Every finding on record at Richland Nursing & Rehab

Based on observation, interview, and record review, the facility failed to provide urinary catheter care according to professional standards of practice to prevent a Urinary Tract Infection for 1 of 3 residents (R1) reviewed for catheter care in a sample of 4.Findings include:R1's Face Sheet documented an admission Date of 3/17/26 and listed Diagnoses including Quadriplegia, Cervical Spine Fusion, and Neuromuscular dysfunction of the Bladder. R1's Minimum Data Set, dated [DATE] documented that R1 had no deficits in cognition. R1's Care Plan dated 3/30/26 documented a problem area, Resident requires EBP (Enhanced Barrier Precautions) related to (indwelling) catheter, with a corresponding goal, Resident will receive care from staff using EBP while maintaining a homelike environment and will remain free from infection through next review, with a corresponding intervention, EBP will be utilized while providing direct care (for example, wound dressing change, showers/bathing, transfers, hygiene, linen change, toileting assist, during therapy, (and) device care. R1's Care Plan also documents a problem area of Resident requires an indwelling urinary catheter r/t (related to) Neurogenic Bladder with a start date of 3/19/26 with interventions of Assess the drainage q (every) shift and prn (as needed). Record the amount, type, color, odor. Observe for leakage.R1's April 2026 Vitals Report document that R1's catheter was emptied once a day on the following dates: 4/6/26 at 10:47pm with an output of 1200cc; 4/7/26 at 2:28pm with an output of 2000cc; and 4/8/26 at 4:40pm with an output of 1400cc. There was no documentation of any urine output on 4/11/26, 4/18/26, and 4/25/26. R1's Urinalysis and Urine Culture dated 4/20/26 documented, Appearance: Cloudy. RBC (Red Blood Cells) 10-15, abnormal. WBC (White Blood Cells): Greater than 100, abnormal. Bacteria: Many, abnormal. Urine Culture: Greater than 100,000 gram negative bacilli recovered. R1's 4/22/26 Provider Note authored by V11, Nurse Practitioner, documented, Staff reports that resident has increased confusion. I am seeing him to follow up. History of present illness: Resident has a UTI. Continue to await final culture and sensitivity. Primary Care Physician started resident on Keflex which is to start this morning.On 5/6/26 at 9:50am, V7, Family Member of R1, stated on 4/7/26 at about 2pm when she came to visit R1, she noted his catheter bag was very full. V7 stated she turned on R1's call light to ask staff to empty it. V7 stated after 20 minutes, nobody responded so she emptied the bag herself, which contained 2000 cc (cubic centimeters) of urine. V7 stated there was an immediate return of 400cc of residual urine which had been backed up into the bladder.On 5/6/26 at 1:40pm, R1 was alert and oriented to person, place, and time. R1 stated he has had a UTI which he believes is due to the facility not providing proper catheter care and allowing his catheter bag to become too full, keeping the urine trapped in his bladder.On 5/7/26 at 10:40am, V4, Certified Nursing Assistant, was observed providing catheter care for R1. A sign on the outside of R1's door read, Enhanced Barrier Precautions. V4 entered the room without donning PPE (Personal Protective Equipment) and gathered supplies needed for the procedure, which she placed on a clean barrier on the overbed table. V4 washed her hands, donned gloves but no gown, asked R1 if he was ready to start, and approached the bed. The Surveyor, standing just inside the door asked V4 if R1 was on EBP, which V4 stated she didn't think so. V4 then began the procedure, again without donning a gown. Applying perineal cleanser to a wet washcloth, V4 cleansed the proximal end of the tubing and then went back and forth with the washcloth on the tubing, rather than going from the proximal to the distal end with one motion. V4 used the same technique to rinse and dry the tubing. Without performing hand hygiene and while wearing the contaminated gloves, V4 removed the clamp from the drainage tube and drained 500cc of urine into a urinal, and without sanitizing it, re-clamped the tube and placed it back in position.On 5/8/26 at 11:05am, V2, Director of Nurses, stated catheter bags should be emptied at least once every 12-hour shift and more often as needed. V2 stated no more than 1000cc of urine should be allowed to collect in the bag before it is emptied. V2 stated the urine output should be documented in the resident's record. V2 stated residents with indwelling catheters are on EBP and staff should wear gown and gloves for contact with residents. V2 stated staff will be reeducated about EBP, catheter care, and documentation.An EBP Policy dated April 21st, 2024, documented, EBP will be used for any resident who meets the following criteria: Indwelling medical devices, such as, central lines, urinary catheters, feeding tubes, and tracheostomies. Residents who meet the above criteria, EBP are recommended when performing the following high-contact resident care activities: Indwelling medical devices care. Staff will wear gloves and a gown for High-Contact Resident Care Activities.An Emptying a Urinary Drainage Bag Policy dated July 2017 documented, Documentation: The following information should be recorded in the resident's medical record: The date and time the procedure was performed. The amount of urine emptied from the drainage bag. Purpose: The purposes of this procedure are to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain a sterile specimen. Empty the urinary drainage bag at least every eight (8) hours or more often if needed to keep the bag from becoming full. Do not allow the drain spout to come into contact with the measuring container, hands, or any other object. (Note: If accidental contamination occurs, wipe the drain spout with an alcohol sponge or swab.) Steps in the procedure: Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Put on disposable gloves. Place a paper towel on the floor beneath the drainage bag. Position the measuring container under the drainage bag. Remove the drain tube from its holder. Open the drainage bag and let the urine flow into the measuring container. After the drainage bag has emptied, close the drain. Wipe the drain with an alcohol sponge or swab. Discard the sponge or swab into the designated container. Replace the drain tube back into its holder.A Urinary Catheter Care Policy dated July 2017 documented, Use standard precautions when handling or manipulating the drainage system. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. Be sure the catheter tubing and drainage bag are kept off the floor. Empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot with the nonsterile container. Empty the collection bag at least every eight hours. For the male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview, and record review, the facility failed implement PROM (Passive Range of Motion) exercises per COTA (Certified Occupational Therapy Assistant) recommendations for 1 of 3 (R1) residents reviewed for range of motion in the sample of 4.Findings include:R1's Face Sheet documented an admission Date of 3/17/26 and listed Diagnoses including Quadriplegia, Cervical Spine Fusion, and Neuromuscular dysfunction of the Bladder. R1's Minimum Data Set, dated [DATE] documented that R1 had no deficits in cognition. R1's Care Plan dated 3/30/26 did not document any problem areas related to R1 requiring restorative nursing or therapy services for quadriplegia.R1's Occupational Therapy Treatment Encounter Report dated 4/20/26 documented, Therapist educated staff on performing PROM (Passive Range of Motion) exercises daily to resident to prevent stiffness and contractures, as patient is unable to move his extremities on his own. Staff verbalized understanding. Therapist initiated self-care in-service this date to educate staff on daily bed baths on days he don't [sic] have showers to prevent odor and extra moisture. Staff verbalized understanding. Staff also educated to reposition patient every 2 hours for change in position to prevent skin breakdown. Therapist found a different type of tilt in space wheelchair for patient to trial since he states his back will hurt after sitting up for an hour in the other wheelchair. Therapist made adjustments to wheelchair to better fit the resident however patient did not want to get up this date as they think he may have a UTI (Urinary Tract Infection) and he isn't feeling well. Response to Session Interventions: Spoke with patients POA (Power of Attorney) this date regarding in-service that therapist educated staff on, and she asked therapist to place in-service reminders on patient's wall regarding daily baths, repositioning, ROM (Range of Motion) and wheelchair for staff to see every day to follow through. Therapist did place reminders on wall this date.On 5/6/26 at 1:40pm, R1 was alert and oriented to person, place, and time. R1 stated he is quadriplegic following a spinal cord injury in September 2025 and he hopes to be transferred to a facility that specializes in rehab for spinal cord injuries. R1 stated until that time, he is hoping not to regress in what abilities he still has. R1 stated he does not feel staff are doing an effective job in completing his ROM. R1 stated the only thing he is able to move is his head and neck. R1 stated he is afraid he will develop contractures.On 5/6/26 at 12:45pm, V9, Certified Occupational Therapy Assistant, stated R1's insurance has approved only 6 therapy visits since his admission and 4 have been used. V9 stated since her time with R1 is limited, she has educated CNA (Certified Nursing Assistant) staff that R1 should receive AROM (Active Range of Motion) to the head and neck and PROM (Passive Range of Motion) to the rest of the body at least once daily, and they could do this while giving R1 a bed bath. V9 stated she is not sure if the CNA's are doing it or not, and V9 stated recently the facility's two Restorative Aids were put back working on the floor and their positions will not be replaced.On 5/7/26 at 10:50am, V4, Certified Nursing Assistant, was observed performing PROM for R1. A sign on the wall by R1's bed read, ROM daily exercise: Please provide gentle PROM daily to patient's shoulders, elbows, wrists and fingers to prevent contractures as he is unable to move them on his own. Do not push above pain. When he says it hurts, only range his arm to that level. This ROM can be done during daily bathing/cleanup times. Please provide slow controlled PROM exercise at least 10 reps (repetitions) each. The following planes did not receive 10 repetitions and received the number of repetitions as stated: Right shoulder-2 (repetitions). Right fingers and thumb-zero. Left wrist: 8. Left thumb and fingers: 4. Left elbow: 6. Left shoulder:5. Left ankle:7. Left knee: 5. Left hip abduction: zero. Right hip extension: 4. Bilateral toes: Zero. The resident did experience some leg spasms, but he had no complaints of pain and tolerated the procedure well. V4 stated R1 is to receive PROM once every 12-hour shift.On 5/8/26 at 940am, V9 stated she wrote up an in-service as stated above on 4/20/26 but apparently it was not shared with CNA staff, so she reprinted it today and it will be shared with staff. V9 stated the sign on R1's wall goes over ROM to the upper extremities, and that she should have also outlined the lower extremities, Which is common sense that those need PROM also. V9 stated she had only specified PROM was to be done once daily, but twice would be better. V9 stated she shared the in-service with V2, Director of Nurses, so that it could be added to R1's Care Plan. On 5/8/26 at 11:05am, V2 stated CNA staff will be in serviced on R1's restorative needs, and she will add them to the Care Plan.A Resident Mobility and Range of Motion Policy dated 10/20/25 documented, Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 7. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives.

Based on interview and record review, the facility failed to ensure that residents were free from medication errors for 2 (R6, R63) of 13 residents reviewed for medication errors in the sample of 51.This failure resulted in R63, after receiving monthly doses of injectable atypical antipsychotic on 1/31/26 and 2/5/26, experiencing extrapyramidal symptoms and sedation. These symptoms resulted in R63 being sent to the local ER (Emergency Room) and poison control being contacted. Findings include: 1. R63's Face Sheet documented an admission Date of 3/24/20 and listed Diagnoses including Metabolic Encephalopathy, Schizoaffective Disorder, Bipolar Type, Hypertension, and Diabetes Type 1. R63's Minimum Data Set, dated [DATE] documented that R63 is severely cognitively impaired. R63's Care Plan dated 3/29/26 documented a problem area, Resident is at risk for adverse consequences related to receiving antipsychotic medication monthly for the treatment of Schizoaffective Disorder, with a corresponding goal, Resident will not exhibit signs of drug related side effects or adverse drug reactions. R63's Physicians Orders for January and February 2026 documented an order for Invega 234mg (milligram) IM (Intramuscular) with a start date of 9/10/23 scheduled once monthly on the 8th of every month. R63's January 2026 Medication Administration Record (MAR) documented that R63 did not receive the Invega injection on 1/8/26, documenting, Reason: Date changed. There was no documentation on the MAR to indicate R63 was given the Invega in January, and there was no documentation in the chart to indicate the Invega order date for the 8th of the month had been changed. R63's February 2026 Medication Administration Record documented that R63 received the Invega injection on 2/5/26, given by V27, Licensed Practical Nurse (LPN). A Long-Term Care Facility Serious Injury Incident Report dated 2/13/26 for R63 documented, 62 y/o (year old) male Schizoaffective disorder, DM (Diabetes Mellitus) Type 1, HTN (Hypertension) anxiety, hallucinations. BIMS (Brief Interview for Mental Status) =4 (severely cognitively impaired). 2/7/26: Resident noted to have increased lethargy, hand tremors, and increased need for assistance with transfers. Upon investion [sic] resident noted to have been administered monthly Invega injection on 1/31/26 and then again on 2/5/26. MD (Medical Doctor) and POA (Power of Attorney) immediately notified, and resident sent to ER (Emergency Room) for further evaluation. Testing included CBC (Complete Blood Count), CMP (Complete Metabolic Panel), Lipase, UA (Urinalysis), respritory [sic] panel, troponin level, EKG, blood gas, chest x-ray. No abnormalities noted on with [sic} testing except possible UTI (Urinary Tract Infection). Resident returned to the facility on 2/7/26 at 17:37 (5:37pm). Orders given to monitor VS (vital signs) for 2 weeks and continue to monitor for adverse drug reactions. 2/13/26: Resident continues to remain at baseline, UTI follow up completed and culture did not yield UTI. Investigation and audits initiated and interventions in place to prevent further med errors. Care plan updated, MD updated on results of investigation. Nursing Progress Notes documented the following: 1/25/26: Invega Sustenna injection not given; accidentally signed off by writer (V28, Agency Licensed Practical Nurse). Pharmacy does not have medication in stock and January injection was not received by facility and confirmed by pharmacy. Spoke to (pharmacy) and injection will be sent when available. 1/31/26: Resident Invega Sustenna injection given by writer (V28) this date in right deltoid; 1.5ml (milliliter) solution via 1.5-inch 22-gauge needle. Injection given on this date related to not being available on scheduled injection date of 1/24 (26). Patient tolerated well. 2/5/26: (R63) having increase in behavior symptoms and acting very resistant to any redirection for the past two weeks. Writer (V27, LPN) investigated when and if he received his last Invega injection, was not received on [DATE]th due to not being in stock. Writer located injection and gave it to (R63). Will update order in the Matrix to be received next month (March 2026) on the 5th. 2/7/25: Noted that resident received Invega injection on 1-31-(26) and again on 2-5-(26). Resident drowsy, experiencing some hand tremors, unsteady and not standing/bearing weight per his normal. Complains of nausea and back pain. Reporter [sic] to (V10, Psychiatric Advanced Practice Nurse) with N.O. (new order) to send to (local emergency room) for eval and tx (treatment) POA (power of Attorney) called and gave consent to send to ER (Emergency Room). 911 called to request an ambulance transfer. (Local ER) called and report given to ER nurse. Administrator called and notified of incident. Ambulance arrived at facility at 11:25 A.M. (and) transported resident to (local ER). Administrator instructed this nurse to notify resident primary MD (Medical Doctor) of incident. MD phone called and message left as he did not answer. No return call at this time. A Hospital Discharge summary dated [DATE] documented, Medication Problem: Chief Complaint: Patient is a resident of (the facility) and had received 230mg. Invega injection on the 31st (January 2026) then again on the 6th (February 2026), nursing home reports that they have noted tremors, and increased unsteadiness on his feet unable to give time line of onset of symptoms, patient normally has dysphagia, had reported back and abdominal pain to EMS (Emergency Medical Services). EKG (Electrocardiogram) shows a normal sinus rhythm with a heart rate of 94, no ST elevations or depression, normal EKGs. Spoke with the poison center and patient will be washed with the next 6 hours and patient then will be discharged to follow up with the primary care physician. CBC (Complete Blood Count) and chemistry are within normal limits, the troponin is negative, and lipase is negative, urine is positive for amorphous and bacteria. Patient is a waited [sic] in the emergency department for 6 hours. After speaking with the poison Center and patient is medically cleared to go back to the nursing home will continue to watch over the next 24 hours. The patient was discharged to home from the Emergency Department in stable condition. Clinical Impression: Medication overdose, accidental or unintentional, initial encounter. On 4/14/26 at 12:56 PM, R63 was observed in the facility dining room, in no apparent distress, up to the wheelchair and self-propelling. R63 was alert only to himself and answered questions incoherent responses. On 04/16/2026 at 3:18 PM, V10 stated the facility contacted her on 2/7/26 when they realized they had given R63 Invega Sustenna 235mg on 1/31/26 and again on 2/5/26, and it was ordered to be given monthly. V10 stated she did not know when it was given prior to 1/31/26. V10 stated staff had noticed R63 being more lethargic and having more tremors. V10 stated she ordered him sent to ER, he got back that same day, and they have been monitoring him for side effects. V10 stated she was not aware of R63 having had any long-term complications from the medication error. On 04/17/2026 at 11:29 AM, V2, Director of Nurses stated she was not yet employed at the facility when the medication error occurred and could not speak to what happened. On 4/14/26 at 12:11 PM, V1, Administrator, stated on 2/10/26, the facility did an Ad Hoc plan of correction for the medication error. On 4/21/26 at 1:16 PM, V27 (LPN) confirmed she administered the Invega on 2/5/26. V27 stated she was working with R63 on 2/5/26, and he was having increased negative behaviors. V27 stated she recalled looking at his record and at the MAR and the nurse's notes and it appeared the Invega had not been given as it was not available when it was due in January 2026, the date of which she could not recall. V27 stated she checked the medication room and the Invega was in there so she went ahead and administered it and changed the scheduling on the MAR to reflect it would now be due the 5th of every month. V27 stated it was later brought to her attention that R63 had received the Invega on 1/31/26. V27 stated she has never previously made any medication errors, but on 2/5/26 she was tired from working 12-hour shifts. At the conclusion of the survey on 4/21/26 at 3pm, V28 (Agency Licensed Practical Nurse) had not responded to the Surveyors phone messages requesting an interview. 2. R6's admission Record documented an admission date of 10/01/2025 and included diagnoses of metabolic encephalopathy, acute kidney failure, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, type 2 diabetes mellitus without complications, anxiety disorder, unspecified, depression, unspecified, mood disorder due to known physiological condition with major depressive-like episode. R6's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, which indicates severe cognitive impairment. Under section N. High-Risk Drug classes: Use and Indication with documentation of resident taking an antidepressant. R6's Physician Orders documented Trazodone 50 milligrams (MG) tablet in the evening between 4:00 PM to 6:00 PM and Rosuvastatin 20 MG tablet in the evening between 4:00 PM to 6:00 PM. On 4/14/2026 at 12:40 PM, V12 (Licensed Practical Nurse/LPN) stated she had been working on 4/1/2026 when R6 had been given some of her evening medications in the morning and not in the evening as ordered. V12 stated, she had selected the wrong screen during the morning medication administration for R6. V12 stated, she had selected scheduled later medications and pulled all medications to be given. V12 stated, after giving R6 her medications she returned to sign them off in her EHR (electronic health record) when she noticed the times for R6's Trazadone 50 MG (Milligrams) by mouth once a day between 4:00 PM to 6:00 PM and Rosuvastatin 20 MG by mouth between 4:00 PM- 6:00 PM. V12 stated, she did notify V2 (Director of Nursing/DON) on the medication error. V12 stated, V2 (DON) notified family and V24 (Physician) and V24 requested R6 be sent to the local emergency room for further evaluation. On 4/14/2026 at 12:52 PM, V2 (DON) stated she had been notified by V12 (LPN) that she had given R6's Trazadone 50 MG (Milligrams) and Rosuvastatin 20 MG with her morning medications that had been scheduled for evening. V2 stated, she did contact V24 (Physician) and family. V2 stated, V24 notified her that he would feel better having R6 sent to the local emergency room for further evaluation. V2 stated, R6 had been sent via ambulance to the local emergency room. R6's Progress Note by V2 (DON) dated 4/1/2026 at 9:30 AM documented received call this am related to nurse stated she had given R6's evening medications (Geodon, Trazodone, Rosuvastatin) with morning medications. On assessment resident vital signs were within normal limits (WNL). Resident at normal level of consciousness (LOC). No signs or symptoms of distress. Contacted V24 (Physician) and received new order to send to emergency room. Contacted ambulance service. R6's Progress Note by V12 (LPN) dated 4/1/2026 at 12:40 AM documented resident returned from the local emergency by ambulance at 12:30 AM. R6's Medication Administration Record documented on 4/1/26 trazodone 50 MG tablet and Rosuvastatin 20 MG tablet under the time of 4:00 PM to 6:00 PM, were marked with V12's initials in parentheses for both medications, which indicates not given. R6's local emergency room After Summary visit dated 4/1/2026 documented under Chief Complaint: R6 had been brought into the emergency room department from the facility. R6 had been given her nighttime medications of trazodone and rosuvastatin in the morning instead. The facility's Medication Administration policy (undated) documented under Procedures.4) FIVE RIGHTS- Right resident right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after dose is prepared and the medication is put away.

Based on interview and record review, the facility failed to provide adequate CNA (Certified Nursing Assistants) staff to meet residents needs. This has the ability to affect all 76 residents living at the facility.Facility Grievance/Concern documents documented the following:On 10/15/26: No one answered call light from 2am or maybe 3am until 6am.On 12/23/26: Call lights not being answered timely.On 1/19/26: Had to wait 45 minutes with light on to get put on the toilet. Then had to wait 45 minutes to get off the toilet. On 04/14/2026 at 12:16 PM, R25 was alert and oriented. R25 stated when there is only one CNA (Certified Nursing Assistant) working, there have been times she has been left on the toilet over an hour. R25's Face Sheet documented an admission Date of 2/15/24.On 04/14/2026 at 2:20 PM, R14 was alert and oriented. R14 stated there is only one CNA working on the Delta Unit on the night shift, and he has waited over an hour on his call light. R14's Face Sheet documented an admission Date of 9/24/19.On 4/15/26 at 10:01am during the Resident Council Meeting, R5, who was alert and oriented, stated it can take up to an hour and a half to get call lights answered on night shift. R51, who was alert and oriented, stated it can take up to 45 minutes to get her call light answered. R5's Face Sheet documented an admission Date of 3/23/26. R51's Face Sheet documented an admission Date of 6/7/23.On 4/15/26 at 12:30 PM, R47 was alert and oriented. R47 stated that the night shift CNA's do not answer the call lights. R47 stated that the CNA's come in and turn off the light and tell her that they will be back because they have too much paperwork to catch up on, and R47 ends up waiting until morning shift comes in to help her. R47's Face Sheet documented an admission Date of 12/17/25.On 04/16/2026 at 12:27 PM, V11, Licensed Practical Nurse, stated she was working the night shift on the Delta Unit up until a few weeks ago and is now on days. V11 stated she has told administration they need another CNA on Delta on the night shift. On 04/17/2026 at 8:33 AM, V2, Director of Nurses, stated she is the staff member responsible for scheduling nurses and CNA's. V2 stated on the 6am to 6pm shift she schedules one nurse and 3 CNAs for the Center/East Unit, one nurse and 2 CNAs for the Delta Unit, and one nurse and 2 CNAs for the Gardens Unit. V2 stated on the 6pm to 6am shift, she schedules 1 nurse for Center/East and one nurse for Delta/Gardens, 2 CNAs for Center/East, 1 CNA for Delta and 2 CNAs for Gardens. On 04/17/2026 at 8:40 AM, V1, Administrator, stated the current census is 29 residents on Center/East, 30 on Delta, and 18 on Gardens. V1 stated the staffing pattern as described by V2 as above is meeting staffing requirements. Daily Assignment Sheets on the following dates documented that from 6pm to 6am, there was one CNA and one licensed nurse for the East/Center Unit, and One Nurse for the Delta and Gardens Units, two CNAs for the Gardens Unit, and one CNA for the Delta Unit: Saturday 3/14/26, Monday 3/16/26, Thursday 4/2/26, and Saturday 4/4/26.A Long-Term Care Facility Application for Medicare and Medicaid form dated 4/15/26 documented a total of 76 residents living at the facility.A Staffing Policy dated November 2021 stated, The facility provides adequate staffing to meet needed care and services for our resident population and according to regulatory staffing requirements (CMS (Centers for Medicare/Medicaid), IDPH (The Illinois Department of Public Health) (and) DHS (Department of Human Services). 3. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the residents comprehensive care plan.

Based on observation, interview and record review the facility failed to establish and maintain infection prevention and control practices. This has the potential to affect all 76 residents living in the facility. The Findings Include: 1. R35's face sheet documents an admission date to the facility of 02/27/2026. The diagnoses listed include spinal stenosis, type 2 diabetes mellitus, generalized anxiety disorder, bipolar disorder, atherosclerotic heart disease if coronary artery, seizures, chronic diastolic heart failure, acute kidney failure, chronic obstructive pulmonary disease, and gastro -esophageal reflux disease. R35's care plan with a start date of 03/10/2026 documents a focus area of resident is frequently incontinent of bowel and bladder. Interventions listed include provide incontinent care as needed and toilet as scheduled and as needed. On 04/14/2026 at 12:10 P.M. R35 was observed sitting in the dining room with a puddle of liquid underneath his wheelchair. R35 rolled himself out of the dining room and into the hallway. R35 was observed rolling himself down center hall, all the way to his room on north hall. On 04/14/2026 at 12:13 P.M. observed V5 (Certified Nurse Assistant) cleaning the wet spot in the floor in the dining room. V5 cleaned the wet spots on the floor two foot outside the dining room and stopped cleaning the floor. On 04/14/2026 at 12:16 P.M. this surveyor observed wet spots on the floor down center hall. Wet spots were observed the entire length of the hallway and stopped at R35's room. On 04/14/2026 at 12:20 P.M. facility staff were observed walking down center hall and pushing wheelchairs out of the dining room stepping in the wet spots on the floor. On 04/14/2026 at 12:22 P.M. V4 (Certified Nurse Assistant) stated that R35 had an incontinent episode in the dining room and the puddle under his wheelchair was urine. On 04/14/2026 at 12:25 P.M., staff observed pushing residents out of the dining room and rolling wheelchair wheels through spots of urine on the floor. On 04/14/2026 at 12:27 P.M. V5 (Certified Nurse Assistant) stated she assumed that the puddle in the floor was urine from R35 being incontinent and she cleaned it up with bleach wipes. On 04/14/2026 at 12:30 P.M. V6 (Licensed Practical Nurse) stated she was unaware of the wet spots of urine in the floor but will have housekeeping clean it up. On 04/14/2026 at 12:32 P.M. the center hall floor was observed to have wet spots smeared down the entire length of the hallway. On 04/14/2026 at 12:35 P.M. staff were observed cleaning the floor. On 04/17/2026 at 12:10 P.M. V2 (Director of Nursing) stated she was not aware that R35 had an incontinent episode in the dining room. V2 stated she was not aware that there were urine wet spots the entire length of the hallway. V2 stated it should have been cleaned up immediately and no one should have walked through the urine spots on the floor. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated it is her expectation if a staff member starts to clean up urine on the floor, they should make sure that the entire area is clean and not just part of it. V1 stated the CNA should have cleaned up the entire hallway and then a housekeeping staff member should have gone behind her and mopped the areas. 2. R5's admission Record documented an admission date of 3/23/2026 and included diagnoses of sepsis, unspecified organism, altered mental status, disease of native coronary artery without angina pectoris, unspecified atrial fibrillation, and type 2 diabetes mellitus without complications. R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates R5 is cognitively intact. Under section M-Skin Conditions documented R5's is at risk for developing pressure ulcers/injuries and had an unhealed pressure ulcer/injury area. R5's Care Plan had a focus area of admitted with skin ulcer/lesion and at risk for further skin impairment that included interventions of completing treatment as ordered. R5's Physician Orders dated 4/15/2026 documented to left heel: cleanse with wound cleanser, or normal saline, cover with calcium alginate with silver, and secure with dry, clean dressing daily and as needed. May use regular calcium alginate until calcium alginate with silver is available. On 04/16/2026 at 2:31 PM, Observed V3 (Assistant Director of Nursing/ADON) and V7 (Certified Nursing Assistant/CNA) completing R5's dressing change to his right heel. Observed V3 and V7 don personal protective equipment that included gowns and gloves prior to dressing change and placed protective barrier under left heel. During R5's dressing change, when V3 placed the calcium alginate with both hands to the right heel, she donned her left glove with no hand hygiene, placed on another glove to the left hand then used her right hand to hold R5's heel and her left hand to place the dressing over the calcium alginate. When attempting to place the dressing, the calcium alginate moved off of the blister. V3 then adjusted the calcium alginate with her right and left hand back to the center of the blister then reapplied the dressing with no doffing of gloves, hand hygiene or new gloves. On 4/16/2026 at 2:47 PM, V3 (ADON) stated, she should have completed hand hygiene when removing her left glove prior to donning a new glove. V3 stated, she should have donned both gloves, completed hand hygiene and donned new gloves prior to adjusting the calcium alginate and applying the dressing. On 04/17/2026 at 10:31 AM, V1 (Administrator) stated, her expectations are for staff to follow standard infection control practices during dressing changes. 3. On 04/17/2026 at 10:31AM V20 (Maintenance Director) stated the old dementia unit which consists of rooms 168 through 192 have been shut down for a long period of time. V20 stated he is not sure how long there have been no residents in that area of the facility. V20 stated he flushes the water lines on the unit that is closed every couple weeks. V20 stated that he does not keep a record of it but he just picks a day and completes it. V20 stated the water that is on the closed unit does not travel to any other part of the building. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated she is not sure how long there have been no residents living in the area that is shut down. V1 stated she is not sure what the policy says as to how often the water lines should be flushed. V1 stated she would expect V20 to keep a log of it. A facility policy titled Legionella Water Management Program with a date of 07/01/19 documents under section titled measures to control introduction / spread of legionella: the chlorine and PH are monitored at least every 4 days to ensure chlorine levels are within the acceptable range and all areas that have the potential for contributing to bacterial growth are flushed every 4 days for 15 seconds at each point of stagnation. A Long-Term Care Facility Application for Medicare and Medicaid form dated 4/15/26 documented a total of 76 residents living at the facility.

Based on interview and record review the facility failed to establish an antibiotic stewardship program that includes protocols to ensure appropriate antibiotic use, and systems to monitor antibiotic outcomes. This failure has the potential to affect all 76 residents who reside at the facility.The Findings IncludeOn 04/16/2026 an infection control log was presented by V2 (Director of Nursing). The log contained a floor plan for the months of January 2026 - April 2026 that were color coated to differentiate between the different types of infections that residents were experiencing. The log contained a monthly summary of antibiotics that were utilized for the months of January 2026 - April 2026. That log had a print date of 04/16/2026 at 12:48 P.M. The log did not document resident symptoms, if any standardized criteria were used to justify and guide antibiotic use, when antibiotics were first initiated, if response to treatment was monitored, or any laboratory results when available to guide appropriate antibiotic use.On 04/17/2026 at 11:23 A.M. V7 (Regional Nurse) stated she has been monitoring the infections in the facility since January 2026. V7 stated she does not have any tracking, she logs into the computer and looks at cultures to see if there is a pattern.On 04/17/2026 at 12:10 P.M. V2 stated she started at the facility on 03/09/2026. V2 stated she is not sure what the previous director was tracking or how she was tracking infections. V2 stated the infection control binder she presented she found in the office when she started. V2 stated she is not sure that there was any tracking being completed on antibiotics, or what organisms were being monitored. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated she was not sure what the previous director of nursing was tracking. V1 stated V7 (Regional Nurse) is certified as an Infection Preventionist, and her understanding is that V7 was doing monitoring. Facility policy titled Antibiotic Stewardship - Review of Antibiotic Use and Outcomes dated October 2017 documents under policy statement antibiotic usage and outcome data will be collected and documented using a facility - approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility -wide antibiotic stewardship.A Long-Term Care Facility Application for Medicare and Medicaid form dated 4/15/26 documented a total of 76 residents living at the facility.

Based on observation, interview, and record review the facility failed to employ an Infection Preventionist who remains on site. This failure has the potential to affect all 76 residents who reside at the facility. The Findings IncludeOn 04/17/2026 at 11:23 A.M. V7 (Regional Nurse) stated she is responsible for the role of infection preventionist until V2 completes the course. V7 stated she is not sure how often she is actually at the facility. V7 stated she logs in remotely and reviews infections for the facility. On 04/17/2026 at 12:10 P.M. V2 (Director of Nursing) stated she has not completed the course, but she will be taking it to be the infection preventionist for the facility. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated V26 (Former Employee) was the infection preventionist for the facility. V1 stated that V26 quit without notice. V1 stated V7 (Regional Nurse) is who the facility is currently utilizing for the infection preventionist role. V1 stated that V7 is not in the building every day and looks at the facility data remotely. A Long-Term Care Facility Application for Medicare and Medicaid form dated 4/15/26 documented a total of 76 residents living at the facility.

Based on interview and record review, the facility failed to ensure quarterly assessments were completed within the required time frames for 7 (R2, R20, R48, R57, R68, R72, and R81) of 7 residents reviewed for quarterly MDS (Minimum Data Set) assessments in the sample of 51. The Findings Include:1. R2's face sheet documents R2 has an admission date to the facility of 11/22/2023. Diagnoses listed include retention of urine, unspecified dementia, major depressive disorder, unilateral primary osteoarthritis, anemia, obstructive sleep apnea, anxiety disorder, and hypothyroidism. On 04/15/2026 at 12:33 P.M. V7 (Regional Nurse) stated R2's quarterly MDS with an ARD (Assessment Reference Date) of 03/12/2026 has not been completed yet.2. R20's face sheet documents R20 has an admission date to the facility of 11/06/2019. Diagnoses listed include unspecified dementia, major depressive disorder, undifferentiated schizophrenia, anxiety disorder, neuroleptic induced parkinsonism, and unspecified intellectual disabilities. On 04/15/2026 at 12:33 P.M. V7 stated R20's quarterly MDS with an ARD of 03/12/2026 has not been completed yet. 3. R48's face sheet documents R48 has admission date to the facility of 12/09/2024. Diagnoses listed include unspecified dementia, pulmonary hypertension, hyperlipidemia, essential hypertension, obstructive sleep apnea, generalized anxiety disorder, and delusional disorder. On 04/15/2026 at 12:33 P.M. V7 stated R48's quarterly MDS with an ARD of 03/10/2026 has not been completed yet.4. R57's face sheet documents R57 has an admission date to the facility of 09/09/2025. The diagnoses listed include type 2 diabetes mellitus, hyperlipidemia, obstructive sleep apnea, chronic obstructive pulmonary disease, cognitive communication deficit and personal history of transient ischemic attack. On 04/15/2026 at 12:33 P.M. V7 stated R57's quarterly MDS with an ARD of 03/13/2026 has not been completed yet.5. R68's face sheet documents R68 has an admission date to the facility of 09/21/2023. The diagnoses listed include seizures, moderate intellectual disabilities, gastro esophageal reflux disease, and essential hypertension. On 04/15/2026 at 12:33 P.M. V7 stated R68's quarterly MDS with an ARD of 03/09/2026 has not been completed yet.6. R72's face sheet documents R72 has an admission date to the facility of 02/14/2022. Diagnoses listed include unspecified dementia, Alzheimer's disease, seizures, generalized anxiety disorder, chronic diastolic heart failure, and insomnia.On 04/15/2026 at 12:33 P.M. V7 stated R72's quarterly MDS with an ARD of 03/10/2026 has not been completed yet.7. R81's face sheet documents R81 has an admission date to the facility of 08/10/2024. Diagnoses listed include unspecified dementia, adjustment disorder, bradycardia, chronic kidney disease, depression, hypothyroidism, and essential hypertension.On 04/15/2026 at 12:33 P.M. V7 stated R81's quarterly MDS with an ARD of 03/11/2026 has not been completed yet. On 04/15/2026 at 12:33 P.M. V7 (Regional Nurse) stated that the facility does not have an MDS nurse. V7 stated that there is a regional nurse that is trying to complete all the MDS's. V7 stated the quarterly MDS's that have not been completed, corporate is working on them. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated V26 (former employee) quit without notice on 03/24/2026. V1 stated she was not aware that V26 was behind on completing MDS assessments. V1 stated the company does not have a policy on when MDS are to be completed they follow the RAI (Resident Assessment Instrument) Manual. V1 stated it is her expectation for the MDS to be completed on time.

Based on interview and record review the facility failed to complete timely quarterly MDS (Minimum Data Set) for 4 (R8, R13, R51, and R56) of 4 residents reviewed for quarterly MDS assessments completed timely in the sample 51. The Findings Include:1. R8's face sheet documents an admission date to the facility of 10/01/2025. The diagnoses listed include metabolic encephalopathy, acute kidney failure, dementia, type 2 diabetes mellitus, anxiety disorder, essential hypertension, hyperlipidemia, gastro esophageal reflux disease, and mood disorder. A final validation report dated 04/14/2026, provided by V1 (Administrator) documents that R8's quarterly MDS (Minimum Data Set) was submitted on 4/14/26 and had a target/ due date of 03/03/2026. The same document had a warning message of assessment completed late: more than 14 days after the assessment reference date.2. R13's face sheet documents an admission date to the facility of 01/28/2020. The diagnoses listed include unspecified dementia, Type 2 diabetes mellitus, Alzheimer's disease, chronic kidney disease, essential hypertension, hypothyroidism, delusional disorder and B12 deficiency anemia.A final validation report dated 04/14/2026, provided by V1 documents that R13's quarterly MDS (Minimum Data Set) was submitted on 4/14/26 and had a target/ due date of 03/05/2026. The same document had a warning message of assessment completed late: more than 14 days after the assessment reference date.3. R51's face sheet documents an admission date to the facility of 06/07/2023. The diagnoses listed include spinal stenosis, low back pain, polyosteoarthritis, cardiomegaly, generalized anxiety disorder, and essential hypertension.A final validation report dated 04/14/2026, provided by V1 documents that R51's quarterly MDS (Minimum Data Set) was submitted on 4/14/26 had a target/ due date of 03/03/2026. The same document had a warning message of assessment completed late: more than 14 days after the assessment reference date.4. R56's face sheet documents an admission date to the facility of 07/17/2025. The diagnoses listed include unspecified dementia, generalized anxiety disorder, hypothyroidism, depression, and urinary tract infection.A final validation report dated 04/14/2026, provided by V1 documents that R56's quarterly MDS (Minimum Data Set) was submitted on 4/14/26 and had a target/ due date of 03/06/2026. The same document had a warning message of assessment completed late: more than 14 days after the assessment reference date.On 04/15/2026 at 12:33 P.M. V7 (Regional Nurse) stated that the facility does not have an MDS nurse. V7 stated that there is a regional nurse that is trying to complete all the MDS's. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated V26 (former employee) quit without notice on 03/24/2026. V1 stated she was not aware that V26 was behind on completing MDS assessments. V1 stated the company does not have a policy on when MDS are to be completed they follow the RAI (Resident Assessment Instrument) Manual. V1 stated it is her expectation for the MDS to be completed on time.

Based on observation and interview the facility failed to ensure that residents were offered activities who chose to stay in their room for 4 of 4 residents (R22, R64, R66 and R80) reviewed for activities in a sample of 51.The Findings Include:1. R64's face sheet documents an admission date of 1/11/24 and includes the following diagnosis: chronic respiratory failure, major depression disorder, heart failure, anxiety, and morbid obesity.On 4/14/26 at 11:00 AM, R64 who is alert and oriented to person, place and time stated that she has not gotten any activities given to her since she can remember. R64 stated that due to her being bed bound she chooses to spend her time in her room rather than being transferred to a chair and out to the dining room for activities and meals. R64 stated that she used to receive puzzles and various items to color or read but honestly cannot remember the last time those were passed out to her. R64 stated that she would like to receive those again. 2. R66's face sheet documents an admission date of 2/6/19 and includes the following diagnosis: unspecified dementia, chronic obstructive pulmonary disorder, and alcohol abuse. On 4/15/26 at 1:30 PM, R66 who is alert to person and place stated that he does not get daily delights or puzzles passed out to him daily. R22 stated that he chooses to not to go to the activities but and he really likes to do word searches and puzzles so he would like to receive them to work on while he is in his room or sitting in the hall. 3. R22's face sheet documents an admission date of 6/16/25 and includes the following diagnosis: anxiety, congestive heart failure, diabetic neuropathy, obesity and anxiety disorder. On 4/15/26 at 2:00 PM, R22 who is alert to person, place and time stated that he does not get any type of daily handouts with activities on them. R22 stated that he doesn't know if he would enjoy them or not, but he would like to see what they are. 4. R80's face sheet documents an admission date of 12/21/23 and includes the following diagnosis: generalized anxiety disorder, chronic respiratory failure, hypertension, morbid obesity, and retention of urine. On 4/16/26 at 11:00 AM, R80 who is alert to person, place and time stated that he does not ever recall receiving daily handouts with reading materials and puzzles. R80 stated that he would like to see what they are and would possibly work on some of the puzzles. On 4/17/26 at 1:00 PM, V19 (Activities) stated that she passes out the daily delights along with the various puzzles and coloring pages in the dining room with the residents who attend the planned activities. V19 stated that she also passes them out the residents who choose to stay in their rooms, but there are days that she doesn't make it to all the rooms due to getting behind. On 4/17/26 at 9:30 AM, V1 (Administrator) stated that all residents should be receiving the activities packets whether they choose to attend the planned activities or not. V1 stated that she does not have an Activities policy, but this is her expectation.

