Every finding on record at PA Peterson at the Citadel

Based on observation, interview, and record review the facility failed to maintain shower water temperatures at a comfortable temperature for two of four main shower rooms reviewed for the long-term care areas in the facility.The findings include:On 8/25/26 at 8:43 AM water temperatures in the facility were checked with V4 Maintenance Director and the hot water temperature in the shower room on the first-floor shower was 95 degrees Fahrenheit. V4 stated that the temperature was not quite on the hot side. V4 stated the water temperatures were to be maintained between 100 degrees and 110 degrees Fahrenheit. V4 stated staff have mentioned a few times that the shower was not hot enough. V4 stated it was an issue when the previous maintenance director was here and he left in March 2026. At 9:00 AM the hot water in the shower room in the third-floor shower used by staff for the residents was 95 degrees Fahrenheit.On 8/25/26 at 10:35 AM, V12 Certified Nursing Assistant - CNA stated the water feels cold to her for the residents' showers. V12 acknowledged the residents on her floor (3rd floor) had dementia and did not say anything about the water temperature.On 8/25/26 at 11:30 AM V6 Licensed Practical Nurse LPN stated staff should be checking the water in the showers to make sure it is not too hot or too cold before they give a shower; they need to make sure the water was a comfortable temperature.On 8/25/26 at 3:19 PM, V9 CNA stated the showers seem cold to her on the third floor and she stated the first-floor shower has problems maintaining the temperature. V9 stated sometimes the water was too hot and sometimes it was too cold. V9 stated residents have complained about the showers being too cold.The facility's Water temperature logs from 5/31/26 -8/23/26 were reviewed and did not show that the third-floor shower had been checked during that time. The last time the first-floor shower was checked was 6/3/26.The facility's Safety of Water Temperatures policy (no date) showed a policy related to keeping tap water in the facility within a temperature range to prevent scalding of residents. Federal regulations are to be followed, 100-110 degrees Fahrenheit.The facility's Shower/Tub Bath policy (August 2002) showed, be sure the bath area is at a comfortable temperature for the resident. Fill the tub approximately one-half (1/2) full with water (105 degrees Fahrenheit) If using a shower regulate the temperature and flow of the water.

Based on interview and record review the facility failed to ensure residents received a shower/or bed bath twice a week for 3 of 3 residents reviewed for showers in the sample of 6.The findings include:1. The Notice of Visit Sheets in the hospice binder for R1 were reviewed for the last three months and showed showers were given on the following dates in 2026: 5/22, 6/2, 6/11, 6/16, 6/23, 6/25, 7/2, 7/16, 7/22, 7/23, 7/28, 8/4, 8/6, 8/11, 8/18, 8/20, and 8/25/26. The sheets showed the hospice aide came on 7/30/26 and 8/13/26 but a shower/bed bath was not given. On 8/25/26 at 11:15 AM, V5 Hospice Certified Nursing Assistant - CNA reviewed the Notice of Visit Sheets for R1 for the last three months and confirmed the showers were done on the above dates. V5 stated on 7/30/26 and 8/13/26 no bed bath or shower was given. V5 stated routine visits were made and they may include peri care, oral care, and dressing.The facility's Shower Sheets for R1 showed she received showers on the additional dates of 7/4/26 and 7/8/26. Based on the information received and reviewed on 8/25/26, R1 did not receive a shower or bed bath for 10 days between 5/22/26 and 6/2/26. R1 did not receive any showers or bed bath for 8 days between 7/8/26 and 7/16/26. On 8/25/26 at 11:30 AM, V6 Licensed Practical Nurse - LPN stated showers are done twice a week, and they are supposed to notify her if they are not done. V6 stated she will follow up with the resident and try to reapproach them to get the resident to take a shower. V6 stated if hospice was unable to give the shower/bath then the facility staff has to do it. The hospice binder has documentation on what was done and shower sheets are filled out for each shower/bath.On 8/25/26 at 3:27 PM, V2 Director of Nursing - DON stated everyone has two scheduled showers per week. They can have another shower as needed; they just have to request it. The showers and bed baths are documented on shower sheets. V2 stated some of the hospice CNA's provide shower/bad baths once per week and others do it twice a week. The hospice aides usually notify staff if they don't do a shower/bed bath for some reason.The Minimum Data Set, dated [DATE] for R1 showed severe cognitive impairment; substantial/maximal assistance for shower/bath.The Face Sheet dated 8/25/26 for R1 showed diagnoses including Alzheimer's disease, hypertension, insomnia, overactive bladder, and unspecified hydronephrosis.The facility's Shower/Tub Bath policy (August 2002) did not show the frequency that showers/baths should be done for the residents. The following information should be recorded on the residents' activities of daily living record and/or in the resident's medical record, if indicated: 1. The date and time the shower/tub bath was performed; 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath; 3. All assessment data.obtained during the shower/tub bath; 4. How the resident tolerated the shower/tub bath; 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken; 6. The signature and title of the person recording the data.2. The Notice of Visit Sheets in the hospice binder for R2 were reviewed for the last three months and showed showers were given on the following dates in 2026: 5/22, 6/11, 6/16, 6/23, 6/25, 7/2, 7/28, 8/4, 8/13, 8/18, and 8/25/26. The sheets showed the CNA saw R2 on 7/16, 7/23, 7/30, 8/6, 8/11 and 8/20/26 but a shower and/or bed bath was not given. On 8/25/26 at 11:15 AM V5 Hospice CNA reviewed the Notice of Visit Sheets for R2 for the last three months and confirmed the showers done on the above dates. V5 stated on 7/16, 7/23, 7/30, 8/6, 8/11 and 8/20/26 that no bed bath or shower was given.The facility's Shower Sheets for R2 for the last three months were reviewed and showed she received showers on the additional dates as follows: 5/25, 5/29, 6/4, 6/5, 6/9, 6/16, 6/23, 6/30, 8/6, 8/12, and 8/18/26. Based on the information received and reviewed on 8/25/26, R2 did not have a shower or bath for 26 days between 7/2/26 and 7/28/26. R2 had 1 shower/bed bath between 7/28/26 and 8/4/26.On 8/25/26 at 11:30 AM, V6 Licensed Practical Nurse - LPN stated showers are done twice a week, and they are supposed to notify her if they are not done. V6 stated she will follow up with the resident and try to reapproach them to get the resident to take a shower. V6 stated if hospice was unable to give the shower/bath then the facility staff has to do it. The hospice binder has documentation on what was done and shower sheets are filled out for each shower/bath.On 8/25/26 at 3:27 PM, V2 Director of Nursing - DON stated everyone has two scheduled showers per week. They can have another shower as needed; they just have to request it. The showers and bed baths are documented on shower sheets. V2 stated some of the hospice CNA's provide shower/bad baths once per week and others do it twice a week. The hospice aides usually notify staff if they don't do a shower/bed bath for some reason.The MDS dated [DATE] for R2 showed impairment of short-term memory, long-term memory, and cognition; dependent for showers.The Face Sheet dated 8/25/26 for R2 showed diagnoses including Alzheimer's disease, hypothyroidism, hyperlipidemia, osteoarthritis, asthma, dementia, insomnia, major depressive disorder, vitamin D deficiency, seizures, and anorexia.3. The Notice of Visit Sheets in the hospice binder for R3 were reviewed for the last three months and showed showers were given on the following dates in 2026: 5/19, 6/2, 6/11, 6/16, 6/23, 7/2, 7/22, 7/23, 8/4, 8/13, 8/18, and 8/25/26. The sheets showed the CNA saw R3 on 5/22, 6/25, 7/28, 7/30, 8/6, 8/11 and 8/20/26 but a shower and/or bed bath was not given.The facility's Shower Sheets for R3 for the last three months were reviewed and showed she received showers on the additional dates as follows: 5/25, 7/3,7/7, 7/21, 7/24, 7/28, and 8/11/26. Based on the information received and reviewed on 8/25/26, R3 received 1 shower instead of two for 9 days between 6/2326 and 7/2/26. R3 did not receive a shower or bed bath for 14 days between 7/7/26 and 7/21/26. R3 received 1 shower instead of 2 for 7 days between 8/4/26 and 8/11/26.On 8/25/26 at 11:30 AM, V6 Licensed Practical Nurse - LPN stated showers are done twice a week, and they are supposed to notify her if they are not done. V6 stated she will follow up with the resident and try to reapproach them to get the resident to take a shower. V6 stated if hospice was unable to give the shower/bath then the facility staff has to do it. The hospice binder has documentation on what was done and shower sheets are filled out for each shower/bath.On 8/25/26 at 3:27 PM, V2 Director of Nursing - DON stated everyone has two scheduled showers per week. They can have another shower as needed; they just have to request it. The showers and bed baths are documented on shower sheets. V2 stated some of the hospice CNA's provide shower/bad baths once per week and others do it twice a week. The hospice aides usually notify staff if they don't do a shower/bed bath for some reason.The MDS dated [DATE] for R3 showed severe cognitive impairment; substantial/maximal assistance needed for shower/bath.The Face Sheet dated 8/25/26 for R3 showed diagnoses including right femur fracture, glaucoma, chronic obstructive pulmonary disease, benign prostatic hyperplasia, vitamin D deficiency, osteoarthritis, vascular dementia, hypomagnesemia, and major depressive disorder.

Based on interview and record review the facility failed to protect a resident from misappropriation of funds. This applies to one of three residents (R1) reviewed for misappropriation in the sample of six.The findings include:The facility face sheet for R1 shows she was admitted to the facility with diagnoses to include but not limited to chronic obstructive pulmonary disease, Type 2 Diabetes Mellitus, atrial fibrillation and chronic pressure ulcers. The facility assessment for R1 dated 6/30/26 shows her to be cognitively intact and requires moderate assistance with her activities of daily living.The facility incident report dated 7/1/26 shows R1 reported to facility staff she was missing over $200 in cash. The report shows R1 stating she had come to the facility with just over $300 on Thursday 6/25/26. R1 refused to have the money locked up because she needed to pay her friends to have her belongings brought to her at the facility. The report shows on admission her cash was counted and there was $368 in cash in her wallet. The report shows R1 stating she believes the money went missing between the time she was admitted on [DATE] and the evening of 6/27/26. R1 said she felt she was missing over $200. The report shows her room was searched for the money and facility staff were interviewed regarding the missing money and the police were notified. The friends R1 said were coming to drop off her belongings could not be reached by the facility. The final report to IDPH showed the missing money had not been found.On 7/7/26 at 9:00AM, R1 said when she was admitted to the facility on [DATE] she had some cash in her wallet because she was needing to pay a friend to bring her belongings to her. R1 said V4 CNA (Certified Nursing Assistant) counted the cash with her on admission. R1 said she had five $50 bills on one side of her wallet and some spending money on the other side of her wallet. R1 said when her friends came to drop off her things a few days later she realized she was missing some money. R1 said she only had three $50 bills and some singles on the other side. R1 stated she never left her room between the time she was admitted and when she discovered the money was missing. At 12:14 PM, R1 said she had not spoken with the friend she paid to deliver her belongings.On 7/7/26 at 10:05 AM, V4 said she was the staff that completed the inventory for R1 on admission. V4 said she asked R1 if she had any cash and she said she did, so we counted the money together and she had $368 in cash. V4 said she wrote the amount on the inventory sheet and gave the sheet to V3 the nurse. V4 said she never told anyone in the facility that R1 had a large amount of cash in her purse.On 7/7/26 at 2:07 PM, V3 RN (Registered Nurse) said he was not aware that R1 had a large amount of cash in her wallet. V3 said on Saturday 6/27/26 he was working on R1's unit and observed two women bringing in things on a cart to R1's room. V3 said he was later told by staff that R1 was stating she was missing some money. V3 said he went to R1's room, and R1's wallet was open, and he saw three $50 bills and eight $1 bills hanging out of her wallet. V3 said R1 told him she was missing money. V3 said R1 gave the $158 to the women who delivered her belongings, and he never saw the women after that. V3 said he notified the Administrator of the missing money.On 7/7/26 at 1:10 PM, V1 Administrator said he completed an investigation on R1's report of missing money and he was unable to determine where the missing money was.The facility patient personal items inventory log dated 6/25/26 for R1 shows $368 cash was inventoried for R1.The facility policy dated 10/2022 for abuse prevention policy shows the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property. The policy defines the misappropriation of resident property means the deliberate misplacement or wrongful temporary, or permanent use of a residents belongings or money without the residents consent.

Based on interview and record review, the facility failed to ensure the facility was free from physical abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 10The findings include:R1's electronic face sheet shows R1 has diagnoses that include dementia and neurocognitive impairment with Lewy body.R2's electronic face sheet shows R2 has diagnoses that include compression fracture of lumbar area, diabetes and cerebral palsyA facility reported incident dated 6/14/26 with final dated 6/19/26 sent to the state agency documents, under allegation-physical abuse. R1 and R2 noted to have physical altercation. R1 noted with a superficial scratch on his face. The staff separated the residents. R1 was noted with a scratch on his right eyebrow when he got up from his nap for dinner. R1 was questioned by staff but did not recall how he obtained the scratch. Per staff, the resident was in his room napping prior to dinner. R1 was assessed and no other injuries were noted, the roommate (R2) was immediately interviewed. The roommate stated, he was touching my DVD player, and I didn't like it, so I scratched him. R1 was sent to the hospital at the request of the family. R2 has had a room change.On 6/25/26 at 8:45 AM R2 was sitting in his wheelchair. R2 was noted to have boxes of personal items including DVDs. A DVD player was noted on the cabinet below the TV. R2 speaks slowly but was able to be understood. R2 said he gets along with everyone provided they do not touch his personal belongings including his DVDs and DVD player. When asked about his previous roommate, R2 said he touched my stuff.On 6/25/26 at 8:35 AM, V3 License Practical Nurse-LPN said she was the Nurse working last 6/14/26 when the incident happened. R1 was noted to have scratches in both of his hands. R1 also had scratches on his right upper eyebrow. R1 has dementia and cannot tell what happened to him. R1 roams around and wanders independently without a device. V3 (LPN) said she went to talk to the roommate R2. R2 admitted to scratching R1 because R1 was touching his DVD player. R2 was moved to 2nd floor in a private room.On 6/25/26 at 8:55 AM, V4 (Certified Nursing Assistant-CNA) said she was R1 and R2's day shift CNA. R1 and R2 were roommates. R1 was in bed 1 by the door, and R2 was in bed 2 by the window. That day, (6/14/26) R1 was noted to be going towards R2 touching R2's DVDs. R1 cannot be redirected. R2 was getting upset at R1 every time he went to R2's space touching his DVD player. V4 said she was repeatedly redirecting R1 to go back to his area. V4 said before she left the day shift. V4 said she put R1 to bed. V4 said later that day, R1 was noted to have scratches.On 6/25/26 at 9:45 AM, V2 (Director of Nursing) said R1 was new at the facility. R1 was mobile, up and about independently needing no device. R1 wandered around the unit and his room. R1 has a roommate, R2. V2 (DON) said she got a call that day 6/14/26 around evening time that R1 was noted to have scratches on his arms and forehead. R1 cannot tell where it came from. R1 has dementia. V2 said she directed the staff to asked R2, R1's roommate. R2 admitted to scratching R1 due to R1 touching his DVDs. V2 said that incident was reported to the state agency as resident-to-resident altercation under physical abuse. The facility Abuse Policy dated 10/22 This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. To do so, the facility has attempted to establish a residents sensitive and resident secure environment. Physical abuse includes hitting, slapping, pitching, kicking, and controlling behavior, through corporal punishment.

Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions of air mattress pumps were on and set to the residents' weights. This applies to 3 of 6 residents (R6, R7 and R9) reviewed for pressure injuries in the sample of 10.The findings include:1. On 6/25/26 at 8:35 AM, R7 was in bed sleeping. Hanging on the foot of R7's bed was an air mattress pump. The air mattress pump was turned off.On 6/25/26 at 8:43 AM, V8 (Certified Nursing Assistant) confirmed R7's air mattress pump was off. R7's Care Plan printed on 6/25/26 showed she was at risk for skin impairment.2. On 6/25/26 at 8:24 AM, R6 was in bed. Hanging on the foot of R6's bed was an air mattress pump. The air mattress weight setting was set to 620 pounds. R6 said her bed was too firm/hard. R6's Weight Summary for 5/20/26 showed R6 weight was 120.6 pounds. A difference of 499.4 pounds from the setting on the air mattress pump. 3. On 6/25/26 at 8:22 AM, R9 was in bed sleeping. Hanging on the foot of R9's bed was an air mattress pump. The air mattress pump was set to 350 pounds.R9's Weight and Vital Summary for 6/2/26 showed R9 weight was 188.4 pounds. A difference of 161.6 pounds from the setting on the air mattress pump.R9's Care Plan showed she was at risk for skin alterations. Listed under interventions was for an air mattress pump. On 6/25/26 at 9:59 AM, V9 (Wound Care Nurse) said air mattress pumps are a pressure relieving intervention. V9 said the pumps should be on and set to the resident's weight.

Based on observation, interview, and record review the facility failed to ensure a resident was transferred using a mechanical lift in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 7.The findings include:R1's electronic face sheet shows that R1 has diagnoses that include chronic respiratory failure, morbid obesity, and anxiety disorder.R1's facility assessment dated [DATE] shows R1 has no cognitive impairment.R1's fall risk assessment dated [DATE] shows R1 is high risk for falls.R1's incident report dated 3/28/26 documents, this writer heard a loud noise and a scream, ran into the room and assessed resident. Upon entering the room, this writer observed [R1] in the [mechanical lift] sling while still in her wheelchair. The leg straps on the lift were still elevated in the air and the top sling straps were off the lift. R1 was found on her head at this time.On 4/3/26 at 10:00 AM, R1 was in bed alert and pleasant. R1 showed this surveyor a large purplish discoloration (bruise) on R1's anterior mid upper arm. R1 said she fell while being transferred in the mechanical lift because the sling came off. R1 said she ended up on the floor with her wheelchair. R1 said she was very nervous and hoping this won't happen again. R1 said she was sent to the hospital but came back [to the facility.] On 4/3/26 at 12:30 PM V3 (License Practical Nurse-LPN) said on 3/28/26, she heard a loud noise coming from R1's room. Upon entering the room, R1 was observed on the floor in her wheelchair which had tipped over. Both of R1's legs remained in the sling of the mechanical lift while the arm slings were already detached. R1 was being transferred from wheelchair to bed using the mechanical lift when the incident happened. On 4/3/26 at 11:10 AM, V4 (Certified Nursing Assistant-CNA) said she was R1's CNA. It was after lunch and R1 requested to be put back to bed. V4 said her and V5 (CNA) transferred R1. V4 said she applied the leg straps while V5 applied the arm sling. During the transfer, she was in front of R1 in her wheelchair while V5 remained behind R1. While R1 was being lifted, R1 was pushing back, stating something was hurting her. Then suddenly R1 tipped backwards in her wheelchair ending up on the floor. The arm slings became loose and detached; we yelled for help. V4 said when R1 was saying something was hurting her, the transfer should have been stopped and R1 checked to make sure she was OK. They should have checked all the straps to make sure they were secured and R1 was safe.On 4/3/26 at 11:46 AM, V5 (CNA) said during the mechanical lift transfer, she was behind R1. R1 was agitated and pushing back. V5 said she noticed the arm sling was loose, but it happened so fast. The arm slings came off causing R1 to fall backwards with her wheelchair. V5 said all slings should be secured for residents' safety.R1's care plan dated 2/5/26 states: R1 requires the use of the mechanical lift for transfers. Intervention to include, Place the sling under the patient and secure it properly before initiating the lift. Position the sling under the patient's body, ensuring the sling fits securely and comfortably. Communication clearly with the residents to ensure they are comfortable and reassured during the process.

Based on observation, interview and record review the facility failed to ensure pressure ulcer prevention interventions were in place for residents at risk for pressure ulcers and failed to ensure treatment orders were implemented for a resident with a pressure ulcer for 3 of 3 residents (R1, R2 and R3) reviewed for pressure ulcers in the sample of 3.The findings include:1.R3's Braden Score dated 1/12/26 shows that she is at high risk for developing pressure ulcers. R3's Physician's Order Sheet shows an order dated 10/11/24 for: protective heel boots to both feet at all times. R3's Skin Integrity Care Plan shows that she is at risk due to impaired cognition, incontinence, impaired mobility and impaired nutrition. R3's interventions include: air mattress, ensure that patient's air mattress is in place and functioning appropriately.On 3/2/26 at 9:50 AM, R3 was lying in bed sleeping. R3's heel protector boots were sitting on the bedside table. R3 had an air mattress. There were no lights on the air mattress indicating that it was on and functioning. V3 pulled down R3's covers and R3's heels were directly on the mattress. R3's right lateral malleolus was reddened. V3 (Wound Licensed Practical Nurse) moved R3's bed and saw that the air mattress was not plugged in. V3 stated that R3 should always have her heel protection boots on and her air mattress should be plugged in and functioning. On 3/2/26 at 1:35 PM, V3 said that R3 is at risk for pressure ulcers due to her contractures, lack of mobility and dependance on staff for turning and repositioning. V3 said that intervention that are in place to prevent pressure ulcers include: an air mattress, heel boots on at all times, frequent incontinence care and frequent repositioning. 2. R2's Braden Score dated 2/23/26 shows that he is at moderate risk for developing pressure ulcers.On 3/2/26 at 9:30 AM, R2 was lying in bed. R2 had protective heel boots in his room, one was on his dresser and one was on the floor. R2's heels were directly on the mattress. R2's bilateral heels were slightly reddened. R2 said that sometimes they put his boots on and sometimes they do not. R2 said that he does not mind wearing them. On 3/2/26 at 1:35 PM, V3 (Wound Licensed Practical Nurse) said that R2 is at risk for pressure ulcers due to his immobility. V3 said that R2 tends to want to lay in bed most of the day. V3 said that R2's interventions in place to prevent pressure ulcers include: heel boots when in bed, turning every two hours and nutritional supplements. 3. R1's Specialty Physician Initial Wound Evaluation and Management Summary dated 2/12/26 shows that R1 has a unstageable pressure ulcer to his sacrum measuring 9 centimeters (cm) x 8.5 cm x 0.1 cm consisting of 80% necrotic tissue and 20% viable tissue. R1's wound was debrided and a treatment plan was ordered. The treatment ordered was sodium hypochlorite solution (dakins) to be applied once daily and as needed, silver sulfadiazine 1% once daily as needed and a bordered gauze dressing as a secondary dressing. R1's Specialty Physician Wound Evaluation and Management Summary dated 2/19/26 shows that R1 had a stage 3 sacral pressure ulcer measuring 9 cm x 9.6 cm x 0.1 cm and was not at goal due to infection. R1's Physician's Order sheet shows an order dated 2/13/26 for: Sacrum: Cleanse site with wound wash, pat dry and apply Silvadene to wound bed and cover with bordered foam daily and PRN (as needed). There is no order to cleanse with dakins until 2/19/26.On 3/2/26 at 1:35 PM, V3 (Wound Care Licensed Practical Nurse) said that a wound nurse does rounds with the wound physician weekly and inputs all new orders into the resident's record. V3 said that all wound physician orders should be followed. V3 said that there is a difference between wound wash and dakins. V3 said that wound wash is a gentle wound cleanser and dakins is a bleach solution that is used to help with debridement and as an antimicrobial. On 3/2/26 at 2:51 PM, V4 (Wound Physician) said that when he first saw R1 he had a big, nasty wound on his sacrum. V4 said that he orders dakins solution if he suspects an infection. V4 said that dakins is a super strong wound cleanser. V4 said that he would expect the facility staff to follow his orders. V4 said that when he saw R1 on 2/19/26, R1's sacral wound was infected and he ordered additional treatments. The facility's Pressure Ulcer and Wound Prevention/Management Policy shows, It is the policy of this facility to:.Ensure a resident who has been admitted with pressure ulcers or develops pressure ulcers in-house receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, when possible.

