Every finding on record at Valley Hi Nursing Home

Based on observation, interview, and record review the facility failed to ensure soft and bite sized foods were cut to 1/2 (inch) x (by) 1/2 x 1/2 sizes before plating and serving. This applies to 4 of 4 residents (R36, R64, R105, and R97). The findings include: Facility provided diet order list dated 3/2/26, shows R36 has a diet order of easy to chew with bite sized meats. R105, R64, and R97 have a diet order of soft and bite sized with ground meats. R124 has a diet order of soft and bite sized. 1. On 3/2/26 at 11:24 AM, V14 (Cook) started setting up the second floor kitchenette for service. This included a pan of coined glazed carrots and a pan of a full pot roast, not yet sliced. V14 removed the tin foil covering the pot roast and took a knife to cut the pot roast into approximately one inch sections across the short side of the pot roast, making large slices of pot roast. During service, at 11:54 AM, V14 was seen removing a portion of the large slice, turned it on its face, then diced it into large cubes. At 12:00 PM, V14 placed coined carrots on plates with diced pot roast and this surveyor asked V14 if that plate was for a resident with a diet order of soft and bite sized. V14 confirmed it was and this surveyor requested V14 pause plating until V12 (Food Service Director) determined the coined carrots were appropriate for soft and bite sized. At 12:03 PM, V12 said the glazed carrots should be cut into 1/2 by 1/2 by 1/2 sizes for all soft and bite sized foods, including the coined carrots and meats. V12 had dietary staff go through the second floor dining rooms and fix any already served plates. At 12:06 PM, V16 (Dietary Aide) said V16 did not see any residents already served in the dining room with coined carrots and a soft and bite sized diet order. At 12:07 PM, V15 (Dining Room Manager) said the only other affected residents were R105, R64, and R97 whose plates were done, but their trays were still in the warming cabinet and not yet served. V15 said V14 removed the coined carrots from R105, R64, and R97's plates and put diced carrots on the plates and placed the plates back into the warming cabinet. V14 continued service, dicing all coined carrots prior to plating the remaining soft and bite sized diet orders. 2. On 03/02/2026 at 12:37 PM, R36 was in the dining room on the second floor during the noon meal. R36 was served a piece of pot roast cut into large chunks. R36 put a piece of the roast in R36's mouth and took it out. R36 asked V20 (Dietary Aide) if V20 could cut the meat into smaller pieces. V20 replied, I'm sorry, I can't. R36 said, I need this to be cut into smaller pieces. On 3/2/26 at 12:41 PM, the facility provided test tray of puree, ground, and soft and bite sized pork, pot roast, and carrots was provided. The soft and bite size pot roast was diced into 1/2 x 1/2 cubes on its face, but when turned onto its side, the longest side was approximately 3/4 to 1 and was larger than the size of two thumbnails. On 3/5/26 at 8:51 AM, V17 (Speech Language Pathologist) said V17 has been working with the kitchen since November 2025 to implement the new International Dysphagia Diet Standardization Initiative (IDDSI) texture modified diet orders for the facility. V17 said the facility is approximately four to six weeks into the full implementation and V17 is providing both nursing staff and dietary staff with frequent education and guidance to ensure compliance. V17 said the soft and bite sized diet order, everything should be cut into 1/2 x 1/2 x 1/2 sizes or smaller and should also be soft. V17 said the facility changed to the updated modified texture guidelines under IDDSI in order to make it easier for the staff and the facility to provide residents with their most recent assessed diet order level. V17 said when residents discharge from the hospital and are admitted to the facility, the residents discharge with a diet texture order that follows the IDDSI guidelines. V17 said if a resident receive food that is greater than their assessed limit, this poses a choking hazard. The facility accident and incident log reviewed since November 2025 shows there have been no resident choking incidents since the implementation of the new modified texture guidelines. Facility provided IDDSI training sheets that were hanging in the second floor kitchenette state, Food . Soft & Bite-Sized . All food should be in bite-size pieces (smaller than .5 x .5).

Based on interview and record review the facility failed to perform MDS-Minimum Data Set assessments every 3 months (92 days) for 3 of 7 residents (R26, R31, R61) reviewed for MDS assessments in the sample of 24.The findings include:On 03/03/2026 R26's MDS assessment has not been performed for 133 days. The MDS started 01/12/2026 shows, in process. R26's last completed MDS assessment was dated 10/20/2025.On 03/03/2026 R31's MDS assessment has not been performed for 126 days. The MDS started 01/26/2026 shows, in process. R31's last completed MDS assessment was dated 10/31/2025.On 03/03/2026 R61's MDS assessment has not been performed for 126 days. The MDS started 01/20/2026 shows, in progress. R61's last completed MDS assessment was dated 10/27/2025.On 03/03/2026 at 12:03 PM, V18 (MDS Coordinator) said, all disciplines must complete the resident assessment before it can be submitted. The MDS assessments should have been completed and submitted sooner. On 03/04/2026 V1 (Administrator) did not provide an MDS policy.

Based on interview and record review the facility failed to accurately reflect R3 and R29's status in the MDS-Minimum Data Set for 2 of 7 residents reviewed for accurate MDS in the sample of 24. The findings include:1.R3's Medical Record-Census on [DATE] shows, R3 expired on [DATE].On [DATE] R3's Medical Record did not have a discharge Minimum Data Set (MDS) assessment. The MDS dated [DATE] shows, Admission. On [DATE] at 12:03 PM, V18 (MDS Coordinator) said, (R3) passed away in 12/2025. I missed updating (R3's) MDS.2. R29's Medical Record-Census on [DATE] shows, R29 was discharged [DATE].On [DATE] R29's Medical Record did not have a discharge MDS. The current MDS dated [DATE] shows, In Process.On [DATE] at 12:03 PM, V18 (MDS Coordinator) said, (R29) was discharged [DATE] and that (R29) passed away in the hospital. The MDS nurse for (R29) has resident care duties and fills in when the residents need help. (R29's) MDS needs to be finished.On [DATE] V1 (Administrator) did not provide an MDS policy.

Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. This applies to 1 of 24 residents (R2) reviewed for activities of daily living in the sample of 24. The findings include: On 03/02/2026 at 10:29 AM, R2 was in his room lying in bed, a strong foul odor was present. He said he had an accident. V11 and V12 (Certified Nursing Assistants) removed R2's incontinence brief. R2's incontinence brief was heavily soiled with large amounts of stool from his backside to his lower back. R2's stool soiled through his pants and incontinence pad. V12 asked V11, did the pants have stool on there too? V11 said yes, his pants were soiled with stool. On 03/02/2026 at 10:40 AM, R2 said he was last changed before breakfast and waited a long time for staff assistance.On 3/02/2026 at 12:02 PM, V7 (Licensed Practical Nurse-LPN) said R2 is alert and oriented, he is totally dependent on staff for cares including incontinence care. Staff should check and change him every two hours. R2's current care plan shows he has urinary incontinence, and staff should check and change him. R2's care plan does not show that he has bowel incontinence. The facility's Peri-care Policy and Procedure reviewed 2022, states, Peri-care will be provided to resident in the am, hs (hours of sleep), whenever soiled and prn (as needed).

Based on observation, interview, and record review, the facility failed to ensure an ordered treatment was in place for one of 24 residents (R42) reviewed for Quality of Care in the sample of 24.The findings include:R42's Face Sheet shows she was admitted to the facility on [DATE], with diagnoses including dementia, chronic diastolic congestive heart failure, atrial fibrillation, hypertension, osteoarthritis, muscle weakness, and localized edema.R42's Orders show an order for Treatment: [NAME] Hose/Tubi Grips special instructions: apply to bilateral (both) lower extremities for edema in the early morning and off at bedtime twice a day. This order started November 20, 2025.On March 2, 2026, at 10:27 AM, V19 (Certified Nursing Assistant-CNA) brought R42 to the bathroom. There were two pairs of tubi grips hanging up on the wall bars that were clean. R42 did not have on ted hose/tubi grips to her lower extremities, nor did the CNA offer to put them on R42. R42's bilateral lower legs were dry and discolored. There was a small amount of edema to both of her legs. V19 helped R42 finish in the bathroom, then brought R42 back out into the dining room. On March 3, 2026, at 11:34 AM V5 (Registered Nurse-RN) said she did not know if R42 had her ted hose/tubi grips on to her bilateral lower extremities. V5 said the ted hose/tubi grips are placed on early morning by night shift. V5 said the treatment is ordered to help eliminate edema and swelling. R42's Medication Administration Record shows that V5 charted that R42 refused her treatment to her lower extremities on Monday, March 2, 2026 3:00 PM-11:00 PM. R42 did not refuse the treatment to her lower extremities on Sunday March 1, 2026 11:00 PM-7:00 AM. R42 did not refused the treatment to her lower extremities any other day from Sunday February 1, 2026-March 1, 2026.R42's Progress Notes for February 2026 show R42's bilateral lower extremities were weeping fluid due to edema and R42 was on an antibiotic for cellulitis. R42's Care Plan, which was started on September 13, 2025, shows R42 is at risk for impaired skin integrity due to fragile skin. Administer treatments as ordered. R42's Care Plan does not include any behaviors that R42 has refused any treatments to her lower extremities.On March 4, 2026, at 12:53 PM, V3 (Director of Nursing-DON) said the facility did not have a policy in regards to following physician orders or treatment orders.

Based on observation, interview, and record review, the facility failed to apply an ordered medicated patch. This applies to 1 of 4 residents (R2) reviewed for medication administration in the sample of 24. The findings include: On 03/02/26 at 10:29 AM, V11 and V12 (Certified Nursing Assistants) provided incontinence care to R2. R2 was heavily soiled with stool from his backside to his lower back. V11 said, He's going to need a new patch. R2's patch was soiled with stool. V11 removed the soiled patch and notified V6 (Registered Nurse- RN). On 03/02/26 at 10:55 AM, V6 (RN) entered R2's room. V6 said the lidocaine patch was placed this morning and removed at night. V6 said I can't put another one on. The patch is on for 12 hours and he's (R2) had it on for 5 hours. V6 said, We are normally not supposed to put on another patch if it comes off. On 03/02/26 at 2:00 PM, R2 was in his room lying in bed. He said V6 has not put the patch back on. On 03/04/26 at 10:03 AM, V5 (RN) said if a resident's medicated patch is removed before the scheduled duration she would call the physician for follow up orders. R2's Medication Administration Record dated March 2026 shows orders to apply adhesive medicated patch 4%, apply two patches to lower back once a day at 6:00 AM and remove after 12 hours at 6:00 PM.