Based on observation, interview and record review the facility failed to provide an environment free of hazards, implement appropriate interventions for falls, and provide a safe transfer with a mechanical lift for 4 (R2, R12, R22, and R81) of 4 residents reviewed for accidents in a sample of 51.Findings include: 1. R12's admission Record documented an admission date of 12/20/2023 and included diagnoses of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hyperlipidemia, unspecified, essential hypertension, unspecified hearing loss, and unspecified ear. R12's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicates severe cognitive impairment. Under section B. B1200. Corrective Lenses documented R6 used corrective lenses for her vision. R12's Care Plan had a focus area of risk for falls related to visual acuity impairments and cognitive impairments with interventions that included: Ensure resident is wearing eyeglasses as warranted. Ensure eyeglasses are clean and in good repair and ensure the floor is free of glare, liquids, foreign objects, with an approach start date of 1/5/2024. R12's Progress Note dated 1/5/2026 at 11:32 AM by V21(Licensed Practical Nurse/LPN) documented R6 was walking in dining room and therapy saw resident foot slip and res unable to correct balance and slide to floor without hitting head. Dining room floor appears to have some powder type substance making floor slippery. On 04/17/2026 at 12:07 PM, V1 (Administrator) stated her expectations would be for staff to clean up spills in a timely manner. On 04/17/2026 12:10 PM, V21 (Licensed Practical Nurse/LPN) stated she did work on 1/02/2025 when R12 had her fall in the dining room. V21 stated she did not witness the actual fall but V22 (Certified Occupational Therapy Assistant/COTA) did witness it. V21 stated V22 notified her that R12 had been walking in the dining room when she slipped in a powder substance. V21 stated, she had almost slipped herself in the substance. On 4/17/2026 at 12:18 PM, V22 (COTA) stated she had been working with another resident in the dining room on 1/5/2025 when R12 had been walking around the recliner and slipped in a powder-like substance in the floor. V22 stated she could see the powder on the floor by the chair but was not sure what it was. V22 stated she did notify V21 (LPN) of the event. 2. R81's admission Record documented an admission date of 8/10/2024 and included diagnoses of unspecified dementia, unspecified severity, with agitation, type 2 diabetes mellitus with other circulatory complications, F43.25 Adjustment disorder with mixed disturbance of emotions and conduct, bradycardia, unspecified, and repeated falls. R81's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, which indicates severe cognitive impairment. Under section GG-Mobility, R81 had documented chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) as dependent meaning helper does ALL of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity. R81's Care Plan had a focus area of risk for falls related to history of falls and cognitive impairments with interventions that included re-educate staff on proper use of fall prevention devices that are in place. On 04/14/2026 at 11:45 AM Observed R81 sitting at the dining room table being assisted with her lunch meal. R81's seat belt had been undone by V16 (Certified Nursing Assistant/CNA). While R81 had been assisted eating, V16 hollered out that R81 was going down and needed help. R81 had slid down to where her bottom was sitting on the wheelchair leg rest support with V16's right leg was holding R81 in place. V14 (CNA) came to assist V16 with moving R81 back into her chair and R81 finished eating by assist. On 4/15/2026 10:44 AM, V14 (CNA) stated, she and V16 (CNA) notified V15 (Licensed Practical Nurse/LPN) about R81 slipping from her wheelchair and sitting on the foot/leg rest areas with V16 applying her knee to stop R81 from going to the floor. V14 stated, she does not know what time it was that she reported to V15, but she did. On 4/15/2026 at 10:05 AM, V15 (Licensed Practical Nurse/LPN) stated V14 and V16 did report to her around 5:30 PM - 6:00 PM that R81 did slide down in her wheelchair but did not hit the floor. V15 stated, since R81 did not slide into the floor, she did not report the occurrence to V2 (Director of Nursing/DON) or implement an intervention. On 4/15/2026 at 10:25 AM, V16 (CNA) stated she had been assisting R81 with her lunch meal and had unbuckled her seatbelt during the meal. V16 stated, while feeding R81 she had been scooting down in her wheelchair and before she knew it, R81 was sitting on the footrest of her wheelchair. V16 stated, she placed her right knee against R81's knees to keep her from sliding into the floor. V16 stated, she requested assist from V14 (CNA) to help pull R81 up in her wheelchair to finish eating. V16 stated, she did report this occurrence to V15 (LPN) shortly after, but she did not get a paper to sign about a new intervention put in place from V15 (LPN). V16 stated, the facility policy to notify the nurse on the floor of the occurrence, then the nurse on the floor would notify V2 (DON) and place a new intervention in place. The facility's Falls Management (revised April 21,2022) documented under Policy: It is the policy of facility name to assess and manage resident falls through prevention investigation, and implementation and evaluation of interventions. Under Definition: The definition of a fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. 3. R22's face sheet documents an admission date to the facility of 06/16/2025. The diagnoses listed include type 2 diabetes mellitus, unspecified atrial fibrillation, anxiety disorder, depression, insomnia, unspecified systolic heart failure, hyperlipidemia, gastro esophageal reflux disease, benign prostatic hyperplasia, morbid obesity, contracture of right knee, contracture of left knee, and chronic pain. R22's physician order report with a date range of 03/16/2026 – 04/16/2026 documents an order for R22 to be transferred with a mechanical lift. R22's care plan with a start date of 06/26/2025, has a focus area of R22 needs set up/supervision to substantial assistance for most activities of daily living. Mechanical lift for transfers. Interventions listed include stand-up lift for transfers with two assist. R22's MDS (Minimum Data Set) dated 12/19/2025 documented in section GG Functional abilities that R22 is dependent for sit to stand and chair to bed / bed to chair transfers. On 04/16/2026 at 11:01 AM, V8 (Certified Nurse Assistant) was observed going into R22's room alone. V8 left the door open while she pushed the mechanical lift into the room. V8 then hooked R22's mechanical lift sling to the mechanical lift. V8 then walked out of the room, grabbed gloves walked back into R22's room and closed the door. Several minutes later V8 walked out of R22's room by herself pushing the mechanical lift. There were no other staff members observed leaving the room. On 04/16/2026 at 11:49 P.M. V8 (Certified Nurse Assistant) stated that she completed the mechanical lift transfer by herself on R22. V8 stated she knew that she needed to use two people for the transfer with the mechanical lift. V8 stated she does not have a reason for not going to get another staff member before proceeding with the mechanical lift transfer. On 04/17/2026 at 12:10 P.M. V2 (Director of Nursing) stated she was not aware any staff were using the mechanical lift by themselves. V2 stated there should always be two staff members present when a resident is transferred with a mechanical lift. V2 stated she plans on educating staff today about mechanical lifts. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated the mechanical lift should only be used when there are two staff members present. V1 stated no staff should be using the mechanical lift by themselves. A facility policy titled Mechanical Lift with a date of 09/08/2023 documented under section titled policy: The mechanical lift may be used and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. Two staff members are required when transferring a resident with a mechanical lift. 4. R2's face sheet documents an admission date of 11/22/2023. This same document includes the following diagnosis: unspecified dementia, major depressive disorder, anxiety, and visual hallucinations. R2's Progress notes dated 12/5/25 at 8:18am documents, Resident was yelling out for help. Found laying on her room floor with her head towards her window and feet towards the door on her rt (right) hip. No deformity noted, states severe pain deep in the joint area. Order received to send to the ER (Emergency Room) for further evaluation d/t (due to) increased pain and discomfort. Redness noted over the hip joint R2's Event Report completed 12/5/25 has multiple sections of the investigation left blank including areas such as History of falls, what was the date of the fall, any recent change of condition, environmental issues identified, etc. This area is used in determining the root cause of the unwitnessed fall and proper interventions to prevent future falls. On 4/17/26 at 11:00 AM, V1 (Administrator) confirmed that this part of the investigation to the root cause of the fall was not completed. V1 stated that she was not working in the facility at the time of the fall and the nurse is no longer an employee at the facility. V1 stated that this portion of the event should be filled out to ensure a thorough investigation into the fall is completed.

Based on observation, interview and record review the facility failed to offer residents food alternatives per personal preferences for 4 of 4 residents (R22, R64, R66, and R80) reviewed for meal alternatives in a sample of 51. The Findings Include:1. R80's face sheet documents an admission date of 2/20/2023. R80's April Physician's Order sheet documents R80 has a regular diet ordered.On 4/14/26 at 12:00 PM, R80 was observed in his room with his lunch tray on his bedside table. R80 who was alert to person, place and time, stated that he will not eat the carrots because they serve them too often. R80 stated that he ate the baked pasta but threw out the rock-hard garlic bread that was in his trash can next to his recliner. R80 stated he never gets to make food choices prior to his meal; he just finds out what is being served when it is delivered. R80 stated that he chooses to stay in his room all day including mealtime and does not participate in the activities by choice. 2. R64's face sheet documents an admission date of 1/11/24. R64's April Physician's Order sheet documents R64 has a regular diet ordered.On 4/15/26 at 11:00 AM, R64 who was alert to person, place and time, stated that she never gets asked what she wants to eat prior to the meal. R64 stated that she gets what is served to her but would like to know what the other choices are. R64 stated that she does not go out to the activities and stays in his room for meals by his own choice. On 4/17/26 at 12:45 PM, R64 stated that she can only get coffee during breakfast hours. R64 states that when she asks for coffee any other time of the day the staff report that it is only available at breakfast. 3. R66's face sheet documents an admission date of 2/6/19. R66's April Physician's Order sheet documents R66 has a regular diet ordered.On 4/16/26 at 2:00 PM, R66 who was alert to person, place and time, stated that he just eats what he gets because he didn't know there were other options to choose from. R66 stated that he does not go to the activities normally by his own choice. R66 stated that he prefers to stay in his room and do his own thing all day. 4. R22's face sheet documents an admission date of 6/16/25. R22's April Physician's Order sheet documents R22 has a regular diet orderedOn 4/16/26 at 2:30 PM, R22 who was alert to person, place and time, stated that he does not get choices on his meal options, he just gets what is served. R22 stated he does not get sheets to fill out the day prior to the meal to make his selections, other than he did yesterday for the first time and he did choose some of the alternates rather than the main choices and he liked that he had an option. On 4/16/26 at 10:00 AM, V18 (Dietary Manager) stated that the activities department is supposed to meet with the residents daily to review the menu and fill out the menu for the following day. This menu has the planned alternatives on the sheet. V18 stated that on Fridays then they fill it out for the weekend through Monday's breakfast. On 4/16/26 at 11:00 AM, V18 (Activities) stated that she fills out the menus with the residents during the day while doing activities. The meal substitutions policy with revision date of 12/2016 documents that appealing alternate options of similar nutritive value shall be available for all meals for residents who choose not to eat food that is initially served or who request a different meal choice. Alternates shall be offered to residents who refuse menu items. In cases where the menu item as well as the alternate is refused, staff shall investigate a reasonable solution within product availability.

Based on observation, interview and record review the facility failed to provide Pneumococcal Immunizations for 4 (R18, R47, R62, and R64) of 9 residents reviewed for Immunizations in the sample of 51. The Findings Include1. R18's face sheet documents R18's date of birth as 10/22/1944 (over [AGE] years of age) and an admission date to the facility of 07/31/2019. The diagnoses listed include polyosteoarthritis, unspecified dementia, psychotic disorder with delusions, major depressive disorder, anxiety disorder, hypothyroidism, essential hypertension, and acute upper respiratory infection.R18's I-Care (Illinois Comprehensive Automated Immunization Registry Exchange) documented that R18 has not had any pneumonia vaccines.R18's vaccine consent release only dated year 2026, documented R18 agreed to the Pneumococcal vaccination.R18's progress note dated 03/20/2026 documented obtained consent for resident requesting pneumonia vaccination. Order put in to be administrated 03/26/2026. 2. R47's face sheet documents R47's date of birth as 11/07/1941 (over [AGE] years of age) and an admission date to the facility of 12/17/2025. The diagnoses listed include primary osteoarthritis, depression, anxiety, thrombocytopenia, peripheral vascular disease, chronic pain, essential hypertension, and overactive bladder.R47's I-Care documented R47 had pneumococcal polysaccharide on 10/21/2015 and Prevnar 13 on 10/21/2021.R47's vaccine consent and release only dated year 2026 documented R47 agreed to the pneumococcal vaccination.R47's progress note dated 03/20/2026 documented resident offered pneumonia vaccine and agreed, consent signed. Order put in for 03/24/2026. 3. R62's face sheet documented R62's date of birth as 03/26/1941 (over [AGE] years of age) and an admission date to the facility of 04/18/2018. The diagnoses listed include unspecified dementia, major depressive disorder, generalized anxiety disorder, delusional disorders, parkinsonism, gastro - esophageal reflux disease, and hyperlipidemia.R62's I-Care does not document that R62 has received a pneumococcal vaccination. R62's vaccine and consent release only dated year 2026 documented that R62 agreed to the pneumococcal vaccination.R62's progress note dated 03/20/2026 documented received written consent for a pneumococcal vaccine from resident. Order put in to be administered 03/24/2026. 4. R64's face sheet documented R64's date of birth as 07/21/1963 (over [AGE] years of age) and an admission date to the facility of 01/11/2024. The diagnoses listed include acute and chronic respiratory failure with hypoxia, heart failure, secondary pulmonary arterial hypertension, major depressive disorder, chronic obstructive pulmonary disease, and insomnia.R64's I-Care does not document that R64 has received a pneumococcal vaccination.R64'a vaccine and consent release only dated year 2026 documented that R64 agreed to the pneumococcal vaccination.R64's progress noted dated 03/20/2026 documented written consent for resident requesting pneumonia vaccine. Order put in for administration for 03/26/2026.On 04/16/2026 at 9:04 AM observation was made of the medication room. In the medication fridge there was a Prevnar 20 for R47 and R62. The order date on the vaccine was 03/20/2026. The medication fridge also contained a Prevnar 20 for R18 and R64. The order date on those vaccines was 03/23/2026. On 04/16/2026 at 12:20 P.M. V21 (Licensed Practical Nurse) stated the vaccines in the fridge, are for residents that do not have consents scanned into the chart and that is why those vaccines have not been given. V6 stated she believes those residents have consents now.On 04/16/2026 at 2:58 P.M. V2 (Director of Nursing) stated when the medical record employee quit, there was a pile of papers that need scanned into the chart that was not done. V2 stated the consents were obtained and a progress note was completed for the day that the consent was obtained. V2 stated the nurses would not give the Prevnar 20 until the consents were scanned into the chart. On 04/17/2026 at 12:10 P.M. V2 (Director of Nursing) stated she started at the facility on 03/09/2026. V2 stated she will be the person that will be responsible for vaccinations moving forward. V2 stated she just got access to I care so she can now see who has had what vaccine. V2 stated she has not had the time to look at vaccines to see who is up to date and who needs vaccines. V2 stated she is not aware who is up to date on pneumonia vaccines and who needs them. V2 stated she did not know that there were vaccines in the medication fridge that needed to be given. V2 stated she will be calling the physician and getting a new order to give the pneumonia vaccines. V2 stated vaccines should be given with a consent, and an order per the policy.On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated it is her expectation that vaccines should be given when they are ordered. V1 stated the staff should follow the policy on vaccinations. V1 stated she is not a nurse and does not have access to the medication fridge, so she was not aware that there were vaccines that were not given. V1 stated she was not aware that the consents had been obtained but were not scanned in the computer. V1 stated she is not aware who was responsible for vaccines prior but the facility had completed an audit because she knew there were issues. Facility policy titled Pneumococcal Vaccine with a date of 02/11/2022 documented it is the policy of this facility that all residents are protected from incident of pneumonia by obtaining pneumococcal vaccines, if desired, per CDC guidelines. According to the Centers for Disease Control website, https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, the following recommendations were retrieved in part as of 8/21/25: Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine or those whose previous vaccination history is unknown. Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need.

Based on observation, interview and record review the facility failed to provide a clean homelike environment for 2 of 2 (R8 and R62) residents reviewed for cleanliness in a sample of 51. The Findings Include: 1. R8's admission Record documented an admission date of 6/03/2004 and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R8's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, which indicates severe cognitive impairment. Under section GG0120. Mobility Devices documented R6 used a wheelchair for mobility. R8's Care Plan documented a focus area of difficulty with communicating needs due to unclear speech and difficulty finding words to complete thoughts with interventions that included observing closely and anticipating needs as needed. On 04/14/2026 at 1:19 PM observed resident self-propelling in wheelchair to room. R8 was happy and pushed call light for assistance. Observed R8's wheelchair in disrepair including a bandage wrapped around the right and left side of the frame next to the end of the seat. Observed red sauce, old cheerios, hair and dirt on the right lower wheelchair frame. Observed R8's non-slip grip under cushion with food stains located on the outside of cushion. On 04/17/2026 at 12:20 PM Observed resident self-propelling in wheelchair to room. R8 was happy and pushed call light for assistance. Observed R8's wheelchair in disrepair including a bandage wrapped around the right and left side of the frame next to the end of the seat. Observed red sauce, old cheerios, hair and dirt on the right lower wheelchair frame. Observed R8's non-slip grip under cushion with food stains located on the outside of cushion. On 4/17/2025 at 12:22 PM, V23 (Certified Nurse Assistant/CNA) stated the night shift nursing staff is supposed to be cleaning the wheelchairs, however, it is not being done. V23 stated, she attempts to clean them during the daytime when she can. V23 stated, there is no documentation for R8's wheelchair being cleaned. V23 stated, she does not know why there is a bandage on R8's wheelchair. 2. On 4/14/26 at 1:30 PM, R62's bed frame was observed to be visibly soiled with dried food and spills. On 4/17/26 at 11:28 AM, R62's bed frame is still in the condition that was seen on 4/14/26. On 4/17/26 at 10:23 AM, V1 (Administrator) stated that R62 likes to eat and drink in his bed and he spills a lot of food and is a messy eater. V1 states that she will get someone in here to clean up the bed frame.

Based on interview and record review the facility failed to complete a comprehensive assessment annually and submit it timely for 1 (R73) of 1 resident reviewed for comprehensive assessments in the sample of 51. The Findings Include:R73's face sheet documents an admission date to the facility of 03/03/2025. The diagnoses listed include Alzheimer's disease, unspecified dementia, chronic kidney disease stage 4, paroxysmal atrial fibrillation, unspecified systolic heart failure, and essential hypertension. A final validation report dated 04/14/2026, provided by V1 (administrator) documents that R73's annual MDS (Minimum Data Set) had a target/ due date of 03/04/2026 and was not completed until 4/14/26. The same document had a warning message of assessment completed late: more than 14 days after the assessment reference date.On 04/15/2026 at 12:33 P.M. V7 (Regional Nurse) stated that the facility does not have an MDS nurse. V7 stated that there is a regional nurse that is trying to complete all the MDS's. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated V26 (former employee) quit without notice on 03/24/2026. V1 stated she was not aware that V26 was behind on completing MDS assessments.

Based on record review and interview, the facility failed to refer a resident for a PASARR (Preadmission Screening and Resident Review) screening following the addition of a diagnosis of Schizoaffective Disorder for one resident (R28) of two residents reviewed for PASARR screening in the sample of 51.Findings include:R28's Face Sheet documented an admission Date of 10/31/17 and listed among the diagnoses was Schizoaffective Disorder Depressive Type with an effective date of 9/7/24. R28's Minimum Data Set, dated [DATE] documented that R28 has moderate deficits in cognition. R28's Care Plan dated 2/16/26 documented a problem area, Resident receives antidepressant medication for appetite and Schizoaffective Disorder, Depressive Type.R28's Illinois Department of Healthcare and Family Services Interagency Certification of Screening Results document dated 10/31/17 documented, Screening indicated nursing facility services are appropriate. Based on all information and data available to me for this person, there is reasonable basis for suspecting MI (Mental Illness) or DD (Developmental Disorder): No. There was no documentation to indicate R28 was referred for reevaluation after the 9/7/24 addition of the Schizoaffective Disorder diagnosis.On 04/16/2026 at 10:57am, V9, Behavioral Health Case Manager, stated at her previous job in community mental health, she had provided case management services for R28, who had a long history of mental illness. V9 stated when R28 was first admitted to the facility, it was for skilled nursing care, not behavioral health services, but she was later moved onto the behavioral health unit. V9 stated she is not sure why upon initial admission the screener would not have had access to R28's history and realized she had history of mental illness. V9 stated she is not sure why the diagnosis was not added until 9/7/24.On 04/17/2026 at 9:14am, V1, Administrator, stated there may be other residents in the facility who need to be rescreened for PASARR, she stated she will do an audit and have these residents rescreened. A Resident Assessment: Coordination with PASARR Program Policy dated October 2017 documented, 6. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual authority for a level 2 resident review.

Based on interview and record review the facility failed to notify the resident or the resident's representative of the transfer/discharge/bed hold in writing for 3 (R2, R6, and R7) of 3 residents reviewed for discharge notification/bed hold in the sample of 51. The Findings Include: 1. R6's admission Record documented an admission date of 10/01/2025 and included diagnoses of metabolic encephalopathy, acute kidney failure, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, type 2 diabetes mellitus without complications, anxiety disorder, unspecified, depression, unspecified, mood disorder due to known physiological condition with major depressive-like episode. R6's Progress Note by V12 (LPN/Licensed Practical Nurse) dated 4/1/2026 at 12:40 PM documented resident returned from the local emergency by ambulance at 12:30 PM. R6's local emergency room After Summary visit dated 4/1/2026 documented under Chief Complaint: R6 had been brought into the emergency room department from the facility. R6 had been given her nighttime medications of trazodone and rosuvastatin in the morning instead. During this survey the facility could not produce evidence a Bed Hold was provided to the resident or resident's representative for R6's emergency room visit on 4/1/2026. 2. R2's face sheet documents an admission date of 11/22/2023. This same document includes the following diagnosis: unspecified dementia, major depressive disorder, anxiety, and visual hallucinations. R2's Progress notes on 12/5/25 document R2 was sent to the emergency room after a fall with pain noted to her joint area. During this survey the facility could not produce evidence a Bed Hold was provided to the resident or resident's representative for R2's emergency room visit on 12/5/25. On 4/16/26 at 2:30 PM, V9 (Behavioral Health Case Manager) stated that the resident families are notified by the facility via telephone call and the transfer papers are sent with the resident in the ambulance. V9 stated that the bed hold and transfer forms are not mailed to the family/Power of Attorney. 3. R7's face sheet documented R7 was admitted to the facility on [DATE]. Diagnoses listed include transient cerebral ischemic attack, paranoid schizophrenia, unspecified psychosis, type 2 diabetes mellitus, chronic obstructive pulmonary disease, anxiety disorder, essential hypertension, and gastro esophageal reflux disease. R7's progress note dated 04/13/2026 with a time of 11:53 A.M. authored by V25 (Registered Nurse) documented that R7 was sent to the hospital as R7 was not responsive to verbal stimuli. R7's progress note dated 04/13/2026 with a time of 5:49 P.M. authored by V25 documented that R7 was admitted to the local hospital with a diagnosis of acute encephalopathy and acute hypoxic respiratory failure. During this survey the facility could not produce evidence a Bed Hold was provided to the resident or resident's representative for R7's hospital visit on 4/13/2026. On 04/16/2026 at 10:15 AM, V1 (Administrator) stated social service director used to do bed holds and transfer documents. V1 stated last week when R7 was discharged to the hospital she realized that no one had been doing the forms. V1 stated she knows it is charted that he had one, but R7 was never given one. V1 stated she plans to start educating the staff on bed hold / transfer notifications because they should be completed by the nurse that is sending them to the hospital. Facility policy titled Notice of a Transfer and or Discharge dated 11/5/2025 documented 2. The written notice (Involuntary discharge form and/or Necessity of Transfer and bedhold policy form) to the resident and/or representative (Sponsor) will include the following: a. the reason for the transfer or discharge, b. the effective date of the transfer or discharge, c. the specific location to which the resident is being transferred or discharged .

Based on interview and record review the facility failed to sign and complete an IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life Sustaining Treatment (POLST) form for 1 (R87) of 1 residents reviewed for Advanced Directives in the sample of 51. Findings included:R87's admission Record documented an admission date of 4/05/2026 and included diagnoses of unspecified dementia, unspecified severity, with anxiety, other chronic pain, cognitive communication deficit, pain, unspecified, edema, unspecified, and insomnia, unspecified.R87's Minimum Data Set (MDS) dated [DATE] documented under section A1600- admission Date of 4/5/2026.On 04/15/2026 at 12:40 PM, V12 (Licensed Practical Nurse/LPN) stated advanced directives are located on the residents medication administration sheet located in the residents electronic health record (EHR). V12 stated, R87 does not have a POLST form in his electronic health record and she is not aware of who inputs that information. On 4/15/2026 at 12:52 PM, V2 (Director of Nursing/DON) stated she does not handle the POLST documentation for residents, however they should have their POLST form located in their EHR under resident documents, POLST information. V2 stated, you should be able to observe the information under residents name in the EHR. On 4/15/2026 at 1:03 PM, V13 (Social Services Director/SSD) stated upon admission to the facility, she will complete the POLST form to send to the physician then scan it into the resident's EHR. V13 stated, she does have R87's POLST form, dated by family on 3/26/2026 with no physician signature. V13 stated, she is not sure how long of a time she had to get the POLST form completed, but she feels it is 48 hours. On 4/15/2026 at 1:10 PM, V1 (Administrator) stated V13 (SSD) should complete the POLST form, send it to the physician to be signed, and upload information into the residents EHR. V1 stated, this information should be completed within 24 hours of admission. R87's POLST form dated 3/26/2026 documented no signature by physician.The facility's Advance Directive Policy (revised October 7, 2025) documented under Policy Statement, advance directives will be respected in accordance with state law and facility policy. Under Policy Interpretation and Implementation, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law.

Based on observation, interview and record review the facility failed to follow physician orders for dating/labeling when changing oxygen tubing and humidifier bottles for 3 of 3 (R64, R66 and R80) residents reviewed for oxygen tubing in a sample 51. The Findings Include: 1. R66's face sheet documents an admission date of 2/6/19. This same document includes the following diagnosis: chronic obstructive pulmonary disease and centrilobular emphysema. R66's April physician orders include an order to change oxygen tubing and humidifier bottle weekly, initial and date once a day on Saturday. R66's Medication Administration Report (MAR) dated 3/21/26-4/20/26 documents that R66's oxygen tubing was changed every Saturday. On 4/15/26 at 1:30 PM, R66 who was alert to person, place and time stated that he does not know when they change his tubing or how often it happens. R66 stated he cannot remember when they did it last. On 4/15/26 at 1:30 PM, R66's oxygen tubing was observed to have a label without a time with a date of 3/14. The humidifier bottle was not labeled with a date or time. On 4/16/26 at 11:00 AM, V7(Regional Nurse) confirmed that the date on R66's oxygen tubing is 3/14 and that it should be changed out weekly as the order states. On 4/16/26 at 9:50 AM, V6 (Licensed Practical Nursing/LPN) stated that nursing is supposed to date and label the oxygen tubing when it is changed weekly. On 4/16/26 at 9:55AM, V7 (Regional Clinical) stated that the company that they use for the concentrators comes and services/switches out the equipment as needed. V7 also confirmed that the tubing and bottle should be dated and labeled as the order is written when changed weekly. 2. R64's face sheet documents an admission date of 1/11/2024 and includes the following diagnosis: acute and chronic respiratory failure with hypoxia, secondary pulmonary arterial hypertension, and Chronic Obstructive Pulmonary Disorder (COPD). R64's physician orders for April 2026 includes an order to change oxygen tubing and humidifier bottle weekly and initial and date once a day on Saturday. R64's MAR dated 4/1/26-4/20/26 documents that R64's oxygen tubing and humidifier bottle was changed on Saturdays. On 4/14/26 at 11:30 AM, R64 who was alert to person, place and time, stated that her tubing does not getting changed as regular as it used to. R64 stated that there is one nurse that will do it if she is working, but otherwise it never gets changed.On 4/14/26 at 1:09pm, on 4/15/26 at 2:12pm, on 4/16/26 at 9:50 am and on 4/17/26 at 9:25am R64's tubing and humidifier bottle did not have a date/time placed on the tubing or humidifier bottle to indicate when it was last changed. 3. R80's face sheet documents an admit date to the facility of 2/20/23. This same document includes the following diagnosis: Chronic respiratory failure, and anxiety. R80's April physician order sheet includes an order to change oxygen tubing and humidifier bottle weekly and initial and date once a day on Saturday. On 4/14/26 at 11:30 AM, R80 who was alert to person, place and time, stated he has no idea the last time his oxygen tubing was changed. At this time R80's oxygen tubing and humidifier bottle were not labeled with the date and time of the last change. R80's MAR dated 3/21/26-4/20/26 documents that the oxygen tubing and humidifier bottle was changed on Saturdays. On 4/17/26 at 11:30 AM, V1 (Administrator) stated that the oxygen tubing should be labeled with date and time of exchange as the order states.The Oxygen Administration policy with a revision date of 2012 documents in part: The purpose of this procedure is to provide guidelines for safe oxygen administration .tubing is to be changed monthly and as needed if soiled or otherwise compromised .

Based on interview and record review the facility failed to ensure residents were free from resident to resident physical abuse for 3 (R2, R7 and R8) of 3 residents reviewed for abuse in the sample of 9. This failure resulted in R2 being woken up to R1 having R1's hands over R2's mouth and nose while pushing down and with R2 yelling out she was trying to kill me., R7 being kicked in the leg above the knee by R5 and R8 being hit in the back by R5 a few hours later. A reasonable person being held down and potentially suffocated, kicked and slapped would feel fearful, intimidated, and threatened while residing in their home.Findings Include: 1.R2's Face Sheet documented an admission date of 10/31/18 with diagnoses that included other schizoaffective disorders, dorsalgia, unspecified, anemia, unspecified, chronic obstructive pulmonary disease, unspecified, and personal history of traumatic brain injury. R2's Minimum Data Set (MDS) annual assessment dated [DATE], documented a Brief Interview for Mental Status Score (BIMS) of 09, indicating R2 is moderately cognitively impaired. R2's Care Plan documented a focus area of psychosocial well-being; resident is considered at risk for abuse/neglect (per assessment) due to diagnosis of mental illness and forgetfulness. Start date 1/2/24.R1's Face Sheet documents R1 was admitted on [DATE] with diagnosis to include: schizoaffective disorder, bipolar type, and anxiety disorder.R1's Care Plan documents a problem area: resident is at risk for adverse consequence related to receiving antipsychotic medication for treatment of schizoaffective disorder with a start date of 7/10/25. Approach created 7/10/25, asses if the resident's behavioral symptoms present a danger to the resident and or/others. Intervene as needed. R1's Care Plan has a problem area: R1 is considered at risk for abuse/neglect with a start date of 7/9/25. Goal with a target date of 1/2/26, will remain free from secondary abuse.The Facility's Initial and Final Report of Incident documented a resident-to-resident altercation involving R1 and R2 on 12/7/2025 with the final report documenting it was reported to Administration on 12/07/2025 that there was an altercation between two residents living on(behavioral) Unit. An investigation was immediately initiated. R2 alleged that while she was sleeping, R1 came into her room and tried to suffocate her. The investigation of alleged abuse concluded that the altercation did occur due to interviews of both residents even though it was unwitnessed. On 2/17/2026 at 12:20 PM, R2 stated she does remember the incident on 12/7/2025 involving another resident. R2 stated she had been sleeping in her bed when she had woken up with R1 having her hands over her mouth and nose while pushing down. R2 stated that, R1 was trying to kill me. R2 stated when she opened her eyes, R1 backed out of her room while she had been yelling at her to get out of her room. R2 stated, if my television had not been in the way, I would have hit R1, because I was so mad. On 2/19/2026 at 11:16 AM, V12 (Licensed Practical Nurse/LPN) stated she did work the morning after the altercation between R1 and R2. V12 stated, she had been given report by V5 that she had heard R2 yelling from down the hallway and when looking down the hallway, R1 had been coming up the hallway. V12 stated V5 reported R2 yelling that R1 had tried to kill her. V12 stated R2 did tell her that she had been sleeping when she woke up to having R1 hovering over her with her hands over her mouth and nose. V12 stated R2 did tell her she thought R1 had been trying to kill her. V12 stated while R1 had been sitting in the wheelchair at the nurses station she did state that she did put her hands over R2's mouth and nose because R2 was injecting her toenails with something and made a comment about her calendar that did not make a lot of sense. V12 stated, R1 did demonstrate how she put her hands over R2's mouth and nose while talking to her about it. On 2/19/1026 at 11:32 AM, V8 (Psychosocial Case Manager) stated he had been made aware of the altercation between R1 and R2 after it occurred. V8 stated R1 had been crying and stated to her that she had entered R2's room and placed her hands on R2's mouth and nose. V8 stated, R2 did tell her the same information that R1 did. V8 stated R2 notified her that she woke up with R1 standing over her with her hands on her mouth and nose and pushing down. V8 stated R2 was upset and told her that if her television had not been in the way, she would have hit R1. On 2/19/2026 at 1:30 PM, V13 (Registered Nurse/RN) stated she did work the morning after the altercation between R1 and R2. V13 stated she had received report from V5, who stated R1 went into R2's room with gloves on and placed her hands over R2's mouth and nose. V13 stated R2 did tell her the same information while assessing her and doing 15-minute checks. V13 stated R2 had been very upset. V13 stated R1 did not tell her specifically what happened but did tell her that she had planned it out because R2 had been keeping all the fentanyl and it was not fair to anyone else. On 2/19/2026 at 2:00 PM, V5 (Licensed Practical Nurse/LPN) stated she had been working the night of 12/7/2025 when an altercation did occur between R1 and R2. V5 stated she and V6 (Certified Nurse Assistant/CNA) had been sitting up at the nurses station around 2-2:30 AM when she heard R2 screaming down the hallway. V5 stated, when she looked down R2's hallway, she observed R1 standing outside of R2's door and R2 yelling at R1 to get out of her room and she was going to kick R1's a*s. V5 stated she went down the hallway with V6 to assess the interaction. V5 stated R2 notified her that R1 had been in her room and when she woke up, R1 had been standing over her with her hands over her mouth and nose pressing down. V5 stated R1 went to her room and when interviewed about what took place, R1 did not deny putting her hands over R2's mouth and nose while pushing down. V5 stated R1 did have white plastic gloves on her hands. On 2/19/2026 at 3:10 PM, V6 (Certified Nursing Assistant/CNA) stated he had worked the night that R1 and R2 had an altercation. V6 stated he and V5 (LPN) had been sitting up at the nurses station when they heard R2 yelling down the hallway for R1 to get out of her room. V6 stated he looked down the hallway and saw R1 coming up the hallway with medical gloves on and R2 hollering for assistance. V6 stated he and V5 went down the hallway to investigate. V6 stated R2 notified them that she had woken up to R1 having her hands over her mouth and nose and was trying to suffocate her. V6 stated R2 was very upset. V6 stated R1 did go back to her room at that time. V6 stated R1 never denied that she did place her hands over R1's mouth and nose. R2's Progress Note dated 12/7/2026 by V5 (LPN) documented at approximately 0225 (2:25 AM) this nurse heard yelling down the hallway. R2 and R1 were outside R2's room and R2 told R1 to get the f**k out of my room and stay out. V6 CNA went down the hall before me and R2 told him that R1 had placed her hands on her face, mouth and nose and was trying to cut off her breathing. Upon assessing the situation, R2 told this nurse that R1 had placed her hands on her face forcefully and was pushing down trying to kill her. R2 told V6 CNA that R1 thought she had taken fentanyl patches from her. This nurse told resident that we would keep R1 out of her room and to let us know if she needs anything to which resident stated, I will probably just kick her a*s instead. This nurse educated against physical altercation and resident understood. 2. R7's Face Sheet documented an admission date of 06/18/2024 with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, aphasia following cerebral infarction, unspecified dementia, severe, with other behavioral disturbance, bipolar II disorder, schizoaffective disorder, bipolar type, major depressive disorder, recurrent, mild, and anxiety disorder, unspecified. R7's Minimum Data Set (MDS) annual assessment dated [DATE], documented under section B0600, Speech Clarity: Select best description of speech pattern with 2. No speech - absence of spoken words and B0700: with 2. Sometimes understood - ability is limited to making concrete requests. This same document had no BIMS Score suggesting R2 is severely cognitively impaired. R7's Care Plan documented a focus area of resident has communication deficit -expressive aphasia; related to cerebral vascular accident. Start date 6/21/24. Approaches include for staff to anticipate needs. With start dates of 6/21/24. R7 also has a focus area of R7 at risk for pain with a start date of 6/25/24. Interventions to include assess effects of pain on the resident by (disturbances in sleep, activity, self-care, appetite, psychosocial, etc.) Created 6/25/24.R5's Face Sheet documents R5 was originally admitted to the facility 8/30/24 with diagnosis to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a cognitive communication deficit.R5's Care Plan documents a focus area of: resident exhibiting behaviors as seen by, wandering, verbally aggressive, physically aggressive (hitting, grabbing staff and residents), resisting care. Start date 9/30/24The Facility's Initial Report of Incident date 2/17/2026 at 4:30 PM documented a resident-to-resident altercation involving R5 and R7. Detailed incident summary documents reported to this writer of a resident-to-resident alleged altercation. Witnessed by 1 staff member. R5 kicked R7. Residents separated.On 2/20/2026 at 11:12AM, V2 (Assistant Director of Nursing/ADON) stated she had been notified of the altercation between R5 and R7. On 2/20/2026 at 12:25 PM, V17 (CNA) stated she had been working on 2/17/2026 when R5 and R7 had an altercation. V17 stated she had looked down the hallway and saw R5 entering R7's room. V17 stated she went down to R7's room to remove R5 and that is when she saw R5 had R7 blocked in the room with her wheelchair in the corner. V17 stated before she could intervene, R5 kicked R7 above the knee with her foot. R7's Progress Noted dated 2/17/2026 by V19 (Registered Nurse/RN) documents resident was kicked by another resident with no injury noted no c/o (complaints of) or s/s (signs/symptoms) of pain or discomfort and reported to V16 (Physician) and V3 (Regional Director), management aware. R7's Progress Note dated 02/17/2026 by V2 (Assistant Director of Nursing/ADON) documented skin assessment was completed by floor nurse after incident. No skin issues noted. POA (Power of Attorney) and V16 (Physician) notified, V1 (Administrator) also updated. Will continue to monitor. R5's Progress Note dated 2/17/26 at 4:55PM documents R5 kicked another resident and was easily directed. 15 minute checks started.3. R8's Face Sheet documented an admission date of 2/14/22 with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, alzheimer's disease with late onset, other seizures, generalized anxiety disorder, major depressive disorder, recurrent, moderate, paroxysmal atrial fibrillation, delusional disorders, and chronic diastolic (congestive) heart failure. R8's Minimum Data Set (MDS) annual assessment dated [DATE] documented a BIMS of 99, indicating R8 is severely cognitively impaired. R8's Care Plan documented a focus area of at risk of abuse/neglect related to dementia with a start date of 5/27/22. The Facility's Initial Report of Incident documented a resident-to-resident altercation involving R5 and R8 on 2/17/2026 at 7:00 PM. Detail summary documented, reported to this writer of an alleged resident to resident altercation. It was reported that R5 hit R8 in the back. Resident's were separated and assessments were completed. No injuries were noted. R8 was placed on 15-minute checks and R8 is to be kept in the direct line of sight of staff until further notice.On 2/20/2026 at 11:10 AM, V1 (Administrator) stated she had been made aware via phone by V19 (RN) that there was witnessed altercation between R5 and R8. On 2/20/2026 at 12:27 PM, V17 (CNA) stated she had been working on 2/17/2026 and witnessed the resident-to-resident altercation between R5 and R8. V17 stated it was towards the end of her shift when she had been sitting up at the nurses station with R8 sitting in her wheelchair. V17 stated, she witnessed R5 self-ambulate her wheelchair up behind R8 and R5 slapped R8 on her back. V17 stated, she did separate R5 and R8 and notified V19 and V1 (Administrator). R8's Progress Note dated 2/18/2026 by V2 (ADON) documented R8's POA (power of attorney) had been called and updated in regard to altercation around 645pm yesterday evening and updated of incident. All questions answered. V11 (Psych NP) also updated and made aware. Floor nurse completed skin assessment and no new issues. Will continue to monitor. R5's Progress Notes dated 2/18/26 at 10:33AM documents in part, at approximately 6:30PM on 2/17/26 this resident hit a different resident in the back.The facility policy titled Abuse Prevention Program (revised November 26, 2025) documented under Definitions: Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This same document under step 6. Protection of Residents documented the facility will take steps to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and will immediately take appropriate steps to remediate the non-compliance and protect residents from additional abuse.

