Every finding on record at Niles NSG & Rehab CTR

Based on interview and record review, the facility failed to permit a resident to return to the facility following hospitalization and failed to demonstrate that a valid regulatory basis for transfer or discharge existed. This failure affected one (R1) of three residents reviewed for transfer and discharge. Findings include: R1 was admitted to the facility from 3/30/2024 to 7/10/2026 with diagnoses that include but are not limited to: Diabetes, Hypertension, Right- sided Bell's Palsy, Intellectual Disability, Autistic Disorder, and Intermittent Explosive Disorder. Minimal Data Set (MDS) assessment of 6/16/2026, section C1000 Cognitive Skills for Daily Decision Making, showed Severe impairment. R1 was transferred to the hospital on 7/10/26 for aggressive behavior. R1 remained hospitalized until 7/15/2026, when R1 was medically cleared for discharge back to the facility. The facility did not take R1 back, and R1 was sent to another facility. R1 is currently residing in another facility after the hospitalization. The hospital medical records, from V11 (Psychiatric Nurse Practitioner), documented that R1 can return to the facility. However, R1 was transferred to another facility with no proper legal guardian approval or notification. On 8/24/26 at 1:28 PM, V3 (Assistant Administrator) said, V1 (Administrator) and I made the decision not to get R1 back, and he would be better at our sister facility because they have Spanish-speaking staff and a resident community there. The surveyor questioned V3, who provided discharge communication with the V8 (R1's Legal state guardian), and she said, I do not call families to discuss discharges from the facility. V3 said, based on our 10-day-bed-hold policy, the facility is expected to receive R1 back. On 8/24/26, V1 said, I decided to send R1 to the sister facility because they have a Spanish community population and have a better behavior program. When question if his residents go to the hospital, does he expect them to come back? The answer is yes. The surveyor asked V1 for records of the discharge communication with V8 and the clinical reason why R1 was not readmitted to the facility, but none were provided. On 8/25/26 at 10:49 AM, V8 (R1's State Legal Guardian) said, I was not notified of the transfer to another facility after the last hospitalization until 7/31/26 via email from the current facility. I spoke with V12 (Case Manager) from the current facility to sign the admission paperwork, and with the information that R1 has been residing there since 7/15/26. I visited R1 in the facility on 7/9/26, and he was in the social services office. On 7/10/26, the facility notified me of his aggressive behavior and that R1 was going to be transferred to a local hospital. On 8/11/26, I spoke with V12, and I did not give permission for the transfer to the current facility and expected R1 to go back to the old facility. V9 (R1's family Member) went to visit R1 and found out that R1 was no longer at the old facility. I have requested that R1 be returned to the old facility. I will not sign the new admission paperwork from the current facility. The surveyor requested records for the plan to discharge R1 to another facility and the notification of R1's guardian, but none were provided. On 8/24/26, at V2 Facility Policy Title Transfer and Discharge Policy and Procedure, undated. Which reads, but is not limited to:GUIDELINE:The facility shall permit each resident to remain in the facility unless such transfer or discharge is made in recognition of the resident's rights to receive considerate and respectful care; to receive necessary care and services; and to participate in the development of the Comprehensive Care Plan and in recognition of the rights of other residents in the facility. The facility will not transfer or discharge a resident due to their source of payment.2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/responsible party.d. A statement that, if the resident may appeal the transfer or discharge to the Department of Health within 10 days of being notified of transfer/discharge.6. The facility will provide provisions for continuity of care and, in non-emergency situations, a care plan meeting will be held with the appropriate parties to determine a relocation plan.7. Before a facility transfers a resident to a hospital or a therapeutic leave, the nursing facility will provide information to the resident/responsible party that specifies the duration of the bed-hold policy and the facility's policies regarding bed-holds.

Based on interview and record review, the facility failed to document and provide a resident/power of attorney with timely notice of transfer and discharge. The facility also failed to provide the legal guardian with the bed hold policy and transfer notification. This failure applied to one (R1) of three residents reviewed for bed hold notice. Findings include: R1 was admitted to the facility from 3/30/2024 to 7/10/2026 with diagnoses that include but are not limited to: Diabetes, Hypertension, Right- sided Bell's Palsy, Intellectual Disability, Autistic Disorder, and Intermittent Explosive Disorder. Minimal Data Set (MDS) assessment of 6/16/2026, section C1000 Cognitive Skills for Daily Decision Making, showed Severe impairment. R1 was transferred to the hospital on 7/10/26 for aggressive behavior. R1 remained hospitalized until 7/15/2026, when R1 was medically cleared for discharge back to the facility. The facility did not take R1 back, and R1 was sent to another facility. R1 is currently residing in another facility after the hospitalization. On 8/25/26 at 10:49 AM, V8 (R1's State Legal Guardian) said, I was not notified of the transfer to another facility after the last hospitalization until 7/31/26 via email from the current facility. I spoke with V12 (Case Manager) from the current facility to sign the admission paperwork, and with the information that R1 has been residing there since 7/15/26. I visited R1 in the facility on 7/9/26, and he was in the social services office. On 7/10/26, the facility notified me of his aggressive behavior and that R1 was going to be transferred to a local hospital. On 7/13/26, the hospital called the on-call services and notified them of a medication adjustment and new consent for medications. On 8/11/26, I spoke with V12, and I did not give permission for the transfer and expected the R1 to go back to the old facility. V9 (R1's family Member) went to visit R1 and found out that R1 was no longer at the old facility. I have requested that R1 be returned to the old facility. I will not sign the new admission paperwork from the current facility. On 8/24/26 at 1:28 PM, V3 (Assistant Administrator) said, V1 (Administrator) and I made the decision not to get R1 back, and he would be better at our sister facility because they have Spanish-speaking staff and a resident community there. The surveyor questioned V3, who provided discharge communication with the V8 (R1's Legal state guardian), and she said, I do not call families to discuss discharges from the facility. V3 said, based on our 10-day-bed-hold policy, the facility is expected to receive R1 back. On 8/24/26, V1 said, I decided to send R1 to the sister facility because they have a Spanish community population and have a better behavior program. When question if his residents go to the hospital, does he expect them to come back? The answer is yes. The surveyor asked V1 for records of the discharge communication with V8 and the clinical reason why R1 was not readmitted to the facility, but none were provided. The surveyor requested records for the plan to discharge R1 to another facility and the notification of R1's guardian, but none was provided. On record review, R1 received a 10-day bed hold policy which reads: 7. This is to inform the resident/POA that it is the policy of this facility and the State of Illinois that the facility will hold a bed for a maximum of ten days when a resident is hospitalized (not necessarily that specific bed), on the 11th day there is no requirement to hold a bed, but the resident is still a resident and should receive the next available bed when they are ready to return even if there is a waiting list. On 8/24/26 at V2 Facility Policy Title Transfer and Discharge Policy and Procedure undated. Which reads, but is not limited to:GUIDELINE:The facility shall permit each resident to remain in the facility unless such transfer or discharge is made in recognition of the resident's rights to receive considerate and respectful care; to receive necessary care and services; and to participate in the development of the Comprehensive Care Plan and in recognition of the rights of other residents in the facility. The facility will not transfer or discharge a resident due to their source of payment. 2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/responsible party.d. A statement that, if the resident may appeal the transfer or discharge to the Department of Health within 10 days of being notified of transfer/discharge.6. The facility will provide provisions for continuity of care, and, in non-emergency situations, a care plan meeting will be held with the appropriate parties to determine a relocation plan.7. Before a facility transfers a resident to a hospital or a therapeutic leave, the nursing facility will provide information to the resident/responsible party that specifies the duration of the bed-hold policy and the facility's policies regarding bed-holds

Based on observation, interview, and record review, the facility failed to implement the fall care plan interventions for a resident (R18) with a history of falls. This applies to 1 of 3 residents (R18) reviewed for falls in a sample of 35.The Findings include:R18 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis including dementia, walking difficulty, and vertebral fracture.On 12/2/25 at 10:22 AM, R18 was observed in her bed with the floor mat folded and kept behind the headboard.A review of the facility-provided fall log documented two falls for R18 on 5/10/25 and 8/19/25, with no injuries.A review of the fall care plan document intervention, including a floor mat on the side of the bed.On 12/03/2025 1:57 PM, V3 (Director of Nursing/DON) stated, our staff should follow the care plan interventions. The floor mat should be at the bedside when a resident who is at risk for falls is in bed.A review of the facility presented guidelines for the document on incidents/accidents/falls:15. Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place.

Based on observation, interview, and record review, the facility failed to follow its indwelling catheter care policy by not applying leg anchors/stabilizers to prevent tugging on the catheter and by not wiping the catheter from the insertion site. This applies to 2 of 2 residents (R10 and R237) reviewed for indwelling catheter care in a sample of 35.The findings include:1.R10 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis including dementia, acute kidney failure, and elevated white blood cells.On 12/04/2025 9:33 AM, observed V21 (Certified Nursing Assistant/CNA) providing indwelling catheter care to R10 and completed without wiping down the catheter from the insertion site.On 12/04/2025 at 10:33 AM, during an infection control interview, V22 (Infection Preventionist/IP) stated, The staff should wipe down the indwelling catheter from the insertion site to prevent infection.2.R237 is an [AGE] year-old female admitted with an admitting diagnosis including neuromuscular dysfunction of the bladder, anxiety, and malnutrition.On 12/04/2025 at 9:15 AM, during wound care observation, R237 was observed with an indwelling catheter tubing under her leg without securing with a stat lock.On 12/04/2025 9:25 AM, V23 (Wound Care Nurse) stated, The stat lock should be there with the resident's thigh to prevent tension/tugging on the catheter. The floor nurse has to apply the stat lock to reduce tension. I will apply the stat lock.A review of the facility presented the Guidelines for Indwelling Catheter Care document:15. Use a fresh, soapy, wet washcloth for each swipe. Clean peri area and at least 4 inches of the catheter, moving in only one direction, away from the body.18. Ensure tubing is not under the resident. Apply a leg anchor/stabilizer to prevent tugging on the catheter.

Based on observations, interviews, and record review, the facility failed to follow their Policy on Unit Refrigerators regarding labeling, storage, and monitoring of expiration dates for foods brought by family members to ensure resident safety. This deficient practice affects 2 of 2 residents (R258 and R15) reviewed for food safety in a total sample of 35.R258 is a [AGE] year-old female resident with diagnoses of but not limited to Displaced simple supracondylar fracture of left humerus, multiple fractures of ribs left side, Diabetes, Osteoarthritis, Acute cystitis, hypertensive heart disease, dysphagia. R258 was re-admitted to the facility on [DATE].On 12/2/2025 at 10:45 AM during resident room rounds, R258 granted permission to inspect her personal refrigerator. The thermometer inside the fridge displayed a temperature of 40 degrees Fahrenheit, however no temperature monitoring log was observed for the refrigerator. There was multiple food item inside the refrigerator that were expired and lacked labels. 2 packages of hard candy - Expiration date 7/31/20251 pack of (smoothie snack) 3.2 oz - Expiration date 1/3/20251 small container of unopened pound cake - No label1 small container of soup (1/3 full) - No label 1 medium glass container of Kimchi - No label2 bottles of Korean Kangjam- No label3 pieces of boiled purple yam in a ziplock bag, observed with patches of grayish-green discoloration and a raised texture, suggestive of spoilage - No label1 medium piece of pound cake stored in a see-through plastic container. The cake had patches of brownish-black raised texture, indicative of spoilage, and no label was present. Upon observing the condition of the cake, R258 immediately stated, Uh-oh, this is old. R258 appeared visibly disgusted and proceeded to discard the item in the garbage.2 cans of peach juice, 240 ml each can. Expiration date 11/2/20251 orange pineapple juice 10 oz. Expiration date 12/16/20242 black plums in a ziplock bag, very soft and mushy with [NAME] juice collected inside the bag - No label5 packs of High-calcium black soy milk 180 ml each bag - No expiration date written on the package R15 is [AGE] year-old male resident admitted to the facility on [DATE]. R15 has diagnosis of, but not limited to diabetes, end stage renal disease, cerebral infarction, dysphasia, hypertensive heart disease, speech and language deficit, arthritis, seizure.On 12/2/2025 at 11:25 AM, R15 was observed sitting in bed and resting. R15 refused to engage in conversation. V9 (Certified nursing assistant/CNA) stated that R15 speaks when he chooses to but may also refuse at times. R15's personal refrigerator was inspected with V9. The following items were noted:Yogurt: 2 containers, 4 oz each - Expiration date 11/30/2025Organic roasted chestnut, 3.5 oz, 1 pack - Expiration date 9/11/2025Dried fish in a ziplock bag - No labelBoiled purple potatoes, 2 pieces - No labelGrapes in a ziplock bag - No labelCherry tomatoes in a ziplock bag - No labelBoiled corn, 1 piece in a ziplock bag - No labelV9 stated that housekeeping maintains the personal refrigerator log. V9 also reported that R15's family regularly brings him food. V9 acknowledged that food needs to be checked for expiration because consuming expired food is not safe. V9 also said that food brought in should be labeled.On 12/3/2025 at 8:48 AM, V10 (CNA) who has worked at the facility for 17 years, was interviewed. V10 was asked regarding the facility's process in handling food brought in by family members. According to V10, one of her resident's family regularly brings food to the facility, usually in the evening prior to dinner. When V10 was asked whether staff are required to check and label food when it is received, V10 stated, Yes, we need to, and if I am the one who receives it, then I label it. But other people, I do not know if they do. We check the food if it's still okay, and 'okay' means if it is still fresh. I only work the 7-3 shift, so food is usually brought in the evening when I am not around. When informed that unlabeled and expired food items were found in some residents' room, V10 responded, Oh, all foods need to have a label to be safe. Yes, it is important to check the food in their personal fridge to see if they are still edible and fresh. It is okay to keep food for 1-2 days. If they are expired and they eat them, they will get sick.On 12/3/2025 at 9:19 AM, V4 (Licensed practical nurse/LPN) was interviewed regarding staff practices for handling and storing food brought in by residents' families. V4 stated that food items kept in a resident's personal refrigerator must be checked daily by the CNAs and housekeeping. V4 added that the housekeeping department is responsible for maintaining the temperature log of the personal refrigerators. V4 further stated, food items should be labeled, and that old ones we throw away. Expired or spoiled food can pose a health risk to residents, as consuming such items may lead to illness. V4 was informed that during the inspection conducted the previous day, 12/2/2025, multiple unlabeled and expired food items were found in R258's personal refrigerator. V4 is observed proceeded to R258's room and open the refrigerator and inspect the contents. V4 removed a ziplock bag containing three pieces of purple yam. Upon seeing the contents, she stated, Oh no, this is spoiled, this needs to be thrown away! Grayish-green patches with a raised texture were pointed out to V4, and she appeared visibly disgusted. Next, V4 examined a package of hard candy and read the expiration date on the bag as 7/31/2025. V4 then picked up a plastic bottle of orange pineapple juice, which displayed an expiration date of 12/16/2024. A ziplock bag containing two black plums was shown to V4. V4 noted that the fruits felt very soft and mushy, and the bag lacked a label. V4 also removed two unopened cans of peach juice (240 mL each) and read the printed expiration date as 11/2/2025. Additionally, unlabeled containers of kimchi and kangjam were identified inside the refrigerator. Finally, V4 inspected two packages of roasted seaweed (4 grams each) and read the expiration date as 9/24/2024.V4 then said that she will continue to inspect each item later. On 12/04/2025 at 8:47 AM, V3 (Director of nursing) was interviewed regarding food brought in by residents' families. V3 stated that staff are responsible for labeling and dating packages of food brought in by family members. V3 stated that the housekeeping department is responsible for checking the food stored in residents' refrigerators for freshness and expiration. V3 added that sometimes CNAs ask family members to write the date on the food items themselves. V3 stated that staff follow the expiration dates written on the packaging. V3 also said that spoiled or expired food can cause discomfort if a resident consumes it. On 12/4/2025 at 10:05 AM, V16, (Housekeeping supervisor) was interviewed regarding the process for maintaining personal refrigerator temperature logs and food handling brought by family members. V16 stated that the housekeeping department is responsible for maintaining temperature logs for personal refrigerators on all floors. According to V16, refrigerator units are checked daily for temperature accuracy, and the food inside is inspected for freshness and expiration dates. V16 explained that all food items should be labeled to indicate when they were opened, and that opened food may be kept for no more than 72 hours. Opened items must also be sealed properly. V16 said that family members often bring food for residents and stated, sometimes we don't have any control. V16 added that family members are advised about food labeling requirements by the admissions staff. When asked about the potential consequences of residents consuming spoiled or expired food, V16 responded that residents can have stomach ache and can make them sick.On 12/4/2023 R258's family was reached via phone call at 2:32 PM. R258's family was interviewed regarding food brought into the facility. The family stated that the facility did not advise them to label any food they bring for R258. Also stated that they bring food for R258 whenever they are in town to visit. R258 said that labeling is important for safety reasons. Review of the facility's Policy and Procedures on Unit Refrigerators (Revised 11/2011): Purpose: To assure that perishable food does not have prolonged storage and is stored at the proper temperature. Policy: All unit refrigerators will be maintained regarding temperature and cleanliness. Each refrigerator will be provided with thermometer to ensure that refrigerators are maintained at 36-41 degrees temperature.The resident's temperature will be cleaned by the housekeeping department every three days to assure that all food stored in the refrigerator is palatable and not beyond expiration date.Refrigerator temperatures will be checked daily to ensure sanitary conditions. Policy on Cleanliness and Food Management: 1. Food Assessment: Housekeeping staff will: Remove and discard any food item that is visibly spoiled or unpalatable. Check all items for expiration date and discard any items that are expired. 2. Resident/Staff Responsibility: Residents and/or their designated caregivers are responsible for ensuring that all perishable food items are properly sealed, dated upon opening, and stored promptly.

