Every finding on record at Renwick Nursing and Rehab

Based on observation, interview, and record review, the facility failed to maintain safe and comfortable temperatures for residents. This applies to all 102 residents residing in the facility. The findings include:The Facility Data Sheet dated January 20, 2026, showed the facility census was 102.On January 20, 2026, at 2:51 PM, V3 (Maintenance Director) said the facility experienced a power outage on Saturday, January 17, 2026. V3 said the power was only out at the facility for approximately 45 minutes so by the time V3 arrived at the facility, the power had been restored. V3 said there were no heating issues when he arrived at the facility on Saturday. V3 said on Sunday, January 18, 2026, V3 received a phone call from V1 (Administrator) that the heat wasn't working in the facility. V3 said he went to the facility and realized he needed to manually reset the facility's boiler system. V3 said the boiler system needed to be reset after the power outage but V3 was unaware. V3 said he reset the boilers, the heat started working and V3 took temperatures throughout the facility and the facility was warming up. V3 said he left the facility once he finished taking temperatures. V3 said he came to work Monday morning, January 19, 2026, and everyone was telling V3 they were cold. V3 said he notified his regional maintenance team, and they determined the water pump was going bad. V3 said a technician was called to the facility and he brought a water pump with him. V3 said the pump was bad and the technician had to get another pump. V3 said the technician repaired the water pump on Monday evening.The facility's temperature logs for January 19, 2026, showed at 8:00 AM temperatures in the facility ranged from 63.2 degrees Fahrenheit to 69.6 degrees Fahrenheit, at 10:00 AM temperatures in the facility ranged from 64.7 degrees Fahrenheit to 69.1 degrees Fahrenheit, at 12:00 PM temperatures in the facility ranged from 64.3 degrees Fahrenheit to 71.1 degrees Fahrenheit, at 2:00 PM temperatures in the facility ranged from 57.8 degrees Fahrenheit to 70.7 degrees Fahrenheit, at 4:00 PM temperatures in the facility ranged from 58.5 degrees Fahrenheit to 71.4 degrees Fahrenheit, and at 6:00 PM temperatures in the facility ranged from 58.2 degrees Fahrenheit to 66.5 degrees Fahrenheit.On January 20, 2026, at 2:22 PM, R1 said it had been cold in the facility since Saturday and R1 was moved to the current room on Sunday because his room was cold. R1 said then the heat stopped working in the facility on Sunday and it was cold everywhere. R1 said the heating issues started Saturday around 6:00 PM when the power had gone out. R1 said the thermostat in his room read 55 to 60 degrees Fahrenheit for 18 hours. R1 said he was finally moved to his new room on Sunday around 2:00 PM. R1 said it was freezing in the facility and uncivilized for the residents to have to be subjected to that cold of temperatures. R1 said even landlords have to ensure the heat is maintained so the facility should have to maintain the heat as well.On January 20, 2026, at 2:26 PM, R2 said it was very cold in the facility over the weekend. R2 said his nose was freezing to the touch. R2 said staff gave R2 some extra blankets because it was so cold.On January 20, 2026, at 12:59 PM, R3's room temperature was checked by V4 (Assistant Maintenance). V4 said his thermometer showed the temperature in R3's room was 62.4 degrees Fahrenheit. R3 walked into his room wearing a winter jacket.On January 20, 2026, at 2:12 PM, R3 was sitting in his room with V12 (R1's son). R3 said his room has been cold for two to three days. R3 said his roommate had already moved out of the room but R3 was waiting for a new room. V12 said R3 called and asked V12 to bring a pair of winter gloves for R3 because he was cold. On January 20, 2026, at 3:35 PM, V1 said staff recognized R3's room as cold this morning. V1 said R3 was offered a new room but initially refused. V1 said the facility does not have documentation of monitoring R3 for hypothermia symptoms after R3 refused to move rooms.On January 20, 2026, at 2:15 PM, R4 said he moved rooms today sometime before breakfast. R4 said last night his room was freezing and R4 had 10 blankets on to stay warm. R4 said multiple people came to his room to try to fix the heater but they were not able to. R4 said it was so cold in his room he thought it might be warmer to just be outside.On January 20, 2026, at 11:11 AM, R5 said the heat was not working yesterday and R5 had four blankets on to stay warm. R5 said he would rather not have to wear four blankets to stay warm. R5 said he was wearing two pairs of pants to keep his legs warm. R5 said he stayed in his room when the heat was not working. On January 21, 2026, at 11:29 AM, V6 (CNA/Certified Nursing Assistant) said she worked on January 19, 2026, from 6:00 AM to 2:00 PM. V6 said the facility was cold when she arrived at work and wore her winter jacket to assist residents in the dining room during breakfast because it was cold. V6 said residents were complaining it was cold. V6 said staff were moving residents to warmer areas of the building. V6 said she did not obtain temperatures on any residents. V6 said the facility was still cold when she left around 2:00 PM. On January 21, 2026, at 11:36 AM, V7 (LPN/Licensed Practical Nurse) said she worked on January 19, 2026, from 6:00 AM to 6:00 PM. V7 said when she came to work the facility was cold. V7 said towards the end of her shift, she started doing more frequent body temperatures on some residents. V7 said she only obtained temperatures on the residents who could not tell her if they were cold. V7 said it was still cold in the facility when she left work around 6:30 PM. On January 21, 2026, at 12:34 PM, V8 (RN/Registered Nurse) said she worked at the facility on Sunday, January 18, 2026, starting at 6:00 PM, and her shift ended at 6:30 AM on Monday, January 19, 2026. V8 said when she arrived for her shift on Sunday the facility felt cold. V8 said as a nurse she doesn't know how to work a heater. V8 said she instructed the CNA to put extra clothing on the residents, and the staff used all the available blankets. V8 said she moved a resident whose bed was close to the window to the other bed closer to the door. V8 said the previous shift had told her it was getting colder in the facility throughout the day. V8 said she did not call anyone about the facility being cold. V8 said she took temperatures on the residents who could not tell her if they were cold. On January 21, 2026, at 12:42 PM, V9 (LPN) said she worked night shifts from 6:00 PM to 6:00 AM, on Saturday, Sunday, and Monday. V9 said they started having heating issues Saturday night. V9 said the staff notified maintenance but were told he did everything he could. V9 said the staff made sure the residents had blankets. V9 said it was cold when she came to work Sunday night and Monday night when she came to work. V9 said on Sunday night, she did not notify anyone of it being cold in the facility.On January 21, 2026, at 12:52 PM, V3 said he was not notified by any staff members or administration Sunday night into Monday morning regarding the heat not working. V3 said he did not know the heat was not working properly until he came into work on Monday morning. V3 said when he was at the facility on Sunday to manually reset the boilers, V3 took temperatures around 10:30 AM and then left. V3 said he did not hear anything else form the facility after he left the faciity on Sunday morning. V3 said on Monday the heating company technician was available to come to the facility at 3:00 PM but the motor he brought did not work and he had to go back to the vendor to get a new motor. V3 said the heat was fixed around 10:00 PM Monday night.On January 21, 2026, at 2:21 PM, V11 (ADON/Assistant Director of Nursing) said she was the on-call nursing manager on Sunday night January 18, 2026. V11 said she did not receive any calls from staff about the heat not working.On January 21, 2026, at 2:24 PM, V1 said he did not receive any calls from the facility Sunday night regarding the heat not working and it being cold in the facility. V1 said staff should have notified V1 or V3 regarding the lack of heat in the facility. On January 21, 2026, at 2:39 PM, V2 (DON/Director of Nursing) said on Monday January 19, 2026, starting at 5:00 PM, facility staff started taking temperatures of the residents. V2 said not all residents' temperatures were checked. V2 said all resident temperatures should have been monitored. V2 said if staff felt the facility was cold Sunday night, temperatures on all residents should have been documented. The facility does not have documentation to show all residents were monitored for signs and symptoms of hypothermia, including monitoring temperatures while the facility had a lack of heat January 18, 2026, at night and January 19, 2026, during the day. The facility's policy dated January 2020, titled Loss of Heat During Cold Weather Policy showed, Policy: To establish guidelines to maintain a safe and comfortable environment in the event of the loss of heat. Policy Specifications: Staff will be oriented and educated to the procedures to address individual room heat malfunction as well as loss of heat to the entire facility. Procedure for individual room heat malfunction: 1. Notify Maintenance Department of malfunction via telephone and maintenance work order.6. The room temperature should be checked as needed (sampling at least every two hours) if the residents are in the room to ensure that they are warm and comfortable. 7. If the room becomes uncomfortably cool for the residents in the affected room (i.e. falls below 55 degrees Fahrenheit for 12 hours of more) it is recommended they be moved to another room if available.Procedure for loss of heat to the facility: 1. Notify Administrator and Maintenance Department of the malfunction via telephone.7. Residents should be observed for signs of adverse effects of the cooler temperature.

Based on interview and record review, the facility failed to maintain essential heating equipment to maintain safe and comfortable temperatures in the facility. This applies to all 102 residents residing in the facility.The findings include:The Facility Data Sheet dated January 20, 2026, showed the facility census was 102.On January 20, 2026, at 2:51 PM, V3 (Maintenance Director) said the facility experienced a power outage on Saturday, January 17, 2026. V3 said the power was only out at the facility for approximately 45 minutes so by the time V3 arrived at the facility, the power had been restored. V3 said there were no heating issues when he arrived at the facility on Saturday, so he was only at the facility briefly. V3 said on Sunday, January 18, 2026, V3 received a phone call from V1 (Administrator) that the heat wasn't working in the facility. V3 said he went to the facility and realized he needed to manually reset the facility's boiler system. V3 said the boiler system needed to be reset after the power outage but V3 was unaware. V3 said he came to work Monday morning, January 19, 2026, and everyone was telling V3 they were cold. V3 said he notified his regional maintenance team, and they determined the water pump was going bad. V3 said a technician was called to the facility and he brought a water pump with him. V3 said the technician was not available to come to the facility until 3:00 PM. V3 said the pump was bad and the technician had to get another pump. V3 said the technician repaired the water pump on Monday evening around 10:00 PM. The heating company's Service Order dated January 19, 2026, by V14 (Heating Company Technician) showed V14 was at the facility on January 19, 2026, from 3:00 PM until 10:00 PM. The Description of Work Performed showed Pump motor determined to be bad by previous site visit. Picked up new motor from vendor and arrived at site. Found new motor purchased was bad out of the box after installation. Due to time of day the vendor was closed, and I had to wait for someone to return to open the store. Picked up and returned back to site. Installed new motor and spring coupler, started up and checked amp (amperage) reading. Motor pulling 2 amps. Building staff rest heat pumps and I stayed until they were comfortable with temps rising in guest rooms. New pump installed and operational.On January 22, 2026, at 2:52 PM, V15 (Heating Company Sales Engineer Account Manager) said the heating company had a technician at the facility on Sunday January 18, 2026, due to a lack of heat in the facility. V15 said the facility was told the heat pump needed to be replaced and was a key component to the heat working, but the facility chose not to have it replaced until regular business hours the next day. V15 said V14 brought a heat pump with him on Monday January 19, 2026, because the company knew the pump needed to be replaced.The heating company's Service Order dated January 18, 2026, by V16 (Heating Company Technician) showed .Needs a new motor for pump along with a new spring coupler. Customer states that they want to wait for tomorrow to replace the pump during normal hours of operation. Advised customer that the pump is a pivotal component for the heat pumps to work and that it needs to be replaced immediately. Customer states that building temperature has risen and they'd like to wait until tomorrow during normal hours.On January 20, 2026, at 12:37 PM, V4 (Assistant Maintenance) said the power in the facility went out on Saturday January 17, 2026. V4 said he went to the facility on Sunday January 18, 2026, to help fix a leaking sink. V4 said V3 came in due to the lack of heat in the building. V4 said V3 did not know he needed to manually reset the boilers after a power outage. V4 said today he made sure all the boilers had been reset. V4 said he had to manually reset one of the boilers which V3 did not reset. V4 said the boiler supplied heat to the administrator's office.On January 21, 2026, at 2:24 PM, V1 said V3 started working at the facility in December 2025. V1 said there is no way V3 could be trained on all aspects about the building. V1 said V3 has a regional maintenance team he can reach out to if there is something he does not know. V1 said V3 should have called the regional team on Saturday when the power went out to ensure there were no additional tasks V3 needed to perform to ensure things were operating as they should be in the facility.

Based on observations, interviews, and record reviews the facility failed to ensure food was prepared and served under sanitary conditions by not ensuring kitchen areas and equipment were maintained in a clean and sanitary condition, not performing hand hygiene when necessary, not wearing hair coverings appropriately, and not discarding spoiled food. This failure applies to all 100 residents eating food from the facility.Findings include:On 11/20/2025 at 10:09 AM, the kitchen hand washing sink was heavily stained with black residue, visible food spatter and particle residue was present on the hand soap and hand sanitizer dispensers above the hand washing sink, a heavy presence of dust was present on the paper towel dispenser above hand washing sink, dark gritty colored stains and residue was present on the lid, surface, and pedal of the garbage bin underneath hand washing sink.On 11/20/2025 at 10:12 AM, yellow stains and food spatter was present on the wall over food prep area with microwave located underneath.On 11/20/2025 at 10:16 AM, A red sticky substance was present on the surface of a large box of bagels in the kitchen deep freezer, and red spatter was present on inner rims and top of the door of two deep freezers. On 11/20/2025 at 10:23 AM, V10 (Cook) touched his mouth and continued with handling dishware and meal prep without performing hand hygiene.On 11/20/2025 at 10:32 AM, A heavy presence of dark gray, red, and black stains were present on the interior lip of the ice machine where ice is dispensed, a gray and white buildup was present on the rim underneath the ice machine lid, and white stains and smudges were present throughout the exterior of the ice machine. Heavy thick white stains were present on the food prep sink faucet. A large box of apples stored underneath the food prep table dated 10/28/2025 held multiple rotted apples. On 11/20/2025 at 10:40 AM, V14 (Dietary Aide) walked through the kitchen with her personal coat on and grabbed a personal cup from the food prep area where clean trays and cups were stored.On 11/24/2025 at 11:10 AM, V11 (Dietary Aide) observed rolling silverware with hair barely covered by hairnet. V11 said the hairnet didn't fit well and she needed a bigger one.On 11/24/2025 at 11:12 AM, V10 (Cook) touched his lips, placed his hand in his pockets, and continued preparing food in the kitchen without performing hand hygiene. Colored stains were present on the surface of the hand soap dispenser above the handwashing sink a heavy presence of dust and thick sticky white stains were present on the surface of the paper towel dispenser, and visible dust and food particles was present on the surface of the hand sanitizer dispenser above the handwashing sink. V9 (Dietary Manager/Consultant confirmed the presence of visible dust, particles, and stains on the hand sanitizer and soap dispensers and paper towel dispenser.On 11/24/2025 at 11:25 AM, V10 (Cook) said kitchen cleaning practices definitely need improvement. Multiple large cracks were present in the surface of the food processor bowl/pitcher sitting on the food prep sink. V9 said she could see the cracks in the food processor bowl/pitcher and that it is was leaking. Sticky stains and food spatter were heavily present on the wall behind the hotbox that was sitting on top of the food prep table, and a heavily stained blue basin was sitting directly behind the hotbox. Food particles and greasy stains were heavily present on the surface of the shelf underneath the food prep table where clean sheet pans were stored and on the meshed side wall of the shelf. Visible food spatter and stains were present on the back wall of the food prep table. Food spatter and grease stains were heavily present throughout the surface of the stove being used to cook a meal. V9 said she could see the food stains and particles throughout the food prep table and behind the hotbox. V8 (Dietary Manager) said the blue basin was old and should be thrown out. On 11/24/2025 at 11:36 AM, V8 (Dietary Manager) said the food processor bowl/pitcher was cracked and particles from the cracked material could get into the food being prepared using the food processor and kitchen appliances should be cleaned daily. The floors throughout the kitchen were heavily stained with a thick dark substance and food spatter and grease stains were heavily present throughout the surfaces of the stove area and the food prep sink areas next to the stove. On 11/24/2025 at 11:46 AM, Thick white removable stains were present on multiple dish racks filled with clean cups and sitting on food carts being used for dining service.On 11/24/2025 at 11:49 AM, Food particles were present on the surface of sheet pans with several clean plates sitting on them inside the plate warmer cabinet. Multiple visible white smeared stains were present on the front door of plate warmer cabinet. Food spatter and greasy stains were heavily present throughout the surface of the plate warmer machines filled with clean plates. Visible food particles were present throughout the surface of the overhead shelf above the steam table where all food being served for lunch was located.On 11/24/2025 at 12:20 PM, In the kitchen area visible thick food particles were present on various parts of the surface of three beverage pitchers with grape flavored beverage and lemonade being served with lunch. Thick white and brown removable stains were heavily present on multiple dish racks holding multiple clean plastic cups.On 11/25/2025 at 12:42 PM V8 (Dietary Manager) said hairnets should completely cover hair to prevent hair from falling out, he will be ordering extra-large caps for staff with more hair due to difficulty concealing more hair, staff should not wear outside clothes in the kitchen such as coats because it's not sanitary, the kitchen should be clean at all times, V8 agreed the kitchen should be free of visible debris, particles, substances, dust, and food spatter, and there should not be any substance buildup on the dish racks because everything in the kitchen or used in the kitchen should be clean. V8 said if staff touch any part of their person they should rewash their hands and don new gloves. V8 said any rotting apples should be thrown out and the apples are used every other day. V8 said food packages stored in the freezer and the freezer itself should not have any visible residue present and the source of the substance should be identified, the food removed, and the interior or surface of the freezer cleaned; there should not be any stains or visible substances on the surface of the ice machine and it should be wiped down and cleaned, there shouldn't be any visible substances or particles on the inside lip of the ice machine where the ice dispenses from, the ice machine should be nice and clean.The facility's Culinary Sanitation and Infection Control Policy received 11/25/2025 states: It is the policy to store, prepare, distribute, and serve food in an acceptable manner as to prevent the growth of food borne pathogens. At all times, facilities shall be thoroughly cleaned and sanitized to protect against potential contamination including spoilage, unacceptable microbial growth, dust, unclean equipment or utensils, hair, and other sources of contamination. The purpose of this policy is to ensure that culinary experience team members prepare, process, handle, package, transport, display, serve and store foods in a sanitary manner protected from contamination and spoilage: and to ensure all team members understand and follow infection prevention: To protect food from contamination and spoilage: To maintain physical plant and equipment in a clean and sanitary manner: and To prevent transmission of infections. Floors, walls, and large equipment shall be cleaned daily and thoroughly cleaned annually, at a minimum or more often as needed. Work surfaces shall be cleaned and sanitized after each use or following any interruption of operation during which contamination may have occurred. Scrape and remove food bits from the surface. Floors shall be scrubbed daily. Splashes on walls or ceilings shall be cleaned as soon as possible.The facility's Food Storage Policy received 12/04/2025 states: It is the policy that all food products will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security. To meet all federal and state guidelines and protecting the safety of the resident from any cross contamination and food born illnesses.The facility's Culinary Policy on Hygiene received 12/04/2025 states: It is the Policy that culinary team members maintain good personal hygiene practices to prevent contamination of food by culinary team members. The purpose of this policy is to ensure that culinary experience team members who are handling, preparing or serving food maintain good personal hygiene practices to prevent contamination of food by culinary team members.Handwashing (priority for infection control). Culinary team members shall wash hands at the following times: After touching face, nose, hair, or any other body parts.

Based on observations, interviews, and record reviews the facility failed to implement safety and fall prevention interventions when transferring a resident during personal care. This applies to 1 of 8 residents (R7) reviewed for falls in a sample of 10 residents.Findings include:R7 is a [AGE] year-old female with a history of Dementia with Moderate Mood Disturbance, Seizures, Recurrent Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood, Disorder of Muscle, and History of Falling who was admitted to the facility 04/19/2024. R7's current care plan shows she exhibits behaviors of combativeness, noncompliance with care, getting out of bed unassisted or not using call light for assistance. and shows she is at risk for falls due to behavior and to encourage compliance with transfer safety devices. On 11/24/2025 at 12:48 PM, R7 was seen sitting in the dining room eating her lunch with a large area of discoloration and bruising above her left eyebrow. R7's incident report dated 11/13/2025 shows at approximately 9:30 AM she had a witnessed fall while in the common bathroom and an open area above her left eyebrow bleeding was identified, she was being assisted to the toilet in the shower room, she raised off the toilet unassisted and legs buckled form under her and she fell, she was observed sitting on the floor in the shower room and confirms hitting her head, intervention of bringing R7 to the nurse station for close monitoring was implemented and R7 was sent to the hospital for assessment and later returned to the facility. Witness statement from V7 (Staffing Coordinator/Certified Nursing Assistant) dated 11/13/2025 documents R7 was trying to self-transfer to the shower room toilet, when assisting R7 with transferring off the toilet back to the wheelchair R7 began fidgeting and trying to pull up her own pants and her foot gave out from underneath her, and she fell and hit the left side of her head on the floor.On 11/24/2025 at 1:56 PM, V7 (Staffing Coordinator/Certified Nursing Assistant) said on morning of 11/13/2025, R7's roommate was in the restroom when R7 had to use the bathroom. According to V7, R7 became impatient and began going to the shower room to use the restroom. Once R7 was ready to be transferred off the toilet, upon standing up R7 insisted she would pull up her own pants and began arguing that she wanted to pull up her own pants; R7 began reaching down and became unstable on her legs; R7's legs gave out and she fell to the side, landed on floor and hit her head. V7 said she tried to break R7's fall but was unable to stop R7's fall. R7 fell and hit her head. V7 said on 11/25/2025 at 10:52 AM, that she was not using a gait belt when assisting R7 off the toilet. V7 said while she was assisting R7 from the toilet back to her wheelchair R7 was holding the grab bars, she let go to pull up her pants and lost her balance. V7 said when assisting R7 from the toilet she placed her arms around R7's back for support and R7 was braced against her. On 11/25/2025 at 2:44 PM, V3 (Restorative Director/Licensed Practical Nurse) said all aides are required to wear gait belts when transferring; when a resident has a fall, nursing completes a risk management assessment and based on the assessment and interviews regarding falls interventions are implemented, R7 requires one person assist for transfers during toileting and gait belts are to be used for toileting transfers.The facility's Policy on Gait Belt Use received 12/04/2025 shows: A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer. A gait belt can support a lower to the floor if the resident begins to fall or loses balance during transfer or ambulation. When combined with proper body mechanics a gait belt improves caregiver safety and prevents back injury.

Based on observation, interview, and record review, the facility failed to monitor and assist a resident with a known risk for malnutrition with restoring her oral eating skills, and failed to provide gastrostomy tube management and care as ordered for a resident who was dependent on enteral nutrition. This failure resulted in R6 experiencing a significant weight loss of 5.8% in one month.This applies to 1 of 1 resident (R6) reviewed for gastrostomy-tubes in a sample of 29. The findings include:On 9/09/2025 at 11:10 AM and 12:20 PM, R6 was in bed sleeping. R6's piston syringe was sealed and a measuring cylinder for her g-tube (gastrostomy-tube) feeding were on her bedside table, unused. At 2:40 PM, R6 was still in bed and unable to fully express or communicate regarding her tube feedings. R6 contacted V17 (Family Member) via her cell phone to assist her with her communication. V17 said they were concerned for R6's nutrition because R6 would report that she did not always receive her scheduled feedings as ordered, and the facility would then report R6 refused her tube feedings at times because she wanted to resume eating orally. V17 continued to say that R6 was receiving ST (Speech Therapy) services and was informed weeks earlier that R6 would be receiving a video swallow study to determine if she could resume eating orally. On 9/10/2025 at 12:00 PM, R6 was in bed awake. R6 gestured that she had not received her scheduled 11 AM bolus feed. R6's still-sealed piston syringe and a measuring cylinder for her g-tube feeding were both on her bedside table, unused. R6's EMAR (Electronic Mediation Administration Record) showed V11 (Licensed Practical Nurse/LPN) had signed off R6's scheduled 11 AM bolus feed and water flush as having already been administered. At 12:50 PM, V11 confirmed she had not administered R6's scheduled bolus and water flush as ordered, and she had pre-signed R6's EMAR. V11 said she would administer R6's bolus feed of Glucerna 1.5, close to two hours late. V11 failed to assess R6's tube site, check for placement, or check for GRV (gastric residual volume). V11 proceeded to flush R6's tube with 30 ml (milliliters) of water, then 340 ml of Glucerna 1.5, and then another 40 ml of water. V11 said she was done administering R6's scheduled feeding. R6's Order Review Report dated 9/11/2025 showed g-tube orders for enteral feed Glucerna 1.5 give 340 ml bolus every 6 hours, flush feeding tube with 375 ml of water every 6 hours, observe peristomal skin for gastric leakage every shift, and check for placement prior to feeding administration by aspirating for gastric residual feeding. V11 said R6 at times would indicate if she was unable to tolerate her full bolus feeds, stating when she felt too full. V11 said R6 was completely NPO (nothing by mouth) and was not sure about the status of R6's swallow study.R6's Electronic Medical Record (EMR) showed R6's 8/9/2025 weight was 140.1 pounds, and her 9/1/2025 weight was 142 pounds. On 9/11/2025 at 10:30 AM, V10 (LPN) said he weighed R6, and she weighed 132 pounds.On 9/11/2025 at 1:40 PM, V2 (Director of Nursing/DON) said nurses were expected to follow g-tube orders as indicated and follow facility policy to ensure residents with g-tubes received appropriate enteral feeding cares.On 9/11/2025 at 11:30 AM, V16 (Speech Language Pathologist/SLP) said she was treating R6 for her communication and swallowing goals. V16 said she had difficulty fully assessing R6's level of cognition, and at times she would display behaviors of refusing speech therapy (ST) education. V16 said R6 was supposed to have an outpatient video swallow study weeks earlier to evaluate if she could safely resume her desired oral diet. V16 said she was concerned because she had not received updates from the facility staff on when R6's swallow study would be scheduled. V16 said at the moment, she had not been able to advance in R6's ST goals for eating because the study had not been done. V16 said she reviewed R6's EMR and was unable to find documentation of any attempt that had been made to schedule R6's swallow study. R6's September 2025 Physician Order Sheet (POS) showed an 8/20/2025 active order for Video Fluoroscopic Swallow Study (VFSS) Modified Barium Swallow Study.On 9/11/2025 at 12:05 PM, V15 (Dietician) said she was monitoring R6's nutrition. V15 said on 8/29/2025, she had assessed R6's nutritional needs and was informed she was refusing her bolus at times because she wanted to resume her oral feeding. V15 said she did not make any further nutritional recommendations and believed R6 would be having her video swallowing study. V15 said that now based on R6's identified significant weight loss of 5.8% in 1 month, she was initiating continuous g-tube feedings to ensure R6's feedings maintained her nutritional needs. V15 said she assumed the facility nursing staff and ST would be following up with the scheduling of R6's video swallow to determine if she could safely resume her oral intake. V15 said on 8/29/2025, R6's weight was not being monitored weekly because her weight had been stable and R6 was not identified as at risk for weight loss. V15 said residents at risk for weight loss should be weighed and monitored weekly to identify and prevent significant weight loss. V15 continued to say R6 should have received her g-tube feeding and hydration flushes as ordered to ensure she received appropriate hydration and nutrition to meet her needs.R6's 8/29/2025 dietary note showed R6's nutritional needs were reviewed. The note showed Resident noted refusing g-tube bolus at times [related to] stated wanting to eat by mouth. There is an order for a swallow study.Plan: Continue present management follow up prn.R6's 9/11/2025 dietary note (during the survey) showed R6 was referred for significant weight loss of 5.8% in 1 month. The note said Resident noted [history] refusing g-tube bolus at times [related to] stated wanting to eat by mouth. Tolerates enteral feeding. [Inter-disciplinary Team] suggesting trialing continuous enteral feeding.Recommend 1) Glucerna 1.5 @ 75 ml/hr x 18 hours; 2) Flush: 300ml [every] 6 hrs; 3) Weekly weights x 4 weeks.R6's care plan showed R6 was refusing her g-tube feedings and was at risk for weight loss. The interventions included Order Video Swallow as ordered or recommended and Provide supplements as ordered.The facility's 9/2022 Enteral Tube Care and Maintenance policy showed Daily care of the gastrostomy/jejunostomy tube and exit site will extend the life of the tube, prevent peristomal skin irritation, and assure appropriate hygiene of the tube exit site.Verify feeding tube placement as appropriate.Check for placement prior to medication, flush or feeding administration The facility's 6/2023 Interventions for Unintended Weight Loss policy showed It is the policy of [Company] that individuals with unintended weight loss or insidious weight loss will be identified and monitored so that appropriate intervention can be implemented

