Every finding on record at South Elgin Living & Rehab Center

Based on observation, interview, and record review, the facility failed to follow their water management plan for legionella and perform hand hygiene during wound care.This applies to all 57 residents residing in the facility. Findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated August 11, 2025, showed the facility's census was 57 residents. On August 13, 2025, at 8:59 AM, V10 (Regional Maintenance Director) said for the facility's water management plan for legionella, the facility flushes the two hot water heaters twice a year to prevent legionella from building up inside the tanks because hot water is stored in the tanks. V10 said the annual water test in June 2025, showed a small amount of legionella in one of the shower rooms. V10 said the recommendation was to flush the hot water heaters. V10 said the hot water heaters were last flushed around June 27, 2025. V10 said there is no documentation the hot water heater was flushed. V10 said there is no documentation of monitoring the temperatures of the hot water tanks. V10 said there is no documentation of cleaning of the shower heads and faucet screens. On August 13, 2025, at 12:13 PM, V1 (Administrator) said the maintenance department should be reviewing and documenting the control measures in the facility's water management plan for legionella. The facility does not have documentation to show the facility monitored the set temperatures and actual temperatures of the hot water heaters and storage tanks. The facility does not have documentation to show the shower heads and faucet screens were removed and cleaned. The facility's Water Management Program dated June 27, 2025, showed . Overview of Domestic Water Systems. In domestic water systems, there are two main points of concern: Is the temperature of the water conducive to bacterial growth? Can the water be aerosolized? The following table describes each domestic water site and its risk value according to the above parameters. Site: Showers, Risk: High. Showers have been documented as a source of legionella bacteria. The use of both hot and cold water in the shower output creates an optimal temperature for bacterial growth. The complex nature of the plumbing systems supplying water to the shower (including dead legs and other stagnant areas) also lend to prime growth. Showers aerosolize water, creating an ideal environment for water vapor inhalation. Site: Hot Water Heaters and Storage Tanks. Risk: High. Hot Water Heaters heat the supply water to provide domestic hot water, and then store the heated water in storage tanks. Because the risk of scalding, many storage tanks are set to a temperature below the minimum to kill temperature for bacteria. This temperature combined with the stagnant nature of hot water systems creates a prime infection environment. Monitoring: Leaks on HVAC (Heating Ventilation, and Air Conditioning) water systems should be repaired as quickly as possible. Temperature settings (and actual temperatures) should be reviewed monthly on hot water heaters and storage tanks. Filters on ice and coffee machines should be changed regularly (per manufacturer's recommendations). Known stagnation sights should be flushed regularly. Shower head and faucet screens should be removed and cleaned. In addition, yearly laboratory testing should be done on High-Risk sites. The facility's policy titled Water Management Program dated October 1, 2017, showed Policy: In the event of an outbreak, or a suspicion of a possible outbreak, or as directed by Public Health Officials it is the policy of this facility to establish procedures to reduce risk of legionella and other opportunistic pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) in the facility's water systems. See: Environmental Risk Assessment of Water Systems should a risk (above) be identified. This risk assessment may be used or another risk assessment identified by the Consultant Water Management Company used to complete assessment. Policy Explanation and Compliance Guidelines: .7. Testing protocols and acceptable ranges (control limits) will be established for each control measure. a. Individuals responsible for testing or visual inspections will document findings. b. When control limits are not maintained, corrective actions will be taken and documented accordingly. 2. R9's EMR (Electronic Medical Record) showed R9 was admitted to the facility on [DATE], with diagnoses that included pressure ulcer of unspecified site and unspecified stage, osteomyelitis of vertebra, sacral, and sacrococcygeal areas. R9's MDS (Minimum Data Set) dated July 4, 2025, showed R9 was cognitively intact. R9 was dependent on staff for all ADLs (Activities of Daily Living) and bed mobility. R9's care plan showed R9 had skin breakdown to sacrum, left plantar foot and left heel due to immobility and incontinence. Interventions included perform wound rounds weekly and apply local treatments as ordered by the physician. On August 13, 2025, at 08:58 AM, V9 (Wound Care Physician) and V8 (Wound Care Nurse) both used hand sanitizer and put on a gown and gloves and entered R9's room to do his wound care. R9 was on EBP (Enhanced Barrier Precautions). V9 removed the dressing from R9's sacral area and then he left the room without removing gloves or performing hand hygiene. V9 then went through the wound care cart and isolation cart looking for something, when he came back into room, he was wearing the same gown and gloves and measured R9's sacral wound that was open to air. After measuring the wound, V9 removed his gown and gloves and left the room without performing hand hygiene. V8 came into the room with dressing supplies and laid them on R9's over the bed table. With the same gloves, V8 opened the normal saline and cleaned R9's sacral wound. V8 removed her gloves but did not perform hand hygiene and put on new gloves to open the dressing packages, then she removed her gown and gloves and left the room without performing hand hygiene. V9 came back into the room wearing a gown and gloves and placed a towel under R9. V9 removed his gloves and put on new gloves without performing hand hygiene. V8 came back into the room with a bottle of hand sanitizer with the other supplies. V9 came back into the room and was wearing gown and gloves, he removed the dressing from R9's left foot. The open area had moderate amount of bloody drainage. V8 opened a dressing and handed it to V9. V8 removed her gown and gloves and left the room to get more supplies without performing hand hygiene. On August 13, 2025, at 3:32 PM, V8 said she should have gathered all her supplies before entering the room and knew to use hand sanitizer when entering and leaving R9's room. V8 said when she started, she did not have hand sanitizer in the room, and hand sanitizer should be used when going from dirty to clean. V2 (DON/Director of Nursing) agreed and said the physician should also use hand sanitizer when leaving the room and when going from dirty to clean. Facility policy provided their policy title, Enhanced Barrier Precautions with a revision date of October 2024. The policy showed, the purpose: Recommendation from the CDC (Center for Disease Control) to protect residents from MDROs (Multidrug resistant organisms) . Enhanced Barrier Precautions involve gown, and gloves use during high contact resident care activities. During care: Gown and glove for these resident care activities.Wound care . After care: . perform hand hygiene with soap and water before leaving room. Facility policy titled Wound Care Protocol with a revision date of September 2024, showed, . Prep wound for treatment: 3. Place red bio-hazard bag at foot of bed. Remove soiled dressing and place in bag. 4. Remove gloves and place in red bio-hazard bag. 5. Sanitize hand and/or wash, if contamination has occurred.7. clean wound as ordered. 8. Remove gloves, place in bio-hazard bag. 9. Sanitize hands and put on clean gloves. Facility policy titled Hand Hygiene with a revision date of December 2024. The policy showed, Purpose: Hand hygiene is the most effective way of preventing the transmission of healthcare-associated infection to resident, staff, and visitors. 1. Hand hygiene shall be performed: . before a clean or aseptic procedure, after exposure or risk of exposure to blood and/or body fluids.

Based on observation, interview and record review, the facility failed to maintain freezer temperatures, failed to follow food temperature guidance for foods stored in the steam table, and failed to store dented cans per facility policy. This applies to all 56 residents that receive foods prepared in the facility kitchen.Findings include:1. On August 11, 2025, at 9:42 AM, the initial tour of kitchen was completed in the presence of V4 (Dietary Manager). In the dry storage room there were 3 cans (6 lbs/pounds, 12 oz/ounces each) of cut sweet potatoes in syrup that were dented at the seam. In addition, there was one can (6 lbs, 8 oz) of sliced apples in water that was also dented at the seam. These cans were placed on the shelving that contained other cans of food items. V4 stated that she usually checks the cans on delivery and returns it to the purchased company. In the reach in freezer, the internal temperature gauge showed 10 degrees Fahrenheit and noted that chicken strips (wrapped in clear packaging) and two bags of frozen vegetables (5 lb/bag) were not firm to touch and had ice crystals inside the bags of frozen vegetables. On August 11, 2025, at 11:00 AM, the same reach in freezer was checked again and the internal temperature gauge showed 12 degrees Fahrenheit. The same chicken strips and frozen vegetables remained softer to touch and there was water condensation and ice crystals inside the bags of frozen vegetables. V4 stated that the freezer is supposed to be 0 degrees Fahrenheit. V4 was notified that the same freezer will be checked again later in the day. On August 11, 2025, at 4:00 PM, the same reach in freezer was checked again and noted to be 15 degrees Fahrenheit. V4 stated I will check with Maintenance. It should not be like that. At this time, the above food items seen earlier appeared to be in further state of defrosting and were soft to touch. Facility policy and procedure (2025) titled Dented Cans included as follows- Policy: To ensure that food is stored, prepared, distributed and served under sanitary conditions the facility will follow the following procedure for handling dented cans. Procedure: No dented cans will be placed on the shelves with canned goods. Facility policy and procedure (revised 2017) titled Storage of Frozen Foods included as follows- Policy: Frozen foods are maintained at temperature level that keeps frozen foods solid. Procedure: Healthcare community staff notifies the person in charge if frozen food is not solidly frozen. Frozen food that is not solidly frozen is evaluated for possibility of being discarded. 2. The facility's spreadsheet for week 3, Monday listed pureed cola glazed ham, pureed macaroni and cheese and pureed wax beans for the lunch meal. On August 11, 2025, at 11:22 AM, V4 was preparing pureed macaroni and cheese in a food processor. V4 pureed the products and transferred it to a pan and placed it on the steam table. V4 did not follow a recipe. V5 (Cook) was at the steam table and had started platting the food items. On request, V4 took the temperature of the pureed macaroni and cheese and it showed 128 degrees Fahrenheit. On request again, V4 took food temperature of other pureed items. The pureed beans showed 130 degrees Fahrenheit and the pureed ham showed 121.6 degrees Fahrenheit. V4 stated that the food items should be 135 degrees Fahrenheit on the steam table. V4 stated that she will reheat the pureed macaroni and cheese and pureed beans to 145 degrees Fahrenheit and the pureed ham to 155 degrees Fahrenheit. When asked what the reheating guidance is shown on the recipe of the pureed items, V4 responded that the recipe is in the computer and that she will have to look it up. The recipe for pureed ham, pureed macaroni and cheese and pureed wax beans showed that after pureeing the products respectively in a food processor, to reheat to 165 degrees for 15 seconds and hold for service at 135 degrees Fahrenheit or above. Facility policy and procedure titled Food Temperatures included as follows-Policy: To ensure food safety, hot food is cooked to a minimum safe temperature and is held at no lower than 135 degrees Fahrenheit. Procedure: Hot foods is held on the steam table at 135 degrees or higher. Corrective action is taken for foods not meeting the temperature standard. Hot foods will be plated at 135 degrees Fahrenheit or higher . The facility's Long-Term Care Facility Application for Medicare and Medicaid dated August 11, 2025, showed the facility's census was 57 residents, facility provided information that there was one resident on NPO (nothing by mouth) status.

Based on interview and record review, the facility failed to ensure residents were free from chemical restraints.This applies to 2 of 5 residents (R4, R10) reviewed for unnecessary psychotropic medications in the sample of 15.Findings include: 1. The EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, major depressive disorder, vascular dementia, and generalized anxiety disorder. R10's MDS (Minimum Data Set) dated May 23, 2025, showed R10 has moderate cognitive impairment. R10's Physician Orders dated August 13, 2025, showed an order dated June 23, 2025, for lorazepam (antianxiety medication) 1 mg (milligram) tablet, give one tablet by oral route every six hours for 14 days as needed. R10's lorazepam order does not show a stop date for the medication. R10's July 2025 MAR (Medication Administration Record) showed R10 received doses of as needed lorazepam on July 8, 9, 10, 12, 17, 18, 19, 22, and 27. R10's August 2025 MAR showed R10 received a dose of as needed lorazepam on August 10. R10's progress notes from July 7, 2025, to present do not show any provider notes with rationale for extending R10's lorazepam as needed order beyond 14 days or the extended duration of the as needed order. On August 13, 2025, at 2:58 PM, V2 (DON/Director of Nursing) said as needed psychotropic medication orders should be for 14 days. V2 said after 14 days, if the as needed medication is to be extended, the order for the as needed psychotropic should be discontinued and a new order should be entered into the medical record. V2 said there needs to be documentation from the provider regarding the ongoing as needed medication. V2 said R10's as needed lorazepam order did not have an automatic stop date and is an ongoing order. V2 said the medication order should have had a stop date of 14 days from the order date. V2 said R10's psychiatry provider notes do not show any documentation regarding the as needed lorazepam order. 2. R4's face sheet showed R4 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the lung, cerebral infarction, and schizoaffective disorder, depressive type. R4's had the following active order dated July10, 2025: Lorazepam 1milligram (mg) tablet, give 1 tablet (1 mg) by oral route every 4 hours for 14 days as needed. Per the physician order, the above listed lorazepam order ended on July 24, 2025. However, R4's medication administration record (MAR) from July 2025 showed that Lorazepam 1mg tab as needed was given to R4 after July 24, 2025 and before a new order was initiated. R4's MAR showed that lorazepam 1 mg tablet as needed was administered to R4 on July 25th, 26th, 28th, 29th, 30th, and 31st, of 2025, and August 1st, 2nd, 3rd, 5th, 7th, 8th, 10th, 11, and 12 of 2025. By the end of the survey, the facility did not produce an order for Lorazepam 1mg tablet as needed for July 25 - August 12, 2025. Provider notes were requested for July 1, 2025 to present. However, the facility did not have any provider notes with rationale for extending R4's lorazepam as needed order beyond 14 days or the extended duration of the as needed order.

Based on observation, interview, and record review the facility to complete a dressing change for a resident's soiled IV (intravenous) dressing.This applies to 1 of 1 residents (R9) in the sample of 15.Findings include:R9's EMR (Electronic Medical Record) showed R9 was admitted to the facility on [DATE]. R9 was recently hospitalized on [DATE], and was readmitted to the facility on [DATE], with diagnoses of hematuria (blood in urine) and UTI (Urinary Tract Infection). R9's MDS (Minimum Data Set) dated July 4, 2025, showed R9 was cognitively intact. R9's care plan showed R9 was receiving IV (Intravenous) antibiotic therapy for an UTI. Interventions included the nurse was to monitor the IV site every shift and as needed. On August 11, 2025, at 10:13 AM, R9 was in bed. There was a midline IV in his right antecubital (front area of elbow). There was a gauze dressing over the insertion site and a transparent occlusive dressing over the entire site. The dressing was dated as last changed on August 7, 2025. The gauze dressing was clean and dry. On August 12, 2025, at 11:58 AM, during the administration of R9's IV antibiotic, the gauze dressing covering the insertion site was discolored from white to tan over most of the gauze and looked wet.On August 12, 2025, at 1:58 PM, IV dressing continues to be discolored and looked tan in color. The date on the dressing was August 7, 2025.On August 12, 2025, at 1:42 PM, V2 (DON) said she the IV dressing should be changed weekly, and she would never put a gauze dressing over an IV insertion site because you want to be able to monitor the site for redness and/drainage. If there is drainage noted on the dressing, it needs to be changed as soon as possible.On August 13, 2025, at 11:41 AM, R9's midline IV dressing was dated August 7, 2025. Gauze dressing had a dark tan color around the edges and lighter tan color towards the center of the dressing. V3 (RN/Registered Nurse) looked at the site and said she would need to change it. On August 13, 2025, at 3:32 PM, V2 (DON) said V3 made her aware this morning that the dressing to R9's IV site was soiled and needed to be changed. The facility provided their pharmacy undated policy titled, Peripheral Intravenous Dressing. the policy showed the objective: to provide a method for continuously viewing IV insertion site without exposing the insertion site. To decrease manipulation of insertion site with frequent dressing changes, therefore decreasing possibility of mechanical irritation . Procedure: . 6.) apply transparent dressing securing it first at the insertion site, then around catheter hub, then soothing out to the edges, 7) Place 2x2 gauze under the infusion plug to IV tubing and secure with tape if necessary to pad the skin .The facility provided their policy titled IV Medication Administration Policy with revision date of January 2025, showed, . IV dressings are changed aseptically every 7 days and as needed.

Based on observation, interview and record review, the facility failed to secure resident oxygen tanks and failed to maintain and lock storage shed for oxygen tanks.This applies to 2 of 2 residents (R4, R48) reviewed for oxygen storage in the sample of 15.Findings include:1.R48's face sheet included diagnoses of chronic obstructive pulmonary disease, unspecified asthma, dependence on supplemental oxygen. R48's face sheet included diagnoses of malignant neoplasm of unspecified part of unspecified bronchus or lung, chronic obstructive pulmonary disease. R4's physician orders included oxygen at 2-3 liters continuous.On August 11, 2025, at 10:47 AM, R48 was seated in a wheelchair with portable oxygen tank pocket in the wheelchair and stated I am a smoker. They let us out and give me a cigarette. They take out my oxygen tank. On August 12, 2025, at 12:59 PM during smoke break, R48 was handed a cigarette by V7 (Activity Aide). V7 then removed the portable oxygen tank from the back of R48's wheelchair and placed it standing vertically on the floor near the side of the sliding door that led to the patio for smoking. Multiple residents in wheelchairs were waiting to smoke near this patio door including R4 who had a portable oxygen tank stored at the back of her wheelchair. V7 also gave R4 a cigarette and removed R4's portable oxygen tank from the back of her wheelchair and placed it near the patio door. When V7 was asked if he always stores the portable oxygen tanks near the sliding doors, V7 stated that he also sometimes puts it in the medication storage room (which was near the patio door). V6 (Registered Nurse) who was standing at his medication cart within hearing distance, removed these portable oxygen tanks from the side of the patio door and placed them standing vertically on the floor of the medication room. V7 then stated that the portable oxygen tanks should be stored in a holder and went to another part of the facility to bring a holder to store these oxygen tanks. 2. On August 13, 2025, at 12:19 PM, during tour with V11 (Housekeeping Supervisor) to the facility garbage storage and disposal area, an open shed that stored multiple oxygen tanks was seen located near the parking lot. The shed had doors that were rusted and loose and had an opened lock hanging on the door handle. Several empty oxygen tanks were stored on the floor and multiple oxygen tanks that were full were stored in carts in holders. The floor of the shed was covered in grime/dirt and several containers were dusty. One of the carts that contained oxygen tanks that were full, had an opened yellow colored lid and the oxygen tanks were able to be pulled out of the cart. V11 stated that its the nursing department that handles the oxygen storage. On August 13, 2025, at 12:26 PM, V10 (Regional Maintenance Director) stated that he is here at the facility this day as the facility Maintenance Manager had quit two weeks ago. After viewing the oxygen tank storage shed, V10 stated that the door should not be open, and it must be kept locked as nobody should have access except staff. V10 stated that the yellow lids above each cart should also be closed. When V10 tried to close the doors to the shed, he was not able to pull it shut, and the doors hung loosely on its hinges. V10 remarked This door is falling apart. It's time for new doors. V10 stated that the nursing staff put empty oxygen tanks in the shed and get the tanks that are filled with oxygen. V10 added that a company comes out and collects the empty oxygen tanks and stocks filled ones after facility staff notifies them. Facility policy titled Oxygen Storage Policy (revised August 2022) included as follows:Oxygen must be stored in locked storage area, tanks must be secured, and room must follow safety regulations. All empty and full oxygen tanks shall be stored in a locked, enclosed area (oxygen room) which is unable to be accessed by residents or visitors. Charge nurse, Nurse supervisor and or maintenance will be the only staff able to lock/unlock oxygen storage room. Keep cylinders and fittings from becoming contaminated with oil, grease or dust.

Based on observation, interview and record review, the facility failed to provide grooming assistance to remove facial hair for a resident with poor vision.This applies to 1 of 3 residents (R48) reviewed for ADL (activities of daily living), in the sample of 15. Findings include: R48's face sheet included diagnoses of type 2 diabetes mellitus with diabetic neuropathy, blindness left eye category 3, normal vision right eye, blindness, one eye, unspecified eye, dry eye syndrome of bilateral lacrimal glands. R48's quarterly MDS (minimum data set) dated showed that R48 was cognitively intact and required partial moderate assistance (helper does less than half the effort) for personal hygiene. R48's care plan effective November 23, 2024 included that R48 has been observed to need assistance in performing some portion of her ADL dressing and grooming as R48 demonstrated the following areas of deficit: Impaired functional strength, impaired functional endurance, impaired hand grasp/coordination, impaired balance in sitting/standing, impaired functional reach. Interventions included as follows: Resident will be able to maintain and or improve current level of performance when performing ADL's .grooming and personal hygiene with set up, verbal cues and supervision and or touching assistance from staff, resident will be placed into dressing or grooming restorative program, break down tasks in simple steps, one step at a time, use verbal cues. On August 11 2025 at 10:43 AM, R48 was in the dining room seated in a wheel chair wearing dark shades and was noted to have extensive facial hair covering her chin and upper lip. R48 stated I can shave but can't see very well. I need some help as I am blind in left eye and my right eye is very blurred. On August 12, 2025 at 12:58 PM, R48 was waiting for her smoke break and noted to still have facial hair that was covering her chin and upper lips. V6 (Registered Nurse) stated that R48 needs assistance with care and V6 was notified of R48's request for assistance for removing facial hair. On August 14, 2025 at 9:35 AM, V2 (Director of Nursing) stated that the assigned CNA (Certified Nursing Assistant) to resident is supposed to take care of grooming and personal hygiene on an as needed basis.

Based on observation, interview, and record review, the facility failed to prevent resident-to-resident physical abuse. This applies to 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 3. This failure resulted in R2 striking R1 on the nose, resulting in R1 being transferred to the hospital and found to have a fractured nose.Findings include:R1's Face Sheet shows R1 admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, mild intellectual disability, and bipolar disorder. R2's Face Sheet shows R2 admitted to the facility on [DATE] with diagnoses including diabetes, seizures, and depression. The facility's 6/19/25 Final Incident Investigation Report shows an incident between R1 and R2 occurred on 6/15/2025 (Sunday) at approximately 5:15 PM. The report showed, the R1 and R2 were roommates and resident-to-resident contact was reported. The report shows R1 and R2 had a disagreement over the thermostat in the room and that R2 struck R1 on the bridge of his nose, which resulted in R1 receiving a broken nose (closed fracture). The 6/15/25 Reporting Officer Police narrative shows R1 and R2 were arguing about the climate control of their room. The report shows R2 admitted to striking R1, with a closed fist, on the bridge of R1's nose.The facility's investigation shows a statement from R2 dated 6/16/2025. The statement shows, My roommate (R1) turned the air conditioner up to 83 degrees. I told him to turn it down and he said no, so (R2) punched (R1). (R1) pushed (R2) into the dresser .The facility's investigation showed a statement from R1 dated 6/16/2025. The statement showed, My roommate (R2) got mad because (R1) wanted the air in the room warmer. (R1) tried to walk out of the room, then (R2) punched me. I don't remember what happened after that. I feel safe in the facility. (R1) don't want to be (R2's) roommate anymore.R1's 6/15/2025 hospital records showed he sustained a broken nose.On 7/2/25 at 10:47 AM, V4 Certified Nursing Assistant (CNA) stated she was working on 6/15/25. V4 said, at approximately 5:20 PM on 6/15/2025, another CNA and she responded to a door that was slammed shut. V4 said as they walked down the hallway, they witnessed R1 in the hallway with blood on his nose. V4 said they opened the door to R1 and R2's room and observed R2 on one knee in the room. V4 said R2 reported that R1 had punched him. V4 said R1 was outside the room, heard this statement from R2 and R2 responded, I punched you because you punched me. V4 said the argument was over climate controls in the room. V4 said the only cause of R1's broken nose was due to being hit in the face by R2. V4 said R1 had not fallen. On 7/2/25 at 11:28 AM, V7 Nurse Practitioner stated he knows R2 well; however, he was less familiar with R1. V7 said he was not aware of any reason R2 should not have a roommate. V7 said the only possible cause of R1's broken nose was from R2 punching R1 in the face. The facility's abuse prevention policy (dated 10/24/2022) showed that the facility affirms the right of our residents to be free from abuse. The policy defines abuse as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury . physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking .

