired, and V7 as the nurse for that wing. V6 stated she works 11 PM - 7 AM. V6 stated in report received from the off going shift that day, they had passed on that she can remember that R166 kept trying to get out of bed on his own, which he wasn't supposed to do and was not steady on his feet. V6 stated it would have been about 11:30 PM on [DATE] when she had first gone to check on R166 in his room and observed him as being very sweaty and trying to get out of bed. V6 stated he was sweating to the point that if you touched him, your hand was wet. V6 stated she immediately reported the observation to V7. V6 stated she knows R166 is diabetic so she was worried something may have been wrong. V6 stated V7 did go check R166's blood glucose at that time, and she couldn't remember the exact number, but it was one hundred and some and V7 said it was ok. V6 stated as the night went on both she and V5 expressed multiple times to V7 that something wasn't right with R166, and they thought he needed sent to the emergency room for evaluation. V6 stated R166 was restless, anxious, pulling on his catheter, needing oxygen, and would not stay in bed, all of which she stated is very abnormal for R166. V6 stated R166's normal status is mildly confused, but easily redirectable, normally slept all through the night, had never seen him require oxygen or pull on his catheter. V6 stated at one point she specifically recalls telling V7 that R166 was not ok. V6 stated this specific incident was when V7 was doing her medication pass and V7 had told V6 she would see about calling R166's doctor later. V6 stated she expressed her concern with R166's condition to V7. V6 stated herself and V5 checked on R166 about every 15 minutes due to R166's status and her fear of something being wrong and R166 would fall getting out of bed on his own. V6 stated around 1:30 AM on [DATE] she had entered in R166's room and observed him lying in his bed with his head at the foot of the bed and oxygen off, breathing at this time. V6 stated she left the room to go get V5 to help her get R166 turned back around in the bed. V6 stated when herself and V5 returned to the room, R166 took a couple of gasping breaths and quit breathing. V6 stated she hollered for V7 who came and observed R166 status, then checking his resuscitation code, noting he was a do not resuscitate. V6 stated the ambulance responded to confirm expiration and V7 instructed V5 and V6 to get R166 cleaned up for family to see him and the funeral home. V6 stated R166 displayed a definite change in his baseline status from the start of her shift until his expiration. V6 confirmed that Cardiopulmonary Resuscitation was not started (due to DNR status). On [DATE] at 2:49 PM, V2 (Director of Nursing) stated that it is the expectation that facility staff notify the physician immediately in the event a resident is experiencing a change in their baseline condition. V2 confirmed that documentation completed by V7 that describes R166 as having increased restlessness, pulling on his catheter, attempting to repeatedly climb out of bed, not sleeping, experiencing an oxygen saturation rate of 82% would all be instances in which the physician should have been immediately notified. V2 stated that on [DATE], R166 had experienced a witnessed fall with no injury, and later that same day also an emesis. V2 states hindsight it seems R166 had several small occurring problems leading up to his distress and expiration. V2 stated V4 had been notified of the fall, due to facility policy, but not the emesis due to relief with no further concerns after the emesis. V2 describes R166 as being mildly confused stating he was oriented to person, time, and recognized he was in a nursing home for therapy but would be unable to give the specific name of the facility. V2 stated R166 propelled himself in a wheelchair around the facility and was planned to be in the facility for short term therapy needs, then return home. V2 stated she was notified of the death by V12 (Minimum Data Set Coordinator) who was on call. V2 stated on [DATE] the facility's Interdisciplinary Team which consists of herself, V13 (Assistant Director of Nursing, ADON), V12, V14 (Care Plan Coordinator), and V1 (Administrator) began an investigation into R166's death due to the unexpected nature. V2 stated it was determined the notable significant decline of R166 began during 3rd shift, which is 11 PM-7 AM on [DATE] in which V7 failed to notify the physician of R166's change in status. V2 stated beginning [DATE] and completed [DATE], the facility completed in-servicing with all nursing staff on the facility change in condition policy and the computer program Interact Pathway-Change in Condition which is described as a program you enter information into and will lead you to notifications and referrals needing made. V2 stated V5 and V6 were determined to have acted appropriately, evaluating and reporting concerns to V7. On [DATE] at 3:18 PM, V9 (Registered Nurse/RN) stated she was the nurse who had worked 6 AM - 6 PM on [DATE]. V9 stated R166 was his normal self that day and had experienced some nausea that resolved after an emesis of food. V9 stated R166 had also had a witnessed fall on [DATE], with no injuries. V9 stated V4 had been notified of the fall with no new orders, but not the emesis, due to the uneventful nature post emesis with R166 expressing relief. V9 stated she would describe R166 as being mildly confused, but always alert to person and time. V9 stated when she left for her shift on [DATE], she recalled seeing R166 lying in bed eating his evening meal with no concerns noted. V9 stated R166 was impulsive and if he wanted to get up, he would get up forgetting his weakness. On [DATE] at 4:52 PM, V15 (Certified Nurse Assistant/CNA) stated that he works the 3PM-11PM shift and confirms he worked on [DATE]. V15 stated he was familiar with R166 and described R166 as being overall his normal baseline self on [DATE]. V15 stated R166 had attempted to self-transfer a couple times that evening which was abnormal and stated R166 seemed a little more confused. V15 stated he passed on the concerns in report to next shift so they could watch him closely. V15 stated he never