Based on observation, interview, and record review, the facility failed to ensure dish machine temperatures were monitored and failed to label/date/seal food items in the kitchen.This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 9/9/25 documents that the total census was 103 residents. On 9/9/25 at 10:13 AM, V2 (DON/Director of Nursing) said there is only 1 NPO (Nothing By Mouth) resident who does not eat food served from the facility kitchen.On 9/9/25 starting at 9:32 AM, the facility kitchen was toured in the presence of V3 (Dietary Manager) and the following was found:In the walk-in cooler:1.Three 5lb (pound) cottage cheese containers with best by date of 9/4/25 located on the top shelf behind 2 cottage cheese containers with best by date of 10/7/25. V3 said, We should have rotated the stock- First in, First out.2. 22qt (quart) plastic tub filled with brown liquid that is not labeled or dated. V3 said, It's juice.In the dry storage:3. 34oz (ounce) carton of shredded potato cheese bake, opened and not resealed. Date opened on carton says 8/12 and has a best by date of 1/9/25.4. Large plastic bin labeled white rice, not dated and not contained. Plastic bin has a lid on it with multiple holes.5. Bucket of packaged honey grahams with broken pieces of opened crackers and crumbs scattered throughout, no lid.6. Large plastic clear bin labeled quick oatmeal, not dated. V3 said, We refill it about every month.7. Large plastic bin labeled all-purpose flour, not dated.8. Scoop sitting on top of a cooler- not contained, covered, or in a designated scoop holder.In dish machine Area at 9:59 AM:9. V3 (Dietary Manager) ran a test strip through the high temperature dish machine twice and the max temperature showed on the strip was 160 degrees. V3 was asked how often the dish machine temperatures were being checked to monitor the temperature and he said, There are no set days to test the dish machine, we probably check it about 3 times a week. V3 said the dish machine should get up to 180 degrees during the rinse cycle and he does not know when the dish machine temperature was last tested. At 10:05 AM V3 tried testing another strip and ran it through the dish machine after it had time to warm up and the strip still only showed 160 degrees max temperature reached.On 9/10/25 at 11:38 AM during the return to kitchen tour the following was found:In the main kitchen area:10. A large plastic bin labeled Cheerios with a use by date of 2/21/25.11. A large plastic bin labeled Corn Flakes only partially covered by the lid with no date.12. A large plastic bin labeled Raisin Bran, not dated.13. A large plastic bin labeled [NAME] Crispies, not dated.14. A large plastic bin labeled Fruit Loops, not dated.15. A large plastic bin labeled Frosted Flakes, not dated.At 11:48 AM, V3 asked to retest the dish machine to demonstrate that it was working properly. V3 used a different kind of test strip and ran it through the dish machine, and the blue bar turned orange (showing the desired temperature was achieved), but the strip only tested that the temperature reached 160 degrees. V3 did not realize the strips were not testing for 180 degrees. V3 searched for strips that tested for 180 temperature, but the strips he had to show the dish machine reached 180 degrees all expired 8/2023. V3 did not have the appropriate strips to test the dish machine and show it reached 180 degrees. V3 said the kitchen staff was not keeping logs of dish machine temperature checks, and he just created the dish machine log right now for the staff to start using.On 9/11/25 at 2:34PM V3 said all food items in the kitchen should be labeled and dated for food safety; to make sure the products are good and safe to serve to the residents. V3 said all opened food items should be tightly covered and/or resealed to prevent any debris from falling into the food, prevent contamination, and to maintain food freshness/quality. V3 said food stock should be rotated and stocked using first-in, first-out method to ensure older products are being used first and the residents are being served the best quality foods. V3 said temperature checks of the dish machine should be done daily and consistently to ensure the dish machine is getting up to the correct temperature to kill all of the bacteria that needs to be killed to prevent resident illness. V3 said the rinse cycle of the dish machine should be reaching 180 degrees because that is the temperature that is required to effectively sanitize the dishes.The facility's policy titled, Food Storage last revised June 2023 states, Policy: It is the policy of [corporation name] that all food products will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security. Purpose: To meet all federal and state guidelines and protecting the safety of the resident from any cross contamination and food borne illnesses. Process.12. Staple foods are stored in an orderly and systematic arrangement with the older stock to the front of the shelves. (FIFO) First in first out, system.15. Food and non-food supplies are to be clearly labeled.18. All exposed foods should be stored tightly covered.The facility's policy titled, Dishwashing and Sanitation last revised June 2023 states, Policy: It is the Policy of [corporation name] to store, prepare, distribute and serve food under sanitary conditions. Purpose: To properly wash and sanitize is necessary to prevent food-borne diseases. Dishware, pots, pans or utensils should be thoroughly cleaned and sanitized before use in food preparation or food serving to prevent the spread of food-borne diseases. Process.3. Dish machine temperatures will be taken twice a day and recorded in a log.Mechanical Dishwashing:5. Wash water temperature should be set at 160 degrees for hot sanitation. 6. Rinse water temperature should be set at 180 degrees for hot sanitation.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) to residents who need assistance.This applies to 4 of 4 residents (R13, R53, R60, R111) in a sample of 29. The findings include: 1.On 9/9/2025 at 10:40 AM, R111 was in his room. He had beard stubble on his face. R111 stated that staff is disrespectful, and he's been asking them to shave him, but they are ignoring him. On 9/10/25 at 9:35 AM, V2 (DON—Director of Nursing) came to R111's room. R111 still complained that he hasn't been shaved yet. V2 stated that CNAs are responsible for shaving residents on shower days or as needed. R111's MDS (Minimum Data Sheet) dated 9/8/25 shows he is cognitively intact. R111's care plan dated 9/3/25 shows he has an ADL self-care performance deficit needs and participation may vary. 2.On 09/9/2025 at 11:59 AM, R60 was lying in bed. He had a beard and stated he wanted to be shaved. He said he's uncomfortable with the beard and said he has asked the staff, but they are always busy. R60's MDS dated [DATE] shows he is cognitively intact. R60's care plan dated 9/9/23 shows he has an ADL self-care performance deficit needs and participation may vary. Facility's policy titled Activities of Daily Living (2/2023) shows Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Hygiene: bathing, dressing, grooming, and oral care 3. On 9/9/25 at 10:39 AM, R13 had scabbed areas on his forehead and long, uneven fingernails- about a quarter inch above the tip of his finger, with dirty brown matter underneath nails. R13 said he did not know how often he gets his fingernails trimmed. On 9/11/25 at 11:41 AM, R13' long fingernails on both hands long and uneven and brown matter under his nails remained. R13 said he did not know when his finger nails were last trimmed and he touched the uncovered wounds/scabs/opened areas on his forehead and face. R13's POS (Physician Order Sheet) shows order dated 8/12/25 for enhanced barrier precaution related to the wounds to face, forehead, right scalp, left buttock, right buttock, and right medial ankle. An order dated 8/6/25 showed treatment to cleanse forehead with normal saline, pat dry and apply mupirocin ointment daily and as needed for wounds. R13's Face Sheet shows he has a history of MRSA (Methicillin Resistant Staphylococcus Aureus) infection dated 8/4/25. R13's Care Plan initiated 4/17/25 states resident has autoimmune disease wound areas related to ruptured blisters sites to scalp, forehead and face. Interventions include avoid scratching and keep fingernails short. R13's Care Plan last revised 11/19/24 states he has an ADL self-care performance deficit related to weakness and confusion. Interventions include resident requires assistance x1 staff member for personal hygiene. On 9/11/25 at 1:34 PM, V2 (DON/Director of Nursing) said resident nails should be trimmed by the CNAs (Certified Nurse Assistants) or licensed nurses. V2 said the staff should be observing the resident's nails daily and trimming them as needed. V2 said it is especially a concern for R13 having dirty, long, uneven fingernails because of him picking at/touching his head wounds. V2 said this is an infection risk. 4. On 09/09/2025 at 12:07 PM, R53 was in bed. R53's fingernails on the left hand were long, hard, yellow, curled in a downward position, with a dark colored substance underneath. R53's fingernails on the right hand were long, thick, yellow, with a dark colored substance underneath. R53 stated he had asked staff several times to cut his fingernails. On 09/11/2025 at 12:04 PM, R53's left hand fingernails continued to be long, hard, yellow, curled in a downward position, with a dark colored substance underneath. R53's fingernails on the right hand continued to be thick, long, yellow, with a dark colored substance underneath. R53 stated I have asked several times for my nails to be clipped. They do not have the equipment to clip my nails. On 09/11/2025 at 12:12 PM, V19 (CNA) stated resident's fingernails should not be long with dirt underneath. V19 stated R53 could scratch himself and get an infection. V19 stated nail care should be performed daily and as needed. On 09/11/2025 at 12:19 PM, V2 (DON) stated R53's fingernails need attention. V2 stated he was not aware of the condition of R53's fingernails. V2 stated It is expected of the staff to bring nail concerns to my attention or the nurse's attention, so the provider could be notified and get the proper nailcare. R53's Face Sheet showed a facility admission of 09/10/24, with diagnoses including chronic obstructive pulmonary disease, emphysema, diabetes, severe protein calorie malnutrition, alcoholic liver disease, and chronic bronchitis. R53's MDS dated [DATE] showed R53 had moderate cognitive impairment. The same MDS showed R53 was dependent upon staff for personal hygiene. R53's ADL self-care performance deficit care plan showed R53 required moderate to total assist with ADLs from one to two staff members.

Based on observation, interview, and record review, the facility failed to wear PPE (Personal Protective Equipment) for residents on EBP (Enhanced Barrier Precautions) and perform hand hygiene during care.This applies to 5 of 5 residents (R6, R46, R87, R97 and R112) reviewed for infection control in the sample of 29. The findings include: 1. On 09/09/25 at 10:44 AM, R112 was in bed. R112 had an indwelling catheter. R112 stated she was admitted to the facility the previous night from the hospital. R112 was wearing an incontinence brief and stated the staff assists her with incontinence care. R112 did not have an EBP sign or isolation kit outside of room door indicating the need for PPE. On 09/09/25 at 10:56 AM, V30 (CNA/Certified Nursing Assistant) assisted R112 with repositioning and draining the indwelling catheter bag. V30 did not wear a gown. On 09/10/25 at 3:29 PM, R112 still did not have an EBP sign or isolation bin with PPE outside of the room. On 09/10/25 at 3:35 PM, V6 (Infection Control Nurse) stated resident when R112 was admitted , an EBP sign should have been put outside of the room door with an isolation bin. V6 stated nurses can put the EBP signage up and get the isolation bins if she is not in the facility. V6 stated EBP should be followed because residents can pass on an infection to the person taking care of them. R112 was admitted to the facility on [DATE] with multiple diagnoses which included chronic obstructive pulmonary disease, cirrhosis of liver, urinary tract infection, multiple sclerosis, diabetes, and otitis media per the Face Sheet. R112's Order Review Report for September 2025 showed Enhanced Barrier Precautions: F/C (Indwelling Catheter) every shift for infection control. R112's Enhanced Barrier Precaution due to indwelling catheter care plan dated 09/09/25 showed an intervention of Gown and gloves use when performing high-contact resident contact activity. 2. On 09/09/25 at 11:05 AM, R97 had an EBP sign outside the room door and an isolation bin. On 09/10/25 3:40 PM, V31 (CNA) and V32 (CNA) were observed going into R97's room. V31 and V32 did not put on PPE when they entered the room. On 09/10/25 at 3:50 PM, V31 and V32 exited R97's room pushing R97 in a shower chair. The trash cans in R97's room had no gowns in the trash. V31 and V32 continued to not wear gowns while providing a shower to R97. On 09/10/25 at 3:56 PM, V6 (Infection Control Nurse) stated R97 is on EBP for CRE (Carbapenem Resistant Enterobacteriaceae). V6 stated staff should wear gloves and gowns when providing care to R97. On 09/10/25 at 3:59 PM, V31 stated she did not have on any PPE while she provided care to R97. V31 stated she knows what EBP is, and she should have worn a gown and gloves while providing care to R97. V31 stated cross contamination can happen if the appropriate PPE isn't worn. R97 was admitted to the facility on [DATE] with multiple diagnoses which included chronic obstructive pulmonary disease, diabetes, dementia, congestive heart failure and atrial fibrillation. R97's Order Summary Report for September 2025 showed Enhanced Barrier Precautions: Organism: CRE and left arm skin tear. R97's MDS (Minimum Data Set) dated 08/07/25 showed R97 had severe cognitive impairment. R97's Enhanced Barrier Precaution care plan dated 06/03/24 showed Gown and glove when performing high-contact resident contact activity. 3. On 9/09/2025 at 11:30 AM, R87 had a sign posted for EBP (Enhanced Barrier Precautions) on her door to instruct staff to wear PPE when assisting with her direct care needs. V14 (CNA) assisted R87 transfer from the toilet seat to her wheelchair while wearing gloves, but no gown, as instructed. R87's Order Review Report dated 9/11/2025, showed an active order for Enhanced Barrier Precautions: Colostomy initiated on 3/05/2025. The facility's policy titled Enhanced Barrier Precautions dated 3/21/2024, said It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism.refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 4. On 9/09/2025 at 9:50 AM, V13 CNA assisted R46 with her partial bed bath. V13 rendered peri-care care and changed R46's soiled incontinence brief. V13 did not perform hand hygiene between each task and continued to use the same gloves. Then V13 said she was done assisting R46 with her personal hygiene care and removed her gloves. V13 failed to perform hand hygiene afterwards. 5. On 9/10/2025 at 12:50 PM, V11 (Licensed Practical Nurse/LPN) said she was going to administer R6's gastrostomy tube feeding. V11 failed to perform hand hygiene prior to donning her gloves and gown. V11 then touched R6's drawers and bed remote with the same gloves. Then V11 proceeded to handle R6's feeding tube and administered her scheduled bolus feeding with the same gloves. V11 failed to perform hand hygiene prior to administering R6's feeding. On 9/11/2025 at 11:10 AM, V6 (Infection Preventionist/IP) said the nursing staff was expected to perform proper hand hygiene before and after rendering care, when changing gloves between different care tasks, when entering and leaving a resident's room, and when handling bodily fluids. V6 said hand hygiene was important in preventing the spread of infections. The facility's titled Hand Hygiene Guideline dated 08/2024, said Purpose: Appropriate hand hygiene is essential in preventing transmission of infectious agents. Hand Hygiene includes soap and water and hand hygiene with alcohol-based hand rub (ABHR).Hand Hygiene is recommended: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.

Based on observation, interview, and record review, the facility failed to maintain their 2 person assist mechanical lifts in operating condition.This applies to all 31 residents (R23, R48, R55, R57, R62, R71, R72, R73, R78, R82, R85, R100, R102, R104, R105, R2, R8, R12, R14, R29, R31, R35, R40, R46, R50, R69, R79, R93, R96, R97, R111) that use the 2 person mechanical lift.The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 9/9/25 documents that the total census was 103 residents. On 9/11/25, a list of all facility residents who require the use of the 2-person mechanical lift for transfer assistance was provided and shows 31 total residents: 13 total residents in the 100 and 200 hallways and 18 total residents in the 300 and 400 hallways.On 9/9/25 at 10:49 AM, R40 said the facility is supposed to have four 2-person mechanical lifts, but 2 of them have been broken for a while. R40 said the other day she got stuck in the air in the lift and the staff had to manually lower her down. R40 said there used to be 1 lift per hallway (four total hallways) and the lack of working lifts leads to her having to wait longer to get up out of bed because the working lifts are not available when she is ready to get up. On 9/11/25 at 12:00 PM, R29 said he is transferred by the 2-person mechanical lift and there are currently only 2 functioning lifts in the building. R29 said there is also a problem with the lift rechargeable batteries; the battery chargers don't charge the batteries well and they have gone dead while he was up in the air in the middle of the transfer. R29 said the lack of functioning lifts causes a delay in the staff being able to help him out of bed because they have to wait for an available lift and/or walk around the facility to find a working lift and battery. On 9/11/25 at 12:04 PM, R40 said it has been at least a couple of months since the facility has had 4 working 2-person mechanical lifts.On 9/11/25 at 11:45 AM, 1 working mechanical lift, #6571, was found in one hallway of the building. On 9/11/25 at 11:55 AM 1 working mechanical lift, #5018, was found in the the other hallway side of the building. Also in a shower room was mechanical lift #5039 and it was tagged as broken. V22 (CNA/Certified Nurse Assistant) was asked to turn it on and see if it was functioning and she was unable to get the lift to work.On 9/11/25 at 11:39 AM V21 (CNA) said there is supposed to be a 2-person mechanical lift in each of the four hallways. On 9/11/25 at 11:45 AM, V14 (CNA) was observed using mechanical lift #6571 to transfer R31 from her bed into her wheelchair. V14 said she thinks they put in a maintenance request to fix one of the broken mechanical lifts. V14 said the facility is supposed to have 4 functioning mechanical lifts. On 9/11/25 at 11:51 AM V19 (CNA) said there is only one working mechanical lift on one of the hallways that is shared. On 9/11/25 at 11:55 AM V22 (CNA) said the facility should have two mechanical lifts for each side of the building, so four total functioning lifts. On 9/11/25 at 11:47 AM, V13 (CNA) confirmed there are only two mechanical lifts working, and two that are currently broken. V13 said for this reason, each side of the building has their own lift, and the lifts are shared between the two hallways. V13 said they should have four working lifts, one for each hallway. V13 said two mechanical lifts for the whole building is not enough because then she has to wait for a CNA in the other hallway to finish with the lift before she can use if for her residents and it causes the residents to have to wait longer to get up out of bed.The facility's Resident Council Meeting Minutes dated 6/30/25 show concern of only two working 2-person mechanical lifts. The facility's Resident Council Concern Follow-Up form dated June 2025 states the residents still have a problem with only two mechanical lifts working and the resolution states the DON will be emailing our support regarding the replacement/repair of the [lift] that is out of service. On 9/11/25 at 1:28 PM, V1 (Administrator) provided all Maintenance Work Order Requests from December 2024- present. All Maintenance Work Order logs were reviewed, none of the work order requests mentioned broken mechanical lifts being fixed.On 9/11/25 at 1:34 PM, V2 (DON) said he was not sure how many mechanical lifts were currently in working order, but he knew there were at least two. V2 said he had to check how many lifts the facility should have when all were in working order. V2 said he knew at least one of the lifts was broken and getting repaired. V2 said the maintenance team tries to fix them and if they are unable to do so, the maintenance team calls the lift company to get them fixed. V2 said it is a concern to only have two functioning mechanical lifts in the facility because that leads to a delay in getting the residents assistance for transfers. On 9/11/25 at 1:55 PM, V23 (Maintenance Director) said they have three working 2-person mechanical lifts, only one is broken. V23 was then told there was only two working lifts and he said that was correct, another one of the lifts was also down so now there are only two working. V23 said one of the lifts has been broken for a while and is in the storage area while he waits to hear back who he needs to send the lift out to, to be fixed. V23 said the lift that more recently broke he did take a look at, but he was unable to fix that lift either and it will also need to be sent out for repair. V23 said he was waiting to hear back when and where the lift will be fixed. V23 said there was not a Maintenance Work Order Request filled out for the broken mechanical lifts, staff told him verbally they were broken. V1 (Administrator) overheard V23's interview and then V1 asked V23 how many lifts were broken and V23 said two. V1 (Administrator) then asked V23 (Maintenance Director) how many more lifts are needed and V23 told V1 two more lifts.The facility's undated policy titled, Equipment and Supplies Management Policy states, Purpose: To ensure safe availability, storage, use, and maintenance of equipment and supplies necessary for resident care, in compliance with IDPH, CMS F-Tags, and manufacturer standards. Policy: The facility will maintain appropriate stock and safe use of equipment and supplies to support resident care, with procedures for ordering, storage, preventative maintenance, and emergency backup.

Based on observation, interview, and record review, the facility failed to provide a resident with a bed that was long enough for his height.This applies to 1 of 1 resident (R111) reviewed for accommodation of needs in a sample of 29.The findings include:On 9/9/2025 at 10:42 AM, R111's feet were dangling off the low air loss mattress. R1 stated he had been at the facility around five days, and his bed is not long enough for him. R111 stated I need a bigger mattress or some kind of extender. R111 stated he was six foot two (74 inches) and the tag on his mattress showed it was 75 inches long. On 9/10/2025 at 9:35 AM, V2 (DON-Director of Nursing) went to his room and R111's feet still dangled off the bed. V2 confirmed that he needs a bigger bed. R111's face sheet shows diagnoses of osteomyelitis of vertebra, lumbosacral region, pressure ulcer of sacral region, stage 4, non-pressure chronic ulcer of other part of left foot with unspecified severity, peritoneal abscess, diabetes mellitus due to underlying condition with diabetic polyneuropathy, paraplegia, complete, and unspecified injury at unspecified level of thoracic spinal cord, sequela. R111's MDS (Minimum Data Sheet) dated 9/8/25 shows he is cognitively intact.Facility's policy titled Bed Safety Guideline (3/2024) shows: Guidelines: The resident's sleeping environment shall be designed based on an interdisciplinary assessment of the resident's safety, medical, comfort and freedom of movement needs. The Director of Nursing Services (or designee) and maintenance director (or designee) shall a.) inspect all hospital bed systems at least quarterly as part of our regular bed safety program.

Based on observation, interview and record review the facility failed to check a diabetic resident's glucose prior to eating and failed to prime an insulin pen.This applies to 1 of 1 residents (R111) reviewed for diabetic management in a sample of 29. The findings include:On 09/10/2025 at 8:45 AM, R111's breakfast tray had been completely consumed. V24 RN (Registered Nurse) tested R111's blood glucose level. R111's blood glucose level was 360 mg/dl (milligrams / deciliter) after having eaten breakfast. V24 stated she was administering his standing dose of 11 units of Insulin Aspart in addition to 10 units of sliding scale dose of Insulin Aspart. V24 RN attached the needle and dialed the insulin pen to a total of 21 units. V24 did not prime the needle on the pen. As V24 was about to administer the insulin, she was asked if the needle was primed. V24 stated she never used an insulin pen before and didn't know it was supposed to be primed.On 09/11/2025 at 4:43 PM, V2 DON (Director of Nursing) the stated insulin pens should be primed before dialing the dose for administration, otherwise the resident won't receive the full dose of insulin. The blood glucose testing is done before the meal because the resident's glucose level will be higher after eating, resulting in the resident receiving more insulin than they need. The insulin should be given before or when the meal is in front of the resident as the doctor orders.R111's sliding scale Insulin Aspart physician orders states insulin is given subcutaneous before meals and at bedtime for blood glucose. R11's current care plan states resident has a potential for hyper / hypoglycemia. Interventions include diabetes medications and blood glucose monitoring as ordered by doctor.The facility policy Insulin Pen Usage dated 8/2022 states the insulin pen is to be primed prior to each use to prevent the collection of air in the insulin reservoir.

