Every finding on record at Aviata at the Palms

Based on record review and interviews, the facility failed to ensure adequate supervision and staff competency in leave of absence (LOA) procedures, resulting in three residents (#3, #4, and #7) of three residents reviewed for elopement exiting the facility without supervision; and failed to provide a safe environment when smoking materials were left unattended in room [ROOM NUMBER] where oxygen equipment was present.Findings included: 1. Record review showed Resident #3 was admitted on [DATE] and re admitted on [DATE] with diagnoses including dementia, anxiety disorder, psychotic disorder, major depressive disorder, and mood disorder. Physician orders dated 1/14/26 permitted LOA with a responsible party and required daily and shift checks of a Wanderguard. Additional orders included a Wanderguard for exit seeking behaviors dated 5/8/26, one to one supervision related to exit seeking dated 6/2/26, and an order dated 6/25/26 stating he may not go on LOA without special doctor approval. A discontinued order for one to one supervision for safety was in place from 5/10/26 to 5/20/26. Review of progress notes for Resident #3 showed repeated exit seeking. On 5/10/26 staff observed him push open the southwest emergency exit door and attempt to leave before being redirected; Ativan 1 mg (milligram) gel was ordered. On 5/11/26 he wandered extensively and was confused. On 5/17/26 he wandered looking for car keys and required redirection. On 5/20/26 he was described as at risk for elopement, and later that day he paced, became agitated, and attempted to exit the front door. On 6/2/26 he attempted elopement, was returned by staff, and placed on constant observation. Psychiatric evaluation on 6/28/26 documented continued elopement risk, pacing, anxiety, agitation, and cognitive deficits. On 7/10/26 he checked doors, stated he was trying to leave, and was redirected. Review of elopement assessments for Resident #3 dated 1/25/26, 2/6/26, and 6/5/26 were positive. The care plan documented elopement risk and behaviors including aggression, agitation, pacing, exit seeking, hallucinations, paranoia, and delusions, with 1:1 supervision initiated on 3/19/26. The 6/4/26 MDS showed a brief interview for mental status (BIMS) score of 99 and independent mobility. Psychiatry notes dated 4/18/26 and 6/3/26 indicated staff reported he was at high elopement risk, had a Wanderguard in place, and had eloped the day prior to the 6/3/26 visit. The incident/accident log from 4/2026 to 7/2026 contained no entries for elopement. Multiple interviews were conducted on 7/14/26 confirming an elopement event for Resident #3. Staff C, Certified Nursing Assistant (CNA) at 1:13 p.m. reported he exited recently. At 1:17 p.m., Staff D, CNA said he pushed the door open and got out. At 1:52 p.m., Staff E, CNA stated he was exit seeking and appeared confused. At 1:58 p.m., Staff F, CNA stated she saw him running in the neighborhood, heard an alarm, and said he was caught when his pants fell; she said the Staffing Coordinator returned him. At 2:39 p.m., Staff G, Licensed Practical Nurse (LPN) stated she saw staff running out of the employee entrance and later saw resident #3 returning with staff. At 2:57 p.m., the Staffing Coordinator stated she heard the south unit alarm, saw him running in the neighborhood, reached him first, and confirmed he was placed on 1:1 supervision after the incident. At 3:30 p.m., the Transportation/Driver stated she heard an alarm and saw the resident running down the road. At 3:45 p.m., Medical Records stated she saw him running outside and no code was called. On 7/14/26 at 4:20 p.m., an interview was conducted with the Director of Nursing (DON), and the Nursing Home Administrator (NHA) was present. The DON stated Resident #3 was exit seeking and did exit the building on 6/2/26 in the afternoon. She said staff were on him and that multiple staff saw him running one street over before directing him back; his pants began falling, slowing him down. He was placed on 1:1 supervision due to his exit seeking history and cognitive status, and the IDT (interdisciplinary team) determined he would remain on continuous 1:1 during wake hours until guardianship was obtained. The DON stated nurses were expected to round on him during the 11:00 p.m. to 7:00 a.m. shift, although staff were not rotating 1:1 at night. She confirmed orders reflected continuous supervision. She reported no documentation of the incident except five staff statements and stated he was assessed verbally but nothing was documented. She said he had been pacing that day and told her he saw his wife outside and was trying to go with her. The DON said she heard the exit door alarm, saw him running, and observed a nurse go one way while she went another. Regarding 5/20/26, she stated Resident #3 did not exit; staff notified psychiatry, new medications were ordered, and the nurse redirected him. On 7/15/26 at 10:34 a.m., an interview was conducted with the Director of Maintenance (DOM). He stated he heard staff saying Resident #3 got out of the facility. He said he saw staff running out the back and front of the facility. The DOM said Resident #3 was found on the side, towards the back of the facility. 