witnessed R166 appearing in any distress at that time. On [DATE] at 08:25 AM, V12 stated she recalls receiving a call from V7 during the night of [DATE], as she was the nursing staff on call that weekend. V12 stated V7 seemed a bit shook up due to the unexpected nature, and when asked what happened, V7 stated she didn't know, that R166 had been restless, anxious, and up and down all night. V12 stated she went through the notifications needed to ensure V7 contacted everyone she needed to. V12 stated she believes she text V2 to notify her of R166's death. V12 stated the facility completed and investigation and implemented a quality assurance performance improvement plan re-training nursing staff on the facility Change in Condition policy and the Interact Pathway-Change in Condition computer program. Review of the local ambulance report dated [DATE] documents at 1:44 AM, an ambulance was dispatched to the facility for report of a male not breathing. Emergency Service Personnel verified R166's DNR status and observed R166 lying in his bed, with his head at the foot of the bed. R166 is documented as being pulseless, apneic, cyanotic, pupils fixed and dilated, and cold to touch. A cardiac monitor is documented as being applied showing asystole, confirming death. Review of the document titled Certificate of Death Worksheet documents R166 expired at the facility on [DATE] at1:37 AM, at the age of [AGE] years old. The manner of death is listed as being natural with the cause listed as Diabetes. V4 is documented as the physician that completed the cause of death. Review of the facility policy titled Change in a Resident's Condition or Status with a revision date of [DATE] documents, A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is (e.g., changes in level of care, resident rights, etc.). The same policy documents the resident's attending physician or on-call physician will be notified then there is a. An accident or incident involving the resident, which results in injury and has potential for requiring physician intervention d. A significant change in the resident's physical/emotional/mental condition psychosocial status to either life-threatening conditions or clinical complications .g. A need to transfer the resident to a hospital/treatment center. The same policy also goes on to state a resident's physician should be notified in the event of a significant change which is defined as a decline or improvement in the resident's status that, a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. b. Impacts more than one area of the resident's health status. Review of the facility policy titled, Making an Emergency Transfer or Discharge with a revision date of [DATE] documents, Residents will be transferred from the facility to the hospital and ensured of timely admission to the hospital when transfer is medically appropriate as determined by the attending physician or in an emergency situation, by another practitioner in accordance with facility policy and consistent with state law. This document states, 1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician of the change in condition and request immediate orders to transfer the resident to the hospital. In an emergency situation, another practitioner may order the hospital transfer and notification of the transfer will be made to the attending physician. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 12:54 PM. The immediacy was removed on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE], prior to the survey date. Prior to the survey date, the facility took the following actions to remove the immediacy and correct the non-compliance as confirmed through observation, interview, and record review: 1. On [DATE], the facility initiated an internal review regarding R166's unexpected death. 2. The investigation concluded an identified opportunity for improvement/deficient practice regarding R166 experiencing emesis, low SPO2, and timely notification of the physician. It is documented the facility concluded potentially all residents were at risk. 3. On [DATE] the facility initiated a quality assurance performance improvement plan (QAPI) in service training with all nursing staff on the facility Change in Condition policy and the Interact Pathway-Change in Condition computer program. All nursing staff are documented as having completed the training on [DATE]. 4. The facility will in-service quarterly on the Interact Change in Condition form and monitor the 24-hour report summary weekly for 4 weeks.

Based on interview and record review the facility failed to provide the required assistance during resident transfer for 2 (R3, R4) of 3 residents reviewed for accidents in a sample of 6. This failure resulted in R3 sustaining a fracture at the distal shaft of the left tibia and fibula. This past noncompliance occurred from 01/04/22 to 01/07/22. Findings include: 1. R3's Resident Profile Sheet documents admission to the facility on [DATE], a re-admitted [DATE], and a discharge date of [DATE]. R3's Medical Diagnoses Sheet documents the following in part - [CONDITION(S)] ([CONDITION(S)]), Dementia, Anxiety, Personal history of Covid-19, Age-related [CONDITION(S)] without current pathological fracture, Fracture of Left Lower Leg - closed fracture with routine healing, Muscle wasting and atrophy, Dependence on wheelchair, and Protein-calorie malnutrition. R3's most recent quarterly MDS (Minimum Data Set) dated 12/13/21 documents the following: R3 is moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 8. R3 was assessed as requiring extensive 2+ person physical assist for transfers with the use of a mechanical lift. R3's Care Plan dated 11/18/19 with an update on 01/04/22, documents the following in part - Focus: I require assistance with my ADLs (activities of daily living) .I use my Geri chair as my primary mode of locomotion which I require assistance with . Interventions/Tasks: Please use a mechanical lift for all transfers with extensive assist of 2 for resident and staff safety .Focus: I am receiving hospice services through Residential Hospice. Goal: I will receive safe and compassionate care .Interventions/Tasks: Notify Residential Hospice of any change in