Every finding on record at Allure of Pinecrest

Based on interview and record review the facility failed to document resident assessments for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3.The findings include:R1s face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to dementia, transient cerebral ischemic attack, atrial fibrillation, presence of cardiac pacemaker, and hypertension.R1s nursing progress notes for [DATE] document at 9:23 AM, resident observed during medication administration to have difficulty swallowing a pill and began exhibiting signs of choking. The Heimlich maneuver was performed, abdominal thrust, CPR (cardiopulmonary resuscitation) was initiated, and she was sent to the emergency room. The record did not indicate R1s return, her assessment upon return including vital signs or any new orders from the emergency department.On [DATE] at 12:47 PM, V3 Licensed Practical Nurse LPN said I want to say I was still her nurse when she came back and definitely should have documented when she came back. A note of the time of arrival, any new physician orders, do an assessment, vitals, listen to her heart and lungs, bowels, if she had any bandages, and do a skin check. That should all be in the progress notes.R1s nursing progress note for [DATE] at 10:14 AM, documents resident complains of chest pain 10/10. Sent to ED (emergency department). No assessment, vital signs or related information was noted in the record. No transfer, change of condition report.On [DATE] at 11:10am V6 LPN said on [DATE] R1 was sitting in her recliner stating she had non-radiating chest pain. She (R1) had increased respirations; they were at 26 or 28. Her blood pressure was 140 something or 80 something, it was not too bad. V6 said she did check her pulse oxygenation level, and it was 91%, she thinks. She did not apply any oxygen at the time of the event. V6 said her color was fine and she was not diaphoretic (sweaty). V6 said after the choking incident (on [DATE]), as soon as (R1) said she had chest pain, she sent her out immediately. V6 said she did not write or document any information in the record.On [DATE] at 12:30 PM, V2 Director of Nursing said when a resident returns from the emergency room or hospital stay, there should be an assessment and documentation of their orientation status, a summary of what happened, vital signs, pain level, a skin check and a review of the orders. She said when a resident is sent out to the ER with chest pain there should be a description of the pain, what was done for that resident, vital signs, if oxygen was placed, and the reason for sending the resident out. After reviewing R1s note for [DATE] she stated the note is missing all the needed information, and any other symptoms R1 was having, and if she was diaphoretic, her orientation- was she confused, was her skin cool, clammy, or hot. V2 stated all that information should have been put in the note.The facility's undated policy for documentation in the medical record shows the policy as: each resident's medical record shall contain an accurate representation of the actual experiences of the resident and includes enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy explanation and compliance guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on interview, and record review the facility failed to provide documentation showing staff was qualified to replace a gastrostomy tube (g-tube) per standards of practice for 1 of 4 residents (R1) reviewed for staff qualifications in the sample of 4. This failure resulted in R1's g-tube migrating into the small intestines leading to complications requiring hospitalization.Findings Include: On 4/13/26 at 12:10 PM, V1 (Administrator) said she did not know if V2 had any certification or training on changing a urinary catheter g-tube and to ask V2 directly. On 4/13/26 at 12:16 PM, V2 (Director of Nursing/DON) said she was not sure what prompted R1's urinary catheter g-tube to be changed, the nurse approached her and said the family wanted her to change it. V2 said it was a routine procedure, a standing order, and she didn't speak with V10 (R1's Physician). V2 said she replaced R1's 16 French with a 20 French urinary catheter because R1's stoma had stretched and the 20 French and the feeding would go in easier. V2 said she didn't speak with V10 regarding the use of the 20 French versus the 16 French either. V2 said the procedure was not something that was normally done at this facility. V2 said she had experience from a previous facility. V2 said she had no certification, just hands on training from her previous employer. V2 said there was not a policy or procedure at this facility for changing the g-tube. On 4/13/26 at 12:57 PM, V2 said she spoke with her previous employer, and they were not able to provide any certifications or competencies regarding urinary catheter g-tube replacements for her.R1's Hospital Discharge summary dated [DATE] shows (R1) with a history of major Cerebral Vascular Attack resulting in right sided hemiparesis and aphasia was admitted from long term skilled nursing facility for a leaking g-tube, fever, and an episode of vomiting. Son who is Power of Attorney is at bedside and states that the facility changed out (R1's) g-tube and the placed a 20 French urinary catheter. The son states it had been leaking since that time. On evaluation (R1's) g-tube was found to be displaced into the proximal jejunum. Labs were significant for an elevated lipase, consistent with pancreatitis. A cat scan (computed axial tomography) of the abdomen confirmed the placement of the g-tube position. Gastroenterology was consulted and successfully replaced the g-tube. The patient was treated with intravenous fluids and medications for pancreatitis. Procedure Note: Standard g-tube, 20 French with outside stopper- The balloon of the old g-tube was deflated (it was a urinary catheter placed through the gastrostomy stoma). It was noticed that urinary catheter use as the g-tube had migrated into the jejunum. Only the tip of the urinary catheter was showing at the skin site. Last it was causing partial bowel obstruction and substantial leakage from the stoma site.The facility's Care and Treatment of Feeding Tubes dated 12/1/25 shows Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible. Directions for staff regarding the conditions and circumstances under which a tube is to be changed will be provided:When to replace and/or change a feeding tube (generally as ordered/scheduled by the physician, when a long-term feeding tube comes out unexpectedly, or when the tube is worn or clogged). The importance of, and frequency of, inspecting the feeding tube and infusion plug to identify splits or crack that could produce leakage.Instance when a tube can be replaced within the facility and by whom.Instances when a tube must be replaced in another setting (e.g. hospital).

Based on observation, interview, and record review the facility failed to monitor a urinary catheter gastrostomy tube (g-tube) placement, failed to have policies in place for the care of a urinary catheter g-tube, and failed to have polices in place for replacing a urinary catheter g-tube for 1 of 2 residents (R1) reviewed for gastrostomy tubes in the sample of 4. This failure resulted in R1's being hospitalized due to her gastrostomy tube advancing into her small intestine causing a partial small bowel obstruction and pancreatitis.Findings Include: On 4/9/26 at 10:09 AM, V13 (R1's son) said after R1's g-tube was replaced, the tube was leaking. The only part of the tube sticking out of R1 was the nipple on the end. V9 and V2 were at the bedside looking at R1's g-tube. V2 asked him if he did this, which he told her no. Shortly after R1 was sent to the emergency room. V13 said R1 was exhibiting pain and the tube feeding was leaking all over. On 4/9/26 at 12:22 PM, R1 was sitting in a wheelchair at the nurses' station with her gastrostomy tube connected to a feeding pump running at 65 cc/hr. V4 (Licensed Practical Nurse/LPN) showed this surveyor R1's gastrostomy (g-tube) site. V4 said R1's g-tube was put in at R1's last hospital stay. R1's g-tube extended out from R1's abdomen with a small circular disc around the entrance site and was connected to tubing leading to the feeding pump. R1's abdominal area around the g-tube site had a small amount of dried tube feeding.On 4/9/26 at 2:08 PM, V2 (Director of Nursing/DON) said R1 admitted to the facility with a surgically placed g-tube. V2 said R1 pulled her g-tube out and was sent to the local emergency room. V2 said there was no surgical team available to put a new g-tube in at the time, so the emergency room inserted a urinary catheter tubing to be used as a gastrostomy tube and sent R1 back to the facility. V2 said R1's discharge orders showed to schedule surgical g-tube placement with the gastrointestinal surgeon within 1-2 weeks. V2 said the family requested to wait for a video swallow test to be done before having the surgical g-tube placed in hopes that R1 would not need a g-tube. V2 said R1's husband requested that R1's temporary urinary catheter g-tube be changed and because she had experience, she changed the catheter. V2 said when she changed the catheter tubing, she did not mark or measure the tubing where it entered R1's abdomen, but she recalled approximately 12 inches or so of tubing extending out of R1's abdomen. V2 said to check that the tube is in the correct place in the stomach, gastric content is aspirated. V2 said staff monitor placement by checking gastric content before administering medication, water flushes, or feeding. V2 said staff does not monitor tube placement by checking for the markings on the tubing or measuring the tubing. V2 said the day after she replaced R1's g-tube, staff reported that the tube was leaking, and she assessed R1's g-tube. V2 said R1's g-tube seemed ok to her. V2 said the next day (2 days after replacement) V9 (LPN) called her and said R1's tube was leaking to the point of soaking the bed. V2 said she told V9 to send R1 to the emergency room, that much leaking was not right. V2 said she did not assess R1's g-tube at that time, she didn't want to mess with it anymore. V2 said she read on R1's hospital paperwork that the g-tube had migrated to R1's jejunum (middle section of the small intestine). V2 said after R1 had been admitted to the hospital, V9 reported to her that R1's g-tube had been pushed all the way in, there was no visible tubing on the outside, except the end. R1's Hospital Discharge Instruction dated 2/1/26 shows Patient's percutaneous endoscopic gastrostomy tube was replaced with a 16 French coude foley catheter. This can be used for tube feeds and medications. Please be gentle when administering medications. Patient will need to follow up with general surgery in the next 1-2 weeks for replacement of the feeding tube with a longer-term g-tube endoscopically. How to care for the tube site: Check the number on the tube (guide mark) where it meets the skin. It should not change. If it does the feeding tube might be coming out. Use tape or an anchoring device to hold the loose end of the tube against the skin. This helps keep the tube from getting pulled on.R1's Physician Orders shows check tube placement before initiation of formula, medication administration, and flushing tube. These same orders do not contain orders to check external tube measurements of R1's g-tube. On 4/13/26 at 9:35 AM, V9 (LPN) said she took care of R1 the day R1 was sent out to the hospital for her leaking g-tube. V9 said that day was the first time she had ever seen a urinary catheter used as a g-tube before. V9 said she was not given any education or training regarding the use of this type of g-tube. V9 said the night nurse just told her it was a 16 French urinary catheter with a 10 milliliter balloon. V9 said when she assessed R1 at the beginning of her shift (6:00 AM) she noted the catheter was flush against R1's stomach and there was feeding all over R1's stomach and bed. V9 said she called V2 who came and looked at the tube and said it was not supposed to look like that. V9 said she called to send R1 out to the hospital. V9 said there was no tape or anchoring device that she recalled. V9 said she checks g-tube placement by aspirating stomach contents. On 4/13/26 at 10:10 AM, V10 (R1's Physician) said nurses should be monitoring the external placement of g-tubes as part of determining that the g-tube is the correct position. There should be a protocol for the nurses to follow. The g-tube should be in the stomach not the jejunum (middle section of the small intestine). R1's g-tube advancing into the jejunum could cause a blockage of the bile duct which in turn could lead to pancreatitis. V10 said he did not recall speaking to staff about changing out R1's urinary catheter g-tube. V10 said that is something that is typically done in the emergency room by a doctor. V10 said he would have had the patient sent out to have the procedure done. V10 said on an emergent basis (the tube came out) a nurse might place the g-tube back but then the patient would still be sent out to the emergency room to make sure the tube was correctly placed. V10 said there would be complications if the g-tube is not in the correct place. On 4/13/26 at 11:30 AM, V11 (LPN) said she doesn't have experience with urinary catheter tubes being used as g-tubes and would check placement by aspirating gastric content. V11 said she was not sure how to tell if the tube had moved in or out of the body. V11 said she had not been educated on that type of g-tube.On 4/13/26 at 11:42 AM, V7 (LPN) said she had not had any education on R1's g-tube and checked placement by listening to the stomach. V7 said R1's was the first type of that g-tube she had encountered. V7 said there were no markings on R1's g-tube external tubing that she could recall.R1's Progress Notes dated 3/6/26 at 12:00 PM shows Resident g-tube continuously leaking, with the majority of tube feeding coming out around stoma. This nurse attempted to reinflate the balloon with 5 ml (milliliters) more of normal saline however the stoma continues to leak an excessive amount of fluids. Received order to send to emergency room. R1's Progress Notes dated 3/6/26 at 6:04 PM shows Resident admitted to local hospital with diagnosis of pancreatitis.R1's Hospital Discharge summary dated [DATE] shows (R1) with a history of major Cerebral Vascular Attack resulting in right sided hemiparesis and aphasia was admitted from long term skilled nursing facility for a leaking g-tube, fever, and an episode of vomiting. Son who is Power of Attorney is at bedside and states that the facility changed out (R1's) g-tube and the placed a 20 French urinary catheter. The son states it had been leaking since that time. On evaluation (R1's) g-tube was found to be displaced into the proximal jejunum. Labs were significant for an elevated lipase, consistent with pancreatitis. A cat scan of the abdomen confirmed the placement of the g-tube position. Gastroenterology was consulted and successfully replaced the g-tube. The patient was treated with intravenous fluids and medications for pancreatitis. Procedure Note: Standard g-tube, 20 French with outside stopper- The balloon of the old g-tube was deflated (it was a urinary catheter placed through the gastrostomy stoma). It was noticed that urinary catheter use as the g-tube had migrated into the jejunum. Only the tip of the urinary catheter was showing at the skin site. Last it was causing partial bowel obstruction and substantial leakage from the stoma site.R1's Care Plan dated 1/9/26 shows the resident requires tube feeding related to dysphagia. This same Care Plan shows on 2/6/26 sent to emergency room for g-tube malfunction, but no interventions for care were updated reflecting the urinary catheter used as a g-tube.The facility's Appropriate use of Feeding Tubes Policy dated 12/1/25 shows Feeding tubes (naso-gastric, gastrostomy, jejunostomy, coude urinary catheter) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.The facility's Care and Treatment of Feeding Tubes dated 12/1/25 shows Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible. The residents' plan of care will address the use of feeding tube, including strategies to prevent complications. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location (e.g. stomach or small intestine depending on the tube): The enteral retention device will be checked daily to assure it is properly approximated to the abdominal wall and that the surrounding skin is intact. Direction for staff will be given on how to provide the following care will be provided: How to secure a feeding tube externally. The policy did not define how licensed staff check the feeding tube is in the right location. This same policy shows Directions for staff regarding the conditions and circumstances under which a tube is to be changed will be provided:When to replace and/or change a feeding tube (generally as ordered/scheduled by the physician, when a long-term feeding tube comes out unexpectedly, or when the tube is worn or clogged). The importance of, and frequency of, inspecting the feeding tube and infusion plug to identify splits or crack that could produce leakage.Instance when a tube can be replaced within the facility and by whom.Instances when a tube must be replaced in another setting (e.g. hospital).On 4/13/26 at 12:10 PM, V1 (Administrator) said she did not believe an in-service was done for nurses on a urinary catheter g-tube. V1 said she did not know if V2 had any certification or training on changing a urinary catheter g-tube and to ask V2 directly. On 4/13/26 at 12:16 PM, V2 said she was not sure what prompted R1's urinary catheter g-tube to be changed, the nurse approached her and said the family wanted her to change it. V2 said it was a routine procedure, a standing order, and she didn't speak with V10. V2 said she replaced R1's 16 French with a 20 French urinary catheter because R1's stoma had stretched and the 20 French and the feeding would go in easier. V2 said she didn't speak with V10 regarding the use of the 20 French versus the 16 French either. V2 said the procedure was not something that was normally done at this facility. V2 said she had experience from a previous facility. V2 said she had no certification, just hands on training from her previous employer. V2 said there was not a policy or procedure at this facility for changing the g-tube. V2 said she did not educate staff on urinary catheter g-tubes but two staff had watched her replace the g-tube. On 4/13/26 at 12:57 PM, V2 said she spoke with her previous employer and they were not able to provide any certifications or competencies regarding urinary catheter g-tube replacements for her.On 4/13/26 at 1:07 PM, V1 said the facility did not have any other policies specific to urinary catheter g-tubes or policies regarding urinary catheter g-tube replacement.

Based on observation, interview, and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.Findings Include:On 4/9/26 at 12:14 PM, V3 (Certified Nursing Assistant/CNA) said R1 is alert to self only and is dependent on staff for all care. V3 said R1 is nonverbal and cries out often. V3 said R1 is incontinent of bowel and bladder. On 4/9/26 at 12:22 PM, R1 was sitting in a wheelchair in the nurses' station. R1 was alert and looking around the room but did not respond when spoken to.On 4/9/26 at 2:16 PM, V6 (CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said later in the shift, V7 told her she did not know V13 was in the room. V6 said told V7 that is why you watch what you say. V6 said V7 was inappropriate and said things that she wouldn't say to her own child. V6 said she talked to someone about it that day but was not sure who. V6 said it is not appropriate to talk to residents that way. On 4/9/26 at 3:05 PM, V8 (Social Service Director) said V6 came to her and told her that V7 had come into help change R1 and said something about leaving R1 naked, here we go again with this sh*t. V8 said she felt very uncomfortable and reported it to V1 (Administrator). V8 said it is not appropriate to talk to residents that way, and so she reported it to V1 the abuse person.On 4/9/26 at 2:52 PM, V1 said V8 reported to her that V7 was inappropriate and used curse words when providing care for R1. V1 said she went and talked to V13, who told her V7 was inappropriate and asked her to educate the nurses. V1 said since V13 didn't seem that concerned about the situation, she completed a grievance form and did not do an abuse investigation. V1 said V13 wanted V7 moved from R1's unit and so she had V7 re-assigned to another unit.On 4/9/26 at 3:02 PM, V7 (LPN) said she did use curse words when providing care to R1 with V6. V7 said she remembered saying what the h*ll did you do now because R1 had torn up her incontinence brief and it was all over the room. V7 could not recall if she said sh*t or not. V7 said what she said was not right to say in front of the resident.The facility's Abuse, Neglect, and Exploitation Policy dated 2025 shows it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Verbal abuse means the use of oral, written or gestured communication of sound that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on interview and record review the facility failed to report an allegation of abuse to the state agency for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.Findings Include:On 4/9/26 at 2:16 PM, V6 (Certified Nursing Assistant/CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said V7 was inappropriate and said things that she wouldn't say to her own child. V6 said she talked to someone about it that day but was not sure who. V6 said it is not appropriate to talk to residents that way. On 4/9/26 at 2:52 PM, V1 (Administrator) said V8 reported to her that V7 was inappropriate and used curse words when providing care for R1. V1 said she went and talked to V13, who told her V7 was inappropriate and asked her to educate the nurses. V1 said since V13 didn't seem that concerned about the situation, she completed a grievance form and did not report the incident to the state agency.The facility's Abuse, Neglect, and Exploitation Policy dated 2025 shows it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes:a. Immediately, but 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 orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review the facility failed to ensure an allegation of verbal abuse was investigated for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.Findings Include: On 4/9/26 at 2:16 PM, V6 (Certified Nursing Assistant/CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said V7 was inappropriate and said things that she wouldn't say to her own child. V6 said she talked to someone about it that day but could not recall whom. V6 said it is not appropriate to talk to residents that way. On 4/9/26 at 2:52 PM, V1 (Administrator) said V8 reported to her that V7 was inappropriate and used curse words when providing care for R1. V1 said she went and talked to V13, who told her V7 was inappropriate and asked her to educate the nurses. V1 said since V13 didn't seem that concerned about the situation, she completed a grievance form and did not do an abuse investigation.The facility's Grievance form dated 3/30/26 for R1 shows the person making complaint was V8 (Social Service Director) and person completing the form as V1. The form shows detail of compliant/grievance: I went to talk to family in room (V13) about comment made to R1 oh you wet yourself again. He seemed like it was just an inappropriate comment. (V13) did not seem bothered by anything that was being said. I told him I would educate the nurse and he thanked me.The facility's Abuse, Neglect, and Exploitation Policy dated 2025 shows it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Verbal abuse means the use of oral, written or gestured communication of sound that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. An Immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator witnessed, and others whom might have knowledge of the allegations.

