Every finding on record at Pearl of St Charles, The

Based on observation, interview, and record review, the facility failed to maintain resident rooms and showers in safe repair. This applies to 4 of 4 residents (R6, R12, R39 and R48) reviewed for physical environment in a sample of 21. The findings include:1. On 7/30/2026 at 9:20 AM, R6 was in his room. R6's room had holes and scratches on the walls and they were in disrepair. R6 said he was the Resident Council representative and had received multiple concerns about the facility's environment. R6 said the residents were reporting that there were holes in the walls in many rooms and shower rooms. R6 said the facility had patched some holes and painted them, however, there were still a lot of rooms in need of repair. On 7/29/2026 at 2:30 PM, environmental rounds were conducted with V8 (Maintenance Director) in the shower room in R6's hallway. There was an exposed sensor alarm on the ceiling. V8 said the shower room was being used by residents and had recently been repaired. V8 said the sensor alarm was removed more than three weeks ago and they had not placed a protective cover to ensure the wires were not exposed. V8 said for the safety of everyone all, exposed wires should be covered. 2.On 7/29/2026 at 2:20 PM, environmental rounds continued with V8 in R39 and R48's hall. R39 and R48's rooms were in disrepair. R39's room wall behind his bed was cracked and had exposed drywall unsanded drywall mud. V8 said there were a lot of resident rooms in need of repair and the facility used outside painters to finish the work. 3. On 7/29/2026 at 2:25PM, V8 said R48's room was also in need of repair. R48's room wall behind his nightstand table had a large linear crack in the drywall and there was also unsanded drywall mud. V8 also said the shower room in the R48's hall needed repair. The ceiling in the shower room had large patches of peeling paint and there was bubbling paint around the area. V8 said the peeling paint was due to the moisture from shower steam. 4. On 7/29/2029 at 2:30 PM, V8 said R12's room was repaired a while back, but the work was not completed. R12's room walls had large portions of unsanded drywall mud behind his bed and the corner. V8 said the shower room in the R12's hall also needed repair. The ceiling in the shower room had multiple patches of peeling paint. There was a partially exposed electric outlet with visible electrical wires. V8 said no wires should be exposed because it is dangerous and unsafe. V8 also said residents' rooms should be maintained to ensure a safe environment. The facility's policy titled Preventative Maintenance Program, dated 12/2025, said the facility developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.

Based on observation, interview, and record review, the facility failed to treat residents with dignity while providing care. This applies to 2 of 2 residents (R5 & R14) reviewed for dignity in a sample of 21. The findings include: 1. On 07/28/2026 from 1:02 PM until 1:28 PM, R14 was in bed and V4, CNA (Certified Nurse's Assistant), was standing over him feeding him his lunch. V4 said when she is working on R14's hall, she never sits down while feeding residents. V4 said there are no chairs and she just gets the feeding done. 2. On 07/28/2026 from 1:05 PM until 1:32 PM, R5 was in bed and V5, CNA, was standing over him feeding him his lunch. V5 said she sometimes stands while feeding residents and she did this time because R5's bed was already in a high position when she got to him, so she just fed him. On 07/30/26 at 10:38 AM, V3, DON (Director of Nursing), said staff should be sitting while feeding residents for dignity and to ensure they are at eye level for comfort. The facility's Food & Nutrition Services, Meal Service, The Dining Experience policy (copy right date 2021) showed meals will be served with respect to the client's dignity as an individual. The policy showed that for those clients that require feeding assistance, the person assisting sits near the client. The facility's Resident Right-Respect, Dignity/Right to have Personal Property policy (Date 12/05/2025) showed the facility will provide care and services in such a manner to acknowledge and respect resident rights. The policy showed that the residents have a right to be treated with respect and dignity. The facility's Resident Rights policy (dated 1/15/2026) showed each resident has the right to be treated with dignity and respect. The policy showed that the resident has a right to a dignified existence. The facility will treat each resident with respect and dignity for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to meet the needs of the residents. This applies to 2 of 2 residents (R5, R14) reviewed for ADLs care in a sample of 21. The findings include:1. On 07/28/2026 at 12:01 PM, R5 was observed trying to put his call button on using his chin. R5, who is alert and oriented, said he needed staff to come in to scratch his chin. R5 said he is unable to move his right hand. R4's chin and above his lip was with about 1inch long hair. R4 said he wanted to be shaved. R4's left hand was observed contracted and his fingernails were long, jagged, and with a brown substance under the nails. R4's right hand was contracted and the skin on his palm was observed yellow and with crusty flaking skin. His nails on his right hand were long and curling over the nails touching the skin on the tips of the fingers. The nails were jagged and with a brown substance under the nails. On 07/29/2026 at 2:05 PM, R5's left hand was observed with his nails long, and jagged with a brown substance under the nails. R5's nails on his right hand were curled over the fingertips and they were jagged with a brown substance under the nails. The skin on R5's palm was yellow with crusty flaking skin. R5 said he didn't know the last time the staff did nail care for him and said it bothers him. R5's 6/2/2026 MDS (Minimum Data Set) shows R5's cognition is intact and R5 is dependent on staff for ADL personal hygiene. R5's 6/18/2026 Care Plan shows R5 requires total assistance with ADL care with interventions including provide total assistance with all ADL care and maintain skin integrity by performing daily hygiene keeping skin clean and dry. On 7/30/26 at 12:01 PM, V13 (Licensed Practical Nurse) said she provides care for R5 at least two times a week and he is to have nail care done on shower days and as needed. V13 said R5 will let you cut his nails and do nail care if you ask him. 2. On 7/28/26 at 11:39 AM, R14 was observed with long facial hair and long jagged nails with a brown substance under the nails. R14, who was alert and oriented, said he did not like his facial hair to be long. R14 said it makes him mad and he wanted staff to shave him. On 07/29/2026 at 2:04 PM, R14 was observed with long facial hair and long jagged nails with a brown substance under the nails. R14's 6/19/26 MDS shows R14's cognition is intact, and R14 is dependent on staff for personal hygiene care. R14's 6/18/26 Care Plan showed R14 is dependent on all ADLs with interventions including staff is to provide total assistance with all ADL and maintain skin integrity by performing daily hygiene. On 07/30/2026 at 10:38 AM, V2, DON (Director of Nursing), said nails should be cut and cleaned and ADLs are to be done daily and as needed. V2 said long jagged nails with brown substances under them poses an infection risk and is a dignity issue. The facility's ADL policy (dated 12/4/25) showed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The facility's Resident rights policy (dated 12/5/25) showed each resident has the right to be treated with dignity and respect.

Based on observation, interview, and record review, the facility failed to ensure residents were transported safely in wheelchairs by utilizing wheelchair footrests during staff-propelled transport. This applies to 3 of 3 residents (R22, R23, and R54) reviewed for accidents in a sample of 21. The findings include:1. R54's Face Sheet included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, myalgia, epilepsy, dementia, and mood disorder. R54's Fall Risk Assessment, dated 6/2/2026, showed R54 was at high risk for falls. R54's MDS (Minimum Data Set), dated 6/1/2026, showed R54 was cognitively intact and did not exhibit behaviors related to the rejection of care. The MDS also showed R54 utilized a wheelchair for mobility and had limited range of motion in one upper extremity and both lower extremities. On 7/28/2026 at 11:45 AM, R54 was observed sitting in a manual wheelchair as V11 (CNA-Certified Nursing Assistant) began pushing the wheelchair down the hallway. The wheelchair did not have footrests in place. As V11 pushed the wheelchair, V11 instructed R54 to lift his feet off the floor. R54's right foot dragged on the floor while R54 lowered his left foot to the floor, causing the wheelchair to stop abruptly. R54 tipped forward toward the floor. V11 immediately grasped R54's torso and repositioned him upright in the wheelchair, preventing R54 from falling. V11 then continued transporting R54 down the hallway without footrests in place. R54's care plan, revised on 3/26/2026, included interventions for staff to assess the physical environment, devices, and equipment, including wheelchairs, to ensure they did not pose a safety risk or hazard. The care plan also directed staff to check the resident's location and activity to ensure R54 was properly and safely positioned in bed or wheelchair. 2. R22's Face Sheet included diagnoses of morbid obesity, lymphedema, acquired absence of the right leg below the knee, diabetic nephropathy, and chronic kidney disease. R22's Fall Risk Assessment, dated 6/29/2026, showed R22 was at high risk for falls. R22's MDS, dated [DATE], showed R22 was cognitively intact and did not exhibit behaviors related to the rejection of care. The MDS also showed R22 used a wheelchair for mobility and had lower extremity functional impairment. On 7/28/2026 at 10:59 AM, R22 was observed sitting in a manual wheelchair while V12 (Wound Care Nurse) pushed the wheelchair down the hallway. The wheelchair did not have leg rests in place. During transport, R22's left foot repeatedly brushed against the floor. When asked whether it was appropriate to transport R22 without leg rests, V12 stated, Yes, and continued transporting R22 without leg rests. R22's care plans, revised on 3/27/2026, included interventions for staff to reinforce proper positioning and assist with mobility as needed. The care plans also directed staff to ensure wheelchairs and other equipment did not pose a safety hazard. 3. R25's Face Sheet included diagnoses of cerebral palsy, scoliosis, dysphagia, and pain in the right shoulder. R25's Fall Risk Assessment, dated 10/17/2025, showed R25 was at high risk for falls. R25's MDS, dated [DATE], showed R25 had impaired cognition and did not exhibit behaviors related to the rejection of care. The MDS also showed R25 used a wheelchair as the primary mode of mobility and was dependent on staff for locomotion on and off the unit. On 7/29/2026 at 9:28 AM, R25 was observed sitting in a manual wheelchair while V14 (CNA) pushed the wheelchair down the hallway toward R25's room. The wheelchair did not have footrests in place. V13 (RN-Registered Nurse), who was at the end of the hallway, was calling out instructions to V14 (CNA). As V14 turned her head toward V13 while continuing to push the wheelchair, the tips of both of R25's feet repeatedly contacted the floor as R25 was propelled forward. V14 continued transporting R25 into the resident's room without footrests in place. R25's care plan related to wheelchair mobility, revised on 6/17/2026, directed staff to ensure the wheelchair, including the brakes, footrests, and armrests, was in safe working condition. The care plan also directed staff to properly position R25 in the wheelchair. Staff were to monitor for fatigue or discomfort during wheelchair use and document R25's tolerance and assistance level. R25's fall care plan, revised on 3/15/2026, directed staff to assess the physical environment, devices, and equipment, including wheelchairs, to ensure they did not pose a safety risk or hazard. On 7/29/2026 at 2:50 PM, V15 (Rehabilitation Director) stated residents who independently self-propel a wheelchair without footrests differ from residents being transported by staff. V15 stated residents who self-propel control the movement of the wheelchair and can stop if their feet contact the floor. V15 stated, during staff-propelled transport, the wheelchair continues moving unless staff stop it. If a resident's feet contact the floor, the wheelchair may stop abruptly, causing the resident to tip or fall forward. V15 stated wheelchair footrests should be utilized during staff-propelled transport since there is a risk the resident's feet could contact the floor, including during longer distances or if the resident becomes fatigued. V15 stated it is safer to err on the side of caution and utilize wheelchair footrests during staff-propelled transport to prevent resident injury. The facility's policy, Free of Accident Hazards/Supervision/Devices and Reporting of Accidents and Incidents, reviewed 3/1/2026, stated the facility will provide care and services in accordance with each resident's needs and goals of care. The policy further stated the facility will provide an environment free of accident hazards and provide adequate supervision and assistive devices to prevent avoidable accidents. The policy directed staff to identify and reduce hazards and risks, monitor the effectiveness of interventions, and modify interventions as needed.

Based on observation and interview, the facility failed to post daily licensed and unlicensed nursing staffing information. This applies to all residents and visitors in the facility.Findings include:On 07/28/2026 at 10:00 AM and on 07/29/26 at 9:10 AM, no daily staffing was posted in the facility. On 07/29/2026 at 9:52 AM, V3 (Receptionist) said the facility used to post the staffing and daily census but has not done it since she came back from maternity leave in March of 2026. V3 said previously, the Staffing Coordinator would give the information to her and then she would post it. On 07/30/2026 at 10:38 AM, V2 (DON) Director of Nursing, said she expects the staff to post the daily staffing information. V2 said the daily staffing is to be posted by the Receptionist and Staffing Coordinator before the start of the shifts. The facility was unable to provide any policy on posting the daily staffing.

Based on observation, interview and record review, the facility failed to provide a resident with foot care. This applies to 1 of 3 residents (R1) reviewed for foot care in a sample of 3. The findings include:R1's Face sheet, dated 1/28/26, shows R1's diagnoses included Type 2 hemiplegia/hemiparesis, epilepsy, and Parkinson's disease. MDS (Minimum Data Sheet) dated 1/2/26, shows R1's cognition was severely impaired and R1 was dependent on staff for putting on and taking off footwear, lower body dressing, and showering/bathing and R1 required substantial/maximum assistance for personal hygiene. The MDS shows R1 had no skin problems at the time of assessment. Physician Order Sheet, dated 1/28/26, shows R1 had physician orders for daily skin check every night shift for prevention if moderate to high risk based on Braden scale and perform daily skin check if any skin issues are identified and a weekly skin check every Monday for his skin assessment. R1 also had physician orders for betadine paint/foam daily to be applied to his right foot daily and an order to apply house stock moisturizing lotion to both lower extremities as needed for dry skin. Podiatry note, dated 11/20/25, shows R1's right and left foot/ankle had dry/thin skin. The note shows R1's feet were to be kept clean and lotion was to be utilized daily. On 1/28/26 in R1's room, V3 (Nurse) stated R1 had no skin concerns or open areas on his feet. V3 removed R1's bilateral pressure relieving boots and socks. R1 had a brownish-orange waxy crust covering the majority of the bottom of his feet and spotty areas of the brownish-orange waxy crust were observed on the sides and top of his feet as well as his ankles and shins of his legs. There was also a large amount of brownish-orange waxy crust buildup between all of R1's toes and some of the areas were peeling away from R1's skin leaving pink, intact skin underneath. V3 examined R1's feet and stated she would clean R1's feet and call the wound nurse to examine the areas. V3 called the facility wound nurse and began to wipe R3's feet with a wet towel. Several small chips of the brown/orange waxy substance broke off and fell on the bed revealing intact, pink, dry skin. At 10:53 AM, V2 (Director of Nursing/DON) entered R1's room, examined R1's feet, and stated the waxy crust was not typically present on R1's feet and R1's feet looked very dry. V2 stated R1's feet should not appear to have the brownish-orange waxy substance and staff should be moisturizing R1's feet daily to prevent dryness. On 1/28/26 at 10:56 AM, V4 (Wound Nurse) arrived and examined R1's feet. V4 stated she applied cream earlier that morning. V4 examined R1's feet and stated his feet should be cleaned and lotions/creams should be applied. V4 stated the brownish-orange waxy substance was present on R1's feet for a long time prior and was not new. On 1/28/26 at 11:20 AM with V5 (Certified Nursing Assistant/CNA), V3 (Wound Nurse) washed R1's feet and chips of the brownish-orange waxy substance chipped off of R1's feet as she washed. V3 stated approximately 10-15% of the brownish-orange waxy substance was removed. V3 stated facility staff were expected to apply cream and ointment every day to R1's feet and wash his feet when providing a scheduled bed bath. V5 stated she did not wash R1's feet or apply lotion during AM care that morning. On 1/28/26 at 11:30 AM, V6 (CNA) stated the brown-orange waxy crust appeared on R1's feet intermittently. On 1/28/26 at 11:32 AM, V3 (Nurse) stated R1's feet were sometimes a bit dry, but she had never seen his feet have the brown-orange crust like observed that morning. V3 stated R1 usually had the crust between his toes and on the bottom of his foot. V3 stated the staff should wash R1's feet daily and not only during bed baths. On 1/28/26 at 11:45 AM, V2 (DON) stated R1's feet should not have had the brownish-orange waxy buildup to the extent see that morning and stated if she saw the buildup on R1's feet when applying lotion during AM care, she would have washed R1's feet to remove the buildup. On 1/28/26 at 12:47 PM, V7 (Nurse Practitioner) examined R1's feet and described the substance on R1's feet as an orange-brown waxy substance. V7 began to chip off the waxy substance on the bottom of R1's feet to reveal pink, dry, intact skin. V7 described the brownish-orange waxy substance as covering approximately 50% of the bottom of both of R1's feet. V7 stated the orange-brown waxy substance condition was preventable with daily foot care by washing and moisturizing R1's feet and the facility staff was expected to do daily cleaning and moisturizing to remove the built-up dead skin that was easily removable with a washcloth. V7 stated if build-up occurred like that observed on 1/29/26, the staff should have returned after R1's moisturizer absorbed and cleaned R1's feet to remove the buildup. V7 (Nurse Practitioner) progress note, dated 1/28/26, shows, the patient currently has dry, flaky skin to his feet; the skin is intact and no wound is noticed; the skin at the bottom of the foot is covered 50% with waxy and yellow looking dry skin which is easy to remove. Advised the skin care to the foot; clean with wet wash cloth and remove the dry skin buildup; apply moisturizer' reassess the foot to monitor for dry skin. Review of R1's Medication Administration Record, dated 1/1/26 to 1/31/26, shows R1's skin check was performed daily at 7:00 PM. Policy/Procedure Foot Care, dated 3/2025, shows, Procedure: To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: 1. Provide foot care and treatment, in accordance with professional standards of practice, including preventing complications from the resident's medical conditions.

Based on interview and record review, the facility failed to ensure a resident was free from significant medication error for 1 of 10 residents (R1) reviewed for medication errors.The findings include:R1's face sheet documents diagnoses which include fracture of left calcaneus with delayed healing, fracture of first metatarsal bone, left foot, fractured shaft of left tibia, displaced fracture of left acetabulum, fractured shaft of left fibula, fractured left pubis and fractured left ileum due to motorcycle driver injury. R1 also with diagnoses of anemia, intestinal obstruction, and hypertension. R1's MDS (Minimum Data Sheet) dated 12/28/25 documents he has intact cognitive functions.On 1/6/26 at 11:00 AM, R1 said on October 19, 2025, around midnight, V17 (Registered Nurse/RN) administered the wrong IV (Intravascular) medication. He said after the medication was infused, he noticed that the medication had a different resident's name. He said he informed the nurse immediately.On 1/6/26 at between 11:20 AM and 12:00 PM, separate interviews with V7 (RN) and V9 (RN/Unit Manager) said that V17 gave R1 the wrong IV medication on 10/19/25. They said R1 had an order for Vancomycin but V7 administered Zosyn instead.R1's October 2025 POS (Physician Order Sheet) documents order for Vancomycin Hcl in Dextrose Solution 1 gram/200 ml, use 1.75 mg three times a day to start on 10/11/25 until 10/20/25 for bacterial wound infection.R1's Progress Notes dated 10/19/25 documents a medication error happened. Piperacillin/Tazobactam 3.375 grams 100 ml was administered to R1 instead of the ordered Vancomycin.On 10/7/26 at 11:30 AM, V2 (Director of Nursing) said she expects her nurses to confirm the five Rs of medication administration (right patient, right drug, right dose, right route and right time) prior to administering meds to make sure they are giving correct medication to correct resident at the right time to prevent harm from giving wrong medication.Facility Medication Administration Policy and Procedure dated 3/20/2020 and reviewed on 4/15/2025 documents the following: Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 5. Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 15. Identify resident using two resident identifiers.

Based on observation, interview, and record review, the facility failed to follow sanitary practices in the facility kitchen. This applies to 74 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS Form 671 dated February 24, 2025 showed that the facility census was 76 residents. Facility provided information that there were 2 residents on NPO (nothing by mouth). On February 24 at 9:15 AM, during initial tour of the facility kitchen, the following observations were made. At the side of the ice machine there was a plastic scoop placed inverted (scoop handle up) in a plastic scoop holder that was attached to the wall. Inside the bottom of the scoop holder there was some pooled water with blackish substances that was touching the inverted top of the scoop. V5 (Dietary Manager) who had come into the vicinity was notified of the same. On a counter in the kitchen, there were several cardboard boxes of various types of breaded items. One box contained four plastic packets (12 count each packet) of hot dog buns with whitish substance noted on some of the hot dog buns. The delivery date marked on the box showed January 15, 2025 and V5 stated that the breaded products should have been refrigerated. On the spice rack, the following opened containers of spices were seen Ground allspice (16 oz/ounce) delivery date of September 13, 2023 with no open on or use by date, Ground Oregano (12 oz) with delivery date of May 31, 2021 and with no open on or use by date. The thermometer that was placed inside the reach in freezer in the kitchen showed 25 degrees Fahrenheit. A packet of frozen vegetables had condensations on it and the vegetables were soft to touch. Another box containing frozen peas were also soft to touch. There were several boxes that contained individual cups of ice cream and gelato that were soft when lids were opened and tested . A cardboard container with waffles was also tested and were soft to touch. Other boxes of food stored in the freezer were not opened to check and V5 was notified that the same freezer will be tested again in a few hours after food prep is completed. On February 24 at 12:22 PM, the same reach in freezer was checked again and the inside thermometer showed 20 degrees Fahrenheit. V4 (Regional Dietary Director) who had come to the area stated that the freezer should be at 0 degrees Fahrenheit. Both V4 and V5 were notified that the freezer will be checked again after meal service. On February 24 at 1:13 PM, the same reach in freezer was checked again and the inside thermometer showed 30 degrees Fahrenheit with the items stored inside the freezer showing further defrosting stages. V5 stated that she will notify maintenance and take necessary action. Facility policy titled Ice Machine, Scoop and Tray (undated) included as follows: Policy: The ice machine and equipment (scoops and trays) will be cleaned on a regular basis to maintain a clean, sanitary condition. Procedure: 8. Store ice scoop beside or on top of the machine in a clean non-porous container, that allows water to drain off (and not pool around the scoop). Facility policy titled Labeling and Dating (reviewed July 30, 2023) included as follows: Policy: Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. Procedure: 2. 30-day shelf life, usually applies to items that are shelf stable until opened. Label includes: b. Discard date (i.e. opened 4/30, discard 5/30). Facility policy titled Freezers and Refrigerators (undated) included as follows: Policy: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. Procedure: 1. Acceptable temperatures should be 35- 41 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers.

