Every finding on record at Spring Creek

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and implement appropriate interventions to prevent falls for residents considered to be at high risk for falls. This applies to 3 of 3 residents (R1, R4, and R9) reviewed for accidents and supervision. The findings include: 1. R1's face sheet showed R1 was admitted to the facility on [DATE]. R1 had multiple diagnoses that included hepatic encephalopathy, major depressive disorder, anxiety, muscle wasting, abnormal gait and mobility, dementia, delirium, Alzheimer's Disease, communication deficit, restlessness, agitation, hypotension, and spinal stenosis.R1's MDS (Minimum Data Set) dated May 08, 2026, showed R1 had severe cognitive impairment and required maximal assistance to total dependence on staff to complete most activities of daily living.R1's progress notes showed R1 had ten falls from March 2026 to July 2026. On June 28, 2026, R1 had a fall that resulted in a bump to the left occipital area of his head. Progress notes dated July 21, 2026, July 09, 2026, April 29, 2026, April 28, 2026, and April 13, 2026 showed R1 was found lying on the floor in the dining room next to his chair.R1's current fall care plan showed R1 had falls related to behaviors of unassisted transfers and ambulation with initiation dates of April 29, 2026, May 01, 2026, June 26, 2026, and July 02, 2026. However, there were no specific interventions listed to address each fall. R1's current care plan showed an intervention for R1 to be placed in supervised area when out of bed and observed frequently on May 19, 2025.On August 04, 2026, at 2:37 PM, V16 (CNA) said that she found R1 on the floor next to his wheelchair last month. V16 said that she could not remember the day, but she was walking into the dining room with V15 (CNA). V16 said that there were no staff members in the dining hall during that time.On August 04, 2026, at 3:05 PM, V7 (CNA), said that she recalled R1 having a fall previously when she was on her way home for the day. V7 said that R1 fell in the dining room and that there were no other staff members in the dining room during that time.2. R4's face sheet showed R4 was admitted to the facility on [DATE]. R4 had multiple diagnoses that included hemiplegia, hemiparesis, dysphagia, dementia with psychotic disturbance, major depressive disorder, Alzheimer's disease, and difficulty walking.R4's MDS dated [DATE], showed R4 had severe cognitive impairment. R4 required maximal assistance to dependence on staff to complete most activities of daily living.R4's incident description notes showed R4 was found on the dining room floor by staff on July 06 and July 08, 2026. The incidents were noted as unwitnessed falls. On July 10, 2026 R4 was found on the floor at the end of the hallway by a CNA. On July 20, 2026 R4 was found on the floor at the end of the hallway by a nurse. They were unwitnessed falls. On July 25, 2026, R4 had an unwitnessed fall and was found on the floor next to his wheelchair.R4's current fall care plan had an intervention initiated on May 15, 2026 that showed R4 should have been placed in a supervised area when out of bed. There were no interventions to address R4's falls on July 20, 2026 and July 25, 2026. An intervention initiated on July 21, 2026 showed that R4 had a fall related behavior of unassisted transfers, but there was no intervention listed.3. R9's face sheet showed R9 was admitted to the facility on [DATE]. R9 had multiple diagnoses that included hallucinations, neurocognitive disorder with Lewy Bodies, dementia with behavioral disturbances, ataxic gait, and anxiety.R9's MDS dated [DATE], showed R9 had severe cognitive impairment. R9 required supervision to moderate assistance from staff to complete activities of daily living.R9's incident description notes showed R9 had a fall in the dining room on May 07, 2026. On May 06, 2026 and June 23, 2026, R9 was found in the bathroom on the floor. On July 05, 2026 R9 was found on the floor next to the nurse's station. On June 26, 2026 and July 1, 2026, R9 was found on the floor in her room.R9's current care plan had an intervention that was initiated on August 12,2025, that showed R9 should have been observed frequently and placed in a supervised area when out of bed. An updated intervention dated June 25, 2026, showed staff should have provided frequent toileting assist during morning and evening shift.On August 04, 2026, at 10:09 AM, V6 (CNA), said that there should always be a staff member in the dining area monitoring residents to prevent falls. V6 said that there is no assigned time, staff just switches off when they can.On August 03, 2026, at 12:15 PM, R1 was in the dining room seated in a high back wheelchair. R1 was agitated and attempted to get out of his chair several times. R1's chair was not locked on the right side. R1's wheelchair continued to move as R1 attempted to get out of the chair. V4 (CNA) was sitting next to R1 and confirmed that R1's wheelchair was not locked. During this time R4 was seated at a separate table attempting to stand from his wheelchair. R9 was rolling up and down the hallway near the dining room. V4 said that R1, R4, and R9 were high fall risk residents and needed to be monitored at all times.On August 03, 2026, at 3:32 PM V5 (CNA) was observed sitting in the corner of the dining room rummaging through her phone during monitoring time for residents.On August 04, 2026, at 1:48 PM, V3 (Restorative Nurse), said that a lot of the falls that occurred were behavior related falls. V3 said that they try to put interventions in place that best helps residents to address that specific occurrence. In reviewing current fall care plans, V3 confirmed that while the care plans addressed that there were behavior related falls for some incidents, it did not reflect implementation or adjustment of interventions to prevent identical occurrences in the future. V3 said that high fall risk residents were placed in areas of high visibility such as the nurses' station or dining area. V3 said that it is hard to re-educate the residents who have cognitive decline, so they try to re-educate the staff. V3 said that most falls occur on the third floor during the day shift and that staff are supposed to monitor residents closely in the dining room. V3 said that there were times when staff were on their phones in the dining area and were not paying attention to their surroundings.On August 04, 2026, at 2:14 PM, there were no aids located in the dining room with residents on the second floor.On August 04, 2026, at 2:40 PM, V9 (LPN) said that she had noticed CNAs on their phones several times when they were supposed to be monitoring residents in the dining room. V9 said that when they were on their phones, they were not paying attention to the residents.On August 04, 2026, at 2:50 PM, V10 (RN), said that she noticed two CNAs on their phone on August 03, 2026, when they were supposed to be monitoring the residents. V10 said that she informed the staff members that the behavior was not appropriate and that they needed to put their phones away.On August 04, 2026, at 3:50 PM, V20 (RN) said that staff were supposed to be monitoring the residents in the dining room to prevent falls. V20 said that she had noticed CNAs on their phones in the dining room and she had asked them to turn them off because they were at work and should have been working.On August 04, 2026, at 4:15 PM, V2 (Director of Nursing) said that there should always be staff members present in the dining room monitoring the residents who are at a high risk for falls. V2 said that it is a bad habit of staff to utilize their phones while at work and staff should be focused on monitoring residents while in the dining room.On August 04, 2026, at 4:40 PM, V1 (Administrator) said that he was aware of the concerns regarding staff members on their phones during monitoring hours. V1 said that he believed that the falls were due to behaviors and an increase in census. V1 said that V2, V21 (Assistant Director of Nursing), and V3 (Restorative Nurse) inform the staff of what the interventions are for each resident. V1 said the staff should know who the high fall risk residents are and implement those interventions. V1 said that when those interventions are not working, they are readjusted. V1 said that staff should be monitoring residents with increased supervision.The facility's Safety and Supervision of Residents policy and procedure dated March 2025, showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident-Oriented Approach to Safety includes:1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents.2. Staff may use various sources to identify risk factors for residents, including the information obtained from medical history, physical exams, observation of the residents, and the MDS.3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident.4. Implementing interventions to reduce accident risks and hazards may include the following:a.) communicating specific interventions to all relevant staff.b.) assigning responsibility for carrying out interventions.c.) providing training, as necessary.d.) ensuring that interventions are implemented; ande.) documenting interventions.5. Monitoring the effectiveness of interventions shall include the following:a.) ensuring that interventions are implemented correctly and consistently.b.) evaluating the effectiveness of interventions.c.) modifying or replacing interventions as needed; andd.) evaluating the effectiveness of new or revised interventions.Systems Approach to Safety1.The facility-oriented and resident-oriented approaches to safety are used together to implement systems approaches to safety, which consider the hazards identified in the environment and individual resident risk factors and then adjust interventions accordingly.2.Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.3.The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice by failing to follow physician orders to reduce the risk of injury from falls. This applies to 1 of 3 (R1) residents reviewed for safety and fall preventions. The findings include:R1's face sheet showed R1 was admitted to the facility on [DATE]. R1 had multiple diagnoses that included hepatic encephalopathy, major depressive disorder, anxiety, muscle wasting, abnormal gait and mobility, dementia, delirium, Alzheimer's Disease, communication deficit, restlessness, agitation, hypotension, and spinal stenosis.R1's MDS (Minimum Data Set) dated May 08, 2026, showed R1 had severe cognitive impairment and required maximal assistance to total dependence on staff to complete activities of daily living. R1's current physician orders summary showed an order dated December 03, 2025 for R1 to wear a soft helmet when up, to reduce risk of injury from fall. Soft helmet may be removed for hygiene and meals. R1's progress notes showed R1 had ten falls from March 2026 to July 2026. On June 28, 2026, R1 had a fall that resulted in a bump to the left occipital area of his head. Several notes reported R1 lying on the floor next to his wheelchair. On August 03, 2026, at 12:15 PM, R1 was in the dining room seated in a high back wheelchair. R1 was agitated and attempted to get out of his chair several times. R1 did not have a soft helmet on his head. On August 03, 2026, at 2:24 PM, R1 was in the dining room sleeping in a high back wheelchair. R1 did not have a soft helmet on his head. On August 04, 2026, at 10:09 AM, R1 was sleeping in a high back wheelchair in the dining room. R1 did not have a soft helmet on his head. On August 04, 2026, at 2:35 PM, R1 was sleeping in high back wheelchair in the dining room. R1 did not have a soft helmet on his head. On August 03, 2026, at 12:14 PM, V4 (CNA) said that R1 required monitoring for fall interventions and said that sometimes they play music for R1. V4 was unaware of an order for a soft helmet for R1. On August 04, 2026, at 10:09 AM, V6 (CNA) said that R1 sits in the dining area most of the day for monitoring. V6 was unaware of a soft helmet for R1. On August 04, 2026, at 2:35 PM, V15 (CNA) said that R1 was a high fall risk. V15 said that staff would monitor R1 and give R1 snacks to try to keep R1 calm. V15 was unaware of a soft helmet for R1. On August 04, 2026, at 3:40 PM, V19 (RN), said that she was familiar with R1 and was the nurse on duty for some of R1's fall incidents. V19 said that R1 was a high fall risk that required monitoring from staff. V19 said that R1 had the ability of a younger gentleman and would often jump out of his chair. V19 was not aware of a soft helmet for R1. On August 04, 2026, at 4:15 PM, V2 (Director of Nursing) said that she was unaware of the order for a soft helmet for R1. V2 said that she was unsure of why R1 was not wearing the soft helmet and would have to look into it. The facility's Safety and Supervision of Residents policy and procedure dated March 2025, showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident oriented approach to safety includes: 4.) Implementing interventions to reduce accident risks and hazards may include the following: d.) ensuring that interventions are implemented; and e.) documenting interventions. 5.) Monitoring the effectiveness of interventions shall include the following: a.) ensuring that interventions are implemented correctly and consistently.

Based on observation, interview, and record review, the facility failed to implement nutritional interventions for a resident (R10) with a known significant weight loss. This failure resulted in R10 experiencing additional significant weight loss of 10.3% in one month. The facility also failed to serve residents double portions as ordered.This applies to 3 out of 4 (R10, R27, and R106) residents reviewed for nutrition in a sample of 27.The findings include:1. R10's nutritional care plan initiated on 11/03/2025 said he was at risk for compromised nutritional status. The care plan's goal was for R10 not to experience any further weight loss. The interventions included for R10 were to serve his nutritional diet as ordered.On 12/09/2025 at 12:55 PM, R10 was confused in the dining room for lunch. R10 was thin and appeared frail. V4 (Restorative Nurse) served him his lunch, which included single portion servings of regular turkey, mashed potatoes, and mixed vegetables. V4 reviewed R10's ticket and said he did not receive the double portions as indicated on his meal tray.R10's meal ticket said he was to receive double portions for all his meals.On 12/10/2025 at 12:55 PM, R10 was sleeping in the dining room. R10 was not served his lunch during the meal service. At 1:30 PM, R10 was still sleeping in the dining room. V11 (Licensed Practical Nurse/LPN) said R10 did not eat lunch because he was sleeping, and they would offer him two peanut butter and jelly sandwiches later. V11 said she was unsure if R10 ate breakfast. Then V11 checked R10's EMR (Electronic Medical Record) meal intake documentation and said R10's last recorded meal was on 11/30/2025. At 2:30 PM, V11 said R10 was able to wake up and ate one peanut butter and jelly sandwich.R10's EMR meal intake document, reviewed for the past 30 days, showed his meal intake was last recorded on 11/30/2025. The document showed a total of fifteen meal intake entries in the 30-day lookback period for R10.On 12/11/2025 at 11:20 AM, V3 (Assistant Director of Nursing/ADON) obtained R10's standing weight and said his weight was 131.8 lbs. (pounds). V3 said R10 had known weight loss recently, and the dietician (V17) was aware. V3 said residents' weights were monitored weekly, and if ordered more frequently.R10's EMR recorded weights:09/05/2025 159.2 lbs (standing)10/14/2025 138.0 lbs (standing)11/04/2025 147.0 lbs (standing)12/05/2025 145.7 lbs (standing)On 12/11/2025 at 1:55 PM, V17 (Registered Dietitian) said she was aware of R10's ongoing weight loss. V17 said on 11/04/2025 she reviewed R10's nutrition, and R10 was identified to have significant weight loss for the past three and six months and a significant weight gain in one month. V17 continued to say that R10's BMI (body mass index) was 19.9 (below normal range). V17 said R10 was already receiving a nutritional supplement of 240 milliliters (ml) three times a day, and she did not make any additional recommendations. V17 said reviewing R10's weights now, she suspects his weight gain in November was possibly an error weight. V17 said on 11/20/2025, the facility informed her of R10's family's request for double portions for his meals due to his weight loss. V17 said she was now very concerned regarding R10's additional significant weight loss of 10.3 % in one month. V17 said she was not on-site and was dependent on nursing staff to accurately and consistently document meal intakes and weights to assess residents' nutritional needs. V17 said R10's last recorded meal intake was on 11/30/2025. V17 said if R10's weight and nutritional intake had been monitored more closely; his significant weight loss could have been prevented.V17's Dietary Progress Note dated 11/14/2025, said res (resident) with hx (history) of weight loss; res triggered for sig (significant) weight loss x 3 and 6 months, sig weight gain x 1 month this month. The note said R10's nutritional interventions were a 240 ml nutritional drink with meals, spill proof cup, and his meal intake was reviewed and varied from 26-100%. The note said No new nutrition recommendation, continue with current dietary interventions as tolerated. Will continue to monitor weight changes per facility protocol. Plan: Continue to follow with RD (registered dietician) available for consult PRN (as needed).V17's Dietary Note dated 12/11/2025 (during survey), said res with hx of weight loss; res with additional sig weight loss this month, weight dropped from 145 to 131.8# this week, res with underweight BMI at 17.9.On 12/11/2025 at 1:40 PM, V18 (General Nurse Practitioner) said she was not aware of R10's weight loss. V18 said she expected the facility to monitor residents' weight monthly and if needed more frequently to ensure weight loss was identified. V18 continued to say the facility's dietician was also to be monitoring and managing residents' weights, intake, and nutritional needs with the goal to ensure their nutritional needs were met.The facility's policy titled Weight Assessment and Interventions, dated 01/2025, said the facility was to ensure that residents were to be monitored for undesirable weight loss or gain so appropriate interventions can be put in place in a timely manner. The residents would be weighed, and the dietician would review the recorded weights to identify and address weight issues. The dietician would also discuss findings with the IDT (Interdisciplinary Team) with the goal identify possible interdisciplinary approaches and interventions. 2. On 12/09/2025 at 12:55 PM, V14 (Certified Nurse Assistant/CNA) was feeding R106 his lunch in the dining room. R106's meal included single portion servings of mechanical turkey, mashed potatoes, and mixed vegetables. V14 said R106's ticket said he was to receive double portions for his lunch but did not receive them.On 12/10/2025 at 12:25 PM, V14 was feeding R106 his lunch in the dining room. R106 was served single portions of mechanical spaghetti and mixed vegetables. V14 said R106 again was not served double portions as indicated on his meal ticket.R106's meal ticket said he was to receive double portions for all his meals.3. On 12/09/2025 at 1 PM, R27 was being assisted with his lunch in the dining room. R27's meal included single portion servings of mechanical turkey, mashed potatoes, and mixed vegetables. V14 said R27's ticket said he was to receive double portions for his lunch, but he did not receive them.On 12/10/2025 at 1 PM, V7 (CNA) was feeding R27 his lunch in the dining room. R27 was served single portions of mechanical spaghetti and mixed vegetables. V7 said R27 was not served double portions as indicated on his meal ticket.R27's meal ticket said he was to receive double portions for all his meals.On 12/11/2025 at 11 AM, V21 (Dietary Manager) said meal trays were prepared by the dietary staff in the kitchen. V21 said staff were expected to review the ticket menus to ensure nutritional interventions, such as double portions, were served as ordered. V21 said nutritional interventions were specific dietary recommendations to meet the needs of the residents. V21 said he was not notified that R10, R27, and R106 did not receive double portions for their lunch as ordered.The facility's policy titled Double Portions, dated 04/2023, said residents with double portions orders will be given double entree, double side, and double starch at meals as reflected in their diet orders.

