Monmouth Rehab And Nursing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement interventions for a resident with a known history of elopement and exit-seeking behaviors to prevent elopement and failed to provide adequate supervision for one of one residents (R5) reviewed for elopement risk in the sample of six. These failures resulted in R5 exiting the facility on 1/5/26 without staff knowledge and being found at a local coffee shop two blocks away, near a busy highway, during cold weather conditions when a concerned citizen called 911, and emergency medical services responded.These failures resulted in an Immediate Jeopardy that began on 1/5/26. V1 (Administrator) was notified of the immediate jeopardy on 1/27/26 at 12:10 PM. While the Immediate Jeopardy was removed on 1/28/26, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and quality assurance.Findings include:The facility's Wandering & Elopement Assessment and Prevention policy revised 6/4/2024 documents all residents in this facility shall be assessed for elopement/unsafe wandering, to ensure their safety and prevention from elopement. Elopement is defined as a resident unable to protect themself, who departs the healthcare facility or enters a non-resident area unsupervised or undetected. An incident report will be completed by the Nursing Supervisor noting all investigative procedures, witness statements, and any other pertinent information.R5's census line documents R5 was admitted to the facility on [DATE].R5's Elopement Assessments dated 9/7/23 and 4/3/25 document R5 is at risk for elopement and has previously eloped from the facility. The 4/3/25 assessment also documents R5 exhibits exit-seeking behaviors.R5's Wandering/Elopement assessment dated [DATE] documents R5 has a history of leaving the facility.R5's care plan was updated on 1/6/26 to include wander guard placement, and physician orders dated 1/6/26 document a wander guard was placed on R5. R5's care plan further documents R5 has Alzheimer's/Dementia, Poor Safety Awareness, is at Risk for Falls and R5 walks with a walker and staff supervision.R5's Nurse Progress Note dated 1/7/26 at 11:47 AM documents R5 remains on 15-minute checks for safety and observation after a recent exit-seeking episode.R5's electronic record revealed no Nurse Progress Note or assessment regarding R5 eloping from the facility on 1/5/26.The National Weather Service report for Monmouth, Illinois, dated 1/1/26-1/24/26, documents that on 1/5/26 the outside temperature was a high of 49 F and a low of 28 F.On 1/26/26 at 9:45 AM, R5 was observed lying in bed with the call light attached to the blanket, watching television. R5 was only alert to self during conversation. A walker and manual wheelchair were at the foot of R5's bed.On 1/26/26 at 11:15 AM, V3 (R5's Friend) stated that on 1/5/26, V3 received a call from V1 (Administrator) informing her that R5 had exited the facility, possibly by following visitors out the door unnoticed. V3 stated V1 told her she was very upset and felt terrible that R5 had gotten out, but V1 had found R5 at a local coffee shop. V1 told V3 that R5 stated he had left to help someone fix their car. V3 stated she was notified only after R5 was found, not when he was missing. V3 further stated that shortly after R5 was admitted to the facility in February 2023, R5 had eloped another time because R5 wanted to go to a parade, and nobody would take him. V3 stated R5 was found walking on a busy street and brought back to the facility.On 1/26/26 at 12:05 PM, V2 (Director of Nursing) stated staff and V1 made her aware they were looking for R5 and could not find him. V2 stated she immediately started searching the back hallways and other resident rooms. V2 stated she was told the facility received a call that R5 was found. V2 stated she does not know why there is no documentation in R5's chart regarding the elopement and that it should have been documented in R5's electronic medical record. V2 further stated she assumed the documentation was there.On 1/26/26 at 12:20 PM, V1 (Administrator) stated that on 1/5/26 an unknown Certified Nursing Assistant came to the front office asking if they had seen R5. V1 stated they began searching bathrooms and resident rooms, and when they realized R5 was not in the facility, they searched the perimeter. V1 stated she drove two blocks east, saw EMS (emergency medical services) lights at a local coffee shop, and found R5 there. V1 stated a concerned citizen had called 911 after seeing R5 walking with his walker. V1 stated she was not aware the incident was not documented in R5's chart.On 1/26/26 at 1:45 PM, V8 (Certified Nursing Assistant/CNA) stated R5 got out of the facility, and nobody knew he had left. V8 stated R5 has gotten out before, though V8 was not present during prior incidents. V8 stated R5 can ambulate with a walker or wheelchair depending on the day.On 1/26/26 at 1:48 PM, V6 (CNA) stated she saw R5 walking in the hallway with his walker between approximately 3:50 PM and 4:15 PM. V6 stated after assisting another aide, she was informed staff could not find R5. V6 stated she joined the search and drove with the activity director, locating EMS lights at a local coffee shop where R5 was found.On 1/26/26 at 1:53 PM, V7 (CNA) stated she was told R5 got out of the facility while she was working, but she was not involved in the search because she was assisting another resident.On 1/26/26 at 2:15 PM, V1 (Administrator) stated R5 did not have a wander guard prior to 1/5/26 because R5 refused to wear it, and this refusal was not documented. V1 confirmed R5 previously eloped in September 2023 and was found walking on a street.The facility submitted an abatement plan on 1/27/26 and was advised by the regional office to make revisions before it would be accepted. The facility submitted the revised abatement plan on 1/28/26. Again, the facility was advised to make revisions to the plan. The final abatement plan was submitted on 1/29/26.On 1/29/26 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.All staff members present were in-serviced on 1/27/26 and 1/28/26 on the elopement policy and procedure. All remaining staff members will be in-serviced via telephone prior to their next shift by administrator and/or designee.2.On 1/28/26, audit conducted by administrator and director of nurses by auditing medical chart to ensure interventions are in place and documentation of event with all action taken is recorded.3. On 1/28/26 all nurses were in serviced on incident charting and completion by Director of Nursing.4. On 1/27/26 all residents had an updated wandering/elopement assessment completed by Director of Nursing and Assistant Director of Nursing. Care plans were reviewed for accuracy by Director of Nursing on 1/28/26.

Based on record review and interview, the facility failed to maintain complete and accurate clinical records for two residents (R3, R5) of three reviewed for documentation out of a sample list of six.Findings include:The facility's Charting & Documentation Policy revised 11/5/2019. The purpose of this policy is to maintain a medical record to serve as a legal document that details the services provided to the residents, or any changes in the residents' medical or mental condition, through charting and documentation. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to: Incidents/ Accidents, Change in Condition, Physician Notification and Responsible party, education provided to resident and or responsible party.1. R5's electronic medical record contained no Nurse Progress Note or assessment regarding R5's elopement from the facility on 1/5/26.R5's care plan was updated on 1/6/26 for wander guard placement, and physician orders dated 1/6/26 documented the wander guard was placed. However, there was no documentation of the elopement event, staff response, or resident condition after returning to the facility.On 1/26/26 at 12:05 PM, V2 (Director of Nursing) stated she assumed documentation was completed but confirmed it was missing from R5's chart.On 1/26/26 at 12:20 PM, V1 (Administrator) stated she was not aware the incident was not documented in R5's chart.2. R3's Medical Diagnosis list documents R3 has Alzheimer's Disease and Dementia.R3's current care plan documents R3 is at risk for Falls and Elopement/Wandering and a wonder guard was placed on R3 on 1/28/26.R3's Nurse Progress Note dated 12/31/25 documents R3 has a bruise under her left eye that is healing. There is no documentation in R3's chart explaining how the bruise occurred, nor any follow-up assessment or investigation.On 1/28/26 at 1:30 PM, V2 (Director of Nursing) stated all incident/accident documentation has been recorded in the facility's internal Risk Management system, which does not carry over into the resident's electronic medical record. V2 stated any assessments related to an incident would not be found in the residents' chart for this reason. V2 further stated she is in-servicing nurses on how to ensure assessments and incident documentation are entered into the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure complete and timely physician notification following a resident accident and subsequent change in condition for one of three residents (R1) reviewed for notification of change out of a sample list of three. This failure resulted in R1 experiencing excruciating pain to her right hand due to a delay in notifying the physician and ultimately leading to a diagnosis of a fracture.Findings include:The facility's Physician Notification Policy revised 11/5/2022 documents a facility will immediately inform the resident; consult with the resident's physician; and notify, of a significant change in condition in a resident's physical, mental, or psychosocial status or a need to alter treatment significantly.The facility's Change in Condition Procedure revised 9/21/2022 documents a change in condition requires notification of Medical Doctor of change and resident assessment information. R1's Nurse Progress Note dated 8/12/25 documents R1, who utilizes a wheelchair was on a supervised outing with facility staff. While navigating a grassy area, R1 slid forward out of her wheelchair, landing on her knees and both hands. Staff immediately assessed the resident on-site. R1 voiced she was fine and attempted to reposition herself independently. Staff assisted her back into the wheelchair without issue and returned R1 to the facility. R1 was assessed upon return to facility and Physician, Director of Nursing (DON), and Administrator were notified, and an intervention was initiated for foot supports to be added to R1's wheelchair to prevent future sliding incidents.R1's Medical Diagnoses revealed R1 has Myasthenia Gravis and Cerebellar Ataxia, both of which affect muscle strength, coordination, and mobility.R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and requires substantial/maximal assistance with standing and transfers. R1's Nurse Progress Note dated 8/12/25 at 3:50 PM, documents R1 reported minimal pain in the right hand following a fall earlier that day. R1's right hand had mild edema and scant discoloration observed on the 3rd, 4th, and 5th fingers. Ice was applied to the right hand. R1 stated It does not hurt really unless she moves her fingers.R1's Nurse Progress Note dated 8/13/25 at 12:30 AM documents R1 was complaining of discomfort right hand, right hand is very swollen and bruised, unable to grip with hand. R1's right great toe is painful and bruised. Ice offered for hand, resident declined, the pressure causes discomfort. R1 states she injured her hand on outing in wheelchair.R1's Nurse Progress Note dated 8/13/25 at 10:30 AM documents R1 was up in her recliner chair with right lower extremity (RLE) elevated due to swelling on the top of right foot area from the previous incident on 8/12/25. Bruising continues to R1's right great toe between toe and top of right foot. R1's right hand remains swollen with bruising. Will continue to monitor.R1's Nurse Progress Note dated 8/13/25 at 11:30 AM documents Ordered through portable X-Ray two view Xray of right hand due to moderate swelling and moderate bruising with pain, per V9 (Medical Director).R1's Nurse Progress Note dated 8/14/25 at 10:45 AM documents R1's X-ray results of right hand reveal prominent displaced fractures involving the base of the proximal phalanges of the third through fifth digits.On 9/10/2025 at 8:50 AM, R1 was seated in a wheelchair and had a hard cast on her right wrist. R1 was pleasant and alert during the interview. When asked about the injury, R1 stated, (R1) was with (V3/Activity Director) on my way to the store. (V3) was pushing me in my wheelchair, and we hit a curb or something on the ground, and (R1) fell out into the grass and broke her hand. R1 stated they had her foot in a boot as well because of her toe, but it's doing better. R1 stated she normally wears foot pedals outside of facility but forgot them that day. R1 stated if she had foot pedals on the chair she would not have fallen out. R1 further stated that she immediately felt excruciating pain in her right hand shortly after her fall and that she made the staff aware of the pain as soon as staff arrived to help R1 up from the ground. On 9/10/25 at 9:54 AM, V3 (Activity Director) stated that the facility regularly takes residents on outings to a local store, located one block from the facility. V3 reported, We take side streets when we walk because it's less busy. There's a three-four-foot patch of grass off the sidewalk. V3 explained that during the outing on 8/12/2025, she remained with R1 while other residents and staff returned to the facility. V3 stated, I told her hold on, I'll put my bags down and help you. V3 reported that R1 self-propels using her arms and feet, and that as V3 attempted to assist R1 through the grassy area, which was uneven, then it happened so fast that R1's wheelchair's front wheels were in the grass and the rear wheels remained on concrete. V3 stated, (R1) slipped out of wheelchair going forward and I think R1 put her feet down to break the fall and was on her knees, put her hands down on the ground to break her fall. (R1) then rolled over in the grass. V3 noted that R1 was not wearing foot pedals at the time, adding, She never does wear them. V3 acknowledged, It was swollen very quickly. I should've done things differently-I probably should have had foot pedals on, or pulled her backwards, or taken her another way. V3 contacted the facility immediately, and two Certified Nursing Assistants (CNAs) were sent to assist, as V3 is not a CNA or nurse.On 9/10/25 at 10:30 AM, V4 (Licensed Practical Nurse/LPN) stated that she was made aware of the fall by V2 (Director of Nursing) and was unsure who assisted R1 at the scene. V4 reported, I don't remember any CNAs leaving the floor to go help. V4 stated that R1 did complain of pain during her assessment upon returning to the facility. However, V2 directed staff to wait a day or two before determining whether R1 needed an X-ray or further evaluation. V4 also stated she was told that V3 was pushing R1 in her wheelchair when they hit something, causing R1 to fall forward. V4 added, I was told that (R1) stopped her fall using her hands on the ground.On 9/10/25 at 12:00 PM, V2 (DON) stated that on 8/12/2025, she received a call from V3 (Activity Director) reporting that R1 had slid out of her wheelchair while outside the facility at a local store and was on the ground. V2 stated she sent two CNAs to assist because V3 was not certified to lift or transfer residents. Upon R1's return to the facility, V2 assisted V4 (LPN) with the assessment. V2 reported that R1 did not complain of pain, swelling, or bruising at that time, so they decided to monitor her condition. V2 stated that on 8/13/2025 at 12:30 AM, V5 documented increased pain, swelling, and discoloration to R1's hand. V2 acknowledged that V5 should have reported this change in condition to the physician. V2 also stated that V6 (RN) documented continued pain and swelling on 8/13/25 without notifying the physician.On 9/10/25 at 1:05 PM, V8 (CNA) stated on 8/12/2025, she and V7 (CNA) were passing lunch trays when V2 (DON) informed them that R1 had fallen outside of a local store and needed assistance. V8 reported that when they arrived, R1 was sitting on the ground. V7 and V8 used a gait belt to assist R1 back into her wheelchair. V8 stated, (R1's) right hand was very swollen, and (R1) was complaining that it hurt. V8 observed that R1's hand became more swollen and bruised over the next few hours. V8 stated she provided care for R1 again on 08/13/2025, and R1 continued to complain of pain in her right hand and foot. V8 reported that she notified V4 (LPN), and that V2 responded, (R1) hand will be fine-it's probably just a sprain. V8 stated that V4 appeared upset and felt R1 needed an X-ray. V8 further stated we are often told by management to not report things.On 9/10/25 at 1:30 PM, V7 (CNA) stated that when she and V8 arrived at the scene on 8/12/2025, R1 was sitting on the ground with her legs extended and hands on the ground. V7 reported that R1 stated her hand was very sore and asked staff to be careful with it. V7 observed that R1's hand was swollen, bruised, and stated, Her hand was hurting her very bad. V7 stated that she and V8 notified a nurse but could not recall which nurse was informed. V7 also stated she was not aware of R1 refusing to wear foot pedals, noting, Sometimes she wears them and sometimes she doesn't.On 9/10/25 at 8:30 AM, V9 (Medical Director) stated he remembers receiving the call on 8/12/25 regarding R1's fall. V9 stated he does not remember exactly what was said to him at that time, but if it was conveyed to him that R1 was in a lot of pain or had swelling V9 would have sent R1 to the emergency room to be evaluated. V9 stated when he saw R1 the next day he ordered an Xray. V9 stated he expects to be notified any time a resident has a condition change or increased pain. V9 stated he does not recall the facility calling him with updates on R1's change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to date and store oxygen equipment as ordered for two of three residents (R1 and R4) and failed to administer oxygen at the prescribed rate for (R4), reviewed for oxygen, in a sample of 5.
Findings include:
The facility policy, Oxygen Administration and Storage, dated (revised) March 8, 2022, directs staff, To ensure staff follow safety guidelines and regulation for storage and use of oxygen. Verify provider's order for the procedure. Turn on oxygen and set flow rate to prescribed amount. Label the tubing connected to the oxygen cylinder with time and date. The nasal cannula or mask should be changed weekly or when soiled. Nasal cannula should be stored in a manner to prevent touching the floor when not in use. The humidifier bottle is to be labeled with the date of application and changed weekly if refillable.
1. R1's facility admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Paroxysmal Atrial Fibrillation, and Chronic Respiratory Failure.
R1's current Physician Order Sheet, dated June 2025 includes the following physician orders: Oxygen at 3 liters via nasal cannula continuously with humidification; Oxygen tubing change weekly, label each component with date and initials every 28 days; Change Humidifier Bottle weekly, date and time on bottle at change.
On 6/28/25 at 8:35 A.M., R1 was sitting in the hallway, across from the nurse's station, in a recliner. R1's fingertips, feet and lower legs were cyanotic. R1 was not currently wearing oxygen, the oxygen tubing was lying in a wheelchair, next to R1. The oxygen tubing and humidifier bottle were undated. The oxygen tubing was connected to a portable oxygen tank that registered refill. V2/Registered Nurse was standing next to (R1), passing morning medications. At 8:55 A.M., an observation of (R1)'S room shows the oxygen concentrator in (R1)'S room still running, despite (R1) not being present in the room. Undated oxygen tubing was laying on the floor. At 8:57 A.M., while R1 remained seated at the nurse's station, V3/RN applied oxygen to 1) via a portable oxygen machine. At that time, V3/RN confirmed that R1 had a physician's order for continuous oxygen. V3/RN stated that R1 would frequently remove her oxygen. V3/RN also confirmed the undated oxygen tubing and oxygen humidifier.
2. R4's facility admission Record documents that R4 was admitted to the facility on [DATE] with the following diagnoses: Acute and Chronic Respiratory Failure with Hypoxia, Chronic Cor Pulmonale, Chronic Congestive Heart Failure and Pan lobular Emphysema.
R4's current Physician Order Sheet, dated June 2025 includes the following physician orders: Oxygen at 2 liters via nasal cannula continuously with humidification; Oxygen tubing change weekly, label each component with date and initials every 28 days; Change Humidifier Bottle weekly, date and time on bottle at change.
On 6/28/25 at 9:07 A.M., R4 was seated in a chair in her room. R4 had continuous oxygen running at 3 liters via a nasal cannula, per an oxygen concentrator. R4's oxygen tubing and the humidifier were undated.
On 6/28/25 at 9:20 A.M., The undated oxygen tubing and humidifier was verified with V3/Registered Nurse (RN). At that time V3/RN also confirmed that R4's oxygen flow rate should be 2 liters per minute.
On 6/30/25 at 8:32 A.M., R4 was up in her wheelchair in her room. R4's oxygen was continuous at 3 liters via a nasal cannula. R4's oxygen tubing remained undated.

Based on interview and record review, the facility failed to ensure two allegations of abuse were immediately reported to the State Agency for three of three residents (R1, R2, and R5) reviewed for abuse in the sample of 5.
Findings include:
1. R2's Nursing Progress Notes, dated 3/12/2025 at 9:38 P.M. document, (R2) was sitting in her room and (R1) entered her room and was seen having a shoe in her hand and it appeared that (R1) struck (R2) on the shoulder. No injuries were noted and (R2) stated that she was not hurt but was fearful of (R1). POA (Power of Attorney), Administrator, MD (Medical Doctor) were all notified.
On 6/30/2025 at 11:48 A.M., V1/Administrator confirmed the incident on 3/12/25 when R1 hit R2 with a shoe. V1 confirms that the incident was a potential abuse incident but states she did not do an abuse investigation nor notify the State Agency of a potential abuse incident.
2. R1's Nursing Progress Notes, dated 6/27/2025 at 9:37 A.M., document, (R1) was noted to be sitting in wheelchair with oxygen on self-propelling around nurses station area. When another resident (R5) came up the hallway (R1) proceeded to grab (R5)'s hair. When (R5) hollered out (R1) released (R5) and grabbed (R5)'S walker attempting to take the walker from (R5). Separated both parties immediately. HCPOA (Health Care Power of Attorney), (Physician), V1/Administrator) and (V2/Director of Nurses) notified at this time.
On 7/1/2025 at 9:00 A.M., V1/Administrator stated she only became aware of the 6/27/25 situation involving R1 pulling R5's hair and grabbing at her clothing, yesterday. At that time, V1 confirmed she had not immediately begun an investigation of the allegation of abuse, nor had she reported the incident to the State Agency.