Based on observation, interview, and record review the facility failed to follow the State Department of Public Health and the Local County Health Department instructions to obtain appropriate facility-wide testing, initiate treatment for a resident (R1) with positive test results, and adhere to the mandated facility-wide masking for the management of their group A streptococcal disease outbreak. This applies to all the residents residing at the facility. Findings include: The facility's resident roaster dated 9/12/2024 showed a census of 56 residents. 1. The CDC (Center for Disease Control and Prevention) website link https://www.cdc.gov/group-a-strep/about/index.html dated 3/1/2024 documents, Group A Streptococcus (group A strep bacteria) can cause serious and deadly clusters or outbreaks. Group A strep bacteria are very contagious. Some people infected with group A strep bacteria don't have symptoms or seem sick. They can still spread the bacteria to others. Generally, people spread the bacteria to others through respiratory droplets or direct contact. The link continued to document, CDC developed these investigation tools to provide detailed approaches to investigating and controlling GAS (Group A Streptococcus) infections and outbreaks in LTCFs (Long Term Care Facilities) .Collaboration is key LTCF staff should work with their local public health departments when investigating suspected GAS outbreaks. On 9/12/2024 at 2:45 PM, V12 (Certified Nurse Assistant/CNA) said she had tested positive for Strep A during the facility's wide outbreak testing for Strep A on 8/1/2024. V12 said she was asymptomatic but received and completed her antibiotic treatment. V12 said she did not believe there was currently an active case of Strep A infection at the facility. On 9/12/2024 at 3:40 PM, V1 (Administrator), V2 (Director of Nursing), and V3 (Assistant Director of Nursing/Infection Preventionist) said the facility had an active Strep A infection outbreak. They said they were all new to their roles at the facility. They said they were not sure when the outbreak started, how many cases there were, and which residents were associated with the facility's outbreak. They continued to say they were aware of the facility's mandated masking for all residents, staff, and visitors from the State Department of Public Health and the Local County Health Department. V1 said on 8/1/2024 the Local Health Department's lab went to the facility to perform the facility-wide testing on all the residents and staff. V1 said she was notified R1's right foot wound culture and V12's (Certified Nurse Assistant/CNA) throat culture resulted positive for Strep A. V1 continued to say that on 8/28/2024 the Local Health Department's lab went back to the facility to retested R1 and V12. V1 said on 9/11/2024 she was notified that R1's right foot wound culture continued to test positive for Strep A. On 9/13/2024 at 9:25 AM, V14 (IDPH Infection Control Coordinator) said he and the Local Health Department had initiated a retrospective investigation and had identified 5 resident iGAS Strep A infections at the facility. V14 said the State Department of Public Health and the Local County Health Department used the CDC's (Center for Disease Control and Prevention) guidelines for Group A Streptococcus Infections in Long-Term Care Facilities to assist the facility with their outbreak management including testing and infection control practices. V14 said the facility's prior management was notified of the facility's outbreak in May 2024 and routine onsite visitations were conducted at the facility to assist them with their outbreak. V14 said the facility's prior management had failed to obtain accurate employee assessment survey questionnaires and perform facility-wide testing for staff in June 2024 as instructed. V14 said the facility had also failed to obtain proper cultures for residents identified at risk in July 2024 as instructed. V14 said because the facility failed to assist the State Department of Public Health and the Local County Health Department with the facility's outbreak management and investigation they decided to mandate masking for all residents, staff, and visitors at the facility in July 2024. V14 said then the Local County Health Department assisted the facility with obtaining appropriate testing for staff and residents on 8/1/2024. V14 said that during the facility's wide-testing 2 additional cases were identified (R1 and V12). V14 said the facility was notified that their mandated masking had to continue till December 2024. V14 said he was concerned during his last onsite visit on 9/9/2024 because he observed several staff and residents without masks. On 9/13/2024 at 3:40 PM, V13 (Local County Health Department Communicable Disease Supervisor) said she notified the facility they had an iGAS Strep A outbreak in May 2024. V13 said she and V14 (State Department of Public Health Infection Control Coordinator) have been trying to guide the facility with their management of the outbreak. V14 said they have been providing the facility with guidance tools and conducting routine onsite visits to further assist them. V13 said they have continued to identify serious infection control concerns regarding the facility's lack of response to their recommendations with obtaining appropriate facility-wide testing and adherence to the facility-wide masking mandate. V14 said the facility is still in an outbreak. V14 said the facility's retrospective investigation is ongoing to further identify any additional iGAS Strep A infections associated with the facility. The document titled Local County Health Department Meeting Minutes dated 6/4/2024 showed the facility was instructed on infection control interventions based on the onsite visitation conducted by the State Department of Public Health and the Local County Health Department for management of their current outbreak of invasive group A streptococcal disease at the facility. The document said, [V14] explained that specimen collection sites must be decided based on the presence of symptoms or conditions; a standard throat swab cannot be utilized for all; [facility] team confirmed that new specimens will be collected from the residents accordingly, and cultures will be made. The document also said, [V13 and V14] reinforced the importance of staff responding the survey accurately to allow for identification of symptomatic individuals (for GAS or iGAS) and appropriate selection of specimen collection sites (i.e., if they have skin or nail wounds, specimen must be collected from those sites) .[V13] recommended that the facility tries to identify and test by culture all epi-linked staff (staff who provide direct care for the case with the last onset date); if this is not feasible, all staff must be cultured. The document continued to say the facility agreed the next steps would be taken, [Facility] will reassess residents and do additional testing as needed for individuals with wounds or ostomy sites. [Facility] will complete reassessment for GAS. [Facility] will identify and test epi-linked staff regardless of symptoms; if unable to identify epi-linked staff, all staff members will be tested (and treated accordingly). The document titled Local County Health Department Meeting Minutes dated 7/10/2024 said, the staff assessment and reassessment had not been completed by the facility. The document continued to document that the facility was again educated and provided basic containment guidance for the management of their Strep A iGAS outbreak. The document titled Local County Health Department Meeting Minutes dated 7/15/2024 showed the facility was notified that a total of 5 cases had been identified as part of the facility's retrospective investiation outbreak and it was highly suspected that disease transmission was ongoing at the facility. The document said, [Physician] (Regional Infection Prevention Program-[NAME]) pointed out to the fact that, since only 2 of the 5 cases in the outbreak had wounds, droplet must be considered as the main mode of transmission; considering that culture screenings from residents were negative, and that no staff has been tested yet, adoption of broad masking is a simple containment measure and should be implemented during the outbreak. The document continued to say the recommended next steps would be taken, Recommended implementing universal masking at [facility]. Recommend testing by culture all facility employees, including contractors, EVS, and non-clinical employees; throat swab is the recommended specimen collection method. Contact (laboratory) to discuss screening of staff at the occasion of specimen collection. If any wounds are identified, (Laboratory) to collect specimens from wounds as well. The facility's document titled Resident Infection Control and Antimicrobial Log dated August 2024 showed on 8/1/2024 lab wound specimen cultures were obtained from R1-R6 and R11-R13. The report said R1 tested positive for Strep A and R1-R3, R5, R6, and R11-R13 also tested positive for MRSA (Methicillin-resistant Staphylococcus aureus). The CDC's (Center for Disease Control and Prevention) document titled Decision Tool for Investigating Group A Streptococcus Infections in Long-Term Care Facilities dated 3/1/2024 said LTC (long-term care) facilities should identify additional symptomatic cases, identify potential asymptomatic carriers, assess infection control measures, and conduct an epidemiologic and laboratory investigation when they have an iGAS outbreak. The document said, Footnotes a. If GAS is isolated from a wound AND accompanied by necrotizing fasciitis or streptococcal toxic shock syndrome, then it is considered an invasive GAS infection case .b. Often cases of invasive GAS will first be identified either by an acute care hospital where the resident of an LTCF has been transferred for additional evaluation and medical care or by a laboratory that processes specimens collected at LTCFs. Thus, these facilities should ensure that invasive GAS infection or positive GAS cultures collected from normally sterile body sites are reported to local public health authorities and the LTCF where the patient resides. Additionally, these facilities should save the isolate for possible future assessments of strain relatedness in case additional cases are identified .Note: Continued use of a facemask by HCP during all wound care activities or when handling invasive medical devices is recommended until the outbreak is over . The facility's policy titled Infection Control Surveillance and Monitoring with a revised date of 4/11/2022 said Policy: It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained .Procedure: 1. Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator, ICP, and DON. This includes but is not necessarily limited to: a. Surveillance of the facility to ensure that required work practices are observed and protective clothing and equipment are provided and properly used; b. Investigation of known or suspected parenteral exposure .c. Improvement in training, work practices, or protective equipment to prevent recurrence. d. Maintain a procedure of notification to physicians, and (State Department of Public Health) as required by regulation, of any infectious cases. e. Review all policies, procedures, and programs relating to infection control including environmental controls . 2. R1's Medical Record showed an admitted [DATE] with diagnoses of necrotizing fasciitis to his right foot wound, non-pressure chronic ulcer of the right heel and midfoot with fat layer exposed, and soft tissue disorders. On 9/12/2024 at 10:15 AM, V3 (Assistant Director Nursing/ADON) said she was the facility's IP (Infection Preventionist). At 10:30 AM during the facility's infection control observation round done with V3, R1's room had an EBP (Enhanced Barrier Precaution) sign tapped outside his room. V3 said that was incorrect because R1 was supposed to be under Contact Precautions because of his Strep A wound infection to his right foot wound. V3 said R1 had tested positive for Strep A to his right foot wound on 8/1/2024 during the facility's Strep A outbreak testing. V3 said R1 was placed on contact precautions and started on an oral antibiotic on 8/9/2024. V3 said R1's wound was retested for Strep A on 8/28/2024 as part of the facility's outbreak management. V3 said the facility was notified on 9/11/2024 that R1 had again tested positive for Strep A. V3 said she notified R1's physician and received an order for an oral antibiotic and to continue with contract precautions. V3 continued to say R1 frequently went out on pass overnight and he was currently out on pass. V3 said R1 went out on pass on 9/11/2024 and was not expected back for 8 days. V3 said she had called R1 and notified him of his test results and the antibiotic order. V3 said she was waiting to hear back from R1 to call in his antibiotic prescription to a local pharmacy. On 9/13/2024 at 10:30 AM, V3 said she still had not made contact with R1 and was planning to call him later that day. On 9/12/2024 at 2:45 PM, V12 (Certified Nurse Assistant/CNA) said she was familiar with R1 and had taken care of him. V12 said she had tested positive for Strep A during the facility's wide outbreak testing for Strep A on 8/1/2024. V12 said she had been asymptomatic but received and completed her antibiotic treatment. V12 said she did not believe there was currently an active case of Strep A infection at the facility. V12 said she believed R1's wound infection was not Strep A. V12 said she uses the precaution signs outside residents' rooms to instruct her what type of precautions and PPE (Personal Protective Equipment) she needed to use when entering the rooms to protect herself and others. On 9/13/2024 at 11:30 PM, V1 (Administrator) said R1 frequently went out on pass overnight. V1 said R1 was frequently non-compliant with his right foot's wound care. V1 said R1 had not started his oral antibiotic treatment ordered on 9/11/2024 for his known Strep A wound infection. V1 said she was unable to locate a facility's out-of-pass policy. R1's Wound Evaluation and Management Summary dated 9/4/2024 said R1 had a full-thickness post-surgical wound to his right dorsal foot. The summary said the wound measured 8.1 x 4.0 x 0.1 cm (centimeters) and had heavy serosanguinous exudate. The summary continued to say that R1 now required daily dressings. R1's physician orders dated 9/11/2024 said start Amoxicillin (antibiotic) 500 mg PO TID x 10 days for Strep group A on foot wound and continue contact isolation for Strep group A on wound. R1's progress note dated 9/11/2024 said R1 was to start Amoxicillin 500mg PO TID x 10 days to start when resident comes back from out on pass for 8 days, resident was called and notified. R1's progress note dated 9/3/2024 said R1 complained of his right foot wound dressing being saturated through his sock. The progress noted said when the dressing was removed it was noted with abnormal smelling and large amount of drainage. The progress note said R1's nurse practitioner was notified and an order for daily dressing changes was obtained. R1's right foot wound culture dated 8/04/2024 showed R1 had a positive culture for Moderate Growth Beta Hemolytic Strep Group A (Abnormal). R1's care plan dated 9/12/2024 showed R1 had a beta hemolytic strep group A infection on his foot initiated on 8/15/2024. The care plan had multiple interventions including Educate resident/family/staff regarding preventive measures to contain the infection and Place in private room with contact isolation precautions initiated on 8/15/2024. R1's care plan also showed that R1 had a behavior problem related to not following the facility's policies regarding the out-on pass initiated on 3/19/2024. R1's care plan said, Resident has a wound on his right lower leg that needs attention, daily dressing change is important which is not done when he is not in the facility overnight. The care plan had multiple interventions including Explain all procedures to the resident before starting .If reasonable, discuss resident's behavior. Explain/reinforce why behavior is inappropriate and /or unacceptable to the resident initiated on 3/19/2024. The CDC's (Center for Disease Control and Prevention) document titled Decision Tool for Investigating Group A Streptococcus Infections in Long-Term Care Facilities dated 3/1/2024 said, Additional PPE use, as described below, is recommended to control a GAS outbreak. Residents with suspected or confirmed GAS infection from a wound, ostomy, or device-insertion site should remain on Contact and Droplet Precautions until 24 hours after the initiation of effective antibiotic therapy and any wound drainage stops or can be contained by a dressing. HCP should then return to use of EBP (Enhanced Barrier Precautions). 3. On 9/12/2024 at 8:230 AM, R6 and R7 were unmasked in the facility's common areas. R6 was sitting in the hallway leading to the open dining room area and R7 was sitting in the open dining room area. At this time other residents were being transported in and out of the dining room. At 9:05 AM V9 (Activity Aide) was unmasked while walking across the dining room where there were residents in the area. At 1:40 PM V9 was talking to R7 in the dining room where there were other residents. V9's surgical mask was placed underneath her nose and R7 was unmasked. At 1:43 PM V9 said she was unmasked in the morning because she entered the facility from the back-side entrance where there were no surgical masks available. V9 continued to say she was required to wear a surgical mask to cover her nose and mouth to protect herself and others. On 9/12/2024 at 3:40 PM, V3 (Assistant Director of Nursing/ADON) said all facility staff, residents, and visitors had to be masked because of the facility's Strep A outbreak. V3 said failure to adhere to the mandated facility-wide masking can result in the spread of the disease. The facility's policy titled Face Mask/Face Shield/Goggles dated 12/2009 showed Policy: Varies types of protective apparel are worn to prevent contamination and the possibility of splattering of blood or body fluids. Protective equipment is to be worn according to the Center for Disease Control Guidelines .A surgical mask is generally worn to provide protection against spread of infectious large-particle droplets that are transmitted by close contact .

Based on observation, interview, and record review the facility failed to safely repair an exposed ceiling area located outside residents' (R8, R9, and R10) rooms. This applies to 3 of 8 residents reviewed for environmental hazards. The findings include: On 9/12/2024 at 8:32 AM, during the facility's environmental rounds, there was an open ceiling area with exposed pipes above the entrance of the housekeeping room. The housekeeping room was in the the resident hall in front of R8, R9, and R10's rooms. The cut-out open ceiling area had a loose plastic covering with a moderate amount of drywall debris. The plastic covering was not properly secured it had scattered pieces of blue painter's tape. At 11:45 AM, V4 (Housekeeper Supervisor) said approximately three weeks ago there had been a pipe leak above the housekeeping room entrance area. V4 said the facility did not have maintenance staff available to fix the open ceiling drywall area. V4 said the open ceiling area had remained with the same plastic covering and tape. V4 said the facility's corporate management was planning to send someone to patch up the ceiling but was unsure when. On 9/12/2024 at 12:05 PM, V1 (Administrator) said approximately a month ago the nursing staff informed her there was a ceiling leak outside the housekeeping room. V1 said an outside plumbing company fixed the leak but the ceiling area remained open with exposed pipes. V1 said the opening measured approximately 3 x 3 ft (feet). V1 said the facility did not have maintenance staff to repair the ceiling. V1 said she requested the corporate management to send someone to patch up the ceiling but was unsure when it would be repaired. The facility's resident roster report dated 9/12/2024 showed R8's room and R9 and R10's room were located directly across from the housekeeping room. The facility's undated document titled Maintenance Minute showed The Maintenance Minute is a one to two page quick update on maintenance [NAME], some tips for routine maintenance and refreshers for Life Safety .maintenance Training Quick Guide .Repair any wall or ceiling damage as soon as possible to maintain smoke barrier.

Based on interview and record review the facility failed to ensure a nurse was competent to administer medications as ordered and transcribe orders for 4 of 4 residents (R3, R4, R7 and R8) reviewed for nursing services in the sample of 8. Findings include: 1. R3's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: polyneuropathy, schizoaffective disorder, neuromuscular dysfunction of the bladder, anxiety, hypothyroidism, insomnia and hyperlipidemia. R3's Minimum Data Set (MDS) assessment dated [DATE] shows that her cognition is intact. R3's August Medication Administration Record (MAR) shows that she takes lamotrigine (anticonvulsant) 25 milligrams (mg)-3 tablets once daily at 8:00 AM for mood stabilization, aripiprazole (antispychotic) 10 mg daily at 8:00 AM for mood and paranoia and gabapentin (anticonvulsant) 300 mg three times a day at 8:00 AM, 12:00 PM and 6:00 PM for anxiety/pain. On 8/13/24 at 10:05 AM, R3 said that V3 (Registered Nurse) gave her her 8:00 AM medication one day and she was missing 2 of the 3 tablets of lamorigine, her aripiprazole and her gabapentin. R3 said that she had to tell V3 that she was missing them and then she corrected it. 2. R4's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: seizures, diabetes mellitus, hypothyroidism, hypertension, edema, gastro-esophageal reflux, high cholesterol, morbid obesity, depression, schizoaffective disorder and obstructive sleep apnea. R4's MDS dated [DATE] shows that her cognition is intact. R4's August MAR shows that she receives the following medications at 8:00 PM: metformin (antidiabetic) 1000 mg, pravastatin (statin) 10 mg, bumetanide (diuretic) 2 mg, divalproex (anticonvulsant) 500 mg, famotidine (acid reducer) 20 mg, levetiracetam (anticonvulsant) 500 mg and ferrous sulfate (supplement) 325 mg. R4's August MAR shows that she receives the following medications at 9:00 PM: mirtazapine (antidepressant) 7.5 mg and olanzapine (antipsychotic) 15 mg. On 8/13/24 at 9:45 AM, R4 said that V3 came to her room awhile back to give her her evening pills. R4 said that she only had 4 pills in the cup and she usually takes 9 pills at bedtime. R4 said she told V3 that she takes more pills than that and she left the room with the pills and then another nurse brought her the correct amount of pills. R4 said that again last Friday, V3 brought her evening pills in and there was only 8 pills in the cup. R4 said that she showed V3 the list of medications that she takes and she said that she must have forgotten the mirtazapine and went and got her another pill. R4 said that she has told the manager that she does not feel comfortable with V3 giving her her pills any longer. 3. R8's MDS dated [DATE] shows that her cognition is intact. R8's August MAR shows that she takes quetiapine (antipsychotic) 25 mg-2 tablets at bedtime for agitation/restlessness and melatonin (supplement) 3 mg- 3 tablets at bedtime. On 8/13/24 at 10:26 AM, R8 said that one evening she was out in the common area when V3 came up to her and gave her one pill in a cup. R8 said that she gave the cup back and told her that it did not look like any of the pills that she takes and she takes more than one pill. R8 said that she then brought me the pills I usually take. R8 said that she has no idea what pill she was about to give her but it was not her pill. R8 said that she does not trust that V3 is giving the right pills. R8 said that she knows her pills so she can tell the nurse when they are wrong but she is really concerned about the residents who can not speak for themselves. 4. R7's July Physician's Order Sheet shows an order entered by V3 for: Haldol (antipsychotic) 5 mg po (by mouth) or IM (intramuscular) PRN (as needed) Q6 hours (every 6 hours) for aggitation (sp) To the left of the order in large writing and underlined twice was Haldol Lactate and signed by V4 (Physician) on 7/9/24. On 8/13/24 at 12:43 PM, V4 said that he gave V3 a telephone order for Haldol lactate for a resident and she transcribed it wrong. V4 stated, I was mad. V3's Supervisor Report of Counsel Form dated 7/11/24 shows, On or around 7/11/24 [V3] was found to have administered medication inappropriately. [V3] was advised to ask for help or additional training to prevent this from occurring and failed to do so. V3's Personnel File did not contain any Nurse Competency Checklists. On 8/13/24 at 11:16 AM, V3 said that she started working at the facility in July. V3 said that during one of her medication passes with R4, she had missed a page of medications but it was corrected and the resident received all her ordered medications. V3 said that since then, she brings all of R4's medications into her so she can review them before taking them in pudding. V3 said that the other night while R4 was reviewing her medications, she was short one pill. V3 said that she went back and got the missing pill for R4. V3 said, When its late, your tired and trying to get things done, it can happen so now I have her verify that I am giving the right medications. V3 said that she is unaware of any medication issues with R3 or R8. At 12:11 PM, V3 said that she did transcribe R7's orders for his Haldol wrong but she already apologized to the doctor. At 2:55 PM, this surveyor showed V3 a Nurse Competency Checklist that was provided by the facility and she said that she has never seen the checklist before and has never had any competency evaluations that she is aware of. On 8/13/24 at 11:55 AM, V2 (Previous Director of Nursing) said that they have had a few issues with V3. V2 said that a good nurse requires good thinking skills and assessment skills and she feels that V3 lacks those skills. V2 said that she has concerns with V3's thoroughness and her competency to provide care. On 8/13/24 at 2:07 PM, V7 (Director of Nursing) said that all nurses should go through an orientation with another nurse for a few days and the nurse should fill out a competency form to ensure the nurse is competent to work with the residents. The facility Resident Council Minutes for July shows, Nurse [V3] needs a little improvement. The facility's undated Job Summary for a Registered Nurse shows, Executes procedures consistent with interdisciplinary nursing care plans, the regulatory manual .consistently demonstrates proficiency in skills applicable to nursing Provides for the safety and security needs of assigned residents . The facility said that they do not have a policy on nurse competencies.

Based on observation, interview, and record review, the facility failed to have a Director of Nursing on a full-time basis. This has the potential to affect all 60 residents who reside in the facility. Findings include: On 6/8/24 at 2:52 PM, V1 (Administrator) submitted a resident roster and facility data sheet that showed 60 residents were in the facility. On 6/8/24 at 10:49 AM, surveyor asked V5 (RN-Registered Nurse) that if she can let the DON (Director of Nursing) know that surveyor is in the building. V5 stated, We don't have a DON. It's been some time now. The administrator is on her way. We used to have an ADON (Assistant Director of Nursing), but she is no longer with us. Someone from corporate is helping us. On 6/8/24 at 11:08 AM, V6 (LPN-Licensed Practical Nurse) stated, We don't have a DON here. But we have a regional lady and we have someone from our sister facility that is helping us. On 6/11/24 at 9:15 AM, V1 stated, (V13--Former DON--Director of Nursing) resigned on 3/29/24. Then (V14--2nd Former DON) took over on 3/30/24. (V14) then worked for a couple of weeks. Then we had both (V3--Regional Director of Clinical) and (V2--Acting DON) cover as DON. (V3) covers for 3 days and (V2) covers for 2 days. (V2) also covers as DON at our sister facility for 3 days. (V3) was not here last week because she has something personal going on and had appointments. (V2) was here last Tuesday but was not here Wednesday to Friday because she was sick. On 6/11/24 at 9:20 AM, V3 (Regional Director of Clinical) stated, I was just diagnosed with [medical condition] during the facility's annual survey (5/28-5/31). I try to come here 3 times a week, but I have other homes that I'm responsible for. (V2) who works in our sister facility also helps out 2 days a week here. There are times when I couldn't come here because I had doctor appointments. I've been assisting, but mainly (V2) is the one doing the job as DON. Surveyor asked V3 if the facility was meeting the federal regulations of having a full time DON. V3 stated, Honestly, not at 100%. We don't have someone here full time to do the duties of a DON the whole time. We are hiring a DON and ADON (Assistant Director of Nursing). I believe they will take the position today. On 6/11/24 at 9:47 AM, V2 (Acting DON) stated, I'm the full time DON at our sister facility. (V3) told me I have to work 20 hours here as well. I started here approximately May 15, 2024. Intermittently, I would go to both places. When I came here, we didn't have a structured clinical meeting on what my job duties were to be. They told me to focus on infection control. On 6/11/24 at 11:55 AM, telephone interview was done with V12 (Health Department Communicable Disease Supervisor). V12 stated, (V2) is the DON for two sister facilities. This shouldn't be happening. She shouldn't be dividing her time. She has to focus on infection control and the outbreaks at this facility. On 6/11/24 at 12:12 PM, V2 (Acting DON) stated, When I do my required 2 days a week here, I work 10 hours a day. This morning, I stopped the by the sister facility for a few hours and now I'm here. I don't have a ADON (Assitant Director of Nursing) here to help me. I know some changes had to happen when I walked in the door. I knew it was going to be challenging. It's unfortunate that we got all the tags that happened during our annual. Facility's job description of Director of Nursing (Unknown Date) shows the following: Job Summary: To plan, organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. 7. Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. 8. Make daily rounds of the nursing service departments to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. 9. Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's needs. 10. Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled.

Based observation, interview, record review, the facility failed to provide structured activities to residents. This applies to 7 of 8 residents (R4, R5, R6, R7, R8, R9, R10) reviewed for activities. The findings include: On Saturday 6/8/24 at random times, residents were in the day room or in their rooms without any activities. The following observations were made: 1. On Saturday 6/8/24 at 11:29 AM, R4 stated, There are no activities on the weekend. I would like some. I know they are working on it. Activities are only between Monday through Friday. I have nothing to do. R4's face sheet shows he was admitted [DATE]. R4's face sheet shows diagnoses of anoxic brain damage and depression. R4's MDS (Minimum Data Set) dated 4/4/24 shows a BIMS (Brief Interview for Mental Status) score of 13, which means he is cognitively intact. 2. On 6/8/24 at 11:31 AM, R5 stated, I would like some activities on the weekend. We have not had activities during the weekend in a long time. They don't offer anything. R5's face sheet shows he was admitted to the facility on [DATE]. R5's face shows a diagnosis of depression. R5's MDS dated [DATE] shows a BIMS score of 15, which means he is cognitively intact. 3. On 6/8/24 at 11:36 AM, R6 stated, They don't really provide activities on the weekend. I would like to do some stuff. R6 face sheet shows he was admitted on [DATE]. R6's face sheet shows diagnoses of paranoid schizophrenia and bipolar disorder. R6's MDS dated [DATE] shows a BIMS score of 11, which means he is moderately impaired in cognition. 4. On 6/8/24 at 11:38 AM, R7 stated, Sometimes there is activities and sometimes not. I have not seen them in a long time, especially on the weekends. I would like to play Bingo and cards. R7's face sheet shows he was admitted on [DATE]. R7's face sheet shows diagnoses of unspecified psychosis not due to a substance or know physiological condition, major depressive disorder, vascular dementia, unspecified severity, with anxiety, depressive and anxiety disorders. Facility did not provide a MDS. 5. On 6/8/24 at 11:41 AM, R8 stated, There are really no activities here on the weekend. I wish there were some. When there's nothing to do, it's boring, man. R8's face sheet shows he was admitted on [DATE]. R8's face sheet shows diagnoses of schizophrenia and bipolar disorder. R8's MDS dated [DATE] shows a BIMS score of 14 which means she is cognitively intact. 6. On 6/8/24 at 1:10 PM, R9 and R10 were lying in bed in their room. Both of them stated that they never have activities on the weekend. They said, It's boring! R9's face sheet shows he was admitted to the facility on [DATE]. R9's face sheet shows diagnoses of major depressive disorder, severe with psychotic features, anxiety disorder, and schizoaffective disorder. R9's MDS dated [DATE] shows a BIMS score of 12, which means moderate impairment in cognition. R10's face sheet shows an admitted [DATE]. R10's face sheet shows a diagnosis of personal history of traumatic brain injury. R10's MDS dated [DATE] shows a BIMS score of 12, which means moderate impairment in cognition. On 6/8/24 at 11:33 AM, V9 (CNA--Certified Nursing Assistant) stated, I don't know what happened this time. Usually there's activities. On 6/8/24 at 1:05 PM, V1 (Administrator) stated, I will talk to the activity director. We are in the process of revising our activity schedules. Activities should be provided 7 days a week for the residents. On the weekends, if the activity aides are not working, then they should leave the activities like games, puzzles, and/or sheets on the table in the dining room for the residents. It's the MOD (Manager on Duty) and nurse's jobs to administer those activities during the weekend. On 6/11/24 at 12:40 PM, V11 (Activity Aide) stated, There's supposed to be someone on the weekends to do the activities. If the activity aides are not working on the weekend, someone is supposed to leave the activity on the table for the resident. That ain't good if no one didn't leave anything for the residents on Saturday. They will get bored. They always need something to do. Facility was unable to provide a policy on activities for residents.