2. Record review showed Resident #4 was admitted on [DATE] and re admitted on [DATE] with epilepsy, schizoaffective disorder, mood disorder, anxiety disorder, and fall history. An LOA order dated 6/25/26 permitted leaving without supervision. A discontinued LOA order required supervision from 8/4/25 to 6/23/26. Care plans documented fall risk, impaired cognition, behavioral concerns, and impaired functional performance. Elopement assessments dated 2/6/26, 4/25/26, 5/14/26, and 6/5/26 indicated he was not at risk. The 5/21/26 MDS showed moderate cognitive impairment and independent mobility. No progress notes documented elopement. Psychiatry notes dated 4/14/26 and 6/26/26 documented moderate to mild cognitive impairment. Interviews conducted with multiple staff regarding Resident #4 indicated an LOA failure as follows: On 7/14/26 at 1:13 p.m., Staff C, CNA stated the receptionist let Resident #4 out and staff retrieved him. At 1:29 p.m., Staff I, CNA stated the resident left once and confirmed he could not leave the facility alone. At 1:58 p.m., Staff F, CNA stated no code was called She said staff were whispering among themselves, and that the receptionist let him out; staff retrieved him near the facility sign. At 2:39 p.m., Staff G, LPN stated staff resident #4 could not leave independently and he had to be supervised. She said the receptionist let him out, but staff got to him quickly. At 2:57 p.m., the Staffing Coordinator stated Resident #4 was upset about breakfast, the receptionist asked if he could leave, was told no, but let him out anyway; several staff redirected him. At 3:56 p.m., the receptionist stated she had only a short orientation; Resident #4 wanted [Name of fast food restaurant], did not sign out, and she asked HR about supervision; the business office manager retrieved him. On 7/14/26 at 4:48 p.m., the DON, with the NHA present, stated that while they were at a conference, they learned Resident #4 had been let out the front door on 6/22/26 by the receptionist. Staff were alerted he had not signed out, and Resident #4 said he was going to [Name of Fast Food Restaurant]. The DON said staff assessed him, notified the physician, and reminded him of the LOA policy. She reported there was no documentation of the incident, including no witness statements or progress notes, and stated the Unit Manager would have assessed him. She said his previous LOA orders required supervision, but after assessment he was allowed to leave without supervision, and his LOA orders were re assessed on 6/23/26 because he was not considered an elopement risk. She stated his BIMS fluctuates, he has a TBI (traumatic brain injury) diagnosis, but was alert and had a plan that day, and staff maintained visual contact. The DON confirmed he should not have left, although staff had eyes on him. The NHA stated he and the AIT (administrator in training) provided training to the receptionist afterward and said she had prior education, although an audit showed the LOA binder did not include all residents. On 7/15/26 at 10:34 a.m., the Director of Maintenance (DOM) stated he arrived at the facility and was informed Resident #4 had exited through the front door. He said he went outside to look for the resident and assisted with bringing him back, noting the resident reached the entrance near the facility's sign. He stated HR staff was ahead of him wheeling the resident back, the alarm did not sound because the resident did not have a Wanderguard, and no elopement drills were completed afterward because the event was considered the receptionist's error.3. Record review showed Resident #7 was admitted on [DATE] and re admitted on [DATE] with epilepsy, muscle weakness, difficulty walking, and need for assistance with personal care. An order dated 8/11/25 required LOA supervision. The care plan documented impaired cognition and impaired mobility. The 3/28/26 MDS showed moderate cognitive impairment and use of a walker and wheelchair. Interviews with staff confirmed two unsupervised departures as follows: On 7/14/26 at 1:58 p.m., Staff F, CNA stated Resident #7 left twice for appointments without staff. At 2:57 p.m., the Staffing Coordinator stated the resident left twice without escort and staff retrieved him. At 3:56 p.m., the receptionist stated he slipped out when a new staff member let him out and, on another occasion, she let him go with the transport driver and the Transportation/Driver later drove the CNA to