Based on interview and record review, the facility failed to ensure the medication regime review was addressed by the physician. This applies to 1 of 5 residents (R2) reviewed for medication review in the sample of 24. The findings include: R2's Pharmacist's Recommendation to Prescriber report dated 2/6/26 shows, (R2) has been ordered the psychotropic medication Escitalopram 20 mg (milligrams) daily. May we attempt a trial dose reduction to Escitalopram 15 mg (milligrams). The prescriber's response and signature are left blank. On 3/4/26 at 11:41 AM, V2 (Director of Nursing) said, The medication reviews are reviewed monthly in our behavior committee. The facility recently switched providers for psych (psychiatric) services and they did not address the medication reviews from last month. R2's Physician Order Sheets dated March 2026 shows orders for Escitalopram 20 mg daily for anxiety. The facility's Psychotropic Medication Reduction Program Policy reviewed 2022 states, The resident's medication regime will be managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well being while included those medications, in doses and for the duration clinically indicated to treated the residents assessed condition.

Based on observation, interview, and record review the facility failed to ensure the served portions of pureed pot roast, pureed pork stir fry, pureed carrots, and pureed soup were served at the appropriate serving size. This applies to 2 of 2 residents (R60, R78) reviewed for pureed foods in the sample of 24. The findings include: Facility provided diet order list dated 3/2/26, shows R60 and R78 receive pureed foods for meals and reside on the second floor. On 3/2/26 at 11:24 AM, V14 (Cook) began preparing for lunch service in the second floor kitchenette by placing the food service pans into and on top of the steam table. V14 finished preparing by placing a green handle scoop into the puree [NAME] pot roast, puree pork stir fry with vegetables, puree glazed carrots, and the puree cream of mushroom soup. V14 said the green handle scoops provide approximately 3 ounces. Menu spreadsheet for the 3/2/26 lunch meal shows the serving sizes should have been as follows: 4 ounces for the [NAME] pot roast, 1 cup (8 ounces) for the pork stir fry with vegetables, 1/2 cup (4 ounces) for the glazed carrots, and 3/4 cup (6 ounces) for the cream of mushroom soup. On 3/5/26 at 9:49 AM, V12 (Food Service Director) said V14 should have used the correct scoops to provide the serving sizes on the diet spreadsheet. Facility provided Accuracy and Quality of Tray Line Service policy states, . 6. Each meal will be checked for: . c. Proper portion sizes .

Based on observation, interview, and record review the facility failed to ensure fall precautions were updated and in place for residents at risk for falls for 2 of 3 residents (R1, R3) in the sample of 3. This failure resulted in R1 falling and sustaining a head injury.The findings include:The facility's Incident Report dated 1/1/26 shows At approximately 6:49 AM, R1 was screaming for help from her bed and bed alarms were sounding. The Certified Nursing Assistant (CNA) (V5) acknowledged her and the resident states she needed to go to the bathroom. Resident was assisted to the bathroom with her walker and placed on the toilet. R1's call light was turned on and CNA returned to assist resident off the toilet around 7:00 AM. V5 entered bathroom and witnessed R1 lying on the bathroom floor.V5's Resident Incident/Accident Report Employee Statement dated 1/1/26 shows At Around 6:44 AM, I came in to help R1 because she was screaming for help, but she was in bed and then stated she needed to use the bathroom, so I helped her with the walker, put her in there in the toilet. Came back around 7:00 AM, her call light was on less than 3 minutes, and I found her on the floor. V11 CNA was there when I helped her to the toilet at 6:50 AM. This same form shows Residents' behavior prior to accident/incident was marked confused and anxious.V11's (CNA) Resident Incident/Accident Report Employee Statement dated 1/1/26 shows R1 was attempting to use her walker by herself to get to the bathroom instead of waiting for staff. R1 call light was on and V5 went in to assist her to the bathroom. R1 made it but was a little clumsy with the walker. I went to check in with V5 to see if he needed information or help with other residents. He and I went out of R1's room to check on other residents. V8's (CNA) Resident Incident/Accident Report Employee Statement dated 1/1/26 shows R1 was using the bathroom, the CNA left her to go answer another call light while she was still going, that's when someone said she fell.On 1/6/26 at 9:06 AM, V4 CNA Supervisor said R1 uses the call light but if you don't come right away, she calls out and if you don't answer she will try to get up by herself.On 1/6/26 at 9:20 AM, V5 said at 6:50 AM, R1's call light was on, and he went in to assist her to the bathroom. V5 said R1 walked with her walker to the bathroom and after assisting her to the toilet, he left and went to do other stuff. V5 said he came back on the floor and R1's bathroom call light was on. V5 said he found R1 on the bathroom floor on her left side with her head facing the toilet. V5 said he saw blood on R1's head, R1's eyes were closed and R1 was nonresponsive. R1 said he called out for assistance from V4, who went and got the nurse. V5 said he has taken care of R1 before and if you don't answer her call light quickly, she would get up by herself. On 1/6/26 at 10:11 AM, V6 Registered Nurse (RN) said R1 was a big fall risk and had been declining in health quickly recently.On 1/6/26 at 10:50 AM, V8 CNA said she had taken care of R1 the day before and R1 had been losing her balance when transferring her to the toilet with the wheelchair. V8 said she stays close by, right outside bathroom door, when she has R1, who doesn't take long in the bathroom.On 1/6/26 at 11:26 AM, V10 was called, a message was left with no return call.On 1/6/26 at 11:30 AM, V12 RN said she had been giving report on 1/1/26 when she heard that R1 was on the floor in the bathroom. V12 said it was not unusual, R1 was a fall risk and was always falling. V12 said she went into R1's room and saw R1 on the bathroom floor on her left side in the fetal position. V12 said R1 had a small puddle of blood under her head, her lips and hands were cyanotic, and she was dusky looking with agonal breathing. V12 said other staff came in and assisted to get R1 off the floor onto her bed. V12 said once in bed, R1's breathing and heartbeat were not detectable and R1 was pronounced dead by several nurses. On 1/6/26 at 1:28 PM, V14 RN said she had taken care of R1 frequently and R1 had been declining recently. V14 said R1 would be lethargic on days and then would have some good times. V14 said R1 was a fall risk and needed frequent monitoring. V14 said R1 would use the call light but was impulsive. V14 said R1 didn't like to be watched in the bathroom, but staff needed to stay close, in the room when R1 was in the bathroom because she didn't like to wait.On 1/6/26 at 2:07 PM, V10 RN said he was giving report when V4 came to the station and reported that R1 was on the floor. V10 said V5 put R1 in the bathroom and then left he room to check on another resident. V10 said R1's light was on and when V5 went back in, R1 was on the floor in the bathroom. V10 said he assisted the other nurses get R1 into bed and try to obtain vitals. V10 said R1 had a laceration to the left side of her scalp above her left ear. V10 said after multiple attempts, vitals were unable to be obtained, R1's pupils were dilated and fixed, and R1 was pronounced dead. V10 said R1 will not wait for help and will get up by herself if she must wait. On 1/6/26 at 4:25 PM, V16 Hospice RN said she saw R1 on 12/31/25 and noted R1 had increased physical weakness by a noticeable loss of strength when trying to sit up. V16 said R1's impulsivity was till noted during her visit. V16 said R1 was clinically sick and fragile.On 1/6/26 at 1:37 PM, V3 Assistant Director of Nursing said R1 was on hospice and slowly declining. V3 said R1 was a fall risk, and had had previous falls, due to her impulsiveness and getting up by herself. V3 said R1's fall intervention was to be monitored when in bathroom. When asked what that entailed, V3 replied frequent checks. V3 said R1 had previously had a habit of being in the bathroom for long periods of time ripping up toilet paper but had not been doing that recently. V3 said R1's fall interventions for the bathroom had not been updated since R1's recent decline and change in bathroom habit. V3 did not comment when asked how does staff do frequent checks if out in the hall or in another resident's room?On 1/7/26 at 1:18 PM, V17 Medical Director was called, and a message was left for a return call.R1's Client Coordination Notes Report from V16 Hospice Registered Nurse dated 12/31/25 shows No signs/symptoms of imminent death but patient very fragile and generally poor prognosis. Severe tiredness and lethargy. Worsening loss of strength, endurance, and stamina. Patient was arousable today but falls back asleep quickly, reviewed fall/safety precautions. Promote bedrest- Due to constraints of disease process and approaching end of life. Patient needs extensive care with all activities of daily living.R1's Progress notes dated 12/29/25 -12/30/25 document Resident lethargic.R1's Face sheet shows R1 has diagnoses of unspecified dementia, moderate, with other behavioral disturbance and history of falling.R1's Care Plan dated 12/3/25 shows R1 is at risk for falls due to unsteady gait and balance during turns and transitions. Will forget to use walker at times. Intervention dated 3/25/25: Staff to monitor resident while in bathroom and an intervention dated 12/6/18: Observe for gait unsteadiness. Proceed accordingly. The same Care Plan shows 12/2/25 Resident has had a decline in condition resulting in need for hospice care.2. On 1/6/26 at 1:31 PM, R3 was in bed. R3's bed had a bed alarm attached to the bed rail. The bed alarm indicator lights were not on or flashing on and off. V15 Certified Nursing Assistant came into R3's room and said R3 is napping and left the room. This surveyor asked V4 Certified Nursing Assistant Supervisor to check on R3's bed alarm. At 1:34 PM, V4 said the light is supposed to be flashing when the alarm is on. V4 checked R3's bed alarm and held up the cord which was on the floor under R3's bed. V4 said the alarm is not even plugged in. V4 plugged the bed alarm in, and the bed alarm flashed red on and off indicating the alarm was on. R3's Care Plan dated 4/21/25 shows R3 is a risk for falls related to weakness and unsteady gait and balance. Fall risk assessment score of 16 indicates she is a risk for fall. 12/3/25 resident noted on the floor next to her bed. Intervention: Bed alarm.R3's Physician Orders dated 4/21/25 shows fall prevention/safety: Mobility Alarm: Bed. Special instructions: Ensure that alarm is in place and functioning properly every shift.The facility's Fall Risk Assessment and Prevention Program dated 12/2017 shows The purpose of this policy is to provide direction for nursing home staff to identify residents at risk for falls, to prevent falls whenever possible; and when unable to prevent falls, minimize the extent of the injury. The Care Plan will identify the resident as being at risk for falls. Interventions will be individualized and attempt to modify, or if possible, eliminate risk factors. There will be evidence of care plan review and update following each resident fall to demonstrate that risk factors and interventions remain appropriate for the resident.