Based on observation and interview, the facility failed to maintain the dining room in a sanitary condition during meal service and failed to clean a resident room. This applies to 8 of 18 residents (R1, R7, R12, R27, R51, R58, R125 and R126) reviewed for environment in the sample of 18. The findings include: 1. On February 25, 2025 at 8:40 AM, V9 (Restorative Aide) was seen taking breakfast meal trays from a free standing cart in the small dining room that served residents that needed supervision or assistance. V9 set up each tray before handing it out to the residents. The dining room tables appeared very dirty with smears of unknown substance and crumbs/debris on it. The floor also was littered with covers of the straws, bits and pieces of paper and food crumbs. R1 was seen seated in a wheelchair wiping the soiled table she was seated at with a disposable wipe. Other residents in the dining room included R7, R27, R51, R58, R125 and R126 who were seated at tables that were soiled with above mentioned unknown smears and debris. R7 and R125 had already started eating as they were served their breakfast trays by V9. V9 was notified that the meal tables were unsanitary and V9 stated that she will clean the same before passing out the trays to the other residents in the dining room. On February 25, 2025 at 1:35 PM, V12 (Housekeeper) stated that he usually cleans the dining room after meals. When asked if the dining room has been cleaned the night before after the dinner meal, V12 stated We were running low [on housekeeping staff]. On February 26, 2025 at 01:56 PM, V1 (Administrator) stated that the facility does not have a policy related to cleaning general areas. On February 26, 2025 at 3:46 PM, V21 (Maintenance Director) stated that after the meal, the meal tables are supposed to be cleaned by kitchen staff and the floor by housekeeping. V21 stated that when this was brought to his notice today, he discussed the matter with V4 (Regional Dietary Director) and was told that some staff were not aware of the same. 43389 2. R12's Face Sheet showed R12 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation, abdominal aortic aneurysm without rupture, Partial intestinal obstruction, Ileostomy Status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. R12's Minimum Data Set, dated dated dated [DATE] showed R12 was cognitively intact. On February 24, 2025 at 10:32 AM, at the bottom of R12's bed, there a white blanket that had brown stains on it. There was also garbage, miscellaneous pieces of crumbled napkins and paper, smears of a sticky substance, and crumbs on the floor. R12 stated they do not clean he room on the weekends and she has not had her floor cleaned since last week. On February 25, 2025 at 1:52 PM, R12 stated the floor still has not been mopped or cleaned. The same stains were on the floor and more balled up tissue and a towel was on the floor. On February 25, 2025 at 1:54 PM, V24 (Housekeeper) stated she had cleaned all the rooms except R12's room, but she was going to clean R12's room now. On February 25, 2025 at 3:39 PM, R12's room had the same garbage and sticky smears on the floor, in addition more was under the resident's bed and on the floor. On February 25, 2025 at 3:43 PM, V21 (Housekeeping Director) went to R12's room and looked at the dirty floor, with all the same tissues, salt packet, crumbs, and garbage on the floor. Surveyor mentioned to V21 that the housekeeper said she would clean the room yesterday, but it had not been done. V21 stated that V24 works 7-3 PM and will be working double duty today because another housekeeper called off. Surveyor informed V21 that stool was spilled on the floor yesterday. V21 stated R12's room should have been cleaned and if stool had spilled on the floor, then the floor should have been mopped and disinfected. On February 26, 2024 at 9:57 AM, R12's floor still had not been cleaned and had the same sticky smear and trash on it. On February 26, 2024 at 10:16 AM, surveyor asked V21 why the room was not cleaned yet. In the evening, they only have housekeepers that does the laundry. V21 stated the housekeepers that mop the floors are only at the facility from 7-3 PM, so that is why the rooms are just now getting cleaned.

Based on observation, interview, and record review, the facility failed to provide grooming and hygiene for residents who requires assistance with Activities of Daily Living (ADL) care. This applies to 5 of 18 residents (R12, R41, R51, R125, and R225) reviewed for ADL care in the sample of 18. The findings include: 1. Face sheet shows that R51 is [AGE] years-old who has multiple medical diagnoses which include dementia and legal blindness. R51's Minimum Data Set (MDS) dated [DATE], shows that she is cognitively impaired and requires substantial/maximal assistance for grooming and hygiene. On February 24, 2025, at 11:21 AM, R51 was sitting in the dayroom, staring in space. R51 displays long jagged fingernails with black/brown substance underneath. 2. Face sheet shows that R125 is [AGE] years-old has multiple medical diagnoses which include dementia, malignant neoplasm of prostate, and secondary malignant neoplasm of bone. R125's MDS dated [DATE], shows that he is cognitively impaired and requires substantial/maximal assistance for grooming and hygiene. On February 24, 2025, at 11:20 AM, R125 was in the dining room sitting in his wheelchair hunched forward sleeping, with uncombed/unkempt hair, and he displayed black/brown substances underneath the fingernails and brownish to yellowish discoloration on the nail beds. On February 26, 2025, at 3:55 PM, V22 (Certified Nursing Assistant/CNA) stated that R51 and R125 are cooperative during provisions of care. Though R125 is a little bit more confused, all they had to do was explain the procedure to him and he readily cooperates. 3. R41 Face sheet shows that R41 is [AGE] years-old who has multiple medical diagnoses which include abnormal gait and mobility. R41's MDS dated [DATE], shows that he requires assistance for grooming and hygiene. On February 25, 2025, at 1:25 PM, R41 was sitting in his wheelchair drooling, with his drool resting on his beard. R41 displayed long unkempt/untidy facial hair and jagged fingernails with black/brown substances underneath, and brownish/yellowish discoloration on the nail beds. V19 and V20 (both CNAs) assisted R41 back to bed and provided peri-care. At 1:25 PM, when surveyor asked, R41 stated that he wanted his facial hair trimmed and nail care done. After the peri-care was completed, V19 and V20 left the bedroom without offering to provide facial hair care and nail care. On February 26, 2025, at 3:58 PM, V2 (Director of Nursing/DON) stated that ADL care is to be provide as scheduled and as needed which include provisions of peri-care, nail, oral, and facial hair care, to ensure comfort and dignity for residents. 43389 4. R12's Face Sheet showed R12 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation, abdominal aortic aneurysm without rupture, Partial intestinal obstruction, Ileostomy Status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. R12's Minimum Data Set, dated dated dated [DATE], showed R12 was cognitively intact. On February 24, 2025 at 10:42 AM, V18 (Licensed Practical Nurse/LPN) changed R12's ileostomy appliance and applied the belt around R12's back that was wet with stool. After attaching the belt, V18 stated the ileostomy was leaking again already and it was open on the top right. V18 then reinforced it with some white cloth tape. V18 stated she would send the (CNA) to help R12 get cleaned up. On February 24, 2025 at 11:07 AM V19 (CNA) entered R12's room and told her she would help her get cleaned up. R12 brought with her a gown and sheets. V19 helped R12 into a clean gown and removed the one that was soiled with brown stains on the inside of the gown. R12's right side of her back and the bed was still wet with what R12 said was stool from her leaking ileostomy bag. V19 did not clean her skin. V19 then picked up R12's slippers (Beige teddy bear material) that had dried brown and black rounds stains on the tops of them and offered them to R1. V19 then then pulled up the elastic waist of R12's incontinence pull-up brief. A brown smear could now be seen on the top right of the incontinence pull up brief. R12 said to V19, can you put something in the chair so that I don't screw up the chair. Once R12 was out of the bed, R12's back was wet and a large wet and brown area about 14 inches in diameter could be seen on the fitted sheet. R12's back was visibly wet. V19 removed the sheets and made the bed with clean linens, R12 did not wash R12's skin nor the bed. V19 also did not offer or change R12's incontinence brief that was wet in the back with brown stain on it. At 11:25 AM, V19 said she was done and left the room. R12 stated she asked for the staff to change her earlier, but they couldn't. R12 stated they don't usually wash her skin after stool spills on her, they just change her clothes. R12 stated she waited so long for someone to help her this morning to go to the restroom and no one came, so she grabbed the garbage can and peed in it. 5. R225's Face Sheet showed R225 was admitted to the facility on [DATE] with diagnoses that include aftercare following joint replacement surgery, presence of right artificial knee joint, and chronic obstructive pulmonary disease. R225's Minimum Data Set, dated dated dated [DATE] showed R225 was cognitively intact. On February 24, 2025 at 9:56 AM, R225 stated he has only been offered a shower once at the facility and the last shower he had was a couple weeks ago. R225 skin on his face was dry and there were sheets of dry skin on his forehead. R225 had on a black shirt, and it was filled with white flakes of skin. R225's hair looked greasy, and his beard was long. R225 stated he should be getting showers twice per week. R225 stated he would like a shower. On February 25, 2025 at 1:41 PM, V20 (CNA) stated that residents are offered showers twice per week. V19 showed surveyor the shower schedule that showed R225 showers are on Monday and Thursday mornings. V19 (CNA) stated she has not offered R225 a shower yesterday or today. V20 stated she thought R225 had an appointment at 9:30 AM yesterday. Surveyor mentioned he didn't go anywhere and asked if V20 had asked R225 later on during the day if he wanted a shower. V20 stated I didn't ask him because I was overwhelmed. I take accountability for that. V20 then stated she had 3 other people to help with showers that day. On February 25, 2025 at 3:00 PM, V2 (DON) stated residents are offered showers on their shower day and if they refuse that morning they are offered a shower later in the same day and as needed. V2 stated staff should document each time a shower is offered or refused. At 3:15 PM, V2 said according to V20 she did offer R225 a shower in the morning of February 24, 2025 and R225 refused. On February 25, 2025 at 4:08 PM, R225 stated no one still has not offered him a shower. R225 stated no one had offered him a shower on the days of his appointment either (2/17/25, 2/20/25, and 2/24/25). R225 stated no one had asked him if he wanted a shower and he did not go anywhere yesterday. R225 was wearing the same black shirt he had on yesterday that was covered with white flakes of skin, he was unshaven, and his face was still flaky. On February 26, 2025 at 10:05 AM with V2 (DON) present, R225 stated no one has asked him if he would like to shower since he had his last shower 2 weeks ago. R225 stated, he needed a shower and wanted a shower today. R225 was still wearing the same black shirt he has had on for 3 days with white flakes of skin on it. R225 face was still flaking, and his hair still looked oily. Surveyor and V2 left R225's room and V2 stated she did not ask R225 yesterday or today if he wanted a shower. V2 stated maybe V18 (LPN) did. At that moment, V18 approached and V18 stated she did not ask R225 yesterday or today if he wanted a shower. R225's Care ADL care plan dated 2/11/25 and revised on 2/15/2024 showed the following: R225 has an ADL self-care performance deficit, and he requires 1 assist with bathing and hygiene. The facility's electronic medical record shower sheet for R225 showed he received one shower since he had been in the facility. The facility did not produce any other shower sheets by the end of the survey. The facility's Supporting Activities of Daily Living (ADL) policy dated 12/5/2024 showed the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview and record review, the facility failed to provide lunch meal options of similar nutritive value and failed to accommodate a resident's dietary intolerances. This applies to 4 of 4 (R35, R43, R58, R59) residents reviewed for dining in the sample of 18. The findings include: 1. Facility daily production sheet for February 24, 2025 lunch meal included Italian Herb chicken (3 oz/ounce), buttered noodles (4 oz), Brussels sprouts (4 oz) dinner roll, and cake of the day. On February 24 at 12:22 PM, V6 (Chef) was seen making a grilled cheese sandwich with 2 slices of bread and 2 slices of cheese for R58 whose tray card showed a diet order of Vegetarian diet. R58 received the same with a 4 oz portion each of noodles and Brussels sprouts and a side of cake for dessert. V10 (Cook) who was on the tray line, stated that R58 gets grilled cheese every day. Facility daily production sheet for February 25, 2025 lunch meal included pork fried rice (8 oz), oriental vegetables, dinner roll, tropical fruit mix. Facility provided information that each 8 oz serving of pork fried rice contained 3 oz of pork. On February 25, 2025 at 12:11 PM, R35 received a grilled cheese sandwich made with 2 slices of cheese. R43 also received a grilled cheese sandwich and V10 stated that she put 4 slices of cheese in the sandwich. V10 stated that R35 and R43 received the same as their diets are no pork. On February 26, 2025 at 9:19 AM, V4 (Regional Dietary Director) stated that the facility uses American cheese to make grilled cheese sandwiches. Nutrition facts on the label for cheese slices used for grilled cheese sandwich showed 4 grams of protein for 2 slices of cheese. On February 26, 2025 at 11:51 AM, V15 (Dietitian) stated that 1 oz of meat =7 grams of protein and therefore a 3 oz portion of pork/chicken = 21 grams of protein. V15 stated that as 2 slices of cheese contained only 4 grams of protein, the facility should consider adding other items like cottage cheese when serving grilled cheese sandwich. Facility policy titled Menu Alternates(revised May 31, 2021) included as follows: Policy: Nutritionally comparable menu items shall be available to accommodate resident food preference. 2. R59's diet order on POS (Physician Order Sheet) showed GLUTEN RESTRICTED diet, Regular texture, Regular (Thin) consistency. On February 24, 2025 at 1:03 PM, R59 stated that she did not receive a lunch meal tray. This was relayed to V7 (Registered Nurse) who went and got a tray from a meal cart and delivered the tray without a meal ticket. The lunch meal consisted of Italian fried chicken, noodles, Brussels sprouts, dinner roll and cake. When asked where the meal ticket was, V7 stated that R59 told her that she is on a regular diet. R59's meal ticket was located crumpled up in the meal cart and showed Regular, Gluten free. Next to the items noodles, dinner roll and cake listed on meal ticket it showed no sub (substitute) found. On returning to the room, R59 was in tears and pointing to the noodles, dinner roll and cake, stated I cannot eat all this. I am going to get a stomachache. I am always getting a stomachache as they serve me foods I am not supposed to eat, which I eat as I am hungry. I can't keep buying my own foods. On February 24, 2025 at 1:14 PM, V5 (Dietary Manager) was notified and V5 stated that R59 should not have got the above items with gluten and should have got gluten free items instead. On February 26, 2025 at 11:16 AM, V15 (Dietitian) stated that the facility should serve R56 the diet as shown on the diet order.

Based on observation, interview, and record review, the facility failed to provide high calorie nutrition supplement as ordered by the Physician. This applies to 4 of 4 residents (R19, R27, R20 and R326) reviewed for supplements in the sample of 18. The findings include: 1. R19's face sheet included quadriplegia, other acute osteomyelitis, left femur, dysphagia, unspecified. R19's quarterly MDS dated [DATE] showed that R19 was cognitively intact and was dependent on staff for eating. R19's diet order on POS (Physician Order Sheet) included General diet, Regular texture, Regular (Thin) consistency, High Calorie Drink four times a day for (Brand Name) Plus High Protein with meals and at bedtime (start date October 11, 2024). On February 24, 2025 at 11:00 AM, R19 was lying in bed watching television with head propped up on a pillow. R19 stated that he is unable to use arms as both were contracted. Stated that he is fed by staff, regular consistency food and did not get any (Brand Name) nutrition supplement for breakfast. Multiple cans of (Brand Name) nutrition supplement was seen on a chair in a corner of R19's room. On February 24, 2025 at 1:12 PM, R19 was fed by V11 (Certified Nursing Assistant/CNA) in his room and no High Calorie Drink was seen with meal tray. On February 24, 2025 at 3:13 PM, V7 (Registered Nurse/RN) stated that she gave R19 one can of (Brand Name) earlier and that R19 took a few sips. When R19 was asked again if he received any (Brand Name) supplement from V7, R19 emphatically stated that he did not get any and stated When? R19 glanced towards the box containing (Brand Name) supplements placed on the chair and added They are still there. On February 25, 2025 at 8:56 AM, R19 was fed breakfast in his room by V11 and no High Calorie Drink was seen with breakfast meal. V11 stated that he fed R19 breakfast on February 24, 2025 and R19 did not get (Brand Name). 2. R20's face sheet showed unspecified Dementia, unspecified severity, with other behavioral disturbance, senile degeneration of brain, gastro-esophageal reflux without esophagitis. R20's diet order on POS included Regular diet, Regular texture, Regular (Thin) consistency High Calorie Drink (Brand Name) one time a day Give 237 ml/milliliter (start date February 10, 2025). On February 24, 2025 at 12:57 PM, R20 was served Regular meal in the dining room. Staff provided a grilled cheese sandwich as R20 refused the meal but R20 did not receive a High Calorie Drink. On February 24, 2025 at 9:02 AM, R20 was served breakfast tray in the dining room which she did not eat, but R20 did not receive a High Calorie Drink. On February 25, 2025 at 12:55 PM, R20 was seen wheeling self away from her table with her lunch meal untouched and it did not include a High Calorie Drink. 3. R27's diet on POS included General diet, Pureed texture, Nectar consistency, High Calorie Drink (Brand Name) two times a day 237 ml (Brand Name) (start date February 18, 2025). On February 24, 2025 at 1:00 PM, R27 received a pureed meal at lunch and was fed in dining room by V8 (Restorative Aide). R27 did not receive a High Calorie Drink with his meal. On February 25, 2025 at 8:49 AM, R27 received a pureed meal at breakfast with nectar thick liquids and was fed in dining room by V9 (Restorative Aide). R27 did not receive a High Calorie Drink with his meal. On February 25, 2025 at 12:57 PM, R27 had finished eating lunch and V9 stated that she fed him a pureed meal and that R27 did not get a high calorie supplement. R27's meal tray checked and verified the same. On February 24, 2025 at 3:13 PM, when asked why R20 and R27 did not receive (Brand Name) supplement during days observed, V7 (RN) stated that only R19 has a stock of (Brand Name) supplement in his room that is provided by family. V7 stated that the facility does not have any (Brand Name) supplement currently as the orders were changed from medication pass supplement to (Brand Name) recently. V7 stated that the facility used to have a box of medication pass supplement before but currently have none. V7 went into the medication storage room to verify and stated that there is no High Calorie Drink in there. On February 26, 2025 at 11:08 AM, V14 (Dietitian) stated that she recommends High Calorie Drink to those residents who have inadequate intake, poor appetite and/or weight loss. V14 stated that she was made aware by email on February 10, 2025 that the facility was switching over from the previous nutrition supplement given at medication pass to (Brand Name). V14 added that the switch took over last week (unknown date). 45303 4. The EMR (Electronic Medical Record) showed R326 was admitted to the facility on [DATE], with multiple diagnoses including stroke, type 2 diabetes mellitus, heart failure, and chronic kidney disease. On February 25, 2025, at 8:36 AM, V15 (RN) said R326 is to receive a diabetic high-calorie protein drink, but the facility does not have any. V15 did not administer a diabetic high-calorie drink to R326. R326's Order Summary Report dated February 26, 2025, showed an order dated February 17, 2025, for Diabetic [High-Calorie Protein Drink], one time a day 237 mL (milliliters). On February 26, 2025, at 8:46 AM, V15 documented R326's high-calorie protein drink was not given due On order.

Based on observation, interview, and record review, the facility failed to follow their policies for EBP (Enhanced Barrier Precautions), TBP (Transmission Based Precautions), and hand hygiene during provisions of care. This applies to 4 of 18 residents (R41, R44, R57, and R326) reviewed for infection control in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R326 was admitted to the facility on [DATE], with multiple diagnoses including stroke, type 2 diabetes mellitus, congestive heart failure, and chronic kidney disease. R326's hospital records dated February 13, 2025, showed R326 had a history of Carbapenem-resistant Pseudomonas aeruginosa (a drug resistant organism). On February 25, 2025, at 8:29 AM, V15 (Registered Nurse/RN) said R326 needed to be repositioned in bed. V15 and V16 (Certified Nursing Assistant/CNA) entered R326's room. V15 and V16 did not wear an isolation gown while repositioning R326 in bed. On February 26, 2025, at 11:02 AM, V2 (Director of Nursing/DON) said R326 should have been place on EBP since admission to the facility. On February 26, 2025, at 3:32 PM, V2 said repositioning a resident is considered a high contact activity. V2 continued to say V15 and V16 should have worn gowns while repositioning R326 in bed. The facility's policy titled Enhanced Barrier Precautions dated 7/22, showed General: Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmissions of Staphylococcus aureus and Multidrug Resistant Organisms (MDRO). EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; Infection or colonization with an MDRO . Examples of MDRO's Targeted by CDC (Centers for Disease Control and Prevention) include: Carbapenemase-producing Pseudomonas spp . 29562 2. The electronic medical record shows that R57 was placed on contact isolation for C-Diff (Clostridium difficile). R57's bedroom door has a posting which showed that R57 is on contact isolation. On February 25,2025, at 9:37 AM, V15 (RN) administered IV (intravenous) antibiotic to R57. V15 was wearing gloves and mask, however, she was not wearing an isolation gown. On February 25, 2025, at 12:06 PM, V15 entered R57's bedroom and started setting up the PICC line dressing wearing only her gloves and mask. After she set up the dressing materials, V15 went outside the bedroom to wear a gown, when she saw surveyor entered the bedroom with an isolation gown. Throughout the dressing change V15 sanitized her hands with alcohol-based hand rub in between tasks and glove changing. V15 used a pillow from another bed to prop up R57's right arm during the dressing change. Afterwards she returned the pillow to the other bed without removing the soiled pillowcase and without ensuring the pillow was sanitized after use. 3. On February 25, 2025, at 1:17 PM, V19 and V20 (both CNA) assisted R41 back to bed to render peri-care. V19 and V20 removed R41's shoes and pulled his pants down. V20 proceeded to provided peri-care, applied new incontinence brief, pulled pants back in place while wearing same gloves. After completion of the peri-care, V19 and V20 removed their gloves and carried the soiled items outside the bedroom without performing hand hygiene. 4. On February 26, 2025, at 12:41 PM, V20 and V26 (CNA) rendered incontinence care to R44 who was wet with urine and had a bowel movement. V26 wiped R44 from front to back. V26's gloves made direct contact with the fecal matter during care. When V26 finished cleaning R44's peri-area, she applied new incontinence brief, repositioned R44, straightened bed linens, and adjusted the privacy curtain, while wearing the same soiled gloves all throughout the procedure. On February 26, 2025, at 3:01 PM, V2 (DON) stated, the staff must perform hand hygiene before start of care, in between tasks and glove changes and after completion of the provision of care. The staff must wear complete PPE (gown and gloves, and mask if needed) when providing any care to a resident on contact isolation or EBP (Enhanced Barrier Precaution) to protect the resident and employees from potential infection. The staff must wash their hands in between tasks when dealing with C-Diff cases. Facility's Hand Hygiene Policy dated April 27, 2024, shows: Policy Statement: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure: 1. Soap and water is required for hand hygiene when: -Before and after entering isolation precaution settings. - After caring for resident with diarrheal infection such as C. difficile. - After removing gloves or aprons. 2. Alcohol-based hand rub may be used for all other hygiene opportunities (e.g., when soap and water is not indicated per #1 above). Hand hygiene is to be performed: - When moving from one contaminated body site to a clean body site such as when changing a brief or a wound dressing. - After caring for a resident including after removing gloves. - After contact with the resident environment.