Based on observation, interview and record review, the facility failed to follow physician's orders for psychotropic medication administration (R36). The facility failed to follow its psychotropic medication policy by failing to monitor residents (R1, R14, R36) for Extrapyramidal Symptoms due to antipsychotic medication use and failing to attempt/request a Gradual Dose Reduction of a Benzodiazepine medication for a resident (R14) no longer exhibiting anxiety behaviors. These failures resulted in the R36 receiving the wrong psychotropic medications and at excessive dosages. R36 experienced side effects of increased abnormal involuntary movements. This applies to 3 of 5 residents (R1, R14, and R36) reviewed for psychotropics in a sample of 19. The findings include: 1. R36's Medical Record (MR) showed R36 was receiving psychiatric care for major depression, anxiety, and insomnia. R36's MDS (Minimum Data Sheet) dated 5/02/2024 showed R36 was cognitively impaired and did not show any mood symptoms such as feeling depressed. On 5/28/2024 at 10:26 AM, R36 was sitting in her wheelchair in the dining room. R36 was observed displaying abnormal truck, facial, and oral movements such as rocking, lip-smacking, puckering, and her tongue moving in and out of her mouth repeatedly. On 5/30/2024 at 8:01 AM, V3 (Registered Nurse/RN) said R36 was receiving psychotropic medications including antipsychotics. V3 said R36 was no longer exhibiting mood behaviors such as depression or anxiety. V3 said he did not believe R36 was having any side effects related to her psychotropics such as abnormal involuntary movements. R36's care plan reviewed on 5/30/2024 showed psychotropic medication (med) use related to behaviors of depression and agitation. The care plan had multiple interventions including Administer anti-psychotic medication as ordered-See POS (Physician's order Sheets) for current med, dose and schedule. Observe for antipsychotic side effects: .parkinsonism .tardive dyskinesia .extrapyramidal reactions, dystonia . Refer to psychiatrist or neuro-psychologist for effective and safe behavior and med management. Assess/record/report drug related Tardive Dyskinesia symptoms. Perform AIMS (Abnormal Involuntary Movement Scale) assessment at least q (every) 6 months. Review quarterly w (with)/plan of care and prn (as needed) change in antipsychotic medication and changes in condition. Report changes in AIMS reported values to MD (Medical Doctor) for consideration and follow up. R36's Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] showed a score of 0, for displaying any abnormal involuntary movements including facial, oral, and trunk movements. R36's pharmacy consultation report dated 4/23/2024 said there was a ***TIME SENSITIVE RECOMMENDATION: PRESCRIBER RESPONSE AND FACILITY ACTION REQUIRED BY 11:59 PM ON APRIL 24 2024 . The report said R36's MR was reviewed and multiple irregularities with her psychotropic medications were identified, **Per [V14's (Psychiatric Nurse Practitioner/NP)] progress notes from 2/19/24, Abilify was decreased twice from 20 mg to 5 mg at bedtime daily. Currently, the order is still for 20 mg***Per [V14's] progress notes from 12/23/23 Seroquel (Quetiapine) (Antipsychotic) was replaced with Trazodone (Antidepressant), however, there is an active order for Quetiapine 25 mg at bedtime and NO order for Trazodone. The report showed a notation that nursing staffing was made aware and per the nurse clarification from psychiatric NP would be obtained, but the report did not show acknowledgment or response to the recommendation. R36's POS (Physician Order Sheets) showed an order dated 5/02/2024 Decrease Aripiprazole (Atyplical Antipsychotic) to 10 mg PO (by mouth) daily QHS (every eveing) x 1 week and then decrease to 5 mg PO QHS x 1 week and then DC (discontinue) and an order dated 5/30/2024 (ordered during the survey) D/C Seroquel 25 mg at bedtime. R36's MAR (Medication Administration Record) from 5/01/2024-5/31/2024 showed R36 received Aripiprazole (Abilify) antipsychotic 20 mg (milligrams) at bedtime on 5/01/2024 through 5/13/2024, and additionally received 10 mg at bedtime on 5/02/2024 through 5/08/2024 and then continued to receive an additional dose of 5mg at bedtime on 5/09/2024 through 5/15/2024. The MAR showed R36 received Quetiapine (Seroquel) antipsychotic 25 mg at bedtime on 5/01/2024 through 5/29/2024. The MAR did not show any order for Trazodone. R36's psychiatric consultation report dated 2/19/2024 showed R36 was receiving ongoing psychiatric care services for behavior and mood management. The report said V14 (NP) had made psychotropic medication adjustments in 2022, During my prior visit with her on 9/5/2022, I replaced her Seroquel with Trazodone as she only uses Seroquel for sleep .I saw her again on 10/24/2022, I decreased her Aripiprazole from 20 mg to 10 mg QHS due to increased lethargy, sedation, falls, hand shaking and trunk rocking. During my prior visit with her on 11/16/2022, I Decreased her Aripiprazole from 10 mg to 5 mg QHS due to increased lethargy, sedation, falls, hand shaking and trunk rocking. The report continued to show R36 was to continue to receive Aripiprazole 5 mg at bedtime for major depression and anxiety, and Trazodone 50 mg at bedtime for insomnia. The facility was unable to provide R36's last psychiatric consultation report from 5/02/2024. On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was managing R36's psychiatric behaviors and psychotropic medications. V14 said he expected staff to appropriately monitor residents and report psychotropic medication side effects to safely manage their psychiatric therapy. V14 continued to say he expected his orders to be followed, his consultation reports to be reviewed, and recommendations followed. V14 said he had ordered R36's Aripiprazole be tapered and discontinued because he noted R36 was displaying side effects including ESP (extrapyramidal symptoms), and her Seroquel be switched to Trazodone in 2022. V14 said R36 should have never been back on Aripiprazole. V14 said on his last visit on 5/02/2024 he was notified of R36's medication discrepancy for Aripiprazole, and he again ordered the medication to be safely tapered and discontinued. V14 said he was not notified of the medication discrepancy for Seroquel and Trazadone. V14 said he expected to be notified of medication discrepancies in a timely manner to prevent additional side effect complications. V14 said during his visit on 5/02/2024 he did not observe R36 displaying abnormal involuntary facial or oral movements such as lip smacking or repetitive tongue movements. V14 continued to say he was never notified of R36's new abnormal involuntary facial and oral movements nor R36's new medication error. V14 said he was never notified his order from 5/02/2024 was not carried out correctly which resulted in R36 receiving increased doses of Aripiprazole and an inappropriate tapering of the medication. The facility policy titled Reduction of Psychotropic Medications Protocol with the reviewed date of 8/22/2018 showed Policy: Residents who must receive medications are to be maintained at the safest, lowest dosage necessary to control the resident's condition .Procedure . 5. Each resident taking psychotropic medications shall have their psychotropic medications reviewed and documented as such by the physician. The consulting Registered Pharmacist will review psychotropic medications on a monthly basis. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. Reduction shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such. 6. These medications shall be used when deemed necessary by each resident attending physician and/or psychiatric consultant. Each resident will be maintained on as low dosage of these medications as possible. Dosage reductions may be attempted whenever the resident's behavior patterns indicate to the attending physician that a dosage reduction may be appropriate. 7. Nursing personnel will report any side effects observed to the appropriate charge nurse. Any side effects shall be charted in the resident's clinical record and the physician shall be notified .11. Individual resident response and/or progress will be documented at least monthly by a Licensed nurse in the clinical record. The facility policy titled Psychotropic Medication Policy with a revised date of 11/28/1017 showed Policy: It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drugs is any drug used: 1. In an excessive dosage, including in duplicative therapy 2. For excessive duration 3. Without adequate monitoring .5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. That these medications be withheld if the resident is lethargic and/or exhibiting any sign of over sedation and the physician will be contacted if these conditions persist .Procedure .9. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team .12. The consultant Pharmacist will request medication reductions as decided on a monthly basis. Recommendations will be printed and sent to the physician in a timely manner. 13. Licensed Nurses will transcribe any new recommendations from the Physician as received to the facility .16. The nurse will monitor for side effects such as drooling, shuffling gait, joint rigidity, mask like face, akathisia, significant weight changes, increased lethargy, decreased appetite, decrease in ADLs, decreased cognition, tardive dyskinesia and document by exception. 17. Any resident receiving psychotropic medications will have an AIMS assessment done at a minimum of every six (6) months .20. Quarterly documentation will be done on a progress note of any resident that currently receives psychotropic medications. This is to include, but is not limited to, individual resident response and/or progress, psychotropic medication assessment, behaviors exhibited, problems or issues which the resident may be having, current medications, recent medication changes, and tolerance of medication regimen . 2. R1's MR showed R1 was receiving psychiatric care for schizoaffective disorder, bipolar disorder, depression, and psychosis. R1's MDS dated [DATE] showed R1 was cognitively impaired. On 5/28/2024 at 10:03 AM, R1 was in bed. R1 was unable to engage in the interview, his speech was incohesive and disorganized. R1 was making inappropriate sexual gestures. R1 was observed displaying abnormal oral movements such as lip smacking with his mouth opening with his tongue moving in and out of his mouth repeatedly. On 5/30/2024 at 08:01 AM, V3 (RN) said R1's behaviors were screaming and making inappropriate sexual comments. V3 said R1 was receiving psychotropic medications including an antipsychotic. V3 said he did not believe R1 was having any side effects related to his psychotropics and R1's abnormal movement were not new. R1's Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] showed a score of 1 for facial muscle expression not including abnormal movements of the lips, perioral area, jaw, or tongue. R1's care plan reviewed on 5/30/2034 showed psychotropic medication use related to behaviors of aggression, physically abusive, uncontrollable screaming, and auditory hallucinations. The care plan had multiple interventions including Assess/record report drug related Tardive Dyskinesia symptoms. Perform AIMS assessment at least q 6 mo. Review quarterly w/plan to care and prn with changes in antipsychotic medication and changes in condition. Report changes in AIMs reported values to MD for consideration and follow up .Observe for antipsychotic side effects: .parkinsonism .extrapyramidal reactions .Notify MD of noted side effects to determine if benefits of therapy outweigh side effects R1's psychiatric consultation report dated 5/22/2024 showed R1 was receiving ongoing psychiatric care services. The report showed R1 was receiving medication treatment for EPS (extrapyramidal symptoms). On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was managing R1's psychiatric behaviors and for his ongoing EPS side effects. V14 said he expected staff to appropriately monitor residents and report psychotropic medication side effects to safely manage their psychiatric therapy. 3. R14's MR showed R14 was receiving psychiatric care for anxiety and adjustment disorder with depressed mood. R14's MDS dated [DATE] showed R14 was cognitively impaired. On 5/29/2024 at 10:00 AM and 5/30/2024 at 11:42 AM, R14 was observed in bed sleeping. R14 was unable to engage in the interview, R14 appeared fatigued and confused. On 5/29/2024 at 1:10 PM, V13 (Activity Aide) said she was familiar with R14, and R14 was always slepping a lot throughout the day. On 5/30/2024 at 8:01 AM, V3 (RN) said R14's behaviors were resisting care and refusing to get out of bed. V3 said R14 was receiving psychotropic medications including an anxiolytic. V3 also said R14 slept a lot throughout the day. R14's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of sadness, agitation, irritability, and refusing care. The care plan's goal was Will respond cooperatively to behavior interventions resulting in maintenance on lowest therapeutic dose of medication and had multiple interventions including Administer anti-anxiety medication as ordered .Observe for antianxiety side effects: drowsiness, sedation, somnolence, difficulty speaking, impaired coordination, memory impairment, fatigue, depression, confusion . R14's pharmacy consultation report dated 2/21/2024 said R14 had been receiving Lorazepam/Ativan (Benzodiazepine) 0.5 mg (milligrams) twice daily since 7/06/2022. The report showed a recommendation to attempt a gradual dose reduction (GDR). The report did not show acknowledgment or response to the recommendation. R14's psychiatric consultation report dated 2/19/2024 showed R14 was receiving ongoing psychiatric care services for mood behavior. The report showed R14's Mirtazapine (antidepressant) was discontinued on 11/16/2022 due to sedation and drowsiness, especially during the day. The report continued to show R14 was to continue with Ativan for anxiety and Lexapro for depression. On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was managing R14's psychotropic medications and behaviors. V14 said he could not remember if he received R14's pharmacy recommendation, but felt a GDR was not recommended because R14 had cycled episodes of being anxious and did not want to take the risk. V14 continued to say he had discontinued R14's Mirtazapine because he was sleepy in the past and R14's Ativan could be causing him to be sleepy currently. V14 said R14's sleepiness throughout the day was a concern.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to 53 residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Longterm-Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 56 residents. On [DATE] at 10:14 AM, V2 (DON-Director of Nursing) stated, there are three NPO (Nothing by Mouth) residents that do not eat from the facility kitchen. On [DATE] starting at 9:35 AM, the facility kitchen was toured in the presence of V6 (Dietary Manager) and the following was found: 1. Macaroni Elbow pasta, 10 lbs opened bag - no date when it was received, no expiration date. 2. Spaghetti noodles pasta, 10 lbs opened bag - no date when it was received, no expiration date. 3. Macaroni Bow pasta, 10 lbs opened bag - no date when it was received, no expiration date. 4. Half loaf of bread and a bag of 4 buns - no date when it was received, no expiration date. 5. Can of [NAME] tomato soup, 50 oz, Expired on ,d+[DATE]. 6. [NAME] Cranberry Juice 33.8 Fl oz - 3 cans - no date when it was received, no expiration date. 7. Orange Juice 33.8 Fl oz - 4 tetra packs - no date when it was received, no expiration date. 8. Clear bag of steak 15 pieces - opened bag - no date when it was received, no expiration date. 9. Clear bag of sausage patties - opened bag - no date when it was received, no expiration date. 10. Clear bag of Breaded fish patties - opened bag - no date when it was received, no expiration date. 11. Unopened Can of Ministrone condensed soup - 4 lbs - no date when it was received, no expiration date. 12. Bread dough for 3 loves in clear plastic in freezer #2 - opened bag - no date when it was received, no expiration date. On [DATE] at 11:00 AM, V6 (Dietary Manager) said all expired items should be discarded, so they are not accidentally given to the residents with the potential to make the residents sick. On [DATE] at 11:30 PM, V7 (Dietician) stated, If expired food is served to residents, they could get sick or get food poisoning The facility's policy for Food titled, Storage (Dry, Refrigerated and Frozen) last revised on ,d+[DATE] showed, Procedure: 1. All items will be dated upon receipt. Individual cans or bags shall each be dated . The facility's policy for Food titled, Refrigerator and Freezer Storage last revised on ,d+[DATE] showed, 2. [NAME] container with name of item. [NAME] the date that the original container is opened or date of preparation .

Based on observation, interview and record review, the facility failed to ensure medications were available for administration to residents with physician's orders. This applies to 5 out 5 (R5, R13, R23, R30 and R48) reviewed for medication administration. The findings include: 1. On 5/29/2024 at 8:05 AM, during medication pass, V5 (RN-Registered Nurse) said there was no available Ascorbic Acid (supplement) 500 MG (Milligrams) so she could not administer it to R13. V5 said Ascorbic Acid 250 mg and Ascorbic Acid 500 mg were both not available in her medication cart. V5 said there was also no Ascorbic Acid in the medication room and in the small closet they keep the extra house stock in. She said Ascorbic Acid medications were not available since Monday, May 27, 2024. V5 went into the closet where house stocks are stored but did not find any Ascorbic Acid. Review of R13's POS (Physician Order Sheet) showed an order for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. 2. On 5/29/2024 at 8:20 AM, during medication pass, V5 was observed administering a total of six medications to R30 that did not include Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. Review of R30's May POS showed an order for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. Review of MAR (Medication Administration Record) of the facility's back nursing station showed R5, R23 and R48 had orders for Ascorbic Acid. May 2024 MAR for R48 showed Ascorbic Acid 500 mg, 1 tablet was signed NA (Not Available) from 5/27/2024 to 5/29/2024. On 5/29/2024 at 10:38 AM, V2 (Acting DON - Director of Nursing) said V5 did not try to look for Ascorbic Acid. She said V5 did not inform her that she did not have Ascorbic Acid to administer since May 27, 2024. V2 said she expects the nurses to look in the medication room, the little closet space where house stocks are kept and in the DON office. V2 said she also expects nurses to inform her immediately if house stocks are depleted so she can order some more. On 5/30/2024 at 11:37 AM, V5 (RN) said if house stocks are not available, she informs a staff member who used to order house stocks. V5 said she informed V8 (ADON-Assistant Director of Nursing) that she did not have Ascorbic Acid to administer on May 27, 2024. She said she had no Ascorbic Acid to administer on May 27, 2024, to May 29,2024 to residents who needed it. She said she might have signed the MAR in mistake that it was given to some residents with order for Ascorbic Acid. On 5/30/2024 at 11:40 AM, V8 said V1 (Administrator) is responsible for ordering house stocks since she started to work in the facility on March 1. 2024. V8 said she does not work on Mondays so V5 did not inform her on the missing medication on Monday, May 27, 2024. She said she expects the nurses to inform her or V2 if house stocks are missing so they can let V1 know to order some more. Facility's Policy on Procurement and Storage of Medication dated 10/06 and revised on 11/6/18 does not address procurement of house stocks.

Based on observation, interview, and record review the facility failed to follow its policy on behavior monitoring for residents with known behaviors and receiving psychotropic medications. This applies to 5 of 5 residents (R1, R8, R14, R36, and R39) reviewed for behaviors in a sample of 19. Findings include: 1. R1's Medical Record (MR) showed multiple diagnoses including schizoaffective disorder, bipolar disorder, depression, and psychosis. R1's MDS (Minimum Data Sheet) dated 3/13/2024 showed R1 was cognitively impaired and did not show any behaviors such as screaming or public sexual acts. On 5/28/2024 at 10:03 AM, R1 was in bed. R1 was unable to engage in the interview, his speech was incohesive and disorganized. R1 was making inappropriate sexual gestures. On 5/29/2024 at 8:09 AM, R1 was in bed again making inappropriate sexual gestures. R1's care plan reviewed on 5/30/2034 showed psychotropic medication use related to behaviors of aggression, physically abusive, uncontrollable screaming, and auditory hallucinations. The care plan had multiple interventions including Perform Behavior Management Program and behavior monitoring tracking. Monitor behaviors and document on behavior flowsheet. On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said R1's behaviors were screaming, making inappropriate sexual comments, and hallucinations. V3 said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. 2. R8's MR showed multiple diagnoses including bipolar disorder, schizophrenia, dementia, psychosis, and anxiety. R8's MDS dated [DATE] showed R8 was cognitively intact and was showing psychotic behaviors such as hallucinations. R8's care plan reviewed on 5/30/3034 showed psychotropic medication use related to behaviors of paranoia, auditory hallucinations, refusing care, and getting out of bed. The care plan had multiple interventions including Perform Behavior Management Program and behavior monitoring tracking. Monitor behaviors and document on behavior flowsheet. On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R8 had behaviors related to her visual and auditory hallucinations. 3. R39's MR showed multiple diagnoses including autism, developmental delay, and anxiety. R39's MDS dated [DATE] showed R39 was cognitively impaired and did not show any behaviors such as screaming. R39's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of anxiety, yelling, hitting hard objects, temper tantrums, and crying. The care plan had multiple interventions including Administer antidepressant medication as ordered by physician. Monitor/document side effects and effectiveness q-shift. On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R39's behavior was yelling frequently. 4. R14's MR showed multiple diagnoses including anxiety and adjustment disorder with depressed mood. R14's MDS dated [DATE] showed R14 was cognitively impaired and was having recurrent behavior of rejecting care. R14's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of sadness, agitation, irritability, and refusing care. The care plan had multiple interventions including Administer psychotropic medication as ordered by physician. Monitor for side effects/effectiveness. On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R14's behaviors were resisting care and refusing to get out of bed. 5. R36's MR showed multiple diagnoses including major depression, anxiety, and insomnia. R36's MDS dated [DATE] showed R36 was cognitively impaired and did not show any mood symptoms such as feeling depressed. R36's care plan reviewed on 5/30/2024 showed psychotropic medication use related to behaviors of depression and agitation. The care plan had multiple interventions including refer to psychiatrist or neuro-psychologist for effective and safe behavior and med management. On 5/29/2024 at 3:56 PM, V2 (Director of Nursing/DON) said social services provides behavioral tracking sheets to the nurses. V2 said she expects nurses to assess and document resident behaviors for those receiving psychotropic medications or exhibiting behaviors daily in their behavioral tracking sheets. On 5/30/2024 at 8:01 AM, V3 (Register Nurse/RN) said the facility's social worker sometimes provided behavior-tracking documentation sheets, but he was not documenting behaviors for any of his assigned residents. V3 continued to say R36 was no longer exhibiting mood behaviors such as depression or anxiety. On 5/30/2024 at 9:43 AM, V14 (Psychiatric Nurse Practitioner/NP) said he was treating R1, R8, R14, R36, and R39 for psychiatric behavioral care services. V14 said he depends on facility staff to monitor and report resident behaviors to assist in managing their psychiatric services. The facility's policy titled Reduction of Psychotropic Medications Protocol with the reviewed date of 8/22/2018 showed Policy: Residents who must receive psychotropic medications are to be maintained at the safest, lowest dosage necessary to control the resident's condition .Procedure: .2. The Behavioral Tracking sheet of the facility will be implemented at this time to ensure behaviors are being monitored.

Based on the interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotic therapy prescribed to residents. This applies to 5 of 5 residents (R10, R12, R22, R50, and R206) reviewed for antibiotics therapy in sample of 19. The findings include: 1.R10 (Physician Order Sheet) showed Bactrim DS (antibiotic) 800-160 milligrams daily in the evening by mouth for ten days. No reason for antibiotic therapy (ABT) was entered either in the Physician Order sheet or in the medication administration log. R10 did not have a McGeer's criteria form in the infection control binder or his medical record for April . Further, the infection control and antimicrobial log did not have the reason for the medication administration. 2. R12's Physician Order Sheet dated 4/20/2024 showed Bacitracin (antibiotic) 2 percent ointment to apply to Gastrostomy tube redness and drainage two times daily until healed. The sheet dated 04/29/2024 showed Keflex 500 milligram four times tablet by mouth for ten days left lower extremity cellulitis. The April monthly infection log showed that R12 did not have a McGeer's criteria form in the infection control binder or his medical record. Further, the onset date for bacitracin in the log did not match the date on the physician's order sheet. 3. R22's Physician Order Sheet dated 05/02/2024 showed Erythromycin (antibiotic) ophthalmic (eye) ointment to apply to the right eye three times a day for five days for blepharitis (infection of the eyelid) and Doxycycline (antibiotic) 100 milligram capsule two times by mouth for seven days. The May 2024 antibiotic Stewardship log shows a start date of 05/02/2024 and an end date of 05/07/2024 for Erythromycin and no start or end date for Doxycycline. R22 did not have a' McGeer's criteria form in the infection control binder or medical records. 4. R50's Physician Order Sheet dated 05/06/2024 showed Cefadroxil (antibiotic)500 milligram tablet two times a day by mouth for seven days for left foot cellulitis. The May 2024 antibiotic Stewardship log shows a start date of 05/06/2024 and an end date of 05/13/2024. R50 did not have a McGeer' sMcGeer's criteria form in the infection control binder or his medical records. 5. R206's Physician Order Sheet showed Augmentin (antibiotic) 250 milligrams by mouth for seven days for an ear infection. The May 2024 antibiotic Stewardship log did not have R206's name or a McGeer's criteria form in the infection control binder or medical records. On 05/30/2024 at 10:30 AM, V2 (Director of Nursing/Infection Preventionist) stated that she is at the facility for a few weeks only and that the facility should follow McGeer's criteria to ensure residents are not getting antibiotics unnecessarily. Labs are to be done before administering medications, with some exceptions, and she was not sure why it was not done. At 11:30 AM, V16 (Physician) said he didn't follow McGeer's criteria and did not want to discuss them further. At 11:46 AM, V3 (Registered Nurse) said when the nurses observe any signs of infection in residents, they call the physician and follow the orders, if any. V3 said he had never heard of McGeer's criteria. The facility's policy, Infection Control Surveillance and Monitoring, revised date 04/11/2022, stated, Update infection control log on a daily basis to analyze data and identify trends. The facility could not provide an Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines.

