Every finding on record at Newman Rehab & Health Care CTR

Based on interview and record review the facility failed to ensure residents dignity and respect for two (R3, R4) residents out of five residents reviewed in a sample list of nine residents.Findings include:1.R4's Electronic Medical Record (EMR) documents R4's medical diagnoses as Hemiplegia and Hemiparesis following nontraumatic Intracerebral Hemorrhage affecting right non-dominant side, Schizoaffective Disorder Bipolar Type, Cerebral Infarction, Anxiety and history of Trans Ischemic Attack (TIA).R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires moderate assistance with transfers.R4's Care Plan intervention dated 3/13/25 documents R4 is totally dependent on one staff member for locomotion using a wheelchair.On 5/3/26 at 11:20 AM V11 [NAME] stated she witnessed V4 CNA use inappropriate language in front of R4. V11 [NAME] stated she was standing by R4's dinner table when V4 CNA walked up to R4 and stated in R4's ear Let's go to f****** (expletive) bed. V11 stated then V4 CNA removed R4 from the dining room. V11 [NAME] stated no staff should ever use profanity in front of residents. V11 [NAME] stated she should have reported this to V1 Administrator immediately but did not because she thought it was already known that V4 CNA used profanity in front of residents.On 5/3/26 at 1:45 PM R4 was laying in bed in his room. R4 stated V4 CNA has used profanity to/in front of him. R4 stated he did not like being spoken to like that but doesn't think (V4) knows what she is saying. On 5/3/26 at 2:00 PM V1 Administrator stated staff should never use profanity in front of residents. V1 stated this facility is the resident's home and all staff should act accordingly. V1 stated the residents have the right to be treated with dignity and respect. 2. R3's Electronic Medical Record (EMR) documents R3's medical diagnoses as Dementia, Seizures, Obstructive and Reflux Uropathy, Spinal Stenosis, Unsteady on Feet, Abnormal Posture and Disorder of Muscle.R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 requires moderate assistance for bed mobility, personal hygiene and is dependent on the assistance of staff for toileting and transfers. R3's Care Plan intervention dated 3/14/214 documents R3 requires one staff member for assistance with Activities of Daily Living (ADL). This same care plan intervention dated 3/14/24 instructs staff to provide dignity, provide sufficient time to complete tasks and avoid rushing R3. The daily schedule staffing sheets dated April 2026 document V3 Certified Nurse Aide (CNA), V4 CNA and V7 Registered Nurse (RN) all worked at the facility 4/28/26 6:00 PM-6:00 AM. On 5/2/26 at 9:30 AM V2 Director of Nurses (DON) stated V7 RN reported that allegedly V4 CNA pulled R3's hair, hit R3 with her own pillow in the face and told R3 to shut the f*** (expletive) up. On 5/2/26 at 11:30 AM V4 Certified Nurse Aide (CNA) stated she knows she can seem loud, angry or negative at times but does not mean to sound like that. V4 CNA stated that is just my personality. V4 CNA stated she was providing incontinence care for R3 on the evening of 4/28/26. V4 stated R3 was yelling and carrying on while V4 CNA was trying to provide incontinence cares. V4 stated she had heard R3 was calling her a b**** (expletive) the next morning. V4 stated she did not think anything of it because she had to do her job. On 5/2/26 at 1:00 PM V7 Registered Nurse (RN) stated 'about' three weeks ago she was walking down the resident hallway and heard R3 yelling out Don't hurt me! Don't hurt my back! repeatedly. V7 stated R3's room door was closed. V7 RN stated she knocked and entered R3's room to see V4 CNA providing incontinence care for R3. V7 RN stated V4 CNA asked What do you want? to V7 who replied she heard R3 screaming from down the hall and came to investigate. V7 RN stated this happened around 2 AM. V7 RN stated at shift change (6AM) the same morning R3 was sitting in her wheelchair next to the nurses station yelling (V4) is a b**** (expletive)! (V4) is evil! (V4) is an evil b**** (expletive)! V7 RN stated she did not report this incident but should have. V7 RN stated she should have called V1 immediately to inform her of R3's statements at 2 AM and at 6AM. On 5/3/26 at 9:00 AM R3 stated They (staff) don't treat me very good here. They yell at me at night. I don't like that. R3 stated she felt safe at the facility but did not like getting yelled at. R3 could not remember days or times or who might have yelled at her. R3 stated I don't remember anything else but I know it happened.On 5/3/26 at 11:45 V8 Certified Nurse Aide (CNA) stated V4 CNA sometimes says things that are not appropriate. V8 CNA stated V4 CNA says things that really shouldn't be said but we all make mistakes. On 5/3/26 at 2:00 PM V1 Administrator stated the facility is currently in servicing on appropriate language/body language to use in front of residents, resident dignity and resident rights. V1 Administrator stated the staff should always treat all of the residents with dignity and respect. V1 Administrator stated she thinks the staff sometimes act in front of the residents as they do in their own home, forgetting that this is the resident's home. V1 Administrator stated she did not believe that V4 CNA willfully abused any resident but that V4 did forget to treat the residents with the dignity they deserve. The Illinois Long Term Care Ombudsman Program pamphlet titled Resident Rights for People in Long Term Care Facilities revised November 2018 documents the facility must treat residents with dignity and respect

Based on interview and record review the facility failed to report allegations of verbal and physical abuse to the abuse coordinator for two of five residents (R3, R4) reviewed for abuse in a sample list of nine residents. Findings include:1.R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired. This same MDS documents R3 requires moderate assistance for bed mobility, personal hygiene and is dependent on the assistance of staff for toileting and transfers. The facility report to the State Agency dated 4/30/26 documents V3 Certified Nurse Aide (CNA) reported an allegation of verbal and physical abuse of R3 by staff member V4 CNA on 4/29/26. This same report documents V3 CNA allegedly witnessed the incident on the evening of 4/28/26 and reported it to V7 Registered Nurse (RN) on the evening of 4/29/26. On 5/2/26 at 1:00 PM V7 Registered Nurse (RN) stated about three weeks ago (early to mid April) at 2 AM, she heard R3 screaming from down the hall, went to investigate and found V4 CNA in the room with R3 providing incontinence cares. V7 RN stated R3 was yelling Don't hurt me! V7 RN stated at 6AM the same morning R3 was yelling (V4) is a b**** (expletive)! (V4) is evil! (V4) is an evil b**** (expletive)! V7 RN stated she did not report this incident but should have. V7 RN stated she should have called V1 Administrator immediately to inform her of R3's statements at 2 AM and at 6AM. V7 RN stated the evening of 4/29/26 V3 Certified Nurse Aide (CNA) reported to V7 RN that V4 CNA had verbally and physically abused R3 the evening of 4/28. V7 RN stated she called V2 DON to report these allegations on the evening of 4/29/26. On 5/2/26 at 1:00 PM V2 Director of Nurses (DON) stated V7 reported to her that V3 CNA reported to V7 allegations of abuse from V4 CNA towards R3. V2 stated V7 RN reported that allegedly V4 CNA pulled R3's hair, hit R3 with her own pillow in the face and told R3 to shut the f*** (expletive) up. V2 DON stated when V3 CNA was interviewed, V3 stated she could not tell anyone because V4 CNA was there and V3 CNA did not want to upset V4 CNA. 2.R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires moderate assistance with transfers.The facility was unable to provide a copy of this report to the State Agency due to V1 Administrator was initially notified of the allegation on 5/2/26.On 5/3/26 at 11:20 AM V11 [NAME] stated about a month ago V1 witnessed V4 CNA use profanity in front of R4. V11 [NAME] stated she should have reported this to V1 Administrator immediately but did not because she thought it was already known that V4 CNA used profanity in front of residents.On 5/3/26 at 2:00 PM V1 Administrator stated V3 CNA reported abuse allegations to V7 Registered Nurse (RN) on the evening of 4/29/26. V1 stated V7 Registered Nurse (RN) reported V3's allegations of V4 CNA's care of R3 to V1 Administrator and V2 Director of Nurses (DON) on 4/29/26. V1 Administrator stated V3 CNA should have reported any allegation of abuse to V1 Administrator immediately (4/28/26). V1 Administrator stated V7 RN should have reported her concerns from a few weeks ago with V4 CNA and R3. V1 stated V11 [NAME] should have reported her allegation of V4 CNA using profanity in front of R4 from a month ago. The facility policy titled Abuse Prevention Program revised November 28, 2016 documents employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator.

Based on interview and record review the facility failed to report an injury of unknown origin to the Administrator and the State Agency for one resident (R1) of three residents reviewed for abuse in a sample list of five residents. Findings include: The facility Abuse Prevention Program revised 11/28/16 states The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. This policy also documents, Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: Name, age, diagnoses, and mental status of the resident allegedly abused or neglected; The original allegation (note day, time, location, the specific allegation, by whom, witnesses to the occurrence, circumstances surrounding the occurrence, and any noted injuries;facts determined during the investigation, review of medical record and interview of witnesses); conclusion of the investigation based on known facts; If there is a police report attach the police report; Attach a summary of all interviews conducted with names, addresses, phone numbers and willingness to testify of all witnesses. This report also states, A written report shall be sent to the Department of Public Health. R1's diagnoses list printed 4/8/25 at 2:52 PM includes the following diagnoses: Encephalopathy, Fall, Urinary Tract Infection, Cardiac Arrhythmia, Anticoagulant Use, Congestive Heart Failure, Hypertension, Hyperlipidemia, Mild Dementia with Anxiety, Protein Calorie Malnutrition, Weakness, and Pressure Ulcers of both heels Stage II. R1's AIM for Wellness note dated 3/11/25 at 12:15AM documents R1 has bruising to R1's right buttock measuring 4 centimeters in length and 2 centimeters in width. The Note documents R1 appears to have sustained an injury that was unwitnessed or is of unknown origin. Event was first noted on 03/11/2025 at 12:15 AM. Evaluation of the resident and event occurred on or about 03/11/2025 12:15 AM. Just prior to/at the time of the event (R1) appears to have been sleeping in bed. R1 is unable to relate details. Witness to the event includes: No one. On 4/9/25 at 2:00PM V1, Administrator stated Quite frankly I didn't do a complete report for the bruise because I wasn't aware the bruise had been found. I also did not report to the (State Agency) because I wasn't aware of the injury of unknown origin. If I had been aware I would have initiated an immediate investigation and reported to the (State Agency).

Based on interview and record review the facility failed to promptly and thoroughly investigate an injury of unknown origin for one resident (R1) of three residents reviewed for abuse in a sample list of five residents. Findings include: The facility Abuse Prevention Program revised 11/28/16 states The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. This policy also documents, Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: Name, age, diagnoses, and mental status of the resident allegedly abused or neglected; The original allegation (note day, time, location, the specific allegation, by whom, witnesses to the occurrence, circumstances surrounding the occurrence, and any noted injuries;facts determined during the investigation, review of medical record and interview of witnesses); conclusion of the investigation based on known facts; If there is a police report attach the police report; Attach a summary of all interviews conducted with names, addresses, phone numbers and willingness to testify of all witnesses. This report also states, A written report shall be sent to the Department of Public Health. R1's diagnoses list printed 4/8/25 at 2:52 PM includes the following diagnoses: Encephalopathy, Fall, Urinary Tract Infection, Cardiac Arrhythmia, Anticoagulant Use, Congestive Heart Failure, Hypertension, Hyperlipidemia, Mild Dementia with Anxiety, Protein Calorie Malnutrition, Weakness, and Pressure Ulcers of both heels Stage II. R1's AIM for Wellness note dated 3/11/25 at 12:15AM documents R1 has bruising to R1's right buttock measuring 4 centimeters in length and 2 centimeters in width. The Note documents R1 appears to have sustained an injury that was unwitnessed or is of unknown origin. Event was first noted on 03/11/2025 at 12:15 AM. Evaluation of the resident and event occurred on or about 03/11/2025 12:15 AM. Just prior to/at the time of the event (R1) appears to have been sleeping in bed. R1 is unable to relate details. Witness to the event includes: No one. On 4/9/25 at 2:00PM V1, Administrator stated I didn't do a complete investigation of the bruise that was found on (R1's) bottom on 3/11/25 because I wasn't aware. I was kind of blindsided when you mentioned it.