Based on interview and record review, the facility failed to ensure a medication was available for administration for 1 of 3 residents (R1) reviewed for medications in the sample of 4. The findings include:R1's electronic face sheet printed on 12/2/25 showed R1 has diagnoses including but not limited to hemiplegia and hemiparesis, end stage renal disease, peripheral vascular disease, and polyneuropathy.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment.R1's care plan dated 8/8/25 showed, (R1) has a risk for pain related to end stage renal disease, chronic pain, impaired mobility, and weakness.administer pain medication as ordered.R1's physician's orders dated 9/21/24 showed, Fentanyl 12mcg/hr Apply 1 patch transdermal every 72 hours for pain and remove per schedule.R1's medication administration record for November 2025 showed R1 did not have his Fentanyl patch applied from 11/21/25-11/28/25.R1's medication progress notes dated 11/21/25-11/25/25 showed, Fentanyl patch not available.On 12/2/25 at 11:23AM, V5 (Licensed Practical Nurse-LPN) stated, (R1's) fentanyl patch was not in the facility for a few days. One of the nurse's (V3-LPN) said she had ordered it and I remember it coming in on my shift, but I didn't apply it because it wasn't due until the 28th. The pharmacy delivers to the facility multiple times each day so there really shouldn't be a reason that he didn't have his patch on. I'm not sure if we have those in our emergency supply or not. If a resident has a current prescription, the pharmacy will send the narcotic; however, if they do not have a current prescription then we will get in touch with the Nurse Practitioner (NP) to have them send a prescription to the pharmacy. I remember it being delivered on Monday (11/24) but it was later in my shift. I only work on that unit on Mondays so I know for sure it was that day of the week.An attempt to contact V3 (LPN) was made with no return call received during this investigation.On 12/2/25 at 11:55am, V2 (Director of Nursing) stated, The nurses have a log in for our emergency narcotic supply and they usually have to call the pharmacy to get a code to pull a narcotic and have to have a witness. The pharmacy would need a current prescription on file, and I believe (R1) needed a new prescription and that's what we were trying to get. The pharmacy delivers 3x/day so there usually isn't an issue of medications running out. Whenever a medication is out, their NP is contacted. Some of them can e-scribe and send to the pharmacy, otherwise we will e-mail the prescription to them, and they will send it back to us and then we send it to the pharmacy.The facility's undated, untitled, emergency narcotic list showed, Fentanyl 12mcg/hr as being available in their narcotic supply.A review of R1's medical records showed R1's prescription for Fentanyl 12mcg/hr was received by the facility on 11/21/25; however, the facility pharmacy proof of delivery slip showed the Fentanyl was not delivered to the facility until 11/25/25. R1's medication administration record showed R1's Fentanyl patch was not applied until 11/28/25.The facility's policy titled, Medication Administration Policy dated March 2014 showed, Drugs will be administered in accordance with orders of licensed medical practitioners of the state in which the facility operates .

Based on interview and record review the facility failed to ensure a resident was safely transferred with a gait belt and failed to ensure a resident was safely moved outside in a wheelchair. This applies to 2 of 3 residents (R1 and R2) reviewed for safety in the sample of 3.The findings include:1. R2's Incident Report dated 11/14/25 showed R2 fell while staff transferred R2 to the toilet. The same documentation showed a Certified Nursing Assistant lowered R2 to the floor. On 11/24/25 at 10:53 AM, V2 (Director of Nursing) said a gait belt was not used by the CNA when R2 was transferred and fell on [DATE]. On 11/24/25 at 11:09 AM, V7 (Licensed Practical Nurse) said she was the nurse taking care of R2 when R2 fell while transferring on 11/14/25. V7 said a gait belt was not used by staff when R2 was transferred and fell. On 11/24/25 at 11:26 AM, V8 (Therapy Manager) said R2 was a one person assist to transfer and a gait belt was to be used when transferring R2. On 11/24/25 at 11:12 AM, V12 (Restorative Nurse) said a gait belt is used to support/guide a resident when transferring and provide staff a way to assist the resident without pulling on the resident's clothing or body parts. V12 added that gait belts are also used to lower residents to the floor if needed. R2's facility assessment done on 11/14/25 showed R2 required substantial/maximal assistance for toilet transfers. R2's Care Plan with an initiated date of 9/9/22 showed R2 was at risk for falls. The facility's Gait Belt/Transfer Guideline policy with a revised date of 2/23 showed a gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfers. 2. R1's Facesheet, dated 11/24/25 shows R1 has diagnoses that include, but are not limited to, rheumatoid arthritis, osteoarthritis of the left hip, and difficulty in walking. R1's Restorative Nursing Screener progress note from 11/1/25 shows R1 used a manual wheelchair to ambulate. The restorative nursing screener progress note also shows R1 did not attempt walking without assistive devices due to R1's medical condition and safety concerns. On 11/24/25 at 11:40 AM, V5 (R1's Family Member) said R1 was admitted to the facility from a local hospital after R1 became unable to walk with pain in R1's left hip from osteoarthritis. On 11/24/25 at 11:20 AM, V3 (Receptionist) said on the evening of 11/2/25, V3 saw R1 self-propel in a wheelchair from the elevator, approximately fifteen feet towards the main lobby. V3 said R1 had called out for help, but nursing staff could not hear R1. V3 asked R1 if V3 could help and R1 had requested V3 bring R1 to the window to wait for V5 to arrive at the facility. When V5 arrived, R1 requested V3 to bring R1 out the front doors to greet V5. V3 said the main front door has two doors. V3 said V3 had wheeled R1 out of the first door and the second door began to close on R1 and V3. V3 then positioned herself to prop open the entrance door with one arm and used the other arm to assist R1 out of the doorway. V3 said when R1 was completely out of the doorway, V3 saw V5 at the bottom of the sidewalk, let go of the wheelchair without ensuring R1 had R1's feet on the ground to prevent the wheelchair from going down the sloped sidewalk. V3 also said V3 did not engage the wheelchair brakes before letting go of R1's wheelchair. V3 then went to turn around and go back inside when R1 uncontrollably wheeled down the sidewalk, eventually falling forward from R1's wheelchair and scraping R1's knees on the sidewalk. On 11/24/25 at 12:07 PM, V4 (Scheduling Coordinator) said once a wheelchair proceeds past the door threshold at the main door, it's almost an immediately downward slope towards the parking lot that would take the wheelchair down the slope by gravity without the resident having their feet on the ground or having staff assisting the wheelchair descend. V4 said V4 has an active certified nursing assistant license and V4 would have ensured R1's wheelchair brakes were engaged or that R1's wheelchair was on a more level surface before letting go of R1's wheelchair. On 11/24/25 at 1:10 PM, V14 (Assistant Director of Nursing) said in hindsight, after the event, V3 should have ensured either R1's feet were on the ground or that R1's wheelchair brakes were engaged before letting go of R1's wheelchair.

Based on observation, interview, and record review, the facility failed to have orders in place for non-pressure wounds, failed to have interventions in place for non-pressure wound healing, and failed to ensure a resident received a specialist consult for vaginal pain for three of 24 residents (R93, R362, R365) reviewed for quality of care in the sample of 24. The findings include: 1. R93's Admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified psychosis, muscle weakness, unsteadiness on feet, cognitive communication deficit, dementia, and mixed incontinence. On May 19, 2025, at 10:14 AM, V14 Certified Nursing Assistant provided peri care to R93. R93 complained of a lot of pain when V14 wiped her front peri area. There was some type of growth to R93's peri area. R93 asked V14 to place the cream in a white bottle onto her vaginal area. V14 said there is no cream in a white bottle and all V14 had was Vaseline. R93 said Vaseline does not do anything for her pain. V14 placed Vaseline onto R93's buttocks. No cream was applied to R93's vaginal area. V14 did not ask R93's nurse to come and assess R93 while V14 was providing cares to R93. R93's Order Summary Report dated May 19, 2025, shows an order for A and D ointment to labia three times a day and as needed every two hours entered on December 3, 2024, and an order for lidocaine external cream 4% apply to labia topically three times a day for pain entered on December 10, 2024. R93's Order Summary Report dated May 19, 2025, shows an order for gynecology consult due to labia growth was entered on December 10, 2024. On May 21, 2025, at 9:52 V2 Director of Nursing (DON) said she could not find any evidence to show that R93's gynecology consult was done or followed through. V2 said R93's son is sometimes difficult to get a hold of. V2 said R93 does have something to her labia. V2 said lidocaine cream is scheduled and as needed. V2 said the CNA should have gotten the nurse to put cream onto R93's vaginal area. The Illinois Long Term Care Ombudsman Program Residents' Rights dated November 2018 shows, Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source. Your facility must provide services to keep your physical and mental health at their highest practical levels. You should receive the services and/or items included in the plan of care. 40798 2. On 5/19/25 at 10:11 AM, R365 had a foam dressing to his right elbow dated 5/12. R365's Admission Record dated 5/19/25 shows he was most recently admitted to the facility on [DATE]. R365's After Hospital Care Plan dated 5/16/25 shows an order under the heading How Should You Care for your Wound as follows: Right elbow: aquacel AG, allevyn foam. R365's Nursing Admission/Re-admission assessment dated [DATE] at 4:38 PM shows R365 has a skin tear on his right elbow. R365's TAR (treatment administration record) for 5/1/25 to 5/31/25 shows no treatment was initiated for R365's elbow wound until 5/19/25, day four of his admission. 3. On 5/19/25 at 9:17 AM, R362 had a foam dressing (undated) to his bottom. R362's Admission record dated 5/19/25 shows he was admitted to the facility on [DATE]. R362's After Hospital Care Plan dated 5/16/25 shows an order under the heading How Should You Care for your Wound as follows: Gluteal cleft MASD (moisture associated skin damage, healed- clean with moisture barrier wipes and gently pat dry, apply zinc cream two times a day and as needed. Leave open to air, can cover with ABD if needed, but do not cover cream with allevyn foam as this can trap moisture and create further skin breakdown. Groin/abdomen/breast folds MASD-clean with moisture barrier wipes and gently pat dry, apply Interdry Ag to folds and change out daily. R362's Nursing: Admission/Re-admission assessment dated [DATE] at 11:53 AM shows R362 has a skin tear to his abdomen and vascular wounds of his right and left inner ankles. No MASD is noted on the assessment. R362's Order Summary Report dated 5/20/25 shows no wound treatment orders and R362's TAR for 5/1/25 to 5/31/25 shows R362's gluteal cleft and MASD of R362's abdomen did not have any treatment until the evening of 5/20/25 (day five of his admission). On 5/20/25 at 1:32 PM, V4, Wound Care Nurse, said when a resident is admitted the floor nurse does the full head to toe body assessment and includes any skin alteration. The wound care nurse will assess the wound(s) within 24 hours. V4 said the wound care nurse's assessment includes the site, type of wound with sub-classification, location, tissue type, amount and type of exudate, measurements (length, width, and depth), pain, description of the peri-wound, if there is odor, and if tunneling or undermining is present. V4 said all wound care assessments are in Wound Rounds in the patient's EMR (electronic medical record). V4 said upon arrival to the facility any skin alterations are to be treated with the orders that came with the patient and treatment begins that day. V4 said she has no wound assessment available for R365, she does not know what kind of wound he has. V4 said she just saw R362 today. On 5/19/25 at 12:33 PM, V6, Registered Nurse said when a resident is admitted the floor nurse will do the assessment and if the resident has wounds, they inform the wound care nurse. V6 said a new admission would come from the hospital with discharge orders for wound treatments. V6 said wound care treatment would begin on the day of admission or the next day and the wound care treatment is documented on the TAR (treatment administration record). The facility's Pressure/Non-Pressure Skin Breakdown Clinical Protocol (effective January 2024) shows, The nurse shall assess and document/report the following: Full assessment of skin condition .and current treatments . The facility's Admission/Re-Admission Checklist dated 7/24/24 shows physician orders must be transcribed onto the TAR within one hour of admission for every admit/readmit. 35178

Based on observation, interview, and record review, the facility failed to ensure an adequate amount of staff were scheduled to meet the needs of residents. This failure has the potential to affect all 36 residents residing on the third floor of the facility. The findings include: The facility roster that was provided by the facility on May 19, 2025, shows there was 36 residents residing on the third floor of the facility. On May 19, 2025, at 9:02 AM, there were two CNAs working with 36 residents on the third floor. V17 LPN (Licensed Practical Nurse) said that is quite a bit of residents for two CNAs to work. V13 and V14 CNAs said the third CNA got pulled from the third floor to work on another floor because the other floor was short. Incontinence care was observed on R34 at 9:21 AM. R34's incontinence brief was saturated, and V14 CNA said this was the first time peri care was provided for R34 on day shift. Incontinence care was observed on R16 at 9:39 AM. R16's incontinence brief was saturated. This was the first time incontinence care was provided to R16 on the day shift. Incontinence care was observed on R93 at 10:14 AM. R93's incontinence brief was saturated. On May 19, 2025, at 9:15 AM, V13 CNA said CNAs are not able to get everything done when there are only two CNAs on the unit. V13 said there are four showers scheduled for that day and only two have been done. V14 CNA said there are still some residents in bed that usually get up for breakfast. On May 21, 2025, at 11:00 AM V19 Staffing Scheduler said the third Certified Nursing Assistant (CNA) was pulled from the third floor on May 19, 2025, because there was a call off on the first floor. The facility tries to staff the ground floor with four CNAs, the first floor two CNAs, the second floor three CNAs, and the third floor three CNAs. V19 said the third floor will work with two CNAs at times. On May 20, 2025, at 10:30 AM during the resident meeting that occurred during the facility's annual certification survey, R42 (attends the resident council meetings regularly) said many residents complain of waiting one-two hours for staff to answer call lights. R88 (attends the resident council meetings regularly) said he has had the staff shut off his call light and never ask what he needs. R56 Resident council president said she has sat by the nurse's station and has seen staff shut the call lights off at the nurse's station. R56 said staff can ask what the residents need through the call light system at the nurses' station. R56 said there is a note above the call light system that says do not talk to the residents over the call light system. Staff are to go to the residents' rooms. R56 said there are days when there are two CNAs working when there should be four. R56 said ice water is not passed everyday. Most of the time you have to ask for ice water. On May 21, 2025, at 10:23 AM, V14 CNA said there are times that she works a double shift. V14 said if there is a call off and no staff pick up the extra shift then only two CNAs work. V14 said showers cannot get done and some residents cannot get up for breakfast. At 10:32 AM, V17 LPN said she helps the CNAs when she can. It is hard to care for all the residents when the unit runs with two CNAs. The CNAs are able to be more attentive when there are three CNAs. At 10:38 AM, V18 Unit Manager said staffing depends on the day. V18 said the facility tries to run the unit with one nurse and three CNAs for 36 residents. V18 said there are times when there are call offs and the unit has two CNAs for 36 residents if the facility cannot replace the call off. V18 said she helps when she can. At 10:52 AM, V13 CNA said staffing is up and down. V13 said when the unit is staffed with three CNAs, the workload is comfortable. V13 said they have ran the unit with two CNAs. V13 said the day shift is harder because the staff doesn't know right away if there is going to be two CNAs or three CNAs. V13 said it is difficult to get all the showers done, get residents up, and toilet all the residents. On May 21, 2025, at 11:25 AM, V15, R74's Daughter said the unit needs more CNAs. V15 said there are times when residents are yelling and there's no staff around. At 11:26 AM, V16, R80's spouse said there is not enough staff in the facility. V16 said there are times when he calls the unit, and no one answers the phone and there are times when there are residents in the dining room and there are no staff in the dining room. At 11:39 AM, R10 said there are times when her bed is not made. R10 said the unit could use an extra CNA. R10 said the CNAs run around a lot. The facility's Working staff schedule dated May 5, 2025, shows the second and third floor had one CNA on the night shift. On May 8, 2025, there were two CNAs on the second shift for the third floor. May 9, 2025, there were two CNAs on the schedule for third floor second shift and one CNA for third shift on the third floor. On May 10, 2025, there was no one written in the working staff schedules that was provided by the facility. On May 11, 2025, there were two CNAs on the schedule for the third floor and one CNA for the second floor for day shift and second shift. On May 16, 2025, there was two CNAs for the third floor during day shift on the third floor. The facility's Resident Council minutes dated December 11, 2024, shows, Call lights not being answered in a timely manner. February 12, 2025, one resident stated on the night of February 11, 2025, her roommates' call light was on for over two hours before a nurse or CNA came into her room. Two other residents stated their beds have not been made in two days. March 12, 2025, Residents are still concerned about the delay in answering call lights. Two residents reported their beds not being made. April 9, 2025, Residents state that they believe they sometimes have to wait longer than they would like when they need assistance. May 14, 2025, Residents state that they believe they sometimes have to wait longer than they would like when they need assistance. No specific situation was brought up, infrequent, but annoying.

Based on observation, interview, and record review, the facility failed to don personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) and failed to change gloves and perform hand hygiene in a manner to prevent cross contamination for five of 24 residents (R66, R93, R34 R16, R362) reviewed for infection control in the sample of 24. The findings include: 1. R66's Admission Record dated May 19, 2025, shows R66 was admitted to the facility on [DATE], with diagnoses including dementia, major depressive disorder, primary generalized osteoarthritis, Alzheimer's disease, anxiety disorder, fatigue, displaced right femur fracture, difficulty walking, and non displaced fracture of right and left little finger. R66's Order Summary Report dated May 21, 2025, shows an order for EBP related to wounds ordered on February 17, 2025. On May 19, 2025, at 12:53 PM, the was a sign on R66's door that showed R66 was on enhanced barrier precautions. V14 Certified Nursing Assistant (CNA) performed incontinence care on R66. There was urine and stool in R66's incontinence brief. V14 wiped R66's front peri area, helped R66 turn onto her side, wiped the small amount of stool from R66's buttocks, placed the clean brief underneath R66 and then helped R66 turn back onto her back. V14 did not perform hand hygiene nor change her gloves when going from dirty to clean surfaces. V14 did not wear a gown during these cares. 2. R93's Admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified psychosis, muscle weakness, unsteadiness on feet, cognitive communication deficit, dementia, and mixed incontinence. On May 19, 2025, at 10:15 AM, V14 performed incontinence care to R93. R93's incontinence brief was saturated with dark urine. R93's vaginal area was reddened. V14 wiped R93's front peri area, helped R93 to turn onto her right side, wiped R93's buttocks, place the clean incontinence brief and helped R93 turn back onto her back. V14 did not change her gloves or perform hand hygiene. 3. R34's Admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including dementia, unspecified psychosis, Alzheimer's disease, and major depressive disorder. On May 19, 2025, at 9:28 AM, V14 took R34 to the bathroom. R34's incontinence brief was saturated with dark urine. There was a strong urine odor. V14 removed R34's incontinence brief, cleaned R34's front and back peri area, placed and new incontinence brief onto R34, and applied a clean dress onto R34. V14 did not change her gloves or perform hand hygiene. 4. R16's Admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including unspecified psychosis, Meniere's disease, and osteoarthritis. R16's Care Plan initiated March 17, 2025, shows, Clean peri-area with each incontinence episode. Keep skin clean and dry. R16's Minimum Data Set (MDS) dated [DATE], shows she is occasionally incontinent of bladder and frequently incontinent of stool. R16 is dependent on staff for toileting hygiene and mobility. On May 19, 2025, at 9:39 AM, V14 performed incontinence care to R16. R16's incontinence brief was saturated with dark urine. V14 wiped R16's front peri area, help her turn onto her side, wiped R16's buttocks, and then placed Vaseline onto R16 buttocks. V14 placed the clean incontinence brief onto R16 and did not change her gloves or perform hand hygiene. On May 21, 2025, at 10:52 AM, V13 CNA said gloves should be changed right after touching soiled items and before touching clean items. On May 20, 2025, at 1:59 PM, V2 Director of Nursing said gloves should be changed after touching dirty items and before touching clean to reduce risk of infection. 40798 5. On 5/19/25 at 9:08 AM R362's room had a sign showing he was on Enhanced Barrier Precautions (EBP). On 5/19/25 at 9:17 AM, V5, Certified Nursing Assistant was in R362's room. With bare hands and no gown, V5 changed R362's gown and said his oxygen tubing was backwards, so she took it out of his nose and turned it around. V5 the applied gloves, but no gown and assisted R362 to turn onto his side. On 5/20/25 at 1:50 PM, V23, Infection Prevention Nurse, said staff need to use EBP for residents with chronic wounds. R362's Nursing: Admission/Re-admission assessment dated [DATE] at 11:53 AM shows R362 has a pressure wound to his groin, sacrum, and right and left posterior thighs. The facility's Enhanced Barrier Precautions Policy (effective 1/20/24) shows it is the practice of the facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO). EBP refer to the use of gown and gloves for use during high-contact resident care for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). EBP are implemented for residents with wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers) and/or indwelling medical devices such as urinary catheters. Gowns and gloves are to be available immediately outside of the resident's room. High contact resident care activities include bathing, dressing, providing hygiene and changing briefs/assisting with toileting. The facility's Hand Washing/Hand Hygiene Policy (effective March 2023) shows it is the policy of the facility to assure staff practice recognized hand washing/hygiene procedures as a primary means to prevent the spread of infections. When hands are not visibly soiled, employees may use an alcohol-based hand rub containing at least 60% alcohol before moving from a contaminated body site to a clean body site during resident care.

Based on observation, interview and record review the facility failed to ensure a resident was treated with dignity and respect for 1 of 24 residents (R88) reviewed for resident's rights in the sample of 24. The findings include: R88's facility assessment dated [DATE] documents R88 has no cognitive impairment. On 5/19/25 at 8:45 AM, during the initial tour, R88 said there was one main concern that had been bothering him. R88 said the staff that was taking care of them at midnight does not treat them well. R88 stated one day last week, I requested her to make sure my wheelchair was by me when I am in bed in case, I need my wheelchair in the middle of the night to go to the bathroom, she instead placed the wheelchair across the room, that made me so upset. Another time, I needed help with my covers (blankets) she said, you can do that yourself. R88 said the reason why he was here was he needed help. R88 said he just wanted to be treated right. R88 said they reported all these concerns to V2 (Director of Nursing-DON) On 5/19/25 at 11 AM, V2 (DON) said R88 had brought a concern to her about V10 (Certified Nursing Assistant-CNA) regarding R88 wanting his pants on at night and V10 did not do as what R88 had requested since it was in the middle of the night. V2 said R88 did not report to her about the wheelchair and blanket issues. V2 said R88 was also a fall risk and R88 should put his light on when he needed to go to the bathroom instead of transferring himself. V2 said she will look into those issues. On 5/20/25, at 1 PM, V2 said she had spoken with R88 after this surveyor brought the concerns yesterday. V2 said she had spoken to V10, and education had been provided to V10 also. V10 will not be assigned to R88, and R88 agreed. All residents should be treated with dignity and respect. The facility policy on Dignity (undated) documents, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well- being, level of satisfaction with life feeling of self worth and self esteem.