Based on observation, interview, and record review, the facility failed to report, assess, and treat residents with wounds.This applies to 2 of 3 residents (R46 and R2) reviewed for skin alterations in a sample of 29. The findings include:1. On 9/09/2025 at 9:50 AM, V13 (Certified Nurse Assisting/CNA) was rendering peri-care to R46. R46 lower abdominal fold was covered with a thick white layer of ointment. V13 said the treatment to R46's groin was zinc ointment (a white ointment). V13 removed the ointment from R46's abdominal area, and R46 had open areas on her right and left sides. V13 said R46 open areas were new, and she would inform the wound care team.On 9/10/2025 at 11:25 AM, V8 (Wound Care Nurse/WCN) and V12 (Wound Care Technician/WCT) said they were done performing R46's weekly wound care assessments, then R46 requested V8 assess her new open wound to her abdominal fold. R46 said she was concerned because the nursing staff informed her she had open wounds, and no one had assessed them. V8 removed the white ointment from R46's abdominal area to assess R46's abdominal areas. V8 said she was not informed prior and would have the Wound Physician assess R46's abdomen to initiate the proper treatment.On 9/11/2025 at 1:00 PM, V8 said she expected nursing staff to report new skin alterations immediately to ensure wounds were assessed and treatments were initiated to prevent wound complications, such as infections and tissue deterioration. R46's care plan reviewed on 9/11/2025, said she was at risk for further skin breakdown. R46's skin interventions included to follow the facility protocols for the treatment of skin injuries. R46's Wound Assessment Details Report dated 9/10/2025 (during the survey) showed R46 had a new infectious partial-thickness open wound to her left abdomen. The wound measured 0.5 cm (centimeters) x 8.0 cm x 0.2 cm. The wound had 100% bright beefy red tissue with a light amount of serous drainage.R46's Wound Assessment Details Report dated 9/10/2025, also showed R46 had a new infectious partial-thickness open wound to her right abdomen, measuring 0.5 cm x 8.0 cm x 0.2 cm. The wound had 100% bright beefy red tissue with a light amount of serous drainage.R46's Order Review Report dated 9/10/2025, showed a new wound care order for her abdominal wounds Mupirocin External Ointment 2 % (Mupirocin) Apply to Abdomen topically everyday shift for Wound AND Apply to Abdomen topically as needed for Wound, not the white zinc ointment.2. On 9/09/2025 at 12:30 PM, R2 was in the dining room. R2 was confused and was assisted with eating his lunch. R2 had one geri-sleeve rolled down his right wrist and no geri-sleeve on his left arm. R2 had open skin tears to his right elbow and left forearm and both were uncovered. The skin on R2's arms was thin and frail with old scars.On 9/11/2025 at 1:00 PM, V8 (WCN) said she expected nurses to follow standing PRN (as needed) wound care orders and standard facility wound protocols to ensure wounds were treated accordingly. V8 said R2 was at a high risk for skin tears, and his skin interventions included for staff to apply his geri-sleeves to both arms daily.R2's care plan showed R2 was at risk for skin breakdown related to his skin tears. R2's skin interventions included monitoring, reporting, and treating his skin tears as ordered.R2's Order Review Report dated 9/10/2025, showed an order for geri-sleeves to his bilateral upper extremities at all times initiated on 8/04/2025. R2 also had active daily and PRN orders for Xeroform and bordered gauze on his left and right arms.R2's Wound Evaluation and Management Summary dated 9/10/2025, said his full-thickness trauma wounds to his left forearm measured 2.0 cm x 0.7 cm x 0.2 cm, and right forearm measured 2.8 cm x 1.0 cm x 0.1 cm.The facility's 01/2017 Dressing Non-Sterile (Aseptic) policy showed The purpose of this procedure is to provide guidelines for the application of non-sterile dressings. Preparation: 1. Verify that there is a physician's order for this procedure (Note: this may be generated from a facility protocol). 2. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. 3. Check the treatment record.The following information should be recorded in the resident's medical record or Treatment Administration Record.5. Complications related to the wound (e.g., pain, redness, drainage, swelling, bleeding). 6. Physician notification of any wound observation changes.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers had pressure ulcer treatments in place.This applies to 2 of 4 residents (R46, R111) reviewed for pressure sores in a sample of 29.The findings include: 1.On 9/09/2025 at 10:42 AM, R111 stated he had no dressing covering his pressure wounds that were on his back. R111 was in bed in a hospital gown and rolled over. R111 had large, exposed wounds on his sacrum and right ischium. There was a dressing to the left ischium. R111 stated that dressings were in place the day before, but during the night he had urinated all over and been changed by male CNA (Certified Nursing Assistant). R111 stated he did not know if the CNA told the nurse that his dressings were no longer in place. R111's MDS (Minimum Data Sheet) dated 9/8/25 shows he is cognitively intact. On 9/9/25 at 10:58 AM, V8 (LPN—Licensed Practical Nurse/Wound Nurse) and V12 (CNA/WCT-Wound Care Tech) both stated that they changed his dressings yesterday 9/8/25 at around 12:30 PM. V8 and V12 stated R111's wounds should be covered and should have dressings. V8 said the wounds on R111's backside are all stage 4 pressure ulcers. V8 said if the dressing comes off when they are not there or during incontinence care, then the floor nurse is responsible for doing the dressing. On 9/10/2025 at 9:25 AM, V2 (DON—Director of Nursing) stated that wounds should be covered at all times with a dressing. V2 said the floor nurse should put a new dressing on if it comes off or becomes contaminated with feces. R111's face sheet shows diagnoses of osteomyelitis of vertebra- lumbosacral region, pressure ulcer of sacral region- stage 4, peritoneal abscess, neuromuscular dysfunction of bladder- unspecified, paraplegia- complete, and unspecified injury at unspecified level of thoracic spinal cord- sequela. R111's wound notes dated 9/3/25 showed he has a stage 4 pressure sore to his sacrum which measures 8.00 x 13.00 x 3.00 cm (centimeters) (L x W x D—length x width x depth), stage 4 to his right ischial tuberosity which measures 5.00 X 2.50 x 4.00 cm, and a stage 4 to his left ischial tuberosity which measures 2.00 x 1.00 x 2.50 cm. R111's POS (Physician Order Sheet) showed the following orders: Left and Right Ischium—Cleanse with wound cleanser, apply Dakins moist gauze and gauze island dressing daily and as needed for wound and every day shift for wound. Sacrum—Cleanse with wound cleanser, apply Dakins moist gauze and gauze island dressing daily and as needed for wound and everyday shift for wound. R111's care plan dated (9/4/25) shows he has stage 4 pressure ulcer or potential for pressure ulcer development related to history of ulcers and immobility. Goal: [R111]'s pressure ulcer will show signs of healing and remain free from infection. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. 2. On 9/09/2025 at 9:50 AM, V13 (Certified Nurse Assisting/CNA) was rendering peri-care to R46. R46's sacral foam dressing was saturated with serosanguineous drainage and falling off. R46's sacral stage 4 pressure ulcer wound was not fully covered and the wound bed was partially exposed. V13 said R46's sacral dressing should have been changed because it was soiled. The next day on 9/10/2025 at 10:00 AM, R46 was in bed and said she was waiting for the wound care team to dress her uncovered sacral wound. R46 said she received her scheduled shower before breakfast, and her sacral pressure ulcer dressing was removed. At 11:25 AM, V8 (Wound Care Nurse/WCN) and V12 (Wound Care Technician/WCT) assisted R46 with her wound care assessment. They turned R46 on her side, and her sacral wound was uncovered and exposed. V8 asked R46 why her wound was uncovered, and R46 said it was removed during her shower because it was soiled. On 9/11/2025 at 1:00 PM, V8 said it was important for all wounds to be treated as ordered. V8 said staffed nurses were expected to perform PRN (as needed) treatments to prevent wound complications, such as infections and tissue deterioration. R46's Wound Assessment Details Report dated 9/10/2025, said R46's sacral stage 4 pressure ulcer wound measured 4.0 cm (centimeters) x 4.0 cm x 0.5 cm. The wound tissue type was 70 % bright pink or red and 30% soft necrotic adherent tissue with moderate serous drainage. R46's Order Review Report dated 9/10/2025, showed an active order for Tx: Sacrum: Cleanse with wound cleanser, pat dry, apply Dakins moist gauze and bordered gauze daily and as needed initiated on 8/20/2025. R46's care plan reviewed on 9/11/2025, said R46 had an active stage 4 pressure ulcer to her sacrum and was at risk for further skin breakdown. R46's interventions included, Administer treatments as ordered and monitor for effectiveness. The facility's policy titled Pressure Ulcer and Wound Prevention Management Program dated 12/05/2006, said It is the policy of this facility to.Ensure a resident who has been admitted with pressure ulcers or develops pressure ulcers in-house receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, when possible. To prevent and manage wound care through a group of health care professionals.3. Residents' skin will be inspected during daily bathing, dressing, showering, and incontinency care with special attention to bony prominences by C.N.A.'s and staff nurses.

Based on observation, interview, and record review, the facility failed to maintain podiatry care for a dependent resident.This applies to 1 of 1 resident (R53) reviewed for podiatry services in the sample of 29. The findings include:On 09/09/25 at 12:07 PM, R53 was in bed. R53's toenails on both feet were long, yellow, and curled in a downward position. R53 stated he had not had his toenails cut in weeks. On 09/11/25 at 12:04 PM, R53's toenails continued to be long, yellow, and curled in a downward position. On 09/11/25 at 12:19 PM, V2 (DON/Director of Nursing) stated R53's toenails need attention. V2 stated he was not aware of the condition of R53's toenails. V2 stated It is expected of the staff to bring nail concerns to my attention or the nurse's attention, so the provider could be notified and get the proper nailcare.R53's was admitted to the facility on [DATE] with multiple diagnoses which included chronic obstructive pulmonary disease, emphysema, diabetes, severe protein calorie malnutrition, alcoholic liver disease, and chronic bronchitis, per the Face Sheet. R53's MDS (Minimum Data Set) dated 07/03/25 showed R53 had moderate cognitive impairment. The same MDS showed R53 was dependent upon staff for personal hygiene. R53's ADL (Activities of Daily Living) self-care performance deficit care plan showed R53 required moderate to total assist with ADLs from one to two staff members. R53's 7/17/2025 encounter visit from [contracted podiatry company] showed R53 had tinea unguium and nail dystrophy. The same visit showed follow up in 2-3 months or as needed for a more acute problem.The facility's Nail Care Guideline dated 02/23 showed Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. The facility's Podiatric Services Policy dated 11/03 showed 4. If the podiatric services are emergent, the podiatrist is contacted to see the resident. If the need is not urgent, the resident is placed on the podiatry list for the podiatrist to see at their next scheduled visit.

Based on observation, interview, and record review, the facility failed to ensure residents were positioned safely in their wheelchairs to mitigate accident risk. This applies to 3 of 3 residents (R96, R31, and R14) reviewed for accidents/supervision in a sample of 29. The findings include:1. On 9/10/2025 at 9:50 AM, R96 was sitting in his recliner wheelchair in the common area across the nurse's station. R96 was severely confused and appeared uncomfortable. R96 was scooting downward repeatedly in his wheelchair. R96 was leaning awkwardly onto his left buttock, causing his right leg to hang over his wheelchair. The right armrest was absent from his wheelchair, which caused his upper right leg to hang off the seat of his wheelchair. V5 (Registered Nurse/RN) said R96 was a high-fall risk and required constant supervision. V5 said R96 also required frequent repositioning in his wheelchair because he would frequently slide downward. V5 stated staff should be ensuring R96 was properly positioned and that his wheelchair's armrest was in place for his safety.R96's care plan reviewed on 9/11/2025, said R96 was at risk for falls related to his weakness and impaired mobility. R96's fall interventions included for staff to conduct purposeful rounding and educate staff on the causes of falls. R96's care plan also indicated he was dependent on staff for his mobility needs.2. On 9/09/2025 at 11:35 AM, R31 in her wheelchair in the common area across the nurse's station. R31 was severely confused and appeared uncomfortable. R31 was sliding off her wheelchair and her mechanical lift sling was bunched up on her back. No non-slip device was present on R31's wheelchair seat to prevent her from sliding off further. V5 (RN) instructed V13 and V14 (Certified Nurse Assistants/CNA) that R31 needed to be safely positioned. V13 said she believed R31 continued to slide off her wheelchair because she needed a different type of wheelchair for proper positioning. Then V13 and V14 used their arms to anchor under R31's armpits and slung her in an upward motion to sit her upright in her wheelchair.R31's care plan reviewed on 9/11/2025, said R31 was at risk for falls related to her impaired judgement, poor balance, and behavior of scooting herself when in her wheelchair. R31's interventions included for staff repositioning accordingly to prevent injuries. R31's care plan also indicated she was dependent on staff for her mobility needs.3. On 9/09/2025 at 12:10 PM, R14 was sitting in her wheelchair in the dining room. R14 was confused and appeared uncomfortable. R14 was leaning on her right side awkwardly, causing her arm and hand to be positioned firmly against the wheelchairs inner arm rest. R14 was unable to reposition herself because she had severe left-side weakness.R14's care plan reviewed on 9/11/2025, said R14 was at risk for falls related to her impaired mobility and history of falls with serious injury. R14's interventions included for staff to anticipate and meet her needs. R14's care plan also indicated she was dependent on staff for her mobility needs.On 9/11/2025 at 11:00 AM, V9 (Restorative Nurse) said R96, R31, and R14 were high fall risk due to their impaired mobility and behaviors. V9 said R31 required a non-slip device to her wheelchair seat to prevent her from sliding down unsafely. V9 continued to say nursing staff was expected to monitor residents continuously for safe positioning to prevent accidents or injuries. V9 said staff should safely assist residents with positioning with the use of a lifting device and not lift residents with their arms to prevent injuries.The facility's policy titled Positioning dated 10/2021, said To promote resident comfort, safety, and dignity. To prevent complications of improper positioning.3. When a resident is in any type of chair.Positioning aides will be placed as needed to keep the resident upright. The facility's policy titled Falls Guideline dated 08/2024, said Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention. To consistently identify and evaluate residents who fallen and to treat or refer for treatment appropriately.to prevent or reduce injuries related to falls.Individualize interventions for each resident.

Based on observation, interview, and record review, the facility failed to implement nutritional interventions for a resident with known weight loss.This applies to 1 of 3 residents (R61) reviewed for nutrition in a sample of 29. The findings include:On 9/09/2025 at 12:25 PM, R61 was in the dining room for lunch. R61 was served a single portion of his lunch items, which included mechanical-soft chicken, mashed potatoes, steamed brussels sprouts, a dinner roll, and cookies. R61 appeared hungry and ate his entire meal except his brussels sprouts because he was unable to chew them. R61 did not have any teeth and used his gums to chew his food.On 9/10/2025 at 12:20 PM, R61 was in the dining room for lunch. R61 was served a single portion of his lunch items, which included meat lasagna, steamed broccoli, garlic breadstick, and cheesecake brownie. R61 appeared hungry and ate his entire meal except his broccoli and breadstick because he was unable to chew them. R61's lunch meal ticket indicated he should be served Double portions and Pudding with his lunch meals. V3 (Dietary Manager) assessed R61's served meal and ticket and said R61 should have been served another serving of his meat lasagna and pudding. V3 then served R61 another portion of the meat lasagna, and R61 ate the entire serving.On 9/11/2025 at 12:00 PM, V15 (Dietician) said R61 was being monitored for significant weight loss, and his interventions included him receiving double portions for lunch and dinner, and pudding. V15 said double portions included all entree items to ensure he received increased calories to meet his nutritional needs.R61's last dietary assessment review note dated 6/06/2025, said R1 was being monitored for significant weight loss for the past 6 months. The note said V15 reviewed R61's medical record and recommended he continued to receive double portions for lunch and dinner and pudding at lunch. R61's Order Review Report dated 9/11/2025, showed a diet order for General diet, Mechanical soft texture, Regular (Thin) consistency double portion for lunch and dinner. R61's care plan reviewed on 9/11/2025, said R61 had problems with malnutrition and dysphagia. The care plan said R61 required a mechanically altered diet as ordered by his physician. R61's diet intervention was Provide and serve diet as ordered.The facility's policy titled Interventions for Unintended Weight Loss dated 06/2023, said It is the policy of [Company] that individuals with unintended weight loss or insidious weight loss will be identified and monitored so that appropriate intervention can be implement. Purpose To address the needs of high-risk residents.

Based on observation, interview, and record review, the facility failed to provide IV (intravenous) care and services.This applies to 1 of 2 residents (R111) reviewed for IV maintenance in a sample of 29.The findings include:On 9/9/2025 at 10:42 AM, R111 was lying in bed. R111's right arm had a PICC (Peripherally Inserted Central Catheter) line with the antibiotic Ceftriaxone running through the IV via gravity dial. The tape on the IV tubing was dated 9/6/25 (three days earlier). R111 couldn't remember when his IV tubing was last changed. R111's MDS (Minimum Data Sheet) dated 9/8/25 shows he is cognitively intact. There was no label on the antibiotic bag that showed the date and time the bag was hung, or who it was hung by. On 9/9/2025 at 11:50 AM, V5 RN (Registered Nurse) stated she has been working in the facility for 16 years. She stated IV tubing is changed every 24 hours. She said, You need to put the date and initials and time on the medication bag and IV tubing.On 9/10/2025 at 9:25 AM, V2 DON (Director of Nursing) stated that the IV tubing should be changed every 24 hours. V2 stated there should be a date on the IV tubing. V2 said, I'm not sure if the IV medication bag must be dated, time or initialed. I can get back to you on that. I have to review our policy.On 9/10/2025 at 9:35 AM, V2 came to R111's room. The IV tubing had nothing on it to show when the IV tubing was first used, and the IV antibiotic had no label to show when it was started or by who. V2 confirmed that the IV tubing should be dated. On 9/11/2025 at 11:14 AM, V6 LPN (Licensed Practical Nurse/Infection Preventionist) stated that nurses have to date IV tubing and change it daily to keep it clean and prevent infections.R111's face sheet shows diagnoses of osteomyelitis of vertebra, lumbosacral region, peritoneal abscess, and unspecified injury at unspecified level of thoracic spinal cord, sequela, paraplegia. R111's POS (Physician Order Sheet) shows orders for Ceftriaxone Sodium Intravenous Solution Reconstituted-Use 2000 MG (Milligrams) intravenously one time a day related to osteomyelitis of vertebra, lumbosacral region and peritoneal abscess, for 2 weeks. Insert and maintain PICC line. Monitor for signs and symptoms of infection, infiltration and/or extravasation. R111's care plan dated (9/3/25) shows he has infection related to peritoneal abscess/osteomyelitis and other wounds. Goal: (R111) will be free from complications related to infection.Facility's policy titled Catheter Insertion and Care: Administration Set/Tubing Changes (9/1/2016) shows: Policy: Administration sets and tubing will be changed at specific intervals in order to prevent infections associated with contaminated IV therapy equipment. General Guidelines: 6. Label all tubing with start and change date and time. Change and then label accordingly any tubing that is observed not to have a label.Primary or secondary intermittent administration sets: 1. Change every 24 hours, or if suspected contamination of tubing or catheter has occurred.Procedure: 11. Label administration set and tubing with date, time, and initials.

Based on observation, interview, and record review, the facility failed to perform tracheostomy care in a sterile manner and failed to ensure emergency tracheostomy equipment was at the bedside for a resident with a tracheostomy.This applies to 1 of 3 residents (R6) reviewed for respiratory care in a sample of 29. The findings include:On 9/10/2025 at 1:15 PM, R6's tracheostomy dressing appeared soiled and not fully secured in place. V11 (Licensed Practical Nurse/LPN) said R6 received daily tracheostomy (trach) care by the night-shift nurse and as needed (PRN). V11 said R6's dressing was soiled, and she would clean her stoma and apply a new steri-dressing. V11 applied clean gloves and then opened a steri-dressing tracheostomy kit. V11 said she did not perform tracheostomy care often but believed it was a non-sterile procedure. V11 then removed her gloves, and without performing hand hygiene, proceeded to don the sterile gloves from the kit. V11 removed R6's soiled tracheostomy dressing with the sterile gloves. Parts of the dressing had dry brownish residue. V11 said she was unsure when R6's dressing was last changed. V11 then said she was unable to find sterile saline solution and opened a prefilled oxygen humidifier bottle, which said it contained sterile saline water for inhalation. V11 then soaked the gauze and cleaned R6's tracheostomy stoma area in continuous repetitive circular motions. V11 then applied a new sterile split gauze dressing while wearing the soiled gloves. V11 said she was also going to change R6's trach valve cap and used the same gloves to change the trach valve cap. V11 said she was unsure what R6's trach tube type or size was. V11 left and returned and said R6's EMR (Electronic Medical Record) said she had a size 6 cuffed trach. V11 searched R6's bedside for both size 6 cuffed and downsized tracheal tubes for emergency use and was unable to find them. V11 said residents with tracheostomies required emergency tracheal tubes of the correct sizes to ensure the stoma could be maintained open and to prevent injury from oversized tracheal tubes.On 9/11/2025 at 1:20 PM, V2 (Director of Nursing/DON) said nurses were expected to perform proper tracheostomy care every shift as ordered and per policy. V2 said proper tracheostomy care was essential to prevent respiratory complications for residents with traches. V2 continued to say R6 had severe tracheal stenosis and nurses should be checking daily to ensure emergency tracheal tubes were always available at bedside.R6's Order Review Report dated 9/10/2025, showed the following orders for tracheostomy care every shift and PRN, and to change Biovana size 6 cuffed tracheostomy tube monthly. R6's care plan reviewed on 9/11/2025, said R6 required a tracheostomy and would remain free of infection or other respiratory complications.The facility's policy titled Tracheostomy Care Policy undated, said Purpose To ensure safe and effective care of residents with tracheostomies in accordance with Illinois Nursing Home Care Act, IDPH regulations, and facility clinical standards. Policy The facility will provide comprehensive tracheostomy care to maintain airway patency, prevent infection, and promote resident safety. Only trained and competent licensed staff and respiratory therapists may perform tracheostomy care.Assessment- Assess stoma site and airway every shift for redness, swelling, drainage, or obstruction.Routine Care- Provide trach care at least once per shift or as clinically indicated.Clean stoma with approved antiseptic solution and apply sterile dressing.Emergency Preparedness- Keep a spare trach tube of same size and one size smaller, obturator, and suction equipment at bedside at all times. All staff must know emergency trach reinsertion procedures.

Based on interview and record review the facility failed to maintain documentation of pharmacist monthly Medication Regimen Review (MRR) and prescribing practitioners' response to pharmacy recommendations. This applies to 2 of 5 residents (R11, R66) reviewed for unnecessary medications in a sample of 29. The findings include:1.R11's diagnoses include chronic obstructive pulmonary disease, hemiplegia, morbid obesity, dementia, major depressive disorder, spinal stenosis, epilepsy, suicidal ideations, hypothyroidism and malignant neoplasm of uterus.Pharmacy recommendation provided for R11 7/7/2025 and 8/22/25 had no recommendations on the MRR. Recommendations for an AIMS evaluation was made to the DON (Director of Nursing) on 1/31/25 and 2/23/25. No other documentation of MRRs conducted over the prior twelve months were available for R11.2.R66's diagnoses include cerebral infarction, type 2 diabetes, hyperlipidemia, hypertension, osteoarthritis, hyperkalemia, malignant neoplasm of skin and breast, chronic kidney disease, anemia, fibromyalgia and Parkinson's disease.MRR provided by the facility from 12/20/24 encouraged a dose reduction of metformin and renal function monitoring every three to six months. R66's MRR 1/31/25 recommended a gradual dose reduction for Fluoxetine 15mg daily and Venlafaxine ER 37.5 mg. R66's MRR dated 2/23/25 recommended R66 had been on Pantoprazole 40 mg daily since 1/30/24 and suggested review of resident's symptoms to determine if therapy was still necessary. The MRR for 7/25/25 a gradual dose reduction for Trazadone 50 mg Fluoxetine 15mg daily and again, R66's Venlafaxine ER 37.5 mg. The MRR recommendations for 8/22/25 recommended an A1c (Glycated Hemoglobin) be done at the time and every six months. The MRR recommendation for 8/22/25 suggested a fasting lipid panel at that time and annually.On 09/10/2025 at 2:12 PM, V2 DON (Director of Nursing) stated he had no further documentation related to the MRR's for R11 and R66.On 09/11/2025 at 2:15 PM, V2 DON stated the pharmacy emails him the MRR's, but he did not have the entire 12 months of MRR's for R11 and R66. V2 stated he did not have any documentation of providing the MRRs to the physician for review or documentation of physician responses to the recommendations. V2 stated he did not have any documentation showing the recommendations were addressed. The facility policy Medication Regimen Review dated10/25/14 states the consultant pharmacist performs a comprehensive review of each resident's MRR (Medication Regimen Review) at lease monthly. The MRR includes evaluating the resident's response to medication therapy to determine the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and attending physician, and if appropriate, the medical director and or the administrator. Recommendations are acted upon and documented by the facility staff and or prescriber.

Based on observation, interview, and record review, the facility failed to administer a resident's anemia treatment injections as ordered.This applies to 1 of 3 residents (R31) reviewed for medications in a sample of 29. The findings include:On 9/09/2025 at 11:35 AM, R31 was sitting in her wheelchair in the common area. R31 was confused and appeared frail. R31's skin pigmentation was pale in color and she had scattered old bruises on her extremities.On 9/10/2025 at 3:00 PM, V5 (Registered Nurse/RN) said R31 had recently been readmitted from a hospitalization for anemia on 8/13/2025. V5 said R31 was ordered to received Epogen (protein to help the body produce red blood cells) injections every 14 days. V5 said she reviewed R31's EMAR (Electronic Medication Administration Record) and R31 had not received her scheduled injections because they were not delivered by the pharmacy. V5 continued to say R31's medication was not available because it required the facility to follow-up with the pharmacy recommendation to change the medication Procrit. V5 said Procrit was R31's insurance-approved interchange for Epogen.On 9/11/2025 at 10:40 AM, V18 (Pharmacist) said the pharmacy received an initial order for Epogen for R31 on 8/14/2025 (28 days earlier). V18 said R31's pharmacy records showed the medication was denied by her insurance, and the facility was notified of Procrit as an alternative medication. V18 said the facility as of 9/10/2025, had not yet responded to the notification, and no injections had been dispensed for R31. V18 said the injections were used for the treatment of those with chronic anemia, and the medication directly triggered the formation of red blood cells. V18 said the medication required multiple doses to see improvement in lab results, including the red blood cells (RBCs), hematocrit (Hct), and hemoglobin (Hgb).On 9/11/2025 at 1:20 PM, V2 (Director of Nursing/DON) said nurses were expected to administer medications as ordered, and if unavailable, they should follow up with the pharmacy to ensure the medication can be obtained. R31's Order Review Report dated 9/10/2025, showed an active order started on 8/14/2025 for Epoetin Alfa Injection Solution 20000 units/ml injections subcutaneously one time a day every 14 days for anemia. R31's EMAR for August 2025 showed R31's Epoetin Injection was not administered on 8/14/2025 or 8/28/2025 as scheduled, and R31's EMAR for September 2025 also had R31's Epoetin Injection scheduled on 9/03/2025 and it was not given.R31's lab report dated 8/14/2025 showed her RBC was 3.01 (reference 4.2-5.4), Hct was 26.8 (reference 34.0-47.0), and Hgb was 8.1 (reference 12.0-16.0). R31's lab report dated 9/01/2025 showed her values continued to decrease, as her RBC was 2.56, Hct was 23.6, and Hgb was 7.0.The facility's policy titled Medication Administration dated 10/25/2014, said Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.11. If a medication with a current, active order cannot be located.after further investigation, the pharmacy is contacted.Medications are administered in accordance with written orders of the prescriber

Based on observation, interview, and record review, the facility failed to ensure a resident at high risk for falls received adequate supervision and assistance to prevent accidents. This applies to 1 resident (R2) reviewed for accident hazards in a sample of 3. This failure resulted in R2 who was transferred via the sit to stand with the assist of one sustaining an injury to her left eyebrow from falling forward and hitting her head on the machine Findings include: On 6/18/25 at 11:30 AM, R2 stated, V8 (CNA-Certified Nursing Assistant) was transferring her from chair to bed using a sit to stand machine. As V8 (CNA) was moving R2 on the lift, R2 fell forward and hit her head on the machine. R2's left eyebrow was bleeding as she was on a blood thinner. R2 stated, the CNA did not have anyone to help her during the transfer. On 6/18/25 at 2:30 PM, R2's face-sheet showed, R2 was a 94 y/o (years old) female admitted to facility on 1/10/23 with diagnoses to include cerebral infarction, dementia, depression, hypertensive heart disease and protein-calorie malnutrition. R2's MDS (Minimum Data Set) dated 5/28/25 showed R2's Brief Interview of Mental Status (BIMS) as 12 indicating moderate cognitive impairment. R2's Care Plan dated 5/25/25 does not specify any fall precautions. On 6/18/25 at 2:30 PM, R2's Fall assessment dated [DATE] showed R2 was at high risk for falls. On 6/18/25 at 2:30 PM, Progress notes dated 5/25/25 at 4:05 AM showed, the nurse was alerted of the fall and observed resident on the floor laying across the legs of the sit to stand. On 6/18/25 at 12:20 PM, V8 (CNA) stated, she was by herself while transferring R2 on the sit to stand machine. V8 (CNA) stated, facility required two staff for the procedure. V8 (CNA) stated, after she sat R2 on the bed, as she was moving the machine to the side, R2 fell forward onto the floor and hit her forehead. On 6/18/25 at 11:40 AM, V10 (LPN-Licensed Practical Nurse) stated, two persons must be present to transfer a resident on a sit to stand lift machine. If not, there are chances of accidents / injuries. On 6/18/25 at 9:30 AM, V2 (DON-Director of Nursing) stated, on 5/24/25, at around 8:00 PM, V8 (CNA-Certified Nursing Assistant) was transferring R2 by herself using a sit to stand lift machine. After sitting R2 onto the bed, V8 (CNA) removed the straps and as she was moving the machine away, R2 fell forward from the bed onto the floor. On 6/18/25 at 9:30 AM, V2 (DON-Director of Nursing) stated, sit to stand transfer lift must be operated by 2 persons as per facility policy. On 6/18/25 at 3:00 PM, Facility reported incident was reviewed. No concerns. Facility policy on 'lifting machine revised in 08/2008 showed the portable lift must be used by two staff members.