Based on interview and record review the facility failed to provide CPR (cardiopulmonary resuscitation) according to current standards of practice for one resident (R1) of three residents reviewed for Cardiopulmonary Resuscitation in a sample list of five residents. Findings Include: R1's diagnoses list printed [DATE] at 2:52 PM includes the following diagnoses: Encephalopathy, Fall, Urinary Tract Infection, Cardiac Arrhythmia, Anticoagulant Use, Congestive Heart Failure, Hypertension, Hyperlipidemia, Mild Dementia with Anxiety, Protein Calorie Malnutrition, Weakness, and Pressure Ulcers of both heels Stage II. R1's Hospital Discharge Orders dated [DATE] document R1 was hospitalized from [DATE] to [DATE] for Urinary Tract Infection with Sepsis and Metabolic Encephalopathy. R1's Admission Progress Note documents R1 was admitted to the facility [DATE] with orders for Physical Therapy and Occupational Therapy with the intent of Rehabilitation to home. R1's POLST (Uniform Practitioner Orders for Life-Sustaining Treatment) form dated [DATE] Documents R1's representative chose to have CPR and other life sustaining measures in the event R1 stopped breathing or R1's heart stopped beating. R1's MDS (Minimum Data Set) dated [DATE] documents R1 is moderately cognitively impaired, requires staff assistance to complete ADLs (Activities of Daily Living), and R1 uses a wheelchair for mobility. R1's progress note dated [DATE] at 2:24 PM by V8, LPN (Licensed Practical Nurse) documents (R1) found unresponsive in dining room at 1230 PM by (V11), CNA, (Certified Nurse's Aide) (R1) brought to (V8) no pulse, no respirations, cold to touch. (V8) yelled for (V9), LPN to grab crash cart and head to (resident room number). Started CPR immediately by (V8) and (V9). (V11) took over compressions while (V8) notified 911 and Power of Attorney (POA) at 1245 PM and we continued CPR. Ambulance arrived and called (stopped CPR) at 1:04 PM (R1) expired County Coroner (V5) arrived reviewed body spoke with family. Received orders to release body to County Coroner. Exited facility at 2:55 PM with County Coroner. R1's progress note dated [DATE] at 3:58PM by V9, LPN (Licensed Practical Nurse) documents (V9) was working [NAME] Hall and speaking with family from that hall when the (V8) called out to get the crash cart (12:30pm). I retrieved the crash cart and proceeded to room (number) where resident was unresponsive, and cold to touch. (V9) started CPR while (V11) started O2 (Oxygen) and set up ambu bag. (V8) called 911 while CPR was in progress. (V10 CNA) took over compressions and (V9) utilized ambu bag to give O2 (Oxygen). Aides switched out after 2 rounds. Emergency Medical Services (EMS) arrived approx. 15m (minutes) later and started defibrillator. (R1) was shocked twice with no success, continuous compressions in place while EMS continued on ambu bag. Paramedics arrived at 12:55PM, placed (R1) on their monitor and stated if (R1) were asystole he would call it. Monitor showed no activity and paramedic called time, (V9) was advised no more CPR or compressions to resident. At that time, (V9) stood outside residents' door while family was arriving. On [DATE] at 9:47AM V11, stated On [DATE] I was the CNA caring for (R1). After Breakfast (R1) wanted to sit in the dining room and talk to the other ladies. I rolled (R1) midmorning and sat her at a table with other residents. I then went to help (V10) the other CNA get other residents ready for lunch. I looked in later and saw (R1) with her head lying on the table. (R1) looked like (R1) was napping. I went in at 12:30PM to ask (R1) if she was ready for lunch but (R1) was cold and unresponsive. I ran with (R1) in the wheelchair to the nurse's station where (V8) was charting. (V8) felt for a pulse in (R1's) wrist and couldn't get one. V8 called out for (V9) to get the crash cart. I called out to (V10) who came running. We took (R1) to (R1's) room and laid (R1) on the bed and started CPR. I was nervous. It was my first-time doing CPR on a person. We were in a hurry and didn't get a backboard. We just laid (R1) on the soft mattress. When the first responders came, they put (R1) on the floor and continued CPR. About ,d+[DATE] minutes later the paramedics were here and (R1) didn't have a heartbeat so they stopped CPR and (R1) died . On [DATE] at 11:00AM V10, CNA stated on [DATE] at around 12:30PM (V11) called to me and they were taking (R1) to (R1's) room because (R1) was unresponsive and not breathing. I hurried in the room. We took (R1) out of the wheelchair and put (R1) on the mattress on the bed and started CPR. We do have two backboards, but it was crazy, and we didn't use them. (V11) and I took over compressions and (V9) used the ambu bag while (V8) went to the desk and called 911 and (R1's) POA. At about 12:30 EMS came and put R1 on the floor and hooked up an automatic electronic defibrillator and shocked (R1) and continued CPR. About ,d+[DATE] minutes later the paramedics got here and (R1) didn't have a pulse so the coroner came and pronounced (R1) dead. On [DATE] at 12:10PM V8, stated On Saturday [DATE] I was the nurse assigned to (R1). I was at the Nurse's desk charting and the CNAs (V10, V11) were getting residents down to eat lunch. I had helped (R1) eat breakfast (R1) was her usual, slightly confused, hard of hearing, and shouting at times. At 12:30PM (V10, V11) came running out of the dining room with (R1) in the wheelchair. (R1) was cold to touch and unresponsive. We immediately took (R1) to (R1's) room and moved (R1) to the bed and along with (V9) we started CPR because (R1) was a Full Code. I'm not going to lie to you. Things were moving fast, and we did not think to use a backboard or put (R1) on the floor to do compressions. The rest of the team continued CPR on the bed while I rushed to the desk to call EMS and family. Within 20 minutes the first responders were here, and they moved (R1) to the floor, hooked up the defibrillator and continued CPR. About 10 minutes later the paramedics came, hooked (R1) up to the monitor, and (R1) had no pulse. The paramedic then stopped the code. When asked V8 stated (V8) was not aware that it is the expectation in a healthcare facility that when CPR is being administered, perfusion of oxygen to through the circulatory system is verified by periodically checking the femoral or carotid pulse to verify the compressions are perfusing. On [DATE] at 2:52PM V15, Advanced Practice Nurse working with the facility's medical director verified it would be her expectation that anyone receiving chest compressions during CPR be placed on an even solid surface such as a back board or the floor to ensure the compressions are effective and that it is common practice to check a femoral or carotid pulse during compressions to verify this. The American Red Cross website documents Giving CPR: step four: Kneel beside the person. Place the person on their back on a firm, flat surface. The facility's policy Cardiopulmonary Resuscitation Policy dated [DATE] states If the resident is a full code, per the medical record, a staff member that is certified in CPR will initiate CPR until the emergency response team arrives.

Based on interview and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 35 residents residing in the facility. Findings include: On 9/15/24 at 8:16 AM, there were opened food items in the refrigerator that were not labeled with open dates and there were open food items in the dry storage room that were not labeled with open dates. At this same time there was dust and debris hanging directly above the cook top and the toaster was dirty with crumbs inside and around the outside. On 9/16/24 at 9:00 AM, V19 Dietary Manager stated that she is not a certified Dietary Manager. V19 stated that she has taken some courses but has not had time to complete all of the courses. The facility assessment dated [DATE] documents that a dietician or other clinically qualified nutrition professional will serve as the director of food and nutrition services. The Long-Term Care Facility Application for Medicare and Medicaid dated 9/15/24 documents 35 residents reside in the facility.

Based on observation, interview, and record review the facility failed to properly label the open date on open food items, failed to have an internal thermometer in a refrigerator and failed to maintain the range hood and the toaster in sanitary conditions to protect food that was being prepared on the range and in the toaster. This failure has the potential to affect all 35 residents residing in the facility. Findings include: The facility's storage policy with a revised date of October 2020 documents, It is the policy of (the facility) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food costs. Procedure: 1. All items will be dated upon receipt. Individual cans or bags shall each be dated to ensure that stock is rotated properly. 5. Store leftovers in covered, labeled and dated containers under refrigeration or frozen. 6. When using only part of a product, the remaining product should be in the original package or air tight container(s) and labeled and dated. The facility's Kitchen Sanitation policy with a revised date of October 2020 documents, 1. The Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. 3. The Food Services Manager will develop a cleaning schedule for the department and ensure that dietary employees complete cleaning tasks as scheduled. 4. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen, and specify which chemical and personal protective equipment should be used for each task. On 9/15/24 at 8:16 AM during the initial tour of the kitchen with V17 Dietary Aide and V18 Cook, the first refrigerator inside the kitchen did not have an internal thermometer and this refrigerator contained cold drinks including milk. This refrigerator contained a pitcher of tomato juice which had no lid or cover and was not labeled with identification or dates of preparation. V18 confirmed there was no lid or any labels on the pitcher of tomato juice. Another refrigerator contained cartons of liquid eggs. There was one opened carton that was not labeled with a date in which it had been opened. This refrigerator contained a metal bowl with ripped aluminum foil over the top of it. The contents of this bowl were unidentifiable and was not labeled with it's contents or a date in which it was prepared. The range hood had dust and debris hanging from it and from the pipes located above the cook top. There was a toaster on a cart in the dry storage room that had crumbs inside on the bottom of it and on the cart around the outside of the toaster. There was an open and used gallon jug of pancake and waffle syrup on the top shelf with no open date and a small bottle of butter flavored syrup that was opened and used that did not have an open date on it. On 9/16/24 at 9:00 AM, V19 Dietary Manager confirmed the thermometer was not in the first refrigerator, it was laying on the preparation table and she stated that it fell out the other day and did not get put back inside the refrigerator. V19 stated that she cleaned out the refrigerator yesterday and threw away unlabeled items. V19 confirmed everything should have been labeled with the preparation date and identification. The stove top still has dirt and debris hanging down from above and V19 confirmed the dust and debris was there. V19 stated that she cleaned it not too long ago but could not confirm that there was a plan or a cleaning schedule for the range hood or pipes above the stove top. V19 confirmed the tomato juice should have been labeled. The toaster still had crumbs all around the inside bottom and the tray around it. V19 stated that it should be cleaned after each use. The unlabeled syrup was still unlabeled and on the shelf in the dry storage area and V19 confirmed it should be labeled. On 9/16/24 at 9:48 AM, V19 confirmed the liquid eggs should be labeled when opened. The Long-Term Care Facility Application for Medicare and Medicaid dated 9/15/24 documents 35 residents reside in the facility.