Based on interview and record review the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for 1 of 3 (R1) residents reviewed for death in the sample of 13. This failure resulted in facility staff not initiating CPR for R1 when R1 was found unresponsive on [DATE]. R1 was found unresponsive by V7 (Certified Nurse Assistant/CNA) and V8 (CNA). V8 notified V4 (Registered Nurse) that R1 was unresponsive. V8 asked V4 if R1 was a Full Code or DNR (Do Not Resuscitate), and V4 responded she did not know. V4 stated she did not initiate CPR because there was nothing in her chart saying R1 was a Full Code or DNR. R1's progress note dated [DATE] documents R1 was a full code. R1 was pronounced dead at the facility by V4 and V6 (Licensed Practical Nurse). This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when facility staff failed to initiate CPR after finding R1 with no pulse and no respirations. The failure resulted in R1 who was without a pulse and respirations not receiving life sustaining measures. R1 was pronounced deceased at the facility.V1 (Administrator), V2 (Director of Nursing) V3 (Regional Operations Director) and V10 (Regional Clinical Director) were notified of the Immediate Jeopardy on [DATE] at 3:36 P.M. This surveyor confirmed by interview and record review the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance.This Past Noncompliance occurred between [DATE] and [DATE].Findings Include:R1's Resident Face Sheet dated [DATE] documents that R1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction due to embolism, acute respiratory failure with hypoxia, acute on chronic diastolic heart failure, type 2 diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, and unspecified intellectual disabilities. R1's Physician Order Summary with a date range of [DATE] - [DATE] does not document a code status.R1's care plan had no documentation of R1's code status.R1's out of state hospital discharge summary with a print date of [DATE] documented under section titled Current Code Status R1 is a full code.R1's Progress Notes document the following on [DATE]:2:26 P.M., report received from out of state hospital. [AGE] year-old female, full code, recent history of stroke on 10/02 and 10/06. Signed by V13 (Licensed Practical Nurse/LPN - Agency).R1's History and Physical dated [DATE] with a time of 2:04 P.M. authored by V11 (Nurse Practitioner) documented under code status Unknown. The same history and physical goes on to document under End-of-Life Treatment Status: none defined.R1's Vital Report documents the following vital signs: [DATE], 7:57 P.M. - temperature 97.6; 7:59 P.M. blood glucose of 115. On [DATE] at 11:48 A.M. blood pressure 128/80.R1's Progress Notes document the following on [DATE]:6:09 A.M., Upon assessment of resident, resident had no pulse, no respirations, no blood pressure at this time. 2nd nurse confirmed findings and time of death was called at 0550 (5:50AM). Called V11 (Nurse Practitioner) at approximately 552 (5:52 AM). Called R1's POA and informed of resident passing at approximately 555 (5:55 AM). Awaiting for the arrival of family to inform this nurse which funeral home she would need to be transported to. Signed by V4 (Registered Nurse).On [DATE] at 11:53 A.M. V7 (Certified Nurse Assistant/CNA) stated that rounds were completed on R1 at 3:00 A.M. on [DATE] and R1 was alive. V7 stated around 5:30 A.M. she and V8 (CNA) went in R1's room to wake her and she was unresponsive. V7 stated V8 went to get V4. V7 stated V4 declared R1 deceased , and she started postmortem care. V7 stated that she is CPR certified but cannot find her card. V7 stated the only way she knows to verify if a resident is full code or a DNR is to get in the electronic medical record to see. V7 stated she was not aware of V7's code status. V7 stated she asked V4 if R1 was a full code or a DNR and V4 responded she did not know. On [DATE] at 11:59 A.M. V8 (CNA) stated V7 and herself were in R1's room at 3:00 A.M. on [DATE] doing a bed check. V8 stated they had gone into R1's room around 5:30 A.M. to get her ready for the day. V8 stated that R1 didn't immediately respond so she went to uncover her to get her dressed. V8 stated when she uncovered R1 she realized that she was deceased and immediately went to get V4. V8 stated that V4 and V6 verified that R1 was deceased . V8 stated that during postmortem care on R1, she realized she wasn't sure if R1 was a full code or a DNR. V8 stated she left the room and went to the nurse's station to ask V4 if R1 was a full code or DNR. V8 stated V4 told her she did not know. V8 stated that she went back to R1's room and finished getting her ready for family to see. V8 stated she is not CPR certified and wasn't sure if she should initiate CPR or not. V8 stated the shift she was working was her third shift at the facility and she was not familiar with R1. V8 stated that R1 was still warm and herself and V7 had to remove a sweatshirt and sweatpants and put R1 in a gown. V8 stated R1 was not stiff at all and changing her clothes was not a problem. V8 stated that R1's room is always cold because she keeps the air on and a fan to help with her breathing. On [DATE] at 10:20 A.M. V4 (Registered Nurse/RN) stated that R1 was her normal self during her shift that started at 6:00 P.M. on [DATE]. V4 stated R1 took her medications and had no complaints of pain or anything. V4 stated that V7 (CNA) and V8 (CNA) had last completed bed check on R1 around 03:00 A.M. on the morning of [DATE]. V4 stated V7 and V8 went into R1's room to provide care and found her unresponsive. V4 stated R1 had no pulse or respirations. V4 stated she then went to the nurses station and called for V6 (Licensed Practical Nurse/LPN - Agency) to verify that R1 had passed. V4 stated that V6 agreed that R1 had no pulse or respirations. V4 stated she left the room and went to the nurse's station to call the nurse practitioner and R1's family. V4 stated she was not familiar with R1 because she had not been at the facility very long. V4 stated she did not realize that R1 was a full code. V4 stated it is not an excuse, but there was nothing in R1's electronic medical record documenting whether R1 was a full code or a DNR. V4 stated since nothing was documented, she assumed that R1 was a DNR. V4 stated that R1 was unresponsive to touch and was warm to touch. V4 stated she now realizes that if you do not know a resident's code status, you should treat them as a full code. On [DATE] at 11:19 A.M. V5 (LPN - Agency) stated she arrived for work on [DATE] around 06:00 A.M. and sat down to get report from V4 (RN), V5 stated that V4 told her that R1 had passed away this morning and she had notified family and nurse practitioner. V5 stated that V4 told her that R1 was a DNR. V5 stated at that point she just started passing morning medications. V5 stated R1's family arrived around 6:30 A.M. and gave the name of the funeral home to the facility. V5 stated that around 08:00 A.M. she called the funeral home. V5 stated around 9:30 A.M. and 10:00 A.M. V2 (Director of Nursing) informed V5 that R1 was a full code and CPR wasn't started on R1. V5 stated V2 told her it was a reportable and to call the coroner. V5 stated that V2 came back to her awhile later and instructed her to call the police. V5 stated she then called the local police department. V5 stated later in the day around 1:30 P.M. V2 told her to call the doctor that V4 had notified, the Nurse Practitioner, and the physician because they all had to be notified per the facility policy. V5 stated that code status is on the banner in the resident's electronic medical record. V5 stated that if you look there it will tell you if the resident is a full code or a DNR. V5 stated R1's code status was not listed there, and CPR should have been initiated. V5 stated V4 said R1 was a DNR, and she did not think anything about checking to verify the code status. V5 stated she is CPR certified and received education the same day. V5 stated she was educated about what to do if a resident is a full code or a DNR and had to sign an in-service sheet.On [DATE] at 11:43 A.M. V6 (LPN - Agency) stated she was working the morning R1 passed away. V6 stated she was the nurse on the delta / garden's unit of the facility. V6 stated she was giving report to the oncoming nurse and heard a page. Upon answering the page, V4 was needing a second nurse to verify a death of a resident. V6 stated nothing seemed out of the ordinary. V6 stated when she got to the east / center unit, there was not a code going on. V6 stated V4 went to the room with her. V6 stated she checked for a carotid and radial pulse then used her stethoscope to verify there were no respirations. V6 stated she confirmed at 5:50 A.M. that R1 had passed. V6 stated that she had no idea that R1 was a full code. V6 stated that she assumed V4 knew the code status of her resident. V6 stated she does not usually work on east / center and was not familiar with the resident.On [DATE] at 12:11 P.M. V2 (Director of Nursing) stated she was made aware that R1 died before she arrived at work the morning of [DATE]. V2 stated she had received a message in the administration chat group that R1 had passed away. V2 stated she had her computer with her so she logged in to see if R1 was coded because she thought that R1 was a full code. V2 stated the nurse did not call her and notify her of the death. V2 stated she got to work around 9:00 A.M. on [DATE] and she asked in morning meeting if they were going to discuss R1. V2 stated she looked at V9 (Social Services Director) and said there was nothing done for R1. V2 stated she was talking to her regional nurse and was having V5 help with notifications. V2 stated she had V5 call the coroner because it was not done yet. V2 stated she also had V5 notify the local police department because this was an unexpected death and reportable. V2 stated she had V5 notify R1's physician because V4 had only notified the nurse practitioner. V2 stated V9 is supposed to complete the POLST (Physician Order for Life Sustaining Treatment) for admissions. V2 stated she thought V9 had spoke with R1 about a code status but could not get it completed. V2 stated the facility policy is that if there is not a POLST in place the resident should be treated like a full code. V2 stated that R1 had been at the facility for 12 days and there was not a POLST completed in that time. V2 stated there are stars outside of the resident rooms by their name plates that have either a green star or a red star. V2 stated a green star means the resident is a full code and a red star means the resident is a DNR. All staff should know about the stars and the code status is listed on the banner in the electronic medical record. V2 stated that her expectation is for the nurse to perform CPR. V2 stated if a resident does not have a code status listed, the resident is to be treated as a full code. V2 stated that through her investigation and interviews, it was brought to her attention that V4 told a staff member that R1 was a DNR. V2 stated that she thinks all nurses and CNA's must be CPR certified. V2 stated that the facility is holding a CPR class on [DATE]th and 12th to get staff who are not certified can get their certification. On [DATE] at 12:38 P.M. V9 (Social Services Director) stated she prefers the residents come from the hospital with the POLST in place. V9 stated that R1 was difficult due to her having behaviors. V9 stated that during her assessment she noted R1 to score a 6 on the BIMS (Brief Interview for Mental Status). V9 stated she did not feel that R1 could sign it at that time and that automatically made her a Full Code. V9 stated she had not gone through all the paperwork from the hospital, but all residents should be classified as a Full Code until the POLST form is signed. V9 said it is common knowledge that if there is no POLST in the chart that the resident is a full code and CPR should be done. V9 stated the code status does go on the banner and any nurse can put the status there. V9 stated that R1 was her own POA (Power of Attorney) and did not feel with her BIMS score that she was appropriate to make those decisions. V9 stated that she had been busy helping in the business office and had not had time to go back and make sure the POLST was completed. V9 stated that once she heard that R1 had passed she was worried that no one had started CPR. On [DATE] at 1:00 P.M. V1 (Administrator) stated she came in around 8:00 A.M. on [DATE]. V1 stated that V5 told her that R1 had passed. V1 stated she asked V5 if R1 was a code or if the ambulance was called and V5 responded no. V1 stated that she was made aware that R1 did not receive CPR by V2 (Director of Nursing). V1 stated that CPR should have been initiated because there was not a POLST form in the medical record. V1 stated that it is not customary to wait a long period of time to complete the POSLT form. V1 stated she is not aware of what the policy says the time frame is on completing the POLST form, but she feels that it should be completed by day 4 or 5 after admission. V1 stated the last CPR training the facility provided was in August of 2025. V1 stated the facility is holding CPR classes on [DATE] and 12th. V1 stated that there was an all-staff meeting scheduled for today [DATE] but it was canceled and rescheduled for next week. V1 stated that staff will be educated on several policies. V2 stated that they have verified that all residents currently residing at the facility have a POSLT form in their chart.On [DATE] at 10:18 A.M. V11 (Nurse Practitioner) stated she saw R1 at the facility. V11 stated she attempted to talk to R1 about several things and R1 would not respond appropriately. V11 stated she did not have the opportunity to talk with R1's family regarding her wishes. V11 stated when she has a resident without a code status, she discusses it with V9. V11 stated that R1 did not have a code status and that automatically makes her a Full Code. V11 stated if there is no code status it is her expectation that CPR should be initiated. V11 stated she has been in healthcare for 40 years and that has not changed. V11 stated that V4 called her on the morning of [DATE] and notified her of R1's death. V11 stated she was still asleep and did not ask any questions because she just thought it was a courtesy call. V11 stated that it is outside of her scope of practice to confirm a death and V4 should have called R1's medical doctor. V11 stated that she was not made aware by V4 that R1 did not receive CPR nor was she made aware of the time of death.On [DATE] at 11:18 A.M. V1 (Administrator) stated V4 was terminated [DATE].On [DATE] at 10:31 A.M. V12 (Detective) stated he was notified by V18 (Sergeant) there was a death at the facility that needs investigated. V12 stated he spoke to V2 regarding the death of R1. V12 stated he was told by V2 that R1 was alive at 3:30 AM on [DATE], and around 5:50 AM R1 was found deceased . V12 stated that the facility did not know if R1 was a full code or DNR. V12 stated that he has concerns on the facilities ability to follow policy. V12 stated that the coroner is not getting notified of deaths that occur at the facility. V12 stated when he spoke to V1, V1 was unaware that a nurse had called the police to report the death. V12 stated he was made aware that her chart was not completed at the time of death. V12 stated he felt that was odd because R1 had been at the facility for 12 days. V12 stated he felt the facility was negligent in the care of R1 and should have initiated CPR when R1 was found unresponsive.Facility policy titled CPR with a revision date of [DATE] documented Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician order and the resident's advance directive. Under section titled Procedure: 1. CPR should only be performed on residents who are found unresponsive, and who are Full code. 2. If the resident is not breathing and does not have a pulse, then you should immediately have another nurse or staff member check the resident's chart for their code status, and of the resident is a full code, announce a code on the public address system with the location of the resident and call 911. 3. If you find a resident who is unresponsive, and the resident is not breathing and has no pulse, but you have not yet determined the resident's code status, then it is acceptable for you to begin CPR.The Immediate Jeopardy that began on [DATE] was removed on [DATE]. The deficient practice was corrected on [DATE] after the facility took the following action to correct the noncompliance:V2 (Director of Nursing), V14 (LPN / MDS) and V20 (LPN) were educated by V10 (Regional Clinical Director) on [DATE] on code status policy, death of a resident and change of condition policy, and the CPR policy.V4 (Registered Nurse) was educated on [DATE] by V2 on Code status policy, death of a resident, change in condition policy, notifications, and CPR policy.V9 (Social Services Director) and V14 completed an audit on [DATE] of all residents to ensure an order for a code status was in place, POLST form was in place and care plan indicates the order appropriately.V3 completed an audit on [DATE] of all staff who are CPR certified and schedule a class for the staff who are not.On [DATE] V3 reviewed the facility policy on CPR. V2 initiated and completed the following in-servicing with all nursing staff on [DATE] on CPR initiation policy including immediate initiation of CPR for all full code residents when unresponsive, documentation of a death, code status when to initiate CPR and change in condition policy.V9 (Social Service Director) will be doing ongoing monthly audit to ensure all code status orders remain accurate and current for 3 months.V2 (Director of Nursing) will monitor daily x 5 days, weekly x4 weeks, then monthly x3 months. Random audits of 3 resident records per week for accuracy of code status and 2 staff interviews to verify knowledge of protocol. Results will be reviewed by V1 (Administrator) and the Quality Assurance Committee monthly for 3 months. Completion date [DATE].

Based on interview and record review the facility failed to prevent resident to resident abuse for 3 of 6 (R1, R3 and R4) residents reviewed for abuse in a sample of 6. This failure resulted in R3 being bit on the wrist by R4, leaving a bruise, and R4 being grabbed by the shirt and slapped on the face by R3. A reasonable person being bit and slapped would feel fearful, intimidated, and threatened.Findings include:1. Facility form titled Long-Term Care Facility-Serious Injury Incident and Communicable Disease Report dated 10/10/2025 documented R3 resides at this facility and has diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety among others. This report documented R4 also resides at this facility and has diagnoses of cerebral infarction, aphasia following cerebral infarction, unspecified dementia, severe, with other behavioral disturbance; bipolar II disorder; Guillain-Barre syndrome; major depressive disorder among others.This same form titled Long-Term Care Facility-Serious Injury Incident and Communicable Disease Report dated 10/10/2025 documented under Detailed Incident Summary-Final: It was reported to Admin (Administration) on 10/10/2025 that two residents living on the (dementia unit) had an altercation. Staff witnessed (R3) grab (R4) by the shirt and slap (R4) across the face. (R3) stated that (R4) was in (R3's) room and she (R3) was walking (R4) out. (R4) bit (R3) on the wrist and (R3) grabbed (R4) by the shirt and slapped (R4). Residents were immediately separated and placed on 15-minute checks for 24 hours with no further incidents.On 10/20/2025 at 1:45pm, V7 (CNA) said she was working the dementia unit on 10/10/2025. V7 said around 3:00pm, she seen R4 and R3 starting to have issues, but they were down at the end of the hall, but she could see them well. V7 said R3 and R4 were grabbing towards each other and R3 slapped R4 on the face because R4 had bit R3 on the wrist. V7 said V5 (Licensed Practical Nurse) was also a witness.On 10/20/2025 at 1:55pm, V5 said she witnessed R3 grab R4's shirt and then slapped R4 across the face. V5 said she asked R3 why she hit R4 and R3 replied She was in my room, and I was walking her out and she bit me. V5 said R3's left wrist had a small, bruised area but was not open or bleeding. V5 said R4's face was not injured but R4 had a small bruise on the right upper arm that she felt may have been caused by R3 grabbing R4's shirt, but she wasn't sure. V5 said R3 and R4 were immediately separated with no further issues.On 10/22/2025 at 8:43am, R4 was noted to be edentulous. On 10/22/2025 at 8:45am, when asked, V15 (CNA) verified R4 did not have teeth.Facility policy titled Abuse Prevention Program (revision date 9/29/22) documented in part, Abuse is (defined as) the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish and willful means the individual must have acted deliberately. This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment.2. R1's Care Plan documented admission to the on 3/9/2024 and included diagnoses of dementia with other behavioral disturbances and anxiety disorder. R1's Care Plan documented on 3/9/2024, R1 has focused problem areas of wandering behaviors, at risk for injury related to impaired safety awareness, cognitive impairment due to dementia and at risk for falls due to history of falls, cognitive impairment and decreased strength and endurance.R2's Care Plan documented admission to this facility on 9/23/2025 and included diagnoses of dementia without behavioral disturbance, Diabetes type 2, history of traumatic brain injury, bipolar and major depressive disorder without psychotic features. R2's Care Plan documented on 9/23/2025, R2 has focused problem areas of new to facility, needs to adjust to new environment, needs assistance with activities of daily living, and at risk for falls due to history of falls and cognitive impairment. On 10/9/2025, R2's Care Plan was updated to include a new focused problem area of behaviors of wandering and physical aggressiveness towards other residents.On 10/20/2024 at 8:45am, V1 (Administrator) said R2 was recently admitted to this facility on 9/23/25 from a sister facility. V1 said R2 has dementia and has severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 4. V1 said nothing in R2's transfer paperwork documented any previous aggressive behavior and specifically documented R2 was non-aggressive but needed a more secure unit due to high elopement risk. V1 said the sister facility was not secure enough for R2's needs. V1 said R2's family agreed to R2 transferring to this facility and R2 was admitted to the dementia unit. V1 said since being admitted , R2 has not shown any aggressive behavior and has not been involved with any incidents or peer-to-peer altercations until 10/9/2025 when R2 hit R1. V1 said after the incident, R2 was placed on 1:1 supervision and moved to a different secured unit in the facility. V1 said R2 is doing well on the new unit and has not had any issues or aggressive behaviors. V1 said the incident between R1 and R2 was witnessed by V10 (Wound Care Nurse), V3 and V4 (both Certified Nursing Assistants/CNAs).On 10/20/2025 at 12:30pm, V3 said on 10/9/2025 around 2:00pm, she was in the hallway on the dementia unit. V3 said she could see R1 walking down the hallway and was by R2's bedroom doorway. V3 said R2 came out into the hallway and hit R1 on her right shoulder. V3 said R1 took a few steps then lost her balance, fell towards the wall and to the floor. V3 said she told V4 to go get the nurse while she stayed with R1 and R2 went and sat on his bed. On 10/20/2025 at 1:00pm, V4 said she also witnessed the same event. V4 said she was a few feet away from R1 and R2 when she saw R2 hit R1 on the shoulder. V4 said R1 took a few steps away, lost her balance, and fell to the floor. V4 said R2 went and sat down on his bed, and she ran to get the nurse (V10). V4 said when she returned, she asked R2 why he hit R1 and R2 answered, I thought she was going in my room. I was trying to keep her out of my room.On 10/20/2025 at 12:15pm, V10 said when she arrived, R1 was sitting on the floor in the hallway. V10 said R1 was not bleeding but she felt R1's right leg looked injured. V10 said she called 911 got R1 sent to the hospital where it was determined R1 had a broken right hip. V10 said R2 was immediately placed on 1:1 supervision and the next day was moved to a new unit. V10 said she had not seen any aggressive behavior or issues with R2 since he was admitted to this facility.Facility form titled Long-Term Care Facility-Serious Injury Incident and Communicable Disease Report dated 10/9/2025 documented under Detailed Incident Summary-Final: It was reported to Administrator by Wound Nurse of a resident-to-resident altercation. (R1) was walking by (R2's) room when (R2) stepped out and hit (R1) in the right side of her shoulder and face. (R1) fell on her left side. Residents were immediately separated, and (R1) was assessed by the nurse and transported to the hospital with a right hip fracture. (R2) was moved to the (name of behavioral unit) before (R1) returned to the facility. One on one supervision with (R2) was initiated immediately. Check ins with Social Services were also initiated. No further aggressive behaviors have been observed since the incident. Families, Police and MD were notified.Hospital records for R1 dated 10/9/2025 documented R1 presented to the emergency room via EMS (emergency medical service) for right hip pain. SNF (Skilled Nursing Facility) reports patient was pushed down, landed on right hip with immediate pain with movement to RLE (right lower extremity) and unable to get up post fall. On arrival with RLE shortening and external rotation. These same hospital records documented on 10/10/2025, R1 underwent right hip fracture repair procedure where a right intramedullary rod was inserted to repair the fracture.

Based on interview and record review, the facility failed to provide proper resident supervision during ambulation for 1 (R1) of 3 residents reviewed for accidents in the sample of 6. This failure resulted in R1 falling and sustaining a fracture to the right arm and elbow. Findings included: R1's Face Sheet documented an admission date of 8/25/2025 and diagnoses including unsteadiness on feet, metabolic encephalopathy, nondisplaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, wedge compression fracture of thoracic11-12 vertebra, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.R1's Minimum Data Set (MDS) dated [DATE] documented in section C, that R1 had a BIMS (Brief Interview of Mental Status) of 7 indicating R1 had severe cognitive impairment. This same MDS documented under section GG- Mobility that R1 is dependent, which means helper does all of the effort. Resident does none of the effort to complete activity, or the assistance of 2 or more helpers is required for the resident to complete the activity.R1's Care Plan documented a focus area of Falls with a start date of 8/26/25. Resident at risk for falling related to: history or falls, cognitive impairments, communication impairments, decreased safety awareness, difficulty using call light and/or requesting staff assistance, requires ADL (Activities of Daily Living) with transfers and mobility, incontinence, decreased strength and endurance and use of psychotropic drugs.R1's Fall Risk assessment dated [DATE] documented resident as a high risk for falls. R1's Physical Therapy Evaluation and Plan of Treatment dated 8/26/2025 documented under function mobility assessment of R1, walk 10 feet; dependent, distance; not applicable; assistive device; two-wheeled walker; assistance needed = max assistance x2, walk 50 feet with two turns; dependent, walk 150 feet; dependent, walking 10 feet on uneven surfaces; not applicable.The facility's Incident Report dated 9/1/2025 with the final investigation documented R1 had a witnessed fall in hallway staff was unable to reach resident to prevent fall. R1 sent to local emergency room at 4:02pm and sent back to the facility with a cast to right arm and orthopedic to follow.The local emergency room After Summary visit dated 9/1/2025 documented an imaging result of R1's right elbow with a comminuted fracture of the proximal humerus and mildly displaced fracture at the base of the olecranon process at the elbow. R1's Progress Note by V4 (Licensed Practical Nurse/LPN) dated 9/1/2025 at 4:11 AM documented at 1:50 AM, V5 (CNA) notified her that R1 had a fall in the hallway outside of his room. V4 documented that V5 stated, R1 stood up and fell before he could get to him with his walker. R1's Progress Note by V6 (LPN) dated 9/1/2025 at 4:06 PM, documents she had received a call from the imaging company that R1 did have a fracture present in elbow and shoulder. V6 documented ambulance was contacted at 1:50 PM and R1 left the facility via ambulance to local emergency room. On 9/11/2025 at 12:30 PM, V3 (Certified Nurse Assistant/CNA) stated, she did work the night R1 did have his fall on 9/1/2025. V3 stated, she had been up at the nurses' station around 1:50 AM on 9/1/2025, after completing resident bed checks and documenting her rounds while V5 (CNA) had been with R1 in the hallway down by R1's room. V3 stated, R1 had stood up from his wheelchair and had been walking. V3 stated, V5 (CNA) did attempt to get R1's walker, but R1 stumbled and fell into the handrail. V3 stated, V5 did reach out to grab R1 after he hit the handrail, so he did not hit the floor. On 9/11/2025 at 12:47 PM, V4 (Licensed Practical Nurse/LPN), stated she had been the nurse working the night R1 had his fall on 9/1/2025. V4 stated, she had been taking care of another resident when V4 (CNA) came to get her to assess R1. V4 stated, R1 had been sitting in the hallway with his feet stretched out in front of him on the floor. V4 stated, she was notified by V5 (CNA) that R1 stood up from his wheelchair while holding the handrail and when V5 turned to go get R1's walker from his room, he noticed R1 stumbled and fell into the handrail. On 9/11/2025 at 1:30 PM, V6 (LPN) stated, she did have direct patient care with R1 the day he had his fall event on 9/1/2025. V6 stated, she was given report by V13 (LPN) that R1 had fallen on the night shift and had been complaining of right arm pain and swelling present. On 9/11/2025 at 2:16 PM, V5 (CNA) stated, he did work on the night R1 had his fall event on 9/11/2025. V5 stated, around 1:50 AM, he was trying to get R1 to sit back down in his wheelchair while walking in the hallway. V5 stated, R1 was standing and had a grip on the handrail. V5 stated, he then moved the wheelchair behind R1 and locked the wheels. V5 stated, he took 2 steps towards R1's room that is a couple of feet away, behind where R1 had been standing to get R1's walker. V5 stated, when he was a few feet away from R1, R1 stumbled and hit his right elbow on the handle rail. V5 stated, R1 is unsteady on his feet and requires assistance with mobility. On 9/11/2025 at 11:24 AM, V12 (Certified Occupational Therapy Assistant/COTA) stated, she actively works with R1 in therapy services. V12 stated, R1 had been admitted to the facility with a right hip and back fracture related to a fall. V12 stated, R1 is not safe to be left to self-ambulate and in her opinion R1 should not be left alone when attempting to stand or while standing. On 9/11/2025 at 2:45 PM, V6 (LPN) stated, R1 is unsteady on his feet and very impulsive. V6 stated, R1 should not be left unassisted while standing or walking. On 9/11/2025 at 2:54 PM, V1 (Administrator) stated, R1 is unsteady on his feet. V1 stated, it would be her expectation that V5 (CNA) remained with R1 and had another staff member bring him R1's walker. On 9/11/2025 at 3:10 PM, V2 (Director of Nursing/DON) stated, R1 is not steady on his feet and should not be left unassisted when standing or walking. On 9/11/2025 at 3:18 PM, V7 (Physician) stated, R1 is unsteady on his feet and should not be walking or standing without assistance. V7 stated, V5 (CNA) should have remained at R1's side and not left him unassisted. The facility's Fall Management Policy (revised 2018) documented under Policy: it is the policy of (Name of Facility) to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measure which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Sample interventions for high-risk patients.use gait belts for all non-mechanical lifts and assists with transfers .

Based on observation, interview, and record review the facility failed to ensure residents were assisted with activities of daily living (ADL's) and call lights were answered in a timely manner promoting dignity for 3 of 5 (R3, R4, R5, R10 and R13) residents reviewed for dignity in the sample of 26. This failure resulted in R13 asking for assistance to toilet for at least 35 minutes while in the dining room and common area and subsequently having an episode of incontinence. R13 was visibly upset and crying out for help during this 35-minute time frame. This would cause any reasonable person to feel embarrassed and humiliated. Findings include: 1. R13's Resident Face Sheet with a print date of 5/6/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia, moderate, with anxiety. R13's MDS (Minimum Data Set) dated 2/5/25 documents a BIMS (Brief Interview for Mental Status) score of 01, indicating R13 has a severe cognitive deficit. This same MDS documents R13 is frequently incontinent of urine and bowel and requires substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfer. On 5/6/25 from 12:25 PM until 12:58 PM this surveyor conducted continuous observation of the common area/dining room. At 12:25 PM, when this surveyor entered this area, R13 was sitting in the dining room in her wheelchair talking with V25 (Patient Aid/PA). R13 asked V25 to take her to the bathroom. V25 responded to R13 that she couldn't but they (Certified Nursing Assistants/CNA's) would take her as soon as they could. V25 told R13, They can't stop feeding residents to take you. R13 continued to ask V25 who then told R13, They can't take you right now. They will take you as soon as they can. At 12:27 PM, R13 stopped an unknown staff member who entered the unit and asked them where she was supposed to go. R13 told this staff member she was about to pee my pants. This unknown staff member told R13 they would get to her as soon as they could. At 12:29 PM, R13 self-propelled her wheelchair out of the dining room and through the common area surrounding the nurse's station. R13 was crying out, I got to go to the bathroom. Why can't I go to the bathroom. Someone help me. R13 was visibly upset. V21 (Dietary Manager) entered the unit and R13 said Help me someone, help me. V21 told R13 she would get someone to help her. Throughout this observation, V22 and V23 (Certified Nursing Assistants/CNA's) were feeding residents in the dining room. At 12:31 PM, R13 yelled, Help, I am going to pee in the floor. R13 continued to yell for help. At 12:35 PM, R13 stated, It is an awful place when you can't get waited on in the nursing home. At 12:44 PM, R13 asked for help again with no response from staff. At 12:48 PM, R13 cried out, Help, help, help. At 12:49 PM, R13 told V21 (Dietary Manager) Help me, help me. I just peed myself. V21 moved R13's wheelchair next to a chair in the common area and sat down next to R13 and began to talk with her. R13 was visibly upset throughout this observation. On 5/6/25 at 12:59 PM, V22 (CNA) stated R13 yells out for help even if the staff have just taken her to the bathroom. V22 stated she had been told R13 was asking to toilet, and she would take her after she charted lunch. On 5/6/25 at 1:02 PM, V23 (CNA) stated they had three CNA's when they came to work this morning but one got sick and had to leave early. V23 stated they currently have two CNA's and one PA working. When asked if that was enough staff to meet the residents needs timely, V23 stated, No. V23 stated, We had people hollering to go to the bathroom while we were feeding, and we aren't allowed to stop feeding to take them to the bathroom. V23 stated they had taken R13 to toilet right before lunch (around 11:00 AM). V23 stated R13 hollers out a lot but she can tell when she urinates. On 5/6/25 at 1:13 PM, this surveyor reviewed the observation with V24 (LPN/Licensed Practical Nurse) and V24 stated R13 yelled out for help frequently and was previously on a bladder training program. V24 stated staff need to stop what they are doing and help. When asked if they were allowed to stop feeding residents to provide needed care to other residents, V24 stated she only worked on Tuesdays, so she wasn't sure if something had changed but they used to stop and help residents. On 5/6/25 at 1:31 PM, V25 (PA) stated she is not allowed to provide direct resident care, she is only there for extra eyes and support. V25 stated R13 constantly asks to go the bathroom, even after they have just taken her. On 5/6/25 at 1:37 PM, V26 (CNA) stated she clocked in for her shift at 1:00 PM and took R13 to the bathroom. V26 stated R13 had feces in her incontinence brief, and it was soaked with urine. V26 stated she also had to change R13's pants because they were wet. On 5/6/24 at 2:58 PM, V2 (Director of Nurses/DON) stated V22 (CNA) should have taken R13 to the bathroom instead of charting lunch. V2 stated they don't stop feeding because the meal will get cold, but someone should have taken over with feeding residents so the CNA's could have provided care. The facility Quality of Life Dignity policy dated 2/2012 documents, Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Procedure: .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance . 2. On 5/6/25 at 9:37AM, R3, who was alert and oriented to person, place, and time, stated she has lived here a few years at least. R3 stated that the call light wait times are too long. R3 stated, Sometimes I even take myself to the bathroom because they don't answer it soon enough, and I don't want to have an accident. They (the staff) get mad at me, but I don't want to have an accident. 3. On 5/5/25 at 11:41AM, R10, who was alert and oriented to person, place and time, stated, Sometimes during lunch hour my call light can be on for an hour or longer. 4. On 5/6/25 at 9:20 AM, R5, who was alert and oriented to person, place, and time, stated that call light wait times have improved in the past two months but are still too long. She said there are residents who require two CNA's (Certified Nurse's Aides) to assist them, and that takes away from staff that can answer call lights. She says they only have two CNA's on her hall, and they need three. 5. On 5/6/25 at 9:26 AM, R4, who was alert and oriented to person, place, and time, stated that call light wait times are too long. R4 stated that on average it takes fifteen minutes to get them answered, sometimes longer. R4 stated that call light wait times are worse on evening shift when they have less staff. 6. Resident council meeting minutes dated 1/30/25 documents call light wait times as a concern for the residents. On 5/7/2025 at 11:52 AM, V1 (Administrator) stated that he would consider a reasonable amount of time to wait for a call light to be answered as ten to fifteen minutes at most. When asked if he thought that it was appropriate for a resident to take herself to the toilet without assistance, knowing that she needs assistance, but unable to wait for staff to answer her call light because of fear she may have an episode of incontinence, V1 stated no, that was not acceptable practice for assisting residents with toileting needs. Facility's call light policy dated July 2014 in step 8 under heading General guidelines documents, Answer the resident's call as soon as possible.