Based on interview and record review the facility failed to immediately verify a resident (R1) had not eloped from the facility after an exit door alarm sounded. The facility alos failed to supervise a resident (R1) in a manner to prevent that resident from eloping from the facility. These failures apply to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: R1's progress notes dated 9/8/24 showed R1 was found outside of the facility around 1:30 AM. The notes showed R1 was last seen in bed by staff at 12:45 AM. The notes showed, At 1:12 AM, a (first-floor) door alarm was going off for the northwest courtyard door. Checked the door, no one seen outside, but is was dark. At 1:15 AM, resident not found in bed or bathroom . Search for resident commenced. Resident was seen though window . outside (of facility) by northwest courtyard . The notes showed staff immediately brought R1 back into the building. R1 appeared confused. R1 sustained no injuries or falls during the elopement. R1 was placed on every 15 minutes checks by staff, a wanderguard was placed on R1, and a bed alarm was reconnected on R1's bed. R1's physician and POA (power of attorney) were notified of the incident. R1 made no additional attempts to leave the facility on 9/8/24. On 9/8/24 at 7:10 AM, R1 was sent to a local hospital for a psychiatric exam. R1 did not return to the facility. R1's hospital records dated 9/4/24-9/6/24 were reviewed. The notes showed R1 was cognitively intact. R1 resided in his own home prior to his hospitalization for his elective hip surgery. The hospital records showed no documentation of R1 attempting to elope or exit the hospital during his stay. R1's admission note dated 9/6/24 showed R1 was admitted to the facility, from a local hospital, for short-term rehab and therapy. The note showed R1 was cognitively intact. R1's progress notes dated 9/6/24-9/7/24 showed no documentation of R1 exhibiting any exit-seeking behaviors. On 9/16/24 at 8:09 AM, V4 CNA stated she was R1's CNA from 2:30 PM on 9/7/24 until 7:00 AM on 9/8/24. V4 stated she repositioned R1 in bed around 12:45 AM on 9/8/24. V4 stated, He was alert, not confused for me. Around 12:55 AM, I let the other CNA know that I was going on break. She was on the other wing. I was getting on the elevator, a little after 1 AM, when I heard the door alarm go off but I couldn't stop the elevator door from closing so I went upstairs and did what I had to do. When I came back down (to the first floor), the door alarm was off. I started checking rooms on my floor. That's when I couldn't find (R1) in his room . That's when I let the other staff know he was missing. We started searching the building . On 9/16/24 at 9:15 AM, V8 RN stated, I was in the kitchen area on the first floor when I heard the door alarm go off. I went to the door panel and it showed the courtyard door was alarming. (V7 CNA) and I went over to the door, which appeared shut, and looked out into the courtyard. It was very dark but we didn't see anyone. I silenced the door panel alarm. I went back to what I was doing. A few minutes later, (V4 CNA) returned from her break and let us know she couldn't find (R1). V8 RN stated staff began searching the facility and the grounds of the facility. V8 RN stated about 10-15 minutes later, V7 CNA was found outside the facility by staff. V8 stated R1 was immediately brought back inside the facility and assessed. V8 stated R1 appeared agitated and stated, I must have been sleepwalking. V8 stated R1 had no falls or injuries as a result of his elopement incident. V8 stated, (R1's) room was around the corner from the exit door. I should have gone room to room, on that hall, to make sure everyone was there after the alarm went off. On 9/16/24 at 10:33 AM, V2 Assistant Administrator stated if an exit door alarm is activated, staff are to go the door alarm panel to verify which door is alarming. Once verified, staff are to go to the alarming door, check the door and walk outside to search the immediate area for residents. V2 stated staff should immediately verify the residents, in the rooms near the alarming exit door, are accounted for. The facility's Door Status Annunciator Policy and Procedure policy dated 7/2022 showed, If the door is opened without entering the code or the door had no keypad to enter the code the door will alarm. When the door closes the alarm at that location quits sounding. The door must be checked and reset . Staff shall go to the sounding alarm door, physically check to see if someone had exited by going into the exterior space .

Based on interview and record review the facility failed to resolve a grievance/concern verbalized by a resident's POA (power of attorney) for 1 of 3 residents (R1) reviewed for grievances in the sample of 3. The findings include: R1's care plan dated 3/12/24 showed R1 was cognitively impaired due to her diagnosis of dementia. The care plan showed R1 was at risk for falls due to her impaired cognition, impulsivity, weakness and poor safety awareness. A progress note for R1, dated 12/4/23, showed, POA must be notified at time of event of any change in condition or any care item added to the care plan. R1's fall incident report dated 3/23/24 showed R1 sustained an unwitnessed fall in the bathroom. R1 received no injuries from the fall. The report showed V10 (R1's POA) was not notified of R1's fall until 4/2/24. On 4/8/24 at 11:33 AM, V10 (R1's POA) stated, My concerns with a lack of communication from the facility have been going on for months. I have had multiple conversations and sent emails back and forth with (V1 Administrator) about the lack of communication from the facility. We had a care plan meeting, via phone, in December (2023) with (V1 Administrator), (V2 Assistant Administrator), and (V3 Director of Nursing/DON) on the call. I told them then that I was to be notified, day or night, if (R1) has any falls or changes in condition. I get a call on April 2nd (2024) from someone asking me if I knew (R1) had fallen on March 23rd. No one had told me a thing. I had just visited (R1) on Easter and no one said a word. On 4/8/24 at 12:50 PM, V9 Licensed Practical Nurse stated, I review all of the accident and incident reports in the facility. I saw that (R1) had a fall on 3/23/24 but didn't see any documentation that (V10 R1's POA) had been notified of the fall so I called her. (V10) was very upset no one had called her. She went from crying to yelling. She said she was so sick of the lack of communication from us. On 4/8/24 at 11:45 AM, V2 Assistant Administrator stated she attended R1's care plan meeting, via phone, on 12/4/23. V2 stated V10 (R1's POA) expressed her concerns related to a lack of communication from the facility during the meeting. V2 stated, (V10) was upset about the lack of communication. She was upset that she was not notified in real time when things were happening with (R1). That is when she said we are to call her immediately, day or night, if (R1) falls or has a change in condition. We dropped the ball with this one. (R1) had a fall on 3/23/24 and we didn't notify (V10) until 4/2/24. V2 stated grievances can be filed, verbally or in writing, by a resident or resident's family. V2 stated grievances should be resolved as soon as possible. On 4/8/24 at 12:04 PM, V1 Administrator stated he also attended R1's care plan meeting, via phone, on 12/4/23. V1 stated V10 (R1's POA) voiced her concerns about a lack of communication from the facility during the meeting. V1 stated, (V10) did say she wanted to be called immediately if anything happened with (R1), day or night. The facility's Resident Grievance Policy dated 1/2018 showed, It is the policy of (the facility) to address all resident and/or family concerns as quickly as possible and as best as possible .