Based on interview and record review, the facility failed to ensure as needed anti-anxiety medications had a stop date for two of five residents (R66, R104) reviewed for chemical restraints in the sample of 24. The findings include: 1. R66's Admission Record shows she was admitted to the facility on [DATE], with diagnoses including dementia, major depressive disorder, Alzheimer's disease, anxiety disorder, unspecified psychosis, insomnia, and difficulty walking. R66's Order Summary Report dated May 19, 2025, shows an order for clonazepam 0.5 mg by mouth every eight hours as needed (PRN) for anxiety ordered on December 27, 2024, and an order for lorazepam give 0.25ml by mouth every four hours as needed for anxiety ordered on January 2, 2025. Neither order has a stop date. 2. R104's Admission Record shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and insomnia. R104's Order Summary Report dated May 20, 2025, shows an order for lorazepam 0.25ml by mouth every four hours as needed for agitation/restlessness started on May 3, 2025. There is no stop date for this medication. On May 29, 2025, at 10:02 AM, V2 Director of Nursing said as needed psychotropics should have a 14 day stop date. V2 said herself and the Assistant Director of Nursing monitor the psychotropic medications for stop dates. The facility's Psychotropic Medications Policy not dated shows, Chemical restraint-a psychotropic medication that is clinically indicated to treat identified medical symptoms. This medication is usually in PRN form.

Based on interview and record review, the facility failed to conduct a thorough investigation and failed to obtain and/or maintain documentation of a thorough investigation of monetary misappropriation for 1 of 24 residents (R364) in the sample of 24 reviewed for abuse. The findings include: On 5/19/25 at 10:50 AM, R364 said she knows she had $120 in her purse because she checked her purse for money around 6:00 PM on Sunday (5/11/25) because she was going to order pizza but didn't. R364 said on 5/12/25 she went to the bathroom to get ready and V7, Certified Nursing Assistant (CNA) was in her room. R364 said when she finished getting dressed, she checked her purse and only had $20 left. R364 said she knows there was a CNA in her room during the night shift from 5/11/25 to 5/12/25. On 5/20/25 at 10:42 AM, V1, Administrator, said R364 told him she had a feeling V7, Certified Nursing Assistant (CNA) took money from her purse around 8:30 AM (on 5/12/25). V1 said he interviewed some night shift staff on the phone but did not write down or type their interviews regarding R364's allegations of stolen money. V1 said video footage was not reviewed as it would have just confirmed staff went in and out of R364's room. V1 said R364 had previously reported missing money in March 2025 which was found in her purse. On 5/21/25 at 11:26 AM, V3, Regional Nurse, said we have never typed out the interviews or statements of employees taken for an (abuse) investigation. V3 said they will sometimes type out the resident interviews. When asked how they would know what the person(s) said months or years later, V3 replied that they wouldn't know. On 5/21/25 at 8:43 AM, V7 said she worked with R364 all day on 5/12/25 and everything seemed fine; they had a really good day. V7 said V1 called her at home later that day and she was suspended from that time until 5/20/25 when she returned to work for her previously scheduled shift. The facility's investigation was reviewed, and no documentation of specific resident interviews were included aside from V1's written notes regarding R364's statements. No evening or night shift staff who worked 5/11/25 to 5/12/25 interviews or statements were included. The facility's initial report sent to IDPH was dated 5/12/25 and their final report sent to IDPH was dated 5/16/25. No written/typed statements from any employee or resident were included. The facility's Abuse Prevention Policy dated 10/2022 shows, Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. The final investigation report shall contain interviews of witnesses. The facility's Abuse Investigation Policy (revised 12/2009) shows witness reports will be reduced to writing. Witnesses will be required to sign and date such reports.

Based on observation, interview, and record review the facility failed to ensure activities of daily living (ADL) assistance was provided for dependent residents for three of 24 residents (R16, R34, R93) reviewed for incontinence care in the sample of 24. The findings include: 1. R16's Admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including unspecified psychosis, Meniere's disease, and osteoarthritis. R16's Care Plan initiated March 17, 2025, shows, Clean peri-area with each incontinence episode. Keep skin clean and dry. R16's Minimum Data Set (MDS) dated [DATE], shows she is occasionally incontinent of bladder and frequently incontinent of stool. R16 is dependent on staff for toileting hygiene and mobility. On May 19, 2025, at 9:39 AM, V14 (Certified Nursing Assistant) CNA said that R16 was not cleaned up for the day yet. V14 said that R16 had breakfast in bed. R16's incontinence brief was completely saturated with dark urine. 2. R34's Admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including dementia, unspecified psychosis, Alzheimer's disease, and major depressive disorder. R34's Care Plan initiated December 21, 2023, shows R34 has an ADL self-care performance deficit related to activity intolerance. R34's MDS dated [DATE], shows R34 is frequently incontinent of bowel and bladder. R34 requires substantial/maximal staff assistance for toileting hygiene, personal hygiene, and bed mobility. On May 19, 2025, at 9:21 AM, R34 self propelled her wheelchair into her doorway. V14 CNA wheeled R34 back into her room and said she will clean R34 up for the day. V14 said R34 has not been cleaned up for the day yet. There was a strong urine odor in R34's doorway and bathroom. V14 said R34 must have urinated on the floor as there was a liquid noted on the bathroom floor. V14 placed R34 onto the toilet after wiping the liquid from the floor. R34's incontinence brief was completely saturated with dark urine. R34's incontinence pad that was on her bed was damp with a dark urine circle on it. V14 said her pad had urine on it. R34 did not show any aggressive behaviors or refusals while V14 was assisting R34 with toileting and dressing. 3. R93's Admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified psychosis, muscle weakness, unsteadiness on feet, cognitive communication deficit, dementia, and mixed incontinence. R93's Care Plan initiated August 30, 2024, shows R93 is at risk for incontinence related to activity intolerance and to clean peri-area with each incontinence episode. R93's MDS dated [DATE], shows R93 is always incontinent of urine and frequently incontinent of stool. R93 requires substantial/maximal staff assistance for toileting hygiene. On May 19, 2025, at 10:08 AM, R93 was laying in her bed. At 10:12 AM, V14 CNA said that R93 will need to get cleaned up. At 10:14 AM V14 went into R93's room to provide incontinence care to R93. V14 said incontinence care has not been performed on R93 yet. R93's incontinence brief was saturated with urine. On May 21, 2025, at 10:52 AM, V13 CNA said incontinence care is done at least every two hours or more. On May 20, 2025, at 1:59 PM, V2 Director of Nursing said incontinence care should be done every two hours or more because its best for the residents' skin and it can decrease infection. The facility's Urinary Incontinence Clinical Protocol dated April 2018 shows, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status.

Based on interview and record review, the facility failed to assess and implement treatment interventions for pressure wounds, and failed to ensure pressure relieving interventions were in place for 3 of 8 residents (R77, R365, R362), reviewed for pressure wounds in the sample of 24. The findings include: R365's Admission Record dated 5/19/25 shows he was most recently admitted to the facility on [DATE]. R365's After Hospital Care Plan dated 5/16/25 shows an order under the heading How Should You Care for your Wound as follows: Buttocks: zinc paste apply daily and as needed. R365's Nursing Admission/Re-admission assessment dated [DATE] at 4:38 PM shows R365 has a pressure wound of his sacrum. R365's TAR (treatment administration record) for 5/1/25 to 5/31/25 shows no treatment was initiated for R365's sacral wound as of 5/21/25. R365's Order Summary Report dated 5/19/25 shows no wound treatment/care orders for R365's sacrum. R362's Admission record dated 5/19/25 shows he was admitted to the facility on [DATE]. R362's After Hospital Care Plan dated 5/16/25 shows an order under the heading How Should You Care for your Wound as follows: Left posterior thigh healing stage 3 pressure ulcer- clean with saline wound wash and pat dry, cover wound with cut to fit aquacel Ag, secure with allevyn foam, change Tuesday, Thursday, Saturday and Right posterior thigh healed- leave open to air. R362's Nursing: Admission/Re-admission assessment dated [DATE] at 11:53 AM shows R362 has a pressure wound to his groin, sacrum, and right and left posterior thighs. R362's Order Summary Report dated 5/20/25 shows no wound treatment orders and R362's TAR for 5/1/25 to 5/31/25 shows R362's thighs had no treatment initiated until 5/21/25 (day six of his admission). R362's groin and sacrum were not addressed on the TAR. On 5/20/25 at 1:32 PM, V4, Wound Care Nurse, said when a resident is admitted the floor nurse does the full head to toe body assessment and includes any skin alteration. The wound care nurse will then assess the wound(s) within 24 hours. V4 said the wound care nurse's assessment includes the site, type of wound with sub-classification, location, tissue type, amount and type of exudate, measurements (length, width, and depth), pain, description of the peri-wound, if there is odor, and if tunneling or undermining is present. V4 said all wound care assessments are in Wound Rounds in the patient's EMR (electronic medical record). V4 said upon arrival to the facility any skin alterations are to be treated with the orders that came with the patient and treatment begins that day. V4 said she has no wound assessment available for R365, she does not know what kind of wound he has. V4 said she just saw R362 today. On 5/19/25 at 12:33 PM, V6, Registered Nurse said when a resident is admitted the floor nurse will do the assessment and if the resident has wounds, they inform the wound care nurse. V6 said a new admission would come from the hospital with discharge orders for wound treatments. V6 said wound care treatment would begin on the day of admission or the next day and the wound care treatment is documented on the TAR (treatment administration record). The facility was unable to provide wound care nurse assessments for R362 and R365 which were completed prior to 5/20/25. The facility's Pressure/Non-Pressure Skin Breakdown Clinical Protocol (effective January 2024) shows, The nurse shall assess and document/report the following: Full assessment of skin condition .and current treatments . The facility's Admission/Re-Admission Checklist dated 7/24/24 shows physician orders must be transcribed onto the TAR within one hour of admission for every admit/readmit. On 05/19/25 at 12:55PM, R77 was lying in bed on her back. R77 looked like she was sleeping. R77 had a wound vacuum on the floor by the foot of her bed. The tubing extended from the vacuum to the dressing on her LEFT heel. R77 had a pressure reduction boot on her RIGHT foot. Another pressure reduction boot was on a chair in her room. R77's left heel was resting on the bed. On 05/19/25 at 1:04 PM, V12 CNA-Certified Nursing Assistant said, R77 has a wound vacuum to her left heel. The pressure reduction boot is only applied to one foot. R77 current Physicians Order on 05/19/25 at 1:24 PM, shows, offload heels. R77 current Care Plan on 05/19/2025 shows, put protective boots on when in bed. On 05/20/25 at 2:18PM, R77 was sitting up in bed. R77's left heel was resting on the bed. R77's pressure reduction boot was in the dresser drawer. On 05/20/25 at 2:18 PM, R77 stated, I have 2 boots, I do not know why I only have one on. On 05/20/25 at 2:23 PM, V22 RN-Registered Nurse said, the pressure reduction boot keeps pressure off the heel. On 05/20/25 at 2:45 PM, V4 Wound Care Nurse said, it is a standard of care to off load heels to ensure the heel does not have direct pressure with a surface. If there are heel boots, they should be used, if no heel boots, we should use a pillow or wedge to off load the heels. The facility Pressure/Non-Pressure Skin Breakdown policy effective January 2024 shows, the physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces .

Based on observation, interview and record review the facility failed to ensure splints were in place for residents with contractures for 2 of 5 residents (R30, R12) reviewed for limited range of motion in the sample of 24. The findings include: 1. R30's Physician Order Sheet (POS) show R30 has diagnoses of stroke with left sided paralysis. R30's facility assessment dated [DATE] show R30 is alert and able to verbalize his needs. R30 has limited range of motion due to history of CVA (stroke). The same assessment show R30 has no behaviors of rejection of care. On 5/19/25 at 10 am, R30 was sitting in his wheelchair in his room. R30's contracted left hand- (fingers were all curled/clenched towards the palm) was in his lap. R30 said no one does anything to his left hand, then used his right hand to lift his contracted left hand to show this surveyor. R30 said he has a splint that no one applies. R30 said no one exercises his contracted left arm. At 1:12 PM, R30 was sitting in his wheelchair in his room watching TV. R30 had no splint to his left hand. On 5/20/21 at 8AM, R30 was in the dining room just finished his breakfast. R30 had no splint to his contracted left hand. R30's care plan dated 5/20/21 documents-The resident has limited physical mobility r/t contracted left hand. R30 has left side hemiplegia, due to recent CVA with intervention of, Splint to be worn on Left hand daily as tolerated. On 5/20/25 at 9:44 AM, V2 (Director of Nursing-DON) said she is also the Restorative Nurse at this time. R30 had stroke so he has left hand contractures. R30 should wear his left hand splint as ordered. The splint is to prevent further contractures. If R30 refused to wear his splint, the refusals should be documented in progress notes, if there was no documentation, that means that it was not done. V2 (DON) said R30 will be referred to therapy. R30's progress notes as confirmed by V2 DON did not document that R30 had refused wearing his left hand splint. R30's tasks (for Certified Nursing Assistant-CNA) that show application of splint to be done for the month of May (2025) was also blank as confirmed by V2. On 5/20/25 at 1PM, V11 (Occupational Therapy-OT) said R30 was referred for therapy today (5/20/25) due to R30's contractures and splint need. 34506 2. R12's Admission Record dated April 4, 2025, shows R12 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side and reduced mobility. R12's Order Summary Report dated May 19, 2025, does not include any orders for splint placement to R12's left arm. R12's Care Plan initiated August 9, 2024, shows R12 refuses to wear splint sometimes. Remind resident on importance to wear splint. Approach again if resident refuses splint. There is no other documentation found to reflect R12's refusals. R12 Minimum Data Set (MDS) dated [DATE], shows R12 did not have any behaviors of rejecting evaluation or care that is necessary to achieve the resident's goals for health and wellbeing. R12's MDS shows he received brace or splint assistance three days of the last seven days. R12's MDS also shows that he has no impairment to either upper extremity for functional range of motion. On May 19, 2025, at 10:29 AM, R12 was sitting in his room. R12 left arm was out of his long sleeve zip up shirt and was pressed against his abdomen. R12 said he wears a splint sometimes. R12 said it is too hard for him to put it on and if staff would help him, he would wear it. R12 did not have a splint to his left hand or arm. R12's Certified Nursing Assistant tasks in the electronic charting does not contain a task for the CNAs to apply R12's splint. On May 20, 2025, at 9:44 AM, V2 Director of Nursing/Restorative nurse said R12 has a brace that staff put on and take off to his left arm/hand. V2 said R12 wears the splint everyday and sometimes takes it off at mealtimes. V2 said staff put the splint on. V2 said she does not know if there is an actual time limit for having the splint on. V2 said R12 should wear it for at least one hour per day. V2 said splints are used for residents with contractures. Splints help the limbs from contracting, it can help keep the shape of the limb, and helps the contractures from getting worse as long as the splints are worn. V2 said staff document under the tasks tab and in the medication administration record or the treatment administration record. Refusals are documented by the nurse in a progress note. V2 said if there is no documentation that a splint is applied, then it means it was not done. The facility's Application of Splints policy dated November 2023 shows, Purpose: To properly apply a splint for support, comfort, or aid in contractures prevention. Equipment: Physician's order, specific splint for the resident. Note the time the splint was applied, and time splint is to be removed per physician order.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred safely for 1 (R66) of 24 residents reviewed for safety/supervision in the sample of 24. The findings include: R66's Admission Record dated May 19, 2025, shows R66 was admitted to the facility on [DATE], with diagnoses including dementia, major depressive disorder, primary generalized osteoarthritis, Alzheimer's disease, anxiety disorder, fatigue, displaced right femur fracture, difficulty walking, and non displaced fracture of right and left little finger. R66's Fall Scale dated March 17, 2025; shows she is a high risk for falling. R66's Care Plan last revised on April 12, 2022, shows R66 has an activities of daily living (ADL) self-care performance deficit related to impaired mobility, impaired cognition. R66's care plan shows R66 requires a limited one assist for bed mobility and transferring. R66's Minimum Data Set (MDS) dated [DATE], shows R66 requires substantial/maximal assistance for transferring and sit to lying. On May 19, 2025, at 12:53 PM, V13 and V14 Certified Nursing Assistants (CNAs) transferred R66 from her chair to her bed by holding her underneath her arms and by holding onto the waistband of her pants. R66 did not bear any weight to her legs. On May 20, 2025, at 1:59 PM, V2 Director of Nursing said if a resident is being transferred with two staff members, then the staff should use a gait belt and stand on each side of the resident. If the resident is not standing, then they could give the resident a break and try again. Otherwise, staff could use a mechanical lift. If a resident is transferred using their arms and waist bands, then the resident could be injured. On May 21, 2025, at 10:52 AM, V13 CNA said a gait belt should be used when transferring a resident. If the resident is not standing, then the resident should be transferred via a mechanical lift. The facility's Gait Belt/Transfer Guideline revised February 2023 shows, A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for resident who are at risk for falls and those who require assistance during transfer. Securely apply the gait belt around the resident waist positioning the buckle on the anterior side of the resident over the top of the clothing. Assist residents to stand and allow them to gain balance. If the resident is morbidly obese and cannot bear weight, consider using lift equipment to transfer the resident instead of a gait belt to ensure safety and prevent caregiver injury.

Based on observation, interview, and record review the facility failed to ensure R44's steel oxygen cylinders were stored to prevent damage to the cylinders for 1 of 5 residents (R44) reviewed for respiratory services in the sample of 24. The findings include: On 05/19/25 at 12:04 PM, R44 was lying in bed. There was an oxygen tank leaning against the wall in her closet area. The oxygen tank was not secured to keep the cylinder upright. Leaning against the bedside table, near the head of R44's bed, was a second oxygen tank. The oxygen tank was not secured to keep the cylinder upright. On 05/19/25 at 12:05PM, V8 LPN-Licensed Practical Nurse said, when R44 is up in her wheelchair the oxygen tank is attached to the back of the wheelchair. When the oxygen tank is not in use it should be stored in the oxygen cylinder storage room. The facility's Oxygen Safety Policy effective date February 2019 shows, all oxygen cylinders must be stored in racks with chains, sturdy portable carts, or approved stands and never left free-standing or in any resident room or living area.

Based on observation, interview, and record review the facility failed to assess and monitor a resident's(R94) ankle. This failure resulted in R94 developing an infected ankle that caused a post-surgical screw to protrude out of her ankle and be admitted to the local hospital for surgical cleaning and repair. The facility failed to identify, assess and implement treatment interventions for a resident(R24) with new wounds. This applies to 2 of 25 residents (R24 and R94) reviewed for quality of care in the sample of 25. The findings include: 1. R94's Minimum Data Set assessment dated [DATE] shows that her cognition is intact. On 7/8/24 at 9:27 AM, R94 was self propelling down the hallway in her wheelchair. R94's right lower leg was swollen. There was a gauze wrap around her ankle. Above the wrap, R94's skin was reddened and had dry peeling skin present. R94 said that her right ankle is very painful because she has a screw sticking out of her ankle that has been like that for a while and she is waiting to see an orthopedic doctor. On 7/9/24 at 12:00 PM, R94 was lying in bed. R94 did not have a dressing on her right ankle. R94 had a surgical screw protruding through her skin on her right medial ankle. The screw was protruding out 1 centimeter (cm). R94's right leg was swollen and had a 9.5 cm x 7.5 cm reddened area around the screw. On 7/9/24 at 12:16 PM, V21 (Registered Nurse-RN) said that she did a dressing change to R94's ankle yesterday along with V20 (RN). This surveyor asked V21 if R94's ankle was like that yesterday as well and she responded with, yes. On 7/10/24 at 2:32 PM, V21 said that when she did the dressing change on 7/8/24 with V20, R94's leg was swollen and there was redness present. V21 said that she did not report the findings to anyone because she was just following the treatment order and wounds have redness. V21 said that she had not seen R94's ankle before so she is not sure if it was red in the past. R94's Nursing Notes documented for 7/8/24 as a late entry by V20 shows, This nurse with a second RN completed treatment to right ankle. No swelling or redness present. pt (patient) had no CO (complaints of) pain. R94's Hospital History and Physical dated 7/9/24 shows, The patient states that her pain started about 4 days ago when she noticed her right medial ankle red and with a screw poking out of the skin . R94's Orthopedic consult dated 7/9/24 shows, Presents from [local extended care facility (ECF)] with several day complaint of worsening right ankle pain .Patient states she noted worsening redness and pin-point prominence over her medial ankle. 4 days ago, she states she informed ECF a screw had popped through the skin. Patient notes global pain and erythema around her medial ankle and hardware is exposed ankle diffusely tender, noted medial screw with purulence (pus-like drainage), induration and erythema along medial ankle Plan for operative intervention-Incision, irrigation and excisional debridement of right ankle, removal of hardware, bone biopsy, possible antibiotic bead placement, possible wound vac by [orthopedic surgeon] 7/10/24. R94's Operative Report dated 7/10/24 shows, Procedure .Removal of plate and screws distal medial tibia in contact with obvious purulent infection. Irrigation and debridement skin subcutaneous tissues muscle fascia and bone associated with chronic postoperative infection and likely osteomyelitis. The last Wound Assessment Details Report of R94's right medial ankle was from 6/20/24 that showed that her vascular wound that was present on admission on her right inner ankle had closed. R94 still had swelling of her bilateral lower legs with no redness and stated, my ankle is painful, when she moves it . The last shower sheet that was provided was from 7/1/24 that showed no skin alterations. R94's Nurse Practitioner Note dated 6/21/24 shows, X-ray to right foot/ankle? Septic arthritis/osteomyelitis of lateral malleolus with recommendation for joint aspiration. Ortho (Orthopedic) consult for possible aspiration and cultures. R94's Nurse Practitioner Note dated 6/26/24 shows, She has chronic intermittent aching pain to right foot that worsens with therapy, Norco (narcotic pain medication) and rest helps relieve .Plan. Norco started per physiatry on 6/12/24.scheduled ES (extra strength) Tylenol BID (twice a day). Diclofenac (anti-inflammatory drug). R94's Physiatry Notes dated 7/6/24 shows, She reports continued right ankle pain. She reports that her BLE (bilateral lower extremities) has gotten very swollen. On 7/10/24 at 10:43 AM, V7 (Physiatry-Nurse Practitioner) said that he saw R94 on 7/6/24. V7 said that when he saw R94 on 7/6/24 she had [rolled gauze] wrapped around her right ankle and her leg was swollen. V7 said that R94 always had swollen legs but when he saw her that day, her right leg was a little more swollen than usual and she was still having pain in her right ankle. On 7/10/24 at 12:52 PM, V30 (Hospitalist) said that he saw R94 in the emergency roiagnom on [DATE]. V30 said that based on the way R94's right ankle looked (screw sticking out with yellow crusted drainage around it, redness and swelling) that he would estimate that it has been protruding out of the skin anywhere between 48 hours to a week. V30 said that R94 gave him a pretty good history and said that she noticed it about 4 days ago. 2. On 7/8/24 at 1:50 PM, V18 and V19 (Certified Nursing Assistants) provided incontinence care to R24. R24 did not have any dressings to her posterior thighs, buttock or groin area. R24's bilateral posterior thighs and buttock area was bright red with multiple open, bleeding wounds present. R24's front groin and upper thigh area was bright red and had open, bleeding areas on each upper thigh. On 7/8/24 at 1:50 PM, V18 said that R24's thighs and groin areas have looked like that for a few weeks. On 7/09/24 at 2:14 PM, V9 (Wound Nurse) said that according to R24's clinical records, R24 has a pressure ulcer on her left heel, a venous ulcer on her left lower leg and MASD (Moisture Associated Skin Damage) on her left thing and nothing else. V9 said that if a resident develops new skin alterations, the CNA should notify the nurse and the nurse should do an assessment, call the physician for appropriate treatments and document their findings in the medical record. V9 said that she was not aware of any new skin alterations for R24. V9 went into R24's room to do a skin check. Multiple wounds were observed on R24's left and right posterior thighs and her left and right groin area. R24 did not have any dressings on her thighs or groin area wounds. R24's Skin/Wound Note dated 7/10/24 shows that R24 has a broken blister on her right medial thigh near her groin measuring 1 centimeter (cm) x 2.2 cm x 0.1 cm, a broken blister on her left medial thigh measuring 0.5 cm x 0.4 cm x 0.1 cm, a superior right posterior thigh trauma measuring 1.3 cm x 1.2 cm x 0.1 cm, a right distal posterior thigh trauma measuring 0.5 cm x 6.5 cm area of redness with a 0.5 cm x 1.2 cm wound with a firm yellow wound bed and a left superior posterior thigh reddened area measuring 7.5 cm x 8 cm with scattered open areas with pale pink wound beds. R24's Wound assessment dated [DATE] shows that she has MASD (Moisture Associated Skin Damage) to her left back thigh measuring 15 centimeters (cm) x 9 cm x 0.1 cm. No wound notes were documented regarding R24's right posterior thigh or groin/thigh areas until 7/9/24. R24's Physician's Order Sheet (POS) printed on 7/9/24 shows an order initiated 6/19/24 for, Clean wounds left posterior thigh with wound cleaner, apply xeroform (petroleum dressing), then cover with bordered foam gauze dressing, change daily and as needed. The POS did not contain any additional orders for wounds on her posterior thighs or groin area. The facility's Measurement of Alterations in Skin Integrity Policy dated January 2017 shows, At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and/or describe skin condition in the clinical record Skin conditions such as bruises, skin tears, abrasion, rashes, and moisture/incontinence associated dermatitis will be described upon initial observation and documented in the clinical record. The facility's Perineal Care Policy revised February 2018 shows, The purpose of this procedure are to observe the resident's skin condition documentation .any discharge, odor, bleeding, skin care problems or irritation Report other information in accordance with facility policy and professional standards of practice. The facility's Shower/Skin Sheets Policy revised on November 2009 shows, Body inspection is to begin at the head and with the feet. Look at all areas of the body. Pay special attention to back, buttocks, peritoneal area, feet and between the toes and heels Report any skin alteration or reddened areas to the nurse immediately while the resident is still undressed so it can be clinically assessed, treated and appropriately documented When appropriate, the family and doctor are to be notified. If applicable, treatment orders are obtained from the physician.