Failures at this level require more than one deficient practice statement. A. Based on interview and record review the facility failed to identify high risk areas for Legionella and implement control measures. This failure has the potential to affect all 35 residents that reside in the facility. B. Based on observation, interview, and record review the facility failed to ensure staff wore personal protective equipment (PPE) properly during a COVID-19 (human coronavirus infection) outbreak. This failure affects eight of sixteen residents reviewed for infection control in the sample list of 25. Findings include: a.) The facility's undated Legionella Policy and Procedure, provided by V1 Administrator, documents Legionella is a bacterium that is common in the natural water system (ponds, [NAME], lochs, etc (etcetera)) and Legionella are widespread in the environment they may contaminate and grow in artificial water systems ( cooling towers, hot and cold water systems, storage tanks, pipe work, taps and showers). Legionella survive at relatively low temperatures of between 20 degrees C (Celsius) and 45 degrees C especially if the conditions are right (if a supply of nutrients are available such as rust, sludge, scale, algae and other bacteria). High temperatures of 60 degrees C and above will kill the Legionella bacteria, Legionnaires Disease is a potentially fatal form of Pneumonia caused by inhaling the Legionella bacteria. The infection is caused by breathing in droplets of water contaminated by the bacteria, but this cannot be passed from one person to another. Legionella Bacteria thrive and multiply in hot or cold water systems and storage tanks and then spread through spray from showers and taps. Should concerns are identified the following measures may be initiated to minimize and control the risks: Have the water system inspected, maintained and cleaned. (Annually) Ensure water cannot stagnate anywhere in the system remove redundant pipe work. (As needed) Run through taps and showers no longer in use or used infrequently for a minimum of I minute X once a week. (Weekly) Check hot and cold water temperature after water has been running for l minute. (random weekly) Take shower heads apart every 3 months clean and disinfect. (Quarterly) Keep water tanks and cisterns covered, clean and free from debris. Insulate tanks and pipe work. Ensure water stored in the hot water tank or cylinder is above 60 degrees C. Annual servicing of boiler and thermostatic mixing valves. (Annual) The facility's Legionella Risk assessment dated [DATE] documents answering yes to any of the questions listed suggests a potential risk for Legionella exposure. This assessment documents V9 Maintenance Director completed the assessment, and yes was answered to having multiple housing units with a centralized hot water system and conditions are right for bacterial growth for water temperatures between 20 and 45 degrees C. There is no documentation that the facility identified specific high risk areas for Legionella growth and implemented routine control measures to address high risk areas. On 9/16/24 between 3:10 PM and 3:25 PM V9 stated V1 Administrator and V9 collectively completed a Legionella risk assessment and they did not identify any high risk areas for Legionella in the facility. V9 stated V9 was not aware if the facility has any dead ends in the plumbing and V9 did not use a map of the facility's plumbing to evaluate this. V9 stated V9 was not aware of any control measures implemented to address the risk for Legionella since there were no high risk areas identified from the assessment form. On 9/16/24 at 3:15 PM V1 stated a fish tank was the only standing water and high risk area that the facility identified, and the fish tank was removed. At 3:45 PM V1 stated V1 does not have a plumbing layout/floor plan and has never seen one for this facility. On 9/17/24 at 2:00 PM V1 confirmed the facility's maintenance director is responsible for implementing Legionella control measures and confirmed there was no documentation of routine control measures to address high risk areas. V1 stated we thought our policy was enough documentation. The Long-Term Care Facility Application For Medicare and Medicaid dated 9/15/24 documents 35 residents reside in the facility. b.) The facility's COVID-19 Control Measures policy dated 5/19/23 documents that employees should wear an N95 mask while the facility is in outbreak status. On 9/15/24 at 7:53 AM there was a sign posted on the facility's entrance door that documented the facility has active COVID-19 cases and to wear an N95 mask. On 9/15/24 between 12:35 PM and 12:53 PM V17 Dietary Aide wore an N95 mask with V17's nose and mouth exposed while V17 served meals to R1, R26, R15, R13, R4, R36, R11, and R12. On 9/15/24 at 1:30 PM V17 confirmed V17 wore her mask pulled down with her nose and mouth exposed while V17 served resident meals. V17 stated V17 has difficulty breathing at times, which is why she pulls her mask down. On 9/17/24 at 10:12 AM V2 Director of Nursing/Infection Preventionist stated the facility has been in COVID-19 outbreak since 8/22/24 and a lot of staff and residents have been asymptomatic when testing positive. V2 confirmed during a COVID-19 outbreak, staff should wear an N95 mask covering both nose and mouth when they are near residents. The facility's August and September 2024 Infection Control logs document nine residents and ten employees have tested positive for COVID-19 since the outbreak began on 8/22/24.

Based on interview and record review the facility failed to ensure a Level II PASARR (Preadmission Screening and Resident Review) was completed for two (R11, R10) of two residents reviewed for PASARR screening in the sample list of 25 residents. Findings include: 1.) The facility provided admission sheet dated 9/15/24 documents that R11 was admitted to the facility on [DATE]. R11's (State) Department of Healthcare and Family Services Interagency Certification of Screening Results sheet dated 10/6/11 documents that R11 should have further assessment to determine the need for a Level II screening. R11's September 2024 physician order sheet documents a diagnosis of Schizoaffective Disorder and an order for Buspirone (antidepressant) 5milligrams daily. R11's Care Plan dated 3/18/24 documents diagnoses including Anxiety, Depression, and Schizoaffective Disorder with behaviors that include inappropriate sexual remarks to staff and visitors, demanding/attention seeking behaviors, false accusations and resistance of care. On 9/16/24 at 1:36PM, V7 Pharmacy Medical Records said that R11 had been taking Buspirone 5 milligrams since 12/11/23. On 9/15/24 at 9:50AM, V1 Administrator stated R11 was being seen for mental health issues; however R11 did not get the requisite Level II PASRR screen when given the new Schizophrenia diagnosis nor when the psychotropic medication was first ordered and that it should have been done. On 9/15/24 at 10:00AM, V8 Business Office Manager stated she had not gotten a Level II PASARR for R11, but was going to request one today. 40385 2.) R10's September 2024 Physician Order Summary documents R10 has a diagnosis of Affective Psychosis and Dementia with Behavioral Disturbances. R10's order dated 5/18/24 documents to give Olanzapine (antipsychotic) 5 milligrams (mg) by mouth twice daily for Affective Psychosis. On 9/15/24 R10's Preadmission Screening and Resident Reviews (PASARRs) were requested from V1 Administrator. R10's Interagency Certification of Screening Results dated 6/28/23, provided by V1, documents R10 admitted to the facility on [DATE] and mental illness was not suspected. There is no documentation in R10's medical record that a Level II PASARR was completed. On 9/15/24 at 11:55 AM V1 Administrator and V2 Director of Nursing stated they weren't sure if they could locate R10's admission history and physical and admission diagnosis list. V1 stated V1 will look through R10's medical record. V2 confirmed a Level II PASARR would need to be completed if R10 did not admit with a diagnosis of psychosis. At 12:07 PM V1 stated V1 looked through R10's medical records and stated R10 did not have a diagnosis of Psychosis in 2015, but it was listed in R10's 2021 records. V1 stated therefor R10 was diagnosed with psychosis some time between 2015 and 2021. V1 stated V8 Business Office Manager (BOM) recently checked all of the residents' PASARRs, especially the older ones. V1 stated V1 will follow up with V8 to see if a Level II was completed for R10. On 9/16/24 at 9:50 AM V8 BOM confirmed a Level II PASRR was not completed for R10. On 9/16/24 at 1:27 PM V7 Pharmacy Medical Records stated R10 began receiving Olanzapine on 7/13/22 at 5 mg twice daily. On 9/17/24 at 10:29 AM V1 stated facility does not have a policy for PASARR, the facility refers to the regulation.

Based on observation, interview and record the facility failed to initiate care plans to include resident centered problems, goals, and interventions for one (R11) of 16 residents for care plans from a sample list of 25 residents. Findings include: The facility Comprehensive Care Planning Policy dated 7/20/22 documents that the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The comprehensive care plan shall be revised as necessary to reflect the resident's current medical, nursing, mental and psychosocial needs. On 9/15/24 at 9:19AM, R11's right hand was contracted. R11 said that she has hand splints to prevent contracting and that she wants to wear them but the girls forget to put them on. No splints were in R11's hands at this time. On 9/16/24 at 10:45AM, V21 Licensed Practical Nurse found a right hand splint and hand roll in R11's bedside drawer. On 9/16/24 at 10:47AM, V5 Certified Nursing Assistant stated R11 had her hand roll in her right hand this morning before she assisted R11 with a shower. R11's undated care plan does not document anything about a splint or hand roll or any type of positioning aid. On 9/15/24 at 9:15AM, R11 was laying in bed wearing oxygen at two liters per nasal cannula, via a concentrator. On 9/15/24 at 9:16AM, R11 stated she usually only wears oxygen at night. R11's physician order sheet dated September 2024, documents an order for oxygen to be administered at two liters per nasal cannula as needed to keep oxygen saturation levels greater than 92 percent. R11's treatment administration record dated September 2024, documents oxygen administered daily to R11. R11's undated care plan does not include oxygen administration or maintaining oxygenation levels for R11. On 9/17/24 at 8:00AM, V2 Director of Nursing stated R11's care plan should reflect both positioning aids and oxygen.

Based on observation, interview, and record review the facility failed to provide hygienic incontinence and urinary catheter care to prevent cross contamination for two (R12, R18) of four residents reviewed for urinary care in the sample list of 25. Findings include: 1.) R12's Minimum Data Set, dated dated dated [DATE] documents R12 has severe cognitive impairment, is always incontinent of bowel and bladder, and is dependent on staff assistance for toileting hygiene. On 9/16/24 at 2:33 PM V11 and V12 Certified Nursing Assistants transferred R12 into bed with a full mechanical lift and R12 was incontinent of urine. V12 provided R12's incontinence cares starting with R12's buttocks. V12 wiped R12's buttocks three times with wash cloths and bowel movement was visible on the cloths. V12 turned R12 onto R12's back, and used wash cloths to cleanse R12's frontal perineal area using the same gloves worn to cleanse R12's buttocks. V12 did not change gloves until after V12 applied R12's clean incontinence brief. On 9/16/24 at 2:49 PM V12 stated the facility has given education on incontinence cares and V12 should have performed perineal care moving from front to back. V12 stated V12 was unsure when gloves should be changed while providing incontinence cares. V12 confirmed V12 did not change gloves during R12's incontinence care. On 9/17/24 at 10:12 AM V2 Director of Nursing/Infection Preventionist confirmed staff should first cleanse the frontal perineal area and then the buttocks when providing incontinence cares. V2 confirmed V12 should have changed gloves during R12's incontinence care after cleansing R12's buttocks and prior to cleansing R12's frontal perineal area. The facility's Perineal Cleansing policy dated December 2017 documents for female incontinence care wash the pubic area first followed by the peri-anal area. This policy documents to remove gloves after washing the peri-anal area and perform hand hygiene prior to applying a clean incontinence brief. 32853 2.) R18's Physician's Orders dated 9/1/24 to 9/30/24 documents diagnoses including Obstructive Uropathy and Urethral Erosion by Catheter. These Physician's Orders document orders for a Suprapubic catheter for the diagnosis Obstructive Uropathy. These Physician's Orders document an order for a Urinalysis with a culture and sensitivity dated 9/4/24 and an order dated 9/12/24 for Amoxicillin 500 mg (milligrams)/Clavulanic Acid 125 mg (antibiotic) via gastrostomy tube every 12 hours for seven days. R18's Nurse's Notes dated 9/12/24 documents a new order received for the Amoxicillin/Clavulanic Acid for diagnosis of UTI (Urinary Tract Infection) and ESBL (Extended Spectrum Beta-Lactamase). R18's laboratory result sheet dated 9/12/24 documents culture results of 50,000 to 100,000 CFU(Colony Forming Unit)/ml (milliliter) of ESBL producing Proteus Mirabilis, Multiple Drug Resistant Organism isolated. R18's Care Plan dated 3/18/24 documents R18 has a suprapubic catheter with an intervention to position the catheter bag and tubing below the level of the bladder. On 9/15/24 at 9:30 AM, 12:46 PM and on 9/16/24 at 11:07 AM, 2:14 PM and 2:56 PM, R18's urinary catheter drainage bag was hooked on the side of the bed and laying on the floor. On 9/16/24 at 2:56 PM during incontinence care V11 and V16 Certified Nursing Assistants passed the urinary catheter drainage bag over R18 from one side of the bed to the other, lifting the drainage bag and least 1 1/2 feet over the top of R18 allowing urine to flow back down the tubing to the bladder. On 9/17/24 at 11:26 AM, V2 Director of Nursing stated that the urinary catheter drainage bag should not be laying on the floor and should not be lifted about the level of the bladder.