Based on interview and record review the facility failed to offer and provide education regarding the seasonal influenza and pneumococcal vaccines. This applies to 4 of 5 residents (R1, R53, R57, R58) reviewed for immunization in the sample of 18. The findings include: 1. R1's medical record showed R1 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including cerebral palsy, anemia, and essential hypertension. There was no documentation to show R1 was offered or provided education regarding the seasonal influenza vaccine for 2024-2025 season. 2. R53's medical record showed R53 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis due to cerebral infarction, cardiac arrythmia, myalgia and essential hypertension. There was no documentation to show R53 was offered or provided education regarding the seasonal influenza vaccine for the 2024-2025 season. 3. R57's medical record showed R57 was [AGE] years old, admitted to the facility on [DATE], with multiple diagnosis including chronic obstructive pulmonary disease, interstitial lung disease with progressive fibrotic phenotype, chronic diastolic heart disease, and chronic kidney disease stage 3B. The facility provided a consent dated October 16, 2022, for PPSV23 (Pneumococcal Polysaccharide Vaccine) that R57 signed consenting to vaccine administration. There was no documentation that R57 was administered the vaccine. The facility provided documentation that R57 was offered the pneumonia vaccine 20 on January 12, 2023, that showed the family refused the vaccine, but also showed no education was provided regarding the vaccine. 4. R58's medical record showed R58 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including acute on chronic congestive heart failure, hemiplegia and hemiplegia following cerebral infarction, neuromuscular dysfunction of the bladder with urogenital implants, and chronic kidney disease stage 3. There was no documentation to show R58 was offered or provided education regarding the pneumococcal vaccine for the 2024-2025 season. There was no documentation to show R58 was previously vaccinated with a pneumococcal conjugate vaccine. The CDC (Center for Disease Control and Prevention) recommendation dated October 26, 2024, showed for adults aged 50 or over it is recommended to receive a pneumococcal conjugate vaccine if not previously vaccinated or if vaccination status is unknown. On February 24, 2025, at 2:20 PM, V3 (Infection Preventionist) stated V3 reviews resident's immunization status upon admission and influenza vaccine should be offered annually and pneumococcal offered to eligible residents. V3 stated there was a vaccination clinic for influenza offered on December 18, 2024, and provided a list of 29 residents who received the influenza vaccine. There was no documentation offered that residents who did not receive the vaccine were educated and offered the opportunity to decline the vaccine. CMS Form 671 completed on February 24, 2025, showed the facility census was 76, which indicated only approximately 38% (percent) of the residents were offered the influenza vaccine. The Facility's policy titled Influenza and Pneumococcal Immunizations for Residents, dated June 3, 2024, showed Intent: It is the policy of the facility to ensure that the resident receives Influenza and Pneumococcal immunizations in accordance with State and Federal Regulations and national guidelines .Procedure .Influenza Immunization .2. Each resident is offered an influenza immunization October 1 through March 31 annually, .Pneumococcal Immunization .2. Each resident is offered pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized.

Based on interview and record review, the facility failed to provide education and obtain consent or declination for the COVID-19 booster vaccine for the 2024-2025 vaccine. This applies to 5 of 5 residents (R1, R47, R53, R57, and R58) reviewed for immunizations in the sample of 18. The findings include: 1. R1's medical record showed R1 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including cerebral palsy, anemia, and essential hypertension. There was no documentation to show R1 was offered, or education provided regarding the COVID-19 booster vaccine for 2024-2025. 2. R47's medical record showed R47 was [AGE] years old, and was admitted to the facility on [DATE], with multiple diagnosis including human immunodeficiency virus, anoxic brain damage, hemiplegia, and hemiparesis due to cerebral infarction, unspecified asthma, and presence of cardiac pacemaker. There was no documentation to show R47 or representative was offered, or education provided regarding the COVID-19 booster vaccine for 2024-2025. 3. R53's medical record showed R53 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis due to cerebral infarction, cardiac arrythmia, myalgia and essential hypertension. There was no documentation to show R53 was offered or provided education regarding the COVID-19 booster vaccine for 2024-2025. 4. R57's medical record showed R57 was [AGE] years old, admitted to the facility on [DATE], with multiple diagnosis including chronic obstructive pulmonary disease, interstitial lung disease with progressive fibrotic phenotype, chronic diastolic heart disease, and chronic kidney disease stage 3B. There was no documentation to show R57 was offered or provided education regarding the COVID-19 booster vaccine for 2024-2025. 5. R58's medical record showed R58 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including acute on chronic congestive heart failure, hemiplegia and hemiplegia following cerebral infarction, neuromuscular dysfunction of the bladder with urogenital implants, and chronic kidney disease stage 3. There was no documentation to show R58 was offered or provided education regarding the COVID-19 booster vaccine for 2024-2025. The CDC (Center for Disease Control and Prevention) COVID-19 booster guidelines dated January 7, 2025, showed getting the 2024-2025 COVID-19 vaccine is extremely important if you have never received a COVID-19 vaccine, are age [AGE] years old or older, and live in a long-term care facility. On February 24, 2025, at 2:20 PM, V3 (Infection Preventionist) stated there was a COVID-19 vaccine clinic held on December 18, 2024, and provided a list of residents who received the COVID vaccine, which totaled 25. There was no documentation provided regarding other residents' education or declination of the COVID vaccine. Form 671 completed on February 25, 2025, showed the facility census was 76, which indicated only approximately 32% of residents were offered the COVID vaccination for 2024-2025. The Facility's policy titled COVID 19 Guidance dated May 20, 2024, showed The Facility will encourage residents, staff, and families to remain up to date with COVID 19 vaccination, including all eligible booster doses.

Based on observation, interview, and record review, the facility failed treat a resident with dignity by offering the resident slippers that were soiled with stool and by not cleaning the same slippers. This applies to 1 of 18 residents (R12) reviewed for dignity in the sample of 18. The findings include: R12's Face Sheet showed R12 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation, abdominal aortic aneurysm without rupture, Partial intestinal obstruction, Ileostomy Status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. R12's Minimum Data Set, dated dated dated [DATE] showed R12 was cognitively intact. On February 24, 2025 at 10:42 AM, V18 (Licensed Practical Nurse/LPN) entered R12's room to change R12's ileostomy. R12's gown, abdomen, fitted sheet, and back were wet with liquid stool. V18 wiped R12's abdominal area with an incontinence wipe and changed her ileostomy dressing. V18 left the room and said she would send a Certified Nursing Assistant (CNA) to help get R12 cleaned up. On February 24, 2025 at 11:07 AM, V19 (CNA) entered R12's room, with a gown and sheets and told R12 she would help her get cleaned up. After V19 helped R12 into a clean gown, V19 then picked up R12's slippers (beige teddy bear material) that had dried brown and black round stains on the tops of them and offered them to R12. The top of R12's right slipper was almost completely covered with the stains. V19 placed the slippers on the floor and helped R12 stand and put on the stained slippers. After V19 had changed R12's gown and linens, she left the room. R12 stated stool from her colostomy bag dropped on her slippers last week when she pulled down her incontinence brief. On February 25, 2025 at 11:49 AM, R12's slippers were still covered in stool at her bedside. R12 stated it has been that way since last week and no one has offered to clean them. R12 stated she would like to have them washed. On February 26, 2025 at 10:00 AM, V2 (Director of Nursing/DON) went to R12's room and saw the stool stained slippers at R12's bedside. V2 said, Oh no, and told the resident that she would have laundry wash R12's slippers. On February 26, 2025 at 2:37 PM, V2 stated staff should have taken R12's slippers to the laundry and washed them because they are washable. V2 stated, the reason for cleaning the slippers, is that the slippers could containment things. V2 stated that offering and assisting R12 into stool-stained slippers and not having them washed is considered a dignity issue. The facility's Resident Rights policy dated January 17, 2025 showed the following: procedure: 9. Each resident will be treated with dignity and respect.

Based on observation, interview, and record review, the facility failed to ensure that the indwelling urinary catheters of residents were secured, and the urinary bag was not resting on the floor. This applies to 3 of 6 residents (R11, R41, and R57) reviewed for indwelling urinary catheters in the sample of 18. The findings include: 1. Face sheet shows, R57 is [AGE] years-old who has multiple medical diagnoses including chronic kidney disease, stage 3B, urethral stricture, male, unspecified site, obstructive and reflux uropathy, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, presence of urogenital implants. R57's Minimum Data Set (MDS) dated [DATE], shows, R57 is alert and oriented and requires assistance for toileting. R57's Care Plan with revision date of February 11, 2025, shows: R57 has chronic indwelling catheter related to BPH and urethral stricture. The goal is for R57 to be free from complications related to the use of catheter. The same care plan shows multiple interventions which include Retention Strap in place to assist in maintaining catheter tubing alignment as tolerated. On February 24, 2025, at 11:06 AM, during initial rounds with V23 (Certified Nursing Assistant/CNA), R57 was resting in bed. R57's had an indwelling urinary catheter that was not anchored or secured to his thigh. R57 stated that his catheter tube has been unsecured for a while now but was unable to tell how long. There was no sign of anchor or retention strap on the tube or on his thighs. On February 25, 2025, at 1:40 PM, R57's indwelling urinary catheter remained unsecured, with the urinary catheter bag resting directly on the floor. 2. Face sheets shows, R41 is [AGE] years-old who has multiple medical diagnoses including infection and inflammatory reaction due to indwelling urethral catheter, and obstructive and reflux uropathy, unspecified. R41's MDS dated [DATE], shows that R41 requires assistance for toileting. R41's Care Plan which has a target date of April 14, 2025, shows: R41 has indwelling urinary catheter due to urinary retention related to uropathy. The same care plan shows that R41 has two prior hospitalization s in 2024, due to gross hematuria, urinary tract infection (UTI), end stage bladder, bladder fungus ball and sepsis. On February 25, 2025, at 1:17 PM, V19 and V20 (both CNAs) assisted resident back to bed for peri-care. R41 had an indwelling urinary catheter which was not secured. The catheter tubing was pulling while R41 was being repositioned or when care was being provided. There was no sign of anchor or strap on R41's catheter tubing or on his thighs. 3. Face sheet shows, R11 is [AGE] years-old who has multiple medical diagnoses including benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, chronic kidney disease stage 4, neuromuscular dysfunction of bladder, and unspecified hydronephrosis. R11's Care Plan with a target date of March 7, 2025, shows R11 has suprapubic catheter related to sacral wounds and recurrent UTI. The goal is to be free from complications related to use of catheter. On February 25, 2025, at 1:32 PM, R11 was sleeping in his bed. Upon assessment of R11's indwelling (suprapubic) catheter with V18 (Licensed Practical Nurse), it was observed that R11's catheter tube was detached from the anchor, leaving the tube unsecured. On February 26, 2025, at 3:19 PM, V2 (Director of Nursing) stated that the resident's indwelling urinary catheter must be always secured to prevent from getting pulled and being dislodge. V2 added, the catheter bag must be always off the floor to prevent infection. Facility's Policy for Perineal Care/Indwelling Catheter Care dated 11/1/2018 shows: 7. Ensure Foley Catheter is positioned correctly and secured. and 10. Ensure the bag is off the floor.

Based on observation, interview, and record review, the facility failed to follow physician's order for management of Peripherally Inserted Central Catheter (PICC) line. This applies to 1 of 2 residents (R57) reviewed for care of intravenous catheter in the sample of 18. The findings include: On February 25, 2025, at 9:37 AM, V15 (Registered Nurse) administered an IV (Intravenous) antibiotic (Ceftriaxone 2 grams) medication to R57 who had a PICC line on his right upper arm. The PICC line dressing, which was dated February 3, 2025, was loose and opened halfway. Physician Order Summary (POS) Report dated February 9, 2025, shows PICC line dressing change once a week and as needed one time a day every 7 days for infection prevention. R57's care plan with revision dated of February 11, 2025, shows R57 has PICC line on the right basilic for IV antibiotic infusion. The goal is for the PICC line to remain free from signs of infection. This same care plan shows multiple interventions which include to change dressing weekly, or sooner, if it is soiled, loose, or damp. Use sterile aseptic technique when changing the dressing. On February 25, 2025, at 12:06 PM, V15 provided dressing change to R57's PICC line. V15 stated that the dressing must be change every 7 days and as needed. V15 confirmed that the dressing was dated 2/3/25. V15 changed the dressing, however, V15 did not measure the length of the catheter and arm circumference. On February 26, 2025, at 3:12 PM, V2 (Director of Nursing) stated, when staff are changing the PICC line dressing, the staff must measure the length of the catheter to check for migration of catheter and measure arm circumference, to check for swelling. V2 also stated PICC line dressing must be change every 7 days and as needed to prevent infection. V2 further stated the staff must ensure that dressing is always intact.

Based on observation, interview, and record review the facility failed to have a physician order and care plan for oxygen administration in accordance with their policy. This applies to 1 of 1 resident (R325) reviewed for oxygen use in the sample of 18. The findings include: R325 was admitted to the facility on [DATE], with multiple diagnosis including chronic obstructive pulmonary disease, dependence on oxygen, chronic respiratory failure with hypoxia, centrilobular emphysema, influenza A, and cyst of the pancreas. On February 24, 2025, at 12:10 PM, R325 was observed with oxygen infusing via nasal cannula. R325's Health Status note dated February 24, 2025, at 11:12 PM showed continuous oxygen was administered at 3L (Liters) per NC (Nasal Cannula). On February 26, 2025, at 10:10 AM, R325 was observed with oxygen infusing via nasal cannula. V15 (RN/registered Nurse) stated the oxygen was infusing at 3L per NC and R325 can have 4L per NC if R325 gets anxious. R325's hospital H&P (History and Physical) dated February 16, 2025, showed under history of present illness R325 baseline oxygen use at 2L per NC continuously. R325's physician order summary dated February 23, 2025, through February 25, 2025, showed there was no order for oxygen administration. R325's care plan initiated on February 26, 2025, for the problem of shortness of breath, had no specified settings for the use of oxygen in the care plan interventions. On February 26, 2025, V2 (DON/Director of Nursing) provided a list of all residents in the facility who utilize oxygen and R325 was not identified on that list. On February 26, 2025, at 4:30 PM, V2 stated there should be physician orders to administer oxygen and the order should include the amount of liter flow and method of delivery. The Facility's policy titled Oxygen, dated April 2024, showed Policy Statement .it is the facility's policy to ensure that oxygen .use is compliant with acceptable standards of practice .Procedures .4 .Physician's order will be obtained.

Based on interview and record review, the facility failed to provide a resident's medical records within two working days upon request for two of three residents (R1, R7) reviewed for medical records request in the sample of eight. The findings include: 1. R1's Face Sheet dated February 20, 2025 shows she was admitted to the facility on [DATE] with diagnoses including spinal stenosis, low back pain, history of falling, urinary retention, and lack of coordination. R1 was discharged from the facility January 16, 2025. On February 20, 2025 at 9:34 AM, V7 (R1's Spouse) said he has been waiting to receive R1's medical records for over a month. V7 said they requested the records from V8 (Medical Records). V7 said that R1 just had another surgery on her back. V7 said R1 is entitled to those records. V7 said that he nor R1 has heard anything back from the facility regarding their medical records request. On February 20, 2025 at 11:18 AM, V8 (Medical Records) said if someone is requesting medical records, then she has them fill out a form and she sends that form to her legal team. V8 said the legal team processes the medical records request. V8 said she received a request from R1's medical records request on January 25, 2025 and she sent that off to her legal department. V8 said she was always told that there was 30 days to get the request fulfilled if they were not current residents in the facility and two days if they were. V8 said she has not followed up with R1's request to see if she had received her medical records or not. V8 said that R1 called the facility on February 20, 2025 and said she had not received her records yet so V8 emailed her legal team to follow up. R1's Authorization for Use and Disclosure of Protected Health Information request was signed by R1 on January 24, 2025. 2. On February 20, 2025 at 11:42 AM, V6 (R7's Power of Attorney) said she requested R7's medical records on January 27, 2025 and still had not received them as of February 20, 2025. V6 said she has reached out to the facility on e other time since the request and the facility said they would get R7's medical records to V6. R7's HIPPA Privacy Authorization for Disclosure of Protected Health Information Relevant to Litigation or Pending Claims request was signed by V6 on January 17, 2025. On February 20, 2025 at 11:18 AM, V8 (Medical Records) said R7's request was originally and incorrectly made to a sister facility. But the current and correct facility received the request on January 27, 2025. V8 said she has not heard from R7's family if they have received the medical records has not followed up to see if they have. The facility's Medical Records Request policy dated February 27, 2023 shows, Residents are always entitled to their medical records, but must follow the process for requesting them. Time to process a Record Request: Residents that have been discharged from the facility-30 days. The Illinois Long-Term Care Residents' Right booklet revised November 2018 shows, Your facility must allow you to see your records within 24 hours of your request (excluding weekends and holidays). You may purchase a copy of part or all of your records at a reasonable copy fee within two working days of your request.

Based on interview and record review the facility failed to safely assist and position a resident (R1) in bed when rendering care. This failure resulted in the resident falling out of bed and sustaining left tibial and ankle fractures. This applies to 1 out of 3 (R1) residents reviewed for accidents. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, post-orthopedic surgery to both ankle tendons, history of other disease of the nervous system, and history of malignant neoplasm of the brain. R1's Hospital Records dated 12/8/2024, said [R1] fell approx. (approximately) 4 ft from bed while being changed by CNA. She states she rolled off on the right side of the bed landed on left side. The hospital records continued to say R1 sustained left tibial and ankle fractures. On 12/12/2024 at 12:50 PM, V4 (Licensed Practical Nurse/LPN) said on 12/7/2024 she assessed R1 after her fall incident. V4 said R1 was complaining of pain and had to be transferred to the hospital. V4 said R1 returned to the facility with a long leg cast to her left lower leg because she had sustained multiple fractures. V4 said R1 had always needed a 2-person staff assistance with bed mobility because she had chronic left-side weakness in both her upper and lower extremities. On 12/12/2024 at 1 PM, V9 (Restorative Nurse) said she assessed R1's mobility function on 9/14/2024 and determined R1 required the use of bilateral enablers (quarter-size side rails) and 2-person staff assistance when receiving care in bed on her air-loss mattress. V9 said R1's ADL care plan showed she required extensive assistance with bed mobility. V9 was unable to locate in R1's comprehensive care plan her intervention indicating that R1 required a 2-person staff assistance with bed mobility and positioning when in bed. On 12/12/2024 at 1:15 PM, V10 (Therapy Rehab Director) said he was familiar with R1 because she was discharged from therapy services on 10/14/2024. V10 said R1 required substantial to maximal assistance of 2-staff members with her bed mobility. V10 said he had trained the facility's CNAs on how to safely position residents in bed when rendering care. V10 said R1 should have been assisted by 2-staff members, one on each side of the bed to ensure her safety when being turned in the bed. On 12/12/2024 at 1:40 PM, V3 (Certified Nurse Assistant/CNA) was interviewed regarding R1's fall incident on 12/7/2024. V3 said at approximately 4 PM she assisted R1 in bed with incontinence care. V3 said R1 slid and rolled out of the bed when she turned her on her right side. V3 said she was new and felt rushed because she was unfamiliar with R1's care needs. V3 said she noticed R1 had a sticker on her bed indicating she was a 2-person total mechanical lift transfer but was unsure how much assistance she required with bed mobility. V3 said she was not trained on how to determine the level of assistance a resident requires with their ADLs (Activities of Daily Living) of bed mobility and positioning. On 12/12/2024 at 2 PM, V2 (Director of Nursing/DON) said she expects new CNAs to be trained on bed mobility during orientation. V2 said V3 (CNA) was educated on 12/7/2024 (after R1's fall incident) on the need to provide 2-person staff assistance when rendering care to resident on an air-loss mattress. V2 said V3 failed to have another staff member assist her while she was providing incontinence care to R1 on 12/7/2024. On 12/12/2024 at 2:15 PM, V11 (Physician) said R1 required staff assistance with her ADLs because she had chronic hemiparesis to her left side related to her stroke. V11 said she depends on therapy and nursing to assess residents to determine how much assistance they require with their ADLs. V11 said R1's fall on 12/7/2024 resulted in her sustaining fractures to her left leg. V11 said she expected facility staff to follow safety protocols when rendering care to ensure the safety of residents. R1's Mobility assessment dated [DATE], showed R1 had a poor ability to roll from side to side with the use of her left side. The assessment also showed R1 had a poor range of motion, muscle strength, mobility, and balance to her left upper and lower extremities. R1's Physical Therapy Discharge Summary dated 10/14/2024, showed R1 required substantial/maximal assistance from facility staff for bed mobility when rolling left to right side. R1's Fall assessment dated [DATE], showed R1 was at Moderate Risk for falls. R1's Fall Event dated 12/7/2024, said R1 fell out of bed when the CNA rolled her on her right side. R1's Progress Note dated 12/9/2024 said an IDT (Interdisciplinary Team) Review was done regarding R1's fall on 12/7/2024. The Progress Note showed Root Cause: inability to maintain balance during ADL care .Interventions .staff to complete cares in pairs. R1's Care Plan reviewed on 12/12/2024, showed a fall prevention intervention initiated on 12/7/2024 (post-fall) for Positioning: Staff will ensure that resident is centered in bed .and trunk and extremities are properly aligned and supported. R1's care plan also showed an intervention of Resident currently requires assistance with ADLs: Bed Mobility: Extensive initiated on 2/2/2024. R1's comprehensive care plan does not indicate the number of staff members R1 requires for her extensive bed mobility care needs. The facility's policy titled Fall Prevention and Management dated 4/8/2024, said The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained .Interventions will depend on identified and assessed risk factors, including root cause/s every after each fall or when a pattern has been identified. Some of these interventions may include but not limited to .Restorative Program .Bed Mobility .Development of the fall interventions plan is based on results of the Falls Assessment as well as investigation of all circumstances and related resident outcomes . The facility's policy titled Supporting Activities of Daily Living (ADL) dated 11/7/2024, said Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .including appropriate support and assistance with .b. Mobility (turning, re-positioning .) .A resident's ability to perform ADLs will be measured using clinical tools .The resident's response to interventions will be monitored, evaluated, and revised as appropriate .