Based on observation, interview, and record review the facility to report new pressure injuries. The facility failed to ensure pressure injury prevention interventions were in place. The facility failed to identify a resident's pressure injury prior to the injury becoming a Stage III injury. These failures resulted in R101 developing a Stage III pressure injury to her coccyx and Stage II pressure injuries to each of her buttocks. The facility failed to ensure pressure treatment interventions were in place and failed to complete weekly assessments on residents(R82, R24) with pressure injuries. This applies to 3 of 11 residents (R101, R82, R24) reviewed for pressure injuries in the sample of 25. The findings include: 1. R101's Admission Record showed R101 was admitted to the facility on [DATE] with diagnoses of a compression fracture of her spine, morbid obesity, Type 2 Diabetes Mellitus, and congestive heart failure. R101's care plan dated 5/15/24 showed R101 was at risk for alterations in skin integrity. The plan showed facility staff were to monitor and document any skin injuries on R101 and keep skin clean and dry. R101's resident assessment dated [DATE] showed R101 required staff assistance for repositioning and toileting/incontinence care. R101's last shower sheet/skin assessment dated [DATE] showed no wounds, no redness, and no excoriation to R101's buttocks/lower back. On 7/8/24 at 9:05 AM, R101 was in bed, lying on her back. A urinary catheter bag hung off the side of R101's bed. R101 complained of pain to her buttocks and lower back. At 9:09 AM, V3 Certified Nursing Assistant (CNA) repositioned R101 on her side. V3 CNA pulled down the side of R101's incontinence brief, exposing R101's buttocks. R101's buttocks appeared red with multiple open areas noted to the skin of her buttocks. A nickel-sized wound was noted to R101's coccyx area with a scant amount of bleeding noted from the wound. Large, irregular shaped wounds were noted to each of R101's buttocks. R101's incontinence brief was soiled with a small amount of stool and urine as R101's indwelling urinary catheter appeared to be leaking onto R101's brief. R101 again complained of pain to her buttocks. V3 CNA then applied zinc oxide cream to R101's buttocks and secured R101's soiled brief back in place. V3 stated, I know I haven't been in to change you yet today. I will be back shortly to get you cleaned up. V3 exited R101's room. On 7/9/24 at 8:27 AM, V9 Wound Care Nurse stated R101 did not have any pressure injuries. V9 stated, Nothing new has been reported to me. V9 stated staff are to notify her and the resident's physician when any new wounds or skin alterations are found. On 7/9/24 at 1:38 PM, V10 Licensed Practical Nurse (R101's nurse) stated, No one has told me that (R101) has any new wounds. On 7/9/24 at 1:50 PM, V3 CNA was asked about the cares she provided to R101 on 7/8/24. V3 CNA stated, Yea, I saw that her catheter had been leaking a little. I didn't report her open areas (to R101's buttocks) to anyone. I'm pretty sure they already knew about it. On 7/9/24 at 3:10 PM, V9 Wound Care Nurse stated, I evaluated (R101) this morning. She has a new Stage III to her coccyx and Stage II's to each buttock. According to the documentation, it looks like she went from having no wounds to a Stage III and Stage II's. She did tell me she had a history of having wounds to those areas previously. She has a catheter (urinary) but if the catheter is leaking the wounds could be caused by her laying in urine and/or stool. She is one that needs to be cleaned up immediately if she is incontinent. She also can't reposition herself. Her wounds don't appear to be infected These should have been caught prior to becoming Stage II and III's. R101's Wound Notes/Wound Assessment Report dated 7/9/24 showed R101 had a Stage III pressure injury to her coccyx measuring 1.51 cm (centimeters) x 0.8 cm x 0.3 cm, a Stage II to her right buttock measuring 4 cm x 3 cm x 0.1 cm, and a Stage II to her left buttock measuring 4 cm x 3 cm x 0.1 cm. On 7/10/24 at 9:25 AM, V11 Nurse Practitioner stated, I saw (R101) yesterday and saw the wounds to her buttocks, but I don't do any staging of wounds . I know she has a history of MASD (moisture associated skin damage) to that area. Her catheter has been leaking and we are trying to treat that. She can't move on her own. She is someone who would need frequent changing (of her incontinence brief). I would say that if she is being changed frequently and repositioned, the development of these pressure injuries most likely would not happen . The facility's Shower/Skin Sheets policy dated 11/2009 showed, Report any skin alteration or reddened area(s) to the nurse immediately while the resident is still undressed so it can be clinically assessed, treated and appropriately documented . The facility's Perineal Care policy dated 2/2018 showed, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . The policy showed facility staff are to document any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort. 35178 2. On 07/08/24 at 12:29 PM, R82's left, and right heels were resting on the bed while the resident was lying on his back. On 07/08/24 at 12:30PM, R82 said, I usually wear the heel boots, they are in the closet. I had them on yesterday, the night shift did not put them on last night. I must ask for them to be put on. I ended up falling asleep before I could ask anyone to help me. On 07/09/24 at 3:16 PM, V9 Wound Nurse said, heel boots protect the wound. When in bed R82 should have his heels off-loaded. R82's ankles should be suspended so there is no pressure to the heels. R82's Wound Notes dated 07/03/2024 at 10:14AM, shows, left heel stage 3 pressure ulceration 0.4 x1.0 x 0.1 centimeters. R82's current Care Plan on 07/08/2024 shows, put protective boots on when in bed initiated: 04/15/2024. R82's Physician's Order on 07/08/2024 shows, off-loading heel boots to be worn in bed. Every day and night shift for wound care. Initiated: 04/15/2024. 34490 3. On 7/9/24 at 11:44 AM, R24 was lying in bed. R24 did not have an air mattress in place. R24's Wound Assessment Details Report dated 6/19/24 shows that she has a facility acquired left heel pressure ulcer measuring 5 centimeters (cm) x 4.5 cm x 0.2 cm that was identified on 6/13/24. No additional wound assessments of R24's left heel pressure ulcer after the 6/19/24 assessment was documented until 7/10/24 (21 days later). V2 (Director of Nursing) verified that no additional assessments after 6/19/24 of her left heel pressure ulcer were in R24's clinical records. R24's Physician's Order Sheet printed on 7/9/24 shows an order for an air mattress dated 6/14/24. R24's Skin Integrity Care Plan shows that she has a blister pressure injury of her left heel with an intervention added of an air mattress on 6/14/24. On 7/10/24 at 12:07 PM, V2 (Director of Nursing) said that wound assessments including measurements should be done weekly on all pressure wounds to ensure the pressure wound is getting better and not getting worse. The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol revised April 2018 shows, Treatment/Management-The physician will order pertinent wound treatments, including pressure reduction surfaces The facility's Measurement of Alterations in Skin Integrity Policy dated January 2017 shows, All wounds/ulcers (i.e., pressure, arterial, diabetic, venous) will be measured weekly and results recorded in the clinical record.

Based on observation, interview, and record review the facility failed to ensure a resident (R121) was assessed, in-person, by a Certified Dietary Manager or Registered Dietician, upon admission to the facility. The facility failed to obtain and monitor a resident's (R121) weight as per physician order. These failures resulted in R121 sustaining a significant weight loss of 20.3 % (49.4 pounds) in 25 days. This applies to 1 of 10 residents (R121) reviewed for weight loss in the sample of 25. The findings include: R121's hospital record dated 5/20/24-6/14/24 showed R121 was admitted to the hospital with a diagnosis of a GI (gastrointestinal) bleeding on 5/20/24. While hospitalized , R121 underwent radiologic imaging which revealed a new, malignant mass in R121's colon. R121 subsequently underwent surgery to remove the mass in her colon as well as to have a colostomy placed. Post surgery, R121's records showed R121 required an appetite stimulant medication and TPN (intravenous nutritional feeding) due to her poor appetite and diagnosis of severe protein malnutrition and caloric deficit. R121's hospital discharge medical records showed R121 weighed 243 pounds (lbs) on 6/13/24. R121 was discharged to the facility on [DATE] for skilled therapy services and rehab. R121's admission care plan dated 6/15/24 showed R121 was at risk for weight loss. The plan showed R121 will not have unplanned significant weight loss/gain through next review. The plan showed R121 was cognitively intact. A physician order for R121 dated 6/15/24 showed, On admission, weekly weights x 4 (weeks) and then per protocol. On 7/8/24, R121's Weights and Vitals Summary was reviewed and showed R121 weighed 243 lbs upon admission to the facility on [DATE]. The record showed no documented weights for R121 from 6/15/24-7/8/24. On 7/8/24 at 1:01 PM, R121 was asleep in bed. An uneaten roast beef sandwich was on the table in front of R121. On 7/9/24 at 7:55 AM, R121 was seated in bed. R121 was asked if she had ever been weighed in the facility. R121 stated, They have never weighed me here. They have never asked if they could weigh me. The uneaten roast beef sandwich remained on the table in front of R121. R121 pointed at the sandwich and stated, My son brought that in. I haven't been hungry. On 7/9/24 at 9:44 AM, this surveyor asked V3 Certified Nursing Assistant (CNA) to weigh R121. R121 was weighed by V3 CNA, with this surveyor present. The facility's scale showed R121's weight as 193.2 (lbs). On 7/9/24 at 10:13 AM, V4 Registered Dietician (RD) and V5 Certified Dietary Manager (CDM) were interviewed. V4 RD stated new admissions (residents) are weighed once a week for the first four weeks, after admission, to monitor residents for any weight changes. V4 RD stated she does not see all new admissions to the facility but only the resident's that have wounds, are on dialysis, or are at high risk for weight loss. V4 RD stated, All residents are to be assessed by me or (V5 CDM) within 72 hours of their admission. (V5) sees and does the nutritional assessments on the new admissions that are non-high risk for weight loss. V4 stated she had never seen or evaluated R121 in the facility. V4 stated she was not aware of R121's medical history or diagnoses. R121's weight record, showing only R121's weight of 6/14/24, and R121's recent hospital records were then reviewed with V4 RD. V4 RD was also informed R121 was weighed by facility staff that morning which showed R121's weight as 193.2 lbs. V4 RD stated, I don't see where her weekly weights were done. She should have had weights done weekly. I had no idea what her history was. I should have assessed her upon admission. R121's nutritional assessment, documented as being completed by V5 CDM on 6/15/24, was then reviewed with V4 RD and V5 CDM. V5 CDM stated, I didn't actually see (R121) in-person and assess her myself. I had one of my dietary aides go see her to see if she had any concerns. I completed the (dietary) assessment on (R121) based on what I read in her nurses notes and what the dietary aide told me. V5 CDM stated, I should be doing the dietary assessments on new admissions myself, but it just depends on my workload. If the resident doesn't have any concerns, I don't always do see them in-person. V5 stated he was aware R121 had a diagnosis of protein calorie malnutrition upon admission to the facility but stated he was not aware that R121 also had diagnoses of colon cancer and colostomy placement. On 7/9/24 at 12:45 PM, V4 RD stated R121 had been reweighed by V4 and facility staff. V4 stated R121's re-weight was 193.6 lbs which confirmed R121 had sustained a significant weight loss of 20.3 % (49.4 lbs) in 25 days (6/14/24-7/9/24). V4 stated she had just completed her evaluation on R121. V4 stated R121's significant weight loss was likely avoidable if she had assessed R121 upon admission and had R121 been weighed weekly. V4 stated, I should have assessed her upon admission based on her diagnoses. V4 stated if R121 had been weighed weekly, her weight loss could have potentially been caught sooner. V4 stated, It is not okay for a dietary aide to do any assessments on residents. I wasn't aware that (V5 CDM) was not assessing all new admissions in-person. V4 stated she had just spoken with R121's son who stated he had been bringing in food for R121 because R121 had not been eating well in the facility and he was trying to get her to eat. On 7/9/24 at 2:26 PM, V11 Nurse Practitioner (NP) for R121 stated R121 should have been weighed weekly for the first four weeks she was in the facility. V11 NP stated it was the expectation that each newly admitted resident was seen and assessed by either a registered dietician or certified dietary manager. V11 NP stated that R121's weight loss was substantial however, she stated the cause of R121's significant weight loss was multi-factorial as it was related to R121's cancer diagnosis, prolonged hospitalization , poor appetite, and R121 not being weighed weekly as ordered. V11 NP stated had R121 been weighed weekly, they could have seen her weights trending down and intervened. The facility's Weight Assessment and Intervention policy dated 12/2009 showed, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month- 5% weight loss is significant; greater than 5% is severe. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. 6 months- 10% weight loss is significant; greater than 10% is severe .

Based on observation, interview, and record review the facility failed to safely feed a resident with difficulty swallowing and failed to ensure a resident's mouth was clear of food. This applies to one of eight residents (R70) reviewed for safety in the sample of 23. These failures resulted in R70 being found expired after being found in the dining room with food in his mouth. The Immediate Jeopardy began on [DATE] when R70 was first observed not swallowing his food while staff continued to spoon food in his mouth. R70 was left with food in his mouth. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 2:45 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility face sheet for R70 shows diagnoses to include acute kidney disease, Bell's palsy, acute respiratory failure, adult failure to thrive and hypertension. R70's Physician Order Sheet shows R70 was under hospice care and was a Do Not Resuscitate. The facility assessment dated [DATE] shows R70 has severe cognitive impairment, requires staff assistance for most activities of daily living, and has complaints of pain and difficulty swallowing. On [DATE] between 12:30 PM and 1:13 PM, V4 Licensed Practical Nurse (LPN) was observed assisting R70 with his lunch. V4 was observed spooning food into R70's mouth and R70 was observed holding food in his mouth. Food was running back out of his mouth. At 1:12 PM, V4 was observed trying to get R70 to swallow some juice and it was observed running out of his mouth. V4 then attempted to clean the food from R70's mouth. V4 used several wipes and was bringing food out of R70's mouth. V4 then walked away from R70, leaving him with his head tilted back in the common area where he was being fed. R70 coughed and large amounts of food shot out of his mouth. At 1:15 PM, V9 Certified Nursing Assistant (CNA) walked over to R70 and said, Look at all the food in his mouth!. V9 then grabbed a cup and a spoon and began scooping food from his mouth. Several swipes with the spoon were observed, as she removed more food from R70's mouth. V4 then returned to the side of R70 and V9 asked V4 to help her lay him down. R70 was pushed down the hall and food was observed in his open mouth. When R70 arrived too his room, V4 looked down at R70 and realized he was no longer breathing. Food could still be observed in the back of his mouth. At 1:30 PM, V16 Registered Nurse (RN) came to R70's room and listened to R70's chest for five minutes and stated R70 did not have any heart tones (R70 had expired).She said R70 has been having trouble eating the last few days. At 1:56 PM, V2 Director of Nursing was asked to come to R70's room to inspect R70's mouth. V2 looked into R70's mouth and said, Phlegm? Applesauce? Let me get a swab, V2 placed a swab into R70's mouth and said, That looks like food in his mouth. On [DATE] at 2:19 PM, V4 said, R70 has been holding food in his mouth. It has been going on for a while but is definitely worse today. He has been declining the last few weeks. We have to take it slow and encourage him to swallow his food. Today when I was feeding him, he was doing OK but not really. I had to encourage him all the time to swallow. When he was letting the juice run out of his mouth, I decided to clean him up and stop feeding him. On [DATE] at 2:29 PM, V5 Hospice Nurse said when she visited R70 yesterday she was told by V3 Unit Director that R70 was no longer able to swallow, and it was not safe to continue to feed him. On [DATE] at 2:40 PM, V3 (LPN, Unit Manager) said he is not able to determine if a resident is swallowing well enough or if foods should be held. V3 said the hospice team decides that and would get the orders to hold oral foods. V3 felt the discussion about R70 swallowing was just a discussion and not a directive from hospice. V3 did agree that if a resident is not swallowing food, feeding that resident should not continue. On [DATE] at 8:40 AM, V9 CNA said she saw all the food in R70's mouth and knew she had to try and get it out. V9 said the staff were told by V4 not to feed R70 any food that day due to him not swallowing well. On [DATE] at 8:55 AM, V10 CNA said she was watching R70 being fed on Monday [DATE] (the day before the incident) by another CNA and the food was just running back out of his mouth. On [DATE] at 9:00AM, V6 CNA in training said she had fed R70 his breakfast on Tuesday morning, [DATE], and he was not swallowing his food. V6 said at one-point R70's eyes rolled back in his head. V6 said she refused to feed him anymore and went and told V4 what was happening and that R70 did not seem right. V6 then said at lunch, she was sitting next to R70 feeding another resident and V4 was putting food into R70's mouth even though he was keeping it in his mouth. She kept putting food in his mouth. On [DATE] at 9:35 AM, V11 CNA said she was attempting to feed R70 on Monday (the day before the incident) [DATE] and he was not swallowing his food. On [DATE] at 9:45 AM, V7 CNA said on Monday (the day before the incident) [DATE], R70 was not swallowing his food and kept holding in his mouth. V7 said she tried to give him a drink of juice and R70 just coughed. V7 said she told V3 and the Hospice Nurse (V5) when she came to visit R70 on Monday. On [DATE] at 10:40 AM, V8 Medical Doctor (MD) said a nurse can determine if a resident is capable of swallowing food safely. V8 said it's common sense to notify the MD or hospice if a resident is having trouble swallowing food and not to continue to feed them. The hospice RN visit note dated [DATE] shows collaboration with [V3]. The note shows [V3] telling [V5] that R70 is not doing well and thinks he is going downhill. [V3] said R70 is no longer safe to be fed, he is unable to swallow and feeding him will only be a choking hazard. The note also shows that a CNA reported to the hospice nurse that R70 is no longer eating and R70 was not being fed any more due to not swallowing food. R70's facility nursing progress note shows no documentation regarding R70's inability to swallow on [DATE]. The facility care plan for R70 shows a goal for the resident will have clear lungs, no signs and symptoms of aspiration, and the resident will have no choking episodes when eating. The interventions included: all staff to be informed of resident's special dietary and safety needs and check mouth after meals for pocketed food and debris. Provide oral care to remove debris. R70's Physician orders shows an order for a general pureed consistency texture and nectar-mildly thick consistency for liquids. The facility policy with a revision date of [DATE] for assistance with meals shows residents will receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. Facility immediately educated all facility employees on the following topics: Feeding residents safely and monitoring residents. Staff training on environmental safety. Identifying residents with swallowing difficulty. Staff training on communicating changes in condition. Staff training on coordinating communication with hospice. Staff training on safe feeding techniques. Staff training on resident at risk for choking/aspiration. Staff training on signs and symptoms of aspiration with ongoing evaluation of feeding techniques. Education started [DATE], conducted by the Director of Nursing, Corporate Nurse Consultant and Nurse Administration. All Employees on duty will receive education before their shift ends. The remaining facility employees will be educated prior to their next scheduled shift until 100% of facility employees have been educated. The Administration will be at the facility to conduct education at the start of their shifts. The facility Quality Assurance Team which includes Administrator, DON, ADON, Medical Director, facility directors will: QAPI will meet tomorrow [DATE] to discuss incident and then will meet monthly to review policies and procedures related to feeding residents. Facility DON and nursing staff will conduct ongoing audits to include identification of any swallowing difficulty weekly for the next 60 days. QAPI will discuss and review policy as needed through the QAPI process. On [DATE] at 12:00PM, a review of the facility's in-service records showed all nursing and CNA staff had been educated on environmental safety, notification of diet changes, change in a resident's condition or status, hospice, emergency procedure for choking, assistance with meals, and aspiration. A QAPI sign sheet dated [DATE] shows a meeting had taken place.