Based on observation, interview and record review the facility failed to follow facility policy and document/record the daily amount of enteral feeding administered to a resident for one of one resident (R18) reviewed for Gastrostomy tube feedings in the sample list of 25. Findings include: The facility's Enteral Feeding policy with a revised date of February/2008 documents, Purpose: To ensure a safe, nutritionally appropriate product which provides a source of complete nutrition in a form that will pass through a tube into the digestive system and which will maintain nutritional status as designated. 1. The Dietician/Consultant will monitor all diet orders for tube feedings and will recommend as appropriate changes in product according to resident need. 4. The fluid intake for the resident receiving a tube feeding should be equivalent to the fluid needs as assessed by the Dietician. Fluid need not be met by product alone in which case water flush ordered may be recommended to meet the needs of the tube fed resident. A record of daily intake of the tube feeding and the flushes for the resident will be kept by the nursing department. R18's Physician's Orders dated 9/1/24 to 9/30/24 documents diagnoses including Alzheimer's, Failure to Thrive, Dysphagia, Metabolic Encphalopathy and Gastroesophageal Reflux Disease. These Physician's Orders document an order for Fibersource HN (High Nitrogen) via G-Tube (Gastrostomy tube) at 70 ml (milliliters)/hr (hour) continuous on at 6:00 AM and off at 2:00 AM (20 hours). These orders also document an order to flush G-Tube with 200 ml of water every 6 hours at 4:00 AM, 10:00 AM, 4:00 PM and 10:00 PM. R18's Treatment Administration Record (TAR) dated 8/1/24 to 8/31/24 documents output every shift but does not document any intake. R18's TAR dated 9/1/24 to 9/30/24 documents output every shift but does not document any intake. R18's Report of Monthly Weight and Vitals documents R18's weight in August as 196.7 and R18's weight in September as 189.4 which is a 3.71% weight loss in one month. This report documents a weight loss from April to May, June to July, July to August and August to September. V15 Dietician's progress note dated 5/29/24 documents R18 should have a total of 2231 cc (cubic centimeters) total free water daily. There is no documentation in R18's medical record to show how much feeding R18 is receiving per day. On 9/15/24 at 9:13 AM, R18 was in bed in his room with the G-tube feeding running at 70 ml/hr (milliliters/hour). The feeding that is hanging is Fibersource HN and was hung at 11:00 PM on 9/14/24 according to the writing on the bag. On 9/16/24 at 1:20 PM, V2 Director of Nursing confirmed that they do not document the amount of intake for R18's G-tube feedings. V2 confirmed that R18 has had weight loss and she has not informed the Dietician yet since the Dietician comes at the end of the month. On 9/17/24 at 1:26 PM, V15 (Dietician) stated when asked if the facility is expected to document R18's daily intake that she expects them to document when they start and stop the feeding. V15 stated that she assumes they are following R18's orders for the feeding and assumes that he is getting what is ordered. V15 stated that she has not been notified of R18's weight loss. She stated that she gets the weight report when she comes at the end of the month and that is how she gets notified of weight loss.

Based on interview and record review the facility failed to obtain consents, complete assessments, document nonpharmacological interventions, develop a care plan and document stop dates for psychotropic medications for two (R10, R12) of six residents reviewed for unnecessary medications in the sample list of 25. Findings include: The facility's Psychotropic Medication Policy dated 12/30/13 documents to attempt to rule out social and environmental factors as causes for behaviors, initiate a Pre-Psychotropic Medication Assessment, attempt nonpharmacological interventions prior to prescribing psychotropic medications, and obtain consent for psychotropic medication use from the resident or resident representative. This policy documents psychotropic medication assessments will be completed at least quarterly, and psychotropic medication use, potential side effects and targeted behaviors will be included in the resident's plan of care. This policy does not address stop dates for psychotropic medications ordered to be given as needed. 1.) R10's Minimum Data Set (MDS) dated [DATE] documents R10 has severe cognitive impairment. R10's September 2024 Physician's Order Summary documents R10 receives hospice care and R10's diagnoses include depression, dementia with behavioral disturbances, and psychosis. R10's physician orders includes an order dated 8/26/24 for Lorazepam (antianxiety) 2 milligrams per milliliter (mg/ml) give 0.25 ml every four hours as needed (PRN) for anxiety/restlessness, an order dated 9/5/24 for scheduled Lorazepam give 0.25 ml twice daily, and an order dated 5/18/24 for Olanzapine (antipsychotic) 5 mg twice daily. There is no stop date for the Lorazepam PRN order. R10's Care Plan dated 6/7/24 documents R10 uses psychotropic medications, but Olanzapine and Sertraline are the only listed psychotropic medications. R10's nursing note dated 4/1/24-4/4/24 document no changes in behaviors related to decrease in Olanzapine. R10's nursing notes dated 4/6/24-4/7/24 document R10 yelling at staff and residents, swatting at staff during cares, and R10 putting her fingers down her throat to cause vomiting. These notes do not document specific nonpharmacological interventions that were used to respond to R10's behaviors. R10's nursing note dated 4/11/24 at 1:30 AM documents Zyprexa was increased back to prior dose. R10's nursing notes dated 9/4/24 document R10 yelled leave me alone during cares and yelled help during meals and there is no documentation what nonpharmacological interventions were implemented to address these behaviors. R10's nursing note dated 9/5/24 documents hospice gave orders to increase Lorazepam to scheduled twice daily. R10's medical record does not include consents or psychotropic medication assessments for the use of Lorazepam. R10's Psychotropic Medication Quarterly Evaluations document assessments were completed on 3/5/24, 6/5/24, and 9/3/24 for Olanzapine. There is no documentation that a psychotropic medication assessment was completed prior to increasing Olanzapine on 5/18/24. The pharmacy Consultation Report dated 8/28/24 documents R10 has a PRN Lorazepam order with no stop date and to either discontinue the medication or document the indication for use, duration of therapy, and rational for the extended time period. This form is signed by a hospice provider and documents to continue use related to hospice care, but does not include a duration or stop date. On 9/16/24 at 12:17 PM V2 Director of Nursing provided a pharmacy recommendation for R10 PRN Lorazepam order, and confirmed there is no stop date or duration for this order. V2 confirmed R10 should have a consent and assessments for Lorazepam. V2 reviewed R10's medical record and confirmed there was no Lorazepam assessments or consents documented. V2 stated psychotropic medication assessments are completed quarterly with the MDS schedule and not with new orders or changes in dosages. V2 stated an assessment was not completed for R10's Lorazepam since it was a fairly new order, but that is something we should probably be doing. V2 stated V2 was unsure why R10's Lorazepam was increased to scheduled twice daily and V2 was not aware of the medication order. V2 reviewed R10's nursing notes and stated R10 had increased anxiety at meal times and hospice ordered scheduled Lorazepam. V2 confirmed there is no documentation of nonpharmacological interventions used to address R10's behaviors prior to scheduling Lorazepam. V2 stated an agency nurse worked that day and that is why V2 was not notified of the order. V2 stated V10 MDS Coordinator is responsible for completing the psychotropic medication assessments and updating the care plans with psychotropic medications, and V2 is responsible for ensuring these things are completed. At 12:39 PM V2 stated V2 was unable to locate R10's Lorazepam consent and the nurses are responsible for obtaining the consent. V2 stated the consent likely wasn't done since an agency nurse worked that day. V2 confirmed there is no documentation that an assessment was completed when R10's Zyprexa was increased in May 2024. 2.) R12's MDS dated [DATE] documents R12 has severe cognitive impairment. R12's September 2024 Physician's Order Summary documents R12's diagnoses include dementia with behavioral disturbances and anxiety disorder. R12's physician order dated 7/12/24 documents Lorazepam 2 mg/ml give 0.5 ml every four hours PRN for anxiety/restlessness, and there is no stop date for this order. R12's September 2024 Medication Administration Record documents Lorazepam was administered on 9/7, 9/8, and 9/9 for nerves, anxiety, and crawling out of bed. The pharmacy Consultation Report dated 2/13/24 documents R12 has a PRN Lorazepam order with no stop date and includes a recommendation to continue the PRN order through August 2024 when the medication will be re-evaluated, and this form is signed by V22 Nurse Practitioner. The pharmacy Consultation Report dated 8/28/24 documents R12 has a PRN Lorazepam order with no stop date and to either discontinue the medication or document the indication for use, duration of therapy, and rational for the extended time period. This form is signed by a hospice provider and documents to continue use related to hospice care, but does not include a duration or stop date. R12's Care Plan dated 3/19/24 documents R12 receives hospice care and uses antidepressant medication. R12's care plan does not document use of Lorazepam. There are no documented assessments for Lorazepam in R12's medical record. On 9/16/24 at 9:39 AM V2 stated we try to keep a stop date for PRN Lorazepam when the resident is on hospice. V2 stated the pharmacy is good about giving V2 the forms to remind V2 of stop dates needed, but hospice isn't always timely in returning the forms back to V2. On 9/16/24 at 12:17 PM V2 provided a pharmacy recommendation for R12's PRN Lorazepam order, and confirmed there is no stop date or duration recorded for this order. At 1:40 PM V2 confirmed there are no documented psychotropic medication assessments for R12's Lorazepam. V2 stated V2 believes the Lorazepam orders for R10 and R12 were overlooked since they are both on hospice care.

Based on observation, interview and record review the facility failed to store and secure controlled medications behind a separately locked compartment for three (R10, R12 and R23) of three residents reviewed for medication storage from a total sample list of 25 residents. Findings include: The facility provided Procurement and Storage of Medications Policy date reviewed October 2006, documents that Schedule II drugs are to be stored under a double-lock subject to a different key. On 9/16/24 at 3:03PM, an unlocked refrigerator contained five bottles of Lorazepam (schedule IV controlled substance) 30 milliliters, with a concentration of 2 milligrams per milliliter. One bottle was documented for R23, three bottles were documented for R12 and one bottle was documented for R10. On 9/16/24 at 3:04PM, V3 Registered Nurse stated the refrigerator should have been locked because it had Lorazepam in it. On 9/16/24 at 3:06PM, V2 Director of Nursing observed that the refrigerator housing five bottles of Lorazepam was unlocked and confirmed that the refrigerator should have been locked.

Based on interview and record review the facility failed to maintain documentation of COVID-19 vaccination for three (R9, R19, R36) of five residents reviewed for immunizations in the sample list of 25. Findings include: The facility's Immunization of Residents policy dated 5/19/23 documents the facility will offer immunizations to aid in preventing infectious diseases. This policy documents to offer the current recommended COVID-19 vaccine upon admission for residents who are not considered up to date with the vaccine, review consent forms to verify timing of previous vaccinations and document immunizations on the resident's Immunization Record. 1.) R9's Face Sheet documents R9 admitted to the facility on [DATE] and R9 is over age 65. R9's Cumulative Diagnosis Log documents R9's diagnoses include Congestive Heart Failure, Coronary Artery Disease, and Type 2 Diabetes Mellitus. R9's COVID-19 Vaccination Record Card documents vaccine administrations on 2/4/21, 3/4/21, 11/4/21, and 6/29/22. There is no documentation that R9 was offered a COVID-19 booster vaccine after 6/29/22. 2.) R19's Face Sheet documents R19 admitted to the facility on [DATE] and R19 is over age 65. R19's September 2024 Physician's Order Summary documents R19's diagnoses include Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. R19's COVID-19 Vaccination Record Card documents vaccine administrations on 12/28/20, 1/18/21, 11/15/21, and 6/29/22. There is no documentation that R19 was offered a COVID-19 booster vaccine after 6/29/22. The facility's September 2024 Resident Infection Control and Antimicrobial Log documents R19 tested positive for COVID-19 on 9/4/24. On 9/16/24 at 9:42 AM V2 Director of Nursing/Infection Preventionist stated residents are offered COVID-19 vaccination upon admission and any time there is a new booster. V2 stated all residents were offered the booster vaccine in 2023, but we don't have documentation of declination for this vaccine as it was done through an outside company. At 12:55 PM V2 stated R9 and R19 refused the last COVID-19 booster vaccine, but V2 does not have documentation of this. 3.) The facility's binder containing resident COVID-19 vaccination information was reviewed and did not contain R36's information. R36's Face Sheet dated 4/29/24 documents R36 admitted to the facility on [DATE] and R36 is over age 65. On 9/16/24 at 1:35 PM V20 Social Services Director stated V20 contacted R36's family today to request COVID-19 vaccination information and the facility should have this information by tomorrow. On 9/17/24 at 9:35 AM V1 Administrator provided R36's COVID-19 vaccine documentation dated 9/17/24. V1 confirmed R36 is not up to date with COVID-19 boosters and confirmed there is no documentation that a booster was offered to R36 after admission. R36's Immunization Summary dated 9/17/24 documents COVID-19 vaccine administrations on 12/8/21, 2/28/21, and 1/31/21. There is no documentation that R36 was offered a COVID-19 booster vaccine.