Based on observation, interview and record review the facility failed to secure and store cleaning supplies, safely transfer residents, and implement positioning and fall interventions.This applies to 4 of 6 residents R29, R61, R106, R111 reviewed for safety hazards in a sample of 27.Findings include: 1) On 12/09/2025 at 11:12 AM, an unsecured cleaning cart in a residents' room hallway had an 8oz (Ounce) bottle of dermal wound cleanser with blue liquid, a 1qt (Quart) generic spray bottle with fluid, and a 1 qt bottle of pine cleaning product. On 12/09/2025 at 11:22 AM, V22 Housekeeper returned to the unsecured cart stating she stepped away to throw out garbage. V22 stated she retrieved the wound cleanser bottle from the trash. V22 stated she put glass cleaner in the wound cleanser bottle because her previous bottle had broken. She was going to request a new bottle from her supervisor later. V22 stated the generic spray bottle contained bleach. V22 stated the cart did not have a locked compartment to secure items. V22 stated there is a storage room where carts are kept secured when they are done cleaning. On 12/11/2025 at 9:44 AM, V25 Housekeeping Supervisor stated when the housekeepers walk away from their carts, they should be secured in the cleaning closet or garbage room. They are stored in a locked room to prevent residents from taking items from the cart and avoid any incidents of theft. V22's glass cleaner bottle had broken, but she should not have used a bottle from the trash because it is not hygienic. The SDS (Safety Data Sheet) for the germicidal bleach hazard statement states it causes skin irritation and serious eye damage. Inhalation of vapors in high concentrations may cause irritation of respiratory system. Avoid contact with eyes may cause burns. Avoid contact with skin may cause irritation. Maybe harmful if swallowed. The SDS for the glass cleaner states it is an eye irritant. Hands should be washed thoroughly after handling. Store in original container in an upright position in cool, dry area. Do not store near oxidizers, alkalizes, acids and bleach. Do not mix with other chemicals. The SDS for pine cleaner states to handle in accordance with good industrial hygiene and safety practice. The undated facility policy Housekeeping Guidelines declares the purpose is to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors. The policy provides no direction on the proper storage or use of hazardous cleaning products. 2. On December 9, 2025, at 10:12 AM, V6 (CNA/Certified Nurse Assistant) was assisting to transfer R111 from the bed to the high back wheelchair. V6 put her hand underneath R111's left arm, held the waistband of R111's pants and pulled her up to a standing position and pivoted her into the high back wheelchair. V6 did not use a gait belt. On December 11, 2025, at 11:31 AM, V16 (CNA) said when she transferred the residents who required a one assist, she would stand in front of them, put her right leg in front and bring the chair close to the left side, and use their waistband to hold and transfer them. On December 11, 2025, at 11:46 AM, V4 (Restorative Nurse) said for transfers, the staff have to use a gait belt to transfer residents. V4 said the staff should not be using the residents' waistbands to transfer the residents. V4 said R111 required extensive assist with two staff for transfers and needed a staff on each side of her to assist transferring her. On December 11, 2025, at 11:38 AM, V14 (Restorative CNA) said staff should use gait belts to transfer residents who required a one assist. V14 said R111 needed two assist to transfer to the bed, adding that R11 actually had recently been changed to needing the mechanical lift to transfer instead. On December 11, 2025, at 2:10 PM, V2 (DON/Director of Nursing) said the staff should not be pulling residents by their waistbands but should use a gait belt to transfer. V2 said it was a safety concern which could hurt their skin, their pants could rip, and they could fall. R111's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis affecting right dominant side, chronic pain, failure to thrive, encounter for palliative care, repeated falls, and altered mental status. R111's MDS (Minimum Data Set) dated November 25, 2025, showed R111 required substantial assistance for sit to stand, and chair to bed to chair transfers. R111's Care Plan dated April 8, 2025, showed R111 has history of falling [related to] poor safety awareness, impulsive behavior and believe she is more independent than capable. R111's Care plan dated January 30, 2025, showed R111 has a self-care deficit with showed an intervention for extensive assist x2 for transfers and transfer with mechanical lift x2 onto shower chair. The facility's Gait Belt policy revised January 2025 showed to Place the gait belt around the resident's waist.Grab belt webbing securely at resident's back and resident's right or left side to support resident balance during transfers. 3. On December 10, 2025, at 3:01 PM, V8 (CNA) and V6 (CNA) hooked R61 to the mechanical lift to transfer R61 from the wheelchair to the bed. R61 had fall mats down and in place on both sides of her bed. V8 lifted R61 from the wheelchair using the mechanical lift and moved the mechanical lift towards R61's bed. V8 rolled the mechanical lift over the fall mat on the right side of the bed and lowered R61 into the bed. R61's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis affecting right dominant side, pain in left knee, altered mental status, and speech disturbances. R61's MDS dated [DATE], showed R61 had moderate cognitive impairment and was unable to transfer herself in or out of the chair or bed. R61's Care Plan dated February 18, 2025, showed R61 was at risk for falls [related to] hemiplegia. On December 11, 2025, at 11:46 AM, V4 (Restorative Nurse) said fall mats should be moved prior to the resident being transferred back into bed. V4 said the fall mat should be up when transferring the resident because it could cause the mechanical lift from being able to roll over them and get under the bed properly. V4 said the base of the mechanical lift needed to be properly underneath the bed. On December 11, 2025, at 2:10 PM, V2 (DON/Director of Nursing) said fall mats should not be down when transferring a resident back to bed as it was a tripping hazard and could also cause the mechanical lift to tip. The facility's Safety and Supervision of Residents policy revised March 2025 showed the facility-oriented and resident-oriented approaches to safety are used together to implement systems approaches to safety, which consider the hazards identified in the environment and individual resident risk factors and then adjust interventions accordingly. 4. R29's fall care plan said he was at a high risk for falls. The care plan included an intervention initiated on 9/02/2025 to provide R29 with a chair appropriate for his stature and on 12/05/2025 for staff to be educated on fall prevention and strategies in keeping him safe. On 12/09/2025 at 10:20 AM, R29 was in the dining room in his (specialized high-back) chair. R29 appeared uncomfortable with his unsupported legs dangling and resting his head on the right armrest. At 10:50 AM, R29 remained in the dining room sitting in a (specialized high-back) chair in a slouched position. R29 appeared uncomfortable. R29 had a shorter stature, and his legs were dangling unsupported because the chair's leg rest and footrest were missing. R29 was confused and non-interviewable. On 12/10/2025 at 11:50 AM, R29 was in the dining room sitting unsafely across the seat of his (specialized high-back) chair with his legs placed over the left armrest. Nursing staff were present but failed to assist R29 with safe positioning. R29's chair again had no leg rest or footrest attached. The facility's Fall Incident report from October to December 2025 said R29 had fallen four times. On 10/07/2025, 11/01/2025, 11/12/2025, and 12/04/2025, R29 was observed on the floor in front of his wheelchair in the nursing common areas. 5. R106's fall care plan said he was at a high risk for falls. The care plan included an intervention initiated on 11/07/2025 to provide a non-slip material device to his chair. R106's care plan was last updated on 11/20/2025 with an intervention to provide non-slip seating material when up in the chair. On 12/09/2025 at 10:45 AM, R106 was in the dining room in a (specialized high-back) chair leaning and resting his head on the right arm rest. R106 did not have a non-slip material in his seat. On 12/11/2025 at 10:20 AM, R106 was in the dining room in a high-back wheelchair. R106 again did not have a non-slip material in his seat. Also, R106's feet were dangling because they were unsupported. The wheelchair did not have a footrest attached. The facility's Fall Incident report from November-December 2025 said R106 had fallen four times. On 11/07/2025, 11/19/2025, 11/23/2025, and 12/08/2025, R106 was observed on the floor in front of his (specialized high-back) chair in the dining room. On 12/11/2025 at 10:30 AM, V7 (Certified Nurse Assistant/CNA) said there was a posted communication sheet for high-risk fall residents throughout the nursing unit to ensure staff were aware and implement their identified safety precautions. V7 said R29, R106, and R27 were also frequent fallers as indicated in the posted communication sheet. On 12/11/2025 at 10:40 AM, V3 (Assistant Director of Nursing/ADON) said R29, R106, and R27 had recurrent falls and required staff to monitor them closely for their safety. V3 assessed R106 and said he did not have his non-slip device intervention in place. V3 said staff were expected to implement the specific fall interventions as indicated in the fall communication sheet. On 12/11/2025 at 12:20 PM, V4 (Restorative Nurse) said residents were assessed and evaluated after a fall incident with the goal to identify the root cause. V4 said once the IDT (Interdisciplinary Team) reviews a fall incident, they then develop resident-centered interventions with the purpose to prevent injury or reoccurrences. V4 said then residents' care plans were updated to communicate the interventions to the staff. V4 continued to say staff should be monitoring and assisting residents with safe sitting positioning to prevent injury or accidents. The facility's policy titled Safety and Supervision of Residents, dated 03/2025, said the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. They use facility systems and resident-oriented approaches to implement safety. They address resident safety and accident hazards via an individual approach. The IDT team will analyze risk factors based on observations and information reviewed. Then they implement interventions by communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented and documented.

Based on observations, interviews, and record reviews, the facility failed to label and securely store drugs and biologicals for 7 out of 7 residents (R86, R111, R130, R57, R49, R73, & R91) reviewed for medications in a sample of 27.The findings include:1.On [DATE] at 1:00 PM a check of the facility's medication cart #3 was conducted with V3 ADON (Assistant Director of Nursing) and the following was found: R86's open bottle of antiacid and anti-gas without an open date on it. R111's open bottle of Levetiracetam (Keppra) (Anticonvulsant) 100mg/ml quantity 300 without an open date on it. R130's open bottle of Lactulose (Laxative) 16 oz without an open date on it. R57's open bottle of Valproate Sodium (Anticonvulsant) 250/5ml 16 oz bottle without an open date on it. The following stock medications and biologicals were found: 1 open bottle of Geri-Tussin DM 16 oz bottle (cough suppressant and expectorant) without and open date on it. 1 open bottle of Polyethylene Glycol 3350 (laxative) 17.9 oz without an open date on it. 1 open bottle of Reguloid 13 oz (Laxative) without an open date on it. 1 container with a 1/4 cup of a white powder in it that the snap-on lid was missing. The container was not labeled or dated. V3 said that the substance was a liquid thickener. On [DATE] at 1:00 PM, V3 said that she doesn't date all the medications that she opens. V3 said that the white substance should have been properly contained because if not the substance can get contaminated. V3 said that if the medications do not have an open date on them, you do not know when to dispose of them. On [DATE] at 1:33 PM, V2 DON (Director of Nursing) said that all open medications are to have an open date on them and all containers should be labeled to identify the content. V2 said that if the medication or biological is not properly contained it can become contaminated. V2 said that if a contaminated medication or biological is given to a resident, they can become ill. V2 said that if the open medication or biological is not labeled with an open date, you don't know when it is expired. V2 said that if an expired medication or biological is given to a resident, they can become ill. R57's [DATE] physician's order showed Valproate Sodium Oral Solution 250 mg/5ml give 10 ml by mouth two times a day for agitation: anxiety. R111's [DATE] physician's order showed Keppra Solution 100 MG/ML give 5ml by mouth two times a day related to epilepsy. R130's [DATE] physician's order showed Lactulose Oral Solution 20 GM/30ml give 30 ml by mouth two times a day related to toxic encephalopathy. R86's [DATE] physician's order showed Maalox Max Oral Suspension 400-400-40 MG/5ml give 15 ml by mouth every 6 hours as needed for indigestion. The facility's Medication Storage policy dated [DATE] showed that medications and biologics are stored safely, securely, and properly. When the original seal or a manufacturer's container or vial is initially broke, the container or vial will be dated. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. 2. On [DATE] at 11:27 AM, R91 was sitting up in bed. R91 had a nebulizer machine and two unopened vials of Albuterol Sulfate for inhalation on the bedside table. R91 stated he adds the Albuterol Sulfate for inhalation to the machine on his own. R91 stated the nurses do not watch him as he adds the medication to the machine or applies the mask for inhalation. R91 stated he gives himself the nebulizer breathing treatment every day. On [DATE] at 4:07 PM, V2 (Director of Nursing) stated the facility did not have any residents that could self-administer medications. V2 stated no medications should be stored at the bedside unless the resident had an order for it. V2 stated residents could get hurt or take the wrong dosage if medications are left at the bedside. R91's admission Record showed R91 was admitted to the facility on [DATE] with multiple diagnoses which included chronic obstructive pulmonary disease, nuclear cataract, myopia, dementia, major depressive disorder, anxiety, and polyarthritis. R91's Order Summary Report for [DATE] showed an active order for Ipratropium-albuterol Solution 0.5-2.5 (3) mg (milligram)/mL (milliliter). Inhale orally every four hours as needed for SOB (Shortness of breath) or wheezing via nebulizer. The Order Summary Report showed no active orders for medications to be stored at the bedside. 3. R49 On [DATE], at 11:28 AM, R49 had a medication cup with a small, circular white pill inside of it, which had the letters AC 145 written on it. R49 said she was not sure what the medication was for but thought it may be her medication for high blood pressure. R49's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side, hypertension, cerebral edema, and nontraumatic intracerebral hemorrhage. R49's POS (Physician Order Sheet) dated [DATE], showed an order for Chlorthalidone Tablet 25 MG (Milligrams) Give 1 tablet by mouth one time a day related to essential primary hypertension. 4. R73 On [DATE], at 10:42 AM, R73's fridge contained Fluticasone Propionate Nasal Spray 50 MCG (Micrograms). R73's fridge was not locked. R73's face sheet showed he was admitted to the facility with diagnoses including chronic obstructive pulmonary disease. R73's POS (Physician Order Sheet) dated [DATE], showed an order for Fluticasone Propionate Suspension 50 MCG/ACT (Micrograms/Activation) 1 spray in each nostril at bedtime for allergies. The facility's Storage of Medications policy revised [DATE], showed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevents foodborne illness.This applies to all 114 residents receiving dietary services.Findings include:On 12/09/2025 9:40 AM, V21 Dietary Manager confirmed 114 residents were receiving dietary service on the survey start date of 12/09/25.On 12/09/2025 9:40 AM, the kitchen tour was begun with V21 Dietary Manager.Dry Storage contained a 25 lb. (Pound) bag of great northern bean that were open to air.The Kitchen cooler #2 had a facility container that contained hard boiled eggs with an expiration date of 7/14/25.A 30lb bucket of beef base was open to air with the lid sitting loosely on top of it, and a 30lb. bucket of chicken base were being stored underneath the kitchen sink.Two silver facility pans containing yellow cake were on the counter in splashing distance of the kitchen sink.Two red sanitization buckets were in use both testing at 400 PPM (Parts Per Million)The serving utensils in open bins were dirty with dried crusted food. Two stacks of three silver mixing bowls under the food prep counter contained crumbs and a dried white substance.On 12/11/2025 at 11:41 AM, V21 Dietary Manager stated food should be sealed to prevent damage, contamination and bacteria. Dating food items is important to assure the freshness of the food product. If food that is outdated or misdated need to be discarded because it can cause sickness. V21 stated he didn't know things should not be stored under the sink. V21 stated now I know storing under the sink can cause contamination and water could get in it. Food should not be held near the sink for the same reason water could potentially contaminate the food items. Using dirty utensils will cause cross contamination and cause sickness. I didn't know I needed a separate log for the red buckets. The red bucket sanitizer level should be 200 ppm. I knew I was supposed to keep the logs I just didn't have the room to keep them.The facility policy General Preparation & Cooking Practices dated 4/2017 states the facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness.The facility policy Guidelines for Labeling Unopened and Opened Food Items dated 4/2023 states any items past the use by date will be discarded of immediately. All foods that are opened are to be wrapped or put in a sealed container for storage to prevent contamination.The facility policy Storage of Dry Foods / Supplies dated 4/2017 states opened products will be labeled and stored in tightly covered containers.The facility policy Sanitizing Buckets dated 4/2022 states the facility will follow manufacturers recommendations on the amount of sanitizing solution used.

Based on observation, interview, and record review, the facility failed to use PPE (Personal Protective Equipment) and perform hand hygiene when rendering care.This applies to 4 out of 4 (R7, R9, R29, and R118) residents reviewed for infection control in a sample of 27.The findings include:1. On 12/11/2025 at 10 AM, V19 (Registered Nurse/RN) was administering R9's enteral feeding via her gastrostomy tube (g-tube). R9 had an EBP (Enhanced Barrier Precaution) sign on her door. V19 was only wearing gloves when rendering care to R9. R9's care plan said she required the implementation of EBP due to her g-tube, urinary catheter, and wound. The care plan's goal was to prevent the spread of infection. 2. On 12/11/2025 at 10:15 AM, V19 (RN) was assessing and flushing R7's g-tube. R7 had an EBP sign on his door. V19 was only wearing gloves when rendering care to R7. R7's care plan said he required the implementation of EBP due to his g-tube and wound. The care plan's goal was to prevent the spread of infection. 3. On 12/11/2025 at 11:25 AM, V20 (Licensed Practical Nurse/LPN) was administering R29's bolus g-tube feeding. R29 had an EBP sign on his door. V20 was only wearing gloves when rendering care to R29. R29's care plan said he required the implementation of EBP due to his g-tube. The care plan's goal was to prevent the spread of infection. On 12/11/2025 at 2:15 PM, V2 (Director of Nursing/DON) said staff were expected to adhere to EBP when rendering direct resident care to prevent the spread of infection. The facility's policy titled Enhanced Barrier Precautions, dated 4/28/2025, said the purpose of EBP was to reduce the transmission of novel or target multidrug-resistant organisms. EBP required the use of gown and gloves during high-contact resident care activities, including when providing device care, including the handling of feeding tubes. 4. On 12/10/2025 at 3:17 PM, V23 CNA (Certified Nurse Assistant) came into R118's room closed the room door and put on gloves without performing hand hygiene. V23 then uncovered R118 unfastened the undergarment and turned her to the left side. V23 pulled back and removed the undergarment that was soaked with urine and smeared with stool. V23 then walked to the opposite side of the bed turned the call light off with soiled gloved hand, while closing the privacy curtain bumped into the over bed table knocking R118's roommates stuffed bear on the floor. V23 picked the bear up off the floor with the soiled gloves. V23 then went to R118 placing her on her back and with same soiled gloves wiped under her reddened abdominal fold and vaginal area with the same towel multiple times. V23 then turned R118 on her left side wiping her buttocks and between the gluteal cleft with the same washcloth multiple times. V23 then placed R118 on her back covered her with the blankets removed gloves and left the room. On 12/11/2025 at 12:50 PM, V2 DON (Director of Nursing) stated not cleaning residents properly during incontinence care and cause a UTI (Urinary Tract Infection). The CNAs should not wipe residents' multiple times with the same towel or touching things in the environment with soiled gloves. It is an infection control concern. Staff should perform proper hand hygiene. The facility policy Incontinence Care dated 1/2025 states resident will be checked periodically for bowel and / or bladder incontinence and be provided with perineal and genital care to prevent infection and improve the quality of resident's care. The facility policy Hand Hygiene dated 1/2025 state the purpose to provide guidelines on proper and appropriate hand washing and hygiene techniques that will aid in the transmission of infection. Washing hands with soap and water when hands are visibly dirty or soiled with blood or other body substances. If hands are not visible soiled use an alcohol-based hand rub. Before applying gloves and after removing gloves or other PPE (Personal Protective Equipment). After handling items potentially contaminated with blood, body fluids or secretions. Before moving from a contaminated body site to a clean body site during resident care. After providing direct resident care. After contact with inanimate objects.