Based on interview, observation, and record review, the facility failed to prevent a cognitively impaired ambulatory resident (R1) from exiting the facility unwitnessed and without staff supervision for 1 of 3 residents reviewed for elopement in the sample of 3. This failure resulted in R1, unknown to staff, exiting the facility and walking approximately one block away, falling and sustaining a skin tear over his left temporal region and scattered abrasions over both hands, wrists, and elbows, and then entering a private citizens unlocked vehicle. R1 was treated at the local ER (emergency room ) for the skin tears and released later that evening. The Immediate Jeopardy began on [DATE] between 6pm and 6:18pm when R1 exited the facility's Dementia Care Unit unsupervised, walked about a block away, fell in the street, gained access to an unlocked vehicle, and was then found by police, bleeding from the head and confused about his whereabouts. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 3:32pm. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's Face Sheet documented an admitted [DATE] and listed Diagnoses including Alzhiemer's Disease and Hypertensive Heart Disease with Heart Failure. R1's Minimum Data Set (MDS) dated [DATE] documented that R1 is severely cognitively impaired, wanders, and exhibits behaviors not directed toward others. The same MDS documents that R1 has no impairments in upper or lower body range of motion and requires partial to moderate assistance for walking. R1's current Care Plan documented a problem area, Problem start date: [DATE]. Resident is at risk for injuries due to exit seeking behaviors. Attempts to exit the building unattended. ELOPEMENT RISK. Approach includes: Re-direct as needed/cues; Notify all staff of residents tendency to seek exits; Diversional activities as tolerated; Check residents whereabouts; all with a start date of [DATE]. Staff to Initiate 30-minute checks, with start date of [DATE]. R1's Elopement Evaluation date [DATE] documents R1 is cognitively impaired, poor decision-making skills, and/or pertinent diagnosis (Example, dementia, Organic Brain Syndrome, Alzheimer's, delusions, hallucinations, anxiety disorder, depression, manic depression, and schizophrenia). R1's evaluation documents R1 has a history or wandering (into unsafe area), makes statements that they are leaving and displays behavior(s) that may indicate an attempt to leave, body language etc., indicating an elopement may be forthcoming. R1's evaluation documents resident is at risk for elopement, elopement care plan initiated. A Power of Attorney (POA) Health Care form dated [DATE] listed V11 as R1's POA. A Police Report dated [DATE] at 6:18pm documented, in part, On [DATE], I, (V6, Police Officer) was off-duty, when I viewed an older male sitting in the drivers seat of a Chevrolet SUV in the (name of street located 0.2 miles away from the facility) with what appeared to be blood coming from the left upper head area. As I went around the block to come back to the male subject, I called (local city) dispatch on what I viewed and kept them on the phone while I made contact with the male in the vehicle. Before approaching the vehicle, I gave the Illinois registration information to dispatch. Once at the vehicle, the male opened the drivers door, and I viewed scrapes on the palm of his right hand, skin tears that were open and bleeding, and a laceration on the outer left eyebrow area. I requested an ambulance come and check on the male, with dispatch toning out an ambulance to my location. At this time I hung up with dispatch and stayed with the male. While speaking with the male, I learned his name was (R1) and that he had fallen down in front of his vehicle. (R1) advised that he was just sitting in his car for a minute, but he was ready to go now. I viewed (R1) not to be responding correctly, and he did not seem to know where he was at. When I asked (R1) what his address was, he could not tell me and said that 'he lived on that street over there.' I asked (R1) why he was out of his vehicle and how he fell down, he advised 'that he was working on a house and was going home now.' At this time (R1) began reaching for the ignition, but I got his attention back to me advising him that I wanted him to get checked out by the medics before he goes home. (R1) then advised that this was ok, and began thanking me for stopping and helping him. I was then able to reach across the steering column and feel for ignition keys, but they were not there. At this time (R1) told me that they were probably out in the road where he fell , then pointing to the (name of two streets) intersection. At this time (name of responding Officer) was arriving on scene, as well as (name of local ambulance). I advised Medic (name of medic) on the injuries to (R1) and how he didn't know where he was, then recommending he get transported to (name of local hospital). I then went and checked the intersection (R1) pointed to to (sic) see if there were keys out there. No keys were found in the road, at the intersection, or around the vehicle that (R1) was found in. I then decided to contact (Name of Long Term Care Facility), being approx a block away and asked to speak to a supervisor. Once a supervisor got on the phone, I advised them who I was and asked if they knew a (R1). The supervisor advised that (R1) is a resident in their Alzheimer's wing. I advised that supervisor that (R1) is currently a block away from their facility, . being loaded up in an ambulance. I was then told that they would have someone there shortly. Approx 10 minutes later, two staff members arrived at my location and advised that they do not work on the wing where (R1) resides, but actually work on the behavioral wing, but were familiar with (R1). Both looked into the open rear door and advised that the male was in fact (R1). At this time one of the staff members asked who had found (R1), and I advised that I had. I explained to them who I was and who I worked for and that I would be making a report on the matter once I am back on duty. They understood and advised me that they would have their boss contact me on Monday ([DATE]). At this time that ambulance transported (R1) to the hospital to address his injuries, and I left the scene along with everyone else .On [DATE], . I then called (name of Long Term Care Facility) and spoke (to) Administrator (V1). I advised (V1) of who I was and who I work with, and how I was actually on scene this weekend when (R1) was found. (V1) advised that from what they have put together, (R1) was there for dinner and then left and was gone for approx an hour. I asked if their doors have alarms on them and he advised that they do and they are all operating and in working order. (V1) stated that there was a screen off from one of the windows on the front of the building and believe him to have exited out of this window . Emergency Department Provider Notes dated [DATE] at 7:39pm documented, [AGE] year old male who presents to the emergency department for evaluation of a ground level fall. Reportedly the patient lives in the Dementia Care Unit at a local skilled nursing facility and escaped (from) the unit. He reportedly was running, tripped and fell on the street. Emergency Management System was called and the patient brought into ER (emergency room ) for evaluation. Skin: Skin tear over left temporal region. Scattered abrasions over hands, wrists, and elbows bilaterally. No lacerations. The patients labs, EKG (Electrocardiogram) and imaging were reviewed and reveal no significant findings as read by the Radiologist. We will discharge him back to his skilled nursing facility. Nursing Progress Notes documented the following: [DATE] at 11:05am: (R1) is exit seeking this am (morning). He is going to the front door and then is redirected and then the backdoor. When I asked what he was doing he stated, I am trying to get home. I showed him his room and where he stays. He then said Bulls**t, and walked off. He requested a ride home from me. I declined and told him I did not drive. He walked away. [DATE] at 1:18pm: Resident continues to try to go out the doors and wanting someone to let him out. This writer was going into the medication room to get a few supplies and resident stated, Give me the keys. Politely said that is not possible. Resident said, Let me try the keys to get out. Politely again stated no that the keys are not used for that. Resident still wanted the keys but he did not ask again. Resident is currently in his room watching TV. [DATE] at 4:30pm: Resident has been slapping the tables, laughing out at random times, and trying to leave out the side doors. He is difficult to redirect and states he is trying to get to his car. I redirected resident to common area and provided him with vanilla pudding. Resident has been making sexual comments to other female residents and telling them he thinks they look real good and puckering his lips. Resident redirected to disengage conversation. [DATE] at 5:00pm: Resident continues trying to exit out the side door, it took this writer and CNA (Certified Nursing Assistant) to redirect resident from the door. Resident stated to me Hey, you look good and leaned in for a kiss. I politely declined and redirected resident to a chair near the nurse's station. Resident began yelling out and laughing. I asked resident to please stop yelling as this is upsetting the other residents. [DATE] at 8:57pm: Call received at approximately 1830 (6:30pm) from off duty police officer identified as (V6). States he has a gentleman who says his name is (R1). This nurse has advised there is a resident by that name. (V6) is advised this nurse will come to sight (sic) and identify resident. On arrival at location as directed by (V6). Individual is identified as (R1). Ambulance has arrived on scene prior to this nurse and (R1) is on gurney in sitting position with safety buckles on. Calm demeanor. Note head laceration left scalp et (and) minor abrasions on left f/a (forearm). Ambulance has advised will transport to (name of local hospital) for evaluation due to possible head injury. Reported to (V2, Director of Nurses) et have given report to (V1), Facility Administrator. Call received for report from (name of ER Nurse). Resident stable w (with) all x-rays negative . Resident has stated he was looking for someone when he was walking and he fell in the gravel somewhere. (V2) notified for update. [DATE] at 9:34am: Report received from (V3, Registered Nurse). Resident returning to facility from (name of local hospital). VS (Vital signs) stable. Awaiting arrival back to facility. [DATE] at 11:04pm: Resident up walking in hall. Redirected to bedroom. Resident assisted to bathroom. He states I'm not tired, I want a snack. I responded politely that he just ate a snack and should try to get some rest. Resident agreed and was assisted back to bed, shoes removed, and lying comfortably in bed. A/O x1. (alert only to self) Speech clear. Answers questions appropriately. [DATE] at 12:00am: Resident up ambulating in halls and common area. I observed him in the common area refrigerator; redirected resident to area next to nurse's station. Resident began asking for another snack; redirected patient back to room. Resident ambulated back to nurse's station complaining of a headache, he states his head pain is bad. I gave resident Tramadol 50mg (milligrams) .for head pain. Resident then ambulated back to refrigerator and opened it and tried to grab an apple. I shut the door and discussed he cannot have a whole apple and redirected resident back to nurse's station. CNA helped resident back to bed and resident is lying comfortably in bed. A Neurological Observations Form documented that R1 received neurological checks, all of which were within normal limits, as follows: [DATE]: Every 15 minutes from 10pm to 11pm. [DATE]: Every 30 minutes from 11:30pm to 12am. [DATE]: Every hour from 1am to 3am. [DATE]: Every four hours from 7am to 11am. A 30 Minute Checks Sheet documented that R1's thirty-minute checks were initiated on [DATE] at 11:30am. An Event Report-Safety Events-Elopement dated [DATE] stated, Event date: [DATE] at 6:30pm. Where and when was resident found? (Name of street that runs behind the facility.) Did resident sustain any injury during the elopement period? Left scalp laceration and left forearm skin tear. Mental status, describe if necessary: As reported to this nurse, resident has participated in negative behavior throughout the day, opening doors, banging on furniture, agitating staff and other residents, loud yelling and exaggerated loud laughing. Interventions: As reported to this nurse, staff unable to redirect throughout shift, behaviors have escalated with louder yelling, looking for his keys to his car and motorcycle. Anger expressed over diet. Evaluation: Elopement Care Plan updated and door handle changed. A Daily Assignment Sheet dated [DATE] documented one nurse and 2 CNA's (V7 and V8) working on the Dementia Care Unit on the 7am to 7pm shift. An IDPH (Illinois Department of Public Health) final Investigation dated [DATE] documented, This is a Final Investigation regarding the report of a resident elopement on [DATE]. (R1) a [AGE] year old male with a diagnosis of Unspecified Dementia was located at the corner of (name of intersection) at the back side of the facility by an off-duty police officer at 6:35pm. (R1) was seen in the dining room of the (name of Dementia Care Unit) at 6:09pm by (V4, Licensed Practical Nurse) and at 6:15 by the CNA on duty. From investigations, (R1) had mentioned that day that he wanted to leave and find his vehicle. Redirection was given to (R1) according to Care Plan and behavior had stopped. (R1) opened door to front office door between 6:15 last time and 6:36 time phone call made to facility by off-duty police and climbed out of the window. The front office on that unit was unlocked and the screen was out of the open window. (R1) was sent to (name of local hospital) for evaluation. (R1) had a Power of Attorney, Medical Doctor, and police notified. Resident Care Plan updated upon return to include 30 minute checks. Resident remains in facility with no other incident. On [DATE] at 9:27am, V6 stated he was off duty and headed home when he observed an elderly man looking confused and with a bloodied head, sitting in a vehicle parked in front of a residence. V6 stated the man's foot was on the brake but there were no keys in the ignition. V6 stated the man was unable to answer most questions and it was very obvious he was cognitively impaired. V6 stated the man had skin tears on both arms, blood on his face from a laceration over his left eye, and abrasions to his right hand When asked about the injuries, he told V6 he fell . He stated to V6 he had been working on a house nearby and he was headed home. When asked where he lived he couldn't answer with an address but pointed and said, over there. V6 called EMS, and when they responded, one of the Paramedics recognized the man as R1, whom he had previously transported to the hospital. V6 stated he phoned the facility and asked for a supervisor, who confirmed R1 was a resident. V6 stated then 2 staff members responded to the scene and positively identified R1. V6 stated when he spoke to V1 on [DATE], V1 stated they had determined that R1 pushed out the screen of a window to elope. On [DATE] at 10:15am, V1 stated there is no video surveillance anywhere in the facility. On [DATE] at 11:35am, V4, Licensed Practical Nurse (LPN) stated she worked on the facility's Dementia Care Unit on [DATE] from 2pm to 10pm. V4 stated she had been told in report that R1 had been having increased behaviors. V4 stated from 2pm on, R1 displayed behaviors of verbal aggression, exit seeking, yelling for his keys, car, and motorcycle, yelling at and mocking other residents, and doing laps around the unit, pushing the exit doors and activating the alarms. V4 stated she had to block R1's attempts to elope by getting between him and the exits several times. V4 stated redirection with snacks, drinks, and diversion did not work at all. V4 stated she was working with 2 CNA staff and there was a lot to do with 25 residents on the unit, most of whom have behaviors, are incontinent, and require maximal assistance with ADL's (Activities of Daily Living). V4 stated after supper, at about 6:00pm, R1 was in the dining room and she gave him his scheduled medications. V4 stated she then had been sitting at the nurses station within eyesight of R1, and the 2 CNAs were doing a mechanical lift on another resident down the hall. V4 stated she left the nurses station to assist a resident and, The next thing she knew, V3, Registered Nurse, was telling her she needed to do a head count, because the police had found (R1) outside the facility. V4 stated she was surprised R1 eloped as all the exits are alarmed. V4 stated it is her understanding that apparently activity staff left an unlocked door to a small office next to the front exit, and when she and other staff checked the unit, they noticed the window in the office was open and the screen was out and laying on the ground. V4 stated she believes R1 is physically capable of climbing out a window, and it probably took R1 less than a minute to get out. V4 stated she did not have a key to that office, doesn't know who does, and has never tried to open it. V4 stated her shift ended at 10pm, which was approximately the time R1 returned from ER. V4 stated she stayed with R1 until he fell asleep at about 2am because upon his return he continued to have exit seeking behavior. V4 stated she contacted V11 (R1's POA) when R1 returned from ER and informed her R1 had gotten out of the facility, had fallen, was treated at the ER for minor injuries and had returned to the facility. V4 stated after the elopement, all residents at risk for elopement on that unit, which is the majority of them, are now on every 30-minute checks to be documented in the Elopement Binder. V4 stated if the office door had been locked, and/or if they had had another CNA or perhaps a Unit Aid, they could have provided increased supervision for R1 and he would not have eloped. On [DATE] at 12:10pm, V7, CNA, stated on [DATE] she worked 7am to 7pm on the Dementia Care Unit. V7 stated all shift, R1 was exit seeking, saying sexual things to and trying to grab staff, and asking for his motorcycle saying he was, Getting out of here. The off going shift said he had been displaying these behaviors on their shift also. V7 stated for redirection, she tried snacks, talking to R1 one to one, frequent toileting, his favorite TV shows, and playing music for him, but nothing worked. V7 stated R1 displays these behaviors often, and they fluctuate from day to day. V7 stated for the past couple of weeks, his behaviors have been worse. V7 stated on [DATE] she recalled seeing R1 after dinner sitting in the dining room at about 5:30pm. V7 stated at some point after 6pm, she heard other staff talking about R1 having eloped. V7 stated when it was discovered R1 eloped, she checked the unit and it was discovered that a small office used for storage had the door unlocked, the window was open and the screen had been pushed out. V7 stated she assumes R1 climbed out the window. V7 stated looking back, when R1 pushed on the exit doors on the north and south sides of the building, the alarms were working. V7 stated she does however think R1 has figured out that if you push on the alarmed doors they will open after 15 seconds, but stated they did not hear any door alarms going off when he was out of staffs sight. V7 stated the following day when she came to work, there was an elopement book that all elopement risk residents are to be charted on every 30 minutes. V7 stated having more staff could have prevented R1's elopement, even if it was a Unit Aid or an Activity Aid. V7 stated she feels R1's behaviors are aggravated by boredom. V7 stated multiple staff have told administration they need more help on the unit but are told the Corporation who owns the facility says they are not needed. On [DATE] at 11:25am, [DATE] at 8:45am, and [DATE] at 8:30am messages were left on V8, CNA ' s voice mail, but the Surveyors calls were not returned. On [DATE] at 2:00pm, R1 was ambulating independently around the Dementia Care Unit, alert only to himself. When asked about the elopement, R1 said he did not remember. On [DATE] at 2:37pm, the shower room on the Dementia Care Unit's north hall was observed to have an unlocked door, and a double window, the right side of which was unlocked, with no screen and no devices to prevent the window to be raised to within approximately 4 inches of the full height. V5, Maintenance Director, who was present, stated R1 could have eloped from that window, but it egresses a courtyard with a locked gate, and no evidence had been found that the gate was left unlocked. On [DATE] at 2:39pm, the alarmed glass double door exit on the north hall, which has a keypad, was checked by the Surveyor, and it was noted that 15 seconds of pressure on both doors did not activate the alarm, but the doors could be pushed open after 15 seconds. The Surveyor called over V5, who was standing at the end of the hallway, and V5 pushed on the doors and confirmed the alarm was not working but the doors were automatically opening. V5 was also able to open the doors using the keypad. V5 stated he was not sure why alarms to the exit door were not working properly, and that he checks all the exits once a week, and it was in working order last time he checked it. V5 could not recall what date he had last checked the door. When the doors opened, a residential area with an intersection of two streets was observed, which V5 stated that was the area where the police had found R1. V5 stated he would fix the door as soon as possible. V5 stated it was possible R1 could have eloped from that exit if the alarm was not working. On [DATE] at 3:10pm, V1 was notified that the Surveyor had observed the above referenced issues with the Dementia Care Unit north exit door self-releasing but not alarming. V1 stated he would be consulting with V5 about it. On [DATE] at 11:05am, V1 stated on [DATE] at around 6:45pm, he was notified by V3 that R1 had been found by police less than a block away from the property. V1 stated he was told R1 had a laceration to the head and was being sent to ER. V1 stated he instructed staff to write down their statement of events and for V7 to inspect the building to see how R1 eloped. V1 stated a Complete sweep of the property, showed the door to the small office by the front entrance was unlocked, the window was open, and the screen was out. V1 stated on [DATE] at 1pm, V1 was at the facility for an Easter egg hunt, and he observed that the window where R1 allegedly eloped as being closed with the screen in it. V1 stated activity staff had been accessing the small office where some of the supplies were kept for the Easter egg hunt. and could have left the door unlocked. V1 stated he instructed V5 to put a self-locking handle on the door of that office, which was done on [DATE]. V1 stated staff are doing every 30-minute checks on all residents at risk for elopement on the Dementia Care Unit. V1 stated V9, Social Services Director, came to the facility on [DATE] and began reeducating staff on checking exits and windows and doing visual checks on elopement risk residents every 30 minutes. On [DATE] at 8:15am, the north hall double door exit on the Dementia Care Unit was checked by the Surveyor with V5. The alarm was still not working, but the doors did not release when pressure was applied. The keypad was working. V5 stated he, Messed with, the door the previous day but could not get the alarm to work. V5 stated he called the company that services the alarm doors, but they could not come out until the following week. On [DATE] at 2:25pm, V2, Director of Nurses, stated staff chart behaviors that are unusual for the resident on an Event Report document. V2 stated staff do not do behavior tracking, but chart behaviors that are usual for the resident in the Nurses Notes. On [DATE] at 11:27 A.M. V1 stated that R1 upon his return to the facility was on neurological checks, and that after the neurological checks were completed the facility started the 30-minute checks. On [DATE] at 1:40 P.M. R1 was observed standing at the end of the hallway on the Dementia Care Unit pushing on the north exit door, and then wandering into a resident room a few seconds later. On [DATE] at 1:43 P.M. R1 was observed standing at the exit which adjoins the Behavior Unit, pushing the buttons on the keypad. On [DATE] at 8:40am, V11 (R1's POA) stated on [DATE] she was called by a facility nurse, name unknown, who told her (R1) had got outside and he fell , he had just come back from ER, but he was ok. V11 stated she was extremely upset about staff not calling her when they first became aware of the elopement, nor did they provide the full details of the event. V11 stated she has been questioning the facility's ability to adequately supervise R1 and she has been looking for an alternative placement. V11 stated, It is way more likely he got out an exit than climbing out a window, though it is possible. On [DATE] at 11:40am, V10, Physician/Medical Director, stated he was on [DATE] of the elopement. V10 stated he has concerns that the facility may be understaffed, but stated he has no control over making decisions about staffing patterns. The facility's Door Alarm/System Check Logs for March and [DATE] documented the alarmed exit doors for both of the facility's buildings were being checked once weekly. The April Log documented the alarms were checked on [DATE] and in working order, were not checked when due on [DATE], but were again checked on [DATE] after the elopement occurred. An Elopement Prevention Policy dated [DATE] stated, It is the policy of (the facility) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. 11. Door alarms are checked daily by maintenance for function. On [DATE] at 3:00pm, when asked why V5 had not been checking the alarmed doors daily per facility policy, V1 stated he was unaware that this was the policy. A Safety and Supervision of Residents Policy dated [DATE] documented, 9. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment. 10. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards or if there is a change in the resident's condition. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review: R1 was placed on 30-minute checks which began on [DATE] at 11:30am. R1's Care Plan was updated to reflect elopement interventions on [DATE]. On [DATE], V9 ensured the office door from which R1 was believed to have accessed a window to elope, was locked. On [DATE], V5 installed a self-locking doorknob, replaced the window screen and secured the window. All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Elopement Binder by V9 on [DATE]. On [DATE], V5 installed a self-locking doorknob on the north hall shower room, and secured the window so as not to allow opening. On [DATE] at 4:01pm, V5 and V13, Corporate Regional Director, confirmed the north exit door did not automatically open with 15 seconds of pressure. On [DATE], V9 completed Elopement Assessments on all residents of the Dementia Care Unit. On [DATE], V14, Minimum Data Set Coordinator, completed a Care Plan audit on all residents of the Dementia Care Unit to ensure Care Plans addressed elopement risk. On [DATE], V13 reviewed the Resident Supervision Policy with no changes made. On [DATE], V2 and V15, LPN/Assistant DON, completed staff education on resident supervision with all staff. On [DATE], V13 completed education for V5 regarding window and door security. V5 will complete window and door audits daily for one week, twice weekly for two weeks. V2 will complete a Facility Activity Audit to identify exit seeking behavior of residents daily for one week, twice weekly for two weeks, and weekly for 4 weeks. V9 will complete an audit of the Elopement Binder to ensure it is up to date according to Elopement Assessments daily for one week, twice weekly for two weeks, and weekly for four weeks.

Based on interview and record review, the facility failed to safely transfer residents according to Transfer Assessments and Care Plans for three residents (R2, R3, R4) of four residents reviewed for falls in the sample of six. This failure resulted in R2, on 1/27/25, falling during a transfer and fracturing his 8th left rib and dislocating his left shoulder. Findings include: 1. R2's Face Sheet documented an admitted [DATE] and listed Diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant side, Dissociative Disorder, Intermittent Explosive Disorder, and Unspecified Dementia, Mild, With Other Behavior Disturbance. R2 Minimum Data Set (MDS) dated [DATE] documented that R2 has severe deficits in cognition and requires substantial or maximal assistance for transfers. R2's Fall Risk assessment dated [DATE] indicated R2 is at high risk for falls. R2's Transfer assessment dated [DATE] indicated R2 requires the assistance of 2 staff and a gait belt for transfers. R2's Care Plan dated 3/6/25 documented a problem area, Resident at risk for falling related to weakness and history of putting self on floor from wheelchair. Resident will become upset and will act out by causing self to fall to the floor, with corresponding interventions, Educate staff to make sure brakes (on wheelchair) are locked during transfers, and, Reeducate/Inservice staff to not leave resident unattended while on toilet. The same Care Plan documented a problem area, Resident has a history of episodes of yelling and screaming, refusing and resisting care, agitation and angry outbursts. Observed putting self on the floor out of the wheelchair, and attempting to come in close contact with other residents with his wheelchair. After having angry outbursts, resident will cause himself to fall out of his wheelchair, with a corresponding intervention, Return at later time when resisting care/treatment. R2's Incident Report sent to the Department submitted by V2 (Director of Nurses/DON) documents , On 1/27/25 R2 was transferring with assist to wheelchair from toliet and sat on the floor. The report also documents on 1/29/25 x-ray results revealed R2 has a fractured rib and dislocated shoulder. R2's 1/27/25 Fall Investigation documented, (R2) has come to the desk with request for CNA (Certified Nursing Assistant)/toilet, advised CNA will be available when current resident care completed. (R2) demonstrates anger stating,I've been waiting for 45 minutes, advised (R2) that he had just left the dining area a few minutes ago, (now) anger has escalated and spun wheelchair around, hitting wall and objects in hallway and proceeded to room. CNA has went to resident room and during transfer back to wheelchair, unpredictable quick transfer by resident, (he) missed wheelchair and sat on floor, no injury, however note severe tight spasming of both left arm and left lower extremity, resulting in left lower extremity rigid and straight, unable to adjust to within normal limit positioning. R2's Nursing Progress Notes, authored by V11, Registered Nurse, document the following: 1/27/25 at 6:00pm: (R2) has come to desk with request for CNA/toilet. Advised CNA will be available when current resident care completed. Demonstrates anger stating I've been waiting for 45 minutes. Advised that he has just left dining area a few minutes ago, anger has escalated and spun wheelchair around, hitting wall and objects in hallway and proceeded to room. CNA has went to resident room and during transfer back to wheelchair, unpredictable quick transfer by resident, missed wheelchair and sat on floor. No injury, however note severe tight spasming of both left arm, and left lower extremity, resulting in left lower extremity rigid and straight, unable to readjust to within normal limits positioning. 1/28/25 at 7:43am: This nurse completed skin assessment today due to post fall status. Note light purple bruising along left lower rib cage. Palpated site with no abnormalities felt. No complaints of pain/discomfort during assessment, however resident has shared with CNA (staff) today that my ribs and arm are broken. Reported to in house NP (Nurse Practitioner) earlier in shift with no orders received. No respiratory distress or difference in baseline abilities for repositioning/transfers were noted, administered 4:00pm hydrocodone and applied lidocaine patch over palm sized bruising of rib cage. In house NP (was) notified of resident continued complaints of soreness of this area and nursing measures completed at this time. Order received for x-ray of areas of concern (left arm and left rib cage) . 01/29/2025 at 06:29pm: Radiology results received, abnormal findings are acute nondisplaced left lateral 8th rib fracture, (and) suspected inferior subluxation of left shoulder. All other results are negative for findings. Abnormal findings reported to (V2, Director of Nurses) and in house NP for follow up this afternoon. (R2) has had no reports of increased pain or discomfort. R2's 1/29/25 X-ray Patient Report documented, :Left clavicle: Suspected inferior subluxation of the (left) shoulder, and, Acute non-displaced left lateral rib fracture. On 3/6/25 at 10:25am, R2 was alert but oriented only to self and could not give the name of the facility, current president, or the date. When R2 was asked if he remembered his 1/27/25 fall, he stated, Yes, I was in the bathroom with the CNA going from the toilet to the wheelchair and she did not lock the brakes and the wheelchair slid, and I fell . R2 stated he could not remember the name of the CNA or anything about her. On 3/11/25 at 9:00am, V11 stated R2's fall on 1/27/25 happened about 6:50 pm. V11 stated she was sitting at the nurses station charting when R2 approached, upset and yelling that he needed to go to the bathroom. V11 stated this behavior is typical for R2. V11 stated she asked him to go to his room and a CNA, whom she believes was V12, CNA, would be down there as soon as possible. V11 stated less than 5 minutes elapsed when V12 went to the room. V11 stated the next thing she knew, V12 notified her that R2 fell while getting off the toilet. V11 stated when she responded and went to the room, the wheelchair had been tipped on its side and the brakes were locked. R2's left leg and left arm, which is the side affected by his previous stroke, were very stiff. V11 stated when R2 gets agitated and mad, his left arm and leg will stiffen. V11 stated she assessed R2 and found no injuries, and R2 stated he was not hurt. V11 stated she notified V15, Nurse Practitioner, who gave no new orders. V11 stated when she worked with R2 on the following day, he had begun complaining about pain in his left shoulder and left torso and had a palm sized bruise to the left torso. V11 stated she notified V15 who ordered x rays. V11 stated the X-rays revealed a fractured rib and dislocated left shoulder. On 3/11/25 at 10:25am, V12 stated R2 is impulsive with low frustration tolerance and has a history of falls, some of which were related to attempting to self transfer. V12 stated R2 requires the assistance of one staff for transfers and, Is pretty easy to transfer, unless he is mad. V12 stated at the time of the fall, R2 was angry and agitated. V12 stated when she went to R2's room, he was already sitting on the toilet, having been transferred there by V13, CNA. V12 stated she waited outside the bathroom door as R2 does not like having staff in the bathroom with him. V12 stated R2 said he was finished, so she opened the door in time to see him falling, with the left side of the wheelchair rolling out from underneath him as the right brake was locked, but the left one was not. V12 stated if it had been locked, it probably would have prevented the fall. V12 stated she immediately notified V11, and R2 stated he was not injured. On 3/11/25 at 11:10am, V13 stated she did not recall the events on 1/27/25 and is not sure if she transferred R2 onto the toilet or if she did or did not lock the wheelchair brakes. On 3/11/25 at 11:45am, V16, Licensed Practical Nurse/Minimum Data Set Coordinator, stated R2 requires one staff for transfers, or two staff if he is having behaviors. On 3/11/25 at 12:30pm, V2, Director of Nurses, stated staff should have made sure the wheelchair brakes were locked. V2 stated R2 may have needed two staff for the transfer, or staff could have waited until he was more calm to put him on the toilet. V2 stated R2 does not like having staff in the bathroom with him, and the intervention of staying in the bathroom with him should be removed. On 3/11/25 at 3:00pm, V15 stated as a result of the fall, R2 sustained a rib fracture and shoulder dislocation, for which she referred him to an Orthopedic Surgeon. V15 stated R2 has refused to go to that appointment. 2. R3's Face Sheet documented an admitted [DATE] and listed Diagnoses including Cerebral Palsy and Hypertensive Heart Disease Without Heart Failure. R3's MDS dated [DATE] documented that R3 has no deficits in cognition. The same MDS documented that R3 requires substantial/maximal assistance for transfers. R3's Fall Risk assessment dated [DATE] documented that R3 is at high risk for falls. R3's 1/20/25 Transfer Assessment documented that R3 requires one staff and a gait belt for transfers. R3's 3/6/24 Care Plan documented a problem area, Dependent for transfers, with corresponding intervention,Staff assist with all transfers with Gaitbelt, CGA x1 (Contact Guard Assistance with one staff member), and 2WW (Wheeled Walker) after applying long socks and AFO (Ankle Foot Orthotic) to right leg. R3's Fall Investigation dated 1/27/25 documented, At approximately 8:40pm this shift, resident was being transferred to the bed per staff assist when her legs gave out and the resident had to be lowered to the floor per staff. No noted injuries at this time. Resident was not wearing shoes when legs gave out. Shoes need to be worn with all transfers. On 3/7/25 at 8:45am, R3 was alert and oriented to person, place, and time. R3 confirmed she fell during a transfer on 1/27/25. R3 stated she was in the wheelchair coming back from the toilet, and an unknown CNA did not apply her shoes, long socks, or right leg brace before attempting to transfer her to the bed. R3 stated a walker was not used. R3 stated she reminded the CNA she was supposed to have those interventions in place prior to transferring, but the CNA said, That's ok, we can do this. R3 stated as a result, her legs gave out and she began sliding when the CNA caught her with her leg and lowered her to the floor. R3 stated she was not injured. On 3/7/25 at 1:35pm, V6, CNA, stated she was the staff member present wen R3 fell on [DATE]. V6 stated she took R3 off the toilet and into the wheelchair. V6 stated she did not apply R3's leg brace, socks, or shoes prior to the transfer, nor did she use a gait belt or walker. V6 stated at the time of the fall, she was aware of these interventions being in place but she did not implement them. V6 stated R3's legs gave out and she began to slide, so V6 braced R3 against her leg and lowered her to the floor. V6 stated R3 was not injured. 3. R4's Face Sheet documented an admitted [DATE] and listed Diagnoses including Parkinsons Disease and Neurocognitive Disorder with Lewy Bodies. R3's MDS dated [DATE] documented that R4 has moderate deficits in cognition and requires substantial/maximal assist for transfers. R4's Fall Risk assessment dated [DATE] documented that R4 is at high risk for falls. R4's Transfer assessment dated [DATE] documented that R4 requires the assistance of two staff and a gait belt for all transfers. R4's Care Plan dated 2/27/25 documented a problem area, Resident at risk for falling,with corresponding intervention,Provide toileting assistance as needed. A 2/27/25 Fall Investigation documented, Resident was transferring to bedside commode with assistance for (CNA) Resident was almost to commode just adjusting to align (to commode) and lost his balance. Resident fell on side of bed and bedside table caught his fall. (CNA) lowered him to floor. Nurse assessed resident and during assessment noticed small abrasion to left shoulder, (and) small skin tear on an older healed wound on both left forearm and buttocks. On 3/7/25 at 9:05am, R4 was alert and oriented to person and place but not time. When asked about the 2/27/25 fall, R4 stated there was one CNA, name unknown, transferring him from the recliner to the bedside commode using a gait belt, and, She let go of the gait belt for whatever reason, and I lost my balance and fell . R4 stated he sustained a couple of skin tears but no serious injury. On 3/7/25 at 11:20am, V6 stated on 2/27/25 at about 2am, she transferred R4 from the recliner to the bedside commode with a gait belt. V6 stated R4 required the assistance of one staff and a gait belt for transfers. V6 stated she put on R4's shoes and a gait belt and got him to a standing position and they started moving toward the commode. V6 stated she noticed his oxygen tubing was pulling, so she let go of R4, told him to stand still, and went to unplug the oxygen concentrator. V6 stated R4 began to fall, with the bedside table catching his fall, and she was then able to lower him to the floor. V6 stated after the fall, she was informed by the Therapy Department that R4 was to have been two assist for transfers. On 3/11/25 at 12:30pm, V2 stated staff should always transfer all residents according to their assessed needs. The facility's Safe Patient Handling Program Policy dated 9/8/23 documented, To identify, assess, and develop strategies to control the risk of injury to residents, nurses and other healthcare workers associated with lifting, transferring, repositioning, or movement of a resident. This program applies to all staff assisted resident lifts, transfers, and ambulation performed by employees under normal conditions, during the performance of non routine tasks and in the event of emergencies. All resident care will be provided in a safe, appropriate and timely manner in accordance with the resident's Care Plan. All residents will be assessed by the facility for the need for assistance transfer activities, mobility,or repositioning.

Based on observation, interview, and record review, the facility failed to respond to residents' requests for assistance in a timely manner to ensure dignity and respect for quality of life for 3 (R3, R6 and R7) of 7 residents reviewed for dignity. This failure resulted in care not being provided timely, causing R3, R6 and R7 to experience discomfort/pain, and caused R3 to feel humiliation and anxiousness from sitting in urine and/or feces for extended periods of time, not knowing how long it will take for her to receive necessary assistance. Findings Include: 1. R3's Resident Face Sheet with a print date of 12/27/2024, documented R3 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, heart failure, secondary pulmonary arterial hypertension, major depressive disorder, type 2 diabetes mellitus, and anxiety disorder. R3's Physician Order Summary with date range from 11/27/2024 - 12/27/2024 documented an order to apply zinc cream to gluteal fold and buttocks twice daily and as needed with incontinence. R3's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. Section GG of R3's MDS documented R3 is a mechanical lift for transfers, and Section M Skin Conditions documented R3 was at risk for developing pressure ulcers/injuries with treatments documented as application of ointments/medications. R3's current Care Plan documented a Focus Area of Dependent transfers. May use stand up lift. Date Initiated 11/20/2024. This focus area included the following interventions: Descend from chair/bed with instruction for proper hand placement. R3's Resident Progress Note dated 12/23/2024 authored by V15 (Family Nurse Practitioner/FNP) .she is sitting up in wheelchair eating lunch. States she can tolerate sitting up for about an hour or two hours and then needs to go back to bed. States that over the weekend she sat up way to long and her bottom hurt a lot. On 12/26/2024 at 12:45 PM, R3's call light was noted to be lit above the door and the audible alert could be heard going off at the nurse's station. This surveyor was on R3's hall continuously from 12:45 PM to 1:43PM and completing intermittent observations of the call light being illuminated and heard during this time. This surveyor entered R3's room at 1:43 PM and verified with R3 that no staff had come to answer her call light. At 1:46 PM, V11 (Certified Nursing Assistant/CNA) entered R3's room and shut the call light off. V12 (CNA) also arrived and assisted V11 with putting R3 back to bed. On 12/26/2024 at 1:43 PM, R3 stated every day she has issues getting her call light answered. R3 stated that it is not a lack of the staff wanting to answer it, there just isn't enough staff to do the job. R3 verified that she turned her call light on at 12:45 PM because she wanted assistance to be put back in bed. R3 stated that it is not unusual to wait up to an hour and a half to get someone to answer her call light. R3 stated that when she has to wait long periods of time it causes her to have pain in her coccyx area that continually gets worse. R3 stated that on a weekend she waited 4 hours for a staff member to answer her call light. R3 stated that on the weekend they have less staff than during the week. R3 stated that when therapy comes in on the weekend to do her exercises, she will not get out of bed because she never knows when she will get to go back to bed. R3 stated she tells the staff when they pick up her lunch tray that she wants to go back to bed as soon as they have time. R3 said she generally waits a few minutes then turns on her call light. R3 stated that the CNA's are treated terribly and that is why the facility has trouble getting them. R3 stated that the transportation aide came in to take her vitals today and she had to ask her who she was because she has never seen her before. R3 stated that when she has to wait long periods of time, she is often incontinent of bowel and bladder. R3 stated that when she is incontinent and has to sit in it, it is humiliating. R3 stated that the areas on her coccyx burn and sting when she has to sit in urine and feces. 2. R6's Resident Face Sheet, with a print date of 12/27/2024, documented R6 was admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy bodies, peripheral vascular disease, chronic kidney disease, unspecified atrial fibrillation, essential hypertension, spinal stenosis, and unsteadiness on feet. R6's MDS dated [DATE] documented a BIMS of 10, indicating R6 has moderate cognitive impairment. The same MDS documented R6 required substantial/maximal assistance for transfers and that R6 was at risk for developing pressure ulcers with treatments documented as applications of ointments/medications and application of dressing to feet. R6's Physician Order Report with a date reference of 11/27/2024-12/27/2024 documented an order for zinc barrier cream to buttocks twice daily, betadine to tops of toes and to right and left heel daily, and calcium alginate to bilateral heels daily. R6's current Care Plan documented a focus area of Resident has a potential for diminished range of motion, date initiated 07/25/2024. This focus area includes the following interventions: .observe for signs and symptoms of discomfort and report to nurse. On 12/27/2024 at 8:58 AM, R6 stated that he has to wait to receive care a lot of days. R6 stated that he has waited over an hour for his call light to be answered. R6 stated he requires two staff to provide care for him. R6 stated that the facility needs more staff, especially on the weekends. R6 stated he has a catheter, but he does need assistance for other toileting needs. R6 stated he cannot reposition himself and has wounds. R6 stated when he waits for an hour for his call light to be answered so he can be repositioned, it causes him pain. 3. R7's Resident Face Sheet with a print date of 12/27/2024, documented R7 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure, hyperlipidemia, essential hypertension, retention of urine, and constipation. R7's MDS dated [DATE], documented a BIMS of 15, indicating R7 is cognitively intact. The same MDS documented R7 is at risk for developing pressure ulcers/injures with treatments documented as applications of ointments/medications. R7's Physician Order Report with a reference date of 11/27/2024 - 12/27/2024, documented an order for clean open area to scrotum, apply pink polymem foam, cover change daily and as needed. R7's electronic medical record in the section under Wound Management documented R7 has shearing to right buttock. On 12/27/2024 at 9:00 AM, R7 stated the care in the facility lacks due to not enough staff. R7 stated there is trouble getting call lights answered. R7 stated there are times he waits up to an hour for his light to be answered. R7 stated he looks at his cell phone when he turns the light on, so he knows how long it takes for them to respond. R7 stated that it is all shifts and weekends are typically worse. R7 stated the facility does not have enough staff to care for the residents. R7 stated he has sores on his coccyx and waits over an hour for the staff to put cream on him. R7 stated that the pain in his coccyx gets worse when he has to wait long periods of time. On 12/26/2024 at 1:50 PM, V11 (CNA) stated there are only 2 CNA's on this side (East/Center) of the building today. V11 stated she is exhausted trying to care for this many residents with just one other CNA. V11 stated that it takes 45 minutes to complete checking on residents on one hall and the other residents who need help often have to wait longer than what they should. V11 stated that the Transportation Aide/CNA was supposed to help today but she only did some vitals and answered a few call lights. On 12/26/2024 at 1:57 PM, V1 (Administrator) and V2 (DON/Director of Nurses) stated that there were two call-in's today. V2 stated the Transportation Aide was helping on the floor for a little bit until she had to leave to take an appointment, leaving two CNA's to cover all the residents on East/Center, which is 34. On 12/27/2024 at 9:05 AM, V14 (RN/Registered Nurse) stated staffing is a problem in the facility. V14 stated there are some mornings there is one CNA and one PA (Personal Assistant) to start the day off. V14 stated that residents have to wait for care to be provided because the PA cannot provide any care. V14 stated the CNA schedule is posted with not enough staff and she will ask the department heads to come in and help. V14 stated that there are times none of them will come in to help. V14 stated this is an ongoing issue with the facility but it is worse currently. V14 stated the nurses nor the CNA's can provide the care that the residents need. On 12/27/2024 at 11:31 AM, V18 (Ombudsman) stated that she has had several complaints from residents about the facility being understaffed. V18 stated that the residents are complaining that the staffing shortage is causing the residents to have to wait long periods of time for call lights to be answered. Company policy titled Answering the Call Light with a revision date of June 2020 documented under section General Guidelines 8. Answer the resident's call light as soon as possible.

Based on interview and record review the facility failed to prevent physical abuse of a resident from another resident with a known history of aggression towards other residents in 1 of 3 residents (R1) reviewed for abuse in the sample of 33. This failure resulted in R1 being slapped, choked, and hit in the stomach by R2. These actions would cause a reasonable person to have feelings of fear and insecurity while living in their home. Findings included: R1's Resident Face Sheet documented R1 was admitted to this facility on 5/1/2023 with diagnoses of Dementia without behaviors, Psychotic Disturbance, Mood Disturbance and Anxiety. R1's MDS (Minimum Data Set), dated 5/13/2024, documented R1 with a BIMS (Brief Interview for Mental Status) score of 8 out of 15 total indicating R1 has severe cognitive impairment. R2's Resident Face Sheet documented R2 was admitted to this facility on 12/9/2023 with the diagnoses of Moderate Dementia with Agitation Intermittent Explosive Disorder, Delusional disorders and Cognitive Communication Deficit among others. R2's MDS, dated [DATE], documented R2 with a BIMS score of 0 out of 15 total indicating R2 has severe cognitive impairment. R2's Care Plan documented a focus problem of: Exhibiting problems of wandering, physical aggressiveness towards staff and other residents, sexually inappropriate towards other residents with a start date for this focus problem of 12/11/2023. On 8/3/2024 at 8:55am, V10 (Family of R1) said R2 has been a resident at this facility for about three months. V10 said R2 thinks R1 is his wife. V10 said R2 wants to sit by R1 in the dining room and at times puts his arm around R1. V10 said R2 will follow R1 around the unit and if R1 does not go with R2 then R2 becomes angry and becomes belligerent. V10 said R2 has attacked R1 twice, the first time R2 hit and choked R1 and the second time R2 punched R1 in the stomach. V10 said R1 was not injured, did not need to go to the hospital, quickly forgot what happened and calmed down after 90 minutes. V10 said she has told R1 to avoid R2 but R1 can't remember anything. On 8/5/24 at 9:30am R1 was noted in the dining room. At that time R1 was confused and unable to give any details of any altercations involving R2. A facility form titled Grievance/Concern/Complaint form completed by V10 (Family) on 8/2/2024 documents the following, On two separate occasions (R2) has hit (R1). Previous interventions have failed. (R2) thinks (R1) is his wife and will not leave (R1) alone. A form in R2's EHR (electronic health record) titled Event Report and dated 6/9/2024 documented R2 had slapped and pushed (R1) up against a wall and started choking her. A Progress Note in R2's EHR documented, on 6/9/2024 at 1:47pm, V12 and V13 (both Certified Nursing Assistants/CNAs) witnessed (R2) slap (R1), pushed her against the wall and started choking her, CNAs were able to separate R2 and R1. A form titled Long Term Care Facility-Serious Injury, Incident and Communicable Disease Report dated 6/9/2024 at 1:00pm, documented a physical altercation between R2 towards R1 in which R2 became upset with R1, slapped R1 on the face, pushed R1 into the wall and placed his hands on her neck. Staff immediately intervened and separated R2 and R1. R1 was assessed and found to have no physical injuries. On 8/5/2024 at 9:45am, V9 (Licensed Practical Nurse/LPN) said on 7/31/2024 in the afternoon, R2 became confused and thought R1 was his wife. V9 said when R1 disagreed with R2 and said she was not his wife, R2 became physically aggressive towards R1. V9 said, I tried to get to R1 because I could see R2 getting angry with R1, but before I could get to them, R2 slapped R1 on the face, pushed R1 into the wall and put his hands on R1's neck. V9 said she, V12 and V13 immediately separated R1 and R2 and neither were found with any injuries after the event. A form in R2's EHR titled Event Report and dated 7/31/2024 documented R2 hit R1. A Progress Noted in R2's EHR documented the following on 7/31/2024 at 3:29pm, (R2) grabbed a hold of (R1's) walker and would not let go. (R1) yelled out and when staff came to help, R2 punched R1 in the stomach. A form titled Long Term Care Facility-Serious Injury, Incident and Communicable Disease Report dated 7/31/2024 at 3:30pm, documented a resident to resident altercation in which (R2) grabbed a hold of R1's walker and would not let go. (R1) yelled out for help and as staff approached , (R2) hit (R1) in the stomach. Staff separated R2 from R1. R1 was assessed and found to have no physical injuries. On 8/5/2024 at 10:00am, V11 (Housekeeper) said on 7/31/2024, she witnessed R2 become angry with R1 for not believing she was his wife and when R1 refused R2, R2 hit R1 in the stomach. V11 said she and V5 (CNA) immediately separated R1 and R2. V11 said neither R1 nor R2 had any injuries from the event. On 8/5/2024 at 10:45am, V1 (Administrator) said she investigated two allegations of abuse for R2 towards R1 for dates of 6/9/2024 and 7/31/2024 in which R2 was physically abusive to R1 and both events are substantiated as abuse. V1 said R2 did physically abuse R1 on both of those dates and new interventions have been put into place for both events. V1 said on 7/31/2024, R2 was placed on 15 minute checks and will remain on 15 minute checks indefinitely due to R2's cognitive level and repeated events with R1. A facility policy titled Abuse Prevention Program (revision date 9/29/2022) documents the following: Definition of abuse in part as, The willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish and This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment.