Based on interview and record review the facility failed to provide a safe discharge for a resident with insulin-dependent diabetes and end-stage renal failure, requiring hemodialysis. This failure resulted in R1 being discharged from the facility and sent to a homeless shelter without the shelter's knowledge or ability to accept and care for the resident. Because of the resident's homelessness, R1 was transported to the local hospital, where he remained as of August 22, 2024, awaiting placement in another long-term care facility. These failures resulted in an immediate jeopardy. This applies to 1 of 3 residents (R1) reviewed for discharge in the sample of 3. The findings include: The immediate jeopardy began on August 14, 2024 when the facility involuntarily discharged R1 to a homeless shelter. V1 (Administrator) was notified of the Immediate Jeopardy on August 22, 2024 at 1:33 PM. The surveyor confirmed by observation, interview, and record review that the immediacy was removed on August 26, 2024, at 2:36 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. On August 18, 2024 at 6:42 PM, R1 said, On August 14, I was called to the front of the building, and they said they had to talk to me. I went up to the front and the police were up front, waiting for me. They handed me discharge papers. They said something about involuntary discharge for being a danger to myself and others. They said I was drunk, which was nonsense. I have a doctor's order for alcohol. They said there was a ride waiting for me, and I had to get my stuff together. This was the first time I'd heard they were going to discharge me. There was a van out in front, and they didn't tell me where I was going. I thought I was going to another nursing home. We started driving, for what seemed like a long time, and I asked the driver where we were going, and he said Joliet. I had a couple of boxes with me that were each measured probably 2 feet by 3 feet, and my wheelchair. We pulled up, and I couldn't get out of the van without help. Someone came out of the building and said this is a homeless shelter and they weren't expecting me. One of the shelter's administrators called the facility where I had just come from, and the shelter's administrator was told administration made this decision. So, I didn't know what else to do. The shelter couldn't accept me, and I had nowhere else to go. I called 911 to get help from the police. I ended up agreeing to go to the hospital because there was nowhere else for me to go. I've been at the hospital ever since and receiving my dialysis here in the hospital. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was involuntary discharged from the facility on August 14, 2024. R1 had multiple diagnoses including, diabetes, end-stage renal disease, acute pulmonary edema, heart failure, acute respiratory failure, anxiety disorder, anemia, alcohol abuse, and glaucoma. Hospital records provided to the facility prior to R1's admission to the facility dated November 4, 2022 show R1 had anxiety, uncontrolled diabetes, alcohol abuse, cigarette smoking, acute psychiatric concerns, aggressive behavior, paranoid delusions, suicidal and homicidal remarks in the ER (emergency room ). He threatened to shoot up the shelters and shoot himself because he was tired of his illness. He was belligerent with the healthcare team and had to be placed in restraints. R1's MDS (Minimum Data Set) dated June 12, 2024 shows R1 was cognitively intact, used a walker or wheelchair for mobility, and was able to perform all ADLs (Activities of Daily Living) independently. R1 was always continent of bowel and bladder. The MDS continues to show R1 participated in the MDS assessment and goal setting, did not have active discharge planning occurring to return to the community, and did not want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. Facility documentation shows R1 started on hemodialysis in January 2024. R1 received hemodialysis outside of the facility three times a week. Facility documentation shows the following order for R1 dated June 20, 2024 and discontinued on August 14, 2024 (R1's date of discharge): May have alcohol. The facility's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing dated August 14, 2024 shows R1 was discharged to a homeless shelter over 35 miles away from the facility on August 14, 2024, due to the health of individuals in the facility would otherwise be endangered as documented by a physician in your clinical record. The IVD (Involuntary Discharge) notice continues to show, As discussed with [R1] on August 14, 2024, and as documented in your clinical record pursuant to Section 3-408 of the state law, the reason for the proposed transfer or discharge is: the physical safety of other residents, the facility's staff or visitors . The effective date of the proposed transfer or discharge is August 14, 2024. The IVD notice was signed by V1 (Administrator) on August 14, 2024. On August 14, 2024 at 2:45 PM, V1 (Administrator) documented, Involuntary Discharge was explained and issued with witnesses. Resident verbally agreed to pack his own belongings and donate whatever he leaves. Medications and prescriptions given to resident. Explained that his personal vehicle would need to be removed by the end of day 3 which is 8/17/24. Resident verbalized understanding and placed some of his belongings in his personal vehicle. Entire incident witnessed by two [local] police officers, SSD (Social Service Director), DON (Director of Nursing, Regional SS (Social Service) and Maintenance Director. Resident picked up by [ride company] at 2:50 PM and left facility. On August 14, 2024 at 5:03 PM, V3 (SSD) documented, [Local] Police department (near homeless shelter) contacted the facility and call was transferred to this writer. Police officer inquired, why was [R1] placed in a vehicle and sent to [homeless shelter]. This writer informed because he received an Involuntary Discharge from the facility, please request to see the document. Officer stated, thank you and disconnected the call. On August 14, 2024 at 5:05 PM, V3 (SSD) documented, [Homeless Shelter] case manager contacted this writer and inquired, why was [R1], discharged to our shelter? Replay was [R1] received an Involuntary discharge, he has the document, please request to review. Case manager explained, We do not accept nursing home residents, typically the process is we review the clinicals. Case manager informed this writer he stated he is going to the hospital. On August 19, 2024 at 11:15 AM, V1 (Administrator) said, R1 was extremely unhappy and manipulative. He calls staff names, he will leave the facility without permission, he orders his own ride share, he has a drinking problem and returns late, and we believe he was intoxicated. He takes other residents out to go out on the sidewalk and go to the store. (R2, R3, R4). He threatens to call (state surveying agency) on us. He would throw parties on the patio and invite people and they came through the back gate. We know he has a problem. Every agreement he makes he turns around and breaks it. Leading up to that day (August 14), he was encouraging the other residents to go out, and being intoxicated. His physician was trying to convince him to go to detox or stop engaging in this behavior. We have not tried petitioning him out for a psych evaluation since I started here in October 2023. He wants to get an apartment. The regional team combed through the records, and they showed he came from a shelter and just decided that would be the best place for him to go, or the only place to go. He left the facility in a wheelchair. He goes to dialysis on Tuesday, Thursday, and Saturday. We sent him to the homeless shelter, and [R1] got there and said he did not know why he was there and that he did not know he was going there. He said he did not consent to going there. He was a danger to some other residents (R2, R3, and R4) directing them to do what they wanted to do. Facility documentation shows R2, R3, and R4 are cognitively intact residents. On August 19, 2024 at 11:45 AM, V10 (Senior Social Worker) said, I was looking at different shelters for [R1]. To be eligible you have to experience homelessness, and once he got the involuntary discharge, he was homeless. There was an evening he came back to the facility intoxicated, and he was manipulating other residents to drink. He was becoming more and more challenging with disruptive behavior. He had an order from the physician to be able to drink alcohol. On August 7, 2024 at 3:09 PM, V13 (Psych Nurse Practitioner/NP) documented: [R1] is seen today per request of the facility Administrator and staff. [R1] is known to our service, last seen in March of this year for verbally inappropriate comments and disruptive behaviors. He is cognitively intact x 4 and is knowledgeable about his medical issues and medications. [R1] is on HD (Hemodialysis) 3x/weekly at an outside center and has returned from dialysis heavily intoxicated from both ETOH (alcohol) and cannabis. [R1] is allowed to have three beers daily per his primary MD at the facility however, he is sharing his alcohol with other residents who are cognitively impaired and should not be drinking ETOH with their medical issues and dementia. [R1] is manipulative and tries to turn other residents who are in lower functioning against the staff. He bribes them with alcohol or cannabis and tells them that they do not have to listen to the staff or follow any rules. He calls the State to report on the facility, threatening to bust them for being a big dump. [R1] does not need to be in the care of a facility, can be independent with all his ADLs, and stays at the facility due to his homelessness. He has no family relations and has a history of SUD (substance use disorder) and battery towards his spouse. He has always denied any of the above actions and refuses any medications for mood.Mood: euthymic mood and congruent affect were seen on exam. Thought processes and associations: thought processes showed associations/processes/abstractions WNL (within normal limits). Thought content: Patient did not endorse suicidal ideation, homicidal ideation, violent ideation, auditory/visual hallucinations, or delusions. Insight/judgement: The patient's insight and judgement are appropriate. Assessment: This patient has multiple psychiatric complexities and would benefit from continued management with monitoring of mood and behavior. Will titrate medications based on current symptom progression. Pharmacologic/Non-Pharmacologic Interventions: [R1] refuses any psychotropic medications and does not follow facility rules, continues to use alcohol and smoke cannabis. He is disruptive and manipulates and poses a significant danger to the other residents and staff at the facility. The facility does not have documentation to show R1 had a positive alcohol or drug test. On August 19, 2024 at 1:14 PM, V13 (Psych NP) said, I saw him on August 7, 2024. I had not seen him since March 2024. When he first came to the building he had been living in his car and had been suicidal. He is alert and oriented. The current problems are new, maybe since he started going to dialysis (January 2024). I guess he was coming back to the facility intoxicated. I never saw him intoxicated. He is very bright, he is smart, he knows what he is doing. The facility felt they were held hostage by his behavior. Where do you put someone like this? We have never petitioned him for a psychiatric evaluation. I guess if you are giving drugs or alcohol to other residents who cannot make decisions that could be a problem, though I do not believe [R2], [R3], or [R4] are cognitively impaired. I think the Medical Director allowed [R1] to have alcohol and that escalated other behaviors. He created a [NAME] of other residents who don't want to follow the rules. I said he was a danger to the other resident for giving them alcohol. That was the danger. He wasn't really a problem, he was annoying. My notes and the letter I wrote were a request from the facility. That was my first time writing something like this. V13 continued to say she had not seen R1 intoxicated or in the possession of alcohol or cannabis. On August 20, 2024 at 3:59 PM, V5 (Assistant Director of Nursing/ADON) said, When [V13] (Psych NP) wrote that note on August 7 and said [R1] was a danger to himself and others, nothing was implemented to protect other residents from him. We did not do a one-to-one sitter or send him to dialysis with a facility staff member. There was no frequent monitoring. On August 20, 2024 at 1:03 PM, V11 (Medical Director/Physician) said, [R1] was my patient. I think the bigger problem was he was drinking excessively and not following the house rules about being intoxicated and influencing other resident with drinking. He was kind of acting like a college student. I can agree that the resident was admitted to the facility in November 2022 with the same issues and the facility was aware of his alcoholism and behaviors at that time. I know the NP wrote a note on August 7 that showed he was a danger to himself, and others and we waited seven days to involuntarily discharge him and give him the notice. We looked into all of this with legal and the social worker and I think the delay in discharging him was in that process. We wanted to make sure we made proper arrangements for him and coordinated his care. They should have coordinated his care with the receiving facility. I did not take any involvement on how it was done. I expect the facility to follow the Federal regulations for involuntary discharges, and to follow the facility's policy for involuntary discharge. I was not aware [R1] was dropped at the homeless shelter or that 911 had to be called or that he was sent to the hospital and is still awaiting placement in a facility. It was not the intention to discharge him to the streets. [R3], another resident currently residing at the facility, is making poor choices as well. If he doesn't improve on his act, we have to make a choice for him. When asked about hospital records dated November 2022 showing R1 had similar behaviors in the hospital, prior to his admission to the facility, including alcohol abuse and belligerence towards medical staff, and the need for restraints in the hospital, V11 admitted the facility was aware and admitted the resident to the facility in November 2022 knowing that information. On August 19, 2024 at 12:32 PM, V3 (SSD) said, The decision to involuntarily discharge [R1] was made at the Regional level. I did not have a conversation with the homeless shelter, and I did not choose that place. It was 5:00 PM on August 14, and the shelter called and said they could not keep him. I cannot speak to why he was not discharged a week earlier, on August 7, 2024 after the psych NP (Nurse Practitioner) (V13) saw him and said he was a danger to himself and others. On August 20, 2024 at 1:43 PM, V9 (Hospital Case Manager) said, [R1] is still in the hospital and we are still trying to find him placement. We sent out 46 referrals. 32 facilities declined, 11 did not respond, and two accepted, and one is interested. We have to see if [R1] will qualify to go to these facilities due to his dialysis needs. On August 19, 2024 at 1:38 PM, V8 (Homeless Shelter Case Manager) said, I manage the homeless male residents at the shelter. No one from the facility ever called me and talked to me about placing [R1]. We have a procedure for taking people. They have to send us paperwork, including discharging paperwork. They have to make contact with someone here in order to send a person. We explain the shelter and let them know they have to be self-sufficient to be here. I watched him, and he could not transfer himself from the [ride share vehicle] to the wheelchair. The paramedics had to help him. I saw that happen. We did not know he was coming that day. It was almost 4:30 PM, and our guest coordinator told us someone was being dropped off and we needed to go downstairs immediately. [R1] wasn't even aware where he was sent to. We do not accept residents from the county [R1] was coming from. On August 20, 2024 at 9:28 AM, V7 (Homeless Shelter Director of Programs) said, It is not uncommon for nursing homes or hospitals to do a patient dump, but we have a procedure for when a resident is going to be sent to us, to get prior authorization. That did not happen with [R1]. On August 14, 2024 around 4:00 to 4:15 PM, a van pulled up in our parking lot and [R1] was getting out and we addressed him, and he said he was involuntarily discharged from [the facility]. I immediately got on the phone and talked to [V3] (SSD), and she said she did not do the discharge that it came from Administration. She said he was a danger to others. I said they just dropped off someone who cannot qualify for services in our county. I told her we are not a medical facility. I asked him to go the hospital and have them contact the physician. No one from the facility reached out to us. There was no authorization for him to come here. Not even a call to ask if we could accommodate him. We would not have accepted him. We would not have been able to take care of him. We are a temporary solution; we are not long-term housing. He needs dialysis, he needs to take medications, we don't do that here. On August 21, 2024 at 11:44 AM, V7 (Homeless Shelter Director of Programs) said, The sleeping arrangements at the shelter are on a first come, first served basis. The sleeping quarters are open from 6:00 PM to 7:00 AM, seven days a week. Everyone in the sleeping quarters is given a wake-up notice between 6:15 AM and 6:30 AM, and everyone has to be out, with all of their belongings at 7:00 AM when the doors are locked until the evening. People can get three meals a day in our cafeteria, but the cafeteria closes between meals. We do not pack meals for people leaving to go to a job or to dialysis. We would not have been able to provide [R1] with meals to take with to dialysis. We have a drop-in center that is open from 8:00 AM to 11:45 AM and 1:00 PM to 4:45 PM where people with no place to go can hang out. During the period of April 1 to October 1, the drop in shelter is closed on Saturdays and Sundays, and homeless people have to find their own shelter during the day, so for instance [R1] would have had to find somewhere to go during the day on Saturdays and Sundays until October 1. If he had to have dialysis on Saturdays, he would have to arrange and pay for his own transportation, and they would have to pick him up somewhere else since our shelter is closed in the summer. He also would have had to carry all of his belongings with him everywhere he went because we do not store any belongings here. The facility's Discharge Planning policy dated June 24, 2024 shows: It is the policy of the facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions, in accordance with State and Federal Regulations. Procedure: 1. The facility's discharge planning process will be consistent with the discharge rights set forth at 483.15(b) as applicable.6. The facility will involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan . The facility's policy entitled Involuntary Discharge (IVD), dated June 19, 2020, and reviewed January 28, 2024 shows: To provide proper notification to all parties regarding a resident who is being involuntarily discharged . Guideline: 1. The facility will provide notification of an involuntary discharge or transfer according to guidelines established by Federal and State agencies. 2. An involuntary discharge will be issued under the following circumstances: a. An appropriate alternative placement is located, b. The transfer or discharge is necessary for the resident's welfare, c. The discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, d. The facility discharges a resident because the health of other individuals in the facility would otherwise be endangered, e. The facility discharges a resident because of late or non-payment for services. 3. The resident responsible party (if appropriate) and agencies are notified in writing of the discharge 30 days prior to the discharge date . This is done via a notice of Involuntary Discharge form with an opportunity for hearing. 4. A copy of this notice must also be sent to the Department of Public Health and the local Ombudsman's office, if the resident is receiving Medicare, the Department of Public Aid. 5. The request for hearing form delivered to the resident. 6. Document in the resident record that the discharge and procedure were discussed with the resident and/or their representative if appropriate. 7. The resident cannot be involuntarily discharged from the facility until the process is completed. The facility presented an abatement plan to remove the immediacy on August 22, 2024 at 5:53 PM. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented an abatement plan to remove the immediacy on August 26, 2024 at 9:18 AM. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented an abatement plan to remove the immediacy on August 26, 2024 at 11:35 AM. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented an abatement plan to remove the immediacy on August 26, 2024 at 2:05 PM. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented an abatement plan to remove the immediacy on August 26, 2024 at 2:36 PM, and the survey team accepted the abatement plan on August 26, 2024 at 2:36 PM. The Immediate Jeopardy that began on August 14, 2024, at approximately 4:00 PM was removed on August 26, 2024, at 2:36 PM when the facility took the following actions to remove the immediacy: 1.) The Social Service Director audited and identified nine (9) residents with similar challenging behaviors. The nine residents were assessed via observation and review of clinical documentation, care plan, appropriateness of discharge location related to resident's needs and discharge criteria. All identified residents remain at facility. 2.) The facility initiated and completed education on August 22, 2024 for the clinical staff and IDT (Interdisciplinary Team) regarding the discharge process which includes discharge address, necessary equipment, medications and/or prescriptions, transportation, community services, physician notification, discharge orders, and reason for discharge. Education of agency staff, PRN (as needed) and vacationing staff will be completed prior to the start of their next shift. 3.) New hires will receive discharge education in orientation. 4.) Education was completed with the Social Service Director on appropriateness of discharge location related to the resident's needs on August 26, 2024. 5.) The facility reviewed and updated the policy and procedure regarding involuntary discharge and transfer on August 22, 2024, and then again on August 26, 2024. 6.) The facility Administrator and/or designee will monitor all discharges, using the discharge tool, for four weeks to ensure appropriateness to include accurate discharge address, necessary equipment, medications, transportation, community services, physician notification with orders and reason for discharge, prior to actual discharge. 7.) The administrator and/or designee will review the discharge tool prior to each discharge to ensure a safe discharge for four weeks. 8.) The Administrator and/or designee will bring the discharge tool to Quality Assurance meeting for review and recommendations for the duration of the audit. 9.) An ad hoc QAPI (Quality Assurance and Performance Improvement) was completed with the Medical Director on August 22, 2024 to review the removal plan.

Based on interview and record review the facility failed to ensure a resident's pain was being managed after being discharged from the hospital for an ankle fracture. This failure resulted R1 experiencing uncontrolled pain for 4 days. This applies to 1 of 3 residents reviewed for pain (R1) in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] from a local community hospital with diagnoses including Bipolar Disorder, Mood Disorder, Depression and Pathological fracture to her right ankle. R1's 10/20/23 facility assessment shows her cognition is intact and she has no memory impairments. R1's hospital records show she was admitted to a local community hospital on 10/14/23 following a fall resulting in displaced fractures of the medical and lateral malleoli (ankle bone fractures). R1's hospital discharge transfer summary completed on 10/17/23 shows R1 should continue to take the following medications for pain at the facility Hydrocodone-acetaminophen 5-325 milligrams (mg). (Norco- pain medication) 1-2 tablets every four hours as needed. R1's nursing summary notes shows she was admitted to the facility on [DATE] at 7:40 PM. A nursing progress note completed by V9 (Registered Nurse/RN) on 10/18/23 at 12:29 AM states, resident's medications were reviewed with the provider and reconciled. R1's Physician Order Summary (POS) shows her order for the pain medication Hydrocodone-acetaminophen was not entered into the POS until 10/20/23. R1's Medication Administration Record (MAR) from 10/1/23-10/31/23 shows R1's Hydrocodone was entered into the MAR with a start date of 10/18/23 but no doses were signed off as given until 10/21/23. The MAR shows on 10/18/23 R1 received Tylenol 500 mg 2 tablets and documents a pain of 5 on a pain scale of 1-10. R1's nursing notes for 10/21/23 at 6:35 AM, show the facility called the pharmacy due to R1's medication not being at the facility. The pharmacy informed the facility R1's Norco still needed a physician prescription. There is no documented progress note that V3 (R1's Primary Care Physician) was contacted about changing or R1 needing pain medication prior. R1's MAR shows beginning 10/21/23 (once the medication was available) to present she started asking for and receiving her pain medication (Norco) 2-4 times a day and had documented pain levels ranging from 5-10. On 10/31/23 at 8:25 AM, R1 said I came here for my broken ankle. I kept telling anyone and everyone who would listen to me that I needed pain medication. At 12:28 PM, R1 said It was a very rough first few days here, in addition to the medication not being here I was being told I had to wait for the doctor to send over prescriptions for my Norco. After a while I just quit asking because all the staff would say is the script isn't here yet, and Tylenol was not even touching my ankle pain. Now that I have the Norco my pain is much more manageable. On 10/31/23 at 10:16 AM, V8 (Social Service Designee and RN) said about 3 days after R1 was admitted to the facility she was told by R1 that her pain medication was not at the facility, and she needed them. V8 said R1 did appear to be very restless in bed and complained of pain. She said she did report these concerns to the nurse on duty but was unable to recall who that was. On 10/31/23 at 12:14 PM, V3 (R1's Physician) said he gets a lot of text messages from agency staff, and he cannot say exactly when he was first contacted about the pharmacy needing scripts for R1's medications but he does know he sent the prescriptions over for R1's Norco on 10/21/23. V3 said if he was contacted sooner by pharmacy or the facility, he could have given a verbal order for an emergency supply of R1's Norco. V3's physician note for R1 on 10/25/23 at 9:39 AM, shows R1 was complaining of pain to her ankle as a 10/10 on a pain scale but is better since she is now receiving Norco. On 10/31/23 at 12:25 PM, V11 (Certified Nursing Assistant/CNA) said R1 has always complained of pain since she was admitted and ask for pain medication, and they would tell the nurse. On 10/31/23 at 12:40 PM, V10 (CNA) said R1 routinely complained of pain to her leg, and they would tell the nurses that she wants pain medication. On 10/31/23 at 1:15 PM, V2 (Director of Nursing) said she was not aware there were any issues with R1's medications until today. V2 said certain medications are available in their onsite medication dispensing system and the nurses could have called the pharmacy for an emergency access code to obtain R1's Norco. The facility provided Pain Screening and Management policy revised on 3/26/21 shows the facility will screen residents for pain and watch for symptoms of pain. It also says a resident's history and physical and physician orders should be reviewed and obtained as necessary for pain management.