Based on observation, interview and record review, the facility failed to maintain a resident's bodily privacy. This applies to 1 of 1 resident (R96) reviewed for resident's dignity in the sample of 27. The findings include:On 12/11/25 at 10:14 AM, R96 was sitting on the floor, in the common area across from the nurses station, in front of the elevator. R96's pants were pulled down to his knees. R96's penis was not contained in the incontinence brief. V29 (Social Services Director) was sitting at the nurses station with his back towards R96. On 12/11/25 at 10:16 AM, V30 (CNA/Certified Nursing Assistant) stepped off of the elevator and saw R96 sitting on the floor. V30 alerted V29 and they walked over to R96 and assisted him with getting up from the floor. When R96 stood up, his penis was fully exposed outside of the incontinence brief. On 12/11/2025 at 11:10 AM, V29 stated R96 had a behavior of undressing in public places. V29 stated R96 should not have been in the common area undressed. V29 stated it is not appropriate, and other residents may not feel happy about it. V29 stated he was sitting at the nurses station texting the DON (Director of Nursing) while R96 was sitting on the floor undressed. R96's admission Record showed R96 was admitted to the facility on [DATE], with multiple diagnoses which included encounter for surgical aftercare, autistic disorder, epilepsy, dementia, schizophrenia, impulse disorder, and intellectual disabilities. R117's MDS (Minimum Data Set) dated 10/05/25 showed R96 had severe cognitive impairment. The same MDS showed R96 had behavioral symptoms that intrudes on the privacy of others and disrupts care or living arrangement. R96's Progress Notes dated 12/11/25 at 10:53 AM, showed Resident in and out of resident's rooms, unable to redirect. Pushing past staff. Laying on the floor exposing self.The facility's Policy and Procedure Dignity revised 01/25 showed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain and protect resident's privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview and record review, the facility failed to allow prompt access to requested personal funds. This applies to 1 of 1 resident (R117) reviewed for resident's personal funds in the sample of 27. The findings include:On 12/09/25 at 11:45 AM, R117 was sitting in a wheelchair in his room. R117 stated he asked V28 (Assistant Administrator/Human Resources) for $40 from his personal funds account three weeks ago. R117 stated he never received the requested money.On 12/11/2025 at 8:58 AM, V28 stated R117 had a balance $160 dollars in his account. V28 stated two weeks ago R117 asked for $40. V28 stated she did not get a chance to go to the bank to get the money. V28 stated residents should not have to wait for two weeks or more to get requested money from their account. V28 stated she was the only person who could get money from the bank. R117's admission Record showed R117 was admitted to the facility on [DATE], with multiple diagnoses which included hemiplegia and hemiparesis, morbid obesity, diabetes, major depressive disorder, and polyosteoarthritis. R117's MDS (Minimum Data Set) dated 11/17/25 showed R117 was cognitively intact. The facility's Resident Personal Funds policy dated 05/14 showed, Our facility manages the personal funds of residents when such request is made by the resident. The resident may choose to have the facility hold, safeguard, and manage his/her personal funds.

Based on interview and record review the facility failed to report an allegation of abuse.This applies to 1 of 2 residents R121 reviewed for allegations of abuse in a sample of 27.Findings include:R121's MDS (Minimum Data Set) dated 10/16/25 shows she is cognitively intact. R121's diagnoses includes Arnold Chiari Syndrome, craniofacial dysostosis, monocular exotropia right eye, seizures. Scoliosis, dysthymic disorder. Current care plan includes R121 has a selfcare deficit. R121 is usually continent of bowel and bladder. She has limited use of extremities and uses a motorized wheelchair for locomotion. She requests bedpan during the night, uses a push pad call light system 1 to 1 staff assist with meals. Interventions include 1 assist with dressing, assist to toilet 1 person assist, provide extensive assist with toileting and toilet hygieneOn 12/09/2025 at 11:44 AM, R121 stated she requested toileting assistance and to be showered from V26, Certified Nurse Assistant (CNA). R121 stated her period had started and she needed to be toileted. R121 stated V26 told her to go to the toilet in her pants and that she did not change period pads. R121 stated this statement was very upsetting to her as she is continent and cognitively intact. R121 stated she reported the incident directly to V1 Administrator. R121 stated V26 told her she never would have said that to her if she knew she was in her right mind.On 12/09/2025 at 1:24 PM, V1 Administrator stated he had not submitted a report to IDPH (Illinois Department of Public Health). V1 stated R121 told him V26 CNA did not provide her shower and refused to change her period pad.On 12/10/2025 at 3:51 PM, V2 DON (Director of Nursing) stated V26 CNA was fired for refusing to toilet R121, taking long breaks and her bad attitude. V2 stated she heard V26 refusing to toilet R121.On 12/11/2025 at 12:50 PM, V2 DON stated she had told V1 Administrator about V26 refusing to toilet R121, but she did not remember when she told him.On 12/11/2025 at 2:39 PM, V1 Administrator stated V26 was fired for taking long breaks, her attitude and not meeting the standards of the facility. V1 stated V26 did not refuse to toilet R121. V1 stated he had looked at V26 discharge form. V1 stated refusing to toilet someone who is alert oriented, and continent of bowel and bladder is not abuse. V1 Administrator confirmed he was the abuse coordinator and allegations of abuse are reported to him.The Corrective Action Notice for V26 dated 12/4/25 list discharge for refusal to do work. V26 refused to toilet resident during shift, taking long breaks and attitude during counseling.The facility policy Abuse Prevention Program dated 1/2025 states residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. To describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property and exploitation will be accomplished by filing accurate and timely investigative reports. The facility has a no tolerance philosophy persons found to have engaged in such conduct will be terminated. Abuse is defined at the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide ensure the Nurse Practitioner or MD (Medical Doctor) were notified about missed medications, and failed to perform assessments and obtain orders for the use of continuous blood glucose monitoring. This applies to 2 of 2 residents (R34, R5) reviewed for quality of care in a sample of 27.The findings include: 1) On December 9, 2025, at 12:21 PM, V9 (RN/Registered Nurse) prepared R34's medications for her. V9 said R34 refused her morning medications earlier as she was nauseous. V9 said she gave R34 Zofran earlier and she had just gone to check on her and R34 had told her she would take her medications. V9 pulled R34's medications, which included three medications that had twice daily dosing: -Amantadine hydrochloride 100 MG (milligrams) tablet, due at 9 AM and 5 PM, -Docusate sodium 100 MG tablet, due at 9 AM and 5 PM, -Gabapentin 300 MG capsule, due at 9 AM, 1 PM, and 5 PM. On December 9, 2025, at 1:05 PM, V9 administered R34's medications to her. On December 11, 2025, at 2:26 PM, V18 (NP/Nurse Practitioner) said R34 was one of her residents, and she was not contacted regarding any medications not being administered to R34. V18 said if a resident was nauseous, she expected the nurse to administer antinausea medications or call to get one ordered. V18 said she would then expect them to wait about an hour to see if the resident was able to take their medications. V18 said if a medication was due at 9 AM, the window of medication administration would be between 8 AM to 10 AM. V18 said if it was beyond that time, the nurse should be calling the doctor or NP to clarify which medications to administer. V18 said it was not up to the nurse to decide, as it could be too soon to the next dose as different medications have different half-lives and it could cause toxicity to the resident. V18 said she was not notified R34 had not taken her morning medications. On December 10, 2025, at 12:34 PM, V10 (RN) said if a resident was complaining of nausea during their medication administration time, she would provide an antinausea medication, wait 30 minutes to an hour, and then if the resident was still unable to take the medications, she would notify the doctor to let them know. V10 said if a medication was due at 9 AM and 5 PM, 1 PM could be too soon if the next dose was due at 5 PM. On December 10, 2025, at 2:22 PM, V5 (LPN/Licensed Practical Nurse) said if a resident did not receive their medications at the time due, the nurses should contact the doctor and allow the doctor to decide which medications to administer outside the medication administration window of when the medication as due. V5 said the doctor needed to decide if the resident would skip the dose or make up the dose at a different time of the day. V5 said certain medications could cause undesirable side effects. On December 11, 2025, at 2:10 PM, V2 (DON/Director of Nursing) said the nurse should contact the doctor if medications are held to be administered past the due time. V2 said it could be an overdose if the next dose was due around the same time. R34's face sheet showed she was admitted to the facility with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness. R34's MDS (Minimum Data Set) dated October 29, 2025, showed R34 was cognitively intact. R34's POS (Physician Order Sheet) dated December 11, 2025, showed orders for Amantadine HCl- Give 1 capsule by mouth two times a day, Docusate Sodium 100 MG- Give 2 tablet by mouth two times a day, and Gabapentin Capsule 300 MG Give 2 capsule by mouth three times a day for neuropathy. R34's progress notes were reviewed, and there were no notes written by V9 (RN) showing she spoke to the doctor or NP regarding R34's medications. R34's Medication Admin Audit Report dated December 11, 2025, showed R34 was administered Gabapentin 300 MG 9 AM dose at 1:16 PM, and the 1 PM dose was signed off at 1:19 PM. The facility's Administering Medications policy revised January 2025 showed Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. Medications should be administered within one (1) hour of the prescribed times. The facility's Change in Resident's Condition policy reviewed January 2025 showed Nursing will notify the resident's physician or nurse practitioner when: e. It is deemed necessary or appropriate in the best interest of the resident. 2) On 12/09/2025 at 4:29 PM, R5 stated she tells the nursing staff what her blood glucose is from her CGM (Continuous Glucose Monitoring) system. The facility does not check her blood glucose with their equipment. R5 stated she manages her CGM herself. The staff provides interventions based on the readings she gets from her CGM. On 12/10/2025 at 4:15 PM, V24 (LPN) stated R5 has a CGM that she manages herself. Insulin is provided to R5 based on her monitor reading. The reading is documented in the EMR (Electronic Medical Record). Interventions related to her blood glucose are based on her readings and documented in the EMR. On 12/10/2025 at 3:51 PM, V2 DON (Director of Nursing) stated R5 has a CGM, and staff obtain and document her glucose reading from the CGM. R5 maintains and connects it herself. R5's competency for using her CGM was not assessed. V2 stated she was not aware of how QA (Quality Assurance) checks were done on R5's CGM or if she was even doing them. The staff does not have instructions or knowledge of how her equipment works. V2 stated she is unaware of facility policy regarding the use of CGM system or have manufactures instructions for the device. On 12/11/2025 at 2:39 PM, V1 Administrator stated the facility did not have policies regarding the assessment and use of CGM systems. There are no policies regarding how nurses medicate based on results from resident managed CGM devices. R5 had no physician order noted for the self-directed use of a CGM system prior to this survey. R5 had no care plan interventions in place for the use of a CGM device prior to this survey. The facility did not provide an assessment of R5's use of a CGM device. The facility policy Continuous Glucose Monitoring dated 4/25 states to obtain a physician's order, monitor device for signs of infection, follow manufacture's instruction for application, set up, care, alert setting, storage, disposal.

Based on observation, interview, and record review, the facility failed to follow gastrostomy tube feeding orders, label feeding bottles, and maintain the tube site.This applies to 1 out of 3 (R7) residents reviewed for gastrostomy tubes in a sample of 27.The findings include: On 12/09/2025 at 10 AM, R7 was in bed receiving his g-tube (gastrostomy tube) feeding via a pump. R7's hanging feeding was in a clear bag connected to a water bag, both were not labeled. R7 had an open g-tube feeding bottle of (Nutritional Product) on his bedside table.On 12/10/2025 at 11:40 AM, R7 said he was dependent on staff for his care, and his feeding was just disconnected. R7's gastrostomy tube site did not have a dressing and had brown-thick adherent drainage around his tube.On 12/11/2025 at 9 AM, R7 was in bed connected to his g-tube feeding. R7's hanging feeding bag again was not labeled with the type of feeding being infused. The pump had a beeping alarm notifying that the pump was inactive. At 9:25 AM, V27 (Wound Nurse) assessed his tube site, and again there was brown-thick adherent drainage around his tube. V27 said nurses should be assessing and cleaning tube sites to prevent complications.At 10:15 AM, R7's pump was still beeping. V19 (Registered Nurse/RN) assessed the feeding infusion and said she was unsure of the type of feeding that was hanging because it was not labeled. V19 said feeding bags should be labeled accurately to ensure the correct feeding was being infused.R7's tube feeding care plan said nursing staff was to utilize clinical standards of practices when managing his tube to prevent complications. The care plan's interventions included infuse feeding as ordered and check tube site regularly for drainage.R7's order summary report said he was to receive (Nutritional Product) 1.5 g-tube feeding, and if needed, could be supplemented with (Nutritional Product) 1.5. There was also an order to clean the g-tube site with normal saline daily and as needed.

Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders to maintain a medication error rate of less than 5%. There were 38 opportunities for error with 4 medication errors, resulting in an error rate of 10.53%.This applies to 1 of 3 residents (R34) observed during medication pass.The findings include: On December 9, 2025 at 12:21 PM V9 (RN/Registered Nurse) was preparing R34's medications. V9 said she did not administer R34's medications at 9 AM as R34 was nauseous. At 1:05 PM, V9 finished preparing R34's medications and administered them to her. V9 came back to the computer and signed off her medication and said she had completed administering R34's medications. Upon medication reconciliation, the following medication errors were found: 1. Amantadine Hydrochloride (HCL) 100 MG (Milligram) oral tablet, to be administered at 9 AM and 5 PM, was administered at 1:05 PM. 2. Docusate Sodium 100 MG oral tablet, to be administered at 9 AM and 5 PM, was administered at 1:05 PM. 3. Gabapentin 300 MG oral capsule, to be administered at 9 AM, 1 PM, and 5 PM, was administered at 1:05 PM. 4. Multiple Vitamin Tablet, to be administered at 9 AM, was not administered to R34. On December 10, 2025 at 12:34 PM, V11 (LPN/Licensed Practical Nurse) said there was a medication administration window, which meant if medications were due at 9 AM, they could be administered between 8 AM to 10 AM. V11 said if medications were given outside the window, it could have interactions with the next dose of the medications due. On December 11, 2025 at 2:10 PM, V2 (DON/Director of Nursing) said the nurse should contact the doctor if medications due at a certain time are past the window of administration. V2 said it can cause an overdose of the medications. On December 11, 2025 at 2:26 PM, V18 (NP/Nurse Practitioner) said the window of time for the 9 AM medication pass would be from 8 AM to 10 AM. V18 said if it was beyond the time frame, the nurse should be calling the doctor or NP to clarify which medications to administer. V18 said it could be too soon for the next dose, as different medications have different half-lives or effectiveness, which could negatively affect the resident and potentially cause toxicity if given too close together.R34's face sheet showed she was admitted to the facility with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness. R34's MDS (Minimum Data Set) dated October 29, 2025 showed R34 was cognitively intact. R34's POS (Physician Order Sheet) dated December 11, 2025 showed orders for Amantadine HCl- Give 1 capsule by mouth two times a day, Docusate Sodium 100 MG- Give 2 tablet by mouth two times a day, Gabapentin Capsule 300 MG- Give 2 capsule by mouth three times a day for neuropathy, and a Multiple Vitamin Tablet to be given one time a day. R34's progress notes were reviewed, and there were no notes written by V9 (RN) regarding consultation with a doctor or Nurse Practitioner to administer medications beyond the medication administration window. R34's Medication Admin Audit Report dated December 11, 2025 showed the following for December 9, 2025: R34's Amantadine HCl due at 9 AM was signed off as administered by V9 at 1:15 PM, Docusate Sodium due at 9 AM was signed off by V9 at 1:15 PM, Gabapentin 300 MG due at 9 AM, was signed off by V9 at 1:16 PM, and the 1 PM dose was signed off at 1:19 PM. R34's Multiple Vitamin Tablet due at 9 AM was signed off by V9 at 1:18 PM. The facility's Administering Medications policy revised in January 2025 showed Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. Medication should be administered within one (1) hour of the prescribed times.

Based on interview, and record review, the facility failed to ensure a timely ambulance transfer for a resident experiencing respiratory distress. This applies to 1 resident (R1) reviewed for change in condition in a sample of 4. The findings include: On 6/26/25 at 11:47 AM, V6 (LPN/Licensed Practical Nurse) said on 6/22/25, R1 requested to go the emergency room multiple times because she was short of breath and didn't feel well. V6 said she called for a routine ambulance for R1, but the ambulance dispatcher told her to call 911 due to R1's abnormal vital signs. Nursing Progress Note dated 6/22/25 at 20:30 documents R1's vitals were as follows: Blood pressure 79/49, heart rate 103, respiratory rate 18, and oxygen saturation 79% on 4 liters per nasal cannula. V6 said that when she increased R1's oxygen, R1 did not say she felt better and R1 told her to call 911. On 6/27/25 at 2:25 PM, V12 ADON (Assistant Director of Nursing) said for a change condition related to respiratory distress, nursing staff should not wait and should call 911 without delay. On 6/27/2025 at 11:10 AM, V8 (LPN) stated R1 is alert an oriented and has a lot of respiratory issues with her quadriplegia diagnosis and she has a hard time coughing. V8 stated if vital signs change all at once, she would call 911. On 6/27/2025 at 1:30 PM, V9 (LPN) stated if a resident has a decrease in blood pressure with increased heart rate and is complaining of difficulty breathing, that warrants a 911 call. V9 stated R1 is a full code and she would not hesitate to call 911. On 6/26/25 at 12:28 PM, V4 (EMT/Emergency Medical Technician) said V20 (Ambulance Dispatcher) advised V6 (LPN) to call 911 due to the time it would take for ambulance to arrive, but V6 said she was going to try other ambulance companies instead. V4 said V6 called V20 back 20 minutes later requesting their service again. V4 said when she arrived at the facility on 6/22/25, there was no nurse present at R1's bedside and R1 was observed gasping for air. V4 said at 9:15 PM upon her arrival to facility, R1's vital signs were as follows; heart rate 108 bpm (beats per minute); respirations 28 bpm (breaths per minute); blood pressure was critically low at 66/46 mmHg (millimeters of mercury), and oxygen saturation was 91% on 5 liters of oxygen via nasal cannula. V4 said R1 told her that she was not usually on oxygen. Upon assessment, V4 noted R1 with diminished breath sounds in all fields. V4 said she was concerned R1's lungs sounded junky (congested). V4 said V6 did not mention why she didn't call 911. V4 said she started a breathing treatment right away and R1 was transferred to the hospital. Per V4, she was concerned because R1 is paraplegic and is unable call 911 herself. On 6/27/2025 at 2:45 PM, V2 DON (Director of Nursing) stated if an ambulance dispatcher said to call 911 instead of waiting for routine ambulance transport due to a resident's condition and vital signs, staff need to call 911. V2 said if something is off with a resident and it looks like it could be an emergency and the resident is requesting 911, the nurse should just call 911. On 06/29/25 at 2:39 PM, V19 (NP/Nurse Practitioner) said that on 6/22/25, she was notified about R1 after she was transferred to the emergency room. V19 said that if a resident's vital signs show a drop in blood pressure, a rise in heard rate, a drop in oxygen saturation (to the 70s), and an increased need for oxygen, her expectation would be for the nurse to send the resident out via 911. Per V19, the risk involved in waiting for routine ambulance transportation instead of calling 911 is that the resident could deteriorate and may even code (go into cardiac or respiratory arrest). R1's POS (Physician Order Sheet) shows an advanced directive order for Full Code. R1's Face Sheet shows medical history of acute respiratory failure with hypoxia, sepsis, shortness of breath, and quadriplegia. R1's Care Plan dated 6/06/25 shows R1 is at risk for respiratory complications due to history of pneumonia, centrilobular emphysema, and repeated hospitalizations related to shortness of breath. Care Plan interventions include staff responding promptly to all requests for assistance and anticipating R1's individual needs, monitoring for signs and symptoms of infection, and notifying R1's physician for any significant changes with the goal to improve respiratory status and be free from respiratory distress. The facility's policy titled; Emergency Care last reviewed January 2025 lists Acute Respiratory Distress as an example of residents' urgent and critical care needs. The facility's policy states the protocol for managing residents with Acute Respiratory Distress includes assessing the airway, repositioning in high fowler's position, giving respiratory treatment as ordered, and calling 911.

