**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an altered diet for a resident with dysphagia for 1 of 3 residents (R6) reviewed for therapeutic diets in the sample of 22. This failure resulted in R6 experiencing a choking episode requiring the Heimlich Maneuver and abdominal thrusts to dislodge. The Immediate Jeopardy began on 4/26/24 when an order was received to downgrade R6's diet from regular consistency to a mechanical soft consistency and R6 continued to be served a regular diet. V18 (Registered Nurse) was notified of the Immediate Jeopardy on 6/28/24 at 11:10 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/28/24 at 3:47 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R6's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include sepsis, Type 2 Diabetes, Acquired Absence of right leg below knee, hyperlipidemia, arteriosclerotic heart disease of native coronary artery, ischemic cardiomyopathy, cognitive communication deficit, abnormal posture, oropharyngeal phase dysphagia, and vascular dementia. R6's most recent quarterly dietary assessment was completed on 10/2/23 (approx. 8 months prior). R6's care plan initiated 11/6/23 showed, The resident has nutritional problem or potential nutritional problem related to Type 2 Diabetes . Provide, serve diet as ordered . Another care plan initiated for R6 on 11/6/23 showed, The resident has a need for oral/dental health maintenance . Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted . R6's facility assessment dated [DATE] showed he has severe cognitive deficits and no swallowing deficits. R6's Physician Order Sheet showed an order dated 4/26/24, Diet Downgrade to Mechanical Soft/TL (thin liquid) per ST (Speech Therapy). R6's Speech Therapy Discharge notes showed he participated in Speech Therapy from 4/15/24 through 5/10/24. The same Speech Therapy discharge note showed recommendation for oral intake to be Mechanical Soft/Chopped Textures . The facility's Diet Type Report dated 5/8/24 showed R6 was a regular diet and it was crossed off and mechanical was written next to it. R6's 6/16/24 Nursing Note entered at 5:50 PM showed, Resident eating in dining room with several residents and a staff member (V10) (Certified Nursing Assistant/CNA). Resident took a bite of bread and meat, an Italian beef sandwich. Resident began to have signs and symptoms of choking. (V10) reports she did the Heimlich, as resident sitting in his chair. Staff member called for additional help, I approached, resident not responding, color poor, we laid him on the floor, [V10] did abdominal thrusts, turned him on his side, still choking, did another set of abdominal thrusts, turned him on his side, object/food expelled resident breathing, alert . R6's Acute Care Hospital Emergency Department documents dated 6/16/24 showed, Todays Visit Reason for Visit: Choking . R6's Physician Order Sheet showed an order dated 6/19/24, Meals: Cut food into bite size pieces, offer drink every 2-3 bites with meals to prevent choking. On 6/25/24 at 1:07 PM, V14 RN (Registered Nurse) said, . It was supper time. Everyone was in the dining room. [R6] sits in the back corner. I was across the hall in the TV room assisting a resident into a chair. I saw the aide, [V11] running. I saw action in the dining room so I went in and saw [V10] and she said [R6] was choking. [R6] could not speak or breathe. He does not stand so we put him on the floor and did abdominal thrusts. A chunk of food came out, it was a bread ball with beef. It looked like he did not chew it . His diet was regular at the time. It is mechanical soft now. He had a regular tray . On 6/25/24 at 1:45 PM, V12 (Dietary Manager) said the nurse is supposed to send diet changes to the kitchen in paper form. V12 said they do not make changes until the order comes from the nurse and that is when the dietary card would be changed. V12 said she does not have a way to track when the dietary card was actually changed because she does not have R6's old cards. On 6/25/24 at 2:34 PM, V11 (CNA) said, [V10] was feeding [R6] and I was feeding another resident. [V10] started doing the Heimlich and I went to get the nurse. Me and [V10] picked him up and put him on the floor. The nurse just stood there while we were doing the Heimlich. [R6] was completely blue before the food came up a little. When the food came up the nurse put her finger in his mouth and pulled it out. He went to the hospital . his diet was regular at that time but they changed it after that to mechanical soft. On 6/26/24 at 9:40 AM, V10 (CNA) said, I was the one that was feeding him. He was eating regular food. He started choking. I went behind his wheelchair and had another aide go get the nurse. My arms wouldn't go around him. We pulled him to the floor. The kitchen asked if we needed 911. I did stomach thrusts . He was not breathing, his lips turned purple His whole face was purple . His diet got changed now to pureed . On 6/27/24 at 12:34 PM, R6 was in the dining room. R6 was served tomato soup, pasta salad, and a grilled ham and cheese sandwich (not mechanically altered) and cut into halves. V23 (CNA) was sitting near R6 while he was eating. R6 took a large bite of his ham and cheese sandwich and began coughing. V23 said to R6, That was a pretty big bite, better slow down. On 6/27/24 at 1:36 PM, V12 (Dietary Manager) said, [R6] was not seen by the dietitian after his choking episode. [R6] was a regular diet but there was a change around the beginning of May. On 7/2/24 at 1:10 PM, V2 (Director of Nursing) said, Diet changes are entered as an order in the computer by the nurse. They print out a copy and give it to the kitchen. If they don't give it to [V12] and they just put it in the kitchen sometimes things disappear. It is important to ensure the correct diet is entered and changed right away to avoid choking. I don't know where the breakdown happened. I don't know if the dietary card did not get changed or they just didn't read it. The surveyor attempted to call V30 (Registered Dietitian) multiple times with no response. The facility's policy and procedure with review date of April 2006 showed, Therapeutic & Mechanically Altered Diets; It is the policy of [the facility] that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietitian. A therapeutic diet is ordered to manage problematic