Based on observation, interview, and record review, the facility failed to initiate a safe transfer to a wheelchair for 1 of 3 resident (R2) reviewed for safety in a sample of 5. This failure resulted in R2, during a transfer, receiving a laceration to her leg requiring an emergency room visit and a total of 16 stitches to the wound. Findings include: R2's Face Sheet documented an admitted [DATE], and listed diagnoses including Bipolar Disorder, Unspecified Dementia, Diabetes Type 2, and Chronic Peripheral Venous Insufficiency. R2's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status Score of 8, indicating R2 had moderate deficits in cognitive functioning. The same MDS documented R2 utilized a wheelchair for mobility and was totally dependent on staff for transfers. R2's Care Plan, dated 2/19/24, documented a problem area,Dependent transfers, with a corresponding goal, Transfer from chair/bed without injury, safely, using (mechanical lift). The Care Plan further documented a problem area, Resident has impaired skin integrity due to: Chronic Lymphedema to the (bilateral lower extremities), a skin tear to left calf, a laceration to right outer calf with stitches, and a deep tissue injury to right heel, with a corresponding goal, Resident will have skin show signs of healing, and associated interventions, Assist with mobility and transfers, and, Ensure proper body alignment when in bed or chair. R2's Physicians Orders documented an order for Xarelto (anticoagulant) 10 milligrams take one tablet daily in the afternoon, with a start date of 7/11/23. R2's Facility Incident Report sent to the Department on 2/26/24 documents: Incident date: 2/16/24 .BIMS is an 8. Diagnosis Edema, unspecified. Unsteadiness on feet. Muscle weakness (generalized). Other lack of coordination. (R2) was being transferred to her w/c (wheelchair) and received skintear that she went to (Name of Hospital) ER and received stitches for. Res (resident) was 3 assisted to w/c (wheelchair) when during transfer to w/c pool noodle that was in place to w/c on area to attach foot pedals came off from r (right) side of wheel chair and res received a skintear/ laceration to RLE (Right lower extremity). Pain management in place . Therapy evaluating a carefoam chair for resident transfers. An Event Report for R2, dated 2/16/24, documented, At 1615 (2:15pm) 3 assist for resident from toilet to wc (wheelchair). In process of transfer noted large amt (amount) blood pooling under rt (right) foot. Padding required for wheelchair in place on left, however right has fallen off. Approximately 100-150 milliliters of blood noted on floor. On call administration (staff) notified and was advised to send to ER (emergency room ). R2's 2/16/24 Emergency Department Report stated, [AGE] year old female presents to the emergency department for evaluation of a wound to her right leg. The patient reportedly was taking a shower and the patients leg got caught on a sharp object, causing a wound. They put a bandage on it and she was sent to the ER (emergency room ) for evaluation. History is very limited as the patient has dementia. Most of the history was obtained from the EMS (Emergency Management System) who transported the patient to the ER. 15 centimeter 'V' shaped laceration over lateral aspect of right lower leg. The wound was irrigated and then closed without difficulty. Number of sutures: 16. A document titled, (R2) laceration to RLE (right lower extremity) investigation completed 2/19/24 stated,(R2) was 3 assisted from toilet to wheelchair. She received laceration to RLE and was sent to (local ER) for treatment. She received 16 sutures r/t (related to) incident. Root cause of laceration was pool noodle was in place and became dislodged during transfer. On 2/21/24 at 1:25pm, V2, Director of Nursing, stated when the incident occurred on 2/16/24, there were pool noodle pieces attached to both legs of the wheelchair to protect R2's fragile skin from the armature where the foot pedals attach to the frame. V2 stated, Somehow at some point the right pool noodle piece fell off, and when they were transferring her back into the wheelchair her leg made contact with the exposed wheelchair leg, and even though the surface was not sharp, it cut her leg and she had to have 16 stitches. On 2/22/24 at 8:20am, R2 was lying in bed and was alert only to herself. R2's wheelchair was in the room and the foot pedals were not attached. Taped on each side of the frame to the armature where the pedals attach were pieces of pool noodle approximately 6 inches in length. R2's right leg was visible and the shin was covered with an elastic bandage. The Surveyor asked R2 if she remembered her leg getting hurt and she said,Yes, but the rest of her responses were non sensical. On 2/22/25 at 2:05pm, V17, Licensed Practical Nurse, was observed providing wound care for R2. R2 was noted to have a v-shaped laceration, approximately 3.5 inches long on each angle, to the right outer shin. The wound had multiple stitches and appeared to be healing well, with no drainage, redness, or odor. On 2/22/23 at 2:20pm, V15, Certified Nursing Assistant (CNA) stated she, V16, CNA, and V8, Registered Nurse, were transferring R2 from the toilet in the shower room to R2's wheelchair. V15 stated during the transfer, the piece of pool noodle on the right side of the wheelchair fell off and R2's shin made contact with the frame of the wheelchair where the foot pedal attaches on that side, causing a skin tear and profuse bleeding. V15 stated the pool noodle had a slit so it could be slid over the part of the frame where the leg support/foot pedals attach, but it was not secured on. On 2/22/24 at 245pm, V16 stated V15 and V8 had R2 on the shower room toilet and asked V16 for help transferring R2 to her wheelchair. V16 stated V15 and V8 stood on either side and lifted R2 while V16 pulled up R2's pants. V16 stated as they were pivoting R2 into the wheelchair, the pool noodle on the right side came off and they saw R2 was bleeding. V16 stated she had never previously witnessed the pool noodles come off. V16 stated both the pool noodles were on the wheelchair when V16 entered the shower room. V16 stated she thought the pool noodles were taped on, but she was not sure. V16 stated after the incident, staff were educated that they need to be more careful with R2's legs during transfers and to make sure the pool noodles are attached prior to transfers. On 2/23/24 at 8:10am, V8 stated she, V15, and V16 transferred R2 from the toilet to R2's wheelchair when suddenly they saw blood pooling on the floor and determined it was coming from R2's right leg. V8 stated she immediately put pressure on the leg and was not paying attention to the wheelchair, but found out later the pool noodle came off the wheelchair on the right side. V8 stated R2's skin is very fragile and additionally she is on Xarelto. V8 stated she did not personally witness it, but had heard R2 had previously been injured in identical circumstances. V8 stated after the incident, staff used ductwork tape to secure the pool noodles on. V8 stated staff have also been discussing the possibility of getting a different wheelchair for R2. An Event Report for R2, dated 1/10/24, documented, Skin tear to left lower extremity. Activity during skin tear: Repositioning. A Nursing Progress Note dated, 1/10/24, documented, Resident received skin tear to lower left extremity when repositioning resident in wheelchair. Skin tear measures 7.5 centimeters by 0.1 centimeter. Foot pedals were not in place at time of transferring resident from bed to chair, (new intervention added is) placing pool noodle on foot pedal area. On 2/23/24 at 10:00am, V2 stated on 1/10/24, R2 received a skin tear while being repositioned in her wheelchair and her leg came in contact with the part of the chair where the foot pedals attach. V2 stated the intervention of placing the pool noodles was added after the 1/10/24 incident. V2 stated initially, the pool noodles were not attached, but slid over the armature and were to be used when the resident was self propelling and did not need the foot pedals. V2 stated at some point, V2 attached the pool noodles semi permanently using medical grade tape. V2 stated she believes she notified the therapy department of this intervention, And they were OK with it. V2 stated she was not sure if therapy had evaluated R2's wheelchair. V2 stated on 1/29/24, R2's transfer status went from 3 staff assist to mechanical lift due to progressive weakness in R2's legs. On 2/23/24 at 11:00am, R2's wheelchair was again observed. The pool noodle pieces were taped to the armature where the foot pedals attach, but the one on the left leg was loose and able to be spun around, exposing the metal armature. On 2/23/24 at 12:05pm, V14, Physical Therapy Assistant/Director of Therapy Services, stated she was aware of the intervention involving the pool noodles for R2. V14 stated the therapy department has evaluated R2 several times since her admission, but not since the 1/10/24 or 2/16/24 incidents. V14 stated they have tried changing R2's wheelchair several times, but R2 refuses them by not wanting to sit in a new chair or trying to get out of it. V14 stated a custom chair could be ordered, but it would cost thousands of dollars, R2's insurance might not cover it, and R2 might still refuse to use it. V14 stated, I guess we could get permission (from insurance) to do another evaluation and call in a wheelchair specialist. The Surveyor notified V14 the pool noodle on the left side was loose, potentially exposing R2 to injury. V14 stated, I guess we could try something more secure. . On 2/23/24 at 12:30pm, V2 stated after the 2/16/24 incident, staff were educated to always use a mechanical lift to transfer R2. V2 stated it was determined in addition to the issue with the pool noodle coming off, the skin tear might have been avoided by using a mechanical lift, which at the time staff were supposed to be using. V2 stated she has now discussed the issue with the therapy department, and therapy is going to evaluate R2 for the use of a pressure reducing mobile specialty chair. V2 stated they already have such a chair which had belonged to another resident and is no longer being used. An Inservice Sign In Sheet dated 2/19/24 documented, Topic: Use of (trade name mechanical lift). When someone is recommended to be a (mechanical lift), we need to follow through and use the (lift).

Based on interview and record review, the facility failed to assess for risk of dehydration, to contact a medical provider to report lack of food and fluid intake, and to implement in a timely manner orders for labs to identify dehydration for 1 of 3 residents (R1) reviewed for hydration in the sample of 5. This failure resulted in R1 requiring hospitalization from [DATE] through 2/14/24 for a diagnosis of dehydration and requiring IV (Intravenous) fluid replacement. Findings include: R1's Face Sheet documented an admitted [DATE], and listed diagnoses including Huntington's Disease, Unspecified Dementia, Unspecified Psychosis, and Moderate Protein-Calorie Malnutrition. R1's Minimum Data Set(MDS), dated [DATE], documented R1 requires substantial/maximum assistance from staff for eating, defined as, The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident,and a BIMS (Brief Interview for Mental Status Score) of 99, indicating R1's cognition is so impaired that the examination could not be completed. This MDS documented R1's admission weight as 123lb (pounds) and height as 62 inches. R1's Care Plan, dated 1/31/24, documented a problem area,Resident is at risk for alteration in weight due to Huntington's Disease and Malnutrition, with a corresponding goal, Encourage fluids with meals and in between. R1's Initial Nutrition Assessment, dated 1/23/24, authored by V11, Registered Dietician, documented R1's diet order was for a regular diet with mechanical soft texture and thin liquids. This Assessment further documented R1 was experiencing swallowing problems, R1's 1/23/24 weight was 125.5 pounds, and R1 required 1500ml (milliliters) of fluid intake per day. R1's 1/31/24 Dietary Progress Note authored by V12, Dietary Manager, documented,How many full meals does resident eat daily: Less than one full meal. Does resident consume 2+ servings of fruit or vegetables per day?: No. How much fluid (water, juice, coffee, tea, milk) is consumed per day?: 3-5 cups. A 1/23/24 Speech Evaluation documented, Reason for Referral: [AGE] year old female resident of the (facility) who was referred for Speech Therapy related to difficulty chewing and swallowing. She also has difficulty communicating related to Huntington's disease. Diet recommendations: Solids, puree consistencies. Liquids, thin liquids. R1's Daily Vitals Log documented the following: 1/27/24: No fluid intake documented. 1/28/24: No fluid intake documented. 1/29/24: 1900ml fluid consumed. 1/30/24: 975ml fluid consumed. 1/31/24: 1000ml fluid consumed. 2/1/24: 475ml fluid consumed. 2/2/24: 400ml fluid consumed. 2/3/24: No fluid intake documented. 2/4/23: 920ml fluid consumed. 2/5/24: Fluids not taken. 2/6/24: Fluids not taken. A General Order for R1 with an order received date of 1/26/24 documented,Physician order: Order Description: CBC with diff (Complete Blood Count with Differential), (vitamin) B12 (level), vitamin D (level), Folate (level), Depakote level. There was no corresponding Nursing Progress Note and no Physicians Progress Note to indicate why this lab order was given. A Lab Report with a specimen collected date of 2/5/24 and a specimen reported date of 2/5/24 documented,Sodium-greater than 180 (no reference range listed). Blood Urea Nitrogen: 117 (reference range 7-25). Creatinine 2.2 (reference range 0.6-1.2). Nursing Progress Notes for R1 documented the following: 2/4/24: No behaviors noted from resident all weekend. Resident with poor appetite and fluid intake. Will only take 3-4 bites each meal and sometimes will spit it out. Residents front teeth appear to have caries. Dentist appointment may be necessary. Will pass on to night nurse to inform day nurse tomorrow. Labs to be drawn in a.m. No signs or symptoms of distress. Has taken medications all weekend. 2/6/24: Writer obtained lab results from (local lab), noted many abnormal lab results and high critical BUN (Blood Urea Nitrogen) of 117. Writer faxed results to (V9, Physician) office and reported to on call (Physician). Writer notified (V9) of (R1) refusing bedtime medication and also other medications as well. (R1) is refusing to eat and drink. Writer requested if (V9) would like to place her on comfort care. 2/6/24: Labs were faxed to (V9) earlier this am for review. Call received from (V13, Nurse Practitioner) at office for orders to contact family concerning future plan of care as resident has commented to staff that she wants to die and has refused any oral fluids, food and some medications when offered. Administration is unable to contact family at this time with numbers provided. Order also received for [NAME] (emergency room Department)(transfer) for IV fluids related to abnormal labs if family and/or resident are in agreement to this course of treatment. PSR(Psychosocial Rehabilitation Staff) and Social Service were at bedside to talk with resident. She has agreed to hospital and has taken most of her medications at all times throughout day. Has eaten approximately 2 ounces with Occupational Therapy at bedside today. Resident rests comfortably in padded bed. Noted sporadic uncontrolled movements, especially of all extremities continues. Resident has very unwell appearance with waxen skin tone, bruises (as a result of self-injurious behavior) are healing. 2/6/24: EMS (Emergency Medical Services) transported resident to (local hospital) as directed with report given to EMS team. Resident is cooperative with a calm demeanor at time of leaving facility. 2/6/24: Verified status of resident and is admitted to (local hospital) for observation due to abnormal labs. 2/14/24: Readmit from (local hospital) per EMS on cart. Responsive and aware of staff at bedside. Transferred from cart to padded bed with EMS and staff support. incontinent of small amount soft tan stool and clear urine, skin care per staff and barrier cream applied as preventative. No skin impairment of back or buttocks. no paperwork was provided with transfer. Report was received from (nurse) at (local hospital). Admission discharge for hospital was increased sodium, dehydration and failure to thrive. IV(Intravenous Fluid infusion) was removed from right lower extremity at discharge. Resident is NPO(Nothing by Mouth) with no swallow reflex. Edema to bilateral lower extremities. Family have been contacted by hospital and have made decision for Hospice/Comfort Care at this time. Daughter is POA(Power of Attorney). Nursing Progress Notes from 1/27/24 through 2/3/24 contained no documentation related to R1's poor fluid intake nor of any attempts to contact R1's Physician. Nursing Progress Notes from 1/26/24 through 2/4/24 contained no documentation about labs being drawn. An 1/24/24 R1's Rehabilitation evaluation status post functional decline, note, authored by V10, Nurse Practitioner (collaborating with V9, Physician), stated,Patient to be seen today for rehab evaluation status post functional decline. Patient is a [AGE] year-old female admitted to skilled facility from a sister facility. Patient admitted to behavioral health unit with plan to remain on unit long term. Current diagnosis of Huntington's disease with past medical history of generalized anxiety, unspecified dementia, psychosis, depressive disorder, iron deficiency anemia, disorder of the eye and adnexa, protein calorie malnutrition, and specified abnormal involuntary movements, chest pain, vitamin deficiency, and hypercalcemia. (R1) will be receiving speech services for cognition and dysphasia. Patient evaluated today in hallway with staff present period staff reports patient arrived recently was transferred here from sister facility. Staff state patient has been very active and wandering throughout unit, and says patient has been very inconsistent and impulsive. Noted to have head helmet on for protection. Staff report she has had anger outbursts and has put herself on the floor. Awaiting orders for medication to calm patient down. Patient allowed staff to assess her in hallway and in her room. Patient sat outside a bed calm but quickly wanting to get up. Able to move all extremities appropriately. Does not appear to be in any pain currently. Speech has no concerns for their ability to work with the patient at this time. No further issues voiced. There was no documentation to indicate V10 had assessed R1's hydration status during this visit, and there was no documentation V10 had evaluated R1 after 1/24/24. A Hospital Discharge Summary, dated 2/14/24, documented, Active hospital problem (on admission): Diagnosis: Principal problem: Hypernatremia. Hypokalemia, Acute Kidney Injury, Thrombocytopenia, Functional Quadriplegia, Dehydration, Huntington's Disease. Labs (on admission): Sodium: 146 (reference range 136-145). Blood Urea Nitrogen: 40. (reference range 10-20). Potassium: 3.1(reference range 3.5-5.1. Chloride: 123 (reference range 98-107). R1 is a [AGE] year old female with a history of Huntington's Disease who presented to the hospital for dehydration. She was admitted through the emergency room with severe dehydration, she was started on IV fluids, she did respond to this, it did take quite some time to rehydrate her as her sodium level was quite elevated and she was able to be brought back to nearly normal levels. We made attempts to try to feed her, and she was seen by speech therapy, unfortunately she was not safe to be fed. Discussed with her family about a possible feeding tube, they did not wish for her to have a feeding tube, and wish for her to be made hospice care. Will discharge her back to the nursing home under hospice care. On 2/21/24 at 1045am, V4, Certified Nursing Assistant (CNA), stated prior to returning from the hospital on hospice, R1 required extensive feeding and fluid assistance from staff. V4 stated she would estimate R1's daily fluid requirement to be about 2000 ml daily. V4 stated CNA and nursing staff had all discussed among them R1's decline and refusal to take in food and fluids and decrease in urine output. V4 stated R1 had difficulty swallowing as well as physical acting out behaviors and movements due to Huntington's Disease which made feeding R1 food and fluids difficult. V4 stated when R1 was first admitted , she had almost constant behaviors including self-injurious behavior, but she was eating and drinking pretty well and could ask for fluids. V4 stated staff tried specialty cups and utensils when feeding R1 but R1 began spitting out food and fluids. V4 stated R1 continued to decompensate and required hospitalization in early February 2024. V4 stated CNA and nursing staff are responsible for documenting residents fluid intake in the medical record. V4 stated if the resident consumes no fluid or refuses fluid, there are menu options in the system to indicate that. On 2/21/24 at 11:05am, V5, CNA, stated she started working at the facility on 1/26/24. V5 stated when she first started taking care of R1, R1 was able to ask for a drink and her fluid intake was pretty good. V5 stated she would estimate R1's fluid needs to be about 64 ounces (approximately 1856 ml) per day. V5 stated she does not remember exactly when, but R1 began refusing food and fluids. V5 stated her approach to keep R1 hydrated was to ask her often if she wanted a drink. V5 stated unless residents have congestive heart failure, fluids should always be encouraged. V5 stated the CNA and nursing staff were all aware R1 had decompensated and was not taking in adequate fluids and had a decrease in urine output. V5 stated there were days when R1 had no fluid intake at all. V5 stated she communicates with nursing staff multiple times per day about the status of the residents she is responsible for, including R1. V5 stated CNA staff is responsible for charting fluid intake in the medical record. V5 stated there is a drop down option for residents refusing fluids but the record should not be left blank. V5 stated, There are days we are so busy it's possible things weren't charted the way they should have been. On 2/21/24 at 11:45am, V8, Registered Nurse, stated CNA staff were keeping her appraised of R1's poor fluid intake and urine output. V8 stated R1 was not getting anywhere near 1500ml of fluid per day at any point when V8 worked with her. V8 stated R1's jaw was really lax and food and fluids would drain out of her mouth. V8 stated she remembers R1 at some point going two days without any fluid intake. V8 stated she did not recall contacting R1's medical provider until she reviewed R1's labs on her night shift from 6pm to 6am on 2/5/24 and 2/6/24,and she recalled the sodium level being was extremely high. V8 stated V13, one of the Nurse Practitioners who collaborates with V9, gave the order to send R1 to the hospital, which was done immediately. V8 stated before R1 went to the hospital, she was not hospice or comfort care. V8 stated the idea had circulated among staff, but they couldn't get ahold of the family to discuss those options. V8 stated on 2/6/24, R1 said, I want to die. V8 stated if V9 or V10, Nurse Practitioner who collaborates with V9 and is present in the facility Monday through Friday, saw R1 during her stay at the facility, she was not aware of it. On 2/21/24 at 1:25pm, V2, Director of Nursing, stated when R1 was first admitted to the facility, she could ambulate and at times self feed. V2 stated R1 was very unhappy about being placed in a facility, and had maladaptive behaviors in addition to her issues with Huntingtons Disease. V2 stated they sent R1 to the emergency roiagnom on [DATE], but they sent R1 back with no new orders. V2 stated the facility then attempted to get R1 hospitalized in a behavioral medicine unit, but the ones they checked either had no beds or would not accept R1. V2 stated after a couple days, R1 was calmer and exhibited fewer behaviors. V2 stated to her knowledge, neither V9 nor V10 evaluated R1 from her admission until she went to the hospital on 2/6/24. V2 confirmed it is the CNAs responsibility to document residents fluid intakes. V2 stated her staff did not keep her updated about the fact that R1 was not eating or drinking. V2 stated if labs are routine, the lab will come and draw them on Mondays, Wednesdays, and Fridays, but R1's labs should have been drawn as soon as possible upon receiving the order, and V2 stated the facility has been having problems with this issue of late, and she has been providing staff retraining. On 2/21/24 at 1:45pm, V10 stated she evaluated R1 on 1/22/24 for a new resident history and physical. V10 stated to her knowledge, the facility did not attempt to contact her about R1 not eating or drinking. V10 stated she counts on the staff to contact her if there is a change in a resident's condition. On 02/23/2024 at 12:58pm, V2 was asked if there is a routine screening for assessing a residents hydration. V2 stated a Dehydration Evaluation is done when staff notice the resident is not eating and drinking or is losing weight. V2 acknowledged a Dehydration Evaluation had not been done for R1. A Hydration Policy, dated December 2016, documented, It is the policy of (the facility)to provide residents with adequate fluids, including water and other liquids that are consistent with resident needs and preferences, and are sufficient to maintain resident hydration. A Change in a Resident's Condition or Status Policy dated November 2016 documented,A facility must immediately inform the residents, consult with the residents Physician, and notify, consistent with his or her authority, the residents representative when there is (example given changes in level of care, resident rights, etcetera.) 1. The Nurse Supervisor/Charge Nurse will notify the residents Attending Physician or on-call Physician when there has been: D A significant change in the residents physical/emotional/mental condition/psychosocial status to either life-threatening conditions or clinical complications. 2. A significant change of condition is a decline or improvement in the resident's status that: A. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self limiting').

Based on interview and record review, the facility failed to provide anti-anxiety medications as prescribed for 1 (R47) of 3 residents reviewed for behavior in the sample of 40. This failure resulted in R47 engaging in severe behaviors, including self-injurious behavior, and R47 was transferred to the local hospital for evaluation and treatment, requiring 6 staples to a head laceration. Findings Include: R47's Face sheet documented an admitted to the facility of 11/6/19. Diagnoses on this same form include, but are not limited to Major Depressive Disorder; Undifferentiated Schizophrenia; Schizoid Personality Disorder; Dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance; Anxiety Disorder; and Suicidal Ideations. V9 (Physician) is documented as being R47's physician. Review of R47's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status score of 9, indicating she has moderate cognitive impairment. Review of R47's Physician Orders document an open ended order with a start date of 12/11/23 for Lorazepam, 0.5 mg (milligrams), 1 tablet, by mouth twice a day. R47's Plan of Care documented a problem area category of Behavioral Symptoms with problem start date of 07/09/21, and an edited date of 11/3/23 that stated, Resident exhibiting problems as seen by: coming out of room and into common areas while being undressed, history of: rolling on floor, causing self inflicted wounds, throwing self against wall, furniture or the floor, physical aggression. An Approach listed for this problem area included an entry dated 07/09/21 that stated, Provide meds as ordered and monitor effectiveness. Review of R47's Medication Administration Record from 1/1/24 - 1/8/24 documented R47's did not receive any doses of her prescribed Lorazepam on 1/5/23, 1/6/23, 1/7/23, or morning dose on 1/8/23. R47's Progress Notes on 1/7/24 at 12:47 pm, document the following entry, at 1100 (11:00 AM) resident was found in hallway outside her bedroom door naked, rolling back and forth on floor. She was escorted back into her room, redressed. she immediately disrobed again and began running into doors et (and) walls. Took bed apart et pieces strewn about room. She began rolling over bed parts et onto the tile floor. Staff has intervened, resident assisted to standing pos. (position) et immediately throws self to floor again. 2 staff assist required due to resident running out of room, 3 doors down, witnessed throwing self onto floor, bed frame et onto mattress purposely banging head on wall behind her. Escorted back to her room, gown placed on her, CNA (Certified Nurse Assistant) w (with) resident for safety et this nurse to phone to call (V10, physician) (on call). While nurse is on phone CNA has requested assist et resident has thrown self onto floor, hitting head on electrical receptacle. small laceration just above rt (right) temple. Blood loss moderate. Order recvd (received) to send to [NAME] (emergency room Department) due to head injury. Code yellow initiated for additional staff support. Lying face down on tile floor when this nurse entered room. Log roll to assess w no impairment of extremities noted. Code yellow initiated for additional assist. Resident aware of surroundings et staff, limited verbal, pearl, pale, cool skin, resp (respirations) even et relaxed. ble ^ (bilateral lower extremities elevated) above level of heart. EMS (Emergency Medical Services) notified for transport, arrival, report et vs (vital signs) provided. Blanket lift by EMS team to cart, out of facility w EMS at 1125 (11:25 AM). stable w (with) c collar on per EMS. The local hospital After Visit Summary, dated 1/7/24, documents final diagnoses as: scalp laceration, initial encounter; head injury, initial encounter; ground-level fall. A computed tomography of her brain without contrast was completed with no acute intracranial hemorrhage noted. Procedure Orders documented in the same hospital documents provide note laceration repair was needed. Review of R47's Progress Note documented an entry dated 1/8/24 at 2:23 pm, which stated Report recvd (received) from (local hospital) for return to facility after tx. (treatment) scans were completed on neck, shoulders and back w no fx (fracture) identified. Mult (multiple) contusions, bruising et small skin injuries identified over posterior body surface. rt (right) temple lac (laceration) repair w (with) 6 staples placed. EMS has transported resident back to facility via cot, securement straps released after resident has agreed to lie still. Placed in recliner (due to bed remains disassembled at this time) via 2 man blanket lift, comfortable et stable. Staples are intact, large bandaide to left mid back area. Moving all extremities w no pain. Resident is quiet for approx (approximately) 1 hr (hour) et then becomes somewhat restless, fidgeting but manageable. Disrobing self repeatedly. Redressed et blanket provided for comfort, redirection is successful for brief time et activity is soon repeated. report to oncoming nurse at 1530 (3:30 PM) w (with) bed in process of being reassembled. On 01/19/24 at 12:02 pm, V1 (Administrator) stated she acknowledges there was a delay in the facility receiving R47's Lorazepam medication, which resulted in R47 receiving missed doses of the medication. V1 stated they recently changed pharmacies, and despite their repeated faxing of the orders, the pharmacy was saying they were not receiving the order. V1 stated the medication could not be taken from the convenience kit due to being a controlled medication, with no physical prescription on file with the pharmacy. On 01/19/24 at 12:42 pm, V1 stated she spoke with V8 (Nurse Practitioner/NP). V1 stated V8 expressed she believed she was notified of the medication not being available for R47. V1 stated V8 expressed the medication was left on hold until available due to R47 not experiencing any behaviors at that time. On 1/19/24 at 10:01 am, V9 (Physician) stated his expectation would be for residents to receive medications as ordered. V9 stated R47 not receiving her anti anxiety medication could definitely play a role in the behavioral episode R47 experienced on 1/7/24, resulting in injury. V9 stated he is not sure why R47 wouldn't have received this medication, as he is available by phone 24 hours a day to give necessary orders. V9 stated he does not recall if he was notified, but can assume not, if it was not documented, and R47 continued to not receive her medication. The undated facility policy titled Unavailable Medications documented, Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion .The facility must make every effort to ensure that medications are available to meet the needs of each resident.

Based on observation, interview, and record review, the facility failed to ensure dietary supplements were provided for 2 of 2 (R60 and R63) residents reviewed for nutrition in the sample of 37. This failure resulted in R60 having a significant weight loss of 5.98% in one month and 14 pounds (12.1%) in six months, and R63 having a 5.21% significant weight loss in one month, and a 14 pound (12.2%) significant weight loss in six months. Findings Include: 1. R60's Resident Face Sheet, with a print date of 2/23/23, documents R60 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, dementia, psychotic disturbances, major depressive disorder, anxiety disorder, dysphagia, muscle weakness, and depression. R60's MDS (Minimum Data Set), dated 1/23/23, documents R60 has a moderate cognitive impairment. R60's Physician Order Report, dated 2/23/23 to 2/23/23 documents a physician order, dated 9/13/22 to 10/03/22, for a regular pureed diet with nectar thick liquids. This same report documents an order, dated 10/03/22 to current, for a regular diet, mechanical soft with nectar thick liquids. Special instructions under this same order are documented as, super cereal at breakfast and power potatoes at lunch, magic cup at dinner. R60's Care Plan, dated 2/22/23, documents a Problem Area, with a start date of 1/5/23 of Resident has experienced weight loss. With interventions listed for this problem area as, Assess for dehydration Assure (dentures, partial plates, etc.) are in place before meals. Assure a proper fit. Diet: Mech (mechanical) Soft, Nectar thick liquids. Encourage oral intake of foods and fluids. Monitor and record intake of food. Monitor for signs of malnutrition .Monitor/record weight. Notify MD (physician) and family of significant weight change. Provide PRN (as needed) assistance for meals. Provide supplements: Super cereal at breakfast, Power potatoes at lunch, Magic Cup at dinner. Report abnormal labs Report labs indicative of malnutrition . R60's Vitals Report, dated 2/23/22 to 2/23/23, documents the following weights; 7/16/22- 125 pounds, 8/2/22- 116 pounds, 8/15/22- 116 pounds, 8/22/22 117 pounds, 9/5/22- 110 pounds, 9/12/22- 108 pounds, 9/19/22 - 106 pounds, 9/26/22- 108 pounds, 10/03/22- 110 pounds, 10/26/22- 103 pounds, 10/31/22- 103 pounds, 11/07/22- 105 pounds, 12/05/22- 103 pounds, 1/9/23 - 104.5 pounds, and 2/3/22 102 pounds. This indicates R60 has had a significant weight loss of 17.6% from 7/16/22 to 2/3/22, and 5.98% from 8/22/22 to 9/5/22. R60's dietary progress notes document the following. 9/28/22 Noted significant wt (weight) loss of 7.7% x (times) 1 month and 13.6% x 2 months. Wt 108 lb. (pound) BMI (Body Mass Index) 21.8, low for age. Resident (R60) on regular, pureed diet with nectar thick liquids, super cereal at breakfast, power potatoes at lunch and Magic Cup at supper and 60 ml (milliliters) 2.0 Cal (calorie) supplement BID (twice daily). Intake generally less than 50% Noted orders for diuretic. Recommend adding appetite stimulant to help promote intake, as additional food will likely not increase intake. Monitor and refer to RD (Registered Dietitian) as needed. 10/26/22 Noted significant wt loss of 12.0% (15 lb) x (times) 3 months. Wt 110 lb. BMI (Body Mass Index) 22.2, low for age. Wt stable x 1 month Noted orders for diuretic. Resident on regular, mech (mechanical) soft diet with nectar thick liquids, super cereal at breakfast, power potatoes at lunch, Magic Cup at supper, and house supplement 60 ml BID. Intake ranges 0-100%, but intake averages approximately 50%. No diet changes recommended as wt stable x 1 month. 12/21/22 Noted significant wt loss of 11.2% (13lb) x 4 months. Wt 103 lb. BMI 20.8, low for age Resident (R60) on regular, mech soft diet with nectar thick liquids, super cereal at breakfast, power potatoes at lunch, Magic Cup at supper, and 60 (sic) house supplement BID. Intake ranges 26-100%, fair. No diet changes recommended at this time. RD (Registered Dietitian) to follow prn (as needed). 1/18/23 Noted significant wt loss of 16.4% (20lb) x 6 months. Admission wt likely an error. Current wt 104.5 lb. BMI 21.2, low for age. Resident (R60) on mechanical soft diet with nectar thick liquids, super cereal at breakfast, power potatoes at lunch and Magic Cup at supper, and 60 ml (milliliters) House supplement BID. Intake ranges 0-100%. Recommend d/c (discontinue) Magic Cup and add Mighty Shake BID, as Magic Cup has been difficult for dietary staff to order. RD to follow PRN (as needed). 2/15/23 Noted significant wt loss of 12.1% (14lb) x 6 months. Wt down slightly x 1 and 3 months. Wt 102 lb. BMI 20.6, low for age. Resident (R60) on a regular, mech soft diet with nectar thick liquids, super cereal at breakfast, power potatoes at lunch and Magic Cup at dinner. Intake generally 26-75% Recommend adding 60 ml house supplement 1 x daily to help prevent further wt loss. RD to follow prn. On 02/21/23 at 11:48 AM, R60 was observed in the dining room eating the noon meal. R60 was served a mechanical soft diet of pork, scalloped potatoes, lima beans, and dessert. There were no power potatoes observed on R60's plate. On 02/23/23 at 12:01 PM, R60 was observed in the dining room eating the noon meal. R60 was served a mechanical soft diet of chicken a la king, with green beans and dessert. There were no power potatoes observed on R60's plate. R60's meal card that accompanied this meal was observed, and documented super cereal under Breakfast, with no supplements or directions documented under Lunch or Dinner. 2. R63's Resident Face Sheet, with a print date of 2/23/23, documents R63 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, vascular dementia, major depressive disorder, generalized anxiety disorder, and dysphagia. R63's Physician Order Report, dated 2/23/22 to 2/23/23, documents a physician order, dated 2/22/23, for regular, pureed diet with thin liquids. Under special instructions this order documents, Magic Cup BID (twice daily), Super cereal at breakfast, Power potatoes at lunch and dinner. Textured maroon spoon. This same Physician Order Report documents a physician order, dated 10/04/22 to 2/22/23, for regular, pureed diet with thin liquids, and under special instructions documents, Magic cup BID, super cereal at breakfast, power potatoes at lunch and dinner. R63's Care Plan, dated 1/20/23, documents a Problem Area of, Resident has experienced weight loss, with interventions documented as, Assure (dentures, partial plates, etc.) are in place before meals. Assure a proper fit. Diet: Pureed. Encourage oral intake of food and fluids. Monitor and record intake of food. Monitor for signs of malnutrition .Monitor/Record weight. Notify MD and family of significant weight change. Offer available substitutes if resident has problems with the food being served. Provide assistance with meals. Provide supplements: Magic Cup BID, super cereal at breakfast, power potatoes at lunch and dinner, house supplement 60 cc (cubic centimeters) TID (three times daily). Report abnormal labs . Report labs indicative of malnutrition . R63's Vitals Report, dated 2/23/22 to 2/23/23, documents the following weights: 2/28/22- 116 pounds, 3/2/22 116 pounds, 3/8/22- 120 pounds, 4/4/22- 124 pounds, 8/10/22- 113 pounds (indicates a 8.87% weight loss), 8/15/22 - 115 pounds, 8/22/22 - 109 pounds (indicates a 5.21% weight loss), 8/29/22- 107.5, 9/5/22- 103 pounds, 9/12/22- 104 pounds, 9/19/22- 104 pounds, 9/26/22- 106 pounds, 10/03/22 - 100.5 pounds (indicates a 5.18% weight loss), 10/10/22- 102 pounds, 10/26/22- 104 pounds, 10/31/22- 103 pounds, 12/05/22- 104 pounds, 1/2/23- 100 pounds, 2/3/23- 96 pounds, 2/13/23- 101 pounds, 2/13/23 - 101 pounds, 2/20/23 - 103 pounds. This indicates R63 has had a 11.20% weight loss in one year. R63's progress notes were reviewed, and documents R63 refused to be weighed on 6/3/22, 7/6/22, and 8/2/22. On 2/24/23 at 10:15 AM, V2 (Director of Nursing) stated R63 frequently refuses to be weighed and has a care plan for refusal of care. R63's Progress Notes document the following; 4/27/22 RD WT (Registered Dietitian/weight) Note- Noted significant wt (weight) gain of 6.9% (8lb/pounds) x (times)1 month and 7.8% (9lb) x 2 months. Wt 124lb. BMI (Body Mass Index) 24.2, normal for age. Resident on regular diet with regular texture and consistency with 60ml (milliliters) house supplement 2.0 Cal (calorie) BID (twice daily). Intake generally 51-100%, but noted few meals less than 50%. No note of edema. Recommend decreasing house supplement to 60mL 1x (times) daily as intake is good and BMI normal for age. Monitor and refer to RD as needed. 8/29/22 RD Wt Note- Noted significant wt loss of 12.1% x 140 days. Wt 109lb. BMI 21.3, low for age. No skin issues to note. Medication reviewed. No new labs available to review. Resident on regular, pureed diet with thin liquids and 60ml 2.0 Cal supplement BID. Mighty Shake is to temporarily replace 2.0 Cal until it is back in stock. Intake of meals generally ranges 1-50%, low. Recommend adding Magic Cup BID to help prevent further wt loss. Monitor and refer to RD as needed. 9/28/22 RD Wt Note- Noted significant wt loss of 14.5% x 3 months. Wt fairly stable x 1 month. Wt 106lb. BMI 20.7. Resident on regular, pureed diet with thin liquids, Magic Cup 1 x daily and power potatoes at lunch and supper with 60ml 2.0 Cal supplement BID. Intake generally less than 50%, low. Recommend adding Mighty Shake as snack 1x daily to help promote wt gain. Monitor and refer to RD as needed. 11/02/22 Annual Nutrition Assessment-86 y/o F (year old female) with dx (diagnosis) including Alz (Alzheimer's), dementia, depression, anxiety, HTN (hypertension), HLD (hyperlipidemia), GERD (gastroesophageal reflux disease), dysphagia. Noted significant wt loss, as of 10/31, of 10.4% (12lb) x 2.5 months. Wt 103lb. BMI 20.1, low for age. Resident continues on regular, pureed diet with thin liquids and 60ml house supplement TID (three times daily). Intake ranges 51-75%. Medication reviewed. No new labs. Skin intact. Estimated needs listed in assessment. Recommend adding Magic Cup 1x daily to help prevent further wt loss. RD to follow prn. 1/18/23 RD WT Note-Noted wt loss of 11.5% (13lb) x 5 months. Wt stable x 3 months and wt down x 1 month, not significant. Wt 100lb. BMI 19.5, low for age. Resident on regular, pureed diet with thin liquids with 60ml house supplement TID. Intake 26-100%. No skin issues to note. No new labs. Noted orders for laxative. Recommend adding super cereal at breakfast to help promote intake. RD to follow prn. 2/15/23 RD Wt Note-Noted significant wt loss of 12.2% (14lb) x 6 months. Wt stable c 1 and 3 months. Wt 101lb. BMI 19.7, low for age. Resident on regular, pureed diet with thin liquids, Magic Cup BID, super cereal at breakfast, and power potatoes at lunch and dinner. Intake generally ranges 1-75%. No skin issues to note. No new labs. Noted orders for laxative. No diet changes recommended at this time as wt stable x 1 and 3 months. RD to follow prn. On 02/23/23 at 12:19 PM, R63 was observed in the dining room being fed the noon meal by staff. R63 had three bowls of pureed food, two with a tan/cream colored substance, one with a green substance and a small cup with a purple substance. The meal card that accompanied R63's meal was observed, and documents pureed diet, with no supplements or instructions documented on the meal card. On 02/23/23 at 12:27 PM, V3 (Dietary Manager) stated if someone was served a pureed diet on 2/23/23, they would have received three bowls of food, one with green beans, one with chicken a la king, and one with a biscuit. V3 stated if they were served power potatoes, the resident would have gotten a fourth bowl of food. V3 stated on 2/21/23, if a resident had gotten power potatoes, they would have have been served mashed potatoes as well as scalloped potatoes. When asked how staff know what supplements to serve, V3 stated it would be listed on the residents meal cards. This surveyor reviewed with V3 the meal cards that accompanied R60 and R63's noon meals, and she stated each resident has two cards, one for breakfast, and one for lunch and dinner. V3 stated she has had an issue with the cooks using the breakfast cards to serve lunch and dinner. V3 stated if they do that then they wouldn't know what supplements were to be served. On 02/24/23 at 11:47 AM, V8 (Registered Dietitian) stated both R60 and R63 have had significant weight loss over six months. V8 stated R60 and R63 should have been served power potatoes at lunch. V8 stated she would expect the facility staff to follow the dietary orders documented in the medical record. When asked if not getting the supplements would be the cause of R60 and R63's significant weight loss, V8 stated she couldn't determine the exact cause, because there could be so many other things involved, but it has the potential to effect weight. V8 stated when she was at the facility on 2/15/23, she observed R60 and R63 eat, and the facility staff used the correct meal cards, and they were served the correct supplements. On 2/23/23 at 3:11 PM, V6 (Nurse Practitioner) stated she would expect the staff to follow the dietary recommendations, but she didn't think it would make a difference for R60 and R63. V6 stated they have both had a decline in condition and neither one (R60 and R36) eat well anyway. The facility Nutritional Assessments policy dated 1/2012 documents, All residents who experience significant or undesirable weight loss shall be assessed for nutritional status and required interventions by the registered, licensed dietitian. A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for improvement of medical status. Under Procedures this policy documents, 1. Residents shall be weighted and weights reported monthly to the RDLD (Registered Dietitian/Licensed Dietitian). If significant weight loss is identified or low body weight is identified, a request for supplementation for once daily, twice daily, or three times daily shall be made by the consultant dietitian to the physician through the Director of Nursing or his/her designee. 2. Once the order is approved, the Dietary Manager shall communicate the request to the dietary staff through documentation on the tray card. 3. Dietary staff shall provide the increased calories according to the physician order