Based on observation, interview, and record review the facility failed to ensure assessed elopement interventions were in place for 3 of 3 sampled residents (R1, R2, R3) at risk for elopement and failed to ensure the elopement alert system was implemented at exit doors in resident areas. These failures resulted in R1 exiting through a resident wing door on 3/26/26 at 5:35 AM and found by staff at 5:38 AM walking outside in the dark approximately 50 feet down the facility's sidewalk with a slope to the right side, without a walker, and without wearing her elopement alert bracelet or temperature appropriate clothing.Findings include:1. On 4/1/26 at 9:00 AM, the facility's wing 3 had an exit door at the end of the hall. This exit door had a banner with a stop sign across the door, attached to each side of the door frame. This surveyor opened the door, and an alarm was heard overhead wing 3 door open. There was a sidewalk beyond the door that went straight out approximately 20 feet and then turned sharply left continuing until turning sharply left again to go into the door to resident wing 1. Beyond the sidewalk was grass covered hill ending into a parking lot. On 4/1/26 at 10:19 AM, V5 (Certified Nursing Assistant/CNA) said she was working the morning R1 got outside on 3/26/26. V5 said she last saw R1 in bed sleeping around 5:30 AM. V5 said she went to answer a call light in another resident's room and when she was finished and coming out of that room heard the alarm go off for wing 3. V5 said she heard the alarm go off twice and then ran down the hall of wing 3. V5 said she looked out the door to the right and to the left and didn't see her until she went out further and looked all the way to the left. V5 said R1 was on the sidewalk without her walker, halfway between wing 3 and wing 1. V5 said she went to R1 who seemed confused, and walked R1 to the wing 1 door. V5 said R1 was wearing a striped long sleeve t-shirt, pants, and had socks on. V5 said R1's socks were not the grippy kind. V5 said R1's slippers were on her walker in her room. V5 said R1 asked her where her room was and said it was dark out there. On 4/1/26 at 10:56 AM, V7 (Licensed Practical Nurse/LPN) said she was the nurse on duty on 3/26/26 when R1 got out. V7 said R1 is alert and sometimes confused in general, but on that day was particularly confused due to a urinary tract infection. V7 said she last saw R1 in her bed sleeping around 4:30 AM when she was passing morning medications. V7 said she heard the alarm sounding when she was in a room with another resident. V7 said she went down the hall and looked out the door but didn't see anything from just looking straight out the door. V7 said V5 went outside and found R1 on the sidewalk. V7 said V5 escorted R1 into the building to her room to get her walker. V7 said R1's elopement alert bracelet was on her walker, which was in R1's room. V7 said the elopement alert bracelets are supposed to be placed on resident ankles, but when she tried to place it on R1's ankle the band was too tight, so she placed it on R1's wrist. V7 said R1 was brought to the nurses' station so staff could keep an eye on her and R1 became somewhat agitated. V7 said R1 told her she didn't know what she was doing outside. V7 said R1 was on the secured dementia unit, but R1's family didn't feel that R1 needed to be down there so R1 was moved upstairs to the non-locked unit. V7 said R1 was put on 15-minute checks and later that day was moved back to the secured dementia unit. V7 said she would see R1 walk up to the desk from her room on occasion prior to this incident.On 4/1/26 at 12:17 PM, V1 (Administrator) said the elopement alert alarms are only on the front door and the solarium doors of the facility. V1 said if a resident wearing an elopement alert bracelet gets close to the doors with the elopement alert alarm, the door automatically locks. V1 said the doors at the ends of the resident hallways in wings 1-6 do not have elopement alert alarms. V1 said those doors have alarms but can be opened after pushing for 15 seconds. V1 said elopement alert bracelets are used for residents at risk for elopement. V1 said elopement alert bracelets are used for residents in the secured dementia unit in case those residents are upstairs and try to go out the doors. On 4/1/26 at 12:32 PM, R1 was sitting at the dining room table eating lunch. R1 had a 4 wheeled walker to her right side. R1 had an elopement alert bracelet on her right wrist. R1 responded to her name and answered questions about her lunch but could not answer what day it was or where she was. R1 said she had gone outside to take a walk, and the staff had helped her back in. On 4/1/26 at 12:34 PM, V8 (LPN) said she is the primary nurse on the dementia unit. V8 said R1 is alert to her name and the location of her room, but needs cues for the time of day, where she is at, personal care, and when to change clothes. V8 said R1 is mostly independent and walks with a walker but is a fall risk due to her diagnoses and the medications she takes. On 4/1/26 at 12:43 PM, V9 (LPN) said she was walking in to start her shift the morning of 3/26/26 when she heard the alarms going off. V9 said she heard the alarm for wing 3 and then within a minute or so heard the alarm for wing 1 go off. V9 said a staff member walked by and she asked what was going on and was told R1 went out. V9 said she went down to R1's room and R1 was very confused. V9 said R1 said she didn't know what she was doing. V9 said R1 was on antibiotics for a urinary tract infection. V9 said she brought R1 to the nurses' station with her. V9 said R1's elopement alert bracelet was on her walker, but after this incident it was moved to her wrist. V9 said the normal placement for the elopement alert bracelet is on the ankle, but it was too tight for R1's ankle. On 4/1/26 at 12:46 PM, V10 (Maintenance Director), with this surveyor walked the distance from the door of resident wing 3 to the halfway point to resident wing 1. V10 said the distance was approximately 50 feet. V10 said the only doors at the facility with elopement alert alarms are the front door and the solarium. V10 said the resident wing hall doors just have alarms, so if a resident with an elopement alert bracelet pushed on those doors, the alarm will sound, and the door will open in 15 seconds. On 4/1/26 at 1:30 PM, V1 said R1's elopement assessment was done on 3/12/26 as part of a plan of correction for another resident elopement on 3/10/26. V1 said R1's elopement alert bracelet was implemented at that time. V1 said orders to check placement were not put in until 3/26/26. R1's admission elopement assessment dated [DATE] shows R1 is at risk for elopement.R1's fall risk assessment dated [DATE] shows R1 is at risk for falls.R1's Care Plan shows R1 has diagnoses of dementia, repeated falls, and bipolar. This same Care Plan shows R1 is at risk for elopement updated 2/23/26 with interventions resident get confused and need reoriented to surroundings at times. The intervention of elopement alert order to be obtained was added 3/12/26. This Care Plan shows has limited physical mobility related to past falls and weakness and requires supervision of one staff to walk (updated 3/2/26).R1's Physician Orders do not contain orders to monitor R1 elopement alert band for placement until 3/26/26.The Time and Date website shows the temperature for the facility's location on 3/26/26 at 5:44 AM was 44 degrees Fahrenheit.The facility was cited on 3/12/26 for F689 for an elopement that occurred on 3/10/26.2. The facility's elopement risk list dated 4/1/26 shows R2 and R3 are at risk for elopement and reside in wing 5 (not a secured unit).On 4/1/26 at 1:00 PM, R2 was sitting in a recliner in her room. R2's wheelchair was in the room and had an elopement alert bracelet on the handle of her wheelchair. R2 said she doesn't go outside unless the temperature is just right. R2 said she uses her wheelchair to get around the facility.R2's Face Sheet shows R2 resides on wing 5 and shows diagnoses of other specified disorders of the brain and major depressive disorder.R2's Elopement Risk assessment dated [DATE] shows R2 is at risk for elopement.R2's Care Plan dated 9/29/25 shows R2 is at risk for elopement by attempting to leave the facility without a responsible escort.3. On 4/1/26 at 1:05 PM, R3 was sitting in her wheelchair in her room. R3 had an elopement alert bracelet on the handle of her wheelchair. R3 said she uses a wheelchair to get around and sometimes she goes outside.R3's Face Sheet shows R3 resides on wing 5 and shows diagnoses of Alzheimer's disease and unspecified dementia.R3's Elopement Risk assessment dated [DATE] shows R3 is at risk for elopement.R3's Care Plan dated 1/9/26 shows R3 is at risk for elopement by attempting to leave the facility unattended and has impaired safety awareness.On 4/1/26 at 1:11 PM, V11 (Registered Nurse/RN) said R2 and R3 ambulate with their wheelchairs. V11 said R2 has had behaviors of going to the front door and wanting to leave. V11 said R3 was talking about leaving. V11 said R3 cut her elopement alert band off of her leg and R2 complained the bracelet was bothering her so for both of them the bracelets were placed on their wheelchairs.

Based on observation, interview, and record review the facility failed to prevent a cognitively impaired resident from leaving the facility unsupervised for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.The findings include:On 3/12/26 at 11:50 AM, R1 was in her room with V14 (Licensed Practical Nurse-LPN). R1 was heard screaming. V14 was attempting to help R1 zip her coat. R1 was adamant about wearing her coat, even though she was inside the building. V14 was attempting to get R1 to lay in bed for some rest. R1 was resistive and back up wandering out into the hall. V14 said she was assigned to provide one on one supervision for R1 today. R1 continued to ambulate throughout the unit and was very difficult to redirect. R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include vascular dementia with other behavioral disturbance, hypertension, insomnia, and disorders of muscle. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment.R1's Elopement/Wandering assessment dated [DATE] showed, I demonstrate behavior that may be interpreted as (wandering, pacing, roaming, exit seeking). Symptoms are manifested by attempting to leave the facility without a responsible escort/elopement; pacing, roaming, or wandering in and out of peers' rooms; becoming agitated and upset looking for family - I will respond to staff redirection from attempt to elope from the facility. Apply wanderguard [a wearable electronic monitoring device] to monitor elopement attempt.R1's Incident Report dated 3/10/26 showed, Resident opened door number 4 on the [memory care unit] and exited the building, walking on the sidewalk behind the building. She was wearing a heavy sweater and long pants. The temperature was 54 degrees and sunny. She [R1] tapped on the door and was let in the foyer door by staff. She was taken to the unit and the nurse completed body audit which revealed no injury.R1's 3/10/26 Health Status Note entered at 4:33 PM showed, At approximately 8:27 AM, [R1] identified as an elopement risk, exited the facility through the #4 door without staff knowledge. The door alarm activated, but staff did not hear the alarm due to environmental noise at the nurses' station. Resident was located outside by the door in the foyer area tapping on the door to be let back in. She was then let back in the building by the activity aide (V11) at 8:30 AM. Resident assessed for injuries: no injuries identified. Vitals stable. Elopement risk reassessed; care plan updated to reflect additional safety measures. Staff educated/reminded regarding monitoring of high-risk residents. R1's 3/9/26 Behavior Note entered at 5:41 AM showed, Resident restless and pacing unit frequently at start of NOC [night] shift, intrusive into several peer's rooms, calling out for parents, removing items from rooms, carrying several items around unit. Very difficult to redirect behavior, resident states she's tired, allows staff to assist her into bed but gets out of bed as staff is leaving room. Frequent checks maintained. R1's 3/2/26 Nursing Note entered at 2:37 PM, Resident has been combative and agitated all day. Lorazepam x 2 ineffective. order received for IM haloperidol 5 mg [milligrams] one time dose. Resident trying numerous times to exit facility. Going into other rooms and difficult to redirect. On 3/13/26 at 11:52 AM, V4 (Certified Nursing Assistant-CNA) said, We were still getting people up, I had seen her in the dining room and the next thing I know, she was brought back in, I checked all the doors, door 4 was disengaged. It was unlocked; I could open it. The alarm was not going off. It usually does go off. She was brought in by [V11 - Activity Aide]. She brought her in through the main entrance way. they were working on the doors yesterday. She did have a wanderguard on, it only sets off this main door right here. There is a lock and an alarm on each door. [R1] wanders a lot. She does exit seek, goes to the doors and pushes on them; we are usually on top of it. she wanders all day. She got out of the main entrance last week; I think maybe on Sunday. I wasn't here that day, but I heard about it because they sent out a notification. That time she just made it a few feet out of the main door, not outside.On 3/12/26 at 12:27 PM, V11 (Activity Aide) said, I wasn't here when she went out the door. I was the one who brought her back in the door. I was coming in about 20 minutes early for my 9:00 AM shift. I sit on the couch out by the fireplace; I was sitting there and heard a 'tap' on the window. I looked up and [R1] was standing there. I went out and took her by the hand. I brought her back into the nurse that was on duty. I would say it was about 8:40 AM to 8:45 AM because I delivered her to the nurse and went upstairs to punch in for my shift. I had to wait a couple of minutes to punch in at 8:55 AM. She wasn't really upset. she had no facial expression at all. She was glad to get in that door because she came right in with me. She was wearing a 3/4 length dark colored blouse and dark colored pants. Her hands were cold. [R1] goes to all the doors, and she is twisting the knob and pushing, trying to get through. I didn't hear the alarm sounding. I was surprised to hear the 'tap tap'. When out and about, I hear the alarm sounding, it is pretty loud.On 3/12/26 at 12:21 PM, V10 (Housekeeper) said, I was over in the purple hall, I didn't hear anything, no alarm. I would have typically heard the alarm from where I was. She has set alarms off before and I've had to relock the doors. It's very loud. I heard nothing that day.On 3/12/26 at 1218 PM, V9 (Housekeeper) said, I was on the pink hallway, one of the other housekeepers came in and said [R1] just got out. She had tried to get out at the end of the pink hall, and I said 'no' and we reengaged the door. I know if the door is not blinking the alarm is not engaged, I did not hear the alarm go off. [V11] brought her back in. She comes in at 9 AM and she saw [R1] knocking on the window to come back in.On 3/12/26 at 11:32 AM, V5 (CNA) said, I was in another resident's room at the time, I didn't hear any alarms. They were in fixing the doors yesterday to make sure all the alarms are working. they were checking and fixing all the doors and did reeducation on how to lock and check the doors. I think the door is automatic, but I think they are supposed to check it. she does try to go out.On 3/12/26 at 11:41 AM, V7 (CNA) said, [R1] does a lot of wandering, and she doesn't take redirection very well. It is normal for her to go to the doors and press on it and walk away but it has just become more persistent, where she just keeps going to the door. she does try all of them. She doesn't say where she is going, just wants to get out.On 3/12/26 at 1:24 PM, V13 (Maintenance Director) said, Two companies came in and corporate maintenance was here too. We want to make the alarms louder, so we are adding new alarms to the system as well. Same system as before, just want them louder and they changed the locks on the emergency doors going out. Because it was the same key for all the resident doors. There was nothing wrong with it, it has been working fine, we just wanted it to be updated as far as noise. Unless it was disengaged. The door must be disengaged for it to open. If it's engaged and they push on it, the alarm goes off. If it was disengaged, we don't know how it got disengaged. The new system allows only the nurse to have the key to disengage. they also brought in the lock [NAME] to change the locks out.On 3/12/26 at 1:46 PM, V15 (Regional Nurse Consultant) and V16 (Regional Director of Operations) said through the interviews with staff, they determined approximately what time R1 had exited the facility. V15 said they determined which door R1 exited through interview with the [V4 CNA] who reported that door 4 was found disengaged. The facility's policy and procedure reviewed 12/1/25 showed, Elopements and Wandering Residents. Policy: This facility ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 4. Monitoring and Managing residents at Risk for Elopement or Unsafe Wandering. d. Adequate supervision will be provided to help prevent accidents or elopements. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.