Based on interview and record review, the facility failed to provide care and maintenance of a tunneled PICC (Peripherally Inserted Central Catheter). This applies to 1 resident (R1) reviewed for central intravenous catheter line care in a sample of 1. The findings include: On 6/26/25 at 9:57 AM, V3 (Hospital RN/Registered Nurse) said when R1 was admitted to the hospital on [DATE], R1's PICC line dressing was dated 5/28/25 (22 days earlier). V3 said PICC line dressings are supposed to be changed every 7 days. R1's POS (Physician Order Sheet) shows she has a right upper chest dual lumen tunneled PICC with order for weekly site care, cap change, and dressing change. R1's MAR (Medication Administration Record) for the month of June shows documentation V8 (LPN/Licensed Practical Nurse) changed R1's dressing on 6/10/25 and 6/17/25. Both R1's TAR (Treatment Administration Record) and MAR for the month of June do not show any documentation of PICC line cap changes. On 6/27/25 at 11:11 AM, V8 (LPN) said central line dressings are changed when the resident is admitted , and then every 7 days after that, but V8 does not provide central line care including dressing or cap changes because an RN (Registered Nurse) has to do it, not an LPN. V8 said she has never received any training in the facility on changing central line dressings. V8 said she does not know how often PICC line caps need to be changed because the RNs take care of it. V8 said alcohol caps for central lines are hard to come by, but when they have some available, they use them. On 6/27/25 at 1:03 PM, V8 said if she documented something on the MAR or TAR it means she did it. V8 then stated she did document in R1's MAR that she changed her PICC line dressing on 6/10/25 and 6/17/25, but she did not change the PICC lines dressing on those dates. V8 said she would have asked an RN to change R1's PICC line dressing, but she doesn't remember who she asked. V8 said she might have forgotten to double check if R1's PICC dressing was changed. On 6/27/25 at 2:42 PM, V2 DON (Director of Nursing) said central line dressings are to be changed upon admission and every 7 days thereafter. V2 said if a nurse signs off a task was done on the MAR or TAR, it means that nurse completed the task. V2 said an LPN cannot change a central line dressing, it needs to be an RN. V2 said the she herself and another RN provide annual education on central line care to nurses, but she is not sure how often PICC line caps need to be changed or if alcohol caps are used on central lines. V2 said they do not have residents that have central lines often and it has been brought to their attention that nurses need to be reeducated on central line care. On 6/27/25 at 2:39 PM, V19 (NP/Nurse Practitioner) said she is providing care for R1 and she expects the facility staff to follow their policy regarding central line care, dressing changes, and cap changes. V19 said if central line dressings and/or caps are not changed as ordered, there is a risk of central line infection for the resident. The facility's policy titled, Guidelines for Preventing Intravenous Catheter-Related Infections last revised 9/1/2016 states, Policy: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters .Catheter Site Dressing Regimens: 1. Change initial dressing after catheter placement within 24 hours .4. Change . dressings . every 5-7 days or PRN if damp, loosened, or visibly soiled. This does not require a physician's order .Replacement of Administration Sets, Needleless System Equipment: .2. Replacement of the Needleless System Equipment .b. Change needleless connections devices if there is blood or debris in the connector, before obtaining blood samples for culture, after blood draws, upon contamination, and in accordance with manufacturer recommendations .Documentation: The following information should be recorded in the resident's medical record: .2. Any interventions that were done (dressing change, cultures, etc.) .

Based on observations, interviews and record reviews the facility failed to implement safety interventions and provide supervision to prevent a resident from injury when drinking hot liquids. This failure resulted in R1 sustaining 1st and 2nd degree burns to her chest. This applies to 1 of 3 residents (R1) reviewed for dependent assistance with feeding in a sample of 4. The findings include: R1's electronic health record showed that on 3/9/25, R1 was sent to the local community hospital for evaluation and treatment to burns on her chest. R1 has diagnoses including quadriplegia (loss of motor and sensory function in all four limbs), C5 - C7 complete. On 3/18/25 at 10:50 AM R1, who is alert and oriented, was in her bed with a picture of water and a large cup of ice coffee with extra-long flexible straws that reached R1's mouth. R1 said that on 3/9/25 she was alone drinking her hot cup of coffee. The cup of coffee did not have a lid on the cup, and she used a straw to drink it. R1 said coffee came out of the straw and burned her chest and she was sent to the emergency room for the burns. R1's 3/13/25 11:12 AM Nursing Progress Note showed that on 3/9/25 R1 was sent to the emergency room for burns to her chest due to coffee spillage. The progress note showed that R1 said that the coffee came out of the straw and on to her chest. R1's emergency report of 3/9/25 showed that the left side of R1's chest wall, and along the left side of the clavicle had 1st and 2nd degree burns with 2 areas of blistering. R1's 9/25/24 Fluoroscopic Swallowing Study recommendations showed, supervision 1:1, and liquid viscosity thin, no straws. R1's 3/9/26 MDS (Minimum Data Set) section GG showed that R1 is dependent on staff for eating. R1's 2/17/25 care plan showed R1 is at risk for aspiration with interventions of no straws and assess for residual food in mouth. R1's 3/10/25 Wound Notes showed that R1 had 15.2 cm x 16.8 cm burns to upper chest with a surface area of 255.36 cm, along with fluid filled blisters. The report showed an order for Silver Sulfadiazine to be applied twice a day for 30 days. On 3/18/25 at 2:08 PM, V4 CNA (Certified Nurse's assistant) said that on 3/9/25 around 10 - 1030 am R1 asked her to warm up her cup of coffee. V4 said she warmed the coffee up in the microwave for 30 seconds and gave it back to R1. V4 said that R1 said it was still not hot enough and V4 said she warmed it up again for another 30 seconds. V4 said that R1 tested it again, and this time R1 said it was okay. V4 said the cup of coffee was without a lid and had a straw in it. V4 said she left R1 with the cup of coffee to drink it unsupervised. V4 said about 10 minutes later she was told that R1 had burned herself from the coffee. On 3/18/25 at 2:35 PM, V5 (Nurse) said that on 3/9/25 R1 was heard screaming and saying she had burnt herself from her coffee. V5 said that there was a cup of coffee in front of R1 with no lid and a straw in the cup. V5 said that R1's gown was soaked with coffee and her chest from her breast to her neck was with redness. V5 said that she called the doctor and the EMT (emergency medical team). On 3/18/25 at 1:43 PM V3 (Speech Language Pathologist) said he does not recommend anyone drink hot coffee from a straw unsupervised for safety issues. V3 said that staff should have only given R1 sips of hot coffee from a cup without a straw. On 3/18/25 at 2:50 PM, V6 NP (R1's Nurse Practitioner) said that R1 had a swallow study in 2024 and it recommended that R1 not use a straw. V6 said that staff should have been helping R1 drink hot coffee without using the straw. V6 said that if staff had been there, they would have taken the straw away and R1 would not have gotten burned. On 3/18/25 at 4:52 pm V2 DON (Director of Nursing) said that R1 was drinking hot coffee out of a cup with no lid with a straw and was unsupervised. V2 said that if R1 had not been drinking out of a cup with no lid, through a straw, without supervision, R1 would not have gotten burned. V2 said that her expectations are that the staff maintain supervision while drinking hot coffee. On 3/18/25 at 5:10 PM V1 (Administrator) said that R1 should not have been drinking hot coffee out of a straw unsupervised. V1 said that because staff allowed R1 to drink hot coffee with a straw unsupervised it caused her to get 1st and 2nd degree burns to her chest. The facility's Feeding and Assisting Residents to Eat policy dated 1/25 shows that the facility staff shall follow safe practices in feeding or assisting residents during mealtimes. The policy showed that staff may offer a straw if it is not contraindicated.

Based on interview and record review, the facility failed to staff Registered Nurses (RNs) 8 consecutive hours, 7 days a week. This has the potential to affect all the residents in the facility. The findings include: The facility's 671 (Long Term Care Application for Medicare and Medicaid) dated October 22, 2024 documents a total of 107 residents in the facility. On October 23, 2024 at 3:11 PM, the surveyor and V18 (Scheduler/CNA/Certified Nurse Assistant) went over the schedule from September 28, 2024 through October 23, 2024. V18 said there were managers on call every weekend, which included V2 (DON/Director of Nursing), V3 (RN), V19 (Wound Care Nurse/RN), V7 (Infection Preventionist/LPN), V18 (Scheduler/CNA) and V12 (Restorative Nurse/LPN). -On Sunday, September 29, 2024, the schedule showed there was no RN in the facility for 24 hours. The on-call manager schedule showed V18 was on call the weekend of September 29, 2024. -On Sunday, October 13, 2024, the schedule showed there was no RN in the facility for 24 hours. The on-call manager schedule showed V2 (DON) was on call the weekend of October 13, 2024. -On Saturday, October 19, 2024, the schedule showed there was no RN in the facility from 12 AM until 11 PM. At 11 PM, an RN came to the facility, but did not meet the standard requirement of RNs on site for 8 hours consecutively. The on-call manager schedule showed V19 was on call the weekend of October 19, 2024. On October 24, 2024 at 1:47 PM, V3 (ADON) said she worked Monday through Friday and did not work on the weekends unless something was happening at the facility. V3 said she did not work September 29, 2024, October 13, 2024, or October 19, 2024. On October 24, 2024 at 1:48 PM, V19 (RN) said she worked Monday through Friday and did not work on the weekends unless necessary. V19 said V3 and V19 had not had to come to the facility in September or October 2024 when they were on call. On October 24, 2024 at 3:08 PM, V2 (DON) said she did not have documentation to show she was in the facility on September 29, 2024, October 13, 2024, or October 19, 2024. V2 said it was a goal to have an RN in the facility for 8 hours a day, but for weekends, she would need to check and get back to the surveyor on the answer. On October 24, 2024 at 3:20 PM, V1 (Administrator) said he was aware the facility needed to have RNs in the building minimally 8 hours a day. V1 said he was not aware there were days there were no RNs in the building. The facility's Registered Nurse Staffing policy dated January 2024 showed The facility shall ensure that a Registered Nurse is available for supervision in the facility .The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, except when waived.

Based on observation, interview, and record review, the facility failed to obtain physician orders for medications brought from home and to be placed at the bedside. The facility also failed to complete self-administration of medication assessments for residents. This applies to 6 of 6 residents (R14, R32, R53, R70, R91, R103) reviewed for medications in a sample of 26. The findings include: On 10/22/24 the following observations were made during initial tour: 1. On 10/22/24 at 10:35 AM, R70 was lying in bed. On his bedside table, there was a Lidocaine pain relief roll on, a container of smooth antiacid tablets, and two Bactine Max Pain Relieving Cleansing sprays. R70 stated that he brought these from home and it's always kept in his room. R70 stated no one assessed him if he could take the medications. Review of R70's POS shows that he has no orders for these medications and no order for them at the bedside. Review of R70's electronic medical record shows there was no self-administration of medication assessment done. R70's MDS (Minimum Data Set) dated 10/17/24 shows a BIMS (Brief Interview for Mental Status) score of 15 which means he is cognitively intact. 2. On 10/22/24 at 11:00 AM, on R14's bedside table, there was a Deep Sea saline nasal moisturizing spray. R14 stated it's always kept in her room and she administers it by herself. Review of R14's POS shows she has an order for the nasal spray, but there is no order for it to be at the bedside. Review of R14's electronic medical record shows there was no self-administration of medication assessment done. R14's MDS dated [DATE] shows a BIMS score of 15, which means she is cognitively intact. 3. On 10/22/24 at 11:05 AM, on R53's bedside table there a sodium chloride nasal spray, artificial tears eye drops and genteal tears eye drops. R53 stated she brought them from home. She stated she administers it by herself. Review of R53's POS shows she has no orders for the medications and no orders for them to be at the bedside. Review of R53's electronic medical record shows there was no self-administration of medication assessment done. R53's MDS dated [DATE] shows a BIMS score of 15, which means she is cognitively intact. 4. On 10/22/24 at 11:25 AM, on R91's shelf, there was a Nystatin topical powder. R91 stated, It's always kept here. Review of R91's POS shows she has an order for the medication, but no order for it to be at the bedside. Review of R91's electronic medical record shows there was no self-administration of medication assessment done. R91's MDS dated [DATE] shows a BIMS score of 15, which means she is cognitively intact. 5. On 10/22/24 at 11:55 AM, on R103's bedside table there was a Deep Sea nasal spray. R103 stated that it's always kept in her room and she administers it by herself. Review of R103's POS shows there is order for the nasal spray and no order for it to be at the bedside. Review of R103's MDS dated [DATE] shows a BIMS score of 15, which means she is cognitively intact. Review of 103's electronic medical record shows there was no self-administration of medication assessment done. R14, R53,70, R91, and R103 did not have any care plans discussing self-administration of medications. On 10/22/24 at 12:30 PM, V2 (DON-Director of Nursing) stated, Meds brought from home should have orders for them. Any medication that is left in the resident's room should have orders for it to be at the bedside. The resident has to be assessed if he or she can safely administer the medications. I'm the one who does it, not the nurses on the floor. The assessments are in the electronic medical record. I don't have any residents that currently self administers medications. Facility's policy titled Self-Administration of Medications Procedure (9/2020) documents the following: 1. Residents who request to self-administer drugs will be assessed at the time of admission or thereafter, to determine if the practice is safe. This will include documentation when medications are used. 2. The assessment results will be discussed with the attending physician and an order obtained to self administer, if appropriate. 8. Drugs in the room should be written on the medication record as may keep at bedside and the expiration date. 11. Drug storage is the responsibility of the nursing staff, even when the resident self administers. 12. A care plan indicates the resident's self administering of medications. 45906 6. On 10/22/24 at 11:08 AM, a bottle of bisacodyl 5 mg (milligram) stimulant laxative was seen on the bedside table of R32. On 10/24/24 at 9:40 AM, R32 said she takes the bisacodyl when she is constipated. R32 said she last took the bisacodyl about a week prior and did not tell her nurse that she took it. R32 said her nurse will also give her a stool softener when she asks for it. On 10/24/24 at 1:53 PM, V8 (LPN/Licensed Practical Nurse) said all of her residents (including R32) get their medications from her, there are no residents that can keep their medications at the bedside. V8 said the risk with residents keeping medications at the bedside include: over-medicating, drug interactions, and another resident wandering into the room and taking the medication. On 10/24/24 at 2:28 PM, V2 (DON/Director of Nursing) said there are currently no residents in the building that are able to keep oral medications at the bedside to self-medicate. V2 said the harm in residents self-medicating includes drug interactions with their other prescribed medications and other residents coming into the resident's room and taking the medications left sitting out. R32's Face Sheet shows a diagnosis of constipation. R32's POS (Physician Order Sheet) does not show a current order for bisacodyl stimulant laxative. R32's POS shows an order dated 5/20/24 for Sennosides- Docusate Sodium tablet 8.6-50 mg (milligrams) 1 tablet by mouth every 12 hours as needed for constipation and an additional order dated 5/21/24 for Sennosides-Docusate Sodium tablet 8.6-50 MG 1 tablet by mouth one time a day for constipation scheduled. The facility's policy titled, Storage of Medications effective 10/25/14 states, Policy: Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .

Based on observation, interview, and record review, the facility failed to apply splints and braces to residents who required them. This applies to 2 of 2 residents (R11, R15) reviewed for splints and braces in a sample of 26. The findings include: 1. On October 22, 2024 at 1:12 PM, R11 was sitting in bed and the fingers on her right hand were curled inwards and she was unable to open them without assistance. R11 did not have a splint or brace applied. On October 23, 2024 at 9:56 AM, R11 did not have a splint or brace on. On October 24, 2024 at 12:44 PM, R11 did not have a splint on the right hand. R11's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic pain, cerebral infarction, nontraumatic intracerebral hemorrhage, and altered mental status. R11's POS (Physician Order Sheet) dated April 18, 2024 showed an order for [patient] to wear right resting hand splint during the day as tolerated. R11's Restorative assessment dated [DATE] showed R11 had Range of Motion impairment in the right upper and lower extremity and was recommended a splint/brace by the restorative nurse. R11's care plan dated April 19, 2024 showed Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and would benefit form wearing right resting hand splint during the day as tolerated to prevent further contracture of the right wrist/hand. On October 24, 2024 at 1:53 PM, V12 (Restorative Nurse) said R11 was supposed to wear the splint during the day as tolerated, and the splint should be on. V12 said if the splint was not applied, it could increase the contraction. 2. On October 23, 2024 at 11:57 AM, R15 was lying in bed and there was no palm protector on the left hand. At 2:54 PM, R15 had the palm protector on the left hand but not on the right hand. On October 24, 2024 at 9:47 AM, R15 was in the dining room in her high back wheelchair, and neither hand had the palm protectors on them. R15's face sheet showed R15 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, contracture of muscle, multiple sites, right hand and left hand, and need for assistance with personal care. R15's POS dated October 10, 2024 showed to Apply palm protector to bilateral hands. Check skin for redness, irritation, or skin breakdown. As tolerated. The POS also showed an order dated August 15, 2024 showing to Apply palm protector to left hand. Check skin for redness, irritation, or skin breakdown. As tolerated every day shift related to contracture, left hand. R15's care plan dated August 13, 2024 showed R15 would benefit from participation in the splint/brace program. [R15] to wear bilateral palm protectors [due to] muscle stiffness manifested by [diagnosis] of CVA (Cardiovascular Accident) with hemiplegia and hemiparesis. R15's Restorative assessment dated [DATE] showed R15 was recommended to continue splint/brace usage. On October 24, 2024 at 1:53, V12 said she had not had a chance to put R15's splints on that day and when she had gone to her room, R15 was already in the dining room. V12 said R15 wore palm protectors, and it was not supposed to be off. V12 said the night CNAs (Certified Nurse Assistant) took them off to give her hands a chance to breathe, but the orders did not say to remove them. V12 said if the palm protectors were not on, it could cause her hands to contract. V12 said she would expect the nighttime staff to keep it on unless they were doing hygiene. V12 said she would expect them to put them back on after the hygiene was completed. On October 24, 2024 at 12:56 PM, V16 (LPN/Licensed Practical Nurse) said if there were orders for splints, they should be on the residents. V16 said if the residents were refusing to wear their splints, the staff should be documenting refusals. On October 24, 2024 at 1:20 PM, V17 (CNA) said the restorative staff were the ones who knew who had the splints and would put them on the residents. On October 24, 2024 at 2:19 PM, V2 (DON/Director of Nursing) said the residents should have splints and palm protectors on. V2 said if the residents refuse to wear them, they should document refusal and the resident should be care planned for refusing to wear the splints or palm protectors. The facility's Activities of Daily Living (ADLS) policy dated September 2020 showed to Use orthotic device as ordered and Apply splint safely and with correct position.