Based on observation, interview, and record review, the facility failed to wear appropriate Personal Protective Equipment in enhanced barrier precaution rooms. The facility failed to provide proper catheter care and perform hand hygiene during gastrostomy tube care. This applies to 4 of 4 residents (R11, R30, R47, R50) reviewed for infection control in sample of 19. The findings include: 1. On 5/28/24 at 10:41 AM, during initial tour, surveyor went to R47's room. R47 had a G-Tube (Gastrostomy Tube) running and as per the floor nurse V3 (RN-Registered Nurse), R41 also has a pressure sore to his right heel. There was no sign on R47's door about enhanced barrier precautions. On 5/29/24 at 12:20 PM, there were signs posted on R47's door. One sign said, Stop and See Nurse. The other sign showed, Stop! Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing linens, Providing hygiene, Changing briefs for assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. On 5/29/24 at 12:25 PM, V3 (RN) stated, I don't know why those signs are there. (R47) is not on isolation. I don't know what enhanced barrier precautions are. Please ask the ADON (Assistant Director of Nursing. V3 put on gloves and entered R47's room without wearing a gown. V3 removed R47's dressing on his right foot. V4 (Wound Doctor) put on gloves and came inside without wearing a gown. V4 measured (R47's) pressure sore wound on his foot. V3 then completed the dressing change on R47's foot as per the physician's orders. R47's face sheet shows a diagnosis of gastrostomy status. R47's POS (Physician Order Sheet) has no orders for enhanced barrier precautions. R47's care plans show he has a gtube and stage 3 pressure ulcer to his right heel. R41 does not have a care plan for enhanced barrier precautions. V4's (Wound Doctor) note dated 5/22/24 shows that R47 has a stage 3 pressure wound to the right heel. Primary dressing: Alginate rope with silver. Apply once daily for 23 days. Secondary dressing: Foam silicone border. Apply once daily for 23 days. 2. On 5/28/24 at 10:14 AM, R50 stated he had a pressure sore to his left foot. There was no sign for enhanced barrier precautions on his door. On 5/29/24 at 12:30 PM, there was still no enhanced barrier precaution sign on R50's door. On 5/29/24 at 12:37 PM, V3 (RN) applied hand sanitizer to his hands and put on gloves. V3 did not put a gown on. V3 entered R50's room. V3 removed R50's heel boots, socks, and dressing on his left foot. V4 (Wound Doctor) came in wearing gloves, but no gown. He applied pain medicine (Benzocaine Aerosol Spray) and debrided the wound. V3 then applied the treatment which included wound cleanser Idosorb, and Optifoam dressing. Throughout the whole procedure, V3 and V4 did not wear a gown. R50's face sheet shows a diagnosis of pressure ulcer of left heel, stage 3. R50's POS shows no order for enhanced barrier precautions. R50's care plans show R50 has a pressure sore, but there is no care plan for enhanced barrier precautions. V4's wound note dated 5/22/24 shows that he has a stage 4 pressure wound to the left heel. Primary dressing: Iodosorb get apply once daily for 30 days. Secondary dressing: Foam silicone border-apply once daily for 30 days. Facility's policy titled Enhanced Barrier Precautions (7/13/23) shows: Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, infection or colonized with a MDRO (Multi-Drug Resistant Organism). Enhanced Barrier Precautions require the use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for car that occurs within a resident's room, when high-contact resident care activities are bundled together. Procedure: 1. Educate staff on EBP. 3. Review contact precautions to ensure that enhanced barrier precautions are appropriate. 3. Post approved EBP signage that indicates high-contact activities. On 5/29/24 at 1:02 PM, V2 (DON) stated, Enhanced barrier precautions means standard precautions. Any resident that has enhanced barrier precautions means they have an opening on the skin. Those residents are residents with wounds, gtubes and catheters. I started putting up the signs yesterday. I'm working on it. I did some today. It's a project I'm working on. Staff is supposed to wear gown and gloves when they give care to those residents. (V3-RN) should know that. I just in-serviced him on that yesterday and today. (V3) should have known what enhanced barrier precautions when he took the NCLEX-RN (National Council Licensure Exam-Registered Nurse). 46380 3. R30 has a suprapubic catheter for diagnoses of neuromuscular dysfunction of bladder and urinary retention. On May 28, 2024, at 1:44 PM, R30's suprapubic catheter care observed done by V5 (RN-Registered Nurse). V5 performed hand hygiene and applied gloves. V5 said suprapubic catheter care is done every shift. V5 unfastened the incontinent brief. She squeezed NSS (Normal Saline Solution) onto a gauze and proceeded to clean the catheter. V5 observed to be cleaning the catheter towards the base of the catheter more than ten times with the same gauze. There was minimal bleeding noted at the base of the catheter and V5 said R30's skin gets irritated at times but always dries up. Using the same glove, V5 took a gauze from the treatment cart, opened the package, and cut the gauze with scissors. V5 then took gloves off, applied hand sanitizer and applied new gloves. On May 30, 2024, at 11:37 AM, V5 said when cleaning catheters, the motion should be away from the base to prevent urinary tract infections. On May 30, 2024, at 11:40 AM, V8 (ADON-Assistant Director of Nursing) said she expects the nurse to perform suprapubic care every shift. She said the nurse should wipe the catheter clean and should clean away from the base. She said if the catheter is cleaned towards the base, the dirt and germs are being brought back to the site and might cause infections. Facility's Policy on Suprapubic Catheter Care dated 1/2002 and reviewed on 2/2028 and 3/15/2023 does not address how catheter tubing should be cleaned. 39182 4. On 5/28/24 at 2:30 PM, observed V5 (RN-Registered Nurse) change GT (gastrostomy) dressing for R11. V5 (RN) did not wear PPE (Personal Protective Equipment) as required for a resident on EBP (Enhanced Barrier Precaution). V5 wore gloves and removed the soiled dressing. Did not do any hand hygiene before or after removing the soiled dressing. With the same gloves, V5 (RN) took clean gauze and cleaned the site with normal saline. With the same gloves and no hand hygiene, V5 (RN) took a split gauze and placed it around the gastrostomy tube. V5 (RN) did not secure the split gauze with a tape nor label the dressing with date, time and signature of the nurse. With the same used gloves and no hand hygiene, V5 (RN) patted R11 on his arms to reassure him. V5 removed gloves and discarded into the trash bag. Did not wash hands or use hand sanitizer. Replaced all the remaining clean items back in the drawers. Then used hand sanitizer on her hands and wheeled the cart out of the room. On 5/29/24 at 12:11 PM, V2 (DON-Director of Nursing) stated, R11 was on GT feeding and hence on EBP. V2 stated, the nurse should have washed her hands before starting the procedure of GT care. V2 (DON) stated, after cleaning the site, V5 should have washed her hands or done hand sanitization. V2 stated, touching clean items and clean surfaces with soiled gloves is a potential for contamination of the clean items and possible infection. Facility policy on 'Hand Hygiene' updated 8/14/2023 showed, . Indications for Hand-Washing . 2. Before and after direct resident care .Indications for ABHR (Alcohol Based Hand Rub) - When hands are not visibly soiled, . 3. After contact with resident's intact skin, 4. After contact with inanimate objects, 5. After removing gloves. Facility policy on 'Dressing Change' reviewed on 3/16/23 showed, ' . Procedure 7. Set up clean area for supplies. 8. Wash your hands. 9. Put on non-sterile gloves 23. Discard all equipment appropriately. 24. Wash your hands .

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 37 opportunities with 4 medication administration errors resulting in a 10.81% medication error rate. This applies to 3 out of 4 residents (R13, R19 and R30) reviewed for medication administration in the sample of 19. Findings include: 1. On 5/29/2024 at 8:05 AM, V5 (RN-Registered Nurse) was administering medication to R13. V5 administered the following medications: Fish Oil (supplement) 1000 mg (milligrams), 1 capsule; Allopurinol (Uric Acid Inhibitor) 100 mg, 1 tablet; Daily-vite (supplement), 1 tablet; Divalproex (antiepileptic) Na (Sodium) ER (Extended Release) 250 mg, 1 tablet; Divalproex Na ER 500 mg, 2 tablets; Polyethylene Glycol (stool softener) 17 gm (gram); and Metoprolol (Antihypertensive) 25 mg, 1 tablet. V5 said there was no available Ascorbic Acid (supplement) 500 mg so she could not administer it to R13. V5 said Ascorbic Acid 250 mg and Ascorbic Acid 500 mg were both not available in her medication cart. V5 said there was also no Ascorbic Acid in the medication room and in the small closet they keep the extra house stock in. She said Ascorbic Acid medications were not available since Monday, May 27, 2024. V5 went into the closet where house stocks are stored but did not find any Ascorbic Acid. V5 counted and administered a total of seven pills and Polyethylene Glycol dissolved in water. Review of R13's POS (Physician Order Sheet) showed an order for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. 2. On 5/29/2024 at 8:20 AM, V5 was administering medication to R30. V5 administered Vitamin B1 (supplement) 1000 mg , 1 tablet; Vitamin D3 (supplement) 50 mcg (micrograms), 1 tablet; Escitalopram (Antidepressant) 20 mg, 1 tablet; Famotidine (Acid Reducer) 20 mg, 1 tablet; Multivitamin with minerals (supplement), 1 tablet; and Polyethylene Glycol (stool softener) 17 gm. V5 counted the medication in the cup, there were 5 pills in the cup and the Polyethylene Glycol she dissolved in water. V5 gave a total of six medications. Review of R30's May POS showed an order for Calcium 600 mg/Vitamin D3 (supplement) 400 mg, 1 tablet and Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. Both medications were not administered at 8:00 AM as ordered. 3. On 5/29/2024 at 8:30 AM, V5 was administering medication to R19. V5 administered Diltiazem (Calcium Channel Blocker) 30 mg, 1 tablet; Valproic Acid (anticonvulsant) 250 mg, 2 capsules; Losartan (antihypertensive) 25 mg, 1 tablet; Vitamin D3 (supplement) 125 mcg, 1 capsule and Baclofen (muscle relaxant) 10 mg, 1 tablet. V5 counted and administered five medications to R19. Review of R19's POS showed that V5 did not administer Docusate Na (stool softener) 100 mg, 1 capsule due at 8:00 AM as ordered. Facility's Policy on Medication Administration dated 10/07 and revised on 7/3/13/ and 11/18/17 states the following: .Definition .The complete act of administration entails removing an individual dose form a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given.

Based on interview and record review, the facility failed to give residents appropriate written notices that their Medicare Coverage was coming to an end. This applies to 2 of 2 residents (R36, R41) reviewed for Medicare coverage in a sample of 19. The finding include: On 5/28/24 at 9:45 AM, entrance conference was completed with V1 (Administrator). Surveyor gave V1 the form titled Beneficiary Notice-Residents discharged Within the Last Six Months. Surveyor asked V1 to fill out the sheet with the names of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months. On 5/29/24 at 1:00 PM, V1 returned the form back to surveyor with only two resident's names (R36 and R41) on the form. V1 stated that V18 (Business Office Manager) completed the form. On 5/29/24 at 1:46 PM, V18 (Business Office Manager) stated, I started on 4/22/24. I'm new. I don't have a list of residents who were given a NOMNC (Notice of Medicare Non-Coverage) form and SNF-ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) in the last 6 months. I just know of 2 residents (R36 and R41). I told them verbally that they had so many days remaining. I don't remember exactly how many days remaining they had. I was not aware that you need to give something in writing. I don't know what the NOMNC and SNF-ABN forms are. I don't have the names of the residents who had benefit days remaining. On 5/29/24 at 1:52 PM, surveyor submitted two forms titled SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review to V18. V18 filled out both forms for R36 and R41. On both forms, V18 wrote she did not give the NOMNC and SNF-ABN forms to both R36 and R41 because she was not aware of the forms. 1. On 5/29/24 at 2:35 PM, surveyor asked R36 if V18 ever told her that she had this many remaining days with Medicare or was given anything in writing. R36 stated, No! (V18) never told me anything and I never got anything in writing from her. R36's face sheet shows an admitted [DATE]. Payer information shows she has Medicaid Pending and Medicare B. R36's MDS (Minimum Data Set) dated 5/2/24 shows a BIMS (Brief Interview for Mental Status) score of 15 which means she is cognitively intact. Review of R36's medical record shows no NOMNC and SNF-ABN forms. 2. On 5/29/24 at 2:45 PM, surveyor asked R41 if V18 ever told him how many remaining days he had left with Medicare or was given anything in writing. R41 stated, She never told me anything and she never gave me anything in writing. R41's face sheet shows an admitted [DATE]. Payer information shows he is private pay and has Medicare B. R41's MDS (Minimum Data Set) dated 4/30/24 shows a BIMS score of 9, which means he is moderately impaired in cognition. Review of R41's medical record shows no NOMNC and SNF-ABN forms. Facility was unable to provide a policy.

Based on interview and record review, the facility failed to obtain orders and provide physical therapy services to residents. This failure resulted in a resident with a functional decline (R103) having a delay in receiving physical therapy and taking longer to return to his baseline function. This applies to 3 of 3 residents (R101, R102, and R103) reviewed for therapy services in the sample of 9. The findings include: 1. R103's Medical Record showed R103 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, epilepsy, dementia, and nontraumatic subarachnoid hemorrhage. R103's MDS (Minimum Data Set) dated January 28, 2024, showed R103 had moderate cognitive impairment. The MDS continued to show R103 could independently transfer to and from a bed to a chair, toilet transfer, and walk 150 feet. A progress note dated February 26, 2024, at 4:30 AM, by V18 (RN/Registered Nurse) showed, resident awake and alert, verbally responsive. Breathing non labored and with symmetrical chest wall expansion. Observed that resident no longer takes a walk whenever he is awake. Incontinent of bowel and bladder. Tried to get him up and down but resident unable to do task. Conferred with the night CNA (Certified Nursing Assistant) if she noticed the same thing and she reaffirmed nurse observation. Assessment done: temperature 98.3 degrees, blood pressure 144/90, pulse rate 75, respiratory rate 18, oxygen saturation at room air 95% (percent). Facial expression symmetrical, no drooling noted, no numbness, nor muscle weakness, no mental confusion, repaid involuntary eye movement, hand grasp strong and equal, no difficulty speaking nor slurring of speech. Resident with difficulty of mobility, unable to sit upright without assistance. A progress note dated February 29, 2024, at 6:00 PM, by V13 (RN) showed, readmitted a [AGE] year old male from [local hospital] via [ambulance company] up in a wheelchair, extensive assist of two with transfer. On April 22, 2024, at 1:00 PM, V3 (RN/Registered Nurse) said R103 cannot get out of bed and walk. V3 continued to say R103 used to be able to walk independently, but in February, R103 suddenly stopped walking and was sent to the hospital. On April 22, 2024, at 2:58 PM, V13 (RN) said on February 26, 2024, R103 was walking independently and then stopped walking so R103 was sent to the hospital. V13 said she readmitted R103 to the facility on [DATE], and spoke with V11 (Physician). V13 said she did not get an order for physical therapy for R103. V13 continued to say social services will assist in determining if a resident needs physical therapy. V13 said R103 started receiving therapy on March 22, 2024. On April 23, 2024, at 11:09 AM, V12 (Social Services Director) said there was a delay in R103 receiving physical therapy because the facility did not have a therapy company to provide residents with physical therapy. On April 23, 2024, at 9:34 AM, V11 (Physician) said R103 should have been evaluated for therapy when he was readmitted from the hospital on February 29, 2024. V11 said he was not notified of R103's continued functional decline upon readmission to the facility and was not asked about a physical therapy evaluation. V11 continued to say if he would have been notified of R103's continued functional decline, V11 would have ordered a therapy evaluation. V11 said the facility is having issues with funding and the last therapy department left because of funding issues. V11 said R103 should have received therapy sooner and believes R103 did not receive therapy in a timely manner because the facility did not have therapy services. On April 23, 2024, at 10:36 AM, V5 (Rehab Director) said R103's prior function was supervision, and R103 could ambulate. V5 said R103 was evaluated by physical therapy on March 22, 2024, and the therapist did not walk R103 because R103 could only stand for 10 seconds. V5 continued to say it was a concern R103 was not started on therapy right after being readmitted to the facility on [DATE]. V5 said it will take longer for R103 to get back to his functional baseline because there was a delay in therapy. R103's Physical Therapy Evaluation and Plan of Treatment dated March 22, 2024, by V17 (Physical Therapist) showed, Functional Mobility Assessment: Ambulation: Walk 10 feet = Not attempted due to medical conditions or safety concerns. Gait Pattern/Deviations: Did not ambulate on evaluation; unable to stand greater than 10 seconds with moderate/maximal assist. 2. R102's Medical Record showed R102 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, anxiety, and urinary tract infection. R102's MDS dated [DATE], showed R102 was cognitively intact. The MDS continued to show R102 was dependent on facility staff for transfers to and from a bed to a chair, toilet transfers, and bathing. R102's physician order dated December 23, 2024, showed, Occupational Therapy and Physical Therapy evaluation and treatment order. Physical Therapy clarification order five times a week for 12 weeks. On April 23, 2024, at 1:27 PM, R102 said she had been receiving physical therapy in February with V19 (Physical Therapist), but then R102 went a month without physical therapy. R102 said she started receiving physical therapy again about three weeks ago. R102's Physical Therapy Therapist Progress note by V19, dated February 7, 2024, showed, Remaining Functional Deficits/Underlying Impairments: Patient continues to require skilled therapy due to weakness, balance deficit, poor endurance and poor safety which influence ability to perform activities of choice. R102's Physical Therapy Daily Treatment Note by V19, dated February 16, 2024, showed Patient performed therapeutic exercises to develop strength, endurance, range of motion and flexibility. Effective February 19, 2024, [Rehab Company] will no longer be a therapy provider. The facility did not have documentation to show R102's therapy was discontinued or ending due to R102 meeting her highest practicable level of function. The facility did not have documentation to show R102 received physical therapy between February 16, 2024, and March 22, 2024. On April 23, 2024, at 10:54 AM, V5 said R102 previously received therapy from a different therapy company and when the current rehab company came to the facility on [DATE], R102 was evaluated so therapy services could resume. On April 23, 2024, at 11:11 AM, V12 (Social Services Director) said R102 was receiving therapy services from the previous therapy company. V12 continued to say R102 was not sent to an outside company to resume therapy services after the previous company stopped services in the facility. V12 said the facility did not send any residents to an outside company for therapy services because the facility thought the new therapy company was starting, but it kept getting delayed. V12 said R102 received therapy when the new company came on March 22, 2024, about a month after the previous therapy company stopped services. 3. R101's Medical Record showed R101 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, dementia, atrial fibrillation, and anemia. R101's MDS dated [DATE], showed R101 was cognitively intact. The MDS continued to show R101 required maximal assistance of facility staff for bed mobility, transferring to and from a bed to a chair, and toilet transfers. R101's ADL (Activity of Daily Living) care plan initiated on April 13, 2023, showed, Self care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to completed ADLs . R101's care plan continued to show multiple interventions initiated on April 13, 2023, including IDT (Interdisciplinary Team) to review for need of PT (Physical Therapy) services. R101's Medical Record showed a Physician Order dated January 12, 2024, for Physical Therapy/Occupational Therapy/Speech Therapy evaluation and treatment. Physical Therapy clarification, five times a week for 12 weeks. R101's February 2024 Physician orders showed, Rehabilitation: five times a week times 12 weeks per Plan of Care. R101's Physical Therapy Therapist Progress note dated February 8, 2024, by V19 Patient continues to require skilled physical therapy services to focus on: therapeutic exercise, neuromuscular reeducation, gait training, manual techniques, group therapy, and therapeutic activities. The facility did not have documentation to show R101's therapy was discontinued or ending due to R101 meeting his highest practicable level of function. The facility did not have documentation to show R101 received physical therapy between February 9, 2024, and March 22, 2024. On April 23, 2024, at 9:47 PM, V11 (Physician) said R101's physical therapy should not have been stopped because R101 was not discharged from therapy. V11 continued to say R101 stopped receiving therapy services because the facility did not have a therapy company to provide services. On April 23, 2024, at 11:11 AM, V12 said R101 was receiving therapy services from the previous therapy company. V12 continued to say R101 was not sent to an outside company to resume therapy services after the previous company stopped services in the facility. V12 said the facility did not send any residents to an outside company for therapy services because the facility thought the new therapy company was starting, but it kept getting delayed. V12 said R101 received therapy services when the new therapy company started on March 22, 2024, about a month after the previous therapy company stopped services.

Based on observation interview and record review, the facility failed to maintain a safe, clean, comfortable homelike environment following the disruption of water services due to broken pipes in the facility. The failure resulted in a lack of available handwashing facilities and the accumulation of human feces/urine in the toilets. The lack of response caused a risk for psychosocial harm to residents as evidenced by their disgust for having to eliminate in toilets full of urine/feces and subsequently not have hand washing facilities available to wash hands. This applies to 35 of 60 residents (R2, R4, R8, R10-R13, R15-R17, R19-R23, R25, R26, R30-R32, R35, R40, R41, R43-R51, R58, R59 R60) reviewed for homelike environment who could utilize facility bathrooms/toilets in a sample of 61. The Immediate Jeopardy began on 1/17/24 at 9:30 PM when the initial water pipe break occurred. V1 (Acting Administrator), V2 (Director of Nursing), V3 (Regional Director of Operations), and V7 (Division Director of Operations) was notified of the Immediate Jeopardy on 1/25/24 at 3:00 PM. The surveyor confirmed by observations and interview that the Immediate Jeopardy was removed on 1/25/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the training and monitoring. The findings include: On 1/23/24 at 8:33 AM, the State Regional Office was informed by V13 (Maintenance Director) that the facility had frozen pipes from Wednesday, 1/17/24 through Monday, 1/22/24. V13 state during that period, the water was shut down periodically up to two hours at a time to replace twelve frozen pipes. V13 stated the facility had emergency water supplies on site during the water shut down period. V13 stated as of 1/23/24 at 8:33 AM, all running water was restored to the building and only dry wall repairs remained to be completed. On 1/23/24 at 10:00 AM with V2 (Director of Nursing) and V3 (Regional Director of Operations), V1 (Acting Administrator), stated the facility water pipes recently broke but running water was restored to all parts of the facility. V1 stated the water was only off for short periods of times while repairing the pipes but was turned on immediately. V1 stated the only repairs remaining were dry wall installation to cover the holes in the ceilings where the pipes burst. On 1/23/24 at 10:46 AM, R23 stated there was no running water in the community bathrooms for the past five to six days. R23 stated while the water was shut off, the toilets filled up with stool and urine. R23 stated earlier that morning he tried to use the 200 hall community bathroom but the toilets were full of urine and feces. R23 walked down to the 200 hall community bathroom but the toilet was emptied. There was no bucket in the 200 hall community bathroom for flushing toilets. The sink was turned on and only had cold water available from the sink. R23 stated he was being given bottled water for drinking and to brush his teeth. R23 stated the shower in the 200 hall community bathroom was the only shower in the facility with working hot water. On 1/23/24 at 11:05 AM, V13 (Director of Maintenance) and V3 (Regional Director of Operations) both re-stated the running water was restored to all areas of the facility since the first water break on 1/17/24 after water being shut off intermittently to repair several pipe bursts. V13 and V3 stated when the facility fixed one broken pipe, they would turn the water back on and another pipe would burst and require repairs. V3 and V13 stated there were numerous pipe that burst since 1/17/24. On 1/23/24 at 12:46 PM, V3 stated V6 told her he was expecting plumbers to arrive that day to restore water to the executive office area, but he was not aware any toilets/sinks/hot water was not in service to resident areas in the facility. V3 stated she was unaware of the lack of service to resident areas as well. On 1/23/24 at 11:07 AM during tour of the facility with V1 (Acting Administrator) and V18 (Illinois Department of Public Health Certified/Licensed Plumbing Inspector), the following observations were made and resident interviews obtained: - The shared bathroom between 111/113 (utilized by R12 and R13) had no running water to the toilet or the handwashing sink. R12 stated the water was shut off for approximately a week in his room and the staff flush down the toilets possibly once a day. R12 stated the toilets built up with feces and urine during the day. There was no bottled water or sanitizer in the bathroom or any bucket with water in the bathroom for flushing the toilet. - The shared bathroom between rooms 112/114 (utilized by R8 and R10) had no running water to the toilet or handwashing sink. The toilet was full of stool and urine and the toilet was unable to be flushed. There were no water buckets in the bathroom for flushing or water bottles for washing hands near the sink. R8 stated her sink never had any hot water, but now she had no water flowing from her sink or to her toilet. R8 stated she shared a toilet with R10 in room [ROOM NUMBER] and she had to use the 200 hall community toilet because her toilet was full of waste. R8 stated he also found the 200 hall community toilet full of waste when she needed to use it. - The shared bathroom between rooms 108/110 (utilized by R15) had no running water to the toilet or sink. R15 stated, I'm going in my pants! What else can I do!? R15 stated she had to urinate or defecate in her incontinence brief because she did not have a choice due to the toilets not working. R15 stated the pipes broke approximately a week ago and the toilets had not been working since the pipes broke. There were no buckets of water near the toilet for flushing and no bottled water or sanitizer for handwashing near the sink. - rooms [ROOM NUMBERS] were both designated isolation rooms requiring contact precautions to enter the rooms. The room [ROOM NUMBER]/213 shared bathroom (utilized by R4 and R30) had no running water to the toilet and no hot water available from the handwashing sink. There was no bucket of water available near the toilet for flushing the toilet. R4 stated, I haven't been able to use the toilet on and off for about a week! R4 stated he recently moved to room [ROOM NUMBER] from room [ROOM NUMBER]. R4 stated he eliminated his stool/urine in the toilet of his old room which built up in the toilet because the toilet would not flush. R4 stated the staff were not flushing down the wastes in the toilet. R4 stated, I tried to use the toilet in my old room [ROOM NUMBER] or the one next to 106 when mine was full! - Shared bathroom between rooms 207/209 had faucets falling off the sinks and no running water from the sink or to the toilet. There was no bucket of water near the toilet for flushing and no bottled water or sanitizer near the sink for handwashing. - Shared bathroom of rooms 203/205 had no running water to the toilet and no hot water available in the handwashing sink. There was no bucket of water near the toilet for flushing. V5 (Family) stated, the water has been off a couple of days in room [ROOM NUMBER]. The toilet in room [ROOM NUMBER] had no water running to the toilet and no bucket of water near the toilet for flushing. - The back nursing station handwashing sink had no running water - Women's 300 hall community bathroom (utilized by R40, R41, R43-50) had no hot or cold water available from the shower and no hot water available at the only working handwashing sink. The second handwashing sink was covered in plastic wrap and not available for use. - V4 (Director of Housekeeping) stated the housekeeping staff walked through the facility with a large container of water on a cart and flushed all of the toilets periodically. - V3 called V6 (Regional Maintenance Director) and V6 stated he thought the toilets were shut off by the plumbers but was not sure how long they had no running water. V1 stated he did was not aware that the pipes were shut off to the toilets and sinks that were not functioning during tour of the facility. - V8 (CNA- Certified Nursing Assistant) stated the facility had water leaks since 1/17/24 and the water was shut off in the building on and off. V8 stated there was another leak on 1/20/24 and V8 thought the water was shut off because the facility was still trying to repair it. - V11 (Laundry) stated the facility had shut off water to residents since 1/17/24 and V10 (Housekeeping) stated she was aware the facility turned off water to residents since 1/20/24 - V12 (CNA) stated the toilets in resident rooms were being flushed on and off by housekeeping from a large water container pushed through the hall by housekeeping On 1/23/24 at 1:50 PM with V1 (Acting Administrator) and V18 during tour of the facility the following observations were made and interviews were obtained: - R16 stated he utilized the 100 hall community bathroom but the toilet and handwashing sink were not working, so he had to soil his brief since 1/20/24 if he needed to urinate/defecate because the toilet was not working in the community bathroom. R16 stated the staff were only changing his brief once a shift and was forced to sit in his soiled brief. R16 stated staff never gave him an alternative toilet to use when he was informed the toilet was not working in his community bathroom. On 1/24/24 at 1:57 PM with V3 (Regional Director of Operations), R16 again stated while the toilets were not working, he was forced to urinate/defecate in his incontinence brief instead of utilizing the toilet in the hall community toilet per his preference. - R19 was in his room, sitting in his wheelchair, and had a urinal sitting on the floor in front of him. R19 stated since the water was shut off to the 100 hall community bathroom, he was filling a urinal with urine because the toilets were filled up with urine and feces for the last four or five days. R19 stated the toilet did not flush and there was no running water to the toilets. R19 stated, I have no alternative! [The toilets] are all the same! R19 stated all of the facility toilets were full of human waste for the last four to five days. - The men's and women's 100 hall community bathrooms (utilized by R16, R17, R19, R23, R58, R59, and R60) had no water running to their toilets or their handwashing sinks. There were disconnected pipes in the women's bathroom visible through an exposed hole in the bathroom. There were no buckets of water near the toilet for flushing and no bottled water or sanitizer near the sink for handwashing. - R17 stated he normally utilizes the 100 hall community bathroom but there was no running water to the toilet or handwashing sink. R17 stated he was using the 200 hall community bathroom but had difficulty finding a toilet that was not full of human feces/urine waste when he needed to use the bathroom. On 1/23/24 at 2:05 PM during tour of the facility the following observations were made, and interviews obtained: - R20 stated 1/23/24 was the first day in four to five days that their hall had a toilet that flushed. R20 stated, If you had to go, you held your nose and went in because the toilet was full of feces and urine. R20 stated the facility staff began flushing the toilet 1/22/24 but were not flushing the toilets over the weekend. R20 stated, It would get heavy enough to make itself flush but not all the way. R20 stated the handwashing sink had no running water and residents only had the sanitizers on the hallway wall to clean their hands. - R21 stated he used the 400 hall community bathroom which had no running water to the toilet/handwashing sink for days. R21 stated the bathroom continued to not have hot water running to the handwashing sink. R21 stated, Oh God, we were filling them up! Piss and crap in there! They would get a bucket of water and flush it down maybe three or four times over a few days! - The 400 hall community bathrooms had cold water only running from the handwashing sinks On 1/23/24 at 2:55 PM, R22 stated he had previous bowel surgeries which caused him to have blood in his stools. R22 stated when the toilets were not working, he had a bowel movement with blood which remained in his toilet his bathroom (shared by R32) for two days before staff flushed it down. R22 stated he was urinating in mouth wash bottles and empty water gallon containers because there was no room in his toilet for additional waste. R22 stated he sealed up the bottles/containers of urine and then dumped them in the toilet when the water was turned back on. R22 stated he had no hot water in his handwashing sink and had not had hot water in the sink for two years. On 1/23/24 at 2:55 PM, the shared bathrooms between rooms 304/306 (utilized by R35), between 300/302 (utilized by R22 and R32), and between 301/303 (utilized by R31) had no hot water available from the handwashing sink. On 1/24/24 at 1:40 PM with V3, R35 stated he utilized a urinal when he needed to urinate while the toilets were not working and later flushed it down the toilet himself when the toilets were eventually flushed by staff. R35 stated he had a bowel movement during the day and someone later came and flushed the bowel movement during the night. R35 stated no staff gave any instructions on what to do when the toilets would not flush. R35 stated, It didn't feel comfortable! On 1/24/24 at 1:57 PM with V3, R47 stated, We had to go on top of what was there! It was gross! R47 stated she had to use the toilet which was full of feces and urine all weekend. R47 stated the residents could not wash their hands and had to use the sanitizer in the hall. On 1/24/24 at 1:10 PM with V3, R20 stated the lack of an available, clean/flushed toilet made her feel very gross, yucky, very gross! R20 stated, I am not used to that. We always had clean bathrooms. This has been disgusting! On 1/24/24 at 1:50 PM with V3, R40 stated the facility had no water in the sink or toilets over the weekend and the human waste built up in the toilets. R40 stated having to urinate/defecate in a full toilet made her feel not good! On 1/23/24 at 11:07 AM, the front nursing station, employee bathroom near the nursing station, and beauty shop all had no hot water available from the handwashing sinks. On 1/24/24 at 11:58 AM, V6 (Regional Maintenance Director) stated on 1/22/24 he toured the facility to see what work the previous plumbers completed in the facility. V6 stated they left the facility assuming the toilets and sinks were still frozen. V6 stated he believed V1 was working in the facility at the time of his visit. On 1/23/24 at 12:30 PM, V15 (Building Code Enforcement Superintendent - Village of South [NAME]) stated he was at the facility three times on 1/22/24 and was told the facility restored all the water to all of the facility areas other than the executive office. On 1/24/24 at 1:15 PM during tour of the facility with V3 (Regional Director of Operations), the following residents were identified as utilizing facility toilets: R2, R4, R8, R10-R13, R15-R17, R19-R23, R25, R26, R30-R32, R35, R40, R41, R43-R51, R58, R59 R60. On 1/24/24 at 2:25 PM, V2 (DON) stated the residents did not have access to hand sanitizer in their rooms but only that which was available from dispensers in the hallways. Facility Timeline, dated 1/25/24, shows the facility had an initial water pipe break on 1/17/24 at 9:30 PM. The timeline shows the facility experienced multiple, daily, ongoing water pipe breaks from 1/17/24 to 1/23/24. Emergency Water Plan, dated 9/25/12, shows, Water from the water heater tanks will be used as a primary source to flush toilets and resident bathing. This water will be placed in a bin with wheels that can be moved around the building. Cleaned, empty 5 gallon pails in which chemicals and detergents were received should be kept filled with non-potable water near each toilet stool for flushing toilets. Water basins will be available to be filled with non-potable water for resident bathing as necessary. The plan also shows, Use alcohol or other approved disinfectants for all hand washing. Physician telephone order, dated 1/10/24, shows R30 was placed on contact isolation. Physician telephone order, dated 1/24/24, shows R30's isolation was discontinued. Physician telephone order, dated 1/22/24, shows R4 was placed on contact isolation precautions. Most recent MDS (Minimum Data Set) documentation for the following residents showed the residents were cognitively intact: R4 (!/3/24), R15 (1/8/24). R16 (12/2/23), R17 (12/13/23), R18 (12/2/23), R19 (10/23/23), R20 (12/1/23), R21 (11/16/23), R22 (12/8/23), R23 (1/18/24), R35 (12/28/23), R40 (11/1/23), and R47 (11/9/23). MDS, dated [DATE], showed R12's cognition was moderately impaired. The Immediate Jeopardy that began on 1/17/24 was removed on 1/25/24 when the facility took the following actions to remove the immediacy: - The affected 35/60 residents assessed/interviewed by members of the IDT (Interdisciplinary Team( team staff and no acute changes, s/s (signs/symptoms) of infection, or any distress noted. - All plumbing was restored and back to normal operations as of 1/24/24 - The facility completed a QA (Quality Assurance) process review on 1/25/24 with the facility QA members. - On 1/23/24 designated staff were assigned to check and flush all toilets in the facility every 15 minutes and documenting on a form, until certainty of entire system was fully functioning. - All residents residing in the facility assessed by IDT team for acute changes, S/S of infection, or any distress and none noted on 1/24/24. - The facility QA team reviewed facility water loss procedure, emergency water and hand hygiene during duration of the emergency and again on 1/25/24. - As of 1/25/24, greater than 75% of staff inserviced on Hand Hygiene Policy, including Hand Hygiene when loss of water, as well as Emergency Water Policy, including handling of human waste. All other staff will be inserviced prior to the start of their next shift. - All staff will be in serviced at the time of and through the duration of any declared emergency with loss of water on Hand Hygiene Policy, including Hand Hygiene when loss of water, as well as Emergency Water Policy, including flushing of toilets, communication to staff and residents on emergency situations with updates as needed, delegation of duties to departments during emergencies. - Immediate QA meeting held with facility QA Committee and Regional Team on 1/25/24. Regional Team to monitor effectiveness of facility Emergency Preparedness through next Quarterly QA meeting. - Administrator or designee will inservice staff on emergency water policies and procedures twice a month for the next three months. Administrator, DON or Designee will randomly question 3 staff members a week for 8 weeks on emergency water policies and procedures.