Based on interview and record review the facility failed to ensure a resident's medical record contained documentation of a change of condition for 1 of 3 residents reviewed for medical record accuracy in the sample of 4.The Findings include:R3's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including gastrostomy status, and cognitive communication deficit. R3's 1/9/26 care plan documents she requires a tube feeding related to dysphagia (difficulty swallowing).The 2/1/26 emergency department documents R3 arrived at 5:36 AM with a chief complaint of a pulled out feeding tube. The notes show a temporary tube was placed with an outpatient procedure to be scheduled to replace the percutaneous endoscopic gastrostomy (PEG).R3s facility record was reviewed and had no details relating to an incident of R3s PEG tube being dislodged or coming out. The notes do not show she left the facility. On 2/10/26 at 12:06 PM, V5 certified nursing assistant said during her rounds last week, she found R1 in bed, and her feeding tube was on the floor with the bulb intact. R3 had very minimal blood present at the site. She reported the incident to V4 Registered Nurse (RN) and completed vital signs and prepared R3 for transport to the emergency room. She said R3s vital signs were normal, nothing stands out to her. R3 was in no apparent distress or pain.On 2/10/26 at 11:52 AM, V4 said she was on another wing in the facility when V5 reported R3s PEG tube had been removed. V4 had V5 get vital signs, and she (V4) notified the on-call manager and the physician prior to sending R3 out to the emergency room. V4 said she had multiple emergencies at the same time, and it would not surprise her if nothing was documented. V4 said she would have charted the details as they occurred.On 2/10/26 at 10:43 AM, V6 Licensed Practical Nurse (LPN) said there should have been an order for the transfer to the hospital, progress notes with details of what happened, and notifications to the family and physician.On 2/10/26 at 1:46 PM, V2 Director of Nursing said the nurses should be putting in a progress note why a resident is leaving the facility and when they leave, including who they left with and their condition. It is important to have the documentation, so staff know why they were sent and where they were sent.The facility's 12/2025 policy for documentation in medical record states each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy explanation and compliance guidelines: 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on interview and record review the facility failed to notify the wound care provider of a resident's critical lab value prior to wound care. This applies to 1 of 3 residents (R1) reviewed for notification in the sample of 5. The findings include:R1's admission Record (Face Sheet) showed an admission date of 8/12/25 with diagnoses to include but not limited to stage four pressure ulcer to the left heel, atrial fibrillation (rapid/irregular heartbeat), and left hip fracture. R1's Face Sheet showed she was discharged from the facility on 11/6/25. R1's October 2025 electronic medication administration record (eMAR) showed an order for 3 milligrams of Warfarin (anticoagulant) to be given at bedtime. The eMAR showed the order was started on 9/23/25; it was not given on 10/8/25 then the order was discontinued on 10/9/25. R1's Lab Result Report from 10/8/25 collected at 6:32 AM and reported at 5:26 PM showed her International Normalized Ratio (INR, a lab result used to measure a person's ability to clot and is used to determine therapeutic dosages of anticoagulants like Warfarin. Higher INR values indicate less clotting ability. Typical therapeutic INR range for atrial fibrillation patients is 2.0 to 3.0.) was 7.8. This INR value was highlighted in red, and it was flagged. R1's Progress Notes from 10/8/25 showed no provider or family notification regarding R1's INR results. R1's 10/9/25 Skin/Wound Note from 3:36 PM showed V10 Wound Care Physician assessed and treated R1's left heel pressure wound. The note showed, After debridement, (procedure of removing infected, dead, or damaged tissue) wound was bleeding heavily and provider cauterized it. Pressure bandage applied. Nurse notified to monitor this area. R1's 10/9/25 Health Status Note from 5:23 PM, showed R1's Power of Attorney wanted to speak with V11 regarding R1's wound care performed that day. On 12/13/25 at 1:35 PM, V3 Corporate Regional Nurse stated warfarin is an anticoagulant and INR lab draws are used to measure and determine therapeutic dosages for warfarin. V3 stated warfarin thins the blood and makes it more likely for a person to bleed. V3 stated it is the nurse's responsibility to notify the provider of all INR results. On 12/13/25 at 1:35 PM, V11 Wound Care Nurse (interviewed in tandem with V3) stated she was rounding with V10 on 10/9/25. V11 stated at the time of R1's wound care on 10/9/25, she was not aware of R1's high INR. V11 stated it is the floor nurse's responsibility to notify her of abnormal lab results so she can notify V10. V11 said, R1's wound was debrided and dressed then the CNA notified her the wound had bled through R1'd dressing. V11 said, R1's dressing was removed and V10 cauterized (burned) the bleeding. On 12/13/25 at 11:32 AM, V10 Wound Care Physician stated he was not aware of R1's INR lab value on 10/9/25 prior to debriding her wound. V10 stated he assesses residents when he first takes on their care then after that point the facility needs to notify him of resident changes. V10 said the nurse or the provider who ordered the INR should have notified him of the high value. V10 stated, had he been notified of R1's INR, he would not have debrided her wound due to the risk of bleeding. V10 stated R1 did bleed; however, it was not clinically significant and he was able to stop the bleeding. The facility's Notification of Changes policy (undated) showed The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The policy stated Circumstances requiring notification include.Circumstances that require a need to alter treatment.

Based on interview and record review, the facility failed to ensure the safety and supervision was maintained for 2 of 3 residents (R1, R2) reviewed for elopement in the sample of 3. The findings include:On 8/6/2025 R1 was observed in the activity room, sitting in a recliner. R1 looked at surveyor and smiled when surveyor waved at him. R1 was observed at 3:46 PM in the dining room in another activity. R1 was sitting at a table with other residents and their family. R1 was smiling while sitting at the table. R2 was observed on 8/6/2025 sleeping while sitting up, on a couch on the 300 wing. R2 was observed on 8/7/2025 during the lunch meal eating. V2 (unit coordinator/social services) was sitting next to R2 encouraging intakes. R2 was observed being assisted with walking to his room and being provided personal cares. R2 was resistive to care at first, but staff were able to convince R2 to allow them to assist him. On 8/6/2025 at 3:07 PM, V3 (Licensed Practical Nurse-LPN) said she was not working when the incidents occurred. V3 said she was told R1 and R2 both got off the memory care unit. V3 said R1 and R2 both have a wander guard in place. The wander guards work for the main entrance to the memory care unit. They do not work for the exit doors. V3 said at the beginning of her shifts, she checks to make sure all the exit doors are secure and do not open when she pushes on them. V3 said she makes sure the light is blinking; that means the door is secure and locked. V3 said she makes sure the alarm sounds when the handle is pushed in. V3 said R2 is new to the facility and staff. He has been at the facility for less than a week and staff are all getting to know him. He walks a lot. Today he has been pushing the door. It will make the initial sound, and he would walk away from it. He has done it at least once, maybe a couple times. V3 said it was on second shift that R2 got out. She is not sure what shift R1 got out. V3 stated, I am a floor nurse. my job is to keep the residents on the unit as safe as possible.On 8/6/2025 at 3:30 PM, V2 (Memory Care Coordinator/Social Services) said she was not at the facility for either incident. V2 said both incidents happened on second shift. V2 said she wasn't aware of what all happened, or how they both got out. V2 said the exit doors on the memory care unit have a dual alarm and the bar alarm. The dual alarm is on the door and goes off when the door is opened. The bar alarm goes off when the bar is pushed on the door handle. V2 said she does not know what happened to allow both R1 and R2 to get out without the doors alarming. V2 said she knows R2 had triggered the alarm earlier, but she does not know how much later it was before he got out of the building. V2 said she does not know if the door was alarmed or not. V2 said she asked the nurse about R2's incident. V2 said she asked if the door alarm was set. V2 said the nurse said it was flashing and when the handle was pushed in, it alarmed. V2 said she was not sure about the details of when R1 got out of the building. V2 identified V11 (LPN) as the nurse on duty when R2 got out of the building. V2 said V11 is new to the facility. V2 identified V5 (LPN) as the nurse on duty when R1 got out of the building. On 8/6/2025 at 3:50 PM, V5 (LPN) said R1 got out of the building on 7/3/2025, after dinner, between like 6:00 -7:00 PM. V5 said there were certain times where R1 would start having episodes of confusion. R1 would get agitated easily. R1 thought he was supposed to be going home to his wife. V5 said that day we had to redirect him more frequently. R1 went to the end of hall 1, took his walker, banged it up against the door and set the alarm off. V5 said he (V5) was passing medications on hall 300. I heard the Activity Aide say the alarm was off and someone is trying to get outside. V5 said he and V12 (CNA) ran to the door. It was open. V5 said R1 was about 10-15 feet from the door. on the sidewalk. (V12) and I ran out to R1. V5 said they were able to easily redirect R1 back into the building and gave him his after-dinner snack. V5 said he has been told during reports that R1 has tried to get out before by banging his walker against the door and set the alarm off. V5 said the nurse must manually reset the door alarm, after the door is opened and it alarms. V5 demonstrated how the door alarm is reset. V5 said the light could be red but not blinking if the latch is not all the way shut. To reset the alarm, you put the key in, turn it, then you make sure the latch is on the inside of the door, and push on the door to make sure it does not come open. You remove the key. the light will be red at first, then if set right, it will start blinking. V5 said you push the handle in, and the door will beep. At 4:20 PM, V5 came up to this surveyor and said the Aide yelled alarm going off, not alarm is off.On 8/7/2025 at 8/7/25 at 8:39 AM, V8 (Activity Aide) said she has been an activity aide on the Terrace unit since Mid-May. V8 said she was working on 7/3/2025 when R1 got out of the building. V8 said it was between 7:00-8:00 pm. V8 said after dinner we went to the TV room. At first, (R1) was fine, but he gets overstimulated. V8 said R1 gets mad and wants to leave. V8 said she let V5 (LPN) know that R1 wanted to leave the TV room and V5 told her to let him go down the hall and we will watch him. V8 said she saw R1 go down hall 1. She did not see him for about 5 minutes, so she asked V5 if he had seen R1. He said no. V8 said she started looking in resident rooms on hall 1. As she got to the end of the hall, she saw the exit door was opened a crack. V8 said the alarm was not sounding. V8 said she looked out and saw R1 near the end of the sidewalk by the parking lot. V8 said she had her foot holding the door open. she asked R1 what he was doing and R1 said I'm going home. V8 said she kept trying to get him to come in and he said no. V8 said she opened the exit door and yelled for help. V12 (CNA) and V5 (LPN) came out a minute later. They came out the visitor door by the terrace entrance and came around the building. V8 said it took about a minute after they came out to get R1 to come inV8 said R1 gets aggressive at times and punches at staff. V8 said she was not informed R1 was an elopement risk. I'm not aware of an elopement list for residents. V8 said after she got off work, she reported the incident. V8 said it was about two hours after the incident occurred and she does not believe V5 had reported the incident to V1 yet. V8 said I'm guessing someone turned the alarm off and did not reset it, because they got tired of hearing it. V8 said she has seen R2 try to get out. He will push on the door handle, it beeps, and staff redirect him. V8 said a resident is an elopement risk if they wander and talk about wanting to leave.On 8/7/2025 at 4:09 PM, V12 (CNA) said she was working the night R1 got out of the building. V12 said she thinks she was in with another resident providing care. She thinks she was going out of the room to get something and saw R1 outside as she was going past the window. V12 said she let V5 (LPN) know, and they both went out there immediately. V12 said the alarm was not sounding. V12 said she was not aware that R1 was exit-seeking. V12 said she had been employed at the facility for 5 months, but she floats all over the building. V12 said a resident is an elopement risk if they wander. V12 said once we saw R1, he was easily redirected back into the building. I believe he was wearing jeans and a flannel shirt and shoes. V12 said R1 was still on the sidewalk when we went out to get him.R1's progress note dated 7/03/2025 21:27 written by V5 (LPN) showed, While assisting other patients to their bedrooms and CNAs also provide care for other patients in their bedrooms. The tv room staff member monitoring the patients, suddenly she heard exit door alarm sound off. She noted that a patient set the alarm off at one of the exits on the unit by opening a door while exit seeking. The patient then wandered out the door onto the sidewalk outside the door. The patient was 15 steps out the door on the sidewalk. I the Nurse was updated by the CNA, so we then both ran outside to the patient. We then redirected patient to come back into the building and he agreed. Patient had on his shoes and was using his walker with a steady gait and no injuries. Patient is confused and states where am I. Assisted patient to a recliner in the TV room, where a staff member could supervise patient's behaviors and exit seeking attempts. Patient stated where am I, and when can I go home. Offered to toilet the patient and he stated No, I don't have to use the bathroom. Patient assisted back into building by using redirection. Educated the patient on safety and educated patient that exit when opened will set off alarms. Patient unable to learn d/t diminished cognitive skills. Assisted Back to his recliner. Re-locked exit door and set alarm again and alarm is activated and functional. Will continue to monitor. Please see nurse's notes for more details. R1's progress note dated 7/2/2025 showed he was exit-seeking. R1's facility assessment dated [DATE] showed he had severe cognitive impairment, had wandering behaviors daily, used a wheelchair or walker for ambulation, and required supervision or touching assist with walking. R1's care plan initiated on 12/6/2024 showed he was at risk for wandering/Elopement.R1's Elopement Risk Assessments dated 12/6/2024, 3/12/2025, 7/7/2025 and 8/6/2025 all showed he was at risk for elopement.R1's progress note dated 7/03/2025 21:27 written by V5 (LPN) showed, While assisting other patients to their bedrooms and CNAs also provide care for other patients in their bedrooms. The tv room staff member monitoring the patients, suddenly she heard exit door alarm sound off. She noted that a patient set the alarm off at one of the exits on the unit by opening a door while exit seeking. The patient then wandered out the door onto the sidewalk outside the door. The patient was 15 steps out the door on the sidewalk. I the Nurse was updated by the CNA, so we then both ran outside to the patient. We then redirected patient to come back into the building and he agreed. Patient had on his shoes and was using his walker with a steady gait and no injuries. Patient is confused and states where am I. Assisted patient to a recliner in the TV room, where a staff member could supervise patient's behaviors and exit seeking attempts. Patient stated where am I, and when can I go home. Offered to toilet the patient and he stated No, I don't have to use the bathroom. Patient assisted back into building by using redirection. Educated the patient on safety and educated patient that exit when opened will set off alarms. Patient unable to learn d/t diminished cognitive skills. Assisted Back to his recliner. Re-locked exit door and set alarm again and alarm is activated and functional. Will continue to monitor. Please see nurse's notes for more details. R1's progress note dated 7/2/2025 showed he was exit-seeking. R1's facility assessment dated [DATE] showed he had severe cognitive impairment, had wandering behaviors daily, used a wheelchair or walker for ambulation, and required supervision or touching assist with walking. R1's care plan initiated on 12/6/2024 showed he was at risk for wandering/Elopement.R1's Elopement Risk Assessments dated 12/6/2024, 3/12/2025, 7/7/2025 and 8/6/2025 all showed he was at risk for elopement.On 8/6/2025 at 4:25 PM, V6 and V7 (maintenance) tested the alarms on the four exit doors on the memory care unit. V7 said they have not figured out what happened when R1 got out. Maybe someone went out and forgot to reset the alarm. V7 said the exit door on wing 1 is not a normal passage door. V7 said they tested all the doors the next day on the unit and the alarms worked properly. V6 pushed on the handle to the exit door on wing 1 and the alarm beeped. When he opened the door, the alarmed sounded. The wing 1 exit door opened onto a sidewalk that went to the terrace entrance parking lot. Between 4:34 PM-4:40 PM the alarms for the exit doors on wings 2, 3, and 4 were observed. All the doors alarmed when the door was opened. Wing 4 exit door opened to a grassy area, then gravel area, then more grass that led up to the apartments next door. V7 said he is not sure where R2 was found, but it was somewhere between the exit door and the apartments next door. V6 said the facility has ordered new dual alarms because the only one that worked properly when maintenance checked the next day was the dual alarm on wing 1. V6 said the door alarms were working, but not the secondary alarms that were in place. Waiting on new alarms to be delivered. On 8/1:32 PM, V11 (LPN) said she was the nurse working on the terrace unit on 8/3/2025. V11 said R2 wanders. He has terminal restlessness. He can be exhausted and still walk. V11 said she heard the door alarm go off for hall 4. V11 said she reset the alarm, pushed on the door and the door did not give. the red light was blinking. V11 said later, she was informed by another nurse that someone from the apartments behind the terrace called and said an older man was walking behind the terrace. V11 said she went around the building and walked the perimeter. V11 said she saw R2 walking on the sidewalk about 10-15 feet from the hall 4 exit door. V11 said she is a terrible judge of distance. V11 said it was about halfway between hall 3 and hall 4 exit doors. V11 said R2 was just walking. He had on shoes. gray lounge pants and a t-shirt. V11 said it was probably between 7:30-8:00 PM. V11 said the alarm did not go off when R2 went out. V11 said the wing 4 door alarm was not working properly. V11 said she did not know if it was due to the heat/humidity that the door stuck in the jam. V11 said it was solid in the door jam, but there was a small space between the jam and the door and for some reason it knew the door was in the jam but not far enough to alarm. V11 said she walked with R2 around the courtyard and sat on the bench for a few minutes. V11 said R2 wanted to walk again so they walked and sat on the next bench. V11 said she knocked on the window and told a staff member to bring her a wheelchair. V11 said R2 always tries to get out of building to go home. To go to dinner with his kids, or to go to work. V11 said R2 is always going somewhere. On 8/7/2025 at 10:14 AM, V9 (CNA) said she works on the terrace unit 90% of the time. I worked on 8/3/2025 on the terrace. I left at 6:00 PM. V9 said R1 and R2 are both elopement risks. R1 has said he wants to go home. V9 said she has seen R2 push on the exit doors. V9 said she was not sure if there was a list on the terrace of residents at risk of elopement. V9 said R1 and R2 both have a wander guard. The wander guard only works on the main entrance to the Terrace unit. V9 said Sunday evening she got a message saying she had to get marked off on the door again. V9 said the last one time she recalls being marked off for training on the exit doors was about a year and a half ago, adding her timing could be off a little. R2's progress note dated 8/2/2025 showed he was ambulating all over unit, undressing and setting off door alarms. Very difficult to redirect. Did take his medications tonight. Would not stay put to eat any supper. R2's 7/30/2025 BIMS evaluation showed R2 had severe cognitive impairment. R2's 7/30/2025 Elopement assessment showed he had wandering behaviors that could affect the privacy of others, and he was at risk of elopement. R2's Elopement Risk Evaluation dated 7/30/2025 showed he was at risk of elopement. R2's care plan initiated 7/30/2025 showed he demonstrates behaviors that may be interpreted as wandering, pacing, roaming, exit-seeking. Symptoms are manifested by pacing, roaming, or wandering in and out of peers' rooms. R2's progress notes dated 8/3/2025 at 10:58 AM showed he was pacing the unit for extended periods of time, anxiousness, and being easily distracted impair his ability to sit for extended periods of time.R2's progress note dated 8/3/2025 showed a skilled evaluation was done for R2 at 9:39 PM. No documentation of R2's elopement was in the evaluation, or in the progress notes on 8/3/2025.The facility's investigation for R2's 8/3/2025 incident showed typed statements from V11 and V19 (CNA) saying the alarm had been sounding. Neither statement was signed by V11 or V19. Neither statement was handwritten by V11 or V19 (V11 said in interview with this surveyor that the alarm was not sounding). The facility's policy and procedure titled Elopements and Wandering Residents, with a revision date of 12/1/2024, showed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . The policy defines elopement as occurring when a resident leaves the premises. The policy showed 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. the policy and procedure showed the procedure for locating a missing resident included a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. (e.g. internal alert code). B. The designated facility staff will look for the resident. C. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The Administrator or designee should also notify the company's corporate office. D. DON (Director of Nursing) or designee shall notify the physician and family member or legal representative. E. Police will be given a description and information about the resident; include any photos. F. All parties will be notified of the outcome once the resident is located. G. Appropriate reporting requirements to the State Survey agency shall be conducted.