Based on interview and record review the facility failed to call to clarify a medication order and failed to obtain prescriptions for a resident's medication. This failure resulted in a 4-day delay in R1 receiving her psychotropic medications and experiencing symptoms of mania. This applies to 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] from a local community hospital with diagnoses including Bipolar Disorder, Mood Disorder, Depression and Pathological fracture to her right ankle. R1's 10/20/23 facility assessment shows her cognition is intact and she has no memory impairments. R1's hospital records show she was admitted to a local community hospital on 10/14/23 following a fall resulting in an ankle fracture. R1's hospital discharge transfer summary completed on 10/17/23 shows R1 should continue to take the following medications upon admission to the facility: Dextroamphetamine-amphetamine XR (Adderall XR- a stimulant medication for attention deficit hyperactivity disorder) one time a day in the morning, lamotrigine (Lamictal-a mood stabilizer for bipolar disorder) 450 milligrams (mg) every night at bedtime, clonazepam (Klonopin- medication used to treat panic disorder) 1 mg every night at bedtime, Quetiapine (seroquel- anti-psychotic medication to treat bipolar disorder) 200 mg every night at bedtime, and Hydrocodone-acetaminophen 5-325 mg (Norco- pain medication) 1-2 tablets every four hours as needed. R1's nursing summary notes she was admitted to the facility on [DATE] at 7:40 PM. A nursing progress note completed by V9 (Registered Nurse/RN) on 10/18/23 at 12:29 AM states, resident's medications were reviewed with the provider and reconciled. That note also says she is alert and oriented and has no behavioral symptoms and no neurological deficits. R1's Physician Order Summary (POS) shows the following medications were entered into the system on 10/18/23 Amphetamine-Dextroamphetamine, Clonazepam, and Quetiapine. R1's Hydrocodone-Acetaminophen and Lamotrigine orders were not entered into the POS until 10/20/23. R1's Medication Administration Record (MAR) from 10/1/23-10/31/23 shows she did not receive the following medications: Amphetamine- Dextroamphetamine was not given on the following dates: 10/18/23, 10/19/23, 10/20/23 and 10/21/23. A code of 12 was entered into the MAR indicating the medication was not available. Clonazepam was not given on 10/18/23, 10/19/23 and 10/20/23 and is coded the medication was not available. Lamictal was not entered into the MAR prior to 10/20/23 (was supposed to start at the facility on 10/17/23) and was documented as not given due to being unavailable on 10/20/23. Quetiapine was not given on 10/18/23 due to being unavailable. R1's Hydrocodone (scheduled as needed) was entered into the MAR, but no doses were signed off as given until 10/21/23. R1's nursing notes show on 10/20/23, V7 (RN) called a physician to clarify the order for R1's Lamictal and entered it into the POS. R1's nursing notes for 10/21/23 at 6:35 AM, show the facility called the pharmacy due to R1's missing medications and pharmacy informed the facility the following medications still need a physician prescription: Hydrocodone-acetaminophen, Amphetamine-Dextroamphetamine and clonazepam. A nursing note completed by V5 (RN) on 10/21/23 at 9:19 AM, shows that prescriptions for the medications were received by R1's Primary Care Physician (V3) (4 days after her admission). There are no additional nursing notes from 10/18-10/20/23 that indicates anyone called to follow up with the pharmacy or V3 about R1's medications. On 10/31/23 at 8:25 AM, R1 said I didn't get most of my psychotropic medications here for about 5 days. I have been on medications for bipolar disorder for about [AGE] years. I kept telling anyone and everyone who would listen to me that I needed those medications. I was feeling psychotic, hearing voices and didn't sleep for several nights. I was also on isolation for Covid-19 which didn't help. At 12:28 PM, R1 said It was a very rough first few days here, in addition to the medication not being here I was being told I had to wait for the doctor to send over prescriptions for my Norco, Adderall and Klonopin. And I also didn't get my Lamictal. After a while I just quit asking because I felt so out of it and would get the same answers from staff that they are waiting on the scripts that's why the medications are not here. On 10/31/23 at 10:16 AM, V8 (Social Service Designee and RN) said about 3 days after R1 was admitted to the facility she was told by R1 that her pain medication and anxiety medications were not at the facility, and she needed them. V8 said R1 did appear to be very restless in bed and complained of pain and anxiety. She said she did report these concerns to the nurse on duty but was unable to recall who that was. On 10/31/23 at 12:14 PM, V3 (R1's Physician and Medical Director) said he gets a lot of text messages from agency staff, and he cannot say exactly when he was first contacted about the pharmacy needing scripts for R1's medications but he does know he sent the prescriptions over for R1's Adderall, Klonopin and Norco on 10/21/23. V3 said he is not sure why R1's Lamictal was not started on 10/18/23 because that order does not need a script and it should have been started. He said without R1 receiving these medications she would have exhibited increased psychiatric symptoms of mania. V3 said if he was contacted sooner by pharmacy or the facility, he could have given a verbal order for an emergency supply of R1's Norco. V3 also said he saw R1 on 10/25/23 and wrote a note. V3's physician note for R1 on 10/25/23 at 9:39 AM, shows R1 complained she had missed several days' worth of her medication and as a result experienced mania. The same note states, pt. stable on lamotrigine, clonazepam and quetiapine dosage. After restarting medication, denies any current mania or depressive episodes, was manic off of the medications. The note also refers to R1 complaining of pain to her ankle as a 10/10 on a pain scale but is better since she is now receiving Norco. On 10/31/23 at 12:52 PM, V4 (Unit Manager) said she contacted V7 (RN) because she had done the chart audit after R1's admission. V4 said on 10/20/23, V7 called V3 to clarify something about R1's Lamictal and then she carried out the order. She is not sure if anyone else had called to clarify R1's Lamictal orders, but if they did then they should have documented that in nursing progress notes. On 10/31/23 at 1:15 PM, V2 (Director of Nursing) said she was not aware there were any issues with R1's medications until today. She said the pharmacy will not send the medications without written prescriptions for Norco, Adderall and Klonopin. She said nurses should follow up with the physician and pharmacy if a resident's medication is not available and make sure the scripts are sent to obtain those medications. V2 said certain medications are available in their onsite medication dispensing system and the nurses could have called the pharmacy for an emergency access code to obtain R1's Norco. On 10/31/23 at 1:53 PM, V7 (RN) said she did place a call on 10/20/23 to V3 to clarify a question about R1's Lamictal order. She thinks the issue was the medication needed a diagnosis for it. R7 said she thinks she clarified on a couple other issues with medications also but did not ask about prescriptions for the other medications. On 10/31/23 at 2:10 PM, V12 (Pharmacist) said according to their computer system R1's order for her Lamictal was not sent over to them until 10/20/23. V12 verified that the reason for the delay in R1's Clonazepam, Norco and Adderall was due to waiting on prescriptions from the physician. V12 said the facility must call them to alert them that they need assistance to contact the physician if there is a delay in getting the prescriptions sent. V12 verified that Lamictal, Klonopin and Adderall would not be in the onsite medication dispensing system at the facility, but Norco is, and the facility could have requested a code to put in to obtain that medication. The facility provided Medication Administration policy revised on 7/21/23 says medications should be administered in a timely manner. If medication for newly admitted residents are not present in the onsite medication dispensing system at the facility the pharmacy and physician should be contacted and new orders should be received.

Based on observation, interview, and record review the facility failed to ensure weekly weights were obtained for a resident receiving enteral nutrition. This failure resulted in R73 sustaining an 18.2 lb (10.47%) weight loss in three weeks. This applies to 1 of 2 residents (R73) reviewed for enteral nutrition in the sample of 19. The findings include: R73's Admission Record sheet shows the following diagnoses: right humerus fracture, hemiplegia and hemiparesis, type 2 diabetes mellitus, respiratory failure, dysphagia, cerebral infarction, paroxysmal atrial fibrillation, Barrett's esophagus, dysphagia, aphasia, and chronic kidney disease stage 2. R73's Minimum Data Set (MDS) dated [DATE], showed R73 was receiving 51 percent (%) or more of total calories through a tube feeding. R73's Order Summary Report printed on 1/24/23 at 4:26 PM, shows an active order for weekly weights with a start date of 9/16/2022. The directions state, to weigh R73 in the morning every 7 days for weight monitoring ***MUST BE WEIGHED R/T TUBE FEEDING***. This report also showed R73's diet order of nothing by mouth (NPO) with a start date of 7/29/2022 during the period of weight loss. This report also shows a R73 had and order for (brand name of enteral nutrition) at 65 cc/hour via feeding tube for 18 hours with auto flush at 150 cc/hour every 4 hours. On at 6pm and off at 12noon. INFUSE FOR 18 HOURS TOTAL OF 1170ML during the period of weight loss from 9/16/22 to 10/21/22. R73's Weights and Vitals Summary printed on 1/24/2023 at 4:28 PM, shows the following weights on and after 9/16/2022 until 10/21/2022. 9/16/2022 167 pounds (lbs), 9/23/2022 168 lbs, 10/7/2022 167.2 lbs, 10/21/2022 149.7 lbs. Weights were not obtained on the week of 9/30 and 10/14. Between 10/7 and 10/21 R73 sustained an 18.2 lb (10.47%) weight loss. On 10/25/2023 at 12:12 PM, V13 (Registered Dietitian/RD) said that weekly weights are important to monitor tube feeding tolerance. On 10/25/2023 at 1:02 PM, V22 (Nurse Practitioner) said that a tube fed resident whose diet is not supplemented with food or supplements should not sustain a significant weight loss. V22 also said that weights are done to identify if an intervention should be implemented immediately to prevent a significant weight loss. The facility's Weighing/Weight Loss Protocol revised on 3/5/2021 states, Weekly and daily weights may be obtained per RD or Physician orders in order to monitor clinical status of a resident requiring closer monitoring and intervention.

Based on observation, interview, and record review the facility failed to ensure weekly weights were obtained for a resident receiving enteral nutrition. This failure resulted in R73 sustaining an 18.2 lb (10.47%) weight loss in three weeks. This applies to 1 of 2 residents (R73) reviewed for enteral nutrition in the sample of 19. The findings include: R73's admission Record sheet shows the following diagnoses: right humerus fracture, hemiplegia and hemiparesis, type 2 diabetes mellitus, respiratory failure, dysphagia, cerebral infarction, paroxysmal atrial fibrillation, Barrett's esophagus, dysphagia, aphasia, and chronic kidney disease stage 2. R73's Minimum Data Set (MDS) dated [DATE], showed R73 was receiving 51 percent (%) or more of total calories through a tube feeding. R73's Order Summary Report printed on 1/24/23 at 4:26 PM, shows an active order for weekly weights with a start date of 9/16/2022. The directions state, to weigh R73 in the morning every 7 days for weight monitoring ***MUST BE WEIGHED R/T TUBE FEEDING***. This report also showed R73's diet order of nothing by mouth (NPO) with a start date of 7/29/2022 during the period of weight loss. This report also shows a R73 had and order for (brand name of enteral nutrition) at 65 cc/hour via feeding tube for 18 hours with auto flush at 150 cc/hour every 4 hours. On at 6pm and off at 12noon. INFUSE FOR 18 HOURS TOTAL OF 1170ML during the period of weight loss from 9/16/22 to 10/21/22. R73's Weights and Vitals Summary printed on 1/24/2023 at 4:28 PM, shows the following weights on and after 9/16/2022 until 10/21/2022. 9/16/2022 167 pounds (lbs), 9/23/2022 168 lbs, 10/7/2022 167.2 lbs, 10/21/2022 149.7 lbs. Weights were not obtained on the week of 9/30 and 10/14. Between 10/7 and 10/21 R73 sustained an 18.2 lb (10.47%) weight loss. On 10/25/2023 at 12:12 PM, V13 (Registered Dietitian/RD) said that weekly weights are important to monitor tube feeding tolerance. On 10/25/2023 at 1:02 PM, V22 (Nurse Practitioner) said that a tube fed resident whose diet is not supplemented with food or supplements should not sustain a significant weight loss. V22 also said that weights are done to identify if an intervention should be implemented immediately to prevent a significant weight loss. The facility's Weighing/Weight Loss Protocol revised on 3/5/2021 states, Weekly and daily weights may be obtained per RD or Physician orders in order to monitor clinical status of a resident requiring closer monitoring and intervention.

Based on observation, interview, and record review, the facility failed to provide timely incontinence care for a resident who is identified as high risk for skin breakdown. This failure caused R3 pain/discomfort, and aggravation of the skin condition to his buttocks. This applies to 1 of 7 residents R3 reviewed and observed for incontinence care in the sample of 15. The findings include: R3 has multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (minimum data set) dated 6/12/21 documents R2 is alert, oriented, requires extensive assistance with toileting. On 8/11/21 at 11:15 AM, R3 was resting in bed, awake, alert, and oriented. R3 stated he needs his incontinence brief changed, and the last time he was changed was between 4:00 AM-4:30 AM. R3 also said since he came to the facility, he had a UTI multiple times, because he was not being changed routinely and they were not cleaning him properly. On 8/11 21 at 11:46 AM, V7 (CNA) who was assigned to R3 responded to R3's request for incontinence care. V7 stated that he had not change R3 since the beginning of the shift. V7 proceeded to provide incontinence care. R3 was heavily saturated with urine and had a bowel movement. R3's skin on his buttocks looks peculiar, with textured warty appearance (with grooves in between the cluster of warts like skin texture), looks raw, red, and tender. On 8/13/21 at 9:00 PM, R3 stated the last time he was changed was before dinner around 5-5:30 PM. On 8/13/21 at 9:40 PM, V24 (Certified Nursing Assistant/CNA who was assigned to R3) stated they (CAN's) are supposed to check and change residents for incontinence every 2 hours. V24 also stated she completed her assignment at this time. On 8/13/21 at 10:05 PM, V29 (Night shift CNA) provided incontinence care to R3. R3 was wearing double layered incontinence brief and was heavily saturated with urine. The buttocks part of the diaper has tinge or stains of blood. The bleeding was coming from one of the grooves in between the warty like formation of the skin R3's buttocks. It was red in color and has raw appearance. R3 stated it's painful with a burning like sensation. On 8/13/21 at 11:15 PM, V30 and V31 (both nurses) stated that the skin is denuded with MASD (Moisture Associated Skin Damage) with striations. On 8/15/21 at 2:48 PM, V20 (Wound Physician) stated the last time he saw R3 was the year before. R3 has Elephantiasis Nostras Verrucosa to the buttocks, it's like a [CONDITION(S)]. He has dependent [CONDITION(S)] in the buttocks and is high risk for skin breakdown. R3 had severe/chronic MASD (Moisture Associated Skin Damage) or Incontinent Associated [CONDITION(S)]. Exposure to urine can aggravate skin condition. R3's most recent skin assessment dated [DATE] documents R3 has no skin impairment. R3's active care plan document's R3 has potential for skin alteration related to moisture- associated [CONDITION(S)] and generalized rash related [CONDITION(S)], impaired mobility related to spending days in bed using his laptop, watching Netflix, playing video games, and poor hygiene. R3 is continent of bowel and bladder but at times will just go in bed wanting to be cleaned by staff. Keep skin clean and dry. R3's to practice good personal hygiene; encourage to be (Out of Bed) daily. Use lotion on dry skin.