Based on observation, interview, and record review the facility failed to ensure residents were served food at a safe temperature. This failure resulted in R273 spilling hot soup and receiving full thickness burns on his right forearm and abdomen. The facility failed to safely transfer residents with a mechanical lift. The facility failed to ensure medications were stored in a safe manner away from a cognitively impaired resident. The facility also failed to ensure residents at risk for choking were supervised during meal times and provided thickened liquids as prescribed. This applies to 6 of 18 residents (R17, R9, R51, R52, R53 & R273) reviewed for safety and supervision in the sample of 18. The failure to ensure safe food temperatures resulting in R273 sustaining a burn due to hot foods resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility failed to ensure residents were served soup at a safe temperature to prevent burns. V1 Administrator was notified of the Immediate Jeopardy on [DATE]. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on [DATE] however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and staffing levels. The findings include: 1. On [DATE] at 11:46 AM, the soup on the second floor was measuring 181.7 degrees Fahrenheit (F). R52's facility event report dated [DATE] shows, Hot soup during lunch was spilled on resident's right hand and leg. R52's progress note dated [DATE] shows, During lunch time resident was served hot soup. Bowl slipped from universal worker's hand and was spilled on resident's right hand and lap . V4 Dietary Manager's statement for R52's event shows, he saw V5 Resident Aide (universal worker) trip and spill hot soup on R52. He heard R52 yell that she was burning and hot. On [DATE], V4 Dietary Manager confirmed his statement. On [DATE] at 9:01 AM, R52 stated, she remembered when soup was spilled on her. She didn't know what happened but that hot soup was spilled on her. It was very hot. I cried a lot because it hurt. She also stated, you have to let the soup sit and cool down because it is boiling hot before you can eat it. R52's Minimum Data Set, dated dated dated [DATE] shows, she is cognitively intact. On [DATE] at 1:05 PM, V4 Dietary Manager stated, they have not done anything different after R52 had hot soup spilled on her. The minimum temperature of the soup is kept at least 165 degrees F. R273's facility event report dated [DATE] shows, spilled hot soup during lunch on right arm. R273's progress notes dated [DATE] at 1:04 PM shows, Resident continues to refuse to get up from the bed to his wheelchair for meals. During lunch time he spilled hot soup on his right arm. Arm painful and red . The same progress notes at 11:48 PM shows, Received report about resident soup incident . Observed a blister on resident right side of the abdomen. R273's progress notes dated [DATE] at 2:35 PM shows, Observed fluid filled blister on the anterior of the right upper arm and open area approximate 7 cm (centimeter) x 5.5 cm partial thickness. Resident c/o (complain of) pain on the site . R273's wound doctor evaluation and management summary dated [DATE] shows, he has a full thickness burn wound of the right, upper, medial arm measuring 5.0 x 7.1 x 0.1 cm (length x width x depth). Additional wound detail: Area of partial, deep-partial and likely some full thickness thermal burn from where pt (patient) spilled coffee on himself. There is nothing documented about the burn on his abdomen. R273's wound doctor evaluation and management summary dated [DATE] shows, he has a full thickness burn wound of the right, upper, medial arm measuring 5.0 x 5.1 x 0.1 cm and a full thickness burn wound of the right, lower abdomen measuring 4.1 x 1.3 x 0.1 cm. On [DATE] at 10:49 AM, V6 Wound Care Nurse stated, R273 had between 2nd and 3rd degree burns on his forearm and abdomen. On [DATE] at 6:05 PM, V37 Advanced Practice Registered Nurse (APRN) stated, she was aware of R237 spilling hot soup on himself and obtaining full thickness burns to his right arm and abdomen. The expectation would be not to serve soup that is too hot for residents to eat. 185 degree F soup is too hot to serve to residents. On [DATE] at 1:19 PM, V4 stated, he did not have temperature logs for the soup. They are taking the temperatures of the soup but not logging them. The facility did not provide any food temperature logs for the soup. The facility's food temperatures policy dated 2017 shows, Policy: The temperatures of all food items will be taken and properly recorded prior to service of each meal. Procedure: 1. b. Hot food items may not fall below 135 degrees F after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F prior to serving. Caution should be taken to avoid serving food and liquids at temperatures that are too hot to avoid the risk of burns. The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on [DATE]. The survey team reviewed the abatement plan and was still unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a third abatement plan on [DATE]. The survey team reviewed the abatement plan and was still unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a fourth abatement plan on [DATE] and the survey team accepted the abatement plan on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. Facility Dietary Director updated the daily meal temp log to include soup temperatures; completed during survey and initiated with dinner [DATE]. 2. Facility dietary staff were immediately retrained on the procedure for taking meal temps at every meal, using the new log, and the appropriate ranges before the start of their next shift, this will be completed by the facility Dietary Director starting with staff currently on shift and will be completed by [DATE] 3. Facility Administrator will review and update the facility policy for food temperatures, will send to the facility RD for approval by [DATE] a. Policy will be updated to reflect soup temperatures between 135 degrees to 150 degrees Fahrenheit to ensure soups are delivered to resident's at a safe temperature 4. Facility Dietary Director and Dietician will conduct a dietary department training on food safety, including proper food temperature monitoring and the updated policy after adoption; completed by [DATE] 5. Facility Assistant Administrator will hold an emergency dietary QA meeting on [DATE] that will be attended by all dietary staff; the medical director was invited to attend either in person or via phone 6. Facility Administrator notified the Medical Director of the IJ on [DATE] and invited him to the emergency QA meeting 7. Facility Dietary Director will provide the Quality Assurance Committee with a monthly summary report identifying any food temps outside of policy range for 6 months or longer if determined necessary by the Committee 2. R273's facility event report dated [DATE] shows, Two CNA's (V38 & V39 Certified Nursing Assistants) had pt (patient) on the [mechanical lift] and bumped his head creating two skin tears on top of cranium . Measurement of Injury: 1.8 x 1.3 cm and 1x1 cm. Evaluation: On [DATE], resident was being transferred in [mechanical lift] and upon being lowered into chair, resident hit his head against pad on the lift and two skin tears were obtained . Nurse did immediate re-education with two CNAs on how to lower lift without bumping chair. On [DATE] at 9:15 AM, V39 CNA stated, V38 and her were transferring R273 from his bed to the wheelchair when he bumped his head on the mechanical lift. He hit his head on the cross bar of the mechanical lift. R273 had 2 open areas on the top of his head. The facility's transfer and positioning policy dated ,d+[DATE] shows, 6. EZ lift (mechanical lift)- when someone is an EZ lift that means they cannot bear weight and are totally dependent for transfers . The most important thing to remember with the EZ lift is that the bars spin sideways and back and forth as well as around, so use extreme caution when moving the lift around the resident . 40798 3. On [DATE] at 09:24 AM V27, R17's daughter, said she was not happy because her mom, R17, got hit with a (mechanical) lift. V27 said she was called and informed R17 had a mark under her eye from the incident on a Tuesday ([DATE]) and when she arrived to the facility on Saturday ([DATE]) to visit R17, R17 had a huge black eye. V27 said she worried R17's facial bone could be fractured and asked for an x-ray to be done. V27 said during this visit with R17 (on [DATE]) R17 wanted to go back to bed. V27 said when the CNAs came in to transfer R17 to bed, they were not watching what they were doing and they hit R17 with the main bar of the lift again. On [DATE] at 2:22 PM, V21, CNA, said she along with another CNA were transferring R17 with the mechanical lift (on [DATE]). V21 said the footrest of R17's wheelchair got caught on the leg of the mechanical lift, so when the lift was lowered, the wheelchair came down fast and R17 came forward and bumped her head on the lift. V21 said, That was my error. V21 said R17 did bruise up and have swelling, but she did not go to the hospital. On [DATE] at 10:41 AM, V22, CNA, said she was one of the CNAs assisting R17 to transfer from her wheelchair to her bed (on [DATE]) with the full mechanical lift. V22 said they began moving the lift toward R17's wheelchair and did it slightly too quickly; we definitely could have done it a little slower and they bumped R17's head with the scale box on the lift. V22 said it was definitely user error on our part. On [DATE] at 11:20 AM, V30, CNA, said she was assisting to help transfer R17 from her wheelchair to bed with the full mechanical lift (on [DATE]). V30 said they were getting R17 hooked up to the lift and were trying to maneuver it and I guess we were not careful enough and not watching and we bumped R17's head with the weight box on the lift. R17's Minimum Data Set (MDS) dated [DATE] shows she has severe cognitive impairment. R17's current Care Plan (edited [DATE]) shows R17 sustained a bruise to her face below her left eye measuring 5 cm (centimeters) by 2 cm due to an incident with a full mechanical lift of [DATE]. The same care plan shows R17 was bumped on her forehead with a mechanical lift machine when staff were giving care. The same care plan shows R17 requires extensive assistance with ADLs (activities of daily living) and two staff member for transfers with a mechanical lift. 45540 4. On [DATE] at 11:45AM, V17 Home Health Aide said she was transferring R48 with the assistance of V14 - Certified Nursing Assistant. V17 said the full mechanical lift started to tip and R48 bumped her head on the lift, no bleeding or bruising noted. On [DATE] at 1:40PM, V14 said he was helping V17 with a full mechanical lift transfer and the lift started to tip and R48 bumped her head on the cross bar of the lift, no bleeding or bruising noted at that time. On [DATE] at 12:27PM, V7 Licensed Practical Nurse (LPN)/ Rehab Coordinator said if the lift is used correctly, it should not tip over or start to tip over. R48's Care Plan, revised on [DATE] states . At this time R48 needs max asst with adl's (activities of daily living). Transfers with total mechanical, w/c pushed by staff, and ambulation is not feasible at this time. 47552 5. R9's Speech Therapy Evaluation and Plan of Treatment dated [DATE] states, Patient referred to SLP (speech language pathologist) due to new onset of signs/symptoms of dysphagia and risk for aspiration causing change in swallowing abilities related to dementia . Self Feeding = Patient requires assistance, to address in treatment plan . R9's Physician's Orders form (no date) shows R9's Dietary Order is general, honey thick, mechanical soft. R9's Dietary Order states, Needs 1:1 (one-to-one). Alternate solids/liquids. Small bites/drinks. No straws. Upright 90 degrees. Multiple swallows. On [DATE] at 8:37 AM, R9 was lying in bed with the head of the bed elevated approximately 45 degrees. On R9's bedside table, within R9's reach, was a breakfast tray with a half full bowl of cereal with thin 1% milk in it, a half full carton of thin 1% milk, and a half full cup of thin apple juice. Staff was not present. On [DATE] at 12:40 PM, the first floor kitchenette did not have any honey thickened milk but it did have honey thick juice and honey thick water. On [DATE] at 12:43 PM, V4 (Dietary Manager) showed this surveyor a full case of honey thick milk in the dry storage area in the main kitchen. V4 said even if staff run out of honey thick milk at the point of service, staff know to run to the kitchen and grab what is needed. V4 also said that there are thickening packets available in each kitchenette if staff need to thicken beverages at the point of service. On [DATE] at 11:44 AM, V4 said any resident ordered to receive honey thick liquids should never receive thin apple juice or thin 1% milk. If served thin liquids, their risk for aspiration, choking, or food in lungs can increase. V4 also said that a certified nursing assistant (CNA) should never leave that room if they require one-to-one assistance with meals. The tray should have been picked up and removed after finishing assisting R9 with feeding. There should be no food or drink in front of them and left with them if they are one-to-one and no staff are present. Facility Dining Room Seating, Swallow Protocol and Supervision Policy dated ,d+[DATE] states, . Residents identified as 1:1 or close supervision cannot eat or drink in their rooms without a refusal of treatment. Swallow Precaution Status Definitions: 1:1- CPR certified CNA or nurse sitting at the table that only focuses on one resident. Staff member cannot leave the table while the resident is eating. No food or drinks set at the table until the designated staff member serves the resident's tray. 6. R59's Event Report dated [DATE] states, Resident is impulsive, forgetful, confused d/t (due to) UTI (urinary tract infection), just returned from hospital yesterday. On [DATE] at 4:01 PM, V11 (LPN) said on [DATE] at approximately 9:15 AM, V11 prepared a small plastic pill cup (2 tablespoons in volume) with approximately one-half tablespoon of calmoseptine cream. After dispensing the cream into the pill cup, V11 went into R59's room and placed the cup down, waiting for R59 to return from breakfast. The pill cup with the cream in it was left unattended in R59's room. While waiting for R59 to return to the room, V11 was called to two different rooms back to back to send two residents out to the local hospital to receive emergency care. When V11 returned to R59's room, R59 was already taken for therapy. On [DATE] at 1:54 PM, V19 (Occupational Therapist) said on [DATE] at approximately 9:00 AM, V19 went to R59's room to get her ready for therapy. R59 was found in her wheelchair and V19 noticed something white on R59's lips and inside of R59's mouth. V19 asked R59 if she had taken her medicine and R59 could not recollect. V19 then called the unit secretary to let them know about the incident and the unit secretary informed the unit nurse. V18 (CNA) then came to the therapy room and returned R59 to R59's room. On [DATE] at 11:33 AM, V18 said on [DATE] at approximately 9:45 AM, V18 used a washcloth with warm water and a sponge to rinse out R59's mouth to remove the remaining cream. V18 said V59 had a pinkish white film coated on R59's teeth and all inside of R59's mouth. On [DATE] at 4:01 PM, V11 said after realizing that R59 had potentially ingested the cream that was left in R59's room, V11 went into R59's room and found the plastic pill cup of cream in R59's trash can. The cup looked as if a finger was used to scoop out the cream. V11 said R59 was recently placed on an antibiotic for a new diagnosis of a urinary tract infection. Due to the infection, V11 said that R59 was more confused and forgetful compared to R59's baseline. V11 called poison control with V15 (RN) and poison control said to monitor R59 for nausea, vomiting, and diarrhea. V11 said R59 did not experience any nausea, vomiting, or diarrhea throughout the rest of V11's shift. V11 said the cup with cream should not have been left in R59's room unattended. On [DATE] at 1:27 PM, V2 (Director of Nursing) said that ointments or treatments for confused residents shouldn't be left unattended. It is recommended that the task is completed while you are in there with the resident.