Based on observation, interview, and record review the facility failed to ensure pureed pork was pureed to a pudding-like consistency. This applies to 4 of 4 residents (R390, R60, R339, R1) reviewed for pureed diets in the sample of 19. The findings include: Facility provided list of residents on a pureed diet shows R390, R60, R339, and R1 receive pureed diets. On 4/28/25 at 10:04 AM, V13 (Cook) started the puree process for the pureed pork. V13 measured out and weighed enough pork for four servings of pureed pork. V13 placed the pork into a blender pitcher with broth and started to puree the pork. At 10:09 AM, V13 stopped the blender and tested the consistency. V13 said it wasn't quite ready at that time and that the pork tends to be a little stringy and more difficult to puree. At 10:10 AM, V13 stopped the blender, tested it a second time and said it was much better. V13 placed the pureed pork into a food service pan and into the oven. On 4/28/25 at 10:11 AM, the first finished batch of pureed pork appeared to be lumpy as V13 scooped it into the food service pan. On 4/28/25 at 10:14 AM, V13 began the second batch of pureed pork and weighed out enough for three servings. V13 placed the pork into a blender pitcher with broth and started to puree the pork. At 10:15 AM, V13 stopped the blender and tested the pureed pork and said it was not quite ready. At 10:16 AM, V13 stopped the blender, tested the pureed pork again, and said it was good. On 4/28/25 at 9:58 AM, V13 said the consistency of the purees should be a pudding-like consistency. On 4/28/25 at 1:00 PM, the facility provided test tray of pureed pork was stringy, not fully blended, and required chewing. On 4/28/25 at 1:12 PM, V12 (Food Service Director) agreed that the pureed pork was stringy and not of an appropriate texture. Facility Puree Food Preparation policy dated 12/1/2023 states, . Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding.

Based on observation, interview, and record review the facility failed to ensure residents were issued an advanced beneficiary notice form. This applies to 3 of 3 residents (R9, R83, and R289) reviewed for beneficiary notices in the sample of 19. The findings include: 1. R9's NOMNC (Notice of Medicare Non-Coverage) form signed on 3/6/25 shows R9's last covered day of services from Medicare Part A was 3/8/25. Facility completed SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form for R9 shows that R9 was provided a NOMNC form but was not provided an ABN (Advance Beneficiary Notice) form. R9's census profile shows R9 still resides in the facility and is using personal insurance is R9's payer source. 2. R83's NOMNC (Notice of Medicare Non-Coverage) form signed on 2/21/25 shows R83's last covered day of services from Medicare Part A was 2/23/25. Facility completed SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form for R83 shows that R83 was provided a NOMNC form but was not provided an ABN (Advance Beneficiary Notice) form. R83's census profile shows R83 discharged from the facility on 2/28/25 and had a payer source of private pay from 2/24/25 until 2/27/25. 3. R289's NOMNC (Notice of Medicare Non-Coverage) form signed on 3/14/25 shows R9's last covered day of services from Medicare Part A was 3/16/25. Facility completed SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form for R289 shows that R289 was provided a NOMNC form but was not provided an ABN (Advance Beneficiary Notice) form. R289's census profile shows R289 still resides in the facility and is using private pay as R289's payer source. On 4/30/25 at 12:18 PM, V22 (Social Services Director) said V22 and V24 (Memory Care Coordinator/Social Services) provide the residents with the NOMNC forms. When this surveyor asked V22 and V24 about their ABN form, V22 stated that the form looked familiar, but V22 does not provide it to the residents and V24 stated V24 has never seen the ABN form before. V22 stated V23 (Business Office Manager) would be the one to go over the financial aspect of the discharge process with residents. On 4/30/25 at 12:26 PM, V23 said he does not complete or provide the residents with an ABN form. V23 did say he goes over the financial portion of the discharge, but V23 does not document these interactions anywhere. On 4/30/25 at 12:34 PM, V24 said when V24 provides the residents with the NOMNC form, V24 is not in attendance. Facility Advance Beneficiary Notices policy dated 12/23 states, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage . 5. The current CMS (Centers for Medicare and Medicaid)-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-1005.

Based on observation, interview, and record review, the facility failed to ensure activity of daily living (ADL) assistance was provided for a dependent resident for 1 of 19 residents (R40) reviewed for ADLs in the sample of 19. The findings include: R40's Admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including major depressive disorder, osteoarthritis, and alzheimer's disease. R40's Care Plan initiated January 6, 2025, shows R40 has an ADL self-care performance deficit. On April 28, 2025, at 10:06 AM, V4 and V5 Certified Nursing Assistants (CNA) went into R40's room to provide incontinence care. R40 told V4 and V5, I'm wet. V4 CNA told this surveyor that R40 was a get up. Meaning R40 should have been gotten up by night shift early in the morning. V4 removed R40's incontinence brief. There was a thick incontinence pad inside of R40's incontinence brief. Both the pad and R40's incontinence brief were saturated with dark urine from front to back. V4 said she did not know why R40 had an incontinence pad plus an incontinence brief on. V4 also said she does not know when R40's incontinence brief was last changed. On April 29, 2025, at 12:28 PM, V7 CNA said incontinence care should be done at least every two hours so the residents skin stays dry. It helps to prevent sores. V7 said an incontinence pad should not be place with an incontinence brief. R40's Minimum Data Set (MDS) dated [DATE], shows, she does not have any history of refusing cares. R40 is occasionally incontinent of urine and is dependent on staff for toileting and personal hygiene. The facility's Activities of Daily Living (ADLS) policy revised December 1, 2024, shows, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and record review the facility failed to initiate a pre-surgical order for a resident prior to his abdominal surgery. The facility failed to implement treatment orders for a resident with compression fractures of her spine. These failures apply to 2 of 19 residents (R43 and R390) reviewed for quality of care in the sample of 19. The findings include: 1. R43's Admission Record showed R43 was admitted to the facility on [DATE] with diagnoses of dementia, Alzheimer's Disease, atrial fibrillation (a-fib), and long-term use of anticoagulation medications. R43's current care plan showed R43 was cognitively impaired related to his diagnoses of dementia and Alzheimer's Disease. R43's December 2024 Medication Administration Record (MAR) showed R43 was prescribed Pradaxa 150mg (milligrams), give one tablet twice a day for anticoagulation therapy related to his diagnosis of a-fib. On 4/28/25 at 1:15 PM, V14 (Family of R43) stated, My biggest concern is the lack of communication at the facility. (R43) was a scheduled to have (abdominal) hernia surgery in December (2024). It was originally scheduled for December 11th (2024). When I visited him a few days before the surgery, I found out that they never stopped his blood-thinning medication. They were supposed to stop the medication for three days prior to his surgery. (V15 Nurse for R43's Surgeon) faxed all his pre-op (operation) orders and instructions to them (the facility) at the end of November (2024). Since they didn't stop his medication, we had to reschedule (R43's) surgery. A fax dated 11/27/24, sent from R43's surgeon's office to a fax number at the facility, contained R43's pre-op instructions, orders, and date of the surgery. It showed R43's hernia surgery was scheduled for 12/11/24. The fax showed, Surgery date and pre-op instructions .Please hold (R43's) Pradaxa for 3 days prior to surgery . A progress note dated 12/9/24 for R43 showed R43's hernia surgery was rescheduled for 12/13/24 due to R43's Pradaxa medication not being held three days prior (12/8/24-12/11/24) to his original surgery date of 12/11/24. R43's December 2024 MAR showed R43 was given both doses of his Pradaxa on 12/8/24 and 12/9/24. On 4/29/25 at 12:50 PM, V1 Administrator stated, As far as I can tell, it looks like the doctor's office faxed us (R43's) pre-op date and instructions on November 27th (2024) but we either couldn't find them or didn't get them. There are many (fax) machines here in the facility They re-faxed the orders to us on December 9th (2024) . On 4/30/25 at 10:52 AM, V8 Assistant Director of Nursing was shown the fax, dated 11/27/24 from R43's surgeons office, along with the number of the fax that R43's orders were sent to on that date. V8 stated, That's the fax number to the machine by where our receptionist sits. On 4/29/25 at 10:10 AM, V15 (Nurse for R43's Surgeon) stated she herself faxed R43's pre-op orders, instructions, and confirmed surgery date of 12/11/24 to the facility on [DATE]. On 4/30/25 at 8:23 AM, V15 (Nurse for R43's Surgeon) stated, I know someone from the facility had gotten my initial fax (on 11/27/24) because someone called from the facility on December 6th (2024) to schedule (R43's) two-week post-op appointment for his December 11th surgery. I have it documented in (R43's) chart . V15 was unable to remember the name of the employee from the facility that called on 12/6/24. V15 stated, On December 9th, (V14 Family of R43) called me to tell me they had never held his Pradaxa, so we had to reschedule his surgery. I called the facility and whoever I spoke with told me the fax that I had originally sent had gone to some reception desk at the facility. I then re-faxed the information I had initially sent to the facility on [DATE]th, which showed a new surgery date of December 13th . 2. R390's Admission Record showed R390 was admitted to the facility on [DATE]. R390's hospital discharge instructions and orders dated 4/4/25 showed R390 had a diagnosis of compression fractures to her spine. The orders showed R390 was admitted to the facility with an order for R390 to wear a back brace, for treatment of her spinal fractures, when out of bed. R390's April 2025 Order Summary Report showed an order for R390 To wear back brace when OOB (out of bed) and active. Back brace to be off when in bed. On 4/28/25 at 8:57 AM, R390 was seated in the recliner in her room. No brace was noted to R390's back. On 4/28/25 at 12:30 PM, R390 remained seated in the recliner in her room. No brace was noted to R390's back. On 4/29/25 at 9:00 AM, R390 was seated in the recliner in her room, visiting with family. No brace was noted to R390's back. On 4/29/25 at 9:15 AM, V17 Licensed Practical Nurse stated, (R390) does have a brace for her back she is supposed to wear when she is out of bed. I believe it's because she has fractures in her back. The facility's Consulting Physician/Practitioner Orders (undated) showed, Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician . For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will . Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record .

Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner for 2 of 19 residents (R30 and R40) reviewed for safety and supervision in the sample of 19. The findings include: 1. R30's Fall Risk Evaluation dated 4/15/25 showed R30 was at risk for falls due to her history of falls, decreased muscular coordination, and use of ambulatory assistive devices. R30's Restorative assessment dated [DATE] showed R30 required the assistance of one staff member for transfers and toileting. On 4/28/25 at 9:45 AM, R30 was seated in a recliner in her room. R30 told V18 Certified Nursing Assistant (CNA) that she needed to go to the bathroom. V18 CNA transferred R30 from the recliner to a wheelchair by holding onto the waistband of R30's pants and lifting R30 out of the recliner. V18 then wheeled R30 into the bathroom. V18 transferred R30 from the wheelchair to the toilet by holding onto the waistband of R30's pants. No gait belt was used by V18 CNA for either of R30's transfers. On 4/29/25 at 11:35 AM, V19 CNA stated R30 requires the assist of one person for all transfers which means we use a gait belt when transferring her. The facility's Use of Gait Belt policy (undated) showed, It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety . 34506 2. R40's Admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including bilateral osteoarthritis of knees, anemia, major depressive disorder, osteoporosis, and alzheimer's disease. R40's Care Plan initiated December 30, 2024, shows R40 has had an actual fall related to poor balance and unsteady gait. Sensor alarm place in chair and bed for safety. R40 's Fall Risk Evaluation dated March 24, 2025; shows she has had 1-2 falls in the past three months. R40's gait/balance is not checked and does not contain a total fall risk score. On April 28, 2025, at 10:06 AM, V4 and V5 Certified Nursing Assistants (CNAs) transferred R40 from her bed to her chair. V4 and V5 were holding onto a gait belt, but R40 did not bear any weight on her legs. V4 and V5 transferred R40 to her wheelchair by lifting R40 via the gait belt. R40 needed to be scooted back into the wheelchair and V4 and V5 lifted R40 back by holding under her arms and her legs. R40's bed alarm did not sound when R40 was transferred into her wheelchair nor was a wheelchair alarm applied to her chair. R40's Skin Wound Notes dated March 31, 2025, shows R40 experienced a skin tear during a transfer. R40's Nurses notes show on April 24, 2025, R40 was lowered to the ground by a (CNA) while in the resident bathroom. Resident states her knees quit working. On April 28, 2025, R40 lost her balance during a shower and had to be assisted back in her shower chair by the CNA and R40 experienced another skin tear. On April 30, 2025, at 10:02 AM, V3 CNA said if a resident seems weak before transferring, then she notifies the nurse. V3 said if residents are not bearing weight, then the nurse and therapy needs to re-evaluate them. V3 said if a resident is not bearing weight, then the resident or staff could get injured. V3 said the R40 does not bear weight to her legs. V3 said that R40 has been a very tough transfer. The facility's Safe Resident Handling/Transfers policy revised on December 1, 2024, shows, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendation.

Based on observation, interview, and record review, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (R73 and R76) reviewed for dementia care in the sample of 19. The findings include: 1. R73's Admission Record dated April 29, 2025, shows R73 was admitted to the facility on [DATE], with diagnoses including neurocognitive disorder with lewy bodies, alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling. R73's Care Plan revised on November 1, 2024, shows, R73 exhibits resistance to cares: (refusing/resisting medication, refusing/resisting activities of daily living assistance, refusing/resisting food and/or fluids; refusing requests to get out of bed, refusing to cooperate with care plan objectives) related to psychiatric illness, severe mental illness, dementia, fear/paranoia, misunderstanding caregiver requests. Create a warm, safe, and inviting environment for care. Emphasize dignity. Emphasize soothing, kind, slow, and compassionate speech. Give resident time to respond verbally and physically. If attempts to redirect are unsuccessful, try switching staff. Remind resident that they are safe, and staff will protect them. Staff to have a wheelchair with them when resident is showing signs of being resistive to cares. On April 28, 2025, at 11:14 AM, V5 Certified Nursing Assistant (CNA) said, Come on [R73] lets go to the bathroom. V5 held R73 hand and guided him to stand up. V4 CNA was standing behind R73. R73 was planting his feet and not walking. V5 was attempting to slowly guide R73 by holding his hand. V4 had both of her hands to R73's back and was pushing R73 towards the bathroom with both of her hands and her body. It took V4 and V5 more than a few minutes to walk R73 to the bathroom as he did not want to walk. On April 29, 2025, at 12:28 PM, V7 CNA said if R73 is not walking somewhere, then she would get a chair so he could sit down. V7 said time should be given to R73 and then re-approach him later. V7 said she sometimes offers R73 snacks or dances with him to help him reach his destination. V7 said it takes R73 a while to get to a destination, he just needs time. 2. R76's Admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, contusion of scalp, restlessness and agitation, and dementia. R76's Care Plan initiated October 10, 2024, shows R76 may exhibit resistance to cares: Create a warm, safe, and inviting environment for care. Emphasize dignity. If attempts to redirect are unsuccessful, try switching staff. Staff will assist with ambulation as needed with use of assistive devices and give the resident as many choices as possible about care and activities was initiated September 27, 2024. On April 28, 2025, at 11:25 AM, R76 was sitting in the units dining room. R76 kept trying to stand up and walk. V4 CNA stood behind R76, place V4's hands onto R76's shoulders and said hey down and guided R76 to sit back down into the chair and walked away. At 11:29 AM, R76's was continuing to stand and try to walk. The unit manager took R76 for a walk around the unit and then brought R76 back to the dining room and R76 sat down to eat her lunch. On April 29, 2025, at 8:30 AM, V7 CNA was walking the unit with R76 because R76 was continuing to stand up and attempting to walk. On April 29, 2025, at 12:28 PM, V7 said if R76 is trying to stand then staff should try and involve R76 in an activity or take R76 for a walk. The facility's Dementia Care Policy dated December 1, 2024, shows, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnoses with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being.

Based on interview and record review, the facility failed to address an irregularity found by the pharmacist during the monthly medication review for 1 of 5 residents (R73) reviewed for drug regimen review in the sample of 19. The findings include: R73's Admission Record dated April 29, 2025, shows R73 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with lewy bodies, alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling. R73's Medication Regimen Review Prescriber Recommendation (MRR) dated March 11, 2025, shows, Resident is receiving quetiapine and furosemide but has not had any recent labs evaluated. Please consider: CMP (Comprehensive Metabolic Panel) now and every six months thereafter. The recommendation was signed off by the physician and says the order was faxed to lab on March 21, 2025, by a licensed practical nurse. R73's Medication Regimen Review Prescribe Recommendation dated April 15, 2025, shows, Lab results missing: Prescriber checked to get CMP now and every six months per MRR recommendation from March 2025. However, results are not available, and lab order has not been entered. Please enter order if still indicated by provider. The facility's Advanced Practical Nurse signed off the order and wrote April 21, 2025: Schedule for next lab day if not already done. The facility staff signed, Ordered for April 23, 2025. R73's Order Summary Report dated April 30, 2025, +\| which includes discontinued orders show that no CMP lab draw was ordered in March 2025. An + 06.2 3++3602 |order for CMP to be completed next available lab day and every six months was entered on April 21, 2025. On April 30, 2025, at 10:45 AM, V8 Assistant Director of Nursing (ADON) said she did not see an order entered for R73's labs for March. V8 said the order was entered April 2025. The facility's Medication Regimen Review policy revised December 1, 2024, shows, Facility staff shall act upon all recommendations according to procedure for addressing medication regimen review irregularities.