Based on interview and record review, the facility failed to ensure a resident was positioned safely in bed for cares. This failure resulted in R1 falling and sustaining fractures of her right femur and right tibia, and a right knee dislocation. This applies to 1 of 3 residents (R1) reviewed for safety/falls. The findings include: R1's Face Sheet showed she was admitted to the facility on [DATE], and her diagnoses include hemiplegia and hemiparesis following a cerebral infarction (affecting right dominant side), rheumatoid arthritis, polyneuropathy, obesity, and chronic pain. The facility's 1/3/2025 Final Report for R1's 12/31/24 fall incident showed Occurrence Resolution The root cause was determined to be the resident's lower extremities sliding off the bed during turning, changing, and repositioning as part of routine care During the incident, the resident's lower extremities became too close to the edge of the bed and slid off . R1's Progress Notes dated 12/31/24 at 12:45 PM showed . Nurse alerted by nursing staff that resident had fallen out of bed. Nurse observed resident lying on her back on the floor. Resident stated she was in the bed and was turned on her right side to get her brief changed. Resident stated she fell out of bed while being changed. Resident stated she had pain in her right knee. Patient transferred to bed via facility protocol . New orders for resident to be sent to ER (ER/emergency room ) for evaluation and treatment given. Ambulance arrived at the facility for transport resident to (Hospital) at approximately 12:00 PM. The Findings section of R1's 12/31/24 diagnostic imaging report from the local hospital showed 1. Posterior dislocation of the right tibial prosthesis of the knee, and 2. Proximal right tibial fracture. On 01/14/25 at 1:52 PM V11 CNA (Certified Nursing Assistant) stated she was the CNA that was taking care of R1 when she fell . V11 stated R1 had been sitting up in the bed when she entered the room and she put the bed flat for cares. V11 stated she directed R1 to turn onto her right side (R1's affected side), facing the door. V11 stated she gave peri-care to R1 while she was lying on her right side and V11 herself was on the opposite side of the bed (the left side of R1's bed). V11 stated R1 was closer to the edge of the bed on the right side, not closer to her. V11 stated she reached over to the nightstand to get some cream and she heard R1 say something, but she couldn't understand her. V11 stated she finally understood R1 to say, I'm slipping and she turned around. V11 stated she saw R1's hips moving, and she tried to grab R1's hips and she could not hold her and R1 went to the floor. V11 stated R1 had grabbed the halo bar. V11 stated she guessed R1's leg slipped over her other leg, and she began to slide to the floor. V11 stated that she had taken care of R1 before and had other staff members assist with changing her, but no one was available to assist that day. On 01/14/25 at 2:22 PM, V13 (Wound Care Nurse) stated she was in the hallway when she heard R1 yell out. V13 stated she saw R1 holding onto the bed rail and her knees were on the floor. V13 stated she went and got R1's nurse and the mechanical lift to get R1 off the floor. V13 stated there was only one CNA in the room assisting R1. On 01/14/25 at 2:10 PM, V12 (Licensed Practical Nurse) stated she was the nurse taking care of R1 on the day she fell out of the bed. V12 stated she was at the nursing station and was told her R1 was on the floor. V12 stated she assessed R1 and after she was back in bed, R1 complained of knee pain and R1 was sent to the hospital. R1's 12/31/24 progress note from 6:35 PM showed Nurse on duty contacted (local hospital). Resident is being transferred out to another hospital. (Local hospital) does not have an ortho doctor on call. Waiting to find out which hospital resident will be transferred to. R1's 1/1/2025 progress note from the second hospital listed musculoskeletal issues of right prosthetic knee dislocation, right periprosthetic femur fracture, and right periprosthetic tibia fracture. R1's CNA Point of Care (POC) charting for Roll Left and Right two-person assist regarding the ability to roll from lying on back to left and right side and return to lying on back on the bed from 12/25/24 until 12/31/24 was reviewed. R1's POC charting had 17 entries, with 16 entries as Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. R1's weight summary showed R1's weight on 12/26/24 was 342 pounds. R1's MDS (MDS/Minimum Data Set) dated 10/25/24 showed R1 had upper and lower extremity impairments on one side of her body. The same MDS showed R1 used substantial to maximum assist with rolling side to side while in bed. R1's 7/10/24 Nursing Rehab Bed Mobility care plan showed a Focus for Resident to turn from left to right while in bed with assistance x(times)2 staff participation and the frequency. The Goal for the care plan showed Resident with a goal to be able to do one person assist for bed mobility. The date initiated for the goal was 7/10/24, and the target date is 1/31/2025. On 01/10/25 at 2:22 PM, V4 (MDS Coordinator) stated R1 should have had two people with turning and repositioning due to her size and her hemiplegia. V4 stated those two factors contribute to R1's lack of mobility. V4 stated R1 was documented as being dependent in POC, which means she should have two people for repositioning and toileting hygiene in bed. R1's second hospital Consult Initial Report dated 01/01/25 .Patient stated she 'kept telling them that she was too close to the edge.' Right upper extremity with mild wrist and finger contractures likely chronic from [cerebrovascular accident] with residual right sided deficits. Right leg is extremely rotated. Right knee is swollen and diffusely tender to palpitation. Patient underwent open reduction of the right prosthetic knee with application of a short leg splint .

Based on interview and record review, the facility failed to follow therapy's recommendations for safe transfer of a resident. This failure resulted in R345 sustaining a laceration on R345's left leg requiring six sutures due to an improper transfer. This applies to 1 of 3 residents (R345) reviewed for resident injury in the sample of 19. The findings include: The EMR (Electronic Medical Record) showed R345 was admitted to the facility on [DATE], with multiple diagnoses including dementia, peripheral vascular disease, heart failure, and lymphoid leukemia. R345's MDS (Minimum Data Set) dated August 9, 2024, showed R345 had severe cognitive impairment. The MDS continued to show R345 required substantial assistance from facility staff for bed to chair transfers. R345's ADL (Activity of Daily Living) care plan dated June 6, 2024, showed, The resident has an ADL self-care performance deficit needs and participation may vary related to cognitive deficits, impaired speech, weakness. The care plan continued to show multiple interventions dated June 6, 2024, including Mechanical lift for transfers. On October 22, 2024, at 2:16 PM, V15 (CNA/Certified Nursing Assistant) said on September 28, 2024, V15 transferred R345 by herself using a gait belt. V15 continued to say R345 scraped his left leg into the wheelchair and then she noticed some bleeding from his leg and alerted the nurse. V15 said R345 was supposed to be transferred with a mechanical sit-to-stand lift with two facility staff members. V15 continued to say R345 had very fragile skin and V25 needed to be very careful when transferring R345. V15 said the transfer was a part of routine care and there was not an emergency. The facility's Facility Incident Report Form completed by V2 (DON/Director of Nursing) on September 28, 2024, showed, Description of Occurrence: Resident who is alert times one, was observed with bleeding from his left lower leg during transfer from bed to his wheelchair. Left lower leg was cleansed and dressing applied, and resident was assessed for pain, no pain observed or reported. Physician was called and orders were given to send resident to hospital for evaluation and treatment. Family notified of incident and new orders. Resident was sent out to hospital. Resident has returned back from hospital with six sutures to left lower leg, pain assessment completed, and pain being managed appropriately per orders. Investigation in process. Occurrence Resolution: During transfer with staff aide on September 28, 2024, [R345]'s left lower extremity came in contact with the top of his leg rest on wheelchair resulting in skin alteration to left lower extremity, resident is taking anticoagulant, and orders were received by primary care clinician to send to hospital for evaluation and treatment. [R345] has returned back to facility after receiving treatment at hospital for laceration to left lower extremity. Six sutures were applied to left lower extremity that will be removed in 10 days in house by wound care nurse, extremity is assessed every shift for change in condition. Primary care clinician aware of new orders and family also made aware. Pain assessed and managed appropriately per orders. Cushion has been applied to top part of leg rest. Therapy to screen for transfers. Plan of care updated to reflect changes. On October 22, 2024, at 2:57 PM, V16 (Director of Rehab) said R345 was discharged from Physical Therapy and Occupational Therapy on August 9, 2024. V16 said upon R345's discharge from therapy, therapy's recommendations were for facility staff to utilize a mechanical sit to stand lift. V16 continued to say two facility staff members are required when using a mechanical sit to stand lift. V16 said facility staff are to follow the special instructions shown in the resident's EMR. V16 said R345's EMR showed R345 was a mechanical sit to stand transfer. V16 continued to say it is the expectation facility staff follow therapy's recommendations for a safe transfer. On October 22, 2024, at 3:32 PM, V17 (Nurse Practitioner) said it is the expectation that facility staff follow therapy's recommendations for a resident's safe transfer. V17 continued to say facility staff should have transferred R345 per therapy's recommendations to prevent R345 from getting injured. On October 23, 2024, at 3:40 PM, V2 said facility staff should be following the special instructions in the EMR for how a resident should be transferred. V2 continued to say V15 should have transferred R345 with a second facility staff member using a mechanical sit to stand lift. R345's hospital records dated September 28, 2024, showed R345 had a leg laceration requiring sutures. The facility's policy titled Safe Lifting and Movement of Residents dated August 2008, showed Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care this facility uses mechanical lifting devices for the lifting and movement of residents. Policy Interpretation and Implementation: 1. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted . 7. The transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan .

Based on observation, interview, and record review the facility failed to ensure temperatures in the building remained within a comfortable range for residents when the air conditioning was not functioning properly. The facility also failed to follow their hot weather policy and measure room temperatures and humidity levels when the air conditioning was not functioning properly to determine if resident safety could be maintained. This failure resulted in room temperatures as high as 91 degrees Fahrenheit in areas occupied by residents and residents complaining of feeling hot. The Immediate Jeopardy began on April 12, 2024, at 5:29 PM when the facility was notified by V9 (Account Manager HVAC-Heating Ventilation Air Conditioning Contractor) the facility would have no heating or cooling capacity whatsoever without necessary repairs. V1 (Administrator) was notified of the Immediate Jeopardy on June 13, 2024, at 10:40 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was not removed at the time of exit. This applies to all 98 residents residing in the facility. The findings include: The Facility Data Sheet dated June 12, 2024, shows the facility census as 98 residents. On June 12, 2024, at 11:42 AM, V1 (Administrator) was not present in the building. V2 (DON-Director of Nursing) stated, They are still working on the air conditioning situation. We have some portable air conditioners in the hallways and fans. On June 12, 2024, at 12:00 PM, a general tour of the facility was conducted with V3 (Maintenance Director). V3 stated he has been the Maintenance Director of the facility for several weeks. V3 continued to say, There are leaks at the bottom of the cooling tank for the air conditioning, so the air conditioning does not work. V3 stated he does not have a device to measure and obtain humidity readings. V3 continued to say he does not have a thermometer to obtain air temperature readings and uses an infrared temperature gun for reading surface temperatures. V3 used the infrared temperature gun to obtain surface temperatures of walls, floors, and ceilings during the general tour of the facility. When V3 pointed the gun into the air inside the building, and outside of the building, a temperature reading would not display on the infrared temperature gun, and no air temperature reading could be obtained. During the tour, V3 showed multiple resident rooms and resident areas where thermostats were present showing the air temperature in the room. Those readings were as follows (all temperatures in degrees Fahrenheit): Tour of facility June 12, 2024, with V3: 12:15 PM, R8 and R9's room: 86 degrees. R8 stated he was thirsty, and he had not been provided with a fresh cup of water today. The water cup on R8's table showed the date 6/11/24. R8 stated the water was old and warm. R9 stated, It is too hard to sleep because it is so hot in our room. 12:20 PM, R2 was sitting in her room wearing a sleeveless shirt and shorts. R2 stated she felt very warm in her room. The thermostat in R2's room showed 84 degrees. 12:35 PM, Main dining room: The thermostat in the dining room showed 85 degrees. Multiple residents were present in the dining room eating lunch. V3 pointed the infrared temperature gun at the wall across the room from the wall-mounted thermostat, approximately 20 to 30 feet away. The surface temperature of the wall showed 84.4 degrees on the infrared temperature gun. 12:35 PM, V6 (LPN-Licensed Practical Nurse) stated, I am not taking frequent vital signs on anyone or checking intake and output. We pass water with medication administration but no extra water. 1:19 PM, R36 stated, It is very warm in here. I feel uncomfortable. 1:27 PM, R37 said, We haven't had air conditioning for days. It feels so hot in here, and our rooms are very hot. 1:44 PM, R3 was lying in bed wearing oxygen. R3 had a fan blowing towards her. R3 stated, I am very hot even with the fan blowing on me. The air conditioning unit is throwing out hot air at me. The air blowing from R3's air conditioning unit felt warm. 1:51 PM, R5's room, the thermostat in the room showed 86 degrees. R5 stated, It feels so hot in here. Our rooms are very hot. 6:20 PM, Main dining room. The thermostat mounted on the wall in the dining room showed 91 degrees. R10, R11, R12, and R14 were present in the dining room and did not have water within reach. No staff were present with R10, R11, R12, and R14. R10-R14 stated they felt hot. R12 stated, We don't have a choice, we have to sit here until they take us somewhere else. V1 (Administrator) was immediately notified by this surveyor of the high temperature in the dining room and residents sitting in the dining room without water. 6:21 PM, R8 and R9's room showed 86 degrees on the thermostat in the room. R9 was standing at his bedside and had removed his clothing from the waist down. R9 stated he felt hot and was trying to cool off by removing clothing. R8 stated he felt very hot and asked if this surveyor could get a fan in their room to make the room feel cooler. 6:22 PM, R15 and R16's room, the thermostat in room showed 84 degrees. 6:23 PM, R13's room, the thermostat in the room showed 87 degrees. On June 12, 2024, at 3:34 PM, V7 (VP-Vice President of Service-HVAC Contractor) stated, the facility's air conditioning problems were related to the mechanical issues the facility experienced with the lack of heat earlier in the year. V7 continued to say, You cannot measure air temperature with an infrared or laser temperature gun. Those devices only measure surface temperature. For instance, point it at the floor, and you get the temperature of the floor. Point it at the wall and you get the temperature of the wall. Of course, if you point it at the floor, you will get a cooler reading than the actual air temperature in the room. We have been talking to the facility and other facilities in their group. They signed up for preventative service agreements over the past few months. At least a couple of months ago, we identified an issue with their piping for the heating and air conditioning system and we told them they were not going to have air conditioning this year. We told them some major steps needed to be taken and they have called us out on many occasions to try to fix different things. The system is not able to operate because there is a leak underground. If the system is working properly, the system circulates water to all of the rooms. With the pipes broken underground, water just pours out of the cooling tower and into the ground, never reaching the pipes inside the facility. We cannot fill that piping with water because of the leaks, and we cannot locate the broken piping unless we break up concrete and concrete floors in the facility. They were notified on April 12, 2024, about the piping issues, and just authorized isolating the leak on June 10, 2024. We tried to identify where the leak was on Monday, and we found that multiple pipes were leaking. By the end of that day, they knew if could not be fixed. We proposed we would provide temporary cooling that day. We did not receive authorization to move forward with the temporary cooling until just about an hour ago. They have authorized temporary cooling for the four resident wings. We will obtain outside cooling units and temporarily place them outside the facility at the end of their four resident wings. It should be enough cooling to temper the resident rooms enough. We are hoping the cooling capacity will make the rooms comfortable. On April 12, 2024, we sent an email to the facility and notified them they would not have air conditioning this year due to the underground pipe leaks. We did not hear from them, and a month later we touched base with them again, reminding them we could not turn on the air conditioning for them due to the pipe leaks. We never told them we would fix the leaking pipe. They wanted us to repair the cooling tower and I told them we could try to repair the cooling tower. We tried to explain to them that would not fix the problem. An email dated April 12, 2024, from V9 (Account Manager HVAC Contractor) and addressed to the facility Administrator (no name), V4 (VP Plant Operations), and V17 (Corporate Facilities Manager) shows: Subject: [URGENT] Critical Issues - [Facility] HVAC System Piping. We were on site today to assess the HVAC system loop/broken piping. The conclusion is that the piping is in a dire need of being repaired. Without repairs on this piping, [the facility] will have no heating or cooling capacity whatsoever . I would suggest that we have a meeting soon to discuss a plan of action to get this addressed in the timeliest manner possible. An email dated May 9, 2024, at 9:36 AM from V9 (Account Manager HVAC Contractor) and addressed to facility Administrator (no name), V4 (VP Plant Operations), and V17 (Corporate Facilities Manager) shows: Subject: [URGENT] Critical Issues - [facility] HVAC System Piping. Just following up on this matter again. We cannot do any seasonal (cooling) changeover without the piping issues being addressed. Please let me know if you have any questions. Thank you. On June 12, 2024, at 1:55 PM, V4 (VP Plant Operations) stated the facility has problems with water from the cooling tower getting to the building due to broken pipes underground. V4 stated, There are too many leaks in the pipes to fix. I want to say around early May 2024 we started to have trouble with the system. The facility provided a quote for rental cooling systems dated June 11, 2024. The facility does not have any other documentation to show quotes were obtained for rental cooling units prior to June 11, 2024. On June 12, 2024, at 4:06 PM, V1 (Administrator) stated, We were taking room temperatures with an infrared temperature gun. I did not know air temperature could not be checked using those infrared guns. We were not measuring humidity as shown in the policy. We were not checking temperatures and humidity every two hours. I believe we felt we were doing everything we needed to do. It is a complicated problem. There are a lot of different layers. We did not have a conversation about renting temporary chilling units until Monday, June 10. V1 continued to say the facility's air conditioning concerns were not reported to the Department of Public Health. On June 13, 2024, at 10:40 AM, the facility continued to feel very warm inside. V3 (Maintenance Director) stated he did not have the proper device to measure air temperatures or humidity and had not been monitoring the temperatures or humidity readings every two hours. V3 stated he was not aware the facility has a policy to obtain temperature and humidity readings every two hours when the air conditioning is malfunctioning. On June 13, 2024, room temperatures were checked, beginning at 10:50 AM and the following temperature readings were obtained based on the thermostats mounted in the rooms, due to the facility not having the equipment to measure air temperatures (all temperatures in Fahrenheit): June 13, 2024: 10:50 AM, Main dining room, the thermostat on the wall showed 87 degrees. V15 (Activity Aide) was playing a board game with 16 residents. V15 stated the following residents were present in the room: R3, R8, R6, R7, R9, R11, R18, R19, R25, R26, R27, R28, R31, R32, R35, and R40. V15 continued to say, Some residents have complained of feeling hot. No one told me to pass water to the residents or juice. I have not given them anything to drink. The 16 residents did not have water or fluids in front of them, or water visible and available in the room. 11:00 AM, R6 and R7's room, the thermostat showed 82 degrees. R6 stated she felt hot. 11:05 AM, R14's room, the thermostat showed 82 degrees. R14 was present in the room. 11:15 AM, V14 (Cardiology NP-Nurse Practitioner) was in R38 and R39's room. V14 stated the room felt very hot. It has been very hot in the facility since last week. They have to push fluids. These people are more prone to dehydration. Residents with cardiac issues should have input and output monitored when it is this hot in the facility. 11:17 AM, R29 was lying in bed. Her room felt very warm. No thermostat was present in the room to measure the air temperature. R29 was holding an empty plastic cup in her hand and crying, Water, water, I need water. R29 had a meal tray on her bedside table with a cup of lemonade. R29 stated she does not like to drink lemonade because, It is too sweet. R29 continued to call out for water and was unable to turn on her call light. No staff were in the vicinity of R29's room to hear R29 calling for water. No staff were observed passing supplemental water to residents. 11:20 AM, R13's room, the thermostat in the room showed 85 degrees. R13 complained of feeling hot. 11:23 AM, R32's room, the thermostat in the room showed 85 degrees. R32 complained of feeling hot. 11:25 AM, R33 and R34's room, the thermostat in the room showed 86 degrees. R33 and R34 were present in the room and complained of feeling very hot. R34 stated he was given water during the night and the water at his bedside was now warm and old. A foam drinking cup on the bedside table was dated 6/12/24 NOC (Night). 11:27 AM, R22 was lying in bed and V13 (Son of R22) was present. The thermostat in R22's room showed 88 degrees. R22 was not able to be interviewed due to his medical condition. V13 stated R22's room had felt hot the last two days. 11:30 AM, R23 and R24's room, the thermostat showed 88 degrees. Both residents were present in the room. 11:35 AM, R5's room, the thermostat showed 88 degrees. On June 13, 2024, at 1:15 PM, V10 (Medical Director) stated, I know they found a problem with the air conditioning in April 2024. You need to reach out to the owners of the building about the problem, it is not my job. I am hearing they have rooms that are 86 degrees for the first time from you. No one called me to tell me. This is the first I am hearing about the problem. On June 13, 2024, at 5:00 PM, the facility had obtained a device to measure air temperatures and humidity and the following temperature and humidity readings were obtained with V2 (DON) and V16 (Admissions Director) (all temperatures in Fahrenheit): R14's room, 36.5 percent humidity, 86.6 degrees R23 and R24's room, 36.8 percent humidity, 86.0 degrees R41 and R42's room, 37.2 percent humidity, 86.3 degrees R43's room, 36.8 percent humidity, 86.0 degrees R44 and R45's room, 37.2 percent humidity, 85.6 degrees R46 and R47's room, 36.9 percent humidity, 85.5 degrees R13's room, 38.8 percent humidity, 85.0 degrees R15 and R16's room, 36.7 percent humidity, 84.1 degrees R8 and R9's room, 36.9 percent humidity, 83.2 degrees On June 14, 2024, between 1:20 PM and 1:50 PM, temperature and humidity readings were obtained with V2 (DON) and V16 (Admissions Director) (all temperatures in Fahrenheit): R14's room, 41.8 percent humidity, 84.0 degrees R41 and R42's room, 36.4 percent humidity, 86.3 degrees R23 and R24's room, 41.8 percent humidity, 85.8 degrees R43's room [ROOM NUMBER].8 percent humidity, 83.7 degrees R44 and R45's room [ROOM NUMBER].6 percent humidity, 84.3 degrees R46 and R47's room [ROOM NUMBER].8 percent humidity, 85.6 degrees On June 17, 2024, at 9:47 AM, temperature and humidity readings were obtained with V3 (Maintenance Director) (all temperatures in Fahrenheit): R22's room, 50.7 percent humidity, 82.9 degrees. R22 was lying on top of his plastic/vinyl mattress with no sheet covering. R22 stated he felt hot and uncomfortable. R21's room, 49.8 percent humidity, 82.2 degrees. Main dining room, 55.4 percent humidity, 83.0 degrees. Eight residents were present in the dining room. R38 and R39's room, 57.6 percent humidity, 80.0 degrees. On June 17, 2024, at 12:04 PM, the thermostat in the main dining room showed the temperature in the dining room was 85 degrees. Lunch was being served to the following residents: R2, R5, R8, R9, R11, R15, R17, R18, R19, R20, R21, R27, R28, R30, R31, R44, R46, R48, R49, R50, R51, and R52. R2, R8, R9, R19, R21, R48, and R50 were asked if they felt uncomfortable and they replied they were warm and uncomfortable. The facility's undated Hot Weather Policy shows: If the air conditioning is not functioning appropriately; follow the following procedure: 1) Temperature and humidity should be measured in several rooms on each floor on unit that has been identified as being the warmest area of each floor or unit. This should be done approximately every two (2) hours during the day and evening. These rooms should include day rooms (activity), dining rooms and hallways. 2) If the facility temperature and humidity combined value falls within the shaded region of the chart for Relative Humidity and Temperature, proceed with the following: i. Fluids (water) should be easily accessible at all times.For additional information, please refer to the Extreme High Temperature Procedure policy. The facility's Extreme High Temperature Guideline revised 04/03/2024 shows: Purpose: To provide guidance to facility in times of unseasonably hot weather and/or cooling system malfunction. Responsible Party: Facility staff. Should the temperature index for relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures. Should a specific area of the facility rise above 80 degrees, it may be necessary to relocate residents to a cooler section of the facility. If the high temperature procedures do not sufficiently maintain resident safety, the facility shall consult with the Department of Public Health regarding the advisability of resident evacuation. Maintenance: Monitor air temperatures at least every 2 hours between 8:00 AM and 10:00 PM in resident areas and every 4 hours between 10:00 PM and 8:00 AM. Temperatures should be taken at the warmest point identified through baseline monitoring on each floor or wing. Include day rooms, dining rooms, activity rooms and resident rooms.Assure that water lines to the building are working appropriately. The facility's undated Summer Temperature Monitoring Policy shows: Purpose to provide a comfortable, safe environment for all residents. To determine if the Hot Weather Policy is to be implemented. Procedure: a. Routine temperature and humidity monitoring of the facility will occur at a minimum of two times per day during the daylight hours. For example, 10:00 AM and 4:00 PM. These temperatures/humidities are to be taken in the warmest areas of facility identified through baseline monitoring. These values are to be recorded on the bottom of the Temperature and Humidity Chart provided by Public Health. The temperature and humidity combined value is to be determined and circled on the chart. Should the combined value fall in the shaded area of the chart the Hot Weather Policy must be implemented. Should the combined value fall to the right of the heavily darkened line within the shaded area, you must immediately contact the VP of Physical Plant Operations and your VP of Operations. b. Should it be determined that the high temperature procedures do not sufficiently maintain resident safety for an extended period of time determined by facility Administrator in concert with the VP of Plant Operations, VP of Regional Operations and the Chief Operating Officer, the facility will consult with Public Health regarding the advisability of resident evacuation . The facility presented an abatement plan to remove the immediacy on June 13, 2024, at 2:11 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on June 13, 2024, at 5:40 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on June 14, 2024, at 2:17 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The immediate jeopardy that began on April 12, 2024, was not removed at the time of the survey exit because the facility failed to provide a removal plan showing a date for when their heating, ventilation and air conditioning system will be fixed permanently.