Based on observation and record review, the facility failed to investigate two allegations of abuse for three of three residents (R1, R2, and R5) reviewed for abuse, in the sample of 5.
Findings include:
The facility policy, Resident Right to Freedom from Abuse, Neglect and Exploitation, dated October 16, 2023, directs staff, When the facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: Conducting a thorough investigation of the alleged violation.
1. The facility form, Physical Aggression, dated 3/12/2025 at 6:50 P.M., documents, Staff member reported that when she entered (R2)'s room, she saw (R1) strike (R2) on the shoulder with a shoe.
On 6/30/2025 at 11:48 A.M., V1/Administrator confirmed the incident on 3/12/25 when R1 hit R2 with a shoe. V1 confirms that the incident was a potential abuse incident but states she did not do an abuse investigation.
2. R1's Nursing Progress Notes, dated 6/27/2025 at 9:37 A.M., document, (R1) was noted to be sitting in wheelchair with oxygen on self-propelling around nurses station area. When another resident (R5) came up the hallway (R1) proceeded to grab (R5)'S hair.
On 7/1/2025 at 9:00 A.M., V1/Administrator stated she only became aware of the 6/27/25 situation involving R1 pulling R5's hair and grabbing at her clothing, yesterday. At that time, V1 confirmed she had not immediately begun an investigation of the allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement fall precautions for one of three residents (R1), reviewed for falls, in a sample of 5.
Findings include:
The facility policy, Fall Reduction policy, dated (revised) November 5, 2019, directs staff, Purpose: To provide an environment that remains as free of accident hazards as possible. To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. Residents with a Fall Risk Assessment score greater that 10 should be considered to be at high risk for falling. Identified risk factors should be addressed in the resident's Care Plan to assure individualized interventions to reduce the risk are implemented.
R1's facility admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Paroxysmal Atrial Fibrillation, Unsteadiness on Feet, Dementia, Anxiety, Chronic Respiratory Failure and Osteoarthritis.
R1's current Care Plan, dated 3/15/25 documents that R1 is, High Risk for Falls with previous falls on 4/23/25, 4/23/25, 4/27/25, 4/30/25, 5/14/25, 6/6/25, 6/7/25, 6/14/25, 6/15/25, 6/20/25, 6/22/25, 6/24/25 and 6/29/25. This same plan of care includes the following Interventions: Gripper socks.
On 6/28/25 at 8:35 A.M., R1 was sitting in the hallway, across from nurse's station, in a recliner, with her feet on the floor. At that time, R1 had no socks or gripper grips on. V3/Registered Nurse was standing next to R1, preparing to pass morning medications. At 8:57 A.M., R1 remained seated in the recliner, with her bare feet on the floor, with no gripper socks on.
On 6/30/25 at 8:34 A.M., R1 was seated in a wheelchair at nurse's station, attempting to stand from the chair. R1's feet were bare, with no gripper socks in place. V9/Licensed Practical Nurse (LPN) was seated at the nurse's station, attempting to get R1 to sit down. At that time V9/LPN verified R1 was to wear gripper socks at all times as she had sustained many falls and was at high risk for further falls.

Based on interview and record review the facility failed to ensure a resident's rights were maintained for one of three residents (R2), reviewed for resident rights, in sample of 5.
Findings include:
The (undated) facility Resident Rights for People in Long Term Care Facilities form documents, As a long-term care resident in (State), you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to safety: You must not be abused, neglected or exploited by anyone- physically, financially, verbally, mentally or sexually. Your facility must be kept safe, clean, comfortable and homelike.
R2's current Minimum Data Set Assessment, dated 5/21/25 documents, Section C-Cognitive Patterns: 13:15 (Cognitively intact).
R2's Nursing Progress Notes, dated 3/12/2025 at 9:38 P.M. document, (R2) was sitting in her room and (R1) entered (R2)'s room and was seen having a shoe in her hand and it appeared that (R1) struck (R2) on the shoulder. No injuries were noted, (R2) stated that she was not hurt but was fearful of (R1).
R2's Nursing Progress Notes, dated 5/23/2025 at 4:06 A.M. document, (R2) called for this nurse to ask me to get (disinfectant) out of her closet and spray her room as (R1) pooped all over her floor. (R2) states that she was sleeping and opened her eyes to (R1) pooping on the floor right by her chair and there was poop all over her bed as well as (R1) climbed into (R2)'s bed afterward.
On 6/28/25 at 8:52 A.M., R2 was seated in a wheelchair in her room. R2 was alert and oriented to person, place, time. R2 states she has had an adjoining room with (R1) for the past few months. R2 states she currently has a slide lock on the outside of her bathroom door, that she shares with (R1). R2 states staff finally placed it there as (R1) comes through the bathroom door frequently. R2 states (R1) has come into her room many, many times and urinated and defecated on her floor and bed. R2 states at one time, (R1) came in her room and threw a shoe at her and hit her with the shoe. R2 states (R1) has come into her room and thrown a pitcher of water at her. R2 states she keeps the bathroom door locked, but (R1) will enter her room through the room door at all times of the day and night. R2 states she feels afraid in the facility, that (R1) acts menacing towards her and states she has told (V1/Administrator) and (V2/Director of Nurses) multiple times of these incidents, and the only thing they have done is placed the lock on the bathroom door, which does not stop (R1) from still entering her room.
On 6/30/25 at 9:43 A.M., V11/Social Services Director (SSD) stated she is aware of a situation where (R1) came into (R2's) room while (R2) was sleeping and was standing over her. V11/SSD stated (R2) came to her very upset about the situation and (R2) stated she was afraid of (R1). V11/SSD states (R2) told her she woke up in the middle of the night and was very frightened as (R1) was standing over her bed and took some of her clothing that was laying in her chair. (R2) also stated that (R1) removed her pants and defecated and urinated on her floor and bed. (R2) stated she was able to pull her call light and when staff came, they removed (R1) from (R2's) room. V11/SSD stated the solution the facility came up with was to place a lock on (R2's) bathroom door, so that (R1) couldn't enter via the adjoining room. V11/SSD acknowledged that the lock doesn't stop (R1) from entering (R2's) room via the room door.
On 6/30/25 at 11:48 A.M., V1/Administrator confirmed the incident on 3/12/25 when (R1) hit (R2) with a shoe. V1/Administrator confirmed (R1) wanders and frequently goes into (R2's) room.

Based on interview and record review, the facility failed to protect two of two residents (R2 and R5) from physical abuse by another resident (R1), in a sample of five.
FINDINGS INCLUDE:
The facility policy, Resident Right to Freedom from Abuse, Neglect and Exploitation, dated October 16, 2023, directs staff, The facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation. The facility shall review altercations from resident to resident as a potential situation of abuse. Staff shall monitor for any behaviors that may provoke a reaction by residents or others which include Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects.
1. The facility form, Physical Aggression, dated 3/12/2025 at 6:50 P.M., documents, Staff member reported that when she entered (R2)'s room, she saw (R1) strike (R2) on the shoulder with a shoe. (R1) was redirected back to her room. (R1) was experiencing increased agitation and demanded that her daughter be called and (R1) thought (R2) had her belongings. POA (Power of Attorney), M.D. (Medical Doctor) and (V1) Administrator notified. Statements: (V12/Certified Nursing Assistant) was in the bathroom with (R2). (R1) kept opening the door and told them to get out. (V12/CNA) told (R1) she was helping someone. (V12/CNA) finished with (R2) and wheeled her out of the bathroom and took dirty clothes to the utility room. When (V12/CNA) arrived back to room, (R1) was in (R2)'s room with two shoes in her hand and (R1) tapped (R2) on the back. (State Agency) notified on June 30, 2025. Local Police Department notified on 3/12/25.
R1's Nursing Progress Notes, dated 3/12/2025 at 9:38 P.M. document, (R2) was sitting in her room and (R1) entered her room and was seen having a shoe in her hand and it appeared that (R1) struck (R2) on the shoulder. No injuries were noted and (R2) stated that she was not hurt but was fearful of (R1). POA, Administrator, MD were all notified.
On 6/28/25 at 8:52 A.M., R2 stated she has an adjoining bathroom with R1. States at one time, R1 came in her room and threw a shoe at her and hit her with the shoe. States R1 has come into her room and thrown a pitcher of water at her. States she keeps the bathroom door locked, but R1 will enter her room through the room door at all times of the day and night. States she feels afraid in the facility, that R1 acts menacing towards her and states she has told (V1/Administrator) and (V2/Director of Nurse) multiple times of these incidents, and the only thing they have done is placed the lock on the bathroom door, which does not stop R1 from entering her room.
On 6/30/2025 at 11:48 A.M., V1/Administrator confirmed the incident on 3/12/25 when R1 hit R2 with a shoe. V1 confirms that the incident was a potential abuse incident but states she did not do an abuse investigation nor notify the State Agency of a potential abuse incident as she states despite the fact (V12/CNA) witnessed R1 hitting R2 with a shoe, when she interviewed R2, the resident stated R1 did not make contact with her.
On 6/30/2025 at 12:15 P.M., R2 stated the facility administrator (V1) did not interview her concerning the incident with R1 (on 3/12/25). R2 also states she would not have said R1 didn't hit her, as R1 did in fact pick up a shoe, come into R2's room and hit her with the shoe. R1 states (V12/CNA) witnessed R1 hit R2.
On 6/30/2025 at 12:50 P.M., V13/Licensed Practical Nurse stated, I did not witness the incident when (R1) hit (R2) with a shoe. I did talk to (R2) about the incident, and she told me that R1 entered her room and hit her hard with a shoe. I reported it to (V1/Administrator) and (V2/Director of Nurses).
On 6/30/2025 at 2:08 P.M., V12/Certified Nursing Assistant states she did witness (R1) tap (R2) on the shoulder with a shoe. V12 states she didn't know how hard R2 was hit, but she did immediately report the incident to (V13/LPN) who was the nurse on duty at the time.
2. R1's Nursing Progress Notes, dated 6/27/2025 at 9:37 A.M., document, (R1) was noted to be sitting in wheelchair with oxygen on self-propelling around nurses station area. When another resident (R5) came up the hallway (R1) proceeded to grab (R5)'s hair. When (R5) hollered out (R1) released (R5) and grabbed (R5)'s walker attempting to take the walker from (R5). Separated both parties immediately. HCPOA (Health Care Power of Attorney), (Physician), V1/Administrator) and (V2/Director of Nurses) notified at this time.
On 6/30/2025 at 10:06 A.M., V9/Licensed Practical Nurse (LPN) stated she was the nurse present on 6/27/25 when R1 reached up and grabbed R5's hair, when (R5) was walking past. (V9/LPN) states (R5) yelled out when her hair was grabbed. (V9/LPN) states she reported the incident to V1/Administrator and V2/DON as she felt the incident was potential abuse. V9 states she documented the incident in R1's Progress Notes.
On 7/1/2025 at 9:00 A.M., V1/Administrator stated she only became aware of the 6/27/25 situation involving R1 pulling R5's hair and grabbing at her clothing, yesterday. At that time, V1 confirmed she had not immediately begun an investigation of the allegation of abuse, nor had she reported the incident to the State Agency.