Based on record review and interview, the facility failed to ensure residents exhibiting symptoms of urinary tract infections were properly identified, treated, and assessed for medical management for 1 of 1 resident (R3) reviewed for urinary tract infections in a sample of 37. This failure resulted in R3 being hospitalized with sepsis for 4 days. The Findings Include: R3's resident face sheet documents an admitted [DATE], and a date of birth as 11/10/41. This same document includes the following medical diagnoses: bipolar disorder, unspecified psychosis, major depressive disorder, anxiety disorder, unspecified dementia, retention of urine, overactive bladder, cognitive communication deficit, urinary tract infection and constipation. R3's Minimum Data Set (MDS) assessment, dated 1/19/23, documents in section C that R3 has a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section H of the same MDS assessment documents R3 has an indwelling catheter. R3's care plan documents a problem area of having an indwelling catheter. The goal is to have resident care managed appropriately as evidenced by not exhibiting signs of a urinary tract infection or urethral trauma, dated 1/24/23. Approaches to this problem and goal are: assess the drainage every shift and as needed; record the amount, type, color, and odor along with observing for leakage; and report signs of a urinary tract infection (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine). R3's care plan also documents a problem of occasional incontinence of bowel and bladder, dated 1/16/23. Approaches include call light within reach, notify MD (Medical Doctor) as needed, observe skin condition during care for red and open areas, provide incontinent care as needed, toilet as scheduled and PRN (as needed), and turn and reposition while in bed or in chair for comfort and to reduce risk of impaired skin. February Physician Order Report documents R3 has an order for a catheter, dated 1/23/23 and an order dated 2/4/23, for ciproflaxacin 500 mg twice a day with administration times of 7:00 AM to 10:00 AM and 3:00 PM to 6:00 PM, both ordered by V12 (Physician). R3's progress note, dated 2/3/23 at 7:49 PM, documents R3 was found unresponsive when staff entered her room. R3 was transferred to the local emergency room . R3's progress note, dated 2/4/23 at 12:11 AM, documents, Resident returned to the facility via w/c (wheelchair) van with CNA (Certified Nurse's Assistant). Dx (diagnosis) UTI (Urinary Tract Infection) . R3's nurse progress note on 2/5/23 at 8:42 PM documents .(R3) is very foul and resistive demeanor at this time. Has been resistive to care with staff all day. Has refused her p.o. (by mouth) medication all day as well. Stating to staff 'I'm dead I cannot swallow!' (R3) was diagnosed with a UTI (urinary tract infection) recently in the ED (Emergency Department) at (Name of local hospital). Dut (sic) to her s/s (signs and symptoms) of dementia she has poor memory and possibly cannot understand the importance of taking her medication especially while having an infection. Will notify her PCP (primary care physician), possible change of route of ABT (antibiotic). February Physician Order Report documents R3 has an order, with a start date of 2/5/23 and ending on 2/13/23 for amoxicillin 875 milligrams one tab twice daily, with administration times of 7:00 AM to 10:00 AM and 3:00 PM to 6:00 PM, ordered by V12. On 2/7/23 at 10:18 AM, nursing progress notes document .Foley (catheter) in place with cloudy yellow, strong odor drng (drainage).' On 2/7/23, R3's nursing progress notes at 4:19 PM documents noted just 50 mL (milliliters) output in catheter drainage bag emptied. Tubing assessment requires resolving a kink in tubing near entry site of cath (catheter). Irrig. (irrigated) w (with) 60 mL of NSS (normal sterile saline) et (and) return of 60 mL clear yellow urine via syringe. Cath tubing posi (positioned) to allow proper drainage, note slightly cloudy yellow urine free flowing into drainage bag. On 2/8/23 R3's nursing progress note documents at 1:18 PM resident continues to refuse medication. During morning med (medications) pass the resident spat out her medicine once the medicine was in mouth. At lunch the resident did the same and was questioned as to why and she replied 'the devil made me do it.' On 2/9/23 at 2:36 PM, R3's nursing progress notes document resident has refused both breakfast and noon medications. She is speaking incoherently when prompted and spits her medication out with multiple attempts. On 2/9/23 at 3:53 PM, R3's nursing progress notes authored by V11 (Wound Nurse) documents resident is very confused and floor nurse stated she wouldn't eat, take meds or talk to anyone. On 2/11/23 at 10:03 AM, R3's progress note documents that resident's daughter called and was informed of her mother's condition. Resident is refusing to eat today. Medicine administration resulted in resident spitting out medicine. On 2/13/23 at 5:53 PM, R3's nursing progress note documents (R3) has eaten very little today. Spits anything out that is offered. She refused all am meds including amoxicillin. Took lunch meds but refused supper meds. (R3) has the appearance of declining condition with poor comprehension when spoken to speaking at times of her past and at times scattered non related conversation w (sic) to self. On 2/14/23 at 1:53 PM, R3's nursing progress notes document (R3) has refused all medications and food today when offered . Mult (multiple) attempts at med (medication) admin (administration) were met w (with) resistance, hitting at nurse, spitting on nurse and telling nurse to leave her alone. On 2/14/23 at 2:03 PM, R3's nursing progress notes document that a call was made to (R3's) daughter regarding refusal of medications/food, decreased cognitive level and resistance to care, and discussed alternate routes of feeding such as tube feeding or possible comfort care focused treatment. On 2/14/23 at 11:45 PM, R3's nursing progress notes document that R3 has refused all her medication including her urinary tract infection antibiotic. R3's catheter at this time is draining medium yellow urine. On 2/15/23 at 10:04 AM, R3's nursing progress notes documents, Resident refused AM (morning) medications. CNA (Certified Nurse Assistant) offered water and resident attempted to grab the cup and throw water back at CNA. On 2/18/23 at 4:25 AM, R3's nursing progress notes documents, When resident saw this nurse arrive outside of her room with medication cart, she immediately stated 'I can't take medicine again. Thank you though sweetie.' Fluids encouraged but spit back out. Resident denies any pain or discomfort. On 2/18/23 at 5:05 AM, R3's nursing progress notes authored by V10 (Registered Nurse/RN) documents this nurse entered resident's room to empty foley catheter, and again offered resident's AM medication to her. Again, resident refused medicine and stated 'I can't honey. I'm over a thousand years old. I really am. I really can't take any medicine this morning.' Foley catheter had 200 cc (cubic centimeter) dark/amber colored urine with small amt (amount) of sediment present. Resident is afebrile and denies any pain/discomfort. Will report to day shift nurse about possibly obtaining UA (urinalysis). Resident tolerated very small amt (amount) of water by mouth with much encouragement . On 2/18/23 at 9:55 AM, R3's nursing progress note authored by V9 (Licensed Practical Nurse/LPN) documents resident refused am meds (medications) despite multiple attempts. (R3) said 'If you give it to me I'll spit it out.' Nurse attempted to encourage resident to take the medication. She refused. On 2/20/23 at 11:25 AM, R3's nursing progress notes documents, CNA notified nurse that (R3) was found unresponsive in the dining room. Nurse assessed resident and could not rouse resident. Contacted (V12's) office for orders to send resident .Called POA (Power of Attorney), ADON (Assistant Director of Nursing), and Eroom (emergency room ) to notify of event and give report. There was no documentation in the progress notes above that V12 or V6 (Nurse Practitioner) were notified of R3's refusing of the antibiotic and other medications prescribed and urine output or color prior to the resident being sent to the emergency room (ER) on 2/20/23. On 2/20/23 at 2:12 PM, R3's nursing progress notes documents, contacted (hospital) ER to check on resident. Hospital stated (R3) is septic and that they are waiting on a urine and CT (Computed Tomography) and that she will be admitted . R3's hospital After Visit Summary documents R3 was hospitalized from 2/20/23 to 2/24/23 for severe sepsis with septic shock. On 2/24/23 at 12:30 PM, V2 (Director of Nursing) provided a written and signed document stating, I spoke with (Name of V9/LPN) regarding R3. (V9) stated she was made aware of the amber colored urine during report on 2/18/2023. Night nurse (V10) stated R3 was afebrile and didn't have any complaints. V9 then went in to assess R3. R3 denied any complaints and vitals were WNL (within normal limits). V9 stated that she did not meet criteria for UA (urinalysis). V9 monitored fluid intake. V2 also confirmed at this time that the physician was not notified by V9 of urine color and sediment in catheter bag. On 02/24/23 at 12:43 PM, V6 (Nurse Practitioner) stated the facility should have done a Situation, Background, Assessment, and Recommendation (SBAR) or a more thorough assessment to determine if the symptoms warranted an antibiotic or further intervention and should have called the physician to report findings observed in the catheter bag. V9 (LPN) and V10 (RN) were not available for interview during the time frame needed during the survey. There was no reproducible evidence in R3's medical record to show physician notification was made regarding R3's dark/amber colored urine with sediment present the morning of 2/18/23.

Based on observation, interview, and record review, the facility failed to use the appropriate lift sling per manufacturer's instructions to ensure a safe mechanical lift transfer for 1 of 3 residents (R2) reviewed for mechanical lift transfers in the sample of 3. This failure resulted in R2 falling and sustaining a left femur comminuted intratrochanteric fracture. This past noncompliance occurred from 6/17/22 to 6/21/22. Findings include: R2's Face Sheet documents R2 has the following diagnoses: [CONDITION(S)], Arthritis, Hx [CONDITION(S)] with [CONDITION(S)]/hemiparalysis, [CONDITION(S)], [CONDITION(S)], Hx (history) of Wedge Compression Fracture of T11 and T12 vertebrae, Hx of multiple Rib Fractures, Hx of Fracture of the lower end of Right Radius, Hx of non-displaced Bicondylar Fracture of Left Tibia, Hx of Chronic Embolism and [CONDITION(S)] of deep vein left distal lower extremity, [CONDITION(S)] due to excess calories, Hypertension, Aortic Aneurysm and Chronic Kidney Disease. R2's Minimum Data Set, dated dated [DATE] in Section C, documents R2 has a Brief Interview for Mental Status of 13, indicating R2 is cognitively intact with some forgetfulness. In Section C of R2's MDS, it is documented R2 was totally dependent with 2+ assistants for transferring. R2's Care Plan, dated 6/21/22, documents R2 is limited in mobility/Functional Status and requires the use of a mechanical lift/sling from wheelchair to bed and bed to wheelchair. This same care plan documents R2 prefers his personal sling be utilized during transfers related to comfort. R2's Care Plan for Falls, dated 9/17/21, under Problem: Resident at risk for falling R/T: History of falls, Cognitive Impairments, Communication Impairments, Visual Acuity Impairments, Decreased Safety Awareness, Impulsiveness with attempts to stand or self transfers without assistance from staff, Difficulty using call light and/or requesting staff assistance, Requires ADL assistance with transfers and mobility, Impaired ROM and/or loss of functional movement of joints, Incontinence, Decreased strength and endurance, Leaning forward in chair with attempts to pick up objects. The undated manufacturer's instructions for the facility's mechanical lift under WARNING documents, the mechanical lift slings are made specifically for use with the manufacturer's patient lifts for the safety of the patient. DO NOT use slings and patient lifts of different manufacturers. R2's Progress Note, dated 9/16/21, documents R2 was admitted to the facility and his admission weight was 311 pounds, and in April 2022, R2's weight was 348 pounds. R2 refused to be weighed in May or June of 2022. R2's Serious Injury Incident Report, dated 6/17/22, documents R2 had a fall with a physical injury from a mechanical lift. Under Detail Incident Summary it documents; R2 is a [AGE] year old male with a Brief Interview for Mental Status of 13. R2's diagnoses include, [CONDITION(S)], [CONDITION(S)], Chronic Kidney Disease and Reduced Mobility. On 6/17/22 at 4:32 PM, staff reported a witnessed fall during a transfer with a mechanical lift. Two staff, V4 (Certified Nurses Aide) and V5 (Certified Nurses Aide) were assisting R2 in the mechanical lift when the lift tipped sideways and V4 and V5 lowered R2 to the floor. V6 (Licensed Practical Nurse) immediately assessed R2 and he complained of left hip pain. V8 (Physician) and V9 (Family) were both notified and an order was received to send R2 to the emergency room for evaluation and treatment. The local hospital notified the facility that R2 had been transferred to an out of state hospital due to R2 having a left hip fracture. R2's Emergency Department report, dated 6/17/22, documents under Computed Tomography (CT) Left Hip, Findings/Impression: 1. Stable previous fractures and Open Reduction and Internal Fixation changes with upper pelvis. 2. New findings of left femur comminuted intratrochanteric fracture with slight angulation. No dislocation of the left hip. Left pelvic fixation hardware is in the expected position. There is an acute fracture involving the proximal left femoral diaphsis. On 7/14/22 at 9:40 AM, V4 stated she and V5 had to do a mechanical lift transfer on R2 from his electric wheelchair to his bed. V4 stated V5 hooked up the lift pad to the mechanical lift, and they both checked to see if it was hooked up correctly. V5 stated they lifted R2 up from his wheelchair and were rolling the mechanical lift toward his bed, and the lift pad with R2 in it wasn't swinging. V4 stated they got close to the bed and were turning the lift to the left, and the mechanical lift tipped over toward V5. V4 stated she thought the reason the mechanical lift tipped over was because R2 has severe contractures and is very heavy, and R2 insisted on using his own lift pad, and that lift pad didn't come all the way up to his shoulders, but hit him mid back. V4 stated R2 refused to use the nursing home lift pad because it hurt his neck. V4 stated she was standing on the left side of the mechanical lift with her shoulder holding the mechanical lift, and she had her hand and right leg under R2's buttocks, and V5 was holding onto the lift pad strap, and also had her leg under R2, as they slowly lowered R2 toward the floor. V4 stated R2 didn't hit his head, and he didn't land on the mechanical lift legs, and he didn't hit the floor because she and V5 were basically underneath R2. V4 stated V5 got out from under R2, and she went to get help. V4 stated V1 (Administrator) and V6 (Licensed Practical Nurse) came and assessed R2. V4 stated they didn't notice any shortening, but he said he heard a pop, and he complained of left hip and left knee pain. V4 stated they were given an in-service by V2 and V12 (Treatment Nurse) on 6/17/22 on the right lift pads to use and how to use the new mechanical lifts. On 7/19/22 at 9:00 AM, V5 stated she and V4 were getting R2 back into bed from his electric wheelchair. V5 stated R2 had his own lift pad, and it crisscrossed around his legs. V5 stated he refused to use one of the nursing home lift pads, and his lift pad hit him in the center of his back rather than hitting his shoulders. V5 said she tried to get R2 to use the nursing home's lift pads trying to convince R2 that it would be safer, but he refused and said he wasn't going to use it because it hurt too much. V5 stated V4 turned the mechanical lift to the left and to get the mechanical lift to go under the bed, she had to close the mechanical lift legs. V5 stated R2's weight shifted, and the mechanical lift started tipping over onto her. V5 stated she had R2 land on her, not the mechanical lift legs or the floor. V5 stated she got out from under R2 so she could go get help, while V4 continued to hold R2. V5 stated R2 was complaining about left hip pain and that he heard a pop . V5 stated V1 and V6 came to help them and they did an assessment of R2, and then called an ambulance. V5 stated she was in an in-service on 6/21/22 given by V13 (Registered Nurse) on the correct lift slings to use, and on how to operate the new mechanical lifts. On 7/20/22 at 2:30 PM, V14 (Certified Nurses Aide) and V15 (Certified Nurses Aide) both stated they were in-serviced on 6/17/22 on using the correct mechanical lift sling, and how to operate the new mechanical lift. On 7/14/22 at 11:30 AM, V2 (Director of Nursing) stated she investigated the accident involving R2 by actually having V4 and V5 demonstrate what happened. V2 stated the investigation showed the 2 C.N.A.s actually shielded R2 from landing on the floor. V2 stated R2 landed on the 2 C.N.A.s who were trying to prevent him from landing on the legs of the mechanical lift and onto the floor. V2 stated the turn may have shifted R2's weight and caused the mechanical lift to tip, but it was very hard to determine what happened. V2 stated R2 was very stiff, and he had fractured his left leg and pelvis when he had an automobile accident about 3 years earlier. V2 stated R2's bones are weak due to him not being able to stand, and R2 also has a diagnosis of Osteopenia and [CONDITION(S)] that also makes R2's bones fragile. On 7/20/22 at 3:34 PM, V2 stated they didn't evaluate R2's personal lift pad/sling to verify it was the correct size for R2, or that the lift sling was compatible to use with the mechanical lift used to transfer R2 on 6/17/22. V2 stated they tried to obtain R2's personal lift pad from the hospital on 6/17/22 to see if the lift sling was compatible with the mechanical lift, but no one could locate the lift sling R2 owned. V2 also stated V5 tried to talk to R2 about using the nursing home sling because it was safer. V2 stated it wasn't written anywhere concerning counseling R2 about using the sling that was supposed to be used with the mechanical lift. V2 stated on the day of the incident with R2, 6/17/22, and on 6/21/22, in-services were conducted on using the right size of mechanical lift slings and how to correctly use the mechanical lifts. V2 stated for the in-service training they used the Mechanical Lift policy and procedure, and the Validation of Competency form was used to explain how to use the mechanical lift and the importance of using of the correct sling. V2 stated they also used the Transfer Assessment Tool to determine residents who can transfer and how they are to be transferred. On 7/19/22 at 10:30 AM, V6 stated she wasn't in the room when the mechanical lift tipped over, but she went in to assess R2, and he was complaining of left hip pain. V6 stated when she went into R2's room, V4 was supporting R2 with her leg and she was holding onto him. V6 stated R2 wasn't on the floor, and he wasn't sitting on the mechanical lift legs. V6 stated R2 did have his own lift pad under him because he said it was more comfortable than the nursing home lift pads. On 7/19/22 at 10:45 AM, V3 (Assistant Director of Nursing) stated R2 used his own lift pad because the nursing home lift pads came up to his neck and pushed his head forward causing him pain. R2 insisted on using his own personal lift pad, and he refused to use the nursing home lift pads. V3 stated R2's bones were weak and he had a diagnosis of Osteopenia and Arthritis, and he hadn't stood on his legs for a very long time, making R2's bones weak. On 7/14/22 at 1:30 PM, V1 (Administrator) stated once the accident happened, they had another mechanical lift brought in from their sister facility just to ensure the safety of the residents. V1 stated they took all of the older model mechanical lifts out of service and rented newer mechanical lifts that were heavier and more sturdy. V1 stated the older lifts were designed to hold someone who weighed 400 pounds and R2 weighed around 340 pounds. On 7/20/22 at 2:12 PM, V10 (Physical Therapy Assistant/Rehab Director) stated R2 was in therapy for a while, and he wasn't cooperative with his therapy treatments. V10 stated she didn't ever see R2's personal lift pad because he was always up in his wheelchair. V10 stated R2 had gained a lot of weight since his admission, and it is possible the lift pad was too small for him. V10 also stated she heard him tell the C.N.A.s that he wouldn't use the facility's lift pad, and he demanded them use his personal lift pad and a certain mechanical lift or he wouldn't get up. On 7/20/22 at 3:10 PM, V11 (Medical Director) stated he was aware of R2's fall with left hip fracture related to the mechanical lift tipping over. V11 stated the facility staff should have used the lift sling recommended by the manufacturer of the mechanical lift to ensure the transfer was safe. V11 stated he was aware R2 was insistent on using his personal lift sling, but the facility should have counseled him on the safety risks associated with the use of a lift sling not designed for the mechanical lift. V11 stated that way, if there was a fall, it wouldn't be an issue related to an improper lift sling. The facility's Mechanical Lift policy, dated October 2017, documents under Policy: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. Prior to the survey date, the facility took the following actions to correct noncompliance: 1. The facility's QAPI Ad Hoc plan, dated 6/17/22, under Identified Opportunity for Improvement/Deficient Practice; Mechanical Lift transfers: 1.) Immediate Corrective Action for those affected by deficient practice: a.) Initiated investigation to determine root cause of incident 6/17/22. b.) Staff education initiated for mechanical lift 6/17/22. 2.) Process/Steps to identify others having the potential to be impacted by the same deficient practice: All other residents using mechanical lifts have the potential to be impacted. R1, R3, R4, R5, R6, R7, R8, R9. 3.) Measures put into place/systemic changes ensure the deficient practice does not recur: a.) Ongoing in-servicing on mechanical lifts prior to next working shift. Initiated 6/17/22 b.) Random audits for proper use of mechanical lift 6/20/22 c.) Implement monthly prevention maintenance checks on all shifts. 6/20/22 d.) Monthly audits for preventative maintenance. Initiated 6/20/22 e.) Therapy/Nursing to determine appropriate sling to use for all lift residents. Initiated 6/20/22 f.) Care Plans to be updated to include type of transfer and sling to be used. 4.) Plan to monitor performance to ensure solutions are sustained. a.) Administrator responsible for compliance of mechanical transfers/maintenance. b.) DON and Administrator will report findings to QA meeting. 2. All current mechanical lifts in the facility were taken out of service. 3. A mechanical lift was borrowed from our sister facility. 4. The loaned mechanical lift was the only lift used until the 3 new rental mechanical lifts arrived on 7/7/22. 5. The facility will monitor and observe mechanical use quarterly. 6. The facility will ensure yearly mechanical lift use in-service. 7. Ensure new hires are checked for competency on slings and mechanical lift use. 8. Employees were in-serviced on 6/17/22 and 6/21/22. The in-service material used was the facility policy and procedure on Mechanical Lifts, Validation of Competency regarding Mechanical lifts and the Transfer Assessment Tool to determine who can transfer and how they are to be transferred.

Based on interview and record review, the facility failed to assess for a patent airway and attempt to clear an obstructed airway in an unconscious resident for 1 of 1 resident (R2) reviewed for emergency basic life support in the sample of five. This failure resulted in staff providing ineffective rescue breathing, and R2 subsequently expiring. The Immediate Jeopardy began on [DATE] at approximately 6:20pm, when V5 (Certified Nurse Assistant/CNA), upon finding R2 without pulse and respirations, placed a pillow under R2's head, did not visually check R2's airway for occlusion, and did not perform a finger sweep to check for airway occlusion, prior to beginning rescue breathing, subsequently resulting in R2's death on [DATE] at 6:51pm. This past noncompliance occurred from [DATE] to [DATE]. This has the potential to affect 47 residents identified as being full code status. An Immediate Jeopardy was identified to have begun on [DATE]. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 1:40pm. The surveyor confirmed by observation, interview, and record review that the immediacy was removed on [DATE]. R2's Continuity of Care Document listed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [DATE] POLST (IDPH/Illinois Department of Public Health Uniform Practitioner Order for Life Sustaining Treatment) form documented, Full treatment-attempt CPR (Cardiopulmonary Resuscitation). A Serious Injury Incident Report submitted via fax to the Illinois Department of Public Health, dated [DATE], documented, (R2) unexpectedly passed away on the evening of [DATE] .At approximately 5:45pm, (R2's) meal tray was delivered to him. Set up of the meal was provided by staff. He was appropriately seated in his recliner. At approximately 6:10pm, a CNA went to his room. He had removed his food soiled gown, which was his common practice. The CNA and (R2) had a brief conversation. The CNA picked up his tray and all food items. She took the tray and all food items from room and retrieved a clean gown and brief for him. Approximately 3 to 5 minutes later, she returned to his room and found him with his hand folded and head dropped in his chair. She immediately called for nurse assistance. (The) nurse checked for pulse and breaths. Finding no pulse or breaths, CPR (Cardiopulmonary Resuscitation) was initiated and continued until EMS (Emergency Management Services) arrived on the scene to take over. EMS hooked him up to a (trade name mechanical chest compression device) and attempted to intubate. Upon intubation, a partially chewed brussel sprout was discovered. EMS pronounced him dead at 6:51pm. (The) Coroner transported his body to the morgue pending an autopsy. An autopsy was performed on [DATE]. The preliminary results indicated that his death was accidental due to choking on food due to advanced Alzheimer's Disease with no signs of negligence. (R2) had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His BIMS (Brief Interview for Mental Status) indicated a staff assessment was necessary. He had long and short term memory problems and had moderately impaired daily decision making ability. He was on a mechanical soft diet. Per autopsy, all food found in his system was appropriately chopped per diet order. On [DATE] at 10:30am, V3 (Emergency Medical Technician/EMT) stated on the evening of [DATE], the ambulance service for which V3 is employed, received a call to respond to the facility for a possible [CONDITION(S)]. V3 stated when the team arrived on scene at around 6:30pm, two facility staff were performing compressions and rescue breathing for R2. V3 stated V3 relieved the staff member providing rescue breathing, and checked the patency of R2's airway. V3 stated upon visual inspection, V3 saw a large green mass lodged in the airway. V3 attempted to suction the object out, but was unsuccessful. V3 then used forceps to pull out the object, which V3 stated was a solid, unchewed, whole brussel sprout. V3 stated one of the facility staff relayed R2 had brussel sprouts for dinner, and R2 was on a mechanical soft diet. V3 stated EMS staff continued with rescue breathing and compressions, but R2 failed to respond, and the team's lead paramedic contacted their physician, who pronounced R2's time of death at 6:51pm. V3 stated the brussels sprout was sent to the coroner's office along with body. On [DATE] at 11:05am, V4 (CNA) stated V4 found R2 sitting in R2's recliner, unresponsive, without a pulse or respirations. V4 stated V4 ran to get V6 (Licensed Practical Nurse/LPN), who stated R2 was a full code. V4 stated V4 and V5 (CNA) lowered R2 to the ground, V5 put a pillow under R2's head, and V4 began performing chest compressions, while V5 performed rescue breathing. V4 stated V4 does not recall V5 doing a visual inspection or finger sweep of the mouth prior to providing rescue breaths, and V4 stated she also did not check for airway patency. V4 stated staff did not discuss a potential choking incident, because staff assumed R2 had a [CONDITION(S)] or a stroke. V4 stated neither V4 nor V5 attempted the [MEDICATION(S)] maneuver. V4 stated V4 and V5 changed positions a few times until EMTs responded and took over. V4 stated V4 recalled V4 did not think air was going into R2's lungs, but neither V4 nor V5 attempted to check the patency of R2's airway. On [DATE] at 11:45am, V6 (LPN) stated while V4 and V5 performed CPR, V6 was calling the ambulance and notifying R2's physician and family. V6 stated V6 was not in R2's room for the entirety of the event, and therefore cannot be sure if the patency of R2's airway was checked. V6 stated V6 recalls watching V4 and V5 perform CPR, and noting R2's abdomen, not chest, was rising during rescue breaths. V6 stated V6 did not attempt to intervene by checking the patency of the airway, nor performing the [MEDICATION(S)] maneuver. V6 stated staff assumed R2 had a stroke or cardiac event. On [DATE] at 12:30pm, V5 (CNA) stated when V5 and V4 (CNA) found R2 unresponsive with no pulse and respirations, they moved R2 from the recliner onto the floor. V5 stated V5 placed a pillow under R2's head. V5 stated V5 then placed a valve mask apparatus, without the bag, over R2s mouth and nose and began providing rescue breaths. V5 stated V5 did not check the patency of the airway prior to providing rescue breaths, either by performing a visual inspection, or finger sweep for occlusion. V5 stated V5 was not sure if air was going into R2's lungs, and at some point, V4 also stated V4 did not think R2's lungs were inflating. V5 stated V5 did not attempt to reposition R2's head, do a finger sweep, or do a visual inspection. V5 stated staff did not discuss the possibility of choking, so the [MEDICATION(S)] maneuver was not attempted. V5 stated V5 and V4 switched positions two or three more times until EMTs arrived on the scene and took over. On [DATE] at 8:30am, V25 (Doctor of Osteopathy/R2's Physician) stated R2 had swallowing issues due to Alzheimer's dementia. V25 stated R2 was full code status. V25 stated since R2 became unresponsive during a meal, choking should have been suspected, and staff should have checked the airway via visual check and finger sweep, followed by the [MEDICATION(S)] maneuver if a blockage was identified, and if the [MEDICATION(S)] maneuver proved ineffective, the next step would be trying to blow the object into lungs. On [DATE] at 8:45am, V26 (Medical Doctor/Medical Director) stated the facility had not notified V26 of the above referenced incident with R2. V26 stated V26 was aware R2 was the patient of V25. V26 stated, It sounds like a lot of re-education needs to happen with staff regarding therapeutic diets, supervision (of residents during eating) and CPR. V26 stated V26 was going to call administrative staff and set up an immediate meeting. On [DATE] at 12:40pm, V11 (Coroner) stated V11 was present for R2's autopsy which was performed on [DATE] by V23 (Medical Doctor/Medical Examiner/Pathologist). V11 stated the Deputy Coroner was on the scene and obtained the vegetable matter which V3 (EMT) retrieved from R2's airway. V11 stated R2's stomach contents also contained pieces of the vegetable. V11 stated V23 determined R2's death was due to accidental asphyxiation. A Death Certificate, dated [DATE], documented, Cause of death: Choking on a food bolus. A CPR Policy, dated [DATE], stated, .To perform CPR, after you have determined that the resident is unresponsive, is not breathing, and has no pulse, first lay the patient on their back on a hard surface. Tilt the residents head back slightly and lift the chin to open the airway and check for breathing. If the resident is not breathing, use a (trade name bag valve mask) with a mask attachment for unventilated residents with one staff holding the mask tightly and keeping the head in a chin tilt position and the second staff member squeezing the bag to instill air to ensure full ventilation of the lung field. Guidance at The American Red Cross www.redcross.org, states, CPR Steps: .Open the airway. With the person lying on his or her back, tilt the head back slightly to lift the chin .Deliver rescue breaths. If the chest does not rise with the initial rescue breath, re tilt the head before delivering the second breath. If the chest doesn't rise with the second breath, the person may be choking. After each subsequent set of 30 chest compressions, and before attempting breaths, look for an object, and if seen, remove it. A list provided by the facility on [DATE] documented a total of 47 residents as being full code status. An Immediate Jeopardy was identified to have began on [DATE]. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 1:40pm. The surveyor confirmed by observation, interview, and record review that the immediacy was removed on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE], prior to the survey date. Prior to the survey date, the facility took the following actions to remove the immediacy and correct the non-compliance: 1. On [DATE], V13, Human Resources Staff, reviewed the CPR certifications of all staff. 2. On [DATE] and [DATE], V2 educated all nursing and CNA staff on providing emergency care/CPR/the [MEDICATION(S)] Maneuver. On this date, V2 scheduled CPR classes for staff who needed new certifications, or to have their certifications renewed. 3. All nursing staff will be trained by V2 during orientation and quarterly for one year regarding CPR, emergency care, and following the correct diet orders. 4. V1 will conduct random meal audits (to ensure the meal served is consistent with physicians orders) three times weekly for four weeks, beginning [DATE].