Based on observation, interview and record review the facility failed to ensure opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates. The facility failed to discard an expired medication. These failures apply to 5 of 5 residents (R23, R12, R41, R19, R31) reviewed for medication storage in the sample of 18. The findings include: 1. R23's March 2024 Prescription Order form showed R23 was prescribed an Albuterol Sulfate inhaler, 90 mcg (micrograms), inhale 2 puffs, twice a day. On 3/18/24 at 9:36 AM, a second floor medication cart was reviewed with V11 Licensed Practical Nurse (LPN). One opened, undated, albuterol inhaler, prescribed to R23, was found in the top drawer of the cart. V11 LPN stated, She (R23) gets that (inhaler) twice a day. It should be dated when opened so we know when it expires. I think inhalers are good for 90 days when opened. 2. R12's prescription order dated 10/26/21 showed R12 was prescribed Latanoprost 0.005% eye drops, one drop to each eye, once a day for her glaucoma. The order showed a bottle of the eye drops expired 42 days after being opened. R41's March 2024 Prescription Order form showed R41 was prescribed an Albuterol Sulfate inhaler, 90 mcg (micrograms), inhale 2 puffs, every 4 hours as needed. R19's March 2024 Prescription Order form showed R19 was prescribed an Albuterol Sulfate inhaler, 90 mcg (micrograms), inhale 2 puffs, every 4 hours as needed. R31's March 2024 Prescription Order form showed R31 was prescribed Oragel 3x Toothache/Gum Gel, to be applied twice a day. On 3/18/24 at 9:40 AM, a second floor medication cart was reviewed with V12 LPN. The following opened/not dated or expired medications were found: a. One opened, undated bottle of Latanoprost eye drops prescribed to R12. b. One opened, undated albutrol inhaler prescribed to R41. c. One opened albuterol inhaler, dated 10/1/23, prescribed to R19. d. One opened, undated tube of Oragel prescribed to R31. At 9:45 AM, V12 LPN stated she was unsure as to when inhalers expire once opened. On 3/19/24 at 10:17 AM, V2 Director of Nursing stated all medications need to be dated when opened so staff know when the medications expire. V2 stated, Most medications expire 28 days from the day they are opened. Inhalers expire 30 days from the day they are opened. The facility's Medication Pass Guidelines policy dated 4/2019 was reviewed and showed to check each medication's expiration date prior to administration. The policy showed no guidance in regards to dating medications once opened. The policy did not specify the expiration dates of oral gels or albuterol inhalers once opened.

Based on interview and record review the facility failed to screen for and offer the COVID-19 immunization to residents for 4 of 5 residents (R64, R38, R59, R65) reviewed for the COVID-19 immunization in the sample of 18. The findings include: 1. R64's Resident Face Sheet showed R64 was admitted to the facility on [DATE]. R64's Preventative Health Record form printed 3/19/24 showed no documentation of R64 receiving any doses of the COVID-19 vaccination. R64's admission records and progress notes dated 10/30/24-3/18/24 showed no documentation R64 was ever screened for or offered the COVID-19 vaccine while in the facility. A progress note for R64, dated 3/19/24 at 11:12 AM, showed, Left message for POA (power of attorney) regarding consent for COVID vaccine, awaiting return call. 2. R38's Resident Face Sheet showed R38 was admitted to the facility on [DATE]. R38's Preventative Health Record form printed 3/18/24 showed R38 last received a dose of the COVID-19 vaccination on 12/16/21. R38's admission records and progress notes dated 12/28/23-3/19/24 showed no documentation R38 was ever screened for and/or offered the COVID-19 vaccine while in the facility. A progress note for R38, dated 3/20/24, showed, Spoke with resident regarding eligibility for COVID vaccine. Discussed benefits of the vaccine. Resident gave consent for the vaccine. 3. R59's Resident Face Sheet showed R59 was admitted to the facility on [DATE]. R59's Preventative Health Record form printed 3/18/24 showed R59 last received a dose of the COVID vaccine on 3/25/21. R59's admission records and progress notes date 3/1/24-3/19/24 were reviewed and showed R59 was not screened for or offered a COVID-19 vaccine until 3/19/24 at 10:50 AM. 4. R65's Resident Face Sheet showed R65 was admitted to the facility on [DATE]. R65's admission records and progress notes dated 1/27/24-3/19/24 were reviewed and showed R65 was not screened for or offered a COVID-19 vaccine until 3/19/24 at 10:08 AM. On 3/19/24 at 9:00 AM, V9 Infection Preventionist (IP) stated residents are screened for the need to receive the COVID-19 vaccine/boosters upon admission to the facility. V9 stated, We screen them on admission. If they need the vaccine, we educate them on the vaccine, and get them signed up for the next COVID vaccine clinic. We don't have a consent form for the COVID vaccine. If a resident wants the vaccine, we document the education and the consent in a progress note. Nursing then notifies me if the resident wants the vaccine. On 3/19/24 at 9:30 AM, V9 IP stated she was unable to find any documentation that R64, R38, R59, or R65 had been screened for and offered the COVID-19 vaccine while in the facility. The facility's COVID-19 Response Plan dated 6/2023 showed the facility will make the vaccine available to all employees and residents who wish to receive the vaccine and subsequent boosters .

Based on observation, interview, and record review, the facility failed to ensure a non-pressure sacral wound was treated, as ordered, for 1 of 5 residents (R370) reviewed for non-pressure wounds in the sample of 18. The findings include: On 3/18/24 at 9:36 AM, R370 said she has a wound to her bottom and staff have been applying cream to the area. On 3/18/24 at 9:38 AM, V24, Certified Nursing Assistant (CNA), took R370 to the bathroom. R370 had no dressing to her sacrum. On 3/18/24 at 9:49 AM, V6, Wound Care Nurse, said she saw documentation in the wound book showing R370 has an open area to her bottom, but R370 is not seeing the wound doctor at this time. R370 was back in her bed and said her bottom hurts. R370 had an open wound to her sacrum. V6 cleaned the wound with normal saline, measured the wound, then applied barrier cream. On 3/20/24 at 10:18 AM, V6 said R370's sacral wound is not a pressure ulcer, but she will have the wound care doctor see it this upcoming Monday. R370's Physician Order Report for the dates 2/18/24 through 3/18/24 shows a treatment order was placed on 3/15/24 for R370's sacral wound. The order shows R370's sacral wound is to be washed with soap and water, patted dry, and then Hydrogel is to be applied to the wound base and covered with a bordered foam dressing every three days and as needed when it becomes soiled or removed. On 3/20/24 at 9:01 AM, V26, Licensed Practical Nurse (LPN), said a wound should always have a dressing if one is ordered. V26 said if she came across a wound without a dressing, the nurses are responsible to replace the dressing.

Based on observation, interview, and record review the facility failed to ensure a catheter drainage bag was maintained below the level of the bladder for 1 of 1 residents (R49) reviewed for catheters in the sample of 18. The findings include: On 3/18/24 at 1:54 PM, V23 and V24, CNAs (certified nursing assistants) were using a mechanical lift to transfer R49 from his wheelchair to his bed. V23 and V24 hung R49's catheter bag on the sling strap above R49 as they raised R49 with the lift. Once R49 was lying in bed, V23 told V24 to set R49's catheter drainage bag on his bed where it remained as they provided a bed bath. On 3/19/24 at 1:25 PM, V25, CNA, said the catheter drainage bag should be positioned lower than the bladder so urine does not go back up in the bladder. If urine backflows back into the bladder, the resident could get a urinary infection, chronic kidney disease, and neuromuscular bladder dysfunction. R49's Face Sheet printed 3/20/24 shows his diagnoses include, but are not limited to, quadriplegia, diabetes mellitus type 2, chronic kidney disease, and neuromuscular bladder dysfunction. The facility's Foley Catheter Care Policy (revised 3/2016) shows the urinary catheter drainage bag should be kept lower than the bladder.

Based on observation, interview, and record review the facility staff failed to ensure a resident took all medications during medication administration. This applies to 1 of 3 (R48) reviewed for medication administration in the sample of 18. The findings include: 1. On 3/19/2024 at 8:29AM, V16 License Practical Nurse (LPN) prepared the medications for R48's medication administration. V16 placed the pills into a medication cup and dissolved the Miralax into a cup of water. V16 went to administer the medications to R48 at 8:40AM. V16 watched the resident take her pills and left the cup of water with MiraLAX on the resident's breakfast table in the dining room. R48 did not drink the MiraLAX and water. V16 was observed talking to other residents on the opposite side of the dining room from R48 while the MiraLAX was still sitting next to R48. At 8:51AM the MiraLAX in water was [NAME] sitting on the table next to R48, untouched by the resident. On 3/19/2024 at 8:51AM, Surveyor asked V16 about the MiraLAX sitting on the table near R48. V16 then returned to R48's table and asked her if she was going to take her MiraLAX and R48 refused the medication. V16 said he normally leaves MiraLAX for R48 with her and comes back to check on her later. On 3/19/2024 at 1:27PM, V2 Director of Nursing (DON) said staff should stay with resident during medication administration. V2 said medications should not be left near the resident on the table because someone else could take them. The facility's Medication Pass Guidelines policy, dated 4/19, states . watch the resident swallow all medications. Do NOT leave any meds with the resident to take later. before going to the next resident, double-check that all medications have been administered for that pass time.

Based on interview and record review the facility failed to ensure PRN (as needed) anti-anxiety (psychotropic) medications had a duration/end date. This applies to 2 of 5 (R53, R63) reviewed for unnecessary medications in the sample of 18. The findings include: On 3/19/2024, R53's Orders show resident has an active order since 7/18/2023 for lorazepam give 0.5mg/0.25mL PO (by mouth) Q (every) 2 hours PRN (as needed) for anxiety, agitation, or restlessness, with no stop date. On 3/19/2024, R63's Orders show resident has an active order since 2/27/2024 for lorazepam give 0.5mg tab PO Q 4 hours PRN for anxiety, with no stop date. On 3/20/2024 at 9:58AM, V2 Director of Nursing (DON) said PRN psychotropic and antipsychotic medications should have a 14 day stop date. The facility's Procedure for Psychotropic Medication Evaluation policy reviewed 3/2022 states . PRN medications psychotropic medications . will be limited to 14 days.