Based on observation, interview and record review the facility failed to ensure residents safety by not monitoring space heaters during a heating system failure and failed to ensure the safety of the residents during a loss of heat. This resulted in the facility having cold temperatures in the facility and the facility utilizing unmonitored space heaters. These failures resulted in an Immediate Jeopardy affecting the safety and health of all 111 residents residing in the facility when the facility experienced a heating system failure and placed 20 portable space heaters in resident rooms with no monitoring. The Immediate Jeopardy began on 1/12/2024 when the Facility placed 20 portable space heaters in resident rooms. V1, Administrator was notified of the Immediate Jeopardy on 1/24/24 at 10:00am. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 1/25/24, the facility remains out of compliance at a Severity Level II because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff and implementation of audit tools. The findings include: The facility roster dated 1/21/24 showed 111 residents reside at the facility. On 1/21/24 at 9am, during tour of the facility, the facility air felt very cold to this surveyor. Residents were ambulating in the hall wearing jackets and or sweaters. Some staff were also observed wearing sweaters and or jackets. On 1/21/24 at 9:00am V3 Housekeeping Director stated, The heats been going out off and on for about a couple of weeks. They started handing out these space heaters to help about a week ago. On 1/21/24 at 9:20am V4 Maintenance Director stated, the dining room is closed right now. We only have one boiler that is working. The company we were working with was not getting the problem fixed so we started using a new company. I do not write the temperatures down when I take them. If it is cold, I just turn up the heat. The problem has been about a week or so now off and on. I am not sure about the policy for cold weather and where the heat should be. I think 68 degrees Fahrenheit is okay. I am not sure when we started using the space heaters. On 1/21/24 from 9:30am through 10:30am temperatures of the environment were as follows: main dining area 63 degrees Fahrenheit, 200 hall 68 degrees Fahrenheit, 100 hall 68 degrees Fahrenheit, lobby 65 degrees Fahrenheit, conference room (used by families for gatherings) 62 degrees Fahrenheit, hall 500 68 degrees Fahrenheit and hall 400 66 degrees Fahrenheit. Space heaters were identified in 20 resident rooms throughout the facility. The following residents had space heaters turned on and running in the rooms, R1 and R3-R31. On 1/21/24 at 9:40am during tour of the facility with V3 it was noted that he was not writing down temperatures as they were taken. V3 stated, I don't write it down. If it is cold, I just turn up the heat. The facility had no documentation since July 2023 and very little inconsistent documentation of the air temperatures in the facility maintenance log for air and water temperatures. On 1/21/24 at 9:45am R1 was in his wheelchair in the hall near his room. R1 had on a sweater with a blanket on his lap and over his shoulders. R1 stated, Mostly we stay in our room to stay warm. I have to eat in my room because the dining room is closed. 1/21/24 at 9:48am R1 has a space heater in his room and the door to his room was closed. R1 said that it stays warmer that way. R1's MDS (Minimum Data Set) dated 1/08/24 showed that R1 is not cognitively impaired. On 1/21/24 at 10:05am R2 was in the hallway in her wheelchair. R2 had on a sweater with a blanket over her shoulders with a sweater on. R2 stated, We are supposed to stay in our rooms. The MDS dated [DATE] showed that R2 is not cognitively impaired. R2 did not have a space heater in her room. The room was 69 degrees Fahrenheit. On 1/21/24 at 10:17am R3 was lying in her bed. There was a space heater in the room. R3 has a sweater on and is covered in blankets. R3 stated, It's better the last couple of days. It is cold in here. My roommate (R4) is still cold. The MDS dated [DATE] showed that R3 is not cognitively impaired. On 1/21/24 at 10:19am R4 was sleeping in bed. R4 had on a heavy robe with several blankets covering her. R4 had a portable heater in the room. R4's MDS dated [DATE] showed that R4 is cognitively impaired. On 1/21/24 at 11:00am V1 Administrator stated, We have been having trouble with the boilers for a couple of weeks now. I am not sure when corporate sent the space heaters out. I am not sure how many heaters we put in residents' rooms. V1 confirmed that 20 space heaters were in use and that there was no policy for using or monitoring space heaters. On 1/22/24 at 9:30am V4 Vendor company for boiler repairs stated, I was here Friday and Saturday (1/19/24 and 1/20/24). The boilers are not working. Making some repairs today that are causing the problem. We have an answering service that takes all of the calls. We work 24/7. Someone is always on call. Something is leaking underneath the boilers. V4 would not answer questions as to the specifics as to what was wrong with the boilers. On 1/24/24 at 1:15pm V6 LPN (Licensed Practical Nurse) stated, We have had problems with the heat since before Christmas. I want to say the portable heaters were around since the 13th of January. On 1/24/24 at 1:20pm V7 CNA (Certified Nursing Assistant) stated, Monday was very cold. We had to get space heaters. On 1/24/24 at 1:25pm V8 RN (Registered Nurse) stated, I usually get about 26 residents. I don't think I could monitor space heaters and do everything I have to do. I would have to check at least 3 or 4 residents for space heaters. According to the National Oceanic and Atmospheric Administration, National Weather Service at:https://www.weather.gov/lot/2023_08_2324_Heat#:~:text=Chicago%20officially%20observed%20a%20high,was%20116%C2%B0F**. The local temperatures were as follow: Minimum Maximum Temperature Fahrenheit 1/12/24 28 33 1/13/24 22 38 1/14/24 -10 37 1/15/24 -11 -9 1/16/24 -11 0 1/17/24 -11 6 1/18/24 6 21 1/19/24 8 29 1/20/24 -4 29 1/21/24 -1 28 1/22/24 0 25 1/23/24 32 36 The facility Policy for Cold Weather dated 1/2014 did not show that staff were to use space heaters and there were no guidelines for safe use of a space heater. The package insert from the manufacturer of the space heaters showed that touching the heater can cause burns .; keep paper, combustibles, linen at least 3 feet from heater, do not place towels on top of heater. It instructs user to keep away from high traffic area to prevent trip hazard. It tells the user not to block areas of air intake or exhaust to prevent fire. The insert showed to not use in areas where flammable liquids may be used and to use extreme caution around children and the disabled when leaving unattended. On 1/24/24 at 9:00am it was noted that several trucks from the heating and cooling vendor were at the facility. Residents were observed in regular indoor clothing, no residents were wearing jackets or blankets to keep warm. Tour of the facility showed all temperatures to be within 70 to 79.1 degrees Fahrenheit. No space heaters were observed during the tour. The facility presented a removal plan on 1/24/24 at 12:05pm. The plan was returned to V1 at12:25pm for corrections. A corrected removal plan was presented on 1/24/24 at 1:05pm for review. The plan was returned for corrections at 1:14pm to V1. The final removal plan was accepted at 1:40pm. The plan includes all residents at the facility. The Immediate Jeopardy that began on 1/12/24 was removed on 1/25/24 when the facility took the following actions to remove the immediacy of the situation: The facility has removed all space heaters from resident's rooms and out of the facility as of January 23rd, 2024. The facility utilized (heating company name) to repair heating system to ensure the functioning of the heat system providing safe room temperatures. The company was contacted on January 11th, 12th, 14th, 19th, 22nd, 23rd, and 24th of 2024. All residents in the facility are likely to be affected by the alleged deficiency. Facility has trained staff to ensure that there be no space heaters in the facility. Facility has educated staff on the facility Cold Weather Policy to address any possible loss of heat in the facility. Steps include notifying the administrator for further instructions. Residents to be moved to the warmest physical plant area available as needed. Staff should attempt to block drafts, using blankets, towels, sheets, plastic, etc. Extra measures should be implemented to keep residents comfortable such as providing extra blankets and dressing residents warmly. When extreme cold temperatures are forecasted, the facility will begin to take precautions by monitoring air temperatures every shift until the extreme weather subsides. Staff not present in the facility will be trained prior to starting their shift. This training will be ongoing for new hires in the orientation process and agency staff. Air temperatures will be monitored by maintenance staff or designee daily for 30 days and then weekly using a log, to ensure furnace is working properly. Immediate action will be taken if furnace is not working properly. The maintenance director or designee will check on furnace status twice a day for 30 days and then daily using a log, to ensure furnace is working properly. Immediate action will be taken if furnace is not working properly. The administrator or designee will conduct random checks on staff to ensure they have an understanding of the policy using a QA tool three days a week for the next 30 days. Findings of the quality review audits will be brought to the facility QA meeting until such time as the committee has determined substantial compliance has been achieved and recommends ongoing monitoring. Emergency QA Meeting conducted on 01/24/2024 at 11:13am.

Based on observation, interview, and record review, the facility failed to monitor and apply interventions for residents experiencing weight loss. This failure resulted in a resident (R26) experiencing significant weight loss of 19.86% from 11/7/23 to 12/14/23. This applies to 2 of 2 residents (R26 and R34) reviewed for significant weight loss in a sample of 25. The findings include: 1. On 12/12/23 at 10:52 AM, R26 was observed in bed sleeping. R26 appeared thin. On 12/12/23 at 01:01 PM, R26 was observed laying in bed eating lunch by himself. R26's tray table had pureed foods and regular consistency liquids. On 12/13/23 at 01:13 PM, V35 (CNA/Certified Nurse Assistant) said R26 usually ate 25-50% of his meals. R26's POS (Physician Order Sheet) showed an order for R26 to be a 1:1 feed, feeding assistance is required. The frequency showed three times a day for 1:1, feed patient with all meals. The POS also showed an order for monthly weights. On 12/12/23, R26's EMR (Electronic Medical Record) showed the last recorded weight for R26 was taken on 11/7/23 at 02:52 PM, which showed R26 weighed 115.8 pounds. On 12/14/23 at 10:23 AM, surveyor requested R26 to be weighed. R26 was wearing a patient gown, a new and clean incontinence brief, and a nonskid sock on the left foot. V6 (Restorative CNA) weighed R26 using the mechanical lift and his weight was 92.8 pounds. At 10:41 AM, V6 said the restorative CNAs were supposed to weigh the residents monthly. V6 said the daily and weekly weights are done by the floor CNAs. V6 said the weights are due by the fifth day of each month. V6 said the weights are given to the DON (Director of Nursing) to check for discrepancies. V6 said the DON then either inputs the weights into the EMR or gives the weights to the residents' nurse to input them. On 12/14/23 at 09:54 AM, V5 (Registered Dietitian) said when he last evaluated R26 on 11/14/23, R26's BMI (Body Mass Index) was 22.6, which was on the lower end of what it should be. V5 said it looked like they had not done the monthly weight for December, and it should have been entered. V5 said if the resident had a monthly weight ordered, it should be completed monthly. On 12/14/23 at 12:24 PM, V2 (DON) said the order for frequency of weighing residents should be followed. V2 said the facility monitors the weights to see if the residents have any changes in their weights, such as losing or gaining weight. V2 said it was her expectation the order should be followed, and the weights should be reported to the charge nurse. V2 also said residents who required extensive assistance for feeding should be fed with assistance of staff. V2 also said the CNAs should be documenting the residents' oral intake into the EMR and it was part of their required documentation. V2 said if the weight was not documented, it was not taken. V2 said if the weights were not taken and documented, the facility could not track to see if the interventions in place were working. On 12/14/23 at 12:39 PM, V3 (ADON/Assistant Director of Nursing) said they had a weekly dietary meeting to discuss residents who need interventions and recommendations. V3 said it was her expectation that the floor nurses track to ensure the weights were being taken. V3 said if the staff did not document the information in the EMR, they either forgot to chart it or did not do it. V3 said the facility cannot track the trends if the numbers do not get put into the EMR. V3 said the weights were taken starting the first of each month and completed by the seventh of each month. On 12/14/23 at 02:17 PM, surveyor attempted to reach V38 (Attending Physician) for R26. V38 did not answer. At 02:38 PM, V38 was called again on a different number, but did not answer or call this surveyor back. On 12/15/23 at 09:33 AM, V38 was called again, but did not answer or call back surveyor. On 12/14/23 at 03:45 PM, V3 said V38 did not have a nurse practitioner and she was unable to find any progress notes written by V38 from 9/25/23 to 12/14/23, to indicate he had seen R26 during this time. On 12/15/23 at 09:39 AM, V1 (Administrator) said the facility was unable to find any notes from V38 from 9/25/23 to present. On 12/15/23 at 11:02 AM, V36 (Medical Director) said he had never previously been contacted about R26. V36 said R26 had experienced the significant weight loss. V36 said R26 was severely malnourished, and his weight loss could have been avoided if the staff had been monitoring his weights and following the protocols set in place. V36 also said R26's weight loss could have been avoided if V38 had come and assessed R26. V36 said if he had been made aware, he would have been following R26's care closely to understand what was going on and implement interventions. R26's face sheet showed R26 was admitted to the facility with diagnoses including protein-calorie malnutrition, muscle wasting, dysarthria and anarthria, dysphasia, hemiplegia and hemiparesis affecting right dominant side, chronic pain syndrome, contracture, and muscle spasms. R26's MDS (Minimum Data Set) dated 10/2/23 showed R26 had severe cognitive impairment. R26 required maximal assistance for eating, and was dependent on staff for oral hygiene, toileting, shower/bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. R26's care plan showed a focus of the potential for nutritional risk as evidenced by a possible significant weight loss, a mechanically altered diet, and a reduced BMI. R26's interventions included provide diet and serve as ordered, monitor meal intake, requires assistance with feeding, report unplanned/unexpected weight loss to nurse/physician, weigh resident monthly per facility schedule, and to offer substitutes if 50% or less is consumed. R26's point of care charting for eating did not show any documentation for percentage of meal consumed prior to the start of the survey. 2. On 12/12/23 at 11:21 AM, R34 was in the bed and appeared thin. At 01:04 PM, R34 was observed eating her regular consistency lunch by herself in her room. On 12/12/23 at 01:48 PM, the POS (Physician Order Set) showed an order starting 11/7/23 for weekly weights. R34's weight trends were reviewed and on 6/1/23, R34 weighed 84.4 pounds and on 11/7/23, R34 weighed 72.4 pounds. This reflected a 14.22% weight loss in five months. There were no recorded weights documented after 11/7/23. On 12/14/23 at 09:45, V5 (Registered Dietitian) said R34's weights were trending down over the last eight months. V5 said on 11/7/23, he recommended R34 be weighed weekly to track her weight trends to evaluate for acute changes in weight. V5 said it was an issue that the weights had not been tracked, and it was his expectation the staff completed weekly weights when it was ordered. On 12/14/23 at 02:48 PM, V39 (NP/Nurse Practitioner) said she had seen R34 four to six weeks ago and she had been experiencing weight loss. V39 said it was her expectation the weekly weights were completed. V39 said it was important because the resident could be losing more weight without the facility staff realizing sooner. V39 said she had not heard from the facility about whether she had gained any weight. R34's face sheet showed R34 was admitted to the facility with diagnoses including protein-calorie malnutrition, dysphagia, vitamin D deficiency, gastro-esophageal reflux disease, and Parkinson's disease. R34's most updated MDS dated [DATE] showed R34 had moderate cognitive impairment and required supervision for eating, moderate assistance for oral hygiene and upper body dressing, maximal assistance for showering/bathing, and was dependent on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. R34's care plan dated 11/21/23 showed R34 was at risk for malnutrition with interventions to weigh resident per facility schedule or physician order. The facility's Weight Assessment and Intervention policy revised on 8/2008 showed Weights will be recorded in the clinical record of the resident. Any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation. If the weight is verified and triggers a significant weight change, the physician will be notified. Resident's physician and resident's family/responsible party should be notified of any significant weight loss or gain. The facility's Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol revised 8/2008 showed to Monitor and document the weight and nutritional status of residents in a format which permits readily available month-to-month comparisons. The physician and staff will monitor the nutritional status, response to interventions, and possible complications of such interventions of individuals with impaired nutritional status.

Based on interview and record review, the facility failed to facilitate transportation services for resident's dialysis as ordered by the physician. This failure resulted in change of condition and hospitalization of R254. This applies to 1 of 1 resident (R254) reviewed for dialysis in a sample of 25. Findings include: R254's Face sheet shows he was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Dependence on Renal Dialysis. R254's POS (Physician Order Sheet) shows an order for dialysis on Tuesdays, Thursdays, and Saturdays with a 1PM pickup time and 2PM chair time. R254's MDS (Minimum Data Set) dated 10/29/23 shows his cognition is intact. On 12/12/23 at 12:12 PM, R254 said he goes to dialysis on Tuesdays, Thursdays, and Saturdays and transportation picks him up around 1 PM, but he missed dialysis the week of Thanksgiving. R254 said he missed dialysis on Saturday November 18 due to a water main break at the dialysis facility, he missed dialysis on Tuesday November 21st because transportation did not show up, and he missed dialysis on Thursday November 23rd because it was the holiday and there was no transportation. R254 said he knows he went to his daughter's house on Thanksgiving, but he does not remember coming back to the facility on Thursday night; he remembers waking up in the hospital the Saturday morning after Thanksgiving. On 12/13/23 at 1:00 PM, V10 (Dialysis center RN) said R254's dialysis for November 18th was rescheduled for Monday November 20th because of a water supply issue at the dialysis facility. V10 said R254 did not show up for dialysis on Monday November 20th due to a transportation issue. V10 said R254 did not show up on Tuesday November 21st and she did not have documentation addressing why. V10 said the dialysis center was open on Thursday November 23rd (Thanksgiving), but her notes show R254 did not go to dialysis that day because the facility did not have transportation to get R254 to dialysis on the holiday. V10 said because R254 could not get transportation on Thursday November 23rd, he was rescheduled for Friday November 24th, but he did not come that day because he was hospitalized . V10 said it is harmful for R254 to miss dialysis because the cleaning of the blood isn't happening and that leads to extra toxins in the blood, fluid overload, and shortness of breath that can harm the patient. V10 said if a patient is not able to get transportation to the dialysis center, they can be sent to the hospital to be dialyzed. On 12/13/23 at 10:22 AM, V3 (ADON/Assistant Director of Nursing) said that V11 (Receptionist) is responsible for setting up dialysis transportation. V3 said if transportation falls through or the dialysis facility cancels a session, V3 would advise V11 to find another mode of transportation or send the resident to the hospital emergency room to be dialyzed. V3 said the facility has multiple companies that provide transportation for them. On 12/13/23 at 1:36 PM, V11 (Receptionist) said R254's scheduled dialysis days are Tuesday, Thursday, and Saturday and she schedules his dialysis transportation. V11 said her records show that R254 did not go to dialysis on Saturday November 18th, Monday the 20th, Tuesday the 21st, or Thursday the 23rd (Thanksgiving). V11 said if a resident refuses to go to Dialysis, the DON (Director of Nursing) or ADON would tell her the resident refused and she would write that on her appointment sheet. V11 provided an incomplete appointment sheet for R254 for Saturday November 18th that does not show if R254 went to dialysis or not. V11 said she did not have an appointment sheet for Monday November 20th, Tuesday November 21st, or Thursday November 23rd. V11 said she knows it is not good for a resident to miss dialysis. On 12/13/23 at 4:33 PM, V3 (ADON) said the facility staff could not find any documentation about R254 refusing to go to dialysis on November 18th, 20th, or 21st, or any documentation showing why R254 did not go to dialysis. On 12/14/23 at 9:32 AM, V2 (DON) said there is a risk of abnormal blood work, illness, and hospitalization if a resident misses dialysis. V2 said if there is a transportation issue with one company, then another company should be called to transport resident to dialysis. V2 said the staff should have communicated with the physician that R254 missed dialysis. V2 said that V3 (ADON) told her there was no documentation showing that R254 missed dialysis or why he missed it. R254's Care Plan initiated on 11/7/23 shows he requires hemodialysis related to end stage renal disease. Interventions include: Dialysis 3 times a week on Tuesday, Thursday, and Saturday and make transportation arrangements for dialysis. R254's EHR (Electronic Health Records) from November 18th through November 24th do not document why R254 missed dialysis. R254's Health Status Note dated 11/24/23 at 8:30 AM shows that nurse found R254 confused, unable to sit upright without support, and with puffy eyes. 911 was called and at 8:44 AM, R254 was transported to hospital. R254's Hospital Record discharge instructions show admitted [DATE] with reason for visit: End Stage Renal Disease Dialysis, Missed Dialysis and medical problem of fluid overload. R254's Hospital Record from 11/26/23 titled, Physician Report: Hospitalist Progress Note shows R254 came in to hospital with general weakness and shortness of breath due to missed dialysis. Note reads, acute hypoxic respiratory failure due to volume retention from missed dialysis. R254's hospital record from 11/27/23 titled, Physician Report: Nephrology Progress Note shows R254 presented to the emergency room for evaluation of generalized weakness and missed hemodialysis due to lack of transportation. The facility's transportation agreement titled Service Agreement Elite Medical Transportation LLC signed on 8/2/22 reads, .1. Elite Transportation- Ambulance shall make ambulance services available to SNF twenty-four (24) hours per day, seven (7) days per week, including holidays . The facility's dialysis agreement with R254's dialysis center titled SNF OUTPATIENT DIALYSIS SERVICES AGREEMENT effective 6/5/13 reads, A. Obligations of Nursing Facility and/or Owner .4. Transport and Referral of ESRD Residents A. The Nursing Facility shall be responsible for arranging for suitable and timely transportation of the ESRD Residents to and from the ESRD Dialysis Unit, including the selection of the mode of transportation .in accordance with the applicable federal and state laws and regulations .

Based on interview and record review the facility failed to initiate immediate cardiopulmonary resuscitation (CPR), failed to correctly provide emergency interventions, and failed to initiate 911 timely. These failures resulted in the delay of efforts to revive R3 and has the potential to affect 43 residents (R2, R7, R13-R53) at the facility who are full-code status. The Order Listing Report dated [DATE] documents 43 residents residing at the facility with an advanced directive of a full code. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at approximately 4 AM when R3 was found on the floor unresponsive. V1 (Administrator), V2 (Director of Nursing) and V18 (Regional Director of Clinical Operations) were notified of the Immediate Jeopardy on [DATE] at 11:58 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training for staff on the initiation and reaction to an unresponsive resident and the correct and timely implementation of emergency interventions. Findings include: R3's Admission Record dated [DATE] documents R3 as an [AGE] year-old admitted [DATE] with diagnoses to include Cerebral Vascular Accident, Chronic Ischemic Heart Disease, Cardiomyopathy, Hypertension, and Diabetes. R3's Practitioner Order for Life-Sustaining Treatments dated [DATE] documents if R3 does not have a pulse and is not breathing, attempt CPR and provide full treatment to sustain her life by medical means. On [DATE] at 11:10 AM, V14 (Nurse) stated he was working on the same side of the building as V3 (R3's assigned Nurse). At around 4 AM V3 urgently summoned V14 to assist her in R3's room and he immediately responded. V14 stated when he entered the room R3 was partially on the floor and partially on the bed, which was an air mattress. R3's head was on the floor at the foot of the bed, her trunk was partially off of the bed and her legs still on the bed. V14 stated he quickly realized a code needed to be called and he left the room to overhead page the code to alert other staff for assistance. At 11:32 AM, V14 stated after making the overhead page, he then went back into R3's room and assisted with placing R3 back in bed, then left to get the crash cart which he brought to R3's room and then left again to call 911 and did not return. On [DATE] 9:30 AM, V17 (Agency Nurse) stated she was working on the nursing unit on the opposite side of the building when an overhead announcement was made for a code blue. V17 stated she arrived to R3's room approximately 4 minutes later after securing narcotic drugs she was in the process of preparing. When V17 entered R3's room the crash cart was in the room and V3 was the only staff member present. V17 stated CPR had not been initiated by V3, and R3 was in the bed with blood to the right side of her face from the top of the skull to her neck from a fall. V24 (Agency Nurse) then entered the room, R3 was placed back onto the floor from the bed and CPR was started. V17 further stated, V3 had to be instructed where to obtain the manual resuscitator (ambu bag) mask, to provide ventilation's (breaths) with the manual resuscitator, and to tilt R3's head up from a chin tucked position to open her airway for ventilation. V17 stated V3 was using the manual resuscitator that was hooked to oxygen but was not keeping the manual resuscitator mask on R3's face while compressions were being done to provide additional oxygen. On [DATE] at 12:11 PM, V3 stated CPR was initiated between ,d+[DATE] minutes after V3 found R3 on the floor and continued for ,d+[DATE] minutes until the Emergency Medical Technicians (EMT's) arrived and took over. V3 was unable to provide an exact time R3 was found on the floor, but stated it was between 3:,d+[DATE] AM. On [DATE] at 2:21 PM, V24 stated she and V17 are agency nurses that were working on the opposite side of the building that R3 resided at the time of this incident. V24 stated she was administering medications to a resident via a feeding tube and did not clearly hear the overhead page calling a code blue. V24 stated as she was exiting the resident's room another page came overhead for a code blue and V24 saw V17 heading towards R3's room and V24 entered R3's room right behind V17. As V24 entered R3 was on the air mattress and V24 instructed the staff present to move R3 to the floor to provide effective CPR. After R3 was placed back on the floor CPR was started. A Progress Note dated [DATE] documents 911 was contacted no later than 4:10 AM and EMT's arrived at approximately 4:30 AM. The EMT's ceased CPR at 5 AM and R3 was pronounced dead at 6:45 AM by V23 (Coroner). On [DATE] 12:30 PM V15 (Nurse Practitioner) stated R3 should not have been put back to bed on her air mattress after the fall to perform CPR and should have been left on the floor. V15 stated R3 was a full-code and CPR and life saving measures are to be started immediately in hopes to revive them. V15 further stated, delays in initiating life saving measures can reduce a person's chance of survival. The Police Department Case Report documents the 911 call received by dispatch as occurring at 4:09:42 AM. The Code Blue and CPR Policy revised on [DATE] documents the facility standard as: This facility will honor the resident/resident's representatives wishes either with the provision or withholding of CPR. To ensure that each facility is able to and does provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of EMT's in accordance with related physician orders and the resident's advanced directives. CPR Guidance includes the sequence to provide CPR as to check the resident for responsiveness, if unresponsive call for help and activate 911 or direct others to do so, check for breathing and pulse and if no pulse and not breathing, begin CPR. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. On [DATE], facility initiated on-going licensed nurse's re-education related to: Performing a Code Blue (Mock Codes) Ambu bag usage Paging overhead during a code Crash Cart process Identification and response to a resident found to be unresponsive - assessment/evaluation, initiation of CPR. 911 notification ***(Staff will not work without receiving this education) ***(Newly hired employees will receive education on above in orientation) 2. On [DATE], facility initiated on-going Certified Nurses Aide/facility staff re-education related to: Assisting in a Code Blue Low Air loss mattress pulls for CPR ***(Staff will not work without receiving this education) ***(Newly hired employees will receive education in orientation) 3. On [DATE] the facility initiated MOCK code drills each shift until licensed nurses have received education. 4. Systematic Change: Reeducation to staff on: o Standard and Guideline: Code Blue (protocol for what to do when a resident is found unresponsive) Monitoring will be ongoing: 5. The facility DNS/designee will conduct daily mock code drills on alternating shifts X 30 days and then 3 times a week x 30 days, then 2 times a week x 30 days to ensure advance directives/code process is being carried out. 6. Findings of these quality reviews will be reported to the facility QA/Risk Management meeting until such time as substantial compliance has been determined and recommends on-going monitoring by the Regional Director of Clinical Operations when conducting facility visits and quality systems reviews. Quality Assurance/ Performance Improvement On [DATE] an Ad Hoc QA Meeting was convened to review the above plan; the facility Medical Director reviewed and approved the plan related to CPR. The Executive Director/facility leadership team will hold daily Ad hoc QA Meetings until such time as the immediacy has been removed and will then conduct weekly QAA Meetings until such time as substantial compliance has been determined.