Based on interview and record review, the facility failed to assess side effects and adjust medication for one resident (R2) out of three residents reviewed for medication adjustment based on blood level result. This failure resulted to R2 being hospitalized on [DATE] with diagnosis of altered mental status and lithium toxicity. Findings include: On 3/19/2025 at 1:34, V12 (Registered Nurse-RN) said V12 was the nurse for R2 on 2/28/2025. V12 said that she received the lithium blood test result of 1.53 mEq/L (milliequivalent/Liter). V12 said that the normal range of lithium blood level is between 0.6 - 1.20 mEq/L. V12 said lithium level of 1.53 is high. V12 said that V12 notified the V15 (Medical Nurse Practitioner/NP) that was making rounds on the residents. V12 said that no new order was received from V15. V12 also said that V12 charted that V15 reviewed the lab results. V12 said that R2 was alert and oriented x 3 -4 and able to make her needs known. V12 said that R2 is ambulatory and goes downstairs for lunch with her friends. V12 said that V12 administered R2's medications to her as ordered. On 03/20/2025 at 11:06 AM, V12 said that the normal range for lithium level is 0.6 - 1.20. V12 said that high lithium level can result in patients having tremors, altered mental status, weakness, confusion, coma, and death. On 3/19/2025 at 12:55 PM, V11 (RN) said that V11 has taken care of R2 when R2 was a patient of the facility. V11 said that R2 is alert, and oriented x3. V11 said that R2 was cooperative, continent, and ambulatory. V11 said that R2 is able to express her needs. V11 said that normal lithium level is between 0.6 - 1.20 mEq/L. V11 said that V11 notifies the doctor of lithium level result regardless of whether it is normal or abnormal. V11 said that she was not the nurse that took care of R2 on February 28, 2025. On 3/20/2022 at 9:49 AM, V11 said that the reason why the lithium blood level is checked every month is to determine if the level is high or low. V11 said that lithium blood of 1.53 is high. V11 said that signs and symptoms of high lithium level are diarrhea, vomiting, abdominal pain, altered mental status such as disorientation, not able to speak clearly, confusion, and unsteady gait. V11 said that she was the day shift RN on 3/7/2025. V11 said that V11 was aware of R2's lithium level result of 2.81 mEq/L. V11 said that V10 (Assistant Director of Nursing) notified V16 (Psych Nurse Practitioner) of R2's lithium level result. V11 said that V10 received an order for R2's lithium carbonate to be discontinued. On 3/19/2025 at 2:56 PM, V13 (RN) said that V13 had R2 as one of V13 residents for about one year. V13 said that V13 always works the PM shift. V13 said that R2 was oriented x 4 and very cooperative. V13 said that R2 walks with normal gait and with no assistive device. V13 said that R2 only needs supervision with ADL's (Activities of Daily Living). V13 said that around March 4th, V13 received report from the previous shift nurse that R2 was having a minor cough, and general weakness. V13 said that V15 (Medical Nurse Practitioner) gave an order for respiratory panel and ordered cough syrup. V13 said that all the respiratory panel came back negative. V13 said that in a couple of days, R2's condition changed from general weakness to confused state and V13 reached out to V15 for detailed labs. V13 said that V13 received an order on 3/6 evening shift for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Chest X-ray, and urine culture to rule out UTI (Urinary Tract Infection) and sepsis to be drawn on the morning of 3/7. V13 said that every medication is prefilled by pharmacy, and V13 only dispenses it. V13 said V13 never dispenses more than what is ordered. On 03/20/2025 at 10:20 AM, V14 (RN) said that V14 is familiar with R2 because V14 provided care to R2 before. V14 said that R2 was oriented x 3-4, able to make her needs known, and ambulatory. V14 said that V14 was the nurse that sent R2 to (Local emergency room /ER). V14 said that V14 makes a quick assessment before getting shift report and observed that R2 was weak, and not like herself. During shift report, V14 said that V11 (off going RN) reported to V14 that R2's lithium level was elevated, and the lithium carbonate was discontinued. V14 said that V11 reported that R2 is weak and V14 should monitor R2 closely. V14 said that made V14 put R2 on V14's priority list. V14 said that V14 continued to monitor R2. V14 said that V14 checked R2's blood sugar, and it was normal. V14 said that V14 proceeded to assess other residents. V14 said after about 5 minutes, V14 went back to check on R2 and observed that R2 was getting weaker, and V14 said that V14 felt R2 needs to be transferred to the hospital. V14 said that V14 called the shift supervisor. V14 said the shift supervisor called V15 (Medical Nurse Practitioner) who was in the facility at the moment but on a different floor. V14 said that V15 came to assess R2 and V15 gave the order to transfer R2 to (Local ER). V14 said that monthly lithium levels are ordered so that medication can be adjusted depending on the test result. V14 said that the normal lithium level is between 0.6 - 1.20 mEq/L. V14 said that a Lithium level of 2.81 is high. V14 said that some of the side effects of high lithium levels are weakness, seizure, confusion, dizziness, and altered mental status. On 03/20/2025 at 11:20 AM, V10 (Assistant Director of Nursing), said that lithium levels are drawn in order to adjust the medication, and to find out if any toxicity is happening. V10 said that toxicity happens when levels go above normal range, and it can affect the mental status. V10 said that when mental status is altered symptoms include confusion, unable to walk, severe headache, vomiting, abdominal pain, seizure, coma, and death. V10 said that the normal range for lithium blood level is between 0.6 - 1.20. V10 said that a lithium of 1.53 is mildly abnormal because it is above the normal level. V10 said that staff follow the doctor's order. V10 said that on 3/7/2025, V10 reviewed the lithium lab result of 2.81 at 1:23 PM. V10 said V10 called V16 (Psych NP) and notified V16 of the 2.81 lithium level result. V10 said that V16 discontinued the lithium carbonate 450 mg (milligrams). V10 said that moderate toxicity is between 2.5 - 3.5, and severe toxicity is greater than 3.5. On 03/20/2025 at 12:08 PM, V2 (Director of Nursing), said that the lithium blood draws are ordered to monitor the levels. V2 said that the purpose is to make sure that the medication is actually treating the patient. V2 said that V2 does not memorize the range for normal lab results. V2 said that when V2 looks at the lab results, V2 looks at the range. V2 said that toxicity is when the result is above the normal range. V2 said that signs of lithium toxicity are nausea, vomiting, abdominal pain, restlessness, weakness. coma, and maybe death. V2 said that V2 was aware of R2's lithium level result of 2.81 on 3/7/2025. V2 said that when V10 called V16 (Psych NP), V16 discontinued R2's lithium Carbonate. V2 said that when V15 (Medical NP) came later and saw R2, V15 ordered for R2 to be sent out to the hospital. On 3/20/2025 at 12:50 PM, V15 (Medical NP) said that lithium carbonate was ordered for R2 because R2 has schizoaffective disorder. Levels are drawn to make sure that she is being treated with a dose that is appropriate for her to prevent toxicity. V15 said that toxicity is too high of the lithium level. V15 said that altered mental status is a sign of lithium toxicity such as nausea, vomiting, confusion, and kidney failure. V15 said that you want the level to be less than 1.5 and also assess the patient condition. V15 said that she will say that a lithium level of 1.53 is on the high side, but she will also assess the patient symptoms. V15 said that she was aware of R2's lithium level on 2/28/2025. V15 said that V15 collaborates with the psych NP and V15 told the nurse to inform the psych NP R2's lithium level result. V15 said that it is the decision of the psych NP to adjust the lithium carbonate dose for R2. V15 said that she was not managing R2's psychotropic medication. On 3/20/2025 at 1:19 PM, V16 (psych NP) said that R2 was V16's patient. V16 said that R2 is alert, oriented and usually pleasant. V16 said that V16 was not aware of R2's lithium level of 1.53 mEq/L on 2/28/2025. V16 said that if he was notified of the 1.53 mEq/L lab result on 2/28/2025, V16 would have discontinued R2's lithium carbonate. V16 said that staff was to notify psych NP about results of psych medications and notify medical NP of medical medications. V16 said that V16 saw R2 last in January. V16 said that V16 is required to see residents every 60 days. V16 said that V16 was notified of the lithium level of 2.81 on 3/7/2025. V16 said that V16 ordered for the lithium carbonate to be discontinued. V16 said that lithium toxicity is above 2.5 mEq/L. V16 said that lithium toxicity signs include nausea, vomiting, diarrhea, and confusion. V16 said that he ordered for the patient to be monitored. V16 said that V15 (Medical NP) is responsible for sending residents out to hospital for medical reasons, and V16 sends patients to the hospital for behavioral reasons. V16 said that V16 did not contact V15 regarding R2's high lithium level. V15 said that she was notified of the level on 3/7/2025 of 2.81 in the morning. V15 said that V15 told the staff to make sure that the psych NP is notified. V15 said that when V15 came to facility, V15 assessed R2. V15 said that R2 was confused. V15 said that R2 could not answer her questions appropriately like R2 normally does, so V15 sent R2 out to the hospital. R2 is a [AGE] year-old female admitted to the facility on [DATE]. R2's order indicates that R2 was on Lithium Carbonate tablet 450 mg twice a day. Review of the medical administration record from 10/24/2025 to 3/7/2025 indicated that R2 received Lithium Carbonate 450 mg twice daily as ordered. R2's blood lithium level from 10/24/2025 to 3/7/2025 indicated that R2's blood lithium level for 2/28/2025 = 1.53 mEq/L and for 3/7/2025 = 2.81 mEq/L were above the normal range of 0.6 - 1.20 mEq/L. R2's electronic medication administration record indicated that R2 continued to be medicated with Lithium carbonate 450 mg twice daily after a lithium level of 1.53 mEq/L. Review of R2's progress note indicated that R2's weakness started on 3/4/2025. V13 (RN) indicated that R2 was weak on 3/4/2025; V11 (RN) indicated that R2 was weak both on 3/5 & 3/6; V15 (Medical NP) indicated that R2 had general weakness on 3/6 and indicated in V15's note that R2 should continue lithium 450 mg twice daily; On 3/7/2025, V15 indicated that R2 was not able to follow commands and was only speaking minimally. V14 (RN) indicated that R2 had increased confusion and general weakness on 3/7. Lab result from (Local ER) indicated that R2's lithium level on 3/7/2025, was 2.8. It was indicated on R2's ER record that R2 was admitted with 1) Altered Mental Status (AMS) and 2) Lithium Toxicity. The facilities Policy and Procedure for Psychotropic Drugs Usage indicates: Policy: Factors that may contribute to or are responsible for changes in a resident's behavior will be identified by the facility. Such factors may include but are not limited to psychosocial and/or environmental stressors, medical conditions, etc. Procedure: 1. Each resident receiving an antipsychotic medication for organic brain disorders is observed for. Adverse reactions and side effects.

Based on observations, interviews, and record review, the facility failed to follow the pharmacy policy by not noting and implementing open date labels for three of 31 (R76, R196, and R203) residents reviewed during medication storage and labeling task in the sample of 61. Findings include: On 12/03/24 at 10:01 AM inspection of the 3rd floor (high side) medication cart was conducted. Opened and undated medication was observed for: R76 - Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT (Fluticasone-Salmeterol) - no open date written. R196 - Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) - no open date written. R203 - Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate-Vilanterol) - no open date written. R76's active physician order dated 10/04/2024 reads in part, Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT (Fluticasone-Salmeterol) 1 puff inhale orally two times a day for Acute respiratory failure with hypoxia. R196's discontinued physician order dated 02/11/2023 - 05/06/2024 reads in part, Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally at bedtime related to OTHER ASTHMA. R203's active physician order dated 11/08/2023 reads in part, Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. R76's November 2024 medication administration record shows that R76 has been getting the inhaler as scheduled, two times a day. R203's November 2024 medication administration record shows that R203 has been getting the inhaler as scheduled, one time a day. On 12/03/24 at 10:20 AM V20 (Registered Nurse) stated, I always put an open date on inhalers when I initially open them. I don't know if it makes any difference, but it is better when they're dated because when it's not used regularly it may be used long after its opened. Certain medication, especially with shortened expiration date, such as inhalers, have to be used within specific date, those medication lose its effectiveness. On 12/03/24 at 02:53 PM V3 (Director of Nursing/DON) stated, it is important to date shortened expiration date medications upon opening, in order to know how long they're good for. If nurses don't date shortened expiration medications upon opening, they may get used passed recommended time, and then those medications become ineffective and don't work as they should. Two out of three inhalers identified to be undated during medication label and storage task, are good to use for 6 weeks from open date and one is good for 3 months. V3 (DON) presented surveyor with visual evidence that the above inhalers are dated now, surveyor asked how does V3 (DON) know when those inhalers were opened, V3 (DON) responded, We estimated the open date. Pharmacy policy United R: Expiration guidelines for inhalation products dated 07/2013 reads in part, Once these products are opened, they, must be used within a specific timeframe to avoid reduced potency, and potentially, reduced efficacy. Advair diskus (fluticasone/salmeterol) 1 month after removed from foil pouch, Symbicort (budesonide/formoterol) 3 months after removed from foil pouch, Breo Ellipta Discard 6 weeks after removal from foil tray.

Based on observation, interview, and record review the facility failed to follow their policy and procedures for making efforts to ensure resident's grievances regarding late mealtimes were resolved promptly and to the resident's satisfaction. This failure affects three of three residents (R80, R165 and R22). This failure has the potential to affect all 283 residents in the facility who receive meals. Findings include: Per facility census provided during the course of this survey, there are currently 283 residents in the facility. The Facility's Meal Schedule documents lunch times for 4th and 5th floors are from 12:10 PM - 12:30 PM. On 11/13/23 from 12:30 PM - 1:29 PM Observed several residents waiting in the 4th floor dining area for lunch to be served. V8 (Dietary Director) stated the lunch meal was delayed due to a dietary staff being injured and informed she had to assist with meal prep and service. V19 (Certified Nursing Assistant) and V11 (Transportation Coordinator) stated lunch is normally served at 12:30 PM. On 11/13/23 at 1:29 PM Observed lunch being delivered to 4th floor dining area. On 11/14/23 at 11:33 AM during resident council meeting, R80 and R165 stated meals are frequently late. R165 stated this happens about 40% of the time. R80 and R165 stated there's a dietary staff shortage. R165 stated about 2-3 months ago he documented 7 weeks' worth of observations of late meals and turned it in to the facility. R165 stated he reported the times meals were served as opposed to when they should have been served. Resident Council Concern Form dated 08/17/2023 documents R165 expressed concern about meals being served late. Resident Council Meeting Report from August 08/17/2023 documents residents are concerned about meals being late. A grievance form dated 09/21/2023 documents a concern regarding MDR (Main Dining Room) issues stating 90% of these problems would be solved with proper staffing. Resolution includes assigning department managers along with a certified nursing assistant to monitor and assist for all meals and assistant administrator continuously overseeing as well. The facility's Grievance Policy reviewed 11/16/2023 states: The Grievance Official will: If necessary, take any required immediate action to prevent further potential violations of any resident right while the violation is being investigated. 40987 R225's physician orders for diet indicate 4/19/23 general diet mechanical soft with pureed meat texture, thin liquids consistency, Korean food, super cereal @ breakfast. Whole milk BID. The 10/19/23 care plan indicates R225 with potential for nutritional risk related to new CVA Cerebrovascular Accident; Dysphagia, Dementia. Diet downgraded to pureed. Needs assistance with eating. Interventions indicate prepare/serve the resident's nutritional diet as ordered. Prescribed diet is: general/pureed. Mechanical soft with pureed meat. On 11/13/23 at 01:14 PM, lunch arrived to the 5th floor dining room. At 1:45 PM, R225 does not have a lunch tray prepared. R225 is a mechanical soft diet with puree meat. V4 ADON (Assistant Director of Nursing) in the dining room who were preparing lunch trays. V4 and staff were unable to locate R225's lunch meal. V4 ADON placed a call to the kitchen from her cell phone informing them to prepare a lunch tray for R225. V4 said, I just called the kitchen, they're going to make R225 a tray and bring it up. On 11/16/23 at 10:00 AM , V8 Dietary Manager said, Our food is fresh, it's a challenge. We are working on managing our time better. I had a cook that was injured so I helped out on Monday. We're not late all the time. Lunch for 5th floor didn't arrive until 1:14 PM. V8 said, We have a sheet that we mark when the food leaves the kitchen. Once it leaves it's out of our control. The 5th floor lunch times for the high side is 12:20 PM and low side 12:40 PM. It was late on Monday. We have staff on the units to help serve. V8 said, I missed a couple resident council meetings. I received a grievance from R165, he's from the 1st floor. I signed off on it. The staff didn't bring it up to me about other resident concerns about late meals. Moving forward today I'm going to in-service my staff on meal times. That's my solution. V8 did not have an answer to how the late meals could affect residents. On 11/16/23 at 10:09 AM, V4 ADON Assistant Director of Nursing said, The kitchen supervisor is trying hard to prepare it. The preparation is from fresh food, it's Korean. It's like home cooked, it takes time. R225's tray wasn't in his room at the time. V4 said, One of the CNA's Certified Nurse Assistant found it after you left. It was on one of the other carts. When V4 was asked, Why was the tray not found while staff were looking for it on the carts? V4 said, I don't know. V4 said, We address it in our stand up meetings, we say it's a problem. It's addressed through leadership to the Kitchen Supervisor, the Administrator and Director of Nursing to communicate. We offer to help pick up the trays from the kitchen. We help pass trays to residents. Each manager has a floor to help everyday. I'm on 5th floor. I help make sure everything is organized and everyone is practicing infection control. V4 said, It affects the residents, they get upset when they're hungry. It frustrates them.

Based on observation, interview, and record review the facility failed to provide an environment that was clean and free of pervasive odor by failing to clean a resident's room per facility policy and protocols. This failure affected one resident (R64) of one resident reviewed for housekeeping on the sample list of 50. Findings include: R64 is a [AGE] year-old female who was originally admitted to the facility on [DATE], with past medical history of Heart failure, type 2 diabetes, weakness, need for assistance with personal care, sepsis, morbid (severe) obesity due to excess calories, major depressive disorder, psoriasis, weakness, anxiety disorder, etc. On 11/13/23 at 12:00PM R64's door was closed with contact isolation sign on the door and an isolation bin with personal protective equipment (PPE). After opening the door, R64 was sitting on her bed, awake, alert and oriented and stated that she is doing okay. R64's room was very dirty with pervasive odor, paper towel was littered all over the bathroom floor and garbage can was overflowing with garbage. R64 said, I am sorry my room is dirty, no one comes in to clean the room because they said I have a disease. I came back from the hospital on Friday and since then, no housekeepers have entered the room. R64 stated that it is very frustrating to her, they act as if they will die if they come into her room. On 11/13/23 at 12:20PM, R64 was standing at her door with her walker and complaining to the nurse (V5) who was in the hallway passing medication about her room that has not been cleaned. V5 (nurse) told resident that her room was cleaned yesterday but resident insisted that no housekeeper has been in her room since Friday. Review of medical record showed that resident was sent to the hospital for fever and chills, was treated for sepsis, cellulitis and leg wound infection, was readmitted to the facility on Friday, 11/10/2023 and on contact isolation for MDRO in wounds. The facility's grievance/concern log showed a concern filed on 9/21/2023 by a resident regarding improper cleaning of her room. On 11/13/23 at 12:08PM, V20 (Housekeeper) was observed cleaning resident's rooms on the low side of unit 3 near R64's room, V20 was asked whether she cleaned the resident's room, and she said not yet. V20 added that she is scared of going into the room because she has cancer but she thinks the room was cleaned by the 3 to 11pm shift the previous day. On 11/14/2023 at 2:10PM, V21 (Housekeeping Director) said that V20 did not clean the resident's room because she was afraid, she relied on V20 to switch the room with another housekeeper. There are nine housekeepers on day shift, two on each floor (2, 3, 4, and 5) and one on the first floor. V21 said that she can move V20 to another floor to avoid a repeat of what happened yesterday, she added that she saw resident's room after concerns were noted and it was filthy. V21 said the room was cleaned right away and that the resident being on isolation is not an excuse not to clean her room. Housekeeping policy (undated) provided by V2 (Assistant Administrator) stated its purpose as to provide a clean, attractive, and safe environment for residents, visitors, and staff. The section of the policy titled infectious area cleaning policy and procedure daily cleaning states the same purpose as above, responsibility indicated housekeeping staff/laundry staff. Under protective equipment, the policy states in part to check with nursing staff on requirements for entering isolation room and ensure there is a sign on the door. Wear proper PPE and any other item recommended by the manufacturer. Daily cleaning procedures item 4 states, empty trash and put the filled liner in the isolation garbage within the room. 7. Using cleaning cloths impregnated with a disinfectant cleaner, start at one side of the door and working around the entire room, clean all surfaces of cabinets, lockers, bedside tables, overbed tables, IV poles, wheelchairs, commode, call bell/cord, blood pressure cuff, medical apparatus, etc. Follow manufacturer's guideline or product supplier recommendation. Daily cleaning of infectious area section of the policy under Note for Viruses stated in part, for MRSA, Noro virus influenza, or Covid 19, use Clorox clean up disinfectant cleaner with bleach, Clorox healthcare bleach wipes with a dwell time of 5 minutes, 30 seconds to be left on the surface.

Based on observation, interview, and record review, the facility failed to implement care plan interventions addressing behaviors of anxiety, agitation, and physical aggression for a resident with cognitive impairment and mental disorder. This failure applied to one (R87) of one resident reviewed for behavior management on the sample list of 50. Findings include: R87 is a [AGE] year-old, male, initially admitted in the facility on 03/14/2014 with diagnoses of Huntington's Disease; Bipolar Disorder, Current Episode Depressed, Mild or Moderate Severity, Unspecified; Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance; Schizoaffective Disorder, Unspecified; Schizophrenia, Unspecified; Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition and Degenerative Disease of the Basal Ganglia, Unspecified. R87's POS (Physician Order Sheet) dated 08/29/23 documented: Physical Aggression every shift. Resident has signs and symptoms of physical aggression at times. Anxiety every shift. Clonazepam (Benzodiazepine) tablet 0.5mg (milligrams) give one tablet by mouth three times a day, Haloperidol (Antipsychotic) tablet 2mg give 2 tablets by mouth two times a day, Seroquel (Antispychotic) tablet 400mg give 1 tablet by mouth at bedtime. On 11/15/23 at 12:25 PM, R87 was observed in the dining room, sitting in his wheelchair. There were other residents observed in the dining room eating lunch. Suddenly, R87 stood up, his chair alarm went off. V17 (Certified Nurse Assistant, CNA) went to R87 to stop him from standing up. He (R87) sat down but stood up again. V5 (Registered Nurse, RN) went to R87 and assisted V17 to stop him (R87) and have him sit in his wheelchair. R87 insisted to stand up and walk away but V5 and V17 were holding his (R87) arms and hands suppressing him (R87) to walk and made him sit in the wheelchair. Both V5 and V17 stated, You need to sit down, you might fall. What do you need? R87 did not respond but kept on standing up while both (V5 and V17) staff insisted him to sit in the wheelchair. At this time, as V5 and V17 restricting him to stand up and walk, R87 became more agitated and started pushing V5 and V17. V5 stated in a quite loud manner, You need to let go of me, you need to sit down. He (R87) sat down in the wheelchair but still insisted on standing up and pushing V5 and V17 again in an aggressive manner. At this time, R87 became uncontrollable. V5 left to get some assistance by calling code gray. V17 tried to make R87 sit in the wheelchair but he kept on standing up, walked towards the chair in front of him (R87) and sat down, while V17 tried to ask what he needs, he (R87) responded that he wants to go back to his room. V17 was asked regarding R87's behavior. V17 stated, He do that at times. We try to call somebody for help. He is really strong. V5 was interviewed regarding R87's behavior. V5 replied, Recently yes, he's standing up from his wheelchair or from bed. That is why he has a chair and bed alarm. He was on Clonazepam and Haldol. We just redirect him to sit down and ask what he needs. He is too heavy, so we need a second person. We make sure he is not getting harm. If he is not listening and might be harmful to others, we have anti-anxiety medication to give. On 11/15/23 at 12:50 PM, V18 (Social Services Director) was asked regarding R87. V18 mentioned, He has a history of that behavior but has not done it in a while. He usually yells out. We make sure he has bed alarm and chair alarm on. We watch and stay with him. Report to CNA and RN. If he calms down, it's okay and continue to monitor. If he does not calm down, reach out to physician. R87's care plan on behavioral distress dated 06/01/22 documented the following interventions: If the resident becomes verbally or physically abusive attempt to calm the resident by explaining that ladies and gentlemen do not talk/behave this way. We do not touch other people. If talking to the resident is not successful in stopping the behavior, try to walk with the resident to a quiet area, away from other individuals. Intervene by speaking calmly and professionally in a soft tone of voice. Staff should avoid raising own voice, since this tends to make the resident more upset. This may cause the situation to escalate. Ask the resident to calmly explain what is causing this upsetting behavior. Praise the resident to speaking calmly and appropriately. On 11/15/23 at 2:05 PM, V3 (Director of Nursing) was asked on the right approach to R87 to prevent behavior escalation. V3 stated, Sometimes he is verbally abusive and physically aggressive. He could swing. There was an incident before that he wants to get coffee, he stood from wheelchair, and he swung his arms at staff. It happened in the hallway. He gets agitated when tries to get something and thinks staff is preventing him to do so. We have to talk to him on a clear soft tone. At times he could be aggressive, at times he could be redirected. If not able to redirect him, speak to him and bring him to his room. Separate from other residents by bringing him back to his room. Then, ask him what he needs. With the incident today, code gray was announced, which means violent resident. I went there and approached him in a calm manner. I redirected him and took him to his room. He told me that he wants to go to bed. We laid him down to bed. After two minutes, he said he wanted to go to the toilet. I asked the CNA for assistance. I also asked Social Services to provide one on one. Facility's policy titled Behavior Management Psychotropic Medication Protocol undated, stated in part but not limited to the following: Procedure: 3. Established resident receiving psychotropic/psychoactive medications/behavior management program: d. The interdisciplinary care team will update the care plan to include the problem behavior goals and approaches. e. The planned interventions for each individual resident's behavior will be communicated to the appropriate staff members, interventions and response will be documented.