Based on observation, interview and record review the facility failed to implement interventions that would prevent fall injuries and cigarette smoking hazards this applies to 6 of 11 (R15, R32, R46, R47, R73 and R93) residents reviewed for accidents in a sample of 26. Findings include: 1. R46 admitted to the facility with diagnoses that includes cellulitis of the right lower limb, muscle wasting, protein calorie malnutrition, hemiplegia/ hemiparesis, type 2 diabetes, anxiety, glaucoma, hypertension and legal blindness. R46's MDS (Minimum Data Set) dated 9/25/24 indicates he cognitively intact and uses a manual wheelchair for mobility. Per the MDS R46 has impairment to on side of his upper extremities and require partial staff assistance with mobility. On 10/24/24 at 09:36AM, (R46) was being pushed by activity staff onto the smoking patio. R46's wheelchair did not have footrests attached to his chair. R46 was attempting to hold his feet off the ground as he was being pushed. While being pushed by staff R46's feet hit a raised section of the concrete. R46 yelled out watch my feet. 2. R73 admitted to the facility with diagnoses that includes vascular dementia with agitation, peripheral vascular disease, Alzheimer's disease, localized swelling mass and lump to bilateral lower limbs. R73's MDS (Minimum Data Set) dated 9/12/24 indicates he has severe cognitive impairment and does not use any assistive devices for mobility. R73's current care plan states he demonstrates movement behavior that maybe interpreted at pacing or roaming related to the diagnosis of dementia and problems understanding the immediate environment. R73 demonstrates cognitive impairment related to dementia. Symptoms are manifested by poor insight, reasoning, and impulse control. R73's fall assessment dated [DATE] shows he takes 1-2 medications that may impact his fall risk, has poor vision without glasses, is ambulatory, incontinent, disoriented x 3 (person, place and time) at all times, exhibits loss of balance while standing, balance problems while walking, changes gait when walking through doorways and has decreased muscle coordination. On 10/22/24 at 11:27 AM, the room occupied by R73 had two beds. The unoccupied bed 2 being stored did not have a mattress and the metal bed frame was exposed. 3. R93 admitted to the facility with diagnoses that includes dementia, anxiety, hypertension, muscle weakness, restlessness and agitation. R93's MDS (Minimum Data Set) dated 9/8/24 indicates she has severe cognitive impairment and does not use a mobility device. R93's fall risk assessment dated [DATE] shows she takes 1-2 medications that may impact her fall risk, ambulatory, incontinent, has a decrease in muscle coordination and has 1-2 predisposing conditions. On 10/22/24 at 11:18 AM, R93 was walking the third-floor hallways without shoes and wearing regular socks without skid protection. On 10/24/24 at 01:59 PM, V2 DON (Director of Nursing) stated R73 is ambulatory and does not have a roommate. Maintenance is responsible for making sure bedframes have a mattress in place. A metal bed frame without a mattress is not safe. Someone may attempt to sit on the frame and could potentially be injured. Ambulatory resident should have nonskid socks or well-fitting shoes to prevent fall injuries. V2 DON stated R46 is blind and can self-transfer short distances, but he does not generally walk. R46 would not be walking from his room to the patio to smoke. He normally has footrests on his wheelchair and should have them in place if he is being pushed by staff in his wheelchair. On 10/24/24 at 02:54 PM, V10 Activity Aide stated R46 placed himself in his wheelchair. V10 stated she rolled him out to the patio to smoke. V10 stated she didn't know if he had footrests for his wheelchair. R46 feet were dragging and caught on the cement, but the issue was R46's not hers. V10 stated she may have overlooked the bump in the cement. V10 stated she did not know if having footrests would have made a difference to keep his feet up. V10 stated she is not a CNA (Certified Nursing Assistant) and not responsible to put footrests on the wheelchair. V10 stated she was not trained in wheelchair safety as she works in the activities department. The facility policy Safety and Supervision of Residents dated 9/2022 states the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility wide priorities. Employees shall be trained and in-serviced on potential accident hazards ad how to identify and report accident hazards and try to prevent avoidable accidents. 46409 4. On October 22, 2024 at 10:32 AM, R15's was lying in a low air loss mattress and was angled in the reverse Trendelenburg position and the bed was not in a low position. V15 (RN/Registered Nurse) was disconnecting R15's G-tube (Gastrostomy) tube feeding and then left the room with R15's bed high. On October 23, 2024 at 9:45 AM, R15's bed was about three feet high, which was not in the lowest position. R15 did not have fall mats and her call light was behind the resident, out of reach to the resident. At 11:01 AM, V3 (ADON/Assistant Director of Nursing) came to R15's room to provide repositioning for R15 and did not lower the height of the bed, which was about four feet high off the ground. At 11:24 AM, V8 (LPN/Licensed Practical Nurse) started R15's feed and left her bed about four feet off the ground. R15 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, contracture of muscle, multiple sites, and a history of falling. R15's care plan dated August 13, 2024 showed [R15] is at risk for falls [related to] other injury of unspecified kidney disease; depressive episode; pressure ulcer of sacral regional stage 3; [Chronic Obstructive Pulmonary Disease; diabetes mellitus with neuropathy; aphasia following cerebral infarction; contracture of [right] shoulder, left elbow, bilateral hip, knee, and ankle; retention of urine, history of falling [As Evidenced By] inability to use call light or request staff assistance. R15's Fall Risk Review dated September 2, 2024 showed R15 was a moderate fall risk. On October 24, 2024 at 1:53 PM, V12 (Restorative Nurse) said R15's bed should be in the low position and should not be elevated if no one is in the room. 5. On October 22, 2024 at 10:52 AM, R47 was lying in bed which was about four feet off the ground. R47 had one fall mat folded up and behind the head of the bed, against the wall. On October 23, 2024 at 10:05 AM, R47's bed was at the same height, and no fall mats were in place or found in the room. On October 24, 2024 at 9:49 AM, R47's bed was around three feet off the ground and there were no fall mats in place. R47 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, and dysarthria. R47's MDS (Minimum Data Set) dated August 1, 2024 showed R47 had moderate cognitive impairment. R47's care plan dated January 26, 2024 showed [R47] is at risk for falls [related to Cardiovascular Accident] with hemiplegia. [R47] prefers to keep bed in high position .with interventions including Floor mats on both sides of the bed. R47's Fall Risk Review dated August 1, 2024 showed R47 was a moderate fall risk. On October 24, 2024 at 1:53 PM, V12 said R47 liked his bed high, and they have spoken to him about the height of the bed. V12 said they were supposed to put floor mats on both sides of R47's bed when he was in bed, and she was not aware they were not in place. On October 24, 2024 at 12:47 PM, V11 (LPN) said the height of the bed should be in the lowest position for residents on fall precautions as it was a shorter distance if the resident did fall and could cause less injury. V11 said if the resident was care planned for fall mats, they should be in place. On October 24, 2024 at 12:56 PM, V16 (LPN) said the height of the bed should be at the lowest position and this would prevent them from falling from higher heights and if the resident's fall prevention interventions include fall mats, the fall mats should be in place. V16 said the fall mats were to soften the fall. On October 24, 2024 at 1:20 PM, V17 (CNA/Certified Nurse Assistant) said the resident's bed should not be in a high position. V17 said if a resident was a fall risk, the bed should be low, the rails should be up, and the fall mats should be in place. V17 said the fall mats help the resident not hit their head on the floor. V17 said R47 liked his bed high up but said he does have fall mats. At 1:24 PM, V17 looked at R47's bed and said she did not pay attention to see if he had his fall mats in place. On October 24, 2024 at 1:32 PM, V3 (ADON/Assistant Director of Nursing) said there should be fall mats in place if there was a care plan for fall mats to be in place. On October 24, 2024 at 2:19 PM, V2 (DON) said the bed should be in the lowest position if residents were at risk for falling. V2 said R47 would manipulate his own bed height and preferred to be up high. V2 said fall mats should be in place if it was in his care plan as an intervention, as the fall mat was used to try to reduce the risk for injury. The facility was unable to provide a Fall Prevention policy. The facility provided a Safety and Supervision of Residents policy dated September 2022 which showed, Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; d. ensuring that interventions are implemented .Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently. 45906 6. On 10/22/24 at 11:08 AM, a lighter that said keep your spirit high was found on the bedside table of R32 next to an aerosol spray can of body spray. On 10/24/24 at 9:40 AM, R32 said she does not smoke cigarettes, she only smokes weed. R32 said she had never been assessed for safe smoking. R32's MDS (Minimum Data Set) dated 10/1/24 shows her cognition is intact. R32's Care Plan initiated on 5/9/24 states the resident will be monitored to fully assess compliance and ability to smoke independently. R32's most current Smoking Risk Review assessment dated [DATE] was competed by V5 (SSD/Social Services Director), which shows R32 may not be capable of handling/carrying any smoking materials and requires supervision when smoking. On 10/23/24, during the survey, V5 (SSD) revised R32's Care Plan, after being made aware of R32 having a lighter in her possession. V5 revised R32's Care Plan on 10/23/24 to say that R32 demonstrated compliance with safe smoking. V5 updated R32's Care Plan without completing a new Smoking Risk Review Assessment. On 10/24/24 at 12:23 PM, V5 (Social Services Director) said he was unsure if R32 smoked or not, as he did not always go outside with the smoking residents. On 10/24/24 at 1:53 PM, V8 (LPN/Licensed Practical Nurse) said R32 requires supervision with smoking and her last smoking assessment on 10/1/24 said R32 may not be capable of carrying smoking materials. On 10/24/24 at 2:28 PM, V2 (DON/Director of Nursing) said if a resident is not safe to smoke independently, their smoking materials should be kept with the staff, so they do not attempt to smoke without supervision, risking their safety. The facility's undated policy titled, Facility Smoking Safety Policy states, Policy Objective: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member, and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Guidelines: 1 .The facility has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety, and security reasons .3. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan of care .

Based on interview and record review, the facility failed to provide supervision to a cognitively impaired resident, while outdoors, to prevent prolonged sun exposure that resulted in burns to the skin. This applies to 1 of 3 (R1) residents reviewed for improper nursing care. This failure resulted in R1 obtaining full thickness burns to the upper back and posterior neck due to prolonged sun exposure. The findings include: R1 was identified by the facility with a skin condition incident report dated July 28, 2024, and identified on the facility wound report as a resident with full thickness skin injury. R1's New Skin Condition report, dated July 28, 2024, written by V9 (RN) showed R1 was noted with blisters left shoulder to mid back. The report also showed R1 required a cream be applied to R1's face and arms. On September 9, 2024, at 2:43 PM, V9 stated that she recalls R1's face and arms were also discolored and required treatment and stated the skin injuries were determined to be caused by sunburn. R1's Initial Wound Evaluation and Management Summary dated July 29, 2024, documented by V3 (Wound Physician) identified a burn wound to the left upper back full thickness that measured 5.3 x 14.3 x 0.1 cm (centimeters) that required debridement and identified a second wound burn wound to the posterior neck full thickness that measured 2.1 x 1.5 x 0.1 cm. On September 9, 2024, at 3:05 PM, V3 stated the cause of R1's wounds were from sunburn due to prolonged sun exposure. V3 identified R1 as having dementia and stated to prevent sunburn, facility staff should know how long R1 was exposed to the sun especially since R1 was cognitively impaired. V3 stated R1's dementia had also resulted in delayed wound healing due to R1's behavior of removing the wound dressing and not eating resulting in weight loss. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease unspecified, fibromyalgia, basal cell carcinoma of the skin overlapping sites, chronic pain syndrome, and adjustment disorder with mixed anxiety and depressed mood. R1's MDS (Minimum Data Set) dated June 25, 2024, showed R1 was severely cognitively impaired, and required assistance with ADL's including dependent on staff assistance for bathing, required substantial staff assistance with dressing, toileting and personal hygiene, supervision with bed mobility, transfer and walking 150 feet and set up assistance with eating. On September 9, 2024, at 3:54 PM, V13 (LPN) stated she worked on July 28, 2024, during the day shift on R1's unit. V13 stated the door to the patio was left unlocked so independent residents and staff were able to exit at any time. V13 stated R1 was able to ambulate independently and liked to go outside a lot. V13 stated it was possible for R1 to go outside and staff may or may not have known when R1 did go out. On September 9, 2024, at 11:50 AM, R1 was seated in a reclining padded wheelchair, in the dining room and being fed an ice slushy drink by V6 (CNA) with V7 (CNA) in attendance. V6 stated R1's condition is declining, R1 is not eating, and she is walking less and R1 use to independently walk around the unit and liked to go outside on the patio. V7 stated R1 was able to ambulate independently and like to go outside at the time R1 was found with the sunburn. R1's progress note dated September 6, 2024, at 1:54 PM, written by V5 (LPN) showed R1 was noted to be walking down the hallway when staff noted a skin tear to R1's left forearm, with an unknown etiology. On September 9, 2024, at 4:10 PM, V14 (Activity Assistant) stated on July 28, 2024, she worked from 8:30 AM until 4:45 PM and supervised the patio during the smoking breaks, as she does as part of her daily work assignment. V14 stated the patio doors are kept unlocked however V14 takes smoking group outside for 15-20 minutes at a time during the smoking times of 9:30 AM, 11:30 AM, 2:00 PM, and 4:30 PM. V14 stated when the smoking group is over V14 returns to do her activity groups inside the building. V14 stated other than the assigned smoking breaks staff are not assigned to supervise outside. V14 stated she has worked in the facility for 5 months and is unsure who R1 is. R1's care plan with date initiated of January 29, 2024, problem statement showed R1 was known to have a movement behavior which may be interpreted as wandering, pacing, or roaming and had problems understanding the immediate environment. R1's care plan had an intervention added to the care plan on June 25, 2024, that showed If the resident leaves the building, goes in a peer's room, or becomes aggressive, redirect by: Walk in the same direction as the resident. Do not initially try to force the person to change direction. Chat with the resident about his/her theme. Eventually, use a strategy such as therapeutic fib to bring the person to the area where you would like him or her to be. On September 9, 2024, at 4:03 PM, V2 (DON, Director of Nursing) stated there is no investigation regarding how long R1 was outside in the sun, and when and how long the sun exposure occurred prior to the sunburn and remains unknown. V2 did state the patio door was unlocked and remains unlocked during daytime hours. V2 stated the redness to R1's upper back and neck was first reported during the evening shift (3PM-11PM) on July 27, 2024, the redness then developed into blisters on July 28, 2024. V2 stated there is not a log of when people go outside the patio door to determine how long someone such as R1 was subjected to sun exposure, even during the weather change to hot, sunny weather. V2 stated that R1's caregivers were unable to identify the amount of time or when R1 was on the patio exposed to the sun that resulted in the sunburn. V2 stated there is no facility policy regarding Supervision of Residents while outdoors on the patio.