Based on interview and record review, the facility failed to serve a resident food consistent with a mechanical soft diet for 1 (R2) of 5 residents reviewed for therapeutic/mechanically altered diets in the sample of 5. This failure resulted in R2 aspirating a whole brussels sprout, with R2's airway becoming occluded, and R2 subsequently expiring. The Immediate Jeopardy began on [DATE] at approximately 5:45pm, when R2 was served a meal inconsistent with R2's prescribed mechanical soft diet. On [DATE] at approximately 6:20pm, staff found R2 unresponsive after having ingested a whole brussel sprout, which occluded his airway and caused R2 to stop breathing, subsequently resulting in R2's death on [DATE] at 6:51pm. This past noncompliance occurred from [DATE] to [DATE]. This has the potential to affect 17 residents identified as a choking risk, all of whom are on a mechanical soft diet. An Immediate Jeopardy was identified to have begun on [DATE]. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 1:40pm. The surveyor confirmed by interview, observation, and record review, the immediacy was removed on [DATE]. On [DATE], the facility provided a list of 17 residents identified as being at risk for choking, all of whom are on a mechanical soft diet. R2's Continuity of Care Document listed an admitted [DATE], and diagnoses of Alzheimer's Disease, unspecified, effective date [DATE], status: Active, and Dysphagia, oropharyngeal phase, effective date [DATE], status: Active. A Speech Therapy Plan of Care, authored by V9 (former Speech Language Pathologist/SLP), documented, Treatment Diagnosis: Dysphagia, Oropharyngeal phase. Start of care: [DATE]. End of Care: [DATE]. Therapy (is necessary) for increased safety/efficiency of swallow(ing) to tolerate safe and adequate tolerance of (the) least restrictive diet. Without therapy, the patient is at risk for choking/weight loss/malnutrition. A [DATE] Speech Therapy Progress and Discharge Summary. authored by V9 documented, The patients gains during this course of skilled speech therapy have resulted in diet advancement from puree to mechanical soft. Mild dysphagia given the mechanical soft diet. Staff education given regarding continuation of all food in bowls, and assisting patient as needed with transition from bowl to bowl. A Serious Injury Incident Report submitted via fax to the Illinois Department of Public Health, dated [DATE], documented, (R2) unexpectedly passed away on the evening of [DATE] .At approximately 5:45pm, (R2's) meal tray was delivered to him. Set up of the meal was provided by staff. He was appropriately seated in his recliner. At approximately 6:10pm, a CNA (Certified Nursing Assistant) went to his room. He had removed his food soiled gown, which was his common practice. The CNA and (R2) had a brief conversation. The CNA picked up his tray and all food items. She took the tray and all food items from room and retrieved a clean gown and brief for him. Approximately 3 to 5 minutes later, she returned to his room and found him with his hand folded and head dropped in his chair. She immediately called for nurse assistance. (The) nurse checked for pulse and breaths. Finding no pulse or breaths, CPR (Cardiopulmonary Resuscitation) was initiated and continued until EMS (Emergency Management Services) arrived on the scene to take over. EMS hooked him up to a (trade name mechanical chest compression device) and attempted to intubate. Upon intubation, a partially chewed brussel sprout was discovered. EMS pronounced him dead at 6:51pm. (The) Coroner transported his body to the morgue pending an autopsy. An autopsy was performed on [DATE]. The preliminary results indicated that his death was accidental due to choking on food due to advanced Alzheimer's Disease with no signs of negligence. (R2) had a diagnosis of Alzheimer's Disease, PVD (Peripheral Vascular Disease), CKD III (Chronic Kidney Disease Stage 3), other seizures, and Major Depressive Disorder. His BIMS (Brief Interview for Mental Status) indicated a staff assessment was necessary. He had long and short-term memory problems and had moderately impaired daily decision making ability. He was on a mechanical soft diet. Per autopsy, all food found in his system was appropriately chopped per diet order. R2's [DATE] quarterly Minimum Data Set (MDS) documented R2 required limited assistance from at least one staff member for eating, and R2 was severely visually impaired. The same MDS documented a Brief Interview for Mental Status score of zero, indicating R2 had severe deficits in cognition, and required a mechanically altered diet. R2's Continuity of Care Document listed diagnoses of Alzheimer's Disease, Moderate Protein Calorie Malnutrition, and [CONDITION(S)] [CONDITION(S)]. R2's Physicians Order Sheet, dated [DATE], documented an order for a mechanical soft diet with thin liquids, with special instructions to serve all food in bowls. R2's Care Plan, with a review date of [DATE], documented a problem area, Resident requires a mechanically altered diet, with the corresponding approaches, Provide assistance for meal. Responsible staff: CNA, nursing. (Obtain) Speech Therapy consult. Follow recommendations. Assure dentures, partial plates, etc. are in place before meals. Assure a proper fit. A [DATE] Speech Therapy Diet Order signed by V9. Former Speech Therapist, documented, Mechanical soft, thin liquids. On [DATE] at 12:05pm, V8 (Cook) stated V8 was working the evening of [DATE]. V8 stated the supper menu included ham, au gratin potatoes, and brussel sprouts. V8 stated for mechanical soft diets, cooked food is pulsed in a commercial food processor with liquid until chopped. V8 stated R2 was on a mechanical soft diet. V8 stated V8 placed frozen brussel sprouts on the stove at 2:00pm, and they were cooked until 3:15pm. V8 stated the brussel sprouts were then soft, and V8 pulsed them in the food processor until chopped small. V8 stated the sprouts were processed with cooking liquid and butter. V8 stated they were then held on the steam table until service began at approximately 4:30pm. V8 stated each resident's diet card is placed on the tray, and the card is checked prior to the food being plated to ensure each resident receives the correct diet. V8 stated the kitchen received no negative feedback that evening about the sprouts. V8 stated residents on regular diets were served the whole sprouts, prepared the same way, but not chopped. A [DATE] Dinner Diet Spreadsheet listed, Brussel Sprouts: (mechanical soft): (serve) 4 ounce spoodle, (cooked) soft (and) chopped. On [DATE] at 10:30am, V3 (Emergency Medical Technician/EMT) stated on the evening of [DATE], the ambulance service for which V3 is employed, received a call to respond to the facility for a possible [CONDITION(S)]. V3 stated when the team arrived on scene at around 6:30pm, two facility staff were performing compressions and rescue breathing for R2. V3 stated V3 relieved the staff member providing rescue breathing, and checked the patency of R2's airway. V3 stated upon visual inspection, V3 saw a large green mass lodged in the airway. V3 attempted to suction the object out, but was unsuccessful. V3 then used forceps to pull out the object, which V3 stated was a solid, unchewed, whole brussel sprout. V3 stated one of the facility staff relayed R2 had brussel sprouts for dinner, and R2 was on a mechanical soft diet. V3 stated EMS staff continued with rescue breathing and compressions, but R2 failed to respond, and the team's lead paramedic contacted their physician, who pronounced R2's time of death at 6:51pm. V3 stated the brussel sprout was sent to the coroner's office along with body. On [DATE] at 11:05am, V4 (CNA) stated on the evening of [DATE], V4 and V5 (CNA) were working together on the Center/East Hall/Suites units during dinner. V4 stated V5 was passing trays and V4 was feeding residents. V4 stated they began getting trays to resident rooms at about 5:45pm. V4 stated V4 did not bring in R2's tray or set up his meal; V4 assumes V5 did. V4 stated R2 was on a mechanical soft diet and has food served to R2 in separate bowls, due to visual deficits. V4 stated R2 used a combination of fingers and utensils to eat. V4 stated R2 never wore dentures. V4 stated staff would give R2 a bowl and utensil, then come back and check on R2, and give R2 another bowl and continue until R2 was finished. V4 stated V4 was done feeding residents, and looked in on R2 at about 6:10pm. V4 stated R2 had food everywhere and soiled clothing, which was usual for R2. V4 stated R2 looked tired, and V4 asked R2 if R2 wanted to go to bed, and R2 said yes, I'm tired. V4 stated V4 picked up R2's tray and bowls, and noticed the brussel sprouts were whole. V4 stated other residents on mechanical soft diet had also been served whole brussel sprouts that evening, and residents on regular consistency diets had complained they were chewy, so V4 had taken them off the trays of the residents on mechanical soft diets. V4 stated V4 took the tray and bowls out of the room, and left to go get R2 a clean gown and brief. V4 stated V4 was gone only a couple of minutes, and when V4 returned, R2 was sitting with R2's head down with [MEDICATION(S)] coming from R2's mouth and nose, R2 was cold, and unresponsive. V4 stated V4 ran and alerted V6 and V7, (both Licensed Practical Nurses/LPN's). V4 and V5 got R2 onto the floor and began CPR until the EMTs arrived in five or ten minutes. V4 stated V4 then went out into the hall. V4 stated V4 didn't see the EMTs intubate R2, but one of the EMTs brought V4 a whole, solid brussel sprout and said they took it out of R2's airway, and they said for V4 to save it. V4 stated R2 did have a roommate, R5, but R5 always ate in the hallway, and R2 was unable to ambulate without assistance and could not have accessed R5's tray. V4 stated in retrospect, she now wonders if R2 had a brussels sprout laying in his chair and put it in his mouth when she left to get his clean linens. On [DATE] at 11:45am, V6 (LPN) stated on [DATE] at about 6:20pm, V6 was giving report to V7 (LPN) at the nurse's station, when they were alerted by V4 that R2 was unresponsive. V6 corroborated V4's account of the events as stated above. V6 stated V6 did not see EMTs intubate R2, but V4 brought V6 the whole, solid brussel sprout, and said, We need to keep this, they found it in (R2's) airway. V6 stated the sprout was then sent with the body to the coroner's office. V6 stated R2 was on a mechanical soft diet, and R2 always took R2's pills crushed mixed with pudding, as R2 was at risk for aspiration. V6 stated V6 does not know who set up R2's tray that evening. V6 stated R2 was visually impaired and had dementia. V6 stated R2's food was served in bowls one at a time; R2 would put it up to R2's mouth and use fingers or utensils depending on R2's mood. V6 stated staff would leave the room and come back to check on R2, and switch out R2's bowls. On [DATE] at 1:00pm, V5 (CNA) stated V5 was working with V4 (CNA) the evening of [DATE]. V5 stated V5 was passing trays and took R2 his tray at about 5:45pm. V5 stated V5 noticed R2's tray contained ground meat and potatoes, but R2 had been given whole brussels sprouts. V5 stated other residents had already complained to V5 the sprouts were too tough and chewy. V5 stated at that time, it did not occur to her R2 might choke on the sprouts. V5 stated V5 placed R2's tray on R5's over bed table within R2's reach, and handed R2 a bowl of chopped meat. V5 stated R2 could switch out the bowls by himself when R2 was finished, and V5 assumed R2 got the bowl of sprouts when R2 was done with the meat. V5 stated V5 continued passing trays, and did not enter the room again until V5 and other staff responded when R2 was found unresponsive. On [DATE] at 10:35am, V9 (SLP) stated R2 had difficulty swallowing in part due to advanced dementia, hence the need for a mechanical soft diet. V9 stated it would not have been safe for R2 to consume brussel sprouts which were not cooked soft and had been chopped. V9 stated R2 would typically have eaten in the dining room, had Covid precautions not been in place at the time of his death, where R2 would have received more supervision. V9 stated with communal dining currently on hold, residents who require more supervision or cueing are typically placed in the hallway at mealtimes. V9 stated R2 should have had more direct supervision and placing R2 in the hall at mealtime would have provided this. On [DATE] at 8:30am, V25 (Doctor of Osteopathy/R2's Physician) stated R2 had swallowing issues due to Alzheimer's dementia. V25 stated R2 was full code status. V25 stated since R2 became unresponsive during a meal, choking should have been suspected, and staff should have checked the airway via visual check and finger sweep, followed by the [MEDICATION(S)] maneuver if a blockage was identified, and if the [MEDICATION(S)] maneuver proved ineffective, the next step would be trying to blow the object into lungs. On [DATE] at 8:45am, V26 (Medical Doctor/Medical Director) stated the facility had not notified V26 of the above referenced incident with R2. V26 stated V26 was aware R2 was the patient of V25. V26 stated, It sounds like a lot of re-education needs to happen with staff regarding therapeutic diets, supervision (of residents during eating) and CPR. V26 stated V26 was going to call administrative staff and set up an immediate meeting. On [DATE] at 12:40pm, V11 (Coroner) stated V11 was present for R2's autopsy, which was performed on [DATE], by V23 (Medical Doctor/Medical Examiner/Pathologist). V11 stated the Deputy Coroner was on the scene and obtained the vegetable matter which V3 (EMT) retrieved from R2's airway. V11 stated R2's stomach contents also contained pieces of the vegetable. V11 stated V23 determined R2's death was due to accidental asphyxiation. An Autopsy Preliminary Report, dated [DATE], authored by V23, documented, Immediate cause of death-choking on a food bolus-brussels sprout-(measuring) 4.5 by 2 by 2 centimeters. A Death Certificate, dated [DATE], documented, Cause of death: Choking on a food bolus. An undated Resident Nutrition Services Policy documented, Each resident shall receive the correct diet, with preferences accommodated as feasible, and shall receive prompt meal service and appropriate feeding assistance .Nursing personnel will ensure that residents are served the correct food tray. Prior to serving the food tray, the Nurses Aid/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the nursing supervisor will check the written physician's order. If an incorrect meal has been delivered, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. A Therapeutic Diets Policy with a revision date of [DATE] documented, Mechanically altered diets modified for medical or nutritional needs, will be considered 'therapeutic diets.' An Immediate Jeopardy was identified to have begun on [DATE]. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 1:40pm. The surveyor confirmed by interview, observation, and record review that the immediacy was removed on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE], prior to the survey date. Prior to the survey date, the facility took the following actions to remove the immediacy and correct the non-compliance: 1. On [DATE], V27, Dietary Manager, was educated by V28, Clinical Operations Director, on following proper food preparation guidelines and ensuring proper diet consistency is observed. 2. On [DATE], dietary staff were educated by V27 on following proper food preparation guidelines and ensuring proper diet consistency is observed. 3. On [DATE], frontline staff who deliver food trays were educated by V1 on ensuring proper diets are served and meal set up is provided. 4. On [DATE], V27 reviewed all physicians diet orders to ensure they matched orders on kitchen diet cards. 5. On [DATE], V2 reviewed all medical records for speech therapy diet recommendations to ensure all staff were aware of these recommendations. 6. V1 will conduct random meal audits (checking that the meal served is consistent with physicians orders) beginning [DATE], 3 times a week for 4 weeks and report the findings to the Quality Assurance Committee. 7. All staff will be trained by V2 at orientation, and quarterly for one year regarding following diet orders.

Based on interview and record review, the facility failed to provide supervision during meal service to a visually impaired resident with dementia for 1 (R2) of 5 residents reviewed for supervision during meals in the sample of 5. This failure resulted in R2 aspirating a whole brussels sprout on [DATE], with R2's airway becoming occluded, and R2 subsequently expiring on [DATE]. This past noncompliance occurred from [DATE] to [DATE]. R2's Continuity of Care Document listed an admitted [DATE], and diagnoses of Alzheimer's Disease, unspecified, effective date [DATE], status: Active, and Dysphagia, oropharyngeal phase, effective date [DATE], status: Active. A Speech Therapy Plan of Care, authored by V9, former Speech Language Pathologist, documented, Treatment Diagnosis: Dysphagia, Oropharyngeal phase. Start of care: [DATE]. End of Care: [DATE]. Therapy (is necessary) for increased safety/efficiency of swallow(ing) to tolerate safe and adequate tolerance of (the) least restrictive diet. Without therapy, the patient is at risk for choking/weight loss/malnutrition. The patient does have upper dentures in place. A [DATE] Speech Therapy Progress and Discharge Summary, authored by V9 documented, The patients gains during this course of skilled speech therapy have resulted in diet advancement from puree to mechanical soft. Mild dysphagia given the mechanical soft diet. Staff education given regarding continuation of all food in bowls, and assisting patient as needed with transition from bowl to bowl. A Serious Injury Incident Report submitted via fax to the Illinois Department of Public Health, dated [DATE], documented, (R2) unexpectedly passed away on the evening of [DATE] .At approximately 5:45pm, (R2's) meal tray was delivered to him. Set up of the meal was provided by staff. He was appropriately seated in his recliner. At approximately 6:10pm, a CNA (Certified Nursing Assistant) went to his room. He had removed his food soiled gown, which was his common practice. The CNA and (R2) had a brief conversation. The CNA picked up his tray and all food items. She took the tray and all food items from room and retrieved a clean gown and brief for him. Approximately 3 to 5 minutes later, she returned to his room and found him with his hand folded and head dropped in his chair. She immediately called for nurse assistance. (The) nurse checked for pulse and breaths. Finding no pulse or breaths, CPR (Cardiopulmonary Resuscitation) was initiated and continued until EMS (Emergency Management Services) arrived on the scene to take over. EMS hooked him up to a (trade name mechanical chest compression device) and attempted to intubate. Upon intubation, a partially chewed brussels sprout was discovered. EMS pronounced him dead at 6:51pm. (The) Coroner transported his body to the morgue pending an autopsy. An autopsy was performed on [DATE]. The preliminary results indicated that his death was accidental due to choking on food due to advanced Alzheimer's Disease with no signs of negligence. (R2) had a diagnosis of Alzheimer's Disease, PVD (Peripheral Vascular Disease), CKD III (Chronic Kidney Disease Stage 3), other seizures, and Major Depressive Disorder. His BIMS (Brief Interview for Mental Status) indicated a staff assessment was necessary. He had long and short-term memory problems and had moderately impaired daily decision-making ability. He was on a mechanical soft diet. Per autopsy, all food found in his system was appropriately chopped per diet order. R2's [DATE] quarterly Minimum Data Set (MDS) documented R2 required limited assistance from at least one staff member for eating, and R2 was severely visually impaired. The same MDS documented a Brief Interview for Mental Status score of zero, indicating R2 had severe deficits in cognition, and required a mechanically altered diet. R2's Continuity of Care Document listed diagnoses of Alzheimer's Disease, Moderate Protein Calorie Malnutrition, and [CONDITION(S)] [CONDITION(S)]. R2's Physicians Order Sheet documented an order for a mechanical soft diet with thin liquids, with special instructions to serve all food in bowls. R2's Care Plan, with a review date of [DATE], documented a problem area, Resident requires a mechanically altered diet, with the corresponding approaches, Provide assistance for meal. Responsible staff: CNA, nursing. (Obtain)Speech Therapy consult. Follow recommendations. Assure dentures, partial plates, etc. are in place before meals. Assure a proper fit. A [DATE] Speech Therapy Diet Order signed by V9. Former Speech Therapist, documented, Mechanical soft, thin liquids. On [DATE] at 12:05 pm, V8, Cook, stated V8 was working the evening of [DATE]. V8 stated the supper menu included ham, au gratin potatoes, and brussel sprouts. V8 stated for mechanical soft diets, cooked food is pulsed in a commercial food processor with liquid until chopped. V8 stated R2 was on a mechanical soft diet. V8 stated V8 placed frozen brussel sprouts on the stove at 2:00pm, and they were cooked until 3:15pm. V8 stated the brussel sprouts were then soft, and V8 pulsed them in the food processor until chopped small. V8 stated the sprouts were processed with cooking liquid and butter. V8 stated they were then held on the steam table until service began at approximately 4:30pm. V8 stated each resident's diet card is placed on the tray, and the card is checked prior to the food being plated to ensure each resident receives the correct diet. V8 stated the kitchen received no negative feedback that evening about the sprouts. V8 stated residents on regular diets were served the whole sprouts, prepared the same way, but not chopped. A [DATE] Dinner Diet Spreadsheet listed, Brussel Sprouts: (mechanical soft): (serve) 4-ounce spoodle, (cooked) soft (and) chopped. On [DATE] at 10:30am, V3 (Emergency Medical Technician/EMT) stated on the evening of [DATE], the ambulance service for which V3 is employed, received a call to respond to the facility for a possible [CONDITION(S)]. V3 stated when the team arrived on scene at around 6:30pm, two facility staff were performing compressions and rescue breathing for R2. V3 stated V3 relieved the staff member providing rescue breathing, and checked the patency of R2's airway. V3 stated R2 was not wearing dentures. V3 stated upon visual inspection, V3 saw a large green mass lodged in the airway. V3 attempted to suction the object out but was unsuccessful. V3 then used forceps to pull out the object, which V3 stated was a solid, unchewed, whole brussels sprout. V3 stated one of the facility staff relayed R2 had brussel sprouts for dinner, and R2 was on a mechanical soft diet. V3 stated EMS staff continued with rescue breathing and compressions, but R2 failed to respond, and the team's lead paramedic contacted their physician, who pronounced R2's time of death at 6:51pm. V3 stated the brussel sprout was sent to the coroner's office along with body. On [DATE] at 11:05am, V4 (CNA) stated on the evening of [DATE], V4 and V5 (CNA) were working together on the Center/East Hall/Suites units during dinner. V4 stated V5 was passing trays, and V4 was feeding residents. V4 stated they began getting trays to resident rooms at about 5:45pm. V4 stated V4 did not bring in R2's tray or set up his meal, V4 assumes V5 did. V4 stated R2 was on a mechanical soft diet, and had food served to R2 in separate bowls due to visual deficits. V4 stated R2 was very confused, but at times could engage in limited conversation with staff. V4 stated R2 used a combination of fingers and utensils to eat. V4 stated staff would give R2 a bowl and utensil, then come back and check on R2 and give R2 another bowl, and continue until R2 was finished. V4 stated this was the routine staff used with R2 during meals. V4 stated V4 was done feeding residents and looked in on R2 at about 6:10pm. V4 stated R2 had food everywhere, and soiled clothing which was usual for R2. V4 stated R2 looked tired, and V4 asked R2 if R2 wanted to go to bed, and R2 said yes, I'm tired. V4 stated V4 picked up R2's tray and bowls, and noticed the brussels sprouts were whole. V4 stated other residents on mechanical soft diet had also been served whole brussels sprouts that evening, and residents on regular consistency diets had complained they were chewy, so V4 had taken them off the trays of the residents on mechanical soft diets. V4 stated V4 took the tray and bowls out of the room, and left to go get R2 a clean gown and brief. V4 stated V4 was gone only a couple of minutes, and when V4 returned, R2 was sitting with R2's head down with [MEDICATION(S)] coming from R2's mouth and nose; R2 was cold, and unresponsive. V4 stated V4 ran and alerted V6 and V7, (both Licensed Practical Nurses/LPN's). V4 stated V5 and V5 got R2 onto the floor and began CPR, with V4 doing compressions and R5 performing rescue breathing, until the EMTs arrived in five or ten minutes. V4 stated V4 then went out into the hall. V4 stated V4 didn't see the EMTs intubate R2, but stated one of the EMTs brought V4 a whole, solid brussel sprout and said they took it out of R2's airway, and they said for V4 to save it. V4 stated R2 did have a roommate, R5, but R5 always ate in the hallway for supervision and support, and R2 was unable to ambulate without assistance and could not have accessed R5's tray. V4 stated in retrospect, V4 now wonders if R2 had a brussel sprout laying in his chair and put it in R2's mouth when V4 left to get his clean linens. On [DATE] at 11:45am, V6 (LPN) stated on [DATE] at about 6:20pm, V6 was giving report to V7 (LPN) at the nurse's station when they were alerted by V4 that R2 was unresponsive. V6 corroborated V4's account of the events as stated above. V6 stated V6 did not see EMTs intubate R2, but V4 brought V6 the whole, solid brussel sprout and said We need to keep this, they found it in (R2's) airway. V6 stated the sprout was then sent with the body to the coroner's office. V6 stated R2 was on a mechanical soft diet, and R2 always took R2's pills crushed mixed with pudding as R2 was at risk for aspiration. V6 stated V6 does not know who set up R2's tray that evening. V6 stated R2's food was served in bowls one at a time, R2 would put it up to R2's mouth and use fingers or utensils depending on his mood. On [DATE] at 1:00pm, V5 stated V5 was working with V4 the evening of [DATE]. V5 stated V5 was passing trays and took R2 his tray at about 5:45pm. V5 stated V5 noticed R2's tray contained ground meat and potatoes, but R2 had been given whole brussel sprouts. V5 stated other residents had already complained to V5 that the sprouts were too tough and chewy. V5 stated at that time, it did not occur to V5 that R2 might choke on the sprouts. V5 stated V5 placed R2's tray on R2's over bed table within R2's reach, and handed R2 a bowl of chopped meat. V5 stated R2 could switch out the bowls by himself when R2 was finished, and V5 assumed R2 got the bowl of sprouts when R2 was done with the meat. V5 stated V5 continued passing trays, and did not enter the room again until V5 and other staff responded when R2 was found unresponsive. V5 stated during CPR, V5 was ventilating R2 with a bag valve mask, and was not sure if air was going into R2's lungs or not. V5 stated EMTs arrived on the scene and took over rescue efforts. On [DATE] at 1:20pm, V4 stated V4 and V5 did not attempt to get R2 to eat in the hall that evening, as R2 required staff assistance with ambulating, and they did not have time that night. On [DATE] at 1035 am, V9 stated R2 had difficulty swallowing in part due to advanced dementia, hence the need for a mechanical soft diet. V9 stated it would not have been safe for R2 to consume brussel sprouts which were not cooked soft and had been chopped. V9 stated R2 would typically have eaten in the dining room, had Covid precautions not been in place at the time of R1's death. V9 stated with communal dining currently on hold, residents who require more supervision or cueing are typically placed in the hallway at mealtimes. V9 stated R2 should have had more direct supervision, and placing R2 in the hall at mealtime would have provided this. On [DATE] at 10:50am, V10, CNA, stated there had been occasions just prior to R2's death when R2 ate his meals in the hall so he could be monitored, but V10 stated V10 is not sure why, or under whose direction it was. V10 stated there was a list posted at the nurse's station of residents who were to eat in the hallway. On [DATE] at 12:20 pm, V2, Director of Nursing, stated some residents who need more assistance or cues are placed in the hall at mealtimes. V2 stated R2 had been eating in the hall when R2 was agreeable to it, as R2 would sometimes refuse to leave R2's room. V2 stated V2 felt staff giving R2 a bowl of food and coming back to check on R2 in a few minutes was adequate supervision for R2. V2 stated V2 was unsure if staff had tried to get R2 to eat in the hallway on the evening R2 passed away. On [DATE] at 11:00am, V18, CNA, stated until [DATE], at the nurse's station was a handwritten list of residents, including R2, who were to eat in the hall for increased supervision. V18 stated V18 is not sure who authored the list, and V18 stated it is no longer there. V18 stated were it not for Covid precautions, R2 would have eaten in the dining room where R2 would have had increased monitoring and supervision, but with communal dining currently on hold, V18 would put R2 in the hall, make sure R2's food was cut up, and hand R2 a bowl. V18 stated V18 made sure the other bowls were covered and out of R2's reach so R2 could not access them until V18 came back and gave R2 another bowl. On [DATE] at 11:15am, V2, stated V2 did not know of the existence of the above referenced list nor who might have authored it. On [DATE] at 8:30am, V25, Doctor of Osteopathy, R2's Physician, stated R2 had swallowing issues due to Alzheimer's dementia. V25 stated was full code status. V25 stated since R2 became unresponsive during a meal, choking should have been suspected and staff should have checked the airway via visual check and finger sweep, followed by the [MEDICATION(S)] maneuver if a blockage was identified, and if the [MEDICATION(S)] maneuver proved ineffective, the next step would be trying to blow the object into lungs. On [DATE] at 8:45am, V26, Medical Doctor/Medical Director, stated the facility had not notified V26 of the above referenced incident with R2. V26 stated V26 was aware that R2 was the patient of V25. V26 stated, It sounds like a lot of re-education needs to happen with staff regarding therapeutic diets, supervision (of residents during eating) and CPR. V26 stated V26 was going to call administrative staff and set up an immediate meeting. On [DATE] at 12:40pm, V11, Coroner, stated V11 was present for R2's autopsy which was performed on [DATE] by V12, Medical Doctor/Medical Examiner/Pathologist. V11 stated the Deputy Coroner obtained on the scene from V3 the vegetable matter which V3 retrieved from R2's airway. V11 stated R2's stomach contents also contained pieces of the vegetable. V11 stated V12 determined R2's death was due to accidental asphyxiation. A Death Certificate, dated [DATE], documented, Cause of death: Choking on a food bolus. An Assistance with Meals Policy, with a revision date of 2019, documented, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Facility staff will serve resident trays and will help residents who require assistance with eating. An undated Resident Nutrition Services Policy documented, Each resident shall receive the correct diet, with preferences accommodated as feasible, and shall receive prompt meal service and appropriate feeding assistance. Prior to the survey date, the facility took the following actions to correct the noncompliance: On [DATE] at 4:00pm, V1 stated the [DATE] education V1 did on Provision of Emergency Care/CPR/[MEDICATION(S)] Maneuver/Residents at higher risk for choking included education on providing proper meal supervision individualized for each resident. V1 stated on [DATE], V2 compiled a list of residents who present a choking risk and placed the lists in the respective nurses' stations. V2 stated staff will be assigned to monitor any resident that is required or chooses to eat in their room that requires assistance due to safety deficit. V2 stated on [DATE], V2 added Meal Monitoring to the nursing staff's Report Sheet as a reminder for V2 to assign a staff on each shift for this task. On [DATE], All Nursing and CNA staff were trained by V2 on assisting and supervising impaired residents with in-room meals. On [DATE], nursing staff and dietary staff were trained by V1 on the Resident Nutrition Services Policy. Residents needing dining assistance will be brought to dining room for meals as allowed by COVID 19 recommendations. Front line staff who deliver food trays were trained on [DATE] by V1 to ensure proper diets are served and set-up provided. Beginning [DATE], V2 began assigning staff to monitor any resident that is required or chooses to eat in their room that requires assistance due to safety deficits. On [DATE], V2 identified residents that are at increased risk of choking and placed the list of residents in each respective nurse's station. Ongoing monitoring will include all staff will being trained by V2 during orientation and quarterly for 1 year regarding CPR, emergency care, and following correct diet orders. V1 will conduct random meal audits (ensuring meals served are consistent with physician's diet orders) 3 times a week for 4 weeks. V1 will report the audit findings to the QA committee monthly for 6 months.

Based on observation, record review and interview, the facility failed to provide: education/training to Certified Nurse Aides (CNA) to be knowledgeable and follow resident Care Plans, to apply and use required assistive devices, and provide hands on physical assistance with supervision to prevent a fall with injury. These failures lead to a fall with extensive facial fractures (blowout fracture of the left orbit, lateral wall fracture of the left orbit, a fracture extending through the maxillary sinuses above the hard palate, fluid in the maxillary sinuses and hospitalized for [REDACTED]. The findings include: On 2/9/15 at 10:00 AM E3 (Certified Nurse Aide, CNA) stated she usually does not work the hall that R1 resides on. She stated that on 2/5/15 about 6:30 PM she helped R2 to the bathroom and put her back to bed with her personal alarm on. E3 stated she helped R1 to the bathroom and thought R1 was a stand by assist. She stated she did not use a gait belt or R1's knee brace. She stated she had R1 in the bathroom in front of the toilet when R2's personal alarm went off. She stepped away from R1, letting R1 stand by herself, and went to the door that is connected to R2's room and the bathroom. E3 stated she told R2 to sit down on the bed. She heard R1 fall. She stated R1 was on the floor and her pants were to her thighs with the wall in front of her. E 3 went on to say R1 fell forward hitting her face on the wall. She left R1 in the bathroom to get the nurse in the hallway to report the fall. E3 stated she did not look at the care plan before starting her shift that day. After the nurse assessed the resident, she sat R1 on the toilet, dressed her in a gown, placed her in a wheelchair, and took her to the nurses station to wait on the ambulance for transport to the emergency room . Nurse's Notes, dated 2/5/15 6:20 PM, documents 'R1 requested assistance to bathroom, CNA at her side assisted her to bathroom. Resident that shares bathroom in room next door tried to come into the bathroom also stating that she needed to go too. When CNA stepped away from R1 she fell forward with the walker and hit her face/forehead ant left eye area and nose on the floor. There was much blood coming from her nose. Resident also has large bruise with swelling above the left eye. Three staff members assisted R1 up to the toilet bathroom and to the wheelchair, bleeding was stopped shortly after. Dr called to report fall. Nurses Notes document on 2/5/15 at 6:50 PM resident left facility to hospital with ambulance service'. R1's Therapy Inservice sheet dated 2/4/15 documents 'minimum assist of two with the black knee braces on both knees secondary to her knee weakness. Utilize two people for transfers to and from the bed, wheelchair, recliner, and toilet along with a gait belt and rolling walker. R1's Section G on the Minimum (MDS) data set [DATE] documents one person physical assist for transfer, walking, dressing, and toilet use. It also documents Section G 0300 Balance During Transitions and Walking as not steady, only able to stabilize with staff assistance. Care Plan dated 12/22/14 for Falls documents on 1/6/15 knee braces ordered for support during transfers and ambulation. On 2/9/15 at 11:45 AM R1 is noted to have a purple discoloration around both eyes, both sides of her nose, including her nose, on both sides of her mouth, and on her neck. On 2/9/15 at 11:40 it is note that the toilet, between R1's and R2's rooms, is 40 inches from the door of R2's room. It is 7 feet from the bathroom door to R1's bed. R1's skin On 2/9/15 at 9:15 AM E2 (Director of Nurses, DON) stated R1 fell on [DATE] on evening shift, was sent to the emergency room , and then transferred to a higher acuity hospital. On 2/9/15 at 11:15 AM E4 (Treatment Nurse) stated she encourages all CNAs to read the Care Plan before taking care of the residents. E4 stated on the evening shift on 2/5/15 there were 28 residents and 3.5 CNAs. The half CNA is shared between 2 units. She went on to say before the CNAs start to care for the residents they listen to a verbal report from the nurse. This nurse's report includes temperatures, illness among the residents, confusion, residents readmitted , new residents, and changes in resident's condition. E4 stated care plans are available to the CNAs and are changed by the Care Plan Coordinator. On 2/9/15 at 12:15 PM E5 (Care Plan Coordinator) stated the Care Plans are updated quarterly with the MDS (Minimum Data Set), when therapy make a recommendation, or there is a significant change in the resident. She went on to say the Care Plans are kept at the nurses station and In-service Sheets are made when changes are made in the resident's care and helps to draw attention to these changes. E5 stated new staff to the units need to look at the Care Plan and work with another CNA to facilitate learning the residents, their needs and conditions. On 2/9/15 at 2:10 PM E5 (Care Plan Coordinator) stated on the Long Term Care Plan the Level of Assist, LA-Limited Assist and EA-Extensive Assist, can be a 1 or 2 person assist. E5 went on to say for R1 the Long Term Care Plan EA- Extensive Assist which is one person should have been up-dated to a EA2- 2 person assist. E5 updated the Long Term Care Plan from EA- one person assist to EA2 which indicates a 2 person assist. There is documentation on the Care Plan to ambulate and transfer with a gait belt and walker. Policyand Procedure for Use of the Gait Belt, revised 11/26/2014, documents that gait belts will be used at all times while ambulating residents requiring assistance or supervision. If the use of a gait belt is contraindicated for some reason, that reason shall be clearly documented in the resident's clinical record or care plan. R1's Therapy Inservice sheet dated 2/4/15 documents 'minimum assist of two with the black knee braces on both knees secondary to her knee weakness. Utilize two people for transfers to and from the bed, wheelchair, recliner, and toilet along with a gait belt and rolling walker. R1's Section G on the Minimum (MDS) data set [DATE] documents one person physical assist for transfer, walking, dressing, and toilet use. It also documents Section G 0300 Balance During Transitions and Walking as not steady, only able to stabilize with staff assistance. Care Plan dated 12/22/14 for falls documents on 1/6/15 knee braces ordered for support during transfers and ambulation.

Based on record review and interview the facility failed to provide adequate assistance and/or failed to develop effective interventions based on toileting needs/potential side effects of medications/cognitive status to ensure resident safety for 2 of 9 residents (R13 and R19) reviewed for falls in the sample of 24. These failures resulted in 2 emergency room visits, a MRI, a Lumbar-3 Fracture to R19 with a referral to a neurosurgeon and an order to wear a corset when out of bed. Findings include: 1. The March, 2014 physician's orders [REDACTED]. The 11/28/13 Minimum Data Set (MDS) states R19 has a Brief Interview for Mental Status (BIMS) score of 7 (severely impaired)) with fluctuating behavior of inattention and disorganized thinking. The MDS dated [DATE] states R19 requires extensive assistance of two plus people for transfers and toilet use. The Facility's "Assessment of Fall Potential" form states a resident with a score above 8 is at "High Risk" for potential falls. An assessment was completed on R19 on the following dates: 11/28/13-a score of 7 12/02/13- a score of 8 12/09/13-a score of 10 01/17/14-a score of 8 01/17/14-a score of 10 02/07/14-a score of 12 02/17/14-a score of 13 03/03/14-a score of 13 The Incident Reports for R19 indicate that R19 has had 8 falls since admission to the facility on [DATE] as follows: The Incident Report dated 11/29/13 states R19 fell at 7:20AM in his room and was found sitting on the floor by staff. The report states R19 sustained a 2-3 inch abrasion to the right upper extremity and notes he is confused at times. The "Incident Investigation" report dated 11/29/13 states the resident was attempting to independently transfer and the pressure alarm did not sound and that he knows how to "turn off/unplug" the monitor. The report states R19 needed to go to the bathroom. The "Preventative steps taken and put in place" area of the form is blank. The "Fall Communication For Week of December 12, 2013" states to see initial fall care plan, therapy services, Personal Safety Alarm (PSA) in bed and chair, close supervision so that he does not turn alarm off. The Incident Report dated 12/08/13 states R19 fell at 2:30AM. The report states a CNA heard the personal safety alarm sounding and when they entered the resident's room he was sitting up in a bedside chair with a drinking cup knocked over and water on the floor. The report states he sustained an abrasion on the left upper eyelid and a bump/bruise to the outer left eyebrow. The report states R19 is alert and responsive with confusion at times. The report further states R19 was sent to the emergency room . The "Incident Investigation" dated 12/08/13 states the cause of the incident is that R19 is unsteady and fell when trying to ambulate to get the urinal. The "Preventive steps taken and put in place" states: "Reminded resident to use call light, informed that when he hears PSA sounding to sit back down and wait for help." The "Fall Communication For the Week of December 12, 2013" states to see initial fall care plan, therapy services as ordered, PSA in bed and chair and to see head injury care plan. The updated 12/10/13 Fall/Vision Care Plan states the PSA was discontinued related to non-compliance 01/16/14. The Incident Report dated 01/16/14 states R19 fell at 12:40PM. The report states R19 got up to look out the window and got dizzy and fell with no injuries noted. The report states R19 is pleasant and confused. The "Incident Investigation" dated 01/16/14 states the cause of the incident is that R19 stated he got light headed and fell up against the bed and fell to the floor. The "Preventative steps taken and put in place" states: "Moved room around so chair and bed are closer to window so its closer to look out." The Nurse's Notes dated 01/16/14 states Z2 (Power of Attorney) was notified after the fall and informed the PSA was discontinued. The notes also state Z2 stated it was noticed during a visit that the PSA "agitated him at times." The 01/17/14 Incident Report states at 11:05AM R19 was found on the floor in his room with his head against the wall and his walker on it's side with no injury noted. The "Incident Investigation" report dated 01/17/14 states R19 was attempting to independently transfer from the bathroom to the chair with a walker and R19 complained of losing his balance and becoming dizzy. The "Preventative steps taken and put in place" states-"Call to doctor to report, got order for PSA in bed and chair. Further orders pending." E19 (Care Plan/MDS Coordinator) stated on 03/13/14 at 11:30AM that R19 had taken himself to the bathroom unassisted by staff. The Nurse's Notes dated 01/17/14 at 11:30AM state R19 complained of low back pain, at 11:45AM R19 complained of dizziness when he stood, at 1:45 PM Z1 (Physician) discontinued Norvasc and gave orders to monitor the blood pressure every shift, at 4:10PM R19 was sent to the emergency room for an x-ray of the back. The 01/17/14 Lumbar Spine Diagnostic Imaging Report states R19 had a possible acute fracture of the Lumbar-3 spine and recommended a Cat Scan or Magnetic Resonance Imaging (MRI). The 01/21/14 MRI report states R19 has a [DIAGNOSES REDACTED]." The "Fall Communication For Week Of January 23, 2014" notes the 01/16 and 01/17/14 falls on this log with interventions of: Resident's room rearranged so that he could look out of window easier, PSA in bed and chair at all times, Norvasc discontinued related to orthostatic hypotension and dizziness, monitor blood pressures as ordered and report findings, provide increased assist related to dizziness and back pain, encourage rest and decreased ambulation at this time, x-ray MRI showed Lumbar 3 fracture-referred to a neurosurgeon. The updated 12/10/13 Fall/Vision Care Plan states R19 was referred to a neurosurgeon. This evaluation was done on 01/28/14 and a corset brace was ordered to be worn when out of bed. The "Incident Report" dated 02/06/14 stated R19 fell at 5:01PM while getting up to use the bathroom. The report states R19 did not use the call light and fell on his "bottom/left leg." The report states a bruise was noted to the right wrist on 02/07/14. The "Preventive step taken and put in place" were: "Constant reminders to use call light, ensure proper PSA placement." The "Incident Report" dated 02/14/14 at 9:20AM states R19 "was trying to get out of recliner, while assisting resident he got dizzy and falling forward, pulled resident on me and sat in recliner." The report states no injury was sustained and R19 was sent to the emergency room . The "Incident Investigation" dated 02/14/14 states the cause of the incident was R19 became dizzy and started to fall forward and staff got him to his chair before falling. The report states R19 was pleasant, confused and anxious and he had a "blank stare, eyes fixed." The "Preventative steps taken and put in place" were: "Remind resident to use call light." The report further states R19 had been up several times to go to the bathroom to get his bowels to move and had been attempting to go again, pressure alarm sounded and a nurse went into the room. The report states R19 has a history of syncopal episodes. The report states, "When resident stopped feeling dizzy staff was going to assist to bathroom but resident denied needing to go." The "Preventative steps taken and put in place" were: "Remind resident to use call light." The "Incident Report" dated 02/14/14 at 9:45AM states R19 was walking to the bathroom without his walker and was found holding onto the bed and wall with his right leg on the ground. The "Incident Investigation" dated 02/14/14 states the cause of the incident was R19 stated he was dizzy and his right leg gave out on him. The "Preventative steps taken and put in place" were: "reminded resident to use call light when needing assistance, put in wheelchair and given one on one." The "Fall Communication For Week Of February, 2014" log states R19 was sent to the local hospital on [DATE] and returned with a [DIAGNOSES REDACTED]. The "Incident Report" dated 03/03/14 at 12:30PM states R19 was attempting to independently transfer and when staff entered the room he lost his balance and was lowered to the floor by staff. The report states there was no injury. The "Preventative steps taken and put in place" were: "Encouraged use of call light." This surveyor interviewed R19 on 03/10/14 at 1:55PM. R19 stated he does not recall falling and when asked how he gets help he stated he uses "a box" but stated he has never used it and could not find it right now. The call light was observed attached to his shirt. R19 stated he likes "getting up alone". R19 was able to push the call light button and E20 (CNA) entered the room during this observation and stated he does not push his call light and attempts to get up on his own often. Also during this observation, E21 (Physical Therapy Assistant) entered the room who stated she feels R19 will not be independent with ambulation and will require the assist of 1 or 2 to ambulate. On 03/11/14 at 3:00PM, E19 confirmed E20's statement that R19 does not use his call light and attempts to ambulate independently often. E19 stated on 03/13/14 at 11:30AM the 12/10/13 Fall/Vision Care Plan is the "Initial Care Plan", Occupation Therapy was started on 11/22/13, Physical Therapy was started on 11/23/13 and the PSA was placed on 11/23/13. E19 stated the hospital did inform the facility that E19 attempts to self transfer. E19 stated R19 was admitted to the facility on Restoril 15 milligrams one by mouth at bedtime and Celexa 20mg one by mouth daily. E19 stated the Celexa was increased to 40mg daily on 01/03/14. E19 stated the Nurse's Notes indicate R19 was non-complaint in regard to calling for help and attempted to get up alone often. E19 further stated R19 was not put on a toileting schedule due to the falls and that he is continent and the staff offer or take him to the bathroom when in the room. E19 stated the pharmacist is sent the "Fall Communication" logs at least monthly and when he visits the facility he "checks off" on the facility's log that it was reviewed in the "Pharmacy Review" column. E19 added the pharmacist did not recommend medication changes in relation to R19's falls. The 2007 "Drug Information Handbook for Nursing" states Restoril (Temazepam) "causes CNS (Central Nervous System) depression (dose-related) which may impair physical and mental capabilities. Use with caution in patients receiving other CNS depressants or psycho-active agents. Benzodiazepines have been associated with falls and traumatic injury and should be used with extreme caution in patients who are at risk of these events (especially the elderly)." This reference further states, "Geriatric Considerations: Because of its lack of active metabolites, temazepam is recommenced in the elderly when a benzodiazepine hypnotic is indicated. Hypnotic use should be limited to 10-14 days. If insomnia persists, the patient should be evaluated for etiology." Review of R19's record does not provide information that indicates the pattern regarding toileting concerns in relation to falls on 11-29-13, 12-8-13, 1-17-14, 2-6-14, and the two falls on 2-14-14 was addressed until 03/10/14. The interventions that were put in place on 3-10-14 were not individualized to R19's needs regarding toileting. The Incident Reports for R19 on 12-8-13, 2-6-14, both falls on 2-14-14 and on 3-3-14 indicate as interventions to remind R19 to use the call light; not taking into consideration the BIMS score of 7 with R19 being severly impaired cognitively. 2. The facility's Incident Report dated 3-2-14 for R13 indicates they had a fall at 4PM while being transferred from their bed to wheelchair. The report notes R13's knees buckled and E14, (Certified Nurse Aide-CNA), had to lower the resident to the floor. No injury was noted but the resident complained of neck pain. R13 was sent to the emergency room for evaluation and treatment. The Report notes R13 was confused and lethargic prior to the fall. The Incident Investigation Form dated 3-2-14 indicates a gait belt was in use. Preventive steps taken and put in place were noted to be information passed on to doctor for possible new order to evaluate with physical therapy. The Investigation Form failed to note E14 was attempting to transfer R13 alone. The medical record admission sheet 10-20-13 indicates [DIAGNOSES REDACTED]. The most recent Minimum Data Set, (MDS) is a quarterly review dated 1-27-14. The MDS notes R13's height as 64 inches and weight as 238 pounds, Section GO110B indicates two plus persons for transfer and Section GO400 notes range of motion limits on both sides of upper extremities and one side of lower extremity. E2, (Director of Nursing, (DON), stated at 2PM on 3-4-14, E14 was not inserviced on their failure to follow the plan of care (two assist) for R13 to ensure their safety.