Based on observation, interview, and record review, the facility failed to address residents' nutritional status and implement pertinent interventions to ensure residents did not experience significant weight loss. This failure resulted in R1, R2, R3, and R4 experiencing significant weight loss. This applies to 4 of 4 residents (R1-R4) reviewed for improper nursing in the sample of 4. The findings include: 1. On September 20, 2022 at 9:58 AM, R1 was lying in his bed, wearing a hospital gown. R1 appeared thin/emaciated, with protruding collarbones, and a gaunt appearance to his face, with protruding cheekbones. R1 could not answer questions due to his cognitive status. The facility's undated face sheet shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated August 10, 2022 shows R1 has severe cognitive impairment, is totally dependent on facility staff for dressing, toilet use, and personal hygiene, and requires extensive assistance with all other ADLs (Activities of Daily Living), including eating. R1 is frequently incontinent of bowel and bladder. Facility documentation shows the following weights and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] August 3, 2022 - 146.0 pounds August 4, 2022 - 146.5 pounds August 5, 2022 - 146.7 pounds August 10, 2022 - 138 pounds (-5.48 percent weight loss in one week) August 19, 2022 - 138.8 pounds August 19, 2022 at 1:15 PM - Physician order: Refer [R1] to dietitian - V4 (Dietitian) was never notified August 26, 2022 - 135 pounds August 28, 2022 - Physician order: Double portions - the order for double portions was never started August 31, 2022 - 130 pounds September 2, 2022 - no weight obtained September 6, 2022 - 131 pounds (-10.27 percent weight loss in one month) September 8, 2022 - Physician order: Double portions September 9, 2022 - 130.9 pounds September 11, 2022 - 131.4 pounds September 16, 2022 130.3 pounds (-10.75 percent weight loss since admission) On September 20, 2022 at 11:56 AM, V4 (Dietitian) said, I came to the facility on [DATE], and August 23, 2022. I was never told by facility staff R1 was a new admission from August 3, 2022 or that [R1] was experiencing significant weight loss. I was never told there was a dietitian referral for [R1] from August 19, 2022. I did not see the resident at all during August. Today will be the first time I am seeing him since his admission on August 3. If he was a new admission, [V5] (FSM-Food Service Manager) should have informed me and I would have seen him during one of my visits in August. If there was a physician referral to the dietitian, I would most definitely have seen him. I depend on the facility to provide me with all of the new admissions. When a resident has a significant weight loss, I expect the staff to notify the physician first, and then notify me. They did not do that in the case of [R1]. I would have told them to do a three-day calorie count to see what he was eating and then made diet changes as appropriate. On September 20, 2022 at 1:22 PM, V7 (Physician) said, I am aware [R1] has a significant weight loss of 15 to 16 pounds since his admission six weeks ago. I ordered a dietitian consult and double portions for this resident. It is my expectation facility staff follow my orders. This resident now has a significant weight loss that could have been avoided if interventions were done as ordered. 2. On September 20, 2022 at 12:48 PM, R2 was lying in bed. R2's bedside table was adjacent to her bed. A lunch tray was on top of the bedside table. None of the meat, carrots or dessert were eaten from the lunch tray, but 100 percent of the fortified ice cream was eaten. R2 was unable to reach her silverware or food due to the distance of the food tray from the resident. R2 was not able to be interviewed due to her cognitive status. R2's undated face sheet shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS dated [DATE] shows R2 has severe cognitive impairment, requires extensive assistance with eating and dressing, and is totally dependent on facility staff for all other ADLs. Documentation from the facility's Monthly Weight Grid dated September 9, 2022 shows the following weights for R2: June 2022 - 120.0 pounds July 2022 - 128.0 pounds August 2022 - 126.0 pounds September 9, 2022 - 115 pounds (-8.73 percent weight loss in one month) On August 23, 2022, V4 (Dietitian) recommended to increase R2's sugar-free protein supplement to four times a day and start a frozen fortified ice cream supplement three times a day. Facility documentation shows V4's recommendation dated August 23, 2022 was not carried out by the facility until September 1, 2022, and R2 experienced a weight loss of 11 pounds between August 2022 and September 9, 2022. Facility documentation dated September 20, 2022 shows V7 (Physician) ordered a three-day calorie count and dietitian consult for R2. On September 21, 2022 at 11:47 AM, V1 (AIT-Administrator in Training) said, the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On September 22, 2022 at 1:50 PM, V4 (Dietitian) said, I was not informed by the facility staff that [R2] has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When I put in dietary recommendations, I expect the staff to follow up immediately. If the physician declines my dietary recommendations, I expect the facility staff to notify me. I was never notified by the facility staff that my recommendations for [R2] did not start immediately. I was also never notified of her weight loss. The addition of the frozen nutritional dessert would have given [R2] 870 extra calories, and the sugar-free supplement was to give her extra protein because she developed pressure ulcers at the facility. 3. On September 21, 2022 at 12:34 PM, R3 was sitting up in her bed eating her lunch. R3 ate approximately 10 percent of her potatoes, but no other food. Carrots and meat remained on her plate. R3 said no one cut her meat into smaller pieces, so she was unable to eat the meat. R3 was attempting to remove cellophane wrapping from her piece of cake but was unable to do so without staff assistance. R3's undated face sheet shows R3 was admitted to the facility in February 2022. R3 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS dated [DATE] shows R3 is cognitively intact, is able to eat with supervision with meal set up, requires limited assistance with bed mobility, locomotion on and off the unit, and extensive assistance with all other ADLs. The facility's Monthly Weight Grid, dated September 9, 2022 shows the following weights for R3: May 2022 - 240.40 pounds June 2022 - 239.50 pounds July 2022 - 239.30 pounds August 2022 - 224.80 pounds (-5.67 percent weight loss in one month) September 2022 - 217.70 (-10.01 percent weight loss in three months) The facility's undated Weekly Weight Monitoring Record shows the following weights for R3: September 9, 2022 - 215.7 pounds September 16, 2022 - 213 pounds (-5.25 percent weight loss in one month, and -11.06 percent weight loss in three months) The facility does not have documentation to show the physician or dietitian were notified by the facility of R3's significant weight loss to obtain dietary recommendations. 4. R4's undated face sheet shows R4 was admitted to the facility on [DATE]. The facility's nursing progress notes show R4 was transferred from the facility to the local hospital on August 24, 2022 and did not return to the facility. R4 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE] shows R4 had moderately impaired cognition, required extensive assistance with dressing and eating, and was totally dependent on facility staff for all other ADLs. The facility's Monthly Weight Grid, dated August 25, 2022 shows the following weights for R4: April 2022 - 158.00 pounds May 2022 - no weight recorded June 2022 - no weight recorded July 2022 - 134.20 pounds (-15.06 percent weight loss in three months) August 2022 - 120.00 pounds (-10.58 percent weight loss in one month) Facility documentation shows V4 (Dietitian) ordered 120 ml (Milliliters) of nutritional supplement three times a day due to R4's significant weight loss on July 21, 2022. On September 22, 2022 at 1:06 PM, V1 (AIT) said V4's recommendation for 120 ml of nutritional supplement three times a day was never carried out by the facility. V1 said, The recommendation by the dietitian was never sent to the physician or called to him, so it was never started. On September 22, 2022 at 1:54 PM, V4 (Dietitian) said, When I ordered the nutritional supplement for [R4], I was looking to increase his calories because he was losing weight, and I wanted to stop the weight loss. The supplement I ordered is very high in calories. He would have gotten an extra 720 calories a day had he been given the supplement. V4 continued to say all residents with weight loss issues are supposed to filter through the Director of Nursing position. Because the facility does not have a Director of Nursing, there is no one specifically to report the weight loss issues to, and no specific person to follow up and ensure orders are started on the residents. On September 22, 2022 at 1:45 PM, V12 (MDS Nurse) said, We have not had a DON for a long time. They asked me to act in her absence, but I said no. It has been a few months since we had a weekly weight committee meeting. Sometimes in morning meetings they mention weight loss, but it is not focused on at those meetings. On September 22, 2022 at 1:57 PM, V1 (AIT) said, We do not have a weight committee at this time. We have a daily general meeting with staff that includes Social Services, Activities, Maintenance, Housekeeping, and Therapy, but not a specific weight committee. We do not have a DON. The facility's policy entitled Resident Weight Monitoring, revised 3/19 shows: Policy: It is the policy of [the facility] that resident weights are recorded and monitored at least monthly. Procedure: 1. New admission weight is obtained within 24 hours of admit and on the following two consecutive days after admission by CNA (Certified Nursing Assistant) as directed by nurse. 2. Monthly weights are obtained by CNAs or designated staff by the 5th of the months. 4. The monthly weight report is printed and reviewed by the Dietary Manager and DON (Director of Nursing) by the 8th of the month. 5. If the monthly weight shows a significant change in 30 days (i.e., 5% +/-) the resident will be re-weighed. Re-weights are done by CNA or designated staff. Re-weights are again reviewed, and entered in the computer by the Dietary Manager, Care Plan Coordinator or designee. The monthly weight report is finalized and printed by the 10th of the month. 7. If there is an actual significant weight change (i.e., +/- 5% x 1 month, +/- 7.5% x 3 months, +/- 10% x 6 months), the resident, POAHC (Power of Attorney for Health Care)/family/guardian, physician and dietitian are notified. The physician shall be notified using the MD notification of weight change form. 8. The Food Service Manager and interdisciplinary team review the resident's weights and nutritional status and make recommendations for intervention. 9. The Dietitian shall review and document all significant weight changes along with any recommended nutritional interventions in the dietary progress notes in the medical record monthly. 10. Nursing contacts the physician to convey recommendations from the interdisciplinary team and/or dietitian and obtains any new orders. 11. Significant weight changes are reviewed in the weekly Weight Committee Meeting. The Weight Committee will also identify any trends of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. 12. Residents who have been determined by the Weight Committee to be at increased risk for weight loss will be put on weekly weights for at least 4 weeks. After four weeks, if weight has stabilized monthly weights will be re-established. 13. All new admissions and re-admissions will be weighed weekly for at least 4 weeks. If weight is stable, weight will be monitored monthly. The facility's policy entitled Dietary Services Communication dated 4/16 shows: It is the policy of [the facility] that dietary services recommendations are communicated to nursing and provided to the physician to promote health and well-being of the residents. Procedure: 1. The dietitian or designee completes Dietary Services Communication forms on appropriate residents. 3. The Dietary Services Communication form(s) are forwarded by the Director of Nursing or designee to the resident's physician to be acted upon. 4. The resident's physician will review the Dietary Services Communication form. The physician will check the form accordingly (Approved or Not Approved). The physician will sign and date the Dietary Services Communication Form. 5. Upon receiving the physician-signed Dietary Services Communication form, the Director of Nursing or designee will ensure transcription of the order(s). 7. The Dietary Services Communication form will be placed in the clinical record in the appropriate section. 8. The Food Service Manager or designee is responsible for monitoring the proper completion of the Dietary Services Communication form. The facility's policy entitled, Dietitian Consults dated 4/16 shows: It is the policy of [the facility] that a Dietitian Consult List is completed by the Food Service Manager or designee prior to the dietitian's visit(s). Procedure: 1. The Food Service Manager or designee will record the resident's name, of whom the dietitian needs to review, on the Dietitian Consult List. 3. The Dietitian Consult List is provided to the dietitian on or before his/her visit. The facility's policy entitled, Nutritional assessment dated ,d+[DATE] shows: It is the policy of [the facility] that each resident receives a comprehensive nutritional assessment upon admission, annually and whenever the resident is deemed to have a significant change in condition. Re-admission will have a complete nutritional assessment if the Interdisciplinary Team determines that a complete MDS will need to be done. Procedure: .2. The Dietitian will complete the nutritional assessment upon her/his next scheduled visit.

Based on observation, interview, and record review, the facility failed to ensure residents received pressure ulcer treatment as ordered by the physician. The facility also failed to follow dietitian recommendations for residents with pressure ulcers. This failure resulted in R2 and R4 developing pressure ulcers at the facility. This applies to 2 of 3 residents (R2, R4) reviewed for pressure ulcers in the sample of 4. The findings include: 1. On September 20, 2022, at 12:48 PM, R2 was lying in bed. R2's bedside table was adjacent to her bed. A lunch tray was on top of the bedside table. R2 was unable to reach her silverware or food due to the distance of the food tray from the resident. R2 was not able to make position changes in bed without staff assistance. R2 was not able to be interviewed due to her cognitive status. R2 was observed multiple times on September 20 and 21, 2022, and was never observed in another position than lying on her back in bed, with the head of the bed slightly elevated. No staff were observed changing R2's position in bed or getting her up in a chair. R2's undated face sheet shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated August 22, 2022, shows R2 has severe cognitive impairment, requires extensive assistance with eating and dressing, and is totally dependent on facility staff for all other ADLs (Activities of Daily Living), including bed mobility. The facility's undated Weekly Wound Report shows R2 was admitted to the facility with a right heel pressure ulcer. The report continues to show R2 developed a right lateral ankle pressure ulcer measuring 1.3 cm. (Centimeters) x 0.6 cm. x 0 cm (Length x Width x Depth), an unstageable left heel pressure ulcer measuring 1.9 cm. x 2.7 cm. x 0.2 cm., and a right lower lateral calf unstageable pressure ulcer measuring 7.4 cm. x 2.2 cm. x 0.2 cm. The facility could not provide the date of onset for the three pressure ulcers R2 developed at the facility since her admission on June 4, 2022, despite multiple requests. The following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] September 7, 2022: Sponge boot to right heel. September 14, 2022: [Heel protector boot] left heel. September 21, 2022: [Heel protector boot] left heel. The facility does not have documentation to show heel protector/sponge boots were applied to R2's feet daily as ordered by the physician. Documentation from the facility's Monthly Weight Grid dated September 9, 2022, shows the following weights for R2: June 2022 - 120.0 pounds July 2022 - 128.0 pounds August 2022 - 126.0 pounds September 9, 2022 - 115 pounds (-8.73 percent weight loss in one month) On August 23, 2022, V4 (Dietitian) recommended to increase R2's sugar-free protein supplement to four times a day and start a frozen fortified ice cream supplement three times a day. Facility documentation shows V4's recommendation dated August 23, 2022, was not carried out by the facility until September 1, 2022, and R2 experienced a weight loss of 11 pounds between August 2022 and September 9, 2022. On September 21, 2022, at 11:47 AM, V1 (AIT-Administrator in Training) said, the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On September 22, 2022, at 1:50 PM, V4 (Dietitian) said, When I put in dietary recommendations, I expect the staff to follow up immediately. The addition of the frozen nutritional dessert would have given [R2] 870 extra calories, and the sugar-free supplement was to give her extra protein because she developed pressure ulcers at the facility. The previous month there was one wound and then there were four pressure ulcers. I increased the protein for wound healing. On September 22, 2022. at 3:56 PM, V11 (Wound Physician) said, If the dietitian orders a nutritional supplement for wound healing, the facility needs to do that. Why am I ordering heel protector boots if they are not going to put them in use? I go in the room and the resident does not have them on, so I order them again and again. I ordered the protocol for her to be moved every two hours to keep her from getting pressure ulcers. If she doesn't get repositioned, she will get pressure ulcers. With no DON (Director of Nursing) to follow through on the orders, how can you improve the pressure ulcers? 2. R4's undated face sheet shows R4 was admitted to the facility on [DATE]. The facility's nursing progress notes show R4 was transferred from the facility to the local hospital on August 24, 2022, and did not return to the facility. R4 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE], shows R4 had moderately impaired cognition, required extensive assistance with dressing and eating, and was totally dependent on facility staff for all other ADLs. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show R4 was turned and repositioned July 1-31, 2022, and August 5, 10, 13, 14, 19, 20, and 21, 2022. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show R4 received daily skin checks July1-31, 2022, and August 3, 13, 14, and 21, 2022. Facility documentation shows R4 developed an unstageable pressure ulcer on his left hip, and a DTI (Deep Tissue Injury) to his right foot on August 3, 2022. R4 was seen by V11 (Wound Doctor) at the facility on August 3, 2022. V11 documented wound treatment, including surgical debridement of R4's two pressure ulcers, and Plan to discuss patient's abnormal BMI (Body Mass Index) with current dietitian. It the patient does not currently have a dietitian following, recommend dietary consultation for abnormal BMI. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show R4 received the wound care as ordered on August 7, 21, and 22, 2022. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show the wound treatment was completed as ordered on August 7, 21, and 22, 2022. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show sponge boots were applied to R4. The facility's Monthly Weight Grid, dated August 25, 2022 shows the following weights for R4: April 2022 - 158.00 pounds May 2022 - no weight recorded June 2022 - no weight recorded July 2022 - 134.20 pounds (-15.06 percent weight loss in three months) August 2022 - 120.00 pounds (-10.58 percent weight loss in one month) Facility documentation shows V4 (Dietitian) ordered 120 ml (Milliliters) of nutritional supplement three times a day due to R4's significant weight loss on July 21, 2022. On September 22, 2022, at 1:06 PM, V1 (AIT) said V4's recommendation for 120 ml of nutritional supplement three times a day was never carried out by the facility. V1 said, The recommendation by the dietitian was never sent to the physician or called to him, so it was never started. On September 22, 2022, at 1:54 PM, V4 (Dietitian) said, When I ordered the nutritional supplement for [R4], I was looking to increase his calories because he was losing weight, and I wanted to stop the weight loss. The supplement I ordered is very high in calories. He would have gotten an extra 720 calories a day had he been given the supplement. V4 continued to say all residents with weight loss issues are supposed to filter through the Director of Nursing position. Because the facility does not have a Director of Nursing, there is no one specifically to report the weight loss issues to, and no specific person to follow up and ensure orders are started on the residents. On September 22, 2022 at 1:45 PM, V12 (MDS Nurse) said, We have not had a DON for a long time. They asked me to act in her absence, but I said no. It has been a few months since we had a weekly weight committee meeting. Sometimes in morning meetings they mention weight loss, but it is not focused on at those meetings. Facility documentation dated August 24, 2022 shows R4 developed the following five additional pressure ulcers on August 24, 2022: Unstageable DTI of the left medial ankle measuring 2.6 cm. x 1.5 cm. x not measurable depth Unstageable DTI of the left heel measuring 3.5 cm. x 4.6 cm. x not measurable depth Unstageable DTI of the right heel measuring 2.6 cm. x 2.3 cm. x not measurable depth Unstageable DTI of the right hip measuring 7.9 cm. x 7.9 cm. x not measurable depth Unstageable DTI of the left upper hip measuring 3.5 cm. x 7.8 cm. x not measurable depth On September 22, 2022 at 3:40 PM, V11 (Wound Care Physician) said, Nutrition is one of many issues that caused these pressure ulcers, though it is not just the nutrition. If you don't do the wound care, then that is not right. I expect them to do the wound care as ordered. You have to turn the resident. You have to apply the foam boots; you have to do the care. The facility's policy entitled Decubitus Care/Pressure Areas revised 1/18 shows: Policy: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Responsibility: Licensed Nursing Personnel. Procedure: 1) Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses.4) Notify the physician for treatment orders. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order must have specific frequencies. Vi) Initiate physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .7) Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support and monthly reviews by the Registered Dietitian.