Based on observation, interview, and record review the facility failed have an effective cleaning policy and practice to remove urine odors in the resident room and bathroom. This affects 1 (R1) of 3 residents reviewed for odors and cleanliness. Findings include: On 2/25/23 at 11:31am R1 was observed resting in low bed R1 was observed to be awake but not verbal at this time, orientation was undetermined. On 2/25/23 at 11:31am observation of R1's room noted to have an odorous smell near bathroom door. Upon opening the bathroom door, the odorous smell became more pronounced. The toilet bowl was noted to have a dark stained area in the back of the toilet where the toilet base met the floor. At 12:00pm V1 (Housekeeper) toured with surveyor. V1 said this was her first time going into R1's room today. V1 pulled down her mask and said, I smell urine; I'm going to clean it now. At 12:30pm V1 was observed to be cleaning the adjunct room to R1's room. V1 said she was finished cleaning R1's room including the bathroom. At 1:21pm during follow-up observation of R1's bathroom with V2 (Housekeeper), V2 said, I smell urine. V2 said he would clean the bathroom immediately. V2 was made aware that the housekeeper cleaned it recently. V2 replied he used to work this section and when he worked in this section, there was an issue with the bathroom smelling like urine. The dark stained area/debris remained in the back of the toilet where the toilet base met the floor. V2 said the facility has a solution that they use for urine odors. V2 escorted surveyor to the housekeeping closet. On the housekeeper cart, there was a bottle of (brand name) urine remover noted. V2 said the housekeeper should be using this solution for urine odors. V2 was asked if the solution is effective against urine smells. V2 replied sometimes the urine is saturated through the floor. V2 was asked if that was the situation for R1's bathroom. V2 said sometimes that is the issue. On 2/25/23 at 1:52pm V3 (Director of Housekeeping) said when cleaning the resident room, the housekeeper does an ocular inspection for safety hazards, like spills, and cleans safety hazards first. V3 said the housekeeper then checks the walls, removes the trash, replaces bags, wipes dressers, sweeps and mops. V3 said the housekeeper then cleans the bathroom, cleaning the sink first, wipes down handrails, then clean the toilet bowl, wipes the toilet seat, cleans the inside of the bowl with toilet brush, and mopping is the last task. The housekeeper puts solution in bucket, wets the mop, then mops the floor using a figure 8 motion removing debris as they mop. V3 said the floor should be mopped 2 to 3 times. V3 said regular solution is used for mopping, however if there is urine on the floor or if a urine smell is present, the urine remover solution should be used. V3 said she was aware that R1's family had concerns with R1's room being dirty, and issues were resolved with housekeeping cleaning the room. V3 said she is aware that there are concerns with R1's room and bathroom smelling of urine. V3 replied that the housekeeper cleans the bathroom twice a day, and they are following the manufacturer's instructions for usage. V3 said the resident room and bathroom should not smell like urine, this (facility) is their home, and their home should not smell like urine. Review of facility concern log, concern form dated 1/22/23 for R1, denotes in part family stated that room is very dirty again, floor is sticky, food particles on floor, bedding, and chair. Resolution date 1/23/23. Review of the (brand name) urine remover cleaning solution denotes general instructions: spray directly onto stains until completely covered. Rinse with water or wipe with a clean damp cloth. For grout and tougher stains, spray directly onto stain until completely covered, wait 5 minutes, then rinse with water or wipe down. Facility General Cleaning Resident Rooms policy documents in part to provide a clean, attractive and safe environment for residents, visitors and staff.

Based on observation, interview and record review the facility failed to ensure a resident was free from physical abuse. This applies to 1 of 3 residents (R5) reviewed for abuse in the sample of 9. The findings include: On 5/13/22 at 9:15 AM, R5 was in her room sitting in her wheelchair. Six staples were observed to the top of her head. R5 said she got hit with a shoe on the back of her head. R5 said a woman (R6) was looking at her shoes trying to take them. R5 said she told the woman (R6) to stop, and she hit me on the top of my head with the shoe. R5 said It hurt and she was bleeding from the top of her head. On 5/13/22 at 11:06 AM, V9 (LPN) said she was the nurse on 4/29/22 during the incident. V9 said that morning R6 was wandering and pacing the halls. V9 said she was in another room, and she heard screaming. V9 said she saw R6 with a shoe in her hand coming out of R5's room. V9 said when she went to R5's room and she saw R5 sitting on the floor with blood all over her head. V9 said she asked R5 what happened and R5 said R6 came into her room trying to take her shoe and R6 hit her on the top of the head. V9 said R5 is alert and oriented x2 and was able to tell me exactly what happened. V9 said R6 is confused and likes to wander into other resident rooms, and she is not easily directable. V9 said when R6 goes into other resident rooms it's very difficult to her get her out and there is a history of being very aggressive like she's going to hit you. V9 said R5 was sent out to the local hospital and had staples to the top of her head. R6's face sheets shows she is a [AGE] year-old female with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Minimum Data Set assessment dated [DATE], shows her cognition is severely impaired with wandering behaviors significantly intrudes on the privacy of others. R6's current care plan shows R6 has behavioral symptoms related to dementia. R6 has a history of going into other resident rooms and taking their belongings. The interventions in place include R6 being re-directed when presenting with symptoms. R5's nurses note dated 4/29/22 documents V9 (LPN) heard noise coming from R5's room. R5 was observed sitting on the floor next to her bed with bleeding from the top of her head. R5 had a cut to the top of her head. R5 said another resident (R6) entered her room and took one of her shoes and in attempting to get her shoe back (R6) hit her in the head with the shoe and pushed her. The Incident Report dated 4/29/22 documents that at about 6:30 AM, R6 was seen coming out of another resident's room (R5) with a shoe in her hand R5 reported inappropriate behavior from R6. R5 was sent out to the local hospital and returned with staples to the top of the head. On 5/13/22 at 2:30 PM, V1 (Administrator) said physical abuse is when someone is hit by another person. On 5/13/22 at 2:35 PM, V2 (DON) said it's unfortunate what happened with R5. V2 said R6 was admitted for inpatient psych due to her behaviors and remains hospitalized . V2 said residents should be free from physical abuse. The facility's Abuse Prevention Policy revised 2019, states, This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents Physical abuse: hitting, slapping, punching Abuse: The willful infliction of injury .willful as used in the definition of abuse means the individual must have acted deliberate, not that the individual must have intended to inflict injury or harm .

Based on observation, interview and record review the facility failed to maintain storage temperatures for refrigerated medications in one of four medication rooms reviewed for medication storage. Findings include: On 3/10/22 at 11:15 AM a medication refrigerator had a digital thermometer that indicated that the temperature was 73.6 degrees (Fahrenheit). The refrigerator contained three 10 ml (milliliter) vials of [MEDICATION(S)] N insulin, two 10 ml vials of asparte insulin, two 3 ml [MEDICATION(S)] pens, four 3 ml [MEDICATION(S)] insulin pens, ten insulin detemir pens, ten 3 ml asparte insulin flexpens in a plastic bag with condensation, four 1 ml [MEDICATION(S)] vials, six 2 mg [MEDICATION(S)] vials in a plastic bag, one box of 25 [MEDICATION(S)] vials, two 30 ml bottles of [MEDICATION(S)]. All of the medications were unopened. V13 (Registered Nurse) said, the night shift checks the refrigerator temperatures. The temperature log was requested but was not provided. On 3/10/22 at 1:30 PM V4 (Assistant Director of Nursing) said, those medications should be thrown out. The refrigerator temp should be about 40 degrees (Fahrenheit) not 70 degrees. A policy titled Medication Storage In The Facility, dated 6/29/11, indicates; 11. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator. Medications requiring storage 'in a cool place are refrigerated unless otherwise directed on the label. 12. A thermometer must be kept in the refrigerator containing medications to allow proper temperature monitoring.

Based on observation, interview, and record review the facility failed to maintain privacy of electronic medical records, and maintain visual privacy for two residents (R258, R458) of four residents reviewed for medication administration and six residents reviewed for wound care in the sample of 37. Findings include: 1. On 3/9/22 at 8:25 AM V21 (RN-Registered Nurse) prepared medications to administer to R258. V21 left the computer open to the MAR (Medication Administration Record) for R258. V21 administered medication to R258 via the g-tube (gastric tube). V21 did not close the privacy curtain for R258. R249, a roommate, was seated in a chair with R258 in her direct line of sight. During the medication administration R30, roommate, came around the curtain to the open area with R258 in her line of sight. V21 said, I should have closed the privacy curtain and turned off the computer. On 3/10/22 at 1:30 PM V4 (Assistant Director of Nursing) said, the nurse should pull the privacy curtain when giving those meds through the g-tube (gastric tube). The computer screen should be left blank when it is unattended. A policy and procedure titled Enteral Tube Care and Feeding, revised 1/12/22 indicates 4. Introduce self, explain procedure and provide privacy. A policy titled Medical Records, undated, indicates Electronic clinical system kiosks are designed with HIPAA (Health Insurance Portability and Accountability Act) privacy screens to limit casual viewing of resident information when in use in public areas. 2. 03/09/22 10:34 AM - During R458's wound care, (V27) CNA (Certified Nurses Assistance), in preparation for the resident's wound care, unfastened R458's adult diaper without pulling the curtains fully or closing the door. R458 has a roommate. V6 (Wound Care Nurse) closed the door before changing R458's wound. At 10:48 AM, while the wound care was in process, V28 (CNA) came into the room without knocking at the door. V27, on 3/9/22 at 10:50am, V27 was asked what he should have done before unfastening R458's diaper, and she said, pulled the curtains and closed the door. V28, on 3/9/22 at 10:51am was asked what she should have done before entering the room, and she said knock and wait to be invited in. V6, on 3/9/22 at 10:55 am, said V27 should have pulled the curtain and closed the door before unfastening R458's diaper, and also said that V28 should have knocked on the door and wait to be invited in. V4, on 3/10/22 at 2:00 pm, said she expected her staff to knock at the resident's door, wait to be invited in, close the door, introduce themselves, and pull the privacy curtain if there is a roommate before providing direct care to the residents. Policy and Procedure Resident Privacy and dignity Purpose: To ensure that all residents are provided with dignity and privacy. To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility. Policy: 2. Staff will knock on the resident's door prior to entering the resident's room. Staff will be invited into the resident's room if the resident is capable of the invitation. The staff will announce their presence after knocking to any resident that is unable to respond to the request to the request for entrance. 3. Privacy will be maintained for all resident's receiving ADLs such bathing, dressing and peri-care with the resident room/shower room door closed and curtain drawn.

Based on observation, interview and record review the facility failed to follow its abuse prevention program by failure of the staff to immediately notify the abuse coordinator (Administrator) of a resident-to-resident altercation that occurred in the facility. This deficiency affects two ( R226 and R109) of three in a sample of 37 residents reviewed for Abuse prevention program management. Findings include: On 3/8/22 at 11:17am, Observed by the corner of the hallway closer to the public phone on second floor beside the nursing station, R226 was screaming and yelling for help as she carried the chair in front of her to use as a shield from R109 who is aiming both of his clenched fists towards her. V7 RN (Registered Nurse) and V10 CNA ( Certified Nurse Assistant) came to help and separated the two residents. R109 went to his room and R226 stayed by the public phone seated on the chair. V10 CNA said that R109 used to sit in the chair in the corner by the hallway, but R226 used it and he got mad. On 3/9/22 at 9:50am, V13 RN said that she did not hear any report about a resident-to-resident altercation on the second floor yesterday. Reviewed both R226 and R109's progress notes, no documentation of resident-to-resident altercation occurred yesterday. V13 said that if she observes or becomes aware of an altercation between residents, she will immediately report it to the administrator and document the incident. On 3/9/22 at 10:43am, V10 CNA said that R226 and R109 were fighting about the chair yesterday. V10 CNA said that R109 used to sit in that chair, but R226 used it and he got mad. V10 said that she did not report it to the administrator because she expects V7 RN to report it because she also observed and helped to separate both residents. She added that if she observed it by herself, she would report it to the nurse, supervisor, or administrator. On 3/9/22 at 10:50am, V15 Social Service Director said that she is not aware of the altercation that happened between R226 and R109. She said that if she observed or if the incident was reported to her, she would notify the administrator immediately. She would also document the incident and update both resident's care plan. On 3/9/22 at 10:57am, V7 RN said that R109 was trying to hit R226 because she used the chair, R109 usually sits on it by the corner of the hallway. They separated the two residents. She said she did not document the incident and did not report it to the supervisor or to the administrator, but she reported it to V17 Social Worker. She said she should have documented it and completed an incident report, but forgot it. She said that she has been working in the facility since [DATE] and has not attended abuse in-services. On 3/9/22 at 11:06am, V17 Social Worker said that V7 RN told her about R226 and R109 altercation, but he did not witness it. He said that he did not report to V15 Social Service Director or to Administrator, and did not document the incident because he did not witness it. He said he should have reported it to the administrator and documented it. He said that he has been working in the facility since [DATE] and has not attended abuse in-services. On 3/9/22 at 12:09pm, V4 ADON said that any staff who witness altercations between residents should report immediately to the administrator. On 3/9/22 at 1:38pm, V1 Administrator said that he just learned today about the altercation between R226 and R109. He said the staff should report to him immediately any resident-to-resident altercation that occurs in the facility. He said that he initiated a resident to resident abuse investigation and submitted initial report to IDPH. On 3/9/22 at 2:00pm, V2 Assistant Administrator (AA) provided copy of the initial resident to resident abuse report submitted to IDPH. Report indicated that the incident happened on 3/9/22 instead of 3/8/22. Showed discrepancy of the report to V2 to have it corrected. On 3/9/22 at 2:20pm V2 provided a copy of the revised incident which indicated: incident dated 3/8/22 and reported to administrator on 3/9/22. R226 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R109 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility's Abuse prevention program indicated: V. Identification of Allegation/Internal reporting requirements: Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, misappropriation of resident property, mistreatment, or a crime against a resident they observed, hear about, or suspect to the administrator if available or an immediate supervisor who must immediately report it to the administrator. In the absence of the administrator, reporting can be made to the DON. Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident is reported to a covered individual; covered individuals are notified annually of these reporting requirements.

Based on observation, interview and record review the facility failed to notify the physician of an edematous (swelling) right hand and arm for one of one resident reviewed for notification of change in condition in a sample of 37. Findings include: On 3/9/2022 at 11:00am R80 was observed coming out the washroom, and her right arm and hand has 2-3 plus [CONDITION(S)] and hanging down on her side. R80 is observed using left arm to move right hand. On 3/9/2022 at 11:05am V22 (Registered Nurse) observed R80 right hand and arm with surveyor and said yes, it's always edematous. The certified nursing assistant-(CNA) should apply the sling or the restorative staff, I think. On 3/9/2022 at 11:10am V26(Restorative Nurse) said R80 receives (Active assistive range of motion-AAROM) daily she does not wear a sling anymore. I did not know that R80's right hand and arm has [CONDITION(S)], I would have had the physical therapy department to evaluate and then take their recommendations from there. The restorative aid did not notify me of any [CONDITION(S)]. On 3/9/2022 at 11:20am V24(Restorative Aid) said I did active assistive range of motion with R80. I did notice that her right hand was edematous, I did not notify the nurse, they already knew about it. I should have notified the restorative nurse I didn't do that. On 3/9/2022 at 12:00 pm V23(Primary Attending Physician) said I was not aware that R80 right hand and arm was edematous if so, I would have ordered an x-ray and elevate the extremity until results are in. 3/11/2022 at 10:50am a review of R80's face sheet indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall incident report dated 9/19/2021 that indicates R80 had an injury to the right forehead with swelling. A root cause analysis that resident fell to her right side. And returned on 9/23/2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 9/19/2021 that indicated R80 tried to get out the bed and lost her balance and fell . R80 hit her right forehead on the floor and sustained a bump on the right forehead. Physician ordered to monitor resident and do Neuro checks. On 9/24/2021 A Illinois department of public health incident report indicated the conclusion Resident fell on ,d+[DATE].2021 to her right side. MD-medical doctor was notified. Received orders to monitor. Swelling to right eye increased on 09/20/2021. MD and family notified. Received orders to transfer to ER-emergency room for evaluation. Resident was admitted . Resident returned on 09/23/2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care-plan dated 10/1/2021 indicated a problem with impaired mobility and limited strength at risk for joint stiffness/limitation secondary to musculoskeletal, neuromuscular, and cognitive disorder. On 09/19/2021 a history of falls. On 10/05/2021 right arm sling, on 11/3/2021 right arm weight bearing as tolerated on. Intervention number 10. Collaborate with Physical therapy and Occupational therapy PT/OT for changes/decline w/joint mobility function. A restorative program for R80 indicated (active range of motion-AROM) on 3/3/2022, 3/4/2022, 3/5/2022, 3/6/2022, 3/7/2022, 3/8/2022, 3/9/2022. Facility Policy: dated 6/26/2011 Policy and Procedure/ Change in Resident's Condition or Status Purpose: To ensure that the resident's attending physician and representative is notified of changes in the resident's condition and /or status. Policy: 1. The nurse will notify the resident's attending physician when: . There is a significant change in the resident's physical, mental and psychosocial status. 3. A significant change of condition is a decline or improvement in the resident's status. . Will not normally resolve itself without intervention by staffing or by implementing standard disease related clinical interventions. 6.The nurse will record in the resident's medical record any changes in the resident's medical condition or status.