Based on interview and record review, the facility failed to implement its abuse policy of immediately reporting abuse to the State Agency and investigating an allegation of resident-to-resident physical abuse for two separate occurrences, for three of three residents (R1, R2, and R5) reviewed for abuse in the sample of 5.
Findings include:
The facility policy, Resident Right to Freedom from Abuse, Neglect and Exploitation, dated October 16, 2023, directs staff, When the facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: Taking steps to prevent further potential abuse; Reporting the alleged violation and investigation within required timeframe's pursuant to Federal and State statutes and regulations; Conducting a thorough investigation of the alleged violation.
1. The facility form, Physical Aggression, dated 3/12/2025 at 6:50 P.M., documents, Staff member reported that when she entered (R2)'s room, she saw (R1) strike (R2) on the shoulder with a shoe. (R1) was redirected back to her room. (R1) was experiencing increased agitation and demanded that her daughter be called and (R1) thought (R2) had her belongings. POA (Power of Attorney), M.D. (Medical Doctor) and (V1) Administrator notified. (State Agency) notified on June 30, 2025. Local Police Department notified on 3/12/25.
On 6/30/2025 at 11:48 A.M., V1/Administrator confirmed the incident on 3/12/25 when R1 hit R2 with a shoe. V1 confirms that the incident was a potential abuse incident but states she did not do an abuse investigation nor notify the State Agency of a potential abuse incident.
2. R1's Nursing Progress Notes, dated 6/27/2025 at 9:37 A.M., document, (R1) was noted to be sitting in wheelchair with oxygen on self-propelling around nurses station area. When another resident (R5) came up the hallway (R1) proceeded to grab (R5)'s hair. When (R5) hollered out (R1) released (R5) and grabbed (R5)'s walker attempting to take the walker from (R5). Separated both parties immediately. HCPOA (Health Care Power of Attorney), (Physician), V1/Administrator) and (V2/Director of Nurses) notified at this time.
On 7/1/2025 at 9:00 A.M., V1/Administrator stated she only became aware of the 6/27/25 situation involving R1 pulling R5's hair and grabbing at her clothing, yesterday. At that time, V1 confirmed she had not immediately begun an investigation of the allegation of abuse, nor had she reported the incident to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement appropriate safety interventions for cognitively impaired residents and failed to complete therapy evaluations after multiple falls for two (R1 and R2) of three residents reviewed for falls. These failures resulted in R1 sustaining a left foot fracture and experiencing three falls over a 24-day period, and R2 sustaining a displaced rib fracture and right radial neck fracture following an unwitnessed fall. R2 was later placed on hospice services due to declining condition.
Findings include:
The facility's Fall Reduction policy revised 11/5/19 documents a therapy screen will be recommended for residents who are at risk of falling. The care plan should be reviewed after every fall and updated with a new intervention. Residents with falls should be reviewed weekly to identify root cause, effectiveness for interventions, and make care plan revisions.
1.) R1's Minimum Data Set MDS dated [DATE] documents R1 is cognitively impaired.
R1's fall risk assessment dated [DATE] documents R1 is high risk for falls.
R1's current care plan documents R1 has a diagnosis of Dementia and R1 is at risk for falls due to poor safety awareness. R1 has fallen on 5/6/25, 5/20/25, and 5/30/25. R1's current care plan further documents R1 is independent with transfers, toileting, and mobility in R1's room.
R1's Unwitnessed Fall report dated 5/6/25 at 5:30 AM, documents R1 was found in R1's room sitting on the floor beside R1's bed. R1 was barefoot at the time of the fall. R1 stated R1 slipped trying to get up to go to the bathroom.
R1's Nurse Progress Note dated 5/6/25 documents R1 had an x-ray of left foot which revealed a fracture to the head of the fifth metatarsal on left foot. R1 is non-weight bearing to the left foot.
R1's Nurse Progress Note dated 5/20/25 documents R1's roommate yelled for help because R1 had fallen out of R1's bed and was on the floor. R1 was sitting on R1's bedroom floor in front of her bed with her legs straight out in front of her. R1's bed was not in lowest position and R1 did not have gripper socks on. R1's room was dark, and her call light was within reach. R1 stated I just fell out of bed and I was trying to go to the bathroom. Fall Intervention is to apply anti slip strips on floor beside R1's bed.
R1's Nurse Progress Note dated 5/30/25 documents R1 was seen sitting on the floor by the side of the bed. R1 stated R1 slid off the bed. R1 was sitting with her back supported by the side of the bed and R1's bilateral lower extremities were extended in front of R1. R1 was assisted back to bed by two staff members, R1 was instructed to turn on call light on when wanting to go to bathroom.
R1's electronic medical chart does not contain documentation of a therapy evaluation after R1's falls on 5/6/25, 5/20/25, and 5/30/25.
On 6/17/25 at 9:30 AM, R1 was lying in R1's bed with R1's eyes closed. Metal half rails were up on the side of the bed.
On 6/17/25 at 9:15 AM, V1 (Administrator) stated that R1 is confused and rolled out of bed onto the floor. R1 was inching to the side of the bed and rolled out. R1 had not been evaluated by therapy since admission to the facility.
On 6/17/25 at 10:00 AM, V2 (Director of Nursing) stated R1's falls are usually at night when R1 gets up to go to the bathroom. V2 is unsure when R1 was last screened for a therapy evaluation. V2 further stated that some of R1's safety interventions are not appropriate because R1 takes off R1's gripper socks and will not leave them on. V2 also stated R1 would not remember to use a call light for assistance. V2 confirms R1 does not have very good memory recall especially at night R1 becomes more confused. V2 confirmed R1 should have been evaluated by therapy to ensure it was safe for R1 to be toileting and ambulating in R1's room independently.
On 6/17/25 at 9:35 AM, V3 Certified Nursing Assistant (CNA) stated V3 was unaware of R1's fall with a fracture to left foot. R1 gets up on her own and does her own thing in her room. We push R1 in a wheelchair to the dining room because R1 cannot walk very far and R1 is confused and disoriented.
On 6/17/25 at 1:31 PM, V6 (R1's Family Member) stated R1 has dementia and was placed in the facility after a fall at home. R1 is unable to care for herself and is very forgetful and does not recognize her family anymore. V6 stated R1 would need help with toileting and ambulating as R1 has had past falls and is very forgetful and unsteady.
2.) On 6/17/25 at 12:50 PM, R2 was lying in bed with eyes closed. R2 was not responsive to voice. R2's family was at the bedside. R2 had half rails on each side of the bed.
R2's Fall assessment dated [DATE] documents R2 is at moderate risk for falls.
On 6/17/25 at 1:00 PM, V6 (R2's Family Member) stated when R2 admitted to the facility approximately four weeks ago R2 was alert and oriented and had been doing things on her own at home. R2 sustained a fall at home and was admitted to the facility for rehab. V6 further stated R2 had a diagnosis of Cancer but had been doing well health wise. V6 stated R2 has fallen approximately four times since being admitted to the facility and has continued to decline each time. V6 stated R2 had an unwitnessed fall on 5/29/25 and sustained a fractured elbow, rib and shoulder. R2 was admitted to hospice after the fall per recommendation of the facility. There is not enough staff here to provide care, R2's call light doesn't show when it is on at the nurse's station because the panel is broken. V6 further stated V6 regrets bringing R2 to this facility and feels if he had not, R2 would not currently be in the condition she is in.
R2's admission Nurse Progress Note dated 5/7/25 documents R2 was admitted to the facility for therapy. R2 was cognitively intact and required assistance of one staff member and a walker for ambulation and transfers.
R2's Social Services Note documents R2 is alert and oriented and was admitted to the facility on [DATE] for short term therapy with plans to discharge home after therapy in completed.
R2's Nurse Progress Note dated 5/13/25 documents R2 was found on the floor of R2s room crawling on her hands and knees stating R2 thought there was water on the floor coming from the hallway. R2 stated she did hit her head and touched her right-side temple. With the help of staff R2 was helped up and into her wheelchair. R2 was reeducated to use the call light system, location and how and when to use it. R2 was encouraged to call for help when needed. R2 states I thought there was water all over the floor.
R2's Nurse Progress Note dated 5/20/25 documents R2 was observed on her bottom in front of R2's recliner with her knees bent. R2 had a small skin tear on her left elbow. Educated R2 on the importance of calling for assistance when she needs to use the bathroom to ensure her safety so R2 does not fall and harm herself. R2 was helped into her recliner.
R2's Nurse Progress Note dated 5/21/25 documents R2 was observed on her hands and knees on the floor looking under her bed. When asked if she needed help R2 stated she was looking for something she had dropped. No signs of injury, R2 is alert and oriented, no abnormalities to head or back or discoloration. R2 was assisted back to bed.
R2's Nurse Progress Note dated 5/29/25 documents R2 had an unwitnessed fall and was observed sitting in R2's wheelchair inside her room. R2 apparently was outside of her room trying to go home. A head-to-toe assessment completed. R2 was able to move all extremities and was unable to raise her right arm all the way but was able to elevate her left all the way up. R2 has large abrasion on her right side back. R2 is complaining of inability to catch her breath although she says it is due to her lung cancer.
R2's Nurse Progress Note dated 5/29/25 documents R2 is complaining of pain on right side and right arm from the fall. R2's physician was notified and ordered a mobile x-ray to be performed at the facility.
R2's X-Ray results dated 5/30/25 documents R2 has a displaced rib fracture to the eighth rib and a right radial neck fracture.
R2's Census documents R2 was admitted to Hospice on 6/1/25.
On 6/17/25 at 10:00 AM, V6 (Certified Nursing Assistant) stated when R2 admitted to the facility R2 was alert/oriented and walked with a walker and was an assist of one. R2 was often unsteady and slowly became worse to where two staff had to help R2. R2 was not confused until around the end of May. After R2 fell on 5/29/25 R2 did not get out of bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an entrapment assessment for bedrails prior to bedrails being applied to a bed as a fall intervention for one (R1) of three residents reviewed for bed rail assessments out of a sample list of three.
Findings include:
The facility's Side Rail Assessment Policy revised 11/5/24 documents bedrails are considered restraints; this includes full and half bed rails. The only time a bed rail can be used in the facility is after an evaluation for appropriateness and a Side rail assessment has been completed prior to applying bedrails. Consideration for the resident's cognitive ability to understand the use of bed rails also needs assessed. If determined side rails are appropriate the maintenance needs to determine prior to application that side rails are compatible with the bed and that safety is not compromised.
On 6/17/25 at 9:30 AM, R1 was lying in R1's bed with R1's eyes closed. Metal half rails are up on side of the bed.
R1's current care plan documents on 5/30/25 an intervention of half side rails was added to R1's care plan after R1's unwitnessed fall on 5/30/25. This same care plan documents R1 has poor safety awareness and is at risk for falls.
R1's Entrapment assessment was not initiated until 6/2/25 and was not completed as of 6/17/25.
R1's current Minimum Data Set (MDS) dated [DATE] documents R1 does not have bed rails. This same MDS documents R1 is cognitively impaired.
On 6/17/25 at 11:00 AM, V2 stated she normally completes the medical entrapment assessment when bed rails are put on a bed. V2 stated R1's entrapment assessment wasn't started until 6/2/25 and was never completed. V2 stated she was not aware assessment needed completed prior to rails being put on the bed.
The facility's Quarterly Bed Entrapment Prevention Checklist dated 6/3/25 documents a bed rail assessment completed by V5 (Maintenance Director).
On 6/17/25 at 11:15 AM, V5 stated V5 completes an Entrapment Prevention Checklist assessment quarterly on residents with bedrails. V5 stated that he does not complete a new assessment when bed rails are applied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** These failures resulted in two deficient practices.
A. Based on record review and interview the facility failed to provide adequate supervision to prevent two cognitively impaired residents from exiting the facility without staff supervision for two of three residents (R4 and R7) reviewed for elopements in the sample of seven.
B. Based on record review and interview the facility failed to implement two staff for transfers as indicated in the resident's plan of care to prevent falls for one of three residents (R2) reviewed for falls in the sample of seven.
Findings include:
A. The facility's Elopements Policy dated 12/2007 documents, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.
1. R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 is severely cognitively impaired.
R4's Elopement assessment dated [DATE] documents,(R4) is cognitively impaired and independently mobile. (R4) has a desire to leave the facility and wandering activity. (R4) has the diagnosis of Alzheimer's Disease or Dementia. (R4) is at risk for elopement. Goal: (R4) will not leave facility unattended through the review date.
R4's Care Plan dated 3-21-24 documents R4 is an elopement risk/wanderer and is at risk for falls.
R4's Health Status Note dated 2-28-25 at 6:54 PM and signed by V5 (LPN/Licensed Practical Nurse) documents, CNA (Certified Nursing Assistant/V13) was helping another resident to bed and heard door alarm going off. (CNA) stopped (and) came out to nurses' station to see what door alarm it was. Front and back (door alarms) were going off. Staff went to back door and to front door and (R4) was down the ramp out the front door laying in the grass on back. (R4) stated she was just trying to get out of here. (R4) assessed and (R4) stated she had no injuries. (R4's) leg was just a little sore. (R4) lifted with gait belt and two assist back into chair at this time. (R4) brought into building and body assessed. No injuries noted at this time. VS (Vital Signs) WNL (Within Normal Limits). (V6/POA/Power of Attorney), (V4/Physician), and (V2/ DON/Director of Nursing) notified at this time.
On 3-14-25 at 2:30 PM V5 (LPN) stated, I was in the breakroom (on 2-28-25) and heard door alarms going off. I came in and (V13/CNA/Certified Nursing Assistant) was out front with (R4). I went outside and saw (R4's) wheelchair at the end of the ramp and (R4) was in the grass on her back. (R4) did not have any injuries except for a slightly reddened area to her right leg. The reddened area disappeared thirty minutes later. (R4) goes to the front door frequently and exit-seeks but has never gotten outside before. No other residents have gotten outside before.
On 3-15-25 at 1:00 PM V13 (CNA) stated, On 2-28-25 around 7:00 PM I heard the front door alarm going off. I went outside and saw (R4) on the ground in front of her wheelchair. (R4) had gone down the ramp and it looked like (R4's) wheelchair hit the grass and (R4) slid out of the wheelchair onto the ground. (R4) only had a small red mark to her right leg. (R4) wanders around the facility and is confused.
2. R7's MDS dated [DATE] documents R7 is severely cognitively impaired
R7's admission Record documents R7 has the diagnoses of Dementia and Behavioral Disturbance.
R7's Health Status Note dated 3-13-25 at 5:50 AM and signed by V16 (LPN) documents, (V16) heard front door alarm go off. Upon approaching the door (V16) observed (R7) standing in the road with no coat on and holding her purse. (R7) had her oxygen tubing off and was holding it in her hand. As soon as (V16) reached out to help (R7), she had swung the oxygen tubing at (V16) attempting to make contact. (V16) and 2 other staff members were able to walk along side of (R7) and get (R7) back into the building. (V16) called (V2/Director of Nursing) and (V1/Administrator). (R7) was placed on 15-minute checks. (R7) does not have wander guard (electronic monitoring bracelet) on.
On 3-16-25 at (V16) stated, On 3-13-25 as soon as I heard the front door alarm go off, I went to see what set the alarm off. When I went outside, (R7) was just getting to the edge of the sidewalk, into the parking lot of the facility. (R7) was in the parking lot and not in the actual road. (R7) was confused. (R7) had no injuries.
B. The facility's Falls Clinical Protocol dated 09/2012 documents, Based on assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls to address risks of serious consequences of falling. If interventions have been successful in preventing falling, the staff will continue with current approaches.
R2's MDS dated [DATE] documents R2 was cognitively impaired.
R2's Incident Note dated 12-4-24 at 9:47 AM and signed by V15 (LPN) documents, This nurse was called into (R2's) room by (V14/Agency CNA) who states she lowered (R2) to the floor while transferring (R2) from the bed to the wheelchair. (V14) states (R2's) feet slid out from under her causing (V14) to lower (R2) to the floor. (R2's) legs hit the wheelchair causing a 1.6 x (by) 0.1 x 0.1 cm (centimeter) skin tear to RLE (Right Lower Extremity), a 2.5 x 0.7 x 0.1 cm skin tear to left medial shin, and a 2.0 x 0.7 x 0.1 skin tear to the left knee. Skin tears were cleansed. Steri-strips and dressings applied. (R2) was stood up by two assists with gait belt and placed into her wheelchair. Resident denies any pain.
R2's Care Plan dated 1-4-24 documents, Focus: (R2) is at risk for falls related to mental status. Goal: (R2) will be free of falls through the next review date 3-11-25. Interventions: 9-4-24 Two staff for all transfers with a gait belt. 12-4-24 Staff was re-educated on two staff with gait belt for all transfers for (R2).
On 3-15-25 at 10:30 AM V2 (Director of Nursing) stated, (V14/Agency CNA) transferred (R2) on 12-4-24 by herself which caused (V14) to have to lower (R2) to the floor. (R2) was supposed to have two staff to always assist (R2) with transfers. (V14) was an agency CNA. We (facility staff) had to educate (V14) on ensuring two staff were being used to transfer (R2) at all times.

Based on record review and interview the facility failed to ensure that resident's met the standards for infections for 2 residents (R4 and R23) and the facility failed to have standards in place for residents who were experiencing infection symptoms but did not meet the standards to be infections. The facility also failed to educate health care providers about Antibiotic Stewardship. This failure has the potential to affect all 40 residents who reside in the facility.
Findings Include:
The Facility's undated The Core Elements of Antibiotic Stewardship for Nursing Homes documents Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven Core elements which are necessary for implementing successful ASPs. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.
The Facility's undated The Core Elements of Antibiotic Stewardship for Nursing Homes policy documents Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available.
On 12/18/24 at 9:00 AM V2 (Director of Nursing) stated that the facility uses the MCGeer Criteria to determine if a resident has an active infection.
The McGeer's Criteria Tool provided by V2 (Director of Nursing) documents that for a UTI (Urinary Tract Infection) without indwelling catheter Must fulfill both 1 and 2. At least one of the following sign or symptom: acute dysuria or pain, swelling, or tenderness of testes, epididymis or prostate; fever or leukocytosis, and (more than) one of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. If no fever or leukocytosis, then (more than) 2 of the following: suprapubic pain, gross hematuria, new or marked increase in urgency, new or marked increase in frequency. At least one of the following macrobiotic criteria: (greater than) 1,000,000 cfu (colony forming unit)/ml (milliliter) of any organism(s) in a specimen collected by an in and out catheter.
The McGeer Criteria Tool documents for a UTI (Urinary Tract Infection) with indwelling catheter Must fulfill both 1 and 2. 1. at least one of the following sign or symptom: fever, rigors, or new-onset hypotension, with no alternate site of infection, either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis, new onset suprapubic pain or costovertebral angle pain or tenderness, purulent discharge from around the catheter or acute pain, swelling or tenderness of the testes, epididymis or prostate. 2. Urinary catheter specimen culture with (greater than) 1,000,000 cfu (colony forming units)/ml (milliliter) of any organism.
The Facility's Infection Control Log dated October 2024 documents that on 10/22/24 R4 was prescribed Ceftriaxone 500 mg (milligrams) daily for 7 days for UTI (Urinary Tract Infection).
R4's Infection Screening Evaluation dated 10/22/24 documents R4's symptoms of infection were urinary frequency, urinary incontinence and urinary urgency. R4's Infection Screening Evaluation also documented that McGeer Criteria for UTI without a catheter were met to determine that R4 did have an infection.
The Facility's Infection Control Log dated October 2024 documents that on R23 was prescribed Nitrofurantoin 100 mg twice daily for 7 days for a Urinary Tract Infection.
R23's Infection Screening Evaluation dated 10/23/24 documents R23's symptom of infection were urinary frequency, urinary incontinence and urinary urgency. R23's Infection Screening Evaluation also documented that McGeer Criteria for UTI with an indwelling catheter were met to determine that R23 did have an infection.
The Facility's Infection Control Log dated October 2024 documents on 10/31/24 R34 was prescribed Cephalexin 500 mg three times a day for ten days for cellulitis.
The Facility's Infection Control Log dated November 2024 documents that on 11/30/24 R23 was prescribed Levofloxacin 250 mg daily for 6 days for a Urinary Tract Infection.
R23's Infection Screening Evaluation dated 11/30/24 documents R23's symptoms of infection were delirium, new onset of confusion, urinary frequency, urinary incontinence and urinary urgency. R23's Infection Screening Evaluation also documents that McGeer Criteria for UTI with an indwelling catheter were met to determine that R23 did have an infection.
On 12/18/24 at 11:00 AM V2 (Director of Nursing) stated that the facility did not have any written or verbal standards or policies to follow for the residents when they do not meet the definition of an infection. The doctors order the antibiotics when we call them with symptoms. We have to give them. V2 could not provide any documentation of education given to health care providers regarding antibiotic stewardship. V2 confirmed that R4 and R23's infections in October and November did not meet the McGeer Criteria for infections.
The Facility's Resident Census and Condition Report dated 12/17/2024 documents 40 residents that currently reside in the facility.

Based on record review and interview the facility failed to allow one resident (R11) to choose her own doctor of 12 residents reviewed for choices in a total sample of 26.
Findings Include:
The Illinois Long-Term Care Ombudsman Residents' Rights for People in Long Term Care Facilities documents You have the right to choose your own doctor.
R11's Nurse's Notes dated 7/21/24 at 5:45 PM documents Resident told this nurse that she did not want to be seen by (V10/Doctor) any longer.
On 12/19/24 at 8:45 AM R11 confirmed that she did not want (V10) as her doctor. I just don't care for him. R11 stated I have told them (facility staff) but (V10) still comes to see me. I don't like him.
On 12/19/24 at 9:00 AM V4 (Social Service Director) confirmed that all residents can pick their own doctor and that no one had notified V4 that R11 wanted to switch doctors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents electronic medical records and care plans matched the Physician's Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for three of five residents (R4, R6, R22) reviewed for Advanced Directives in the sample of 26 residents.
Findings include:
The Advanced Directives policy reviewed 2/2021 documented the facility will gather information about whether or not the resident has executed an advanced directive and place this information in the medical record. The plan of care for each resident will be consistent with the resident's treatment preferences and/or advanced directives. The resident has the right to refuse treatment and will not be treated against his or her own wishes. If the resident or representative refuses treatment, the facility will document specifically what the resident is refusing. Advanced directives are written instructions for healthcare relating to the provisions of health care when the individual is incapacitated.
The state's Uniform Practitioners Orders for Life-Sustaining Treatment (POLST) Form indicates whether the resident in cardiac arrest wishes to have cardiopulmonary resuscitation performed/full code or to not attempt resuscitation efforts/do not resuscitate/DNR. The POLST also has three options for a resident not in cardiac arrest: full treatment which the primary goal is to attempt to prevent cardiac arrest by using all indicated treatments; selective treatment which the primary goal is to treat medical conditions with limited measure, do not intubate or use mechanical ventilation, may use non-invasive forms of positive airway pressure, administer intravenous fluids, antibiotics, cardiac medications and transfer to hospital if needed; comfort focused treatment which the primary goal is maximizing comfort through symptom management, allow a natural death, do not use treatments listed in the full treatment or selective treatment unless consistent with comfort goal.
1. R4's Physician's Order dated [DATE] documented R4 was a full code.
R4's Current Care plan documented Advanced Directives will be honored through the end of the review period, although does not specify specific resuscitative wishes per the POLST.
R4's POLST dated [DATE] and signed by R4's Power of Attorney (POA), documented R4 chose comfort-focused treatment only/DNR.
2. R6's Physician's Order dated [DATE] documented R6 was a DNR.
R6's Current Care plan did not document any advanced directive preferences.
R6's POLST dated and signed by R6 on [DATE], documented R6 chose Selective Treatment.
3. R22's Physician's Order dated [DATE] documented R22 was a DNR.
R22's Current Care plan documented R22 was a DNR.
R22's POLST dated [DATE] and signed by R22's POA, documented R6 chose Selective Treatment.
On [DATE] at 1:30 PM, V1 (Administrator) stated the care plans should identify the resident's Advanced Directive and the physician orders should match the POLST form.