Based on interview, and record review, the facility failed to supervise a resident (R1), who had a medical condition of dysphagia (difficulty swallowing foods or liquids). As a result of this failure, R1 had choked while eating a roast beef sandwich and ultimately expired due to food aspiration on [DATE]. This applies to 1 of 4 residents (R1) reviewed for safety related to aspiration risk. The findings include: R1, a 78 - year old long term resident with diagnoses of [CONDITION(S)], acute kidney injury, [CONDITION(S)], [CONDITION(S)], following CVA (Cerebral Vascular Accident), vascular dementia, anxiety disorder, hypertension, muscle wasting, and atrophy of multiple sites, dysphagia with oropharyngeal phase and was positive for COVID-19. R1 was originally admitted to the facility on [DATE]. The progress notes dated [DATE] showed that R1 was sent to the hospital because R1 started to decline, was weak, had difficulty swallowing and was positive for COVID -19 infection. R1 was admitted to the hospital with diagnoses of dehydration, [CONDITION(S)], [CONDITION(S)] and positive for COVID-19. The hospital record dated [DATE] showed that R1's prescribed diet was a pureed diet and nectar thick liquid with 1:1 staff supervision due to aspiration precaution. R1 was transferred back to the facility on [DATE]. The hospital transfer record dated [DATE] showed a prescribed diet of a mechanical soft diet and nectar thick liquid for R1. The POS (Physician Order Sheet) for the month of [DATE] showed the following orders for R1: -on [DATE], diet was downgraded to a mechanical soft diet and nectar thick liquid. -on the readmission order dated [DATE] were: 1) Mechanical diet and nectar thick liquid 2) Full Code status 3) Physical and occupational therapy 4) Speech therapy for dysphagia management and diet tolerance The Nursing Admission Summary dated [DATE] showed that R1 was alert, oriented to person, and place. The summary also revealed that R1 was a Full Code status. The summary also showed that R1 had dementia in which he forgets to eat and drink. As indicated on this summary, R1 was on aspiration precautions and that he required supervision when eating. The facility's incident report dated [DATE] showed that R1 was served Italian Beef sandwich for lunch by V6 and V7 (CNAs) on [DATE]. After V6 and V7 had opened the wrapper of the Italian beef sandwich for R1 to use his hands to eat, both V6 and V7 had left R1, unsupervised while eating beef sandwich, and french fries that was served to him. V6 and V7 proceeded to pass lunch trays to the rest of the residents in the nursing unit. After V6 and V7 was done passing lunch trays, they passed by R1's room and saw R1 slumped over, skin was pale, and R1 was not responsive, not breathing and no pulse beat. V4 and V5 (Nurses) were summoned immediately and initiated CPR (Cardiopulmonary Resuscitation) and another CNA had called 911 emergency life service. Paramedics worked on R1 and tried to revive him to no avail. R1 expired and pronounced dead at 1:21 P.M. on [DATE]. The nurse's progress notes dated [DATE] showed the following events prior to R1's demise: -11:45 A,M. - Entered by Activity Staff: (R1's) daughter, and granddaughter came around 11:45. The granddaughter brought the food to the front desk. I then took it and delivered it. I left it on his table out of his reach because he was sleeping. I don't know what was in the bag. - 1145 A.M. - Portillo's bag dropped off to facility and front desk delivers food to resident's room and food is placed on bedside table - 1230 - (V6) passed by residents room and noticed he was slumped over, pale skin color, and immediately yelled out to V5 (Nurse) for help, (V5) runs to V4 (RN) for help. - 1232- (V4) and (V5) initiate CPR (Cardio Pulmonary Resuscitation) and (V4) swipes softened substance out of (R1's) throat, CNA called 911, (V7) went to get oxygen tank, (V6) went to get crash cart. - 1240- EMS arrives at facility and takes over CPR with Police officers waiting by the main door entrance. - 1:30 P.M., (V5) calls (R1's) POA (Power of Attorney) daughter. - 1:40 P.M., (R1's) daughter arrives at facility, states to (V4) if he choked eating an Italian beef, then he died happy please tell the coroner I do not want an autopsy to be done to him, please don't let them do that to him - 3:00 P.M. - Coroner came to facility and took pictures and did evaluation. - 3:00 P.M. - funeral home came to pick up (R1) During the survey, interviews were held with the following staff who were involved with the care regarding R1's dysphagia treatment and aspiration/swallowing precautions: 1) On [DATE] at 11:30 A.M., interview with V1 (Former Administrator, in charged at the facility at time of R1's choking incident). V1 stated that R1 was on mechanical soft diet and anyone prescribed with altered/modified diet requires some form of supervision. My CNAs left (R1) room after they set up the Italian Beef from Portillo's that (R1's) family had brought for him. My CNAs then left (R1's) room with the Italian Beef sandwich was within R1's reach without supervision. My CNAs proceeded to pass lunch trays to other residents in the nursing unit. My Activity staff was the one who brought the Italian beef bought from [NAME] by (R1's) family for (R1's) lunch. During lunch time on [DATE], R1 was found unresponsive, with the Italian beef sandwich loosely on (R1's) hand. CPR initiated timely, paramedics took over, however, was not able to revive (R1). The (2) CNAs and the Activity were no longer being employed at the facility after this choking incident. 2) On [DATE] at 1:59 A.M., interview with V8 (Activity Aide), stated that R1's daughter had brought a bag of [NAME] sandwich to the facility for R1's lunch around 11:45 A.M. on [DATE]. V8 also added that this is nothing new since R1's family had always brought [NAME] food for R1. V8 added that she delivered the [NAME] sandwich bag to R1's room and placed it on the bedside table where R1 cannot reach. V8 also added that she had informed V6 and V7 that she had placed the Portllos sandwich and placed it on R1's bedside table. 3) On [DATE] at 2:05 P.M., interview with V7 (CNA), stated that together with V6, both of them have elevated R1's head of bed while R1 was lying in bed in preparation for lunch on [DATE]. V7 also added that R1 was sleepy and weak. V7 stated that she opened the sandwich bag that R1's family had brought. V7 added that it was a [NAME] Italian Roast Beef sandwich, 2 precut sandwiches measuring approximately ,d+[DATE] inches long of French/submarine bread and in it were slices of roast beef. There was also a bag of french fries that came with it. V7 does not remember if there was a carbonated drink that came with it nor if this drink was thickened to nectar thick consistency. V7 also stated that neither she nor V6 had cut the beef, or french bread. V7 also stated that she was aware that R1 was on mechanical soft diet. V7 added that R1 was a risk of aspiration that was why they have elevated the head of R1's bed. V7 also stated that both she and V6 left R1, unsupervised while eating the Italian roast beef sandwich and french fries. V7 also added that R1 was eating the french fries. V7 also added that R1 was holding the precut Italian beef sandwich in his right hand. V7 stated that both she and V6 proceeded to pass lunch trays to the rest of the residents in the nursing unit. V7 also added that after passing the lunch trays for the residents in the unit, both she and V6 passed by R1's room and saw R1 slumped over, unresponsive and immediately summoned V4 and V5 (Nurse) for help. 4) On [DATE] at 3:00 P.M., interview with V6 stated that both she and V7 served the [NAME] Italian Roast Beef sandwich to R1. V6 added that they opened the sandwich wrapper, left R1 eating the sandwich without supervision and her and V7 proceeded to pass lunch trays to other residents. V6 added that R1 was on mechanical soft diet and honey thick liquid but no one told her that R1 needs to be supervised. V6 also stated that her employment from the facility was terminated because she did not follow the facility's policy but does not know what kind of policy but was in regards to R1's choking. 5) On [DATE] at 3:10 P.M. interview with V4 (Registered Nurse) stated that on [DATE] around 12:30 P.M., V6 and V7 yelled for help because R1 was found unresponsive. V4 added that she and V5 immediately went to R1's room. V4 found R1 lying in bed, unresponsive, not breathing and no pulse. V4 also stated that R1 was loosely holding a precut Italian beef sandwich in his right hand. V4 added that there was a bite or two from the sandwich. V4 also added that she swiped R1's mouth and was able to remove some amount of mushy type off white/light brown color that most definitely resemble part of the chewy and hard French bread and the sliced roast beef. V4 added that R1 was on a mechanical soft diet and on aspiration risk and needed supervision for eating. V4 added that CPR was initiated immediately, paramedics called and took over R1's care. Despite of paramedics' effort, R1 had expired at the facility as V4 continued to state. V4 also added that she called R1's daughter, came to facility while paramedics were still working on R1. V4 also added that when R1 was pronounced dead, R1's daughter had stated at least he died happy eating his favorite food. 6) On [DATE] at 9:15 A.M, interview with V5 (Licensed Practical Nurse) stated that she was aware that R1 was on mechanical soft diet, and on aspiration precaution and should have been supervised when eating. V5 also added that she was not informed that R1 was served with the Italian roast beef sandwich, because if she would have known, she would have not let R1 eat it since definitely R1 will choke. V5 also added that even a person with no swallowing difficulty have problems swallowing french bread that was chewy and tough and sliced beef, that though was thinly sliced, they were long. V5 stated that CPR was immediately initiated, paramedics took over but R1 expired at the facility despite efforts were made to revive him V5 also added that R1's daughter was at the facility when paramedics were working on R1. V5 also stated that R1's daughter had stated that at least he died happy eating his favorite food. 7) On [DATE] at 5:45 P.M., interview with V9 (R1's Attending Physician) stated that she deferred all plan of care regarding swallowing difficulty management and diet tolerance to the speech therapist. V9 also added that she refused to sign the death certificate since R1 was pronounced dead by the paramedics. 8) On [DATE] at 10:30 A.M., interview with V10 (Speech Therapist) stated that he had provided a speech therapy treatment to R1 prior to hospitalization on [DATE] because R1 had swallowing difficulty. V10 also added that he downgraded R1's diet on [DATE] to a mechanical soft, was placed on aspiration precaution due to risk of aspiration. V10 also added that he assessed, evaluated and provided plan of treatment regarding R1's dysphagia/swallowing difficulty on [DATE] when R1 had returned back to the facility from the hospital on [DATE]. V10 also added that R1 was placed on a mechanical soft diet, placed aspiration precaution and needed direct supervision to provide verbal cues to (R1) for safety swallowing techniques like taking a small bite/ swallow, clear throat alternate with honey thick liquid. (R1) will not be able to do this on his own because (R1) lack safety awareness. I told the plan of care regarding safety swallowing precaution to staff and (V5). I did not informed (R1's) family because I did not get a chance and before given a chance (R1) had already choke from the Italian roast beef. (R1) should not have been given that Italian roast beef, it was not the right diet consistency for him and will he definitely choke from it especially no staff was there to supervise and give verbal cues for safety swallowing. I wrote on my documentation distant supervision because in the real, perfect world, they cannot provide that to him because the CNAs were doing other task, but indeed (R1) needed to be directly supervise. His food should be ground meat like the ground meat that was use to mix with a spaghetti sauce. The Speech Therapy Assessment and Evaluation dated [DATE] made by V10 showed that R1 was assessed as follows: Short Term Goals: 1. (R1) will safely swallow mechanical soft and nectar thick fluids using alternation of liquids/solids, hard throat clear/re-swallow, effortful swallow, no straws, and general swallow techniques/precautions with 80% of attempts and 20% verbal cues in order to decrease signs and symptoms of oral and or pharyngeal dysphagia. 2. (R1) will complete oral motor exercises given skilled instruction and 35 %. Verbal cues in order improve mastication of solids and to improve lingual ROM (Range of Motion) and strength. Long Term Goals: 1. (R1) will safely swallow mechanical soft and nectar thick liquids using alternation of liquids/solids, hard throat clear/re-swallow, effortful swallow, no straw and general swallow techniques/precautions with 90% of attempts and with occasional verbal cues in order to decrease signs and symptoms of oral and or pharyngeal dysphagia. Patient Goals: (R1) goals on dysphagia management and diet tolerance. Potential for Achieving Goals: (R1) demonstrates good rehab potential as evidenced ability to swallow 1 step directions, supportive caregivers/staff, participation in passive activity and able to make needs known. Participation: Patient/Caregiver participated in establishing POT (Plan of Treatment). The speech assessment also showed that R1 had an oropharyngeal phase of swallowing difficulty. The facility policy for Food and Nutrition Services dated [DATE] with revision date of [DATE] showed that Mechanical Soft- a Regular diet with meat ground and other foods cooked to a soft consistency. The facility's Guidelines for Aspiration Precautions were: Residents who require swallowing/aspiration precautions are to have the following carried out: - Speech therapy evaluation - Plan of care to reflect targeted precautions as recommended by speech; may include but not limited to: - No straws - Small bites/drinks - Monitor for secretions - Head of bed (HOB) elevation - Increased 1:1 supervision The death certificate showed R1 had expired on [DATE] at 1:21 P.M. with immediate cause of death as aspiration of food bolus. The death certificate also showed that significant factors that cause the death were: dysphagia and CVA.

Based on interview, and record review, the facility failed to follow physician order regarding a prescribed modified diet to a resident (R1) who had a medical condition of dysphagia (difficulty swallowing foods or liquids). As a result of this failure, R1 had choked while eating a roast beef sandwich and ultimately expired due to food aspiration on [DATE]. This applies to 1 of 4 residents (R1) reviewed for safety related to aspiration risk. The findings include: R1, a 78 - year old long term resident with diagnoses of [CONDITION(S)], acute kidney injury, [CONDITION(S)], [CONDITION(S)], following CVA (Cerebral Vascular Accident), vascular dementia, anxiety disorder, hypertension, muscle wasting and atrophy of multiple sites, dysphagia with oropharyngeal phase and was positive for COVID-19. R1 was originally admitted to the facility on [DATE]. The progress notes dated [DATE] showed that R1 was sent to the hospital because R1 started to decline, was weak, had difficulty swallowing and was positive for COVID -19 infection. R1 was admitted to the hospital with diagnoses of dehydration, [CONDITION(S)], [CONDITION(S)] and positive for COVID-19. The hospital record dated [DATE] showed that R1's prescribed diet was a pureed diet and nectar thick liquid with 1:1 staff supervision due to aspiration precaution. R1 was transferred back to the facility on [DATE]. The hospital transfer record dated [DATE] showed a prescribed diet of a mechanical soft diet and nectar thick liquid for R1. The POS (Physician Order Sheet) for the month of [DATE] showed the following orders for R1: -on [DATE], diet was downgraded to a mechanical soft diet and nectar thick liquid. -on the readmission order dated [DATE] were: 1) Mechanical diet and nectar thick liquid 2) Full Code status 3) Physical and occupational therapy 4) Speech therapy for dysphagia management and diet tolerance The Nursing Admission Summary dated [DATE] showed that R1 was alert and oriented to person and place. The summary also revealed that R1 was a Full Code status. The summary also showed that R1 had dementia in which he forgets to eat and drink. As indicated on this summary, R1 was on aspiration precautions and was on prescribed diet of mechanical soft diet. The facility's incident report dated [DATE] showed that R1 was served Italian Beef sandwich for lunch by V6 and V7 (CNAs) on [DATE]. After V6 and V7 had open the wrapper of the Italian beef sandwich for R1, using his hands to eat, both V6 and V7 had left R1, unsupervised while eating beef sandwich and French Fries that was served to him. After V6 and V7 was done passing lunch trays, they passed by R1 room and saw R1 slumped over, skin was pale, and R1 was not responsive, not breathing and no pulse beat. V4 and V5 (Nurses) were summoned immediately and initiated CPR (Cardiopulmonary Resuscitation) and another CNA had called 911 emergency life service. Paramedics worked on R1 and tried to revive him to no avail. R1 expired and pronounced dead at 1:21 P.M. on [DATE]. The nurse's progress notes dated [DATE] showed the following events prior to R1's demise: -11:45 A,M. , Entered by Activity Staff: (R1's) daughter, and granddaughter came around 11:45. The granddaughter brought the food to the front desk. I then took it and delivered it. I left it on his table out of his reach because he was sleeping. I don't know what was in the bag. - 1145 A.M. - Portillo's bag dropped off to facility and front desk delivers food to resident's room and food is placed on bedside table - 1230- (V6) passed by residents room and noticed he was slumped over, pale skin color, and immediately yelled out to V5 (Nurse) for help, (V5) runs to V4 (RN) to help. - 1232- (V4) and (V5) initiate CPR (Cardio Pulmonary Resuscitation) and (V4) swipes softened substance out of (R1's) throat, CNA called 911, (V7) went to get oxygen tank, (V6) went to get crash cart. - 1240- EMS arrives at facility and takes over CPR with Police officers waiting by the main door entrance - 1:30 P.M., (V5) calls (R1's) POA (Power of Attorney) daughter - 1:40 P.M., (R1's) daughter arrives at facility, states to (V4) if he choked eating an Italian beef, then he died happy please tell the coroner I do not want an autopsy to be done to him, please don't let them do that to him - 3:00 P.M. - Coroner came to facility and took pictures and did evaluation. - 3:00 P.M. - funeral home came to pick up (R1) During the survey, interviews were held with the following staff who were involved with the care regarding R1's dysphagia treatment, and aspiration/swallowing precautions: 1) On [DATE] at 11:30 A.M., interview with V1 (Former Administrator, in charged at the facility at time of R1's choking incident). V1 stated that R1 was on mechanical soft diet and anyone prescribed with altered/modified diet requires some form of supervision. My CNAs left (R1) room after they set up the Italian Beef from Portillo's that (R1's) family had brought for him. My CNAs then left (R1's) room with the Italian Beef sandwich was within R1's reach without supervision. My CNAs proceeded to pass lunch trays to other residents in the nursing unit. My Activity staff was the one who brought the Italian beef bought from [NAME] by (R1's) family for (R1's) lunch. During lunch time on [DATE], R1 was found unresponsive, with the Italian beef sandwich loosely on (R1's) hand. CPR initiated timely, paramedics took over, however, was not able to revive (R1). The (2) CNAs and the Activity were no longer being employed at the facility after this choking incident. 2) On [DATE] at 1:59 A.M., interview with V8 (Activity Aide), stated that R1's daughter had brought a bag of [NAME] sandwich to the facility for R1's lunch around 11:45 A.M. on [DATE]. V8 also added that this is nothing new since R1's family had always brought [NAME] food for R1. V8 added that she delivered the [NAME] sandwich bag to R1's room and placed it on the bedside table where R1 cannot reach. V8 also added that she had informed V6 and V7 that she had placed the Portllos sandwich and placed it on R1's bedside table. 3) On [DATE] at 2:05 P.M., interview with V7 (CNA), stated that together with V6, both of them have elevated R1's head of bed while R1 was lying in bed in preparation for lunch on [DATE]. V7 also added that R1 was sleepy and weak. V7 stated that she opened the sandwich bag that R1's family had brought. V7 added that it was a [NAME] Italian Roast Beef sandwich, 2 precut sandwiches measuring approximately ,d+[DATE] inches long of French/submarine bread and in it were slices of roast beef. There was also a bag of French Fries that came with it. V7 does not remember if there was a carbonated drink that came with it nor if this drink was thickened to nectar thick consistency. V7 also stated that neither she nor V6 had cut the beef, and the French bread. V7 also stated that she was aware that R1 was on mechanical soft diet. V7 added that R1 was a risk of aspiration that was why they have elevated the head of R1's bed. V7 also stated that both she and V6 left R1, unsupervised while eating the Italian roast beef sandwich and French Fries. V7 also added that R1 was eating the French Fries. V7 also added that R1 was holding the precut Italian beef sandwich in his right hand. V7 stated that both she and V6 proceeded to pass lunch trays to the rest of the residents in the nursing unit. V7 also added that after passing the lunch trays for the residents in the unit, both she and V6 passed by R1's room and saw R1 slumped over, unresponsive and immediately summoned V4 and V5 (Nurse) for help. 4) On [DATE] at 3:00 P.M., interview with V6 stated that both she and V7 served the [NAME] Italian Roast Beef sandwich to R1. V6 added that they open the sandwich wrapper, left R1 eating the sandwich. V6 added that R1 was on mechanical soft diet and honey thick liquid. 5) On [DATE] at 3:10 P.M. interview with V4 (Registered Nurse) stated that on [DATE] around 12:30 P.M., V6 and V7 yelled for help because R1 was found unresponsive. V4 added that she and V5 immediately went to R1's room. V4 found R1 lying in bed, unresponsive, not breathing and no pulse beat. V4 also stated that R1 was loosely holding a precut Italian beef sandwich in his right hand. V4 added that there was a bite or two from the sandwich. V4 also added that she swiped R1's mouth and was able to remove some amount of mushy type off white/light brown color that most definitely resemble part of the chewy and hard French bread and the sliced roast beef. V4 added that R1 was on a mechanical soft diet and on aspiration risk . V4 added that CPR was initiated immediately, paramedics called and took over R1's care. Despite of paramedics' effort, R1 had expired at the facility as V4 continued to state. V4 also added that she called R1's daughter, came to facility while paramedics were still working on R1. V4 also added that when R1 was pronounced dead, R1's daughter had stated at least he died happy eating his favorite food. 6) On [DATE] at 9:15 A.M, interview with V5 (Licensed Practical Nurse) stated that she was aware that R1 was on mechanical soft diet, and on aspiration precaution. V5 also added that she was not informed that R1 was served with the Italian roast beef sandwich, because if she would have known, she would have not let R1 eat it since definitely R1 will choke. V5 also added that even a person with no swallowing difficulty have problems swallowing French bread that was chewy and tough and the sliced beef, that though was thinly sliced, they were long. V5 stated that CPR was immediately initiated, paramedics took over but R1 expired at the facility despite efforts were made to revive him V5 also added that R1's daughter was at the facility when paramedics were working on R1. V5 also stated that R1's daughter had stated that at least he died happy eating his favorite food. 7) On [DATE] at 5:45 P.M., interview with V9 (R1's Attending Physician) stated that she deferred all plan of care regarding swallowing difficulty management and diet tolerance to the speech therapist. 8) On [DATE] at 10:30 A.M., interview with V10 (Speech Therapist) stated that he provided a speech therapy treatment to R1 prior to hospitalization on [DATE] because R1 had swallowing difficulty. V10 also added that he downgraded R1's diet on [DATE] to a mechanical soft, was placed on aspiration precaution due to risk of aspiration. V10 also added that he assessed, evaluated and provided plan of treatment regarding R1's dysphagia/swallowing difficulty on [DATE] when R1 had returned back to the facility from the hospital on [DATE]. V10 also added that R1 was placed on a mechanical soft diet, placed aspiration precaution and needed direct supervision to provide verbal cues to (R1) for safety swallowing techniques like taking a small bite/ swallow, clear throat alternate with honey thick liquid. (R1) will not be able to do this on his own because (R1) lack safety awareness. I told the plan of care regarding safety swallowing precaution to staff and (V5). I did not informed (R1's) family because I did not get a chance and before given a chance (R1) had already choke from the Italian roast beef. (R1) should not have been given that Italian roast beef, it was not the right diet consistency for him and will he definitely choke from it especially no staff was there to supervise and give verbal cues for safety swallowing. I wrote on my documentation distant supervision because in the real, perfect world, they cannot provide that to him because the CNAs were doing other task, but indeed (R1) needed to be directly supervise. His food should be ground meat like the ground meat that was use to mix with a spaghetti sauce. The Speech Therapy Assessment and Evaluation dated [DATE] made by V10 showed that R1 was assessed as follows: Short Term Goals: 1. (R1) will safely swallow mechanical soft and nectar thick fluids using alternation of liquids/solids, hard throat clear/re-swallow, effortful swallow, no straws, and general swallow techniques/precautions with 80% of attempts and 20% verbal cues in order to decrease signs and symptoms of oral and or pharyngeal dysphagia. 2. (R1) will complete oral motor exercises given skilled instruction and 35 %. Verbal cues in order improve mastication of solids and to improve lingual ROM (Range of Motion) and strength. Long Term Goals: 1. (R1) will safely swallow mechanical soft and nectar thick liquids using alternation of liquids/solids, hard throat clear/re-swallow, effortful swallow, no straw and general swallow techniques/precautions with 90% of attempts and with occasional verbal cues in order to decrease signs and symptoms of oral and or pharyngeal dysphagia. Patient Goals: (R1) goals on dysphagia management and diet tolerance. Potential for Achieving Goals: (R1) demonstrates good rehab potential as evidenced ability to swallow 1 step directions, supportive caregivers/staff, participation in passive activity and able to make needs known. Participation: Patient/Caregiver participated in establishing POT (Plan of Treatment). The speech assessment also showed that R1 had an oropharyngeal phase of swallowing difficulty. The death certificate showed R1 had expired on [DATE] at 1:21 P.M. with immediate cause of death as aspiration of food bolus. The death certificate also showed that significant factors that cause the death were: dysphagia and CVA. The facility policy for Food and Nutrition Services dated [DATE] with revision date of [DATE] showed that Mechanical Soft- a Regular diet with meat ground and other foods cooked to a soft consistency.

Based on observation, interview, and record review, the facility failed to ensure that staff safely assisted a resident to transfer using a full-body mechanical lift. This failure resulted in the resident being sent to the emergency room for head trauma evaluation, treatment with eight staples for a [MEDICAL CONDITION], and sustaining a head injury and chest contusion (bruise which may cause pain, tenderness and swelling). This applies to one of three residents (R56) reviewed for safety during mechanical lift transfers in the sample of 20. The findings include: R56's Face Sheet showed she was admitted to the facility on [DATE]. R56's [DIAGNOSES REDACTED]. R56's [DATE] MDS (Minimum Data Set) Assessment showed R56 is cognitively intact, she needs extensive assistance of two or more staff members to be transferred, and she has impaired range of motion in her lower extremities. R56' Care Plan, dated [DATE] to [DATE], documented that risk for falls is a concern in her care. On [DATE] at 10:58 AM and [DATE] at 1:02 PM, R56 was interviewed in her room. She was alert and oriented, and she moved slowly and looked like she was in pain. R56 complained she felt pain every time she moved. R56 stated, I have bruised ribs. I move, and I have pain . I was dropped on my head from the (full body) lift. It happened on a Friday. I went to the hospital. I had 8 staples put in .my ribs are bruised .my shoulder was injured. I have dark bruising on my neck. They got me up in the lift and all of a sudden I'm on the floor. R56 said, Now I am afraid to get into the sling. I hear a loud noise and I am afraid. I'm scared of falling. It was not like that before. At the back of R56's neck was a large amount of bruising. R56's Incident/Accident Report, dated [DATE], documented R56 sling came off the hook of the mechanical lift, and she struck her had on the metal base. At 02:47 PM on [DATE], V8 (RN caring for R56 the day of the incident) was interviewed. V8 stated, I did not see the incident . When I saw her, she was on the floor. V12 (Certified Nurse's Aide/CNA) came and got me. She told me the resident had fallen. I saw another CNA . and I told her to come with me. We all three went into the room. R56 was already on the floor with a pillow under her head. Her legs were still leaning on the bed. Three of the lift sling loops were on the hooks, but one was off . (R56) was awake answering questions, but very 'out of it' . confused. Blood was on her pillow. She had possible neck, head and shoulder injuries. I went to the hall and called another nurse and told her to call 911. This happened around 4PM. (R56) is a two-person assist. R56's Physician order [REDACTED]. On [DATE] at 11:02 AM, V2 (RN, Director of Nursing) was interviewed. V2 stated she completed the investigation into R56's incident involving staff use of the full body mechanical lift on [DATE]. V2 stated that the CNA moved R56's legs in a manner that caused the machine to be unbalanced and the loops slipped off the hook. On [DATE] at 04:00 PM, V13 (Maintenance Director) was interviewed. He stated that he checked the lift when he worked on [DATE]. V13 described this lift being different from the other mechanical lifts in the building which had clips on their hooks. V13 also showed how the hook to the mechanical lift could flip over and allow the sling to come off. On [DATE] at 11:54 AM, V15 (a technician from the seller of the mechanical lift's company) was requested by the facility to explain the operation of this mechanical lift. V15 confirmed the mechanical lift design does not include a clip on the hook to keep the sling loop in place, and the bar is able to move. V15 stated As long as the patient is being maneuvered properly it should not move. V15 added If the sling is properly in place and the resident's weight is evenly distributed, the sling should not move. V15 stated, The lift is not going to tilt if the body weight is kept steady and evenly distributed and because of R56's weight of 330 pounds, V15 said it may take three persons assisting to ensure her weight remains balanced. At 02:27 PM on [DATE], V1 (Administrator) and V4 (RN, Nurse Consultant) stated the CNAs and other nursing staff were not in-serviced specifically on this particular lift prior to R56's incident. V4 was asked what the root cause of R56's fall was. V4 stated when the CNA picked up (R56's) legs, it caused a shift in weight which caused the (sling) loop to come off (the hook). V4 was asked if the CNA should have waited until R56's bottom was raised off the bed (so R56's weight would hold the loops in place) before R56's legs were moved. V4 answered yes. At 4:05 PM on [DATE] 04:05 PM, surveyors accompanied the medical records clerk to the medical supply room to look at the lift. Danger: Read the lift user manual and sling instruction sheet prior to use. V1 (Administrator) was asked to provide the Manufacturer's Instructions for maintenance and operation of this lift. Initially, V1 provided the wrong booklet, then stated he would obtain the correct one by the next morning. The full body lift's manufacturer's operation and maintenance Owner's Manual dated [DATE] documented the following: WARNING! . Before attempting to lift anyone, please practice operating the lift and read this manual completely . Also, do not transfer without having studied the instructions and practice operating the lift several times. WARNING! Always plan your lifting operations before commencing . Always check the safe working load of the lift to be sure it is suitable for the weight of the patient . DO NOT attempt to maneuver the lift by pushing on the mast, boom, or patient . DO NOT lift a patient unless you are trained and competent to do so. On page 12 under Operating Instructions in the manual, it showed Lift the resident above the bed by using the hand control while watching and reassuring them .