Based on observation, interview and record review the facility failed to communicate a resident change in condition to the Physician and to other staff in the facility. This facility failure resulted in R70 being fed a meal when he could not safely swallow the food and was later found deceased with food in his mouth. This applies to one of one resident (R70) reviewed for notification in the sample of 23. The findings include: The facility face sheet for R70 shows diagnoses to include acute kidney disease, Bell's palsy, acute respiratory failure, adult failure to thrive and hypertension. R70's Physician Order Sheet shows R70 was under hospice care and was a Do Not Resuscitate. The facility assessment dated [DATE] shows R70 has severe cognitive impairment, requires staff assistance for most activities of daily living, and has complaints of pain and difficulty swallowing. The hospice RN visit note dated [DATE] shows collaboration with [V3 (Unit Manager, Licensed Practical Nurse)]. The note shows [V3] telling [V5] (Hospice Nurse) that R70 is not doing well and thinks he is going downhill. [V3] said R70 is no longer safe to be fed, he is unable to swallow and feeding him will only be a choking hazard. The note also shows that a CNA reported to the hospice nurse that R70 is no longer eating and R70 was not being fed any more due to not swallowing food. On [DATE] between 12:30 PM and 1:13 PM, V4 Licensed Practical Nurse (LPN) was observed assisting R70 with his lunch. V4 was observed spooning food into R70's mouth and R70 was observed holding food in his mouth and food was running back out of his mouth. At 1:12 PM, V4 was observed trying to get R70 to swallow some juice and it was observed running out of his mouth. V4 then attempted to clean the food from R70's mouth. V4 used several wipes and was bringing food out of R70's mouth. V4 then walked away from R70, leaving him with his head tilted back in the common area where he was being fed. R70 was then observed by this surveyor coughing and large amounts of food shot out of his mouth. At 1:15 PM, V9 Certified Nursing Assistant (CNA) walked over to R70 and said, Look at all the food in his mouth!. V9 then grabbed a cup and a spoon and began scooping food from his mouth. V4 then returned to the side of R70 and V9 asked V4 to help her lay him down. R70 was pushed down the hall and food was observed in his open mouth. When R70 arrived too his room, V4 looked down at R70 and realized he was no longer breathing. Food could still be observed in the back of his mouth. On [DATE] at 2:29 PM, V5 Hospice Nurse said when she visited R70 yesterday she was told by V3 Unit Director that R70 was no longer able to swallow, and it was not safe to continue to feed him. On [DATE] at 2:40 PM, V3 said the hospice team decides when a resident should no longer be fed and should get the order from the physician. V3 felt the discussion about R70 swallowing was just a discussion and not a directive from hospice. V3 said he never notified the Physician with R70's swallowing concerns. On [DATE] at 9:00AM, V6 CNA in training said she had fed R70 his breakfast on Tuesday morning, [DATE], and he was not swallowing his food. V6 said at one-point R70's eyes rolled back in his head. V6 said she refused to feed him anymore and went and told V4 what was happening and that R70 did not seem right. On [DATE] at 9:45 AM, V7 CNA said on Monday [DATE], R70 was not swallowing his food and kept holding it in his mouth. V7 said she tried to give him a drink of juice and R70 just coughed. V7 said she told V3 and the Hospice Nurse (V5) when she came to visit R70. On [DATE] at 10:40 AM, V8 Medical Doctor (MD) said a nurse can determine if a resident is capable of swallowing food safely. V8 said it's common sense to notify the MD or hospice if a resident is having trouble swallowing food and not to continue to feed them. On [DATE] at 10:51 AM, V2 DON said when a resident is having a change in condition, such as not swallowing, the Physician should be notified. The facility care plan for R70 shows a goal for the resident will have clear lungs, no signs and symptoms of aspiration, and the resident will have no choking episodes when eating. The interventions included: all staff to be informed of resident's special dietary and safety needs and check mouth after meals for pocketed food and debris. Provide oral care to remove debris. R70's Physician orders shows an order for a general pureed consistency texture and nectar-mildly thick consistency for liquids. R70's nursing progress notes shows documentation regarding his inability to swallow foods on [DATE]. The facility policy dated ,d+[DATE] for change in a resident's condition or status shows: Our facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition . The nurse will notify the resident's attending Physician when there has been: d. significant change in the resident's physical/emotional condition, e. need to alter the resident's medical treatment significantly. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review the facility failed to ensure a resident received the necessary emergency care and services in a timely manner after a fall with a fracture, while displaying signs of facial grimacing and yelling out in pain. This applies to 1 of 3 resident (R4) reviewed for falls. The findings include: R4's Face Sheet shows she was admitted on hospice on 12/23/22. The same document shows R4's diagnoses included encephalopathy, myocardial infarction, dementia, anxiety, depression, occlusion and stenosis of carotid artery, chronic kidney disease, and disorientation. On 2/16/23 at 12:30 PM, V15 RN said R4 had an unwitnessed fall on the morning of 1/2/23. V15 said she assessed R4 and found her to be without injuries so V15 (and staff) used a mechanical lift to put R4 in a wheelchair and called V10 NP (Nurse Practitioner) and the POA (Power of Attorney). V15 said R4's pain increased so she called V10 again and she (V10) ordered a STAT (to be done immediately) X-ray. On 2/16/23 at 2:00 PM, V10 said when a resident experiences an unwitnessed fall, the nurse should do an assessment that includes active and passive range of motion, assess for point tenderness, observe if one leg is shorter than the other, and note any rotation of the limbs. V10 said it's possible that R4's hip displaced after being placed in the wheelchair. V10 said R4 had a very small dose of morphine ordered. V10 said it would have been reasonable for the nurse to call her back when the X-ray company didn't show in a timely manner, while R4 was still experiencing pain. V10 said, I could have sent her (R4) to the emergency room or ordered more pain medication. On 2/16/23 at 3:00 PM, V2 DON (Director of Nursing) said if the stat X-ray has not been performed within 4 hours the company should be called, and the NP should be called to see if the resident needs to go to the emergency room . On 2/17/23 at 9:30 AM, V11 Hospice CNA (Certified Nursing Assistant) said, on 1/2/23 at 10:00 AM, she saw R4 in a wheelchair. V11 said R4 was grimacing in pain. V11 said R4 refused a shower because she was in too much pain. R4's MAR (Medication Administration Record) shows she had an order for Morphine Sulfate Oral solution 10 mg (milligram)/5 ml (milliliters) and could receive 0.25 ml by mouth (0.5 mg) every 2 hours for pain as needed. R4 had an order for Hydrocodone/Acetaminophen 7.5/325, 1 tablet every 12 hours for moderate to severe pain but it was never dispensed for the length of her stay. R4's Progress notes and MAR (Medication Administration Record) shows the following timeline: On 12/23/22 at 11:25 AM, R4 was admitted to the facility on hospice for long term care placement. On 1/2/23 at 7:54 AM, R4 was found on the floor of her room. V15 did an assessment of R4's injuries and determined R4 had no limitation. R4 was transferred to a wheelchair using a mechanical lift. V15 then notified V9 POA (Power of Attorney), V10 NP, and V2 DON (Director of Nursing). On 1/2/23 at 9:48 AM, R4 was experiencing pain at an 8 on the pain scale (based on the pain scale, where 1 is mild, 5 is moderate, and 10 is the worst pain ever). Morphine was given at a dose of 0.5 mg. On 1/2/23 at 10:37 AM, R4 showed facial grimacing and showing signs of pain, and screaming help me to V15. V15 called V10 in regard to R4'S pain and to see if R4 could get an order for an X-ray. On 1/2/23 at 3:39 PM, R4 was experiencing pain at a 9 on the pain scale. Morphine was given at a dose of 0.5 mg. On 1/2/23 at 5:48 PM, R4 was experiencing pain at a 9 on the pain scale. Morphine was given at a dose of 0.5 mg. On 1/2/23 at 9:42 PM, the X-ray company arrives and X-rays R4's left femur, which showed a left femoral neck fracture. V10 was informed and ordered R4 out to the local emergency room . The time between the X-ray order and when it was performed was 11 hours and 5 minutes. On 1/2/23 at 10:08 PM, R4's hospital documentation shows R4 was complaining of severe pain. On 1/2/23 at 10:21 PM, R4's hospital documentation shows staff gave R4 Morphine 4 mg for pain. On 1/9/23 at 9:29 AM, R4 experienced another fall. On 1/9/23 at 4:00 PM, the Physician ordered morphine sulfate 10 mg every 4 hours (regular scheduled), and morphine 10 mg every 4 hours PRN (as needed for pain). On 1/11/23 at 2:26 PM, R4 had no heart sounds upon auscultation. The DON and hospice were notified, the family was present with R4. R4's 12/26/22 Interim Care plan shows she was a high fall risk. R4's 12/26/22 Morse Fall scale shows a score of 75 which indicates a high fall risk. The 1/2/23 X-ray report shows R4 suffered an acute displaced femoral neck fracture of her left femur. R4's 12/29/22 MDS (Minimum Data Set) shows she needs extensive assistance with the help of 2 people to transfer. R4's 1/2023 POS (Physician Order Sheets) shows her morphine went from 0.5 mg every 2 hours to 10 mg every 4 hours on 1/9/23. R4's 1/7/23 IDT (Interdisciplinary Team) notes shows, the root cause for R4's fall was poor safety awareness related to her dementia and other comorbidities. The intervention will be to keep R4's bed in a low position at all times and frequent reminders to ask for help with getting up. IDT will reassess for effectiveness and update POC (plan of care) as indicated. The Policy and Procedure, Assessing Falls and Their Causes (revised 3/2018) shows, after a fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. 6. Observe for delayed complications of a fall for after an observed or suspected fall and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. A Policy and Procedure was requested for in house, stat X-rays and V2 said the facility doesn't have one.

Based on interview and record review the facility failed to ensure R2 and R3 were free from sexual abuse by R1 and failed to have interventions in place for R1 who had known sexual behaviors. The facility also failed to ensure R4 was free from physical abuse by R1. This applies to 4 of 5 residents (R1, R2, R3, and R4) reviewed for abuse in the sample of 5. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on June 16, 2022, when R1 masturbated in front of R3. The Immediate Jeopardy was identified on June 27, 2022. V1 Administrator was notified of the Immediate Jeopardy on June 29, 2022. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed on June 30, 2022; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. On June 27, 2022, at 11:17 AM, R3 stated, R1 came into her room, stopped in front of her bed, and pulled out his penis. R1 had his penis in his hand and was masturbating. It made me mad. I don't think I did anything to provoke it. R2 (R3's roommate) stated, when this happened, she was in the bathroom, and she heard R3 telling him to leave. When she came out of the bathroom, R3 told her what happened. The facility's IDPH (Illinois Department of Public Health) notification/incident report dated June 20, 2022, shows, Name of resident: R1, Date incident: June 16, 2022, Time of incident: 8:30 PM, Describe what happened: Staff nurse called abuse coordinator and reported resident R2 stated that R1 entered her room, did not touch her or roommate or talk to them but started touching himself . Final Report. R2's progress notes dated June 16, 2022, show, Writer (V8 RN) called V1 administrator to inform him what R2 reported to staff (that R1 came into their room and masturbated in front of R3). R2 stated R1 entered her room at approximately 1930 (7:30 PM). R2 stated she believed R1 began masturbating in front of her . R3's progress notes were reviewed on June 16, 2022, there is no documentation of R1 coming into her room and masturbating in front of her. R1's progress notes dated June 16, 2022, show, CNA (V9 Certified Nursing Assistant) came to writer (V8 RN) at approximately 1930 this evening to report what R2 reported to her. Writer (V8 RN) went to R2's room to speak with her. R2 stated that R1 entered her room and she believed he began masturbating in front of her . On June 27, 2022, at 2:15 PM, V8 Registered Nurse (RN) stated, she was the nurse the night of the incident on June 16, 2022. V9 CNA had come to her and said R3 told her that R1 came into their room, pulled out his penis and began masturbating in front of them (both R2 and R3). When V9 CNA told her about the situation R1 wasn't in the hall and she didn't see him. She went straight down to R2 and R3's room to talk to them. R3 was visibly upset. V8 RN added, she seen R1 masturbating in the TV room before this incident. On June 27, 2022, at 3:24 PM, V9 CNA stated, R1 normally wanders around the unit. She was working by herself that night and saw R1 down by R2 and R3's room. She was busy and continued helping the resident she was with. She heard the call light going off and stopped what she was doing to see what was going on. She was heading towards R2 and R3's room when R3 was coming towards her visibly upset. R3 told her that R1 had come into her room, pulled down his pants, pulled out his penis and started moving it. V9 stated, she sat R3 down and gave her some water. R1 was at the end of the hall by the time V9 made down the hall. V9 took R1 to the dining room and gave him some ice cream while she went to talk to R2. R2 then explained the same thing as her roommate R3 said. She added, that R1 can be very aggressive so she is very careful with him because he will hit her. R1's electronic medical records (EMR) list his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes dated February 13, 2022, show, Staff found patient (R1) masturbating in public area of unit. R1's progress notes dated February 16, 2022, show, NOD (nurse on duty) reports that resident did not sleep last night and continued to be agitated and pacing throughout the halls. This writer (V3 3rd floor manager) contacted psychiatry for potential direct admit due to increasing behaviors. R1's progress notes dated February 16, 2022, show, This writer (V3 3rd floor manager) called psychiatry and had reception page V7 R1's psychiatrist. Orders received and carried out for direct admit to psychiatry hospital due to increased behaviors and aggression . R1's progress notes dated February 16, 2022, show, This writer (V3 3rd floor manager) spoke with intake department at psychiatry hospital who stated they, could not take the patient at this time due to staffing challenges, that with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intake coordinator stated she would contact V7 R1's psychiatrist for update. This writer (V3 3rd floor manager) informed MD (medical doctor) in house for visit and requested that he review for potential medication adjustments for managing behaviors. R1's progress notes dated February 16, 2022, show, This writer (V3 3rd floor manager) informed SSD (social service department) and IDT (interdisciplinary team) of current situation including nursing being aware to maintain frequent checks and send to ER (emergency room ) if unable to redirect for behaviors . This writer requested SSD to consider referral to other facility to manage psych. On June 28, 2022, at 2:24 PM, V10 Social Service Director stated, the facility did not follow through with the referral to another facility because they felt they were managing his behaviors. R1's progress notes by V11 Nurse Practitioner dated February 16, 2022, show, CC (chief complaint): Staff requested for patient to be seen due to aggressive behavior, making sexual advances to residents and playing with himself . Assessment/Plan: 3. Hx (history) of depression with aggressive behavior- [MEDICATION(S)] (anti-psychotic medication) changes to 100 mg (milligram) at bedtime and 50 mg at noon, U/A C & S (urinalysis with culture and sensitivity), CBC (complete blood count), CMP (comprehensive metabolic panel) (both lab draws). 4. Dementia with behavior disturbance- U/A C & S, CBC, CMP, [MEDICATION(S)] changes to 100 mg at bedtime and 50 mg at noon. R1's progress notes dated March 3, 2022, show, Resident in the wrong room. Other resident was upset and both residents started yelling at each other . R1's progress notes dated March 29, 2022, show, Resident has been wandering on unit this shift exhibiting sexually inappropriate behaviors. Sitting in recliner in common area near nurses' station, pulling private parts out of pants. R1's progress notes dated May 7, 2022, show, Patient up walking the halls all night. Patient offered a snack and when the nurse went into the clean utility to find something patient pushed his way through and grabbed a slice of pizza. R1's progress notes dated May 11, 2022, show, Resident observed with penis in his hand in the common area while watching a movie . R1's progress notes dated May 20, 2022, show, Patient was found by staff to be masturbating in common area. When attempted to redirect patient to do activity in private area, became agitated. He stopped for a few seconds and then continued masturbating. Patient was unaccepting of redirection . R1's progress notes dated May 22, 2022, show, Resident observed with penis in hand near nurses' station . On June 27, 2022, at 2:15 PM, V8 RN stated, she did not call R1's physician to inform him of what happened (Incident of June 16,2022). R1's psychiatry progress notes were reviewed from February 21- June 13, 2022, and showed, no mention that masturbation or physical aggression were reported to psychiatry. R1's EMR (Electronic Medical Record) shows, his [CONDITION(S)] medications have not been changed since March 14, 2022. R1's care plan last revised on May 23, 2022, shows, The resident has a behavior problem (sexually inappropriate in public, masturbating in day room) related to dementia with behavioral disturbance. 3/29/22- Wandering and exposing privates in hallway/common areas, 5/21/22- Sexually inappropriate behaviors; AEB (as evidenced by) masturbating in DR (dining room), grabbing food off food cart. Interventions/Tasks: administer medications as ordered. Monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by, Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, provide a program of activities that is of interest and accommodates resident's status. R1's EMR does not show any interventions were put into place for R1's sexual behaviors. On June 27, 2022, at 11:34, V5 CNA stated, R1 masturbates everywhere, all the time. He is a big guy, and he will hit nurses. See how small I am? Depends on his moods. We can only redirect him. They don't do anything. He's always been like this. On June 27, 2022, at 1:16 PM, V3 3rd floor manager confirmed, R1 has sexual behaviors and has been found masturbating. On June 27, 2022, V8 RN and V9 CNA both stated, R2 and R3 are alert and oriented. They both know what is going on with some forgetfulness. On June 28, 2022, at 2:24 PM, V10 Social Service Director stated, confirmed that R1 has sexual behaviors of masturbating in common areas. She stated, they had some interventions in place, but they needed to add more interventions. They had not updated R1's care plan with new interventions as his behaviors were occurring. On June 28, 2022, at 2:52 PM, V2 Director of Nursing confirmed, she was aware of R1's sexual behaviors. She also stated, it is sexual abuse if a resident is masturbating in front of another resident. On June 28, 2022, at 3:07 PM, V11 Nurse Practitioner stated, if the facility had reported sexual or aggressive behaviors, she would make some medication changes and consult psychiatry. If they continued to have the behaviors, she would send them out to the hospital. The Immediate Jeopardy that began on June 16, 2022, was removed on June 30, 2022, when the facility took the following actions to remove the immediacy: Facility will immediately educate all facility employees on the following topics: Abuse policy and procedures: sexual abuse, physical abuse, reporting, deescalating behavior interventions, care plan interventions to address behaviors. Education will start June 29,2022 conducted by the DON/Corporate Nurse Consultant/Nurse Administration. All employees on duty will receive education before their shift ends. The remaining facility employees will be educated prior to their next scheduled shift until 100% of facility employees have been educated. The administration will be at the facility to conduct education at the starting of their shifts. Attending physician saw R1 on June 29, 2022. Primary PCP reviewed medications and made a medication change in an attempt to curb masturbation. Facility auditing current residents for any sexual behaviors and putting interventions in place if needed. Facility updated R1's care plan to include new interventions and will update physician and NP of any new sexual behaviors if they occur. Orders were written and R1 was sent to ER for evaluation. Completion Date: July 2, 2022 The facility quality assurance team which includes Administrator, DON, ADON, medical director, facility directors will meet tomorrow June 30, 2022 to discuss incident and then will meet monthly to review abuse and neglect policies and procedures. DON or Administrator will conduct ongoing audits of any abuse and neglect reports. Observations to ensure compliance once a week for the next 60 days. QAPI will discuss and revise abuse policy as needed through the QAPI process. Facility Administrator and DON will contact facility Social Services Consultant to conduct a facility audit to include identification of any sexual behavior, abuse reports, and review of behavior policies and procedures. Social Service Consultant will be scheduled on a quarterly timeframe on an ongoing basis to ensure compliance. 2. The facility's IDPH (Illinois Department of Public Health) notification/incident report dated April 20, 2022, shows, Date of incident: April 15, 2022. Describe what happened: Resident A and B had altercation while going through a common area . Resident A: R4, Resident B: R1. R4's progress notes dated April 15, 2022, show, Overheard yelling from lounge area. R4 was seen and heard yelling at another patient to leave her alone. The other resident (R1) then struck at R4. R4 stated, that patient (R1) had been tugging on her wheelchair, which she had told him not to do. She then yelled at him. She told him to leave her alone. The other resident then struck at her. R4 stated he did not hit her face, only hit her glasses . R1's progress notes dated April 15, 2022, show, Nurses overheard yelling from the lounge area. R1 was seen tugging on another patient's wheelchair. The other patient (R4) yelled at R1 to leave her alone. R1 was seen slapping at the other resident (R4). When asked what had occurred resident stated, She was hitting me. Patient's accounts contradicts events witnessed by staff . On June 27, 2022, at 3:24 PM, V9 CNA stated, she observed the incident with R1 and R4. R1 came over to R4. R4 didn't want him around her. R1 had something of hers and she wanted it back. R4 said give it back and R1 said no and hit her. He slapped her. On June 28, 2022, at 2:52 PM, V2 Director of Nursing stated, if a resident made contact with another resident, she would consider that physical abuse. R1's care plan last revised on February 18, 2022, shows, R1 has the potential to be physically aggressive related to dementia. 2/16- increased behaviors and aggression, did not sleep last night and continued to be agitated and pacing throughout the halls. Resident attempting to enter the COVID unit, multiple attempts to redirect were made however resident became verbally aggressive and visibly agitated. Resident was observed pacing hallways and making statements of being pissed off- unable to verbalize causative factors- and I will be fine when I get the hell out of here, your people are keeping me here and I'm not staying. The facility's abuse prevention program- policy (no date) show, Abuse prevention policy: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms . The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is also willful infliction injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 C.F.R. & 483.5) . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code & 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior thorough corporal punishment (State Operations Manual, Appendix PP at F600). Sexual abuse is non-consensual sexual contact of any type with a resident. (42 C.F.R. & 483.5).