meet him. On 7/14/26 at 4:20 p.m., an interview was conducted with the DON, and the NHA was present. The DON stated Resident #7 had an appointment on 7/9/26 and the restorative aide was supposed to accompany him. She said the restorative aide walked away, the transport company arrived, and the receptionist allowed the transport driver to take Resident #7 in the van. The DON said she was informed of the situation by the Transportation/Driver staff member and stated the receptionist knew the resident required an escort. She said the appointment location was nearby, and the Transportation/Driver transported the restorative aide to the appointment, arriving at the same time as the van transporting Resident #7. She said the incident was addressed with the receptionist on the same day. The DON stated there was no documentation completed and said she did not believe documentation was necessary because family often meets residents at appointments; she stated, Technically, that's okay. She said the nursing dashboard in the electronic medical record contained the resident's appointment information and that appointments were now being added to physician orders. The DON and NHA stated they were not aware of any additional incidents where Resident #7 attended an appointment without a staff escort. On 7/15/26 at 9:30 a.m., an interview was conducted with the Transportation/Driver and Medical Records staff. The Transportation/Driver stated Resident #7 had an appointment on 7/2/26 and required an escort; she said she was told the resident left with the transportation company without staff. The Medical Records staff stated she overheard the assigned CNA say, Why would you let him leave, and confirmed Resident #7 had already left. She said she immediately called the driver, who returned after approximately two minutes. The Transportation/Driver stated that on 7/9/26, the resident's rescheduled appointment date, she noticed he was gone and asked the receptionist, who said the resident went to his appointment. She said the receptionist had access to the dashboard indicating an escort was required. The Transportation/Driver said she transported the CNA to the appointment, arriving at the same time as the van. She said Resident #7 did not enter the appointment without the CNA and stated the resident's sister also attended his appointments, along with facility staff. 4. On 7/14/2026 at 9:40 a.m., observation in room [ROOM NUMBER] showed a pack of cigarettes and a lighter on bed A's dresser with oxygen and tracheostomy equipment on bed B's side. At 9:55 a.m., the DON stated residents should not have lighters in their rooms. At 10:02 a.m., the Regional [NAME] President (RVP) stated the same. A review of the facility's LOA process/procedure revealed the following, 3. Reception Desk Log Configuration Master Log Management: Transfer the names of residents with approved LOA orders to the master tracking log. Face Sheet Attachment: Insert a current copy of the resident's face sheet into the log folder or binder. Categorization: File each resident's profile and face sheet within the log under their corresponding clinical and neighborhood description. 4. Front Desk Logistical Controls Central Location: Maintain the physical LOA log and accompanying face sheets permanently at the front reception desk for visibility and emergency access. Accountability Protocol: Require all residents to physically sign out when exiting the facility and sign in immediately upon return. Staff Verification: Front Desk personnel will verify the resident's specific LOA status from the Master Log before executing the supervised or unsupervised protocol. Discrepancy Resolution: If any discrepancy arises regarding a resident's leave status, Front Desk staff must instantly validate it with Clinical Staff to ensure proper process execution before allowing the resident to depart. 5. Unsupervised Sign-Out Protocol Status Validation: Locate the resident's profile in the log to confirm they are cleared for independent, unsupervised leave. Independent Logging: Instruct the resident to personally sign their name, destination, departure time, and return time at the front desk upon departure and re-entry. A review of the facility's policy titled Daily Skilled Nursing Progress Note, dated 9/29/17, revealed the following, Policy: Residents receiving skilled care have progress documented daily in the medical record by the nurse. Further review of the policy, under procedure, revealed the following, Document abnormal findings in a narrative note on the form. Also, Document in a narrative note the indications for continued skilled care using the Skilled Documentation Reference Guidelines . A review of a policy, revised on 2/7/2020, titled, Smoking – Supervised revealed the procedure 5: The center will retain and store matches, lighters, etc. for all residents.