Based on observation, interview and record review the facility failed to provide a bilateral knee brace to prevent/decrease knee flexion and tightness as ordered in a timely manner. This failure affects one(R223) of three in a sample of 37 residents reviewed for Restorative Program Management. Findings include: On 3/8/22 at 10:48am, Observed R223 resting in bed. V8 RN (Registered Nurse) and V9 CNA (Certified Nurse Assistant) said that R223 is a total care resident and is nonverbal. Observed bilateral heel protectors in place and the resident was not wearing bilateral knee braces. On 3/8/22 at 11:58am, Observed V9 CNA providing morning care to R223. No bilateral knee brace observed. On 3/8/22 at 1:28pm, V9 CNA said that she is the regular CNA for R223. She only applied bilateral heel protectors. He does not wear bilateral knee braces. On 3/9/22 at 9:30am, V9 CNA said that she has not seen R223 wearing bilateral knee braces. For splint and braces, the restorative aide is the one to apply. On 3/9/22 at 9:58am V13 RN said that she is the nurse for R223 and she is not aware if the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Check skin frequently for any redness, any skin irritation or any discomfort. Surveyor and V13 went to R223's room. Observed R223 resting in bed, not wearing bilateral knee braces. V13 searched the room and found both knee braces inside the drawer. On 3/9/22 at 10:52am V16 Restorative Aide said that he is assigned to 2nd floor and 3rd floor restorative program. R223 is not listed for splint or braces. She was called by V13 RN regarding R223 bilateral braces as ordered. She took the bilateral braces and said that she will show it to V18 Restorative Nurse for approval, and if she could apply it. She said that for the resident's splint and braces, she applies them after breakfast and removes it before the end of her shift. Reviewed 2nd floor restorative program list for residents dated 3/4/22 indicated that R223 is not listed for splint/ braces. R223 is listed for AAROM ( Active Assistive Range of Motion) and grooming program. On 3/10/22 at 9:42am V18 Restorative Nurse said that she is responsible for the restorative program for all residents in the facility. Asked V18 if she is aware of R223's order for bilateral knee braces on 3/3/22. She said that she has to wait for 5 to 7 days to evaluate the resident after receiving the order .She said that they initiated it on 3/8/22 when the knee brace arrived. She is not aware if R223's physician was notified of the delay in application of knee brace. Informed V18 that surveyor has interviewed both nurse and CNA who worked with R223, both said that R223 has not been using bilateral knee braces. V18 was made aware that V4 ADON provided documentation of bilateral knee brace was applied on 3/8/22, but both V16 Restorative aide and V9 CNA stated they did not apply R223's knee braces. V18 said that they should not document if it was not done. On 3/10/22 at 9:58am, V6 WCN ( Wound Care Nurse) said that she has been doing R223's wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/10/22 at 10:06am, V20 Physical Therapist said that she as the one who took the order and documented for R223's use of bilateral knee braces to prevent/decrease knee flexion tightness, to use for 4 to 5 hours/day as he tolerates it. V20 said that she gave in-services to the nursing staff on the same day she wrote the order on 3/3/22. V19 Therapy Director provided copy of in-service attendance provided to floor Nurse, Restorative aide, and CNA. V20 said that R223's knee braces are available for them to apply since 3/3/22. V20 provided copy of her therapy documentation dated 3/3/22 that staff training, and education was provided. On 3/10/11 at 11:22am, V9 CNA said that she did not apply the knee brace on 3/8/22 and 3/9/22 and she just mistakenly documented it. She added that she is very busy and just marking it without reading. Facility's Range of Motion and Splint policy and procedure provided by V4 ADON indicates: ( V4 said that they use the same policy for braces) Procedure for splints: 4. Once the resident has been evaluated by skilled therapist and the facility has recommendations for the splint; the Restorative Nurse and the Skilled therapist will select an appropriate splint and order per current vendor. 7. Once the splint arrives, the Restorative Department will update the care plan, will label the splint with resident name, will initiate the daily splint application tracking log in the point of care. 9. Educate resident and staff on use of the adaptive equipment upon arrival and PRN as indicated. Facility's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to follow their change in condition policy by not calling 911 for a resident with acute change in condition unstable vital signs. This failure affected 1 resident (R1) of 3 residents reviewed for change in condition. This failure resulted in a delay in receiving hospital treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 2-22-22, at 1:15 PM, concerned party said he believes the facility should have called 911 for emergent transfer rather than calling ambulance for ETA transfer of 40 minutes. On 2-22-22 at 12:16 PM, V2 (DON) said primary nurse was aware of 2 episodes of loose bowel movements, B/P (blood pressure) was 89/57 (lower than base line) and HR was 110 (greater than baseline). R1's vital signs is a critical change in condition. Based on R1's appearance (no signs of distress) The 2 supervisors, felt R1 was stable enough for 40 min ETA transfer to hospital. V2 would prefer to call 911 due to R1's critical change in vital signs. On 2-18-22 at 2:41 PM, V3 (RN) said nursing supervisor called private ambulance company. In the morning R1 was alert and oriented, vitals stable 110/69, pulse 96, 18, temp 97.6, o2 sat(saturation of oxygen in blood %) 94%, ate 50% for breakfast, refused lunch due to change in condition (after 2:00 PM). R1 B/P 89/51, 117, 18, o2 sat 71% RA (room air) - put on 3 liter (oxygen) - 94%, temp 94 temporal. Notified NP, NP gave order to send to hospital. nursing supervisor acknowledged o2 sat 94% on 3 liters and decided to call private ambulance company. On 2-22-22 at 10:44 AM, V4 (Nurse Supervisor) said she was not aware of order to send to hospital via 911 or medical transport from NP. V4 was not staff who ordered medical transport. V4 was not aware of 40 minute ETA. V4 is familiar with R1 who appeared stable and per her baseline. V4 was not aware of B\P of 89/51 or HR of 117. If V4 knew these values for R1, V4 would have called 911 for R1 transport. On 2-22-22 at 11:16 AM, V5 (Nursing Supervisor) said primary nurse reported R1 had 2-3 loose bowel movements and labs ordered. Change in vitals BP 89/58 and heart rate 110, o2 sat was fluctuating, oxygen nasal applied and was stable at 95% with 3 liters per minute. Primary nurse updated NP who gave orders to send to hospital. V5 ordered medical transport for R1 and received the ETA of 40 minutes. R1 appeared alert and responsive. No distress noted. R1 was stable. 89/58 and 110 is a critical change in condition and requires emergent care. Comparing baseline to new change in vitals, this would warrant emergency ambulance (911). On 2-22-22 at 9:42 AM, V8 (NP) said primary nurse updated V8 regarding bowel movement and labs ordered. Primary nurse updated regarding saturation and V8 ordered to send out due to change in condition (desaturation, low oxygen). V8 would have preferred to transfer via 911 due to desaturation. V8 said she did not specifically say transfer via 911 but thought it was assumed due to critical change in condition (oxygen desaturation). R1's Medical Records document the following vital signs: at 12:30 PM, blood pressure 110/60, heartrate 96, oxygen saturation 96% (room air), at 2:00 PM, blood pressure 89/57, heartrate 110, oxygen saturation 71% (RA) the 94% (3 lpm), at 2:30 PM, blood pressure 89/51, heartrate 117, 94% (3 lpm). Ambulance Run Sheet dated 2-17-22 at 3:58 PM, documents blood pressure 83/51, heartrate 104, oxygen saturation 84 (on supplemental oxygen). Run Sheet documents dispatch was notified at 2:32 PM, at scene (facility) at 3:19 PM, and at destination at 4:02 PM. Ambulance Run Sheet documents Chief Complaint-Unresponsive R1's Hospital Record (dated 2-17-22) documents Critical Care: 120 minutes of critical care time spent at the bedside performing history, physical, diagnostic evaluation, complex data interpretation, discussion with consultants, creating a diagnostic and therapeutic plan for this critically ill patient at risk for significant or life threatening decompensation and/or imminent organ failure. ED Course: MDM: [AGE] year old female here for unresponsiveness. R1 is hypotensive, hypoxic. R1 had melena in diaper suspicion for possible upper GI bleed. R1 was emergently intubated due to inability to protect airway. R1 found to be likely in combination of hemorrhagic and septic shock. CT scan suspicious for possible ischemic bowel and possible neoplasm. Labs are significant for leukocytosis to 18.4. VBG shows significant acidosis. ICU has come down to evaluate the patient, they have spoken with brother about the likely outcome. Family member states is ok with transition to comfort care. Decision to withdraw care made due to extremely poor prognosis. R1 was extubated and shortly thereafter developed asystole. Time of death at 10:49 PM. Condolences given to family. Change in Resident's Condition or Status Policy (no date) documents during medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding, and responsiveness 911 will be notified for transport to the hospital. Medical Emergency (Code Blue) Policy (revised 12-5-12) documents the licensed nurse will be notified when any resident is determined to be non-responsive and Code Blue will be called.

Based on interview and record review the facility failed to follow the plan of care intervention of utilizing 2 person assist for bed mobility while repositioning 1 of 3 (R1) residents reviewed for staff assisted bed mobility. This failure resulted in R1 sustaining a commuted fracture of the 4th left finger and required treatment at the local hospital. Findings Include: R1 face sheet shows R1 has diagnosis of [CONDITION(S)], muscle wasting and atrophy right upper arm, [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] disease affecting unspecified side, need for assistance for personal care, lack of coordination, weakness, intellectual disabilities. Facility incident report dated 12/28/21 shows in-part, R1's name, incident location R1 room, CNA (Certified Nursing Assistant) reported resident has a bruise and swollen, pain on left ring finger. Resident unable to give description. Assessed resident head to toe, noted bruise, pain swelling on left hand ring finger, no other injury noted. Resident alert, verbally responds, non-verbal pain. Resident don't know it happened, Tylenol 335 mg 2 tabs given for pain, vital signs stable, called V5 (Physician) with new orders, X-ray for left hand stat, left message to state guardian. No injuries observed at this time, pain level 3, alert with periods of confusion, confused/ disorientated, bruise left hand(palm), adequate lighting, confused, impaired memory, bed in low position, DON, guardian, and physician notified. Resident (R1) complaint of pain to left hand. Noted with bruising, warmth and swelling to left hand fourth finger. Order obtained for left hand X-ray, results reveal: acute fracture of the proximal phalanx fourth digit. MD and POA notified with order to send resident to hospital for further treatment. Resident came back from hospital with metal finger splint to left 4th digit finger. Initial report was sent to IDPH. Resident unable to describe what happen as resident is confused d/t (due to) dementia, diagnosis. Per interview of all staff assigned to the floor no incident or accident have occurred involving the resident. Resident requires extensive assist with ADL's (activities of daily living). Resident has idiopathic [CONDITION(S)] d/t multiple co-morbidities such as cancer, muscle wasting and atrophy, [CONDITION(S)] and [CONDITION(S)] and severe protein- calorie malnutrition, which could have resulted in pathological fracture. Resident referred to therapy and has ortho f/u (follow up) to be scheduled. Care plan updated related to issue. R1's radiology results of 12/28/21 shows clinical information: pain and swelling, test procedures: left hand 3 plus views, clinical indications: pain, findings: bones and joint: acute comminuted fracture of the proximal phalanx fourth digit, soft tissue are unremarkable, no foreign body is identified, impression: acute comminuted fracture of proximal phalanx fourth digit. R1's progress note dated 12/28/21 at 10:37a.m shows in-part, CNA reported resident has bruise, swollen, pain on left hand ring finger. Assessed resident head to toe, noted bruise, pain, swollen on left hand ring finger, no other injury noted. Resident alert, verbally responds. Non-verbal pain. Resident don't know how is happened. Unable to describe. Tylenol 325 mg 2 tabs given for pain, vital sign stable. Called the doctor with new order. X ray for Left hand STAT. left message to Stat (sic) Guardian. All staff made aware, endorsed next shift to monitor and F/U. R1 progress note dated 12/28/21 at 10:02p.m stat x ray completed during the shift. Received results, showed acute left comminuted fracture of proximal phalanx fourth digit, results conveyed to the doctor. Order received to send to hospital. Called (name of hospital) and gave report to the Registered Nurse. Ambulance came pick up the patient at 9.45 pm. On 02/05/22 at 9:53a.m R1 was observed lying in bed, R1 was able to communicate with simple words. R1 appeared to understand the questions asked. When asked about pain R1 showed his teeth and nodded his head in a yes motion. When asked about finger pain, R1 raised his hand to show his finger. On 02/05/22 at 11:05a.m V8 CNA (Certified Nursing Assistant) said on 12/28/22 she was the aide responsible for R1's care, V8 said around 8:30a.m that morning, she observed R1's left ring finger to be discolored, V8 said she reported this immediately to V3 (Nurse). On 02/05/22 at 11:41a.m V3 (Nurse) said on 12/28/21 in the morning, V8 informed V3 that R1's left ringer was bruised. V3 said during her assessment observed R1's finger was bruised and R1 had signs of pain. V3 said she gave R1 something for pain and notified the physician and R1's POA (Power of Attorney). V3 said R1 had not been out of the facility that she was aware of. V3 said the X-ray was completed and it showed R1 had a fracture to the left ring finger. On 02/05/22 at 1:10p.m V5 (Physician) said a comminuted fracture could result from a trauma, fingers don't just break. V5 said there are many possibilities on how the fracture could have occurred but that it would be speculation, because she does not know how R1 acquired the fracture to the left 4th digit. V5 said the location of R1's fracture could have resulted from the finger being overly extended, or overly bent. V5 said R1 could have gotten the finger caught under his body during movement, she does not know.V5 said R1 is able to move his left extremity. V5 said R1's X-ray did not show any evidence that the fracture was pathological. V5 said the facility should encourage the residents to maintain their functioning ability. If R1 needs a two person assist with bed mobility, the facility has to assess the resident to make that determination. Review of R1's ADL report, V4 documented that she provided ADL care to R1 on 12/27/21 for the second and third shift, 3, 3 is documented for bed mobility, review of the POC ledger report shows 3- (extensive assist- resident involved in activity staff provide weight bearing support) and 3- (two plus person physical assist). On 02/05/22 at 3:17p.m V4 CNA (Certified Nursing Assistant) said she was the aide responsible for R1's care on 12/27/21 and that it was her user identification noted on R1's ADL report. V4 said she worked a double shift on 12/27/21 and both shifts she worked with R1. V4 said during her shifts she provided ADL care to R1, she gave R1 his bath and she also turned and repositioned R1 several times during her shifts. V4 said when she repositioned and pulled R1 up in bed, she had R1 to assist her, V4 said R1 had to pull himself up by pulling up on the headboard, and she (V4) would pull the pad that R1 rested on. V4 said R1 is only able to use his left hand to pull himself up, R1's right arm/ hand does not have full range of motion. V4 said she has repositioned R1 in this manner for a very long time. V4 said R1 does require a two person assist with bed mobility, but sometimes it hard to find someone to help. V4 did not inform the nurse or other aides that she needed assistance with repositioning R1 in the bed. V4 said she didn't pay attention if R1 had any issues with his hand after he used the headboard to pull himself up, V4 said she's not aware of R1's finger getting caught under his body. Review of V4's documentation for 12/27/21 bed mobility, V4 documented 2 plus person assistance provided. V4 did not give response to the documentation when asked. On 02/05/2022 at 4:37p.m V7 (Restorative Nurse) stated R1 can assist with bed mobility using his left arm/ hand, it's okay for R1 to use the headboard to pull himself up, the facility encourages the residents to participate as much as they can. V7 said R1 needs a two person assist with this task for safety purposes. V7 said when R1 has to pull himself up while holding the headboard and using one extremity, that is a lot of weight bearing that R1 would have to perform. On 2/6/22 at 1:46pm V7 said R1 needs a two person assist to provide weight bearing support, two person assistance is used to prevent injuries to staff and residents. R1 cannot complete bed mobility tasks independently due to weakness. V7 said the aides are in-serviced on bed mobility and what the signage above each resident bed means. V7 stated there's signage posted above R1's bed and the M represents mechanical left, and 2B represents two person assist needed, as reflected in the plan of care. On 2/6/22 at 1:17p.m V2 (Director of Nursing) said the facility encourages the residents to function at their highest potential. V2 stated R1 can use the headboard to assist with bed mobility but the staff should provide weight bearing support of two people. V2 said V4 was written up for not using the appropriate level of staff assistance during bed mobility for R1. V2 said that the facility uses a two person assist for staff and resident safety to prevent injuries. V2 stated R1 does not understand safety awareness due to his intellectual disabilities, and does not understand that injuries could result from not using the appropriate level of staff assistance. V2 said she was made aware during the survey that V4 was providing one person assistance for bed mobility for R1. V4's employee disciplinary form dated 02/05/22 states staff did not follow the proper policy for ADL care, resident needed 2 staff assist for repositioning and bed mobility. R1's MDS (Minimum Data Set) dated 12/06/21 shows in section G functional status bed mobility 3 for ADL self-performance (extensive assist- resident involved in activity staff provide weight bearing support) and 3 for ADL support provided (two plus person physical assist). Upper extremity (shoulder, elbow, wrist hand) coded for 2 (impairment on both sides, lower extremity (hip, knee, ankle, foot) coded for 2 impairment on both sides. R1's plan of care for transfer needs/bed mobility with the most recent review date of 12/6/21 shows the resident has been assessed for their transfer needs and continues to require the following support, contributing factors, [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)] (left side), dysphagia, hypertension, [CONDITION(S)], type 2 diabetes, total dependence, resident will have signage / symbols above their bed to identify transfers and bed mobility needs, M= full/ mechanical lift type M2B, for all transfers via mechanical and stand lift device, 2 staff assist is required (SSS2B/M2B). Restorative program ADL assistance -self-care deficit with most recent review date of 12/06/21shows the resident exhibits impaired ability to perform or complete activities of daily living, potential contributing diagnosis: h/o [CONDITION(S)], [CONDITION(S)], dysphagia, [CONDITION(S)]. Resident will safely perform self-care activities to optimal level of participation and will prevent/minimize complications r/t impaired mobility through next review date. Cautiously assist with transfers and mobility. Provide assistance to level of needs. R1's plan of care for physical and psychosocial needs with last review date of 12/07/21 shows I (R1) have a diagnoses and intellectual disability I have the following diagnosis, diagnosed developmental delay/ disability, intellectual disabilities, [CONDITION(S)], major depressive disorders, I have the following problems and deficits, grooming and hygiene, communications skills, social and interaction skills, community integration and survival skills, vocation skill deficits. I am a person with cognitive impairment related to diagnosis of mental [CONDITION(S)] intellectual disabilities, [CONDITION(S)], major depressive disorders. Resident has diagnosis of [CONDITION(S)], problems are manifested by difficult with fine motor skills, difficulty swallowing, slurred speech, spastic diplegia, [CONDITION(S)], unsteady or waddling gait, weakness in extremities, change in facial expressions, spastic [CONDITION(S)]. R1's restorative nursing review dated 12/07/21 shows bed mobility extensive assistance two plus person physical assistance. Facility policy Titled Resident Handling Limited Lifting with revised date of 09/21/12 shows the resident handing policy exist to ensure a safe working environment for resident handlers. The policy is to be reviewed and signed by all staff that perform or may perform resident handing. This policy will be reviewed annually with changes made accordingly. Resident transfer will be designated into one of the following categories: M= mechanical left transfer- full lift/ Hoyer (2 care givers). Facility policy Titled Interim and Comprehensive Care plans shows, policy: the facility will develop an interim care plan upon admission followed by a comprehensive care plan for each resident that include measurable objective and timetables to meet the resident medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to notify a resident's legal representative (POA/Power of Attorney) of a change in medical condition and provision of new treatment. This applies to 1 of 3 (R1) residents reviewed for notification of change in medical condition. The findings include: R1, was an [AGE] year-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record showed that R1 was admitted to the facility from hospital on 12/4/2020. R1 was COVID positive when admitted and was placed on the quarantine unit. Record also showed that R1 was unvaccinated due to POA's personal choice. On 12/21/21, R1, who was unvaccinated resident was moved out from room to a room in the YELLOW ZONE x 14 days (quarantine unit) due to exposure to COVID19+ staff. V8 (R1's POA) was notified by social service director as per documentations of NOTIFICATION OF ROOM CHANGES ASSESSMENT. The progress notes documented on 1/3/2022 at 2:33 P.M., showed that R1 was observed with SOB (shortness of breath) and was desaturating with oxygen with level of 87% on room air. V4, (Nurse) had immediately administered oxygen at 2-3L thru Nasal Canula and assessed R1 with an elevated pulse rate of 101/minute. V5 (Nurse Practitioner) was notified with orders for stat chest x-ray, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Profile), oxygen inhalation of 3 liter per minute and to monitor R1 closely. Further review of the progress notes showed that V5 also saw and examined R1 based on documentation entered on 1/3/2022 at 3:05 P.M. V5 ordered same and to monitor closely. The progress notes entered 1/4/2022 at 1:52 P.M. showed that R1 had desaturated with his oxygen level again down to 89%. At 2:07 P.M., R1 was with labored breathing, unable to eat and swallow, responding to touch and not verbalizing. The laboratory results done 1/3/2020 came back with critical results. R1 was sent to the hospital via 911 per order of V5. V8 was notified at this time of R1's transport to the hospital. R1 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The progress notes dated from 12/30/2021 to 1/3/2022 showed that R1 was alert, no SOB, no cough, no oxygen administration and oxygen saturation were normal. There was no documentation that V8 was notified on 1/3/202 when R1 had a changed in medical condition. On 1/14/2022 at 2:00 P.M., V4 said that she did not notify V8 when R1 had SOB and had low oxygen level and all the new treatments such as oxygen level and diagnostic tests ordered as stat order in the morning of 1/3/2022. V4 added that R1 was not in distress so she did not notify V8. On 1/15/2022 at 10:00 A.M., V6 (R1's Attending Physician) stated that he was notified by the facility to talk to V8 and discuss what happened to R1. V6 added that he reviewed R1's hospital documentation of 1/4-5/2022 and that R1 had passed away on 1/5/2022 because of [CONDITION(S)] due to aspiration pneumonia related to advance progressive dementia, neurological cognitive decline and multiple comorbidities. V6 also added that the facility should have updated V8 when there was a change on 1/3/2022 to keep the family informed of what was going on. V6 also stated that anything could have happened because R1 had already COVID infection twice. On 1/15/2022 at 11:00 A.M., V5 stated that she examined R1 sometime in the afternoon of 1/3/2022. V5 added that R1 had low oxygen level and desaturated in the morning of 1/3/2022 accompanied with SOB and cough. V5 also added that R1 was coughing when she examined him. V5 further said that she had ordered oxygen to ease in breathing and to increase oxygen level, ordered chest-ray to rule out pneumonia and complete blood work to rule out impending significant medical change. V5 also stated that she had planned to update V8 when blood results are available. V5 also added that she thought the nurse on duty updates residents' family for new medical treatments and change in medical condition/status. On 1/14/2022 at 9:30 A.M., V8 stated that he was in disbelief when he saw R1 at the hospital. (R1) was almost dead, like 85% dead. V8 added that he questioned the nurse (not know the name, but took care of R1 on 1/3/2022) why was he not notified when all the diagnostic test were done and that R1 had episode of SOB and was administered oxygen. V8 added that he was given an answer that R1 was fine on 1/3/2022. The facility had provided an in-service to nursing staff dated 1/5/2022 that showed that it is the responsibility of nurses to update residents' family for any changes in condition and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The undated facility's policy for Notification of Change showed It is the facility's policy to ensure that the resident's Attending Physician and Representative are notified of changes in resident's condition and status.