Based on observation, interview and record review the facility failed to ensure that facility staff has current healthcare provider CPR (cardiopulmonary resuscitation) certification, failed to ensure that nursing staff was trained and knowledgeable of facility procedures for identifying resident code status, failed to ensure staff was competent in assessing the need for CPR and able to correctly implement CPR. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on (MONTH) 29, (YEAR) at 7:40 AM when facility staff failed to initiate CPR on a resident (R1). V19 (Administrative Consultant) and V20 (Regional Director of Operations) were notified of the Immediate Jeopardy on (MONTH) 15, (YEAR) at 3:20 PM. While the immediacy was removed on (MONTH) 16, (YEAR), the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the new policies, the plan of action and Quality Assurance monitoring tools. This failure applies to all 72 residents residing in the facility. The findings include: The Facility Data Sheet dated (MONTH) 13, (YEAR) indicated that 72 residents were in the facility during the survey. 1. Facility documentation showed R1 sustained a fall at the facility on (MONTH) 29, (YEAR) at 2:30 AM. At 3:30 AM, V10 (RN-Nurse) administered [MEDICATION NAME] (sedative) to R1 due to screaming and agitation. V4's (RN-Registered Nurse) documentation dated (MONTH) 29, (YEAR) at 7:40 AM shows that V4 was called to R1's room by staff when the resident was noted to be cold. V4 then called 911 and other staff stayed with R1. V4 continued to document that CPR was done by the 911 responders and R1 was noted dead at 8:15 AM. R1's undated face sheet shows R1 was a [AGE] year old resident, admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's Illinois Statutory Short Form Power of Attorney for Healthcare, signed by R1 on (MONTH) 21, (YEAR) shows R1 initialed the following statement: I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures. On (MONTH) 13, (YEAR) at 12:32 PM, V4 said, I started work at 6:00 AM on (MONTH) 29, (YEAR). (V10) reported to me that (R1) had a fall during the night but there were no problems. I checked her after report and she was okay. They gave her [MEDICATION NAME] (sedative) during the night. She was sleeping when I saw her. I checked her two times. I told (V7) (CNA-Certified Nursing Assistant) to check on her more often. At 7:40 AM, (V7) delivered the room tray to (R1). They called me to go to the room because she was cold on her lower extremities when they tried to boost her. She moaned when they boosted her, but I went and called 911 because something didn't seem right. I called 911 and told them she's cold but still responsive. I didn't check her vitals at 7:40 AM when I went in the room. I did not check a blood pressure or a pulse oximeter, and I did not document a pulse rate. Another nurse (V5) (RN) came about 10 minutes after. I never started CPR (cardiopulmonary resuscitation). Right before they came she deteriorated but we didn't start CPR. She was a full code. The paramedics started CPR when they got here. On (MONTH) 15 (YEAR) at 12:51 PM, V4 said, I did a sternal rub on (R1). I thought she was still alive. I did not apply oxygen to her. We are supposed to start oxygen. On (MONTH) 13, (YEAR) at 12:59 PM, V5 (RN) said, I was here doing paperwork. My CNA called me and said (V4) wanted me. He was on the phone with 911. I went to find the room where the problem was, but I didn't know what room it was. I saw a CNA with a resident. She was cleaning her. The resident appeared sleepy. I did not check to see if (R1) was breathing. We usually call a code blue when something like this happens and someone does paperwork, but we did not call a code blue that day. I did not know her code status. She was unresponsive when I got there. I thought I felt a faint pulse on her wrist but I didn't assess her breathing. On (MONTH) 13, (YEAR) at 1:37 PM, V7 (CNA) said, I did rounds and (R1) appeared asleep. The nurse notified me she had a fall and she should be checked frequently. I was calling her name and she wasn't responding. I cleaned her up before the paramedics arrived. She wasn't saying anything at all. I rubbed her chest and there was no response. I grabbed her wrist and there was no pulse. We are all CPR certified. I went and grabbed the nurse and I stepped aside. When I was trained on CPR they said you should start chest compressions, but I'm not sure how often to do breaths. I never started CPR on her. 2. V17's (LPN-Licensed Practical Nurse) documentation dated (MONTH) 31, (YEAR) at 6:00 AM shows that V17 was notified by the nurse aide that R2 was unresponsive and V17 to document that after seeing the resident, V17 checked the chart to determine R2's code status. V17 then charted that 911 was called. Documentation in the medical record dated (MONTH) 31, (YEAR) 4:50 AM, Resident pronounced dead at 4:22 AM per paramedics by (local hospital). R2's undated face sheet shows R2 was a [AGE] year old resident, admitted to the facility in (MONTH) 2009 with multiple [DIAGNOSES REDACTED]. R2's Illinois Statutory Short Form Power of Attorney for Healthcare, dated (MONTH) 22, 2012 shows R2's relative initialed the following statement: I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures. On (MONTH) 13, (YEAR) at 3:09 PM, V17 (LPN) said, (R2) was normal when I got him at 10:00 PM on [DATE]. I work from 10:00 PM to 6:00 AM. I checked him a few times and he was sleeping. (V9) (CNA) checked him and told me he was unresponsive around 2:30 AM on (MONTH) 31, (YEAR). I checked his pulse and there was none and I checked his breathing, and he wasn't breathing. I had to go check the chart to see his code status at the nurse's station down the hall. He was a full code, so I called 911 and then I went to the room and tried to resuscitate him. The resident assistant was close by and I had her get the nurse. It took me a few minutes to check the chart, and another 2 to 3 minutes to call the paramedics, so it was about 5 minutes later when I started CPR. I'm not sure who is supposed to start CPR on the resident. Someone else could have started CPR but they did not. On (MONTH) 13, (YEAR) at 5:25 PM, V14 (RN) said, I was working in the back hall. The resident assistant came to get me to send me to a patient's room. I did not know what room the resident was in because (V17) was on the phone with (V2) (DON-Director of Nursing) trying to figure out the resident's code status so I did not initially go to the resident's room. We were trying to figure out if (R2) was a full code or not. We were looking at (R2's) chart and we were on the phone for about 5 minutes before 911 was called. They came a couple of minutes later. I went to check (R2) and one of the resident assistants was cleaning him. I checked the pulse and there was none, and I checked the pulse oximeter and there was no reading. (V17) started CPR. No one gave rescue breaths or applied oxygen. I was looking for a (bag valve mask) on the crash cart, but I could not find one. I was going to start CPR on (R2), but then (V17) came into the room. I don't know why (V9) (CNA) was cleaning the resident instead of doing CPR. (V21) (CNA) was not available to help with (R2) during the entire time. She was on her break. The paramedics came and did CPR for quite a while. On (MONTH) 13, (YEAR) at 2:30 PM, V2 (DON) said, (V17) called me at home in the middle of the night, about 2:00 AM on (MONTH) 31, (YEAR). He asked me, aside from the chart, is there anything he needs to check to see if a resident is a full code. He called to say (R2) was unresponsive and he wanted to make sure he was a full code. I told him to call 911. I expect staff to start CPR, call a code blue and have another staff member call 911. I would have expected (V9) to be performing CPR on (R2) if (V9) had CPR certification, not cleaning (R2). The progress notes should show an assessment with vital signs and a code blue record should be filled out to show what was done during the code. That did not happen with (R2). All nurses are required to have CPR certification. Our ADON (Assistant Director of Nursing) used to track the staff CPR cards, but she has been gone for a couple of months. On (MONTH) 14, (YEAR) at 11:20 AM, V16 (Assistant Chief Local Fire Department) said, The fire department personnel would follow the POLST forms in the resident's medical record. If the resident does not have advance directives in the medical record, we would perform CPR. On (MONTH) 14, (YEAR) at 3:15 PM, V18 (Physician/Medical Director) said, When they found (R1) without a pulse or breathing, I would have expected them to start CPR right away. I also would have expected them to notify me during the night after she fell , especially when she had the screaming behaviors. If I would have been notified, I probably would have sent her out to the hospital. When someone codes, I would expect the staff member to call 911 and go back to the resident to do CPR. If two people in the facility have CPR certification, I would expect one to notify 911 and the other to start CPR. If there are no papers in the chart to show the resident is a DNR, I would expect the staff to start CPR as soon as they can. Whoever discovers the resident without pulse or breathing should start CPR. All staff needs to be certified in CPR. Online classes are not acceptable. You need to practice on the dummy. The facility should have a process in place for them to perform CPR quickly without delay. They should not be taking time to call the DON to find out the code status. I was not aware of the problems with the code status not being readily available. I wasn't aware of a delay in CPR for (R2). Documentation provided by the facility shows V4, V5, V9, V17 and V7 do not have the required CPR certification. On (MONTH) 13, (YEAR) at 5:11 PM, V11 (RN) said, I think my CPR card is up to date. Facility documentation shows V11 does not have the required CPR certification. On (MONTH) 13, (YEAR) at 5:13 PM, V12 (LPN) said, I took CPR recently. The facility did not have documentation to show V12 has the required CPR certification. On (MONTH) 14, (YEAR) at 9:06 AM, V15 (RN) said, I have CPR certification, but I don't know when it expires. The facility did not have documentation to show V15 has the required CPR certification. On (MONTH) 14, (YEAR) at 3:15 PM, V18 (Physician/Medical Director) said, When they found (R1) without a pulse or breathing, I would have expected them to start CPR right away. I also would have expected them to notify me during the night after she fell , especially when she had the screaming behaviors. If I would have been notified, I probably would have sent her out to the hospital. When someone codes, I would expect the staff member to call 911 and go back to the resident to do CPR. If two people in the facility have CPR certification, I would expect one to notify 911 and the other to start CPR. If there are no papers in the chart to show the resident is a DNR, I would expect the staff to start CPR as soon as they can. Whoever discovers the resident without pulse or breathing should start CPR. All staff need to be certified in CPR. Online classes are not acceptable. You need to practice on the dummy. If the POLST form is signed and the resident and/or family change their mind about the code status, it is not acceptable to cross anything out. You need to fill out another form and resigned by the physician. The facility should have a process in place for them to perform CPR quickly without delay. They should not be taking time to call the DON to find out the code status. I was not aware of the problems with the code status not being readily available. I wasn't aware of a delay in CPR for (R2). On (MONTH) 13, (YEAR) at 2:30 PM, V2 (DON) said, We have a log book in my office to track our employee's CPR certification. Our ADON (Assistant Director of Nursing) used to track the staff CPR cards, but she has been gone for a couple of months and we only recently hired a new ADON. We don't have updated records on the staff CPR certification. The facility provided a list of all nursing staff which includes CNAs, RAs (resident assistants) and nurses. Of the 54 staff members identified as nursing staff by the facility, 43 staff members did not have the required CPR certification documentation. On (MONTH) 15, (YEAR) at 8:40 AM, V8 (American Heart Association Instructor) said CPR certification cards for healthcare providers must show either Healthcare Provider CPR or BLS (basic life support) Provider on the certification card to prove the holder of the card received training for healthcare providers. CPR cards that show First Aid CPR AED (automated external defibrillator), or BLS CPR, or Standard - CPR/AED are not healthcare provider CPR certifications. The facility's undated Advance Directive policy shows: Policy: The Patient Self Determination Act states that individuals have the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state and federal legislation relating to advance directives.9. Implementation of a code is as follows: i. Direct and Non-Direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. ii. The nurse shall be summoned to respond, and upon review of chart documents determine code status. iii. The nurse shall evaluate the code status and notify appropriate staff for task assignment. If CPR is indicated only certified personnel shall administer CPR. iv. Activation of the Emergency Medical System shall be initiated or the ambulance service notified. The physician shall also be notified to inform him/her of the resident condition. v. Upon completion of notifications and necessary paper work, the nurse shall relieve those performing CPR. The appropriate certified staff will continue until emergency medical team arrives and takes over.11. This facility shall provide education to all employees regarding advance directives and the implementation of such. In-servicing of advance directive policy and procedure shall be conducted annually. Staffing schedules for the period (MONTH) 17, (YEAR) to (MONTH) 15, (YEAR) were reviewed. R1 was found unresponsive at 7:40 AM and expired at 8:15 AM on (MONTH) 29, (YEAR). R2 was found unresponsive on (MONTH) 31, (YEAR) at 3:40 AM and expired at 4:22 AM. Based on the staffing schedule provided by the facility for the AM shift on (MONTH) 29, (YEAR), no nursing staff had current CPR certification for Healthcare providers through a CPR provider whose training includes hands-on practice and in-person skills assessment as mandated in regulation 483.24 (F678). Based on the staffing schedule provided by the facility for the night shift on (MONTH) 31, (YEAR), V21 (CNA-Certified Nursing Assistant) was the only staff member with healthcare provider CPR certification. On (MONTH) 13, (YEAR), V14 (RN-Registered Nurse) said V21 was on her break at the time of the incident and was not available to assist with CPR for R2. Documentation provided by the facility showed V2 (DON-Director of Nursing) has Standard CPR certification from an online source dated (MONTH) 29, (YEAR). The facility's Employee Handbook dated (MONTH) (YEAR) shows: Certain positions require certification, continuing education units, registration or licensure. If you fall into this category, please make sure you 1) maintain certification, registration or licensure in a current status and 2) provide the facility with copies of your current certificate, registration or licensure for your personnel file. Further, all employees, at their own cost, must be CPR trained and recertified bi-annually. If you do not know where to obtain this training, please see your supervisor. Through observation, record review and interviews conducted on (MONTH) 16, (YEAR), the survey team confirmed that the facility took the following action to remove the immediacy of the situation: 1. The staff, V22 (Social Service Director), V20 (Regional Consultant), V24 (Corporate Risk Manager) completed an audit of resident medical records for current status of advanced directives related to code status and POLST (Practitioner Orders for Life Sustaining Treatment). The staff completed subsequent audits of resident medical record for current status of advanced directives related to CODE status and POLST. This audit was conducted on (MONTH) 15 and 16, (YEAR). 2. The social Service Director completed all POLST forms for resident code status discrepancies identified during the audit of advanced directives related to completion of POLST. This was conducted on (MONTH) 15 and 16, (YEAR). 3. An audit was completed to determine nursing personnel current CPR certification. The facility contacted a CPR instructor to schedules classes for licensed staff certification on [DATE] to begin at 10:00 AM and go throughout the day to ensure certification of all licensed staff. The audit was completed by V2 (Director of Nursing), V20 (Regional Consultant), V24 (Corporate Risk Manager) and V1 (Administrator). V25 (BLS instructor) conducted the classes in the facility (MONTH) 16, (YEAR) with classes scheduled for (MONTH) 17, (YEAR). 4. Staff was in-serviced by V20 on POLST forms or Identifiers of code status and the location of forms in the chart. To further identify, residents who are full code will wear a green bracelet and DNR will wear red bracelets. Temporary bracelets have been donned on residents until bands are received. This in-service training took place on (MONTH) 15 and 16, (YEAR). 5. Staffs have been in-serviced that CPR certification must be Health Care Provider and cannot be obtained on line. In the event of finding a resident who is full code in need of resuscitation, CPR is to be initiated immediately. Anyone certified in Health Care Provider CPR may initiate resuscitation. V20 conducted the training on (MONTH) 15 and 16, (YEAR). 6. Staff has been in-serviced explaining Advanced Directives indicate resident wishes regarding code status. POLST forms must be read to determine Code Status. This training was done by V20 on (MONTH) 15, (YEAR). 7. Licensed staff was in-serviced on restocking the crash cart ASAP after accessing and then securing the cart. The crash cart must be checked nightly. All items checked for expiration. This training was done on (MONTH) 15 and 16, (YEAR) by V20 and V2. 8. The Social Service Designee was in-serviced on completion of Advanced Directive Forms on admission. This training was done by V20 on (MONTH) 15, (YEAR). 9. The Regional Director, Administrator, DON, ADON, Department managers clarified with all staff during in-service that identification of resident code status is located in each resident medical record in the front of the chart on the POLST form or identified of code status. This training was done on (MONTH) 15 and 16, (YEAR). 10. The Regional Director and Retired EMS instructor will hold mock stations for resident assessment and resuscitation. Licensed staff will demonstrate competency. This training took place (MONTH) 15 and 16, (YEAR). 11. Resident charts have been moved to a more accessible area of the nursing station. Safety gates have been installed until a more permanent door can be installed. This has been completed as of (MONTH) 16, (YEAR). 12. The Medical Director approved the removal plan on (MONTH) 16, (YEAR) 13. for Quality Assurance Measures: a. Licensed personnel will be current with CPR Certification as of [DATE] b All newly hired licensed personnel will be Health Care Provider CPR certified prior to being placed on the schedule c The DON/Designee will monitor CPR expirations monthly d The Social Service Designee will obtain advanced directives on admission and will audit monthly 14. The Quality Assurance Team will review quarterly for compliance.

Based on observation, interview and record review the facility failed to initiate CPR (cardiopulmonary resuscitation) on a resident designated as a full code for R1, significantly delayed the implementation of CPR for R2 due to inadequate information about R2's code status, failed to follow the facility's policy for advanced directives and maintaining individual resident code status and failed to have a system in place so staff could promptly determine the code status of a resident. The facility also failed to ensure that staff had current healthcare provider CPR certificates for staff on duty, failed to ensure that staff was knowledgeable about assessing a resident that codes and failed to ensure that facility crash carts were stocked with needed equipment. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on (MONTH) 29, (YEAR) at 7:40 AM when facility staff failed to initiate CPR on a resident (R1). V19 (Administrative Consultant) and V20 (Regional Director of Operations) were notified of the Immediate Jeopardy on (MONTH) 15, (YEAR) at 3:20 PM. While the immediacy was removed on (MONTH) 16, (YEAR), the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the new policies, the plan of action and Quality Assurance monitoring tools. This failure applies to all 72 residents residing in the facility. The findings include: The Facility Data Sheet dated (MONTH) 13, (YEAR) indicates that 72 residents resided in the facility at the time of the survey. 1. Facility documentation showed R1 sustained a fall at the facility on (MONTH) 29, (YEAR) at 2:30 AM. At 3:00 AM, R1 was screaming and requested to have her bed adjusted by V10 (RN-Registered Nurse). At 3:30 AM, V10 administered [MEDICATION NAME] (sedative) to R1 due to screaming and agitation. At 6:30 AM, V10 faxed information regarding R1's fall to V18 (Physician/Medical Director). V4's (RN-Registered Nurse) documentation dated (MONTH) 29, (YEAR) at 7:40 AM shows: Writer was notified to report to (R1's room). (R1) was repositioned by staff for her breakfast but extremities are cold, but moaning when repositioned. Pulse noted at right arm, fingernail color within (R1's) norm, and the staff stayed with the resident and writer called 911 with report. Sternal rub was done and 911 crew came and take over. CPR done by 911 crew. 8:15 AM, 911 crew informed writer that the time of death was 8:15 AM. Son was informed of what had happened. MD informed. (V2) DON (Director of Nursing) aware and administrator notified. R1's undated face sheet shows R1 was a [AGE] year old resident, admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's Illinois Statutory Short Form Power of Attorney for Healthcare, signed by R1 on (MONTH) 21, (YEAR) shows R1 initialed the following statement: I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures. On (MONTH) 13, (YEAR) at 12:32 PM, V4 said, I started work at 6:00 AM on (MONTH) 29, (YEAR). (V10) reported to me that (R1) had a fall during the night but there were no problems. I checked her after report and she was okay. They gave her [MEDICATION NAME] (sedative) during the night. She was sleeping when I saw her. I checked her two times. I told (V7) (CNA-Certified Nursing Assistant) to check on her more often. At 7:40 AM, (V7) delivered the room tray to (R1). They called me to go to the room because she was cold on her lower extremities when they tried to boost her. She moaned when they boosted her, but I went and called 911 because something didn't seem right. I called 911 and told them she's cold but still responsive. I didn't check her vitals at 7:40 AM when I went in the room. I did not check a blood pressure or a pulse oximeter, and I did not document a pulse rate. Another nurse (V5) (RN) came about 10 minutes after. I never started CPR (cardiopulmonary resuscitation). Right before they came she deteriorated but we didn't start CPR. She was a full code. The paramedics started CPR when they got here. On (MONTH) 15 (YEAR) at 12:51 PM, V4 said, I did a sternal rub on (R1). I thought she was still alive. I did not apply oxygen to her. We are supposed to start oxygen. On (MONTH) 13, (YEAR) at 12:59 PM, V5 (RN) said, I was here doing paperwork. My CNA called me and said (V4) wanted me. He was on the phone with 911. I went to find the room where the problem was, but I didn't know what room it was. I saw a CNA with a resident. She was cleaning her. The resident appeared sleepy. I did not check to see if (R1) was breathing. We usually call a code blue when something like this happens and someone does paperwork, but we did not call a code blue that day. I did not know her code status. She was unresponsive when I got there. I thought I felt a faint pulse on her wrist but I didn't assess her breathing. On (MONTH) 13, (YEAR) at 1:37 PM, V7 (CNA) said, I did rounds and (R1) appeared asleep. The nurse notified me she had a fall and she should be checked frequently. I was calling her name and she wasn't responding. I cleaned her up before the paramedics arrived. She wasn't saying anything at all. I rubbed her chest and there was no response. I grabbed her wrist and there was no pulse. We are all CPR certified. I went and grabbed the nurse and I stepped aside. When I was trained on CPR they said you should start chest compressions, but I'm not sure how often to do breaths. I never started CPR on her. Documentation provided by the facility shows V4, V5 and V7 do not have the required CPR certification. 2. V17's (LPN-Licensed Practical Nurse) documentation dated (MONTH) 31, (YEAR) at 6:00 AM shows, At 3:40 AM I was notified by the aide that (R2) was unresponsive. After seeing (R2), I checked the chart to see if the patient was DNR (do not resuscitate). I called 911 and paramedics came to take over CPR. Documentation in the medical record dated (MONTH) 31, (YEAR) 4:50 AM, Resident pronounced dead at 4:22 AM per paramedics by (local hospital), coroner called with order to release the body, to call them once funeral arrangement is done. R2's undated face sheet shows R2 was a [AGE] year old resident, admitted to the facility in (MONTH) 2009 with multiple [DIAGNOSES REDACTED]. R2's Illinois Statutory Short Form Power of Attorney for Healthcare, dated (MONTH) 22, 2012 shows R2's relative initialed the following statement: I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures. On (MONTH) 13, (YEAR) at 3:09 PM, V17 (LPN) said, (R2) was normal when I got him at 10:00 PM on [DATE]. I work from 10:00 PM to 6:00 AM. I checked him a few times and he was sleeping. (V9) (CNA) checked him and told me he was unresponsive around 2:30 AM on (MONTH) 31, (YEAR). I checked his pulse and there was none and I checked his breathing, and he wasn't breathing. I had to go check the chart to see his code status at the nurse's station down the hall. He was a full code, so I called 911 and then I went to the room and tried to resuscitate him. The resident assistant was close by and I had her get the nurse. It took me a few minutes to check the chart, and another 2 to 3 minutes to call the paramedics, so it was about 5 minutes later when I started CPR. I'm not sure who is supposed to start CPR on the resident. Someone else could have started CPR but they did not. On (MONTH) 13, (YEAR) at 5:25 PM, V14 (RN) said, I was working in the back hall. The resident assistant came to get me to send me to a patient's room. I did not know what room the resident was in because (V17) was on the phone with (V2) (DON-Director of Nursing) trying to figure out the resident's code status so I did not initially go to the resident's room. We were trying to figure out if (R2) was a full code or not. We were looking at (R2's) chart and we were on the phone for about 5 minutes before 911 was called. They came a couple of minutes later. I went to check (R2) and one of the resident assistants was cleaning him. I checked the pulse and there was none, and I checked the pulse oximeter and there was no reading. (V17) started CPR. No one gave rescue breaths or applied oxygen. I was looking for a (bag valve mask) on the crash cart, but I could not find one. I was going to start CPR on (R2), but then (V17) came into the room. I don't know why (V9) (CNA) was cleaning the resident instead of doing CPR. (V21) (CNA) was not available to help with (R2) during the entire time. She was on her break. The paramedics came and did CPR for quite a while. Documentation provided by the facility shows V9, V14 and V17 do not have the required CPR certification. On (MONTH) 13, (YEAR) at 2:30 PM, V2 (DON) said, (V17) called me at home in the middle of the night, about 2:00 AM on (MONTH) 31, (YEAR). He asked me, aside from the chart, is there anything he needs to check to see if a resident is a full code. He called to say (R2) was unresponsive and he wanted to make sure he was a full code. I told him to call 911. I expect staff to start CPR, call a code blue and have another staff member call 911. I would have expected (V9) to be performing CPR on (R2) if (V9) had CPR certification, not cleaning (R2). The progress notes should show an assessment with vital signs and a code blue record should be filled out to show what was done during the code. That did not happen with (R2). All nurses are required to have CPR certification. Our ADON (Assistant Director of Nursing) used to track the staff CPR cards, but she has been gone for a couple of months. During intermittent observations on (MONTH) 13, (YEAR) between 10:00 AM and 4:00 PM and (MONTH) 14, (YEAR) between 9:15 AM and 11:30 AM, resident medical charts were not labeled with the resident's room number and were not in corresponding labeled cubicles. Charts were also missing from the nurse's station, and nursing staff was not aware of the location of the charts. Multiple interviews were held with staff members, and staff members could not provide consistent answers where the resident code status was located. On (MONTH) 13, (YEAR) at 5:11 PM, V11 (RN) said, I look in the resident's chart for a DNR paper. If there is no DNR paper, we act as if they are a full code. I think my CPR card is up to date. Facility documentation shows V11 does not have the required CPR certification. On (MONTH) 13, (YEAR) at 5:13 PM, V12 (LPN) said, I took CPR recently. A label on the side of the chart shows if the resident is a DNR or not. If no label on the side of the chart, then the resident is a full code. The facility did not have documentation to show V12 has the required CPR certification. On (MONTH) 13, (YEAR) at 5:16 PM, V13 (LPN) said, My CPR certification expires (MONTH) 22, (YEAR). We can't work if it is expired. To determine a resident's code status, we look in the chart. We look for the pink form. If nothing in the chart, then the resident is automatically a full code. On (MONTH) 14, (YEAR) at 9:06 AM, V15 (RN) said, I go through the chart to find a resident's DNR paper. If I can't find a resident's chart, I would have to call around the facility to find the chart before I could determine a resident's code status. I have CPR certification, but I don't know when it expires. The facility did not have documentation to show V15 has the required CPR certification. On (MONTH) 14, (YEAR), the facility provided a list of residents in the facility with their code status dated (MONTH) 11, (YEAR). Chart audits were done to compare the code status designated on the facility-provided list to the code status in the resident's charts. Some resident charts were not available, and the facility did not have any other means to identify these residents' code status. The following discrepancies between the facility's provided list and resident charts were found: R4 - The facility provided list shows R4 is a DNR. R4's POLST (Practitioner Orders for Life-Sustaining Treatment) form dated (MONTH) 9, (YEAR) shows attempt resuscitation/CPR if patient has no pulse and is not breathing. R5 - The facility provided list shows R5 is a DNR. R5's POLST form dated (MONTH) 7, (YEAR) shows attempt resuscitation/CPR. A photocopy of the same form dated (MONTH) 7, (YEAR) shows attempt resuscitation/CPR crossed out with the word VOID written next to the attempt resuscitation/CPR, and a check mark in the box next to the words Do Not Attempt Resuscitation/DNR. There are no initials or date next to the alterations made on the POLST form. There was no DNR order on R5's POS (physician order [REDACTED]. R6 - The facility list shows R6 is a full code. Facility form in medical record entitled Responsible Party/Advance Directive Election Review shows Code Status Designation: Resident/Responsible Party has chosen: Do not Resuscitate Effective on receipt of signature of Resident/Responsible Party and order by physician. No dates were filled out on the form. V2 (DON) was asked to determine the code status of R6. V2 said, The code status should be on the face sheet of the residents. V2 was unable to determine R6's code status and enlisted the assistance of V22 (Social Services) and V23 (RN). V22 and V23 were unable to determine R6's code status. V2 said, The facility face sheet shows (R6) is a full code. R6's POA (Power of Attorney) papers show full code. The Code Status sheet shows DNR (do not resuscitate). I am not sure. The process of determining R6's code status took 10 minutes and 20 seconds to determine. A form found in the medical record shows R6's code status as DNR, which contradicts the sheet provided by the facility. There was no DNR order on R6's POS. R7 - The facility provided list shows R7 is a DNR. There were no forms in the medical record to show R7 was a DNR. V2 said R7 should be a full code. R8 - The facility provided list shows R8 is a DNR. There were no forms in the medical record to show R8 was a DNR. V2 said R8 should be a full code. R9 - The facility provided list shows R9 is a full code. Forms in the medical record show R9 is a DNR. V2 confirmed R9 should be a DNR. There was no DNR order on R9's POS. R10 - The facility provided list shows R10 is a DNR. There were no forms in the medical record to show R10 was a DNR. V2 said R10 should be a full code since no papers were in the medical record. R11 - The facility provided list shows R11 is a DNR. There were no forms in the medical record to show R11 is a DNR. V2 said R11 should be a full code. R12 - The facility provided list shows R12 is a DNR. There were no forms in the medical record to show R12 is a DNR. V2 said R12 should be a full code. R13 - The facility provided list shows R13 is a DNR. R13's DNR papers could not be located in the medical record. R13 did not have a DNR order on the POS. R14 - The facility provided list shows R14 is a full code. Forms in the medical record show R14 is a DNR. There was no DNR order on R14's POS. On (MONTH) 14, (YEAR) at 11:20 AM, V16 (Assistant Chief Local Fire Department) said, The fire department personnel would follow the POLST forms in the resident's medical record. If the resident does not have advance directives in the medical record, we would perform CPR. In the case where two forms exist for one resident (R6) with a crossed off resuscitate preference, and DNR written in, we would not honor that form and we would perform CPR. A new form should be made when a resident changes their code status. On (MONTH) 14, (YEAR) at 3:15 PM, V18 (Physician/Medical Director) said, When they found (R1) without a pulse or breathing, I would have expected them to start CPR right away. I also would have expected them to notify me during the night after she fell , especially when she had the screaming behaviors. If I would have been notified, I probably would have sent her out to the hospital. When someone codes, I would expect the staff member to call 911 and go back to the resident to do CPR. If two people in the facility have CPR certification, I would expect one to notify 911 and the other to start CPR. If there are no papers in the chart to show the resident is a DNR, I would expect the staff to start CPR as soon as they can. Whoever discovers the resident without pulse or breathing should start CPR. All staff needs to be certified in CPR. Online classes are not acceptable. You need to practice on the dummy. If the POLST form is signed and the resident and/or family change their mind about the code status, it is not acceptable to cross anything out. You need to fill out another form and resigned by the physician. The facility should have a process in place for them to perform CPR quickly without delay. They should not be taking time to call the DON to find out the code status. I was not aware of the problems with the code status not being readily available. I wasn't aware of a delay in CPR for (R2). The facility's undated Advance Directive policy shows: Policy: The Patient Self Determination Act states that individuals have the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state and federal legislation relating to advance directives. Procedure: .4. Any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Advance directives specifying full code/Attempt Resuscitation/CPR, or the absence of determination shall be recorded as a Full Code. Advance directives specifying Attempt Resuscitation/CPR shall be recorded as Full Code. Those residents indicating Do Not attempt resuscitation/DNR but requests limited additional interventions shall be recorded as signifying DNR-DNI (do not intubate) or requests comfort measures only shall be recorded as signifying DNR-Comfort as indicated on the Uniform Do-Not-Resuscitate (DNR) Advance Directive Form. Code status shall also be recorded on the resident's Physician order [REDACTED]. It is the intent of (the healthcare corporation) to implement the terms of the advanced directive placed in the resident's medical record in accord with the appropriate direction of the Power of Attorney and resident's physician. If a resident communicates a revocation of an advance directive to an employee of this facility, that communication, constituting revocation, shall be noted in the resident's medical record and placed in a central file to avoid any misunderstanding. 8. Any advance directive will be reviewed quarterly with the interdisciplinary team and the resident/responsible party. Advance directives may be reviewed more frequently as condition warrants. 9. Implementation of a code is as follows: i. Direct and Non-Direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. ii. The nurse shall be summoned to respond, and upon review of chart documents determine code status. iii. The nurse shall evaluate the code status and notify appropriate staff for task assignment. If CPR is indicated only certified personnel shall administer CPR. iv. Activation of the Emergency Medical System shall be initiated or the ambulance service notified. The physician shall also be notified to inform him/her of the resident condition. v. Upon completion of notifications and necessary paper work, the nurse shall relieve those performing CPR. The appropriate certified staff will continue until emergency medical team arrives and takes over.11. This facility shall provide education to all employees regarding advance directives and the implementation of such. In-servicing of advance directive policy and procedure shall be conducted annually. On (MONTH) 13, (YEAR) at 2:30 PM, V2 (DON) said, We have a log book in my office to track our employee's CPR certification. Our ADON (Assistant Director of Nursing) used to track the staff CPR cards, but she has been gone for a couple of months and we only recently hired a new ADON. We don't have updated records on the staff CPR certification. The facility provided a list of all nursing staff which includes CNAs, RAs (resident assistants) and nurses. Of the 54 staff members identified as nursing staff, 43 staff members did not have the required CPR certification documentation. The facility's Employee Handbook dated (MONTH) (YEAR) shows: Certain positions require certification, continuing education units, registration or licensure. If you fall into this category, please make sure you 1) maintain certification, registration or licensure in a current status and 2) provide the facility with copies of your current certificate, registration or licensure for your personnel file. Further, all employees, at their own cost, must be CPR trained and recertified bi-annually. If you do not know where to obtain this training, please see your supervisor. On (MONTH) 15, (YEAR) at 9:00 AM, the facility's two crash carts were inspected. The crash carts were open, disorganized, and no logs were present to show regular inspection of the crash carts. One crash cart was inspected with V4 (RN) and V3 (ADON). The crash cart did not have a bag valve mask on the cart. V4 (RN), said, The crash cart was just used. They probably didn't restock it yet. V4 was asked when the crash cart was used last and V4 replied the crash cart was last used when R2 expired on (MONTH) 31, (YEAR). Through observation, record review and interviews conducted on (MONTH) 16, (YEAR), the survey team confirmed that the facility took the following action to remove the immediacy of the situation: 1. The staff, V22 (Social Service Director), V20 (Regional Consultant), V24 (Corporate Risk Manager) completed an audit of resident medical records for current status of advanced directives related to code status and POLST (Practitioner Orders for Life Sustaining Treatment). The staff completed subsequent audits of resident medical record for current status of advanced directives related to CODE status and POLST. This audit was conducted on (MONTH) 15 and 16, (YEAR). 2. The social Service Director completed all POLST forms for resident code status discrepancies identified during the audit of advanced directives related to completion of POLST. This was conducted on (MONTH) 15 and 16, (YEAR). 3. An audit was completed to determine nursing personnel current CPR certification. The facility contacted a CPR instructor to schedules classes for licensed staff certification on [DATE] to begin at 10:00 AM and go throughout the day to ensure certification of all licensed staff. The audit was completed by V2 (Director of Nursing), V20 (Regional Consultant), V24 (Corporate Risk Manager) and V1 (Administrator). V25 (BLS instructor) conducted the classes in the facility (MONTH) 16, (YEAR) with classes scheduled for (MONTH) 17, (YEAR). 4. Staff was in-serviced by V20 on POLST forms or Identifiers of code status and the location of forms in the chart. To further identify, residents who are full code will wear a green bracelet and DNR will wear red bracelets. Temporary bracelets have been donned on residents until bands are received. This in-service training took place on (MONTH) 15 and 16, (YEAR). 5. Staffs have been in-serviced that CPR certification must be Health Care Provider and cannot be obtained on line. In the event of finding a resident who is full code in need of resuscitation, CPR is to be initiated immediately. Anyone certified in Health Care Provider CPR may initiate resuscitation. V20 conducted the training on (MONTH) 15 and 16, (YEAR). 6. Staff has been in-serviced explaining Advanced Directives indicate resident wishes regarding code status. POLST forms must be read to determine Code Status. This training was done by V20 on (MONTH) 15, (YEAR). 7. Licensed staff was in-serviced on restocking the crash cart ASAP after accessing and then securing the cart. The crash cart must be checked nightly. All items checked for expiration. This training was done on (MONTH) 15 and 16, (YEAR) by V20 and V2. 8. The Social Service Designee was in-serviced on completion of Advanced Directive Forms on admission. This training was done by V20 on (MONTH) 15, (YEAR). 9. The Regional Director, Administrator, DON, ADON, Department managers clarified with all staff during in-service that identification of resident code status is located in each resident medical record in the front of the chart on the POLST form or identified of code status. This training was done on (MONTH) 15 and 16, (YEAR). 10. The Regional Director and Retired EMS instructor will hold mock stations for resident assessment and resuscitation. Licensed staff will demonstrate competency. This training took place (MONTH) 15 and 16, (YEAR). 11. Resident charts have been moved to a more accessible area of the nursing station. Safety gates have been installed until a more permanent door can be installed. This has been completed as of (MONTH) 16, (YEAR). 12. The Medical Director approved the removal plan on (MONTH) 16, (YEAR) 13. for Quality Assurance Measures: a. Licensed personnel will be current with CPR Certification as of [DATE] b All newly hired licensed personnel will be Health Care Provider CPR certified prior to being placed on the schedule c The DON/Designee will monitor CPR expirations monthly d The Social Service Designee will obtain advanced directives on admission and will audit monthly 14. The Quality Assurance Team will review quarterly for compliance.