Based on interviews and record review, the facility failed to implement its antibiotic stewardship protocol and failed to monitor antibiotic use as required by facility policy. The facility did not maintain surveillance tools, tracking forms, or monthly line listings for seven months. This failure had the potential to result in inappropriate antibiotic prescribing and ineffective monitoring of infections for all residents in the facility. Findings included:A review of the facility's antibiotic stewardship binder revealed incomplete monitoring. The binder did not contain line listings for February through May 2026. The binder also did not contain a surveillance tool to identify and track ongoing infections throughout the facility.During an interview on 7/15/2026 at 1:33 P.M., the Director of Nursing (DON) stated she had not updated the antibiotic stewardship binder since December 2025. The DON stated she did not have a current or complete stewardship binder. The DON stated the facility did not have an Infection Preventionist, and she was responsible for completing the antibiotic stewardship binder. The DON stated the infection control module login for the [name of the facility's documentation software] was not updated. The DON stated she did not have any surveillance tools to monitor ongoing infections in the facility.A review of a policy titled Antibiotic Stewardship, revised December 2016, revealed the purpose of the program was to prescribe and administer antibiotics under the guidance of the facility's antibiotic stewardship program. The policy stated the program was responsible for monitoring antibiotic use in residents.A review of a policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, revealed that antibiotic usage and outcome data must be collected and documented using a facility approved surveillance tracking form. The policy directed the Infection Preventionist (IP), or designee, to review all clinical infections treated with antibiotics, evaluate antibiotic utilization, identify situations inconsistent with appropriate antibiotic use, notify the provider of findings, and document all antibiotic regimens on the surveillance tracking form.

Based on record review and interviews, the facility failed to ensure accurate and complete documentation of tracheostomy care for one resident (#2) out of two residents sampled. This failure resulted in missing documentation of required tracheostomy treatments, which created the potential for airway obstruction, infection, and respiratory compromise.Findings included: A review of the Minimum Data Set (MDS) Section O showed Resident #2 had a tracheostomy.A review of Resident #2's physician orders indicated the resident was to receive multiple tracheostomy related treatments, including: Attaching the trach to a compressor with humidification once daily for an overnight 8 hour treatment at 9:00 P.M. Changing trach ties every day shift. Changing the inner cannula (Shiley #6) every day shift. Monitoring oxygen saturation every shift and maintaining saturation above 92%. Suctioning the trach every shift.A review of the treatment administration record (TAR) showed these treatments were not documented as completed on 7/8/2026, 7/9/2026, and 7/10/2026.A second review of Resident #2's physician orders showed additional tracheostomy care requirements, including: Tracheostomy site dressing change every day shift. Maintaining the head of the bed at 30 degrees or higher each shift, unless contraindicated. Observing the skin around the stoma site every shift. Keeping an Ambu bag with an E cylinder, an extra Shiley size 6 no cuff trach tube, and one smaller size at the bedside every shift. Performing tracheostomy care (#6) every shift.A review of the TAR showed these treatments were not documented as completed on 7/8/2026 and 7/9/2026.During an interview on 7/15/2026 at 9:30 A.M., Staff A, Respiratory Therapist (RT), stated the inner cannula should be cleaned and replaced every day, and both the inner cannula and the stoma site should be cleaned every shift and as needed. Staff A, RT, also stated the trach ties and tubing should be changed once a week and as needed.During an interview on 7/15/2026 at 1:40 P.M., the Director of Nursing (DON) stated that if documentation was not present, she would assume the task was not completed. The DON said nurses are expected to document whether they completed a treatment or did not complete it, including the reason for non completion. The DON confirmed Resident #2's TAR contained missing documentation. Review of a facility policy titled Respiratory Therapy, revised 1/29/2026, revealed, tracheostomy care is a skilled respiratory therapy intervention performed to maintain airway patency, prevent infection, ensure proper function of the tracheostomy tube, and promote resident safety and comfort.