Based on interview, and record review, the facility failed to supervise a resident at risk for aspiration during a meal. This failure resulted in R1 having a choking episode during the evening meal on (MONTH) 21, 2019, requiring [MEDICATION NAME] maneuver. R1 subsequently died . This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: R1's Face Sheet dated (MONTH) 23, 2019 showed R1 had [DIAGNOSES REDACTED]. R1's Speech Therapy evaluation and treatment plan dated (MONTH) 26, 2019 shows a new onset of dysphagia in the oropharyngeal phase. R1 was referred to speech therapy due to a new onset of dysphagia placing the patient at risk for aspiration, dehydration, pneumonia, malnutrition and weight loss. Patient demonstrating oral pocketing and decreased mastication (chewing) of regular solids. Patient is currently on regular solids, and thin liquids. R1 had a dysphagia work up which showed a swallowing disorder involving the oral phase and pharyngeal phase. R1's Speech therapy note dated (MONTH) 20, 2019 shows, R1 was seen for skilled speech therapy for dysphagia treatment at the evening meal of mechanical soft diet and thin liquids. R1 required moderate verbal cues for use of rate control and small amounts. R1's Minimum Data Set, dated dated dated (MONTH) 20, 2019, shows R1 cognition is severely impaired with a BIMs (Brief Interview for Mental Status) score of 7. R1 requires limited assistance of one staff member for eating. The facility's Incident Report dated (MONTH) 23, 2019, showed the resident (R1) began having difficulty breathing during dinner, assessed as choking and staff intervened with the [MEDICATION NAME] maneuver. Paramedics took over care and the resident was breathing via nonrebreather with her eyes open on the stretcher while being moved through the front door. On (MONTH) 23, 2019 at 8:42 AM, V15 (Assistant Chief Deputy Coroner) stated R1's autopsy was performed on (MONTH) 22, 2019. The preliminary cause of death was aspiration of a food bolus. On (MONTH) 22, 2019 at 11:21 AM, V1 (Administrator) and V2 (Director of Nursing) reported there was an incident the night before where R1 was sent to the hospital. Around 5:45 PM, R1 was in the assisted dining room with other residents and staff. R1 had an episode and the staff responded and did the [MEDICATION NAME]. The staff thought she was choking. R1 was gasping, her dentures were removed. A small amount of meat was expelled. R1 continued in respiratory distress. At the same time an ambulance service was returning a resident to the facility from an appointment. They asked the staff if they needed help, the nurse said yes. They placed a nonrebreather mask on and someone went to call 911. When R1 left the building, she was still breathing, and her eyes were open. She was taken to the local emergency room . R1 arrested and they attempted to intubate but were unsuccessful. R1 had a valid DNR- Do Not Resuscitate order. They stopped resuscitation and R1 was pronounced dead at the emergency room . On (MONTH) 22, 2019 at 11:52 PM, V3 (CNA- Certified Nursing Assistant) stated R1 was able to feed herself. She used her fingers and her spoon. R1 would gobble her food and we would have to tell her to slow down. Sometimes she would, other times she would not. V3 stated she was working the night of the incident. She was on hydration duty in the assisted dining room. She was passing beverages in the assisted dining room. She gave R1 her drinks. She was alone at the table. Then she turned her back to R1 and passed the drinks to the next table. V3 stated then a resident tried to leave the dining room and she went over to bring the resident back to the dining room. When she turned around she saw R1 turning blue. V3 noticed the tray in front of her. V3 asked R1 if she was okay and R1 did not respond. V3 said she tried the [MEDICATION NAME] and R1 did not respond. V3 then called out to V4 (CNA) that R1 was choking. They stood R1 and did the [MEDICATION NAME]. The guy in the kitchen (V12) ran for help. We were able to get a little piece of meat out but not much. The nurses (V6 and V7) came. There were some EMS here and they did the [MEDICATION NAME]. R1 was drooling and then some of her color came back. The nurses took out her dentures. They put her on the gurney. The EMS put oxygen on R1. She was wheezing and then they took her out. On (MONTH) 22, 2019 at 2:15 PM, V7 (Registered Nurse) stated she was R1's nurse the night of the incident. V7 stated R1 eats in the assisted dining room because R1 has swallowing issues and needs to be supervised when she eats. R1 can feed herself but requires cueing to slow down because she tends to eat too much and too fast. The night of the incident she was in another resident's room. The resident had just been brought back via ambulance from an appointment and V7 was checking her in. V7 stated she heard someone screaming for help and she went out of the room. She saw R1 standing and V4 performing the [MEDICATION NAME] maneuver. R1 was breathing and she had red punch running out of her mouth. V7 stated she took over for V4 and performed a few abdominal thrusts. Someone took over for her and she removed R1's dentures. V7 stated she did not see any food in her mouth. V7 reported when V3 and V4 were doing abdominal thrusts some meat came out. V7 stated the EMS personnel came over to help and said they were paramedics. V7 stated R1 was breathing but wheezing at the time. EMS did some more abdominal thrusts. R1 was put on the stretcher and EMS started oxygen with a nonrebreather mask. R1 breathing was easier. On (MONTH) 22, 2019 at 11:43 AM, V6 (Licensed Practical Nurse) stated R1 eats in the assisted dining room. She needs to be supervised. R1 can feed herself. When R1 sees her food, she starts to gulp it right away and doesn't wait for staff. The staff are to sit at the table to feed her and monitor her. The night of the incident she was in the main dining room. She heard they needed assistance in the small dining room. When she arrived R1 was standing and they (CNAs) were doing the [MEDICATION NAME]. R1's nurse V7 was trying to get her dentures out. The paramedics were in the building and they saw us and came over to help us. At that point V6 left to make copies for the transfer. On (MONTH) 22, 2019 at 4:02 PM, V8 (CNA) stated she worked the night of the incident but did not see the incident. She was on hall trays and was running late to pass them. V8 stated R1 was able to feed herself. R1 ate fast and everyone had to tell her to slow down. V8 said you would tell her to slow down and she would go back to scarfing down her food. On (MONTH) 22, 2019 at 3:43 PM, V9 (CNA) stated R1 ate in the assisted dining room. She needed supervision with eating. Someone had to sit at the table when she ate. V9 stated he worked the night of the incident. V9 stated R1 was sitting with her back to him when she was eating. He could not see what she was eating. There was no staff at the table when she was eating. V3 started yelling, She's choking, she's choking! V3 started doing the [MEDICATION NAME]. Then there was ambulance person who took over to do the [MEDICATION NAME]. R1 expelled a piece of meat and it came flying out unto the table. On (MONTH) 22, 2019, V10 (Restorative Nurse) stated R1 ate in the assisted dining room because she required cueing when she was eating. R1 ate fast. R1 was at the feeder table. We would tell her to slow down when she was eating. At times we would need to put our hand on hers and remind her to slow down and at times we needed to feed her. V10 stated there should be a CNA at the table when she and her table mates were eating. If no one was there she (R1) would gobble it quickly, so a CNA needed to be there when she got her food. V10 stated someone needed to be at the table to prevent possible aspiration, not just for her but the others at the table. On (MONTH) 22, 2019 at 12:46 PM, V5 (Speech Therapist) stated R1 was referred to speech for difficulty with swallowing. R1 eats quickly. V5 stated she performed a bedside swallow evaluation and the testing showed R1 had difficulty with chewing. R1 doesn't chew her food well. R1 was eating and swallowing quickly and not chewing her food. R1's diet was changed to mechanical soft. R1 was to always be supervised when eating. She was to be monitor and cued to slow down by myself and the staff. R1 was given a plate guard and covered cups to prevent spilling. R1 was to be supervised for the rate at which she ate. She required constant eye contact by staff. The staff monitoring her should not have been occupied with other tasks and had direct eye contact with her to monitor the rate at which she was eating. R1 has a telephone order dated (MONTH) 17, 2019 for speech therapy to evaluate and treat. R1's diet texture is to be adjusted as appropriate. A telephone order dated (MONTH) 26, 2019 for skilled speech therapy 4 times a week for 4 weeks for swallowing. R1's Care Plan Meeting Note dated (MONTH) 18, 2019 shows R1 is .being monitored in small dining room; she uses a covered cup and plate guards at each meal related to her eating fast . R1's Nurse Note dated (MONTH) 17, 2019 showed, R1 was seen by dietician; recommended speech therapy to evaluate and treat and adjust diet texture as appropriate. On (MONTH) 22, 2019 at 3:20 PM, V11 (Dietician) stated R1 was eating in the assisted dining room for the past few months. The change was made by the restorative nurse. R1 was being impulsive and eating really fast. She was told by nursing that R1 was having difficulty with eating and swallowing. She made a referral to speech therapy. Speech made a recommendation for mechanical soft texture. R1's Dietician Note dated (MONTH) 17, 2019 showed, V11 (Dietician) was informed that R1 is having issues chewing/swallowing bread. Per CNA resident eats fast and chews very little. (R1) Eats in the ADR (Assisted Dining Room) for supervision. Diet: Regular. Nursing staff questioning if the diet should be downgraded to mechanical soft . R1's Dietary Recommendation dated (MONTH) 17, 2019 shows a request for speech therapy to evaluate and treat and adjust diet texture as appropriate. R1's Diet Requisition Form dated (MONTH) 1, 2019 shows a diet change to regular mechanical soft with thin liquids. Resident to eat in assisted dining room. R1's current Care Plan dated (MONTH) 2, 2019 shows, R1 has a problem with her right wrist and is having problem with her eating she is currently being given PROM (Passive Range of Motion) and is being monitored in the large dining room due to spilling of her liquids she has been given a Sippy cup and a plate guard. There is no mention of R1's tendency to eat fast, lack of chewing, referral to speech therapy or move to small assisted dining room. On (MONTH) 22, 2019 at 3:30 PM, V12 (Dietary Aide) stated he was serving the residents in the assisted dining room the night of the incident on (MONTH) 21, 2019. V12 stated there were two CNAs, V3 and V4, in the dining room. V12 stated he usually started to serve when there were 3 or more CNAs, so the food would not get cold. That night V4 told him to start, they (CNAs) were running behind. V12 stated when he started to serve there were 4 or 5 residents in the dining room including R1. He plated the other residents their regular food and then he plated R1's mechanical soft diet. V12 stated he saw R1 eating with her food and there was no staff sitting at her table. V12 stated he thought it was strange because normally there is staff at the table when she eats. V12 stated about two minutes after she received her food, he heard V3 start yelling, She's choking, she's choking. V4 went over to R1. V3 and V4 started during the [MEDICATION NAME]. V12 stated normally there is a nurse in the dining room during the meal. But that night there was not. V12 stated he ran through the kitchen and to the other dining room to get a nurse. V12 stated V3 and V4 were passing trays and drinks when R1 started choking. The next thing there were a lot of people there. There were paramedics in the building and they came to help. On (MONTH) 23, 2019 at 9:01, V14 (CNA) stated R1 sat at the table where residents are fed. R1 was able to feed herself, but she sat at the feeder table because you have to watch her because she would eat really fast. The night of the incident V14 stated she was in the dining room but her back was toward R1. V14 was loading the hall trays on the cart. She turned toward R1 when she heard V3 yelling she's choking, she's choking! V14 stated V3 and V4 were busy passing trays and drinks in the dining room. There was no staff sitting at the table with R1. R1's ambulance run report dated (MONTH) 21, 2019, shows the ambulance crew had just dropped off another resident at the facility and they saw a resident was choking in the dining area. The ambulance crew stood by while the facility staff attempted to do the [MEDICATION NAME] maneuver on the patient. The patient was turning cyanotic and the staff member were not having any luck getting the foreign body out of the patient's airway. The ambulance crew asked the staff if they wanted their assistance. The staff member agreed, and the ambulance crew took over. The patient was assessed, and no air was going through her airway. Due to the fully obstructed airway, the ambulance crew started the [MEDICATION NAME] maneuver again. On the fifth thrust of the belly the patient was able to expel a piece of food as well as her dentures. The patient was now breathing with shallow rapid breaths. A stridorous wheeze was present. The patient's oxygen saturation was in the 50th percentile. A nonrebreather mask was applied at 15 liters per minute. The ambulance crew offered to take resident to emergency room . The ambulance crew contacted medical control and told to continue nonrebreather mask with valve-bag until they could intubate. AN intravenous line was initiated and Versed was given prior to intubation. The patient rhythm changed from sinus [MEDICAL CONDITION] to asystole. The patient's carotid artery was palpated, and the patient was now pulseless, and was no longer breathing. CPR was initiated with two rounds of [MEDICATION NAME] given. The ambulance arrived at its destination with CPR in progress. The DNR was present to physician at the destination, decision made to stop CPR. The patient was pronounced dead at 6:26 PM.