status, falls, or incidents. Focus: I am at risk for falls related to impaired cognition, forgetfulness, abnormal posture, non-ambulatory, dependence on Geri-chair, right lower extremity and left lower extremity contractures, mechanical lift x 2 assist transfers .On 01/04/22, I sustained a left lower extremity fracture due to improper staff transfer. The staff member was suspended for pending investigation, immediate staff on duty were educated to read care cards for proper transfer status and educated on policies for transfers with gait belt and policies on mechanical lift transfers. I received orders to apply splint to left lower extremity splint and elevate as tolerate related to [CONDITION(S)], check pedal pulses left lower extremity every shift, [MEDICATION(S)] every 3 hours for pain, Acetaminophen-[MEDICATION(S)] one tablet every 6 hours. Goal: I will remain free from fall or injury through next review. Interventions/Tasks: Please use a gait belt when assisting me with transfers .See previous fall interventions . R3's Care Card documents the following in part - .I need +2 assist to transfer. I use a mechanical lift .I need to use the following devices: B (bilateral) fixed leg rest on w/c (wheelchair); Right side lateral support in w/c; B leg rests with blue drop stop footrest; Pt (patient) to wear shoes every day; mechanical lift for transfers . R3's progress note dated 1/4/2022 at 2:30 PM documents the following in part - Incident Note - This nurse (V4 - Licensed Practical Nurse - LPN) called to resident room by CNA (V18) r/t (related to) CNA had assisted resident from Geri-chair to bed. CNA stated I went to change her depend and lifted resident from Geri-chair to bed with my arms under the resident underarms to set her down on the bed. I heard a noise, and her leg was against my leg and the bed. So, I set her in bed and then I noticed how she was holding her left leg. I then told the nurse. R3's same progress note further documents V4 reported this incident to V2 (Director of Nursing - DON) and V9 (LPN/MDS - Minimum Data Set). V2 and V9 performed assessment of resident left leg and instructed this nurse to notify hospice along with family. Resident in bed at this time laying on right side . Recommendations: Order given to get x-ray 2 views of left tibia/fibula along with ankle dx (diagnosis) acute pain from Hospice nurse when called. R3's x-ray report dated 01/04/22 at 6:50 PM documents the following - Procedure: Left tibia and fibula, two views .Impression: Acute non-displaced comminuted fracture at the distal shaft of the tibia and the fibula. R3's facility Incident/Injury Report Investigation dated 01/04/22 at 2:30 PM by V4 (LPN) documents the following in part - Resident: R3. Incident Location: Resident's Room. Incident/Nursing Description: This nurse called to resident room by V18 (CNA) r/t (related to) V18 had assisted resident from Geri-chair to bed. V18 stated she went to change R3's incontinence brief and lifted R3 from Geri-chair to bed with her arms under resident's underarms to sit her down on the bed. V18 reported hearing a noise and R3's leg was against V18's leg and the bed. V18 sat R3 down in bed and noticed R3was holding her left leg. V18 then told V4 who then reported the incident to V2 (DON) and V9 (LPN/MDS). V2 and V9 performed R3's assessment of left leg and instructed V4 to notify hospice along with family. A handwritten document provided as part of the facility incident investigation dated 01/07/22 by V9, documents that V18 acknowledged the purpose of care cards, mechanical lift pad under R3 in the Geri-chair, and knowing R3 was a x2 assist with mechanical lift for all transfers since employment. In this document, V18 is quoted as saying, I've never mechanical lifted (R3). She's lighter than my kid, doesn't weight much. It's easier and quicker to use my body. I just tell her to put her arms around me. V9 documents the conversation occurred between 4:00 PM to 4:30 PM in R3's room. On 01/14/22 at 10:13 AM, V9 (LPN/MDS) stated that on 01/04/22, V18 reported the incident between V18 and R3 to V9 and V2 (DON). V9 stated she and V2 went to R3's room to assess her and observed R3's care card at the doorway, and mechanical lift pad in place in her Geri-chair beside the bed. V9 stated when she interviewed V18 after the incident, V18 confirmed she was transferring R3 from the Geri-chair to the bed to change her. V9 stated R3 was obviously in pain and the inner part of her left leg and ankle had already began to show discoloration. V9 confirmed she told V18 that R3 required a mechanical lift with 2+ person transfer. V9 stated, V18's response was that she knew that, but she never used the mechanical lift because it was easier for V18 to transfer R3 without because she did not weight much. V9 stated V18 was immediately taken off the floor and sent home pending the investigation that had been initiated. On 01/14/22 at 10:20 AM, V3 (Regional Director of Clinical Operations) stated she was aware of R3's improper transfer incident involving V18. V3 stated that unfortunately, the facility made the decision that V18 would likely continue to provide care in the same manner given her statements during the investigative process and providing education would not change future outcomes concerning resident care. Therefore, the decision was made to terminate V18's employment at the facility. On 01/14/22 at 10:46 AM, V6 and V8 (CNAs) both stated resident care cards are placed outside resident doorways to provide a quick overview of the care and assistance required for each resident. V6 and V8 confirmed they received education and training on resident transfer, gait belt use, and mechanical lift procedures on 01/04/22. On 01/14/22 at 2:43 PM, V18 (CNA) was interviewed via phone conversation related to the incident on 01/04/22 involving herself and R3. V18 stated she went to R3's room to change her. V18 stated she turned R3's Geri-chair around and positioned it like she always did. V18 lifted R3 up stating R3 was never difficult to lift - that R3 usually just grabs on to her shoulders and they have no issues, which is what occurred on 01/04/22. V18 continued to describe turning R3 during transfer like she always