Based on observations, interviews, and record review, the facility failed to implement transmission based precautions according to infection control standards for one resident (#1) out of one resident reviewed for infection control, creating the potential for transmission of suspected scabies or impetigo to other residents and staff.Findings included: An observation on 7/15/2026 at 12:17 P.M. revealed Resident #1 was inside another resident's room. The two residents were conversing while seated in their wheelchairs facing each other approximately 12 inches apart.An observation on 7/15/2026 at 12:31 P.M. revealed Resident #1 was working out in the therapy gym with therapy equipment. Resident #1 was wearing shorts that exposed the right lower extremity.A review of Resident #1's medical record revealed the following physician orders: Dermatology consult to evaluate for possible skin scraping to rule out scabies versus dermatitis. Enhanced Barrier Precautions r/t (related to) wound. Doxycycline 100 MG (milligrams) orally every 12 hours for for RLE [Right Lower Extremity] for Impetigo for 10 Days.A review of a physician progress note dated 6/30/2026 documented Resident #1 reported severe itching of the top of the right foot and right shin, with multiple broken skin areas due to scratching. The note stated dermatology was to evaluate and consider skin scraping to rule out scabies.A review of a physician progress note dated 7/11/2026 documented Resident #1 was receiving doxycycline 100 milligrams orally every 12 hours for treatment of right lower extremity impetigo.A review of the Centers for Disease Control and Prevention (CDC) Isolation Precautions, Appendix A, retrieved on 7/15/2026, recommended any resident with a diagnosis of scabies or impetigo be placed on contact precautions until 24 hours after initiation of effective therapy.During an interview on 7/15/2026 at 12:19 P.M., Staff B, Licensed Practical Nurse (LPN), stated she did not know whether Resident #1 was on transmission based contact precautions. Staff B, LPN, stated she did not know Resident #1 had an order for a dermatology consult to evaluate for possible scabies. She stated she did not know whether dermatology had recently seen Resident #1 and did not know the reason Resident #1 was receiving antibiotics.During an interview on 7/15/2026 at 1:33 P.M., the Director of Nursing (DON) stated Resident #1 believed they had scabies and wanted to be evaluated. The DON stated that if a resident was suspected of having scabies, ideally the resident should be placed in a private room and on contact precautions until scabies was ruled out. The DON stated Resident #1 was not placed on contact precautions. The DON stated Resident #1 had a diagnosis of impetigo and residents with impetigo should also be on contact precautions. The DON confirmed Resident #1 was not placed on contact precautions.A review of a policy revised August 2019, titled, Isolation - Initiating Transmission-Based Precautions revealed, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection. The policy interpretation and implementation 1: If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse, or Nursing Supervisor notifies the Infection Preventionist and the resident's attending physician for evaluation of appropriate Transmission-Based Precautions.A review of a policy revised October 2018, titled Isolation - Categories of Transmission-Based Precautions revealed, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection. The policy interpretation and implementation 3: The Center for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions.Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.

Based on observations, and interviews the facility failed to provide a homelike, safe, clean and sanitary, and pest free environment for four (#7, #16, #17, #18) out of four residents reviewed. Findings included:1. On 4/13/2026 at 10:32 AM an observation was made of the facility's maintenance shed full of debris on the inside; a toilet, a black bin with garbage in it, wooden platforms stacked on one another, a bathroom commode, a wheelchair, an opened safe, two large-industrial portable air conditioning units with bio growth present, multiple garbage cans, and carts scattered around the shed.On 4/13/2026 at 10:34 AM an interview was conducted with Staff L, Maintenance Assistant (MA). Staff L, MA stated they are waiting for the Maintenance Director to come up with a solution for all of the supplies and items present outside of the maintenance shed and is waiting for direction on what to do with the items outside of the shed since the shed is full.2. On 4/13/2026 at 11:07 AM an observation was made of the facility's grounds. Inspection of the ground revealed a large broken window of a residents room, wasps nests between windows and the screen, and fallen gutter pieces not disposed of properly. Outside of the facility's kitchen door was a wheelchair, empty plastic bins, a shop vacuum, garbage can lids, and plastic trays thrown on the grounds of the facility.On 4/13/2025 at 7:50 PM an interview was conducted with Resident #7. The resident stated they do not know how their window broke but knows they woke up one morning in January to it being broken. Resident #7 stated they have told staff and maintenance about the window since the day it happened, but they have been slow with providing the repair.3. A review of Resident #17's admission record revealed an admission date of 2/21/2026 with diagnoses to include multiple rib fractures, a history of falling, and chronic pain syndrome.A review of Resident #17's Quarterly Minimum Data Set (MDS) assessment, dated 