Based on observation, interview, and record review, the facility failed to ensure a resident's medication labeling was legible for 1 of 19 residents (R32) reviewed for medication storage and labeling in the sample of 19. The findings include: R32's Order Summary Report dated April 30, 2025, shows she was admitted to the facility on [DATE], with diagnoses including heart disease, unsteadiness on feet, convulsions, dementia, alzheimer's disease, and anxiety disorder. On April 30, 2025, at 9:53 AM, there was a blue bottle that contained white round pills in the locked memory care unit medication cart. R32's name was legible on the pill bottle label. The medication name was illegible and so was the full dispensed date. V20 Licensed Practical Nurse said she did not know what medication it was, but believed it was a hospice medication. On April 30, 2025, at 10:45 AM, V8 Assistant Director of Nursing (ADON) said medications should be legible and if they are not, then it should be replaced. The facility's Labeling of Medications and Biologicals Policy revised December 1, 2024, shows, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Medication labels must be legible at all times. Any medication label that is soiled, incomplete, illegible, worn, of makeshift must be returned and replaced by the issuing pharmacy, not merely covered.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions for 1 of 19 residents (R63) reviewed for infection control in the sample of 19. The findings include: R63's face sheet printed on 4/28/25 indicated R63 had a feeding tube. On 04/28/25 at 09:35 AM, there was a sign on R63's door indicating R63 was on enhanced barrier precautions. The sign indicated staff must wear gloves and gowns for high-contact resident care activities such as changing an incontinence brief or assisting with toileting. On 04/28/25 at 09:35 AM, R63 was in bed connected to his tube feeding. V10 (Certified Nursing Assistant- CNA) and V11 (CNA) entered the room to provide incontinence care and changed R63's incontinence brief as it was soiled with urine. V10 and V11 had gloves on but no gown. V10 and V11 both touched the tubing of R63's tube feeding while providing incontinence care. On 04/28/25 at 10:01 AM, V10 said for a resident on enhanced barrier precautions staff should wear gloves and gowns when providing care. On 04/29/25 at 11:29 AM, V8 (Infection Control Nurse) said a resident with an implanted medical device such as a tube feeding would be on enhanced barrier precautions. V8 said staff should wear gloves and gowns when providing incontinence care to a resident on enhanced barrier precautions. R63's Care Plan with an initiated date of 5/7/24 showed R63 required enhanced barrier precautions because of a tube feeding. Listed under interventions was for staff to wear the necessary PPE when preforming high contact care activities. The facility's Enhanced Barrier Precautions policy with a reviewed date of 12/1/24 showed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employs targeted gown, and gloves use during high contact resident care activities. High contact care activities included changing briefs.

Based on interview and record review the facility failed to obtain the necessary weights on residents (R1, R5) with diagnosis of congestive heart failure (CHF). The facility failed to obtain and complete the necessary lab work on resident (R1) with diagnoses of CHF and chronic kidney disease. These failures contributed to R1 being re-hospitalized with diagnoses of fluid overload and an exacerbation of CHF. These failures apply to 2 of 5 residents (R1, R5) reviewed for necessary care and services in the sample of 5. The findings include: 1. R1's hospital discharge instructions dated 12/20/23 showed R1 was hospitalized , from 12/10/23-12/20/23, due to bacterial endocarditis (infection around the heart) and respiratory failure. The discharge instructions also showed R1 had diagnoses of congestive heart failure (CHF) and chronic kidney disease. The instructions showed R1 was discharged to the facility on [DATE], for skilled therapy and rehab services, with an order for, Labs: CBC (complete blood count), Creatinine (measures kidney function), and ALT (measures liver function), every Monday. R1's was to have lab work done on Monday, 12/25/23. The instructions showed R1's hospital weight as 150.4 pounds (lbs). R1's admission order dated 12/20/24 showed R1 was to be weighed once a week, for 4 weeks. R1's Weights and Vitals Summary record showed no documented weight for R1, upon admission to the facility, on 12/20/23. The summary showed R1's first documented weight as 154.2 lbs on 12/27/23. R1's physician history and physical report dated 12/21/23 showed R1 was seen and examined by V4 (R1's Physician) in the facility. The note showed V4 found R1 to have no edema or swelling to her lower extremities. R1's electronic medical records dated 12/25/23 and 12/26/23 were reviewed and showed no lab work was completed on R1 on 12/25/23 or 12/26/23, as per R1's hospital discharge instructions. R1's nurses note dated 12/28/23 showed R1 had developed some edema to her bilateral feet and ankles. The note showed R1's physician (V4) was notified. R1's Order Reports dated 12/28/23 showed two new physician orders were placed on R1. These orders were: 1) Draw a CBC, CMP (metabolic panel), A1C (blood sugar level), and TSH (thyroid studies) on R1. The order showed to text V4 (R1's physician) with R1's lab results. 2) Weigh R1 daily for the next 7 days. Facility staff were to report R1's weights to V4 (R1's Physician). R1's electronic medical records dated 12/28/23 showed no lab work was drawn or completed on R1 on 12/28/23. R1's electronic medical records showed no labs were drawn on R1 until 1/3/24. R1's Weights and Vitals Summary record showed no documented weight for R1 on 12/28/23. R1's Physician/NP (Nurse Practitioner) progress note dated 12/29/23 showed R1 was seen and examined by V11 NP with V5 (Family of R1) in attendance. The note showed V11 NP found R1 to have mild edema to her feet and ankles. The note showed V5 (Family of R1) was very concerned about R1's lower leg swelling. V11 NP explained to (V5) that if the edema starts to creep up the leg, (R1) becomes increasingly short of breath, confused, etc., that this would be of concern . R1's nurses note dated 12/29/23 showed R1's oxygen saturation levels had decreased while on supplemental oxygen. The note showed R1 required an albuterol inhaler treatment and a brief increase in oxygen, from 3 liters to 5 liters via nasal cannula, to maintain R1's oxygen saturation levels within the prescribed parameters. R1's skilled evaluation nurses note dated 12/30/23 showed R1's weight had increased to 155.6 lbs on 12/29/23. The note showed the edema (swelling) to R1's lower extremities had increased (worsened) to +3 pitting edema. R1's Weights and Vitals Summary record showed no documented weights for R1 on 12/30/23 or 12/31/23. The summary showed R1 weighed 154.5 lbs on 1/1/24. R1's nurses note dated 1/2/24 showed R1 continued to have pitting edema to her bilateral lower extremities. R1's nurses note dated 1/3/24 showed staff found R1 to be more confused, with low oxygen saturation levels. The note showed R1 had lung crackles present with +3 pitting edema bilaterally to R1's lower extremities. R1 was sent emergently, via ambulance, to a local hospital for an evaluation. R1's hospital records dated 1/3/24 showed R1 was readmitted to the hospital due to an exacerbation of congestive heart failure. The hospital records showed R1 was brought back to the hospital due to increased confusion and was found to be fluid overloaded. On 9/18/24 at 1:35 PM, V11 NP stated weights should be obtained and monitored on residents with congestive heart failure because if the resident is putting on too much fluid, their condition could spiral into CHF and the resident could wind up back in the hospital. V11 stated, (R1's) weight really needed to be monitored due to her edema (to her lower extremities). V11 NP stated she noted R1 had mild edema to her lower extremities on 12/29/23. On 9/23/24 at 9:41 AM, V4 (R1's Physician) stated he ordered lab work on R1 on 12/28/23 to check her kidney function and electrolyte status. V4 stated no lab work was done on R1 on 12/28/23. V4 stated R1 had no lab work drawn, in the facility until 1/3/24, just prior to her being sent back to the hospital for a change in condition. V4 stated he ordered daily weights to be done on R1, starting 12/28/23, because R1 was becoming more edematous. When I saw her on December 21st (2023), she had no edema to her lower extremities. V4 stated, Labs and weights are to be done on residents as ordered. Residents, such as (R1), with CHF and/or kidney failure need to be monitored closely because if their kidneys worsen or CHF worsens, the resident can become more edematous. I (V4) monitor residents with CHF by examining them along with monitoring their weights and labs. If residents aren't weighed as ordered or labs aren't done, it can impede the way I (V4) medically manage the resident. If a resident is becoming more edematous and weights and labs are not done as ordered, that resident's health could deteriorate . On 9/23/24 at 10:36 AM, V3 Assistant Director of Nursing stated all residents should be weighed up admission and readmission to the facility to verify the accuracy of a resident's weight. V3 stated nursing is responsible for ensuring residents are weighed and lab work is completed, as per physician order. V3 stated the admitting nurse is responsible for reviewing all resident's hospital discharge instructions and physician orders to ensure these orders are put into place. The Director of Nursing (DON) would then double check the admitting orders to make sure nothing was overlooked. On 9/23/24 at 10:45 AM, V1 Administrator stated she didn't know why R1's weights and labs were not done as per physician order. V1 stated, (V12 Former DON) was overseeing the weights and labs for (R1) at that time. I (V1) don't know why they weren't done. V1 stated V12 (Former DON) no longer worked at the facility. On 9/23/24, this surveyor made two attempts to contact V12 (Former DON) via phone for an interview but was unsuccessful. The facility's Provision of Physician Ordered Services policy dated 12/1/23 showed, The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders . Qualified personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity . 2. R5's Admission Record dated 7/5/24 showed R5 was admitted to the facility with diagnosis of congestive heart failure (CHF). A physician order dated 8/7/24 for R5 showed for R5 to be weighed daily. The order showed staff were to report to R5's physician if R5 gained 3 lbs or more in one day or 5 lbs or more in one week. R5's Weight and Vitals Summary dated August 2024 and September 2024 showed no documented weights for R5 on 8/7/24-8/8/24, 8/15/24-8/17/24, 8/20/24-8/22/24, 8/25/24-8/27/24, 9/3/24, 9/7/24, or 9/8/24.

Based on interview and record review the facility failed to assess and monitor a resident that experienced a change in condition and failed to implement interventions as ordered by the physician resulting in the death of one of 18 residents (R93) reviewed for quality of care in the sample of 18. The Immediate Jeopardy began on [DATE] at 11:00 AM when V9 CNA (Certified Nursing Assistant) reported a change in condition to V10 LPN (Licensed Practical Nurse) and V10 instructed V9 to wait until R93's lunch tray arrives. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 11:08 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE] at 10:00 AM, but non compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the inservice training. The findings include: R93's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including mild intellectual disabilities, Parkinson's Disease, history of recurrent pneumonia, major depressive disorder, dementia, and dysphagia (trouble swallowing). R93's Admission Record dated [DATE] shows R93 was [AGE] years old. R93's Practitioner Order for Life-Sustaining Treatment Form dated [DATE] shows R93 was a no CPR, comfort focused treatment. Comfort Focus Treatment includes maximizing comfort through symptom management. Allow Natural death. Use medication by any routes as needed. Use oxygen, suctioning and manual treatment of airway obstruction. Transfer to hospital only if comfort cannot be achieved in current setting. R93's Nurses Note dated [DATE] at 1:25 AM shows around 1:00 AM, the CNA alerted the night shift nurse that R93 was clammy and had increased respirations. The night shift nurse went in to assess R93 and R93 said I feel great. The night shift nurse assessed R93's vital signs and noted his pulse and respirations were elevated. But all other vital signs were normal. V12 NP (Nurse Practitioner) was notified and stated R93 could be sent to the hospital if that was what R93's power of attorney wanted, otherwise to keep at the facility and keep R93 comfortable. A message was left on V11's (R93's Power of Attorney-POA/mother) voicemail asking to return the facility's call immediately. A Nurses Note entered by V10 LPN on [DATE] at 9:50 AM, shows R93's lorazepam medication was held due to R93 still sedated. At 10:29 AM, V10 documented a nurses note that show R93's mother returned the phone call from the facility in regards to R93's health incident prior to and stated that if R93 were to become diaphoretic, increased pulse, and respirations, to go ahead and send R93 to the local emergency room . Another Nurses Note dated [DATE] at 1:08 PM entered by V10 shows R93 was coughing on food and had audible breathing sounds. R93's oxygen was 89% on room air, his respirations were 25, and V10 was not able to get R93's blood pressure with an automatic blood pressure machine. V12 NP was notified to obtain an order for a chest x ray. At this time, [V12] asked if [R93's] mom was on board with the plan of care. This nurse [V10] informed [V12] that the mom only wanted [R93] sent to the emergency room if he were to have another episode like the previous night. V10 then placed the order for the portable chest x ray. The next nurses note entered by V10 on [DATE] at 2:45 PM shows, CNA went into [R93's] room to clean up resident for the chest x ray. CNA immediately called this nurse [V10] into the room. Resident had passed. Verified by this nurse. R93's nurses notes on [DATE] shows that V12 NP was notified of R93's death at 2:47 PM and V11 R93's mother/POA was notified of R93's death at 2:50 PM. R93's Weights and Vitals Summary shows R93's oxygen levels ranged between ,d+[DATE]% on room air during the month of [DATE]. R93's breaths per minute ranged ,d+[DATE] for the month of [DATE]. R93's respiration rate on [DATE] at 2:18 AM was 28 breaths per minute. On [DATE] at 1:22 PM, V10 LPN said on [DATE], R93 was asleep in bed because R93 was still tired. V10 said she gave R93 his morning medications and that he swallowed those without difficulty. (R93's Medication Admin Audit Report dated [DATE] shows V10 LPN administered R93's morning medications at 7:04 AM.) V10 said that when R93 woke up, V9 CNA attempted to feed R93 lunch and R93 was coughing on the liquids and food. V10 said a chest x ray was ordered because she could hear audible breathing sounds without her stethoscope. V10 said the second shift CNA (V13) went to clean R93 up for his chest x ray, when she came and got V10 and told V10 to bring her stethoscope. V10 said she listened to R93's chest and could not find any heart beat or any breath sounds. V10 said she took R93's vital signs when he was coughing on food and liquids and V10 could hear audible breath sounds coming from R93. V10 said that she was not able to obtain a blood pressure on R93 and V10 felt it was due because R93 was coughing so much. V10 said she did not call and tell V11 (R93's POA/mother) that R93's oxygen was low or that she was not able to get a blood pressure. On [DATE] at 12:15 PM, V9 CNA said she went into R93's room at about 6:15 AM and R93 was still asleep. V9 said she went back into R93's room at about 8:00 AM and R93 was not able to be woken up. V9 said R93 just kind of mumbled when V9 changed R93. V9 said she went out of R93's room and told V10 that V9 was not able to wake R93 up. V10 told V9 that it was normal for R93 and to let him sleep until 10:00 AM or 11:00 AM and to try again later. V9 said she went into R93's room again around 10:00 AM and R93 was still sleeping but was clean and dry so V9 did not change R93's incontinence brief. V9 said she then went into R93's room around 11:00 AM-11:30 AM and tried to wake R93 up again but R93 was still not arousing. V9 said she even tried to sit R93 up but he would not open his eyes or respond to V9. V9 said she told V10 again that R93 would not wake up and V10 told V9 to wait for lunch time. V9 said, I was worried about [R93] at this time because [R93] was always up for lunch time. V9 said she brought R93's lunch tray to him around 12:30 PM and sat R93 up in bed. V9 said that R93 was still not awake but she tried to give him a small bite of gelato (ice cream). V9 said that R93 just kept it in his mouth and then started coughing. V9 said she went and got V10 and V10 came into R93's room and told V9 to give R93 another bite. V9 said she did and R93 started coughing again and turned a grayish color. V9 said that V10 then took over care of R93 because V9 had to get other residents back to their rooms from lunch. V9 said she then saw R93 again around 1:00 PM and R93 did not have oxygen on. V9 said that V10 told her she was calling 911 so V9 was surprised to still see R93 there but then V10 told V9 that R93 was getting a chest x ray instead. V9 said she left the unit at about 2:00 PM to work a different unit. V9 said she talked to V13 CNA at about 2:45 PM, and V13 told V9 that R93 died . On [DATE] at 2:01 PM, V13 CNA said she came in to work her shift at 2:00 PM. V9 told V13 that R93 had been unresponsive. V9 said she passed out ice waters and clean linens and then went to give R93 a bed bath. V13 knew that R93 was going to get a x ray. V13 said when she went into R93's room, R93 was sitting straight up in bed with the head of the bed elevated and saw that R93's head was hanging down with drool coming from his mouth. V13 said that R93's left arm had a purple discoloration to it. V13 said she left R93's room to get V10 and told her to bring her stethoscope. On [DATE] at 10:58 AM, V12 Nurse Practitioner said that V10 spoke with V12 on [DATE] at about 1:00 PM and said they were going to proceed with a chest x ray. V12 said that V10 told her that R93's oxygen level was 89% on room air and that she could not get a blood pressure on R93. V12 said she told V10 to put oxygen on R93 and to take a manual blood pressure on R93. V12 said she received a second notification from V10 at 2:48 PM that R93 had passed away. V12 said she would expect the nurse to notify her if a residents blood pressure was abnormal. V12 said she did not know why V10 could not get a blood pressure on R93 with an automatic cuff. V10 said R93's POA should for sure be updated with any change in condition in R93 so that R93's POA could make the decision if she wanted R93 sent out to the hospital. On [DATE] at 1:00 PM, V10 said that V12 did not give her any other orders beside the chest x ray. V10 said that V12 did not tell V10 to take a manual blood pressure nor to apply oxygen. V10 said she did not take a manual blood pressure on R93, did not apply oxygen, and did not attempt to suction R93. On [DATE] at 3:00 PM, V12 said she was not told that R93 had a change in skin color. V12 said she depends on the nurses assessments for her orders as to what to do. V12 said she is not at the facility so she relies solely on the nurse and what the nurse reports to her. V12 said she was not aware that V10 did not follow the orders she gave V10 to take R93's manual blood pressure and place R93 on oxygen. On [DATE] at 10:39 AM, V2 DON (Director of Nursing) said if the nurse gets report that a resident is not arousable, she would expect staff to do an assessment, notify the provider, and send the resident to the hospital. V2 said she was not aware of R93's change in condition. V2 said that R93 probably needed to go out to the hospital. At 1:25 PM, V2 said if the nurse cannot get a blood pressure with an automatic blood pressure machine, then she expects the nurses to try a different extremity or perform a manual blood pressure. If a resident is having trouble breathing and oxygen saturation is lower than normal, the nurse should place the resident on oxygen and call the nurse practitioner and see what the orders are. R93's State of Illinois Certificate of Death Worksheet shows R93's date of death as [DATE]. R93's cause of death is listed as Respiratory Failure, Aspiration Pneumonia, and Developmental Delay. The facility's Notification of Changes policy dated [DATE] shows, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. Resident incapable of making decisions: The representative would make any decisions that have to be made. The facility's Change in a Resident's Condition or Status policy revised [DATE] shows, Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The Immediate Jeopardy that began on [DATE] was removed on [DATE] at 10:00 AM, when the facility took the following actions to remove the immediacy: 1. The facility provided education in regards to ensuring their nursing staff are performing thorough assessments and the monitoring of resident with a change in condition. 2. The facility will ensure that physician orders are being implemented for resident with a change in condition. 3. A full house audit of all residents' physician orders started on [DATE] at 11:20 AM. 4. Inservices in regards to facility policies on: Change in a resident's condition or status, conducting an accurate resident assessment, consulting physician/practitioner orders and notification of change of condition. 5. The licensed professional nurse will demonstrate competencies and complete knowledge checks after in servicing and ongoing then annually and as needed. 6. The Director of Nursing or designee will conduct rounds throughout the facility to ensure change of conditions are accurately monitored and accurate orders are implemented and report to the administrator daily. 7. Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent.