Based on interview and record review, the facility neglected to follow the facility's policy and procedure for advanced directives regarding initiating CPR (cardiopulmonary resuscitation) on a resident designated as a full code, and delayed providing CPR to a resident designated as a full code. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on (MONTH) 29, (YEAR) at 7:40 AM when facility staff failed to initiate CPR on a resident (R1). V19 (Administrative Consultant) and V20 (Regional Director of Operations) were notified of the Immediate Jeopardy on (MONTH) 15, (YEAR) at 3:20 PM. While the immediacy was removed on (MONTH) 16, (YEAR), the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the new policies, the plan of action and Quality Assurance monitoring tools. This applies to 2 of 3 residents (R1, R2) reviewed for improper nursing and death in the facility in the sample of 14. The findings include: The facility's undated Advance Directive policy shows: Policy: The Patient Self Determination Act states that individuals have the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state and federal legislation relating to advance directives.9. Implementation of a code is as follows: I . Direct and Non-Direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. ii. The nurse shall be summoned to respond, and upon review of chart documents determine code status. iii. The nurse shall evaluate the code status and notify appropriate staff for task assignment. If CPR is indicated only certified personnel shall administer CPR. iv. Activation of the Emergency Medical System shall be initiated or the ambulance service notified. The physician shall also be notified to inform him/her of the resident condition. v. Upon completion of notifications and necessary paper work, the nurse shall relieve those performing CPR. The appropriate certified staff will continue until emergency medical team arrives and takes over.11. This facility shall provide education to all employees regarding advance directives and the implementation of such. In-servicing of advance directive policy and procedure shall be conducted annually. 1. Facility nursing notes showed R1 sustained a fall at the facility on (MONTH) 29, (YEAR) at 2:30 AM. At 3:30 AM, V10 (RN-Nurse) administered [MEDICATION NAME] (sedative) to R1 due to screaming and agitation. V4's (RN-Registered Nurse) documentation dated (MONTH) 29, (YEAR) at 7:40 AM shows that V4 was called to R1's room by staff when the resident was noted to be cold. V4 then called 911 and other staff stayed with R1. V4 continued to document that CPR was done by the 911 responders and R1 was noted dead at 8:15 AM. R1's undated face sheet shows R1 was a [AGE] year old resident, admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's Illinois Statutory Short Form Power of Attorney for Healthcare, signed by R1 on (MONTH) 21, (YEAR) shows R1 initialed the following statement: I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures. On (MONTH) 13, (YEAR) at 12:32 PM, V4 said, I started work at 6:00 AM on (MONTH) 29, (YEAR). (V10) reported to me that (R1) had a fall during the night but there were no problems. I checked her after report and she was okay. They gave her [MEDICATION NAME] (sedative) during the night. She was sleeping when I saw her. I checked her two times. I told (V7) (CNA-Certified Nursing Assistant) to check on her more often. At 7:40 AM, (V7) delivered the room tray to (R1). They called me to go to the room because she was cold on her lower extremities when they tried to boost her. She moaned when they boosted her, but I went and called 911 because something didn't seem right. I called 911 and told them she's cold but still responsive. I didn't check her vitals at 7:40 AM when I went in the room. I did not check a blood pressure or a pulse oximeter, and I did not document a pulse rate. Another nurse (V5) (RN) came about 10 minutes after. I never started CPR (cardiopulmonary resuscitation). Right before they came she deteriorated but we didn't start CPR. She was a full code. The paramedics started CPR when they got here. On (MONTH) 15 (YEAR) at 12:51 PM, V4 said, I did a sternal rub on (R1). I thought she was still alive. I did not apply oxygen to her. We are supposed to start oxygen. On (MONTH) 13, (YEAR) at 12:59 PM, V5 (RN) said, I was here doing paperwork. My CNA called me and said (V4) wanted me. He was on the phone with 911. I went to find the room where the problem was, but I didn't know what room it was. I saw a CNA with a resident. She was cleaning her. The resident appeared sleepy. I did not check to see if (R1) was breathing. We usually call a code blue when something like this happens and someone does paperwork, but we did not call a code blue that day. I did not know her code status. She was unresponsive when I got there. I thought I felt a faint pulse on her wrist but I didn't assess her breathing. On (MONTH) 13, (YEAR) at 1:37 PM, V7 (CNA) said, I did rounds and (R1) appeared asleep. The nurse notified me she had a fall and she should be checked frequently. I was calling her name and she wasn't responding. I cleaned her up before the paramedics arrived. She wasn't saying anything at all. I rubbed her chest and there was no response. I grabbed her wrist and there was no pulse. We are all CPR certified. I went and grabbed the nurse and I stepped aside. When I was trained on CPR they said you should start chest compressions, but I'm not sure how often to do breaths. I never started CPR on her. 2. R2's undated face sheet shows R2 was a [AGE] year old resident, admitted to the facility in (MONTH) 2009 with multiple [DIAGNOSES REDACTED]. R2's Illinois Statutory Short Form Power of Attorney for Healthcare, dated (MONTH) 22, 2012 shows R2's relative initialed the following statement: I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures. V17's (LPN-Licensed Practical Nurse) documentation dated (MONTH) 31, (YEAR) at 6:00 AM shows that V17 was notified by the nurse aide that R2 was unresponsive and V17 to document that after seeing the resident, V17 checked the chart to determine R2's code status. V17 then charted that 911 was called. Documentation in the medical record dated (MONTH) 31, (YEAR) 4:50 AM, Resident pronounced dead at 4:22 AM per paramedics by (local hospital). The American Heart Association (YEAR) Guidelines for CPR & ECC (Emergency Cardiovascular Care) shows out-of-hospital [MEDICAL CONDITION] victims and in-hospital [MEDICAL CONDITION] victims should receive immediate high-quality CPR upon recognition of [MEDICAL CONDITION]. On (MONTH) 13, (YEAR) at 3:09 PM, V17 (LPN) said, (R2) was normal when I got him at 10:00 PM on [DATE]. I work from 10:00 PM to 6:00 AM. I checked him a few times and he was sleeping. (V9) (CNA) checked him and told me he was unresponsive around 2:30 AM on (MONTH) 31, (YEAR). I checked his pulse and there was none and I checked his breathing, and he wasn't breathing. I had to go check the chart to see his code status at the nurse's station down the hall. He was a full code, so I called 911 and then I went to the room and tried to resuscitate him. The resident assistant was close by and I had her get the nurse. It took me a few minutes to check the chart, and another 2 to 3 minutes to call the paramedics, so it was about 5 minutes later when I started CPR. I'm not sure who is supposed to start CPR on the resident. Someone else could have started CPR but they did not. On (MONTH) 13, (YEAR) at 5:25 PM, V14 (RN) said, I was working in the back hall. The resident assistant came to get me to send me to a patient's room. I did not know what room the resident was in because (V17) was on the phone with (V2) (DON-Director of Nursing) trying to figure out the resident's code status so I did not initially go to the resident's room. We were trying to figure out if (R2) was a full code or not. We were looking at (R2's) chart and we were on the phone for about 5 minutes before 911 was called. They came a couple of minutes later. I went to check (R2) and one of the resident assistants was cleaning him. I checked the pulse and there was none, and I checked the pulse oximeter and there was no reading. (V17) started CPR. No one gave rescue breaths or applied oxygen. I was looking for a (bag valve mask) on the crash cart, but I could not find one. I was going to start CPR on (R2), but then (V17) came into the room. I don't know why (V9) (CNA) was cleaning the resident instead of doing CPR. (V21) (CNA) was not available to help with (R2) during the entire time. She was on her break. The paramedics came and did CPR for quite a while. On (MONTH) 13, (YEAR) at 2:30 PM, V2 (DON) said, (V17) called me at home in the middle of the night, about 2:00 AM on (MONTH) 31, (YEAR). He asked me, aside from the chart, is there anything he needs to check to see if a resident is a full code. He called to say (R2) was unresponsive and he wanted to make sure he was a full code. I told him to call 911. I expect staff to start CPR, call a code blue and have another staff member call 911. I would have expected (V9) to be performing CPR on (R2) if (V9) had CPR certification, not cleaning (R2). The progress notes should show an assessment with vital signs and a code blue record should be filled out to show what was done during the code. That did not happen with (R2). All nurses are required to have CPR certification. Our ADON (Assistant Director of Nursing) used to track the staff CPR cards, but she has been gone for a couple of months. On (MONTH) 14, (YEAR) at 11:20 AM, V16 (Assistant Chief Local Fire Department) said, The fire department personnel would follow the POLST forms in the resident's medical record. If the resident does not have advance directives in the medical record, we would perform CPR. On (MONTH) 14, (YEAR) at 3:15 PM, V18 (Physician/Medical Director) said, When they found (R1) without a pulse or breathing, I would have expected them to start CPR right away. I also would have expected them to notify me during the night after she fell , especially when she had the screaming behaviors. If I would have been notified, I probably would have sent her out to the hospital. When someone codes, I would expect the staff member to call 911 and go back to the resident to do CPR. If two people in the facility have CPR certification, I would expect one to notify 911 and the other to start CPR. If there are no papers in the chart to show the resident is a DNR, I would expect the staff to start CPR as soon as they can. Whoever discovers the resident without pulse or breathing should start CPR. All staff needs to be certified in CPR. Online classes are not acceptable. You need to practice on the dummy. The facility should have a process in place for them to perform CPR quickly without delay. They should not be taking time to call the DON to find out the code status. I was not aware of the problems with the code status not being readily available. I wasn't aware of a delay in CPR for (R2). Documentation provided by the facility shows V4, V5, V9, V17 and V7 do not have the required CPR certification. The facility's Employee Handbook dated (MONTH) (YEAR) shows: Certain positions require certification, continuing education units, registration or licensure. If you fall into this category, please make sure you 1) maintain certification, registration or licensure in a current status and 2) provide the facility with copies of your current certificate, registration or licensure for your personnel file. Further, all employees, at their own cost, must be CPR trained and recertified bi-annually. If you do not know where to obtain this training, please see your supervisor. Through observation, record review and interviews conducted on (MONTH) 16, (YEAR), the survey team confirmed that the facility took the following action to remove the immediacy of the situation: 1. The staff, V22 (Social Service Director), V20 (Regional Consultant), V24 (Corporate Risk Manager) completed an audit of resident medical records for current status of advanced directives related to code status and POLST (Practitioner Orders for Life Sustaining Treatment). The staff completed subsequent audits of resident medical record for current status of advanced directives related to CODE status and POLST. This audit was conducted on (MONTH) 15 and 16, (YEAR). 2. The social Service Director completed all POLST forms for resident code status discrepancies identified during the audit of advanced directives related to completion of POLST. This was conducted on (MONTH) 15 and 16, (YEAR). 3. An audit was completed to determine nursing personnel current CPR certification. The facility contacted a CPR instructor to schedules classes for licensed staff certification on [DATE] to begin at 10:00 AM and go throughout the day to ensure certification of all licensed staff. The audit was completed by V2 (Director of Nursing), V20 (Regional Consultant), V24 (Corporate Risk Manager) and V1 (Administrator). V25 (BLS instructor) conducted the classes in the facility (MONTH) 16, (YEAR) with classes scheduled for (MONTH) 17, (YEAR). 4. Staff was in-serviced by V20 on POLST forms or Identifiers of code status and the location of forms in the chart. To further identify, residents who are full code will wear a green bracelet and DNR will wear red bracelets. Temporary bracelets have been donned on residents until bands are received. This in-service training took place on (MONTH) 15 and 16, (YEAR). 5. Staffs have been in-serviced that CPR certification must be Health Care Provider and cannot be obtained on line. In the event of finding a resident who is full code in need of resuscitation, CPR is to be initiated immediately. Anyone certified in Health Care Provider CPR may initiate resuscitation. V20 conducted the training on (MONTH) 15 and 16, (YEAR). 6. Staff has been in-serviced explaining Advanced Directives indicate resident wishes regarding code status. POLST forms must be read to determine Code Status. This training was done by V20 on (MONTH) 15, (YEAR). 7. Licensed staff was in-serviced on restocking the crash cart ASAP after accessing and then securing the cart. The crash cart must be checked nightly. All items checked for expiration. This training was done on (MONTH) 15 and 16, (YEAR) by V20 and V2. 8. The Social Service Designee was in-serviced on completion of Advanced Directive Forms on admission. This training was done by V20 on (MONTH) 15, (YEAR). 9. The Regional Director, Administrator, DON, ADON, Department managers clarified with all staff during in-service that identification of resident code status is located in each resident medical record in the front of the chart on the POLST form or identified of code status. This training was done on (MONTH) 15 and 16, (YEAR). 10. The Regional Director and Retired EMS instructor will hold mock stations for resident assessment and resuscitation. Licensed staff will demonstrate competency. This training took place (MONTH) 15 and 16, (YEAR). 11. Resident charts have been moved to a more accessible area of the nursing station. Safety gates have been installed until a more permanent door can be installed. This has been completed as of (MONTH) 16, (YEAR). 12. The Medical Director approved the removal plan on (MONTH) 16, (YEAR) 13. for Quality Assurance Measures: a. Licensed personnel will be current with CPR Certification as of [DATE] b All newly hired licensed personnel will be Health Care Provider CPR certified prior to being placed on the schedule c The DON/Designee will monitor CPR expirations monthly d The Social Service Designee will obtain advanced directives on admission and will audit monthly 14. The Quality Assurance Team will review quarterly for compliance.

Based on record review and interview, the facility failed to provide supervision and cueing to a resident who required supervision with eating. This lack of supervision resulted in R1 choking on food, causing acute hypoxic [MEDICAL CONDITION] and death. This applies to 1 resident (R1) in a sample of 5 reviewed for supervision with eating. Findings include: According to EMS (emergency medical services) run report, an ambulance was called to the facility on [DATE] at 12:20 PM for R1 who was unresponsive and barely breathing. Facility staff initiated chest compressions; the paramedics initiated CPR (cardiopulmonary resuscitation.) Upon inspection of the throat, a foreign body was noted in the airway. Forceps were used to extract a significant amount of what appeared to be chicken from R1's throat. R1 was transferred to the hospital. The emergency department physician report dated [DATE] states, R1 presented in full [MEDICAL CONDITION]. R1 was eating at the facility when he became unresponsive. Paramedics arrived and found R1 to be in respiratory arrest, they attempted to bag R1 but were unable. Forceps were used to pull out large amounts of turkey from his posterior pharynx. Following the removal, R1 was intubated. A physician note dated [DATE] states: R1 will most likely not survive this illness. Impression is status [REDACTED]. The hospital discharge summary list [DIAGNOSES REDACTED]. R1 expired on [DATE] at 8:50 AM. R1's closed record shows a physicians continued diet order dated (MONTH) 1, (YEAR) for a regular diet, thin liquids, supervision at meals for cues for small bites/sips, slow rate, cardiac, low concentrated sweets no added salt. The original order was dated [DATE]. On [DATE] at 12:35 PM , V5( Certified Nurse Aide) said she was assigned to R1 on [DATE] when the incident took place. R1 was put back to bed with the help of V7 (CNA) about 11:15 AM. V5 and V7 used a gait belt to transfer R1. V5 cranked the bed up to a 90 degree angle and R1 was watching TV in his room. V5 passed R1 his lunch tray in bed, his head was up , with tray in front of him. R1 did not want to get up and go to the dining room for lunch. V5 left the room to pass other residents trays. When V5 came back to check on R1, he was blue. This was about 10 minutes later. V5 yelled out for CNA help. R1's food was gone (eaten). V7 (CNA) came and got the nurse. They started doing CPR, V8 (Nurse) called a code blue. V9 (Nurse) got crash cart. 911 was called. R1 had no pulse, CPR was started, but did get pulse after CPR was initiated. Nursing staff continued CPR until paramedics came and took over. V5 said R1 usually would eat in the dining room, but sometimes would eat in his room, about ,[DATE] times a week. R1 could feed himself. On [DATE] at 2:10 PM per telephone interview, V8, nurse, said she saw R1 throughout the day of [DATE] beginning around 6:30 AM. R1 had no problems with breathing or pain. V8 called CNA's to put R1 to bed around 11:00 AM because R1 was trying to self transfer to bed and he was a fall risk. R1 was in bed in an upright position. V8 began passing medication on another hallway when V7, CNA, said to come right away to help R1. R1 had no pulse, his chest was not moving, and he was not breathing.V8 reports staff started CPR with R1 being placed in bed in flat position: after starting CPR we paused to see if anything was in R1's mouth, did a finger swipe /scoop in R1's mouth but nothing was there. Nurse V9 replaced V8 (nurse) doing CPR so V8 could call 911. Nursing staff including CNA continued CPR until the paramedics came and took over. On [DATE] at 2:40 PM V7, CNA, was interviewed per telephone call. V7 said she was in the dining room feeding other residents at the lunch meal on [DATE] when V5 CNA noticed R1 was purple. V5 called for help, V7 called for the nurse and went to help with CPR. R1 was in his room and found unresponsive by V5. The nurse called code blue. V7 said R1 was very alert, sometimes he would eat in the dining room, and sometimes he would eat in his room. Review of the menu plan served on [DATE] shows the noon meal consisted of roast turkey with gravy, bread dressing, broccoli and cheese cake. R1's diet card used to serve his tray lists regular no added salt controlled carbohydrate diet order with note (supervision at every meal). R1's dietary care plan last updated [DATE] states R1 has difficulty chewing or swallowing related to condition missing teeth. R1 will chew and swallow food per recommendations at each meal. Regular diet small bites, give verbal cues to stimulate chewing or swallowing, stroke throat lightly at Adam's apple to stimulate swallow. Give verbal cues or limit amounts available to take small bites or prevent fast paced eating. Observe for indicators of aspiration-coughing, choking, gagging, gurgling in throat. These approaches were started on [DATE].