Based on observation, interview, and record review the facility failed to ensure therapy services were provided for two (R1 and R3) of three residents reviewed for therapy services in the sample of three. Findings include: The facility's Admission Packet (current) documents the following information: Dear Residents and Family Members: Our facility offers services that may be covered by the Medicare Program. These services include skilled nursing care, therapy services, pharmacy, and medical supplies. If you have Medicare benefits and you or a family member consents, we will bill the Medicare program for services that are rendered at this facility. 1. R1's Face Sheet (current) documents R1 being admitted to the facility on [DATE]. R1's Therapy Evaluation and Treatment order dated 1/22/24 per Physician Order Sheet (POS) documents R1 is to receive Therapeutic Treatment for Neurological Re-Education, Gait Training, Group Therapy and Therapeutic Activities 2 times a week for 4 weeks (ending on 2/23/24). R1 is also documented to receive Occupational Therapy for Therapeutic activities, Activities of Daily Living and Activity Group 2 times a week for 4 weeks (ending on 2/23/24). A NOMNIC (Notice of Medicare Non-Coverage) letter dated 2/20/24 documents R1's Medicare A benefits for Rehabilitative Therapy ends on 2/23/34. R1's Therapy Notes document that R1 last received Rehabilitative Therapy on 2/18/24, 5 days short of R1's approved/benefited time. There are no further evaluations in R1's chart for continuing Medicare A or Medicare B benefits. A Social Service Note dated 2/16/24 documents R1's Health Care Power of Attorney (V6) was notified concerning R1's NOMNIC letter and Therapy would not be available to R1 after 2/18/24. This same Note documents family would like to pay privately for room and board, are aware and will address part B service for Therapies when Therapy resumes. On 3/6/24 at 9:00 am R1 was lying supine in bed and confirmed that R1 had not received any therapy services since 2/18/24. R1 stated I really need to get some therapy. I want to be able to go home. 2. R3's Face Sheet (current) documents R3 with an admitted to the facility on [DATE]. R3's POS dated February 2024 documents an order dated 2/13/24 for Physical Therapy for Therapeutic Neurological Re-Education, Gait Training, Group Therapy and Group Activities for 3 times a week for 4 weeks. R3's Therapy Notes document R3's last day of therapy was 2/18/24. R3's Social Service Note dated 2/16/24 documents V3 Social Service Director spoke with (R3) about therapy service for (R1's) part B ending on 2/18/24 and R1 understanding and wants to be reassessed when therapy services resume in the facility. On 3/6/24 at 10:30 pm, R3 was lying in bed and confirmed R3 was not receiving therapy and that R3 is disappointed that R3 cannot move forward until another therapy company is retained by the facility. On 3/5/24 at 11:45 am, V3 Regional Administrator confirmed the facility did not have a Therapy Service provider in the building and hasn't since 2/18/24. On 3/6/24 at 10:05 am, V1 Administrator confirmed that R1 and R3 were eligible for therapy services through the Medicare program. V1 also confirmed that R1 and R3 were not receiving Therapy due to the absence of a Therapy Service provider in the facility since 2/18/24.

Based on record review and interview the facility failed to administer the accurate dose of a liquid concentration, of the physician ordered, Oxycodone (narcotic analgesic) medication. Subsequently, R90 was administered an excessive dose of Oxycodone, twenty times greater than prescribed. The significant medication administration error resulted in R90 experiencing depressed respirations, prolonged apnea episodes, unresponsiveness, and lethargy. R90 is one of one resident reviewed for Hospice/Pain management on the sample list of 20. Findings include: R90's Physician Order Sheet (POS) dated 7/17/23- 7/31/23 documents R90 was admitted on [DATE] on Hospice (care services for terminally ill). R90's same POS documents the following medication order dated 7/17/23: Oxycodone one milligram (mg) per one milliliter (ml), (concentration) oral solution, take five ml (equals five milligrams) by mouth every three hours as needed for pain (PRN). R90's same POS documents for the above medication, one mg per one ml, liquid solution Oxycodone order, was crossed through, and had a triangle shape, with an apostrophe d, to indicate the order had been changed. R90's same POS documents a new physician order was received on 7/24/23, with an increase concentration strength of Oxycodone liquid solution. The new order for R90's Oxycodone documents the more concentrate liquid medication of 20 mg per one (1) ml, give 0.25 (one quarter of a ml) ml (equals five mg), every three hours, PRN. The facility pharmacy receipt/narcotic count supply sheet documents R90's liquid solutions of Oxycodone 100 mg per five ml (equals 20 mg per one ml as noted above 7/24/23 physician order), 30 milliliter bottle was dispensed by pharmacy. The Oxycodone directions for administration documents: 0.25 ml (5 mg, same as the previous dose, at the lesser concentration) by mouth, every three hours as needed for pain. R90's same Oxycodone pharmacy receipt/ narcotic count supply sheet documents on 7/24/23 at 6:40 pm, V18, Licensed Practical Nurse (LPN) signed, and removed five ml (equals 100 mg) of the newly dispensed, 30 ml bottle of R90's higher concentrated liquid Oxycodone. R90's Medication Administration Record (MAR) PRN sheet, dated 7/17/23- 7/31/23 documents the following: Oxycodone 20 mg per ml, give 0.25 ml (equals 5 mg) by mouth every three hours (PRN). On the back of the same PRN, MAR documented by V18's initials to indicate R90 was administered Oxycodone five ml (equal to 100 mg, not 0.25 ml, that equals 5 mg in the higher concentration ordered) on 7/24/23 at 6:40 pm, the same time the Oxycodone concentrated dose was removed from R90's Oxycodone narcotic count supply, as noted above. R90's Oxycodone pharmacy bottle label documents the increased strength of 100 mg per 5 ml and directs nurses to administer 0.25 ml by mouth every 3 hours for pain. The facility Medication Discrepancy Report dated 7/24/23 at 7:57 pm, signed by V2, Director of Nursing, documents the following: V17, LPN and V18, LPN completed the narcotic count at shift change. V17, LPN and V18, LPN discovered the discrepancy. V18, LPN had administered five ml (100 mg) of R90's new concentrated Oxycodone in error, instead of the 0.25 ml (5 mg) ordered. The same Medication Discrepancy Report documents the previous order for the lower concentration Oxycodone liquid was five ml (equals five mg). The new higher concentration of Oxycodone liquid was 0.25 ml (equals five mg). Five ml (100 mg) of the concentrated Oxycodone was administered to R90 in error. The same Medication Discrepancy Report also documents: Possible effects to the resident (R90), shallow breathing, confusion, unresponsiveness, possible death. The same Medication Discrepancy Report also documents at the time of the report on 7/24/23: The actual effects to the resident (R90), shallow breathing, unresponsiveness, vitals (measurement of pulse, respirations, blood pressure and body temperature) stable, aroused at 5:15 am (7/25/23, by progress note). R90's Nurse's Notes dated 7/24/23 at 7:57 pm signed by V18, LPN documents V18, LPN had given R90 the wrong dose of Oxycodone. The same note documents R90's vital signs were measured and R90's blood oxygen was 86 percent on room air. Supplemental oxygen was administered via mask at four liters per minute. (R90) with periods of apnea (stopped breathing, duration was not documented). The same Nurses Note documents R90's blood oxygen level, after supplemental oxygen was provided, was at a saturation level of 95 percent. The same note documents R90's unidentified family members declined Narcan medication administration (Narcan is used for the treatment of an opioid overdose emergency, with signs of breathing problems and severe sleepiness, or not being able to respond). R90's Nurses Notes throughout the evening 7/24/23, overnight into the morning of 7/25/23 document R90 continued to be monitored approximately every 15 to 20 minutes, with Hospice (staff unidentified) and family members (unidentified) at bedside intermittently overnight. R90's nurses note dated 7/24/23 at 10:55 pm documents R90's respirations were measured at six per minute with two episodes of apnea, that lasted 10 seconds, and 23 seconds without breathing. The Nurses Notes on 7/25/23 at 12:20 am documents R90's respirations dropped to two breathes per one minute with apnea episodes that lasted 36 seconds and 23 seconds without breathing. The nurses note dated 7/25/23 at 1:20 am documents R90 was repositioned and unresponsive to care. The Nurses Notes continued to document respirations between 4 and 7 per minute overnight. The Nurses Note dated 7/25/23 at 5:15 am documents R90 spontaneously opened her eyes, responded to contact stimulation, but remained lethargic. Nurses note at 6:30 am documents R90 is lethargic and stated to the nurse she feels sleepy. Nurses note at 8:30 am documents stated her head felt weird, and R90 refused to continue with oxygen. Family member at bedside. On 8/9/23 at 1:30 V13, Regional Nurse, Clinical Director reviewed R90's medical records and confirmed a significant medication error occurred. R90 was given 100 mg (five ml), instead of five mg (0.25 ml) of Oxycodone. On 8/9/23 at 1:35 pm V2, Director of Nursing confirmed R90 received a dose of 100 mg Oxycodone liquid solution instead of the five mg ordered on 7/24/23. On 8/9/23 at 2:37 pm V15, Pharmacist who filled R90's second Oxycodone prescription on 7/24/23, stated he was aware the wrong dose of Oxycodone was administered to R90. V15 confirmed the wrong dose of Oxycodone was administered and stated R90 was supposed to be administered Oxycodone, (liquid concentration of 20 milligrams per milliliter), 0.25 ml which equals five milligrams. V15 stated R90 was administered five milliliters equal 100 milligrams, 20 times the dose prescribed. V15 also stated The most serious potential for harm is death. An excessive dose of Oxycodone can cause Hypoxia (loss of oxygen to the brain, coma, brain damage, and neurological issues. Normally, a resident is very sedated. If a patient remains alert, it would likely be because they had a tolerance for opioid (narcotic) use. V15 Pharmacist then stated (R90's) Oxycodone bottle was labeled correctly. The error should have never occurred. The facility policy ADVERSE DRUG REACTIONS AND MEDICATION DISCREPANCY dated October 2006, documents the following: Policy: Adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nursing notes, and documented on an Adverse Drug Reaction or Medication Discrepancy Report. These reports are to be completed in coordination with the Director of Nursing and filed with the Administrator and reviewed by the Medical Director and Consultant Pharmacist. Responsibility: All Licensed Nurses monitored by the Director of Nursing. Procedure: 1. A medication discrepancy/error has been made when one of the following occurs: *Wrong medication administered. * Wrong dose administered. *Medication administered by wrong route. *Medication administered to the wrong resident. *Medication administered at the wrong time. *Medication not administered.