Based on observation, interview, and record review the facility failed to provide nutritional supplements as ordered for one of three residents (R64) reviewed for weight loss in the sample of 18. This failure contributed to R64 experiencing a 11.41% weight loss in the last six months. The findings include: R64's Order Summary Report dated May 7, 2024, shows she was admitted to the facility on [DATE], with diagnoses including wandering, generalized anxiety disorder, history of falling, depression, alzheimer's disease, dementia, need for assistance with personal care, and difficulty walking. R64 has pudding with lunch ordered on December 15, 2023, and health shake three times per day ordered on October 3, 2023. R64's meal ticket shows for R64 should have received a mighty vanilla shake and a pudding cup at lunchtime. On May 7, 2024, at 12:10 PM, R64 was sitting at the lunch table for her lunch meal. R64 had a general diet food tray in front of her and was eating small bites of food with her fingers. There was a cup of water and cup of apple juice for R64's fluids. R64's apple juice was half gone. There was not a vanilla shake nor a pudding cup at R64's table. R64 left the dining room at 12:25 PM. On May 7, 2024, at 12:28 PM, V19 CNA (Certified Nursing Assistant) said health shakes and pudding is kept in the unit refrigerator. V19 said the dietary staff typically hand out the supplements to the residents. On May 7, 2024, at 12:29 PM, V14 Dietary staff said she passes out resident's health shakes when she hands out the resident's drinks. V14 said she didn't pass out R64's health shake because R64 was not sitting down and another resident that sits near R64 likes to grab things. R64's monthly weights show that R64 weighed 147.2 pounds on November 28, 2023, and weighed 130.4 pounds on May 7, 2024. This is a 11.41% weight loss in six months. On May 9, 2024, at 11:34 AM, V18 Dietitian said health shake and ice cream is ordered to increase R64's caloric intake because she has lost weight. V18 said if R64's supplements are not provided, then R64 may not be getting the calories she needs and may continue to lose weight. The facility's Weight Monitoring Policy revised on December 1, 2023, shows, The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes developing and consistently implementing pertinent approaches. Interventions will be identified, implemented, monitored and modified consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.

Based on observation, interview, and record review, the facility failed to ensure a resident's safety while using a mechanical stand lift machine for 1 of 3 residents (R1) reviewed for safety in the sample of 6. This failure resulted in R1 having a decline in the ability to raise her left arm, and R1's Physician diagnosing R1 with a complete rotator cuff tear. The findings include: R1's Admission Record, printed by the facility on 11/8/23, showed she had diagnoses including enterocolitis due to clostridium difficile (C-diff), generalized osteoarthritis, hypertension, a history of falling, iron deficiency anemia, atrial fibrillation, chronic kidney disease, seizures, unsteadiness on feet, lack of coordination, and weakness. R1's care plan, with a revision date of 11/8/23, showed R1 requires sit to stand by staff to transfer. R1's alteration in skin integrity care plan, with a revision on 11/1/23, showed R1 received a skin tear measuring 0.5 cm (centimeters) x 0.3 cm. Skin is very fragile. Cleansed and dry dressing applied. Stand lift checked and no safety concerns noted. R1's Order Summary Report, printed by the facility on 11/8/23, showed the following order dated 10/31/23 Cleanse skin tear to LFA (left forearm) using normal saline. Pat dry. Apply dry dressing daily and as needed. The Order Summary Report also showed an order for Vancomycin HCL (hydrochloride) 125 mg by mouth two times a day for suspected C-diff for 14 days. R1's facility assessment dated [DATE], showed she was cognitively intact and required extensive assist of staff for toileting. On 11/7/23 at 5:21 PM, V8 (R1's daughter/POA-power of attorney) said a family member (V13) was in the facility on 11/1/23 and noticed that R1 was not moving her left arm. V8 said V13 asked R1 what happened. R1 told her that a CNA (Certified Nursing Assistant) was using the sit-to-stand lift, and she (R1) told the CNA that her arm was hurting, R1 told V13 that the Aide kept going and did not adjust the straps or anything. V8 said R1 told V13 that when the aide lowered R1 down, her whole left arm was hurting. V8 said the incident happened sometime during the night on 10/31/23 and 11/1/23 in the morning. V8 said other than some of the CNAs coming up and saying how sorry they are that it happened, and the Social Worker coming in asking what happened; No one else in management had talked to them about the incident. V8 said R1 also had a skin tear on her left arm. V8 said R1's Doctor came in to see R1 the next day or two and diagnosed R1 with a complete torn rotator cuff. V8 said R1 is not having any pain and was told by V7 (R1's Doctor) that R1 would not feel pain with a complete torn rotator cuff. V8 said an X-ray was done and the results showed no fracture or dislocation. V8 said R1 cannot move her left arm and is not able to feed herself like she used to. V8 said R1 will be [AGE] years old on Sunday and is not a candidate for surgery. V8 said she requested an MRI be completed. V8 said the MRI is scheduled to be done on 11/16/23. V8 said her sister (V9) goes to the facility almost every day to see R1. V8 said R1 had been weak due to her age, having C-diff (Clostridium difficile) infection, and the sit to stand lift is fairly new to R1. V8 said R1 is cognitively intact and able to give details about what happened. On 11/8/23 at 9:18 AM, R1 was in her room, sitting in her chair. V9 (R1's daughter) was in the room with R1. R1 was making potholders for her family, with the assistance of V9. R1 mostly used her right hand to make the potholders. V9 showed this surveyor a picture she had on her phone of R1 from 6/12/23. R1 was holding her left arm straight up in the air. V9 said R1 had been excited because she found her missing cell phone and she (V9) took a picture of her. V9 asked R1 if she could raise her arm up like she did in the picture. R1 tried to lift her arm but was only able to lift it a few inches off her lap. R1 leaned her upper body to the right side to try to get the arm up higher, with no success. R1 was also not able to move her left arm outwards, away from her body when prompted to do so by V9. R1 was alert and oriented. When asked how she got the skin tear on her left arm and why she is not able to move her arm like she was in the picture, R1 said she would say the girl did not know how to use the stand lift machine. R1 said it hurt when the CNA started lifting her up with the machine, adding I felt like I was being hung. R1 said she yelled at the girl, but she did not stop when she screamed that it hurt. On 11/8/23 at 10:49 AM, V2 and V3 (CNAs) transferred R1 from her recliner chair to the toilet using the sit-to--stand lift. R1 was not able to lift her left arm high enough to grab the handles, so V2 grabbed R1's left hand and placed it on the handle for her. R1 was then able to grip the handle. R1 stood up with the lift and followed V2's cues to stand up straight and tall during the transfer. At 11:16 AM, V2 said R1 had a change in her range of motion. V2 said R1 was able to move her arms above her head, put on her bra and shirt and feed herself. V2 said now staff have to help her get dressed on the left side and put her hand on the stand lift for transfers, because R1 cannot lift it. V2 said she worked a double shift from 10:00 PM on 10/29/23-2:00 PM on 10/30/23 and R1 was fine. V2 said the next time she worked was on 11/1/23 on the day shift. V2 said the third shift CNA reported that R1 complained about pain that night in her shoulder and that her arm and shoulder were sore. V2 said R1 told her that when the Aide was lifting her up, she was raising the stand-lift all the way up. V2 said R1 told her that she screamed that it hurt, and the aide kept lifting it up. V2 said she told the nurse; the Social Services person and she thinks the Director of Nursing. V3 CNA) was present during this surveyor's conversation with V2 and said she was the CNA for R1 on 10/31/23 during the day shift (6:00 AM-2:15 PM). V3 said R1 was fine on her shift, V3 said R1 was able to lift her arms, get dressed and had no complaints of pain during her shift. On 11/8/23 at 1:30 PM, V6 (Licensed Practical Nurse-LPN) said she was the nurse for R1 on 10/31/23 on second shift (2:00 PM-10:00 PM). V6 said no staff reported any concerns regarding a resident's report of pain during a stand-lift transfer. V6 said no CNA reported any concerns to her regarding R1 not being able to move her arm per her baseline. V6 said she is an agency nurse and is not familiar with the residents, however she does not recall anything being out of the normal that night. On 11/8/23 at 1:41 PM, V4 (CNA) said she worked on 10/31/23 from 2:00 PM-10:00 PM. V4 said she is new to the facility. V4 said she transferred R1 a couple of times that shift; The first time was without the stand lift machine. V4 said she did a stand pivot transfer and R1 kept trying to sit down. V4 said she was informed by another CNA that they use a stand-lift machine for R1. V4 said later she transferred R1 using the sit-to-stand lift machine. V4 said every time she would try to wipe R1, she (R1) would try to sit down. V4 said she (V4) would then lower the stand-lift. V4 said she got on the walkie-talkie and told V5 (CNA) that she needed help because she was having trouble with R1; adding, it was up and down, up, and down. V4 denied R1 complaining of any pain while she was in with her. V4 said V5 said they could just switch residents. On 11/8/23 at 2:22 PM, V5 (CNA) said she worked on 10/31/23 from 2:00 PM-10:00 PM. V5 said she transferred R1 from the chair to the toilet. V5 said R1 did not complain of pain when she transferred her to the toilet. V5 said she got R1 on the toilet and then V4 came in the room. V5 said Good you're here, can you take over? and V5 said V4 told her Sure. V5 said she had a resident that she was toileting at the same time across the hall. V5 said she went over to assist the resident across the hall, and she got a call on the walkie talkie from V4 to please come back. V5 said she went back and V4 complained that R1 kept lowering herself down. V5 said V4 told her that she (V4) said she would raise the stand-lift higher, and R1 would lower herself down again. V5 said when she went back into R1's bathroom, R1 said Thank God you're here, she was making my shoulders hurt. V5 said she told V4 that she would finish with R1 if V4 went over to take care of the other resident across the hall. V5 said she finished cleaning R1 up and transferred R1 from the toilet to her bed. V5 said that is when she noticed the skin tear on R1's left arm. V5 said R1 did not complain of pain while she was transferring her from the wheelchair to the toilet and from the toilet to the bed after toileting. On 11/9/23 at 6:10 AM, V11 (CNA) said she worked the overnight shift on 10/31/23 (10:00 PM-6:15 AM). V11 said during her shift R1 told her that the girl must not have known what she was doing on the previous shift, because She almost hung me. V11 said R1 had to use her right hand to raise her left arm, or she (V11) would help her lift it up to hold onto the stand-lift handles. V11 said the CNA that gave her report at the beginning of her shift informed her that she had to go in and help with R1, because V4 had the stand lift raised too high when toileting R1. V11 said she believes it may have been V5 that told her that during the shift report. V11 said it was not V4 that told her that. On 11/9/23 at 8:03 AM, V12 (Licensed Practical Nurse-LPN) said she worked the overnight shift on 10/31/23. V12 said no CNA reported any concerns regarding R1 having a decline to her range of motion of her left arm, or saying the previous shift CNA almost hung her. V12 said if they had, she would have called R1's doctor (V7). V12 said the second shift nurse reported R1's skin tear to her and asked her how to document it, so she instructed the nurse on how to do that. V12 said the nurse from the previous shift did not report R1 complaining of her shoulder hurting or a decline/change in R1's range of motion. V12 said when she went in during her shift to check on R1, she was asleep, so she did not voice any complaints of pain. On 11/9/23 at 9:04 AM, V10 (Registered Nurse-RN) said she was R1's nurse on 10/31/23 from 6:00 AM-10:00 AM. (The shift before R1 complaining that a CNA was hurting her shoulder when using a stand-lift). V10 said R1 had no difficulty with her left arm on her shift, and no complaints of pain to her left shoulder or arm on 10/31/23 when she was working. V10 said she was also the nurse for R1 on 11/1/23 from 6:00 AM-10:00 AM. V10 said one of the CNAs informed her that R1's family wanted to talk to her. V10 said R1's family was concerned that she was not able to move her arm. V10 said she assessed R1, and she was not able to move her left arm more than a short way away from her lap. V10 said she put it on the Doctor's Board because she was told the Nurse Practitioner was going to be in the facility that day. On 11/8/23 at 3:33 PM, V7 (R1's Physician) said from what he gathered, they were using a stand-lift and it was a new CNA trying to transfer R1 to the bathroom. V7 said It sounds like R1 kind of slipped down in the sling during the transfer and then got a skin tear on her left forearm and her left shoulder was affected. V7 said he thinks due to R1's loss of muscle control, and it is happening so quick, that before the sling was tight enough and in place, it allowed her to go down. V7 was informed about this surveyor's interviews with R1, V4 and V5. V7 said he guesses if the resident is trying to sit down and the lift is raised, that it could have caused the injury. V7 said with 85-[AGE] year-olds, there can be injuries with the slightest twist or movements due to their fragile tissues. V7 said R1 had a current C-diff (Clostridium difficile) infection and weakness, which makes falls more likely. V7 said he is not sure what the facility's policy says about 1 or 2 staff being needed for a stand-lift transfer. V7 said for a resident with a C-diff infection and weakness, it would be a good idea to have more than one staff present during transfers and toileting with a stand lift. V7 said something happened during the stand-lift transfer and toileting. V7 said he did not think an MRI was needed for the diagnoses of a complete tear in R1's rotator cuff, because R1 has the textbook signs of a complete rotator cuff tear. V7 said he went to the facility and assessed R1. V7 said he would bet a hundred dollars that it is a complete tear in her rotator cuff. V7 said there are very few things that would cause no pain and the resident not being able to move her arm. On 11/9/23 at 10:52 AM, R4 (resident that resides across the hall from R1) said she vaguely remembers having a resident yell out on Halloween night while she was in the bathroom using the toilet. R4 said she could not make out what they said, it was just a quick yell and that was it. R4 said the aide that was helping her (R4) had to go over and help the other girl after that. R1's incident report, dated 10/31/23, showed she obtained a 0.5 cm x 0.3 cm skin tear while transferring using the sit-to-stand. The report showed no complaints of pain or discomfort to the area. The report showed on 11/1/23 additional information was added in the notes section of the report showing 11/1/23 Resident complained of shoulder discomfort and not being able to complete full ROM (range of motion). The note showed V7 (R1's physician) was notified and came in and completed an in-person exam with the patient and then talked with R1's family. On 11/3/23 the notes showed R1's family requested an X-ray be completed. The X-ray was completed on 11/4/23 and the results showed mild degenerative joint disease with no fracture or dislocation noted. Suggested to consult with family about completing an MRI. MRI scheduled for 11/16/23. A hand-written note provided by V1 on 11/8/23, showed R1 asked to see staff on 11/1/23. Went and talked to (R1). She said the CNA was assisting her to use the restroom and (R1) told her that she was hurting her arm. Aide got her to the toilet and then another aide (V5) took over. V7's (R1's Physician) Progress Note date 11/2/23 showed Assessment/Plan .3. Left total rotator cuff tear-We are going to get an X-ray of this area just to make sure that there are no bony lytic lesions, or fractures, or dislocations; although all of that seems very unlikely given the physical exam findings. The progress note showed It does seem like there was a traction type injury in the (mechanical lift) that led to a complete tear. The facility's policy and procedure titled Safe Resident Handling/Transfer, dated 12/1/23, showed It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy showed 4. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts .10. Two staff members must be utilized when transferring residents with a mechanical lift. On 11/14/23 at 9:45 AM, V1 (Administrator) said the policy and procedure titled Safe Resident Handling/Transfer, dated 12/1/23 was 12/1/22, when the new company took over.