health conditions . A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake . A physician's order is written for all diets including therapeutic and mechanically altered diets . The dietitian approves, signs and dates all menus . The facility prepares and serves all therapeutic and mechanically altered diets as planned . The facility's policy and procedure with revision date of April 2015 showed, Diet Orders; Policy: It is the policy of [the facility] to establish procedures for writing and communicating diet orders . The Food Service Manager, upon receiving the diet order, shall check the order against the medical record, making sure that the written order exists and that it agrees with the diet order. Any discrepancies in the Diet Order Form and diet order in the chart are discussed with the Director of Nurses or the nurse in charge . The Diet Order Form is to be kept on file in the Dietary Department for reference. The facility's policy and procedure with revision date of April 2016 showed, Regional Dietitian . Provide dietitian consultation to the facility to help meet the needs of the residents . 1. Collects, analyzes and summarizes relevant data from the resident and/or medical record, including anthopometic and laboratory information, appetite, diet orders, nutrition history, medications, and medical concerns . Evaluates the diet prescription relative to diagnosis and recommends changes as appropriate . Assist in development of menus . The facility's policy and procedure with revision date of October 2013 showed, Quarterly Assessments; It is the policy of [the facility] that all residents will be evaluated at least quarterly to ensure periodic monitoring of the nutritional status of the resident and prevent deterioration of nutritional status . 1. The Food Service Manager or designee re-evaluates and documents each resident's nutritional problems or needs at least quarterly. The Food Service Manager or designee writes the progress note on the Dietary Notes form or the Quarterly Assessment form . 2. Quarterly notes by the Food Service Manager or designee shall include at least the following: A. Current diet order . E. Appropriateness of diet order . The Immediate Jeopardy that began on 4/26/24 was removed on 6/28/24 when the facility took the following actions to remove the immediacy. 1. On 6/28/24 the following was initiated: A. In house audit of all diet orders to ensure accurate reconciled with dietary cards completed 6/28/24. B. IDT will review Speech Therapy recommendations daily in morning meeting. C. Regional Director in-serviced Dietary Supervisor on quarterly and annual dietary assessments. D. Staff in-serviced on appropriate diets by Regional Director and Administrator on 6/28/24. 2. Compliance will be monitored through the QA process. A. Speech orders will be reviewed daily during morning meeting by the IDT. DON/Designee will ensure all new diet orders are communicated to dietary. B. DON/Designee will in-service on diet orders once a month for the next 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility neglected to ensure a resident (R1) was assessed and provided pain management in a timely manner after being dropped from a mechanical lift on 11/21/23 at 5:30 AM which resulted in a right hip fracture. The facility neglected to notify the physician in a timely manner and provide ongoing nursing assessments, pain assessments, and pain management from the time of the incident on 11/21/23 at 5:30 AM through 11/22/23 at 1:25 AM (approximately 20 hours) when R1 was transported to the emergency department for evaluation and treatment of a right hip fracture. These failures resulted R1 being placed on bedrest without necessary care and effective pain management services being provided. R1 required medical evaluation and treatment at the hospital on [DATE] due to a right hip fracture sustained in a fall during a mechanical lift transfer at the facility. This applies to one of three residents (R1) reviewed for neglect in the sample of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/21/23 at 5:30 AM when the facility staff dropped R1 in a mechanical lift resulting in a fracture to her right hip and not providing nursing assessments, pain assessments or pain management from the time of her injury until she left the faciity on [DATE] at 1:25 AM when she was transported to the hospital for evaluation and treatment. The facility was notified of the Immediate Jeopardy on 12/7/23 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/8/23; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The A.I.M. (Assessment, Intercommunicate, & Management) Event Record Late Entry for R1 for the incident on 11/21/23 at 5:30 AM showed there were two CNA's present, the mechanical lift tipped, and the resident fell. R1 was being transferred from the shower to bed. New onset of pain; complaints of pain at the time of the event. The Practitioner, resident responsible party and facility management were not notified at the time of the incident. It happened around shift change so the nurse endorsed to the oncoming nurse to follow up. There weren't any other nursing assessments or pain assessments completed for R1 on 11/21/23. The Health Status Notes for R1 on 11/21/23 showed, 2:50 PM - orders received for a portable x-ray. The Health Status Notes for R1 on 11/22/23 showed, 1:15 AM - Called 911 to get R1 transported to the emergency room; 1:25 AM emergency medical technicians x 3 to transport patient to the hospital. The facility's Final Report dated 11/28/23 to Illinois Department of Public Health for R1's Incident on 11/21/23 showed, R1 sustained a ground level witnessed fall. Resident was immediately assessed by the nurse and sent to the hospital for further evaluation. R1 was diagnosed with a greater trochanteric fracture; surgical repair was noted to be not operative at this time per medical doctor. R1 returned to the facility with new interventions and pain management in place. Further consult was obtained; surgical repair was completed on 11/25/23. R1 is currently at the hospital and plans to return to the facility upon discharge. This is our final report. Signed by V1 - Regional Clinical Director. On 12/1/23 at 9:15 AM V2 DON (Director of Nursing) stated she is the current acting DON. V3 LPN (Licensed Practical Nurse) stated