Based on interview and record review the facility failed to provide a resident with a pureed diet as ordered by the physician. This failure resulted in R1 being found unresponsive while eating, requiring the Heimlich maneuver and CPR (Cardio-Pulmonary Resuscitation). R1 required admission to the local hospital intensive care unit and expired at the hospital on [DATE]. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when V6 (LPN-Licensed Practical Nurse) discontinued R1's pureed consistency diet. V1 (Administrator), V2 (DON-Director of Nursing), and V19 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on [DATE] at 2:48 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE] at 6:48 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on [DATE] and did not return to the facility. R1 had multiple diagnoses including, polyarthritis, chronic kidney disease, morbid obesity, diabetes, left heel pressure ulcer, sacral pressure ulcer, altered mental status, hydronephrosis, anxiety disorder, recurrent depressive disorders, lack of coordination, and history of falling. R1's MDS (Minimum Data Set) dated [DATE] shows R1 had severe cognitive impairment, was totally dependent on facility staff for transfers between surfaces, locomotion on the unit, toilet use and bathing, and required extensive assistance with bed mobility, dressing, personal hygiene, and eating. R1 was always incontinent of bowel and bladder. Facility documentation shows R1 was hospitalized from [DATE] to [DATE] due to dehydration, urinary tract infection and altered mental status. R1 returned to the facility on [DATE]. Hospital discharge instructions show orders for a pureed diet upon hospital discharge. On [DATE] at 2:47 PM, V9 (Hospital SLP-Speech Language Pathologist) documented: Recommendations/Discharge: Swallow Precautions Recommendation: Allow extra time to swallow, clear pocketing left, clear pocketing right, fed only by trained staff/family. Small bites of food. Diet Consistency Recommendation: Dysphagia Pureed Supervision Swallow Recommendation: 1:1. Barriers to Safe Discharge SLP: Safety awareness, medical diagnosis, cognitive impairments, severity of deficits, aspiration risk - possible, 1:1 feeder, dysphagia requiring food/liquid modification, requires safe swallow protocol/techniques. Other short-term goals #1: Patient will tolerate dysphagia puree diet with thin liquids with no clinical s/s (signs/symptoms) of aspiration, #2 reassess for upgrade potential with improved bolus control. The EMR shows R1 returned to the facility on [DATE]. Physician orders dated [DATE] show R1's diet order as pureed consistency general diet. The EMR shows on [DATE], V6 (LPN) discontinued R1's pureed consistency diet. V6 documented the reason for the order change: Wrong diet. V6 changed R1's diet order from a pureed diet consistency to a regular consistency diet. V6 documented the diet order change was obtained from V13 (Physician). The facility does not have documentation to show a speech evaluation was done to ensure a regular consistency diet was safe for R1. The facility does not have documentation to show V6 (LPN) discussed the diet order change with a physician, nurse practitioner, or V11 (POA-Power of Attorney for R1) prior to the diet order change. The facility's Day at a Glance for General Diets, Week 3 Wednesday, printed [DATE] shows the dinner menu served on [DATE] to residents on a general, regular consistency diet included, chicken breast tenders, barbecue sauce, rice pilaf, seasoned corn, mandarin oranges, bread, margarine, milk, coffee/hot tea, and condiments. On [DATE] at 8:04 PM, V6 (LPN) documented: Around 6 PM during dinner time, the resident assistant came to the nurse's station and stated that the resident was unresponsive while eating dinner. Writer rushed to the dining room and noted that the resident was sitting in the dining room table with her plate @ (at) about 80 percent eaten and she was not responding when her writer called her name. Writer noted that the food was coming out of her mouth and her glass of juice was empty. Writer checked her pulse, and it was present. Writer called for help and the Heimlich maneuver was started right away and also finger was used to remove food out of the resident mouth. Writer noted that the food was coming out her mouth. 911 was called and resident was moved to a safer and clear area. During that time an EMT [Emergency Medical Technician] personnel was at the facility, he came, and we all brought resident on floor and started CPR and a [bag valve mask] was also used. Paramedic personnel arrived as quick as possible and took over. Resident had a pulse of 86. Writer called [V10] (NP-Nurse Practitioner) and left a message, [V11] (POA) was notified as well as [V2] (DON) and [V1] (Administrator). Resident was taken to the nearest [hospital]. Local fire department documentation dated [DATE] shows upon arrival and assessment of the resident, R1's airway was completely obstructed and R1's pulses were absent. R1's hospital documentation shows R1 was admitted to the emergency roiagnom on [DATE] with CPR in progress. On [DATE] at 8:10 AM, V7 (Hospital Physician) documented, Out of hospital cardiac arrest - likely due to choking/aspiration of dinner food. V7's documentation continues to show, We will get neurologic and pulmonary input on [R1]. I feel she suffered significant anoxic insult to her brain. Her prognosis is grim. If no neurologic improvement in the next several days we will need to speak with family regarding aggressiveness of this care and possible withdrawal of life support. Hospital documentation continues to show R1 expired at the hospital on [DATE]. R1's death certificate with cause of death is pending with the coroner due to continued investigation into the cause of R1's death. On [DATE] at 2:54 PM, V14 (CNA-Certified Nursing Assistant) said, I was not there when they discovered her choking. I heard the nurse call the other nurse. I noticed [R1] had chicken chunks on the front of her shirt and her head was down, and the nurse said bring her out of the dining room, and they were trying to see if she had anything in her mouth. They called a code blue. There happened to be a fireman in the building that day, and I ran to get him. When he came to the floor he said we had to get her out of the [high back wheelchair] and down to the floor. I don't know what happened after that because I went to hold the elevator for the paramedics. On [DATE] at 3:16 PM, V15 (CNA) said, I was passing dinner trays in my hallway, and I saw them wheeling [R1] out of the dining room in her chair. She was unresponsive. She was slumped over, and they were yelling her name. When the fireman arrived from the other floor, he said let's move her to the floor and let's do compressions. We did chest compressions because she was unresponsive. I did CPR with the fireman until the paramedics arrived. On [DATE] at 3:56 PM, V16 (LPN) said, What I found was [R1] had her eyes open, and I could see an exchange of air. I thought we should look at her outside of the dining room, so we moved her wheelchair to the hallway. At that point I did not hear an exchange of air, but I noticed she started doing the universal choking sign, and I looked to do a sweep of her mouth. I used a spoon to sweep the inside of her mouth, and there were chunks of chicken coming from inside her mouth onto the spoon. Because of the size of the chair she was sitting in, I could not reach around the resident to do the Heimlich maneuver, so I approached her from the front and pushed on her abdomen, and when I did that, food started to come up and out of her mouth. I heard some air exchange and once I did that, her eyes closed. Her pulse went from thready to none. We called 911. We identified there was an occlusion and kept checking for a pulse. We started CPR. She was eating chicken tenders for dinner and evidently drank some red juice because what came out was red juice and chewed food. On [DATE] at 1:06 PM, V6 said, [R1] was on a regular consistency diet before she went to the hospital. When she came back she was on a pureed diet. She was not eating her food. She kept repeating, I don't eat pureed food. She was not eating, and she was refusing her food. She was not eating, nor touching her food. She was asking why she had to eat a pureed diet. I changed the order to a regular consistency diet. I do not know who I got the order from to change her diet. I just cannot recall. I know I put the reason for the diet change was because she was on the wrong diet. She was on a regular diet before she went to the hospital. When she choked, that was the first time in my nursing career that I have had a code blue situation. On [DATE] at 1:57 PM V13 (Physician) said, The staff usually puts my name on every order they enter. The normal practice would be to do a swallowing evaluation. I would never give an order to go from a pureed diet to a regular consistency diet. [R1] should have had a swallow evaluation before her diet was changed. No, I did not give that order, unless there was a swallow evaluation done at that time. She was in the process of eating and food got into her trachea. It is my expectation they provide the diet as ordered. On [DATE] at 12:20 PM, V10 (NP) said, I would not have given an order to upgrade from a pureed diet to a regular consistency diet. If the nurses ask about changing her diet, and not eating the pureed food, I will always say have a speech evaluation. I would never say put her on a general diet if I don't know her swallowing capabilities. If that nurse put in an order, there should be a progress note to follow. Normally, they would put in a note saying who they talked to, and they said it was okay to place this order for this diet. She needed to be assisted with meals, based on her encephalopathy and past history. She needed to be closely monitored. On [DATE] at 12:42 PM, V12 (NP) said, I do not remember giving an order to go from a pureed diet to a general diet. [R1] would not be able to be upgraded until she was evaluated by speech therapy. Obviously, she was on a pureed diet for a reason, and she would need to be reevaluated. She would have to be evaluated by speech therapy first. On [DATE] at 11:52 AM, V17 (ST-Speech Therapist) said, I did not see [R1] after her speech evaluation in February, which was before her most recent hospitalization . I usually get flagged to screen the resident if they come back to the facility on a pureed diet. I did not get any information about [R1] being on a pureed diet. Nursing is not supposed to change the diet order. You should never jump two diet consistencies like that. You would go from pureed diet to a mechanical soft diet and if the resident tolerates it, then you can try the regular consistency diet. The resident would need to be evaluated with each diet change. No one ever reached out to me about her diet change. The facility's Diet Order policy reviewed on ,d+[DATE] shows: General: To ensure that residents receive their specific diets. Guidelines: 1. Upon admission, the nurse will receive a diet order. 4. If a resident is not able to tolerate the diet, the nurse will alert the physician or nurse practitioner for a change in diet and possible Speech Therapy Evaluation. 5. If there is a change in the resident's diet per the physician or nurse practitioner order, the nurse may explain the change to the resident and/or resident's representative. 6. If the resident refuses to follow the diet that is written, the resident and resident's representative should be educated on the reason for the diet and consequences of not following the diet. This should be documented in the nursing notes.9. If the resident refuses to eat, the physician is notified to discuss options with the resident and/or their responsible party. The facility's Diet Manual, approved by the facility on [DATE] shows the following policy developed ,d+[DATE]. Policy: Diet Orders - Policy: The facility will offer house standard diet orders. The diets available will be reflected in the diet manual. Procedure: Upon resident admission or diet change, the nurse will verify the diet order with the physician. The facility presented a removal plan on [DATE] at 3:57 PM, to remove the immediacy. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan on [DATE], and the survey team accepted the removal plan on [DATE] at 6:48 PM. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: All nursing staff were re-educated on following physician orders, properly transcribing physician orders, not changing orders without physician notification and approval, and referral to the Speech Therapist as indicated for referrals and evaluation of diet upgrades. The Administrator/DON/ADON-Assistant Director of Nursing) completed the education. Staff who were educated via phone will sign the education prior to the beginning of the next shift worked. New hires will be educated during orientation. Agency staff will be educated prior to shift. All nursing staff not available in person have been re-educated via phone prior to the beginning of the next shift worked and will be re-educated prior to the start of the shift. All new admissions, readmission, and with change in condition related to the resident's swallowing abilities and/or diet appropriateness will be referred to the Speech Therapist. A house audit was completed on [DATE] to ensure that all residents are receiving the correct diet as ordered by the physician. Audit included comparison of resident's most recent admission/readmission discharge physician orders and compared to EMR report by selecting all active, and discontinued orders to ensure correct physician ordered diet is followed in resident's plan of care and correctly transcribed in resident's physician orders. After confirmation of correctly transcribed physician diet order, an audit was completed to ensure correct transcription to facility's dietary software system that contains resident's diet tickets used by kitchen staff when preparing resident's meals. Speech therapy recommendations were also reviewed to ensure correct diet is reflected in physician orders. A random weekly audit of five (5) residents including admission and readmissions is being performed for two months to ensure the resident's diet orders are correctly transcribed by the licensed nurse, as ordered by the physician. Discrepancies of diet orders transcribed by the nurse shall require re-education by Administrator/DON/ADON and ongoing weekly audits to ensure transcription of physician orders and changes in diet orders are completed with physician notification. A chart audit of new admissions and readmissions will be done within 24 hours to ensure the resident is receiving the correct diet. A root cause analysis was conducted to identify barriers and further education needed. Audits will be completed by Administrator/Nursing Management and an analysis presented to QAPI (Quality Assurance and Performance Improvement). All audits will be analyzed and reviewed in QAPI. This is overseen by the Medical Director and Administrator. Audits will continue for no less than two months and QAPI will determine if the audits will continue at that time. The QAPI committee will determine the need for further audits or sunset the audits after the two months.

Based on interview and record review, the facility failed to meet professional standards of nursing when a nurse changed a resident's diet order from a pureed consistency diet to a regular consistency diet without obtaining a physician's order and without following the facility's policy. This failure resulted in R1 being found unresponsive while eating, requiring the Heimlich maneuver and CPR (Cardio-Pulmonary Resuscitation). R1 required admission to the local hospital intensive care unit and expired at the hospital on [DATE]. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on [DATE] and did not return to the facility. R1 had multiple diagnoses including, polyarthritis, chronic kidney disease, morbid obesity, diabetes, left heel pressure ulcer, sacral pressure ulcer, altered mental status, hydronephrosis, anxiety disorder, recurrent depressive disorders, lack of coordination, and history of falling. R1's MDS (Minimum Data Set) dated [DATE] shows R1 had severe cognitive impairment, was totally dependent on facility staff for transfers between surfaces, locomotion on the unit, toilet use and bathing, and required extensive assistance with bed mobility, dressing, personal hygiene, and eating. R1 was always incontinent of bowel and bladder. Physician orders dated [DATE] show R1's diet order as pureed consistency general diet. The EMR shows on [DATE], V6 (LPN-Licensed Practical Nurse) discontinued R1's pureed consistency diet. V6 documented the reason for the order change: Wrong diet. V6 changed R1's diet order from a pureed diet consistency to a regular consistency diet. V6 documented the diet order change was obtained from V13 (Physician). The facility does not have documentation to show a speech evaluation was done to ensure a regular consistency diet was safe for R1. The facility does not have documentation to show V6 (LPN) discussed the diet order change with a physician, nurse practitioner, or V11 (POA-Power of Attorney of R1) prior to the diet order change. The facility's Day at a Glance for General Diets, Week 3 Wednesday, printed [DATE] shows the dinner menu served on [DATE] to residents on a general, regular consistency diet included, chicken breast tenders, barbecue sauce, rice pilaf, seasoned corn, mandarin oranges, bread, margarine, milk, coffee/hot tea, and condiments. On [DATE] at 8:04 PM, V6 (LPN) documented: Around 6 PM during dinner time, the resident assistant came to the nurse's station and stated that the resident was unresponsive while eating dinner. Writer rushed to the dining room and noted that the resident was sitting in the dining room table with her plate @ (at) about 80 percent eaten and she was not responding when her writer called her name. Writer noted that the food was coming out of her mouth and her glass of juice was empty. Writer checked her pulse, and it was present. Writer called for help and the Heimlich maneuver was started right away and also finger was used to remove food out of the resident mouth. Writer noted that the food was coming out her mouth. 911 was called and resident was moved to a safer and clear area. During that time an EMT [Emergency Medical Technician] personnel was at the facility, he came, and we all brought resident on floor and started CPR and a [bag valve mask] was also used. Paramedic personnel arrived as quick as possible and took over. Resident had a pulse of 86. Writer called [V10] (NP-Nurse Practitioner) and left a message, [V11] (POA) was notified as well as [V2] (DON-Director of Nursing) and [V1] (Administrator). Resident was taken to the nearest [hospital]. Local fire department documentation dated [DATE] shows upon arrival and assessment of the resident, R1's airway was completely obstructed and R1's pulses were absent. R1's hospital documentation shows R1 was admitted to the emergency roiagnom on [DATE] with CPR in progress. On [DATE] at 8:10 AM, V7 (Hospital Physician) documented, Out of hospital cardiac arrest - likely due to choking/aspiration of dinner food. V7's documentation continues to show, We will get neurologic and pulmonary input on [R1]. I feel she suffered significant anoxic insult to her brain. Her prognosis is grim. If no neurologic improvement in the next several days we will need to speak with family regarding aggressiveness of this care and possible withdrawal of life support. Hospital documentation continues to show R1 expired at the hospital on [DATE]. R1's death certificate with cause of death is pending with the coroner due to continued investigation into the cause of R1's death. On [DATE] at 3:56 PM, V16 (LPN) said, What I found was [R1] had her eyes open, and I could see an exchange of air. I thought we should look at her outside of the dining room, so we moved her wheelchair to the hallway. At that point I did not hear an exchange of air, but I noticed she started doing the universal choking sign, and I looked to do a sweep of her mouth. I used a spoon to sweep the inside of her mouth, and there were chunks of chicken coming from inside her mouth onto the spoon. Because of the size of the chair she was sitting in, I could not reach around the resident to do the Heimlich maneuver, so I approached her from the front and pushed on her abdomen, and when I did that, food started to come up and out of her mouth. I heard some air exchange and once I did that, her eyes closed. Her pulse went from thready to none. We called 911. We identified there was an occlusion and kept checking for a pulse. We started CPR. She was eating chicken tenders for dinner and evidently drank some red juice because what came out was red juice and chewed food. On [DATE] at 1:06 PM, V6 said, [R1] was on a regular consistency diet before she went to the hospital. When she came back she was on a pureed diet. She was not eating her food. She kept repeating, I don't eat pureed food. She was not eating, and she was refusing her food. She was not eating, nor touching her food. She was asking why she had to eat a pureed diet. I changed the order to a regular consistency diet. I do not know who I got the order from to change her diet. I just cannot recall. I know I put the reason for the diet change was because she was on the wrong diet. When she choked, that was the first time in my nursing career that I have had a code blue situation. V6 was asked multiple times during this investigation who she obtained the order to discontinue R1's pureed diet and upgrade R1's diet consistency to a regular consistency diet. Each time V6 was asked, her response was Hmmm, I just don't know. On [DATE] at 1:57 PM, V13 (Physician) said, The staff usually puts my name on every order they enter. The normal practice would be to do a swallowing evaluation. I would never give an order to go from a pureed diet to a regular consistency diet. [R1] should have had a swallow evaluation before her diet was changed. No, I did not give that order, unless there was a swallow evaluation done at that time. It is my expectation they provide the diet as ordered. On [DATE] at 12:20 PM, V10 (NP-Nurse Practitioner) said, I would not have given an order to upgrade from a pureed diet to a regular consistency diet. If the nurses ask about changing her diet, and not eating the pureed food, I will always say have a speech evaluation. I would never say put her on a general diet if I don't know her swallowing capabilities. If that nurse put in an order, there should be a progress note to follow. Normally, they would put in a note saying who they talked to, and they said it was okay to place this order for this diet. On [DATE] at 12:42 PM, V12 (NP) said, I do not remember giving an order to go from a pureed diet to a general diet. [R1] would not be able to be upgraded until she was evaluated by speech therapy. Obviously, she was on a pureed diet for a reason, and she would need to be reevaluated. She would have to be evaluated by speech therapy first. On [DATE] at 11:52 AM, V17 (ST-Speech Therapist) said, I did not see [R1] after her speech evaluation in February, which was before her most recent hospitalization . I usually get flagged to screen the resident if they come back to the facility on a pureed diet. I did not get any information about [R1] being on a pureed diet. Nursing is not supposed to change the diet order. You should never jump two diet consistencies like that. You would go from pureed diet to a mechanical soft diet and if the resident tolerates it, then you can try the regular consistency diet. The resident would need to be evaluated with each diet change. No one ever reached out to me about her diet change. The facility's Diet Order policy reviewed on ,d+[DATE] shows: General: To ensure that residents receive their specific diets. Guidelines: 1. Upon admission, the nurse will receive a diet order. 4. If a resident is not able to tolerate the diet, the nurse will alert the physician or nurse practitioner for a change in diet and possible Speech Therapy Evaluation. 5. If there is a change in the resident's diet per the physician or nurse practitioner order, the nurse may explain the change to the resident and/or resident's representative. 6. If the resident refuses to follow the diet that is written, the resident and resident's representative should be educated on the reason for the diet and consequences of not following the diet. This should be documented in the nursing notes.9. If the resident refuses to eat, the physician is notified to discuss options with the resident and/or their responsible party. The facility's Diet Manual, approved by the facility on [DATE] shows the following policy developed ,d+[DATE]. Policy: Diet Orders - Policy: The facility will offer house standard diet orders. The diets available will be reflected in the diet manual. Procedure: Upon resident admission or diet change, the nurse will verify the diet order with the physician.

Based on observations, interviews and record reviews the facility failed to do assessments and put new interventions in place after falls. This failure resulted in R1 sustaining a 1-centimeter laceration to his forehead. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for falls. Findings Include: On 3/10/22 a tour of the facility was made and there were no star symbols placed at the doorway of R1 and R3's rooms. R1 EHR (Electronic Health Record) showed that R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including [CONDITION(S)] and [CONDITION(S)], [CONDITION(S)], altered mental status, senile degeneration of the brain, dementia, depression, [CONDITION(S)], and [CONDITION(S)]. On 1/3/2022, R1 fell and was sent to the local community hospital with a laceration above his right eye. On 2/26/2022 R1 fell again and was sent to the local community hospital with a closed head injury, and on 3/7/2022, R1 fell again, and again R1 was sent to the local community hospital and received sutures for a 1cm laceration to his forehead. R1 remained in the hospital from that last fall for the duration of this investigation. R1's progress notes shows that R1 fell on [DATE], 2/26/2022, 1/2/2021, 1/3/2021, 11/4/2021, 11/2/2021, and 10/29/2021. R1's care plan was reviewed and showed the last review dated of 1/20/22. There were no further updates with new interventions for the falls on 2/26/22 and 3/7/22. R1's records showed that the facility did not complete fall risk reviews for falls dated 3/7/22, 1/3/21, and 11/4/21. R2's progress notes showed that on 2/15/22 R2 fell and sustained a left wrist fracture. R2's care plan showed that no update or new revisions were put in place since that fall. R3's progress notes showed that R3 fell on [DATE] and his last update for falls on his care plan was 1/21/22. The facility had no documentation of Root Cause Analysis forms for R1, R2, or R3's falls. V1 Administrator said that the Root Cause Analysis form is used to determine the need for new interventions to prevent further falls. V1 Administrator said that the facility's Restorative Nurse is the person who does the root cause analysis, and the facility has been without this person since December of 2021and that is the reason the facility did not do them for R1, R2 and R3's falls. V1 said that the interventions and recommendations on the Root Cause Analysis form is used to update the care plan. If this form is not completed and the care plan is not updated, it could cause the resident to fall again and be injured. V5 R1's Primary Care Physician said that after a resident falls, he expects the facility to put interventions in place to prevent future falls. V5 said that R1's 1cm laceration to his forehead (with sutures) was because of his fall on 3/7/22. V4 LPN (Licensed Practical Nurse) said that after a fall the facility is to complete a fall risk review. The facility's fall risk review list dated 9/10/21 to 3/10/22, showed that R1, R2, and R3 were at risk for falls. The facility's Fall Prevention Program policy dated 2/28/22 showed under Standards: 2. A fall risk assessment will be performed at least quarterly . and after any fall incident. 3. Safety interventions will be implemented for each resident identified at risk The facility's Fall Risk and Post Fall Assessment policy dated 6/14 showed under, Policy: . a post fall assessment will be performed after each fall and additional interventions promptly initiated to prevent future falls . Purpose: To identify treatable conditions and improve the overall quality of life for residents. To detect reversible causes of falls and to identify supportive aids to prevent falls. Procedure: 7. if the fall prevention plan failed initiate an immediate new intervention. 8. Document assessment findings, change fall prevention interventions 14 Revise the care plan to include all new fall interventions. The facility's Falls policy date 6/14 showed under Falling Star Program, Star symbol will be placed at doorway of room. The facility's Fall Committee policy date 6/4 showed under Purpose: To meet minimal weekly to analyze the cause of the incident and ensure new interventions are incorporated into the care plan.