does and at that point, V18 didn't know if it was how R3's leg was pressed up against her own leg and then against the bed, but V18 heard a noise, sat R3 down in bed, and went to get the nurse. V18 confirmed she was aware R3 was assessed as a two-person mechanical lift assist, but stated she's just always done it by herself with no problems because R3 doesn't weigh anything.V18 stated She's as light as my kids. The nurse assessed her and V18 understood R3 had a fracture. V18 stated she felt terrible and was sorry this ever happened. On 01/18/22 at 1:20 PM, V21 (CNA) stated she knows the residents' assist requirements, what they can and can't do, but stated there are reminder cards on each door so you can check if you need to. She absolutely does not attempt to lift or transfer a resident by herself if they are 2-assist. V21 stated she was aware of the incident in which R3 sustained a fracture and confirmed all CNAs received education and training, herself included, after the incident on 01/04/22. R3's Certificate of Death Worksheet documents the following in part - date of death : 01/11/22. Cause of Death: a. Cerebral Atherosclerosis. Approximate Interval Between Onset and Death: Unknown. Manner of Death: Natural. Time of Death: 7:45 AM. A facility policy titled, Mechanical Lift dated October 2017 documents the following in part - Policy: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. Responsibility: All nursing personnel. Equipment: Mechanical lift, sling, chair or wheelchair, if needed . A facility educational handout titled, Transfer Program documents the following in part - Purpose of Transfer Program - Enable the resident to transfer safely .Weight Bearing Status: Full weight bearing, partial weight bearing, toe touch, weight bearing as tolerated and non-weight bearing .Transfer Guidelines: .Follow specific orders as to the type of transfer to be performed . 2. R4's Face Sheet documents an admission to this facility on 04/16/16, with a re-admitted [DATE]. R4's Medical Diagnoses Sheet documents the following in part - [CONDITION(S)], Pulmonary fibrosis, dementia, anxiety, a-fib, dependence on wheelchair, muscle wasting and atrophy, need for assistance with personal care, lack of coordination, history of falls. R4's most recent quarterly MDS dated [DATE] documents R4 is assessed as needing extensive 2+ personal physical assist during transfers. R4 was also assessed as being unable to conduct an interview to determine a BIMS score due to R4 being rarely/never understood. R4's care card documents she requires a 2+ person assist with all transfers. R4's Witnessed Fall Incident Report dated 12/03/21 at 4:10 PM documents in part - Incident/Nursing Description: Called to room by another nurse walking past resident's room entered room, resident was laying on her right side on CNA who was laying on her back on the floor. Both resident and CNA head adjacent from head of bed and feet outward toward foot of bed. Wheelchair was locked and at foot of bed .resident was wearing gait belt and non-skid socks. Immediate Action Taken: Area assessed, no signs/symptoms of pain or discomfort .2 cm (centimeter) line on right side of forehead with scant blood noted after resident was up in wheelchair .Other Information: CNA was transferring elder from wheelchair to bed, resident's feet began sliding and resident was leaning towards CNA. CNA lowered resident and self gently to floor, CNA leaned back so that CNA and resident were laying flat on floor. Notes: CNA was transferring elder from wheelchair to bed when her feet slid, and she assisted her to the floor as she could not hold her up. After speaking with CNA, it was determined she used a gait belt and 1 assist during this transfer. Elder is a 2 assist transfer for this reason. Staff education provided again where to find transfer status and to follow the recommended transfer status for each resident. On 01/18/22 at 10:00 AM, V17 (Assistant DON) stated that V20 (CNA) was involved in the improper transfer of R4 on 12/03/21 and would not further communicate with the facility after the incident. V17 stated she read the Summary of Incident to V20 over the phone on 12/06/21, then documented the incident on an Employee Disciplinary Form. V17 stated V20 refused to sign and did not return to the facility. A facility policy titled; Falls Prevention Program dated revised on 10/15/21 documents the following in part - Fall Prevention Program Components: . 1. Method to identify risk factors: b) Resident transfer assessment; c) History of falls; .f) Discussion of individual circumstances .Physical Capabilities: .4. How to determine resident is at risk for falls: e) MDS - Codes the resident as type of assistance required and the amount of assistance required. Addresses standing/sitting balance, mobility, gait, vision and cognitive status . Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. V18 (CNA) was educated and suspended on 01/04/22 pending investigation. 2. All staff on duty on 01/04/22 were educated on gait belt and mechanical lift policies, with all staff being educated prior to starting next shift. 3. On 01/07/22, V18 was terminated. 4. In-services on gait belt, mechanical lift policy, and transfers was completed on 01/06/22. 5. All nursing staff competency for transfers was completed. 6. Nurses were educated on the importance of completing their transfer assessment upon admission, after a fall, and as needed. 7. All staff trained on Care Card and where to find transfer status. 8. Transfer assessments for all residents were reviewed and updated. 9. Resident Care Plans were reviewed and updated as needed. 10. Resident Care Cards were reviewed and updated as needed. 11. Transfer Audits to be conducted 3 x per week for 4 weeks to ensure compliance. Results will be reported at the weekly quality meeting. 12. A Quality Assurance and Performance Improvement meeting was held on 01/04/22 and included V2 (DON), V17 (ADON), (V9) MDS Coordinator, and (V3) Regional Director of Clinical Operations.