Based on observation, interview, and record review, the facility failed to designate a qualified director of food and nutrition services. This failure has the potential to affect 38 out of 39 residents residing in the facility. Findings include: On 8/8/23 at 9:41 am, V3, Director of Food and Nutrition Services (Dietary Manager) was actively managing and directing the services of the facility's kitchen and staff preparing residents food. On 8/8/23 at 9:50 am, V3 exhibited a Certified Food Protection Manager certificate, valid through 8/12/24. V3 stated this certificate was achieved from an 8 hour course in food sanitation. V3 stated she is a high school graduate, does not have a Certified Dietary Manager certificate, nor a Certified Food Protection Professional certificate. V3 stated she is not a Registered Dietician. V3 also stated she did not meet any of the state requirements for a Dietetic Service Supervisor by stating she is [AGE] years old so has had no courses prior to 1990 and does not have any military or hospitality experience. The facility's Resident Census and Conditions of Residents dated 8/7/23 documents 39 residents reside in the facility, all of whom, with one exception, consume food prepared in the facility kitchen. R18 receives nutrition solely through a gastrostomy tube and eats nothing by mouth.

Based on observation, interview, and record review, the facility failed to store food and food service utensils in a manner to prevent cross contamination of residents food. This failure has the potential to affect 38 of 39 residents residing in the facility. Findings include: On 8/7/23 at 9:15 am, there was a 10 pound package of ground beef thawing in the reach-in refrigerator. This thawing ground beef was stored above a package of hard boiled eggs. On 8/8/23 at 9:45 am, V3, Dietary Manager, stated, That meat shouldn't have been above the eggs. On 8/8/23 at 9:50 am, there was a bulk container of flour in the facility's dry food storage room. Inside this bulk container was a foam cup, approximately 12 ounces, laying in direct contact with the flour. On 8/8/23 at 9:50 am, V3 stated, That cup should is not supposed to be left inside the container. The facility's policy Storage dated 10/2020 documents, Do not leave any serving utensils or tools in food containers. The facility's Resident Census and Conditions of Residents dated 8/7/23 documents 39 residents reside in the facility, all of whom, with one exception, consume food prepared in the facility's kitchen. R18 receives nutrition solely through a gastrostomy tube and eats nothing by mouth.

Based on record review and interview the facility failed to provide alternate meals to residents that did not eat what was served/or requested a substitute menu item. This failure affected five R9, R11, R17, R32, and R89 reviewed during resident group on the sample list of 20. Findings include: On 08/08/23 at 1:30 PM during a group meeting, residents stated the following: R9, stated the facility does not offer a substitution menu. R11 stated there are no substitute food items every available. R11 also stated R11 has asked several times. R17, stated there are no alternate menu items available during meals. R32 stated there are no substitutes offered for meals. R32 stated R32 sees many residents (unidentified) that can't speak for themselves, that don't eat what is served. Staff (unidentified) just remove the residents plate and do not offer anything else. R89 stated there are no substitutes for meals. Everybody gets whatever the facility wants to serve. R89 also stated R89 has asked staff (unidentified) and was told there is not anything else available. On 8/9/23 at 10:20 am V1, Administrator stated The facility has had some problems. (V1) has been addressing the issue, of an available substitute menu. V1 also stated With the turn-over in kitchen staff, and a new dietary manager starting, substitute menus items will be offered and available. The facility policy Meal Alternatives dated April 2017 documents the following: It is the policy of [NAME] Health Care to provide appropriate alternates to those residents who dislike or do not eat the main entree and vegetable to help ensure adequate nutritional intake. Procedure: 1. The general menus are posted within the facility. 2. An appropriate entree and vegetable alternate is prepared and readily available at meals. The alternate may be provided to a resident who dislikes the main entree and vegetable and may also be offered to a resident who has not consumed at least fifty percent (50%) of their entree and vegetable at the meal. Other dining options may be available as well; such as, but not limited to, an Always Available menu, Buffet or Restaurant style menu. 3. If a resident refuses the original entree and/or the alternate, the nurse shall be informed. Refusal to eat or poor intake should be documented in the resident's medical record.

Based on observation, interview and record review the facility failed to ensure a severely cognitively impaired resident (R1) was positioned safely away from an electric baseboard heater that had been turned to the highest temperature setting, resulting in R1 suffering second and third degree burns, requiring hospitalization , antibiotics, and skin grafting, when staff positioned R1's bed directly next to the heater. This failure has the potential to affect all 43 residents residing in the facility all of whom have electric baseboard heaters in their rooms. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 2/20/23 when R1 was severely burned when R1's thermostat was turned on high and staff positioned R1's bed directly against the hot electric baseboard heater. V1 Administrator was notified of the Immediate Jeopardy on 3/8/23 at 11:41 am. The surveyor confirmed by record review, observation and interview that the Immediate Jeopardy was removed on 3/8/23, but noncompliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the inservice training. Findings include: The facility Nurses' Midnight Census Report dated 2/24/23 documents 43 residents residing in the facility. On 3/9/23 between 2:00 PM and 2:20 PM the facility was toured with V1 Administrator. An electric baseboard heater was present in all resident rooms. R1's Physician Order Sheet (POS) dated February 1-28, 2023, documents medical diagnoses of Dementia, Parkinson's Disease, Myofascial Pain, Lumbar Radiculopathy, Insomnia, Cardiovascular Accident and Iron Deficiency Anemia. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, dressing, eating, toileting, and personal hygiene and total assistance of two people using a mechanical lift for transfers. R1's Care Plan dated 6/25/22 documents (R1) slides self out of low bed onto floor mat. R1's Assess Intercommunicate Manage (AIM) Report dated 2/20/23 documents This change in condition, symptoms, or signs observed and evaluated are injury which started on 2/20/23. Blood Pressure 150/99, Pulse 101 beats per minute, Respirations 26 per minute, Temperature 99.4 degrees Fahrenheit (F) and Pulse Oximetry was 95% on room air. (R1) not responding to questions correctly. Skin Evaluation: Burn R1's emergency room Record dated 2/20/23 documents Chief Complaint: Burn to left leg. (R1) was found by nursing home staff with right lower leg against a radiator heater. (R1) was sleeping near an old metal space heater and (R1's) leg was against it for the night causing burn to the right leg below the knee. Musculoskeletal: Burn of the lateral leg on the right from the knee to the ankle avoiding joint space of knee. Observational admit for wound care and pain control. Cephalexin (antibiotic) 250 milligrams (mg) every eight hours for seven days starting 2/20/23. Silvadene 1% topical cream Apply a 1/16 inch thick layer to entire burn area daily. Cleanse wound daily with saline dampened gauze, then apply thick layer of Silvadene Cream to each burn, cover with Adaptec, then apply saline soaked gauze over the Adaptec, then absorbent pad, then roll gauze, secure all with stockinet. Follow up with wound clinic. R1's Hospital Record dated 2/20/23 documents (R1) presented to the emergency department this morning from facility after being found by staff lying up against a hot radiator for unknown length of time. (R1) has burns to right lower extremity, along with right toes and left great toe. Chief complaint: Burn. Inpatient diagnosis: Primary Burn and Anemia. Assessment and Plan: Integumentary System: Thermal burn to right lower extremity and left great toe from radiator at Skilled Nursing Facility (SNF). Estimated 9% Total Body Surface Area (TBSA). R1's Hospital Operative Notes dated 3/3/23 document Preoperative Diagnoses: Full thickness third degree burn of right lower leg, right foot and left foot. Brief history and indication: (R1) suffered third degree burns to his right lower extremity, right foot and left foot after his bed was pushed against a radiant heater. Findings: Bilateral foot burns went down to bone with minimal bleeding noted. The right leg burn measured 27.0 centimeters (cm) by 9.0 cm with a thick fibrotic layer covering the wound base. The right lateral foot burn measured 5.0 cm by 3.0 cm with a thick fibrotic and necrotic covering. The left medial foot measured 6.0 cm by 3.0 cm with a thick fibrotic and necrotic covering. (V18) Wound Clinic Podiatrist then applied the meshed fish skin graft to the right lateral leg wound and stapled in place. (V18) then took the remaining meshed fish skin graft and applied over the (bilateral) foot wounds. (V18) then took the remaining meshed fish skin graft to add more fish skin to the Right lateral leg wound. (V18) then placed Adaptec, gauze, absorbent pads and roll gauze over the wounds. R1's Wound Clinic Encounters and Procedures Note dated 3/6/23 documents Chief complaint: nurse visit, wound check. The right lateral and left medial foot were at least third degree, the right lateral foot was still blistered and could not tell the degree yet. The Wound Clinic Note documents (R1) was taken to operating room by (V18) Wound Clinic Podiatrist on 3/3/23 for surgical debridement and skin grafting over the debrided areas on R1's right lateral lower leg, right lateral foot and left medial foot. On 2/24/23 at 9:20 AM V3 Licensed Practical Nurse (LPN) via phone stated That night (evening of 2/19/23 and early morning of 2/20/23) was very busy (V7) Certified Nurse Aide (CNA) rounded on (R1) in between 12:00 AM-1:00 AM by herself. So then (V7) left at 2:00 AM and (V4) CNA came in at 2:00 AM. I am not certain if (V4) CNA did a round at 2:00 AM or not. (R1) is a frequent faller. (R1) also has a lot of behaviors. (R1) cusses, hits and yells at staff. (R1) calls staff derogatory names based on their skin color or weight. Normally, (R1) would be up all night banging on the wall or yelling out 'come in here' and as soon as staff enter to ask what is needed (R1) replies 'I just wanted to see you'. I know (R1) went to bed about 8:30 PM that night. (R1) was really tired because he slept a lot that night. Sometimes the girls (CNA's) will skip (R1) on rounds if he is sleeping just to let him sleep. They (staff) do not want to 'wake the bear' so to speak. I should have been more on top of that. I can't guarantee that (R1) was checked on at the 2:00 AM check which means the next time they (staff) would check him was the 4:00 AM check and that is when they (staff) found him with his legs laying on the radiator. (V4) CNA came to get me at about 4:25 AM to report 'something was wrong with (R1)' and that '(R1) had huge wounds on his legs'. When I walked into (R1's) room, (R1's) skin on face and body was beet red. (R1's) skin was burning hot to touch. (R1's) right lower leg from knee to top of ankle was hot to touch, blistered and beet red. I remember (R1's) temperature being 99.4 degrees Fahrenheit (F). (R1) was laying with his back flat on the bed and his legs bent up at the knees like in a fetal position from the waist down when I walked in the room. (R1's) Left Great Toe was gray and had nasty discoloration, there was a huge blister with fluid in it from (R1's) right knee to right ankle, little burns on toes that were deep purple one of which had opened. The big blister on (R1's) outer right lower leg area popped when (R1) was moved from his bed at the facility to the gurney to be transported to the hospital. (R1) did not have any type of pants, sweatpants, lounge pants etc. on. (R1's) legs were bare. (R1's) bed was in the lowest position clear down to the floor. Sometimes the low beds get stuck to the heater, and we (staff) have to really tug at them to get them separated. The staff moved (R1's) bed so that it sat right in front of the wall with the window right up against the radiator. They (staff) did this because (R1) was sleeping and they (staff) wanted to keep an eye on him. The staff moved (R1's) bed and kept the door to his room open so they could monitor him without waking him up. There was no table or dresser between (R1's) bed and radiator/wall. (R1's) bed was directly up against (R1's) heater. You would have to move the entire bed to get between (R1's) bed and the wall. Those heaters get very hot. It is a little metal radiator. I worked here (facility) as a CNA, and I remember almost burning my own leg because some of the beds were so close to the radiators and I would have to help assist a resident with cares. I would lean my legs against the radiators and would have to move real quick because they (radiators) get so hot. It would have burned me if I left my legs there too long. I can't believe someone would turn the thermostat up so high. It was turned up past the 80 degree mark which is the highest mark on the thermostat. On 2/24/23 at 10:05 AM V4 Certified Nurse Aide (CNA) stated I worked 2:00 AM-10:00 AM on 2/20/23. I started the bed check around 3:00 AM and got to (R1) around 4:30 AM. (R1's) bed was up against the wall with the heater. (R1) was laying on his right side facing the wall with his right lower leg and left foot all laying directly on the radiator. (R1's) right calf was blistered, the outside of his right foot was super red, and the left great toe had skin peeling off and was very red too. (R1) had on a sheet and blanket. (R1) had moved his legs out from underneath the blankets and rested them directly on the radiator. It was so hot in (R1's) room. The thermostat was set over 80 degrees Fahrenheit (F). (R1) was wearing a gown and incontinence brief. I turned the heat down. (R1's) bed was in the lowest position which makes it set right on the floor. (R1's) bed was directly up against the radiator. (R1) had pillows placed behind his back for positioning but that made it so he couldn't roll over to his left side also. Normally (R1) can roll around in bed on his own. Sometimes the low beds get hooked on the radiators. (R1's) low bed was not caught up on the radiator but it was shoved up against it so tight it was right on the bed. On 2/24/23 at 10:20 AM V5 Certified Nurse Aide (CNA) stated I came into work at 4:00 AM that morning (2/20/23). We started helping (V4) CNA with the rounds. I saw (R1) laying on his right side with his bed completely up against the wall. (R1's) right lower leg felt very warm. I could feel (R1's) right lower leg skin move underneath my fingers. (R1's) room smelled like hot burning flesh. (R1) had blisters on his toes. On 2/24/23 at 11:00 AM V10 Regional Maintenance Director stated The heat for the resident rooms comes solely from the electric baseboard heaters which are controlled from thermostats located in each resident room. Each resident room can have a different temperature setting. If someone turns up the heat setting on the thermostat to 70 degrees or 80 degrees, the internal heating element in the electric baseboard heater will run at full speed until it satisfies the thermostats demand for heat. There is no gradual elevation of heat from the electric baseboard heaters. It is either on or off. The heating element can get up to 450 degrees (F). On 2/24/23 at 11:10 AM V13 Certified Nurse Aide (CNA) stated You would think it would be common sense not to put a Dementia resident's bed right up against the radiator and turn the heat up. But not everyone has common sense anymore. On 2/24/23 at 1:00 PM V10 Regional Maintenance Director stated the electric baseboard heaters were installed in 1973. V10 stated We (facility) have looked all over for the manual for those baseboard heaters. We (facility) do not have the manuals for them. I have already asked Corporate for the manuals, and they (corporate) told me there are none to be found. I (Internet searched) the make and it said to provide at least 6 inches from the element to any other furniture and 10 inches from the element to the curtains. The facility has audited these baseboard heaters since that incident and found that the metal can get to 175 degrees (F) on the front side. On 2/24/23 at 1:45 PM V16 Maintenance Director stated, The staff apparently turned up the heat on the thermostat and then pushed (R1's) bed directly up next to the baseboard heater. On 2/7/23 at 10:55 AM V8 Physician stated All I can say really is that there should have been some preventative measure in place so that (R1) was not able to get burned. The facility called me, and I told them to send (R1) to the hospital. I was not there so I cannot say what happened. But the preventative measure should have been in place prior to moving (R1's) bed so close to the heater. On 2/7/23 at 12:45 PM V2 Director of Nurses (DON) stated We (facility) were not aware that staff were pushing beds up against the electric baseboards. They (staff) should not do that. That is dangerous. We (facility) educate and educate but it is hard to find staff with common sense. On 2/8/23 at 11:30 AM V16 Maintenance Director stated all resident rooms in this facility have the same type of electric baseboard heaters. V16 stated all of the heaters in resident rooms function the same way as (R1's) baseboard heater. V16 stated Anyone could just come up and change the thermostat. Anyone could control the heat level in any one of the rooms. On 2/8/23 at 12:00 PM V18 Wound Clinic Podiatrist stated What happened to (R1) was very preventable and caused him unnecessary wound care, hospitalization s and surgery. (R1's) right lateral leg did have some bleeding which means there is perfusion to the tissues but still certainly that burn has severely damaged (R1's) right lateral leg. (R1's) right lateral foot and left medial foot were burned to the bone. There was no bleeding when I debrided those areas on (R1's) feet. That means there is likely going to be more problems due to lack of circulation to the wound bed. (R1) will most likely be a long term wound patient and will certainly require more debridement, possibly more grafts. (R1) is at risk of infection and certainly at risk of losing at least part of both of his feet. This was all preventable. (R1) was not previously a wound patient at our clinic. The Immediate Jeopardy that began on 2/20/23 was removed on 3/8/23 when the facility took the following actions to remove the immediacy. 1. V1 Administrator confirmed that on 2/20/23 all residents and resident items in rooms were immediately positioned correctly away from heat source. Observations were made of residents and resident items being placed a safe distance away from electric baseboard heaters. 2. V2 Director of Nurses (DON) confirmed that on 2/20/23 and 3/8/23 all residents head to toe skin assessments were completed with no new findings. V22 Regional Clinical Nurse verified all skin assessments had been completed. Record review showed no new findings. 3. V1 Administrator and V2 Director of Nurses confirmed 100% of staff have been inserviced. V1 stated all staff who were onsite were inserviced in person and any other staff were all contacted via telephone and inserviced. V1 stated there is no one left that has not been inserviced as of 2/21/23. Staff report that inservicing has taken place. 4. V22 Regional Clinical Nurse verified that all thermostats in resident rooms have had a clear plastic cover placed over them to deter residents or staff from adjusting the thermostat independently as of 2/21/23. V22 stated I put the covers on myself. They all require a key to open them so no one can just do that on their own. Observations were made of clear plastic covers over thermostats. 5. V1 Administrator confirmed that all residents rooms have been assessed for safety and that wood guards have been placed over all of the resident electric baseboard heaters in resident rooms. V1 stated the initial safety assessments were completed on 2/20/23 and the boards were put up on 3/8/23. Observed one inch by eight inch by twelve foot boards screwed into wall just above electric baseboard heaters in resident rooms. 6. V1 Administrator stated resident room checks have been done daily starting 2/21/23 and will continue indefinitely. V2 DON and V22 Regional Clinical Nurse both confirmed rooms checks were being completed with no findings of any items placed near heat source. V16 Maintenance Director stated rooms temperatures and electric baseboard heater temperatures are being monitored daily. V16 stated The initial check on 2/20/23 included seven rooms. We (facility) decided to check all the rooms since all of the rooms have heaters. I started the whole house checks on 3/8/23. Observed V16 taking room and heater temperatures with infrared thermometer on 3/8/23. 7. V2 DON confirmed the Interdisciplinary Team (IDT) reviews the room audit sheets daily during morning meetings. V2 stated the rooms are audited seven days a week, the IDT reviews Monday-Friday and the weekend manager reviews over the weekend or holiday days and would report to V1 Administrator if there is a problem. 8. V1 Administrator stated Quality Assurance (QA) and Quality Assurance Performance Improvement (QAPI) will both be monitoring the logs of room temperatures, resident satisfaction of comfort levels and placement of residents and their items in their rooms. V1 stated QA will monitor daily and all issues related to heaters and resident injuries will be discussed in quarterly QAPI meetings.