Based on observation, interview, and record review the facility failed to serve pureed barbecue beef brisket at safe temperatures. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18. The findings include: R46's lunch meal ticket for 3/18/24 shows that R46 received pureed barbecue beef brisket. R28's lunch meal ticket for 3/18/24 shows that R28 received pureed barbecue beef brisket. R10's lunch meal ticket for 3/18/24 shows that R10 received pureed barbecue beef brisket. On 3/18/24 at 11:59 AM, V20 (Cook) took food temperatures before plating lunch. The pureed barbecue beef brisket was at 130 F. This surveyor repeated the temperature to V20 and V20 confirmed the pureed barbecue beef brisket was at 130 F. V20 did not bring the pureed barbecue beef brisket back to the kitchen to be reheated prior to service. Facility provided temp log for the second floor kitchenette dated 3/17/24 shows the pureed entree was at 157 F; a different temperature than what was confirmed during service by V20. On 3/19/24 at 11:44 AM, V4 (Dietary Manager) said that foods should be greater than 135 F prior to service. If it is not at 135 F, staff should bring the food item back to the kitchen and quickly reheat the item to an internal temperature of 165 F. If the food item is not reheated and is below 135 F, the food could grow bacteria and increase the risks of food borne illness. Facility Food Temperatures policy from 2017 states, . 1. All hot food items must be cooked to the appropriate internal temperatures, held and served at a temperature of at least 135 F . b. Hot food items may not fall below 135 F after cooking, unless it is an item which is to be rapidly cooled to below 41 F and reheated to at least 165 F prior to serving.

Based on observation, interview, and record review the facility failed to provide pureed barbecue beef brisket in a smooth, pudding-like consistency for residents requiring a pureed diet. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18. The findings include: R46's lunch meal ticket for 3/18/24 shows that R46 received pureed barbecue beef brisket. R28's lunch meal ticket for 3/18/24 shows that R28 received pureed barbecue beef brisket. R10's lunch meal ticket for 3/18/24 shows that R10 received pureed barbecue beef brisket. On 3/18/24 at 12:58 PM, facility provided test tray of pureed barbecue beef brisket, pureed squash, and pureed chicken noodle soup was evaluated. The pureed barbecue beef brisket was not smooth and required chewing. On 3/18/24 at 1:10 PM, V4 (Dietary Manager) said before testing the pureed barbecue beef brisket that he could already tell it was not a proper consistency. V4 said that it was stringy and not the proper consistency. The proper consistency for pureed food items is completely smooth, no chunks, and similar to a mashed potato consistency. If residents on a pureed diet receive food that is not at the correct consistency, those residents increase their risk of choking. Facility National Dysphagia Diet Level 1 Pureed policy (no date) states, The dysphagia pureed diet (also known as NDD Level 1) is the least advanced of the texture modified diets. It provides foods that are pureed, homogeneous, and cohesive. The foods should be a semi-solid smooth consistency. No chewing or bolus formation is required. All foods must be pureed or be naturally pudding-like.

Based on observation, interview and record review the facility failed to ensure a resident was safely transferred using a mechanical stand lift device for 1 of 3 residents (R1) reviewed for safe transfers in the sample of 3. This failure resulted in R1 sustaining a left humerus fracture. The findings include: R1's Physician Order Sheet accessed on 1/3/23 show R1 has diagnoses that include morbid obesity, hypertension and heart failure. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. The same assessment show R1 needs extensive assist of 2 or more staff for all transfers with mechanical stand lift device. R1's Facility Reported Incident (FRI) dated 12/7/22 sent to the state agency on 12/8/22 as initial and final report show, on 12/7/22 at approximately 5:40 AM, resident was being transferred with the [mechanical stand lift] and the lift malfunctioned and continued to go up after the button was released. Additional information show, Resident assessed no redness or edema noted. Pain in shoulder .call placed to MD updated and get orders for left shoulder pain. Order received to get stat X-ray of left shoulder .Received X-ray results paged [R1's physician] and gave orders to send R1 to the emergency room (ER.) R1's Emergency Department (ED) notes dated 12/7/22 show, Chief Complaint- Patient presents with arm injury Patient was using sit to stand at NH facility this morning and her arm got stuck. X-ray done to NH shows humerus fracture of left arm. A [AGE] year old female presents the emergency room for evaluation of left arm pain. R1's ER radiology report dated 12/7/22 show, Closed fracture of proximal end of left humerus R1's ED discharge instructions dated 12/7/22 show: Closed fracture of proximal end of left humerus. Sling. Schedule an appointment with [Orthopedic MD]. What causes a humerus fracture? A humerus fracture is most often the result of trauma. This maybe from a fall, a blow, accident . R1's Orthopedic consult dated 12/14/22 documents left proximal humerus fracture .non op management. Remove sling when sitting and for hygiene. Wear sling for PT and ambulation/transfers. No shoulder ROM until follow up .Return appointment about 1 month. On 1/3/23 at 9 AM, R1 was sitting in her wheelchair. R1 was wearing a sling on her left arm. R1's left arm was elevated with pillows. R1 said she has a fracture of her left arm. R1 said it happened last month. R1 said early in the morning the (V7-Certified Nursing Assistant- CNA) went to her room by herself, got her up using the lift and placed her in the bathroom. R1 said the CNA was alone. R1 said normally there were 2 staff when she was being gotten up and being toileted. R1 said the CNA was rushing. R1 said when it was time for her to be gotten up from the bathroom, the CNA pushed the up button of the lift to go up. R1 said the lift machine went up. R1 said then she noticed that the lift continued to go up. R1 said she was repeatedly telling the CNA to pushed the stop button. R1 said she also told the CNA that her arm was stretched to the max. It hurt so bad! R1 stated I was screaming in pain! R1 said it was the worst pain she had ever experienced. The CNA was then trying to stop the machine. R1 said there was no one to help the CNA. Then the CNA came to her senses and turned off the machine. The machine finally stopped but by then, R1 said her arms were extended too far that caused her injury to her left arm. R1 said she was now standing, with both of her hands still extended as far as she can tolerate, it was really painful! worst than childbirth! R1 said finally other staff came to help to get R1 off from the machine. R1 said she had seen the ortho MD and said to continue wearing the sling until her left arm fracture was healed. R1 said because of her injury she cannot dress herself and she was very afraid being gotten up with the mechanical stand lift. R1 also said she will not allow only 1 staff to get her up at all. On 1/3/23 at 10:41 AM, V7 said she was CNA that got R1 up using the mechanical stand lift. R1 said normally there were 2 staff getting R1 up. V7 said she wanted to get done that morning and did not wait for another staff to help her. V7 said she used the mechanical stand lift to get R1 up from her bed then placed R1 to the bathroom. V7 said when it was time to lift R1 up from the toilet, she pushed the up button and R1 was going up. When it was time to pushed the stop button, the stand lift kept going up. V7 said she was pushing the stop button numerous times but it was not responding and the machine kept going up. V7 said R1 was screaming that she was in pain but V7 said she was so focused looking for the power switch button. V7 said finally she was able to turn the stand lift off. V7 said R1 was standing with both arms stretched out crying in pain. V7 said she put the call light button on and yelled out for help. V7 said staff came to R1's room to help R1 get off from the mechanical stand lift. V7 said she should have asked another staff to help when she was transferring R1 for R1's safety. On 1/3/23 at 11 AM, V5 said she was the Registered Nurse (RN) working on 12/7/22 on night shift when the incident happened. V5 (RN) said she was told to go to R1's room quickly. V5 said when she entered R1's room she saw the mechanical stand lift was so high up. R1 was in standing position crying in pain, with both of R1's hands stretched out with the stand lift. V5 said her and other staff placed a gaitbelt around R1 and slowly removed R1 from the mechanical stand lift. V5 said she found out that V7 (CNA) transferred R1 alone when R1 was supposed to be transferred with 2 assist for safety. V5 said there were other CNAs working that night that could have helped V7. V5 said when there were 2 staff, one staff could have controlled the machine and the other staff could have assisted and stay focused on R1. V5 said V7 knew that R1 is a 2 transfer assist on all transfers. On 1/3/23 at 8:40 AM, V6 (License Practical Nurse-LPN) said she was R1's regular day shift nurse. V6 said R1 was sent to the ER after the incident happened. R1 was complaining of pain in her left arm and left shoulder. V6 also said since the incident happened, R1 was scared to be transferred with the stand lift and definitely R1 needs 2 staff to transfer R1. On 1/3/23 at 10:16 AM, this surveyor, V3 (Assistant Administrator) and V10 (Maintenance Supervisor) observed the mechanical stand lift device used with R1. The device was placed in the basement and tagged as: Out of Service do not use .going up on it's own when pressing the down button Both V3 and V10 said they did not know what happened. V10 said he performed preventive maintenance to all durable medical equipment including all lift devices monthly and as needed. On 1/3/23 at 11:20 AM V4 (Rehab Director) said she was responsible for training staff on mechanical lift device protocols. V4 said mechanical lift device like the one that was used with R1 should always have 2 staff, 1 staff to maneuver the machine and one to make sure the resident who is being transferred is always safe. V4 said V7 (CNA involved in the incident) and other staff have been inserviced after the incident. V4 said R1 had significant change since R1's left arm was fractured. R1 had declined with things she can do, (dressing and transfers.) On 1/3/23 at 12:05 PM, V2 (Director of Nursing-DON) said she was notified of the incident regarding R1 early morning of 12/7/22. R1 was sent to the ER and was diagnosed with left arm fracture. V2 said she completed the investigation. V2 said she spoke to V7 (CNA involved) and informed her again that there should be 2 staff when performing this kind of transfer (mechanical stand lift device) for resident and staff safety and to prevent injury. A document under facility investigation by V2 dated 12/8/22 show, [V7] will be receiving disciplinary action for this since an injury was received by a resident (R1) and she only used 1 assist to start the transfer. The facility Policy entitled Transfers and Positioning Policy dated 3/2022 show, 5. Sit to Stand lift is used on residents who are not bearing much weight . You need two people to use this lift. One to operate the machine and the other to monitor and guide the resident.

Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the local health department and the centers for disease control regarding isolation of COVID-19 residents. This failure has the potential to infect high risk residents with COVID-19 and spread the disease to COVID-19 negative residents. This applies to 10 of 21 residents (R1 through R8, R15, R16) reviewed for infection control practices in the sample of 21. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R5 became the first COVID-19 positive resident during the facility's current outbreak and was not separated from her roommate R6 who was COVID-19 negative. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE]. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE]; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R5's [DATE] COVID-19 POC Lab Test Requisition (Point of Care; commonly referred to as a Rapid COVID-19 test) showed she tested positive at 10:00 AM. R5's [DATE] Progress Notes showed, Resident expired at 11:18 AM . R6's [DATE] and [DATE] COVID-19 POC Lab Test Requisition showed she was negative. R6's [DATE] POC Lab Test Requisition showed she was positive. The Facility's Room Census showed that R6 was separated from R5 on [DATE]. (The same day R6 tested positive. R6 was exposed to her COVID-19 Positive roommate for 5 days prior to testing positive.) R6's [DATE] Progress Note showed she was sent to a local area hospital due to her oxygen saturation jumping from 87 percent to 85 percent. Called 911 . R6's [DATE] Progress Note from 10:28 AM, showed Called (local area hospital) for resident status update. Spoke with nurse .who stated that resident has very thick mucus and is at risk for aspiration. Resident is on high flow .warmed oxygen and a CT of the chest has been ordered to r/o (rule out) a PE (pulmonary embolism). Resident is on several antibiotics, and will be evaluated by ST (Speech Therapy) due to swallowing problems from thick blood tinged mucus. On [DATE] at 11:20 AM, V4 Assistant Director of Nursing/Infection Preventionist stated, When (R5) tested positive we moved her and her roommate onto the COVID unit .We did keep them in the same room when we moved them to the COVID unit. (R6) was her roommate at that time. After the second round of testing she (R6) was then moved to separate room and then she tested positive. (R6's second negative was on [DATE], she was not moved till [DATE]) If a roommate tests positive and the other roommate tests negative, we keep them together because they (negative resident) are exposed. We are pulling the curtain, changing PPE (personal protective equipment) between residents and wiping down surfaces between the two residents. I talked to (V6 County Health Department Public Health Nurse in Communicable Disease) at the local health department and (V6) said it was okay to keep them in the same room . CDC guidelines recommend to try and cohort the positive and separate the COVID positive and negative residents. Our thought was because they (COVID negative roommates) have been exposed to keep them together (with their COVID positive roommate). We don't have the space to separate the residents. There are currently 3 open rooms on the second floor. (As of [DATE] all COVID-19 positive residents were on the second floor.) On [DATE] at 12:05 PM, V6 County Health Department Public Health Nurse in Communicable Disease stated, We have not discussed that situation, keeping COVID positive roommates with their COVID negative roommates . I don't ever recall giving that guidance that they can keep a COVID positive with a COVID negative roommate. The positive person should be separated from the COVID negative roommate and the COVID negative roommate should be put on a 14 day isolation period. I do have in my notes that we talked on [DATE] (The day R5 tested positive and the outbreak began) and all we discussed was declaring the outbreak, she (V4) would send me the line list, and she would keep me updated. It would be an extreme case to keep them in the same room together. There would have to be no way of separating the residents if that were the case; that is not something I would recommend. That is far reaching, I would not have said that an exposed resident should be kept with the positive roommate because that person is likely positive anyway . It is possible to be exposed to COVID but not contract the disease. Pulling the curtain would be a last resort. I assumed they would know what to do with the positive and negative roommates, I guess I'm going to have to call them and talk to them .Keeping the residents in the same room puts that negative resident at a high risk of exposure. On [DATE] at 2:43 PM, V6 stated, I reviewed my emails and notes and on a form (the facility) sent to me it indicated they did not have the LTC (Long-Term care) COVID Guidance so I emailed that to them on [DATE]. On the 8th ([DATE]) all we discussed was declaring the outbreak, they would send me the line list, testing twice a week, and she would keep me updated on changes. We did not discuss keeping positive and negative residents in the same room. V6's Notes from [DATE] showed, Outbreak declared with facility. They are testing 2 times a week for whole facility. They currently have 2 staff positive and a positive resident on the second floor. (V4) will be sending a new line list. It was decide with (V4) that she will send me a line lists of staff/residents when they occur. She will send email if no changes or to look out for a line list. (No mention of roommate concerns.) V6 provided the email she sent to facility on [DATE] at 9:41 AM. The email showed it was sent to V3 Director of Nursing and V4. The email showed, When you sent the preliminary report to us (County Health Department) on ,[DATE] there was indication on there you did not have the IDPH (Illinois Department of Public Health) guidelines for LTC. Below is the IDPH guidelines for LTC. V6 provided a link to IDPH's website titled Long Term Care Facilities Guidance - Long Term Care Reopening Guidance. The website also included resources with links to the CDC (Centers for Disease Control and Prevention) Preparing for COVID-19 in Nursing Homes. The CDC website Preparing for COVID-19 in Nursing Homes updated [DATE] showed, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens, including [MEDICAL CONDITION]. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). The CDC website showed, Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP. As roommates of residents with COVID-19 might already be exposed, it is generally not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test. On [DATE] at 1:15 PM, V5 Medical Director stated, Generally that age population, with their comorbidities, they are at an increased risk for complications from COVID-19. We are seeing complication of shortness of breath requiring hospitalization , [MEDICAL CONDITION] (altered brain function), confusion, memory issues, and pneumonia. The COVID positive resident should be isolated and; the negative (roommate) should be separated from the positive and put in isolation as well. If they (positive and negative roommates) are kept in the same room that puts the negative resident at a higher risk of contracting COVID-19. I am involved every step of the way, we have an infection control team that I chair with (V4). As far as I know, the COVID negative and COVID positive roommates are being separated, that would be my recommendation. The facility's COVID-19 Response Plan drafted [DATE] showed, Serious illness occurs in 16 percent of cases. Case fatality rate for people over [AGE] years old is approximately 8 percent. Case fatality rate for people over [AGE] years old is approximately 15 percent. (R6's Face Sheet showed her to be [AGE] years old.) The Response Plan showed for widespread cases at the facility to follow all CDC/IDPH recommendations and guidelines in addition to applicable local health department recommendations and guidelines . The facility's COVID-19 Positive Residents Outbreak Plan drafted [DATE] showed, Establish a dedicated COVID unit . 2. R15's [DATE] COVID-19 POC Lab Test Requisition showed she tested positive. R16's [DATE] COVID-19 Lab Test Requisition showed she tested negative. R16's [DATE] COVID-19 POC Lab Test Requisition showed she tested positive. R15 and R16's Resident Census showed they were roommates on [DATE] and were never separated prior to R16 testing positive on [DATE]. (R16 was exposed to her COVID-19 positive resident for 5 days prior to testing positive.) 3. R7's [DATE] COVID-19 POC Lab Test Requisition showed he tested positive. R8's [DATE] and [DATE] COVID-19 POC Lab Test Requisition showed he tested negative. R8's [DATE] COVID-19 POC Lab Test Requisition showed he tested positive. R7 and R8's Resident Census showed they were roommates on [DATE] and were not separated prior to R8 testing positive. (R8 was exposed to his COVID-19 positive resident for six days prior to testing positive.) 4. R1's [DATE] COVID-19 POC Lab Test Requisition showed she tested positive. R2's [DATE] COVID-19 POC Lab Test Requisition showed she tested negative. R1 and R2's Resident Census showed R1 and R2 were roommates on [DATE]. Their resident census does not show the residents were separated after R1 tested positive for COVID-19. On [DATE] at 10:45 AM, R1 and R2 were observed living in the same room. The general room layout in the facility is, standing at the hallway door to resident rooms, the bed to the left is bed 1 and to the right is bed 2. The foot of the beds face each other with a curtain that is able to be pulled separating the room in half. R1 was in a wheelchair next to her bed and R2 was in a reclining wheelchair next to her bed. R2 was using nasal cannula supplemental oxygen. The curtain was not pulled and the residents were able to see each other. The residents were approximately 9 feet apart, facing each other, and not wearing masks. (Floor tiles are 1 foot by 1 foot and were used to determine distance.) R2's Face Sheet printed on [DATE] showed [DIAGNOSES REDACTED]. 5. R3's [DATE] COVID-19 POC Lab Test Requisition showed she tested positive. R4's [DATE] COVID-19 POC Lab Test Requisition showed she tested negative. R3 and R4's Resident Census showed that on [DATE] they were roommates and were not separated. On [DATE] at 10:22 AM, R3 and R4 were observed in the same room. R4 was in bed 1 (left bed) and R3 was in her chair next to bed 2 (right bed). The dividing curtain was pulled only 6 feet from its most open position. (R4 remained exposed to her COVID-19 positive roommate for 12 days.) The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. On [DATE] the facility began seperating COVID-19 positive roommates from their COVID-19 negative roommates 2. On [DATE] the facility completed the process of cohorting COVID-19 positive staff and residents onto one unit. 3. On [DATE] the facility began training of staff and developed a plan to educate staff who were not on duty. Training included PPE usage, signage indicating COVID-19 positive residents, identification of COVID-19 signs/symptoms, and actions taken for COVID-19 positive residents and exposed residents. 4. On [DATE] the facility developed plans for cohorting COVID-19 positive staff and residents. 5. On [DATE] the facility developed plans for to ensure policy and procedures were consistent with CDC/IDPH guidelines regarding COVID-19 II. The facility failed to implement proper personal protective equipment procedures on a unit with both COVID-19 positive and COVID-19 negative residents. This applies to 1 of 21 residents (R4) reviewed for infection control in the sample of 21. On [DATE] at 10:22 AM, V10 Certified Nursing Assistant exited R20, and R21's room. V10 was wearing a gown, N95 mask, and a face shield. V10 then entered R3, and R4's room (same hallway as R20, R21), without changing her disposable gown. The facility's [DATE] Clinical [DIAGNOSES REDACTED]. The facility's Line List provided on [DATE] showed R3, and R20 tested positive for COVID-19 on [DATE], and R21 tested positive on [DATE]. The Line List only included positive residents, R4 was not on the list. On [DATE] at 10:28 AM, V10 stated R4 was the only resident who was not COVID positive on that hallway. V10 stated staff were instructed to only change their gown if they provided care for R4. V10 stated she does not change her gown if she enters R4's room if she is going to see R4's roommate. On [DATE] at 11:20 AM, V4 Infection Preventionist stated COVID positive, and COVID negative residents were not cohorted. V4 said some units had COVID positive, and COVID negative on the same hall. V4 said staff did not have to remove personal protective equipment (PPE) after exiting a COVID positive room if the staff were going to care for another COVID positive resident, even if COVID negative residents were on the same hallway. On [DATE] at 12:05 PM, V6 County Health Department Public Health Nurse in Communicable Disease stated if the facility does not have a dedicated COVID unit/area and they have COVID positive and negative on the same units, PPE should be donned in the hallway and removed in the resident's room. V6 stated this was to prevent the spread of COVID-19 to unaffected residents.