Based on record review and interview the facility failed to report an in injury of unknown origin to the state reporting agency for one resident (R192) of two reviewed for accidents in a total sample of 26.
Findings Include:
The Facility's Abuse,Prevention and Prohibition policy dated 2021 documents The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. such reports may also be made to the local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegations of abuse or neglect or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. If the event that cause the allegation do not involve abuse and do not result in bodily injury, these will be reported to the administrator immediately and to the State Survey Agency no later than 24 hours.
R192's Nurse's Notes dated 11/3/24 at 1:47 PM documents, resident (complained of) left knee pain. very faint bruise noted to knee cap, when asked how it happened she gave 3 different stories to 3 different people.
R192's MDS (Minimum Data Set) dated 12/17/2024 documents a BIMS (Brief Interview for Mental Status) score of 15/15 points, indicating R192 is cognitively intact.
On 12/17/24 at 9:00 AM R192 stated that her left knee is bruised. R192 stated, I'm not sure how that happened. One time during a (mechanical lift transfer) my leg was caught under my room mate's bed but I don't remember any specific injury with that.
R192's New Skin Issue notation dated 11/4/23 documents that the staff members that had cared for R192 all reported no knowledge of resident's knee being bumped during transfers on any object as resident states. CNA (Certified Nurse Aid) and Nurses report that resident often voices pain during movement.
On 12/18/24 at 1:20 PM V1 (Administrator) confirmed that R192's bruise should have been considered an injury of unknown origin and report to the state agency per the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document the assessment for a resident receiving hospice services in the Minimum Data Set (Minimum Data Set/MDS-a federally mandated assessment) for one of two residents (R3) reviewed for hospice services in the sample of 26 residents.
Findings include:
The MDS/Minimum Data Set documented R3 was admitted on [DATE] with the diagnoses of Traumatic Brain Injury, Mood Disorder, Anxiety Disorder, Dementia and Major Mood Disorder.
A physician's order dated 3/27/23 ordered to admit R3 to hospice services.
R3's record included a notice of admission to hospice services effective 3/27/23.
The care plan dated 9/27/24 documented R3 had hospice services.
The quarterly MDS dated [DATE] and 9/27/24 Section O 0110: Special Treatments, Procedures, and Programs documented R3 was not on hospice services.
On 12/18/24 at 1:45 PM, V5 (Licensed Practical Nurse/LPN, Care Plan/MDS Coordinator) stated R3 elected hospice services on 3/27/23 and currently remained on hospice services. V5 stated the MDS entries on 6/28/24 and 9/27/24 were entered in error and should have indicated R3 received hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure hospice coordinated communication and the plan of cares were available and accessible to facility staff. This deficiency affects two of two residents (R3, R29) reviewed for Hospice care services in the sample of 26 residents.
Finding include:
The Hospice service agreements documented a copy of the plan of care will be furnished to the facility at the time of admission and when updated, of all cares provided, physician orders, election of benefits form, advanced directives, physician certification and recertification of terminal illness, a list of names and contact information for hospice personnel and hospice medication information specific to each hospice patient.
1. R3's admission Record documented R3 was admitted to the facility on [DATE] with diagnoses of intracranial injury with loss of consciousness, mood disorder, anxiety disorder and dementia.
An active physician's order to admit R3 to hospice was dated 3/27/23.
The Hospice admission Agreement dated 3/27/23 and Hospice Admit Letter dated 3/27/24 were the only hospice related documentation scanned into the electronic medical record.
The current care plan stated Advanced Directive/End of Life Care Plan. (R3) has (name of hospice service) Hospice Services. The care plan lacked any other documentation about hospice services provided, frequency of services or specific interventions related to hospice cares.
2. R29's admission Record documented R29 was admitted to the facility on [DATE] with the diagnoses of infective endocarditis from methicillin-resistant staphylococcus aureus, osteomyelitis of vertebrae, discitis of the cervical region and prostate cancer.
An active physician's order to admit R29 to hospice was dated 10/11/24.
The Facility Notification of admission to the hospice dated 10/11/24 was the only hospice related documentation scanned into the electronic medical record.
The current care plan documented D/T (due to) a decline in condition, (R29) has been admitted to (name of hospice service) Hospice services. The care plan lacked any other documentation about hospice services provided, frequency of services or specific interventions related to hospice cares.
On 12/18/24 at 11:20 AM, V9 (Licensed Practical Nurse/LPN) stated there were hospice binders at the nurse's station. V9 found one hospice binder although the binder was observed to have no resident records. V9 stated and demonstrated a dashboard in the electronic medical records that listed the hospice residents and name of provider. V8 stated the staff don't have access to hospice records and just go off of our (facility) care plan.
On 12/18/24 at 1:45 PM, V5 (Licensed Practical Nurse/LPN, Care Plan Coordinator) stated the facility does not have a hospice policy and the hospice agreements are used to outline the hospice and facility's responsibilities. V5 stated if the hospice provided the facility with a hospice care plan or any other records/forms of communication, V5 would scan it into the computer (electronic medical record). V5 stated hospice staff reviews the facility's care plan and that is how care is coordinated between the hospice and the facility. V5 reviewed R3 and R29's facility's care plan and confirmed the facility's care plan did not include specific intervention pertaining to hospice care.
On 12/19/24 at 1:30 PM, V1 (Administrator) verified the facility should obtain and have the hospice's plan of care for staff to review and the facility's care plan should have specific intervention for the care of a hospice resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide appropriate indication for use of antipsychotic medications, attempt gradual dose reductions, and limit the use of as needed psychotropic medications to 14 days for four of five residents (R5, R16, R19, R26) reviewed for unnecessary medications in a sample of 26.
Findings include:
The facility's policy titled Psychotropic Medication Use, reviewed 01/2017, documents, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. Residents who are admitted from the community or transferred from the hospital and who are already receiving psychotropic medications will be evaluated for the appropriateness and indications for use. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-effective disorder; c. Schizophreniform disorder; d. Tourette's Disorder; e. Huntington Disease. Diagnoses alone do not warrant the use of psychotropic medications. Gradual dose reductions of psychotropic medications will be done as outlined per federal regulations.
1. R5's admission Record documents that R5's date of admission to the facility was 7/25/24 and R5's diagnoses on admission include but not limited to Alzheimer's Disease with Late Onset and Dementia in other Diseases Classified Elsewhere, Moderate, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.
R5's Minimum Data Set (MDS) assessment, dated 11/1/24, documents Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment.
R5's Physician Order, dated 7/25/24, documents R5 has an order for Quetiapine/Seroquel (Antipsychotic medication) 25 milligrams(mg) by mouth at bedtime related to Dementia in other Diseases Classified Elsewhere, Moderate, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.
R5's current care plan documents R5 receives antipsychotic medication related to dementia.
R5's Consent for treatment with an Atypical Antipsychotic, dated 7/25/24, documents consent for Seroquel 25mg use for Dementia without behaviors.
R5's Behavior Monitoring and Interventions Report, dated 8/17/24, 8/18/24, 8/27/24, and 12/3/24, documents no behaviors observed. No further behavior documentation available in R5's medical record.
On 12/17/24 at 11:50am, R5 standing at vanity in room, dressed in clean clothes, well groomed. R5 was grabbing for [NAME] pins to place in her hair. R5 is calm when speaking and pleasant.
On 12/18/24 at 10:33am, R5 standing in room, dressed, well groomed, calm looking in mirror.
On 12/19/24 at 08:33am, R5 sitting in wheelchair at dining room table eating breakfast. R5 is calm and conversing with tablemate's.
On 12/19/24 at 10:00am, V2 (Director of Nursing/DON) stated that R5 was admitted to facility on 7/25/24 on Seroquel for Dementia in other Diseases without Behavioral Disturbance. V2 (DON) stated R5 has had no behaviors nor has R5 had a gradual dose reduction attempted. V2 (DON) stated that it is typically the practice of the facility to refer all residents on psychotropic medications to behavioral health but R5 was missed so referral was placed 12/18/24. V2 (DON) would not confirm or deny that the indication for use of R5's Seroquel (Antipsychotic medication) was inappropriate but did state she (V2/DON) is familiar with Centers for Medicare and Medicaid Services (CMS) guidelines.
2. R16's admission Record documents that R16's date of admission to the facility was 4/04/24 and R16's diagnoses on admission include but not limited to Depression, Acute Myocardial Infarction, Chronic Kidney Disease, Stage 3A, and Type 2 Diabetes Mellitus without Complications.
R16's Minimum Data Set (MDS) assessment, dated 10/25/24, documents Brief Interview for Mental Status (BIMS) of 10 indicating moderate cognitive impairment.
R16's Physician Order, dated 4/19/24, documents R16 has an order for Aripiprazole/Abilify (Antipsychotic medication) 2 milligrams(mg) give 2 tablets by mouth one time a day related to Depression.
R16's Physician order, dated 4/19/24, documents R16 has an order for Escitalopram/Lexapro (Antidepressant medication) 20mg give 1 tablet by mouth one time a day related to Depression.
R16's current care plan documents R16 receives antipsychotic medication related to Depression and antidepressant medication related to Depression.
R16's Consent for treatment with an Atypical Antipsychotic, dated 4/5/24, documents consent for Abilify 4mg to enhance antidepressant.
R16's Consent for treatment with an Antidepressant, dated 4/4/24, documents consent for Lexapro 20mg for depression.
R16's Treatment Administration Record, dated August 2024 thru December 2024, documents no behaviors.
On 12/17/24 at 10:10am, R16 is observed lying in bed dressed in clean clothes, well groomed, and calm.
On 12/18/24 at 2:07pm, R16 is observed up in wheelchair, dressed in clean clothes, well groomed, and smiling as she talked to her roommate.
On 12/19/24 at 8:13am, R16 is observed sitting at dining room table, calm, smiling and talking with table mates.
On 12/19/24 at 9:45am, V2 (Director of Nursing/DON) stated that R16 was admitted on Abilify (Antipsychotic medication) on 4/4/24 for Myocardial Infarction then diagnosis was changed on 4/6/24, due to not being an appropriate diagnosis. V2 (DON) stated diagnosis was changed to enhance effectiveness of antidepressant, then R16 went to hospital and returned with diagnosis for use for Abilify as Depression. V2 (DON) also stated that R16 has not had any behaviors since admitting to facility and she is not followed by behavioral health, but the facility typically gets residents on psychotropic medications referred to behavioral health. V2 would not confirm or deny that indication for use of R16's Abilify is not appropriate.
3. R19's Physician Orders document that she takes Olanzapine 20 mg (milligrams) every day for Schizophrenia and Bupropion 150 mg every day for Major Depressive Disorder.
R19's current care plan documents that on 02/22/2021 the resident has a mood problem and receives daily anti-psychotic medication. She voices complaints of having little interest in doing things, she feels down and depressed, she feels tired and has little energy, she feels bad about herself and feels she would be better off dead. The care plan documents on 4/26/23 (Resident) has had improvement in mood. No further documentation or mention of any other behaviors.
R19's Task: Behavior Monitoring documents the behaviors being monitored were refusal of cares and agitation. R19 did not have any behaviors documented in the behavior tracking record for September, October, and November 2024.
R19's Pharmacy review dated 02/1/2024 documents Resident receives the following medication used for depression: Bupropion ER (Extended Release) 150 mg (Milligrams) QD (every day). The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters with at least one month between attempts), within the first year of admission or initiation, and annually thereafter unless clinically contraindicated. Resident is due for an evaluation. Pharmacist Recommended dose reduction to Bupropion ER everyday Monday through Saturday and Bupropion ER 100 mg every Sunday. V13 (Psychiatric Nurse Practitioner) marked the second available option on the form Further dose reduction is clinically contraindicated due to: The resident's target symptoms returned or worsened after the most recent GDR (Gradual Dose reduction within the facility. V13 wrote on the bottom See Psych(iatric) note 3/1/24.
R19's Psychiatric Note dated 3/1/24 documents Behaviors reported include increased confusion and ongoing refusal of cares. The note also documents Resident reported no symptoms of depression. Resident described having no hallucinations.
On 12/18/24 at 1:00 PM V9 (Licensed Practical Nurse) stated (R19) is pretty calm. When she is having a bad day, we can leave her alone if she is agitated and then go back and she will usually be calm and cooperative.
On 12/19/24 at 11:00 AM V2 (Director of Nursing) stated that the facility does not have any documentation of any failed gradual dose reductions for R19.
4. R26's Physician Order document that on 4/1/24 R26 was prescribed Lorazepam .5 mg (milligrams) every 6 hours as needed for anxiety. This order did not have a stop date.
On 12/18/24 at 2:30 PM V2 (Director of Nursing) stated I don't know how (R26's Lorazepam order for as needed Lorazepam) got missed. Everyone here knows that we can only do (as needed) psychotropic medications for 14 days.

Based on record review and interview the facility failed to ensure licensed nurses were trained and competent in skills necessary to care for residents with a G-tube (gastrostomy tube) affecting 1 resident reviewed for Gastrostomy Tubes (R1) in a sample of 3. This failure led to R1 having emesis and diarrhea for two days and being hospitalized .
Findings include:
Policy titled Care and Treatment of Feeding Tubes revised 04/07/22 documents, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 2. Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible. This policy continues, 12. The facility will notify and involve the medical provider or designated practitioner of any complications, and in evaluating and managing care to address the complication and risk factors.
Policy reviewed 01/2017 and titled Changing a Gastrostomy Feeding Tube documents, 1. Verify that there is a physician's order for this procedure. Under a section titled General Guidelines documents, 2. Feeding tube replacement must be performed by a licensed nurse who has received training and demonstrated competency in this procedure as allowed by state practice act.
R1's' Physician Order Sheet (POS) dated 10/01/24 document R1 has diagnoses of dysphagia following cerebral infarction, gastrostomy status, hemiplegia and hemiparesis affecting left non-dominant side, aphasia and aphonia. R1's 09/18/24 POS documents orders to clean G-tube site daily and to provide G-tube feedings four times daily as supplement feeding.
R1's Emergency Department (ED) medical records document R1 was seen in the ED on 09/18/24 for a G-tube dislodgement. R1 arrived in the ED with an indwelling urinary catheter in place which the facility had placed on 09/16/24 and were administering bolus tube feedings through.
On 09/18/24 at 6:17 PM, V5/ED Physician documented he was notified by radiology R1's indwelling urinary catheter was located in her transverse colon, not in her stomach.
R1's Progress note document R1 experienced emesis and diarrhea between 09/17/24 at 5:07 AM and 09/18/24 at 3:06 PM when she was transferred to the ED.
V9/LPN/Licensed Practical Nurse documented in R1's Progress note dated 09/17/24 at 3:45 PM contracted radiology company arrived and obtained a one view X-Ray of R1's abdomen and two view X-Ray of R1's chest due to vomiting and possible aspiration and to check placement of R1's G-tube.
R1's radiology results dated 09/17/24 document, Percutaneous gastrostomy tube overlies the left upper abdominal quadrant. For intraluminal confirmation, follow-up imaging is recommended following the administration of either air or oral contrast.
R1's X-Ray was electronically signed by V22/Physician Contracted Radiology Company on 09/17/24 at 8:27 PM.
R1's Medication Administration Record documents V8/LPN administered 240 cc's/cubic centimeters of feeding per tube on 09/18/24 at 10:00 AM.
V7/Registered Nurse documented in R1's Progress note dated 09/18/24 at 3:06 PM (R1) continues to have emesis episodes. (R1) not tolerating any bolus feeding through G-tube. (R1) had imaging completed through (Contracted Radiology Company) that recommended follow up imaging. R1 was transported via ambulance to the local emergency department.
On 09/26/24 at 2:30 PM V5/ED Physician stated R1 had been to the ED on 09/14/24 and left after having a G-tube replaced. When R1 arrived at the ED on 09/18/24, she had an indwelling urinary catheter in place of her G-tube. V5 stated while it may be common to insert an indwelling urinary catheter in the G-tube site, it should only be done temporarily to keep the site open, and the resident should be immediately sent to the ED. V5 stated he wouldn't recommend feeding through an indwelling urinary catheter. V5 stated, My concern is (the facility) didn't check placement with an X-Ray and fed through it for two days. V5 stated hospital X-Ray confirmed R1's indwelling urinary catheter was located in her transverse colon which caused her to have emesis and diarrhea for two days.
On 09/26/24 at 3:36 PM V3/Assistant Director of Nursing stated V8/Licensed Practical Nurse reported R1's G-tube was not patent. V3 stated she directed V8 to remove the G-Tube and insert an indwelling urinary catheter. V3 stated R1 began vomiting around 5:00 AM on 09/17/24 after her morning tube feeding.
On 09/26/24 at 3:36 PM V3 stated that R1's G-tube which was placed on 09/14/24 would not flush on Sunday (09/15/24) or Monday (09/16/24) per V8/Licensed Practical Nurse. V3 stated, (V8) couldn't get (R1's) tube feeding through. I told her (V8) to take it out and put an (indwelling urinary catheter) in. (R1) started vomiting early Tuesday (09/17/24) around 5:00 AM on my shift. V3 stated she did not contact V4/R1's physician to obtain an order to insert an indwelling urinary catheter. V3 stated she did not advise V8 to check placement or order an X-Ray to check R1's tube placement. V3 stated she did not advise V8 to send R1 to the ED to replace R1's G-tube or to check placement before administering tube feeding through the newly inserted tube. V3 stated I didn't suggest it, maybe I should have. I was charge nurse on duty that day. V3 stated she was unsure what the policy regarding trouble shooting G-tubes stated.
On 09/26/24 at 3:46 PM V8 stated that R1's feeding tube clogged on 09/16/24. V8 stated twice that she called V4/R1's physician to obtain the order, then stated, I got direct orders from my (V3) Assistant Director of Nursing to insert R1's indwelling urinary catheter. V8 stated that she removed R1's G-tube on 09/16/24 and replaced it with an indwelling urinary catheter. V8 confirmed she has not received training or competency on replacing G-tubes and was not sure what the facility policy states regarding troubleshooting G-tubes.
V8 further stated to ensure R1's newly placed indwelling urinary catheter was correctly positioned, I would check for residual, or push it in until it stops (feels resistance), or get an X-Ray, that would be the best option. V8 stated she did not obtain an X-Ray to check for correct placement of R1's feeding tube prior to administering R1's bolus feeding and stated I was not directed to by my (V3) Assistant Director of Nursing. R1's Medication Administration Record documents V8 administered R1's bolus feedings at 10:00 AM on 09/16/24 and 09/18/24 at 10:00 AM, after the 09/17/24 X-Ray recommended follow up imaging with air or contrast.
On 09/27/24 at 9:24 AM, V2/Director of Nursing stated she learned on 9/17/24 that V8 had inserted an indwelling urinary catheter after removing R1's G-Tube on 09/16/24. V2 stated the indwelling urinary catheter should have been checked for placement by X-ray and that R1 was not sent to the ED until two days after R1's indwelling urinary catheter was inserted. V2 confirmed R1's indwelling urinary catheter should not have been used bolus feedings and placement should have been verified but wasn't.
On 09/27/24 at 11:30 AM, V1/Administrator stated the facility has not offered specialized G-tube training to nursing staff.