Based on interview and record review the facility failed to provide supervision during a meal for 1 resident (R1) with cognitive impairment known to eat quickly and require cueing to slow her intake down. As a result of this failure, R1 choked while eating a sandwich and expired. This failure involved 1 resident (R1) out of 3 reviewed for choking. Findings include: On [DATE] at 9:30 am, Z1 (Coroner's Office Personnel) stated that R1's cause of death was choking. Progress note of [DATE] timed at 8:00 PM states that R1 was observed eating quickly and choking on a sandwich in the dining room. She was also observed to put a large piece of food in her mouth which she attempted to swallow. The author of the note (E4-LPN) documented that she attempted to remove some food doing a finger sweep of R1's mouth. She also attempted the Heimlich maneuver. R1 became unresponsive so E4 called for help and placed R1 on the floor and CPR was started. (911 was called, arrived and continued resuscitation efforts and transported R1 to the hospital. The facility learned later from the hospital that R1 had expired. R1's [DATE] MDS (Minimum Data Set) scores R1 as a ,[DATE] for eating, which indicates R1 requires tray set up and supervision for eating. R1's BIMS score (brief interview for mental status) is a 00 indicating cognitive impairment. R1's [DIAGNOSES REDACTED]. POS (Physician order [REDACTED]. On [DATE] at 12:45 PM, E7 (CNA) stated she was working the evening shift of [DATE] stated that residents are to be monitored during while eating. A CNA is to remain present at mealtime. E7 stated that the Group 4 CNA on their schedule is responsible for passing snacks and supervising the residents during snack time. E7 stated she was the CNA who passed snacks that evening. She stated that they usually try to have help when passing snacks, so someone can supervise while the other person continues to pass snacks. E7 stated she began passing snacks around 7:45 PM and E9 (CNA) helped her for a while, but then he had to leave to assist another staff person with resident care. She began passing snacks in the 100 dining room, then went to the main dining room, then the 300 hall and then the 200 hall. She recalled R1 being in the main dining room and giving R1 2 cookies and juice. She stated she offered R1 a sandwich but she didn't want it. E7 stated she gave the man next to R1 (R2) a peanut butter and jelly sandwich stated that she did not remain in the dining room after passing snacks there because she had more snacks to pass. R1 was eating the cookies when E7 left the dining room. E7 stated she believed she saw E4 go to get something out of her medication cart but does not know if E4 stayed in the dining room. E7 stated that while she continued to pass snacks, she heard a code blue called in the main dining room and when she arrived there, R1 was on the ground and nurses were doing CPR (cardiopulmonary resuscitation). On [DATE] at 11:00 AM E4 stated she was familiar with R1 and she was alert and oriented. She could make her needs known and currently resided on the Alzheimer's wing. She was able to eat on her own but required tray set-up and supervision. According to E4, there is always to be a CNA in the dining room when residents are eating, and nurses are also in and out of the dining room. R1 ate in the main dining room which is the dining room used for more independent residents. E4 stated she worked the evening of [DATE] usually 2 CNAs pass snacks, with 1 usually remaining in the dining room for supervision while the residents are eating. On [DATE] at 12:32 PM, E4 stated she left the nursing office located off of the main dining room to begin doing treatments at about 7:00 pm; 7:00 PM was the last time she was in the office where she could see the main dining room. She was doing a treatment in a 400 wing room at approximately 7:45 PM. When she left to do treatments at 7:00 PM, snacks hadn't been passed yet. She stated that somewhere around 8:00 PM she had returned to the station from doing the treatment and observed R1 across the dining room eating a sandwich very quickly. E4 stated she began walking towards R1 and verbally reminded R1 to eat more slowly. R1 did not make any response and did not slow her eating down. Before E4 reached R1, she saw R1 stuff the remaining piece of her sandwich in her mouth. E4 estimates that the piece of sandwich was about 1 and ,[DATE] inches in width. At that point, E4 reached R1 and R1 began to gag and put her hands up to her throat. E4 stated she called for help and performed a mouth sweep with her finger and got out about 3 pieces of food. R1 was still gagging and had her hands up to her throat and appeared pale at that point. E4 then performed a Heimlich maneuver but got no more food out. E4 stated that was no staff in the dining room when she returned from doing her treatment; she could not say why. E4 stated that E3 (ADON) arrived when she was doing the Heimlich maneuver. By then, R1 was cyanotic and not responding, so they laid her down on the floor and they began doing CPR. E4 did compressions and E3 got an ambu and did respirations. Other staff arrived and called 911. The paramedics arrived very quickly and took over resuscitative efforts and transported R1 to the hospital. E4 stated that she heard the paramedics say that R1 had a pulse when they were ready to transport her to the hospital. E4 later learned that R1 had expired in the hospital. On [DATE] at 2:50 PM, E14 (CNA) stated she worked the evening of [DATE]. She was familiar with R1, who required assistance with ADLs (Activities of Daily Living) and ate independently but with tray set up and supervision. Sometimes R1 ate fast and would gulp her food but she usually responded to directions to slow her eating down. Residents are to be monitored during meals and snack time, according to E14. E14 also stated that when snacks are passed, they should start from the back of the building and work their way to the front, so they end with the dining room and can remain there for supervision. E14 stated she did not pass snacks that evening because it was not her assignment and she did not provide any supervision in the main dining room after snacks were passed, as she was working with other residents. After this incident, E3 met with the CNAs to see where they had been and to remind them to do their assignments and provide supervision at meals and snack time. On [DATE] at 2:10 PM, E13 (CNA) stated she worked the evening shift on [DATE] and had cared for R1 in the past several weeks. R1 ate independently but required tray set up and supervision. According to E13, residents are to be monitored when eating. E13 did not provide any monitoring/supervision in the main dining room for any meals or snacks for that shift as that was not her assignment. Although she assisted passing trays at dinner, she did not remain in the dining room to monitor and did not pass snacks. When she passes snacks, she makes the dining room her last stop so she is able to stay in the dining room to monitor. The person who passes the snacks is to supervise in the main dining room. E13 was just finishing a resident shower when she heard the code blue called. After the incident, E3 talked to all the CNAs working that night to find out where they had been and to remind them to do their assignments and to monitor during eating. On [DATE] at 12:00 noon, E6 (CNA) stated that R1 required tray set up and supervision. E6 stated that she would sometimes have to remind R1 to slow her eating down E6 stated that there is always to be staff in the dining room when residents are eating. E6 stated that she was in a resident room transferring a resident to bed when she heard the code blue called. After the choking incident involving R1, E3 met with the CNAs to find out where each of them had been and to remind them to to their assigned tasks. On [DATE] at 1:30 PM, E9 (CNA) stated he worked the evening of [DATE] and he believes that the CNA assigned to monitor in the dining room for meals in the one who would be responsible for monitoring during snacks. E9 stated he initially was helping E7 pass snacks, but he had to leave to assist with a resident, so E7 continued to pass snacks by herself. E9 was in a resident room and denies supervising in the main dining room after snacks were passed. According to E9, it would either have been E7 or E14 who would have been responsible for supervising in the dining room for snacks. E9 was completing a transfer when he heard the code blue called. E9 confirmed the conversation with E3 afterwards when she reminded the CNAs to do their assignments and supervise residents during snack time. On [DATE] at 2:15 PM, E11 (CNA) stated she worked the evening of [DATE] and is familiar with R1. R1 requires supervision and tray set up. Residents are to be monitored when they eat. E4 was just returning from break when she heard the code blue called. According to E11, there is always a CNA assigned to the dining room when residents eat. E11 did not provide any supervision in the main dining room that evening as she had other duties including passing room trays. On [DATE] at 3:00 Pm, E10 (RN) stated she was familiar with R1, who required tray set up and supervision at meals. All residents are to be supervised during meals and snacks. While nurses and CNAs can provide monitoring at meals, nurses are not assigned to dining rooms, as they are in and out of the room more so than the CNAs. R1 occasionally ate too fast but would usually respond to redirection to slow her eating down. She had never choked prior to this incident. E10 was not working on the 400 wing that shift and is not sure who was providing supervision in that dining room. She is aware that E4 was in the area doing treatments. On [DATE] at 11:45 AM, E5 (RN) stated she was working in the 300 hall that shift, and knew that R1 ate in the main dining room. She required tray set up and there is always to be staff in the dining room when residents are eating Both CNAs and nurses can monitor during meals. The CNA passing the snacks is to provide supervision in the dining room . R1 would occasionally eat quickly but she responded to redirection to slow down. E5 was in the main dining room during dinner but not after snacks were passed. At dinner, there had been nothing unusual about R1. On [DATE] at 10:55 AM, E3 stated that she was still in the building on the evening shift of [DATE]. She stated she was in the E2's (DON) office when she heard E4 call for help. When she went to investigate, E4 was doing the Heimlich on R1; R1's eyes were closed and she was not responding. R1's hands were bluish, her face was pale and she had no pulse E3 also called for help; 2 nurses arrived and one called 911, the other got the crash cart. CPR was begun. The paramedics arrived very quickly and took over the code and then transported R1 to the hospital where she later died . On [DATE] at 11:30 AM, E3 stated that 1 CNA is assigned to each dining room during meals and snacks, and nurses can also monitor but they are in and out of the room. There is to be staff in the dining room when residents are eating. E3 stated she discussed with all the CNAs working that shift their whereabouts. E3 stated that 2 were helping other residents, some were showering and all were doing direct care with other residents. The CNA passing the snacks is to stay with residents while they eat. She instructed the CNAs to remain in the dining room or resident room when snacks are passed. On [DATE] at 3:40 PM, R4 stated he eats in the main dining room. He stated he was in the dining room when R1 began to choke. According to R4, there was a time when staff were not in the room; he could not say how long. R1 stated staff came in quickly when R1 started to choke. E2 was asked about the facility policy on supervision during meals on [DATE] and provided a copy of a policy entitled Supervision at mealtime. This policy says , to provide adequate supervision at mealtime for residents who require assistance and supervision. It further states that Nurses and CNAs will provide help to resident in the small dining room during meals. Resident who require assistance will eat in the small dining room with supervision and assistance, as well as residents with swallowing problems. E2 was questioned what supervision was provided in the main dining room, where R1 ate. On [DATE] at 3:25 PM, E2 stated that they do provide monitoring in the main dining room but the people eating in the small dining room require more physical assistance than those in the main dining room. E2 agreed that all residents require supervision at meals and that there should be staff present when residents are eating, regardless of what dining room they are in. No staff interviewed reported monitoring or providing supervision in the dining room while residents were eating their snacks, up until the time E4 walked back into the dining room and observed R1 already stuffing food into her mouth. E7 adamantly stated that she gave R1 2 cookies and juice for a snack and yet R1 choked on a sandwich, according to E4. Additionally, several of the staff noted that R1 had a habit of eating too fast and requiring cueing to slow her eating down. However, despite this known behavior on the part of R1, there was no plan of care developed for this behavior. R1's entire care plan was reviewed, and while there was some behavioral care plan in place, none addressed the behavior of eating too quickly. The inappropriate behavior identified was resisting care and yelling. R1 was identified as having impaired communication and risk factors that required monitoring and intervention to reduce the potential for self-injury related to falls. R1 was also care planned for impaired cognition and was noted that R1 needed adequate time to respond to questions and make her needs known. R1's current care plan for Nutrition indicates R1 is to be fed. On [DATE] at 1:30 Pm, E8 (MDS Coordinator) states that R1 is able to eat independently and she was not aware that her care plan says that she should be fed. According to E8, that is not accurate. E8 stated resident care plans get updated each quarter and they read them quickly and if no changes, sign the bottom and put a new date on it. The date of [DATE] on the bottom of the care plan indicates a review date and E8 stated that they must not have noted that it said R1 was to be fed.

Based on interview and record review, the facility failed to implement nutritional interventions recommended by the dietitian, failed to follow the facility policy for updating the nutritional care plan and failed to monitor a resident 's oral intake. This failure resulted in R1 sustaining a 12.25% weight loss over 6 months, and requiring hospitalization for dehydration, and protein-calorie malnutrition. This applies to 1 of 3 (R1) residents reviewed for weight loss. The findings include: R1 is no longer in the facility. The physician's orders [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] showed R1 had unclear speech and sometimes understood others. R1's MDS also showed R1 required limited assistance with walking and eating. R1 required extensive assistance with bed mobility, transferring between surfaces, dressing, toileting, hygiene and bathing. R1 was incontinent of bladder and bowel. The facility's Nursing Progress Review, dated 2/10/2015, showed R1 ate 50-74% of her meals and snacks in the last 7 days, and drank 50-74% of her fluids. The nursing progress review also showed R1 required her meals to be set up by staff and was able to eat with supervision only. On 3/24/2015 at 2:05 p.m., E8 (CNA-Certified Nursing Assistant) said she sometimes fed R1 her meals if she was having trouble eating. The facility's "Report of Monthly Weight" for R1 showed the following weights: September 2014: 106 pounds (lbs.) October 2014: 106 lbs. November 2014: 105 lbs. December 2014: 101 lbs. January 2015: 99 lbs. February 2015: 97 lbs. March 2015: 93 lbs. R1 had a severe weight loss of 7.92% for the three month period of December 2014 to March 2015, and a severe weight loss of 12.25% for the six month period of September 2014 to March 2015. Z2's (RD-Registered Dietician) dietary notes dated 12/28/2014 showed R1's weight of 101 lbs. and a body mass index of 18, "below standards." Z2 recommended "super cereal and whole milk." On 3/24/2015 at 2:00 p.m., E7 (Dietary Manager) said R1 never received the recommended super cereal or whole milk. On 1/20/2015, Z2's dietary notes showed R1's weight of 99 lbs. Z2 recommended "60 milliliters (ml.) of MedPass (dietary supplement) three times a day." Z3 approved and signed the dietary order. R1's Medication Administration Record [REDACTED]. On 2/13/2015, Z2's dietary notes showed R1's ideal body weight was 110 lbs. and R1's weight was 97 lbs. Z2 again recommended "super cereal and whole milk." Z3 approved and signed the dietary order for super cereal at breakfast and changing menu milk to whole milk. On 3/24/2015 at 2:00 p.m., E7 (Dietary Manager) said R1 never received the recommended super cereal or whole milk. "Maybe it just skipped my mind. I have so much work to do and I forgot about it. Now I won't." On 3/19/2015, Z2's dietary notes showed R1's weight of 93 lbs, and a body mass index of 17, "below standards." Z2 again recommended "60 ml. of MedPass three times a day." At the time the communication was written, R1 was in the hospital. On 3/24/2015 at 11:42 a.m., Z2 (RD) said she was not aware her dietary recommendations had never been put in place. Z2 said each month she met with E1 (Administrator), E2 (DON-Director of Nursing) and E7 (Dietary Supervisor) to discuss her dietary recommendations. Z2 said it was her understanding the facility was ensuring all dietary recommendations were being initiated unless the physician declined the recommendations. Z2 said it was also her understanding the facility was following through on dietary recommendations that physicians never returned or signed. The facility's Diet Listing sheets for the months of October 2014 through March 2015 showed residents' diet needs and supplements. R1's name was not on any of the Diet Listing sheets. R1's MedPass supplement, and super cereal and whole milk was not listed on any of the Diet Listing sheets for the aforementioned period. On 3/24/2015 at 12:38 p.m., E7 (Dietary Supervisor) said if the resident's name was not on the sheets, then the diet recommendations were never put in place. R1's Food/Fluid Intake Sheets did not show any oral intake for supper or bedtime snack/fluids for the months of January 2015 and March 2015. After this investigation started and the facility provided the incomplete March 2015 Food/Fluid Intake Sheet, E3 (RN-MDS Coordinator) asked a nursing assistant on 3/24/2015 at 3:00 p.m., to fill out the food/fluid intake sheet. An unknown nursing assistant completed the form "from her memory" E3 said. R1's care plan entitled "Potential risk for altered nutritional status and/or weight loss" was dated 1/29/2014 with a goal that R1 "will gain 1 pound per month for the next 90 days." R1's care plan showed: encourage self feeding, assist/feed at meal times as needed to complete meal, "follow recommendations of RD/LDN-notify RD/LDN of discrepancy of recommendation with Resident's preferences or care goals." R1's care plan was never updated to reflect her severe weight loss or any of the dietary recommendations. On 3/24/2015 at 11:42 a.m., Z2 (RD) said she does not update the resident's care plans. Z2 said E7 (Dietary Manager) is responsible for updating the care plans regarding weights or interventions. On 3/24/2014 at 12:38 p.m., E7 (Dietary Manager) said he does not update the resident's care plans. "It is not my job to update care plans, it is E3's (RN-MDS coordinator) responsibility." On 3/24/2014 at 1:25 p.m., E3 (RN) said E7 (Dietary Manager) should be updating the resident's care plans with any dietary or weight issues. Section K Swallowing/Nutritional Status of R1's Annual MDS dated [DATE] was coded incorrectly. R1's MDS showed no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, when, in fact, R1's weight in July 2014 was 111 pounds and R1's weight in January 2015 was 99 pounds, which was a 10.81% weight loss for the 6 month period. On 3/12/2015 at 5:15 p.m., R1 was transferred to a local hospital. E5's (RN-Registered Nurse) Nursing Transfer/Discharge assessment dated [DATE] showed R1 "continued with fever 100.4 F (Fahrenheit) to 100.9 F since this A.M. Has poor appetite and not taking fluids at this time. Lethargic, but arousable to verbal and tactile stimuli." Z4's (Hospital physician) consultation report dated 3/13/2015 showed R1 was admitted to the hospital with [REDACTED]." R1 had a nasogastric tube placed in the emergency room , in order to "start free water at 200 ml. per hour, and tube feeding." On 3/18/2015, Z3 (physician) documented R1 had a percutaneous gastrostomy tube inserted on 3/17/2015 to supplement oral nutrition. On 3/24/2015 at 3:28 p.m., Z3 (physician) said he expected the facility to follow his orders for the MedPass, super cereal and whole milk. "It would be my expectation that the orders would be carried out." Z3 said he expected the facility to accurately document oral intake and urine output, and that the oral intake the facility staff tried to recall for the month of March would not be an accurate assessment of R1's actual intake. Z3 said R1 improved with hydration at the hospital. The facility's policy entitled "Intake and Output" revised 12/2001 showed "C. After meals, CNA's document the amount of liquids, Jell-O, ice cream or liquids from soup, which the resident consumed in cc's on the daily assignment sheet, and/or report the total intake for your shift to your Charge Nurse.... D. The Charge Nurse will total all intakes for his/her shift and place in the separate columns on the Intake and Output record." The facility's policy entitled "Resident Weight Monitoring" revised 10/2013 showed "11. Significant weight changes are reviewed in the weekly Weight Committee Meeting. The Weight Committee will also identify any trends of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed."

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (R1) reviewed for hydration needs, had her fluid requirements met to prevent the development of severe dehydration and failed to follow the facility's Intake and Output Policy and Hydration Policy. As a result of this failure, R1 was admitted to the hospital with [REDACTED]. The findings include: On 3/30/2015 at 10:15 a.m., E2 (DON-Director of Nursing) said the last documented temperature for R1, prior to 3/12/2015, "was 96.8 F (Fahrenheit), sometime at the end of February 2015." The facility's nurse's notes for R1 dated 3/12/2015 at 6:00 a.m., showed R1 was "noted to be lethargic and weak with a body temperature of 100.5 F", for which R1's physician was notified. On 3/12/2015 at 7:00 a.m. the nurse's notes showed "cooling measures done. Resident remains lethargic, but responsive to verbal and tactile stimuli." On 3/12/2015 at 12:00 p.m., the nurse's notes showed "Medical Doctor (MD) paged, awaiting reply. Will endorse for next shift to monitor and follow up." On 3/12/2015 at 5:00 p.m., E5's (RN-registered nurse) nurse's notes for R1 showed "Resident continues with fever 100.4 - 100.9. Refusing to drink fluids. Lethargic but responsive. Z3 (physician) informed with new order to send out to local hospital. Temperature 100.5 F (axillary)." At 5:15 p.m., resident was transported to a local hospital via ambulance transport company. R1's "ADL (Activities of Daily Living) Flow Record" for 3/12/2015 lacked documentation to show R1 had any urine output for two consecutive nursing shifts. On 3/12/2015 at 5:15 p.m., R1 was transferred to a local hospital. E5's (RN-Registered Nurse) Nursing Transfer/Discharge assessment dated [DATE] showed R1 "continued with fever 100.4 F (Fahrenheit) to 100.9 F since this A.M. Has poor appetite and not taking fluids at this time. Lethargic, but arousable to verbal and tactile stimuli." Z4's (Hospital physician) consultation report dated 3/13/2015 showed R1 was admitted to the hospital with [REDACTED]." R1 had a nasogastric tube placed in the emergency room , to "start free water at 200 ml. per hour." R1's CMP (blood chemistry) on admission to the hospital on [DATE] showed an elevated BUN of 28 (normal 6-20 mg/dL), an elevated sodium level of 154 (normal range 136-145 mEq/L), and a potassium level of 3.4 (normal range (normal range 3.5-5.1 mEq/L). On 3/24/2015 at 3:28 p.m., Z3 (physician) said R1 improved with hydration at the hospital. Z3 said he was not notified R1 had no urine output for two consecutive nursing shifts, and his expectation was that he be notified for any resident not urinating. Z3 said he expected the facility to promptly document oral intake after meals, and urine output each shift. Z3 said any oral intake or urine output documented at a later date could not be considered accurate. On 3/30/2015 at 11:15 a.m., E10 (CNA-Certified Nursing Assistant) said she cared for R1 on 3/12/2015 beginning at 2:00 p.m. E10 said R1's temperature was 100.3 F at 2:00 p.m., and R1 "was sweaty and barely moved during my shift." E10 said she only changed R1's diaper one time, close to the time of her transfer at 5:00 p.m., and the diaper had a scant amount of urine in it. Z2's (RD-Registered Dietician) nutritional assessment dated [DATE] showed R1's fluid needs were "1323 milliliters (ml.) daily. R1's current diet order was general diet with thin liquids. Food/fluid intake sheets were reviewed for January 2015 through March 2015. Logs for January and March 2015 had spotty documentation. There was no documentation for oral/fluid intake for all evening meals and snacks for both January and March 2015. Documentation on R1's food/fluid intake sheet for the period of March 1 to March 11, 2015 showed R1 received between 360 ml. to 780 ml. of fluids daily. R1's care plan entitled "Fluid Volume Deficit concern for Resident" dated 1/29/2014 showed the following interventions: "Monitor for signs of elevated temperature, observe for signs and symptoms of dehydration such as dry, cracked lips, tenting of skin, increased confusion, decreased urinary output, etc., monitor for fluids loss from fever, vomiting, diarrhea." 2.) During mealtime observation on 3/24/2015 at 12:15 p.m., R2 was being fed by E9 (CNA-Certified Nursing Assistant) in his room. R2 had one 180 ml. cup of water on his tray, covered with a clear plastic wrap. The diet card on R2's tray showed R2 was to receive 2% milk and apple juice with all meals. E9 said she did not know why there was no juice or milk on R2's lunch tray. R2 said it was not her job to put the milk and juice on R2's lunch tray prior to serving his meal, and she would not be obtaining any milk or juice for R2. On 3/24/2015 at 12:38 p.m., E7 (Dietary Manager) said the kitchen is supposed to follow the diet card and R2 should receive 2% milk and apple juice with each meal. "I will have to talk to them about that." The facility's policy entitled "Hydration Program", revised 2/2008, showed "4. Record the amount of fluids resident consumes at meals and any other specified times, on meal/fluid intake log." The facility's policy entitled "Intake and Output" revised 12/2001 showed "C. After meals, CNA's document the amount of liquids, Jell-O, ice cream or liquids from soup, which the resident consumed in cc's on the daily assignment sheet, and/or report the total intake for your shift to your Charge Nurse.... D. The Charge Nurse will total all intakes for his/her shift and place in the separate columns on the Intake and Output record."

Based on Observation, Record Review, and Interview the facility failed to supervise and/or provide assistive devices for one resident (R1) in a sample of three residents reviewed for falls. This resulted in R1 sustaining a fractured Right Femur and being transferred to a local emergency room for evaluation and treatment. This fracture was avoidable due the lack of supervision. Examples include: R1's March 2011 physician's orders [REDACTED]. R1's Minimum Data Set ( MDS ) dated 12/27/10 assessed R1 as dependent for transfers. R1's 02/03/11 Nursing Progress Review documented that R1 is a fall risk - History of falls. On 03/03/11 at 10:00am R1 was sitting up in a wheelchair in her bedroom. A right leg knee immobilizer was in place. The left lower leg was bluish in color. No edema was noted. R1 denied pain. Appeared to confused to time and place. When asked what happened to her leg, she stated, " I fell ". R1 could not describe time , place, or how a fall occurred. E1, Administrator, E2, Director of Nursing, E3, Certified Nursing Assistant, E4, Nurse, and E5, Nurse were interviewed privately and separately. All agreed that R1 had right knee pain, was transferred to a local emergency room , and R1 was diagnosed as having a fractured Right Femur. All denied any knowledge of R1 incurring a fall or other trauma to her right leg. R1's Nursing Notes dated 02/21/11 R1's Right knee was swollen and pain was noted in the area. An X-Ray to the area was ordered and completed. The X-Ray was negative. On 02/22/11 pain continued and R1 was sent to a local emergency room for evaluation and treatment. An X-Ray and a Computerized Tomography Scan were done on 02/22/11. Both of these documented the impression as a Fracture distal femur. On 03/07/11 at 03:30pm a phone interview was conducted with Z2, an Orthopedic Surgeon. Z2 stated, " R1's femur fracture is most likely from a fall -- it's classic. Less likely the fracture may have occurred from a transfer,whereby her leg was caught and the transfer continued without releasing it. Even with R1's severe osteoporosis, the fracture could not have occurred while lying in bed or sitting in a chair. There had to have been some event. This fracture was unlikely to have occurred during a normal transfer. In adults R1's particular type of fracture is caused by impact. In my opinion, the most likely cause of R1's fracture is a fall on the knee."