she is the Resident Care Coordinator. V2 stated R1 was recently injured during an unsafe mechanical lift transfer. V2 stated they ultimately found out the floor was wet, and the mechanical lift fell over with R1 in the lift. V2 stated they found out about 20 hours later that R1 had a greater trochanter fracture (right hip fracture). V2 stated she found out on 11/21/23 at 2:30 PM by V5 CNA (Certified Nursing Assistant) and V6 CNA that R1 complained of back pain and was not feeling well. V2 stated she asked V5 and V6 if V9 (Licensed Practical Nurse) was told and they stated, yes and that R1 had been hurt during a fall that morning. V9 stated she knew R1 had a fall. V2 stated she texted V16 (Physician) at 2:47 PM and told him R1 had a fall and asked him for x-ray orders. V2 stated she showed V9 the text from the physician for the x-ray orders so she could put them in for R1. V2 stated V9 ordered the x-rays to be done stat. V2 stated she left the facility at 4:30 PM - 5:00 PM for the day thinking the x-ray orders would get done stat. V2 stated she did not hear anything until the next day that an injury occurred for R1. V2 and V3 stated V10 LPN (Licensed Practical Nurse/night nurse) did not do any assessment after the incident; V10 did not document anything. V2 stated V10 was on shift on 11/21/23 until 6:00 AM. V2 stated she expected a head-to-toe assessment to be completed and documented after the incident. V2 stated V10 told her R1 complained of pain, she gave R1 Tylenol, and she reported what happened to V9 LPN (the oncoming day nurse). V2 stated, when she asked V9, they told her that when she talked to R1 she wasn't having any pain. V9 never documented an assessment or pain assessment for R1. V2 and V3 stated nurses are to document assessments and if they are not documented then they are not done. V3 stated if they could have done anything differently, they would have provided pain control for R1; that was her biggest concern for R1. V3 stated the scheduled Tylenol that R1 had was not enough. V2 stated R1 suffered in pain on 11/21/23 and 11/22/23 until R1 received pain medication on the evening of 11/22/23. V2 stated R1 was in pain for 24 hours. V2 and V3 stated V10 came in 4-5 days later and entered a late entry for R1 for the incident that occurred on 11/21/23 at 5:30 AM. On 12/1/23 at 10:29 AM, V9 LPN stated she came in at 6:00 AM and she did not know what time the incident with R1 occurred. V9 stated she got report from V10 LPN and was not told about R1's fall. V9 stated she did rounds at 6:30 AM and noticed R1 was sleeping. V12 CNA from nights was still here and told her that R1 fell. V9 stated she asked what was done and was told V10 LPN helped them get R1 up but did not do anything. V9 stated she reported it to V3 (Resident Care Coordinator), and she believes V3 notified V16 (Physician). V9 stated R1 had pain in both of her hips and in her lower back. V9 stated she doesn't remember if she documented an assessment. V9 stated they kept R1 in bed and told staff not to move her. V9 stated when a resident falls the CNA is to notify the nurse. The nurse does an assessment which includes vital signs, head to toe assessment, and range of motion. They would get the resident up with a mechanical lift. They would notify the doctor and family right away. The DON and Administrator would be notified. Risk management documentation is done, and a note populates from the risk management documentation into the electronic medical record charting so everyone can see it. For pain control R1 received her already scheduled Tylenol; she did not receive anything else for pain. It was only when R1 moved that she complained of pain otherwise she was okay. This was a change for her; she is normally up in her wheelchair for meals and some activities. V9 stated she worked from 6:00 AM to 6:00 PM and then reported off to V17 LPN and told her that R1 had a stat x-ray ordered. V9 stated she told V17 what happened to R1 and that R1 was on bedrest until the x-ray results come back. V9 stated a stat x-ray is to be done within 4-6 hours from being ordered. V9 stated she didn't see R1 writhing in pain, or her leg turned out like normal with a hip fracture, so she just did what the doctor said. On 12/1/23 at 11:48 AM, V1 RN (Registered Nurse/Regional Clinical Director) stated R1's medical record (paper and electronic) had very little documentation in it regarding the incident, so it is impossible to know what happened and piece it together. V1 stated she was not sure exactly how the mechanical lift flipped or what the cause was. V1 stated she found out later that an assessment was not done after R1's incident. V1 stated V3 LPN/Resident Care Coordinator told her that there wasn't any injury, but they were going to send R1 to the hospital for pain. V1 stated V10 LPN should have documented right away and not 4-5 days later because she wouldn't remember what happened later. V1 stated the A.I.M. (Assessment, Intercommunicate, & Management) Event Record should be filled out in the electronic medical record at the time of the incident/accident. V1 stated there should have been ongoing monitoring and documentation that ongoing monitoring of the resident is being done. V1 stated V10 did not notify R1's family and physician and she should have. V1 stated yes when asked if she felt neglect occurred for R1 after the incident on 11/21/23. V1 stated the nurse should have sent R1 to the hospital and didn't. V1 stated a lot more could have been done for R1. The stat x-ray should have been done in 4 hours. If staff couldn't get the x-ray done within 4 hours, then R1 should have been sent to the hospital. V1 stated if she had been the nurse, she would have sent R1 to the hospital after the fall as a standard precaution. R1 should have been sent to the hospital and had her pain treated. Everyone knew there was a fall, that she had pain and her scheduled Tylenol would not be effective for pain management. That shouldn't have happened. On 12/1/23 at 1:03 PM, V10 LPN stated, on 11/21/23 at 5:30 AM V12 CNA came and got her because R1 was on the floor. V10 stated she went to R1's room, the floor was wet and R1 was in the mechanical lift sling on the floor crying and in pain. R1 was asking for her mom. V10 stated V12 told her the mechanical lift tipped over. R1 couldn't tell her where