Based on interview and record review the facility failed to provide nutritional interventions and treatment to promote pressure ulcer healing for a resident. This failure affects one of four (R1) residents reviewed for pressure ulcers in a sample of four. This failure resulted in R1's sacral pressure ulcer increasing in size with worsening characteristics (odor, drainage). Findings include: R1's physician's orders [REDACTED]. R1's admit Care Plan initiates skin risk or pressure ulcers, then the problem and interventions were added dated [DATE]. R1's wound assessment from the hospital dated [DATE] documents R1 was admitted to the facility from home with one Stage III decubitus ulcer to R1's left sacrum measuring 2.4 cm (centimeters) length(L) by 0.8 cm. width(W) by 0.1 cm depth(D). Wound bed covered with necrotic slough and poorly defined wound edges. No odor small amount serous (clear) drainage and one Stage I decubitus ulcer to R1's right sacrum measuring 2.5 cm L by 1.2 cm. W by 0.1 cm D. Wound bed covered with necrotic slough and poorly defined wound edges. No odor, small amount serous (clear) drainage. This area was documented as healed by [DATE]. R1's wound assessment from the hospital dated [DATE] documents R1 was transferred to the facility with one decubitus ulcer to R1's left sacrum measuring 0.5 cm L by 0.5 cm. W by 0.1 cm D. Wound bed covered with necrotic slough and poorly defined wound edges. No odor or drainage. Wound photographs dated [DATE] and [DATE] support this assessment. On [DATE] at 9:00 AM V4, Registered Nurse (RN) Certified Wound Care Nurse (CWCN) hospital staff stated I assessed the wound on (R1's) Left sacrum [DATE] (as above) prior to R1's discharge to (the facility) The Stage II pressure area to (R1's) right sacrum had closed by that time. R1's Nursing Admission assessment dated [DATE] (not timed) by V5, Licensed Practical Nurse (LPN) documents pressure areas on an anatomical drawing of R1 on the left side of the sacrum labeled 1.5cm open and one on the right side of the sacrum labeled gray decub(decubitus) 2cm. R1's assessment did not document wound characteristics shape, depth, wound bed appearance, presence of any drainage, or appearance of surrounding tissue. A progress note dated [DATE] at 3:45PM also by V5 states (R1's) Buttocks 3 areas #1.) 1.5cm shear left inner #2.) 0.5cm not open #3.) 2cm rt. inner gray in color. R1's hospital discharge summary by V9 Family Nurse Practitioner (FNP) dated [DATE] at 11:47AM documents 'Foley catheter was placed again. (R1) should follow-up with urology in one week upon discharge. R1's progress note dated [DATE] at 11:15AM documents called (primary physician) and got order to remove catheter. Removed at 11:05AM. R1's Nursing Care Observation report documents [DATE] through [DATE] Incontinent of Bowel and bladder. R1's physician's orders [REDACTED].(calcium) alg.(alginate) cover with [MEDICATION NAME] foam and dry dressing. On [DATE] at 11:10AM V2, Acting Director of Nursing (DON) stated considering the wound care it was probably not a great idea to take out (R1's) catheter. It (the catheter) was only out a few days. R1's physician's orders [REDACTED]. R1's dietary assessment dated [DATE] by V10, Dietary Manager documents R1 feeds self with set-up This document also states Diet Order: Regular/No Added Salt/ Med-Pass 120 Milliliters BID (twice daily)/Multiple Vitamin with Minerals/Prostat (protein supplement) 30 Milliliters BID (twice daily). R1's Minimum Data Set ((MDS) dated [DATE] documents R1 as requiring only set-up and supervision for eating. R1's Medication Administration Sheet for (MONTH) (YEAR) documents that Multiple Vitamin with Minerals/Prostat was not initiated until [DATE]. R1's hospital discharge summary dated [DATE] documents R1's [MEDICATION NAME] as 3.6 which is within the normal range. R1's hospital note dated [DATE] documents R1's [MEDICATION NAME] as 2.3 low. Mayo Clinic laboratory web site states a common cause of low [MEDICATION NAME] is due to diminished protein intake(and) as a result of tissue damage and inflammation. R1's Initial Wound Evaluation & Management Summary documents on [DATE] (no time listed) V11, Medical Doctor, facility contracted wound care, saw R1 at the facility. V11 completed a wound debridement. V11 documented Stage II pressure ulcer right buttock wound size: (Length by Width by depth) 2.1 by 1.0 by 0.1 cm. (centimeters) with light serous exudate (drainage). Unstageable (due to necrosis) pressure ulcer left buttock wound size: (Length by Width by depth) 2.0 by 1.0 by 0.1 cm. (centimeters) with light serous exudate (drainage) and 30% slough (nonviable tissue). The plan documented by V11 at this visit was for R1 to see wound care specialist in seven days. R1's medical record documents on [DATE] at 1:50PM V2, acting Director of nursing documented (primary physician) was in and did not feel an antibiotic would help and wanted to make an appointment with wound clinic at (local hospital). There is no documentation that this appointment was made nor reason for not scheduling. R1's Nurses Notes document the following: On [DATE] at 12a V12, Licensed Practical Nurse (LPN) documented Stage III to coccyx with thick purulent drainage, foul odor. On [DATE] at 8:30AM V13, Advanced Practice Registered Nurse (APRN) documented patient has a large decubitus ulcer to coccyx last week debrided by the wound doctor who is now on vacation. V13 also documented Patient has open area 6cm by 6cm (no depth measurement) to coccyx. V13 ordered a wound culture at that time which V13 obtained and sent to lab. On [DATE] at 10:45AM V5, Licensed Practical Nurse (LPN) documented at approximately 9:15AM therapy called this nurse to (R1's) room. (R1) color was ashen, skin warm, (R1) was short of breath and had some clonic jerking. R1 was sent to the hospital at that time and expired [DATE]. On [DATE] at 5:23PM V4, Registered Nurse (RN) Certified Wound Care Nurse (CWCN) hospital staff documented in R1's hospital record Unstageable pressure injury with significant periwound deep tissue injury noted to patient's coccyx. The open area of skin measures approximately 7 cm by 5cm by 0.1cm. (length by width by depth) There is a small amount of purulent drainage noted on the dressing with a faint odor. The wound margins are poorly defined. The wound bed is completely covered with soft yellow, brown slough. Wound photographs dated [DATE] support this assessment. On [DATE] at 9:14 AM V4, Registered Nurse (RN) Certified Wound Care Nurse (CWCN) from the hospital stated In my opinion the significant decline in this wound was caused by frequent pressure to to (R1's ) coccyx over time. On [DATE] at 9:18AM V7, Advanced Practice Registered Nurse (APRN) hospital staff completed R1's history and physical in the emergency department [DATE], stated While (R1) did have comorbidities, I believe that the decline in the decubitus ulcer to (R1's) coccyx was caused by pressure and could have been avoided if (R1) had been turned and positioned regularly while at the facility. The lack positioning, in my opinion, caused irreparable harm to this patient (R1). On [DATE] at 11:10AM V2, acting Director of Nursing stated I know we didn't do a good job documenting (R1's) wound and it did get worse. The facility's policy Decubitus Care/Pressure areas last revised ,[DATE] states Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. This policy also states Documentation of the pressure area must occur upon identification and at least once each week on the Treatment Administration Record. (TAR) The assessment must include: Characteristic (i.e. size, shape, color, presence of granulation tissue, necrotic tissue, etc.) Treatment and response to treatment. The facility's policy Skin Condition Monitoring last revised [DATE] states Documentation of skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. documentation of the area must include the following: Characteristic 1. Size 2. Shape 3. depth 4. color 5. presence of granulation tissue or necrotic tissue. Treatment and response to treatment.