Based on observation, interview, and record review, the facility failed to provide safety and supervision for a resident recently admitted to the facility with a history of syncopal episodes. This failure resulted in R1 being on the toilet unsupervised, falling off the toilet and sustaining a neck fracture that required surgical repair.This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of three. Findings include: The hospital Physical Therapy Initial Evaluation dated 2/12/22 for R1 showed, High fall risk per nursing assessment. Medical diagnosis: [CONDITION(S)]. Social history: Home situation - lives with spouse. Did you have any falls in the last year? yes. How many times have you fallen in the past 6 months? 2 or more. Describe the fall or injury: fall in the bathtub; lower extremities weak. Clinical impression: R1 .admitted [DATE] for dizziness and fall secondary to possible [CONDITION(S)]. R1 is not currently at baseline functional mobility and presents with a therapy diagnosis of bilateral lower extremity weakness, mobility deficits, gait deficits, balance deficits, decreased safety awareness, decreased activity tolerance and impaired sensation. R1 will benefit from skilled physical therapy to address above impairments to assist with maximizing functional mobility and safety. Recommended disposition: subacute rehabilitation/skilled nursing facility with ongoing physical therapy. R1's Care Plan dated 2/16/22 showed, R1 is a new admission to the facility and presently requires skilled nursing care services. Assess lifestyle patterns and look at ways to help accommodate my needs. R1 has an ADL (activity of daily living) self-care performance deficit related to impaired mobility and comorbidities including: chronic pain, chronic [CONDITION(S)] to the left foot with [CONDITION(S)] Staff will provide the following assistance: transfer - extensive assist; toilet use - extensive assist. R1 is at risk for falls related to impaired mobility, medication that may increase risk for falls and comorbidities Patient will have a safe environment provided Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. 2/23/22 - Staff are to supervise while patient is using the bathroom as will allow. The Nurse Practitioner's Progress Note dated 2/17/22 for R1 showed he was admitted to the facility on [DATE] for physical therapy following surgery to his right and left great toe and left second toe. R1 has a history of low back pain, diabetes mellitus, [CONDITION(S)], [CONDITION(S)] and collapse, weakness, hypertension, [CONDITION(S)], depression, and [CONDITION(S)]. The Health Status Note dated 2/19/21 for R1 showed, Occupational therapy reported to this RN (Registered Nurse) that the patient (R1) was in the bathroom and had [CONDITION(S)] like activity. The Daily Skilled Note dated 2/21/22 for R1 showed he received physical therapy/occupational therapy; required supervision; staff assistance was needed at partial/moderate assistance for walking, transfers, bed mobility, dressing, and toileting. The Health Status Note dated 2/23/22 at 5:53 AM for R1 showed, The CNA (Certified Nursing Assistant) went to check on the patient (R1) in the bathroom, but the patient had fallen off the toilet in a forward motion. R1 stated, I just passed out while I was on the toilet. Small amount of bleeding noted to forehead/nose area, pressure applied, and bleeding stopped almost immediately. The Nursing: Pain assessment dated [DATE] at 5:30 AM for R1 showed he had forehead/neck soreness that was rated as 6/10 on the pain scale and was described as moderate pain post fall to forehead and neck. The Health Status Note dated 2/23/22 at 6:46 AM for R1 showed, Resident sitting in wheelchair in room. Resident states he is having neck pain at 8/10 and states it hurts too bad to hold his own head up. Resident assisted to bed with the head of bed elevated 45 degrees; neck and head supported with pillows. Resident grimacing and jumping due to pain throughout movement. The Health Status Note dated 2/23/22 for R1 showed, 7:15 AM - Resident states his pain remains at 8/10. Resident requesting a cervical collar to support his head and neck. During the conversation the resident began losing consciousness while talking; able to arouse but becoming increasingly lethargic. Nurse practitioner notified of a change in the resident's condition and an order was received to send the resident to the emergency department; 2:45 PM - called the hospital for an update on the resident. The emergency department nurse informed this writer that the resident is being transferred to another hospital related to a neck fracture but was unable to give specifics due to the resident being discharged already; 3:20 PM - This writer contacted the hospital per the other hospital's advisement. Informed that the resident is being admitted to neurotrauma ICU (Intensive Care Unit) room 6 related to a C2 (neck) fracture and will be consulted by neurosurgery shortly. On 3/24/22 at 11:07 AM, V6 CNA (Certified Nursing Assistant) stated, I wasn't present when R1 actually fell . I work 6:00 AM to 2:00 PM. R1 fell right before my shift started and he did complain of neck pain. R1 did ask for a neck brace. V5 RN (Registered Nurse) and I couldn't find any neck brace. It happened so early in the morning. He said he was okay, but his neck was bothering him. On 3/24/22 at 11:17 AM, V7 LPN (Licensed Practical Nurse) stated, If a resident falls, we are to assess them and make sure they are okay. If someone falls and has neck pain, then I don't move them. I get the physician involved to see what they want to do and call 911. I can't just get the resident up and move them. Moving the resident can make it worse. On 3/24/22 at 12:33 PM, V8 NP (Nurse Practitioner) stated she was told R1 was on the toilet, leaned forward and fell . V8 stated V9 LPN called her and said R1 fell , then was up walking around, had some pain but stated he was fine. V8 stated she was told R1 did not have a lot of pain initially or she would have sent him out. V8 stated V5 RN called her and stated R1 was asking for a cervical collar because of pain. V8 stated that she told V5 if R1 was having that much pain then to send him out. On 3/24/22 at 1:03 PM, V3 DON (Director of Nursing) stated, If the resident has a neck injury, then call 911 and send them out. V9 LPN didn't say R1 was having pain. V9 said R1 fell off the toilet, hit his head and he got him up to a chair. V9 said the more R1 sat in the chair the more he complained of pain. I told them to lay R1 in bed and to secure R1's neck. They should have used a cervical collar; they are on the emergency cart. On 3/24/21 at 2:31 PM, V10 (R1's wife) stated, A male nurse called me around 5:00 AM and told me R1 had fallen in the bathroom and complained of neck pain. I got a call later stating R1 still had neck pain, so they were sending him out. R1 hit his head so hard on the floor that there was a tile imprint to his forehead. R1 had a C2 (neck) fracture, they did surgery and C1 and C2 were fused. R1 has never come out of it fully after surgery. R1 could have been paralyzed. R1 had neck surgery the next morning after the fall. He still has a hard padded cervical collar on. They (facility) said five days before R1 had a syncopal episode. They called me so they knew it was a problem. A couple of times when I was there the CNA would wheel R1 into the bathroom and leave him. I told them not to do that because he isn't safe for him to be by himself. R1 has had syncopal episodes before. On 3/24/22 at 3:22 PM, V9 LPN (Licensed Practical Nurse) stated, R1 fell off the toilet in the bathroom. The night CNA helped R1 get up. R1 was standing at the sink. R1 went back to his wheelchair. R1 had neck pain that was more of a soreness. It wasn't while R1 was on the floor, it was after the fact that he had neck pain. R1 complained of neck pain when he was in the wheelchair. It (fall) happened at 5:30 AM and 5:48 AM is when I signed the pain assessment. The facility's Falls and Fall Risk, managing policy (3/2018) showed, Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls include [CONDITION(S)] and other cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, [CONDITION(S)], functional impairments. Medical factors that contribute to the risk of falls include neurological disorders, balance and gait disorders, etc. Resident centered approaches to managing falls and fall risk: The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on interview and record review the facility failed to ensure a resident (R1) was properly identified prior to administering medication to prevent a significant medication error. This failure contributed to R1 developing [CONDITION(S)] requiring emergency medical intervention and hospitalization . This applies to 1 of 3 residents (R1) reviewed for medication errors in the sample of 7. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/26/2021, when the facility failed to administer prescribed opiate medication ([MEDICATION(S)]) to the right resident. R1 was given another residents medication on the morning of 11/26/2021. The Immediate Jeopardy was identified on 11/30/2021.V1 (Administrator) was informed of the Immediate Jeopardy on 12/2/2021 at 8:07 AM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 12/2/2021 however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's face sheet shows he is a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress written on 11/20/2021 by V6 (Licensed Practical Nurse/LPN) shows that R1 is alert and oriented to person, place, time, and situation. R1's physician order summary dated 11/1/2021-11/30/2021 shows R1 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .) ([MEDICATION(S)]-Acetaminophen) Give 10 mg by mouth every 4 hours as needed for pain with an initial start date of 11/23/2021. The same order summary shows there is a second order for the same dosage of [MEDICATION(S)] as needed for moderate to severe pain 6-10 with a start date of 11/24/2021. There is no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's nursing progress notes written by V6 (LPN) on 11/26/2021 at 3:42 PM, show, R1 returned from [CONDITION(S)] stating he feels lightheaded asking for something to eat. Graham crackers and a peanut butter and jelly was given. Approx. 15 minutes later R1 became unresponsive and limp. Was able to get a response with much verbal and tactile stimuli. R1 had a medium green emesis and the NP (Nurse Practitioner) V3 was called and gave orders to watch the resident, and call with any new signs or symptoms. At 4:09 PM, V6 documented in the nursing progress notes that R1 was feeling very warm, a cold cloth was applied to his head and neck. The next note by V6 at 4:15 PM states, Resident unresponsive again. Large emesis. Unable to get a response to any stimuli, color gray. 911 called, taken to a (local community hospital) sister V8 informed. A nursing progress note written by V2 (Director of Nursing/DON) on 11/26/2021 at 10:13 PM, shows that R1 was admitted for [CONDITION(S)]. A Nursing Home to Hospital Transfer Form completed by V2 (DON) on 11/26/2021 at 4:15 PM, shows that R1's usual mental status is alert and oriented and able to follow instructions. R1's hospital records from a local community hospital say, on 11/26/2021 R1 was brought to the emergency department for a [CONDITION(S)] vs. possible opioid overdose due to decreased clearing due to [CONDITION(S)] and possible given wrong medication at rehab facility. The same hospital records also state, This patient's current admission to an acute care setting is essential for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The records give R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The same hospital records show that R1 reported taking 2 tablets of [MEDICATION(S)] on 11/26/2021 instead of 1, and believes it was given by the facility in error. The records show during the course of the hospitalization R1 has had periods of being unstable requiring immediate rapid responses, non- mechanical ventilator support and continued treatments of a [MEDICATION(S)] infusion to reverse opioid overdose. A medication error reported dated 11/30/2021 and completed by V2 (DON) shows that on 11/26/2021 at approximately 5:30 AM, R1 received the wrong medication and was given [MEDICATION(S)] instead of his prescribed [MEDICATION(S)]. On 11/30/2021 at 9:00 AM, V2 (DON) said she was just informed by V3 (Nurse Practitioner/NP) that R1 did have a medication error over the weekend, (which was later identified to be the morning of 11/26/2021). V2 said this is the first time she was notified of this medication error. On 11/30/2021 at 10:00 AM, V2 said the facility has each residents picture in their electronic record and that should be double checked along with the 5 rights (right patient, right dose, right route, right time, right medication) prior to administering medication to residents. On 11/30/2021 at 11:15 AM, V5 (agency Registered Nurse/RN) said that she did in fact make a medication error on the morning of 11/26/2021, just before the 6:00 AM shift change. V5 said she went to give another resident from the assisted living hall (R101) his scheduled [MEDICATION(S)]. She gave him only 1- 100 mg. tablet and when she was signing it out in the narcotic sheet, she realized she was supposed to give him a total of 4- 100 mg. tablets of [MEDICATION(S)]. V5 said she went and got 3 more of the 100 mg. [MEDICATION(S)] tablets (for a total of 300mg) and instead of taking them to R101 she took them to R1 because they have similar names and she got it confused. V5 said she realized soon after she had made this mistake, she felt terrible and called V2 (DON) and V3 (NP) and informed them both. V5 (RN) said V3 (NP) gave orders for her to monitor R1 and call with any changes. On 11/30/2021 at 11:30 AM, V3 (NP) said she was informed about R1's medication error the morning of 11/26/2021. She said she received a text from V5 (RN) saying she switched 2 patients up, was rushing around and made a medication error. V3 (NP) said this was a significant medication error. On 11/30/2021 at 11:51 AM, V6 (LPN) said she was aware that R1 had received a medication error on the morning of 11/26/2021. V6 said after R1 returned from [CONDITION(S)] he became unresponsive, lethargic, and hot, his head was dropped to the side and she had to do sternal rubs to get him to become responsive. V6 said R1 had episodes of vomiting and reported not feeling right. V6 said she wasn't even thinking it could be from the medication error she attributed it to [CONDITION(S)]. V6 said she did notify V8 (R1's POA) of the incident when he was unresponsive and then again when he was sent out to the hospital via 911. On 11/30/2021 at 1:55 PM, V8 said she is the POA for R1 who is her brother. V8 said she had just visited R1 on 11/25/2021 and he was doing well and excited to get physical therapy and return home. V8 said she was notified by V6 (LPN) on 11/26/2021 that R1 had Coded and needed to be sent to the hospital. She said she was never notified that R1 had received [MEDICATION(S)] by mistake, she said the hospital and herself were both under the assumption that R1 was maybe given too much of his prescribed [MEDICATION(S)] by mistake. V8 also said R1 is not doing well in the hospital and she is not sure if he is going to survive. On 11/30/2021 at 2:50 PM, V4 (Pharmacist) said signs of an opiate overdose include loss of consciousness, lethargic, nausea and vomiting. V4 said there is a risk for death with any opiate overdose. On 11/30/2021 at 3:15 PM, V9 (Nephrologist) said he is familiar with R1 and was not aware of the medication error R1 had on 11/26/2021. V9 explained that [MEDICATION(S)] should not be given to residents with poor kidney function, who are receiving [CONDITION(S)] due to the fact it has large volume of distribution and is hard to be dialyzed out of the body. V9 said it makes sense that R1 was okay for hours after the medication error because it takes a while for the medication to build up and break down. He said while R1 was receiving [CONDITION(S)] it was helping his system, but once the [CONDITION(S)] was done the metabolites from the [MEDICATION(S)] would build right back up. V9 stated, One would think 300 mg. of [MEDICATION(S)] for anyone on [CONDITION(S)] would be a huge problem. It is not only possible it is probable that this medication error was the cause of R1 needing hospitalization . V9 also went on to say R1 being treated with [MEDICATION(S)] and responding temporarily, makes sense for an opiate overdose. V9 said an Opiate has the potential to be fatal if a person quits breathing. There was no documentation in R1's medical record of the significant medication error prior to 11/30/2021. The facility policy titled Adverse Consequences and Medication Errors revised in April 2018 states, A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principals of the professional(s) providing services. Examples of medication errors include: a. omission-a drug that is not administered, b. unauthorized drug-a drug is administered without a physician's order, c. wrong dose, d. wrong route of administration, e. wrong dosage form, f. wrong drug, g. wrong time and/or h. failure to follow manufacturer instructions . In the event of a significant medication -related error or adverse consequences, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: a. requiring medication discontinuation or dose modification, b. requiring hospitalization , or extending a hospitalization , c. requiring in disability, d. requiring treatment with a prescription medication, e. resulting in cognitive deterioration or impairment, f. life threatening: and/or resulting in death . The following information is documented in an incident report and in the resident's clinical record: a. factual description of the error or adverse consequences, b. name and time the physician was notified. c. physician's subsequent orders. D. resident condition for 24 to 72 hours or as directed . The Immediate Jeopardy that began on 11/26/2021 was removed on 12/2/2021, when the facility took the following actions to remove the immediacy: 1. All nurses will be educated prior to the start of their shift on the facility process of administering medications using the 5 rights for administering medications initiated on 12/2/21 2. The facility will immediately educate all facility nurses on the medication error policy including reporting/proper notification policy initiated on 12/2/21 3. The facility quality assurance team which includes: Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, Pharmacy Designee and Laboratory Designee will meet on 12/3/2021 to discuss incident and then will meet monthly to review medication administration policies and medication error policy and reporting. 4. Designated nurse administration will conduct on going audits including any medication errors, and medication administration observations to ensure compliance 1 time a week on each shift for the next 60 days. 5. QAPI (Quality Assurance Committee) will discuss, and revise medication policy as needed through the QAPI process. 6. Facility Administrator and Director of Nursing will contact facility pharmacy to conduct a facility audit to include medication administration and medication error policies and procedure. And follow up quarterly.

Based on observation, interview, and record review the facility failed to supervise a resident at high risk of falls to prevent repeated falls. This failure contributed to R1 falling out of bed and sustaining bilateral leg fractures. This applies to 1 of 3 residents (R1) reviewed for falls in the sample 3. The findings include: R1's face sheet shows R1 was admitted to the facility on (MONTH) 22, (YEAR) and has [DIAGNOSES REDACTED]. R1's electronic medical record (EMR) showed that R1 has a moderate cognitive deficit. The EMR showed that R1 had unsteady gait and required extensive assistance of at least one staff for bed mobility, transferring in and out of bed and the wheelchair, and required the use of a walker for additional support to transfer or ambulate. R1's (MONTH) 4, (YEAR) Fall Scale (fall risk assessment), showed that R1 had fallen before, had a weak balance, forgets her limitations, and was a high risk for falls. R1's (MONTH) 10, (YEAR) nursing progress note shows that R1 was exhibiting behaviors of transferring herself in and out of the wheelchair without assistance and becoming combative with staff. R1's (MONTH) 16, (YEAR) nursing progress note shows that R1 was having increasing delusions and she was requesting to move out of the facility. R1's (MONTH) 18, (YEAR) nursing progress note shows that R1 was very confused refused her medications, was being monitored closely in the dining area, and was started on an antibiotic for a urinary tract infect infection. R1's (MONTH) 22, (YEAR) 1:22 PM nursing progress note shows that R1 was stating that she wanted to go home and was given [MEDICATION NAME] (anti- anxiety) medication for anxiety/agitation. R1's (MONTH) 22, (YEAR) 2:20 PM progress notes show that R1 had fallen out of her wheelchair and was observed on the floor in the common area and had sustained a laceration to the left side of her head. R1's progress note shows that the facility's restorative manager was notified of R1's fall. On (MONTH) 13, (YEAR) at 10:10 AM, V17 Registered Nurse (RN) and V18 Licensed Practical Nurse (LPN) stated R1 had been increasingly agitated the week leading up to her fall. R1 had a urinary tract infection, and as a result they were having R1 stay in the dining area for closer supervision and she should not be left alone in her room. V17 stated she called the facility's fall prevention nurse after the fall on (MONTH) 22, (YEAR). On (MONTH) 13, (YEAR) at 11:40 AM, V6 (fall prevention nurse) stated that he was notified of R1's (MONTH) 22, (YEAR) fall and he asked hospice to get R1 a low reclining wheelchair that will help with trunk support. V6 stated that he recommended that R1 be supervised and not left in her room alone if she was awake. R1's (MONTH) 24, (YEAR) 3:24 PM nursing progress notes show that V17 (RN), was called into R1's room by a CNA and, observed patient (R1) lying on her left side on the floor, alert and responding verbally, noted left leg twisted and discolored (2 days after the previous fall). Patient complained of pain to the left leg. Noted resident's bed in the highest position and bed remote on top of the bed . R1's progress note shows 911 was contacted for transport and R1 was sent to a local community hospital. On (MONTH) 13, (YEAR) at 2:15 PM, V17 (RN) stated that before R1 had the change in behaviors R1 would sometimes lay down in the afternoon. During the period when R1 fell between the first and second time R1 was supposed to be monitored and not to be left alone. V17 stated that a hospice CNA had come into the facility and had given R1 a bath that afternoon in her room and left R1 in her room unsupervised. V17 stated as far as I know the hospice CNA knew about R1's behaviors, I don't know what possessed the hospice CNA that day to leave her laying down in bed. I didn't know she was in bed . V17 said she found the resident on the floor with the bed in the highest position and the bed controller dangling on the side of the bed. On (MONTH) 13, (YEAR) at 2:25 PM, V18 (LPN) stated I was so upset that day when she fell , the hospice CNA should have told us she was lying her down. We would have told her not too lay her down because, she (R1) was not taking naps then. She (R1) was too upset and trying to get up on her own . On (MONTH) 13, (YEAR) at 11:40 AM, V6 (fall prevention nurse) stated the hospice CNA should not have left her (R1) alone in her room that day of the fall on (MONTH) 24, (YEAR). V6 said that sometimes when residents have urinary tract infections it can cause them to be even more of a fall risk. On (MONTH) 13, (YEAR) at 12:45 PM, V2 Director of Nursing (DON) said that she was in the building on (MONTH) 24, (YEAR) when R1 had the second fall. V2 said that a hospice CNA had given R1 a bed bath and did not tell anyone that she left R1 alone in bed. V2 said when staff found R1 the bed was raised all the way up and it was not typical of R1 to maneuver the bed remote controller herself. V2 said that R1 had a urinary tract infection and was even more confused in the days prior to the fall. On (MONTH) 13, (YEAR) at 1:45 PM, V19 Certified Nursing Assistant (Hospice CNA) stated that R1 was having issues and was very upset the day of the fall on (MONTH) 24, (YEAR). V19 said she gave R1 a bath and left her in her room alone in bed with the bed remote controller out of R1's reach. V19 stated that she was unaware that R1 was not supposed to be in her room alone. R1's (MONTH) 24, (YEAR) History and Physical (H&P) from a local community hospital showed that R1 presented to the emergency room (ER) after a fall for evaluation. R1 was noted to have bilateral femur fractures, and orthopedics was consulted. R1 was sent to the operating room for a surgical procedure. The H&P showed that the facility reported to them, The patient (R1) fell out of her bed while it was at the highest position . The H&P showed that (R1's) Prognosis is poor and guarded. R1's (MONTH) 24, (YEAR) Radiology report showed R1 was admitted to the hospital following a fall from bed, at a nursing facility and had distal femur fractures to both of her legs. The report showed Markedly comminuted (break or splinter of the bone into more than two fragments) and angulated (the normal position of the bone has been altered) as well as displaced (the bone breaks and moves so that the two ends are not lined up straight), and mildly impacted [MEDICAL CONDITION] distal femur . and comminuted, displaced and angulated [MEDICAL CONDITION] distal femur . R1's care plan shows that R1 was a high risk for falls. R1's Care Plan shows that on (MONTH) 22, (YEAR) an intervention was added to keep R1 in a highly visible area when awake in chair. R1's care plan shows that a floor mat, and room checks every 30-60 minutes, were not added until (MONTH) 24, (YEAR). R1's Care Plan shows that on (MONTH) 2, (YEAR) (9 days after R1's first fall), and after R1's second fall, an intervention was added to not leave resident alone in room while awake. R1's nursing progress notes show that R1 returned to the facility on (MONTH) 1, (YEAR) and is now not able to bear weight, and requires the use of a mechanical lift for all transfers.