her pain was located; just said that she had pain. V10 stated she gave R1 Tylenol and reported off to V10 LPN to do a follow up with R1 and V10 stated she would. V10 stated she told V9 what had happened. V10 stated she checked on R1 before she left and R1 was in pain. They dropped the ball on this and let R1 sit there for greater than 12 hours in pain and no stat x-ray done. There was no follow up. V10 stated after a fall or change in condition an assessment is done and documented. V10 stated she did not document at the time of the incident and came back in to document it. V10 stated she thought V9 would follow up and do an assessment for R1. V10 stated she did check R1's vital signs, did a body check but did not check range of motion. On 12/1/23 at 2:00 PM, V12 CNA stated that her and V14 transferred R1 from the shower chair to the bed using a mechanical lift on 11/21/23 at 5:30 AM and the lift flipped. V12 stated R1 was not lifted above the shower chair, she pulled the shower chair out but R1's butt got stuck on the shower chair, the lift flipped onto the right side. V12 stated she got V10 LPN and the nurse came in and just looked at R1. She bent over and just looked at R1. The nurse did not palpate or check R1 for injuries. No vitals were done or range of motion. V10 assisted the CNAs to get R1 into bed. V12 stated in her opinion R1 should have been sent out; R1 had new pain. V12 stated she told V10 about the fall and told the oncoming CNA's what happened. V12 stated the day CNAs told her that night when she came back for her next shift that R1 had been in pain all day and they had told V9 about it. R1 sat like that too long. R1 was sent out the next day (11/22/23) on our shift at around 1:00 AM after they got the x-ray results. Every time we rolled R1 she complained of pain. Just laying in bed R1 looked fine, when moving she had pain. On 12/5/23 at 11:00 AM, V13 CNA stated she worked with R1 on day shift after her fall. V13 stated they requested that we keep her in bed. V13 stated she didn't know anything happened until V9 came in and was talking about it, that it wasn't reported and to keep R1 in bed and not move her until she knew more about the pain. At first, we didn't reposition R1 or provide care. As the shift went on, we were trying to figure out a way to move and roll R1 without pain. We couldn't leave R1 like that. Maybe around 12:00 PM - 12:30 PM there was 3 CNA's and a nurse, and we had two people on each side. We tried to provide support to R1's hip with the most pain. R1 was in pain so we tried to do this as quickly as possible. R1 was complaining of pain, scrunching her face and making noises when we were moving her. R1 slept a lot during the day. R1 was more vocal about pain with any movement. On 12/5/23 at 11:43 AM V6 NA(Nursing Assistant) stated she worked on 11/21/23 from 6:00 AM to 2:00 PM and received report from V12 CNA who told her that the mechanical lift flipped and R1 fell. V6 stated V12 said R1 had pain and said she told V10 LPN the night nurse. R1 complained of pain that day but did not say what it was from. R1 stated her leg hurts, and her feet were tingling. R1 stated that on and off throughout the shift. R1 was in bed, and they told us to leave her in bed. V6 stated she asked V9 if there was anything they could do because R1 was in a lot of pain and V9 stated no and that R1 was fine, there was nothing we can do. V6 stated she couldn't just let R1 lay there in pain so around 12:00 PM - 1:00 PM she went to V2 DON and told her R1 was in pain. V2 was aware R1 was dropped in the mechanical lift but she was not aware of the severity of it. V6 stated she told V2 that R1 had pain and V2 had V6 call V9 LPN into the office. V2 told V9 to get an x-ray and give some Tylenol. On 12/5/23 at 2:35 PM, V1 RN (Registered Nurse/Regional Clinical Director) stated the facility does not have a policy for nursing assessments after a fall/incident. V1 stated the nurses should assess after an incident, check range of motion, and a pain assessment should be done. This should be documented right away. V1 stated the nurses can put a health status note or do a follow up using the A.I.M record. V1 stated assessments should be done for 72 hours and should be done at least each shift. V1 stated that was not being done for R1. V1 stated this was just nursing 101 to do this. V1 stated R1 only received her scheduled Tylenol and did not have an order for as needed Tylenol. V1 stated if a nurse gave as needed Tylenol for R1, it's not documented in the electronic medical record. On 12/6/23 at 9:03 AM V16 (Physician) stated, it looks like on 11/21/23 at 2:47 PM I was notified of an incident with R1. I was notified the mechanical lift tipped in the shower and R1 had back and leg pain. I was told x-rays were ordered and I said that was fine. There was not a request for pain medication. With a fall of any kind, they should call right away, relay what happened and if the resident hits their head or not. If a resident is on blood thinners and hits their head, then they are sent to the emergency room 100% of the time. If not, and it depends on what has happened, we may opt for x-rays to be done. What happened was not good. The message I received did not have any urgency to it. After a fall, a nursing assessment should be done, and range of motion should be part of the assessment. The facility usually has a fall follow up protocol they follow. I would expect the facility to notify me if the available pain control they have is not effective. If the x-ray is not done in 4 hours and there is no sign of it being done, and the resident has pain then they should just send the resident to the hospital. When there is a fall, they should make sure the resident is safe, an assessment should be done, and I should be notified of the change in condition. It sounds like that wasn't done. I can't help if they don't notify me. On 12/6/23 at 9:35 AM, V1 RN (Registered Nurse/Regional Clinical Director) stated she found the AIM for Wellness Communication Form (A-Assess, I-Intercommunication, M-Manage) policy that she thinks the facility uses as the policy for assessments after a fall/injury/change in condition. On 12/7/23 at 12:28 PM, V21 (R1's son/power of attorney) stated he still did not know exactly what happened and the facility won't tell him. V21 