Based on interview and record review the facility failed to provide required supervision, support and assistance, during an episode of agitation, that resulted in a fall for 1 (R3) of 3 residents reviewed for falls in a sample of 3. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/13/21 at 6:30 am, when the facility failed to implement supervision, physical support/assist for R3 as required, to provide stabilization, while seated on the side of the bed. This failure resulted in R3 attempting to transfer independently and resulted in a fall. R3 sustained a fracture to the right femur, requiring hospitalization , a subsequent surgical repair, and then R3's demise on 10/15/21. This past noncompliance occurred from 10/13/21 to 10/25/21. This has the potential to affect 45 residents, assessed as high risk for falls, residing in the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 11/04/21 at 3:20 PM. The immediacy was removed on 10/25/21. Findings include: R3's Resident Profile Sheet documents admission to this facility on 12/29/20 with a discharge date of [DATE]. R3's Medical Diagnoses Sheet documents the following in part upon admission - History of falls, muscle wasting and atrophy, fatigue, [CONDITION(S)] pneumonia, acute respiratory failure with [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and hypertension. R3's most recent quarterly MDS (Minimum Data Set) dated 09/08/21 documents the following: R3 is moderately cognitively impaired; and assessed as requiring extensive one person physical assist for bed mobility and transfers. R3's MDS also indicates that a one person physical assist is required to balance during transitions - moving from seated to standing position, as resident is not steady and only able to stabilize with human assistance. R3's Fall Risk Evaluation dated 09/08/21 documents a score of 14, with a score of 10 or greater indicating a high fall risk. R3's Care Plan dated 01/20/21with a revision date of 04/21/21, documents the following focus area in part - .I require assistance with my ADLs (activities of daily living) . I am A/O (alert and oriented) x3 with moments of forgetfulness/confusion. I am able to redirect easily and able to make my needs/wants known appropriately. I am legally blind. I require verbal cues and extensive staff assist with my ADL's and mobility . Interventions in part - .I can walk with a wheeled walker, gait belt, and assist . R3's Care Plan also includes the following focus area dated 01/20/21 - I am at risk for falls related to SOB (shortness of breath), weakness, fatigue, legally blind .Interventions in part - . I can be up to my wheelchair or walked with assistance and wheeled walker; Check my positioning in bed to ensure that I am positioned away from the edge; Please use a gait belt when assisting me with transfers and ambulation . R3's progress note dated 10/13/21 at 6:05 AM by V4 (LPN) documents the following - .This nurse in restroom at this time and upon exiting restroom was called to resident room by CNA staff (V5, V7) went into room to investigate hearing resident yell out. (V5) stated to this nurse, I helped her get dressed for breakfast and she would not let the other CNA help. She was dressed with non-skid shoes on and was dressed after given incontinence care. I left her sitting on side of bed because she did not want to let me help her into w/c. She told me to get out of room. This nurse along with (V9 - LPN) did not move resident from laying position on right side of body with head at foot of bed and feet at top of bed. C/o (complaint of) extreme pain and did not roll over. Unable to perform complete assessment. Doctor along with V16 (Family Member/POA - Power of Attorney) called to notify. Vital signs are 99.7, 88, 18, 106/91 95% SPO2 (percent oxygen saturation) at room air. R3's Final Facility Serious Injury Incident Report dated 10/13/21 at 6:30 AM by V17 (Assistant Director of Nursing - ADON) document the following in part - Detailed Incident Summary: Elder found on the floor on her right side at 6:30 AM this morning. Elder has had complaints of pain. Nurse assessed and obtained an order to send to (local hospital) emergency room for evaluation. X-ray at hospital showed mildly angulated intertrochanteric fracture proximal right femur resulting from fall. Update to report dated 10/16/21 at 12:08 PM by V1 (Administrator): Resident had surgery at hospital. Hospital notified facility of resident passing on 10/15/21. Final Report dated 10/20/21 at 12:08 PM by V17 documents the following in part - Elder was noted to be agitated the morning of 10/13/21. CNA assisted elder to clean up and get dressed for the day. According to the CNA, elder was upset at another CNA for not changing her in time. After elder was assisted in getting dressed she continued to be upset and ask that the CNA leave her alone. CNA left elder on the side of the bed to calm down as she requested. Shortly after CNA heard noise and went to elder's room noting her to be on the floor and then informed the nurse. Nurse immediately assessed and noted elder was in significant pain. Elder was sent to (local hospital) emergency room for evaluation where x-ray was obtained noting the fracture to the right femur. Elder would typically get up around this same time every morning, elder also known to get agitated with staff at times and refuse care . On 11/03/21 at 10:22 AM, V7 (CNA) stated that on the morning of 10/13/21, R3 appeared agitated with CNAs and other staff that were coming into R3's room. V7 stated that he (V7) proceeded to assist R3's roommate, R4 in getting up. V7 did ask if R3 would like him to assist her in getting up. R3 stated no. V7 stated R3 was soiled but refused my care. V7 stated he asked V5 (CNA) to go in to R3's room and assist her. V7 stated he had gone to the next room to give resident care and heard R3 yelling at V5 to get out. V7 stated, V5 relayed to him she has been able to provide care and get R3 dressed other than her pants being pulled completely up before R3 kicked V5 out of the room. V7 stated he was still in the room next door when he heard R3 yell. V7 stated he went to R3's door and observed R3 on the floor. V7 stated he got help, but staff were already on their way to assist because they could hear R3 yelling. V7 stated he was not sure what R3's ADL assist requirements were because he worked at night and R3 was usually in bed. V7 stated he does