Based on observation, interviews and record reviews, the facility failed to keep a resident free from experiencing verbal aggression from staff (V3, certified nursing assistance). This applies to one of one resident (R3) observed receiving verbal aggression by staff. As a result, R3 expressed being not safe in the facility, feeling intimidated and threatened. Findings Include: R3 is a [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/2021 at 2:00pm, surveyor observed R3 had his call light on. Surveyor and V5 RN (Registered Nurse) entered into R3's room. R3 stated he had his light on because he wanted a shower. As V5 was answering R3, V3 CNA (Certified nursing assistant) cut her off in a loud and aggressive tone of voice said, they told me you can only get a shower once a week. R3 leaned back on his bed with a blank stare on his face. V3 CNA and V5 RN left the room, Surveyor asked R3 if this is V3's usual behavior? R3 said: Sometimes. R3's roommate (R4) said, Yes, V3 told me I needed to be quiet this morning. On 7/13/2021 at 12:21pm, V3 CNA was interviewed regarding incident with R3. V3 stated He at first wants his clothes changed earlier, then asked if he could have shower. I told him that his shower is tomorrow and we were short staffed yesterday. I have been a CNA (Certified Nurse Aide) for four months. I tend to float around the facility. R3 just moved to the floor. I know him but he has a behavior. We get along pretty well. He would just pull his call light to talk with the head of the building when we already told him they are not in the building, he makes up stories. Usually, he works with me pretty well. Yesterday, I walked into the room and R3 was asking about a shower. I was trying to explain to the state lady that R3 takes showers once a week on the morning shift. R3 is supposed to get a shower twice a week - one in the morning and one on the other shift. R3 is known to have behaviors. We are all aware of that with him, you have to be straight forward. You can't take what the resident says serious all the time. He would tell me he has not been changed in a week and I know I changed him in the morning. As far as I am concerned, there was no incident that happened yesterday. I did not talk to R3 but to the State lady. I did not do any verbal aggression on the resident, V5 RN was there. V3 CNA was asked regarding knowledge on the facility abuse policy. V3 said, I had a long orientation for abuse when I started. I don't know who the Abuse Coordinator is but I do have it written down somewhere. On 7/13/2021 at 1:17pm, R3 was asked regarding the incident between R3 and V3. R3 stated, I don't feel safe here, they stand over you trying to intimidate you, they talk to you like you are garbage, and they don't respect you. I feel scared I don't want to be here. V3 is a stern person, I don't know what was wrong with her yesterday, she sounds scary. On 7/14/2021 at 1:32pm, Interview with V5 (Registered nurse) stated I was helping R3 make coffee that morning when he asked if he could change his clothes. I told R3 they will change him between breakfasts and lunch at 2:00pm. R3 put his call light on and asked about his shower. V3 said she already changed his clothes. No, I don't think it was appropriate the way V3 CNA addressed R3. I told V3 that she needed to go to the nursing office and she left and went home without telling me. I talked to V18 Assistant Director of Nursing (ADON) verbally but I did not do the form. The last in-service on abuse was not long ago. Physical, verbal, sexually and chemical. You are supposed to talk to your supervisor and they will do an investigation and send you home. If I see it, I have to report it. V3 was talking in a loud voice when she tried to explain to the resident about his shower. She looked mad because it was close to the end of the day and was trying to finish up rounds before the end of the shift. I would have just listened to the resident and then try to explain in a calm manner about the shower. No, she didn't do that she was loud and mad. On 7/13/2021 at 3:48 PM, V2 (Director of nursing) was interviewed regarding abuse. V2 stated, I do the abuse in-services per facility policy quarterly, every 6 months or as needed. This month, I did two in-services on abuse. The administrator is normally the one who does the abuse in-services, he educates them on the types of abuse, who is the abuse coordinator, and who they should report to the chain of command. We have sign in sheets and if any staff is missing the administrator will let me know. After hiring staff, the administrator does an in-service on abuse and social services does an in-service on resident rights. On 7/14/2021 at 4:31pm, V17 (Psychologist Nurse Practitioner) was asked regarding R3. V17 stated, I have seen R3 twice since he was admitted , his initial assessment and last June. R3's behavior is sporadic, he can be calm but is easily irritated and can be verbally combative to staff. No, he never hit anyone. He can be uncooperative with staff. I have not seen this behavior but as far as the progress notes reads, but I have heard him irritated. Verbal abuse can possibly have a negative affect on R3 and cause him to feel afraid and not want to remain here anymore that is possible for him to feel that way. I expect for the staff to treat them as a human being, they are there for a reason because they need some type of help. The staff need to try to have patience with them. Sometimes, I feel like I'm losing my patience with them but I choose the option to walk away. All patients deserve to be treated with respect and like humans. On 7/15/2021 at 12:21pm, interview with V2 Director of Nursing stated V5 registered nurse reported to V18 Assistant Director of Nursing (ADON) that V3 Certified nursing assistant was verbally inappropriate with R3, and stating he was lying that's not what they said. R3 really has a behavior problem but I always talk to staff in regards to him being here for a reason and regardless of his behavior we should really know how to handle him that's why we do continuous in-services on resident's rights, customer service and abuse. My expectation of my staff no matter what they should not retaliate and they should hold their emotions. Staff are trained when certified to know that sometimes a resident may be aggressive and verbally abusive. Staff should try to remain calm, separate themselves and report it to the supervisor. Staff should never say anything demeaning or disrespectful to the residents. Facility's policy titled, Abuse Prevention Program last revised 6/21/2021, documented in part but not limited to the following: Under VII. Protection of the resident states: The facility desires to prevent abuse neglect, exploitation and misappropriation by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive quality management approach. Under VII Protection of the resident bullet number 6 states: On a regular basis, supervisors will monitor the ability of the staff to meet needs of residents; staff understanding of individual resident care needs and situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training and if necessary or repeated, the facility's progressive discipline policy.

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-,[DATE]-NH revised on [DATE], Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview, and record review, the facility failed to: have separate areas for sorting of residents' soiled clothing and folding of residents' clean clothing and cover residents' clean clothing during transportation to prevent transmission of COVID-19. This had the potential to affect all 247 residents in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ began on [DATE], at the time of the Presidential declaration of a state of National Emergency for COVID-19. The facility had 31 residents and staff with confirmed COVID-19 and 65 residents and staff that were persons under investigation (PUI) for COVID-19. The facility failed to have separate areas for the sorting of residents' soiled clothing and the folding of residents' clean clothing. The Administrator was notified of the Immediate Jeopardy [DATE] at 4:30 pm. Findings Include: Review of the facilities Outbreak Line Listing and discharged to Hospital due to Suspicion of COVID-19, dated [DATE] to [DATE], revealed the facility had 22 residents with confirmed COVID-19. Review of the facility's resident roster with persons under investigation (PUI) for COVID-19, not dated, revealed the facility had 49 residents that were PUI for COVID-19. Further review of the facility's resident roster with PUI for COVID-19, not dated, revealed the facility had residents that were PUI for COVID-19 on all four floors of the facility in which the residents resided. Review of the facility's Staff Tracking COVID-19, dated [DATE] to [DATE], revealed that the facility had nine staff with confirmed COVID-19 and 16 staff that were PUI for COVID-19. Observation on [DATE] at 11:05 am, revealed the fifth floor Resident Laundry Room had the door open to a resident room hallway. The dryer was observed to be running. No staff were present in the Resident Laundry Room. During the same observation, clean residents' clothing was folded on top of the washing and drying machine and an uncovered rolling cart was observed to be full with unfolded residents' clothing. During an interview on [DATE] at 11:12 am, with Nursing Assistant (NA1), NA1 confirmed that the facility's housekeeping staff is responsible for laundering the residents clothing. NA1 also confirmed that the facility had one Resident Laundry Room on each floor of the facility where resident rooms were present. When asked if the fifth floor laundry room door should be open to the hallway with resident rooms while clean linens are uncovered, NA1 stated, I try to tell her (the housekeeper) this door needs to be closed. Observation on [DATE] at 11:30 am, revealed the Housekeeper in the fourth floor Resident Laundry Room folding residents' clean clothing on top of the washing machine. The Resident Laundry Room door was open to the resident room hallway at the time of the observation. During a follow-up interview, with the Housekeeper, when asked about the facility's process for laundering residents' clothing, the Housekeeper stated that she goes room to room with a rolling bin to pick up the residents' soiled clothing and then brings the soiled clothing to the Resident Laundry Room. The Housekeeper then stated that she sorts the residents' soiled clothing on the washing and drying machines. When asked to confirm that this was the same area the Housekeeper was folding the residents' clean clothing, the Housekeeper stated, Yes. Observation at [DATE] at 11:40 am, revealed the Housekeeper transporting a rolling cart with uncovered clean residents' clothing to several rooms on the facility's fourth floor. Observation on [DATE] at 9:47 am, revealed the third floor Resident Laundry Room, revealed the door was open to the resident room hallway and the drying machine was running. No staff were present in the room. On top of one of the drying machines, folded underwear and socks were observed with a used paper towel lying on top of the folded clothing items. During the same observation, in the hallway outside of the third floor Resident Laundry Room door, revealed a large black garbage bag on the floor in the hallway. A tray cart, being used to collect meal trays from residents' rooms, was observed approximately four feet from the large garbage bag. During a follow-up interview on [DATE] at 9:50 am, with Licensed Practical Nurse (LPN1), when asked about the Resident Laundry Room, LPN1 stated, It's closed. When this surveyor pointed out the open door and running drying machine, LPN1 stated, The laundry supervisor says it was closed but there must have been a load done and then they are closing it. When asked what was in the large garbage bag outside of the third floor Resident Laundry Room, LPN1 opened the garbage bag and revealed a large amount of soiled resident clothing. LPN1 confirmed that the bag contained resident clothing. LPN1 then stated, Some resident may just take it and drop it. When asked where the soiled resident clothing should be placed, LPN1 confirmed that the soiled clothing should be in bins in the soiled utility room. During an interview on [DATE] at 2:50 pm, with the Housekeeping Director and the Administrator, when asked to describe the process for laundering of residents' personal clothing items, the Housekeeping Director revealed that the NA on the floor puts the residents' clothing in bins in the soiled utility room and then the Housekeeper will pick up the soiled residents' clothing and sort the soiled residents' clothing in the Resident Laundry Room. When asked to clarify where the soiled residents' clothing is separated, the Housekeeping Director confirmed the Housekeeper sorts the residents' soiled clothing in the Resident Laundry Room on top of the washing and drying machine. When asked where the Housekeeper folds the residents' clean clothing, the Housekeeping Director stated, Inside the laundry room also. They will sanitize the top of the washer and dryer. When asked when laundry staff is sanitizing the top of the washer and dryer, the Housekeeping Supervisor stated, They sanitize it while the washer and dryer is running and prepare it for folding. When asked the process for returning clean residents' clothing to resident rooms, the Housekeeping Director revealed that the clean resident clothing is returned in a rolling laundry cart. When asked if the Housekeeper is supposed to cover the clean clothing during transportation to the resident rooms, the Housekeeping Director confirmed that the clean clothing should be covered with a plastic or something like that. The Housekeeping Director verified that the Housekeeper was doing the laundry on floors four and five today and another housekeeper was assigned to do laundry on floors two and three. When asked if the facility's process for sorting of dirty resident clothing and the folding of clean resident clothing was the same process on all four of the facility's the floors with resident rooms, the Housekeeping Director, confirmed it was the same process on all of the facility's floors. During the same interview, the Housekeeping Director also confirmed that the door to the Resident Laundry Room is to be closed anytime the staff is doing laundry. During an interview on [DATE] at 4:44 pm, with the Administrator and Director of Nursing (DON), when asked the reason the Housekeeper would be sorting the residents' soiled clothing, the Administrator and the DON reveal the purpose of sorting the residents' soiled linen may be to check for linens so they don't get washed there (in the Resident Laundry Room) and to check the residents' pockets for items. During an interview on [DATE] at 12:19 pm, with the Administrator, the DON, and the Assistant Director of Nursing (ADON), when asked if there is a risk for contamination of clean residents' clothing when it is folded in the same spot that soiled resident clothing is sorted, the Administrator stated, Minimally with sanitation. When asked, what is the risk to the residents if clean clothing becomes contaminated, the Administrator stated, Illness. Hopefully not COVID. When asked, can [MEDICAL CONDITION] that causes COVID-19 be transmitted on soiled clothing before a resident shows symptoms of COVID-19, the DON stated, Yes. Review of the facility's Laundry Policy and Procedure, not dated, revealed: Collection of Soiled Linens: All dirty linen must be handled with care to minimize transmission of microorganisms via dust and skin scales . Soiled linen should not be placed on the floor, chair or any piece of furniture in the room . Sorting All linen can be categorized into 4 groups: Personal Clothing Dirty Linen, Used Linen Soiled Linen Infected/Bio-Hazardous Linen Personal Clothing: Personal clothing to be laundered by the facility is to be sorted into its own container . Folding As soon as linens are removed from the dryer, they should be sorted, folded, hung up, and readied for delivery .There should never be a back-up of clean linens waiting to be folded . Clean linen should be transported and stored by methods that minimize microbial contamination from surface contact and airborne deposit. Clean linen should be transported in containers used exclusively for this purpose. The clean linen cart/container should be kept completely covered during transport. Laundry Room Environment . The design of the laundry should accommodate clean and dirty linen areas, .e.g. dirty linen should be brought into the laundry, processed, and come out as clean linen, without becoming re-contaminated . Laundry personnel shall be present any time the laundry equipment is operating . According to the Centers for Disease Control, How COVID-19 Spreads, last reviewed [DATE], .[MEDICAL CONDITION] is thought to spread mainly from person-to-person .Some recent studies have suggested that COVID-19 may be spread by people who are not showing symptoms .It may be possible that a person can get COVID-19 by touching a surface or object that has [MEDICAL CONDITION] on it and then touching their own mouth, nose, or possibly their eyes .[MEDICAL CONDITION] that causes COVID-19 is spreading very easily and sustainably between people . retrieved from https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html on [DATE] at 3:37 pm. According to the Healthcare Laundry Accreditation Council Checklist Accreditation Standards, 2016 Edition: .Part I - 2.1.1. Based on the workflow pattern principle where processing of soiled textiles flows to clean textiles, the laundry facility's physical layout and maintenance procedures must ensure efficiency, minimize environmental contamination, and protect the material and hygienic integrity of the processed textiles. Part I - 2.1.2.1. The essential laundry facility design must have a functional separation of areas that receive, store, or process soiled textiles from areas that process, handle, or store clean textiles . The Administrator was notified that the Immediacy was removed on [DATE] at 11:45 am, after the surveyor verified implementation of an acceptable removal plan that included: 1. Observations on [DATE] at 10:45 am to 11:45 am, of the second, third, fourth, and fifth floor Resident Laundry Rooms revealed the doors had been locked and the washing and drying machines had been disabled. Interview during the same observations with the Maintenance Director revealed that the facility had determined that the residents' clothing would be laundered in the facility's main laundry room which contained distinct, separate areas for clean laundry and soiled laundry. 2. Review of In-Service Education records dated [DATE] and [DATE] provided to nursing, housekeeping, and laundry staff related to the procedure of collection of soiled laundry, transferring soiled linen, sorting folding, and delivery of clean linen. 3. Interviews were conducted to assess staff's knowledge related the process for laundering residents' personal clothing. After removal of the Immediacy, the noncompliance remained at the level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy until sustained compliance is verified.

Based on interview and record review, the facility failed to have care plan interventions in place to address a resident's impulsive behavior to stand or self- transfer without assistance and individual plan for monitoring and supervising the resident to prevent a fall. This has the potential to affect one of six residents (R286B) reviewed for falls. This failure resulted in R286B having a fall, sustaining a subdural hematoma and subsequently died 12 days later. Findings include: R286B was an [AGE] year old resident with [DIAGNOSES REDACTED]. Incident report dated [DATE] at 2:40 pm stated, Resident suddenly stood up from her wheelchair and fell backwards. Sustained a bump at the back of her head. No loss of consciousness noted. Resident was transferred to the hospital for evaluation. Complete body assessment done. Family notified. It has been confirmed that R286B will be admitted for subdural hematoma. Resident is alert, oriented x1. Resident stood up from her wheelchair and was unable to maintain a steady balance falling backwards resulting in bump to her head. Resident returned to the facility on [DATE] with no medical intervention of the subdural hematoma. On [DATE], an incident note written by V12 (Licensed Practical Nurse) stated, around 2:40 pm, resident was sitting in the dining room when she suddenly got up from her wheelchair and fell backwards. Staff could not get to her fast enough to catch her. Resident said she wants to go back to her room. Complete body assessment done. Noted bump on back of her head. She is able to move all extremities within her normal limits. Neuro check initiated no loss of consciousness noted. Resident not able to describe pain but was holding back of her head. Ice pack applied to back of head immediately. MD notified. Will transfer resident to hospital for CT scan (special x-ray). Family notified. On [DATE], a following nursing progress note read, resident admitted to hospital with [DIAGNOSES REDACTED]. On [DATE], V12 wrote, at 7am, received resident in bed, lethargic, vital signs taken, called and informed doctor of residents condition change. Resident unable to swallow food and medications. 12:35pm resident expired confirmed with 2 registered nurses. Notified family and doctor. V12 on [DATE] at 2:28 pm stated, I was by the large dining room by the door and I saw her (R286B) sitting down. I was not passing medications, but I don't remember what I was doing. I saw her getting up and fall like this. (V12 motioned that resident fell forward from her sitting opposition). I was trying to catch her. Surveyor asked if there were any other staff in the dining room, V12 stated, No, I don't think so. V12 showed surveyor where she was standing and where R286B was seated and fell in the dining room. According to V12, R286B was on the left hand side near the center of the dining room area and she (V12) was outside of the threshold to the dining room. Asked to clarify if there was another staff person in the room, V12 stated, I don't think there was any staff or CNA (certified nurse's aide) there. V2 (Director of Nursing) on [DATE] stated, I interviewed the nurse (V12) to investigate the fall and viewed the video footage in the dining room. There were other residents in the room and the video confirms no staff were present in the dining room. R286B was hospitalized on [DATE] with a [DIAGNOSES REDACTED]. Fall Risk Review (dated [DATE]), Upon readmission R286B was assessed as a high risk for falls. Prior facility fall risk assessments for R286B dated [DATE], [DATE], [DATE] show R286B was at risk at high risk for falls and showed a history of falling. R286B Nursing Progress Note dated [DATE] 10:09 pm documented, Observed bruise on Rt (right) upper arm near axillary, Rt middle of post & fore arm. Lt (left)upper arm. Small size of skin tear on Rt lower arm./hx of fall in the hospital according to physician. physician progress notes [REDACTED]. Risk of fall - follow fall precautions protocol. Patient is at high risk of fall secondary to ataxia, muscle weakness, poor cognition and safety awareness, poor balance and [MEDICAL CONDITION]. V17 (Physician) on [DATE] at 1:42 PM stated, They should have been watching her(R286B) and not left her alone. I remember she was confused so they could have been doing 1:1 with her too but should not be by herself. I remember signing the death certificate. Asked what other interventions should have been in place to prevent R286B from falling, V17 stated, You should ask them (facility). If she had history of fall already, she needed to be monitored and if nobody was in dining room, that's not good. R286B Fall Risk Care Plan (last update [DATE]) includes (but not limited to) the following problem statements: History of Falls, Decreased Safety Awareness, Impulsiveness with attempts to Stand or self-transfer without Assistance from the staff, and Leaning forward in chair with Attempts to pick up objects. Approaches/Interventions include: Gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future recurrence; Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance; Anticipate and meet needs; Complete Fall Risk Assessment per facility protocol; (added date [DATE]) Neuro check until transfer to hospital; Refer to therapy upon return; Staff to assist resident to bed around 2pm; and Toilet resident before assisting to bed. On [DATE] at 12:45pm V2 (Director of Nursing) stated, R286B would constantly try to get up from bed and chair without calling for help and that staff were expected to check on the resident hourly. V2 acknowledged that this was not documented in the care plan and that there was no specific intervention in the care plan to address the resident's impulsiveness, other than for staff to check on her constantly (which was not documented). V2 also stated that the resident's care plan interventions had not been updated since [DATE], except for History of Falls being added to the Problem Statement and the (4) interventions that were added on [DATE] after the resident's fall. According to V2, the care plan interventions were not updated after the resident came back from the hospital with a noted fall in (MONTH) (YEAR). The dates listed under goals/objectives only indicate the dates that the care plan quarterly review was conducted. Death certificate shows R286B died on (MONTH) 22, 2019 in the facility with cause of death listed as Subdural Hematoma due to (or as a consequence of) Fall. Facility provided Fall Prevention and Management policy dated [DATE] includes: 2. Approaches/interventions should focus on risk factors identified and Evaluation of the interventions is completed 1. Quarterly, 2. Post fall, and 3. Interventions are modified as indicated based upon evaluated efficacy of the interventions. Facility's undated policy and procedures for falls titled Fall Prevention Protocol states, Residents who are assessed at high risk for falls, have had multiple falls or have had a significant fall within the last six months may be included in the fall program as determined by the interdisciplinary team. Residents on the program may be observed every two hours or as determined by the interdisciplinary team; this should include all levels of staff. If resident is observed in unsafe action that could lead to falls, staff shall intervene immediately. Interdisciplinary care plan is implemented for residents at risk and may include interventions to prevent falls, physical and or occupational therapy screen and training, assistive devices as appropriate, supervision as appropriate.