stated he was told the mechanical lift tipped and R1 fell. The facility told him the floor was slippery and the wheel got caught. V21 stated this is the second time they broke her bones in a transfer. The last time they only had one person lifting her and should have had two people. V21 stated this happened about 1.5 years ago and R1's leg was broken during that transfer at the facility. V21 stated he did not know it happened at 5:30 AM because he wasn't notified about it until 3:30 PM. V21 stated he is upset that R21 did not have any pain medication and was probably in pain until she was seen at the second hospital. V21 stated the orthopedic doctor that did her surgery said it was an extremely painful break. V21 stated he is upset and worried about R1 at the facility. V21 stated R1 has dementia but knows who he is when they face time. V21 stated R1 is terrified she will be dropped. V21 stated he was not given a timeline on when this incident happened. V21 stated he told the facility he was not happy that he was not getting notified when things happen, or when R1 went to the hospital and when she returned. V21 stated, It is incompetence at all levels. I continue to worry that she is in constant pain, and they can't get R1 back to where she was before they dropped her. On 12/7/23 at 1:02 PM, V5 CNA stated she worked day shift on 11/21/23 and was one of the CNA's that took care of R1. V5 stated V6 NA came to her and stated they have a problem and told her R1 had fallen in the mechanical lift, no one reported it, and R1 was complaining of pain and stating, help me. V5 stated she told V9 LPN at 10:00 AM - 11:00 AM that R1 was complaining of pain, and V9 said, I will figure it out and walked away. V5 stated she never saw V9 check on R1. V5 stated V9 kept ignoring her and she got pissed. V5 stated she went to R1 and R1 was not the same; she was not okay. V5 stated at 1:30 PM - 2:00 PM she went to V2 DON and V2 had no clue what had happened or what was going on. V5 stated her and V6 told V2 they had heard R1 had fallen, she was screaming in pain and begging for help. V2 told them to get V9 who came to the office and V2 told her to give R1 pain medication and get a stat x-ray ordered. The Diagnoses Report dated 12/5/23 for R1 showed diagnoses including cerebral infarction, hypertension, hypothyroidism, hyperlipidemia, major depressive disorder, dementia, age related osteoporosis, and obesity. The November 2023 MAR (Medication Administration Record) for R1 showed she had an order for Acetaminophen 325 mg, give two tablets orally three times daily for pain at 8:00 AM, 12:00 PM, and 5:00 PM. R1 has had this order since 8/1/23. R1 received her scheduled doses of the medication on 11/21/23 and 11/22/23; no pain scale with administration was documented on the MAR. The Care Plan dated 7/19/23 for R1 showed, Alteration in comfort/pain related to right foot drop. Administer analgesic as ordered and assess effectiveness. Monitor every shift for breakthrough pain. Evaluate residents' level of pain every shift and as needed. Ask How would you rate your pain right now? Monitor for indicators of pain. Interview for pain symptoms, causes and relief patterns. Use pain scale prior to administering pain medication and to evaluate effectiveness of pain medication. Utilize pain scale to assess intensity of pain (faces or 1-10 scale). Encourage the same type of scale each assessment to compare consistent values. The facility's Abuse Prevention Program (11/28/16) showed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident Protection Investigation Paths: Possible Neglect. Cause: Based on the allegation, determine what goods or services were not provided to the resident. Result: Determine what physical harm, mental anguish, mental illness, emotional distress or deterioration in the resident's physical or mental condition resulted in the failure to provide goods and services. Intent: Determine if the goods or services were not provided because of a pattern of deliberate negligence, carelessness, or indifference. The facility's AIM for Wellness Communication Form (A-Assess, I-Intercommunication, M-Manage) policy (10/23/18) showed, Policy: To communicate effectively between nurses and primary care providers the facility has developed standardized criteria. This form will be used on residents who have had a change in condition or for shift-to-shift communication among nursing staff. Responsibility: Licensed nursing staff. Procedure: 1. Upon receiving a report in change of condition, review the resident's chart (diagnosis, medications, recent progress note from physician and nurses' notes). 2. Obtain an AIM for Wellness Form .and talk with staff and/or family that is available about the current situation with the resident. 3. Refer to Care Paths or Acute Change in Status File Cards if indicated. 4. Complete every section of the AIM for Wellness Form prior to calling the medical doctor. 5. Have the chart available when making the call to the medical doctor. 6. Complete the AIM for Wellness Form and Progress Note. The Progress Note should be used to document the physical assessment, physician and POA (power of attorney) notification, treatment ordered and given, etc. 7. Place the AIM for Wellness Form and Progress Note in the Nurses Notes section of the medical record. 8. Use the AIM for Wellness Form to assist in shift report. The facility's Pain Prevention & Treatment Policy (12/7/17) showed it is the facility policy to assess for, reduce the incidence of and severity of pain in an effort to minimize further health problems, maximize ADL functioning and enhance quality of life. Assessment of pain will be completed with changes in the resident's condition, self-reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The Pain Management Flow Sheet will be initiated for those residents with but not limited to routine pain medication, daily pain, diagnosis that may anticipate pain (i.e., arthritis, wounds, fractures, etc.). The facility's Notification for Change in Resident Condition or Status policy (12/7/17) showed the facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, Physician, Guardian, HCPOA - Healthcare Power of Attorney, etc.) of changes in the resident's medical/mental condition and/or status. 