Based on interview and record review the facility failed to ensure four of four Certified Nurse Aides/CNA reviewed (V17, V18, V19, V20) in a total sample of four completed the required 12 hours of education per year. This failure has the potential to affect all 41 residents residing in the facility.
Findings include:
The Facility Assessment 2024-2025 documented the facility cares for residents with associated dementia symptoms, such as Parkinson's disease, Alzheimer's disease and residents with Psychiatric/Mood Disorders, The Facility Assessment documented Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse aids providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
The facility's Certified Nursing Assistant job description, not dated, documented Staff Development: Attend and participate in scheduled training and educational classes to maintain current certification as a Nursing Assistant (example 15 hours of in-service required in a 12 month period).
V17 (CNA) was hired on 2/8/23. V17's Employee In-Service/Education Record documented 6.91 hours of training were completed annually from 2/23-2/24 and no dementia management training or care of the cognitively impaired resident training was documented.
V18 (CNA) was hired on 7/15/21. V18's Employee In-Service/Education Record documented 3.58 hours of training were completed annually 7/23-7/24 and no dementia management training or care of the cognitively impaired resident training was documented.
V19 (CNA) was hired on 11/24/04. V19's Employee In-Service/Education Record documented 3.83 hours of training were completed annually 11/23-10/24 and no dementia management training or care of the cognitively impaired resident training was documented.
V20 (CNA) was hired on 1/12/12. V20's Employee In-Service/Education Record documented 8.25 hours of training were completed annually 1/23-1/24 and no dementia management training or care of the cognitively impaired resident training was documented.
On 10/4/24, at 11:40 AM, V16 (Clinical Director) stated the facility's expectation is for the CNAs to complete their 12 hours of education annually from the date of hire. V16 confirmed the required 12 hours of education training had not been completed.
The facility's Resident Listing Report, dated 10/4/24, documents 41 residents are currently residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify a physician of abnormal radiology results and a change in condition for 1 resident (R1) of 3 residents reviewed for change of condition. This failure resulted in R1 experiencing emesis and diarrhea for two days followed by hospitalization.
Findings include:
An undated policy titled Significant Condition Change and Notification documents in part: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status. Emesis and diarrhea or other abnormal assessment findings are included. Within the procedure of this policy documents, when any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. After two attempts, there is no response to the calls, the medical director will be contacted. A section titled Documentation reads, All significant changes will be recorded on the Communication Board and in (an electronic charting system) and in the resident record.
R1's Physician Order Sheet (POS) dated 10/01/24 documents R1 has diagnoses of dysphagia following cerebral infarction, gastrostomy status, hemiplegia and hemiparesis affecting left non-dominant side, aphasia and aphonia. R1's 09/18/24 POS documents orders to clean G-tube (gastrostomy tube) site daily and to provide G-tube feedings four times daily as supplement feeding.
V21/Agency LPN/Licensed Practical Nurse documented in R1's Progress note 09/17/24 at 2:32 PM R1 had two episodes of emesis and loose stool.
V3/ADON/Assistant Director of Nursing documented in R1's Progress note dated 09/17/24 at 5:07 AM R1 had a large emesis and diarrhea. At 5:37 AM V3 documented R1 feels better but has some audible congestion.
R1's radiology results dated 09/17/24 document, Percutaneous gastrostomy tube overlies the left upper abdominal quadrant. For intraluminal confirmation, follow-up imaging is recommended following the administration of either air or oral contrast.
V7/Registered Nurse documented in R1's Progress note dated 09/18/24 at 3:06 PM (R1) continues to have emesis episodes. (R1) not tolerating any bolus feeding through G-tube. (R1) had imaging completed through (Contracted Radiology Company) that recommended follow up imaging. R1 was transported via ambulance to the local emergency department. There is no documentation that V4/R1's physician was notified.
ED/Emergency Department Triage notes dated 09/18/24 at 3:26 PM and signed by V10, ED RN/Registered Nurse, document, (R1) presents to emergency department with complaints of 'concerning outpatient imaging regarding her G-tube'. V10 further documents, Per nurse report, (R1) has been vomiting after every tube feeding. (R1) was seen here on Saturday (09/14/24) and had G-tube replaced after nursing home could not get it back in. (Indwelling urinary catheter) in place on arrival. At 3:36 PM V10 documented, Per (V2/RN and DON/Director of Nurses) (R1) pulled her G-tube out on Monday (09/16/24) and they replaced it with the (indwelling urinary catheter) on Monday (09/16/24) and have been doing the tube feedings through that since then.
R1's Emergency Department (ED) provider note written by V5/ED Physician, dated 09/18/24 at 3:32 PM documents, This is a [AGE] year-old female who presents to the ED for G-tube dislodgement apparently today (we are) not quite sure, nursing home did not report when the tube came out. (R1) was here (ED) on (09/14/24) with G-tube displacement (R1) had a (larger size G-Tube) and that was dislodged, and they replaced it with a (smaller size G-tube). (R1) arrives with (an indwelling urinary catheter) in place today. Patient has a G-tube secondary to stroke and difficulty swallowing. This provider note further documents, (Facility) also reports (R1) has vomiting every time she receives a feed.
As of 10/01/24 R1's electronic medical record did not have documentation of the facility notifying V4/R1's physician that (R1) experienced emesis and diarrhea after bolus feedings on 09/17/24 and 09/18/24 or R1's abnormal X-Ray results on 9/17/24 recommending follow-up imaging.
On 09/26/24 at 3:36 PM V3/Assistant Director of Nursing stated that R1's G-tube would not flush. V3 stated, (V8/Licensed Practical Nurse) couldn't get (R1's) tube feeding through. I told her to take it out and put an (indwelling urinary catheter) in. (R1) started vomiting early Tuesday (09/17/24) around 5:00 AM on my shift.
V3/Assistant Director of Nursing stated that she did not contact V4/R1's physician to report R1's vomiting and diarrhea on 09/17/24.
On 09/26/24 at 3:46 PM V8/Licensed Practical Nurse stated that R1's feeding tube clogged on 09/16/24. V8 stated twice that she called V4/R1's physician to obtain the order, then stated, I got direct orders from my Assistant Director of Nursing to insert (R1's) indwelling urinary catheter. V8 stated she removed R1's G-tube on 09/16/24 and replaced it with an indwelling urinary catheter. V8 stated she did not contact V4/R1's physician before inserting an indwelling urinary catheter and didn't know if (V3/Assistant Director of Nursing) called (V4/R1's physician) prior to giving the order. V8 stated that she did not contact V4 when R1 vomited after the 10:00 AM feeding on 09/18/24.
On 09/27/24 at 9:24 AM, V2/RN/DON/Director of Nurses stated she learned V8/Licensed Practical Nurse had inserted an indwelling urinary catheter after removing R1's G-Tube on 09/16/24 per the direction of V3/Assistant Director of Nursing. V2 stated R1 had begun vomiting early in the morning of 09/17/24. V2 stated V3 had acknowledged V4/R1's physician should have been notified but wasn't.
On 09/27/24 at 1:16 PM V2 confirmed V4/R1's physician should have been notified of R1's G-tube being clogged and R1's change of condition when she was vomiting and having loose stools between 5:07 AM on 09/17/24 and 3:00 PM on 09/18/24 but wasn't.
On 09/26/24 at 4:09 PM V4, stated, No, I was never told staff inserted and fed through an (indwelling urinary catheter). I would never say to insert an (indwelling urinary catheter) to use as a feeding tube. I would have ordered the resident to go to the ED for evaluation and tube replacement if they chose to do so. V4 stated he has never talked with staff at the facility about R1's tube being clogged or removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow facility policy and obtain a physician order for care after a resident's Gastronomy tube (G-tube) became clogged. This failure resulted in R1's G-tube being replaced with an indwelling urinary catheter. This indwelling urinary catheter was used to administer enteral tube feedings for two days resulting in R1 experiencing emesis, loose stools, and being hospitalized . This failure affected 1 of 1 residents reviewed for Gastrostomy Tubes (R1) in a sample of 3.
These failures resulted in an Immediate Jeopardy.
The facility presented an abatement plan to remove the immediacy on 10/1/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned 10/2/24 to the facility for revisions. The facility presented a revised abatement plan on 10/4/24, and the survey team accepted the abatement plan on 10/4/2024.
While the Immediate Jeopardy was removed on 10/4/24, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of their removal plan and Quality Assurance monitoring.
Findings include:
Policy titled Care and Treatment of Feeding Tubes revised 04/07/22 documents, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 2. Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible. This policy continues, 12. The facility will notify and involve the medical provider or designated practitioner of any complications, and in evaluating and managing care to address the complication and risk factors.
An undated policy titled Significant Condition Change and Notification documents in part: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status. Emesis and diarrhea or other abnormal assessment findings are included. Within the procedure of this policy documents, when any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. After two attempts, there is no response to the calls, the medical director will be contacted. A section titled Documentation reads, All significant changes will be recorded on the Communication Board and in (an electronic charting system) and in the resident record.
Policy reviewed 01/2017 and titled Changing a Gastrostomy Feeding Tube documents, 1. Verify that there is a physician's order for this procedure. Under a section titled General Guidelines documents, 2. Feeding tube replacement must be performed by a licensed nurse who has received training and demonstrated competency in this procedure as allowed by state practice act.
Policy Charting and Documentation reviewed 01/2017 documents, Policy 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc. (etcetera), as well as routine observations. 2. Be concise, accurate, and complete and use objective terms. This policy documents, 3. Chart as often as necessary and as need arises. A section titled Procedures documents, 17. Tube Feedings: a. Documentation that proper tube placement is verified prior to each feeding. b. Intake data, c. Resident's tolerance to tube feeding. d. Any removal and/or reinsertion of the tube. e. Any complications as a result of the tube feeding.
Physician Order Sheet (POS) dated 10/01/24 document R1 has diagnoses of dysphagia following cerebral infarction, gastrostomy status, hemiplegia and hemiparesis affecting left non-dominant side, aphasia and aphonia. R1's 09/18/24 POS documents orders to clean G-tube site daily and to provide G-tube feedings four times daily as supplement feeding.
R1's Progress notes have no documentation between 09/14/24 when R1 returned from the local hospital after having a G-tube replaced and 09/17/24 at 5:07 AM when R1 had a large emesis and diarrhea.
V3/ADON/Assistant Director of Nursing documented in R1's Progress note dated 09/17/24 at 5:07 AM R1 had a large emesis and diarrhea. At 5:37 AM V3 documented R1 feels better but has some audible congestion.
V6/LPN/Licensed Practical Nurse/MDS/Minimum Date Set documented in R1's Progress note dated 09/17/24 at 11:26 AM X-Ray d/t (due to) possible aspiration and monitor for placement of G-Tube was ordered. (R1) had episodes of vomiting.
V23/Advanced Practice RN-Registered Nurse documented a Rehabilitation evaluation status post functional decline on 09/17/24 at 1:38 PM stating that (R1) was seen and had emesis all over the front of her gown, and staff reported (R1) was seen in (ED-Emergency Department) on 9/14/24 due to G-tube being pulled out. V23 documented. Staff reports (R1) has had large, soft (bowel movements) in the last 24 hours. (R1) does have rhonchi and an order for chest and abdomen X-rays have been ordered. V23 further documents, Nursing staff notified that if these complications remain, (R1) needs to be seen in the emergency department to rule out aspiration pneumonia, displacement of the catheter tubing or an intestinal blockage. V23's documentation concluded with, Physiatry (sic) on consultation for additional recommendations. Medical management per attending physician and team.
V21/Agency LPN/Licensed Practical Nurse documented in R1's Progress note dated 09/17/24 at 2:32 PM that R1 had two episodes of emesis and loose stool. X-Ray was ordered due to R1 abdomen being distended, crackles in lungs, abdomen firm to the touch.
V9/LPN documented in R1's Progress note dated 09/17/24 at 3:45 PM that Contracted Radiology Company arrived and obtained a one view X-Ray of R1's abdomen and two view X-Ray of R1's chest due to vomiting and possible aspiration and to check placement of R1's G-tube.
R1's Patient Report form with a fax time stamp of 9/17/24 at 8:44 PM documents that Contracted Radiology Company performed a one view X-Ray of R1's abdomen for cough, severe emesis, diarrhea, possible aspiration, pneumonia, verify G-tube placement.
R1's radiology results dated 09/17/24 document, Percutaneous gastrostomy tube overlies the left upper abdominal quadrant. For intraluminal confirmation, follow-up imaging is recommended following the administration of either air or oral contrast.
R1's X-Ray was electronically signed by V22/Physician Contracted Radiology Company on 09/17/24 at 8:27 PM.
R1's Medication Administration Record documents V8/Licensed Practical Nurse administered 240 cc's/cubic centimeters of feeding per tube on 09/18/24 at 10:00 AM.
V7/Registered Nurse documented in R1's Progress note dated 09/18/24 at 3:06 PM (R1) continues to have emesis episodes. (R1) not tolerating any bolus feeding through G-tube. (R1) had imaging completed through (Contracted Radiology Company) that recommended follow up imaging. R1 was transported via ambulance to the local emergency department.
ED/Emergency Department Triage notes dated 09/18/24 at 3:26 PM and signed by V10, ED RN/Registered Nurse, document, (R1) presents to emergency department with complaints of 'concerning outpatient imaging regarding her G-tube'. V10 further documents, Per nurse report, (R1) has been vomiting after every tube feeding. (R1) was seen here on Saturday (09/14/24) and had G-tube replaced after nursing home could not get it back in. (Indwelling urinary catheter) in place on arrival. At 3:36 PM V10 documented, Per (V2/RN and DON/Director of Nurses) (R1) pulled her G-tube out on Monday (09/16/24) and they replaced it with the (indwelling urinary catheter) on Monday (09/16/24) and have been doing the tube feedings through that since then.
(ED) provider note written by V5/ED Physician, dated 09/18/24 at 3:32 PM document, This is a [AGE] year-old female who presents to the ED for G-tube dislodgement apparently today (we are) not quite sure, nursing home did not report when the tube came out. (R1) was here (ED) on (09/14/24) with G-tube displacement (R1) had a (larger size G-Tube) and that was dislodged, and they replaced it with a (smaller size G-tube). (R1) arrives with (an indwelling urinary catheter) in place today. Patient has a G-tube secondary to stroke and difficulty swallowing. This provider note further documents, (Facility) also reports (R1) has vomiting every time she receives a feed. At 3:35 PM, V5 documented, (R1's long term care facility) states they have been giving feeds through the (indwelling urinary catheter) since Monday (09/16/24). V5's Provider Note (continued) documents, Medical Decision Making: Differential includes displacement of G-tube (indwelling urinary catheter), dehydration, electrolyte disturbance, SBO (small bowel obstruction) among other diagnoses.
09/18/24 at 6:17 PM, V5 documented, Radiology just called and states that they see (R1's) feeding tube is actually in the transverse colon and not the stomach.
10/02/24 at 2:07 PM, V3, ADON/Assistant Director of Nursing stated that the facility is notified of radiology results via fax. V3 stated, They come to our fax, they are usually pretty quick.
On 09/26/24 at 3:36 PM V3 stated that R1's G-tube which was placed on 09/14/24 would not flush on Sunday (09/15/24) or Monday (09/16/24) per V8/Licensed Practical Nurse. V3 stated, (V8) couldn't get (R1's) tube feeding through. I told her (V8) to take it out and put an (indwelling urinary catheter) in. (R1) started vomiting early Tuesday (09/17/24) around 5:00 AM on my shift. V3 stated she did not contact V4/R1's physician to obtain an order to insert an indwelling urinary catheter. V3 stated she did not advise V8 to check placement or order an X-Ray to check R1's tube placement. V3 stated she did not advise V8 to send R1 to the ED to replace R1's G-tube or to check placement before administering tube feeding through the newly inserted tube. V3 stated I didn't suggest it, maybe I should have. I was charge nurse on duty that day. V3 stated she was unsure what the policy regarding trouble shooting G-tubes stated.
Employee corrective action form dated 09/27/24 documents V3 was given a three-day suspension for Manager's failure to follow/enforce departmental policies and procedures. Practiced outside of scope - failed to provide nurse manager oversight.
On 09/26/24 at 3:46 PM V8 stated that R1's feeding tube clogged on 09/16/24. V8 stated twice that she called V4/R1's physician to obtain the order, then stated, I got direct orders from my (V3) Assistant Director of Nursing to insert R1's indwelling urinary catheter. V8 stated that she removed R1's G-tube on 09/16/24 and replaced it with an indwelling urinary catheter. V8 confirmed she has not received training or competency on replacing G-tubes and was not sure what the facility policy states regarding troubleshooting G-tubes.
On 09/27/24 at 11:30 AM V2/RN/ DON/Director of Nurses stated the facility has not offered G-tube training to nurses.
Employee corrective action form dated 09/27/24 documents V8 was suspended for three days due to failure to follow department policies and procedures. The corrective action further documents V8 failed to notify a physician or document on difficulty with and changing a G-tube on 09/16/24.
V8 was unable to provide paper or electronic documentation of changing R1's G-tube to an indwelling urinary catheter. V8 stated to ensure R1's newly placed indwelling urinary catheter was correctly positioned, I would check for residual, or push it in until it stops (feels resistance), or get an X-Ray, that would be the best option. V8 stated she did not obtain an X-Ray to check for correct placement of R1's feeding tube prior to administering R1's bolus feeding and stated, I was not directed to by my (V3) Assistant Director of Nursing. R1's Medication Administration Record documents V8 administered R1's bolus feedings at 10:00 AM on 09/16/24 and 09/18/24 at 10:00 AM.
On 09/27/24 at 9:24 AM, V2/RN/ DON/Director of Nurses stated she learned on 09/17/24 that V8 had inserted an indwelling urinary catheter after removing R1's G-Tube per the direction of V3/Assistant Director of Nursing. V2 stated that R1 had begun vomiting early in the morning of 09/17/24. V2 stated that V3 had acknowledged R1's physician should have been notified.
V2 stated the indwelling urinary catheter should have been checked for placement by X-ray and that R1 was not sent to the ED until two days after R1's indwelling urinary catheter was inserted. V2 confirmed R1's indwelling urinary catheter should not have been used bolus feedings and placement should have been verified.
On 09/27/24 at 1:16 PM V2 stated she there is no electronic or paper charting from 09/16/24 when V8 stated she removed R1's G-tube and placed an indwelling urinary catheter. V2 confirmed V4/R1's physician should have been notified and she would have sent R1 to the ED but wasn't.
On 09/26/24 at 4:09 PM V4 stated, No, I was never told staff inserted and fed through an (indwelling urinary catheter). I would never say to insert an (indwelling urinary catheter) to use as a feeding tube. I would have ordered the resident to go to the ED for evaluation and tube replacement if they chose to do so. V4 stated he has never talked with staff at the facility about R1's tube being clogged or removed.
On 10/01/24 at 8:04 AM V10, Emergency Department Registered Nurse stated that it is not safe nursing practice to administer tube feeding through an indwelling urinary catheter. V10 stated it was apparent R1's indwelling had been used to administer feeding because it had feeding residue left in it. V10 stated she called the facility, who advised the G-tube had been changed to the indwelling urinary catheter which they had been using to bolus feed R1 since Monday (09/16/24). V10 stated R1 was vomiting because the tube was in her transverse colon.
On 09/26/24 at 2:30 PM V5/ED Physician stated R1 had been to the ED on 09/14/24 and left after having a G-tube replaced. When R1 arrived at the ED on 09/18/24, she had an indwelling urinary catheter in place of her G-tube. V5 stated while it may be common to insert an indwelling urinary catheter in the G-tube site, it should only be done temporarily to keep the site open, and the resident should be immediately sent to the ED. V5 stated he wouldn't recommend feeding through an indwelling urinary catheter. V5 stated, My concern is (the facility) didn't check placement with an X-Ray and fed through it for two days. V5 stated hospital X-Ray confirmed R1's indwelling urinary catheter was located in her transverse colon which caused her to have emesis and diarrhea for two days.
An Immediate Jeopardy situation was identified to have occurred on 09/16/24 at approximately 10:00am when V8/LPN removed R1's G-tube and replaced it with an indwelling urinary catheter without obtaining a physician order or verifying placement. V8 and other licensed nurses proceeded to administer bolus tube feedings via R1's indwelling urinary catheter intermittently through 09/18/24 causing R1 to have vomiting, diarrhea and hospitalization.
On 10/01/24 at 10:14 AM, V1/Administrator was notified of the Immediate Jeopardy.
On 10/04/24, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy.
1. On 10/1/24, V15/Regional Director of Operations educated V1 and V2/RN and DON/Director of Nurses on their responsibilities to provide nursing staff with education and resources to provide appropriate oversight. Educational Tools included in the teaching also consisted of Audit tools, Weekly Committee Meeting policy, Rounding forms, Nurse's Skills Checklist Schedule, Monthly Education Calendar 2024, and CNA's (Certified Nurses Aide) Competency schedule.
On 10/2/24, V15 ensured V2/RN/ DON/Director of Nurses was competent to perform the education and in-servicing with the staff.
2. On 10/2/24 and 10/3/24, facility nurses were in-serviced, and competencies were completed on Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (one prn staff and one on medical leave) are scheduled to receive training/competency.
3 & 4. The Employee Orientation Nursing Policies/Agency Orientation included a review of the following policies: Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (1 prn/as needed staff and 1 on medical leave) are scheduled to receive training/competency. The Administrator or Director of Clinical Operations ensures when an Agency staff member books an open position, the DON or Nurse Manager receives the required documentation.
5. V8's (Licensed Practical Nurse) Employee Corrective Action Plan Form dated 9/27/24 documented a 3-day suspension for failure to follow department policies and procedures: no MD notification, no documentation of G-tube difficulty or the G-tube was changed on 9/16/24.
V3's (Assistant Director of Nursing/Registered Nurse) Employee Corrective Action Form dated 9/27/24 documented a 3-day suspension for failure to follow/enforce department policies and procedures, practiced outside of scope, failed to provide nurse manager oversight. The Time Detail Reports documented V3 nor V8 worked 9/28/24, 9/29/24 or 9/30/24.
6. On 10/3/24, the Change of Condition Audit was revised and accurately completed.
7. Dietary Order Audit completed by V2/RN and DON/Director of Nurses on dated 9/28/24 and on 10/3/24.
8. The Order Recap Report dated 9/26/24 through 10/3/24 was reviewed for new orders and proper notifications.
9. On 10/2/24 and 10/3/24, the In-service Education Record documented education to all nurses regarding the Change in Condition Bulletin Board Documentation (Electronic Health Record).
10. The New Order Audit tool was reviewed and appropriate for use.
11. The In-service Education Report- admission Policy dated 10/1/24 was attended by V2 (Director of Nursing) and V6 (MDS Coordinator/Care Planning/LPN). Quality Assurance audit tool was reviewed and appropriate for use. admission policy revised on 10/1/24.
12. Medical Doctor notified, and policies reviewed on 10/3/24.