Based on record review and interview the facility failed to ensure the pressure sensitive alarm was turned on and working properly according to the plan of care for R2. R2 is one of four residents reviewed for falls in a sample of 12. This failure resulted in R2 sustaining two falls and the second fall resulted in a Fracture of the Left 8th Rib. Findings include: The physician's orders [REDACTED]. The MDS (Minimum Data Set) dated 5/7/12 states R2 is severely impaired in cognitive skills for daily decision making, requires extensive assist of two with bed mobility, transfers and toileting. The same MDS states R2's balance is not steady and R2 is only able to stabilize with assistance. The facility's form titled "Investigation Report for Falls" dated 6/30/12 states R2 sustained a fall on 6/30/12 at 6:30 PM. The report states R2 was trying to get out of the w/c (wheelchair) and go to the bathroom. Fall interventions that were in place prior to the fall states pressure alarm. The report states the pressure alarm was in place but not turned on. R2 was found lying on her back in front of her bed, incontinent of BM (bowel movement) and sustained left forearm laceration. R2's care plan dated 5/7/12 under problem of falls for approaches states: "Attempt to anticipate needs - toileting, hydration, hunger and provide care before (R2) attempts to fulfill on own." Additional approaches dated 6/30/12 states "Ensure pressure sensitive alarm is on and functioning at all times." The facility's form titled "Investigation Report for Falls dated 8/5/12 states R2 sustained a fall on 8/5/12 at 11:05 AM. The reports states R2 was trying to take herself to the toilet and was found sitting on her buttocks next to the bed. Fall interventions that were in place prior to the fall states chair pressure alarm. The report states the pressure alarm was in place but turned off. The report states R2 complained of pain in the left leg, left shoulder and left side of back. R2's physician was notified, an order was received to send to emergency room for evaluation. The hospital's emergency room report dated 8/5/12 states R2 returning to facility with a [DIAGNOSES REDACTED]. On 9/13/12 at 9:25 AM E2, DON (Director of Nurses) stated " I don't know why the alarm was shut off. I know (R2) does not have the range of motion to turn and shut the alarm off. I interviewed all staff and the staff was not aware when (R2) was last toileted and when the staff had checked the alarm to ensure it was turned on. I understand the staff did not follow (R2's) plan of care regarding the alarm. I put that into place to check the alarm to ensure it was turned on due to her last fall on June 30th when the alarm was also turned off ."

Based on observation, interview and record review, the facility failed to follow the plan of care to prevent falls for R1 and R5, two of 3 residents reviewed for falls, in the total sample of 11. R1 sustained a fractured pelvis, and R5 sustained a fractured right hip. Findings include: 1. Incident Investigation Report dated 09/24/11 at 6:20pm reports R1 removed the Nonrestrictive Alarm (NRA) attached to her shirt, stood up from her wheelchair, and fell in the dining room. The Post Fall Review dated 09/26/11 documents R1s history of removing the NRA. The report states " previous witness to (R1) unclipping a nonrestrictive alarm from her clothing, " R1 " forgets to take walker at times when up, " and ... " she is unable to remember to ask for assistance. " The Nurses ' Notes dated 09/23/11 (erronously per E2, DON, 10/06/11 at 3:00pm)document R1 was " found sitting on floor, feet straight out in front of her ...complains of pain in left knee. " R1 was transported to the hospital, x-rayed, and a pelvic fracture was diagnosed . The After Care Instructions from Provena Medical Center dated 09/24/11 at 11:00pm documents " Pubis Ramus Fracture. " The Minimum Data Set ((MDS) dated [DATE] and 07/26/11 documents that R1's cognition is severely impaired, has short and long term memory loss, chronic confusion, and is dependent on staff for transfer and ambulation.. The Physician order [REDACTED]. The Fall Risk assessment dated [DATE] documents R1 as high risk for falls with functional deficits in gait and balance including "loss of balance-standing, loss of balance-walking, and requires assist to stand." The care plan dated 09/18/11 documents that R1 is at risk for falls and potential for injury. The approach dated 09/18/11 states " Pressure alarm at all times. " On 10/07/11 at 10:50am, E2 acknowledged that a pressure alarm was not used on 09/24/11. E2 further stated that an NRA was used rather than the pressure alarm. R1's care plan included no assessed interventions for the use of the NRA. 2. The facility Incident Investigation Report for Falls dated 05/25/11 reports that R5 fell out of her wheelchair when reaching for her call light. On 10/06/11, E2, DON, reports E7,Certified Nursing Assistants (CNA) and E8, CNA brought E5 to her room after supper and left in her wheelchair unable to reach her call light. E2 also states R5 laid on the floor for an estimated 15 minutes before she was found by staff. The X-ray Report dated 05/26/11 reports " Impacted femoral neck fracture. " The POS dated 10/01/11 through 10/31/11 documents that R5 is an [AGE] year old with [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE] identifies E5 at high risk for falls. The Care Plan dated 03/17/11 documents R5 is at risk for falls and the following approach: " Keep call light within reach at all times. " The MDS dated [DATE] documents R5's cognitive ability as intact (Brief Interview for Mental Status, 14 out of 15). The MDS dated [DATE] documents R5 as needing only supervision and set up assistance with eating. On 10/04/11 R5 fed herself lunch without difficulty. On 10/04/11 at 2:00pm R5 demonstrated manual dexterity needed to use the call light by doing needlework indepently in her room. E2, DON, verified that E7, CNA, and E8, CNA left R5 ' s call light out of reach and were disciplined " for failure to leave call light in resident ' s reach. " The Job in Jeopardy document confirms E7 left " R5 without her call light in a comfortable position and within easy reach. "

Based on observation, record review, and interview, the facility failed to ensure that 1 of 3 sampled residents (R1) was free of mistreatment by facility staff resulting in bruising to R1's left breast. R1's breast was pinched by the employee in response to R1's behavior toward her. The finding includes: According to R1's July 1, 2011 to July 31, 2011 physician's orders [REDACTED]. The facility's 7-22-2011 Final Investigation Report of the bruising of R1's left breast was reviewed. According to the report, it was reported to the Interim Director of Nursing, E2 that E3, Certified Nursing Assistant (CNA) admitted that she pinched R1's breast because R1 pinched E3's breast. E3 informed four staff members E4 (CNA), E5 (CNA), E11(Housekeeper) and E12 (Housekeeper) of this on 7-22-2011 at about 1:45 P.M. E3 was immediately suspended and an investigation was done. E3 was not allowed to have resident contact, the local authorities were notified and E3's employment was terminated. E9, CNA stated on 7-27-2011 at 12:10 P.M. that she regularly cares for R1 during the day shift. E9 stated that on 7-22-2011 between 6:00 A.M. to 6:30 A.M., she was providing care to R1. R1 was seated on the edge of the bed and a large bruise was on her left breast. R1 was asked how she got the bruise. R1 stated she did not know how she got the bruise. E9 reported the bruise to the charge nurse, E10, Licensed Practical Nurse (LPN). E9 stated that during report on 7-22-2011, It was reported that R1 had been very combative and refusing care. E9 stated it was believed that the bruise may have been created during care on 7-21-2011. E9 stated she did not see the bruise on R1's breasts during care on the day shift on 7-21-2011. E9 stated that R1's behavior changed since R1's medications were recently changed. E9 stated "everybody was aware of her changes in her behavior." E5, CNA stated on 7-26-2011 at 12:55 P.M. that she helped E9 with R1 on 7-22-2011 and was aware of the bruise on R1's breast. E5 stated she was outside on 7-22-2011 at about 1:45 P.M. on break with E4, (CNA), E11 (Housekeeper), and E12 (Housekeeper). E3 was coming to work and E3 asked about R1. E3 stated R1 was "horrible last night." E5 stated that E3 said "she pinched me on the breast and I pinched hers right back." E5 and E4 stated they immediately reported to their supervisor E6. E6, CNA Supervisor stated on 7-26-2011 at 12:50 P.M. that after E4 and E5 told her what E3 said, she reported to the information immediately to E2. E2 stated at 11:25 A.M. on 7-26-2011 she immediately found E3 outside in the break area before E3 began to work. E3 was removed from resident contact. E3 was interviewed by E2 before her shift started. E2 stated she had E3 write a statement. The written statement did not address the pinching of the resident. E3 was interviewed on 7-22-2011 at about 2:15 P.M. by E2 with E7, Business Office Manager present. The interview was in E7 office. E7's written documentation of the interview stated "(E2) and (E7) called (E3) into my office to tell her we were sending her home pending an investigation for alleged physical abuse. Told her (E3) what it was about and she (E3) said 'I might have' then covered by saying 'but I didn't mean to.'" E2 stated at 2:30 P.M. on 7-27-2011 that the bruise on R1's left breast was the size of a baseball, and black and blue with yellowing edges. E2 stated she did interview R1. The notes from the interview of 7-22-2011 at 3:20 P.M. states "Resident confused at this time. Unable to recall going to bed last night. Unaware of the purple hematoma to left breast." E2 stated she interviewed R1 again on 7-25-2011 at 10:30 A.M. with Z1, Chief of Police, present. E2 stated R1 was asked if she hurts. R1 responded by pointing to her left breast. R1 was asked when did it occur? R1 stated she did not know. R1 was asked who did it. E2 said R1 responded by saying "They told me not to tell." R1 stated at 2:10 P.M. on 7-27-2011 that she did not recall how she got the bruise, when she got the bruise, or if it was done by someone.