Based on observation, interview and record review the facility failed to ensure a resident (R12) with a change of condition was assessed and monitored after exhibiting an altered mental status. This failure resulted in R12 being admitted to the hospital with, hypoglycemia and sepsis related to a UTI (urinary tract infection). The facility also failed to ensure a resident received x-ray services without any delay for R57 following a fall. This failure resulted in R57 waiting 18 hours for an x-ray, and the x-ray showed a fractured hip requiring surgical intervention. This applies to 2 of 2 residents (R12, R57) reviewed for quality of care in the sample of 18. The findings include: 1. R12's admission record documents her admitted to be 5/12/23 with a most recent hospitalization of 7/15/23 to 7/24/23. The diagnoses list includes morbid obesity, need for assistance with personal care, and protein-calorie malnutrition. A diagnosis of hypoglycemia (low blood sugar) was added 7/24/23. The 7/13/23 office clinic notes for V15 FNP (Family Nurse Practitioner) documents R12 has had a history of frequent hospitalization s for weakness, hypoglycemia, and unable to care for herself. The same document shows the problem list/Past medical history of ongoing diagnoses includes hypoglycemia. The 7/28/23 facility quarterly assessment documents R12 to be cognitively intact, with no signs of delirium or other mental changes. The same assessment documents she requires extensive assistance with bed mobility and transfers. She is dependent upon staff for locomotion on and off the unit, using a wheelchair. R12's progress note dated 7/14/23 shows, at 10:00 AM R12 was acting weird, she will be alert to talk one minute and doze off the next. The MD (medical doctor) was notified and ordered to have her sent out. This note shows no vital signs or assessment of R12, including any oxygen saturation level or blood sugar. This note was authored by V3 LPN (Licensed Practical Nurse). At 10:09 AM, V4 RN (Registered Nurse) documents R12 reported she thinks she has a UTI (urinary tract infection) because her muscles are jumpy. V4 documented no assessment or vital signs. The vital signs summary sheet was reviewed and shows no results for 7/14/23. The nursing progress notes for R12 were reviewed and show no further assessments or vital signs for 7/14/23. On 08/03/23 at 11:33 AM, V3 said normally R12 does not like to get up for breakfast, so her medications are timed later in the morning as well. V3 said on the morning of 7/14/23, R12 was not acting right, she was not able to hold a glass of water and take her pills, and the CNA's (Certified Nursing Assistants) reported her urine had a strong odor. V3 said that day was not a routine lab day for the facility, so the physician ordered for R12 to be sent out to the ER (emergency room ). V3 said R12 refused to go out to the ER, and she notified the physician, and he ordered an antibiotic and labs. V3 said she could not remember doing any vital signs or blood sugar levels as part of her assessment. V3 said she would not check a blood sugar level on R12 because there was no diagnosis of diabetes. V3 said she was unaware R12 had a diagnosis hypoglycemia. R12's progress note dated 7/15/23 shows at 5:42 AM, V3 documents R12's altered mental status continues, she will awaken to her name but not stay awake to finish the task at hand. The nursing progress note shows no physical assessment, vital signs, oxygen saturation level or blood sugar levels. At 6:51 AM, V4 documented R12 was seeing things that are not there, she is oriented x (times) 2 (normally oriented x 3) but slow to respond when questioned. R12 continued to state she has a UTI. The notes show at 7:18 AM 911 was dialed and R12 was sent to the ER per V15's orders. On 08/03/23 at 10:55 AM, V4 said on 7/14/23, V3 was the primary nurse for V12. She said when she saw her, R12 was at her baseline and responding normal. R12 thought she had a UTI but did not want to be sent out. V4 said the nurses can perform a urine dip to check for a UTI and arrange for a stat pick up if necessary. V4 said R12 was incontinent of urine and would have required a straight catheterization to obtain a clean urine sample. V4 said later that night and into the next morning R12 did continue to decline and ended up getting sent out due to her confusion being more exaggerated, she was rolling her eyes and not making any sense at all and talking weird. V4 said she completed vital signs but did not check a blood sugar since there was no diagnosis of diabetes, and V4 was not aware of any hypoglycemia diagnosis. V4 said R12 had declined to the point of needing oxygen, she was more lethargic and confused. V4 said she called V15 and updated her with R12's condition and received an order for transfer to the ER. R12's weights and vital summary sheet shows on 7/15/23 at 6:54 AM, R12's blood pressure was 98/52, temperature was 97 degrees Fahrenheit, pulse was irregular at 89 beats per minute, oxygen saturation level was 88% on oxygen. R12's nursing progress notes were reviewed and do not indicate when R12 was placed on oxygen, the number of liters, or what administration device was used: mask or cannula. R12's nursing progress notes dated 7/15/23 at 10:24 AM shows V4 received an update from the physician in the ER and reported R12's blood sugar was 34 mg/dl (milligrams per deciliter) upon arrival. The CDC.gov (Centers for Disease Control) documents low blood sugar occurs when the level drops below 70 mg/dl. At 1:18 PM, V4 documented R12 was admitted to the ICU (intensive care unit) with hypoglycemia, hypomagnesia, and sepsis related to UTI. On 08/03/23 at 8:45 AM, V13 LPN said when a resident has any change of condition the nurse should do a full assessment from head to toe, listen to their heart and lungs, check pulses, and perform a neurological check if there is any change in their cognition. The assessment should also include a set of vital signs, completed by the nurse herself, blood sugar check and oxygen level. V13 said if a resident as complaints of a UTI, then a urine dip can be performed by the nurse, and then encourage them to drink some cranberry juice and more fluids. She said all of the assessment and vital signs should be documented, and the resident monitored for further symptoms. On 08/03/23 at 11:12 AM, V15 FNP, stated she had received a call on 7/15/23 to send R12 out to the ER due to mental status changes. She said for any resident presenting with an altered mental state the nurse should be conducting a head-to-toe assessment, obtain vital signs, neurological check, blood sugar, and evaluate any recent medication changes. On 08/03/23 at 12:00 PM, V2 DON (Director of Nursing) said for a resident with a change of condition, the nurse should perform an overall assessment before contacting provider, include vitals, oxygen saturation levels. V2 said the nurses would not have thought to check R12's blood sugar because she was not on insulin. V2 said the symptoms of hypoglycemia would be similar to hypoxia (low oxygen level), such as lethargy or being not as alert. She said all of this information should be documented in the progress notes. R12 was in the hospital during this survey and unavailable for an interview. 39543 2. R57's Face Sheet showed an original admitted [DATE] with diagnoses to include: Dementia, Parkinson's, history of falling, weakness, and osteoarthritis of the right knee. R57's 6/6/23 Quarterly Minimum Data Set (MDS) showed severe cognitive impairment with a brief interview for mental status score of 1 out of 15. The MDS showed she required extensive assistance of two people for bed mobility, transfers, and toilet use. The MDS showed she did not walk during the assessment period. On 8/01/23 at 9:54 AM, R57 was near the entrance to the nurse's station in the activity/dining room on the locked memory care unit. R57 was in a high back reclining wheelchair. R57 was non-verbal. R57's Fall Note from 3/10/23 at 8:50 PM showed, 1515 (3:15 PM) Resident sitting at dining room table drinking apple juice. Stood from table with juice in hand and took steps toward nurse's station. LPN (Licensed Practical Nurse) heard crack while letting pharmacy staff off of unit. [LPN] returned and resident laying on back, on floor, at nurse's station door .Activity CNA (Certified Nursing Assistant) witnessed incident and stated, I was only 10 feet from her. She hit her head.BLE (Bilateral Lower Extremities; both legs) without any shortening or rotation .resident denies head pain, neck and back pain, and hip pain . (Note was authored by V9 LPN) R57's Nurses Note from 3/11/23 at 12:21 PM showed, Resident denies pain this shift, but has difficulty with transfers. Able to bear weight on BLE. Offered pain meds (medications), but resident declines. Will continue to monitor weight bearing status. R57's Medication Administration Note from 3/11/23 at 1:22 PM, showed R57 was given one 500 milligram tablet of as needed acetaminophen (non-narcotic pain medication). R57's Nurses Note from 3/11/23 at 4:26 PM showed, Resident favoring RLE (Right Lower Extremity; right leg). Swelling noted to right thigh and knee. Grimace with palpation (touch). Call to [V7 FNP, Family Nurse Practitioner] about getting mobile x-ray for right hip/knee. Orders received and noted. X-ray ordered and [V8, R57's Daughter and Power of Attorney] notified. (Note was authored by V10 LPN) R57's x-ray order, from the contracted mobile imaging company, showed a STAT (to be done immediately and without delay) order was entered by V10 on 3/11/23 at 3:40 PM. The order showed her right hip and right knee were to be imaged due to pain and swelling following a fall. The order showed the purpose of the imaging was to rule out a fracture. R57's Nurses note from 3/12/23 at 4:56 AM showed, Resident has been minimally restless in bed at various times throughout NOC (night) shift. Manipulating blankets with hands often. VSS (Vital Signs Stable). No c/o (complaints of) voiced [incomplete statement], resident nonverbal during assessment, staring at staff during questions. R57's Medication Administration Note from 3/12/23 at 8:16 AM, showed R57 was given one 500 milligram tablet of as needed acetaminophen. R57's Nurses Note from 3/12/23 at 9:45 AM showed, the mobile x-ray company was on site to image R57's right hip and right knee. (Imaging arrived 18 hours after orders were entered.) R57's Nurses Note from 3/12/23 at 10:04 AM showed the x-ray results had been received and R57 had a fractured right hip. The note showed V8 was contacted and V8 requested R57 be sent to the local area hospital; 911 was called. The facility's staff schedule showed V6 CNA worked first shift on 3/11/23. On 8/03/23 at 8:36 AM, V6 stated she recalled the time period between R57's fall and R57 being sent to the hospital. V6 stated R57 was having pain especially during care and repositioning as evidenced by facial grimacing. V6 stated she noticed swelling to the right hip and reported it to the nurse. On 8/03/23 at 12:06 PM, V10 LPN stated she recalled placing the order for R57's imaging. V10 stated the order was to be done STAT. V10 stated she was notified by the imaging company there may be a delay due to the weather. V10 stated, .They were going to try and get there that evening but I don't think they got there till the next day. Well, we weren't sure if there was going to be a delay or not, so I didn't call the [NP, Nurse Practitioner] to let them know. Stat x-ray normally should be done within a few hours. I was aware of the fall the day before. If they were not able to come out within that few hours' time frame, I would call the family and see if they wanted her (R57) to be sent out for evaluation then call the NP and let them know what the family wanted to do. I would have handed that over in report that we were waiting on a stat x-ray. I think we left her in bed because she was having pain and we didn't want to move her .In the back of my mind I was concerned she had a hip fracture. X-ray is the only way to really diagnose the hip fracture . On 8/03/23 at 9:04 AM, V7 FNP stated pain, swelling, and favoring a leg over another can be signs and symptoms of a fracture. V7 said, I would expect to be notified if it's (STAT x-ray) going to run into the next day or be several hours. I would expect to be notified because the resident is under my care; I want to make sure symptoms are managed; the family is updated; and the resident is getting the care they need. I would want to know if the resident is moving or having limited activity. With a hip fracture they are going to the ER anyway unless they are comfort focused care then it depends . V7 said the timeframe from 3/11/23 at 3:40 PM until 3/12/23 at 9:45 AM is too long for a STAT x-ray. On 8/03/23 at 9:29 AM, V7 said she reviewed her documentation regarding R57. V7 stated she was notified of the fall and of the x-ray results. V7 stated she was not notified of the x-ray delay. V7 said, Had I been notified of the delay in the stat x-ray I would have contacted the POA (Power of Attorney) and given them the option to keep her at the facility and make her comfortable if that was possible; or send her out to the emergency room for the x-ray. On 8/03/23 at 9:43 AM, V8 R57 POA/Daughter stated, .If I was given the option between keeping her (R57) there overnight or waiting till the next day for the x-ray, I would have told them to send her out to get the x-ray. I would have said send her out because she is fragile and with her Dementia, we don't really know how she is doing and I want her to feel safe and be comfortable. Sending her to the hospital would have made certain she was safe, comfortable, and getting the prompt care that she needed. R57 ' s Statutory Short Form Power of Attorney for Health Care showed V8 was R57 ' s Healthcare Power of Attorney due to V8 ' s brother had refused the Health Care Power of Attorney role. On 8/03/23 at 11:16 AM, V16 LPN stated a STAT x-ray should be done the same day even if it is ordered in the afternoon. V16 said, If it's been 4-6 hours, I would call the company and see why the delay and get an ETA (Estimated Time of Arrival) and verify the order was received. If they told me, it couldn't be done till mid-morning the next day, I would call the provider and see if they want me to send them (resident) out. 3:30 pm till 9:45 AM would not be a stat x-ray. On 8/03/23 at 10:55 AM, V2 Director of Nursing (DON) If a resident had a fall, then the next day, they were having pain with palpation, swelling, and favoring a leg with transfer my concern would be a hip fracture and the only way to definitively determine that would be with an x-ray so it would be important to get it done as soon as possible. The family may request to keep the resident here if the x-ray could not be done that day but that would be the family's choice. I would have that conversation with the family then notify the NP of the family's wishes to either keep them at facility or send them out. The facility's Diagnostic Testing Services Policy (Implemented 12/1/22) showed, In instances where diagnostic testing is not available to be performed on-site .the facility will work the resident and their family to secure appropriate transportation arrangements for such appointments.

Based on observation, interview and record review, the facility failed to identify a pressure injury before becoming a Stage 2 or greater and failed to provide initial wound assessments for 2 of 4 residents (R14, R5) reviewed for pressure injuries in the sample of 18. This failure resulted in R14 developing two Stage 2 and one Stage 3 pressure injuries. The findings include: 1. On 8/1/23 (between breakfast and lunch), R14 was in his room in his wheelchair. At 12:22 PM, R14 was self-propelling in his wheelchair after leaving the dining room. On 8-/1-8/3/23, this surveyor had no observations of R14 in any other position than up in his chair. On 08/01/23 at 1:10 PM, V2 Director of Nursing (DON) said the facility could not provide a list of residents with wounds (pressure or non-pressure). V2 said the facility did not have a wound nurse and nobody did wound tracking at this time. It fell through the cracks during COVID and was to be a focus this August. V2 was unable to provide the date R14's wounds were first noted and any initial wound assessments on the date they were first noted. On 8/2/23 at 2:25 PM, V2 DON said R14's wound assessments would be in his contracted wound doctor visit notes. V2 said the facility must have known of R14's wounds (sites 3-5) and notified the wound doctor to look at them. V2 was unable to locate any wound assessments done or dates the wounds were identified by staff at the facility prior to the wound doctor evaluation. On 08/03/23 at 9:36 AM, V2 said she would expect a wound assessment to include measurements, a description of the wound, drainage, evidence of redness or edema. It's important to perform an initial assessment to have a baseline to know if a wound is improving/deteriorating and to monitor for signs and symptoms of infection. A resident could have a worsening of the wound, tunneling, undermining and signs and symptoms of infection if there is no baseline assessment to use for reference. Nurses should be doing daily skin checks and weekly wound assessment documentation. Residents should be evaluated for pressure relieving devices. If a wound doctor recommended any interventions, they should go into the resident's orders. The facility's repositioning protocol is every 2-4 hours. V2 said she did not see the wound doctor's recommendations, or she would have care planned them. V2 said she could not find any initial wound assessments for R14's 3 wounds (2-stage 2 and 1- stage 3). V2 was unable to determine the date R14's wound began in the facility due to the lack of documentation. On 08/03/23 at 11:18 AM, V11 facility medical director said he would expect an initial assessment to be documented on any wounds. Assessments should include dimensions, depth, surrounding erythema, vital signs, color, any eschar, tunneling, odor, and drainage. V11 said if there's no baseline assessment you don't know if it's a new wound or chronic wound. A baseline assessment helps gauge if there's healing or a decline in the wound and provides an opportunity to prevent additional skin breakdown. V11 said offloading, nutritional assessments and barrier creams would be appropriate interventions. V11 said he would expect any wound doctor recommendations to be implemented as interventions. R14's face sheet showed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included heart failure, chronic obstructive pulmonary disease, history of Methicillin resistant staphylococcus aureus (MRSA) infection, cardiac pacemaker, and chronic kidney disease. R14's 5/19/23 pressure risk assessment showed he was at risk for developing pressure injuries. R14's 6/20/23 wound doctor note showed one wound, non-pressure to the left ear. R14's 6/27/23 wound doctor note showed a Stage 2 pressure wound of the right medial buttock (site 3) and a Stage 3 pressure wound of the left, upper, medial buttock (site 4). This note showed the doctor recommended to limit sitting to 60 minutes, off load the wound, reposition per facility protocol, and turn side to side in bed every 1-2 hours if able. These interventions are not in R14's care plan. R14's 7/18/23 wound doctor note showed a Stage 2 pressure wound of the left medial buttock (site 5). This note showed the doctor recommended to limit sitting to 60 minutes, off load the wound, reposition per facility protocol, and turn side to side in bed every 1-2 hours if able. These interventions are not in R14's care plan. R14's 7/6/23 facility assessment showed R14 was frequently incontinent of urine and bowel. R14's care plan showed he was totally dependent on staff to provide a bath or shower, extensive to total assistance to turn and reposition in bed, for personal hygiene, requires total assistance by staff for toileting, and extensive assistance of 1-2 staff to transfer. R14's care plan does not include to offload the wound, limit sitting to 60 minutes, turn side to side in bed every 1-2 hours, and to reposition per facility protocol as ordered by the wound doctor. There was no mention of R14's two stage 2 pressure injuries in his care plan and no offloading or repositioning interventions. Facility policies for pressure injury assessment, intervention, monitoring, and tracking were requested. On 08/02/23 at 2:25 PM, V2 said the policy for wound treatment management and pressure injury prevention was all the facility had. The facility's 12/1/22 Wound Treatment Management Policy showed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Treatment decisions will be based on characteristics of the wound: pressure injury stage, size-including shape, depth, and presence or tunneling and/or undermining, volume and characteristics of exudate, presence of pain, presence of infection or need to address bacterial bioburden, condition of the tissue of the wound bed, and condition of the peri wound, location of the wound, and goals and preferences of the resident/representative. The National Institutes of Health website showed a wound assessment standard includes evaluation of the depth, length, and width of the wound. Evaluation of the wound bed for exposed bone, vessels, hardware, or subcutaneous fat. Survey for presence, type, and amount of exudate (drainage). Assess surrounding skin tissue for signs of injury. Check the wound margins. Evaluate for warmth, pain, odor, purulence, delayed healing, or other signs of infection. 2. R5's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included a Stage 4 pressure injury to the back, chronic osteomyelitis, heart failure, high blood pressure, acquired absence of the left leg above the knee, major depressive disorder, morbid obesity, epilepsy, and cerebral infarction. On 8/1/23 at 11:54 AM, R5 was in the dining room seated in her wheelchair. On 8/2/23 after lunch, R5 was in her bed. The head of the bed was upright with her back against the mattress. During observations 8/1-8/3/23, R5 had no pressure relieving interventions to her wound in place. On 08/01/23 at 1:10 PM, V2 Director of Nursing (DON) said she couldn't find an initial wound assessment for R5's infected Stage 4 pressure injury to her back. On 8/2/23 at 2:25 PM, V2 said she put R5's weekly wound assessments in the progress notes once she got the wound vac put on which was the beginning of July 2023. R5's 6/13/23 admission skin assessment showed a wound to the mid/center back. This note had no description of the wounds shape, color, absence or presence of drainage, odor, slough, dressings, peri wound or wound color description or presence of pain. There were no wound measurements. R5's 6/15/23 at 10:05 PM skin/wound note showed the wound measured 4 centimeters (CM) x 3 cm (no depth). There was no description of the wound bed or peri wound, the type of wound was not indicated nor the stage. R5's 6/22/23 skin/wound notes showed no measurements or description of the wound drainage. R5's 6/20/23 facility assessment showed she was cognitively intact and required extensive assistance of two plus persons physical assistance for bed mobility, transfer, and toilet use. R5's care plan showed a Stage 4 pressure injury to the mid back from a back brace she wore at a previous facility. R5's care plan showed she required 6 weeks of intravenous antibiotics for treatment of osteomyelitis of thoracic region/spine Stage 4 ulcer. R5's care plan had no offloading or repositioning interventions in place. This care plan showed a wound vac was placed on the wound on 7/3/23.

Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) for the use of Personal Protective Equipment, (PPE) for resident (R144) in transmission based isolation. This failure has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on June 8, 2021 when V3 (Housekeeper) went in and out of R144's isolation room without doffing PPE prior to leaving the room. V3 entered and exited R144's isolation room a total of three times wearing the same PPE. This failure has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. The Immediate Jeopardy was identified on June 8, 2021. V1 (Administrator) was informed of the Immediate Jeopardy on June 8, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on June 9, 2021; 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: R144's Resident Information sheet printed on June 9, 2021 showed R144 was admitted to the facility on [DATE]; the special instructions showed: Contact/Droplet Isolation 5/29/21 to 6/11/21. There were no diagnoses listed that showed she has had Covid-19. The Immunization record in R144's electronic medical record on June 9, 2021 did not show that she has received and COVID-19 vaccinations. As of 6/9/21, 92% of the residents at the facility have received the COVID vaccine and are fully vaccinated. Seventy percent of the facility's employees have received the COVID vaccine and are fully vaccinated. The Centers for Disease Control Preparing for Covid-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions updated 11/20/2020 shows, HCP (Healthcare Personnel) should wear an N95 or higher-level respiratory, eye protection, gloves, and gown when caring for new admissions and readmissions. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. On June 8, 2021 at 1:24 PM, R144 was sitting in a recliner in her room. V3 (Housekeeper) was wearing goggles, an N95 mask, isolation gown and gloves while cleaning her room. V3 had a bottle of cleaner in her hand and walked out of the resident's room in full PPE, went to her housekeeping cart in the hall and placed the cleaner in her cart. V3 then grabbed the broom and dust pan from the cart, went into R144's room and swept the floor. V3 emptied the dustpan in the resident's room and came out of the room and put the broom and dustpan on her cart in the hall. V3 grabbed the mop and a wet floor sign, placed the wet floor sign on the floor in front of R144's room, went into the resident's room and mopped her floor. V3 removed her gloves, used hand sanitizer and walked out into the hall and put the mop on her cleaning cart. V3 went back into R144's room, removed her gown, used hand sanitizer and came out of the room. V3 removed her goggles and then her N95 mask. V3 did not put a new N95 mask or surgical mask on. V3 placed her contaminated goggles inside the top drawer of the supply dresser in the hallway. V3 stated she could not find the wipes to clean the goggles. V3 went to another supply dresser in the hallway and removed Clorox wipes, walked over to the previous supply dresser, opened the top drawer and removed the contaminated goggles from the drawer, wiped them with the Clorox wipe and placed them back into the drawer. V3 stated she did not know why R144 was on isolation and that she follows the signs on the door for what PPE to wear. V3 stated she has to wear goggles, gown, gloves and an N95 mask for each room and pointed to the other isolation rooms across from R144's room. On June 8, 2021 at 2:28 PM, V2 DON (Director of Nursing) stated, R144 is on the fourteen day quarantine. R144 is a new admission that is not vaccinated. She is on droplet and contact precautions. Donning for any room for the fourteen day, there is a supply dresser with gowns, N95, gloves and eye protection. They are to put all of this on before going into room. Doffing is done just before leaving the room. The room is equipped with biohazard waste and linen hampers if gown is disposable it goes in waste, if it is a reusable cloth gown then it goes in the hamper. Hand hygiene is done in the room after they remove their gloves. They wear an N95 mask, they should have a supply in the chest and ideally it's one use. They can have single person usage for the N95 and can put in baggie that is disposed of at end of day. After the N95 is removed then they apply a surgical mask. Housekeeping should be following the same procedures. Goggles are to be cleaned; they should have disinfectant wipes to be able to sanitize those and then they can be reused. I would think they (housekeeper) would have their cart at doorway so they don't come in and out of the room. On June 8, 2021 at 2:39 PM, V4 (Housekeeping Supervisor) stated, For the fourteen day isolation rooms the housekeeper is to apply the gown, gloves, glasses and mask (N95) outside the door. Cleaning wipes are used when the resident is in the room and they are kept in the closet in the room. They are to be cleaning isolation rooms with the disposable wipes. They clean all high touch areas from the top to the bottom. Spray bottles have a cleaning agent. If they are using the spray bottles then they take their PPE off in room and dispose of it in bins in room and wash hands. They are not supposed to go in and out of the room with PPE on. We put a flat mop in the room that stays there so they don't have to go in and out of room. There is a sticky cloth to bottom of flat mop, they dust mop with it and then pull it off and throw it away in the isolation room garbage. They are not supposed to take the mop in and out of the room. The facilities Contact Isolation & Droplet Isolation Room Cleaning Procedures policy (no date) showed, What goes in stays in! Except for the housekeeper, anything that goes into an isolation room stays in the isolation room, unless it's removed in an isolation bag. Once taken into the isolation room all cleaning supplies will be kept in a locked cabinet. Housekeepers shall wear all prescribed protective clothing and follow all prescribed procedures. Protective coverings may include gloves, masks, gowns, and /or shoe coverings. Daily cleaning: Assemble the following supplies in a disposable bag: 1 package of paper towels (if needed), 1 bottle of liquid hand soap (if needed), 1 bar of soap (if needed), 2 rolls of toilet paper (if needed). Complete procedures #2 through #7 of initial cleaning procedures. Place all supplies needed into a bag to take into the isolation room with you. Sanitize your hands, and put on all protective PPE indicated. Knock before entering the room and announce that you are housekeeping. Enter the room with all of the above isolation room supplies, and explain what you are going to be doing. Starting at the door and working your way around the room to the farthest point and back around to the other side, work your way back to the door wiping all high touch areas (using as many disinfectant wipes as needed). Dispose of the wipes in a trash bag. Using a flat mop head and handle and a tacky cloth, dust mop the floor starting at the farthest point in the room working your way around the room and back to the door. Dispose of the tacky cloth in your garbage bag. Use a disinfectant wipe to wipe up any soiled areas. The policy stated when cleaning the bathroom use cleaning wipes to wipe down all high touch areas and dispose of those wipes in the trash bag. They are to clean the sink thoroughly using disinfectant wipes and then dispose of the used wipes. There were procedures on how to clean the toilet including using cleaning wipes on the outside of the toilet and disposing of those wipes in the trash bag. A cleaning wipe is to be attached to a flat mop system to clean the floor and the wipe is to be disposed of in a trash bag. Upon completion of cleaning the trash bag is to be closed, sealed and disposed of in the infectious waste container. The isolation room supplies in the policy were listed as the following: 1 flat mop system with head and handle, 1 flat mop, 1 bucket of pop up cleaning wipes and 5 disposable tacky cloths in a baggie. The Immediate Jeopardy that began on June 8, 2021and was removed on June 9, 2021 when the facility took the following actions to remove the immediacy: The facility has completed the following plan of correction in regards to the immediate jeopardy to the facility on [DATE]: 1. The facility has updated the policy and procedure entitled Contact Isolation and Droplet Isolation Room Cleaning Procedures: Initial Occupied Room Clean. 2. The facility has provided education to all housekeeping staff regarding this policy and procedure, which included proper multi-surface cleaning procedures for resident rooms under contact/droplet precautions, as well as proper donning and doffing of PPE. 3. The housekeeping supervisor has reviewed all PUI rooms to verify that each room is set up correctly for housekeeping services. 4. The facility has reviewed the Covid 19 Environmental Cleaning and Disinfecting policy and procedure. 5. The facility will establish a QAPI study regarding PUI rooms and the proper infection control procedures by housekeeping. This will be completed by the housekeeping supervisor or her designee. This plan was completed by 8:00 AM on June 9, 2021. II. Based on observation, interview and record review, the facility failed to ensure a resident washed their hands after toileting and before eating to prevent cross-contamination for 1 of 5 residents (R33) reviewed for infection control in the sample of 18. The findings include: R33's Admission Record provided by the facility on 6/10/21 showed she had diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's facility assessment dated [DATE] showed she had severe cognitive impairment and required staff assistance for toileting and personal hygiene. R33's restorative care plan showed she requires assist with dressing and grooming. The care plan showed Complete grooming/hygiene: set-up and break down task into a few manageable tasks. On 6/09/21 at 11:15 AM, V15 (Certified Nursing Assistant-CNA) assisted R33 with toileting. R33 wiped herself. After toileting, V15 did not suggest or encourage R33 to wash her hands. V15 asked R33 if she would like for her to wheel her down to the dining room in her wheel chair. R33 said yes. At 11:20 AM, as they got to the end of the hall, R33 said she needed a tissue. V15 went back to R33's room and got her a tissue. R33 wiped her nose with the tissue. V15 wheeled R33 down to the dining room and pushed her wheel chair up to one of the tables. At 11:25 AM, R33 was sitting at the table and had her hand over her top lip resting her face on her hand. At 11:35 AM, R33 picked up her cup of juice and took a drink. At 11:45 AM, R33 had her right hand on her head and then reached up and adjusted her glasses with her left hand. At 11:55 AM, R33 rested her head on both of her hands, right hand on forehead, left hand on left cheek. At 12:12 PM, R33 started to eat her lunch meal. No handwashing was suggested or provided to R33 prior to eating. On 6/10/21 at 12:12 PM, V16 (CNA) said it is important to encourage residents to wash their hands after toileting, especially when the resident wipes themselves. V16 said it is important to make sure they wash their hands so they do not get sick from bacteria like Ecoli that could be in their urine and so their hands are clean. On 6/10/21 at 12:24 PM, V2 (Director of Nursing) said she expects the CNAs to have the residents wash their hands after toileting for personal hygiene and for infection control. On 6/10/21 at 1:09 PM, V15 said she realized after the fact that she did not have R33 wash her hands after toileting. V15 said she should have had her wash her hands to prevent cross-contamination and prevent infections. The facility's policy and procedure dated 2/18/16 showed 7. Assist resident into a comfortable/safe position following peri-care. Staff member should now wash their hands if unable to complete earlier due to resident safety/dignity. Offer handwashing to the resident, no matter if they participated or not in their own care. Handwashing may be the offering of a warmed wash cloth (soap/rinse) or assisting the resident to their sink for hand hygiene.

Based on interview and record review the facility neglected to operationalize their policy and procedure for CPR (Cardiopulmonary resuscitation) and provide CPR for a resident designated as a Full Code. E4 RN (Registered Nurse), failed to locate and review the code status for R1 when she was found to be unresponsive and without a heartbeat and as a result R1 did not receive any life- saving measures as she had requested. The Immediate Jeopardy began on [DATE] when E4 was notified of R1 being unresponsive and without vital signs and no CPR was initiated. This applies to 9 of 11 residents (R1, R,[DATE]) reviewed for full code status in the sample of 11. This past non-compliance occurred form [DATE] to [DATE]. The findings include: R1's face sheet shows she was admitted to the facility on [DATE]. R1's POLST (Practitioner Orders for Life-sustaining Treatment) form dated [DATE], shows R1 requested CPR if found with no pulse and not breathing. The nursing notes for R1 show on [DATE], E4 was notified by a CNA (Certified Nursing Assistant) R1 was cold, very pale in color and no respirations were noted. E4 documents he grabbed R1's chart and a stethoscope to auscultate heart sounds and heard none. The notes show R1's face, hands and feet were cold to touch. The notes show E4 made no attempt to initiate CPR or call 911 for emergency assistance. On [DATE] at 12:30 PM, E4 said it was the facility policy for any full code resident to have heart stickers located on the name plate of their door, a sticker on the spine of their chart, and on the medication record. E4 said he checked 2 out of 3 of the places for stickers and none were found so he assumed R1 was a DNR (Do not resuscitate) and therefore no CPR was initiated. The facility's undated policy for residents requesting CPR shows if a resident requests CPR, a heart sticker is placed on the binding of their chart and on the name plate of their particular room to designate that the resident requests CPR. The facility's [DATE] procedure for CPR states the facility shall provide basic life support, including CPR to a resident who requires such emergency care prior to the arrival of emergency medical services, consistent with the resident's advance directives and physician orders. On [DATE] at 12:15 PM, E3 ADON (Assistant Director of Nursing) said she audited all resident chart for consistency of the policy for residents requesting CPR and the use of heart stickers. E3 said she reviewed the charts, name plates and medication record where the heart stickers should be located. E3 said only one wing of the 4 in the building was in compliance with the heart stickers. E3 said there was no consistency and some of the full code residents did not have any heart stickers placed in any of the 3 required locations. The facility's [DATE] CPR Audit results show the East wing to have 33 charts and 4 with full codes. Only 2 of the full codes had stickers in all 3 places; R4 and R5 had stickers on the spine of the chart and on the name plate, but not on the medication record; 1 resident did not have a POLST form indicating any code status. The West side had 32 charts with 7 being full codes. The audit shows only 3 of the 7 to have all 3 heart sticker in place; R9 had a heart sticker on the spine of the chart but not on the name plate or medication record; R6, R7 and R8 did not have any heart stickers at all, and 1 resident did not have a POLST form. The audit shows Wing 4 to have 13 charts with 6 full codes, and 2 residents without a POLST form. The Terrace wing had 25 resident charts with 2 full code residents; R10 had a sticker on the spine of the chart and on the door, but not on the medication record; and R11 did not have stickers in any location. On [DATE] at 1:00 PM, E2 DON (Director of Nursing) said social service was discussing the POLST form with families upon admission, and R1 had a form already filled out and signed by the physician. E2 said it would vary as to who would place the heart stickers on the chart and the name plate. E2 said she now realized this sticker system gave a false sense of security regarding code status. E2 said in an intense situation like finding a resident without vital signs, she would not have looked in the chart if there were no stickers on the door or the spine of the chart. Through interview and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: A. The QA committee conducted and root cause analysis and discussed policy changes. An initial chart audit was completed and the heart stickers were removed from the door name plate and the chart. An addtional QA audit was completed and all resident POLST forms were reviewed and updated. Licensed staff were in-serviced on the facility's advance directive policy and procedure, the POLST policy and procedure, and the CPR policy and procedure beginning on [DATE] and the remainder of the staff were to be educated prior to the start of their next sceduled shift. B. A revision of the policy for resident's requesting CPR was completed on [DATE]. C. The Administrator and Director of Nursing shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of this plan of correction as of [DATE].

Based on interview and record review the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) when a resident had no vital signs or respirations. The resident had made the decision to be a Full Code in case of [MEDICAL CONDITION] on [DATE]. The resident was found unresponsive at 2:45 AM on [DATE]. No resuscitative efforts were initiated by facility staff. The Immediate Jeopardy began on [DATE] when the facility did not initiate CPR on a resident who was a full code. This applies to 1 of 11 residents (R1) who were designated as a Full Code if [MEDICAL CONDITION] occurs in the sample of 11. This past non-compliance occurred from [DATE] to [DATE]. The findings include: The physician transfer orders dated [DATE] show R1 was transferring to the facility with a resuscitation status of Modified code - do not intubate (CPR would still be initiated) and a [DIAGNOSES REDACTED]. On [DATE] at 11:45 AM, E5 CNA (Certified Nursing Assistant) said she had observed R1 on [DATE] at 10 PM, then again around 12: 30 AM. E5 said at approximately 2:30 AM on [DATE] she found R1 to be unresponsive and her nail beds appeared bluish in color. E5 said she immediately notified E4 RN (Registered Nurse) of R1's condition. On [DATE] at 12:30 PM, E4 said he had observed R1 at the beginning of his shift at 10 PM, and again at approximately one hour later. E4 said R1 appeared to be fine and made a grunting noise as he flushed her feeding tube. E4 said he was notified by E5 that R1 had possibly died and immediately went to the room. E5 said he grabbed R1's chart and a stethoscope, and assessed R1 and found her to have no vital signs and determined she had died . E4 said he did not immediately look at R1's POLST (Practioner orders for life-sustaining treatment) form to verify code status. On [DATE] at 12:30 PM, E4 said after determining R1 had died he notified the on call physician and the coroner. E4 said the coroner requested for an ambulance crew to evaluate and verify the resident death. E4 said he called for paramedics and upon their arrival was asked about R1's code status. E4 said at that time he advised the paramedic R1 was a do not resuscitate and no CPR had been performed, but offered to show him R1's POLST form. E4 said it was then he realized R1 was full code, and was advised by the paramedic that too much time had passed and CPR was no longer an option. R1 was pronounced dead by the ambulance crew. E4 said he did not open the chart, he looked at the spine of the chart for a heart sticker to indicate a full code, and there was no sticker. E4 said he also looked at R1's name plate outside the doorway and found no full code sticker. On [DATE] at 1:15 PM, E9 (Social Service) said she spoke with R1's family at the time of her admission and they had presented a POLST form indicating R1 was a full code. E9 said she placed the signed POLST form on the chart. E9 said when any resident requests to be a full code heart stickers are placed on the spine of the chart, on the name plate outside the resident room, and the nurses will place a sticker on the MAR (Medication Administration Record). E9 said she did not place stickers in any of these locations for R1, and could not say why this did not happen. E9 said she will place the stickers or sometimes the nurses will place the stickers, but in this instance no one placed a sticker in any of the locations. E9 said she does not recall making any statements about the full code to the nursing staff, she assumed they would see the POLST on the chart. On [DATE] at 1:00 PM, E2 DON (Director of Nursing) said on [DATE], E4 had left her a voicemail regarding R1's full code status and no CPR had been performed. E2 said social service was discussing the POLST form with families upon admission, and R1 had a form already filled out and signed by the physician. E2 said it would vary as to who would place the heart stickers on the chart and the name plate. E2 said she now realized this sticker system gave a false sense of security regarding code status. E2 said in an intense situation like finding a resident without vital signs, she would not have looked in the chart if there were no stickers on the door or the spine of the chart. The facility's advance directive policy and procedure states it is the policy of the facility to establish, implement, and maintain written policies and procedures for advance directive. The facility's undated policy for residents requesting CPR shows: At the time of admission all residents/Power of Attorney complete or review the resident advanced directives (POLST) form, and the form is kept on the resident's chart; If the resident requests CPR, a heart sticker is placed on the binding of their chart and on the name plate of their particular room to designate that the resident requests CPR; If a resident is noted to not be breathing and/or have no heartbeat, the nursing staff will initiate basic CPR; a call is placed to 911 for EMT/ambulance response. The nursing staff provides CPR until the EMT arrives. On [DATE] at 2:40 PM, Z1 (Medical Director) stated if a resident had Full Code listed on the POLST form, resuscitation should happen immediately. Through interview and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: A. The QA committee conducted and root cause analysis and discussed policy changes. An initial chart audit was completed and the heart stickers were removed from the door name plate and the chart. An addtional QA audit was completed and all resident POLST forms were reviewed and updated. Licensed staff were in-serviced on the facility's advance directive policy and procedure, the POLST policy and procedure, and the CPR policy and procedure beginning on [DATE] and the remainder of the staff were to be educated prior to the start of their next sceduled shift. B. A revision of the policy for resident's requesting CPR was completed on [DATE]. C. The Administrator and Director of Nursing shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of this plan of correction as of [DATE].