Based on observation, interview, and record review, the facility failed to ensure a resident identified as an elopement risk was provided adequate supervision to prevent elopement from the facility. The facility also failed to ensure the staff is knowledgeable about alarming exit doors, that exit alarms are in working order, staff respond to triggered exit alarms and elopement binders are kept up to date as shown in the facility's elopement policy. This failure resulted in Immediate Jeopardy when R1 eloped from the facility without being witnessed by facility staff. This applies to 6 of 8 residents (R1, R2, R3, R4, R5, and R7) reviewed for safety concerns in the sample of 8. The Immediate Jeopardy began on March 18, 2022, at 8:25 PM, when R1 eloped from the facility without being witnessed by facility staff. R1 was found lying in a drainage ditch by two bystanders from the local community, who alerted 911 at approximately 10:40 PM on March 18, 2022. R1 required hospitalization due to hypothermia and has not returned to the facility. The Immediate Jeopardy was identified on March 24, 2022. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on March 28, 2022, at 4:10 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 31, 2022 at 6:30 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan, including in-service training of staff on elopement drills and door alarm response, functionality of door alarms, ensuring exit doors are secured with exit alarms, identifying residents as an elopement risk, and updating the resident's medical record and elopement binder. The findings include: 1. On March 22, 2022, at 5:09 PM, V3 (Witness/Bystander) stated, Me and a friend were walking home from a local restaurant around 10:30 PM on March 18. We saw [R1] close to the road, lying in a storm drainage ditch. There is a big ditch and a metal storm drain next to the road we were walking on. [R1] was mostly lying on his side and his entire body, except for his neck and head was in water. He was moving a little bit at that point. We walked over to him, and from a safe distance we said, are you okay? Should we call someone? He did not answer. We walked over to him and could see he was elderly and there was a very visible amount of blood coming from his arm. He said he couldn't get up and said he didn't have a cell phone. We moved him out of the cold water by pulling part of his body up onto the grass next to the drainage ditch. We then dialed 911. While we were waiting for the ambulance to arrive, we removed our winter coats and covered him. It was really cold out and we were without our jackets standing there waiting. I actually checked my phone to see what the temperature was, and my phone said it was 38 degrees out. [R1] was really stiff, especially his legs, when we pulled him out, and we thought he was almost dead. It was less than 3 minutes between our call to 911 and when the paramedics got there. I never saw anyone from the nursing home looking for [R1]. It was just the paramedics, firemen, and then the police. [R1] did leave his sweatshirt near the metal storm drain and we gave the police his sweatshirt. We discovered him at 10:35 PM. On March 22, 2022, at 1:28 PM, V7 (Firefighter/Paramedic) stated, We responded to a call by a bystander of a person lying in a drainage ditch. Upon our arrival to the area, we found [R1] lying in the grass next to a drainage ditch. The drainage ditch is near the road. His clothing was soaking wet. We recorded his oral body temperature as 90.0 degrees Fahrenheit. We warmed him up with warmed intravenous fluids, hot packs to his groin and armpits, and warm blankets. We searched for a wallet but could not find one. He did not have any identification on his body when we found him. He was not able to tell us his name or where he lived due to confusion. We noticed he was wearing an [incontinence brief] filled with feces, and we thought perhaps he had wandered from the nearby nursing home. I asked for someone to go over to the nursing home and see if they were missing anyone. A police officer went into the facility and returned with one of their staff members. Their staff member identified the resident as one of their residents. He was wearing pajama pants, slippers and a top. A sweatshirt was tossed over to the side. V9's (Police Officer) documentation on the local police department's Case Report, dated March 21, 2022, shows, on March 18, 2022, at 10:40 PM, R1 was found in the flood drain located in the northeast corner of the facility. The drain is located approximately 50 yards from the front entrance. R1's hospital documentation dated March 18, 2022, shows R1's body temperature at 11:18 PM on March 18, 2022, was 89.5 degrees Fahrenheit. R1 was admitted to the local hospital with diagnoses of altered mental status, right elbow laceration, and hypothermia. On March 23, 2022, the facility's surveillance video was reviewed with V1 (Administrator). V1 also provided a timeline of the events regarding R1's elopement. V1 stated, [R1] left the building at 8:25 PM on March 18, 2022. [R1] was found outside the facility more than two hours after he left the building. The door alarm did not sound because the door alarm was never activated by our staff. [V15] is the receptionist. She left the facility at approximately 8:15 PM that night. She is supposed to alarm the doors before she leaves, but she did not do that. She did not have enough training, and that is why the front door alarms were never set, and why no alarm sounded when [R1] left the building. The front door has a double entrance. The outside doors are supposed to be manually alarmed from behind the nurse's station, and the inside doors are supposed to be alarmed using a battery-operated box attached to a pull cord. If the inside door is opened, the alarm cord is pulled from the alarm box and alarms loudly, alerting facility staff. Also, staff should do bed checks, and residents should be seen by our staff every two hours at least. The surveillance video reviewed with V1 shows the following events on March 18, 2022: 8:08 PM-The receptionist turned off the lights in the reception area. 8:24 PM-An unidentified staff member is observed sitting at the nurse's station near R1's room. The staff member appears to be looking at something in her hand. R1 is observed walking in the hallway, carrying a sweatshirt over his arm. R1 walks past the staff member, waves in the direction of the staff member, and continues walking. The staff member does not acknowledge R1 when he waves or walks past her. R1 is observed walking towards the facility's front reception area. 8:25 PM-R1 is observed walking out the front door of the facility carrying a sweatshirt over his arm. No facility staff are present in the video. No facility staff are observed to respond to R1 leaving through the front doors of the facility. 10:48 PM-A police officer enters the facility. 10:49 PM-The police officer walks out of the building with two facility staff members. On March 24, 2022, at 11:54 AM, V11 (APN-Advanced Practice Nurse) stated, I am at the facility twice a week. I saw [R1] on March 9, 2022. He has severe dementia. I saw him walking randomly around the facility. You cannot hold a conversation with him, due to his dementia. He is only able to mumble. Due to his dementia, he has poor safety awareness. If he walked outside the facility, he would not know he needed to turn around and go back inside. On March 24, 2022, at 5:35 PM, V14 (LPN-Licensed Practical Nurse) stated, I was caring for [R1] the evening of March 18. He was aggressive at the beginning of my shift. I calmed him down and he walked back to his room. Later, I saw him walking in the hallway while I was passing medications to other residents. He had attempted to go out the front door earlier that evening, but the aide directed him to come back. Usually, we can walk him back to his room and he will stay there. I saw him around 8:00 PM. We are supposed to do rounds on our residents every two hours. I was going to check on him at 10:00 PM, but I had other work to do so I did not check on him. Then, around 10:45 PM, a police officer came in and asked if we were missing anyone. I started doing my rounds. When I saw [R1] wasn't in his room, I went outside with the officer to check if [R1] was outside. [R1] was the resident found in the drainage ditch. No alarm was sounding in the facility to notify us the door alarm had been triggered or that a resident had left the building. I don't know whose job it is to turn on the alarm. It used to be when the receptionist leaves, then the alarm gets turned on. On March 28, 2022, at 1:16 PM, V15 (Receptionist) stated, I work from 4:00 PM to 8:00 PM. [R1] came to the reception desk a couple of times on that day (March 18, 2022). He came up two or three times. Two of the CNAs escorted him back behind the reception area doors. When I go home, I use a little wrench to lock the outer front door. This keeps intruders from coming into the facility, but it doesn't set an alarm to alert anyone if someone leaves the building. After that I turn off the lights, transfer the telephones into night mode, and walk out the front door. I never had to tell anyone I was leaving. I was never taught to set any alarms when I leave the building. Since [R1] eloped, I now have to set an inner door alarm by connecting a wire to the two alarm boxes. This alarms the inside door, but not the outside door. I don't know who sets the alarm on the outside door. As for door alarms going off while I am working, if I hear a door alarm sounding, sometimes I announce overhead there is a door alarming, and then the alarm stops, so I assume everything is okay. I don't have to keep track of door alarms on a log or anything like that. I did not receive any training about the door alarm going off or that anyone has to check the alarm and let me know the alarm is all clear. If I need to use the restroom during my shift, I don't have anyone to cover for me, so I just leave the reception area. I don't have to set the alarm before I leave the reception area. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 had multiple diagnoses including dementia with behaviors. R1's MDS (Minimum Data Set) dated January 7, 2022, shows R1 had severe cognitive impairment. R1 required extensive assistance with personal hygiene, bathing and dressing, and supervision with walking in the room and corridor, locomotion on and off the unit, and eating. R1 did not use any mobility devices for ambulation. R1's care plans dated June 9, 2021, show R1 was an elopement risk/wanderer, with disorientation to place, impaired safety awareness, and aimlessly wandering. The goal of R1's care plan shows: The resident's safety will be maintained through the review date. Interventions in R1's care plan included: Check for proper functioning of the audible alarm system regularly and PRN (as needed). Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, PRN. An elopement risk assessment completed February 23, 2022, shows R1 was at risk for elopement. R1's elopement risk assessment score was 15.0. The elopement risk assessment tool shows a score greater than 5.0 means the resident is at risk for elopement. Facility documentation of R1's behaviors for the period February 24, 2022, to March 18, 2022, shows the following responses: 1) Has the resident wandered? Facility staff answered Yes on the following dates: February 24, 2022 February 25, 2022 February 27, 2022 March 1, 2022 March 2, 2022 March 5, 2022 March 8, 2022 March 10, 2022 March 17, 2022 March 18, 2022 2) Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? Facility staff answered Yes on the following dates: March 1, 2022 March 2, 2022 March 8, 2022 March 17, 2022 On March 24, 2022, at 9:49 AM, V2 (DON-Director of Nursing) stated, In reviewing [R1's] chart, there was an elopement risk assessment conducted in February 2022. The nurse scored [R1] very high. He scored 15. Anything over 5 is considered an elopement risk. If someone triggers as a high risk for elopement, it should be communicated and discussed with the IDT (Inter-Disciplinary Team) within 24 hours and the information should be carried over to the elopement binders. We put elopement risk binders in place towards the end of February 2022, when I started working at this facility. The binders are kept at the front reception desk, and one at each nurse's station, and one in the therapy gym. There is a picture of each resident identified as an elopement risk, to assist facility staff in identifying the resident. The resident's face sheet with all pertinent medical and contact information is also in the binder. [R1's] information was not in the elopement binder at the time of his elopement. Based on the elopement assessment done in February, he should have been placed in the binder to identify him as an elopement risk. On March 23, 2022, at 9:34 AM, all facility exit doors and alarms were checked with V12 (Housekeeping Supervisor). V12 stated V13 (Maintenance Director) has been on vacation since March 18. V12 stated he believes V13 does maintenance checks on the door alarms to ensure the alarms are in working order, including working batteries. V12 stated he was unable to locate any maintenance logs to show when the door alarms had last been checked. V12 stated he does not have any log sheets and has not checked the door alarms since V13 left for vacation five days earlier. V12 showed the exit doors are equipped with a battery-operated alarm. Each battery-operated alarm has a cord, approximately two feet long, attached to the door with a small bracket. A separate alarm box is affixed near the door. One end of the two-foot cord is attached to the door by a small bracket, and the other end of the cord is inserted into the alarm box. As a door is opened, the tension on the cord attached to the door pulls from the alarm box, resulting in a very loud, piercing alarm sound. The only way to stop the alarm is to reinsert the cord into the battery-operated alarm. In addition, some doors are also alarmed with a second electronic alarm which sounds at the front reception desk whenever a door is opened. Multiple doors were opened and checked with V12, starting with door 4, 5, 6, 9, and 8. No overhead announcement was heard when the door alarms were triggered. It was not until 9:45 AM when the alarm to door 8 was triggered that an overhead announcement was made for facility staff to check door 8 due to an activated exit alarm. V12 stated the receptionist is supposed to make an overhead announcement each time a door alarm is triggered, and staff should respond to ensure a resident did not leave the building. No facility staff were observed responding to the door alarms as described by V12. The door alarm inspection continued with V12, and upon approaching door 1, the cord used to trigger the door alarm was hanging loose from the alarm trigger box, and not attached to door 1. V12 stated the trigger cord should be attached to the door. Door 1 was opened, and the battery-operated door trigger alarm did not activate. V12 stated, Good thing you were here to notice the alarm was broken. On March 29, 2022, at 10:40 AM, the door alarm for entrance door 6 triggered at the front reception desk. A loud beeping sound could be heard at the reception desk, and a map of the facility showed a blinking light at entrance door 6 on the facility map. V16 (Receptionist) went to reach for the telephone to make an overhead announcement regarding the door alarm. The sound of the door alarm suddenly stopped. V16 did not continue with the announcement. V16 stated, When a door alarm goes off, I am supposed to make an announcement announcing which door is alarming. Then, the facility staff is supposed to go to the door to ensure no resident left the building through the alarming door. If the area is safe and all clear, then an announcement will be heard overhead by the staff saying the door is all clear. No one announced anything, so I guess everything is okay at door 6? As of 10:51 AM, no overhead announcement was heard by facility staff to say the door alarm was all clear. On March 24, 2022, V2 (DON) provided a list of residents residing in the facility, identified as elopement risks. V2 identified R2-R8 as high risk for elopement. The facility's elopement binders were reviewed. The elopement binder located at the front reception desk did not have R5's picture or face sheet in the binder. 2. On March 23, 2022, at 3:23 PM, R2 was walking in her room. R2 was wearing a sweater and pants and was not wearing socks or shoes on her feet. R2 proceeded to leave her room in bare feet and walk around the facility. R2 stated, I would like to go home. I don't know why I'm here. R2 was observed aimlessly walking around the facility with another resident for the next hour. R2 was not able to answer questions due to her cognitive status. The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, vascular dementia, anxiety disorder, and major depressive disorder. R2's MDS dated [DATE], shows R2 has severe cognitive impairment, requires limited assistance with bathing, and supervision with all other ADLs (Activities of Daily Living). R2's Elopement Risk Screening dated March 19, 2022, shows an elopement risk score of 8.0. The screening continues to show if a resident's elopement risk score is greater than 5.0, the resident is considered to be an elopement risk. R2's care plan, initiated January 31, 2022, shows: The resident is at risk for elopement risk/wander due to severe cognitive impairment, poor safety awareness, wanders aimlessly. 3. On March 23, 2022, at 3:55 PM, R3 was sitting in his room. R3 was unable to answer questions due to his cognitive status. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, multiple rib fractures, [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], asthma, dementia, and personality disorder. R3's MDS dated [DATE], shows R3 has moderate cognitive impairment. R3's MDS continues to show R3 has wandering behaviors that place R3 at significant risk of getting to a potentially dangerous place (stairs, outside of the facility). R3's Elopement Risk Assessments dated January 5, 2022, and March 19, 2022, show an elopement risk score of 10.0. Additional comments on R3's March 19, 2022, assessment show: Even though [R3] hasn't been exit seeking, he is an elopement risk because he verbalizes almost daily wanting to leave and he is ambulatory. R3's care plan, initiated March 19, 2022, shows: The resident is an elopement risk/wanderer. Impaired safety awareness. 4. On March 23, 2022, at 3:52 PM, R4 was sitting in his room. R4 refused to be interviewed. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, [CONDITION(S)], diabetes, kidney transplant, [CONDITION(S)], pancreas transplant, anxiety disorder, major depressive disorder, [CONDITION(S)] disorder, abnormal gait, weakness, dementia, anxiety, and [CONDITION(S)]. R4's MDS dated [DATE], shows R4 has moderate cognitive impairment and is able to walk with limited assistance. R4's Elopement Risk Assessment screening dated March 19, 2022, shows R4's elopement score is 8.0. Additional comments on the screening tool show: Resident has behaviors and from time to time will attempt to leave when he is attention seeking. R4's care plan, initiated March 5, 2021, shows: [R4] is a wanderer, elopement risk r/t (related to) impaired safety awareness. 5. On March 24, 2022, at 1:00 PM, R5 was sitting in his room with a visitor. R5 declined interview. The EMR shows R5 was admitted to the facility on [DATE]. R5 has multiple diagnoses including, lung cancer, malignant [CONDITION(S)], cerebral infarction, [CONDITION(S)], acute respiratory [CONDITION(S)], pneumothorax, heart disease, pneumonia, chronic kidney disease, and [CONDITION(S)]. R5's MDS dated [DATE], shows R5 has moderate cognitive impairment. R5's Elopement Risk Assessment, dated March 19, 2022, shows, R5's elopement risk score is 8.0. Additional comments on R5's risk assessment show, Resident gets angry and threatens to leave. R5's care plan, initiated March 19, 2022, shows: The resident is an elopement risk/wanderer, impaired safety awareness. Interventions initiated March 19, 2022, include, Monitor for tailgating when visitors are in the building. Wander alert: Place resident identifier in elopement binder so that staff is aware of resident's elopement risk. 6. The EMR shows R7 was admitted to the facility in April 2021. R7 has multiple diagnoses including, dementia. R7's MDS dated [DATE], shows R7 has severe cognitive impairment. R7's Elopement Risk assessment dated [DATE], shows R7's elopement risk score is 3.0. Additional comments on the assessment show: Resident's dementia is in a place where she is not actually looking to leave but may walk out behind someone because she wants to be with them. She looks like she could be a visitor and may be seen as one. Resident is ambulatory. R7's care plan dated April 20, 2021, shows: [R7] is a wanderer, disoriented to place. Wanders aimlessly. Interventions dated March 20, 2022 show: Monitor for tailgating when visitors are in the building. The facility's policy entitled Standards and Guidelines: SG Elopement Assessment and ID, revised March 30, 2021 shows: Standard: It will be the standard of this facility to identify residents admitted to the facility who have a potential to leave (actual or attempted) the premises either per their own choice, or due to impaired cognition/unawareness of their actions: Guidelines: 1. Residents will be assessed upon admission, quarterly and PRN for risk of elopement if they display history of wandering, moderate to severe cognitive impairment with the ability to self-propel or ambulate, express desire to exit the facility or are noted attempting to exit the facility. (Refer to Elopement Screen) 4. Resident scoring 5 (five) or above will be considered at risk for potential elopement. 5. An elopement screen ranking 5 or above is brought to the attention of the DNS (Director of Nursing Services) or their designee and reviewed by an interdisciplinary team to determine appropriate follow-up/interventions and if the resident is truly an elopement risk 8. A picture of the resident should be obtained and placed in a binder that is maintained at the front desk or other secure location that is easily accessible for staff to identify residents at risk for elopement. 9. The Elopement Binder should be maintained/updated routinely to ensure a current listing of the high-risk residents is available. The immediate Jeopardy that began on March 18, 2022, at 8:25 PM was removed on March 31, 2022, at 6:30 PM when the facility took the following actions to remove the immediacy: All facility staff members were educated on door security, elopement, and alarm response. This was completed on March 29, 2022. Handouts were given to support the discussion, and staff provided a return demonstration on how to respond to an alarm. Staff (one staff member) that is on vacation will be advised of the need to receive in-servicing upon her return to the country. Staffing coordinator advised agency workers that effective March 30, 2022, they are to arrive early for their next shift to receive in-servicing from V2 (DON), V1 (Administrator), or designee. Agency and permanent staff that wasn't available at the time of in-servicing will not be able to work their next shift until they have received in-service training. Education included a process for checking the 12 door alarms for functionality with an emphasis on doors 6, 10, and 12. The Maintenance Director will check door alarms Monday through Friday by 9:00 AM. Completion log along with any corrective action will be brought to the daily morning stand up meeting beginning March 30, 2022. This will be an ongoing process and documented in daily morning stand-up meeting minutes. The Administrator will re-assign duty if the Maintenance Director is not available. The Administrator will audit the completion of the logs and validate the completion of the process as described above, five (5) times a week for four (4) weeks, then three times a week for two weeks, and then ongoing on a weekly basis. The receptionist's end of shift door alarm and door lock security process validation will include the following: At the end of the receptionist's shift, he/she will engage the assistance of the charge nurse from 100 hallway to validate the engagement of both alarms, front door lock is engaged properly, and alarm panel is showing red to validate lock is on. The receptionist and Charge Nurse will sign off on a validation log. The Administrator will audit the completion of the logs and validate the completion of the process as described above five (5) times a week for four (4) weeks, three (3) times a week for 2 weeks, and then ongoing on a weekly basis Nursing will assist with checking the door alarms on evening and overnight shifts, daily. The facility's exit doors will be divided into two groups. Group 1 will consist of doors labeled 1 through 5, plus door 12, and will be the responsibility of the nurse who is assigned to the 100 hallway. Group 2 will consist of doors 6 through 11 and will be the responsibility of the nurse who is assigned to the 300 hallway. The Administrator will audit the completion of the door alarm logs and validate the completion of the process as described above five (5) times a week for four (4) weeks, three (3) times a week for 2 weeks, and then ongoing on a weekly basis. Each nurse will visualize that the wires that attach the alarms to the doors are in place. They will then check the control panel at their assigned nurse's station to make sure all lights are red thereby verifying that the alarms are set. Beginning on March 30, 2022, nurses will complete this process twice a day, once between 3:30 and 4:00 PM, and then again between 11:30 PM and 12:00 AM. Audit sheets will be kept at the nurse's station and placed in the DON's mailbox after completion. Any and all discrepancies with alarm function and/or security will be immediately reported to the Administrator or DON. The Administrator will audit this process for completion and compliance twice daily for four (4) weeks, daily for two (2) weeks, three (3) times a week for two (2) weeks, and then ongoing weekly. Results of compliance will be shared during a monthly QA (Quality Assurance) meeting for feedback. Beginning on April 2, 2022, the Manager on Duty will complete the alarm check process on Saturday and Sunday mornings by 9:00 AM, using the audit tool provided by the Administrator. This will be an ongoing task for the Manager on Duty responsibilities. Nursing will follow the schedule that is followed during the week for afternoons and overnight shifts. The Administrator will audit this process for completion and compliance twice daily for four (4) weeks, daily for two (2) weeks, three (3) times a week for two (2) weeks, and then ongoing weekly. Results of compliance will be shared during a monthly QA meeting for feedback. On March 29, 2022, educational material on alarm response, elopement, and door security was provided to HR (Human Resources) to become part of orientation for new hires. On March 29, 2022, the same educational material was placed in the agency orientation handbook. On March 19, March 21, March 24, and March 30, 2022, elopement drills were conducted for each shift and the Administrator or designee will continue to hold drills monthly. A record of completion of the elopement drills including attendance records will be maintained by the Administrator. Immediate in-servicing will be provided by managers for non-compliance and documented on an audit tool which will be given to Administrator/DON. Results and trends will be shared monthly at QA meetings. Alarm drills will begin on March 30, 2022, to monitor the staff's response to door alarms. The Administrator will develop a rotation for managers to conduct drills on alternating shifts. This will be done twice a week for four (4) weeks, weekly for four (4) weeks, monthly for three (3) months, and then quarterly. Immediate in-servicing will be provided by managers for non-compliance and documented on an audit tool which will be given to Administrator/DON. Results and trends will be shared monthly at a monthly QA meeting for feedback. On March 28, 2022, signs outlining the 5-step alarm response were placed in high traffic areas for staff. On March 28, 2022, the 5-step alarm response was added to nurse and aide shift report sheets. On March 19, 24, and 26, 2022, all Elopement Binders were updated and education regarding their purpose and location was completed on March 28, 2022. On March 19, 2022, elopement risk assessments were updated for all residents residing in the facility. Nurses will update elopement risk assessments quarterly and with a resident's change of condition.