Based on interviews and record review the facility neglected to follow the facility's policies named: "Reporting Incident and Accidents" (undated), "Physician Notification Policy" (undated), "Use of the Gait Belt" (undated) and "Fall Monitoring, Review and Prevention" (dated March 2010). This failure to follow the facility policies resulted in an unsafe transfer of a resident in accordance with the plan of care, failure to timely report a resident's fall, failure to monitor a resident's condition after a fall, failure to timely notify a physician related to the resident's fall and injuries and failure to monitor medication interactions contributing to complications from the fall for 1 of 5 residents (R1) reviewed on a blood thinning medication who are at risk for falls in the sample of 5. This neglect resulted in an Immediate Jeopardy. While the immediacy was removed on 12-15-11 when the facility staff received inservices on safe transfers, reporting and monitoring incidents, [MEDICATION NAME]/blood thinning medications risks and other drug interactions. The facility also completed a Quality Assurance Tool for all residents on [MEDICATION NAME]/Blood thinning medication including a physical resident exam, review of residents fall status, review for potential drug interactions, lab values and physician notification. Each resident's care plan was updated with this information. The facility also identified each resident's record as high risk medication related to [MEDICATION NAME]/Blood thinning medication. The facility remains out of compliance at Severity Level 2 as the facility continues to educate staff, monitor and evaluate residents at risk for falls and for drug interactions with blood thinning medications. The facility also neglected to devise a system of communication, training and implementation for staff to immediately know which residents are on blood thinners who are at risk for falls and are prescribed other medications that increase the effect of the blood thinner in order to prevent complications. This neglect has the potential to affect 5 of 5 residents (R1, R2, R3, R4 and R5) reviewed on blood thinning medications who are at risk for falls in the sample of 5 and 19 residents on the supplemental sample (R6 through R24). Findings include: 1. R1 was an [AGE] year old resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set Assessment ((MDS) dated [DATE] (Significant Change MDS Assessment), R1 is dependent on 2 staff persons for assistance with bathing, dressing and toilet use. R1 requires total dependence of two plus persons for transfers according to the MDS dated [DATE]. R1's December physician's plan of care dated 12-01-11 to 12-31-11, states R1 is to transfer with weight bearing as tolerated and fall precautions. R1's Physical Therapy Evaluation dated 10-11-11 states R1 is nonambulatory at this time and staff are to use a mechanical lift at all times for transferring R1. R1's care plan dated 11-28-11 with an approach dated 09-19-11 regarding fall prevention, states to use a mechanical lift for all transfers with 2 staff members. The Care Plan approach for constipation/ urinary problems dated 11-21-11 states: "place resident back in bed for bedpan use - using bedpan only". R1 was assessed using the facility's "Assessment of Fall Potential" form dated 11-28-11 to be at "High Risk for Falls. R1 had a fall on 11-26-11 from a recliner after an apparent blackout episode. R1's December physician's plan of care dated [DATE] to 31-.2011, states R1 is to take [MEDICATION NAME] 5mg ([MEDICATION NAME]) Thurs., Sat., and Sun. and [MEDICATION NAME] 2.5 mg daily on Mon., Wed., and Fri. R1 also had a physician's orders [REDACTED]. [MEDICATION NAME] discontinued on 11-30-11 and Keflex 500mg ([MEDICATION NAME]) three times a day for 7 days was ordered based on the urine culture results. R1 was also on routine [MEDICATION NAME]/APAP ([MEDICATION NAME]) 10/325mg every 8 hours. [MEDICATION NAME] 20mg ([MEDICATION NAME]/Selective Serotonin Reuptake Inhibitor (SSRI) daily was ordered on 10-31-11 then changed to [MEDICATION NAME] 30mg (Duloxetine) daily on 11-04-11. R1 also had a physician's orders [REDACTED]. According to the " Drug Information Handbook for Nursing 2007" the following medications may increase the serum levels/effects of [MEDICATION NAME]: [MEDICATION NAME], cephalosporins and SSRI's. Z1 (Physician) stated on 12-13-11 at 10AM, [MEDICATION NAME] Keflex antibiotics along with the [MEDICATION NAME] may have contributed to the increase in the [MEDICATION NAME] Time (P.T.) and International Normalized Ratio (INR) for R1 on 12-02-11. According to the facility's "Incident Report" dated 12-02-11 at 6:15AM, R1 reported to E12 (Certified Nursing Assistant-CNA) then to E9 (Registered Nurse) and E4 (RN) that she was dropped to her knees by E5 and E7 (CNAs) during a transfer from the bedside commode to the bed on 12-01-11 in the afternoon. The report stated on 12-02-11 at 6:15AM, R1 was noted to have an extensive bruise and swelling to the right posterior lower leg (calf) measuring 25 cm x 22 cm with a fluid filled hematoma 9cm x 11cm. Another bruise was noted to the outer right knee measuring 7 cm x 6 cm with a fluid filled area measuring 5.5cm x 5.7cm. According to interview with E4 on 12-07-11 at 2PM and E12 on 12-13-11 at 2PM, R1 stated the fall occurred on 12-01-11 before supper with E5 and E7 assisting her and not using a mechanical lift or gait belt. E9 stated on 12-07-11 at 3:55PM, R1 complained to E9 on 12-02-11 at 7PM that the back of her right leg had excruciating pain. E9 assessed R1's leg and no new bruises were present. Interview with E5 and E7 on 12-07-11 at 2:55PM and 3:20PM, both stated R1 was transferred from the bed to the bedside commode without the use of a mechanical lift or gait belt on 12-01-11 between 4:30PM and 4:45PM with no problem. When R1 was transferred back from the bedside commode to the bed without the use of a mechanical lift or gait belt by E5 and E7, R1's legs gave out and she was lowered to the floor to her knees. E5 stated R1 was immediately pulled up and placed in bed. E5 and E7 stated they did not report the incident to the charge nurse. E5 stated R1 did not bear weight during the transfer and R1 did not complain of pain at the time. Neither E5 or E7 checked R1 for injuries. On 12-07-11 at 3:55PM E6 (RN-11PM-7AM shift) stated she became aware of R1's fall incident (on 12-01-11) and large bruises with hematomas on R1's right leg on 12-02-11 at 6:15AM when R1 told E12 (CNA). E6 stated R1 complained at this time of excruciating pain unrelieved by the routine pain medications ([MEDICATION NAME] 15mg ER and [MEDICATION NAME]/APAP 10/325mg) given at 4AM and a Tylenol 325mg -2 tablets given at 12AM. E6 filled out an incident report and reported the incident and injury to E10 (RN 7AM-3PM shift). E10 stated on 12-08-11 at 12:17PM, she notified Z1 (Physician) between 8AM-8:15AM on 12-02-11 of R1's condition. R1's blood pressure dropped to 90/54, pulse 86, respirations 20 and pulse oxygen was 78%. Z1 ordered to send R1 to the emergency room for evaluation and treatment related to the increased leg pain and decreased oxygen level according to the nursing notes dated 12-02-11 at 8:30AM. According to the nursing notes (late entry) dated 12-02-11 at 6:50AM, a PT and INR lab test (ordered by the physician on 11-18-11) was drawn for R1. The ambulance arrived at 9:10AM and R1 left the facility at 9:15AM. The lab called with R1's PT and INR results after R1 left the facility, with results as follows: INR 14.3 high critical (normal 2-3.0) and PT 60.5 high (normal 16.0-22.6). According to the Hospital's Emergency Physician's Report dated 12-02-11 at 10:24AM, R1 had been falling frequently. R1 fell out of a recliner on 11-26-11 and sustained skin tears to both elbows and right knee. R1 also hit her head and sustained some superficial lacerations in the right temporal region due to being on anticoagulate therapy according to the report. R1 fell again on 12-01-11 injuring her right knee and sustained a large hematoma on her right knee, R1's PT/INR was elevated to 60.5. R1 had a Cat Scan of the head, xray of the right knees and elbows. All xrays were negative for fractures or intercranial bleeding. The Emergency Physician's Report dated 12-02-11 stated R1's blood pressure suddenly dropped and pulse became thready, she became bradycardic. The emergency room staff was unable to find an adequate intravenous line access so an interosseous vascular access was justified. R1 became agonal in her rhythm and stopped breathing. R1 had a Do Not Resuscitate request and death was pronounced at 2:38PM. The emergency room report lists the following assessment: 1)Frequent Falling, 2) Right Knee injury without fracture 3) Large right lower leg hematoma 4) Excessive Anticoagulation and 5) Unexpected cardiopulmonary arrest. R1's death certificate states the cause of death was Acute [MEDICAL CONDITION] Infarction, [MEDICAL CONDITIONS] and Recent Fall. This certificate was certified by Z2 (Coroner) on 12-07-11. E4 (Licensed Practical Nurse) did an investigation on 12-02-11 of R1's incident 12-01-11. E4 determined in the report that the bruise to R1's back of the leg could have been caused by bumping R1's leg on the bed side rail during the transfer. E4 found a mechanical lift was not used in R1's transfer due to R1 wanting to use the bedside commode for a bowel movement. Due to the height differences between E5 and E7, E7 would have to lift harder and the bruise on R1's right leg occurred on E7's side. E4 stated in the report that R1 was sent to the emergency room and per ER nurse stated R1 was to be admitted for "Excessive coagulation and bleeding from somewhere but not sure where". 2. E2 (Director of Nursing) identified 23 current residents (R2 through R24) on [MEDICATION NAME] and at risk for falls on 12-13-11 at 8:30AM. E2 states residents on blood thinning medications are not routinely evaluated for drug interactions with other medications or recurrent falls related to the blood thinning medication. Interview with Z3 (Contract Pharmacy Consultant) on 12-13-11 at 3PM, states he reviews all resident's physician orders [REDACTED].e.. antibiotics). E13 (RN) and E10 (RN) stated on 12-13-11 at 2:45PM and 12:30PM, they were not aware of any drug interactions between [MEDICATION NAME] and other medications. E10 also stated the pharmacist did not review or make recommendations for residents on [MEDICATION NAME] Therapy. E13 and E10 stated no indication/precautions were identified on the prescription label by the pharmacy when filling blood thinning medications and other meds that could have a possible interaction. This was confirmed by interview with Z4 (Pharmacist) on 12-14-11 at 8:55AM. 3. The facility policy for "Reporting Incident and Accidents" (undated) states "When an incident/accident occurs, the witness or person discovering the incident must report to the nurse in charge."...."Emergency care should be provided when necessary, either by the nurse or by sending to the emergency room for evaluation and possible emergency treatment." "The attending physician must always be notified as soon as possible." R1's drop to her knees on 12-01-11 was not reported to the charge nurse. Fourteen hours later R1 reported the incident to E12. No monitoring of R1's condition after the incident was done by staff. R1's physician was not notified until 16 hours after the incident, according to the nurse's notes dated 12-02-11 at 8:30AM. The facility's "Physician Notification Policy" (undated) states "All incidents must be reported to the physician in a timely manner. Head to toe assessment following the fall/incident is a must. Any incident with injury needs to be reported immediately." This policy was not followed. The facility's "Use of the Gait Belt" Policy (undated) was not followed as it states: "1. Gait belts will be used at all times during transfers requiring assistance or supervision..." This policy was not followed on 12-01-11 when E5 and E7 transferred R1 to and from the bed to the bedside commode without the use of a gait belt. The facility's "Fall Monitoring, Review, and Prevention" Policy (dated March 2010) states: "It is the policy of this facility to provide a safe environment for each resident.....The facility will review all falls occurring during the weekly safety meeting..... 3. When resident experiences a "fall", the charge nurse will complete an incident report and an investigation. Staff will ensure the resident's safety and will immediately put any new interventions into place.... 4. Further investigation will be completed by the charge nurse, ADON or another designated nurse. If it is determined that further interventions will be needed, inservices will be provided to staff reflecting the interventions.... 7. A list of residents sustaining fall will be provided to each nurses station following the safety meeting. 8. The Pharmacist will be given a list of the residents' sustaining falls for review of these resident's medication to determine if there might be a contributing factor resulting from medications." This policy was not followed with R1's fall on 12-01-11. The Immediate Jeopardy was identified on 12-13-11 at 12:45PM to E1 (Administrator) and E2. The Immediate Jeopardy was determined to have begun on 12-01-11 at 4:30PM when E5 and E7 assisted R1 in an unsafe transfer, dropped R1 to her knees and did not report the incident. R1 was not monitored for injuries or a condition change during this time. Z1 (physician) was not notified of the incident for 16 hours. The surveyor confirmed through interview, observation and record review the that facility took the following actions to remove the Immediate Jeopardy on 12-15-11. 1. The Quality Assurance Committee met and discussed the Immediate Jeopardy Plan of Action, completed on 12-13-11. 2. Staff identified all resident's records who are receiving [MEDICATION NAME]/Blood Thinning medication therapy with a visibile sticker to alert staff of this high risk medication, completed 12-14-11. 3. A directed inservice for nursing staff included safe transfers, reporting and monitoring incidents, [MEDICATION NAME]/Blood Thinning medication risks, [MEDICATION NAME]/Blood Thinning drug interactions and incident reports. All available staff were inserviced on Dec. 13, 14, and 15, 2011. Unscheduled nursing staff were being actively inserviced by phone. All remaining staff will be inserviced before beginning their next scheduled shift, this was completed on 12-19-11. 4. Z3 (Contracted Pharmacist) reviewed all residents on [MEDICATION NAME]/Blood Thinning medication therapy and other medication interactions. The recommendations were faxed to E2 and the resident's physicians for review and recommendations, completed on 12-15-11. 5. Z3 will review all residents on [MEDICATION NAME]/Blood Thinning medications monthly for possible drug interactions and falls. Z3 will make recommendations as necessary to E2 and the resident's physicians. Completion date is 12-15-11 and ongoing. 6. The Care Plan Team reviewed and updated all resident's care plans that are on [MEDICATION NAME]/Blood Thinning medications. This is to ensure the risk for medication interactions with [MEDICATION NAME]/Blood Thinning meds and the risk for falls is addressed. Resident who are on [MEDICATION NAME]/Blood thinning meds and have fallen in the last six months were identified and care plans were reviewed and updated. This was completed on 12-14-11. 7. The Quality Assurance Committee met and developed a new Quality Assurance tool to review all residents on [MEDICATION NAME]/Blood Thinning medication to ensure resident safety and well being. This tool was implemented immediately and will be completed again next month and then quarterly as part of the Quality Assurance Committee meetings. The tool includes a physical assess for each resident, drug interaction review, fall review, PT and INR lab value review, care plan and physician notification review. The tool was completed on all residents on [MEDICATION NAME]/Blood Thinning medication on 12-14-11. 8. The DON and/or designees will observe 5 transfers a week for safety for the next month and then report findings to the Quality Assurance Committee next month. The safety transfer monitoring will continue and will be addressed at the quarterly Quality Assurance Committee meetings completed on 12-16-11 and ongoing. 9. The charge nurse will immediately investigate accident/incidents. E3 (Assistant Director of Nursing) or designee will perform a comprehensive follow up investigation on every accident/incident and implement preventive measures. E3 will report findings to the weekly Safety Committee Meeting and discuss each individual accident/incident. E3 will identify preventative measures as indicated. The results from the Safety Committee will be reported to the quarterly Quality Assurance Committee. This was completed 12-14-11 and ongoing. 10. The Quality Assurance Committee reviewed and updated the facility policy on "Anticoagulant Policy and Procedure" with Z6 (Medical Director) to ensure resident safety on 12-15-11. E3 inserviced all nurses on the updated policy and procedure. All nurses were inserviced before working their next scheduled shift, this was completed on 12-19-11 and ongoing. 11. The Quality Assurance Committee will continue to meet as needed, next month and quarterly thereafter to address any ongoing issues including review of the Quality Assurance [MEDICATION NAME]/Blood Thinning medication Review Tool to ensure resident's safety.

Based on interviews and record review the facility failed to safely transfer a resident in accordance with the plan of care, failed to timely report a resident's fall, failed to monitor a resident's condition after a fall, failed to timely notify a physician related to the resident's fall and injuries and failed to monitor medication interactions contributing to complications from the fall for 1 of 5 residents (R1) reviewed on a blood thinning medication who are at risk for falls in the sample of 5. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12-15-11 when the facility staff received inservices on safe transfers, reporting and monitoring incidents, Coumadin/blood thinning medications risks and other drug interactions. The facility also completed a Quality Assurance Tool for all residents on Coumadin/Blood thinning medication including a physical resident exam, review of residents fall status, review for potential drug interactions, lab values and physician notification. Each resident's care plan was updated with this information. The facility also identified each resident's record as high risk medication related to Coumadin/Blood thinning medication. The facility remains out of compliance at Severity Level 2 as the facility continues to educate staff, monitor and evaluate residents at risk for falls and for drug interactions with blood thinning medications. The facility also failed to devise a system of communication, training and implementation for staff to immediately know which residents are on blood thinners who are at risk for falls and are prescribed other medications that increase the effect of the blood thinner in order to prevent complications. These failures have the potential to affect 5 of 5 residents (R1, R2, R3, R4, and R5) reviewed on blood thinning medications who are at risk for falls in the sample of 5 and 19 residents on the supplemental sample ( R6 through R24). Findings include: 1. R 1 was an [AGE] year old resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set Assessment ((MDS) dated [DATE] (Significant Change MDS Assessment), R1 is dependent on 2 staff persons for assistance with bathing, dressing and toilet use. R1 requires total dependence of two plus persons for transfers according to the MDS dated [DATE]. R1's December physician's plan of care dated 12-01-11 to 12-31-11, states R1 is to transfer with weight bearing as tolerated and fall precautions. R1's Physical Therapy Evaluation dated 10-11-11 states R1 is nonambulatory at this time and staff are to use a mechanical lift at all times for transferring R1. R1's care plan dated 11-28-11 with an approach dated 09-19-11 regarding fall prevention, states to use a mechanical lift for all transfers with 2 staff members. The Care Plan approach for constipation/ urinary problems dated 11-21-11 states: "place resident back in bed for bedpan use - using bedpan only". R1 was assessed using the facility's "Assessment of Fall Potential" form dated 11-28-11 to be at "High Risk for Falls. R1 had a fall on 11-26-11 from a recliner after an apparent blackout episode. R1's December physician's plan of care dated [DATE] to 31-.2011, states R1 is to take Coumadin 5mg (Warfarin) Thurs., Sat., and Sun. and Coumadin 2.5 mg daily on Mon., Wed., and Fri. R1 also had a physician's orders [REDACTED]. The Cipro was discontinued on 11-30-11 and Keflex 500mg (Cephalexin) three times a day for 7 days was ordered based on the urine culture results. R1 was also on routine Hydrocodone/APAP (Acetaminophen) 10/325mg every 8 hours. Celexa 20mg (Citalopram/Selective Serotonin Reuptake Inhibitor (SSRI) daily was ordered on 10-31-11 then changed to Cymbalta 30mg (Duloxetine) daily on 11-04-11. R1 also had a physician's orders [REDACTED]. According to the " Drug Information Handbook for Nursing 2007" the following medications may increase the serum levels/effects of warfarin: acetaminophen, cephalosporins and SSRI's. Z1 (Physician) stated on 12-13-11 at 10AM, the Cipro and Keflex antibiotics along with the Warfarin may have contributed to the increase in the Prothrombin Time (P.T.) and International Normalized Ratio (INR) for R1 on 12-02-11. According to the facility's "Incident Report" dated 12-02-11 at 6:15AM, R1 reported to E12 (Certified Nursing Assistant-CNA) then to E9 (Registered Nurse) and E4 (RN) that she was dropped to her knees by E5 and E7 (CNAs) during a transfer from the bedside commode to the bed on 12-01-11 in the afternoon. The report stated on 12-02-11 at 6:15AM, R1 was noted to have an extensive bruise and swelling to the right posterior lower leg (calf) measuring 25 cm x 22 cm with a fluid filled hematoma 9cm x 11cm. Another bruise was noted to the outer right knee measuring 7 cm x 6 cm with a fluid filled area measuring 5.5cm x 5.7cm. According to interview with E4 on 12-07-11 at 2PM and E12 on 12-13-11 at 2PM, R1 stated the fall occurred on 12-01-11 before supper with E5 and E7 assisting her and not using a mechanical lift or gait belt. E9 stated on 12-07-11 at 3:55PM, R1 complained to E9 on 12-02-11 at 7PM that the back of her right leg had excruciating pain. E9 assessed R1's leg and no new bruises were present. Interview with E5 and E7 on 12-07-11 at 2:55PM and 3:20PM, both stated R1 was transferred from the bed to the bedside commode without the use of a mechanical lift or gait belt on 12-01-11 between 4:30PM and 4:45PM with no problem. When R1 was transferred back from the bedside commode to the bed without the use of a mechanical lift or gait belt by E5 and E7, R1's legs gave out and she was lowered to the floor to her knees. E5 stated R1 was immediately pulled up and placed in bed. E5 and E7 stated they did not report the incident to the charge nurse. E5 stated R1 did not bear weight during the transfer and R1 did not complain of pain at the time. Neither E5 or E7 checked R1 for injuries. On 12-07-11 at 3:55PM E6 (RN-11PM-7AM shift) stated she became aware of R1's fall incident (on 12-01-11) and large bruises with hematomas on R1's right leg on 12-02-11 at 6:15AM when R1 told E12 (CNA). E6 stated R1 complained at this time of excruciating pain unrelieved by the routine pain medications (Morphine Sulfate 15mg ER and Hydrocodone/APAP 10/325mg) given at 4AM and a Tylenol 325mg -2 tablets given at 12AM. E6 filled out an incident report and reported the incident and injury to E10 (RN 7AM-3PM shift). E10 stated on 12-08-11 at 12:17PM, she notified Z1 (Physician) between 8AM - 8:15AM on 12-02-11 of R1's condition. R1's blood pressure dropped to 90/54, pulse 86, respirations 20 and pulse oxygen was 78%. Z1 ordered to send R1 to the emergency room for evaluation and treatment related to the increased leg pain and decreased oxygen level according to the nursing notes dated 12-02-11 at 8:30AM. According to the nursing notes (late entry) dated 12-02-11 at 6:50AM, a PT and INR lab test (ordered by the physician on 11-18-11) was drawn for R1. The ambulance arrived at 9:10AM and R1 left the facility at 9:15AM. The lab called with R1's PT and INR results after R1 left the facility, with results as follows: INR 14.3 high critical (normal 2 - 3.0) and PT 60.5 high (normal 16.0 - 22.6). According to the Hospital's Emergency Physician's Report dated 12-02-11 at 10:24AM, R1 had been falling frequently. R1 fell out of a recliner on 11-26-11 and sustained skin tears to both elbows and right knee. R1 also hit her head and sustained some superficial lacerations in the right temporal region due to being on anticoagulate therapy according to the report. R1 fell again on 12-01-11 injuring her right knee and sustained a large hematoma on her right knee, R1's PT/INR was elevated to 60.5. R1 had a Cat Scan of the head, xray of the right knees and elbows. All xrays were negative for fractures or intercranial bleeding. The Emergency Physician's Report dated 12-02-11 stated R1's blood pressure suddenly dropped and pulse became thready, she became bradycardic. The emergency room staff was unable to find an adequate intravenous line access so an interosseous vascular access was justified. R1 became agonal in her rhythm and stopped breathing. R1 had a Do Not Resuscitate request and death was pronounced at 2:38PM. The emergency room report lists the following assessment: 1)Frequent Falling, 2) Right Knee injury without fracture 3) Large right lower leg hematoma 4) Excessive Anticoagulation and 5) Unexpected cardiopulmonary arrest. R1's death certificate states the cause of death was Acute Myocardial Infarction, Atherosclerotic Heart Disease and Recent Fall. This certificate was certified by Z2 (Coroner) on 12-07-11. E4 (Licensed Practical Nurse) did an investigation on 12-02-11 of R1's incident 12-01-11. E4 determined in the report that the bruise to R1's back of the leg could have been caused by bumping R1's leg on the bed side rail during the transfer. E4 found a mechanical lift was not used in R1's transfer due to R1 wanting to use the bedside commode for a bowel movement. Due to the height differences between E5 and E7, E7 would have to lift harder and the bruise on R1's right leg occurred on E7's side. E4 stated in the report that R1 was sent to the emergency room and per ER nurse stated R1 was to be admitted for "Excessive coagulation and bleeding from somewhere but not sure where". 2. E2 (Director of Nursing) identified 23 current residents (R2 through R24) on Warfarin and at risk for falls on 12-13-11 at 8:30AM. E2 states residents on blood thinning medications are not routinely evaluated for drug interactions with other medications or recurrent falls related to the blood thinning medication. Interview with Z3 (Contract Pharmacy Consultant) on 12-13-11 at 3PM, states he reviews all resident's physician orders [REDACTED].e.. antibiotics). E13 (RN) and E10 (RN) stated on 12-13-11 at 2:45PM and 12:30PM, they were not aware of any drug interactions between Warfarin and other medications. E10 also stated the pharmacist did not review or make recommendations for residents on Warfarin Therapy. E13 and E10 stated no indication/precautions were identified on the prescription label by the pharmacy when filling blood thinning medications and other meds that could have a possible interaction. This was confirmed by interview with Z4 (Pharmacist) on 12-14-11 at 8:55AM. 3. The facility policy for "Reporting Incident and Accidents" (undated) states "When an incident/accident occurs, the witness or person discovering the incident must report to the nurse in charge."...."Emergency care should be provided when necessary, either by the nurse or by sending to the emergency room for evaluation and possible emergency treatment." "The attending physician must always be notified as soon as possible." R1's drop to her knees on 12-01-11 was not reported to the charge nurse. Fourteen hours later R1 reported the incident to E12. No monitoring of R1's condition after the incident was done by staff. R1's physician was not notified until 16 hours after the incident, according to the nurse's notes dated 12-02-11 at 8:30AM. The facility's "Physician Notification Policy" (undated) states "All incidents must be reported to the physician in a timely manner. Head to toe assessment following the fall/incident is a must. Any incident with injury needs to be reported immediately." This policy was not followed. The facility's "Use of the Gait Belt" Policy (undated) was not followed as it states: "1. Gait belts will be used at all times during transfers requiring assistance or supervision..." This policy was not followed on 12-01-11 when E5 and E7 transferred R1 to and from the bed to the bedside commode without the use of a gait belt. The facility's "Fall Monitoring, Review, and Prevention" Policy (dated March 2010) states: "It is the policy of this facility to provide a safe environment for each resident.....The facility will review all falls occurring during the weekly safety meeting..... 3. When resident experiences a "fall", the charge nurse will complete an incident report and an investigation. Staff will ensure the resident's safety and will immediately put any new interventions into place.... 4. Further investigation will be completed by the charge nurse, ADON or another designated nurse. If it is determined that further interventions will be needed, inservices will be provided to staff reflecting the interventions.... 7. A list of residents sustaining fall will be provided to each nurses station following the safety meeting. 8. The Pharmacist will be given a list of the residents' sustaining falls for review of these resident's medication to determine if there might be a contributing factor resulting from medications." This policy was not followed with R1's fall on 12-01-11. The Immediate Jeopardy was identified on 12-13-11 at 12:45PM to E1 (Administrator) and E2. The Immediate Jeopardy was determined to have begun on 12-01-11 at 4:30PM when E5 and E7 assisted R1 in an unsafe transfer, dropped R1 to her knees and did not report the incident. R1 was not monitored for injuries or a condition change during this time. Z1 (physician) was not notified of the incident for 16 hours. The surveyor confirmed through interview, observation and record review the that facility took the following actions to remove the Immediate Jeopardy on 12-15-11. 1. The Quality Assurance Committee met and discussed the Immediate Jeopardy Plan of Action, completed on 12-13-11. 2. Staff identified all resident's records who are receiving Coumadin/Blood Thinning medication therapy with a visibile sticker to alert staff of this high risk medication, completed 12-14-11. 3. A directed inservice for nursing staff included safe transfers, reporting and monitoring incidents, Coumadin/Blood Thinning medication risks, Coumadin/Blood Thinning drug interactions and incident reports. All available staff were inserviced on Dec. 13, 14, and 15, 2011. Unscheduled nursing staff were being actively inserviced by phone. All remaining staff will be inserviced before beginning their next scheduled shift, this was completed on 12-19-11. 4. Z3 (Contracted Pharmacist) reviewed all residents on Coumadin/Blood Thinning medication therapy and other medication interactions. The recommendations were faxed to E2 and the resident's physicians for review and recommendations, completed on 12-15-11. 5. Z3 will review all residents on Coumadin/Blood Thinning medications monthly for possible drug interactions and falls. Z3 will make recommendations as necessary to E2 and the resident's physicians. Completion date is 12-15-11 and ongoing. 6. The Care Plan Team reviewed and updated all resident's care plans that are on Coumadin/Blood Thinning medications. This is to ensure the risk for medication interactions with Coumadin/Blood Thinning meds and the risk for falls is addressed. Resident who are on Coumadin/Blood Thinning meds and have fallen in the last six months were identified and care plans were reviewed and updated. This was completed on 12-14-11. 7. The Quality Assurance Committee met and developed a new Quality Assurance tool to review all residents on Coumadin/Blood Thinning medication to ensure resident safety and well being. This tool was implemented immediately and will be completed again next month and then quarterly as part of the Quality Assurance Committee meetings. The tool includes a physical assess for each resident, drug interaction review, fall review, PT and INR lab value review, care plan and physician notification review. The tool was completed on all residents on Coumadin/Blood Thinning medication on 12-14-11. 8. The DON and/or designees will observe 5 transfers a week for safety for the next month and then report findings to the Quality Assurance Committee next month. The safety transfer monitoring will continue and will be addressed at the quarterly Quality Assurance Committee meetings completed on 12-16-11 and ongoing. 9. The charge nurse will immediately investigate accident/incidents. E3 (Assistant Director of Nursing) or designee will perform a comprehensive follow up investigation on every accident/incident and implement preventive measures. E3 will report findings to the weekly Safety Committee Meeting and discuss each individual accident/incident. E3 will identify preventative measures as indicated. The results from the Safety Committee will be reported to the quarterly Quality Assurance Committee. This was completed 12-14-11 and ongoing. 10. The Quality Assurance Committee reviewed and updated the facility policy on "Anticoagulant Policy and Procedure" with Z6 (Medical Director) to ensure resident safety on 12-15-11. E3 inserviced all nurses on the updated policy and procedure. All nurses were inserviced before working their next scheduled shift, this was completed on 12-19-11 and ongoing. 11. The Quality Assurance Committee will continue to meet as needed, next month and quarterly thereafter to address any ongoing issues including review of the Quality Assurance Coumadin/Blood Thinning medications Review Tool to ensure resident's safety.

Based on observation, interview and record review the facility failed to accurately assess, develop appropriate interventions, review and revise the comprehensive plan of care to prevent falls and accidents for 3 of 3 residents R1, R2 and R3, reviewed for falls in the sample of 3. The facility also failed to prevent R1 from repeat falls with the fall of 7/30/2011 resulting in a 10 day hospital stay with treatment for [REDACTED]. Findings include: 1. R1 a [AGE] year old woman was admitted to this facility on 1/8/2010 according to the facility's admission record of this date. Physician order [REDACTED]. An incident report dated 7/30/2011 notes that on 7/30/2011 at 5:50 am R1 was found sitting on the floor leaning on her right hip with it stretched out in front of her, complaining of pain to her left back and rib with a skin tear on rib cage along her back. R1 was taken to the hospital and admitted with a [DIAGNOSES REDACTED]. The Diagnostic Imaging report dated 7/30/2011 findings are noted as acute left 8 th and left 9th rib fractures anteriorly. The History and Physical report of 7/30/2011 also notes a urinary tract infection which was growing proteus resistant to multiple antibiotics. History and Physical from the hospital dated 4/12/2011 notes R1 to have recurrent urinary tract infections and Z3 writes he suspects R1 had Pyelonephritis. On 8/10/2011 at 11:30 am R1 was observed sitting in her wheelchair in a small group area having her noon meal with 4 other residents with 2 staff persons assisting. R1 had just returned to the facility from her recent hospital visit from 7/30/2011 thru 8/10/2011. R1 is alert and oriented to person and place. On 8/10/2011 at 4:00 pm R1 was observed sitting in her recliner chair in her room sleeping off and on, she aroused easily when spoken to, at this time when asked R1 denies pain or discomfort. On 8/11/2011 at 10:00 am R1 is again observed sitting in her recliner chair in her room, when approached R1 asked for assistance to remove her sweater as she was "hot" staff was summoned and responded. At 2:00 pm on 8/10/2011 R1 was observed sitting up in a recliner chair in her room with her feet elevated and in a reclining position, the remote control to her chair was not within her reach. An interview was conducted with R1 regarding her recent fall of 7/30/2011 but R1 was unable to recall details of the fall or tell how the fall occurred. On 8/10/2011 at 2:30 pm E2 (Director of Nurses) was interviewed about R1's fall of 7/30/2011, E2 stated R1 fell from the wheelchair trying to pick up her menu that had fallen on the floor. E2 indicated this was the suspected cause of the fall, as the fall was unwitnessed and R1 was unable to say how the fall occurred. On 8/10/2011 at 4:10 pm E3 (Assistant Director of Nurses) was interviewed about R1's fall of 7/30/2011, E3 stated she (E3) had conducted the investigation into this incident. The findings conclude that R1 was using an additional cushion in her chair. The facility failed to determine where the cushion came from or who provided the cushion as it was not one used by the facility. It was found that the cushion was improperly inflated and was suspected as being a possible cause of the fall. E3 further stated, that upon inspection it was determined that R1's wheelchair brake was extremely loose and in need of repair, and that R1 possibly released the brake herself. This was also suspected as a possible cause of the fall. On 8/11/2011 a telephone interview was conducted with Z3 (Physician), Z3 stated he found it believable that R1 fell from her wheelchair as she was reaching for something off the floor. Z3 stated he had asked facility staff to put a "seatbelt" on R1 to be used as a reminder to her as how far she could bend over in her chair. When asked if the recent Hemothorax was directly related to the fractured ribs R1 sustained in the fall of 7/30/2011, Z3 stated "yes", and added she (R1) is doing much better now. A review of R1's History and Physical from a hospital admitted d 11/21/2009 indicates prior to admission to this facility R1 fell and fractured her right hip, and humerus. On 4/12/2011 according to the History and Physical report of that date R1 was taken to the hospital following a fall from a commode at the facility. Nurse's notes for 4/12/2011 state staff assisting R1 to toilet left her unattended and when she returned R1 was found lying on the floor between the bedside table and the commode. Nurses's notes of 4/28/2011 show that on 4/28/2011 R1 fell while standing with her walker and lost her balance striking her right arm on the recliner chair. The Fall Potential Assessment dated 7/19/2011 shows a score of 6 indicating moderate risk for falls. The Care Plan dated 7/19/2011 notes R1 will be considered high risk for falls due to history of falls, use of prn sleeping medications, impaired standing balance, unsteady gait, memory impairment, frequent toileting, and poor transfer technique, the Care Plan also addresses R1's cognitive status noting that R1 does not know year or day, has impaired recall ability, is easily distracted, and easily forgets things. Following interviews on 8/10/2011 with E2 and E3 it was determined that there were no comprehensive assessments after each fall with effective interventions initiated to prevent further falls from occurring. 2. R2 an [AGE] year old woman was admitted to this facility on 6/9/2011 according to the facility's admission record of this date. POS dated 8/1/2011 thru 8/31/2011 lists R2's [DIAGNOSES REDACTED]. An incident report dated 7/8/2011 notes at 4:15 pm R2 was in her room attempting to carry a plant and control her walker at the same time, R2 was found on the floor in a right side lying position. When asked R2 stated she did not know how she fell , but the incident report states water was noted on the floor. R2 was taken to the hospital via ambulance for evaluation and treatment. At 9:30 am on 8/11/2011 R2 was observed in the Physical Therapy dept of the facility actively participating in her scheduled program. R2 is very pleasant, talkative, alert and oriented to person, place and time. R2 is waiting for her daughter Z3 to pick her up for an doctors appointment, they are scheduled to leave the facility at 10:00 am. During an interview on 8/11/2011 at 9:30 am with R2, R2 was asked about her fall of 7/08/2011 R2 stated "that is when I fell and broke 6 ribs and this left shoulder and boy do I still hurt". When asked to describe the fall R2 stated "she was going across the hall to show her roommate a statute and flowers she had received, adding I guess I must have slipped in water on the floor from the flowers, it happened so fast I'm not sure what I did." When asked to describe a more recent fall of 7/12/2011 R2 could not, she could not remember falling on that day. During an interview on 8/11/2011 at 9:45 am with Z2 (Daughter), Z2 stated when mother fell the first time I believe it was an accident that could happen to anyone, but the second fall I believe was because she is hallucinating from getting too much pain medication. Z2 stated "That is why we are going to the doctor's today to have her medication reevaluated and decreased if possible." When asked to tell what she knew about the fall of 7/12/2011, Z2 stated mother told me "she must have been hallucinating because she thought she was in Chicago at a swimming pool and decided to go for a swim and thinking she was jumping into a pool of water jumped off the bed and fell ." A review of nurse's notes for 7/8/2011 at 8:00 pm note a report was received from the hospital alerting the facility that R2 was returning to the facility with a [DIAGNOSES REDACTED]. A review of R2's record also notes an incident report dated 7/12/2011 and nurse's note of 7/12/2011 at 4:00 am reporting R2 was found on the floor near the footboard stating she was looking for her call light that was hooked onto the bed rail. The report states R2 sat on the edge of the bed became dizzy and tumbled to the floor. R2 was sent to the hospital by ambulance per physician's orders [REDACTED]. The Fall Potential assessment dated [DATE] has a score of 3 and the assessment dated [DATE] has a score of 10 indicating R2 is high risk for fall. The Care Plan of 6/15/2011 notes R2 is a potential fall risk due to impaired balance, unsteady gait, history of left humerus fracture, history of compression fracture with vertebroplasty, history of dizziness, recurrent syncope and hypertension, the Care Plan also addresses R2's cognitive status as short term memory problems, moderately impaired cognitive skills, needs cues and supervision especially for safety. On 7/19/2011 R2 was admitted to the hospital with [REDACTED]. This report also notes R2 has a urinary tract infection. Following an interview on 8/11/2011 with E2 and record review it was determined that R2's medications with hallucinations had not been taken into consideration regarding the falls and no effective interventions had been put in place to prevent further falls. 3. R3 a [AGE] year old man was admitted to this facility on 9/16/2011 according to facility admission records of that date. POS lists R3's [DIAGNOSES REDACTED]. On 8/11/2011 at 12:00 pm observation was made of R3. R3 was sitting in a wheel chair in his room as he had just finished eating his noon meal. R3 receives oxygen therapy per nasal cannula. R3 is verbal, alert, oriented to person, place and time. An interview was conducted with R3 at 12:00 pm on 8/11/2011 and R3 was asked about his recent falls. R3 states he is falling because his "left knee is bad, and his legs are weak and give out on him". R3 states he wants to go back home to live and to do that he knows he had to be able to do for himself and that is why he does not ask for help when he needs to get up. R3 begins to cry saying his wife does not visit often because "she can't drive as much as she use to, and she says she can't take care of me if I go home." During a discussion with E2 (Director of Nurses), E2 states R3 is difficult to get along with, he is mean and hateful and has been that way all his life and there is no changing his behaviors. When asked if it is known why R3 continues to fall E2 stated he refuses to ask for help and does as he chooses. A review of R3's records notes incident reports of 5/31/11 where R3 got up from the bed to get a soft drink and fell to the floor, sustaining a small cut to the 4th digit of his right ring finger. An incident report dated 6/15/2011 notes R3 yelling for help as his chair alarm was sounding and he was sitting on the floor in front of his recliner chair, his wheelchair was to the left of him and the brakes were locked on the chair. Incident report dated 7/2/2011 notes R3 ambulating per self, legs gave out and R3 was found sitting on floor in bathroom. 7/5/2011 incident report notes R3 went to bathroom got on toilet forgot to lock brakes on wheelchair, chair rolled away and R3 fell to the floor. Incident report of 7/6/2011 notes R3 was moving from bed to wheelchair and fell to the floor trying to get into the wheelchair. Incident report of 7/6/2011 notes R3 was found on floor between bed and wheelchair, stated "my knees gave out." Incident report dated 7/13/2011 R3 was sitting on bathroom floor when he tried to transfer self he slid to the floor. On 8/10/2011 at 9:30 am R3 again fell trying to transfer self. The Fall Potential assessment dated [DATE] notes a score of 6 indicating moderate risk for falls. R3 has sustained 17 falls from 10/07/10 thru 8/10/2011 (10 mos) according to the Care Plan dated 9/28/2010 and updated 6/3/2011. R3's Psychiatric evaluation is dated 1/14/2011 and notes suicidal ideations due to decline in physical condition. The Care Plan dated 6/3/2011 for falls note R3 as high risk for falls, it also notes R3 does not ambulate, and R3 does not attempt independent transfers. The Care Plan also addresses R3's cognitive status noting adequate memory and recall ability, independent cognition. The Restorative Nursing Mobility Care Plan dated 12/15/2010 and updated 6/3/2011 notes R3 needs two assist, walker, and gait belt to ambulate in the hallway. Following interviews on 8/11/2011 with E2 and R3 it was determined that no comprehensive assessment had been completed with effective interventions to prevent falls.