Based on interview and record review, the facility failed to ensure an allegation of neglect was reported to the State Agency for one of three residents (R1) reviewed for neglect in the sample of three.
Findings include:
The facility's Abuse, Prevention and Prohibition Policy (reviewed 2021) documents the following: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of allegations of abuse or neglect or the Administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. If the event that caused the allegation do not involve abuse and do not result in serious bodily injury, these will be reported to the Administrator immediately and to State Survey Agency no later than 24 hours.
On 05/20/24 at 01:17 PM, V1 (Administrator) stated that approximately one week ago, she received a call from V12 (Nurse at R1's Surgeon's office) vocalizing multiple concerns of neglect. V1 stated that V12 reported the following: R1 had been incontinent and was not wearing an incontinence brief and staff at the office had to provide incontinence care to R1 during his office visit; R1 had fallen multiple times; R1 was not sent to the office with a mechanical lift sling. V1 stated she conducted an investigation and interviewed the staff that accompanied R1 once they returned to the facility from his appointment.
R1's Abuse Allegation Investigation (dated 05/15/24) documents the following: On 05/15/24 at approximately 01:30 PM, (V1) received a phone call from (V12, Nurse at local Surgeon's office). (V12) stated (R1) was, 'a mess the moment he left your building.' (V12) described that (R1) stated to her he had fallen twice that morning. He was not wearing an adult brief and we (facility) did not send him with a (mechanical lift) (transfer) sling. She stated (R1) had a wound on his coccyx that needed re-dressed due to him having a bowel movement, and medical office staff cleaned him up and put a brief on him with a pair of mesh underwear and were returning (R1's) shorts in a bag. This investigation does not document that the State Agency was initially notified of the allegation, or that a final notification was sent upon completion of the investigation.
On 05/21/24 at 02:00 PM, V1 (Administrator) confirmed that the State Agency was never notified of the allegation of neglect involving R1 on 05/15/24.

Based on interview and record review, the facility failed to develop a Dementia plan of care for one of two residents (R35) reviewed for Dementia care in the sample of 45.
Findings include:
R35's electronic diagnoses, dated 11/21/23, documents that R35 has the diagnosis of Vascular Dementia.
R35's Current Care plan, printed 11/20/23, has no documentation of a comprehensive care plan addressing R35's diagnosis of Vascular Dementia.
On 11/22/23 at 10:17 AM, V7 (Care plan Coordinator) confirmed there is no Dementia plan of care for R35.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R35's Physician's orders, dated 11/20/23, document that R35 has an order to receive Seroquel (antipsychotic) 50 mg (milligrams) by gastrostomy tube daily for Major Depressive Disorder.
R35's Psychotropic Assessment, dated 7/24/23, documents that R35 uses Seroquel for the diagnosis of Adjustment Disorder with anxiety and the behavior of agitation.
R35's Behavioral Care Solutions evaluation, dated 11/7/23, documents, Today's visit reviewed Depression, Dementia. Behaviors due to psychiatric condition increased anger, anxiety, and decreased appetite. Patient denies a history of bipolar, schizophrenia.
R35's Care Plan, dated 11/8/23, documents, R35 has diagnosis of agitation and receives an antipsychotic medication. He does become agitated at times, but usually is easily calmed down.
R35's current electronic record has no documentation of behavior monitoring for R35's use of an antipsychotic.
On 11/21/23 at 10:33 AM, V7 (Care Plan coordinator) stated, (R35) has not had any behavior tracking done since he returned from the hospital on 9/19/23.
On 11/22/23 at 10:34 AM, V5 (Registered Nurse/Assistant Director of Nursing) stated, (R35's) diagnosis and behaviors for his Seroquel are Vascular Dementia & Adjustment Disorder with Anxiety Major Depressive Disorder. He has anger issues and increased agitation. None of his behaviors are psychotic or put him or others at risk for harm. Behavior tracking should be done every shift. I wasn't aware that he didn't have behavior tracking in place. It should have been reinstated when he was readmitted on [DATE].
Based on observation, interview, and record review, the facility failed to document a diagnosis and target behaviors to warrant the use of an antipsychotic and perform behavior monitoring for two of two residents (R4, R35) reviewed for antipsychotics in the sample of 45.
Findings include:
The facility's Psychotropic Medication Use policy, dated 1/2017, documents, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Tourette's Disorder; e. Huntington Disease. Diagnoses alone do not warrant the use of psychotropic medication. The staff will observe, document, regarding the effectiveness of any interventions, including psychotropic medications. Nursing staff shall monitor for side effects and adverse consequences of psychotropic medication.
1. On 11/20/23 at 10:00 AM, R4 was sitting in her room in a chair. R4 stated she is doing well and denied any concerns. R4 was not displaying any behaviors.
On 11/21/23 at 9:00 AM, R4 was in her room putting a blanket on her chair and preparing to eat breakfast. R4 was smiling and was not displaying any behaviors.
R4's current Physician Order Sheet, dated 11/21/23, documents R4 has an order for Seroquel (antipsychotic medication)12.5 milligrams by mouth every bedtime on Monday, Tuesday, Thursday, and Saturday.
R4's current care plan, dated 10/4/23, documents R4 has diagnoses including Dementia, Alzheimer's Disease and Anxiety. This same care plan does not document that R4 receives the antipsychotic medication Seroquel.
R4's Medication Administration Records, dated 9/1/23-9/30/23, 10/1/23-10/31/23 and 11/1/23-11/20/23, all document R4 has behavior monitoring of Monitor for the following: (Depression & Psychosis) crying, self isolation, pacing, wandering without purpose, itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucination, psychosis, aggression, refusing care. These same sheets document that R4 did not display any behaviors for the entire month of September, October, and November as of 11/20/23.
On 11/21/23 at 11:09 AM, V7 (Care Plan/Minimum Data Set Coordinator) confirmed that R4's behavior tracking listed a large quantity of generic behaviors that are not specific to R4. V7 stated (R4) does not have any targeted, resident specific behaviors that we monitor.
On 11/21/23 at 11:30 AM, V11 (Registered Nurse) stated (R4) can be feisty and irritable at times. She usually gets more confused and irritable, and it almost always means she has a Urinary Tract Infection (UTI), so we order her a urine. She doesn't have behaviors that are psychotic in nature. (R4) isn't a threat to herself of other residents.
On 11/22/23 at 10:08 AM, V7 confirmed R4's Seroquel is not on her Care Plan. V7 stated I didn't realize that it (Seroquel) should be on there.

Based on observation, interview and record review, the facility failed to ensure staff hair was covered during the plating of food, while in the kitchen, and failed to date opened food items, to ensure use before expiration. These failures have the potential to affect all 39 residents currently residing in the facility.
FINDINGS INCLUDE:
The facility policy, Personal Hygiene and Appearance Nutrition Services, dated (revised) January 2018, directs staff, To support food safety practices and to maintain compliance with Federal, State and Local regulations governing food safety. Hair nets or hair coverings shall be worn while in the kitchen or storage areas.
The facility policy, Dietary Food Storage, dated November 2007, directs staff, All food shall be stored according to regulatory guidelines governing food safety and sanitation and within established facility guidelines, as follows: Leftovers shall be labeled and dated.
On 11/20/23 at 9:34 A.M., during a tour of the facility kitchen, with V3/Dietary Manager a five-pound plastic container of opened potato salad (approximately 1/2 full and an undated) and an opened plastic bag of shredded cheddar cheese was present in the facility refrigerator. At that time, V3/Dietary Manager confirmed the presence of the opened, undated food and stated dietary staff should date and label all opened food products.
On 11/20/23 at 12:10 P.M., V10/Certified Nursing Assistant was in the facility kitchen leaning on the counter while V3/DM plated the noon meal on the same counter with no hair restraint in place.
On 11/20/23 at 2:10 P.M., V3/Dietary Manager verified that V10/Certified Nursing Assistant did not have a hair covering on while in the facility kitchen during the plating of food.