not believe that any resident should be left alone on the side of the bed because they are all a fall risk. On 11/03/21 at 10:32 AM, V5 (CNA) stated on the morning of 10/13/21, she came to work around 5:30 or 6:00 AM. V5 provided the following recount of R3's incident - I came down the hall and her light was on. She asked me to help get her up. V7 came out stating she was distraught and asked if I could help her. She stated the boy that worked before me did not do anything for me. V5 continued to state, I helped her get up, washed her off and got her dressed. She told me she was going to the bathroom. I asked her if she wanted me to help her pull her pants up, and she told me why pull them up, I'm going to the bathroom anyway. V5 stated R3's pants had not been pulled above the hips and were just below her buttocks. V5 stated she remembered R3 had on non-skid socks, no shoes yet. V5 confirmed usually every morning, once R3 gets on the side of the bed and gets help transferring to her wheelchair chair, R3 would roll to the bathroom, brush her teeth and comb her hair. V5 confirmed she left R3's room because she was hollering and screaming and told V5 to go. V5 also confirmed when she left R3's room, R3 was seated on the side of her bed. V5 stated she heard that R3 fell , so V5 and two other LPNs gave assistance. V5 stated R3 did not want to go to the hospital, but when the nurse asked R3 if she wanted to get up and R3 could not, the nurse called the ambulance. V5 confirmed, in hindsight, she would have stayed in the room with R3 but R3 was so agitated, she told me to get out. V5 stated she had not seen R3 that upset before. On 11/03/21 at 10:00 AM, V11 and V12 (Certified Nursing Assistant - CNA) stated they work the 200-hall and were very familiar with R3, as R3 did reside on this 200-hall while a resident in the facility. V11 stated she has worked here [AGE] years. V12 stated she has worked here for [AGE] years. V11 and V12 stated all residents have a care card on their door that reminds staff how a resident is assessed to require assistance and by what method. V11 and V12 stated this helps new staff or reminds long-time staff the resident's status and if it has changed. V11 and V12 stated R3 required transfer using staff assistance and a gait belt. V11 and V12 confirmed R3 would not be safe to sit on the side of the bed for the fact she would try to get up on her own. Both V11 and V12 stated they would have laid R3 back down in bed, prior to leaving the room, or asked another staff member to be in the room. On 11/03/21 at 2:00 PM, V10 (Restorative CNA) stated R3's MDS dated [DATE] documents that R3 needed (2) supportive, meaning touch support (which is what she (R3) was the majority of the time) and R3 required weight bearing with standby assist to stand, turn and pivot to wheelchair. V10 stated personally, after working here [AGE] years, she (V10) would never leave a resident alone on the side of the bed. V10 stated that she (V10) would not have left R3, she (V10) would have laid her (R3) back down in bed or would get another staff to at least do a standby observation in case she (R3) attempted to transfer herself. V10 further stated, R3 often transferred herself without asking for assistance first. She (R3) would say, I know I'm not supposed to do that, but I (R3) just wanted to sit there. On 11/04/21 at 9:40 AM, V4 (LPN) stated she was the nurse who wrote the initial incident report and called the ambulance on 10/13/21 when R3 had her fall. V4 stated, I came in that morning. We were finishing shift to shift duties. I went to the bathroom before I started passing meds. I was organizing my med cart when the midnight nurse (V6 - LPN) and the other CNAs (V5, V7) tell me R3 had fallen. I went to R3's room and V6 was already there stating R3 was complaining of a lot of pain. R3 also complained of pain to me, so I made the decision not to move her. I called the doctor and the ambulance. When asked what level of assistance R3 required for transfers, V4 stated R3 required one person for transfers. V4 stated due to R3's history of falling, being hard of hearing, and not having good sight (legally blind), R3 would not be safe to sit alone on the side of the bed and attempt to transfer to her wheelchair without assistance. When asked whether V4 recalled if R3 was wearing non-skid socks only as V5 reported, V4 stated to the best of her recollection as she put in her report, she observed R3 with socks and shoes on at the time of the incident. On 11/04/21 at 6:14 PM, V13 (Primary Care Physician - PCP) stated she had been R3's PCP for many years. V13 stated she was aware R3 had fallen in the facility, underwent surgery, and subsequently passed away in recovery. V13 stated she does agree that R3 most likely threw a clot. V13 stated R3 could be difficult and insist she could do things on her own, could be very convincing and sometimes even agitated, but R3 was not steady enough to transfer herself from the bed to her wheelchair. V13 confirmed R3 did not have good judgement regarding her physical capabilities, nor the decision-making ability to determine whether she was safe to transfer from a bed to a wheelchair without assistance. R3's hospital history and physical (H & P)) dated 10/13/21 at 7:31 AM documents a chief complaint of - Right hip pain after a fall. History of Present Illness: Patient admitted after a fall in the nursing home this morning. Patient was trying to transfer from bed to the wheelchair to go to the bathroom. She asked for help, but couldn't get help, she lost her balance and fell on her right side, no loss of consciousness, no head injury. X-ray showed intertrochanter fracture of right hip, closed, orthopedic consulted in emergency room . Patient is on anticoagulant [MEDICATION(S)] for [CONDITION(S)]. R3's hospital x-ray report dated 10/13/21 at 8:28 AM documents the following in part - mildly angulated intertrochanteric fracture proximal right femur. No significant displacement. No bone destruction. R3's H & P dated 10/13/21 Medical decision making and plan document - status post mechanical fall; intertrochanteric fracture of right hip, closed fracture; orthopedic consulted in emergency room - Will hold [MEDICATION(S)] per ortho will need to wait 2-3 days to do surgery. R3's hospital Operative/Procedure Report dated 10/15/21 at 8:12 PM by V15 (Orthopedic Surgeon) documents the following in part - Procedure: Open reduction internal fixation (ORIF) hip/trochanteric (fixation nail); Date of Service: 10/15/21; Pre-Op Diagnosis: right intertrochanteric femur fracture; Post-Op Diagnosis: Same. V13's report describes the procedure in detail ending in his observation of R3 in recovery moving extremities with pedal pulses palpable upon assessment. V13 documents an addendum to his operative report as follows - After I saw her in recovery, less than an hour after getting to recovery, she went into [CONDITION(S)]. She was coded, but the family asked the code to stop, stating that she would not want that, so she, R3, passed away. R3's Certificate of Death Worksheet dated 10/15/21 documents the cause of death as: a) Probable pulmonary embolism, due to or as a consequence of b) While recovering from hip surgery, due to or as a consequence of c) Fall at nursing home Date Pronounced: 10/15/21. Time of Death: 7:37 PM. A facility policy titled; Falls Prevention Program dated revised on 10/15/21 documents the following in part - Fall Prevention Program Components: . 1. Method to identify risk factors: a) Fall risk score; b) Resident transfer assessment; c) History of falls; .f) Discussion of individual circumstances .Physical Capabilities: .4. How to determine resident is at risk for falls: e) MDS - Codes the resident as type of assistance required and the amount of assistance required. Addresses standing/sitting balance, mobility, gait, vision and cognitive status. An Immediate Jeopardy was identified to have begun on 10/13/21. V1, Administrator was notified of the Immediate Jeopardy on 11/04/21 at 3:20 PM. The Immediate Jeopardy that began on 10/13/21 was removed on 10/25/21, prior to the survey date. Prior to the survey date, the facility took the following actions to remove the immediacy and correct the non-compliance: 1. On 10/15/21 the facility initiated a quality assurance performance improvement plan (QAPI) to reduce the fall rate within the facility. The QAPI plan included implementation of a fall reduction plan. 2. The facility has implemented a new Fall Prevention Management Policy. 3. All residents residing in the facility received an updated Fall Risk Assessment on 10/15/21 at 3:04 PM to identify residents at risk for falls. 4. All residents residing in the facility had a Transfer Assessment Completed on 10/17/21. 5. All residents residing in the facility had a Care Plan review beginning on 10/15/21 and completed on 10/22/21. 6. Education and training with mandatory in-service on Fall Prevention was conducted and provided to all nursing and CNA staff completed on 10/25/21. 7. Specifically, the Fall Prevention Management Policy, implemented on 10/15/21 addresses identifying risk factors and residents at risk. Per the new policy, residents are easily identified as being at risk for falls by a star at the entrance of their room in addition to their mobility device having a star on it. This was completed on 10/18/21 by V17 (ADON). Upon determination of an individual being at risk for falls, the care plan is updated to reflect why the resident is a fall risk in addition to the individualized interventions put in place. Individualized interventions take into consideration the resident's cognition, behaviors, and agitation if applicable. Residents at risk and any falls that have occurred since the previous week are discussed in morning report and weekly quality assurance meetings to ensure appropriate interventions. Care plan reviews of all residents were completed by V3 (Regional Director) by 10/22/21.

Based on observation, record review, and interview the facility failed to assess and develop a plan of care which provides the appropriate level of assistance, supervision and or assistive devices to meet resident's individual needs to prevent recurring falls for 2 of 6 residents (R5, and R8,) in the sample of 16. The result of the lack of appropriate assistance, supervision and or assistive devices resulted in multiple falls for R5 and R8 and repetitive injuries for R5 including fractured nose (9/28/13) and lacerations to the eyebrow/ forehead (7/29/13, 1/2/14, 1/7/14) and a subdural bleed from the fall on 1/2/14. The findings include: A1. A review of the admission information and diagnosis records for R5 find R5 is a [AGE] year old resident admitted on [DATE] with multiple [DIAGNOSES REDACTED]. 2. A review of R5's care plan, incident tracking log and individual incident reports for R5 found falls beginning on 6/2/12 through 1/17/14 recorded with the these interventions: R5's current care plan for Falls/Unsteady gait found falls noted 6/2/12, 6/8/12, and 6/29/12. The care plan documents 6/7/12 "Went out to ER (emergency room ) and returned with 8 staples to skull" Interventions added to the care plan include; 6/5/12 suggested added set up with meals, 6/7/12 Physical therapy to continue to work with him. 7/12/12 Staff advised to check on him frequently for various needs. 8/7/12 May use waffle cushion (discontinued 4/12/13) 11/26/12 discontinued PVC low bed Change to high low bed with falls mats on both sides r/t poor safety awareness. Undated "anti-tippers and wedge cushion to wheel chair to aid in fall reduction." 1/3/14 Falling star program The care plan continued with a summary of R5's falls: (no times given unless noted) 8/12/12 found on floor with two abrasions, 8/13/12 "Educated wife to turn on call light" 11/3/12 fell in hall no injury, 11/5/12 "Encouraged staff to walk resident with gait belt to and from meals and as resident will tolerate to increase strength and balance". 4/24/13 "fell in hall and hit my head" 4/25/13 ER with sutures "All staff will be made aware to observe him when up self-propelling.... 7/23/13 "fell in hall, laceration to my forehead". 7/24/13 Returned to facility with steri-strips to forehead... "will encourage staff to monitor for toileting needs frequently due to resident was incontinent of stool. 