2/25/2026, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 15, indicating Resident #17 is cognitively intactOn 4/13/2026 at 11:45 AM an observation was made of a dead insect on the closet floor of Resident #17. Further examination of Resident #17's room revealed a large hole on the ground corner of the window wall with broken drywall present and crumbling base-boarding. Small pests were found under the bed of Resident #17's room. Resident #17 stated they always see roaches and bugs crawling around the room and their bed and the staff does nothing about it. Resident #17 stated they are always killing roaches and flies in their room.On 4/13/2026 at 11:32 AM an interview was conducted with Staff K, Licensed Practical Nurse (LPN). Staff K, LPN revealed some rooms have issues with pests and has seen roaches in the rooms of certain residents. Staff K, LPN stated anytime they see pests they are to fill out the sighting log that is left at each nurses station and let maintenance know so pest control can handle the room when they come in.On 4/13/2026 at 11:52 AM an interview and observation was made with Staff M, Certified Nursing Assistant (CNA). Staff M, CNA stated the pest in Resident #17's closet was a roach, as well as the pest under the other bed being a roach. Staff M, CNA moved the other bed in Resident #17's room and under the wheels of the bed revealed multiple pest debris and dust. Staff M, CNA stated pests are found in rooms of residents who have untidy rooms or a lot of food, or rooms with men in them. Staff M, CNA, was unaware of the pest sighting log present at each nursing station. Staff M, CNA stated they were not aware of the large hole in the wall of Resident #17's room so it was never reported to maintenance. 4. A review of Resident #18's admission record revealed an initial admission date of 5/9/2025 with diagnoses to include muscle weakness, major depressive disorder, and unspecified mood disorder.A review of Resident #18's Quarterly Minimum Data Set (MDS) assessment, dated 4/8/2026, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 13, indicating Resident #18 is cognitively intact.On 4/13/2026 at 12:19 PM an observation was made of Resident #18's room. The resident's room was messy with three pairs of shoes scattered on the floor, cups stacked within each other, other drinking cups on the floor, a pest living in the Resident's pack of personal care items, and a large hole present under the window of crumbling dry-wall along the floor next to Resident #18's bed. Resident #18 stated no one cares to fix his room and that he sees roaches present all the time.On 4/13/2026 at 12:19 PM an observation and interview was made with Staff O, CNA. Staff O, CNA stated it was a roach that was present in Resident #18's brief pack. Staff O, CNA stated Resident #18's room tends to have roaches present in it because of the constant condition of the room.5. On 4/13/2026 at 1:46 PM an observation was made of a pest trap in the corner of the facility's kitchen of their preparation table.On 4/13/2026 at 1:40 PM an interview was conducted with Staff N, Cook. Staff N, [NAME] stated despite not seeing any pests in the kitchen, they do know there are some traps present in the kitchen, but was not sure where6. A review of Resident #16's admission record revealed an initial admission date of 7/11/2024 and a re-admission date of 9/9/2025 with diagnoses to include difficulty walking, venous peripheral insufficiency, need for assistance with personal care, and anxiety disorders. A review of Resident #16's Quarterly Minimum Data Set (MDS) assessment, dated 3/25/26, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 15, indicating Resident #16 is cognitively intact. A review of Section B- Hearing, Speech and Vision revealed Resident #16 has highly impaired visionOn 4/13/2026 at 3:10 PM an observation was made of Resident #16's room revealing multiple pests present crawling underneath the residents bedside table. Resident #16 stated they live in terror of being crawled on in bed by the pests, especially because the resident is unable to see them due to loss of eyesight. Resident #16 stated their family is also aware of the pests. Resident #16 stated the light above their bed only works halfway and demonstrated the light switch. Only one light bulb was operational on the light. Resident #16 stated they have reported it to staff multiple times over a few months period, and nothing has been done yet. Resident #16 stated even though they have not been able to use their toilet in months due to recent diagnoses and conditions, the toilet has not been able to properly flush. Resident #16 explained once you flush the toilet once, you are unable to flush it again for at least 20 minutes, it just keeps running. Resident #16 stated they have told nursing about it, but nothing has been done about it. While observing Resident #16's toilet's flushing ability, two pest traps were present behind the toilet. During observation of Resident #16's room, a large gallon bottle of pest killer was found on the resident's bedside table. Resident #16 stated their family member brought it in because of how bad the pests were in the room.On 4/13/2026 at 4:00 PM while advising the NHA of Resident #16's toilet, the Adimistrator in Training (AIT) stated that it is Normal for all toilets, especially in the facility to have at least a 8 minute delay, and that it is normal to not be able to flush the toilet within a couple minutes after the initial flush.On 4/13/2026 at 4:06 PM an observation and interview was made with the Nursing Home Administrator (NHA), Director of Maintenance (DM) and the Regional [NAME] President Officer (RVPO) of