Based on observation, interview, and record review the facility failed to prevent the elopement of a newly admitted resident due to staff immediately disarming the emergency alarm that alerts all staff of an elopement. The facility further failed to immediately act to search for the resident who wandered off unsupervised and thereby sustained multiple injuries and fractures then emergently transferred to the hospital ER for treatment. This failure affects one (R1) of four residents reviewed for dementia with wandering behaviors in a sample of four residents. Findings include: R1 is a [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. Nursing progress notes dated 11/17/18 written by V5 (RN-Registered Nurse) states, Patient is new admitted from other nursing home to here at 1 PM with son. Pt is not used any assist devices. Steady and balanced gait. Alert and Oriented x 2-3 forgetful. Korean speaks better, Diagnosis: [REDACTED]. Dining room at 1st main. vitals taken. Called attending doctor and left message. Continence on both B/B. Faxed hard script for [MEDICATION NAME] and [MEDICATION NAME] to pharmacy. Assist pt at time. Endorse to next nurse. Will give PPD at evening shift. Nursing progress notes written over eight hours later by V3 (RN) at 9:33 PM states, Incident note: Resident left building exit setting off facility alarms. Search was conducted. Police notified. Medical director notified. Son is aware. Resident currently at hospital as he sustained a fall in the community. Interview with V9 (weekend receptionist) on 11/21/18 at 1:23 PM states, I was with V8 (CNA- Certified Nurse's Aide) at the reception desk. V8 was looking at his schedule which is posted at my desk. We were monitoring (R1). I saw the resident come back in the building from the yard. It was cold and he was wearing only a sweater and sweat pants. He went back inside from the backyard entrance. All of a sudden he disappeared from the security camera around 5:50 PM. It was dark outside already. The emergency alarm rings in the front at my desk. I told V8 to go look for him. 3-5 minutes pass and I got a bad feeling so I called V3 (Weekend Nursing Supervisor) and told her we might have a resident that left the building. I decided to call a code purple (missing resident). We continued to monitor the situation and we had called every floor. Asked if the emergency alarms go off on the floors, V9 stated, No just at my desk. I turned them off right away because V8 was standing there and I just told him to go out back and look. Asked what he was supposed to do when the emergency alarms go off, V9 stated, I'm supposed to call a code green, It's when a resident escapes. I know I didn't but I thought he (R1) might have just gone back upstairs. Asked if a code green was ever called so that staff would immediately come down to search outside, V9 stated, Well they started later after doing the code purple and about six CNA's'. came down to look for him on the main level. Asked when the staff went outside to conduct the search, V9 stated, I guess it was 30-40 minutes later. V9 went outside this time and walked around the building but didn't see R1 but by then we got a call from the hospital saying (R1) was there. Interview with V8 at 11/21/18 at 11:15 AM states, He's a new resident (R1). I came around 3 PM when my shift starts and went to the dining room around 5 PM and served the food tray to (R1) I was assigned to. I saw him in the day room up to 5:50 PM. I took all the meal trays and cart to the kitchen door. I redirected (R1) to the elevator then I went to the reception desk and checked my schedule. At that time (R1) came back to the reception area. Then he went outside the patio doors to the yard and V9 saw him on camera. Asked what it was like outside, V8 stated, It was cold out and already dark outside. Asked what R1 was wearing V8 stated, He was wearing a T-shirt and pants so he went back inside the other door. I went to check and R1 wasn't there. I didn't hear the emergency alarm. There is no alarm here (at security door) just at the desk. I then went upstairs and told my nurse and another CNA that I was going outside to look. I searched for 10-15 minutes probably starting around 6:30 PM. Interview with V5 (RN) on 11/21/18 at 11:30 AM states, I admitted (R1) around 1:00 PM. I went with V6 (RN) because I don't speak Korean. I did a head-to-toe assessment and I checked his gait and he walked by himself with a steady gait. He seemed aware and I did an elopement assessment and he was ok. He was pretty much calm. Asked if she heard any alarm go off when R1 triggered the security door, V5 stated, No. Asked if she went outside to do a search, V5 stated, I didn't go. Asked if she was responsible for supervising R1, V5 stated, Yes, he was my resident. Interview with V6 (RN) on 11/21/18 at 12:11 PM states, I helped assess (R1). He was alert, spoke Korean and he knew who he was. He had [DIAGNOSES REDACTED]. Asked if she helped search for R1 outside, V6 stated, No. There was no alarm but I did a head count on the floor and we couldn't find him. Interview with V12 (Physician) on 11/26/18 at 12:30 PM states, I got paged that day but I was told of a new admission but that he was already in the ER. I found this out late in the evening probably around 9 or 10, I'm not sure. Sometimes it is hard for me to hear my pager when I am in the hospital you know. Asked to comment about the elopement, V12 stated, This should not happen but family is usually with resident when they are new and should have stayed with resident. Asked to clarify statement as to who should stay with the resident, V12 stated, This happens a lot (elopements). I see it everywhere. Asked how a [AGE] year old could leave a facility unnoticed, V12 stated, I don't know, you have to ask administration. He cannot walk fast so I don't know how it happened. Hospital radiology reports 11/17/18 shows, Findings: Right prefrontal hematoma without underlying calvarial fracture. Minimally displaced left lateral orbital wall fracture. Minimally displaced left inferior orbital floor/rim fracture and left zygomatic arch fracture. Minimally displaced left anterolateral maxillary sinus wall fracture. [MEDICAL CONDITION] left maxillary sinus wall. Mild bilateral periorbital hematomas. Right prefrontal scalp; hematoma without underlying calvarial fracture. Hospital consultation reports dated 11/21/18 shows, Consultation: obtained from the medical record. Patient does not follow commands. (R1) is a [AGE] year old male with dementia who presented as a trauma after he was found wandering the streets with cutaneous manifestations of facial trauma. He lives in a nursing home and per report he left unsupervised. He was transferred due to concerns for unwitnessed fall and signs of facial trauma. He was evaluated in the ED. CT of the face revealed multiple facial fracture for which Plastic Surgery is consulted for definitive management. Ophthalmology is also at the bedside at the time of my evaluation. CT of Head: Extensive intracranial [MEDICAL CONDITION] and moderate intracranial small vessel ischemic disease. Mild to moderate bifrontal temporal volume loss. Large right prefrontal scalp hematoma without underlying calvarial fracture. Left inferior orbital floor/rim fracture. Minimally displaced fracture anterolateral left maxillary wall. All fractures non-operative. While argument may be made for reducing the left zygomatic fracture, given patient's age, I would not recommend any intervention. Appreciate ophthalmology evaluation of the globes bilaterally. Plan of care relayed to Surgery Service. Plastic surgery to sign off. Eye consult: Patient has history of trauma to left side of head with orbital floor fracture being followed by plastics. He is not able to open either eye because of lid swelling. Facility's undated policy titled Resident elopement and missing resident policy states, It is the policy of this facility that personnel who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action is taken. Procedure: In the event of resident elopement, every reasonable effort will be made to return the resident to the unit. The following will be implemented: A. Code Green will be announced with the exit door that the resident has used. (This also includes all instances of an exit door alarm that goes off and there is nobody seen exiting through that exit door.) B. Staff must respond to the code and go to the exit location that was announced. If a resident is found and redirected back inside, then Code Green will be canceled by announcing Code Green all Clear, If there was no resident upon searching outside, then proceed to C: Do head count and make sure all residents on your floor are accounted for. D. When all residents are accounted for, Code, Green will be canceled. Missing Resident Procedure: Code Purple is initiated on the overhead paging system to alert staff of a missing resident. Contact administrator or designee and Director of Nursing or designee immediately. Initiate coordinated, organized search of the facility grounds, maintain on to two people on each unit to attend to resident's needs during the search. If the resident is not located after the building and the grounds have been searched, call in other departments heads, the responsible party or POA, physician, and the police and expand the search to the local neighborhood. Search the facility and the grounds again.

Based on observation, record review and interview the facility failed to establish and maintain an infection control and prevention program designed to provide an environment for its residents which was free from potential exposure to the Legionella bacteria. The facility failed to have a water management program based on industry standard of practice. R8 tested positive for Legionella pneumophila and subsequently expired due to bilateral pneumonia. Findings include: V2 (Director of Nursing) on [DATE] at 10:30 am stated that V32 (Hospital infection control staff) called the facility on [DATE], informing the facility that R8 died at the hospital and had tested positive for Legionella. According to V2, R8 was sent to the hospital due to an abnormal ultrasound report. V2 stated that R8 did not have respiratory symptoms at the time of transfer. During this same interview, V2 stated that V33 County Health Department also called to inform the facility of R8's death and the positive lab result of Legionella on [DATE]. R8's physician order [REDACTED]. Hospital admission record indicates R8 was admitted to the acute care hospital on [DATE]. R8's case questionnaire completed by V2 (Director of Nursing) and submitted to the local Health Department documents that R8 took showers in the facility on the 5th floor where R8 resided. Average length of shower was listed as ,[DATE] minutes. R8's hospital lab report with date of [DATE] for urine collection documents presumptive positive for the presence of L. pneumophila serogroup 1 [MEDICATION NAME] in urine, suggesting current or past infection. Revised (lab) Report dated [DATE] documents results of 1.87 (high) for Legionella Antibody. This document indicates value > 1.09 is positive. R8's death certificate documents: Immediate cause of death (final disease or cause resulting in death) as Bilateral Pneumonia. On [DATE] at 12:12 pm and on [DATE] at 11:22 am, a general tour of the facility was conducted with V1 (Administrator) and V34 (Former Maintenance Director). The facility is a five story building with floors two through five dedicated to resident rooms. Each floor has a common shower for males and a common shower for females; each shower room has two shower stalls. Each floor also has two common bathrooms with a sink and toilet. Each resident room has its own bathroom with a sink and toilet. R8's room (where R8 resided at time of transfer to acute care hospital) was a three-bed ward with bathroom and sink which was shared by the three residents occupying this room (R8, R9, and R10). On the date of the tour, this room was closed and not occupied by residents. Clinical records for R9 and R10 document that R9 and R10 resided in this room until they were transferred out on [DATE] when the bathroom sink faucet tested positive for Legionella. During interview on [DATE] at 1:24 pm , V1 stated that medical filters were installed in the 5th floor shower stalls and in the faucet on R8's sink on [DATE], (five days after facility received notification that R8 tested positive for Legionella.) Floor plans and observation verify that R8's room on the fifth floor is adjacent to the male shower room. The male shower is adjacent to the soiled utility room and across the hallway from the pantry. Each of the four residential floors has a similar floor plan. During these tours, drinking stations located in the main dining room were labeled out of order. There was a medical filter (labeled with a date of [DATE]) on the faucet in R8's bathroom and medical filters (labeled with a date of [DATE]) on all four shower heads in 5th floor shower rooms. There were no medical filters installed in shower heads on other shower rooms, tubs or on other faucets. V34 (Former Maintenance Director) stated during the tour on [DATE] at 12:00 pm, that the filter for the faucet in R8's room and the filters on the shower heads in the 5th floor shower rooms were initially installed on [DATE] but they were changed on [DATE] due to the presence of sediments. V34 also confirmed that there were no medical filters installed on the other common shower rooms or on any other faucets in the facility at time of either tour. V34 stated they were ordered on [DATE] and should arrive on [DATE]. On [DATE] at 10:42 am, V2 (Director of Nursing) stated that on [DATE] the local Health Department instructed the facility to obtain a three month retroactive surveillance of residents with pneumonia, including those cases that did not recover from antibiotic treatment and those who were transferred to the hospital; monitor residents for respiratory symptoms and provide updates to the local Health Department every week with new cases of upper respiratory infections. According to V2 specific instructions were given on [DATE] by the local Health Department regarding Legionella [MEDICATION NAME], monitoring of residents and staff with respiratory symptoms. The local Health Department instructions also included inservicing staff and residents regarding Legionella to heighten awareness related to any respiratory illness. V2 indicated that inservices were provided to staff related to Legionnaire's infection based on CDC (Centers for Disease Control and Prevention) guidelines. V2 confirmed during this interview that R8's roommates, R9 and R10, remained in the same room with no restrictions related to use of sink in bathroom from [DATE] to [DATE]. V2 (Director of Nursing) stated that R9 has dementia and is ambulatory and R10 needs extensive to total assistance with Activities of Daily Living. On [DATE] at 1:24 pm, V1 (Administrator) stated that V3 (Medical Director) was notified on [DATE] and provided instructions to monitor residents for respiratory symptoms and to follow instructions provided by the County Health Department. According to V1, the Medical Director informed us that nothing had to be done at this time because it was not confirmed that Legionella was from here. V1 indicated during this interview that a meeting was conducted on [DATE] with an outside consulting company for water security solutions and facility management team to discuss the CMS (Centers for Medicare and Medicaid) mandate and compliance and to determine the need for testing and use of medical filters for showers and faucets. V1 confirmed that medical filters were not installed in the 5th floor shower stalls and in faucet on R8's sink until [DATE] (five days after the positive legionella report). On [DATE] at 2:26 pm the County Health Department via electronic mail stated: We were notified by the Illinois Department of Public Health (IDPH) to forward the following IDPH generated message . It is recommended that your facility update its water quality management plan(s) required under the CMS directive (see attached) and immediately take the actions described below. The email continues with descriptive information related to the CMS memorandum and states: We assume you are in the process of implementing your contingency response procedures as outlined in your water quality management plan, encourage you to learn about these resources and begin using them to develop water management plans in your facility as appropriate to prevent further cases of [DIAGNOSES REDACTED] . Later in this same document, the County Health Department recommended the following interim actions: Immediately begin flushing the water regularly in vacant rooms to eliminate stagnation, which may promote Legionella. Good practice would involve flushing hot and cold water supply lines for two minutes. Use a fine stream to minimize aerosol production. Hire an Illinois-registered plumbing contractor to survey the entire water storage and distribution system to determine extent of dead ends. Dead ends result in stagnant water, which can promote the growth of Legionella bacteria. Characterize the water quality by documenting the water temperature range and determining the concentration of the residual disinfectant, e.g. chlorine, assessing the potential for aerosol generation, and identifying the likelihood for occupant exposure to aerosols. Discontinue using faucets in the rooms of the case(s) until sampling results are available since these may potential sources of Legionella exposure. Please ensure the use of sterile water for respiratory therapy equipment. Regularly disinfect respiratory therapy equipment. The email ends with a note stating: The (local health department) does not consult on, review, or regulate for compliance the water quality management plans or the CMS directive. V1 stated on [DATE] at 3:30 pm (when asked about the Survey and Certification Letter ,[DATE] and what was in place prior to the positive Legionella test result), V1 stated he had received an email containing this Letter on (MONTH) 15, (YEAR) from Illinois Health Care Association and on [DATE] from the County Health Department. V1 stated We were under the impression that the water treatment service we had for the HVAC (Heating, Ventilation and Air Conditioning) since ,[DATE] addressed the provisions for the S&C memo. V1 stated that there was water treatment plan for the HVAC system, including testing HVAC system for sediments, infiltrates, PH levels and bacteria, but there was no water management plan for the domestic water system (water used for drinking and showers) until [DATE]. The water treatment plan contract documents dated (MONTH) 28. (YEAR) provided by V1 (Administrator) state that the service plan includes on-site visits to the facility and planned evaluation of the chemical treatment systems. This contract did not address or include a water management plan to address the prevention of Legionella. On [DATE] at 11:00 am, V1 presented a document Hazard and Vulnerability Assessment tool. V1 stated that this is the facility's facility risk assessment, which was developed on [DATE]. V1 stated that this tool was developed by the management team and in collaboration with a (health consulting agency). V1 stated that the Legionnaire's infection would be identified under the heading Mass Casualty Incident (medical/infectious), which documented, Probability = 0 (zero) and Risk = 0 (zero). There was no other documentation for risk assessment related to Legionella on this document. There was no other documentation provided by the facility at the time of the survey which documented any water management plan or resident risk assessment. During this same interview, V1 (Administrator) confirmed that it was not until (MONTH) 19, (YEAR) ( ten days after initial notification of positive Legionella) that samples were drawn from ten sites per direction by the outside consulting company for water security solutions. The ten sites tested were R8's room (bathroom sink), Shower A and Shower B on fifth floor, fifth floor tub, third floor pantry sink, a third floor resident room sink, a second floor resident room sink, second floor utility room, ice cream parlor sink, and conference room bathroom sink on ground floor. The Quantitative Legionella Report dated [DATE] for sampling date of [DATE] notes that of the ten sites tested , three results were positive for Legionella pneumophila. These three sites were the bathroom sink in R8's room, third floor pantry sink, and the second floor soiled utility room sink. No explanation was provided regarding the sample selection of ten sites which does not coincide with the outside consulting company's information provided on [DATE] under Sample Collection. This document notes that the consulting firm recommends 10 samples for every 100 beds. CMS-672 provided at time of the survey indicates that the facility has a current census of 281 residents. [DATE], (YEAR) V1 stated a meeting was held on [DATE] with the administrative team to determine immediate remediation action. Approvals were generated to install a [MEDICATION NAME]/silver ionization system with target installation date of [DATE]. Installation was completed according to V1 on [DATE], however the Illinois Environmental Protection Agency advised that the facility to turn off the system and recommended a boil order for water until testing was completed for the presence of Coliform. At the time of the survey, the system remained off. On [DATE] at 11:00 am, V1 (Administrator) presented a document titled Hazard and Vulnerability Assessment Tool. V1 stated that this is our facility risk assessment, which was developed on [DATE]. V1 stated that this tool was developed by the management team and in collaboration with a health consulting agency. V1 stated that the Legionnaire's infection would be identified under the heading Mass Casualty Incident (medical/infectious), which documented, Probability = 0 (zero) and Risk = 0 (zero). This was a single line on the document with no other documentation for risk assessment related to Legionella. There was no other documentation provided by the facility. On [DATE] at 11:15 am, V2 (Director of Nursing) stated that There is no specific policy for Legionella but it is included in the water-borne pathogen policy. The policy provided by V2 was undated and titled Water Borne Pathogens. V2 stated this policy is not included in the infection control manual and that according to V1 (Administrator), this policy was initiated at the time when the water treatment contract was initiated in (YEAR). The Water Borne Pathogens policy includes under Section B: Assess the environmental risk from potential amplification factors. At the time of survey, facility administrative staff did not provide any documentation that this assessment outlined in the policy had been done prior to (MONTH) 8, (YEAR) when R8 tested positive for Legionella. On [DATE] at 3:00 pm, V1 (Administrator) was asked to explain actions taken related to policy on Water Borne Pathogens as it relates to environmental risks. V1 stated that the facility's domestic hot water systems are being maintained by a contracted company and that this is inspected annually by Illinois State Fire Marshal (yet provided no details related to Legionella prevention). V1 indicated that shower rooms are being constantly used, and cooling and humidifying systems which produce aerosols have been identified and were part of risk assessment done in (YEAR). However, despite multiple interviews, V1 did not provide a water management plan nor did he provide any facility risk assessment specific to Legionella prevention. V1 stated on [DATE] at 3:30 pm (when asked about the Survey and Certification Letter ,[DATE]), that he had received an email containing this Letter on (MONTH) 15, (YEAR) from Illinois Health Care Association and on [DATE] from the County Health Department. V1 stated We were under the impression that the water treatment service we had for the HVAC (Heating, Ventilation and Air Conditioning) since ,[DATE] addressed the provisions for the S&C memo. V1 stated that there was water treatment plan for the HVAC system, including testing HVAC system for sediments, infiltrates, PH levels and bacteria, but there was no water management plan for the domestic water system (water used for drinking and showers) until [DATE]. The water treatment plan contract documents dated (MONTH) 28. (YEAR) provided by V1 (Administrator) state that the service plan includes on-site visits to the facility and planned evaluation of the chemical treatment systems. This contract did not address or include a water management plan to address the prevention of Legionella. On [DATE] at 12:51 pm V21 (Infection Preventionist) stated that the purpose of infection control program is for prevention of spread of infection and for proper management and treatment whenever there is an infection. The facility's infection policy version [DATE] documents: Purpose: To develop and maintain a comprehensive Infection Prevention Program Policy: A comprehensive infection Prevention Program is required in order to prevent infections, prevent transmission of infections, and appropriately manage infections within the facility. It is the policy of this facility to follow infection prevention practices as outlined in this manual. The facility's Infection Prevention Plan version [DATE] documents: Purpose: To develop and maintain a written plan for infection prevention including an assessment of risk, services provided, and the population served and strategies to decrease risk and a surveillance plan. Policy: It is the policy of this facility to implement and follow the written infection prevention plan. Infection/Condition -Legionella: Precautions type- standard precaution, comments: Not transmitted from person to person. There were no other entries documented on Infection control Manual related to Legionnaires' disease. V21 was asked about who the facility considers at risk for Legionella infection and what care and treatment were provided for them. V21 stated that residents at risk for Legionnaire's infections would be those with [MEDICAL CONDITION], Diabetes Mellitus, chronic kidney failure and those with liver failure. V21 stated that there is no specific system in place for care of those at risk but just monitoring for respiratory symptoms and documenting identified infections in the logs. V21 added that there has been no history of other water borne pathogens within a year (for example listeria, salmonella, staphylococcus, pseudomonas, e. coli). V21 stated that for those with identified infections, treatment for [REDACTED]. Resident information related to those at risk for Legionnaires' infection Per CMS 672 on [DATE]: 281 residents in facility 8 residents with pressure sores 6 residents on hospice 1 resident receiving [MEDICAL CONDITION] therapy 4 receiving [MEDICAL TREATMENT] (outside facility) 5 residents with respiratory treatments 2 residents with ostomy care 6 receiving antibiotics 16 receiving tube feedings On [DATE] at 4:00 pm, V1 (Administrator) confirmed statements made regarding facility risk assessment and S&C ,[DATE] Letter and added the following information: On [DATE]: V32 installed medical shower heads in all shower stalls throughout the building. On [DATE]: Re-test Quantitative Legionella Report: R8's room sink cold: ND (Not detected) R8's room sink hot: ND Third floor pantry cold: ND Third floor pantry hot: ND Second floor soiled utility cold: 0.1 cfu/unit Second floor soiled utility hot: 1.5 cfu/unit V1 stated that at this time the [MEDICATION NAME]/Silver Ionizing system is still shut down due to permits. V1 added that there is a decrease in the areas that tested positive, only soiled utility room sink tested positive and that all soiled utility rooms are not being used at this time. Interviews were conducted with staff regarding preventive measures and restrictions related to Legionnaires' Infection. V22 (Assistant Administrator), V39, V49 and V51 (Registered Nurse), V40, V44, V45, V46 and V49 (Certified Nursing Assistant), V12, V42, V43 and V47 (Licensed Practical Nurse) were interviewed on [DATE], between 11:00 am - 1:06 pm. Staff stated that residents have been provided with bottled water for drinking and for tooth brushing since the beginning of (MONTH) (YEAR). Staff stated that there were no restrictions on use of showers at any time and that they have been providing residents with showers according to their shower schedules. Shower sheets for residents on 3rd and 5th floors were reviewed. V2 (Director of Nursing) and V21 (Infection Preventionist) stated that showers are done twice a week per shower schedule. Shower sheets documented that showers were provided to residents or residents took showers: [DATE] - R11, R16 thru R35, R76, R78, R104 thru 108 [DATE] - R1, R6, R9, R10, R36 thru R64 [DATE] - R65 thru R75 [DATE] - R7, R76 thru R103