Based on interview and record review the facility failed to follow their Change in Resident Condition or Status policy. This failure resulted in the facility failing to immediately notify the physician of a significant change in condition for one of 3 residents (R1) who subsequently expired. This past non-compliance occurred from [DATE] to [DATE]. This applies to 1 of 3 residents (R1) reviewed for physician notification in the sample of 8. These failures resulted in an Immediate Jeopardy which was identified to have begun on [DATE] when R1 returned from the local emergency roiagnom on [DATE] at 12:30 PM non verbal and lethargic with an oxygen saturation of 83%. The findings include: R1's Physician order [REDACTED]. R1's physician orders [REDACTED]. Continued 2 liters of oxygen with Bilevel Positive Airway Pressure machine. Monitor oxygen saturations every shift for oxygen monitoring related to acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION]. Oxygen at 2 liters per minute per nasal cannula as needed for oxygen saturation levels less than 88%. R1's MDS- Minimum Data Set, dated dated dated [DATE], shows R1 requires the use of [MEDICAL CONDITION]. R1's Care Plan for heart failure initiated on [DATE] shows interventions to include: monitor and document labored breathing, monitor vital signs and notify physician of significant abnormalities. R1's Care Plan for [MEDICAL CONDITION] and [MEDICAL CONDITION] initiated on February 23, 2017 shows interventions to include head of bed to be elevated, monitor for difficulty breathing, monitor for signs and symptoms of acute respiratory insufficiency, anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence and oxygen via nasal cannula per physician orders. R1's State of Illinois Do Not Resuscitate/Practitioner Orders for Life Sustaining Treatment (POLST) form dated [DATE], shows R1 elected attempt resuscitation/ cardiopulmonary resuscitation (CPR) if the patient has no pulse and is not breathing. The form was signed by R1 and a physician. R1's Nurse's Note dated [DATE], showed, at 6:45AM R1 was transported to local hospital per ambulance stretcher. R1 had called 911. This reporter (E3- Licensed Practical Nurse-LPN) received report from off going nurse stating R1 was in an anxious state and called son/POA (Power of Attorney) when assessed and oxygen saturations were at 85%, stating she needed to go to the hospital . R1's POA/daughter called and aware R1 called 911 and transported to local hospital via ambulance . The local ambulance run sheet dated [DATE], shows R1was transported from a local hospital to the facility. E3 signed for R1's acceptance at 12:29 PM. R1 was unable to sign due to altered mental status. The ambulance run report shows at 12:05 PM, R1's assessment showed R1's airway was partially obstructed by her tongue, her breathing was labored. R1 was confused/disoriented and had decreased consciousness. The report shows at 12:07 PM, R1's respirations were 21 breaths per minute and were labored and regularly irregular. Her oxygenation level was 95 % supplemented by oxygen. R1 was sleeping throughout the transport with some snoring and bilateral wheezing recorded. R1's Nurse Note dated [DATE] at 12:30 PM, showed R1 returned to facility per ambulance transporter and stretcher. R1 leaning to the left on stretcher and transporters made aware and this reporter (E3) was told she will be alright. Transporters then requested assistance to transfer resident from stretcher to bed and it was noted R1 had white frothy sputum in and around mouth as well as right eye bulging out and R1 was not focusing. Vital signs were blood pressure ,[DATE], pulse 48, and oxygen saturation 83%. R1 remained nonverbal. R1's right arm was cold to touch. R1's temperature was 98.7 degrees Fahrenheit. R1's [MEDICAL CONDITION] was applied to resident lying in bed. E3 did not notify R1's physician of R1's oxygen saturation of 83%. On [DATE] at 10:58 AM, E3 stated R1 had a history of [REDACTED]. E3 stated R1 had anxiety medication that was given as needed when R1 was having anxiety. R1 was having more anxiety recently and was encouraged to use her anxiety medication. R1 was on a small dose because the nurse practitioner said larger doses of anxiety medications would make her oxygen intake unstable. E3 stated on [DATE], she was receiving report from E6 (LPN) the night nurse around 6:00 AM. E6 reported that R1 was upset and was calling her son and 911 because she wanted to go out to the hospital. The nurse's phone rang and it was 911 dispatcher calling to see if they should come and pick up R1. E3 stated she told them to come and take her to the hospital. E3 made copies of her medication sheets and face sheet and R1 left the facility around 6:,[DATE]:50 AM. E3 stated Z3 (Family member) called her and told her R1 would be returning to the facility. The emergency room gave her [MEDICATION NAME] 1 mg and her blood pressure medications. E3 said I thought that was a lot for R1 (Anxiety medication). R1 returned to the facility around 12:30 PM via cart and ambulance. R1's arm was hanging off the cart. E3 asked, is she okay?'. The transporter responded yes. E3 stated R1 looked zonked to her and thought they should not have returned R1 to the facility. E3 went down and assisted with the transfer. E3 put on R1's [MEDICAL CONDITION] with oxygen. R1 was restless in the bed so E3 placed her motorized scooter next to the bed so she wouldn't fall out. E3 did not call the physician with the change of R1's responsiveness. E3 stated she left the room around 1:20 PM to continue her medication pass. At around 1:30- 1:35 PM, E3 stated she went to check on R1. Her oxygenation level was 83%. R1 was not responding. E3 stated she took off R1's mask to check if she was breathing, she was. E3 stated, She had me scared. E3 put R1's mask on. E3 went out to the hall saw E4 (LPN) and yelled for her to come down. E3 still did not call the physician. E3 said she told E4 and E5(Registered Nurse-RN) she was a DNR. E5 said R1 was gone. E3 said she then went to the nurses' station to call the family. E3 stated when she opened the chart she saw that R1 was a full code. E3 said she was already gone and she did not go back down to R1's room. E3 still did not call the physician. I called R1's daughter. E3 stated no one called a code or performed CPR on R1. E3 stated she did not call the on call physician until after R1 had expired as part of the people that needed to be notified. E3 stated she should have sent R1 back to the emergency room when she first came back or have called the on call to get an order to send her back. On [DATE] at 1:47 PM, E4 stated she had just come onto the unit on [DATE] around 1:40 PM when E3 asked her to come and look at R1. E4 stated she lifted R1's [MEDICAL CONDITION] mask and saw white frothy substance around her mouth. E3 had the pulse oximetry on and it was not registering. E5(Registered Nurse) came into the room. R1 had no pulse, or heart tones her eyes were fixed and dilated. E5(Registered Nurse) pronounced her dead. On [DATE] at 3:15 PM, E5 stated she was called to R1's room on [DATE] by E3. R1 looked like she was sleeping. E5 stated she called R1's name shook her and gave her a sternal rub. There were no respirations or radial pulse. R1's tongue and lips were ashen. E5 asked what R1's code status was. Someone said I think she is a full code. E5 said she was already gone. On [DATE] at 11:03 PM, E10 (Certified Nursing Assisitant-CNA) stated R1 didn't look right to her when she returned from the hospital and questioned E3 if R1 was okay. On [DATE] at 9:20 AM, E1 (Administrator) and E2 (Director of Nursing) were interviewed regarding the incident with R1 on [DATE]. They said R1 went to the hospital. R1 was having some shortness of breath and called her family. R1 called 911. R1 was brought to local emergency room and came back to the facility around 12:,[DATE]:00 PM. About an hour later R1 expired. R1 was assessed in the emergency room with anxiety disorder and was given [MEDICATION NAME] 1 mg. R1 was sent back to the facility. The nurse receiving E3 said she looked overmedicated. When E3 went back to check on her she was lethargic and difficult to arouse. Around 12:30 PM, E3 assessed R1. R1 could barely talk. R1's usual anxiety medication dose was 0.125mg. E3 was concerned. Her oxygen saturations were in the 80's. Around 1:00PM, E3 checked on R1, and R1 was lethargic. Around 1:45 PM, E3 went to check on R1. R1 was unresponsive and looked like she was gone. E3 called in another nurse E5. E1 and E2 stated E3 should have notified the physician of R1's condition when she returned from the emergency room if she felt R1 was overmedicated. On [DATE] at 1:32 PM, Z1 (Nurse practitioner) stated R1 had [MEDICAL CONDITION] and required the use of oxygen. R1 was a CO2 retainer (retains carbon [MEDICATION NAME]) and when she was given benzodiazepines ([MEDICATION NAME]) it would interfere with her breathing and cause respiratory depression. R1 was weaned from scheduled to a low dose of as needed benzo's so she would not retain CO2. Z1 stated R1 required the use of a [MEDICAL CONDITION] machine when she slept at night and with naps during the day. Z1 stated she was on call for the facility on [DATE]. Z1 stated she was familiar with the incident involving R1. Z1 stated when R1 was starting to have respiratory distress she or 911 should have been called. On [DATE] at 12:42 PM, Z2 (Medical Director) stated the facility should have notified R1's physician when her oxygen saturation was 83% on the [MEDICAL CONDITION] machine. On [DATE] at 1:39 PM, E9 (Unit Manager) stated E3 should not have accepted R1 back from the emergency room . E3 should have notified the on call physician and reported the overmedication and R1's oxygenation level of 83% on [MEDICAL CONDITION]. On [DATE] at 12:05 PM, E2 and E11 (Corporate Nurse) said E3 should have called the physician and informed them of R1's condition upon return to the facility. E3 should have called the physician when R1's pulse oximetry was 83% on [MEDICAL CONDITION]. R1's Nurse Note dated [DATE] at 3:45 PM, R1 was pronounced dead at 1:45 PM by E5. R1 was non verbal, non responsive and no vitals. The facility's Change in Resident Condition or Status dated [DATE], shows, the nurse supervisor/charge nurse will notify the residents attending physician or on call physician when there has been .c). reaction to a medication; d) a significant change in the resident's physical/emotional or mental condition; e) a need to alter the resident's medical treatment significantly (that is a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . 2) A significant change in condition is a decline or improvement in the resident's status that: a) will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The Immediate Jeopardy began on [DATE] when R1 returned from the local emergency roiagnom on [DATE] at 12:30 PM non verbal and lethargic with an oxygen saturation of 83%. R1 expired on [DATE] at 1:45 PM. On [DATE] at 2:25 PM, E1 (Administrator), E2 (Director of Nursing) and E12 (Assistant Administrator) were informed of the Immediate Jeopardy. On [DATE] the surveyor determined through observation, interview, and record review, the facility took the following action to remove the Immediacy: 1. On [DATE], nursing staff was in serviced on change of condition and physician notification; documentation on admission, transfer and discharge. Nursing staff was not allowed to work until they received the in services. Training was completed [DATE]. 2. On [DATE], E3 and E5 were instructed by E2 on admission process, change in condition assessment and physician notification; Code blue and DNR policy; and documentation of assessment. On [DATE], E3 and E5 were recertified in CPR. 3. On [DATE], the facility held a quality assurance meeting. Mandatory in services were completed on change of condition and assessments. The change in condition audits were completed. The quality assurance committee will review ongoing audits of change in condition monthly.

Based on interview and record review the facility neglected to follow its change in condition policy by failing to notify the physician when R1's oxygen saturation was 83% on Continuous Positive Airway Pressure machine; failed to notify the physician when R1 was unresponsive after experiencing a decline in oxygen saturation and failed to notify the physician when R1 had no vital signs. The facility neglected to follow its policies on emergency procedures and calling a code blue by failing to call a code blue when R1 became unresponsive. The facility neglected to follow its policies on emergency procedures and Cardiopulmonary Resuscitation (CPR) by failing to initiate CPR on R1 per R1's POLST (Physician order [REDACTED]. This failure applies to 1 of 3 residents (R1) reviewed for emergency procedures in the sample of 8. These failures resulted in Immediate Jeopardy which was identified to have begun on [DATE] when the facility failed to follow change in condition policy, emergency procedures, and failure to follow POLST for R1 and R1 expired The findings include: The facility's Change in Resident Condition or Status dated [DATE], shows, the nurse supervisor/charge nurse will notify the residents attending physician or on call physician when there has been .c). reaction to a medication; d) a significant change in the resident's physical/emotional or mental condition; e) a need to alter the resident's medical treatment significantly (that is a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . 2) A significant change in condition is a decline or improvement in the resident's status that: a) will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. On [DATE] at 11:03 PM, E10 (Certified Nursing Assistant- CNA) stated on [DATE] around 6:20 AM there were fire trucks and an ambulance at the facility. E10 stated she saw the paramedics taking R1 out of her room via a stretcher. She was on the cart with her mask on and said, There goes E3 (LPN-Licensed Practical Nurse) right there. R1 was alert. E10 stated the next time she saw R1 was around lunch time when she came back from the hospital. E10 stated R1 was not alert or talking. E10 said she didn't look right and I asked E3 if she was okay and E3 asked the paramedics if she was okay and he said she's fine. The local ambulance run sheet dated [DATE], shows R1was transported from a local hospital to the facility. .The crew was told by the nurse that (R1) was brought in following what the doctor believed was an anxiety attack. (R1) was given 1 milligram of [MEDICATION NAME] in the hospital and was ready for discharge back to the facility. (R1) was very lethargic and per hospital request was placed in soft restraints for the transport . E3 signed for R1's acceptance at 12:29 PM. R1 was unable to sign due to altered mental status. The report shows at 12:05 PM, R1's assessment was her airway was partially obstructed by her tongue, her breathing was labored. R1 was confused/disoriented and had decreased consciousness. The report shows at 12:07 PM, R1's respirations were 21 breaths per minute and were labored and regularly irregular and her oxygenation level was 95 % supplemented by oxygen. R1 was sleeping throughout the transport with some snoring and bilateral wheezing recorded. On [DATE] at 10:58 AM, E3 stated R1 had a history of [REDACTED]. E3 stated R1 had anxiety medication that was given as needed when R1 was having anxiety. R1 was having more anxiety recently and was encouraged to use her anxiety medication. R1 was on a small dose because the nurse practitioner said larger doses of anxiety medications would make her oxygen intake unstable. E3 stated on [DATE], Z3 (Family member) called her and told her R1 would be returning to the facility. The emergency room gave her [MEDICATION NAME] 1 mg and her blood pressure medications. E3 said I thought that was a lot for R1 (Anxiety medication). R1 returned to the facility around 12:30 PM via cart and ambulance. R1's arm was hanging off the cart. E3 asked, is she okay?'. The transporter responded yes. E3 stated R1 looked zonked to her and thought they should not have returned R1 to the facility. The ambulance personnel took R1 to her room. E3 went down and assisted with the transfer to the bed. E3 put on R1's [MEDICAL CONDITION] with oxygen. R1 was restless in the bed. E3 stated she did not call the on call physician and report R1's overmedication. I just monitored her. E3 stated she should have sent R1 back to the emergency room when she first came back or have called the on call physician to get an order to send her back. R1's Nurse Note dated [DATE] at 12:30 PM, R1 returned to facility per ambulance transporter and stretcher. R1 was leaning to the left on stretcher and transporters made aware and this reporter (E3) was told she will be alright. Transporters then requested assistance to transfer resident from stretcher to bed and it was noted R1 had white frothy sputum in and around mouth as well as right eye bulging out and R1 was not focusing. Vital signs were blood pressure ,[DATE], pulse 48, and oxygen saturation 83%. R1 remained nonverbal. R1's right arm was cold to touch. R1's temperature was 98.7 degrees Fahrenheit. R1's [MEDICAL CONDITION] was applied to resident lying in bed. On [DATE] at 1:39 PM, E9 (Unit Manager) stated E3 should not have accepted R1 back from the emergency room . E3 should have notified the on call physician and reported the overmedication and R1's oxygenation level of 83% on [MEDICAL CONDITION]. E3 should have increased R1's oxygen. On [DATE] at 12:05 PM, E2 (Director of Nursing) and E11 (Corporate Nurse) were interviewed. E2 and E11 said E3 should have called the physician and informed them of R1's condition upon return to the facility. E3 should have called the physician when R1's pulse oximetry was 83% on [MEDICAL CONDITION]. On [DATE] at 9:20 AM, E1(Administrator) and E2 stated E3 should have notified the physician of R1's condition when she returned from the emergency room if she felt R1 was overmedicated. On [DATE] at 1:32 PM, Z1 (Nurse practitioner) stated she was on call for the facility on [DATE]. Z1 stated when R1 was starting to have respiratory distress she or 911 should have been called. On [DATE] at 12:42 PM, Z2 (Medical Director) stated the facility should have notified R1's physician when her oxygen saturation was 83% on the [MEDICAL CONDITION] machine. The facility's policy dated [DATE] for Emergency Procedure-Cardiopulmonary Resuscitation, shows if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that prohibits CPR and/or external defibrillation exists or b) there are obvious signs of irreversible death (e.g. Rigor mortis). The facility's Code Blue/Medical Emergency Protocol dated [DATE], shows When code blue is paged, make sure to say code blue and location 3 times. Call 911. Code blue will be initiated wherever resident is found .If a resident is unresponsive, initiate CPR following the American Heart Guidelines per resident's code status . Bring crash cart to the location . On [DATE] at 10:58 AM, E3 stated at around1:30- 1:35 PM she went to check on R1. Her oxygenation level was 83%. R1 was not responding. E3 stated she took off R1's mask to check if she was breathing, she was. E3 stated, She had me scared. E3 put R1's mask on. E3 went out to the hall saw E4 (LPN) and yell for her to come down. E4 came down and then left to go punch in. I yelled for E4 and E5 (RN-Registered Nurse) to come down to R1's room. E3 stated she asked E5 to assess R1. E3 said someone asked what R1's code status was. I checked the computer on my medication cart and it wasn't listed. I remembered I had a report sheet and it listed her as DNR. E3 said she told E4 and E5 she was a DNR. E5 said R1 was gone. E3 said she then went to the nurses' station to call the family. E3 stated when she opened the chart she saw that R1 was a FULL CODE. E3 said she was already gone and she did not go back down to R1's room. I called R1's daughter. E3 stated no one called a code or performed CPR on R1. E3 stated she should have called a CODE BLUE when R1 was unresponsive. On [DATE] at 12:05 PM, E2 and E11 said E3 should have called the physician and informed them of R1's condition upon return to the facility. E3 should have called the physician when R1's pulse oximetry was 83% on [MEDICAL CONDITION]. E3 should have called a code when R1 became unresponsive. R1 was a full code and CPR should have been started and a code called. On [DATE] at 1:32 PM, Z1 stated, When R1 was starting to have respiratory distress she or 911 should have been called. The facility should have called a code and started CPR when R1 was found not to have a pulse. On [DATE] at 12:42 PM, Z2 stated a resident that has designated a FULL CODE status should have CPR started when there are no pulse or respirations. The facility should call 911 and call a CODE BLUE. Z2 stated the facility should have called 911 and started CPR on R1 when they determined she did not have a pulse. On [DATE] at 1:39 PM, E9 stated E3 should have called a code when R1 was unresponsive. R1 was a full code and a code should have been called and CPR done. R1 should have been hooked up to the AED machine to see if there was a rhythm. On [DATE] at 9:20 AM, E1 and E2 stated if a resident is a full code and is found with no pulse, CPR is to be started and a CODE BLUE called house wide three times with the location. Staff is to bring the crash cart, AED-Automated External Defibrillator and call 911. CPR is done until EMS arrives and takes over. E1 and E2 were asked if the protocol was followed for R1. E1 said nothing. E2 said no. The Immediate Jeopardy began on [DATE] when R1 returned from emergency room visit at 12:30 PM. The facility staff did not follow their procedures to notify the physician of a significant change in condition when R1's pulse oximetry was only 83% and failed to follow the facility's emergency procedures for a resident who was a full code when she had no vital signs. On [DATE] at 2:25 PM, E1 (Administrator), E2 (Director of Nursing) and E12 (Assistant administrator) were informed of the Immediate Jeopardy. On [DATE] the surveyor determined through observation, interview, and record review, the facility took the following action to remove the Immediacy: 1. On [DATE], E3 and E5 were instructed by E2 on admission process, change in condition assessment and physician notification; Code blue and DNR policy; and documentation of assessment. On [DATE], E3 and E5 were recertified in CPR. 2. On [DATE], nursing staff was in serviced on Code Blue policy; change of condition and physician notification; documentation on admission, transfer and discharge; DNR/ POLST (physician orders [REDACTED]. Nursing staff was not allowed to work until they received the in services. Training was completed [DATE]. 3. On [DATE], a Code Blue Drill was conducted on the evening shift. Code Blue drills were conducted daily for one week. The facility is conducting weekly code blue drills for two months. 4. On [DATE] the facility conducted an audit to ensure all licensed nursing staff had current CPR certification. CPR classes were conducted on [DATE] and [DATE] and ongoing. 5. An audit of all resident clinical records was initiated on [DATE] to ensure all code status is clearly documented and easily accessible. On [DATE] at 9:30 AM, E13 (Social Services) stated all of the resident's charts were reviewed to ensure the code status sticker on the chart matched the resident's POLST. This was completed [DATE]. 6. On [DATE], the facility held a quality assurance meeting. Mandatory in services were completed on DNR/POLST, Code Blue policy and procedure, change of condition and assessments. An in house audit was completed to identify residents with full code status. Human resources completed an audit of nurses with CPR and classes were offered to ensure in house nurse have CPR certification and ongoing classes will be offered. A crash cart audit was done and audits to be ongoing. Code Blue drills were conducted and will be ongoing. The change in condition audits were completed. The quality assurance committee will review ongoing audits at its monthly meeting.