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a. Any symptom, sign or apparent discomfort is: 1. Sudden onset; 2. A marked change (i.e., more severe) in relation to usual signs or symptoms; 3. Unrelieved by measures already prescribed. b. An accident or incident involving the resident; h. A need to transfer the resident to a hospital/treatment center. 2. The nurse supervisor/charge nurse will notify the DON, physician, and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the afore mentioned situations or: a. The resident is involved in any accident or incident that results in an injury including injuries of unknown source; b. There is a significant change in the resident's physical, mental, or psychological status. 3. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The Immediate Jeopardy that began on November 21, 2023, was removed on 12/8/23 when the facility took the following actions to remove the immediacy: Facility actions to remove immediacy include: 1. On 12/07/23 the following was initiated: A. All staff in-serviced by the regional nurse on the abuse prevention policy and procedure prior to working their next scheduled shift. B. Nursing staff in-serviced by the regional nurse on change in condition and notification of change. C. Nursing staff in-serviced by the regional nurse Aims for Wellness (assessment and monitoring). D. Nursing staff in-serviced by the regional nurse on pain assessment and pain management. E. R1 resides at Sandwich Rehabilitation and Healthcare pain assessment and pain management in place per MD orders. F. Medical Director was notified of Immediate Jeopardy for F600. 2. All residents have the potential to be affected by the alleged deficient practice, but due to A-E the deficient practice will not recur. 3. Compliance will be monitored through the QA (quality assurance) Process. A. Staff will be in-serviced on abuse by regional nurse/designee once a month for the next 3 months and then reviewed quarterly during QA. B. Admin/Designee to in-service new employees on abuse prevention policy and procedure during orientation, as needed and annually per policy. C. Nursing staff will be in-serviced on change in condition, notification of change, aims for wellness (assessment and monitoring), pain assessment and pain management once a month for 3 months and reviewed during quarterly QA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. R4's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease. The special instructions on his electronic record banner shows he is to be transferred with the mechanical lift with the assist of 2-3 persons. On 12/1/23 at 11:15 AM, V6 and V4 CNA's said R4 was going to be transferred from his bed into the wheelchair using the mechanical lift. V4 moved the mechanical lift over the bed and attached the loops of the sling to the hooks of the mechanical lift. V4 did not lock the wheels of the lift as she was raising R4 out of the bed. V6 was holding R4's feet and guiding him over his wheelchair as V4 was behind the mechanical lift. No staff were supporting R4's body as he was in the air moving towards his chair. Once R4 was over his wheelchair, without locking the wheels of the wheelchair or the mechanical lift, V4 lowered R4 down into the wheelchair as V6 guided only his legs. V4 then pulled on the sling behind R4 to move him up in his wheelchair. 2. R5's admission record shows he was admitted to the facility on [DATE] with a primary diagnosis of multiple sclerosis. The 7/24/23 care plan documents R5 is dependent on staff for his ADL's (Activities of Daily Living) and requires the use of a mechanical device for transfers using 2 staff members. On 12/1/23 at 11:20 AM, R5 was lying in his bed, dressed, and a lift sling under his back. V4 moved the mechanical lift over the bed and attached the loops of the sling to the hooks of the mechanical lift. The wheels of the mechanical lift were not locked. R5's wheelchair was placed at the end of the bed, without the wheels locked in place. V4 raised R5 using the lift, and V5 was holding only R5's foot and guiding him towards the wheelchair. Once over the wheelchair, V4 did not lock the wheels of the mechanical lift, or widen the base of the lift, and as R5 was being lowered into the wheelchair, the mechanical lift was moving back towards V4, and the leg of the lift was under the front wheels of the wheelchair. The wheelchair was not stable, and the front wheels of the wheelchair were observed to be sitting on the leg of the lift, about 2 inches off of the floor. V4 was lowering R5 into the chair, and V5 continued to hold onto his foot until he was in the wheelchair. During the transfer no staff were observed behind R5 to guide or support him as he was transferred into the wheelchair. On 12/1/23 at 11:33 AM, V4 said she never locks the wheels of the mechanical lift or the wheelchair for transfers. She said staff should be behind the resident up in the sling to support them as they are moved. This would be a safer way to transfer the resident. On 12/5/23 at 11:17 AM, V13 CNA said the mechanical lift used on R4 and R5 has straight legs, and it is hard to try and figure out how to get under the wheelchair. The legs do not open wide enough to get around the wheelchair as it is supposed to, so the legs have to go under the chair with one leg behind the back wheel and the other leg in front of the larger back wheel. On 12/1/23 at 1:20 PM, V2 said the mechanical lift requires 2 staff, and sometimes 3 staff to safely transfer a resident. The resident should have the appropriate sling size and it should be in good repair. She said one staff member should be operating the lift while the second staff is standing next to the resident and guiding them during the transfer. The legs of the lift should be spread out under the resident to stabilize the weight in the lift. The wheels of the lift should be locked before raising the resident up to ensure the wheels do not slip and the lift does not tip over. V2 said if the resident is moving from the bed into a wheelchair, the wheels of the chair should be locked so it does not move as the resident is being guided down. She said the base of the lift should go around the back and front wheels, and the legs of the wheelchair should not be off of the floor during a transfer. I. Based on interview and record review the facility failed to ensure