Based on observation, interview and record review, the facility neglected to follow their policies for skin assessment and change in condition for a resident with an ankle fracture and surgical incision, and neglected to obtain physician orders [REDACTED]. This failure resulted in R1 sustaining a pressure ulcer and wound infection requiring hospitalization and removal of surgically implanted hardware. This applies to 1 of 3 residents (R1) reviewed for improper nursing care and wounds in the sample of 3. The findings include: On (MONTH) 18, (YEAR) at 2:00 PM, R1 was in bed sleeping. R1's right ankle was covered by a dressing, and a wound VAC (vacuum assisted closure) was in place. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 9, (YEAR) shows R1 has severe cognitive impairment, requires extensive assistance with bed mobility, transferring, ambulation, dressing, hygiene and toileting. R1 is totally dependent on facility staff for bathing, and is frequently incontinent of bowel and bladder. R1's MDS dated (MONTH) 21, (YEAR) showed R1 had moderate cognitive impairment, required extensive assistance with bed mobility, transferring, ambulation, dressing, hygiene and toileting. R1 was totally dependent on facility staff for bathing and was frequently incontinent of bowel and bladder. R1's Braden Scale for predicting pressure ulcer risk, dated (MONTH) 7, (YEAR), showed R1 was at moderate risk for pressure ulcer. Nursing progress notes dated (MONTH) 12, (YEAR) show R1 fell outside the facility when (V12) (family member) transferred R1 from the wheelchair to the car. R1 was sent to the local hospital and returned the same day with a right ankle fracture. Nursing progress notes dated (MONTH) 6, (YEAR) show R1 had surgery at the local hospital and returned to the facility on (MONTH) 8, (YEAR). On (MONTH) 21, (YEAR), V3 (surgeon) documented: (R1) is seen in the office today with (family member) present for follow-up of an ORIF (open-reduction, internal fixation) of a bimalleolar ankle fracture to her right ankle. She denies pain or discomfort today. R1 is having difficulty with communication as well secondary to change in R1's psychiatric medication. R1 has no complaints today. On examination minimal [MEDICAL CONDITION] is present to the right ankle. Sutures are intact and skin edges are well coapted and appear to be healed at this time. Neurologic sensation is grossly intact. Vascular status is intact. Plan: (R1) had sutures removed today and a below knee non-weight bearing cast was applied to the right leg. R1 will follow-up with me in two weeks. At this time, a new X-ray will be taken and R1 will be reevaluated. R1 may call with questions or concerns. On (MONTH) 5, (YEAR), V3 documented: On examination, surgical incisions are healed. Small blisters noted near the medial, near the lateral incision. No evidence of infection. [MEDICAL CONDITION] is greatly reduced. There is no crepitus or gross instability with range of motion. Muscle strength is 5/5. X-rays were taken today. Distal fibula appears to be healed at this time. Medial malleolus is in good position. No retrograding of hardware or screws. Plan: (R1) was dispensed a CAM walker today. R1 may begin applying weight for transfer to bed and to chairs. R1 is not to be ambulatory at this time. R1 will follow-up with me in 2 to 4 weeks. R1 may call with questions or concerns. Nursing documentation dated (MONTH) 28, (YEAR) shows: (R1) came back from doctor's appointment with order to send out resident to (local hospital) for right ankle ulcer, hardware exposed, gave report to (nurse). Ambulance called, family notified. Picked up at 2:00 PM. V3's (surgeon) documentation dated (MONTH) 28, (YEAR) shows: R (right) ankle open ulcer, hardware exposed. (R1) to be admitted to (local hospital) today 12/28/17. V3's documentation dated (MONTH) 29, (YEAR) shows: (R1) is known to me from an ORIF of a bimalleolar ankle fracture was performed approximately 6 weeks ago. R1 presented to my office for routine post-operative visit and was noted that she had a large ulceration to lateral aspect of her right ankle measuring 3 x 3.5 cm. (centimeters) with exposed hardware. Decision was made to admit (R1) and R1 scheduled for an I&D (incision and drainage) with removal of hardware today. Preoperative Diagnoses: [REDACTED]. The facility's progress notes were reviewed for the period (MONTH) 5, (YEAR) to (MONTH) 28, (YEAR). The facility did not have any documentation to show R1's right lower extremity was assessed, including the surgical incision, during this time period. The facility's Medication Review Report dated (MONTH) 1 to (MONTH) 31, (YEAR) shows: Order date: (MONTH) 6, (YEAR): Wound nurse to wrap R (right) leg due to boot agitated skin around it. The EMR shows this order was discontinued on (MONTH) 2, (YEAR). There were no orders for the management of R1's CAM boot, including data for the removal of the boot for circulation check, skin inspection, washing and to remove the boot while sleeping. On (MONTH) 6, 14, 18, 20 and 28, (YEAR), V5 (Treatment Nurse) documented, Left buttock skin tear. V5 did not document assessment of R1's right ankle incision. On (MONTH) 17, (YEAR) at 3:55 PM, V5 (Treatment Nurse) said, I never saw the order to wrap (R1's) right leg in gauze due to irritation by the boot. If I knew about it, I would have looked at the ankle. I never looked at (R1's) right leg or ankle incision from (MONTH) 5 to 28, (YEAR). On (MONTH) 7, (YEAR) V6 (LPN-Licensed Practical Nurse) documented on the Unit Nurse Skin Review, No skin issues noted this shift. V6 did not document the assessment of, or presence of R1's surgical incision. On (MONTH) 14, (YEAR), V6 documented on the Unit Nurse Skin Review, Left buttock skin tear, new patch applied. V6 did not document the assessment of, or presence of R1's surgical incision. On (MONTH) 18, (YEAR) at 10:55 AM, V6 (LPN) said, The nurse practitioner told me to put in an order for [REDACTED]. I never removed the boot to see the irritation. I never followed up with the treatment nurse to make sure treatment nurse followed the order. I never removed the (CAM) boot to assess (R1's) skin or R1's surgical incision. The skin assessments I completed in (MONTH) did not include assessment of (R1's) right ankle. I never saw the surgical site after the cast was removed. I've been a nurse less than one year, and I've never taken care of anyone with a CAM boot before. I know (R1) didn't like the CNAs to touch R1's boot. I never called R1's POA or physician to let them know (R1) was refusing to have R1's boot removed. R1's Skin Check/Shower Worksheets dated (MONTH) 7, 11, 14, 18, 21, 25, (YEAR) show R1 refused to have R1's feet checked or to touch the boot during R1's shower. Shower sheets were signed by the CNAs (Certified Nursing Assistant) and nurses caring for R1. The facility did not have documentation to show R1's physician or POA (Power of Attorney) were notified of R1's refusal to remove the CAM boot or that the staff was unable to do a skin assessment of R1's right ankle from (MONTH) 5 to (MONTH) 28, (YEAR). R1's care plan dated (MONTH) 13, (YEAR) shows: Resident has a fx (fracture) of the R bimalleolar ankle fracture. Goals: Resident's fx will heal w/o (without) complications thru next review. Next review date 1/13/2018. Interventions: Observe and check circulation by palpating distal pulses of the affected area or limb. Assess for s/s (signs and symptoms) of infection. Monitor for s/s of irritation and/or breakdown around fracture/surgical site. R1's care plan dated (MONTH) 20, (YEAR) and updated (MONTH) 6, (YEAR) for refusal of care shows: The resident exhibits the symptoms of resisting care which is related to psychiatric illness, severe mental illness. Approaches/Interventions: Resident signed contract stating she will comply with meds, shower schedule and psychosocial groups. Staff to notify POAHC (Power of Attorney for Health Care) for education and resident rights. On (MONTH) 18, (YEAR) at 9:15 AM, V2 (DON-Director of Nursing) said, When a resident comes back from a doctor's appointment, physician orders [REDACTED]. The nurse should call the physician if they need clarification or orders. Physician documentation and orders from (R1's) physician visit on (MONTH) 5, (YEAR) were not requested from the physician until (MONTH) 28, (YEAR). We did not know (R1's) weight-bearing status, when the CAM boot should be removed, or condition of R1's surgical incision after R1's physician visit on (MONTH) 5, (YEAR). It wasn't until after R1 had to go back to the hospital, on (MONTH) 28, (YEAR), that we requested the records from R1's physician visits in (MONTH) (YEAR) and (MONTH) 5, (YEAR). On (MONTH) 6, (YEAR), (V6) put in an order for [REDACTED]. leg was never seen or treated by the wound nurse between (MONTH) 6, (YEAR) and (MONTH) 28, (YEAR). On (MONTH) 18, (YEAR) at 12:11 PM, V3 (surgeon) said, The point of using a CAM walker boot is to remove it during sleeping, showering and cleaning. When (R1) returned to the facility with something new on R1's right leg on (MONTH) 5, (YEAR), and they weren't sure how to care for (R1) with a CAM boot, I would have expected them to call me and clarify. When (R1) came into the office on (MONTH) 28, (YEAR), we could smell a bad odor coming from R1's CAM boot before we even opened it. R1 was not wearing any sock or gauze around R1's ankle, and R1's ankle was rubbing on the boot. There was a pressure ulcer on R1's right ankle, caused by the boot. There was a large opening, and the hardware was exposed. It was not something I had expected. (R1's) surgical incision did not dehis. R1's other health conditions did not cause the wound to open, it was pressure. R1's incision was completely healed on R1's previous visit. Unfortunately, because of the ulcer and the infection that developed, (R1) had to endure a second surgery, and I had to remove the plate and screws I had put in to heal R1's fracture. I had intended for the hardware to remain in place forever. On (MONTH) 29, (YEAR), at 9:17 AM, V2 (DON) said, I would define neglect as the failure to provide proper nursing care. R1 had a care plan in place dated (MONTH) 13, (YEAR) for R1's right bimalleolar ankle fracture. The care plan was updated on (MONTH) 22, (YEAR), and (MONTH) 6, (YEAR). The interventions show R1's surgical site should have been monitored for signs and symptoms of infection or skin breakdown around the surgical site. There is no documentation to show the staff followed the care plan interventions. R1's care plan for refusing care that was initiated on (MONTH) 20, (YEAR) and updated on (MONTH) 6, (YEAR) shows R1's POA should be notified if R1 resists care. There is no documentation in the medical record to show R1's POA or physician were notified of R1's repeated refusals for staff to touch R1's boot and assess R1's right ankle. I believe the situation with R1's skin breakdown and lack of skin assessment began with the wrong transcription of the order on (MONTH) 6, (YEAR). The order to have R1 seen by the wound care nurse and to wrap R1's right leg with gauze never made it to the TAR so it was never done. Also, we never received the documentation from R1's physician after R1's visit on (MONTH) 5, (YEAR) when R1 had the cast removed and the CAM boot was applied. On (MONTH) 29, (YEAR) at 10:00 AM, V1 (Administrator) said, I would define neglect as the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. There were multiple failures by multiple staff members other than (V6) (LPN). Restorative and other nurses also failed. This failure wasn't brought to my attention by the nursing staff, but came to light when transportation was ordered to take (R1) to the local hospital. I order the transportation, so that's how I found out about it. It was a holiday, and (V2) was on vacation, and we probably let our guard down. On (MONTH) 29, (YEAR) at 10:31 AM, V9 (Medical Director) said, (R1) has multiple medical problems including diabetes, obesity, [MEDICAL CONDITIONS] and is difficult to manage due to R1's mental problems. The facility staff should have made sure (R1's) wound looked intact and provided appropriate wound care. I would expect the staff to follow the care plan for her care. I am (R1's) primary care physician, but I do have physician extenders who also see (R1). I was not personally notified of (R1) resisting or refusing care by facility staff. I would have expected the staff to follow through with the order to wrap (R1's) leg in gauze and be seen by the treatment nurse. The staff should have followed through on care plan interventions and should have assessed R1's wound. The facility's Abuse Policy revised (MONTH) 6, (YEAR) shows: This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: .8. Neglect/Mistreatment: Means the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. The facility's policy entitled Risk and Skin assessment dated (MONTH) 19, (YEAR) shows: Policy: Intact skin is the body's first line of defense. It is the policy of this facility to assess all residents for factors that place them at risk for developing pressure injuries. It is also the policy of this facility to monitor the skin integrity of our residents for the development of wounds or other skin conditions. These assessments will begin upon admission and continue throughout the resident's stay in our facility. Procedure: II. All residents will have a visual inspection of their skin. A. A complete head-to-toe skin check is completed by the licensed nurse upon admission. B. Skin checks are completed weekly by the nurse. C. Skin check is completed on each shower day by nursing assistant staff. 1. Shower sheet may be used to document the skin check. D. The nursing assistant visually inspects the skin daily and with care. 1. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate this information. 2. Appropriate measures will be instituted. The facility's policy entitled Change in Resident's Condition or Status dated (MONTH) 26, 2011 shows: 1. The nurse will notify the resident's attending physician when: The resident repeatedly refuses treatment or medications.