Resident #16's room. The DM moved Resident #16's bedside table and found and identified multiple roaches crawling around the resident's wall and floor. Resident #16 stated having these pests in their room makes them feel itchy and uncomfortable knowing that they are crawling around and the resident is unable to see them. The NHA, DM, and RVPO started having Resident #16's room cleaned out immediately and stated they found more roaches behind the items hanging on the residents wall despite the room not being messy.On 4/13/2026 at 4:43 PM an observation and interview was made with the Transportation Director (TD). The TD is on angel-rounds for Resident #16 and visits their room daily. The TD stated during her interviews with Resident #16, she never asked the resident about having bugs in their room, and that it would be difficult for the resident to remember to bring up bugs since she is unable to see them due to her medical condition. The TD stated they check the resident's room during each round where she looks around the room, checks the call light, bathroom light and ensures everything is working in the resident's room. The TD stated bug spray is never to be left in a residents room, and that they did not notice the large bottle of bug spray on the residents bed-side table. The TD stated having bug spray in resident's rooms can be a hazard and lead to effects on the resident's breathing, it is a safety issue.On 4/13/2026 at 5:09 PM an interview was conducted with the DM. The DM stated they started on March 2, 2026, and have been trying to identify the issues within the facility, despite only checking and inspecting the 300-hall so far since their start date. The DM said they noticed the broken window for room [ROOM NUMBER] on the first day they started and brought it to the attention of administration immediately. When they DM brought the issue up to the NHA, the DM was told a deposit was already put down on 2/16/2026 and they are waiting for the window to be replaced. The DM stated the NHA advised him the window was supposed to be fixed the first week he was there. The DM stated the delay in getting the window fixed was an issue with getting ahold of the window company after the deposit was made. The DM stated they have a lack of pest control invoices and documentation because the facility sends their invoices to the head office in New Jersey, so they do not have them on hand. The DM stated staff is supposed to put their pest sighting into the maintenance electronic system, but only some of the staff is doing it. For the staff that is not documenting their pest sightings, they cannot be taken care of if he does not know about them. The DM stated pest traps should not be in the kitchen, but is aware of them being in there, This is not proper infection control by having the traps in the kitchen because it then leads to dead bugs being in the kitchen. The DM stated the pests observed in resident's rooms was unacceptable, and the holes present in the resident's rooms are definite ways for pests to get in and out of resident's rooms. The DM stated it is not normal for a toilet to have a delay in flushing, and Resident #16's toilet was definitely not functioning properly and needed to be fixed and/or replaced. The DM stated since they have started, they have only inspected the 300 hallway but has not gotten around to the other halls to identify issues. The DM stated they have identified a process issue in reporting findings by staff, and will need to complete in-services with all staff to ensure issues are reported right away. The DM stated the items outside of the maintenance shed and kitchen door are never to be left laying outside and was not sure why it was not put away somewhere. On 4/13/2026 at 5:45 PM an interview was conducted with the NHA. The NHA stated it is a huge risk to the resident to have bug spray present in their room had the resident been able to access it on their own, and holds potential hazards of contamination, breathing, and being a health risk. The NHA stated Resident #16's toilet did not act normal, and it is not normal for a toilet to have a delay between flushes. The NHA also stated pest traps should not be present in a residents room, and it is not a homelike environment with miscellaneous items scattered throughout the grounds, none of those items were to be left outside. The NHA stated they have been having difficulty getting in touch with the window company after they had made the deposit, but the window is scheduled to get fixed soon. The NHA stated the staff is not properly cleaning up the rooms after seeing the debris found in Resident #17's room, and it is unacceptable to have the eggs and pests present in the room. The NHA stated the kitchen should not have pest traps present due to contamination if the bugs die within the kitchen.Review of the policy maintenance effective 11/20/2014 with no revision date showed the following: Policy: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify areas/items in need of repair. Procedure: The director of environmental services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All items needing maintenance assistance will be reported to maintenance using the maintenance repair request form.Review of the Policy Pest control effective 11/30/2014 with no revision date showed the following: Policy: The facility will maintain a pest control program, which includes inspection, reporting, and prevention. Procedure: 3. Treatment will be rendered as required to control insects and vermin. 4. Any unusual occurence or sighting of insects should be reported immediately to the supervisor. Proper action will be taken.