Based on interviews and record reviews, the facility failed to provide safety during incontinent care to R1 to prevent an avoidable fall. This applies to 1 out of 3 residents (R1) reviewed for falls in the sample. This failure resulted in R1 rolling off the bed during incontinent care and sustaining a distal femur fracture requiring an overnight hospital stay, application of splint as well as increased pain. Findings include: Incident report of 12/14/19 showed that R1 rolled off the bed and on to the floor while V3 (CNA-certified nurse's aid) was doing incontinent care. The incident report of 12/14/19 showed that R1 had [DIAGNOSES REDACTED]. The incident report of 12/14/19 also showed R1 with a [DIAGNOSES REDACTED]. It also showed that V3 stated he was changing R1's incontinent brief when he pulled the brief off of R1 and R1 rolled and fell on the floor. The incident report reflected that the immediate intervention to prevent similar incidents to occur was to have 2 CNAs assist with peri care. On 1/2/20 at 10:45 AM, V3 (CNA) stated he was the CNA providing incontinent care to R1 on 12/14/19 when she fell from the bed. He had cared for R1 in the past and was familiar with her. R1 was alert. At that time he believed she was assessed as requiring the assistance of 1 for ADLs (activities of daily living) but required assistance of 2 for transfers because she was transferred with a mechanical lift. R1 was lying on her side with her right stump on the top and positioned in front of her full leg. He had one hand on her hip and the other hand was on the brief, and when he pulled the brief out from under her, she rolled off the bed. V3 stated, she was close to the edge, but I thought she was fine where she was in the bed. It never happened before. He also said that she looked like she was in the center or just off center of the bed prior to him rolling her to the door. He immediately got the nurse who assessed R1 and R1 complained of hip pain. They made her as comfortable as they could on the floor until the ambulance arrived to take her to the hospital. He offered to go to the hospital with her and she accepted. He stated that at other times, he has utilized a second person to assist with changing R1, but this time he did not attempt to get assistance, because it was late in the shift and he had already started providing care. On 1/2/20 at 1:00 PM, V4 (RN) stated that she works with R1 regularly, and R1 is always very alert. V4 stated that she was notified by V3 that R1 had fallen from the bed while he was changing her. She went to the room and assessed R1 and because R1 was complaining of pain, they tried to keep her comfortable on the floor until the ambulance arrived. V4 stated that R1 was a large lady and when female staff would go in to change her, they utilized 2 or even 3 staff to change R1. However, V3 was a strong male and could change R1 himself, although she has seen him utilize a second person to change R1 at times. It would have been safer to utilize another staff to stand on the other side of the bed in order to prevent a fall. She requires 2 person assist for transfers and to pull her up in bed. Because she didn't have siderails, she had nothing to hold on to. Currently, when she is moved, since her injury, she complains of pain at about a level of a 7 (7 out of 10). When you touch her leg, she complains of pain out loud. According to V3's progressive discipline form dated 12/15/19, V3 received discipline for the incident dated 12/14/19. V3's progressive discipline form dated 12/15/19 showed a summary that 2 CNAs should be utilized when providing peri care on a resident who has decreased bed mobility and has the potential to roll out of bed. R1's MDS 3.0 (Minimum Data Set) showed that R1 is cognitively intact and R1's fall risk assessment dated [DATE] showed that R1 was at significant risk for falls because R1 has balance problems, weakness, fatigues quickly, has a [MEDICAL CONDITION], history of stroke and paralyzed on left side. R1's transfer code of 9/25/19 showed a recommendation of a valet bar on V1's bed. This was never done. R1's occupational therapy evaluation and plan of treatment dated 9/25/19 showed V1's goal for safe bed mobility was to use siderails for proper positioning and showed V1 had risk factors that were due to R1's physical impairments, which put R1 at risk for fall. On 1/2/20 at 10:00 AM, V1 (Administrator) stated that the facility only has a few electric beds and rents the rest when someone needs one, They do not use siderails anymore but if someone needs an assistive device to help them with repositioning, they can attach a valet bar to the beds, but only the beds they own, not the rented beds, as it entails drilling into the bed frame. On 1/2/20 at 11:45 AM R1 said she fell out of her bed and broke her leg while V3 was changing her. R1 stated I think he didn't pay attention. and stated she told V3 that she was falling out of the bed. She reported that while V3 was performing incontinent care V3 was also talking on his cell phone along with singing and dancing. R1 stated that since the fall she is in constant pain and in constant fear of falling. R1 stated that when R1 was first admitted to the facility V6 (RN) told R1 that R1 was going to have rails on R1's bed for safety but they were never applied. R1 stated that prior to falling R1 had told the nursing staff that R1 didn't want V3 to care for R1 because V3 is not professional. On 1/2/20 R4 said that V3 acts younger than V3 is plays games while working, R4 stated that R4 has seen V3 singing, dancing, talking on V3's cell phone and playing with the facility's intercom system while on duty. R4 stated that she reported that information twice to both V1 and V2. R4 said that R1 told her that since R1's fall, R1 has been in a lot of pain, and having difficulty falling asleep at night. On 1/2/20 R5 said that V3 is always playing around, dancing, singing, on his cell phone and playing with the intercom system. On 1/2/20 at 1:31PM V8 (CNA) said that R1 is very alert and oriented and that R1 has told V8 a few times before the fall that R1 didn't want V3 to care for R1 because R1 doesn't trust V3 because V3 is not professional. V8 stated that R1 is a two person assist and has always been a two person assist. V8 stated she has never performed incontinent care for R1 without two staff. V8 stated that she has seen V3 dancing and singing while on the floor. V8 stated that she prefers not to associate or work with V3 because of V3's lack of professionalism. On 1/2/20 at 1:11PM V6 (RN) said that R1 is alert and oriented. V6 said that R1 is on pain medication related to the fall of 12/14/19 and has reported pain every day. V6 first said she did not remember talking to R1 about side rails on R1's bed but then said she did remember discussing with R1 about a Valet bar for R1's bed but could not recall when V6 talked to R1 about it or what exactly they talked about. V6 said that she has seen V3 singing, dancing, and talking on his cell phone while on the floor while working. V6 said that R4 informed V6 a couple of weeks ago that R4 did like V3 because V3 doesn't know what V3 is doing. On 1/2/20 at 12:50 PM V7 (CNA) said that R1 is very alert and has told V7 that R1 is afraid of V3 and does not want V3 to care for R1. V7 said that prior to R1's fall R1 was Coded 3 person assist and now R1 is a 2 person assist. V7 said that V7 has never done incontinent care for R1 without the assistance of other staff. V7 said that V7 has seen V3 dancing and playing around and talking on V3's phone while working. V7 said that other residents have complained to V7 about V3 dancing, singing and talking on his phone while on the floor. On 1/2/20 at 4:06 PM V9 (occupational therapy assistant) said that R1 has a recommendation for a bed valet and V9 highly recommend R1 be a 2 person assist during incontinent care since R1 does not have the bed valet. V9 also said that R1 had a communication card in R1's room showing R1 is a 2 person assist during incontinent care prior to the fall. On 1/2/20 at 4:06PM V10 (physical therapist) said that V10 recommended R1 have a valet bar attached to R1's bed and highly recommended that R1 be a two person assist with incontinent care if R1 could not have the valet bar. V10 said that prior to R1's fall, R1 was already a two person assist and V10 said he saw R1's communication card in R1's room prior to the fall showing a two person assist. On 1/2/20 at 3:46 PM V11(occupational therapist) said that V11 recommended R1 have a valet bar attached to R1's bed on 9/25/19. V11 said that V11 informed the maintenance man that R1 needed a valet bar attached to R1's bed. V11 said this was the facility's procedure for occupational therapy recommendations for adaptive devices. V11 said that R1 could have used the valet bar with turning R1's self and possibly R1 could have prevented herself from falling out of the bed. V11 said that prior to R1's fall, R1 was a two person assist for bed mobility, ADL and incontinent care. V11 said that V11 highly recommends that R1 be a two person assist since R1 was unable to have valet bar attached to R1's bed. V11 stated that she saw R1's communication card on R1's door, prior to R1's fall and the communication card showed that R1 was a two person assist for incontinent care. On 1/2/20 at 1:20 PM, V2 stated that prior to her fall, R1 was assessed as only needing one person's assistance for ADL's although she required 2 for transfers. This information was on her care card. V2 stated she could not provide a copy of her original care card typically kept in the residents room because it was a running document filled out in pencil and updated as the person's condition changed. It has since been changed to reflect the resident's change in condition. After R1's fall, they put new interventions in place, including a scoop mattress, 2 person assist for changing her incontinent brief, and a low bed with pads on the floor She stated she just learned today from R1's son that R1 had expressed concerns regarding V3's behavior and did not want him caring for her. V2 could not explain why this was confirmed by other staff and yet she hadn't heard of this. V2 denied hearing this information prior to that day V2 stated that she believed that staff stated that they went in to care for R1 with multiple staff because this had been recommended because of manipulative behavior on the part of R1, but those above-referenced staff stated they had multiple staff during R1's care because of her size and multiple medical conditions. After speaking with R1, V2 stated that R1 had refused a valet bar on 1/2/20, and V2 had changed V3's assignment so that V3 would not be caring for R1. On 1/2/20 at 2:35 PM, V5 (MD for R1) stated that the fall caused R1's fracture and that R1 is having pain due to her broken bone. She did not have surgery because they decided on conservative treatment, so she is in a splint. Without surgery, it will take 6 to 8 weeks for her broken leg to heal.

Based on observation, record review, and interview the facility failed to follow the facility's policy to use two staff members while transferring a resident using a mechanical lift. This resulted in R1 sustaining an acute fracture of distal humerus. This applies to 1 of 3 residents (R1) reviewed for accidents in the sample of 3. Findings include: The Face Sheet documents R1 is [AGE] years old and has [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] shows R1 has a BIMS (Brief Interview for Mental Status) score of 7 out of 15 indicating cognitive impairment; is totally dependent on staff for transfers (full staff performance every time) requiring two person physical assistance; has impairment in upper and lower extremity on one side; and is only able to stabilize with staff assistance during surface-to-surface transfer. The Care Area Assessment (CAA) dated 9/12/18 triggered risk factors for ADL (Activities of Daily Living) Functional Status [MEDICAL CONDITION](Cerebral Vascular Disease), [MEDICAL CONDITION], limited range of motion, impaired coordination, impaired balance, [DIAGNOSES REDACTED] and increased weakness/decreased strength. Care plans read: 8/29/18: Fracture of right humerus; transfers will be completed by the staff with mechanical lift as required, Goal date 3/17/19: Intervention- direct staff in-servicing re: proper positioning of mechanical lift pads and wheelchair positioning. Require assistance to transfer with mechanical lift secondary to altered mental status, [MEDICAL CONDITION], right sided [MEDICAL CONDITION]; Goal date- 3/17/19; Intervention- Transfer guest per resident care card (located in resident's closet). 9/18/18: R1 is totally dependent on staff; Goal date- 3/17/19; Intervention- Provide proper assistance for transfers/ protect extremities to decrease risk of injury. 12/21/18 Bruise/swelling noted to hand and wrist; Intervention- CNA in-serviced via phone re: body proximity during transport. The facility Incident/Accident Report dated 3/19/19 documents V5 (Certified Nursing Assistant/CNA) stated R1 complained of pain to the right arm when attempting to place it on a pillow. Nursing Notes dated 3/19/19 at 9:30 AM reads: Guest complained of right arm pain when staff attempted to place arm on pillow while in bed. Right sided [MEDICAL CONDITION] per history. The Transfer Form documents: R1 transferred to the hospital on [DATE] for pain/right arm fracture. The Radiology Report dated 3/19/19 reads: Right Humerus 2+ Views Indication- pain Impression- Acute [MEDICAL CONDITION] humerus. The Incident/Accident Witness Statement by V5 reads: Describe what you heard:- I moved R1's right arm and R1 complained of pain. Where did you last observe this resident and what were they doing?:- I was providing direct care at the time of complaint of pain. No knowledge of any incident prior to care. No complaint of pain earlier. Incident Investigations read: Fracture to right distal humerus. X-Rays confirm fracture What are the resident's remarks regarding the incident? - My arm is broken. Staff Interviews on 3/21/19 at 1:46 PM, V5 stated she was the caregiver for R1 on 3/19/19 when R1 complained of arm pain. V5 stated I took care of (R1) all morning. (R1) did not complain of pain until I put (R1) to bed. Prior to that, no pain. (R1) was up in the recliner chair. I put (R1) to bed. It was just myself. V5 stated she transferred R1 via mechanical lift by herself. When asked the policy for mechanical lift transfers, V5 replied It should be 2 people. I couldn't find anyone to help me. (R1) does not complain of pain with ADLs (Activities of Daily Living), no arm pain. When I put (R1) back to bed, (R1) said (R1's) arm hurts. V5 also stated (R1) does not use (R1's) right arm. (R1) did say it's broken when I asked if it hurts. I don't know what (R1) meant by that. (R1) does not help at all with transfers. When asked how she knows what care interventions are in place, V5 replied They should have care cards in the closet on the door. When asked about R1's care card, V5 stated I didn't look. V5 stated interventions for R1 included mechanical lift with 2 people. (R1) does not ever refuse care. V5 stated she started work at 6:00AM on 3/19/19 and R1 did not complain of pain prior to 9:00 AM during care. On 3/21/19 at 2:02 PM, V6 (Nurse) stated she was the nurse on duty 3/19/19 when V5 informed her that R1 was complaining of arm pain. V6 stated I last saw (R1) in the dining room. I was monitoring the dining room from 8:00 -9:00 AM. (R1) had no complaints of pain. (R1's) spouse fed (R1) and didn't say (R1) had pain. (R1's) RUE (right upper extremity) is flaccid. When asked how the CNAs are informed of care V6 replied It's kind of a habit. There's a care card inside the closet that lets them know how to transfer. I did not give her verbal report. She's known (R1) and we've worked with (R1) for a long time. V5 is one of the regular CNAs on that unit. The care card indicated that (R1) is a mechanical lift transfer with two people, which means two staff has to transfer (R1) with the mechanical lift. When asked what risk factors R1 has, V6 replied (R1) is totally dependent on us. (R1) has not refused care. V6 stated when she entered the room (on 3/19/19), (R1) was in bed with the sling to the mechanical lift under R1's back and R1's arm next to the pillow. V6 added (R1) had no pain prior to this point, (R1) will definitely say when (R1) is in pain. (R1) rarely is. There was no report from the previous shift that (R1) had pain and I saw (R1) in the dining room. There was no pain until (V5) came and told me. I attempted a little ROM (Range of motion) and (R1) stated it hurts, so I didn't move it too much. V6 stated she notified V4 (Nurse Practitioner/Primary Care Provider) who ordered X-rays. V6 stated the results showed acute fracture. On 3/21/19 at 2:27 PM, V7 (Nurse on Duty) stated I've worked with (R1) for 3 years. V7 stated staff are made aware of resident's care through report and care cards which are in the closet that tells you what kind of transfer a resident needs. (R1) is mechanical lift transfer, and has been since I can remember. (R1) has been mechanical lift transfer since (R1) has been here. The policy is for 2 people to use the mechanical lift for transfer. It's not a new policy. (R1) has a right [MEDICAL CONDITIONS]([MEDICAL CONDITION]), right side is flaccid and (R1) is unable to move it. (R1) had no recent complaints of pain in that arm. (R1) had an old fracture in the shoulder that's why (R1) is on Tylenol. That's been a while ago. (R1) was not complaining of pain prior to the weekend. When asked how the nurse communicates care to the CNAs, V7 stated that's in their orientation and on care cards. If something changes, restorative writes it on the care card. On 3/21/19 at 2:37 PM, V8 (Restorative Nurse) stated she is responsible for making resident care cards. V8 stated (R1's) right side is flaccid and (R1) had a prior fracture. (R1) can't move by herself. (R1) is transferred via mechanical lift per two persons. That has been in effect since before I was even in restorative. (R1) has been on that for years, since admission. When asked how CNAs are made aware of transfer status, V8 replied They know by the care card. It is always in the locker. There's also a touch screen in the hallway that has the care plan which would also tell how somebody is transferred. There are two places they can look. I've been doing restorative over a year. V8 stated We had a transfer in-service within the last 6 months. On 3/21/19 at 2:48 PM, V2 (Director of Nursing) stated The policy for the mechanical lift is two person minimum. It's communicated during orientation and routine in-servicing. (V5) received in-servicing. When asked where staff can find the resident's transfer status, V2 stated resident care card in the closet and also on the touch screens that they documents on. (V5) has taken care of (R1) for over two years. I just spoke to (V5) and she just told me she transferred (R1) by herself which she didn't tell me before. V2 stated V5 did not follow the facility's transfer policy. V2 then went to R1's room and showed the care card in R1's closet which read: TRANSFER: total lift (2). On 3/22/19 at 9:20 AM, R1 was awake in bed visiting with V9 (Family Member). R1 had a soft cast over the RUE (right upper extremity) which was in a sling. When asked about the extremity, R1 only groaned. V9 stated I was with (R1) at breakfast. (R1) did not complain of pain prior to the CNA putting (R1) back to bed. The CNA came to the dining room and she had an attitude. She was talking aggressively and was upset because (R1) was not finished eating. Then she put (R1) to bed and then (R1) started complaining of arm pain. The emergency room doctor said it was trauma. You should've seen it, it was swollen all the way up. On 3/22/19 at 1:14 PM, V4 (Nurse Practitioner/Primary Care Provider) stated the facility called her when R1 complained of pain and she ordered the X-ray which showed a fracture. V4 stated the fracture is related to trauma because (R1) didn't have pain there before that transfer. (R1) was not complaining of arm pain prior to the transfer. (R1) had a previous fracture but at a different location. V4 stated because (R1) had a prior fracture I would expect the facility to give extra care to that side, to be extra careful. I would expect them to follow the policy, the care plan and the care card. V4 stated risk factors for R1 sustaining a fracture/injury included prior fracture, [MEDICAL CONDITION], right [MEDICAL CONDITION], and muscle wasting. V4 stated R1's road to recovery will take longer because of R1's age. The Limited Lift Guest Handling Policy reads: Policy- To ensure safe resident transfers and a safe working environment for direct care staff, mechanical lifting devices will be utilized according to an established facility protocol. Protocol- Transfer status will be noted on the Resident's Care Plan and in a designated location established by the facility. The designated location for this facility is inside closet door. V5's signature was on the sheet. The policy titled Total Resident Transfers Using Mechanical Lifts reads: total mechanical lifts require a minimum of 2 trained staff members to complete a resident transfer. The resident's care plan must be followed with regard to the type of transfer as well as the number of staff members required to complete the transfer.

Based on Interview and Record Review the facility failed to monitor and assess a resident with bloody stools. The facility failed to notify the Director of Nursing after there was a change in the resident's condition. The facility failed to follow the policy for residents regarding change of Condition and Infection Control-[MEDICAL CONDITION] Infection. These failures contributed to R3's delay in treatment from [DATE] to [DATE] when R3 expired due to a massive colonic hemorrhage. This applies to 1 of 4 residents reviewed for improper nursing care, assessment, and monitoring after a Change of Condition in the sample of four. The Findings include: R3 was a [AGE] year old resident with a history of [MEDICAL CONDITION] starting on [DATE]. R3 was admitted to the facility on [DATE] status [REDACTED]. On [DATE] at 10:00 AM, R3 ' s nursing note documented that R3 reported having four loose stools. E3, Registered Nurse notified the physician. Order to culture the stool for [MEDICAL CONDITIONS] was received. On [DATE] per nursing note R3's stool culture came back positive for [MEDICAL CONDITION] and was placed on Contact Isolation per physician order. On [DATE] E7, Registered Nurse documented, "Received a call from physician ...order received for [MEDICATION NAME] (anti-diarrheal). " On [DATE] at 7:55am E3 documented, "Writer noted a small amount of bright red blood in the toilet and toilet paper. Guest (R3) also has an external hemorrhoid ". Z1 physician for R3 was notified. Z1 gave an order, " notify MD if stool is black. " At 1:30pm the same day it is documented in the nursing notes that R3 had no further bowel movements. There is no documentation of abdominal assessment, or vital signs after the bloody stool was first observed. There is no further documentation in the nursing notes until [DATE] at 7 AM. E5 Registered Nurse documents at 5:45 AM R3 " had a bloody stool." At 5:47 AM this same note documented R3 was "shaking and having breathing trouble." E5 called 911 and put R3 in bed. A Non-Rebreather mask with oxygen was placed on R3 by E5. At 5:58 AM, " Paramedics arrived, R3 was no longer breathing. " At 6:10 AM the community paramedics pronounced R3 deceased . There is no documentation provided by the facility or in R3's clinical record to show the Director of Nursing was notified of the change of condition for R3. The Change of Condition Policy dated ,[DATE], provided by the facility, under number three guides the nurse to, " ... All such condition changes will be reported to the director of nursing in a timely matter. Under number seven the Director of Nursing is to assess each guest's change of condition daily, review the 24 hour daily log, interview staff and monitor the clinical documentation. The facility did not provide any such documentation. The facility policy, titled Infection Control-[MEDICAL CONDITION] ([MEDICAL CONDITION] Infection), dated [DATE], documents on the first page that resident's with [MEDICAL CONDITION] will have the physician contacted to discontinue the use of anti-diarrheal's. On [DATE] at 9:50 AM E8 Registered Nurse stated, " If I did not agree with the physician orders [REDACTED]. On the same date at 9:50 AM E9 Registered Nurse stated, " If I am not sure of the order I get from the Doctor I would call the Director of Nurse's ". On [DATE] at 12:00 PM E4 Certified Nursing Assistant stated, " R3 took herself to the bathroom. I never really looked at what was in the toilet because she would flush it before I got in there. I would just ask if she had a bowel movement and she would say yes or no. I do remember that she had [MEDICAL CONDITION]. I do not recall her having diarrhea. " On [DATE] at 12:15 PM E3, Registered Nurse stated per phone interview, "I do not recall R3. I would not have tried to get an order for [REDACTED].

During initial tour of the facility on 9/28/2011, R11 was observed sitting up in her wheel chair. R11 had facial bruising and was noted to be very restless. Staff reported R11 was at risk for falls and had a history of [REDACTED]. On 9/28/2011 at 2:07 PM, a surveyor interviewed R11's nurse, E9. The surveyor asked E about interventions put in place to prevent R11 from falling. E9 told the surveyor R11 had facial bruising because she recently fell and she was at risk for falls. So, the surveyor asked E9 what interventions were put in place to prevent R11 from falling. E9 told the surveyor R11 had a chair alarm and bed alarm. E9 indicated R11 was unsafe if left alone in her room. Since R11 was alone in her room, the surveyor accompanied E9 to R11's bedside to observe fall preventive measure being implemented. When E9 and the surveyor observed R11 lying in bed, with no alarm attached to her. E9 told the surveyor R11 should have a bed alarm on her (R11) and she did not know why she was not attached to an alarm. E9 told the surveyor she would get R11 a bed alarm. The certified nurses aide (E8), who was assigned to care for R11, was interviewed on 9/28/2011. When asked, E8 told surveyor R11 was at risk for falls. However, E8 said R11 did not use a bed alarm. E8 stated: "I think the alarm is just for the chair. She (R11) will try to get up occasionally." A review of R11's Physician order [REDACTED]. During the Daily Status Meeting with administrative staff (E1/administrator and E2/director of nursing), the survey team expressed concerns R11 did not have consistent safety measure in place. E2 stated she would ensure that R11 had a pad alarm while in bed. Based on observation, interview & record review the facility failed to: 1. Provide supervision to R 10 who was identified with moderate cognition impairment and high risk for fall. 2. Keep R 10's environment accident free of hazard. 3. Re-assess R 10 for risk for fall after a significant change in condition occurred. 4. Develop and implement consistent individualize interventions to prevent R 10 from sustaining injury and further fall. 5. Evaluate the effectiveness of electronic device for R 10. 6. Provide supervision and consistency with alarm devices to prevent R11 from falling and sustaining injury. These failures resulted in R10 sustaining a comminuted intertrochanteric fracture of the right femur on 09-01-11 and another incident of fall on 09-16-11. R-11was found sitting on the floor next to her wheel chair on 09-22-11with a laceration to the head. R11fell again by leaning forward from wheel chair on 09-29-11. R-11 was noted with facial bruising during the initial tour of the facility on 09-28-11. This is for two of six residents (R10 and R11) who are at risk for falls in the sample of 15 residents. Findings include: On 09-29-11 at 1:30 PM, R 10 was observed in the room with a family member (Z1). R 10 has periods of confusion, contractures noted on both hands and fingers, three foot rests were observed on the floor. Z 1 stated " my mother is very confused, she doesn't remember anything anymore. She fell here twice, the first one she fractured her right hip, then she fell again after that. Both first and second fall she tried to go to the bathroom by herself. " Z 1 stated " I don ' t know why there are three foot rests, she only needed two. " Review of diagnostic imaging report dated 09-01-11 showed R 10 sustained a comminuted intertrochanteric fracture of the right femur. accident/incident? R 10 ' s MDS dated [DATE] showed the following: ? Makes Self Understood: R 10 scored 2-sometimes understood-ability is limited to making concrete requests. ? Ability to Understand Others: R 10 scored 2 -sometimes understand- responds adequately to simple, direct communication only. ? Short-term Memory- with memory problem ? Cognitive Skills for Daily Decision Making- Scored 2- Moderately Impaired -decisions poor; cues/supervision required. ? Functional Status with transfer, bed mobility, & toilet use- R 10 scored 3 (extensive assistance) & 2 (one person physical assist). ? Balance During transitions & walking -(A) Moving to seated to standing position (B) Walking- with assistive device if used, (C) Turning around & facing the opposite direction while walking (D) Moving on & off toilet (E) Surface to Surface transfer- transfer between bed & chair or wheelchair. R 10 was coded 2- Not steady, only able to stabilize with human assistance. Review of the facility incident report dated 09-01-11 at 4:35 AM, showed: RN called by CNA. Guest (R10) found sitting on floor beside bed. The incident/accident witness statement reads: ? Do you have any knowledge as how or when this may be have occurred: Yes, she said she was going to restroom. ? Were any of the following (devices) involve in the Walker R 10's incident summary written by the Director of Nursing (E2) reads: Patient (R 10) ambulating with walker in room and fell . Sent to emergency room for evaluation, admitted with right hip fracture. On 09-29-11 at 12:40 PM, interview with the Occupational Therapist (OT)/ E 3 confirmed based on the Physical Therapy admission assessment / evaluation on 08-24-11, R 10 ' s gait (description/evaluation) -unsteady, waddling type gait and decrease hip and knee flexion. E3 read R 10's medical condition is impaired to the degree that they require skilled services for decrease functional mobility and safety. R 10 is at risk for fall and injury to self or others. Patient (R 10) requires skilled teaching and instruction for increase strength, balance, endurance, safety to moderate independence to return home. On 09-29-11 at 12:55 PM, E 2 stated " she (R 10) 09-01-11, was ambulating with her walker. She's going to the bathroom. I found out the family brought the walker and left it in the room. I don't know when they brought it in. They just told me after the fall. I told the daughter to take it home. I don't know how long that walker's been there. " There was no fall assessment noted in R 10 ' s clinical record and this was confirmed by E 2 on 09-29-11 at 12:55 PM. E 2 stated " I have to ask the Therapist, it should be here (in the chart). On 09-16-11 R 10 had another incident of fall. The incident/accident read was found on the floor next to bed. Incident commentary reads: she got up to go to the bathroom. Patient (R 10) had a BM on the floor, unplugged alarm. On 09-29-11 an interim care plan was presented by the nurse in charge, no full care plan was presented and verified with E2. On 09-30-11 at 11:55 AM, E 2 confirmed there was no full care plan developed or revision that was made for R 10 in order to prevent further falls.