Based on observation, interview and record review, the facility failed to obtain physicianorders, care instructions, and assess a resident's skin following application of a CAM (controled ankle motion boot.) This failure resulted in R1 sustaining a pressure ulcer and wound infection requiring hospitalization and removal of surgically implanted hardware. This applies to 1 of 3 residents (R1) reviewed for improper nursing care and wounds in the sample of 3. The findings include: On (MONTH) 18, (YEAR) at 2:00 PM, R1 was in bed sleeping. R1's right ankle was covered by a dressing, and a wound VAC (vacuum assisted closure) was in place. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 9, (YEAR) shows R1 has severe cognitive impairment, requires extensive assistance with bed mobility, transferring, ambulation, dressing, hygiene and toileting. R1 is totally dependent on facility staff for bathing, and is frequently incontinent of bowel and bladder. R1's MDS dated (MONTH) 21, (YEAR) showed R1 had moderate cognitive impairment, required extensive assistance with bed mobility, transferring, ambulation, dressing, hygiene and toileting. R1 was totally dependent on facility staff for bathing and was frequently incontinent of bowel and bladder. R1's Braden Scale for predicting pressure ulcer risk, dated (MONTH) 7, (YEAR), showed R1 was at moderate risk for pressure ulcer. Nursing progress notes dated (MONTH) 12, (YEAR) show R1 fell outside the facility when (V12) (family member) transferred R1 from the wheelchair to the car. R1 was sent to the local hospital and returned the same day with a right ankle fracture. Nursing progress notes dated (MONTH) 6, (YEAR) show R1 had surgery at the local hospital and returned to the facility on (MONTH) 8, (YEAR). On (MONTH) 21, (YEAR), V3 (surgeon) documented: (R1) is seen in the office today with (family member) present for follow-up of an ORIF (open-reduction, internal fixation) of a bimalleolar ankle fracture to her right ankle. She denies pain or discomfort today. R1 is having difficulty with communication as well secondary to change in R1's psychiatric medication. R1 has no complaints today. On examination minimal [MEDICAL CONDITION] is present to the right ankle. Sutures are intact and skin edges are well coapted and appear to be healed at this time. Neurologic sensation is grossly intact. Vascular status is intact. Plan: (R1) had sutures removed today and a below knee non-weight bearing cast was applied to the right leg. R1 will follow-up with me in two weeks. At this time, a new X-ray will be taken and R1 will be reevaluated. R1 may call with questions or concerns. On (MONTH) 5, (YEAR), V3 documented: On examination, surgical incisions are healed. Small blisters noted near the medial, near the lateral incision. No evidence of infection. [MEDICAL CONDITION] is greatly reduced. There is no crepitus or gross instability with range of motion. Muscle strength is 5/5. X-rays were taken today. Distal fibula appears to be healed at this time. Medial malleolus is in good position. No retrograding of hardware or screws. Plan: (R1) was dispensed a CAM walker today. R1 may begin applying weight for transfer to bed and to chairs. R1 is not to be ambulatory at this time. R1 will follow-up with me in 2 to 4 weeks. R1 may call with questions or concerns. Nursing documentation dated (MONTH) 28, (YEAR) shows: (R1) came back from doctor's appointment with order to send out resident to (local hospital) for right ankle ulcer, hardware exposed, gave report to (nurse). Ambulance called, family notified. Picked up at 2:00 PM. V3's (surgeon) documentation dated (MONTH) 28, (YEAR) shows: R (right) ankle open ulcer, hardware exposed. (R1) to be admitted to (local hospital) today 12/28/17. V3's documentation dated (MONTH) 29, (YEAR) shows: (R1) is known to me from an ORIF of a bimalleolar ankle fracture was performed approximately 6 weeks ago. R1 presented to my office for routine post-operative visit and was noted that she had a large ulceration to lateral aspect of her right ankle measuring 3 x 3.5 cm. (centimeters) with exposed hardware. Decision was made to admit (R1) and R1 scheduled for an I&D (incision and drainage) with removal of hardware today. Preoperative Diagnoses: [REDACTED]. The facility's progress notes were reviewed for the period (MONTH) 5, (YEAR) to (MONTH) 28, (YEAR). The facility did not have any documentation to show R1's right lower extremity was assessed, including the surgical incision, during this time period. The facility's Medication Review Report dated (MONTH) 1 to (MONTH) 31, (YEAR) shows: Order date: (MONTH) 6, (YEAR): Wound nurse to wrap R (right) leg due to boot agitated skin around it. The EMR shows this order was discontinued on (MONTH) 2, (YEAR). There were no orders for the management of R1's CAM boot, including data for the removal of the boot for circulation check, skin inspection, washing and to remove the boot while sleeping. On (MONTH) 6, 14, 18, 20 and 28, (YEAR), V5 (Treatment Nurse) documented, Left buttock skin tear. V5 did not document assessment of R1's right ankle incision. On (MONTH) 17, (YEAR) at 3:55 PM, V5 (Treatment Nurse) said, I never saw the order to wrap (R1's) right leg in gauze due to irritation by the boot. If I knew about it, I would have looked at the ankle. I never looked at (R1's) right leg or ankle incision from (MONTH) 5 to 28, (YEAR). On (MONTH) 7, (YEAR) V6 (LPN-Licensed Practical Nurse) documented on the Unit Nurse Skin Review, No skin issues noted this shift. V6 did not document the assessment of, or presence of R1's surgical incision. On (MONTH) 14, (YEAR), V6 documented on the Unit Nurse Skin Review, Left buttock skin tear, new patch applied. V6 did not document the assessment of, or presence of R1's surgical incision. On (MONTH) 18, (YEAR) at 10:55 AM, V6 (LPN) said, The nurse practitioner told me to put in an order for [REDACTED]. I never removed the boot to see the irritation. I never followed up with the treatment nurse to make sure treatment nurse followed the order. I never removed the (CAM) boot to assess (R1's) skin or R1's surgical incision. The skin assessments I completed in (MONTH) did not include assessment of (R1's) right ankle. I never saw the surgical site after the cast was removed. I've been a nurse less than one year, and I've never taken care of anyone with a CAM boot before. I know (R1) didn't like the CNAs to touch R1's boot. I never called R1's POA or physician to let them know (R1) was refusing to have R1's boot removed. R1's Skin Check/Shower Worksheets dated (MONTH) 7, 11, 14, 18, 21, 25, (YEAR) show R1 refused to have R1's feet checked or to touch the boot during R1's shower. Shower sheets were signed by the CNAs (Certified Nursing Assistant) and nurses caring for R1. The facility did not have documentation to show R1's physician or POA (Power of Attorney) were notified of R1's refusal to remove the CAM boot or that the staff was unable to do a skin assessment of R1's right ankle from (MONTH) 5 to (MONTH) 28, (YEAR). R1's care plan dated (MONTH) 13, (YEAR) shows: Resident has a fx (fracture) of the R bimalleolar ankle fracture. Goals: Resident's fx will heal w/o (without) complications thru next review. Next review date 1/13/2018. Interventions: Observe and check circulation by palpating distal pulses of the affected area or limb. Assess for s/s (signs and symptoms) of infection. Monitor for s/s of irritation and/or breakdown around fracture/surgical site. R1's care plan dated (MONTH) 20, (YEAR) and updated (MONTH) 6, (YEAR) for refusal of care shows: The resident exhibits the symptoms of resisting care which is related to psychiatric illness, severe mental illness. Approaches/Interventions: Resident signed contract stating she will comply with meds, shower schedule and psychosocial groups. Staff to notify POAHC (Power of Attorney for Health Care) for education and resident rights. On (MONTH) 18, (YEAR) at 9:15 AM, V2 (DON-Director of Nursing) said, When a resident comes back from a doctor's appointment, physician orders [REDACTED]. The nurse should call the physician if they need clarification or orders. Physician documentation and orders from (R1's) physician visit on (MONTH) 5, (YEAR) were not requested from the physician until (MONTH) 28, (YEAR). We did not know (R1's) weight-bearing status, when the CAM boot should be removed, or condition of R1's surgical incision after R1's physician visit on (MONTH) 5, (YEAR). It wasn't until after R1 had to go back to the hospital, on (MONTH) 28, (YEAR), that we requested the records from R1's physician visits in (MONTH) (YEAR) and (MONTH) 5, (YEAR). On (MONTH) 6, (YEAR), (V6) put in an order for [REDACTED]. leg was never seen or treated by the wound nurse between (MONTH) 6, (YEAR) and (MONTH) 28, (YEAR). On (MONTH) 18, (YEAR) at 12:11 PM, V3 (surgeon) said, The point of using a CAM walker boot is to remove it during sleeping, showering and cleaning. When (R1) returned to the facility with something new on R1's right leg on (MONTH) 5, (YEAR), and they weren't sure how to care for (R1) with a CAM boot, I would have expected them to call me and clarify. When (R1) came into the office on (MONTH) 28, (YEAR), we could smell a bad odor coming from R1's CAM boot before we even opened it. R1 was not wearing any sock or gauze around R1's ankle, and R1's ankle was rubbing on the boot. There was a pressure ulcer on R1's right ankle, caused by the boot. There was a large opening, and the hardware was exposed. It was not something I had expected. (R1's) surgical incision did not dehis. R1's other health conditions did not cause the wound to open, it was pressure. R1's incision was completely healed on R1's previous visit. Unfortunately, because of the ulcer and the infection that developed, (R1) had to endure a second surgery, and I had to remove the plate and screws I had put in to heal R1's fracture. I had intended for the hardware to remain in place forever. On (MONTH) 29, (YEAR), at 9:17 AM, V2 (DON) said, I would define neglect as the failure to provide proper nursing care. R1 had a care plan in place dated (MONTH) 13, (YEAR) for R1's right bimalleolar ankle fracture. The care plan was updated on (MONTH) 22, (YEAR), and (MONTH) 6, (YEAR). The interventions show R1's surgical site should have been monitored for signs and symptoms of infection or skin breakdown around the surgical site. There is no documentation to show the staff followed the care plan interventions. R1's care plan for refusing care that was initiated on (MONTH) 20, (YEAR) and updated on (MONTH) 6, (YEAR) shows R1's POA should be notified if R1 resists care. There is no documentation in the medical record to show R1's POA or physician were notified of R1's repeated refusals for staff to touch R1's boot and assess R1's right ankle. I believe the situation with R1's skin breakdown and lack of skin assessment began with the wrong transcription of the order on (MONTH) 6, (YEAR). The order to have R1 seen by the wound care nurse and to wrap R1's right leg with gauze never made it to the TAR so it was never done. Also, we never received the documentation from R1's physician after R1's visit on (MONTH) 5, (YEAR) when R1 had the cast removed and the CAM boot was applied. On (MONTH) 29, (YEAR) at 10:00 AM, V1 (Administrator) said, I would define neglect as the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. There were multiple failures by multiple staff members other than (V6) (LPN). Restorative and other nurses also failed. This failure wasn't brought to my attention by the nursing staff, but came to light when transportation was ordered to take (R1) to the local hospital. I order the transportation, so that's how I found out about it. It was a holiday, and (V2) was on vacation, and we probably let our guard down. On (MONTH) 29, (YEAR) at 10:31 AM, V9 (Medical Director) said, (R1) has multiple medical problems including diabetes, obesity, [MEDICAL CONDITIONS] and is difficult to manage due to R1's mental problems. The facility staff should have made sure (R1's) wound looked intact and provided appropriate wound care. I would expect the staff to follow the care plan for her care. I am (R1's) primary care physician, but I do have physician extenders who also see (R1). I was not personally notified of (R1) resisting or refusing care by facility staff. I would have expected the staff to follow through with the order to wrap (R1's) leg in gauze and be seen by the treatment nurse. The staff should have followed through on care plan interventions and should have assessed R1's wound. The facility's Abuse Policy revised (MONTH) 6, (YEAR) shows: This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: .8. Neglect/Mistreatment: Means the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. The facility's policy entitled Risk and Skin assessment dated (MONTH) 19, (YEAR) shows: Policy: Intact skin is the body's first line of defense. It is the policy of this facility to assess all residents for factors that place them at risk for developing pressure injuries. It is also the policy of this facility to monitor the skin integrity of our residents for the development of wounds or other skin conditions. These assessments will begin upon admission and continue throughout the resident's stay in our facility. Procedure: II. All residents will have a visual inspection of their skin. A. A complete head-to-toe skin check is completed by the licensed nurse upon admission. B. Skin checks are completed weekly by the nurse. C. Skin check is completed on each shower day by nursing assistant staff. 1. Shower sheet may be used to document the skin check. D. The nursing assistant visually inspects the skin daily and with care. 1. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate this information. 2. Appropriate measures will be instituted. The facility's policy entitled Change in Resident's Condition or Status dated (MONTH) 26, 2011 shows: 1. The nurse will notify the resident's attending physician when: The resident repeatedly refuses treatment or medications.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. As a result of this failure, R3 was sent to the hospital on [DATE] for debridement of sacral sore which worsened . R3's sacral sore was a stage IV on 10/11/11 measuring 4.5 x 5 x 2.2 cm with 3 cm undermining at 12 o clock and with 100 % eschar/necrosis. Findings include : R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's February 2011 Treatment Administration Record ( TAR ) showed that on 2/4/11, the [MEDICATION NAME] to R3's sacrum was discontinued, and it was marked " healed." Review of R3's Physician order [REDACTED]. However, there was no [MEDICATION NAME] treatment for [REDACTED]. There also was no wound assessment found in R3's skin care assessment and record of this pressure sore, nor is there any mention of this sore, in R3's nurses notes. In R3's May and June 2011 TARs, there also was no mention of this sore. Z1's Physician Wound Care notes dated 7/12/11 indicated that a 10 x 5.5 x 0.1 cm Stage II sore was found on R3's sacrum with 100 % granulation tissue. There was no explanation why a sore this size was found only on 7/12/11 or why it has not progress from a smaller wound first. Z1's recommendation of [MEDICATION NAME] was signed as applied in R3's TAR from 7/12/11 until 7/31/11. However, R3 also has another July 2011 TAR which shows that R3's sacral sore is receiving [MEDICATION NAME] cream daily starting July 8 until the end of July. This TAR also has blanks indicating no nurse signed it as treatment given on the following dates : 7/13, 7/14, 7/15, 7/24, 7/25, 7/26 and 7/28/11. During 1/12/11 interview at 2 PM, E3 ( treatment nurse ) said that sometimes there are emergencies during treatment, so the TAR is not signed. When asked if the blanks on R3's TAR were not signed because there were emergencies during those times, E3 was not able to answer. Per R3's Wound Care Notes dated 7/19/11, R3's sacral sore was bigger at 13 x 10 x 0.1 with undermining of 2.6 x 1 x 0.5 at 12 o clock. Z1 and Z2 ordered Santyl at the 12 o clock wound, and a large [MEDICATION NAME] on the whole wound. This order/ recommendation was not followed in R3's TAR. R3's July TARs as mention above, shows that R3 is receiving [MEDICATION NAME] or [MEDICATION NAME] Cream on similar dates for the same wound. On 8/5/11, R3's Wound Care note ordered Santyl with [MEDICATION NAME] on R3's sacral sore. However, R3's August TAR indicated that R3's sacral sore was getting [MEDICATION NAME] Cream not santyl starting 8/1/11 until the end of the month. There were blanks also on 8/8, 8/11, 8/15, 8/16, 8/17, 8/18, 8/21, 8/23, 8/24, 8/29, 8/29, & 8/30/11. R3 has 2 more August TAR that coincided with her 8/13/11 Wound care notes. These 2 TARs indicated that R3 started getting [MEDICATION NAME] on 8/13/11 as ordered by Z1 in the Wound Care Notes. E3 was not able to explain why there were 3 TARs with different treatments in August 2001. Aside from that, the 2 TARs indicating [MEDICATION NAME] was used on R3's sacral sore also has blanks on 8/16, 8/18, 8/23, 8/25, 8/28, & 8/29/11. Further review of R3's Wound Care Notes showed that on 8/23/11, Z1 or Z2 actually changed the [MEDICATION NAME] treatment to Santyl with moist packing. The above 3 TARs should have reflected this new order change but it did not. Added to this, on 8/30/11, R3's sacral sore treatment was changed from Santyl to Santyl and [MEDICATION NAME] covered with [MEDICATION NAME]. This too was not carried out per August TARs, nor was this carried out in September 2011 TAR. Review of R3's September TAR showed 1 TAR with [MEDICATION NAME] cream treatment to the sacral sore BID starting 9/1/11, another TAR showing [MEDICATION NAME] cream once daily only starting 9/1/11, another TAR showing Santyl to the sacrum starting 9/13/11 and another TAR showing Santyl and [MEDICATION NAME] BID to the sacrum starting 9/13/11. All of these TARs for September 2011 have multiple blanks in 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/18, 9/22, 9/23, 9/26, 9/27, 9/28, 9/29, & 9/30/11. Furthermore, the above orders were not ordered by Z1 or Z2 per R3's Wound Care Notes. R3's Wound Care Notes indicated that Z1 or Z2 should continue with Santyl and [MEDICATION NAME] plus [MEDICATION NAME] on 9/6/11. On 9/13/11, this order was modified not to include the [MEDICATION NAME] dressing. There is no indication that the facility used [MEDICATION NAME] on R3's sacral sore at all. On 9/20/11, a [MEDICATION NAME] dressing around the wound was added to Santyl and [MEDICATION NAME]. This too was not followed by the facility per review of the above September MARs. R3's October 2011 TAR showed that starting 10/1/11, R3's sacral sore received Santyl when it should have been Santyl, [MEDICATION NAME], and [MEDICATION NAME] around the wound per R3's 9/27/22 and 10/4/11 Wound care Notes. This TAR showed blanks in 10/3, 10/4, , 10/6, 10/8, 10/9, 10/11, &10/12/11 on 7-3 shift. There were also blanks on the 9 PM treatment on 10/2- 10/6, 10/10, 10/11, & 10/12/11. Per R3's Wound Care Notes, R3's sacral sore became a stage IV by 8/13/11. On 8/13/11, R3's Stage IV sacrum was measured at center : 3 x 2.2 x 2 cm and periwound : 15 x 10 x 0.1 cm with 100 % eschar /necrosis. As of 10/11/11, R3's sacral sore was 4.5 x 5.2 x 2.2 cm with undermining of 3 cm at 12 o clock. The wound was described in this 10/11/11 Wound care Notes as with 100 % eschar/necrosis, is larger and is now foul- smelling. It was during this visit that Z1 recommended hospitalization for surgical debridement. On 1/18/12 at 10:40 AM, E3 said that starting January 2011, the monthly TAR check will now be done by the treatment nurse because of previous discrepancies. E3 also said that during Wound Care round with Z1 or Z2, she goes with them and that, they hand her the Wound Care Notes via USB ready for printing before Z1 or Z2 leaves the facility. E3 said that she gave E4 ( previous treatment nurse ) R3's Wound care notes after the wound rounds, but doesn't know what E4 did with those notes. E3 said that she is not assigned to R3, but her process is, she looks at these notes and talks to Z2 about the orders in the Wound Care Notes for verification. During 1/12/12 meeting with E2 ( Director of Nursing ) at 2 PM, E2 said that the Wound Care Notes by Z1 or Z2 are considered doctors orders. On 1/18/12, E2 said that E4 is no longer in the facility because of her issues with the wound care notes. Per Z2 during 1/24/12 interview at 11:54 AM, Z2 said that aside from the Wound Care Notes for R3, she also writes the orders in the POS but does not know what happens to those, after she gives them to E3 after the wound rounds. Z2 said that if the orders are not followed or the dressings are not changed, the wound would deteriorate. Per POS, R3 was sent out to the hospital for evaluation of the sacral wound and was admitted there.

Based on closed record review and interview, the facility failed to document swallowing difficulty concerns, conduct a comprehensive swallow evaluation and failed to access emergency response for one resident (R30) in a sample of 30 residents. R30 has a history of coughing while being fed, choked and aspirated food and sent out for emergency treatment 2 hours later. R30 expired approximately 30 hours later. Findings include: R30's closed record review on [DATE] reveals nursing notes dated [DATE] at 5:45pm stating R30 turned blue during evening meal, was sent to hospital and admitted with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Physician's Progress notes dated [DATE] through [DATE] makes no reference to any concerns with food and/or liquid ingestion. Nursing Care Plan dated [DATE] states R30 demonstartes some risk to potentially choke/aspirate foods or liquids due to general problems with chewing and/or swallowing. The Minimum Data Set ((MDS) dated [DATE] states R30 requires extensive assist with meals, with one-person physical assist. Dietary notes dated [DATE] shows R30 on a pureed diet with honey thick liquids. Speech Therapy notes dated [DATE] shows R30 assessed by E20 (Speech Therapist) in response to referral from nursing staff. The screen states "referral requested diet change. Pt. (patient) displayed difficulty in eating and swallowing diet w/ (with) hard swallows and c/c ing (choking/coughing) at lunch." During an interview with E20 and E19 (Speech Therapist) on [DATE] at 2:15pm, E20 confirmed that she did assess R30 on [DATE]. When asked if her assessment constitutes a swallow evaluation, E20 responded that the order for swallow evaluation was unclear, and that she did not know whether the ordering physician wanted an internal swallow evaluation or an external evaluation. E20 went on to say that she conducted an external evaluation which consisted of 1:1 feeding with close observation of R30. E20 stated that R30 was choking and coughing during the screen and she (E20) recommended a downgrade in food consistency from general to puree. E20 stated that in her opinoin, there was no need for further screening. E20 also stated that she did not make any recommendations for further monitoring of R30's tolerance of the new food consistency. E20 stated that if R30 was not tolerating the pureed consistency the department would have known that. According to E20, speech therapy monitors luch meals for all residents with swallowing concerns. E20 described R30 as a self-feeder and when noted to be slow in eating, would receive assist with feeding. E19 stated during this same interview that she (E19) is not familiar with R30, and went on to say that the facility's policy is to monitor residents with swallowing concern on three occasions over a two week period to see how these residents are tolerating the new food consistency. Neither E19 nor E20 knew if R30 was monitored per facility's policy. Both E19 and E20 stated that the therapist who may have monitored R30 no longer works at the facility and were unable to provide documentation to support R30 being monitored. E24, Nurse, was the nurse that took care of R30 during the choking incident. E24's documentation dated [DATE] at 5:45pm states R30's face turned blue and she suctioned R30 and conducted an assessment of R30's vital signs. The documentation goes on to state that she (E24) administered Oxygen by nasal cannula at a rate of 3 liters per minute and the physician was notified, who ordered that R30 be transferred to the hospital and given Tylenol for an elevated temperature. The notes states that the ambulance service was call (no time indicated). According to E24's notes, the ambulance service arrived at 6:45pm to transfer R30 to the hospital. A subsequent note at 7:30pm states ambulance service called to say R30 would be taken to the nearest hospital. At 10pm, E24 wrote that R30 was admitted to the hospital with [REDACTED]. During an interview with E24 on [DATE] at 3pm, E24 requested E2's (Director of Nursing, DON) presence during interview. E24 stated that she was in the same dining room with R30, she heard R30 coughing, immediately told the certified nurses aid (CNA) to stop feeding R30, and immediately went over to R30, immediately supported R30's chest and patted R30 on the back. According to E24, R30 was turning blue and she (E24) began suctioning R30 with a suction that was next to R30 in the dining room. E24 stated she believed there was something in R30's airway obstructing her breathing. During the interview E24 could not recall how long she was suctioning R30, thinks she suctioned for more than 15 minutes, and that R30's skin color returned to normal, and with the assistance of E25 (CNA), transported R30 to her room and transferred her to bed. Once in bed, E24 assessed R30's vital signs, discovered that R30 had a temperature of 101 degrees farenheit and called then physician. E24 stated she could not recall at what time she called the ambulance service but remembers the service arrived very quickly, within ,[DATE] minutes. E24 stated that she did not call 911 emergency service because R30's condition had improved. E25 (CNA) was interviewed on [DATE] at 4:15PM. E25 requested that E2 (DON) be present during the interview. E25 speaks very little English (Korean speaking) and E26 (Accounting Conlultant) was present as translator. E25 stated she was feeding R30 and 2 other residents when R30 began to cough, ,[DATE] coughs. When asked to demonstrate the type of cough, E25 demonstrating a choking cough. E25 stated she asked E24 if she should stop feeding R30 and E24 told her to stop. E25 stated the cough was different from the usual. E25 said while E24 was suctioning R30, she, E25, held R30's shoulder to maintain R30 in an upright position. E25 stated that R30 often leans to the side due to poor trunk control. E25 could not remember what R30's posture was like during feeding and coughing. E25 confirmed that she assisted E24 in transferring R30 back to bed where she (E25) remianed with R30 for ,[DATE] minutes until ambulance service came. E25 stated she was concerned that R30 would have choked again. E25 stated that she assist R30 with evening meal on the ,[DATE] shift daily and that R30 would cough during meals about ,[DATE] times each week. E25 stated when this occurs she monitors R30 to see how long cough would continue. During an interview with Z6 on [DATE] at 10:30am, Z6 stated that E24 requested that R30 be transported to an affliate hospital and a decision was made by the ambulance service to take R30 to the nearest hospital instead. Z6 stated that upon arrival at the facility, R30 was non-responsive. The emergency service reports states the facilty called for service at 6:42pm, one hour after R30 choked on her food.

A. Based on closed record review and interview, the facility failed to monitor, assess and initiate emergency response services for one resident (R30) in a sample of 30, who went into respiratory arrest following a choking incident during dining. R30 was transported to the emergency room approximately 2 hours after choking incident, intubated in the emergency room and subsequently expired 30 hours later. Findings include: R30's closed record review on [DATE] reveals nursing notes dated [DATE] at 5:45pm stating R30 turned blue during evening meal, was sent to hospital and admitted with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Physician's Progress notes dated [DATE] through [DATE] makes no reference to any concerns with food and/or liquid ingestion. Nursing Care Plan dated [DATE] states R30 demonstartes some risk to potentially choke/aspirate foods or liquids due to general problems with chewing and/or swallowing. The Minimum Data Set ((MDS) dated [DATE] states R30 requires extensive assist with meals, with one-person physical assist. Dietary notes dated [DATE] shows R30 on a pureed diet with honey thick liquids. Speech Therapy notes dated [DATE] shows R30 assessed by E20 (Speech Therapist) in response to referral from nursing staff. The screen states "referral requested diet change. Pt (patient) displayed difficulty in eating and swallowing diet w/ (with) hard swallows and c/c ing (choking/coughing) at lunch." During an interview with E20 and E19 (Speech Therapist) on [DATE] at 2:15pm, E20 confirmed that she did assess R30 on [DATE]. When asked if her assessment constitutes a swallow evaluation, E20 responded that the order for swallow evaluation was unclear, and that she did not know whether the ordering physician wanted an internal swallow evaluation or an external evaluation. E20 went on to say that she conducted an external evaluation which consisted of 1:1 feeding with close observation of R30. E20 stated that R30 was choking and coughing during the screen and she (E20) recommended a downgrade in food consistency from general to puree. E20 stated that in her opinoin, there was no need for further screening. E20 also stated that she did not make any recommendations for further monitoring of R30's tolarance of the new food consistency. E20 stated that if R30 was not tolerating the pureed consistency the department would have known that. According to E20, speech therapy monitors luch meals for all residents with swallowing concerns. E20 described R30 as a self-feeder and when noted to be slow in eating, would receive assist with feeding. E19 stated during this same interview that she (E19) is not familiar with R30, and went on to say that the facility's policy is to monitor residents with swallowing concern on three occasions over a two week period to see how these residents are tolerating the new food consistency. Neither E19 nor E20 knew if R30 was monitored per facility's policy. Both E19 and E20 stated that the therapist who may have monitored R30 no longer works at the facility and were unable to provide documentation to support R30 being monitored. E24, Nurse, was the nurse that took care of R30 during the choking incident. E24's documentation dated [DATE] at 5:45pm states R30's face turned blue and she suctioned R30 and conducted an assessment of R30's vital signs. The documentation goes on to state that she (E24) administered Oxygen by nasal cannula at a rate of 3 liters per minute and the physician was notified, who ordered that R30 be transferred to the hospital and given Tylenol for an elevated temperature. The notes states that the ambulance service was call (no time indicated). According to E24's notes, the ambulance service arrived at 6:45pm to transfer R30 to the hospital. A subsequent note at 7:30pm states ambulance service called to say R30 would be taken to the nearest hospital. At 10pm, E24 wrote that R30 was admitted to the hospital with [REDACTED]. During an interview with E24 on [DATE] at 3pm, E24 requested E2's (Director of Nursing, DON) presence during interview. E24 stated that she was in the same dining room with R30, she heard R30 coughing, immediately told the certified nurses aid (CNA) to stop feeding R30, and immediately went over to R30, immediately supported R30's chest and patted R30 on the back. According to E24, R30 was turning blue and she (E24) began suctioning R30 with a suction that was next to R30 in the dining room. E24 stated she believed there was something in R30's airway obstructing her breathing. During the interview E24 could not recall how long she was suctioning R30, thinks she suctioned for more than 15 minutes, and that R30's skin color returned to normal, and with the assistance of E25 (CNA), transported R30 to her room and transferred her to bed. Once in bed, E24 assessed R30's vital signs, discovered that R30 had a temperature of 101 degrees farenheit and called then physician. E24 stated she could not recall at what time she called the ambulance service but remembers the service arrived very quickly, within ,[DATE] minutes. E24 stated that she did not call 911 emergency service because R30's condition had improved. E25 (CNA) was interviewed on [DATE] at 4:15PM. E25 requested that E2 (DON) be present during the interview. E25 speaks very little English (Korean speaking) and E26 (Accounting Conlultant) was present as translator. E25 stated she was feeding R30 and 2 other residents when R30 began to cough, ,[DATE] coughs. When asked to demonstrate the type of cough, E25 demonstrating a choking cough. E25 stated she asked E24 if she should stop feeding R30 and E24 told her to stop. E25 stated the cough was different from the usual. E25 said while E24 was suctioning R30, she, E25, held R30's shoulder to maintain R30 in an upright position. E25 stated that R30 often leans to the side due to poor trunk control. E25 could not remember what R30's posture was like during feeding and coughing. E25 confirmed that she assisted E24 in transferring R30 back to bed where she (E25) remianed with R30 for ,[DATE] minutes until ambulance service came. E25 stated she was concerned that R30 would have choked again. E25 stated that she assist R30 with evening meal on the ,[DATE] shift daily and that R30 would cough during meals about ,[DATE] times each week. E25 stated when this occurs she monitors R30 to see how long cough would continue. During an interview with Z6 on [DATE] at 10:30am, Z6 stated that E24 requested that R30 be transported to an affliate hospital and a decision was made by the ambulance service to take R30 to the nearest hospital instead. Z6 stated that upon arrival at the facility, R30 was non-responsive. The emergency service reports states the facilty called for service at 6:42pm, one hour after R30 choked on her food.