Based on observation, interview and record review, the facility systemically failed to implement facility wide protocols to address respiratory symptoms as evidenced by: failed to recognize respiratory symptoms of facility staff and residents as a possible contagious illness (RSV, COVID 19 Influenza); failed to perform the required COVID-19 testing on staff and residents actively demonstrating signs and symptoms of a possible infectious respiratory illness, or after close contact with a resident or staff member that had tested positive for COVID-19; failed to test for other infectious respiratory illnesses when a COVID 19 test was negative and the resident was symptomatic; failed to immediately implement the required transmission based precautions for residents with suspected respiratory illness; and, failed to wear proper PPE (Personal Protective Equipment) when caring for a COVID-19 positive resident. These failures have the potential to affect all 39 residents currently residing in the facility.
These failures resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 9/21/23 when R34 became symptomatic with congestion, chest discomfort, and a cough. The facility failed to identify that R34's symptoms were potential signs/symptoms of COVID-19 and did not test nor isolate R34 while he was symptomatic.
While the immediacy was removed on 11/29/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice training and Quality Assessment oversite.
Findings include:
On 11/20/2023 at 9:05 AM, Upon entrance to facility, multiple staff were wearing surgical face masks. V2 (DON/Director of Nursing/Infection Preventionist) stated that some staff were not feeling well. V2 also stated there were no positive COVID-19 residents in the facility, and no residents were currently in transmission based precautions.
The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, NIOSH Approved particulate respirators with N95 filters or higher used for: NIOSH Approved particulate respirators with N95 filters or higher can also be used by HCP (Healthcare Professionals) working in other situations where additional risk factors for transmission are present, such as when the patient is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator use by HCP (Health Care Personnel) working in affected areas is not already in place. Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Responding to a newly identified SARS-CoV-2-infected HCP or resident: When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered.
R34's Nurses' notes, dated 9/21/23 at 12:36 a.m., document, Resident states that he thinks he has Pneumonia.
R34's Nurses' notes, dated 9/21/23 at 12:46 a.m., document, Lungs clear states he feels congested and has some discomfort in chest. R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
R28's Nurses' notes, dated 9/22/23 at 9:22 a.m., document, Resident complains of cough and chest congestion. Doctor notified and orders received to offer Geri-tussin as directed PRN (as needed). R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R28's Nurses' notes, dated 9/26/23 at 8:11 a.m., document, Resident had a large emesis this a.m.
R28's Nurses' notes, dated 9/26/23 at 12:30 p.m., document, Resident had no further emesis this shift. COVID test done, and it was negative. R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, Influenza) other than COVID-19 or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing until 10/24/23.
R28's Nurses' notes, dated 10/4/23 at 10:26 a.m., document, Resident voicing concerns related to continuous cough. Resident states that Mucinex and Geri-tussin are not providing enough relief. Doctor was notified and assessed resident and gave orders for Keflex (antibiotic) 500 mg (milligrams) twice a day for seven days. As R28's respiratory symptoms continued, R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
R38's Nurses' notes, dated 10/5/23 at 2:18 p.m., document, This nurse has noted increased cough. Cough producing yellow sputum. Resident also has congestion in the nasal area. R38's current electronic record has no documentation of R38 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R34's Nurses' notes, dated 10/10/23 at 3:49 p.m., document, Resident noted to have a cough this a.m. Cough is occasional and non-productive. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
R38's Nurses' notes, dated 10/11/23 at 1:55 p.m., document, Started antibiotic for URI. Resident has a productive cough with yellow phlegm. Lung sounds are congested. As R38's respiratory symptoms continue, R38's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R7's Nurses' notes, dated 10/16/23 at 1:20 p.m., document, Resident noted to have increased productive cough with purulent sputum. Lung sounds crackles in bilateral lower lobes. Doctor notified. New orders for Levaquin (antibiotic) 500 mg (milligrams) by mouth daily for 10 days and guaifenesin 400 mg by mouth twice a day for 10 days. R7's current electronic record has no documentation of R7 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
R26's Nurses' notes, dated 10/19/23 at 8:24 a.m., document, New order for Mucinex 400 mg one tablet by mouth twice a day for seven days for cough/congestion per doctor. R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
R34's Nurses' notes, dated 10/19/23 at 10:33 a.m., document, Fax sent to doctor in regards to resident having an occasional cough and some congestion, waiting for reply. As R34's respiratory symptoms continued, R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
R21's Medication Administration note, dated 10/22/23 at 8:30 a.m. and 1:13 p.m., document that R21 received PRN doses of guaifenesin 400 mg for sinus drainage. R21's current electronic record has no documentation of R21 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R16's Nurses' notes, dated 10/22/23 at 10:51 a.m., document, Resident noted to have a non-productive cough and nasal congestion. Doctor notified and gave orders for Tylenol 650 mg by mouth every six hours PRN, guaifenesin 400 mg every twelve hours PRN, and Geri-tussin every eight hours PRN. R16's current electronic record has no documentation of R16 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
On 11/21/2023 at 1:35 P.M., a review of the required facility COVID-19 positive report documents on 10/22/23 at 12:09 P.M., V14 (Housekeeping Supervisor) tested positive for COVID-19 and at 12:10 P.M., R3 tested positive for COVID-19. This same report documents that V15 (Dietary Aide) tested positive for COVID-19 on 11/1/23. At that time, V2 (Director of Nurses/Infection Preventionist) confirmed that no contact tracing was done to determine which facility residents or staff that would have been directly exposed to V14, V15, or R3 in the previous 48 hours in order to begin the day 1, day 3 and day 5 COVID-19 testing.
On 11/21/2023 at 1:50 P.M., V2 stated, I have just been testing (COVID-19 testing) when someone has symptoms, that's it. I don't keep a record of any of the tests, only the positive ones. I thought that was the new guidance. V2 verified that she didn't have any policies specific to COVID-19, influenza, or RSV.
The facility's Daily Assignment Sheets, dated 10/20-10/22/23, document that the following staff would have had direct exposure to R3: V11 (Registered Nurse-RN), V16 (Certified Nursing Assistant-CNA), V6 (CNA), V10 (CNA), V17 (Hydration Aide), V18 (RN), V19 (CNA), V8 (LPN-Licensed Practical Nurse), V13 (CNA), V20 (CNA), V21 (CNA), V22 (RN), V23 (CNA), V24 (CNA), V25 (LPN), V26 (CNA), and V27 (CNA).
R26's Nurses' notes, dated 10/23/23 at 8:40 a.m., document, Doctor assessed resident this a.m. and new order received for Keflex 500 mg by mouth three times a day for 10 days. R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions.
R14's Nurses' notes, dated 10/24/23 at 9:15 a.m., document, Resident presents with signs and symptoms of common cold COVID test negative. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R10's Nurses' notes, dated 10/24/23 at 9:16 a.m., document, Resident presents with signs and symptoms of common cold COVID test negative. As R10's respiratory symptoms continue, R10's current electronic record has no documentation of R10 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R26's Nurses' notes, dated 10/24/23 at 9:54 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negatives. As R10's respiratory symptoms continue, R10's current electronic record has no documentation of R10 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R34's Nurses' notes, dated 10/24/23 at 9:56 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R7's Nurses' notes, dated 10/24/23 at 9:57 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R7's respiratory symptoms continue, R7's current electronic record has no documentation of R7 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R28's Nurses' notes, dated 10/24/23 at 9:57 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R28's respiratory symptoms continue, R28's current electronic record has no documentation of R28 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R16's Nurses' notes, dated 10/24/23 at 9:58 p.m., document, Resident presents with signs and symptoms of common cold and is COVID-negative. As R16's respiratory symptoms continue, R16's current electronic record has no documentation of R16 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R14's Nurses' notes, dated 10/25/23 at 1:54 p.m., document, Resident's lung sounds assessed due to signs and symptoms of a cold. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 having follow-up testing for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R34's Nurses' notes, dated 10/25/23 at 2:07 p.m., documents, Resident's lung sounds assessed related to signs and symptoms of a cold. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 having follow-up testing for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R14's Nurses' notes, dated 11/1/23 at 2:21 p.m., document, Resident refused shower times two. Resident stated he was too tired and cold and just did not want to. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions.
R5's Nurses' notes, dated 11/15/23 at 7:50 p.m., documents, Resident lying in bed with 2-3 blankets on her up to her chin also wearing flannel pajamas. Warm to touch. Temperature 101.5 face flushed. Blankets removed and given Tylenol. R5's current electronic record has no documentation of R5 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R5's Nurses' notes, dated 11/16/23 at 10:52 a.m., document, Temperature 101. Appears Lethargic. As R5's respiratory symptoms continue, R5's current electronic record has no documentation of R5 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R26's Medication Administration Note, dated 11/16/23 at 1:06 p.m. and 11/17/23 at 7:21 a.m., document that R26 was administered Tylenol 650 mg by mouth as needed for complaints of a headache. As R26's respiratory symptoms continued, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions.
R8's Nurses' notes, dated 11/16/23 at 6:39 p.m., document, Resident nauseated and has a headache. Given Tylenol other medications held. R8's current electronic record has no documentation of R8 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R8's Nurses' notes, dated 11/17/23 at 7:00 a.m., document, Resident complains of not feeling well. Stomach upset. Temperature 100.9 degrees.
R8's Nurses' notes, dated 11/17/23 at 8:15 a.m., document, Doctor seen resident. States it's viral. No new orders. As R8's respiratory symptoms continue, R8's current electronic record has no documentation of R8 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R18's Nurses' notes, dated 11/17/23 at 1:51 p.m., document, Refused shower times three attempts. Stated he didn't feel well. Came out for both meals. R18's current electronic record has no documentation of R18 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R1's Nurses' notes, dated 11/18/23 at 10:24 a.m., document, Resident has mucous in the base of her throat. Resident encouraged to try and cough it up. R1's current electronic record has no documentation of R1 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R18's Nurses' notes dated 11/18/23 at 12:45 p.m., document, Resident refused to come out for lunch stated he doesn't feel well. As R18 continues to feel ill, R18's current electronic record has no documentation of R18 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R1's Nurses' notes, dated 11/19/23 at 11:30 a.m., document, Resident sleeping most of this morning. Lung sounds congested. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R36's Nurses' notes, dated 11/19/23 at 2:09 p.m., document, Resident has no voice. Resident states other than being generally blah. R36's current electronic record has no documentation of R36 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions.
R26's Nurses' note, dated 11/20/23 at 7:46 a.m. document, Doctor here to see resident. New order for Cephalexin (antibiotic) 500 mg by mouth three times a day for URI (upper respiratory infection.) As R26's respiratory symptoms continue, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions.
R1's Nurses' notes, dated 11/20/23 at 8:05 a.m., document, COVID tested as resident not feeling well with negative results. Doctor saw this am with new orders to start antibiotic for Bronchitis. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R5's Nurses' notes, dated 11/20/23 at 8:09 a.m., document, Resident COVID tested due to reports of resident not feeling well and results are Negative. As R5's respiratory symptoms continued, R5's current electronic record has no documentation of R5 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R25's Nurses' notes, dated 11/20/23 at 8:15 a.m., document, Resident not feeling well COVID test negative. R25's current electronic record has no documentation of R25 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R28's Nurses' notes, dated 11/20/23 at 8:24 a.m., document, Doctor seen resident who is complaining of a cough. New order for Robitussin 10 ml (milliliters) by mouth twice a day for five days. R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) until 11/22/23 or being placed in transmission based precautions.
R36's Nurses' notes, dated 11/20/23 at 11:43 a.m., document, Resident complains of sore throat and afebrile raspy voice COVID tested for symptoms and due to roommate not feeling well with negative results. As R36's continued to feel ill, R36's current electronic record has no documentation of R36 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing.
R1's Nurses' notes, dated 11/21/23 at 10:33 a.m., document, Continues on antibiotic for URI (Upper Respiratory Infection). Has productive cough. Has difficulty coughing it up and out. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being placed in transmission based precautions.
On 11/21/2023 at 11:30 AM, frequent coughing was heard across the hall from facility Family Room coming from R9's room. V2 (DON/Infection Preventionist) verified that it was R9 coughing. V2 stated that R9 was not feeling well and had spiked a temperature during the night with a persistent cough. V2 confirmed that transmission based precautions were not implemented nor was R9 tested for COVID-19 with R9 exhibiting symptoms of an upper respiratory illness.
On 11/21/23 at 12:50 p.m., R9 had droplet isolation precaution signage on his door. V6 (CNA) applied a surgical mask, face shield, gown, and gloves. V6 entered R9 room with R9's meal tray. At 12:58 p.m., V6 exited R9's room. V6 stated, (R9's) hospice nurse just told us that we need to wear isolation stuff for (R9). I think he has COVID, but I'm not totally for sure. When I went into the room, I was wearing a surgical mask, a face shield, a gown, and gloves. I haven't had COVID for over two years now. I can't tell you the last time I was tested here. It's been a while.
On 11/21/2023 at 1:15 P.M., a review of the facility Staff Call-In log from March 2023 through November 2023 documents most recent COVID-19 positive staff member as V13 (Certified Nursing Assistant) on 11/18/2023. At that time, V2 stated, (V13) came into work on 11/18/23 at 6:00 A.M. stating she didn't feel well. She was assigned the residents in rooms 24-36 (R3, R7, R10, R14, R20-R22, R27, R29). About halfway through her shift she began complaining of cough, fatigue, shortness of breath and a fever. (V5 Registered Nurse/ Assistant Director of Nursing) called me and told me what was going on. I told her to test her (COVID-19). Her test came back positive, and we sent her home. I only test people (residents or staff) if they are not feeling well. At that time, V2 confirmed that V13 was not tested prior to working with the residents, despite V13 stating she didn't feel well. V2 also stated that no contact tracing was done to determine which facility residents or staff that would have been directly exposed to V13 in the previous 48 hours in order to begin the day 1, day 3 and day 5 testing for COVID-19.
During the survey on 11/20/23 and 11/21/23, V7 (Care Plan Coordinator/Infection Preventionist) was observed wearing a surgical mask while in the facility. On 11/21/23 at 2:30 p.m., V7 (Care Plan Coordinator) had a raspy voice. V7 stated, These symptoms started a week ago with a sore throat and a headache. I tested and it was negative. I'm still having symptoms, but it's laryngitis. I haven't tested for COVID again since the first one was negative. V7 confirmed that she has not been required to stay home while exhibiting these symptoms.
The facility's COVID-19 testing (Residents) log, dated 11/22/23, documents that R9 tested positive on 11/22/23 with symptoms starting on 11/21/23.
On 11/22/23 at 08:27 AM, a tour of the facility determined only one resident (R9) was currently in transmission based precautions.
On 11/22/23 at 09:29 AM, V14 stated, I can't remember if I tested on (October) 20th or 22nd. But it was that weekend (October 21-22, 2023). I had been to the doctor on Friday because I wasn't feeling well. I came into work late on Friday. I tested myself at home and I was off work the following week (October 23-27, 2023). I am a working supervisor. I am all over the building, helping my staff.
On 11/22/23 at 09:11 AM, V7 stated, I submit the (COVID-19) Testing Log. The dates recorded are the dates I was informed that the COVID Test was done on that date and was positive. I don't keep any testing logs of tests done, that are not positive. Since the pandemic ended, we quit keeping any logs except for positive staff or residents.
On 11/22/2023 at 9:15 AM, the facility was unable to provide documentation of COVID-19 testing of staff or residents. V2 stated, I don't keep a (COVID-19) testing log of negative tests. I tell (V7) when someone tests positive. I tell her the date and time the test was done, and she submits the information. I didn't know I was supposed to keep logs.
On 11/22/23 at 09:32 AM, V5 (RN/Assistant Director of Nursing) stated, Right now I have (R1 & R26) who are symptomatic of an upper respiratory infection. COVID-19 symptoms are cough, congestion, headache, fever, nausea and vomiting. If a resident has symptoms, I notify the doctor and then COVID-19 test them. If they are negative, I just treat them as having an upper respiratory infection. The residents are not put in isolation unless they are actually COVID-19 positive. We don't retest them if they continue to be sick. If a staff member is symptomatic, we immediately test them. If they are negative, they can continue to work. They are not retested. I have only tested on ce, but it was because I tested myself. The facility has not tested me in the last two months.
On 11/22/23 at 09:46 AM, V14 stated, That Friday (10/20/23) at work, I started having symptoms of a head cold. I had a headache and congestion. I didn't think it was COVID. I worked that day, but I didn't test. Over the weekend, my daughter told me that I should really consider testing. I didn't test until after the weekend.
R26's Nurses' notes, dated 11/22/23 at 10:43 a.m., documents, Continues on antibiotic for URI coughing noted. As R26's respiratory symptoms continue, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions.
R28's Nurses' notes, dated 11/22/23 at 11:38 a.m., document, Resident tested for COVID at 11:20 am due to fever of 100.0 resident states that he just feels like he has cold. Results Negative. R28's current electronic record has no documentation of R28 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions.
On 11/28/23 at 12:47 p.m., V9 (Licensed Practical Nurse/LPN) stated, If a staff member is sick no fever and negative, they can work as long as they are wearing a mask. My symptoms started on 11/19/23, I was hot then cold with the chills and aching all over. I tested after my shift was over on 11/19/23 and I was (COVID-19) positive.
The facility's Staff Call Ins Report, dated 11/18-11/29/23, documents that V9 (LPN) tested positive for COVID-19 on 11/20/23 and that she was symptomatic starting 11/19/23.
On 11/22/23 at 3:05 P.M., V1 (Administrator in Training) was notified of the Immediate Jeopardy.
On 11/27/23, V1 submitted the facility's abatement plan for review.
1. V2 (Director of Nursing/Infection Preventionist) and V7 (Care Plan Coordinator/Infection Preventionist) were educated by V28 (Regional Nurse) on the signs and symptoms of COVID-19 infection and other respiratory illness, when COVID-19 testing is required, facility contact tracing and the implementation of transmission-based precautions for any resident experiencing respiratory symptoms, prior to testing on 11/22/23.
2. V2 and V5 (RN/Assistant Director of Nursing) tested all residents and staff for COVID-19 on 11/22/23, 11/24/23, 11/26/23, and they will continue to test every 3-7 days until no more COVID-19 positives for 14 days.
3. V1 and V2 were educated by V28 on initial outbreak and broad-based/contact tracing testing on 11/22/23.
4. V1 and V2 educated all facility staff on the required PPE when they are caring for a COVID-19 positive resident on 11/23/23.
5. V1 and V2 educated all nursing staff on identification of signs and symptoms of COVID-19 and other contagious respiratory illness, in order to implement physician notification, testing, and transmission-based precautions on 11/22/23.
6. V1 began Quality Assurance monitoring daily of all residents and staff with respiratory symptoms and a implemented a system to determine facility testing and isolation on 11/22/23.
7. On 12/4/23, V1 will be meeting with V31 (IDPH Infection Preventionist) for infection control guidance.
Through observation, interview, and record review, it was found[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide speech therapy services to one of one resident (R35) reviewed for specialized therapy services in the sample of 45.
Findings include:
The Facility Assessment, dated 8/31/23, documents, Services and Care Offered: Therapy-PT (Physical Therapy), OT (Occupational Therapy), Speech/Language, Respiratory, Music, Art, management of braces, splints.
On 11/20/23 at 10:08 AM, R35 was alert sitting up in his bed. R35 had a gastrostomy tube capped off coming from his stomach. R35 stated, I don't like the ground meat or the thickened liquids. They are awful! I'm supposed to be getting speech therapy, but the lady is never here. So how am I supposed to get better.
R35's Swallow Study, dated 7/7/23, documents, Today R35 reports that he has had a g-tube for about a year following a CVA (Cerebrovascular Accident). Patient/caregiver concerns: Patient would like for his diet to be upgraded. Therapy Diagnosis: Oropharyngeal Dysphagia. Medical Diagnosis: Dysphagia. R35 referred to Speech Therapy with deficits noted including impairments of swallowing which contribute to the following areas of functional restriction or limitation. Clinical impression at this time: Patient will benefit from ongoing skilled Speech Therapy intervention. Recommend patient continue with pudding thick liquids and pureed solids. Plan of care and diet recommendations to be determined by treating speech language pathologist.
R35's Speech Therapy Plan of Care, dated 9/24/23, documents, Reason for referral: R35 referred by facility physician for skilled ST (Speech Therapy) evaluation/treatment as indicated to address dysphagia. R35 recently admitted to hospital with diagnosis of upper GI (Gastrointestinal) bleed. Past medical history of stroke, dysphagia, Diabetes Mellitus type II. Therapy necessity: Skilled ST indicated to address Oropharyngeal dysphagia. Without skilled ST, patient at risk for further decline in function, increased reliance on caregivers, choking/aspiration, malnutrition/dehydration. Frequency/Duration: Four times in four weeks.
R35's Physician's orders, dated 11/20/23, document that R35 has an order for regular texture food and honey consistency liquids, and that R35 has a PEG (percutaneous endoscopies gastrostomy) tube for the diagnosis of dysphagia. The orders also document that effective 9/24/23, R35 was to receive speech therapy four times in four weeks to address Oropharyngeal dysphagia.
On 11/21/23 at 10:45 a.m., V1 (Administrator in Training) stated, (R35) should still be receiving Speech Therapy services. However, he hasn't been getting them because the Speech Therapist has not been able to make it here. His last Speech Therapy visit was on 10/9/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for the use of an indwelling urinary catheter, side rails, the diagnosis of Diabetes Mellitus with the use of Insulin, antidepressants, and anticoagulants for five of 14 residents (R6, R11, R32, R35, R36) reviewed for care plans in the sample of 45.
Findings include:
The facility's Comprehensive Person-Centered Care Plans policy, dated 2016, documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.
The facility's Using the Care Plan policy, dated 2006, documents, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident.
The facility's Proper Use of Side Rails policy, dated 1/2017, documents, The use of side rails as an assistive device will be addressed in the resident care plan. Less restrictive interventions that will be incorporated in care planning.
1. On 11/20/23 at 11:28 AM, R11 was alert sitting up in her recliner. R11's 1/2 side rail was in an upright position on the right side of R11's bed.
R11's care plan, printed 11/20/23, has no documentation of a comprehensive care plan addressing R11's use of a side rail.
On 11/22/23 at 10:17 AM, V7 (Care Plan Coordinator) confirmed there is no comprehensive care plans for R11's use of a side rail.
2. R32's Physician's orders, dated 11/20/23, document that R32 has an order to receive Eliquis (anticoagulant) 2.5 mg (milligrams) by mouth two times a day.
R32's current care plan, printed 11/20/23, has no documentation of a comprehensive care plan addressing R32's use of an anticoagulant.
On 11/22/23 at 10:17 AM, V7 (Care plan Coordinator) confirmed there is no comprehensive care plans for R32's use of an anticoagulant.
3. On 11/20/23 at 09:54 AM, R35 was alert sitting in a shower chair in his bathroom, following a shower. R35 had an indwelling urinary catheter with cloudy yellow urine present in the tubing and the drainage bag.
R35's Physician's orders document that R35 has an order for Humalog per a sliding scale subcutaneously two times a day and Insulin Glargine 20 units subcutaneously two times a day for R35's diagnosis of Diabetes Mellitus. R35's Physician's orders also document an order for a 16 French 10 milliliter indwelling urinary catheter.
R35's Current Care plan, printed 11/20/23, has no documentation of a comprehensive care plan addressing R35's use of Insulin for his diagnosis of Diabetes Mellitus nor his indwelling urinary catheter.
On 11/22/23 at 10:17 AM, V7 (Care Plan Coordinator) confirmed there is no comprehensive care plans for R35's use of insulin nor his indwelling urinary catheter.
4. R6's current POS (Physician Order Sheet) documents R6 has a diagnosis of Type Two Diabetes Mellitus with Hyperglycemia and Depression.
R6's MDS (Minimum Data Set) dated 9-1-23 documents R6 had a diagnosis of Diabetes Mellitus and Depression. This same MDS identifies R6 was administered insulin and antidepressant medications.
R6's Care Plan revised 9-19-23 did not document a care plan for the use of an antidepressant medication. This same plan did not document a care plan for diabetic management.
5. R36's current POS (Physician Order Sheet) documents R36 had a diagnosis of Diabetes and Depression.
R36's MDS dated [DATE] documents R36 had a diagnosis of Diabetes Mellitus and Depression. This same MDS documents R36 receives insulin and antidepressant medications.
R36's Care Plan revised on 9-18-23 does not document a care plan for the use of an antidepressant medication. This same plan of care does not document a care plan for diabetic management.
On 11/21/23 at 2:35 PM V7 Care Plan/MDS coordinator confirmed R6's and R36's current plan of care does not include a behavioral care plan with use of antidepressant medications or a diabetic management care plan. V7 states, Those should have been on R6 and R36's care plan. I must have missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Active and Passive Range of Motion programming for residents with limited range of motion for two of two residents (R3, R6) reviewed for functional limitations in range of motion in the sample of 45.
Findings include:
The facility's Resident Mobility and Range of Motion policy dated 07/2017 documents, Resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.
1. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 has a limitation in ROM (Range of Motion) to one lower extremity. This same MDS documents R3 has not received any ROM exercises, restorative treatment, or therapy for this limitation.
R3's current Plan of Care revised 11-20-23 documents, (R3) is at risk for immobility. She sits in a recliner, and she sleeps in her recliner. She is incontinent. Transfers per aid. Wheelchair for mobility or ambulate with staff and gait belt. This same plan of care documents interventions for AROM (Active Range of Motion) to all extremities during cares 10-15 reps (repetitions).
R3's Restorative Nursing Program forms dated 10-1-23 to 11-20-23 documents R3 will maintain current level of joint mobility with an approach of AROM to all extremities during cares 10 to 15 reps each. These same forms document R3 has not received any AROM exercises for 12 out of 50 days.
On 11-20-23 at 10:32AM R3 was sitting in R3's recliner. R3 was unable to lift her left leg. R3 states she is not receiving therapy services currently. R3 stated, I would like them (the facility) to do some exercises or ROM to my left leg every day. R3 verified staff have not been performing any exercises or ROM exercises to R3's left leg.
2. R6's Current POS (Physician Order Sheet) documents R6 has a diagnosis of Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction, Parkinson's Disease, and Restless Leg Syndrome.
R6's MDS assessment dated [DATE] documents R6 is cognitively intact. This same MDS documents R6 has a limitation in range of motion to one side of the upper extremity and has not received range of motion exercises, restorative treatment, or therapy for this limitation.
R6's Current Plan of Care revised on 9-19-23 documents, (R6) needs assistance with ADL's (Activities of Daily Living). She is paralyzed left upper/lower extremity. This same care plan documents interventions for AROM to right upper/lower extremities and PROM (Passive Range of Motion) to left upper/lower extremity 10 reps during cares.
R6's Restorative Nursing Program forms dated 10-1-23 to 11-20-23 documents R6 will improve or maintain current functional ROM with an approach of AROM to right extremities and PROM to left extremities with group exercises or with cares 10 reps each. These same forms document R6 has not received any AROM or PROM exercises for 15 out of 50 days.
On 11/20/23 at 10:10AM R6 was laying in R6's bed with the HOB (Head of Bed) slightly elevated. R6's left hand was in a closed position with fingers curled downward. R6 was unable to open her fingers to her left hand. R6 was able to slightly lift her left arm. R6 stated, They never offer to perform ROM exercises to my left arm or hand. I would like them to everyday because it would help me.
On 11/20/23 at 12:40PM V5 (Assistant Director of Nursing/Restorative Nurse) verified R3 and R6's restorative programs for the month of October and November 2023 have not been done at least 15 minutes daily. V5 stated, Any resident who is on a restorative program should be receiving those programs at least 15 minutes daily.
On 11/20/23 at 1:00PM V6 CNA (Certified Nursing Assistant) stated, We don't have time to do the restorative programs most of the time. We are short staffed. I have not performed any PROM or AROM exercises on R3 or R6.
On 11/22/23 at 10:12AM V16 CNA stated, We are not able to get restorative programs done. We sometimes have to sign off that we do them, even if we don't get to them. V16 confirmed she has not performed any PROM or AROM exercises on R3 or R6.

Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter drainage bag was kept below the level of the bladder and off the floor for one of two residents (R35) reviewed for indwelling urinary catheters in the sample of 45.
Findings include:
The facility's Urinary Catheter Care, dated 2014, documents, The purpose of this procedure is to prevent catheter associated urinary tract infections. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor.
R35's Physician's orders, dated 11/20/23, document that R35 has an order for a 16 French 10 milliliter indwelling urinary catheter.
On 11/20/23 at 09:54 AM, R35 was sitting up on a shower chair in his bathroom following a shower. V6 and V10 (Both CNAs-Certified Nursing Assistants) were dressing R35. R35's indwelling urinary catheter drainage bag was lying on the floor next to R35's shower chair. Then, V6 picked up the drainage bag and put it through R35's pant leg, prior to putting the pants on R35, and then laid the drainage bag back down on the floor. V6 and V10 positioned R35 into the stand aid lift. V10 hooked the drainage bag onto the lift, and both proceeded to transfer R35 to his bed. V6 unhooked the drainage bag from the lift aid laying it on the floor, and then V6 and V10 positioned R35 into a lying position in his bed. V6 picked up the drainage bag from the floor and held it above R35 in order to place it into a privacy bag. Cloudy yellow urine was observed in the tubing refluxing towards R35 with the drainage bag being above R35's bladder.
On 11/20/23 at 10:10 AM, V6 stated, The catheter bag should not be on the floor, and the bag should always be below the level of the bladder. I shouldn't have done that.