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place for a resident at high risk for falls. This failure resulted in a resident falling from bed and sustaining a left hip dislocation. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: R1's Face Sheet showed he has [DIAGNOSES REDACTED]. R1's January 4, 2020 Minimum Data Set showed R1 is severely cognitively impaired, requires extensive assistance of two people for transfers, and has a history of falls. R1's January 25, 2020 Fall Risk Review categorized R1 as a high fall risk and showed R1 had previous falls. The facility's March 11, 2020 Facility Incident Investigation Report showed On 3/9/2020 at approximately (10:30 PM), resident was observed out of his bed on the floor positioned on his left side facing the door . On March 11, 2020 at 12:40 PM, R1 was on his back in bed. R1's left leg was rotated internally and it was shorter than his right leg. R1's March 11, 2020 X-ray result from 9:43 PM showed Dislocated total left hip replacement prosthesis. On March 12, 2020 at 9:45 AM, V12 CNA (Certified Nursing Assistant) stated she is always assigned to R1. V12 stated prior to his March 9 fall, R1 was always climbing out of bed .I don't know why . he's antsy. He has dementia. V12 stated if R1 is up in his chair and it is not reclined, R1 also attempts to get up. V12 stated R1 has always had fall mats, and always had alarms. V12 was asked how she knew which residents were fall risks, and she stated she refers to the Care Cards in the residents' closets. The undated Care Sheet in R1's closet showed he is at risk for falls, and uses a bed alarm, chair alarm, fall mat, and bed bolsters as fall interventions. On March 12, 2020 at 10:30 AM, V3 RN (Registered Nurse) stated fall mats are used in case a resident falls. V3 stated you do not want a resident to fall on the cement floor so mats can minimize risks of injury. V3 stated alarms are used for those residents who try to get up unassisted and the alarm reminds the resident and alerts the staff. V3 stated it is everyone's job to make sure that mats and alarms are in place. V3 added whenever a resident is in bed and they have mats, if you see they aren't there, they should be put down. On March 11, 2020 at 4:05 PM, V10 (RN) stated she was working with R1 on March 9, 2020 when he fell . V10 stated the CNA found R1 on the floor when she was doing her rounds. V10 stated when she saw him, R1 was lying on his left side on the door side of his bed. V10 stated R1's alarm was not sounding and it was not on him. V10 stated R1's fall mats were not in place and instead were leaning against the wall. On March 12, 2020 at 10:00 AM, V11 (RN) stated staff members have to follow protocol for fall interventions and have to ensure that the interventions are actually in place to prevent a fall. V11 stated if you know they've fallen you make sure they're in place. V11 stated alarms let us know someone is trying to get up and maybe we can get to them. V11 stated the purpose of the mats is to lessen injury. On March 12, 2020 at 12:35 PM, V6 (R1's Nurse Practitioner) stated R1's left hip dislocation was a result of his fall from bed on March 9, 2020. V6 stated she expects resident's fall interventions to be implemented. R1's Fall care plan focus (revised January 15, 2020) showed the intervention of bed alarm applied was initiated October 21, 2019. The facility's November 27, 2019 Fall Prevention Program policy showed The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions . The policy further showed 4.All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained .

Based on observation, interview, and record review, the facility failed to supervise cognitively impaired residents with dysphagia to prevent them from taking and ingesting food served to other residents. This failure resulted in R1 choking and requiring emergency medical attention. R1 was transported to the local hospital and expired on [DATE] at 9:06 AM. This applies to 2 of 5 residents (R1, R6) reviewed for accidents and supervision during eating in the sample of 7. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility, from the local hospital, on [DATE] for continued physical therapy following a fall. R1 was discharged from the facility on [DATE] following a fatal choking incident at the facility. R1 had multiple [DIAGNOSES REDACTED]., and profound intellectual disabilities. R1's MDS (Minimum Data Set) dated [DATE] shows R1 had adequate hearing, no speech, was rarely/never understood, rarely/never able to understand others, and severe cognitive impairment. R1 required extensive assistance by one facility staff member with bed mobility, transfer between surfaces, locomotion on and off the unit, and was totally dependent on facility staff for eating, toilet use, personal hygiene, and bathing. R1 was always incontinent of bowel and bladder. R1's MDS shows R1 had a swallowing disorder, with loss of liquids/solids from his mouth when eating or drinking and holding food in his mouth/cheeks or residual food in his mouth after meals. R1's order review sheet dated [DATE] to [DATE] shows a diet order for general diet, pureed texture, nectar thick liquids, double portions for all meals for dysphagia. V2's (DON-Director of Nursing) documentation for R1 dated [DATE] at 8:33 AM shows: At approximately 8:30 AM resident (R1) was noted in a wheelchair rolling himself in the dining room with dusky skin color and discoloration around the mouth. A mouth sweep was done revealing undigested scrambled eggs, [MEDICATION NAME] maneuver initiated. Resident became unresponsive, was lowered to the floor and CPR (Cardio-Pulmonary Resuscitation) initiated. Paramedics transported resident to the hospital at approximately 8:40 AM with faint pulse noted. The local fire department documented they were dispatched to the facility for a non-breathing resident (R1) on [DATE] at 8:28 AM and arrived at R1's side at 8:33 AM. (R1) is put on the monitor and shows asystole (no heart rhythm). Pt (patient) airway is attempted to be cleared. Pt has no carotid pulse. Pt airway is suctioned, and some eggs are removed. Eggs are also removed while trying to intubate. Forceps are also used to try and clear the airway but unsuccessful because of the consistency of eggs. Intubation is tried twice unsuccessful since more eggs are down the airway. Pt condition is unchanged on arrival to the hospital. Pt is still asystole. Hospital documentation shows R1 arrived at the emergency roiagnom on [DATE] at 8:50 AM in asystole with ACLS (Advanced Cardiac Life Support) in progress. R1 was intubated by hospital staff at 8:55 AM, and ACLS continued. At 9:06 AM, efforts were terminated. Hospital documentation shows R1 expired at 9:06 AM. On [DATE] at 12:44 PM, V7 (LPN-Licensed Practical Nurse) said, I was working yesterday when the choking happened with (R1). We were in the dining room passing medications. I had my back to (R1). V9 (RN-Registered Nurse) was finished feeding (R1) and went to pass medications to other residents. (R1) snatches food from other residents all the time. We feed him at a separate table, so he can't grab food from other residents while they are eating. (R1) can self-propel his wheelchair, and he was coming up behind me. I noticed he was blue around the mouth. I opened his mouth and did a quick mouth sweep. He was sitting in the wheelchair and I wrapped my arms around the back of the wheelchair and attempted to do the [MEDICATION NAME] maneuver. As soon as I did the [MEDICATION NAME], he went limp in the chair. V9 looked in his mouth too and lowered him to the floor. I went to call 911, and the CNA (Certified Nursing Assistant) called code blue to the third floor. (V9) was doing CPR. I was in the room, but I had my back to him, so I don't know where (R1) got the food from. Normally another resident would yell if he took their food, but no one was yelling yesterday. I'm thinking he snatched someone else's food because it appeared to be regular consistency scrambled eggs and he eats pureed eggs. On [DATE] at 12:53 PM, V8 (CNA) said, The nurse was feeding (R1) and I had my back to him. Two other residents were arguing about the drink cart, so I got up and I took the juice cart out of the room to move it. I could see (R1) propelling his wheelchair towards (V7) (LPN). I yelled out to her that (R1) was coming up behind her because she had her back to the resident. I didn't realize he was choking. He grabs food, and he is really quick. Usually the other residents yell if he grabs their stuff. I didn't hear any yelling. When they were doing CPR, eggs were coming out of his mouth. The eggs looked like regular consistency, scrambled eggs, not pureed eggs. He grabs food a lot. Ever since they moved him up here he's been grabbing food. I was never told to do anything special with him after he was done eating to keep him from grabbing other resident's food. On [DATE] at 1:04, PM V9 (RN) said, I was in the dining room and I fed the resident myself. He had pureed eggs, he had oatmeal and he had some pureed meat as well. I fed him myself. I started around 8:10 AM and finished around 8:20 AM. The last thing I gave him was some nectar thick juice. He ate everything on his plate. He did not have any food in his mouth when we finished. I took his breakfast tray away, and I went to assist another resident. I left (R1) sitting at his table. I didn't see him personally or observe him from the time I finished feeding him until 8:30 AM when (V7) LPN yelled to me for help. When I responded she was doing [MEDICATION NAME] maneuver on the resident, and she was having a hard time. He was sitting in the wheelchair. We were doing the [MEDICATION NAME] maneuver while he was sitting in the chair. When we did the mouth sweep there were eggs in his mouth. He's known to grab food from other people's trays. He had moved from one side of the room, where I had fed him, to the other side of the room in that short period of time. Most of the time when he gets fed he is fine, and we redirect him, but sometimes we get busy and by the time we get back to him he's already grabbed something. The breakfast trays were in the middle of the room, and he had passed the breakfast trays on his way to where the other nurse was. He lost consciousness as we were doing the [MEDICATION NAME], so we had to put him down and started CPR. I couldn't feel a pulse before I started compressions. He's aphasic so he couldn't tell you anything. On [DATE] at 2:14 PM, V15 (Speech Therapist) said, I saw R1 for a treatment prior to his expiration. He was under speech therapy because he came here on an altered diet (pureed diet). He was impulsive and tried to grab food from other people. He required feeding assistance due to his impulsiveness. He needed 100 percent supervision due to his impulsivity, and if he got food in his mouth there was the risk of choking. If no one was watching, he would just shovel in the food. Based on the intellectual disability he had, he couldn't stop himself in any way. Staff had to watch to make sure his mouth was empty. I never saw him pocket or hold food in his mouth. He was impulsive, and he would put so much food in his mouth that he could choke. On [DATE] at 9:05 AM, V16 (Chief Administrative Director-Will County Coroner) said, Food particles, appearing to be eggs were present in R1's airway and mouth during the autopsy. R1's cause of death is pending toxicology results. On [DATE] at 9:22 AM, V13 (Social Worker) said, I am the Social Worker from the group home where (R1) previously resided prior to his recent hospitalization and stay at the nursing facility. We intended for him to return to the group home. We had locks on the refrigerator and the snack cabinets at the group home, so he was unable to get into things on his own. We had staff always monitor him and made sure he was always within eyesight. He would always come in and try to take food even after he was done eating. I attended a care plan meeting for (R1) at the facility on [DATE]. The facility did not reach out to us for help with interventions for his food grabbing, to my knowledge. There were things that he enjoyed chewing on, including his fingers. He also liked beanie babies, and a stuffed monkey that he put in his mouth and a red foam soccer ball that he would put his mouth on. I remember bringing that up at the meeting. At the end of the meeting, there was no plan in place for him to return to the group home. On [DATE] at 1:43 PM, V14 (LPN) documented R1 was putting objects in mouth, stuffing other resident food in mouth, possible choke risk, poor safety awareness. R1 was given redirection, and the behavior remained unchanged. On [DATE] at 6:40 PM, V17 (RN) documented, Resident restless, constant visual contact required, attempting to go into other's rooms, grabbing other's food. Standing up and walking unassisted. Very impulsive with behavior. On [DATE] at 9:09 PM, V18 (Nurse) documented, Slept three quarter of the night, wandering the rest of the night in other resident's rooms and taking their stuff, redirection provided which only worked for about a minute. On [DATE] at 10:04 PM, V19 (LPN) documented, Earlier in shift resident very restless and compulsive, moving back and forth in wheelchair, safety reminders shown to resident to sit back in wheelchair, and to return to chair, after attempts to roam out of chair. Resident has a very unsteady gait. Resident very confused, and unable to express needs, resident repeatedly sucks and chews on fingers. On [DATE] at 12:35 PM, V17 (RN) documented, He has a very good appetite, eats his plate, and any other food he can get a hold of. Propels self in w/c (wheelchair) and at times will stand up suddenly and walk away from w/c. On [DATE] at 1:05 PM, V17 (RN) documented, R1 was attempting to grab someone's food and was prevented. Attempted to bite and scratch staff when he couldn't, he bit his own hand. The intervention the facility tried was putting R1 at a separate table until his food arrived. On [DATE] at 10:32 AM, V2 (DON) said, During my investigation into (R1's) choking incident, it seems likely that he must have grabbed some food from another resident tray. The resident receives one-to-one feeding assistance because of his behavior for grabbing food. He was our only developmentally disabled resident. We do not have any other residents with developmental disabilities residing at the facility. We placed him on the unit with other dementia residents. The staff did not receive any specialized training to deal with a developmentally disabled resident. I did call his previous facility and they told me he liked holding a toy for chewing on. He had a toy here at the facility, but it seems it was misplaced. The interventions we had for (R1) were supervision, feeding him at a separate table, and keeping him in an area where he was visible. He propels himself back and forth in the wheelchair. (R1's) choking incident happened in the middle of the dining room. Despite the fact three facility staff were present in the room, none of them can say that they know how (R1) got access to the food he choked on, nor did they have him in their direct line of sight when he grabbed the food. None of the residents in the area were cognitively intact to ask what happened. None of the residents in the room would have been able to say he's grabbing my food. On [DATE] at 10:00 AM, V2 said, We identified concerns and that there are supervision issues in that third-floor dining room where (R1) resided. On the day of the choking incident, we identified that the nurses had their backs to the residents. 2. On [DATE] at 1:00 PM, 35 residents were present in the dining room with only V8 (CNA) supervising the residents. V8 was feeding a resident. Multiple residents were asking for assistance, including asking for coffee, juice and water, and V8 was unable to attend to all the resident's needs. R6 was sitting in the dining room and had eaten 100 percent of her lunch. R6 had reached across the table and grabbed a plate of food belonging to another resident. R6 was using her fingers to eat the food off the plate. V8's view of R6 was obstructed by a column in the middle of the room. V8 was asked to look at the plate R6 was eating from and V8 responded that R6's tablemate had left the table without eating any of her lunch, and R6 was eating from the tablemate's plate. R6 was unable to be interviewed due to her cognitive status. The EMR shows R6 was admitted to the facility in [DATE] with multiple [DIAGNOSES REDACTED]. R6's MDS dated [DATE] shows R6 has severe cognitive impairment, requires supervision with setup help only for eating, extensive assistance with bed mobility, transfers between surfaces, dressing, toilet use, and personal hygiene. R6 is totally dependent on facility staff for bathing and is always incontinent of bowel and bladder. R6's speech therapy progress and discharge summary report dated [DATE] shows R6 was treated by speech therapy for dysphagia. Clinical impressions by speech therapy include: Pt requires supervision during meal to ensure usage of safe swallow strategies and reduce occurrence of pocketing. Patient/caregiver training since last report: Pt/staff educated on safe swallow strategies (small bites/sips, alternate bites/sips, slow rate) to reduce aspiration risk. Precautions: Aspiration precautions - regular with thin liquids. On [DATE] at 2:45 PM, V2 (DON) said he was not aware R6 was at risk for aspiration or had issues with pocketing food as documented by speech therapy. V2 said he was not aware that one staff member was left to supervise 35 residents during the lunch meal on the third floor, and that more staff should have been present to assist with supervision of residents and assist residents with dining needs. On [DATE] at 10:00 AM, V2 said, There are three CNAs on the third floor. The nurses also help pass the meal trays. There should be two CNAs and the nurses, so at least four staff are present in the dining room. At the minimum, there should be two staff members. V2 said R6 requires intermittent observation for food pocketing. Intermittent observations of the resident mean we have to observe her once or twice a week, not during every meal. On [DATE] at 11:40 AM, V15 (Speech Therapist) said R6 should be monitored during every meal to ensure she is not pocketing food while she is eating. V15 said intermittent observation for food pocketing should be defined as observing the resident during every meal to ensure the resident clears her mouth of food, and R6 should be sitting at a table with staff supervision. Intermittent observation does not mean occasionally observing a resident once or twice a week to check for pocketing food. On [DATE] at 12:00 PM, V9 (RN) said, The third-floor dining room is usually staffed with two CNAs and two nurses during meal time, and a manager might come and help as well. On [DATE] at 12:05 PM, V20 (CNA) said, The third-floor dining room is usually staffed with three CNAs, a restorative aid, and two nurses.

Based on observation, interview and record review, the facility failed to prevent deterioration of a pressure sore for a resident who is identified as a high risk for skin breakdown and has an abrasion in the sacrum. This failure resulted to resident (R1) sustaining a stage 4 pressure ulcer in the sacral area. This applies to 1 of 4 residents (R1) reviewed for pressure ulcer in the sample of 15. The findings include: R1's face sheet showed that R1 is a 75-years old who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's minimum data set ((MDS) dated [DATE] showed R1 requires extensive assistance by one to two staff members with transfer, bed mobility, dressing, hygiene, and toileting, and is always incontinent of bowel. R1's care plan for alteration in skin integrity initiated 12/5/19, showed no updates to intervention even though R1's wound was worsening in the facility. On 12/24/19 at 10:20am, V6 (Wound Care Nurse) provided wound care to R1. V6 removed the saturated adbominal (ABD) dressing and cleansed the wound with normal saline solution. V6 measured the wound length 7.5 centimeter (cm) x width 7.0 cm x depth 5cm. R1's wound had an undermining at (12 o'clock by 6 o'clock) 3cm and at (4 o'clock) was 5cm deep. The wound has 80% granulation with 25%-75% serosanguinous odourous drainage. V6 applied hydrogel to wound bed and the wound was covered with ABD pad and secured with tape. R1's sacrum wound was classified as stage 4 sacral wound. On 12/24/19 at 11:21am, V6 stated R1's wound was first discovered 12/5/19 and that at the time it looked like a slit measuring 1cm x 1cm x 0cm. V6 stated V10 (Wound Care Doctor) examined the wound the same day and prescribed [MEDICATION NAME] dressing twice a week.V6 stated when she made rounds on 12/12/19, R1's wound had gotten bigger with a measurement of 2.5cm x 3.0cm, scant drainage, with slough and no odor. V6 stated V10 was not available to observe the wound on 12/12/19 because he was on vacation. V6 stated when she saw R1's wound on 12/17/19 because R1 was having symptoms of infection-fever, [MEDICAL CONDITION] was hypotensive. V6 stated R1's wound was much bigger (6cm x 4.5cm x 0.5cm) with [DIAGNOSES REDACTED] and slough. V6 stated she texted V10 to inform him about the worsening condition of R1's wound. V6 stated V10 ordered to start R1 on (Keflex) an antibiotic three times a day. V6 stated R1 was sent out to the hospital on [DATE]. V6 stated R1 returned to the facility 12/22/19 with much bigger wound that meausred 7cm x 7cm x 5cm after hospital debridement. On 12/24/19 at 1:22pm, V10 stated he examined R1's wound on 12/5/19 with V6. V10 stated he did not take a measurement of the wound because he expected V6 to do it. V10 stated he was out of town on 12/12/19 and did not see R1. V10 stated when he came to the facility to round on 12/19/19, he was informed R1 was in the hospital. V10 stated he was not aware of the condition change to R1's sacrum wound. V10 stated nursing staff should have notified him if the condition of the wound changes. V10 further stated he would have ordered other treatments like Dakin solution or hydrogel treatment for [REDACTED]. On 12/30/19 at 11:28am, V18 (Nurse Practitioner) stated he would expect R1's wound to improve with treatments. V18 stated he expected nursing staff to notify the physician if there are signs and symptoms of infection to the wound or if the condition of the wound got worse. V18 stated he did not receive a call regarding R1's wound condition. On 12/23/19 at 11:50am, V2 Director of Nursing (DON) stated R1 was originally admitted to the facility 10/21/19. V2 stated R1 was transferred to a Pyschiatry hospital on [DATE] and was re-admitted [DATE]. V2 stated on 12/5/19, R1 developed stage 2 pressure sore on the sacrum area. V2 stated R1 was being managed by V10 and V6 at the facility. V2 stated on 12/17/19, V6 reported to him that R1's wound has gotten worse. V2 stated V10 was notified and anitbiotic treatments were ordered. V2 stated R1 was noted with fevers of 100.0 or more and [MEDICAL CONDITION] V2 stated he notified the primary physician's office for R1's change in condition, and was asked to send R1 out to the hospital. On 12/31/19 at 10:35am, V2 confirmed R1 was high risk for pressure sore from clinical standpoint. V2 further stated the facility put in place interventions to prevent worsening of the pressure sore but failed to update R1's care plan to reflect the changes. On 12/23/19 at 11:30am, V4 (Family Member) stated depending on the staff on duty, R1 was not being turned and incontinence brief was not changed in a timely manner at the facility. V4 stated she came in to the facility to visit and sit with R1 on a daily basis to feed R1. R1's weekly skin alteration review by wound nurse dated 12/5/19 showed R1 with an abrasion in the sacrum/coccyx area measured 1cm x 1cm partial thickness. R1's weekly skin alteration review by wound nurse dated 12/12/19 showed R1 with an stage 2 in the sacrum/coccyx area measured 2.5cm x 3cm with scant serosansuinous . R1's weekly skin alteration review by wound nurse dated 12/16/19 showed R1 with a nonstageable in the sacrum/coccyx area measured 6cm x 4cm partial thickness with 100% slough and purulent drainage. R1 was sent out to the hospital on [DATE]. On returning back from the hospital on [DATE], R1's treatment nurse initial skin alteration review by wound nurse dated 12/23/19 showed R1 with a stage 4 sacrum pressure injury that measured 7cm x 7cm x 5cm, 80% granulation, 25%-75% moderate serosanguinous drainage. Hospital record dated 12/19/19 showed R1 was admitted with fever, [MEDICAL CONDITION] elevated white blood cell count of 14.4, lethargy, and drowsiness. The hospital record R1 underwent a surgical debridement, wound measurement showed sacrum pressure injury 7.5cm x 6.5cm x 3.0cm, wound edges well defined, [DIAGNOSES REDACTED] with purple discoloration to inferior margin. It also showed large serosanguinous drainage. Review of facility's policy titled, 'Pressure Ulcer and Skin Condition Assessment' dated 11/19/19 showed, To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure and other ulcers, and assuring interventions are implemented. The policy also showed, the resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care.