Based on interview and record review the facility failed to monitor, assesses and promptly intervene when a significant change in condition occurred. The facility failed to notify EMS-Emergency Medical Services of a resident who had significantly declined. The facility failed to initiate cardiopulmonary resuscitation (CPR) per advanced directives when a resident (R1) had no vital signs or respirations for one of 8 residents (R1) who subsequently expired. This past non-compliance occurred from [DATE] to [DATE]. This applies to 1 of 8 residents (R1) reviewed for advanced directives in the sample of 8. These failures resulted in an Immediate Jeopardy which was identified to have begun when R1 returned from a local hospital at 12:30 PM on [DATE] where she received anti-anxiety medication for an anxiety disorder, the residents oxygen saturations were 83% with the assistance of a [MEDICAL CONDITION] machine (Continuous Positive Airway Pressure machine). The resident became unresponsive and no vital signs. No interventions were initiated & the facility did not initiate cardiopulmonary resuscitation on a resident who was a full code. The findings include: R1's Physician order [REDACTED]. R1's physician orders [REDACTED]. Continued 2 liters of oxygen with Bilevel Positive Airway Pressure machine. Monitor oxygen saturations every shift for oxygen monitoring related to acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION]. Oxygen at 2 liters per minute per nasal cannula as needed for oxygen saturation levels less than 88%. R1's MDS- Minimum Data Set, dated dated dated [DATE], shows R1 requires the use of [MEDICAL CONDITION]. R1's Care Plan for heart failure initiated on [DATE] shows interventions to include: monitor and document labored breathing, monitor vital signs and notify physician of significant abnormalities. R1's Care Plan for [MEDICAL CONDITION] and [MEDICAL CONDITION] initiated on February 23, 2017 shows interventions to include head of bed to be elevated, monitor for difficulty breathing, monitor for signs and symptoms of acute respiratory insufficiency, anxiety, confusion, restlessness, shortness of breath at rest, cyanosis and somnolence and oxygen via nasal cannula per physician orders. R1's State of Illinois Do Not Resuscitate/Practitioner Orders for Life Sustaining Treatment (POLST) form dated [DATE], shows R1 elected attempt resuscitation/CPR if the patient has no pulse and is not breathing. The form was signed by R1 and a physician. R1's Nurse's Note dated [DATE], showed at 6:45AM, R1 was transported to local hospital per ambulance stretcher. R1 had called 911. This reporter (E3- Licensed practical Nurse-LPN) received report from off going nurse stating R1 was in an anxious state and called son/POA (Power of Attorney) when assessed and oxygen saturations were at 85%, stating she needed to go to the hospital. R1 encouraged to raise her head of bed and resident declined repositioning. POA/daughter was called aware R1 called 911 and transported to local hospital via ambulance. The face sheet and medication information with ambulance. Attempted to call unit manager no response message left. The director of nurses was notified. The local ambulance run sheet dated [DATE], shows R1was transported from a local hospital to the facility. . (R1) was very lethargic and per hospital request was placed in soft restraints for the transport. (R1) was secured x five with no complications . (R1) was transferred x 3 from the stretcher to the bed with no complications . E3 signed for R1's acceptance at 12:29 PM. R1 was unable to sign due to altered mental status. The run report shows at 12:05 PM, R1's assessment was her airway was partially obstructed by her tongue, her breathing was labored. R1 was confused/disoriented and had decreased consciousness. The report shows at 12:07 PM, R1's pulse was 98 and strong, her blood pressure was ,[DATE], her respirations were 21 breaths per minute and were labored and regularly irregular and her oxygenation level was 95 % supplemented by oxygen. R1 was sleeping throughout the transport with some snoring and bilateral wheezing recorded. R1's Nurse Note dated [DATE] at 12:30 PM, showed R1 returned to facility per ambulance transporter and stretcher. R1 leaning to the left on stretcher and transporters made aware and this reporter (E3) was told she will be alright. Transporters then requested assistance to transfer resident from stretcher to bed and it was noted R1 had white frothy sputum in and around mouth as well as right eye bulging out and R1 was not focusing. Vital signs were blood pressure ,[DATE], pulse 48, and oxygen saturation 83%. R1 remained nonverbal. R1's right arm was cold to touch. R1's temperature was 98.7 degrees Fahrenheit. R1's [MEDICAL CONDITION] was applied to resident lying in bed. On [DATE] at 10:58 AM, E3 stated R1 had a history of [REDACTED]. E3 stated R1 had anxiety medication that was given as needed when R1 was having anxiety. R1 was having more anxiety recently and was encouraged to use her anxiety medication. R1 was on a small dose because the nurse practitioner said larger doses of anxiety medications would make her oxygen intake unstable. E3 stated on [DATE], she was receiving report from E6 (LPN) the night nurse. E6 reported that R1 was upset and was calling her son and 911 because she wanted to go out to the hospital. The nurse's phone rang and it was 911 dispatcher calling to see if they should come and pick up R1.R1 left the facility for the hospital around 6:,[DATE]:50 AM. E3 stated Z3 (Family member) called her and told her R1 would be returning to the facility. The emergency room gave her [MEDICATION NAME] 1 mg and her blood pressure medications. E3 said I thought that was a lot for R1 (Anxiety medication). R1 returned to the facility around 12:30 PM via cart and ambulance. R1's arm was hanging off the cart. E3 asked, is she okay?'. The transporter responded yes. E3 stated R1 looked zonked to her and thought they should not have returned R1 to the facility. R1 was restless in the bed. E3 stated she left the room around 1:20 PM to continue her medication pass. At around 1:30- 1:35 PM, E3 stated she went to check on R1. Her oxygenation level was 83%. R1 was not responding. E3 stated she took off R1's mask to check if she was breathing, she was. E3 stated, She had me scared. E3 put R1's mask on. E3 went out to the hall saw E4 (LPN) and yell for her to come down. E4 came down and then left to go punch in. E3 stated a few minutes went by and she yelled for E4 and E5 (RN-Registered Nurse) to come down to R1's room. E3 stated she asked E5 to assess R1. E3 said someone asked what R1's code status was. I checked the computer on my medication cart and it wasn't listed. I remembered I had a report sheet and it listed her as DNR. E3 said she told E4 and E5 she was a DNR. E5 said R1 was gone. E3 said she then went to the nurses' station to call the family. E3 stated when she open the chart she saw that R1 was a FULL CODE. E3 said she was already gone and she did not go back down to R1's room. I called R1's daughter.E3 stated no one called a code or performed CPR on R1. E3 stated she did not call the on call physician until after R1 had expired. E3 stated she should have sent R1 back to the emergency room when she first came back or have called the on call to get an order to send her back. E3 stated she should have called a CODE BLUE when R1 was unresponsive. On [DATE] at 1:47 PM, E4 stated she had just come onto the unit on [DATE] around 1:40 PM when E3 asked her to come and look at R1. E4 stated she lifted R1's [MEDICAL CONDITION] mask and saw white frothy substance around her mouth. E4 left the room and ran down to the nurses' station to punch in and check R1's code status. R1 was a full code. E4 went back to the room. E3 had the pulse oximetry on and it was not registering. E5 came into the room. R1 had no pulse, or heart tones her eyes were fixed and dilated. E5 pronounced her dead. E4 stated no CPR was done. E4 stated if a resident is already gone you don't do CPR regardless of their code status. On [DATE] at 3:15 PM, E5 stated she was called to R1's room on [DATE] by E3. R1 looked like she was sleeping. E5 stated she called R1's name shook her and gave her a sternal rub. There were no respirations or radial pulse. R1's tongue and lips were ashen. E5 asked what R1's code status was. Someone said I think she is a full code. E5 said she was already gone. E5 said no code was called and no CPR was initiated. E5 stated if a resident is a full code you should start CPR. She was dead so we didn't. E5 was asked how long R1 had been dead. E5 stated she had no idea. On [DATE] at 11:03 PM, E10 (CNA-Certified Nursing Assistant) stated around 6:20 AM on [DATE], she saw the paramedics taking R1 out of her room via stretcher. She was on the cart with her mask on and said, There goes E3 right there. R1 was alert. E10 stated the next time she saw R1 was around lunch time when she came back from the hospital. E10 stated R1 was not alert or talking. E10 said she didn't look right and I asked E3 if she was okay and E3 asked the paramedics if she was okay and he said she's fine. E10 said she never heard a code paged. E10 she heard R1 had passed between 1:30 and 2:00 PM. On [DATE], at 11:58 AM, E7(CNA) stated during lunch on [DATE] around 12:30- 12:45 PM, E3, E8 E7 stated she and E8(CNA) assisted E3 with R1's repositioning. R1 had her [MEDICAL CONDITION] on and wasn't talking and was a little sedated. E7 stated she did not see R1 again. On [DATE] at 9:20 AM, E1 (Administrator) and E2 (Director of Nursing) were interviewed regarding the incident with R1 on [DATE]. They said R1 went to the hospital. R1 was having some shortness of breath and called her family. R1 called 911. R1 was brought to local emergency room and came back to the facility around 12:,[DATE]:00 PM. About an hour later R1 expired. R1 was assessed in the emergency room with anxiety disorder and was given [MEDICATION NAME] 1 mg. R1 was sent back to the facility. The nurse receiving E3 said she looked overmedicated. When E3 went back to check on her she was lethargic and difficult to arouse. Around 12:30 PM, E3 assessed R1. R1 could barely talk. R1's usual anxiety medication dose was 0.125mg. E3 was concerned because R1's oxygen saturations were in the 80's. R1's [MEDICAL CONDITION] was placed. Around 1:00PM, E3 checked on R1 and there was no change in vitals and R1 was still lethargic. Around 1:45 PM, E3 went to check on R1. R1 was unresponsive, looked like she was gone. E3 called in another nurse E5. E5 said she was already expired. E1 and E2 asked E3 and E5 if they checked the code status. E3 said she thought R1 was a DNR because her report sheet indicated DNR. E5 said she was a full code. E2 asked if CPR was performed. They said no she was already gone so no CPR was performed. E1 and E2 stated if a resident is a full code and is found with no pulse, CPR is to be started and a CODE BLUE called house wide three times with the location. Staff is to bring the crash cart, AED-Automated External Defibrillator and call 911. CPR is done until EMS arrives and takes over. E1 and E2 were asked if the protocol was followed for R1. E1 said nothing. E2 said no. E1 and E2 stated E3 and E5 were certified in CPR. E1 and E2 stated E3 should have notified the physician of R1's condition when she returned from the emergency room if she felt R1 was overmedicated. E2 stated the old report sheet was not a valid way to check the code status and the report sheets were removed and replaced with new report sheets. On [DATE] at 1:32 PM, Z1 (Nurse practitioner) stated R1 had [MEDICAL CONDITION] and required the use of oxygen. R1 was a CO2 retainer (retains carbon [MEDICATION NAME]) and when she was given benzodiazepines it would interfere with her breathing and cause respiratory depression. R1 was weaned from scheduled to a low dose of as needed benzo's so she would not retain CO2. Z1 stated R1 required the use of a [MEDICAL CONDITION] machine when she slept at night and with naps during the day. Z1 stated she was on call for the facility on [DATE]. Z1 stated she was familiar with the incident involving R1. Z1 stated When R1 was starting to have respiratory distress she or 911 should have been called. The facility should have called a code and started CPR when R1 was found not to have a pulse. On [DATE] at 12:42 PM, Z2 (Medical Director) stated a resident that has designated a FULL CODE status should have CPR started when there are no pulse or respirations. The facility should call 911 and call a CODE BLUE. Z2 stated the facility should have called 911 and started CPR on R1 when they determined she did not have a pulse. On [DATE] at 1:39 PM, E9 (Unit Manager) stated E3 should not have accepted R1 back from the emergency room . E3 should have notified the on call physician and reported the overmedication and R1's oxygenation level of 83% on [MEDICAL CONDITION]. E3 should have increased R1's oxygen. E3 should have called a code when R1 was unresponsive. R1 was a full code and a code should have been called and CPR done. R1 should have been hooked up to the AED machine to see if there was a rhythm. On [DATE] at 12:05 PM, E2 and E11 (Corporate Nurse) were interviewed. E2 and E11 said E3 should have called the physician and inform them of R1's condition upon return to the facility. E3 should have called the physician when R1's pulse oximetry was 83% on [MEDICAL CONDITION]. E3 should have called a code when R1 became unresponsive. R1 was a full code and CPR should have been started and a code called. R1's Nurse Note dated [DATE] at 3:45 PM, R1 was pronounced dead at 1:45 PM by E5. R1 was non verbal, non responsive and no vitals. R1's assigned provider, administrator, family/POAs, local hospital, city coroner and funeral home notified of R1's death. (EMS was never notified.) The facility's policy dated [DATE] for Emergency Procedure-Cardiopulmonary Resuscitation, shows if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that prohibits CPR and/or external defibrillation exists or b) there are obvious signs of irreversible death (e.g. Rigor mortis). The facility's Code Blue/Medical Emergency Protocol dated [DATE], shows When code blue is paged, make sure to say code blue and location 3 times. Call 911. Code blue will be initiated wherever resident is found .If a resident is unresponsive, initiate CPR following the American Heart Guidelines per resident's code status . Bring crash cart to the location . The facility's Change in Resident Condition or Status dated [DATE], shows, the nurse supervisor/charge nurse will notify the residents attending physician or on call physician when there has been .c). reaction to a medication; d) a significant change in the resident's physical/emotional or mental condition; e) a need to alter the resident's medical treatment significantly (that is a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . 2) A significant change in condition is a decline or improvement in the resident's status that: a) will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The immediate Jeopardy began on [DATE] at 12:30 PM when the facility did not initiate interventions to treat a resident who was a full code with a 83% oxygen saturation level on [MEDICAL CONDITION] machine which led to the resident becoming unresponsive at 1:00 PM and no vital signs at 1:45 PM. The facility staff did not initiate cardiopulmonary resuscitation on a resident who was a full code. On [DATE] at 2:25 PM, E1 (Administrator), E2 (Director of Nursing) and E12 (Assistant Administrator) were informed of the Immediate Jeopardy. The immediacy was removed on [DATE]. On [DATE] the surveyor determined through observation, interview, and record review, the facility took the following action to remove the Immediacy: 1. On [DATE], E3 and E5 were instructed by E2 on the Code blue and DNR policy; and documentation of assessment. On [DATE], E3 and E5 were recertified in CPR. 2. On [DATE], nursing staff was in serviced on Code Blue policy; DNR/ POLST (physician orders [REDACTED]. Nursing staff was not allowed to work until they received the in services. Training was completed [DATE]. 3. On [DATE], a Code Blue Drill was conducted on the evening shift. Code Blue drills were conducted daily for one week. The facility is conducting weekly code blue drills for two months. 4. On [DATE] the facility conducted an audit to ensure all licensed nursing staff had current CPR certification. CPR classes were conducted on [DATE] and [DATE] and ongoing. 5. An audit of all resident clinical records was initiated on [DATE] to ensure all code status is clearly documented and easily accessible. On [DATE] at 9:30 AM, E13 (Social Services) stated all of the resident's charts were reviewed to ensure the code status sticker on the chart matched the resident's POLST. This was completed [DATE]. 6. On [DATE], the facility held a quality assurance meeting. Mandatory in services were completed on DNR/POLST, Code Blue policy and procedure; and assessments. A in house audit was complete and resident with Full Code status were identified. Human Resources completed an audit of licensed nursing staff with CPR certification and on going CPR classes for CNAs. A crash cart audit was completed with ongoing audits to be done. The facility conducted Code Blue drills and will continue to conduct drills. The ongoing audits will be reviewed at the quality assurance meeting monthly.

Based on Observation, Interview and Record Review the facility failed to prevent residents from developing new pressure areas by not assessing, monitoring and implementing pressure relieving methods and treatments to help heal and prevent new or worsening pressure ulcers. This failure contributed to R5 developing a pressure ulcer to her left heel that was not identified until 4/11/14 when black, necrotic tissue was present. This is for 2 of 4 residents (R2 & R5) reviewed for pressure ulcers in the sample of 22. The findings include: 1. On 5/20/14 at 9:50am, a cafeteria style plastic tray was covering the left foot pedal and part of the foot rest on R5's wheelchair. Two pillows were placed on top of the plastic tray. E20 (Certified Nursing Assistant - CNA), E21 (CNA), E15 (CNA) and E16 (Unit Clerk/CNA) transferred R5 from her bed to her wheelchair using a mechanical lift device. R5 was lowered into her wheelchair and her heels were at the top of the foot pedals. R5 told the CNA's to position her back farther in her wheelchair. R5 stated, "I don't want another one of those on my heel." On 5/20/14 at 10:02am, R5 stated, "My (left) heel was resting on the end of the foot rest for about 2 weeks. It caused that sore on my heel. Once they found it, they put a tray and pillows on the foot rest to cover it." On 5/21/14 at 11:30am, E9 (Unit Manager for Long Term Care) stated, "R5's pressure ulcer was unstageable when it was found." The Skin Assessment done when R5 was admitted to the facility on [DATE] showed she did not have any pressure ulcers to her heels. The Nurse Practitioner Notes for R5 dated 4/10/14 showed, "R5 seen today in follow up for left ankle fracture. R5 states she had a bad night with increasing pain. R5 has increased wound drainage from pin site on [DEVICE]." The Treatment Record for R5 showed a treatment written on 4/8/14 to apply an elastic bandage to R5 ' s left lower extremity in the morning and remove the bandage at night; On 4/10/14 an order was written on R5 ' s Treatment Record to remove the dressing and do pin site care with sterile saline and peroxide. The Skilled Nurses Notes dated 4/11/14 for R5 showed, "2:00pm - R5 assisted back to bed. During/before transfer the nurse noted R5's heel, on her left lower extremity, was resting on the black plastic of the foot pedal; Blackened area around the heel that is approximately 1.5 inches in diameter." The Nurse Practitioner Notes for R5 dated 3/28/14, 4/1/14, 4/3/14, and 4/8/14 showed, "Skin: [DEVICE] in place to left ankle." There were no assessments or documentation to show any concerns with the [DEVICE] except for pin site care. The Nurse Practitioner Notes for R5 dated 4/11/14 showed, "Seen today in follow up for left ankle fracture. R5 has ongoing drainage from heel; found to have a new blister to bottom of heel." The Wound Care Specialist Initial Evaluation dated 4/23/14 for R5 showed, "Chief complaint: Consulted for left heel wound by R5's doctor. R5 has an unstageable pressure ulcer (due to necrosis) of the left heel of at least 1 day in duration; there is no exudates associated with the wound; Etiology - pressure; Objective - healing and manage pain; Wound size - 4cm x 7cm; Thick adherent black necrotic tissue (eschar): 100%." The Treatment Record dated 4/1/14 for R5 showed the first treatment order for R5 ' s left heel was dated 4/23/14 for " Betadyn and open air daily to left heel. " The Weekly Progress Report dated 5/1/14 showed R5 has a Stage IV pressure ulcer to her left heel that was acquired in the facility and measures 4cm x 5cm. R5's Care Plan dated 5/7/14 showed, "I have impaired skin integrity. I have an [DEVICE] on my left lower extremity for ankle fracture. Wounds are unstageable necrosis 4cm x 7cm; Monitor my skin daily when assisting with activities of daily living and notify nurse of changes - signs of infection; Treatment orders per wound doctor." R5's care plan did not identify possible causative factors for the development of R5's left heel pressure ulcer. R5's care plan did not show what preventative measures were implemented after the pressure ulcer to R5's heel was identified on 4/11/14. The Orthopedic Physician ' s Progress Note dated 5/12/14 showed, " Doing well post operatively; pins benign. The x-rays show good alignment and evidence of fracture healing. Continue current pin care regimen. Place foam between ring to calf to protect skin. Return to clinic in 5 weeks. " The facility's Skin Integrity Policy (no date) showed, "Program Goals: Protecting against the adverse effects of external mechanical forces (pressure, friction and shear); Daily skin assessment by care givers during bathing and dressing who will report any red or open areas to appropriate supervisor; Written documentation as to skin condition shall be made by licensed nurse once every two weeks." The facility's Pressure Ulcer Policy (12/13/10) showed, "Stage IV: Slough and eschar may be present; Unable to stage - When there is presence of deep tissue injury and presence of necrosis or covered by slough in the wound bed; The pressure sore will be assessed and documented weekly by the treatment nurse and shift to shift checks to ensure dressing is intact. The resident care plan and treatment sheet will reflect treatment and interventions." 2. R2 ' s November 2013 Minimum Data Set Assessment shows that R2 needs extensive assistance with bed mobility and is at high risk for developing pressure ulcers. R2 has a history of a healed stage 3 pressure ulcer. R2 ' s Nurses Note show that on 12/24/13 a Left buttock pressure ulcer was identified with the measurement of 0.5 X 0.5 centimeters(cm). R2 ' s Nurses Note show the Physician was called on 12/31/13. R2 had no treatment for [REDACTED]. R2 ' s 12/31/13 Physician order [REDACTED]. On 1/31/14, R2 ' s nurses notes show the Left buttock pressure ulcer measured 0.5 X 0.7 cm (no depth recorded) and had a small amount of drainage. On 2/10/14 the left buttock measured 1 cm X 0.8 cm. R2 had no change in treatment between 12/31/13 to 2/10/14 (over 4 weeks). Z1 1 (Wound Care Specialist) first evaluated R2 on 2/12/14. R2 ' s 2/12/14 Wound Care Specialist Evaluation Report shows R2 ' s Left buttock is a stage 3 pressure ulcer measuring 1 X 1 cm, depth not measurable. Z1 ordered silver absorbing foam agent dressing to be changed daily. R2 was evaluated by Z1 (12 times) on 2/12/14, 2/19/14, 2/26/14, 3/5/14, 3/19/14, 3/26/14, 4/2/14, 4/9/14, 4/16/14, 4/23/14, 4/30/14, and 5/14/14. Each of R2 ' s Wound Care Specialist Report shows R2 ' s treatment order for the left buttock pressure ulcer was sliver absorbing foam agent to be changed once daily. R2 ' s 5/14/14 Wound Care Specialist Report shows the Left buttock wound measured 1.5 X 2.0 X 0.2 cm. R2 ' s pressure ulcer is deteriorated and surgical debridement was performed to Left buttock by Z1. R2 ' s POS ' s and TAR ' s (treatment administration record) for February, March, April and May 2014 shows the order for silver alginate foam dressing should be changed 2 times a week and as needed. On 5/21/14 at 1:20 PM, Z1 assessed R2 ' s wound. Z1 measured the wound to be 0.9 X 1.4 cm. Z1 said the treatment order for twice a week " Is not a typical order that I would write for a wound. I prefer pressure ulcers to be treated daily if not 2-3 times a day. " " Somewhere along the line things got mixed up. " Z1 said R2 ' s pressure ulcer treatment should be done daily. On 5/19/14 at 1:50 PM, R2 was lying on her back in bed with a standard pressure reducing mattress. On 5/20/14 at 7:50 AM, R2 was lying on her back in the same bed R2 had no specialty pressure relief mattress in place. R2 ' s April 2014 Care Plan shows R2 has a Stage 3 pressure ulcer to the left buttock. The Care Plan states " treatment orders for the wound per wound care doctor. Silver absorbing agent and foam dressing once daily. " R2 ' s Care Plan states to " provide measures to decrease pressure/irritation to skin. " Provide R2 with a specialty pressure relief mattress. On 5/20/14 at 2:05 PM, E9(Unit Manager) said R2 was on a specialty pressure relief mattress in the past, but the facility removed it, " We use them when pressure sores are new or worsened. " The facility ' s undated Skin Integrity Policy states if High Risk (12 points or less) provide resident with a " special mattress and/or wheelchair cushion to include water, air and gel. "

Based on observation, interview, and record review the facility failed to accurately identify skin breakdown risk The facility failed to off-load a resident's heels to re-distribute pressure. These failures resulted in R1 developing a stage 2 pressure area after admission which worsened to a stage 3 pressure sore. This applies to 1 of 5 residents (R1) reviewed for pressure sores in the sample of 24. The findings include: The facility's Admission nursing Assessment, dated 10/08/10, does not identify any pressure areas to R1's heels. The wound-care physician's, wound care assessment form, dated 11/03/10, shows R1 developed a stage 2 pressure area to the Left Heel after being admitted to the facility due to pressure and sheer. The wound-care physician's, wound care assessment form, dated 07/20/11, shows R1's Left heel wound has worsened from a stage 2 to a stage 3 due to pressure and sheer. The Pressure sore risk assessment dated [DATE] assesses R1 to be at "HIGH RISK" for developing a pressure sore. On 07/26/11 at 10:10 AM, R1 was laying in bed. R1's heels were on the mattress. R1's heels were not off-loaded to reduce, redistribute or eliminate pressure. On 07/26/11 at 10:10 AM, E24 (LPN) stated, "(R1) is supposed to have a heel bow on at all times when she is in bed." R1's Plan of care updated 07/20/11 states, "Potential for skin breakdown" and shows a goal of "Resident will remain free from breakdown." The same plan of care shows the following interventions: "Position with pads and cushions to prevent pressure." The facility's undated policy titled, Pressure Ulcer Protocol, states, "Definition: ...Pressure ulcers usually occur on bony prominences. The primary sites are: sacrum, ischium, coccyx, heels, ankles, hips (trochanters), iliac crests, elbows, scapulas, ears and knees... Procedures: ...10. Appropriate pressure relief devices for chair and bed will be provided according to the individual resident's need." (pp. 1-2)

Based on observation, interview, and record review the facility failed to monitor the hydration status and oral intakes of a resident (R114) with a Urinary Tract Infection who was receiving antibiotic treatment. This applies to 1 of 14 residents (R114) in the sample of 24. The findings include: R114's Physician order [REDACTED]. The resident's Dehydration Assessment of 5/2/2011 scores the resident a 6. The form shows that a resident scoring a 6 places the resident at moderate risk for dehydration. A Nutritional Assessment (written by Dietitian) documents R114 requires 1772 cc's of fluid in a 24 hour period. The resident's Hydration careplan shows that she is at risk for "fluid volume deficit" related to impaired cognitive status, communication deficits, and daily diuretic use. The careplan is not specific and does not show how the facility will ensure she receives the recommended amount of fluid. Physician order [REDACTED]. A physician order [REDACTED]. Completed yesterday Bactrim X 7 days (BID dosing). Patient noted to have 4 pound weight loss in 1 month. STAT BMP and CBC ordered. Patient found to be in complete [MEDICAL CONDITION]. Very quiet affect. Noted to be Hypotensive and Bradycardic. UTI with E. Coli." Z1 documents the resident's blood pressure as 90/50 and her heart rate 52. The report further documents the resident appears chronically ill, fatigued, with dry mucosa. She is pale. The resident's Hemoglobin was 11.3 (normal 12-15.8), Blood Urea Nitrogen(BUN) 93 (normal 7-17), and Creatinine 5.06 (normal .6-1.0). A 6/14/2010 laboratory result shows a BUN of 34 and a Creatinine of 1.53. Nurses Notes show the resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The Hospital Patient/Discharge Transfer Physician Orders, dated 4/29/2011 documents R114's primary [DIAGNOSES REDACTED]. Nurse's Notes were reviewed from 4/18/2011 through 4/25/2011. There are several entries documenting the resident's appetite as being poor. Multiple entries state "fluids encouraged." It is not known how much fluid the resident took in each shift. There is no documentation showing the staff were assessing R114's hydration status. It is not known if there was any change in R114's mental status until 4/25/2011. On this date nursing documentation at 11:20 AM states, "Called MD called nurse practitioner (Z1) and reported regarding resident's mental status and noted losing appetite and antibiotic (for) UTI already completed..." On 7/28/2011 at 8:20 AM, Z1 was interviewed. Z1 said she was covering for R114's physician because he was out of town. She said she received a call from the facility stating the resident needed to be seen for a UTI. Z1 said, "I was told she wasn't herself. I had never met the resident before 4/25/2011. In my opinion she was very lethargic and difficult to arouse. She couldn't stay awake. When they called me I ordered STAT labs and waited for the results before assessing her. She was very unstable. She was hypotensive and bradycardic. I knew she was in [MEDICAL CONDITION] from looking at her labs. I could tell by looking at her mucous membranes and the labs that she was dehydrated. We sent her immediately to the hospital. When she came back from the hospital stay we needed to continue to push fluids for the 1st 2-3 weeks. Anyone on an antibiotic with a [DIAGNOSES REDACTED]. In my opinion anyone on an Alzheimer's/Dementia special care unit should have their intakes monitored. (R114's) [MEDICAL CONDITION] was directly a result of her [MEDICAL CONDITION] and her poor intake. The antibiotic also contributed to the [MEDICAL CONDITION]." Z1 said that any resident on antibiotic therapy with Dementia should have their oral intakes monitored. On 7/26/2011 at 8:30 AM, E3 (Licensed Practical Nurse - dementia unit manager) said they do not monitor the food/fluid intakes of the residents. She said all residents on the dementia unit are at risk for dehydration. On 7/28/2011 at 10:40 AM, E2 (Director of Nursing) confirmed there is no facility-wide Hydration Policy and Procedure. The unit-specific Hydration policy (undated) states, "Our hydration policy is established to assist residents with dementia in maintaining proper fluid intake throughout the day."