Based on interview and record review the facility failed to thoroughly verify a new resident's name was listed correctly on the hospital transfer sheet and all the hospital medication administration records prior to transcribing the medication orders from these records to the facility's physician's orders [REDACTED].[REDACTED]. This failure resulted in R7 receiving someone else's medications, in addition to her own, for 5 days. This caused an elevation of R7's potassium to a critical level. R7 was admitted to the intensive care unit in serious condition with [DIAGNOSES REDACTED]. E1 (Administrator) was notified of an immediate jeopardy at F309 on [DATE] at 2:45 PM. The immediate jeopardy began on [DATE] and was removed on [DATE] at 7:30 PM. Although the immediacy was removed on [DATE], the facility remains out of compliance at a severity level 2 due to the need to evaluate the implementation of the new nursing admission checklist and the DON Admission Checklist audit tool. The findings include: R7 was admitted to the facility on [DATE] at 9:15 PM from a local hospital according to nursing notes dated [DATE]. The hospital erroneously sent medication documentation for another patient from the hospital (Z3) along with medication documentation for R7. R7 and Z3's names are very similar, but their birth dates are different. R7's name and birth date appear on the top of the "Medication Administration Record" followed by a list of R7's medications. Z3's name and birth date appear on the top of the "Medication Reconciliation/Physician order [REDACTED]. E8 (Nurse) was the admitting nurse according to documentation on the facility's physician's orders [REDACTED]. E8 said she transferred the orders from the Physician order [REDACTED].[REDACTED]. E8 said she pointed out to Z2 that R7 did not have a [DIAGNOSES REDACTED]. E8 said that she also questioned the multiple orders for diuretics. E8 said that when she told Z2 that the medications did not make sense, Z2 said, 'I am the doctor and you are the nurse' and told her to continue the medications. E8 combined the medications on the two lists and wrote them on the facility's POS. E8 said that she still felt strongly that the medications were not right and passed on her concerns to the next shift. E8 said that she did not inform the Director of Nursing about her concerns. The following physician transfer orders were for Z3, but were transcribed to R7's POS on admission to the facility: [MEDICATION NAME] 25 mg ([MEDICATION NAME] XL), dose = 100 mg daily [MEDICATION NAME] 20 mg, dose = 20 mg twice daily [MEDICATION NAME] 50 mg (HCTZ), dose = 50 mg daily [MEDICATION NAME] 500 mg, dose = 500 mg twice daily [MEDICATION NAME] 75 mg ([MEDICATION NAME] XR), dose = 75 mg three times daily [MEDICATION NAME] 20 gm/30 mL, dose = 20 gm four times daily [MEDICATION NAME] 150 mg, dose = 150 mg daily Sitagliptin-[MEDICATION NAME] ,[DATE] mg ([MEDICATION NAME]), dose - 1 tab twice daily The following physician transfer orders were R7's and were also added to R7's POS on admission to the facility: [MEDICATION NAME] 40 mg ([MEDICATION NAME]), dose = 40 mg daily [MEDICATION NAME] 25 mg ([MEDICATION NAME]), dose = 50 mg twice daily [MEDICATION NAME] 5 mg tab ([MEDICATION NAME]), dose = 5 mg daily Potassium Chloride 10 mEq, dose = 20 mEq twice daily [MEDICATION NAME] 300 mg ([MEDICATION NAME]), dose = 300 mg daily [MEDICATION NAME] 40 mg/0.4 mL syr ([MEDICATION NAME]), dose = 40 mg daily [MEDICATION NAME] 300 mg cap ([MEDICATION NAME]), dose = 300 mg daily Magnesium-oxide 400 mg tab (Mag-Ox), dose = 400 mg twice daily Alendronate Sodium 70 mg ([MEDICATION NAME]), dose = 70 mg once a week Vitamin D 400 units tab, dose = 2800 units once a week [MEDICATION NAME] 250 mg tab, dose = 500 mg twice daily [MEDICATION NAME] 100 mcg/patch, dose = every 72 hours R7 also had physician transfer orders for [MEDICATION NAME] 10 mg tablet daily; Keflex 500 mg every 6 hours; [MEDICATION NAME] ([MEDICATION NAME]) 20 mg twice daily; and Lidocain Hcl 5% patch ([MEDICATION NAME]) to each knee - on 12 hours, off 12 hours, but these orders were not added to the facility's POS on admission and there was no documentation explaining why they were discontinued. The facility's Nurse Admission Checklist dated [DATE] directs, "If physician dc's an order, adds an order or changes an order from the transfer sheet, write these orders on the admission POS." However, none of these medications appeared on R7's admission POS. According to the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] ([MEDICATION NAME] XL) 100 mg at 8:00 AM on ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] 20 mg at 8:00 AM and 4:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE]; and at 8:00 AM on [DATE]. - HCTZ 50 mg at 8:00 AM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] 500 mg at 8:00 AM and 4:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] 20 mg/30 mL at 4:00 PM and 8:00 PM on [DATE]; and 8:00 AM, 11:00 AM, 4:00 PM and 8:00 PM on [DATE]. - [MEDICATION NAME] 150 mg at 8:00 AM on ,[DATE], ,[DATE], ,[DATE]/ ,[DATE] and [DATE]. - [MEDICATION NAME] 1000 mg/50 mg at 7:00 AM and 4:00 PM on ,[DATE], ,[DATE], [DATE]; and 7:00 AM on [DATE] and [DATE]. (This order was changed on [DATE] to reduce the 4:00 PM dose to 500 mg/ 50 mg). R7 received [MEDICATION NAME] ,[DATE] mg on [DATE] at 4:00 PM. According to the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] ([MEDICATION NAME]) 40 mg at 6:00 AM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] ([MEDICATION NAME]) 50 mg at 8:00 AM and 4:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE], [DATE]. - [MEDICATION NAME] ([MEDICATION NAME]) 5 mg at 8:00 AM on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. - Potassium Chloride 20 mEq at 8:00 AM and 4:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] 300 mg at 8:00 AM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] ([MEDICATION NAME]) 40 mg at 6:00 AM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] ([MEDICATION NAME]) 300 mg at 8:00 AM, 11:00 AM and 8:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - Magnesium-oxide (Mag-Ox) 400 mg at 8:00 AM and 4:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - Alendronate Sodium ([MEDICATION NAME]) 70 mg at 6:00 AM on [DATE]. - Vitamin D 2800 units at 6:00 AM on [DATE] - [MEDICATION NAME] 500 mg at 8:00 AM and 4:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - [MEDICATION NAME] 100 mcg/patch at 6:00 AM on [DATE]. - Multivitamin with mineral at 8:00 AM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. - Prostat 64 30 mL at 8:00 AM and 4:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. R7 was sent to the emergency roiagnom on [DATE] at 6:30 PM because of a critically elevated Potassium level of 7.8 (3.7 - 5.1 mEq/L) according to nursing note documentation and the laboratory report dated [DATE]. In the emergency room R7's Potassium level was 8.6 mEq/mL, her Blood Urea Nitrogen level was 84, and her Creatinine level was 4.4 according to the emergency department notes dated [DATE]. R7 was admitted to the intensive care unit in serious condition with [DIAGNOSES REDACTED]. Z7 (Renal Specialist) attended to R7 during her [DATE] hospital stay. Z6 was interviewed by telephone on [DATE]. Z6 had R7's hospital record to refer to during this interview. Z7 stated that R7's potassium was at a life threatening level when she was admitted to the hospital. Z7 said that the combination of the multiple diuretics and R7's diarrhea likely caused dehydration, acute [MEDICAL CONDITION], decreased blood pressure and high potassium. Z7 pointed out that the medications of [MEDICATION NAME] and Potasium Chloride all contributed to R7's critically elevated potassium. Z7 said that R7's acute [MEDICAL CONDITION] resolved once she was re-hydrated and some of the diuretics were discontinued. Elsevier (2011) warns against using an ACE inhibitor ([MEDICATION NAME]) concomitantly with [MEDICATION NAME] citing, "Coadministration of ACE inhibitors and [MEDICATION NAME], even in the presence of a diuretic, has been associated with severe [MEDICAL CONDITION]." Elsevier also warns about drug to drug interactions between [MEDICATION NAME] and [MEDICATION NAME], and [MEDICATION NAME] and [MEDICATION NAME]. The Nursing 2011 Drug Handbook (Lippincott) also warns that combining [MEDICATION NAME] with potassium sparing diuretics ([MEDICATION NAME]) or Potassium Supplements (Potassium Chloride), may cause [MEDICAL CONDITION]. Lippincott is the nursing drug handbook used at the facility. E2 (Director of Nursing) was interviewed on [DATE] regarding the facility's system for verifying residents identification. E2 said that the nurses use a Nurse Admission Checklist when admitting a new resident. Additionally, E2 said there is a DON Admission Checklist that is to be completed by the DON. E2 confirmed that neither of these forms contain a requirement to check the resident's name and birth date. E2 said that both forms are currently being revised to include a requirement to check the resident's name and birth date. E2 said that the DON Admission Checklist was completed for R7 the day after R7's admission ([DATE]) but the error was not identified. The DON Admission Checklist for R7 was completed by Z5 (Corporate Nurse Consultant)on [DATE]. The Checklist identified that the orders did not match the admit orders on the transfer sheet. On [DATE] at 10:40 AM Z5 confirmed that she completed the DON Admission Checklist on R7. Z5 stated that she does not recall if she checked R7's name and birth date because it was 4 months ago. Z5 said that she would have identified that the names and birth dates were different if she had checked them. As of [DATE] the facility did not have a Nursing Admission Checklist or DON Admission Checklist that included a requirement to verify the resident name and birth date. On [DATE] at 11:30 AM R7 was interviewed in her room. R7 stated that she does not remember much from her stay at the nursing home between ,[DATE] - [DATE] other than that she was tired all the time. R7 is alert and oriented with no cognitive impairment according to the Minimum Data Sets dated [DATE]. On [DATE] at 1:50 PM Z2 stated that he expects the nurses to verify a resident's name and birth date on admission to the facility, saying, "It must be done." The surveyor confirmed that the facility took the following actions to remove the immediacy of the situation on [DATE]: - On [DATE] all licensed nursing staff in the building were in-serviced on the new Nurse Admission Checklist that specifically mentions checking the resident name and birth date. All off duty staff will be in-serviced prior to starting their next scheduled shift. - On [DATE] a new DON Admission Checklist, that specifically mentions checking the resident name and birth date, has been issued and will be immediately instituted as of [DATE]. - Training of all newly hired licensed nurses will include the revised Nurse Admission Checklist, referencing checking name and birth date. - Monitoring of resident identification will be accomplished via completion of the new Nurse Admission Checklist and the new DON Admission Checklist which are retained for one month per facility policy. Based on observation, interview, and record review the facility failed to: -Have a system in place to ensure residents who have been identified with aspiration precautions have individual and specific interventions developed in the care plan -Ensure communication relating to the residents aspiration precautions are going to all disciplines and direct care staff to ensure residents safety -Ensure direct care staff implements resident's aspiration precautions and are monitored/trained -Ensure a policy and procedure is developed and implemented As the result of this failure, during the evening meal, R6 choked on breaded fish she was eating. This occurred in the facility's assistive dining room (ADR), where there were at least 2 staff present. E4(RN) and E10(CAN) observed R6 choking and grabbing her throat. The [MEDICATION NAME] Maneuver was implemented with no success. Emergency medical system (EMS) was notified, R6 was intubated on site, pieces of foreign body (food) removed. R6 sent to a near by acute care facility on [DATE] at 6:35 P.M., R6 expired on [DATE] at the acute care facility.. R6's coroner certificate of death dated [DATE] documents the cause of death was "ASPIRATION OF A FOOD [MEDICATION NAME] E1 (Administrator) and E2 (DON) were notified of an immediate Jeopardy existing at F309 on [DATE] at 3:00 P.M. The Immediate Jeopardy began on [DATE] and was removed on [DATE] at 6:15 P.M. Although the immediacy was removed the facility remains out of compliance at severity level 2 due to the need to evaluate the implementation of the training and education of the staff on the facility's new policy and procedure. The findings include: -R10 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R10's interim care plan shows she required a comprehensive assessment and management for the following conditions/[DIAGNOSES REDACTED]. R10's most recent MDS dated [DATE] documents R10 is independent with eating but requires assistance with setup. R10's MDS under section K-swallowing/nutritional status assessed R10 as having "complaints of difficulty or pain with swallowing." Care Area Assessment (CAA) dated [DATE] shows R10 has functional problems that affect ability to eat: Swallowing problem; proceed to care plan. Review of R10's therapy progress note dated [DATE] documents the treatment [DIAGNOSES REDACTED]. R10 is on a mechanical soft diet with thin liquids- to continue with dysphagia goals. Observation on [DATE] at 12:20 P.M. to 12:35 P.M., E11 (CNA) was observed sitting at the table with R10. R10 took six bites of chocolate pudding, one bite of meat, four drinks of coffee and three drinks milk from a cup. R10's food was presented in bowls, not on a plate with a plate guard. E11 did not provide any cues or encouragement to R10 during this meal observation. E11 then removed R10 from the dining and took her to her room and removed R10's denatures. E11 said, " I know R10 is on aspiration precautions and she's supposed to alternate between liquids and solids-every other bite. I did not give her any cues today because she does not feel good." The pink card on the dietary door in the ADR read: R10 - diet is level puree with thin liquids, small sips/bites (,[DATE] tsp.), alternate between liquid/food, check dentures are in and fitting well- encourage intake. Review of R10's speech therapy progress notes documents R10's diet order changed [DATE] - "add a plate guard for all meals." E3 said on [DATE] at 12:38 P.M., "Swallowing precautions was not developed on R10 interim care plan. Restorative nurse does the initial care plan, E12 did R10's care plan. No swallowing care plan has been developed." Facility took the following steps to abate the Immediate Jeopardy. FACILITY ABATEMENT PLAN: 1. To ensure that a system failure does not occur, the facility has put the following measures into place: ? The speech therapist will communicate any needed aspiration precautions for a resident by documenting said precautions in the resident's chart, as well as providing the Restorative/Rehab Nurse and the Care Plan Coordinator with the same information. ? The Care Plan coordinator will ensure that the aspiration precautions are written into the resident's care plan (initial, 21 day, or quarterly). ? The Restorative/Rehab Nurse will complete the Aspiration Precautions cue card, place the card in the receptacle in the dining room, and inform the C.N.A.'s via writing on the dietary card that there are aspiration precautions to be observed. The Restorative/ Rehab Nurse will also place the aspiration precaution information on the residents' C.N.A. Care Plan Guide. ? The C.N.A.'s assisting the residents with eating will obtain the aspiration precaution cards, bring them to the table where the residents are eating and follow the precautions, offering cuing, etc. ? This above process of ensuring that the residents' aspiration precautions are being followed during meals will be audited by the Restorative/Rehab Nurse at least three times a week. ? Direct care staff on duty have been in-serviced prior regarding the use of the Aspiration Precaution cards, and all remaining staff shall be in-serviced prior to returning for their next scheduled shift. ? Aspiration Precautions policy has been written and disseminated to staff on [DATE].

Based on interview and record review the facility failed to thoroughly verify a new resident's name was listed correctly on the hospital transfer sheet and all the hospital medication administration records prior to transcribing the medication orders from these records to the facility's physician's orders [REDACTED].[REDACTED]. This failure resulted in R7 receiving multiple medications prescribed for another patient at the hospital from where she was discharged . R7 continued to receive these medications for five days after her admission. This caused an elevation of R7's potassium to a critical level. R7 was admitted to the intensive care unit in serious condition with [DIAGNOSES REDACTED]. This failure has the potential to affect all residents admitted to the facility. The findings include: R7 was admitted to the facility on [DATE] from a local hospital according to nursing notes dated 4/6/11. The hospital erroneously sent medication documentation for another patient from the hospital (Z3) along with medication documentation for R7. R7 and Z3's names are very similar, but there birth dates are different. R7's name and birth date appear on the top of the "Medication Administration Record" followed by a list of R7's medications. Z3's name and birth date appear on the top of the "Medication Reconciliation/Physician order [REDACTED]. E8 (Nurse) was the admitting nurse according to documentation on the facility's physician's orders [REDACTED]. E8 said she transferred the orders from the Physician order [REDACTED].[REDACTED]. E8 said she pointed out to Z2 that R7 did not have a [DIAGNOSES REDACTED]. E8 said she also questioned the multiple orders for diuretics. E8 said that when she told Z2 the medications did not make sense, Z2 said, 'I am the doctor and you are the nurse and told her to continue the medications. E8 combined the medications on the two lists and wrote them on the facility's POS. E8 said she still felt strongly the medications were not right and passed on her concerns to the next shift. E8 said she did not inform the Director of Nursing about her concerns and did not follow-up or pursue her concerns any further. On 8/11/11 at 8:50 AM E2 (Director of Nursing) stated she expects her staff to contact her when they suspect inconsistencies in residents medication orders. E2 said if E8 had contacted her she would have called the supervisor at the hospital to obtain additional information and clarification regarding R7 medications. According to the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] ([MEDICATION NAME] XL) 100 mg at 8:00 AM on 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 20 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10; and at 8:00 AM on 4/11/11. - HCTZ 50 mg at 8:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 500 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 20 mg/30 mL at 4:00 PM and 8:00 PM on 4/7/11; and 8:00 AM, 11:00 AM, 4:00 PM and 8:00 PM on 4/8/11. (R7 did not have a [DIAGNOSES REDACTED]. - [MEDICATION NAME] 150 mg at 8:00 AM on 4/7, 4/8, 4/9/ 4/10 and 4/11/11. - [MEDICATION NAME] 1000 mg/50 mg at 7:00 AM and 4:00 PM on 4/7, 4/8, 4/9/11; and 7:00 AM on 4/10/11 and 4/11/11. (This order was changed on 4/10/11 to reduce the 4:00 PM dose to 500 mg/ 50 mg). R7 received [MEDICATION NAME] 500/50 mg on 4/11/11 at 4:00 PM. (R7 did not have a [DIAGNOSES REDACTED]. According to the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] ([MEDICATION NAME]) 40 mg at 6:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 50 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10, 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 5 mg at 8:00 AM on 4/7, 4/8, 4/9, 4/10, and 4/11/11. - Potassium Chloride 20 mEq at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 300 mg at 8:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 40 mg at 6:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 300 mg at 8:00 AM, 11:00 AM and 8:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - Magnesium-oxide (Mag-Ox) 400 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - Alendronate Sodium ([MEDICATION NAME]) 70 mg at 6:00 AM on 4/8/11. - Vitamin D 2800 units at 6:00 AM on 4/8/11 - [MEDICATION NAME] 500 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 100 mcg/patch at 6:00 AM on 4/9/11. - Multivitamin with mineral at 8:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - Prostat 64 30 mL at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. R7 received the incorrect medications for a period of 5 days. R7 was sent to the emergency roiagnom on [DATE] at 6:30 PM because of a critically elevated Potassium level of 7.8 (3.7 - 5.1 mEq/L) according to nursing note documentation and the laboratory report dated 4/11/11. In the emergency room R7's Potassium level was 8.6 mEq/mL, her Blood Urea Nitrogen level was 84, and her Creatinine level was 4.4 according to the emergency department notes dated 4/11/11. R7 was admitted to the intensive care unit in serious condition with [DIAGNOSES REDACTED]. E2 (Director of Nursing) was interviewed on 8/3/11 regarding the facility's system for verifying residents identification. E2 said the nurses use a Nurse Admission Checklist when admitting a new resident. Additionally, E2 said there is a DON Admission Checklist that is to be completed by the DON. E2 confirmed neither of these forms contain a requirement to check the resident's name and birth date. E2 said both forms are currently being revised to include a requirement to check the resident's name and birth date. E2 said the DON Admission Checklist was completed for R7 the day after R7's admission (4/7/11) but the error was not identified. Elsevier (2011) warns against using an ACE inhibitor ([MEDICATION NAME]) concomitantly with [MEDICATION NAME] citing, "Coadministration of ACE inhibitors and [MEDICATION NAME], even in the presence of a diuretic, has been associated with severe [MEDICAL CONDITION]." Elsevier also warns about drug to drug interactions between [MEDICATION NAME] and [MEDICATION NAME], and [MEDICATION NAME] and [MEDICATION NAME]. The Nursing 2011 Drug Handbook (Lippincott) also warns combining [MEDICATION NAME] with potassium sparing diuretics ([MEDICATION NAME]) or Potassium Supplements (Potassium Chloride), may cause [MEDICAL CONDITION]. Lippincott also identifies a drug to drug interaction with [MEDICATION NAME]. Lippincott is the nursing drug handbook used at the facility. On 8/3/11 at 11:30 AM R7 was interviewed in her room. R7 stated she does not remember much from her stay at the nursing home between 4/6 - 4/11/11 other than she was tired all the time.

Based on interview and record review the facility failed to follow acceptable professional standards when reconciling new admission orders [REDACTED]. This is for 1 resident (R7) out of 11 residents reviewed for medications, in the total sample of 20. This failure resulted in R7 having diarrhea after receiving medication for constipation, a [DIAGNOSES REDACTED]. This failure resulted in R7 receiving excessive dosages of diuretics. This failure also resulted in R7 receiving medications that have contraindications when given concomitantly. R7 was admitted to the intensive care unit at a local hospital with [DIAGNOSES REDACTED]. This failure has the potential to affect all new residents admitted to the facility. The findings include: R7 was admitted to the facility on [DATE] from a local hospital according to nursing notes dated 4/6/11. The hospital erroneously sent medication documentation for another patient from the hospital (Z3) along with medication documentation for R7. R7 and Z3's names are very similar, but there birth dates are different. R7's name and birth date appear on the top of the "Medication Administration Record" followed by a list of R7's medications. Z3's name and birth date appear on the top of the "Medication Reconciliation/Physician order [REDACTED]. E8 (Nurse) was the admitting nurse according to documentation on the facility's physician's orders [REDACTED]. E8 said she transferred the orders from the Physician order [REDACTED].[REDACTED]. E8 said she pointed out to Z2 that R7 did not have a [DIAGNOSES REDACTED]. E8 said she also questioned the multiple orders for diuretics. E8 said when she told Z2 that the medications did not make sense, Z2 said, 'I am the doctor and you are the nurse and told her to continue the medications. E8 combined the medications on the two lists and wrote them on the facility's POS. E8 said she still felt strongly the medications were not right and passed on her concerns to the next shift. E8 said she did not inform the Director of Nursing about her concerns and did not follow-up or pursue her concerns any further. On 8/11/11 at 8:50 AM E2 (Director of Nursing) stated that she expects her staff to contact her when they suspect inconsistencies in residents medication orders. E2 said if E8 had contacted her she would have called the supervisor at the hospital to obtain additional information and clarification regarding R7 medications. According to the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] ([MEDICATION NAME] XL) 100 mg at 8:00 AM on 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 20 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10; and at 8:00 AM on 4/11/11. - HCTZ 50 mg at 8:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 500 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 20 mg/30 mL at 4:00 PM and 8:00 PM on 4/7/11; and 8:00 AM, 11:00 AM, 4:00 PM and 8:00 PM on 4/8/11. (R7 did not have a [DIAGNOSES REDACTED]. - [MEDICATION NAME] 150 mg at 8:00 AM on 4/7, 4/8, 4/9/ 4/10 and 4/11/11. - [MEDICATION NAME] 1000 mg/50 mg at 7:00 AM and 4:00 PM on 4/7, 4/8, 4/9/11; and 7:00 AM on 4/10/11 and 4/11/11. (This order was changed on 4/10/11 to reduce the 4:00 PM dose to 500 mg/ 50 mg). R7 received [MEDICATION NAME] 500/50 mg on 4/11/11 at 4:00 PM. (R7 did not have a [DIAGNOSES REDACTED]. According to the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] ([MEDICATION NAME]) 40 mg at 6:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 50 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10, 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 5 mg at 8:00 AM on 4/7, 4/8, 4/9, 4/10, and 4/11/11. - Potassium Chloride 20 mEq at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 300 mg at 8:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 40 mg at 6:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] ([MEDICATION NAME]) 300 mg at 8:00 AM, 11:00 AM and 8:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - Magnesium-oxide (Mag-Ox) 400 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - Alendronate Sodium ([MEDICATION NAME]) 70 mg at 6:00 AM on 4/8/11. - Vitamin D 2800 units at 6:00 AM on 4/8/11 - [MEDICATION NAME] 500 mg at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - [MEDICATION NAME] 100 mcg/patch at 6:00 AM on 4/9/11. - Multivitamin with mineral at 8:00 AM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. - Prostat 64 30 mL at 8:00 AM and 4:00 PM on 4/7, 4/8, 4/9, 4/10 and 4/11/11. On 4/9/11 all four doses of Lactoluse were held after R7 complained of diarrhea according to documentation on the MAR. All doses of Lactoluse were also held on 4/10 and 4/11/11, but no there was no documentation as to why it was held. This was confirmed by E2 on 8/10/11. R7 received an excessive dose of [MEDICATION NAME], above the recommended Geriatric and Adult dosage, according to the Lexicomp 12th ed. Geriatric Dosage Handbook p. 850. Diarrhea may indicate overdosage according to Lexicomp. Elsevier (2011) warns against using an ACE inhibitor ([MEDICATION NAME]) concomitantly with [MEDICATION NAME] citing, "Coadministration of ACE inhibitors and [MEDICATION NAME], even in the presence of a diuretic, has been associated with severe [MEDICAL CONDITION]." Elsevier also warns about drug to drug interactions between [MEDICATION NAME] and [MEDICATION NAME], and [MEDICATION NAME] and [MEDICATION NAME]. The Nursing 2011 Drug Handbook (Lippincott) also warns combining [MEDICATION NAME] with potassium sparing diuretics ([MEDICATION NAME]) or Potassium Supplements (Potassium Chloride), may cause [MEDICAL CONDITION]. Lippincott also identifies a drug to drug interaction with [MEDICATION NAME]. Lippincott is the nursing drug handbook used at the facility. R7 was sent to the emergency roiagnom on [DATE] at 6:30 PM because of a critically elevated Potassium level of 7.8 (3.7 - 5.1 mEq/L) according to nursing note documentation and the laboratory report dated 4/11/11. In the emergency room R7's Potassium level was 8.6 mEq/mL. Her Blood Urea Nitrogen level was 84 and her Creatinine level was 4.4 according to the emergency department notes dated 4/11/11. R7 was admitted to the intensive care unit in serious condition with [DIAGNOSES REDACTED]. E2 (Director of Nursing) was interviewed on 8/3/11 regarding the facility's system for verifying residents identification. E2 said the nurses use a Nurse Admission Checklist when admitting a new resident. Additionally, E2 said there is a DON Admission Checklist that is to be completed by the DON. E2 confirmed neither of these forms contain a requirement to check the resident's name and birth date. E2 said that both forms are currently being revised to include a requirement to check the resident's name and birth date. E2 said the DON Admission Checklist was completed for R7 the day after R7's admission (4/7/11) but the error was not identified. In addition, R7 had physician transfer orders for [MEDICATION NAME] 10 mg tablet daily; Keflex 500 mg every six hours; [MEDICATION NAME] ([MEDICATION NAME]) 20 mg twice daily; and Lidocain Hcl 5% patch ([MEDICATION NAME]) to each knee - on 12 hours, off 12 hours. These orders were not added to the facility's POS on admission and there was no documentation explaining why they were discontinued. The facility's Nurse Admission Checklist dated 4/3/09 directs, "If physician dc's an order, adds an order or changes an order from the transfer sheet, write these orders on the admission POS." On 8/3/11 at 11:30 AM R7 was interviewed in her room. R7 stated she does not remember much from her stay at the nursing home between 4/6 - 4/11/11 other than that she was tired all the time.