a resident (R1) was safely transferred with a mechanical lift device. This failure resulted in R1 sustaining a hip fracture on 11/21/23 at 5:30 AM during a mechanical lift transfer after the lift device tipped over with R1 in the sling on the device. R1 required medical evaluation and treatment at the hospital on [DATE] due to a right hip fracture that was sustained when the mechanical lift tipped over. This applies to one of three residents (R1) reviewed for safety in the sample of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/21/23 at 5:30 AM when facility staff dropped R1 in a mechanical lift resulting in a fracture to her right hip. The facility was notified of the Immediate Jeopardy on 12/7/23 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/08/23; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The A.I.M. (Assessment, Intercommunicate, & Management) Event Record Late Entry for R1 for the incident on 11/21/23 at 5:30 AM showed there were two CNA's present, the mechanical lift tipped, and the resident fell. R1 was being transferred from the shower to bed. New onset of pain; complaints of pain at the time of the event. Practitioner, resident responsible party and facility management were not notified at the time of the incident. It happened around shift change so the nurse endorsed to the oncoming nurse to follow up. The facility's Final Report dated 11/28/23 to Illinois Department of Public Health for R1's Incident on 11/21/23 showed, R1 sustained a ground level witnessed fall. Resident was immediately assessed by the nurse and sent to the hospital for further evaluation. R1 was diagnosed with a greater trochanteric fracture; surgical repair was noted to be not operative at this time per medical doctor. R1 returned to the facility with new interventions and pain management in place. Further consult was obtained; surgical repair was completed on 11/25/23. R1 is currently at the hospital and plans to return to the facility upon discharge. This is our final report. Signed by V1 - Regional Clinical Director. On 12/1/23 at 9:15 AM V2 DON (Director of Nursing) stated she is the current acting DON. V3 LPN (Licensed Practical Nurse) stated she is the Resident Care Coordinator. V2 stated R1 was recently injured during an unsafe mechanical lift transfer. V2 stated they ultimately found out the floor was wet, and the mechanical lift fell over with R1 in the lift. V2 stated they found out about 20 hours later that R1 had a greater trochanter fracture (right hip fracture). V2 stated she found out on 11/21/23 at 2:30 PM from V5 CNA (Certified Nursing Assistant) and V6 CNA that R1 complained of back pain and was not feeling well. V2 stated she asked V5 and V6 if V9 (Licensed Practical Nurse) was told and they stated, yes and that R1 had been hurt during a fall that morning. V9 stated she knew R1 had a fall. V2 stated she texted V16 (Physician) at 2:47 PM and told him R1 had a fall and asked him for x-ray orders. V2 stated she didn't hear anything until the next day that an injury occurred. V12 CNA and V14 CNA were the CNA's that transferred R1 with the mechanical lift and they said it happened 11/21/23 at 5:30 AM. V10 LPN was the night nurse on duty, and she said that R1 was transferred by one CNA and not two CNA's. V3 stated she opened a risk management documentation and put in what she knew about the situation, and they are supposed to have two people for mechanical lift transfers because it is the facility's policy. V2 and V3 stated V10 LPN (night nurse) and V9 LPN (day nurse) did not document anything about what happened for the incident involving R1 or any assessments. V2 and V3 stated they were upset that they did not find out what happened to R1 right away and then all the different stories they were getting about what happened. V2 and V3 stated 4-5 days after the incident happened V10 LPN documented in R1's chart. V2 and V3 stated they did not take the legs off R1's wheelchair and that was part of the reason the mechanical lift tipped when they were maneuvering the lift around the legs and the floor being wet. V12 and V14 went to get V10 (LPN) after the fall. V12 stated V10 was asleep at the nurse's desk and would not know if 1 CNA did the transfer. V2 and V3 stated the CNAs should have removed the foot pedals and the mechanical lift they used gets stuck under the wheelchair due to the foot pedals. It affects the center of gravity and the mechanical lift tipped. It was an unsafe transfer and unsafe environment. On 12/1/23 at 11:48 AM, V1 RN (Registered Nurse/Regional Clinical Director) stated R1's medical record (paper and electronic) had very little documentation in it regarding the incident, so it is impossible to know what happened and piece it together. V1 stated she was not sure exactly how the mechanical lift flipped or what the cause was. On 12/1/23 at 1:03 PM, V10 LPN stated, on 11/21/23 at 5:30 AM V12 CNA came and got her because R1 was on the floor. V10 stated she went to R1's room, the floor was wet, and R1 was in the mechanical lift sling on the floor crying and in pain. V10 stated V12 told her the mechanical lift tipped over. V10 stated she told V12 that there was supposed to be 2 people for transfers with the mechanical lift. V12 stated to V10 that they always operate the mechanical lift by themselves and not with two people. V10 stated she was asked by V3 LPN/Resident Care Coordinator not to document that there was only 1 CNA for the transfer and to put that there were two CNA's. On 12/1/23 at 1:31 PM, V11 CNA stated she did not work the night when the lift tipped over on R1; V12 and V13 were working. V11 stated she was told by other staff that V12 and V13 were putting R1 to bed and the mechanical lift tipped over. V11 stated they are supposed to use 2 people when they do a transfer with a mechanical lift but there are a lot of girls that will do it by themselves. V11 stated she gets a lot of repercussions from other staff because she won't transfer a resident with a mechanical lift by herself and she gets told you can do it yourself; we do it ourselves. V11 stated there is a mechanical lift with long legs on it and they have had to close the legs on the lift which then shifts it's balance. If they close the legs on the mechanical lift with the resident in it, then it swings, and the weight is not