Based on observation, interview, and record review, the facility failed to prevent a resident from leaving the facility who was previously assessed as high risk for wandering/elopement. The facility failed to personalize interventions to prevent elopement and failed to ensure all staff were trained on newly implemented resident safety procedures. This failure resulted in an Immediate Jeopardy (IJ) and has the potential to affect all seven residents (R1-R7) assessed as wandering/elopement risks living at the facility. The IJ began on (MONTH) 16, 2019 at 10:00 PM when R1 left the facility undetected and was located inside the nearby high school by the school custodian. R1 was noted to leave without shoes and was found wandering in a local high school carrying her pants and wearing only incontinent briefs and a t-shirt. V1 (Administrator), V2 (Director of Nursing), V20 (Corporate Nurse) and V39 (Director of Operations) were notified of the Immediate Jeopardy on 4/30/19 at 1:50 PM. Although the immediacy was removed on 4/30/19, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policy and procedures, training and Quality Assurance monitoring. The findings include: Incident/Accident Report, dated 4/16/19, shows, V8 (RN-Registered Nurse/Charge Nurse/Wound Nurse) received a phone call from (the local high school) that a resident identified by wrist band was at the High School. We were immediately notified and went to pick up resident. The report shows R1 had a pre-existing small bruise on her left lower forearm above her wrist. Final Investigation Report, dated 4/17/19, shows, R1 did verify that she walked out of door 7 because she was having trouble sleeping. R1 described that she went for a walk and then realized that she needed help and walked to the school. The St. [NAME] East staff were able to call the facility because of the green bracelet R1 was wearing with the facility address, and phone number on it, no staff witnessed R1 walk out the door. No staff that were assigned on the north unit for the PM or N[NAME] (Overnight) shift witnessed R1 leave the building. R1 did elope and was unaccounted for about fifteen minutes. R1 walked out door 7 which is 15-20 feet from her prior room. There was no malfunction with the door alarm system. The door alarm system was reset, but no staff member has admitted to resetting the alarm. The report shows the facility was notified R1 was at the high school at approximately 10:15 PM and R1 returned to the facility at approximately 10:45 PM. On 4/22/19 at 10:00 AM, V1 (Administrator), and V2 (Director of Nursing) stated R1 left the facility out of door 7 which was alarmed, and the alarm was functioning at the time R1 left the facility. V1 stated he believed the alarm did go off, a staff looked from the nursing station to see if a resident was at the door but did not go to the door or look outside for a resident. V1 stated the door is approximately 80-90 feet from the nursing station. V1 and V2 stated they are not sure which staff member turned off the alarm when it sounded. V1 stated facility management last trained staff on new resident safety/elopement procedures at the end of (MONTH) 2019. V1 stated training on resident safety/elopement was not part of the new hire packet/training prior to R1 leaving the facility and verified that V3 received no training at the facility. On 4/24/19 at 1:29 PM, V1 stated he was confident the alarm sounded when R1 left the building on 4/16/19 and a facility staff turned off the sounding alarm without going to the door and looking outside. V1 stated no individuals ever exit door 7 and the door alarm would not be turned off for any reason such as taking out trash or employees exiting the building. V1 stated he thought the alarm was turned off due to alarm fatigue. V1 stated the facility rolled out new resident safety/elopement guidelines in the building on 3/28/19 at 1500 and 1545. V1 stated the facility began training with managers, and then continued with staff on the floor as well as dietary staff. V1 stated the staff that were provided training were provided education on the new code green elopement guidelines, the procedure if someone calls a code green, which residents were identified as high risk for wandering/elopement and why, the use of the green binders as reference for high risk wandering/elopement residents. V1 stated those who received the training signed the In-service Attendance Sheet dated 3/28/19. V1 stated subsequent trainings were provided on 4/17/19 at 1400, and 4/18/19 at 1400. V1 stated the training was ongoing and his goal was to train all the staff. On 4/23/19 at 2:20 PM, V15 (Family) stated she was informed by a facility nurse that R1 left the facility, reported to staff she fell while outside but was not injured, was found at the high school in her socks, a t-shirt, and R1 reported to staff she was scared. V15 stated the facility did not report any bruising on R1 related to the incident or otherwise. V15 stated prior to the incident, R1 began pacing approximately a few months prior, but became more intense within the last month. Face sheet, dated 4/17/19, shows R1 was admitted to the facility from the hospital on [DATE]. R1's [DIAGNOSES REDACTED]. Hospital physician note, dated 9/25/17, shows R1 presents to the ER (emergency room ) via ambulance after being pulled over by police and thought to be confused. Patient is poorly kept and states her husband is currently in rehab She states she was out looking for her husband but forgot that he was in rehab. Facility Wandering/Elopement Risk Screening, dated 3/29/19, shows R1 had a history of [REDACTED]. The screening shows R1 was able to walk unassisted, was able to push an exit door open, and was sleeping through the night at the time of the screening. POS (Physician order [REDACTED]. Care plan, dated 3/29/19, shows R1 was assessed to be at risk for elopement and interventions included exit door monitoring in place and placing a green wristband on R1's wrist to alert staff that R1 was at risk. On 4/22/19 at 12:00 PM, R1 had 1:1 staff supervision. R1 stated she has problems with anxiety which started recently. R1 stated she was trying to relax but could not sit still. R1 was aware she recently left the facility and stated, I'll try not to do that today! On 4/23/19 at 11:24 AM, R1 was very anxious, and fidgety. R1 stated the night she left the facility she walked over pebbles, through the grass, and ended up at the school. R1 stated, I stepped on something and fell backwards when on the grass and then there were pebbles. R1 stated she fell backwards at the parking lot and landed on her back and on her right lower forearm near her wrist. R1's right lower forearm just above her wrist had yellowish-purple-brown edges and a purple center. The purple center was approximately the size of a quarter and the entire area approximately the size of a baseball. V37 (LPN- Licensed Practical Nurse) approached R1, pushed down on R1's discolored lower arm, and asked R1 if it hurt. R1 responded, Yes it does! It's going away. R1 stated she was away from the facility approximately twenty minutes when she left. R1 stated she was scared because it was dark outside, so she walked toward the school because she saw people working in the cafeteria. At 11:43 AM, V2 (DON - Director of Nursing) stated the discoloration on R1's lower right arm was very old. V2 estimated R1's discoloration was about a week old. On 4/25/19 at 12:13 PM, V21 (Primary Physician), stated, I think R1 is unable to care for herself and does not have the ability to discern right from wrong and that increases her anxiety and leads to her impulsiveness. V21 stated, She will need a structured setting and appropriate medication. She is not safe to be outside the facility on her own. You don't know what would happen crossing the street or talking to strangers. V21 stated other safety concerns for R1 included falling, inclement weather, and bug/animal bites. V21 stated R1 would always have to have supervision if out on pass but could not go out of the facility independently. Neuropsychological Evaluation, dated 4/12/19, shows R1 demonstrated cognitive impairment, depressed mood, and anxiety at this time R1 also reported increased anxiety for the last two weeks. She reportedly feels restless and has been having trouble falling asleep due to her mind racing. R1 demonstrates mild impairment in attention, calculations, organizing, abstract/categorical reasoning, and routine problem solving. R1 demonstrates moderate impairment in planning, sequencing, cognitive flexibility, novel problem solving, and safety awareness. R1's memory impairments, judgment, insight, safety awareness, logical decision-making ability, and ability to set limits on others may make her susceptible to undue influence. Recommendations: 1. Level of Care: At this time, R1's cognitive deficits and physical health concerns may place her at risk of harm She should, therefore, reside in an environment with twenty-four-hour supervision, and appropriate adaptive equipment for physical safety. On 4/24/19 at 2:22 PM with V22 (High School Head Custodian) and V23 (High School Building Manager), V17 (High School Custodian) stated on 4/23/19 at approximately 10:20 PM, V17 found R1 walking in the hallway of the school near the receiving area. V17 was unsure how R1 gained access to the school. V17 stated R1 looked tired, sad and scared. V17 stated R1 was wearing socks, and no shoes, a red-orange t-shirt, was holding her pants, and wearing only her incontinence briefs. V17 stated he offered R1 the bathroom to be able to replace her pants which R1 did. V22 stated when R1 returned from the bathroom, R1 laid down on the floor. V17 stated he questioned R1, however R1 did not say much other than that she was tired, so V17 called the police. V17 stated he then noticed R1's bracelet with the facility phone number and called the number to inform the staff. V17 stated if R1 walked out the door to the dock, there was an elevated dock, wrenches, and drills on top of a cart and accessible to R1. On 4/22/19 at 12:48 PM, V8 (RN/Charge Nurse/Wound Nurse) stated she worked 6:00-10:00 PM on 4/16/19 and last saw R1 during dinner. V8 stated she later received the call from the high school that R1 was there. On 4/23/19 at 10:32 AM, V7 (LPN) stated she was assigned R1's hall during the day shift on 4/16/19 and then gave V6 (LPN) change of shift report at 10:00 PM as V6 took over R1's hall beginning at 10:00 PM. V7 stated the last time she saw R1 was during medication pass at approximately 8:30-9:00 PM and R1 was in bed. V7 stated she found out R1 left the facility while giving report to V6. V7 stated none of the door alarms sounded that night. V7 stated she believed the door alarm was not turned on because it would have made a noise if R1 walked out the door. V7 stated she drove with V16 (CNA - Certified Nursing Assistant) to pick up R1 from the school. V7 stated V6 performed a skin assessment on R1 when R1 returned to the facility. V7 stated she cared for R1 the entire day prior to the incident and no one reported any bruising, and V7 did not notice any bruising, on R1. On 4/23/19 at 10:15 AM, V6 (LPN) stated her shift began at 6:00 PM on 4/16/19 and V6 took over responsibility for R1's hall at 10:00 PM. V6 stated she and V7 were in the middle of report when they heard R1 was located at the high school. V7 stated she did not remember any of the facility door alarms sounding. V7 stated when R1 returned to the facility, R1 was crying and hysterical and very nervous about the fact that she left the facility, but eventually calmed down. At 3:54 PM, V6 stated she performed the skin assessment on R1 when R1 returned to the facility on [DATE]. V6 stated she noted a blemish on R1's abdomen in addition to a discoloration by her nametag on her arm. It was really light. V6 stated the area was a light reddish color and V6 stated she had not seen the discoloration before. V6 stated no one had ever mentioned discoloration or bruising on R1 prior to then. V6 stated she charted the redness by the wrist band in the clinical record nursing notes. V6 stated she was not sure if (R1) fell . V6 stated, I don't remember if she fell or not. V6 stated she called R1's sister to inform her of R1's incident. V6 stated, I told her everything. When asked if V6 told V15 that R1 fell , V6 stated, I don't want to say yes or no. Exit Door Inspection Log, dated 4/16/19, shows doors 1-11 were all inspected at 11:00 AM and no concerns were identified at any of the doors. On 4/22/19 at 12:10 AM, V9 (Director of Maintenance) stated he checks all the door alarms every day to make sure the doors latch/shut properly and to make sure the alarms are working. V9 stated he had not previously identified any problems with the door alarms. On 4/23/19 at 9:15 AM, the exit to facility door 7 opened to a sidewalk which led to the front of the facility and the main street. Between the sidewalk and a service road leading to an electric substation facility was a grassy area which sloped down toward the service road. Beyond the service road was a large grassy field which included unmarked grass areas and marked soccer fields. Beyond the large field was a combination of roadway and parking lots on the local high school property. The local high school building was located on the far side of the roadway and parking lots. On 4/22/19 at 2:00 PM, V3 (CNA) stated, prior to 10:00 PM on 4/16/19, V3 stated he put R1 to bed at approximately 9:30-9:45 PM. V3 was sitting at the nursing station finishing his shift. V3 stated no door alarms sounded while he sat there. V3 stated he was not trained as to what to do if a door alarm sounds since his employment start date. V3 stated he never had a training day since the beginning of his employment. Employment offer letter, dated 4/1/19, shows V3's employment start date was 4/1/19. Facility Orientation Checklist, dated 4/22/19, shows Elopement/Wandering Policy, Missing Resident Policy, and Door Alarm System/Responding to Exit Door Alarms trainings were added to the checklist after R1 incident on 4/16/19. On 4/23/19 at 3:10 PM, V16 (CNA) stated she last saw R1 on 4/16/19 at approximately 5:30 PM. V16 stated she did not hear any door alarms sounding. V16 stated she was giving a resident a shower and when she brought the resident out of the shower, she was informed R1 was missing. V16 stated she was not aware of any alarms not working at the time R1 left the building. V16 stated the nurse did a skin assessment upon return from the facility and the nurse noticed bruising on R1. V16 stated it was only she and V5 (CNA) on the unit, other than the two nurses, at the time R1 left the building. V16 stated another CNA was scheduled to work, however did not come in on time and was not present during the R1's incident. On 4/23/19 at 3:26 PM, V5 (CNA) stated she last observed R1 at approximately 6:00 PM on 4/16/19. V5 stated at about 10:20 PM or 10:30 PM, a nurse informed her R1 was no longer at the facility. V5 stated that day she worked double shifts and did not hear any alarms sound. V5 stated prior to 10:00 PM, V16 took a resident into the shower and V5 had to go to the bathroom from approximately 9:45 -10:10 PM because she was having stomach upset. V5 stated only the two nurses were available on the unit between 9:45 -10:15 PM because V3 left the unit early at approximately 9:45-9:50 PM. V5 stated she returned to her unit and the next time she saw the two nurses it was approximately 10:20-10:30 PM and they were aware R1 was located at the local high school. V5 stated, if the door alarm sounded, neither V5 nor V16 turned off the alarm because neither were available on the unit. V5 stated a CNA scheduled for orientation was transitioning between the south and north nursing units, however had not yet arrived at the north unit by the time she returned from the bathroom. V5 stated she did not check to verify the door 7 alarm was turned on, or working, prior to beginning her shift with R1. V5 stated she did check the door alarm after R1 returned to the facility and the door alarm was working properly. V5 stated when R1 returned, R1 told the staff at the nursing station that R1 fell while absent from the facility. R1 also stated while outside R1's pants fell down and R1 picked them up and carried them. R1 stated she got scared and began looking for help. Facility policy/procedure Security - Door Alarms, undated, shows, 2. Door alarms will sound when an alarmed door has been opened. All alarms should be in the on position at all times, except for the FRONT entrance, when a receptionist is present 4. Staff working in that area of the building will go visually check the door to determine if a resident has exited out the door. If necessary, staff will go outside and check the area to determine who set off the door alarm. 5. The charge nurse or other staff member will notify the receptionist that the door was checked and why it sounded. 6. The door alarm will be reset only after positively determining that the alarm was not sounded by a resident leaving the facility. 7. If a door alarm sounds and the staff is unable to determine if a resident exited the building a building perimeter search will be initiated immediately, and simultaneously, a head count will be done to account for all resident's whereabouts. All residents determined to be high risk for wandering will be checked first, then all residents on each hall will be checked. If a resident is found to be missing, missing person's protocol will be implemented 9. If at any time a door alarm is turned off to accommodate a delivery, etc. a staff person will be stationed at the door to maintain visual control until the alarm is turned back on. Facility policy/procedure Security - Monitoring of Wandering Residents, undated, shows To reduce the risks associated with wandering and ensure the resident's safety, the facility will identify residents with a potential for, or history of, wandering about the facility or exit seeking behavior. Once identified, appropriate safeguards will be implemented Facility policy/procedure Security - Missing Resident, undated, shows To ensure the safety of our residents, the facility shall follow specific procedures in the event a resident is noted to be missing from the facility. Facility policy/procedure Lockdown, undated, shows Exit lockdown is for the purpose of preventing individuals from leaving due to an existing hazard outside . or the need to screen those leaving due to a missing resident. Review of facility resident safety/elopement training documents, dated 3/28/19, 4/17/19, 4/18/19, and 4/24/19, as well as staffing schedules dated 4/15/19 to 4/24/19, show available facility staff received training on new resident safety/elopement policies/procedures on 3/28/19. The training documents show four staff present at the time R1 left the building undetected (V3, V5, V7, V16) were not trained in the new resident safety/elopement policies/procedures implemented 3/28/19. In addition, the documentation shows: -V7 (LPN) was not provided any further training on resident safety/elopement after 4/16/19 (when R1 left the facility undetected) until 4/24/19. V7 worked several shifts at the facility between 4/16/19 and 4/24/19. -V3 (CNA) never received any facility training on resident safety/elopement training since her employment until 4/17/19 at 1400. -V5 (CNA) never received any facility training on resident safety/elopement training since her employment until 4/18/19 at 1400 -V16 (CNA) did not receive training on the new resident safety/elopement training until 4/18/19 at 1400. -Twelve additional CNA staff worked shifts caring for residents at the facility between 4/16/19 and 4/24/19 without receiving the updated training on the new policies/procedures. The facility staffing schedules show V24 (CNA) worked seven shifts after 4/16/19 (when R1 left the building) with no training on the new resident safety/elopement policies/procedures. V25 (CNA) worked five shifts without the training since 4/16/19, and V26-V35 (CNAs) all worked one or more shifts after 4/16/19 without the training. On 4/22/19 at 1:01 PM with V38 (LPN- Licensed Practical Nurse) at the south nursing station, the South Green Elopement binder showed R1-R7 were all wandering/elopement risks at the facility. Through observation, record review, and interviews conducted 4/30/19, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation on 4/24/19: -On (MONTH) 16, 2019 R1 was immediately placed on one to one supervision upon return to the facility. R1 was re-assessed for Wandering and Elopement and her Wandering/Elopement care plan was updated. R1's medication was adjusted, and R1's room was moved further from the exit door and closer to the nursing station. All residents that resided in the facility were re-assessed for their Wandering/Elopement risk. Residents that were identified as being a positive Wandering/Elopement risk had their care plans updated, had a Green Wrist Band applied, pictures were taken and placed in the Green Wandering/Elopement binders at the nursing stations, therapy room, and reception desk. The facility held an elopement drill as well as elopement in-service for the staff present. All staff present were informed of R1's elopement and her one to one staffing assignment. Wandering/Elopement in-services were presented to staff present on 4/17/19 at 2:00 PM and staff in attendance at the monthly CNA meeting on 4/18/19 at 2:00 PM. - Effective 4/24/19, the facility ensured all staff were provided either initial training or re-training on the facility Resident Security Policies/Procedures (Door Alarms, Monitoring of Wandering Residents, Missing Resident) prior to working any further shifts at the facility. The facility utilized the employee roster to document the education was provided. The documentation will be utilized by the scheduler and charge nurse/Manager on Duty to cross check all employees have been in-service prior to working shifts. - The Charge Nurse/Manager on Duty will verify all staff, including agency, have been trained prior to beginning their shift. This task was added to the Manager on Duty daily checklist. - The facility has added training on elopement procedures to the new hire orientation which will include any agency staff. - The facility will conduct three elopement drills, one on each shift, daily for two weeks. The facility will then conduct three elopement drills, one on each shift, weekly for the next three weeks. Elopement drills will then be conducted quarterly thereafter on each shift. -The administrator or designee will: + Audit staff response to door alarms daily for two weeks. + Interview five employees across all shifts daily for two weeks to acknowledge their understanding of the Resident Security Procedures. Then five employees across all shifts will be interviewed weekly for three weeks thereafter to acknowledge their understanding of elopement. Staff elopement knowledge audits will then be completed quarterly thereafter, and results brought to QAPI. + Review Preventative Maintenance of the doors and alarm functionality audits daily for one week and then weekly. + Monitor compliance of all staff being in-service by checking signed in-services against the employee roster. All employees that do not receive the in-service will not be allowed to work the floor without first being in serviced. - On 4/22/19 additional door alarms were installed on exit doors of the facility which require staff to physically walk to the door to turn off the alarms. Maintenance or designee will inspect all doors and alarms daily to ensure the functionality of the doors and alarms. - The facility held an immediate QAPI (Quality Assurance and Performance Improvement) meetings on 4/17/19 to address the resident elopement and review the elopement policy. At that time no changes were deemed necessary to the elopement policy. On 4/17/19 at 4:00 PM a second leadership incident review call was conducted. On 5/1/19 the facility held a second QAPI meeting to review the plan of correction. - If deficiencies are noted staff will be counseled or disciplined. Results of the audits will be present to the QAPI committee.

Based on observation, interview, and record review the facility failed to choose the correct size of a medical device (cervical collar) to prevent the development of pressure ulcers on R4's bilateral ears, back of the head (occipital area) and chin. Failed to develop and implement a plan of care to promote healing and prevent the development of additional wounds from developing. This applies to 1 of 1 residents (R4) reviewed for medical device related injury. R4 developed multiple stage 3 pressure ulcers as a result of a tight fitting rigid cervical collar. The findings include: The wound documentation report showed that on August 1, 2017 a wound was identified on R 4's posterior scalp measured at 2.8 cm X 3.1 cm X0.3 cm with 80% slough. On September 1, 2017 at 1:03 PM via phone interview, E 8 (Treatment Nurse) explained R 4 developed a Stage 3 on both ears and a wound at the back of the head (occipital area). E 8 explained that the occipital wound started as a hematoma - purple in color and on August 1, 2017, this wound opened up due to pressure from the neck collar. E 8 stated, Because the collar is always on. E 8 also described the wounds are located at the edge of the collar. This occipital wound was initially observed with 80% slough which worsened and became necrotic. On August 21, 2017 a clinical note from Z 2 (Hospice Doctor) showed that on June 26, 2017 R 4 sustained a fall during transfer via a (total) mechanical lift and fell backwards hitting the back of her head. R 4 was sent to emergency room for evaluation and treatment. R 4 was diagnosed with [REDACTED]. A soft cervical collar was placed on R 4 and was transferred back to the facility. This note reads, Since then R 4 has limited mobility. Now has (1) two wounds on the head .and (2) on bilateral ears surrounding the area of the cervical collar .and (3) a new area located in the midline on her chin where cervical collar lies. The cervical collar was noted to be a stiff-rigid cervical collar not the same collar that she was discharged from emergency room with . On September 1, 2017 at 3:20 PM, via phone interview Z 2 (Hospice doctor) explained, When R 4 was discharged from the hospital they (hospital) put a soft perfectly fitting neck collar on R4. R 4 has a short neck and the collar that they put on her at the hospital is just the right fit for her. The facility decided to change it and put a very hard and very rigid collar on R4. I am not surprised that she (R 4) developed these wounds. She developed 2 wounds at the back of her head, 2 on her ears and one at the bottom of her chin that the facility does not even know. These wounds are all from that rigid collar. I do not understand how someone could say it is not from the collar because the wounds are located on top of the collar. I told them to put the soft collar back on, if they had not changed the soft to a hard neck collar she would not have developed these wounds. On September 1, 2017 at 3:40 PM, via phone interview Z 3 (Wound Doctor) stated, She (R4) was given an ancient rigid collar, anatomically not the right fit for her. Yes, the wounds on her ears were due to the neck collar. At 4:45 PM, via phone interview Z 4 (Physical Therapy Director) explained that on June 26, 2017, R 4 was admitted from the hospital with a cheap foam collar, so the ancillary staff ordered a different kind of collar which was put on her on July 7, 2017. R4 was not evaluated by Physical Therapist because she is under hospice care. On July 25, 2017, E 2 (Director of Nursing) said it was rubbing on the bottom of her ears. The collar was too high for her. Her neck is too short. R 4's wound care specialist initial evaluation dated July 18, 2017 showed R 4 developed a Stage 3 on the right and left ear. The notes showed the left ear wound, a Stage 3 of least 2 days duration (no measurement provided), the right ear a Stage 3 when initially found, a date provided but documented less than 9 days, with 20 % necrotic tissue. Z 3 (Wound doctor) additional information showed: R 4 is fairly small and has an XL sized collar, which I believe at this time is too large as a result of her ears being poorly seated, she developed 2 pressure injuries on her ears. The nursing wound documentation /measurement for these areas (right and left ear) was not provided as requested. On September 1, 2017 at 1:03 PM via phone interview, E 8 (Treatment Nurse) explained that the facility has no comprehensive wound assessment for R 4 and E 8 also stated that she does not write the care plan. There was no care plan developed for R 4's wounds.

Based on observation, interview and record review, the facility staff did not transfer R4 safely. One staff transferred R4 using a mechanical sling lift instead of two people as care planned. This failure resulted in R4 sustaining a fractured second cervical vertebra and a subdural hematoma. This applies to 1 of 6 residents reviewed for falls and transfers. The facility also failed to maintain water temperatures at safe levels. This applies to R4, R2, R8 through R55 residents reviewed for safety and supervision in the sample of 57. The finding includes: 1) The face sheet for R4 documents the date of admission as 5/4/14. R4's care plan dated 5/8/17 shows R4 is dependent on the staff for all transfers using a sling mechanical lift for all bed to chair transfers. The care plans states transfers will be completed by a physical assist of two at all times. R4's MDS (minimum data set) of 6/22/17 shows R4 requires two people physical assistance with bed mobility and transfers. The hospital record for R4 dated 6/26/17 states R4 was in a lift when she fell out backward onto her head. There is swelling to the back of her head. The [DIAGNOSES REDACTED]. A cervical collar was in place. The facility incident investigation report of 6/26/17 states R4 is under hospice care, alert and oriented to person only, requires total assist for her activities of daily living including bed mobility and transfers and is non-ambulatory. R4 was being transferred from her bed to chair via lift by E9 CNA (Certified Nurse Aide) when R4 slipped out of the sling onto the floor. The nursing assessment showed swelling on top right side of the resident's head accompanied with pain. R4 was transferred to the emergency room for evaluation. An in-service education meeting attendance sheet documents on 6/26/17 and 6/27/17 thirteen CNA's and one registered nurse were trained on the use of sling and sit to stand lifts requires two people at all times. The facility policy dated 3/31/08 Total Resident Transfers using Mechanical Lifts require a minimum of two trained staff members to complete a resident transfer. On 8/25/17, 8/29/17, and 8/31/17 R4 was observed to have a soft cervical collar on. On 8/30/17 at 12:15 PM R4 was in the dining room wearing a ridged collar calling out and moaning ouch, hurts, ooh. Staff tried to adjust this collar to make R4 more comfortable. On 8/31/17 E8 wound nurse said she got an order to replace the ridged collar with the soft one until a new collar is obtained. On 8/30/17 at 12:55 PM E8 RN would nurse said R4 had a subdural hematoma from the fall of 6/26/17 which opened up on 8/1/17. This wound measured 2.8 cm long, 3.1 cm wide and 0.3 depth. The weekly wound documentation shows the wound continues with a moderate amount of serous exudate. Measurements on 8/29/17 are length 1.5cm, width 5.5 cm, depth 0.3 cm. E8 said the wound probably opened up from laying on the hematoma. On 8/31/17 at 10:10 AM E9 CNA said she did transfer R4 by herself when she slid out of the sling and hit the floor. E9 said she knew she should have had two people and has since attended in-service education along with all CNA's regarding the need for two people at all times for mechanical lift transfers. E9 said R4 has since gotten a bigger sling that fits her better. The sling used on 6/26/17 may have been too small and the material was slippery. On 8/31/17 at 2:20 PM Z1 (R4' primary care physician) said per telephone interview, that the facility staff should have followed the policy to use two people for the transfer. R4 is a bigger person and is more likely to fall with one person using the lift. 2) On 8/29/17 at 12:15 PM the water temperature in the hand washing sink in the main dining room measured 128 F (Fahrenheit). At this time the dining room was full of residents, staff and visitors. At 2:18 PM the water temperature in the 600 hall showers/ bathing room 603 measured 130 F in the hand washing sink. At 2:20 PM R2's hand washing sink in the resident room on the 600 hall measured 130 F, at 2:22 PM the bathing room on the 500 wing room 509 measured 128 F. The bathing rooms of the 600 and 500 halls have showers, toilets and hand washing sinks. The facility was not aware that the water temperatures were at an unsafe temperature at this time. The temperatures were confirmed by E5 maintenance director and called to the attention of E1 the administrator. E5 said the facility has been performing maintenance on the mixing valves to de-lime the valves. The facility has two systems, one for the 500 and 600 halls, and another for units 100 and 200. The holding tank was adjusted to make water temperate fall after this was discovered. On 8/30/17 at 4:20 PM E1 said the facility has ordered new mixing valves. R4, R2, R8 through R55 reside on the 500 and 600 wings, use the bathing rooms, and have hand washing sinks in their rooms.

Based on record review and staff interviews the facility failed to prevent one resident (R11) from falling by not accompanying R11 while in the lobby. This failure led to R11 falling and sustaining a fractured hip in the facility after being admitted for a hip fracture sustained at home. Findings include: Review of R11's clinical record shows that R11, [AGE] years old, was admitted to facility on 6/4/10 following a repair of a fractured right hip sustained at home in May 2010. The admitting MDS (minimum data set) dated 6/15/10 shows that R11 to be a one person extensive assist for all transfer and mobility areas. The care plan dated 6/22/10 states that R11 has short term memory impairment and is unable to recall after 5 minutes, altered ability to understand others, demonstrates impaired cognitive daily decision making skills, has history of falls with injury (hip fracture), weakness, tires easily, poor balance, takes meds that put him at risk and possible episodes of dizziness/vertigo that put him at risk of falls. One of the goals on this care plan is for R11 to maintain his current level of mobility with no increase in incidence or falls/injuries over the next 90 days through staff monitoring and intervention. The facility was unable to achieve this goal as evidenced by a fall R11 sustained on 6/29/10 with resulting hip fracture. Review of facility incident report states that on 6/29/10 about 12:30pm, R11 was sitting in facility lobby in his wheelchair while his family member went to pull the car up. The report says that R11 reported that he got up from his wheelchair and forgot to lock his brakes, lost his balance and fell on the floor. This fall resulted in fracture of the left hip. The incident investigation form dated 6/29/10 under the commentary section states R11 "has been working with PT/OT and is able to ambulate 150 ft with rolling walker and supervision, able to sit down and resume walking another 150'. (R11) is stand by assist with ADL's and transfers." Interview with E3 (ADON and fall coordinator) on 1/20/11 at 1:30pm stated that there was no one waiting with R11 in the lobby on 6/29/10. E1 (administrator) stated on the same day that it is the usual policy of the facility to have a staff person wait with residents in the lobby and have the staff person assist the resident into the vehicle. This did not occur with R11 nor was it a part of their investigation.