7/29/13 , fall from bed, Laceration to the left eyebrow "Encourage staff to keep in low bed and will also encourage staff to sit supervised on toilet" 9/29/13 "found on floor of living room and was bleeding from nose and forehead. 9/30/13 Resident returned from emergency department with fractured nasal bone and laceration. "Encourage staff to assist resident to common areas to self propel when up in wheel chair with smooth surfaces" 11/5/13 11:15pm fall in hallway, no injuries 11/6/13 Will encourage resident be gotten ready for bed earlier in shift. 12/17/13 12:58pm CNA (Certified Nurse Aide) was pushing me out of my room began to fall forward was caught by staff and fell to knees causing an abrasion to my knees. 12/17/13 Instructed CNA to go slower and watch him from putting feet under chair. 1/2 /13 8:23pm I was found on the floor and had an open head injury. Sent to ER and returned with [DIAGNOSES REDACTED]. 1/2/13 Re-educate CNA on importance of monitoring cushion in chair for proper alignment. 1/7/14 Resident was out to ER and Cat scan done at hospital and returned to this facility per son's request to keep comfortable and pain free following this injury. Did return with some degree of subdural bleeding. 1/17/14 1:21pm Found on floor in the dining room with laceration above my left eye, Other staff were in the dining room but they had been assisting other residents and did not witness my fall. 1/17/14 transferred to the ER where sutures were placed. Staff were instructed to more closely monitor all residents in the dining room. 3. A review of progress notes from R5's record found an entry from 1/22/13 7:35am stating a meeting was held with R5's son. The note states "Son made aware that we have asked Hospice to sent their OT (Occupational Therapist) out to look at possible wheelchair modification, cushion and possible protective head gear. We the facility have informed the son that we can not provide one to one care and this is not a locked down unit where there may be more staff to each resident... Both options he could consider if he would like to hire a sitter or look at another facility such as an Alzheimers unit. Interview with E2 (Director of Nursing) and E8 (Assistant Director of Nursing) on 1/27/14 at 1:10 pm confirmed the conversations with E5's son and that the information noted in the progress notes was correct. E2 indicated during this interview the facility's desire to keep R5 safe. E2 verified the facility is not restraint free but desires to be as restraint free as possible. 4. Interview with E1 (Acting Administrator) on 1/22/14 at 11:15am found that upon admission each resident is asked to sign an Acknowledgement of Restraint Policies. E1 indicated that the facility attempts to be as restraint free as possible and currently has one restraint in use at this time. Review of the 6/1999 restraint acknowledgement indicates: "Every resident at this facility will be assessed upon admission regarding the need for appropriate safety measures, and will be periodically reassessed as their needs change throughout their stay at our facility." Review of R5's last fall risk assessments dated 12/16/13 and 1/14/14 find R5 is coded a 20 and 22 respectively at risk for falls. The statement at the bottom of the assessment states "A resident whose score is over 9 is at risk for falls. Consider environment risk factors in the resident's interventions. Consider addition or removal of balance mobility devices." 5. R5 was observed on all days of the survey to be up and about in a wheelchair with a cushion, using the wheels of the wheelchair and the hand rails on the halls to move the wheelchair. R5 was observed on 1/22/14 at 11:00am in the hall with staff. R5 was observed to be repeatedly attempting to stand and be reminded by staff to stay seated. R5 was observed up in a wheelchair on 1/22/14 at 9:00am during a medication pass with E16 (Licensed Practical Nurse) E16 mentioned at the time that due to R5's falling she asks him to stay by her while she is passing medication. R5 was observed in a low bed with mats on the floor on 1/21/14 at 2:09pm . R5 was observed to have a sutured laceration to the forehead and frail appearance. B. R8 a [AGE] year old woman residing in this facility since 11/19/2013 physician's orders [REDACTED]. Review on 1/22/2014 of R8 record notes R8 was found on the floor in the bathroom attempting to self transfer to the toilet, R8 was transferred to the local hospital for evaluation and treatment after complaining of pain to her surgical site. On 12/3/2013 R8 slid out of her chair onto the floor. 12/6/2013 R8 fell trying to self transfer back into her recliner chair. On 12/10/2013 R8 fell trying to turn the oxygen concentrator on. 12/12/2013 when trying to get up unassisted staff found R8 sitting on the foot of her recliner. On 12/15/2013 R8 was found on the floor trying to get out of her recliner chair and into her wheeled chair. On 1/13/2014 R8 fell after walking unassisted to the bathroom. Review of R8's record on 1/22/2014 notes the Fall Risk assessment dated [DATE] with a score of 9 indicating R8 is high risk for falls. The Fall Risk assessment dated [DATE] notes R8's score of 19. The Fall Care Plan for R8 identifies interventions including redirection, education on use of call light, asking for assistance with transferring, skilled therapies to work on safety and positioning, encouragement to attend activities, and frequent offer of assistance with toileting. Review of R8's Brief Interview of Mental Status/BIMS of 1/22/2014 notes with a score of 14/15 R8 to be cognitively intact. Review of Progress Notes dated 11/20/2013 thru 11/25/2013 notes Urinary Frequency, Progress Notes dated 12/1/2013 notes Urinary Tract Infection with urgency to urinate. During interviews with R8 on 1/21/2014, 1/22/2014, and 1/23/2014 , R8 stated she knows how to use the call light but it does not help, staff is slow to respond when she turns it on and when she needs to get to the bathroom she needs to go, R8 added she does not like to sit in urine. R8 also stated she sometimes yells loudly to get staff to respond or makes threats to get their attention and when this does not work she tries to go by herself. R8 added she often sleeps in her wheeled chair so she can take herself to the toilet if staff does not respond.