distributed evenly so it is not safe. On 12/1/23 at 2:00 PM, V12 CNA stated that her and V14 transferred R1 from the shower chair to the bed using a mechanical lift on 11/21/23 at 5:30 AM and the lift flipped. V12 stated R1 was not lifted above the shower chair, she pulled the shower chair out but R1's butt got stuck on the shower chair, the lift flipped onto the right side. V12 stated the lift could have gotten caught under the chair and that they were not able to open the base (legs) of the mechanical lift all the way and that makes the lift unstable. V12 stated when you adjust the lift one way, the residents weight goes the opposite way, and the lift goes the other way and can flip. On 12/6/23 at 9:35 AM, V1 RN (Regional Clinical Director) stated she did not have any competencies for the CNA's including competencies for mechanical lifts. V1 stated competencies should be done at hire and annually. On 12/6/23 at 10:41 AM, V14 CNA stated there were two of them for the transfer that night for R1. V14 stated the other girl (V12) called for help transferring R1 from the shower chair to the bed. V14 stated they used the tall white mechanical lift that gets tricky if it gets swinging it goes unbalanced. V14 stated the mechanical lift sling under R1 was wet and that got water on the floor. They were trying to get R1 to bed as soon as possible. V14 stated the mechanical lift began to swing in an unruly manner and it tipped over. V14 stated V12 was operating the lift. V14 stated she was standing there watching to see if the sling was still hooked. V14 stated it happened so fast, the sling started to swing, and the lift was tilting, and it was too hard to pull it back. V14 stated she was looking at the top of the lift and R1's butt could have gotten caught on the chair with the combination of the chair and floor being wet that could have caused the fall. V14 stated during a mechanical lift transfer one person operates the lift while the other person holds onto the sling and guides it. V14 stated if the sling gets caught when the lift is going up it can throw the lift off balance. V14 stated she wasn't doing anything with the sling lift under R1 because she wasn't out of the chair yet. V14 stated she thought maybe using a bigger shower chair for R1, so she wouldn't get stuck in the chair, would help with the transfers. V14 stated she has been doing mechanical lift transfers for 20 years and does not receive training yearly for competency on using a mechanical lift. On 12/7/23 at 12:28 PM, V21 (R1's son/power of attorney) stated he still did not know exactly what happened and the facility won't tell him. V21 stated he was told the mechanical lift tipped and R1 fell. The facility told him the floor was slippery and the wheel got caught. V21 stated this is the second time they broke her bones in a transfer. The last time they only had one person lifting her and should have had two people. V21 stated this happened about 1.5 years ago and R1's leg was broken during that transfer at the facility. V21 stated R1 is terrified she will be dropped. The facility's Safe Resident Handling and Movement policy (no date) showed, the facility wants to ensure that it's residents are cared for safely, while maintaining a safe work environment for employees. This infrastructure includes resident handling and movement equipment, employee training, and a Culture of Safety approach to safety in the work environment. Goals: Reduce injury potential for both resident and caregiver. Assure staff competency in the safe use of transfer and mobility related equipment. Procedures: It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and their residents during handling activities by following this policy. Use mechanical lift devices and other approved resident handling aids in accordance with instructions and training. Staff will complete and document safe resident handling and movement equipment training initially, annually, and as required to correct improper use/understanding of safe resident handling and movement. Nursing Management: Ensure high-risk resident handling tasks are assessed periodically and staff are completing the tasks safely, using mechanical lifting devices and other approved resident handling aids and appropriate techniques. As of 12/6/23 V12 CNA did not have any competencies/training by the facility for mechanical lifts. V14's last competency on the mechanical lift was dated 7/25/2007. The Diagnoses Report dated 12/5/23 for R1 showed diagnoses including cerebral infarction, hypertension, hypothyroidism, hyperlipidemia, major depressive disorder, dementia, age related osteoporosis, and obesity. The Minimum Data Set, dated [DATE] for R1 showed total dependence for mobility and transfers. The Immediate Jeopardy that began on November 21, 2023, and was removed on 12/08/23 when the facility took the following actions to remove the immediacy: Facility actions to remove immediacy include: 1. On 12/07/23 the following was initiated: A. R1 resides at Sandwich Rehabilitation and Healthcare, pain assessment in place and pain management in place per MD orders. B. All nursing staff in-serviced by regional nurse on safe transfers prior to their next scheduled shift. C. All nursing staff in-serviced by regional team with return demonstration on mechanical lift safe transfers prior to the start of their next shift. D. All nursing staff in-serviced by regional nurse on fall prevention policy and procedure. E. Medical Director notified of Immediate Jeopardy for F689. 2. All residents requiring use of mechanical lift transfers have the potential to be affected by the deficient practice, due to A-D the alleged deficient practice will not recur. 3. Compliance will be monitored through the QA process: A. Staff will be in-serviced on safe transfers and safe mechanical lift use once a month for 3 months and reviewed during quarterly QA. B. DON/Designee will review random transfers 3 times a week for 2 weeks and then once a week for 4 weeks. C. DON/Designee will review competencies of Certified, licensed and registered staff annually and as needed. II. Based on observation, interview and record review the facility failed to ensure safe transfers using mechanical lift devices were provided for two of three residents (R4 & R5) reviewed for safety in the sample of five.