Based on observation, interview, and record review, the facility failed to attempt less restrictive interventions, obtain an informed consent, obtain a physician order, and perform a risk of entrapment assessment for the use of side rails for one of one resident (R11) reviewed for side rails in the sample of 45.
Findings include:
The facility's Proper Use of Side Rails policy, dated 1/2017, documents, The use of side rails as an assistive device will be addressed in the resident care plan. Less restrictive interventions that will be incorporated in care planning. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. The risks and benefits of side rails will be considered for each resident. Consent for side rail will be obtained from the resident or representative.
On 11/20/23 at 11:28 AM, R11 was alert sitting up in her recliner. R11's 1/2 side rail was in an upright position on the right side of R11's bed. R11 stated, They just put that on my bed. I didn't ask for it. I don't use it for anything but to clip my call light on when I go to bed.
The facility's Quarterly Bed Entrapment Prevention Checklist, dated October to December 2023, documents that R11 has one side rail.
R11's current medical record has no documentation of a physician's order or consent for the use of a side rail. The medical record also has no documentation of less restrictive interventions prior to the initiation of the side rails or a risk of entrapment assessment.
On 11/21/23 at 10:26 AM, V2 (Director of Nursing) stated, (R11) does not use a side rail therefore there is no risk of entrapment assessment or consent. V2 confirmed that R11 did not have a physician's order or less restrictive interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R37's Physician Order Sheet, dated 10/5/22, documents an order for Oxygen, per nasal canula, at 1.5 liters (1.5 LNC) continuous.
On 10/4/22, at 11:05 am, 10/5/22, at 9:45 am and 10/6/22, at 9:00 am, R37 had oxygen on per nasal canula.
R37's current Care Plan does not document Oxygen.
2) Facility Care Planning policy, reviewed 2/21, documents To assess each residents care needs. To develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental and physical functioning, and well-being as possible.
On 10/04/22 at 11:49 AM, R3's bed had two 1/4 siderails in the up position. R3 was in a manual wheelchair and stated I use the siderails for positioning in bed.
On 10/04/22 at 1:30 pm, R3 was in her room with oxygen on at 4 liters per nasal cannula. R3 stated I only wear my oxygen sometimes, but I wear it when I feel I need it.
On 10/5/22 at 1:30 pm and 10/6/22 at 11:30 am, R3 was in her room with oxygen on at 4 liters per nasal cannula, and R3's two 1/4 siderails were in the up position on her bed.
R3's Minimum Data Set, dated [DATE], documents in Section O, R3 is on oxygen therapy while a resident.
R3's Device/Restraint Evaluation, dated 7/26/22, documents Type of Device. Side rails for bed positioning or transferring.
R3's current careplan does not include R3's oxygen or side rails.
On 10/6/22 at 12:40 pm, V2 Director of Nursing/DON stated (R3) has been on oxygen a long time, and she wears it at night continuously. (R3) does use her rails for positioning and she wants them.
On 10/6/22 at 12:54pm, V6 LPN/Licensed Practical Nurse Careplan Coordinator stated I get notifications from (online charting system) a summary of new orders and anything that has happened in the past 24 hours or 72 hours if over the weekend for me to update the careplans. I get updates by the (online charting system) and in morning meeting. I update the careplan as soon as I know about any changes or new orders. (R3) should have her oxygen and siderails on her careplan. I will add those now.
Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 3 of 19 residents (R3, R37, R39) reviewed for care plans in a sample of 19.
Findings Include:
The facility's Care Planning - Interdisciplinary Team revised 2/2021 document, 1. To assess each resident's strengths, weakness and care needs. 2. To use this assessment data to develop a comprehensive plan of care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and well being as possible.
1. R39's medical record documents R39 admitted to the facility on [DATE] with a diagnosis of edema.
On 10/04/22 at 10:42 AM, R39 observed sitting in recliner with legs in the raised position. R39 has an open wound on his right lower leg and multiple scabbed wounds on both his lower legs. R39 stated The doctor said the sores are from the weeping edema I have.
On 10/5/22 at 10:35 AM, V2, Director of Nursing (DON) stated I didn't know he had sores on his legs from edema. I wasn't aware he had edema.
On 10/5/22 at 10:35 AM, V6, MDS (Minimum Data Set) Coordinator, stated I don't see (R39)'s edema on his care plan. He's not getting any treatments for it because we weren't aware he had an issue.
On 10/5/22 at 10:40 AM, R39 stated I've had the sores on my legs ever since I've been here.
On 10/6/22 at 10:49 AM, V2, DON, verified R39's referral packet includes a diagnosis of edema and stated You're right, it's right there. We missed it because we went off the hospital records and not the facility he was coming from. It should have been on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify a resident's diagnosis of edema, implement interventions for edema and failed to treat open wounds caused by edema for one of two residents (R39) reviewed for edema in a sample of 19.
Findings Include:
R39's medical record documents R39 admitted to the facility on [DATE] with a diagnosis of edema.
R39's care plan does not address R39's bilateral lower extremity edema or have interventions to address the care for R39's edema.
R39's weekly shower sheet and skin assessments dated 10/3/22 and 9/29/22 does not document R39's bilateral lower extremity wounds.
R39's BIMS (Brief Interview of Mental Status) documents a score of 15. A BIMS score of 12-15 indicates a resident is cognitively intact with 15 being the highest score.
R39's TAR (Treatment Administration Record) dated 8/26/2022 through 10/5/2022 does not document treatments for R39's bilateral lower extremities wounds.
R39's physician order sheet (POS) does not include an order to treat the wounds on R39's lower extremities.
On 10/04/22 at 10:42 AM, R39 observed sitting in recliner with legs in the raised position. R39 has an open wound on his right lower leg and multiple scabbed wounds on both his lower legs. R39 stated The doctor said the sores are from the weeping edema I have.
On 10/5/22 at 10:35 AM, V2, Director of Nursing (DON) stated I didn't know he had sores on his legs from edema. I wasn't aware he had edema.
On 10/5/22 at 10:35 AM, V6, MDS (Minimum Data Set) Coordinator stated I don't see his edema on his care plan. He's not getting any treatments for it because we weren't aware he had an issue.
On 10/5/22 at 10:40 AM, R39 stated I've had the sores on my legs ever since I've been here.
On 10/5/22 at 10:42 AM, V2, DON, observed assessing R39's lower leg edema and stated It looks like he has a one plus edema on both his legs.
On 10/5/22 at 11:20 AM, V2, DON , stated So I just talked to (R39) about the sores on his legs. He said he's been using a back scratcher to apply lotion to his legs and that's what the sores are from. He doesn't have a treatment order for his edema or sores because we didn't know there was a problem. We're adding one now. The weekly skin check and the shower sheet are the same document. I'm not sure why the sores weren't documented on the weekly skin check, but they should have been.
On 10/6/22 at 10:49 AM, V2, DON, verified R39's referral admission packet includes a diagnosis of edema and stated You're right, it's right there. We missed it because we went off the hospital records and not the facility he was coming from.

Based on observation, interview and record review the facility failed to assess, monitor and treat a reddened Coccyx area for a Resident at risk for skin breakdown, that worsened and became an Unstageable House Acquired Pressure Ulcer for one of two residents (R37) reviewed for Pressure Ulcers in a sample of 19. This failure resulted in the worsening of a house acquired Pressure Ulcer that required surgical debridement for R37.
Findings include:
Facility Pressure Ulcer/Pressure Injury Prevention Policy, revised 3/2021, documents: identify whether the resident is at risk for developing or has a Pressure Ulcer/PU or Pressure Injury/PI upon admission; evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a Pressure Ulcer; implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; a Standardized Pressure Ulcer Risk Assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcers and will be completed upon admission, weekly, for four weeks, and quarterly; an individual plan of prevention will be developed to meet the needs of the resident, including the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin conditions and overall clinical condition, as well as risk factors; the goal is for the resident to be free of preventable pressure ulcers; interventions for prevention of pressure ulcers will individualized to meet the specific needs of the resident; Braden Scale Mild Risk score (15-18) and Braden Scale Moderate Risk Score (13-14) requires frequent turning, manage moisture with prompt incontinence care and preventative skin care products, manage nutrition with Registered Dietician to access for additional interventions and weight monitoring, utilize positioning, using positioning devices such as wedges and pressure redistribution support surface in bed and chair; and utilize moisturizers to prevent extremely dry skin, consult with a Registered Dietician and consider supplementation as indicated by the assessment of the Registered Dietician.
R37's Census Report, dated 10/6/22, documents that R37's original admission date to the Facility was 5/22/22, and that R37 returned back to the Facility, from the local hospital on 6/1/22.
R37's Nursing Progress Notes, dated 6/1/22 at 3:45 pm, documents that R37 returned from the local hospital, post surgical for an Open Reduction Internal Fixation (ORIF) to the right ankle, with an electronic wound healing machine (Wound Vac) for the surgical incision. R37 was non-weight bearing.
R37's Braden Scale (Pressure Ulcer Risk), dated 5/22/22, documents R37 at Moderate Risk (Score 13) of pressure ulcers and documents that R37's skin is very moist.
R37's current Care Plan (date initiated 07/27/2022 and revised on 10/04/2022), documents Pressure Ulcer interventions as administer medications as ordered, monitor/document for side effects No other Pressure Ulcer interventions were documented on R37's Care Plan.
R37's Braden Scales (Skin Risk assessment) was not completed upon readmission then weekly for four weeks after readmission to the facility. From 6/1/22 and 10/6/22, R37 had one Braden Scale (Pressure Ulcer Risk) documented. R37's Braden Scale, dated 6/5/22, documents that R37 was a Mild Risk (Score 15) for Pressure Ulcers. The Braden Scale documents that R37's skin is occasionally exposed to moisture. R37's Braden Scale was not completed until 6/5/22, four days after R37's admission back to the facility.
R37's Weekly Skin Check, dated 6/5/22, documents R37's right ankle surgical site and no other skin issues. This Weekly Skin check failed to document the existing pressure ulcer.
R37's Wound Weekly Evaluation, dated 7/27/22, documents a newly identified house acquired Moisture Associated Skin Damage/MASD to R37's Right Buttock, measuring 1.1 centimeters/cm by 1.6 cm, with no depth (not open), and R37 had no pain. The Wound Evaluation documents a collagen and foam dressing were initiated and that R37's Care Plan update was Not Applicable (N/A) update not needed.
R37's Wound Weekly Evaluation, dated 8/2/22, documents shearing to the Right Buttock that was house acquired on 7/25/22, measuring 6.0 cm by 7.0 cm, with no depth. The Wound Evaluation documents that the wound was debrided and a new Physician Order for dressing changes (Calcium Alginate) was added and that R37 has no pain. The Wound Evaluation documents that no changes were made to R37's Care Plan.
R37's Wound Weekly Evaluation, dated 8/22/22, documents that R37's Coccyx (also referred to as Right Buttock) was declining to an Unstageable Pressure Ulcer, measuring 9.0 cm by 10.0 cm by 5.0 cm., with tunneling/undermining from 12:00 to 2:00 o'clock that measures 4.0 cm. The Wound Evaluation documents: slough tissue (yellow, tan, white or stringy) and brown and purulent drainage and a putrid odor.
R37's Wound Weekly Evaluation, dated 9/13/22, documents that R37's wound on Buttocks (also referred to as coccyx wound) was an Unstageable Pressure Ulcer, measuring 8.0 cm by 5.0 cm by 5.0 cm., with tunneling/undermining from 1:00 o'clock that measures 7.6 cm.
R37's Pressure Ulcer Weekly Wound Evaluation, 9/30/22, documents an Unstageable Pressure Ulcer to the Coccyx, with Slough and Eschar tissue, and a putrid odor. The Coccyx wound measures 7.5 cm by 4.5 cm by 5.0 cm in depth and 6.0 cm tunneling at 11:00 o'clock and 7.0 cm at 1:00 o'clock. The Wound Evaluation documents that the wound is worsening and that R37 has mild pain. The Wound Evaluation also documents that no changes were made to R37's Care Plan.
On 10/5/22 at 9:03 am, V3 (Registered Nurse/Assistant Director of Nursing) was performing pressure ulcer care to R37's Coccyx/Right Buttock. The contaminated dressing (dated 10/4/22) was moderately soiled with a brownish color. R37's Pressure Ulcer dressing change observation shows tunneling at approximately 11:00 to 1:00 o'clock and a moderate amount of drainage and pressure ulcer opening the approximate size of a golf ball. No issues were noted with R37's peri-wound.
On 10/6/22 at 1:30 pm, V2 (Director of Nursing) verified that R37's Pressure Ulcer was house acquired and that appropriate interventions and monitoring of R37's Pressure Ulcer were not completed per the Facility Policy and R37 does not currently have a Wound Doctor here at the facility.
On 10/7/22 at 10:50 am, V8 (Wound and Product Specialist) stated, I am a Wound Consultant Nurse that makes recommendations for Physician Orders. I just reviewed (R37's) electronic pressure ulcer notes on my computer. I have not seen R37's pressure ulcer or laid eyes on it, I am going solely on documentation. I usually only go the the facility about once a month. (R37's) pressure ulcer probably needs a referral to a Wound Clinic and also another debridement. It also had a foul odor, so it probably also needs a culture with the laboratory. I do not think that the Facility has a Wound Doctor that comes to the Facility.

Based on interview and record review, the facility failed to follow up and determine the root cause analysis, and implement fall interventions after a fall for one of seven residents (R30) reviewed for falls in a sample of 19.
Findings include:
Facility Fall Prevention Policy, revised February 2021, documents Following any falls details of the fall will be reported and potential causal factors identified and investigated. Interventions will be immediately implemented following each fall. All occurrence reports are viewed at the daily quality assurance meeting. Residents found to be high risk for falls are placed on fall preventions and interventions.
R30's medical record documents R30 has a history of falls, and was assessed as high risk for falls on 7/21/22.
R30's nurses notes, fall risk data collection, and SBAR/Situation Background Assessment Recommendation note, dated 7/21/22 at 9:15pm, documents R30 had an unwitnessed fall, and CNA/Certified Nurse Aid notified that resident was seated on the floor in her room. Upon entering, resident noted to be sitting on floor with legs out and back against wall across from bed. Resident is wearing slippers and walker is behind her. Resident has no redness or bruising noted to body. Resident helped to feet by this nurse and a CNA. Resident rose and ambulated to bathroom and back to bed (with 1 assist and wheeled walker) without incident. Resident denies pain at this time. Resident appears comfortable and has call light in reach.
R30's medical record has no documentation R30's root cause of the fall was identified, investigated, or fall interventions put in place.
On 10/05/22 at 1:34 PM, V2 Director of Nursing/DON stated The nurse put the fall under an SBAR note so it did not populate for us to know to have a meeting with corporate. We discuss all falls with corporate but we did not have a meeting to address (R30's) root cause of the fall or new fall interventions. We do get a notification from (online charting system) of all events/orders from the prior 24 hours, or 72 hours if over the weekend.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an order for oxygen for one of three residents (R3) reviewed for oxygen in a sample of 19.
Findings include:
Facility Oxygen Administration policy, reviewed 02/2021, documents Verify that there is a physician's order for this procedure for oxygen administration.
On 10/04/22 at 1:30 pm, R3 was in her room with oxygen on at 4 liters per nasal cannula. R3 stated I only wear my oxygen sometimes, I wear it after I come back from lunch, and at night because I can't breath. I also wear it when I feel I need it.
On 10/5/22 at 1:30 pm and 10/6/22 at 11:30 am, R3 was in her room with oxygen on at 4 liters per nasal cannula.
R3's current physician orders for October 2022 has no documentation R3 is on oxygen.
R3's medical record documents she has the following diagnoses: Chronic Respiratory Failure with hypoxia and Moderate Persistent Asthma.
R3's Minimum Data Set, dated [DATE], documents in Section O, R3 is on oxygen therapy while a resident.
On 10/6/22 at 12:40 pm, V2 Director of Nursing/DON stated (R3) has been on oxygen a long time, and she wears it at night continuously. I do not see an order for her oxygen and she should have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to gain consent and perform an assessment prior to using side rails for one of three residents (R10) reviewed for restraints in a sample of 19.
Findings Include:
The facility's Use of Restraints policy revised 2/2022 documents 1. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Prior to placing a resident in restraints, there shall be an assessment and review to determine the need for restraint. Review of resident record to determine alternative interventions to the restraint were attempted and documented.
The facility's Proper Use of Side Rails policy 2/2021, documents 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.). 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails and will be reviewed quarterly. 4. The use of side rails will be addressed in the resident care plan. 5. Less restrictive interventions that will be incorporated in care planning. 6. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 7. The risks and benefits of side rails will be considered for each resident. 8. Consent for side rail, when used as a restraint, will be obtained from the resident or representative, after presenting potential benefits and risks. While the resident or representative may request a restraint, the facility is responsible for evaluating the appropriateness of that request. 9. Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders, but are still restraints if they meet the definition of a restraint.
On 10/04/22 at 9:52 AM, R10 observed lying in bed with bilateral side rails in the raised position.
R10's medical record documents R10 was sent to the hospital on 9/20/22 and was re-admitted on [DATE] on hospice services.
On 10/05/22 at 11:25 AM, V2, Director of Nursing (DON), verified R10 has been using bilateral side rails and stated I don't have a consent or evaluation for (R10)'s side rail use. His trapeze was his alternate attempt. I also don't see it in his care plan. What I think happened, is that when (R10) came back on hospice, he was given a bed that has side rails and it wasn't caught before the staff started using them. He should of [NAME] a consent and evaluation for the side rails prior to us using them.
On 10/6/22 at 11:45 AM, V2, DON, stated We're calling to have the bed side rails removed. (R10) can't use them. He used to be a two person assist for mobility, but since he's been back, we switched him to a mechanical lift because he's just been too sick to get out bed, so he isn't able to use the side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a baseline care plan to include the use of bed side rails for one resident (R10) out of four residents reviewed for side rails in a sample of 19.
Findings Include:
The facility's Care Planning - Interdisciplinary Team revised 2/2021 document, 1. To assess each resident's strengths, weakness and care needs. 2. To use this assessment data to develop a comprehensive plan of care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and well being as possible.
On 10/04/22 at 9:52 AM, R10 observed lying in bed with bilateral side rails in the raised position.
R10's medical record documents R10 was sent to the hospital on 9/20/22 and re-admitted to the facility on [DATE] on hospice services.
R10's base line care plan from R10's admission on [DATE] does not include the use of side rails.
On 10/05/22 at 11:25 AM, V2, Director of Nursing (DON), verified R10 has been using bilateral bed side rails since his admission on [DATE] and stated (R10)'s care plan doesn't include his side rails. He was put in the bed when he returned and we didn't catch that the bed had the side rails. (R10)'s baseline care plan is incorporated into the care plan he had when he left. It's just a continuation, but the side rails should have been on there, it just wasn't added because we didn't catch they were on there.

Based on observation, interview, and record review, the facility failed to revise care plans to include diagnoses, weekly weights, medications, and falls with interventions for two (R3 and R30) of 19 residents reviewed for careplan revisions in a sample of 19.
Findings include:
Facility Care Planning policy, reviewed 2/21, documents To assess each residents care needs. To develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental and physical functioning, and well-being as possible.
On 10/04/22 at 12:19 PM, R3 was in her room with bilateral compression socks on. R3 stated she has worn compression socks for years and has swelling of her feet. R3's left foot is edematous.
R3's current orders for October 2022 documents: Weekly weight every Tuesday for edema with an order date of 8/16/22; and Lasix (diuretic) 100mg/milligrams daily for edema with an order date of 5/16/22.
R3's medical record documents R3 has the following diagnoses: Chronic Kidney Disease/CKD Stage 3 and Pulmonary Hypertension (high blood pressure) due to left heart disease.
R3's current edema care plan does not have her CKD or Pulmonary Hypertension diagnoses, weekly weights, or lasix on her careplan as a focus or intervention.
On 10/6/22 at 12:54 pm, V6 LPN/Licensed Practical Nurse Careplan Coordinator stated I get notification from (online charting system) a summary of new orders and anything that has happened in the past 24 hours or 72 hours if over the weekend. (R3) should have her diagnoses, weekly weights, and Lasix on the careplan because she has a significant history for kidney disease and heart disease. I update the careplan as soon as I know about any changes or new orders. I get updates by the (online charting system) and in morning meeting.
2. Facility Fall Prevention Policy, revised February 2021, documents Following any falls interventions will be immediately implemented following each fall and added to the residents plan of care.
R30's nurses notes, fall risk data collection, and SBAR/Situation Background Assessment Recommendation note, dated 7/21/22 at 9:15pm, documents R30 had an unwitnessed fall.
R30's current fall careplan does not include her 7/21/22 fall, or new fall interventions.
On 10/05/22 at 1:34PM, V2 Director of Nursing/DON verified R30's current fall careplan did not include R30's 7/21/22 fall, or have any new interventions in place after R30's fall on 7/21/22 and should.