Based on interview and record review the facility failed to ensure adequate supervision was provided for a resident with Dementia who was at risk for choking. R1 was served a mechanical soft diet but unknown to staff, consumed a regular hotdog. This failure resulted in R1 choking on the hot dog and dying of acute fatal cardiopulmonary arrest secondary to respiratory arrest. The Immediate Jeopardy began on [DATE] when R1 ate a regular consistency hot dog for dinner, choked and later died at a local hospital. E2 (Assistant Administrator) was notified of the Immediate Jeopardy on [DATE]. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2, due to the need to evaluate the effectiveness of any new policies, procedures and training provided to staff. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 4 and 7 residents in the supplemental sample for the extended survey. The findings include: The facility's Final Report to Illinois Department of Public Health Regarding the Incident on [DATE] Involving R1 faxed [DATE] showed, On [DATE] at approximately 5:30PM in the second floor dining room, R1 started choking during the resident meal. R1 was witnessed to be in distress by a nurse and he pointed to his throat and was unable to speak or breathe. Staff in the dining room immediately responded and began abdominal thrusts which was not successful. The resident was taken to his room and staff began chest compressions and suctioning. Food particles were dislodged at that time. Cardiopulmonary resuscitation (CPR) was continued and a palpable femoral pulse was obtained. Upon arrival of paramedics, they took over care and the resident was taken to the emergency room at 5:53PM. R1 passed away at 8:00PM in the hospital with a [DIAGNOSES REDACTED]. Facility staff were interviewed regarding the meal and choking incident. It has been determined that R1 was given the proper diet consistency of mechanical soft when he was given his hot dog that evening. Multiple staff also indicated that R1 has a history of taking food off his tablemate's plates, which may have been how he had eaten a non-mechanical soft hot dog causing R1 to choke. R1 was care planned for impulsive behavior noting that he frequently eats foods he is not supposed to and he (R1) eats too fast. R1 has a weak gag reflex, weak esophageal muscles and is unable to cough effectively. Conclusion: At this time the facility has determined that R1 choked on a hot dog. Facility staff cannot determine where/how he (R1) got a regular hotdog. The hospital Facility Coding Summary dated [DATE] for R1 showed, Chief complaint: Choked on a hotdog; was unconscious and choking. CPR started; Principal Diagnosis: [REDACTED]. The hospital Triage Note dated [DATE] for R1 showed, Unconscious after choking on a hotdog at the nursing home. Glascow Coma Score: 4 - eyes do not open (1); best verbal response - incoherent speech (2); best motor response - none (1); Physical Assessment - per EMS R1 was at the nursing home eating a hotdog when he began to choke, became unconscious and CPR performed. R1 was able to be revived after ,[DATE] minutes with spontaneous breaths once the hotdog was removed but remains unresponsive at this time. On arrival R1 has no motor function nor is he responding to pain or verbal stimulus; family at bedside stating R1 is a DNR; Severe respiratory distress; peripheral cyanosis; skin is prominently pale; skin is markedly cool. At 8:00PM R1 expired in the ER. On [DATE] at 2:45PM, E8 (Food Service Worker) stated, R1 was on a mechanical soft diet. R1 had honey thick liquids. I served R1's food onto his plate and that night he had a mechanical soft hot dog. R1 may have taken another residents hot dog or another resident could have given it to him. He (R1) had diminished memory capacity. On [DATE] at 3:30PM, E5 (CNA) stated, I usually work downstairs and don't know the residents upstairs. I was upstairs feeding 2 residents at the same table as R1 when he started choking. I saw R1 being handed his tray and he had a little information card on how to eat his meal. It said to chew slowly and not put too much in his mouth. The CNA handling his tray read it to him. There was a set of 3 or 4 instructions in front of him in big, bold letters. I didn't see anyone hand R1 any food. I was focusing on the residents I was feeding. On [DATE] at 1:10PM, E10 (Registered Nurse - RN) stated, I was coming through the dining room and saw R1 at a table, he was in distress and pointed to his throat. I asked if he was choking and he nodded yes. I did abdominal thrusts behind R1's wheelchair. I got E12 (CNA) and E14 (RN) to help me with the abdominal thrusts. It wasn't working so I got R1 to a chair and said to take R1 to his room. R1's room is close to the dining room (two doors from dining room). R1 slumped over in his wheelchair so we picked him up and carried him into bed. I felt for a pulse and started CPR. I knew he wasn't gone. Someone came in with suction and I didn't get much out. I don't know how he got the hot dog; possibly a table mate had it for supper. On [DATE] at 10:40AM, E9 (CNA) stated, I turned around the corner and saw a couple of abdominal thrust procedures with R1 standing. Then the nurse wanted to take R1 to his room because so many people were watching. R1 was taken down in his wheelchair. R1 was placed in his bed. The nurse had a machine for suction, put it in his throat to suck out what she can and when that didn't work she started CPR. E9 stated that she has never noticed any behaviors with R1 in the dining room, never witnessed R1 taking others food and did not know if he was on any special diet. E9 stated, When I was trained I was taught that they had specific diets. When I was trained on the floor no one said to make sure diets are okay just to make sure the drinks are the right consistency. On [DATE] at 2:56PM, E6 (Licensed Practical Nurse - LPN) stated, I was in the lounge when a CNA came in and said R1 was choking. There were two nurses out there and I went out there and they already had brought R1 to his room. CPR was in progress by E14 (RN) and E12 (CNA). I took over compressions. EMS arrived, moved R1 from the bed to the floor, did more chest compressions and got more food from R1. We called the hospital to get an update and they said R1 choked on a hot dog and died . I found out in report the next day that they pulled a hot dog from his throat. I am not sure how he got the hot dog. One of his table mates (R4) has a regular diet and offers his food to others. On [DATE] at 3:10PM, E7 (RN) stated, That night I was helping in the dining room. I was waiting by the kitchen and heard someone yell, Call 911 and I took over for the CNA who was calling and giving the information to 911. I witnessed several attempts at abdominal thrusts; several unsuccessful attempts. R1 went unresponsive in a chair on the way to his room. I went to R1's room a couple of times. I went in when EMS was here and they had a laryngoscope and were pulling a piece of something out. When they pulled it out R1 had chest rise but I could tell he wasn't getting full chest rise. On [DATE] at 11:36AM, E11 (CNA/Unit Secretary) stated, R1 was on a mechanical diet and thickened liquids. E11 stated to her knowledge no one knows how R1 got the regular hot dog. On [DATE] at 12:28PM, Z3 (Speech Therapist) stated, R1 had a video swallow study done and they found that he needed honey thick liquids and a mechanical soft diet. R1 was placed on that diet here. R1's swallowing strategies were to swallow three times per bite and alternate consistencies. I wrote that out for him. The kitchen manager typed it out and put it on the back of his diet card so the CNA could remind him. R1 could read the card. R1 knew what was going on. R1 could tell me he had to swallow three times. R1 followed the recommendations when I was with him. R1 ate fast and everyone told him to slow down. If someone offered R1 food he would have taken it. R1's table mate R4 has offered me food and offered chips to R1 once. On [DATE] E2 (Assistant Administrator) stated, The only conclusion we can come to is that R1 grabbed the person's next to him (R4) food. That person (R4) had a regular diet. The person that served R1 is sure that he got the right food. I believe the witness statements stated that R4 will push his food off to others. The Accident and Incident Report Employee Witness Statement Form dated [DATE] for R1 and written by Z3 showed, I witnessed on more than one occasion R4 offering food to R1 from his own plate. R4 was instructed not to offer food to anyone. The Accident and Incident Report Employee Witness Statement Form dated [DATE] for R1 and signed by E11 showed, On numerous occasions I have witnessed and redirected (R1) going into the dining room and pouring his own coffee from the dispenser which is thin liquid when he is supposed to be thickened consistency. And on more than one occasion I have seen him take food off of other resident's plates and eat their food. The Care Plan for R1 showed it was updated on [DATE] and stated, R1 was noted to be taking food from another resident. Both residents counseled. There are no other behaviors care planned for R1 to show that he had impulsive behaviors when eating such as taking other's food or eating foods he is not supposed to have. The Behavior Monitoring Record for R1 dated June and [DATE] showed R1 was being monitored for wandering/elopement. No other behaviors were documented. The Speech Therapy Daily Treatment note dated [DATE] for R1 showed, R1 was seen for speech/swallowing therapy. Kitchen manager present for part of session to observe swallow strategy pattern that is best for R1. Kitchen manager will write down on the back of a meal card the following strategies; small bite, swallow three times, small sip, slow down. Recommend continued utilization of swallow strategies. The Minimum Data Set (MDS) dated [DATE] for R1 showed a Brief Interview of Mental Status Score of 6 = moderate cognitive impairment; extensive assistance required for bed mobility, transfers, dressing, hygiene and bathing; supervision and setup for eating. R4's Minimum Data Set (MDS) of [DATE] shows that R4 has a score of 3 (severe cognitive impairment). On [DATE], at 10:25 AM, R4 was interviewed and was unable to answer simple questions. R1 was unsure how many children he had, maybe 2 or 4. R4 did not recall the names of his children. R4's Care plan for nutritional status did not show any behaviors of giving his food to others until [DATE], (8 days after R1 choked). The only intervention was that R4 will be counseled as needed when he is giving his food away. The facility's Mechanical Soft Diet policy and procedure (2012) stated, The mechanical soft diet is a modification in texture and consistency of the regular diet designed to minimize the amount of chewing. The mechanical soft diet may be served in the form of ground, chopped or whole foods of a soft consistency. The foods should be moist. The mechanical soft diet is used to optimize nutritional intake for individuals who have difficulty chewing or swallowing. Foods to avoid: hotdogs and sausages with casings unless ground or finely chopped. Based on observation, interview and record review the surveyor confirmed the facility took the following steps to remove the immediacy of the situation: 1. Facility staff immediately changed table assignments for residents located at the table of R4 because it was undetermined if R4 gave R1 the hot dog or if R1 took the hot dog from his plate. Locating residents with general diets only at his table, completed on [DATE]. 2. The facility staff immediately updated the seating chart for the second floor dining room to account for the change on [DATE]. 3. The facility nursing, activity and dietary staff were in-serviced on proper placement of residents in the dining room in regards to specific diets as they came on shift for the first time following the incident, this started on [DATE]. 4. The facility nurses were re-inserviced on proper placement of the medication carts during the meals to allow for better supervision as they came on shift for the first time following the incident starting on [DATE]. 5. The facility will review the choking policy with the medical director to determine amendments to include in dining room safety precautions. Communication with specific language related to residents identified at risk for choking, sharing food, taking food, or other contributing factors related to choking. A draft is to be provided to the medical director for his review on [DATE].