Based on observation, interview and record review the facility failed to implement safe bed mobility practices to prevent falls. This applies to 1 of 3 residents (R2) reviewed for falls with injuries in a sample of 15. This failure resulted in R2 incurring a left femur fracture. Findings include: An Incident Report dated 6/9/19, completed by V5 (Nurse), documents R2 fell over side of the bed while receiving care. On 6/19/19 at 1:46 PM R2 laid in bed with a left leg immobilizer in place. On 6/19/19 at 1:46 PM V7 (Nursing Assistant) stated R2 required 2 staff assistance for bed mobility at the time of R2's 6/9/19 fall. On 6/20/19 at 11:30 AM, V15 (Nursing Assistant) stated on 6/9/19 V15 was providing incontinence care which required R2 to be turned from side to side. As V15 turned R2, R2 reached for a purse which was bedside. V15 stated R2 began to fall from the bed and V15 grabbed R2's shirt to keep her upper body from falling but R2's legs and feet still fell from the bed. V15 stated she lowered R2 to the floor because R2 was too heavy to hold onto. V15 confirmed she was providing care to R2 alone. On 6/19/19 V5 (Nurse) stated V15 called V5 into R2's room because R2 had fallen from the bed while providing incontinent care. V5 stated V15 was the only staff member providing care to R2 and R2 required the assistance of 2 staff members to safely turn R2 from side to side. R2's Care Plan for ADL (Activities of Daily Living) Functional/Rehabilitation Potential dated 4/2/2017 documents R2 requiring 2 staff assistance to aid in turning/repositioning in bed. R2's Minimum (MDS) data set [DATE] documents R2 as moderately cognitively impaired and requiring the extensive assistance of 2 staff persons for bed mobility. On 6/20/19 at 12:58 PM, V4 (Nurse Practitioner) stated R2 incurred a [MEDICAL CONDITION] femur after reaching for something bedside and falling from the bed. V4 confirmed she expects staff to implement basic safety measures while turning a resident in bed. V4 stated if it was documented to use 2 staff for bed mobility the facility should have used 2 staff while providing care to R2 to prevent injury. A hospital Orthopedic Consultation report dated 6/10/19 documents R2 with an evaluation due to left leg pain after a fall from bed. This consultation note documents R2 with a left femur fracture and to use a left knee immobilizer.

Based on observation, interview and record review the facility failed to provide assistance to a resident identified as high risk for falls and needing two person physical assistance during transfer to promote resident safety. This applies to 1 of 4 residents (R1) reviewed for falls in the sample of 17. This failure resulted in R1's fall during one staff assisted transfer. R1 was sent to the hospital and was diagnosed with [REDACTED]. The findings include: R1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The facility initial & final reportable report showed that R1 had a fall incident on January 26, 2017 at 3:30 PM. The report showed, At approximately 03:30pm the resident CNA (Certified Nursing Assistant) was using her gait belt to transfer the resident from the wheelchair to the toilet. Upon transfer resident knees buckled, resident lost her balance and the CNA lowered the resident to the floor. CNA immediately called for the nurse. Upon nurse observation, resident right knee was swollen and resident complained of pain. The report showed that the physician was notified of the fall incident with order to send R1 to the hospital ER (emergency room ) for evaluation. The same report also showed that R1 was diagnosed and hospitalized with [DIAGNOSES REDACTED]. R1's quarterly MDS (minimum Data Set) dated January 18, 2017 showed a BIMS (Brief Interview for Mental Status) score of 14 which meant that the resident is cognitively intact. The same MDS also showed that R1 would require extensive assistance of two or more staff members' physical assist for transfers and toilet use. R1's current MDS dated [DATE] showed a BIMS score of 13 which meant that the resident is cognitively intact. The same MDS also showed that R1 would require extensive assistance of two or more staff members' physical assist with transfers and toilet use. R1's fall risk assessment dated [DATE] showed a score of 14, which meant that the resident is at high risk for fall. R1's current care plan initiated on November 21, 2016 (in effect on January 26, 2017) regarding falls showed that R1 Is at increased risk for injury R/T (related to) falls due to history of falls, dementia, episodes of syncope/seizures, incontinence and CVA (cerebrovascular accident) with right hemi. This fall care plan's goal is for R1 to remain free from serious injury related to fall On November 7, 2017 at 9:45 AM, R1 was in bed, alert and oriented, watching television. R1 stated that early this year she broke her right leg after a fall. Per R1, she was attempting to transfer from the toilet to her wheelchair with staff assistance. During the process of transfer, she was trying to reach for the bathroom grab bar but missed it and fell on her right knee on the floor. According to R1 when she fell and landed on her right knee, I heard it pop up and I was in severe pain. R1 stated that during this transfer, there was only one staff assisting her and that no gait belt was used. Per R1 the staff was just holding her by her arm when she fell on her right knee. On November 7, 2017 at 10:55 AM, during morning care observation, R1 stated, Look, this is the scar from the surgery I had after my fall. R1 was pointing on her right femoral area. On November 7, 2017 at 11:07 AM, during transfer observation E12 (CNA) applied a gait belt around R1's waist. R1 was shown the gait belt and was asked, if a similar belt device was applied on her when she had the incident of fall. R1 responded, No, she did not put any belt on me. During this observation and interview, E4 (CNA) and E13 (nurse unit manager) and E12 were present. On November 7, 2017 at 11:28 AM, E4 stated that she was the staff assigned to R1 on January 26, 2017 when the resident had the fall incident. Per E4 she was assisting R1 with transfer from the toilet to the wheelchair using a gait belt on January 26, 2017 at around 3:30 PM. During this attempted transfer, E4 stated that she positioned herself in front of R1 with one of her leg positioned in between R1's legs for stability, then she held the gait belt on both sides, to assist R1. Per E4, R1 stood up and was about to turn when R1's knee buckled so, she slowly sat R1 on the floor and activated the call light for help. According to E4, R1 complained of pain after the resident sat down on the floor. During the same interview E4 stated that when the incident happened she was new to the facility and was not aware that R1 needed a two person assist for transfers and toilet use. On November 8, 2017 at 1:17 PM, E17 (nurse) stated that he was the nurse on duty when R1 had the fall on January 26, 2017. Per E17 he does not remember a lot of details pertaining to the fall. E17 stated that the only thing he remembered is that when he assessed R1 after the fall, the resident was complaining of pain on the right knee during movement and when the area was touched. E17 also stated that he remembered that the right knee was also swollen. Review of the facility's undated policy and procedure regarding, Limited lifting resident handling showed, Use of gait belt for all physical assist transfers is mandatory. R1's emergency room records dated January 26, 2017 showed under history of present illness showed, Location: Right knee. The character of symptoms is pain and swelling. The degree at present is severe. The exacerbating factor is movement. The relieving factor is none. R1's hospital records dated February 1, 2017 showed that the resident was diagnosed with [REDACTED].

Based on observation, interview and record review, the facility failed to provide supervision and a safe environment for the following issues: 1) Failed to provide supervision and interventions to prevent falls for 4 residents (R1, R5, R6, and R26). R1 sustained an acute mild to moderately displaced intertrochanteric fracture of the proximal left femur. 2) Failed to provide a safe environment by leaving the beauty shop unlocked with unsecured oxygen tanks affecting two sampled residents (R21, R22) on the second floor. 3) Failed to keep disposable razors in a locked area away from resident access affecting two sampled residents (R5, R37) on the third floor. 4) Failed to keep a chemical and medications inaccessible for the following residents: (R5, R7-R10, R21, R22, R37) 5) Failed to provide a safe environment by using power strips to plug in durable medical equipment affecting 4 sampled residents (R3, R19, R38, R39). This applies to 15 of 62 residents (R1, R3, R5, R6, R7, R8, R9, R10, R19, R21, R22, R26, R37, R38, R39) reviewed for falls and safety concerns in the sample of 62. The findings include: 1. The facility face sheet dated March 14, 2017 shows R1 was admitted to the facility on [DATE] and discharged on [DATE]. The face sheet shows R1 had multiple [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated February 28, 2017 shows R1 had severe cognitive impairment, required extensive assistance with all ADLs (activities of daily living), and was frequently incontinent of bowel and bladder. R1's fall risk assessment dated [DATE] shows R1 was a high fall risk. R1's care plan dated February 1, 2017 shows, Problem: Resident at risk for falling R/T (related to) right femur fx. (fracture). Approaches included bilateral fall mats, chair alarm when out of bed, keep bed in lowest position with brakes locked, and observe frequently and place in supervised area when out of bed. E16's (RN-Registered Nurse) progress note dated March 5, 2017 at 5:30 PM shows: (R1) was found on floor mats next to bed. CNA (Certified Nursing Assistant) was going into room to assist resident to w/c (wheelchair) for dinner when resident was noted on floor. (R1) on floor guarding left hip. (R1) c/o (complained of) pain in hip area rated 7/10. Transferred from floor to bed with 3 assist complete body assessment completed. No open areas noted, no redness or swelling noted bed was in lowest position floor mats in place. (R1) stated he was trying to take himself to toilet. Wife notified, (Z3) (physician) notified, on call manager made aware, orders received to send to (local hospital) for evaluation. Hospital records for R1 dated March 5, 2017 show, Acute mild to moderately displaced intertrochanteric fracture of the proximal left femur. On March 15, 2017 at 1:38 PM, Z3 (physician) said, (R1's) left hip fracture was caused by the fall. On March 15, 2017 at 2:52 PM, E2 (DON-Director of Nursing) said, If a resident is a high fall risk, we put them on the fall prevention program (L.E.A.F. - Let's End All Falls). We put alarms in place, fall mats, resident room near the nurse's station and a low bed. If a resident is a high fall risk, the L.E.A.F. sheet, with interventions, gets posted in the residents room behind the closet door. We usually try to keep high fall risk residents busy with activities. I expect all residents in the facility to be monitored every 1-1/2 to 2 hours. If a resident has a care plan intervention that includes frequent monitoring, then my expectation would be to monitor the resident every 30 minutes to 1 hour. (R1's) room was at the end of the hall, farthest from the nursing station. There was no system in place to show R1 had been monitored every 30 minutes to 1 hour. R1's undated L.E.A.F. sheet shows R1 was a fall risk, had a chair alarm, floor mats, bed in the low position and extensive assistance with transfers. The sheet did not show frequent monitoring as an intervention for R1. 2. R5's face sheet dated March 15, 2017 shows R5 was admitted to the facility in July 2016 with multiple [DIAGNOSES REDACTED]. R5's MDS dated [DATE] shows R5 has severe cognitive impairment, requires extensive assistance with all ADLs, and is always incontinent of bowel and bladder. R5's Fall Risk assessment dated [DATE] shows R5 is a high fall risk. Nursing documentation shows the following: R5 slid from his wheelchair in his room on February 22, 2017. On March 1, 2017 R5 fell during self transfer to the toilet. On March 3, 2017 R5 lost his balance and fell during transfer to the wheelchair with the CNA. R5's fall care plan dated July 12, 2016 shows: Falls: (R5) is at risk for falling R/T (related to) impaired transfer balance, unsteady gait. Approaches: Place (non-slip rectangular mat) in wheelchair. Chair alarm when out of bed. Keep call light in reach at all times. R5's undated L.E.A.F. care card shows R5 is a fall risk, requires a chair alarm, and non-skid rectangular mat in the wheelchair. On March 14, 2017 at 8:32 AM, R5 was laying in bed. One end of the call light cord was tied to R5's bed rail. The other end was laying on the floor, not attached to the call light switch on the wall. R5 would not have been able to activate the call light system with the call cord disconnected from the wall. On March 15, 2017 at 12:30 PM, R5 was being transported via wheelchair to the dining room by E12 (CNA). R5 did not have a chair alarm in place or the non-slip rectangular mat on the seat cushion of the wheelchair. On March 15, 2017 at 12:30 PM, E1 (Administrator) said R5's non-slip mat should be on top of his wheelchair cushion when R5 is sitting in the wheelchair. On March 15, 2017 at 2:52 PM, E2 (DON) said, The non-skid rectangular mat is a sticky on both sides and should be put under (R5) when he is up in the wheelchair. When R5 is sitting up in the wheelchair he should also have a chair alarm in place. He is very impulsive. 3. R6's face sheet dated March 15, 2017 shows R6 was admitted to the facility in September 2015 with multiple diagnoses, including history of falls, altered mental status, Alzheimer's disease, anxiety, UTI (urinary tract infection), muscle weakness, psychosis and dementia. R6's MDS (Minimum Data Set) dated January 19, 2017 shows R6 has severe cognitive impairment, requires extensive assistance with toileting, hygiene and bathing, and is always incontinent of bowel and bladder. R6's fall risk assessment dated [DATE] shows R6 is a high fall risk. Nursing documentation dated January 7, 2017 shows R6 fell attempting to transfer self from wheelchair to dining room chair. On January 25, 2017, R6 was found on the floor in her room, with the bed alarm sounding, and on February 23, 2107, R6 was found on the floor with the alarm sounding. On March 13, 2017 at 4:45 PM, R6 was sitting in the dining room. A chair alarm was in place. No light was blinking on the alarm to indicate the alarm was powered on. E15 (Activity Aid) lifted the alarm and said the alarm power switch was in the off position. E15 said the alarm should be turned on. On March 23, 2017 at 10:15 AM, E1 (Administrator) said the facility does not have a policy regarding alarms, and CNAs should check the connection between the alarm and the alarm pad, and are responsible for ensuring the alarm is turned on and in place. On March 13, 2017, during initial tour of the facility with E3 (Assistant Administrator), between 11:05 AM and 1:30 PM, the following safety concerns were identified: 4. The beauty shop door on the second floor was open. No residents were present in the beauty shop. Three oxygen tanks were standing just inside the doorway. Two of the three oxygen tanks were free-standing, not secured or in holders. E3 said the oxygen tanks should not be stored in the beauty shop. The facility's policy entitled, Oxygen Fire Safety Precautions dated February 2014 shows: 5. All oxygen cylinders must be stored in racks with chains, sturdy portable carts, or approved stands and never left free-standing or in any resident room or living area. 5. The unlocked shower room on the south hallway of the second floor had approximately one dozen disposable razors sitting on the counter. 6. Four residents had medications at their bedside. R7 had a tube of Clotrimazole topical, antifungal ointment on his dresser. R7 stated, The nurse gave me that medication this morning. I'm supposed to put it on my armpit. R8 had an Advair diskus inhaler on his nightstand. On March 15, 2017 at 4:55 PM, R8 said, The nurse left it on the table in the dining room the other day, so I brought the inhaler back to my room, two or three days ago. It has been sitting on my nightstand since then. I told the nurse it was there, but she left it there. R9 had a Breo Ellipta inhaler at his bedside. R10 had a tube of Betamethasone (steroid) cream on his nightstand. The March 2017 POS (physician order [REDACTED]. On March 15, 2017 at 5:30 PM, E1 (Administrator) and E2 (DON-Director of Nursing) said the facility did not have a system in place to ensure resident medications were kept secured in resident's rooms. The facility's policy entitled, Bedside Medication Storage dated October 27, 2014 shows: Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. Procedures: A. A written order for the bedside storage of medication is present in the resident's medical record. 7. The room shared by R9 and R22 had a bottle of rubbing alcohol on the dresser shared by the residents. 8. R26 was sitting in the activity room in a wheelchair. A chair alarm was connected to the back of her wheelchair, however, the alarm did not have a cord to connect the alarm to the resident. E15 (Activity Aid) said, Restorative took the alarm off. 9. R3's air mattress on the bed was plugged into a power strip. 10. R19's tube feeding and oxygen were plugged into a 3-outlet adaptor located above R19's headboard. 11. R38's bed and phone charger were plugged into a power strip. 12. R39's bed was plugged into a power strip. The facility did not have a maintenance program or documentation to show the power strips were regularly monitored by E4 (Maintenance Director). On March 15, 2017 at 11:30 AM, E4 said, A 3-outlet adaptor is is just like an extension cord. There is no problem using the adaptor in the resident's room. E4 did not have information regarding amperage of power strips. The facility's policy entitled Power Strips Requirement and Safety Policy dated September 2014 shows: Policy: To ensure al personnel are aware of fire safety regulations for the use of power strips in patient care rooms and patient care vicinity. Policy Specifications: Power strips may be used in a patient care vicinity, provided all of the following conditions are met as required by section: The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles.The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program. Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe.Resident rooms using line-operated patient-care related equipment in the patient care vicinity must comply with the NFPA 99 power strip requirement and may elect to utilize this categorical waiver. 13. On March 13, 2017 at 4:39 PM, a medication cart on the third floor was unlocked and a Spiriva inhaler was sitting on top of the unlocked medication cart. The unlocked drawers faced away from the resident's room. E9 (nurse) was inside a resident's room and was not in visual control of the medication cart. E9 exited the resident's room and said the medication cart should have been locked and medications locked inside when the cart was not in her visual control. The facility identified R21 and R22 as ambulatory residents with intermittent confusion residing on the second floor. The facility identified R5 and R37 as residents residing on the third floor with intermittent periods of confusion and mobile via wheelchair.