Based on interviews and record review, the facility failed to ensure voiced concerns from resident council meetings were documented as a grievance and acted upon during two meetings (held on 1/5/26 and 2/4/26) out of three meeting minutes reviewed, as well as three food committee meetings (held on 3/10/26, 3/24/26, and 4/7/26) out of three meeting minutes reviewed.Findings included: On 4/13/26 at 1:40 p.m., an interview was conducted with Resident #23. He said Staff E, Activities Assistant documented the resident council minutes. Resident #23 said the residents expressed their concerns, they were written in the meeting minutes, but there was no follow-through or resolution. He said it was the same old and new business concerns every month.A review of Resident #23's minimum data set (MDS) assessment, dated 1/8/26, revealed under section C - cognitive patterns, a brief interview for mental status (BIMS) score of 15, indicating cognitively intact.On 4/13/26 at 1:58 p.m., an interview was conducted with Staff E, Activities Assistant. She confirmed she wrote down the resident council minutes by hand on a sheet of paper. Staff E, Activities Assistant said she gives them to the Activities Director who typed the notes and puts them in a binder. She said she did know what happened with the resident council minutes after she provided them to the Activities Director.The facility provided resident council minutes for 1/2026, 2/2026 and 4/2026, but did not provide 3/2026 meeting minutes.A review of the resident council meeting minutes revealed the following:- On 1/5/26 the resident council meeting conducted at 10:15 a.m., showed the following concerns were documented to include: housekeeping not cleaning resident rooms daily and poor customer service.- On 2/4/26 the resident council meeting conducted at 10:14 a.m., showed the following concerns were documented to include: staff using personal items such as cell phones and headphones, maintenance issues and lack of follow-through/resolution with reported issues, and housekeeping staff moving resident items then not putting them back and fitted sheets reported as too small.A review of the food committee meetings minutes revealed the following:- On 3/10/26 the meeting minutes showed the following concerns were documented to include: meal ticket and tray accuracy, lack of condiments on tray, and snacks not being offered at night.- On 3/24/26 the meeting minutes showed the following concerns were documented to include: food was overcooked, residents did not like canned fruit, and the taste of juice was described as too strong.- On 4/7/26 the meeting minutes showed the following concerns were documented to include: plates not hot, lack of condiments on tray, canned fruit consistency was too hard/difficult to chew, and snacks not consistently available.A review of the grievance logs for 1/2026, 2/2026 and 3/2026 did not show documented concerns for the resident council group or individual concerns for the residents who attended resident council meetings. Further review of the grievance logs did not show documented concerns from the food committee group or individual concerns for the residents who attend the food committee meetings. The review confirmed there were undocumented and unresolved grievances from resident council and food committee meetings.On 4/13/26 at 5:07 p.m., an interview was conducted with the nursing home administrator (NHA). He stated grievances, Could be from anyone. He said concerns are documented on the grievance log. The NHA said the majority of the grievances come from the facility's angel rounds. He said the grievances go to Social Services and documented on the grievance log. The NHA said the grievance is communicated to the designated department. He said the department that was assigned the grievance is responsible for the resolution. The NHA said the expectation was to return the resolved grievance to social services. He said the social services staff goes to the resident to let them know about the outcome and that the grievance was resolved. He stated for resident council he was, Still learning that process. He said there was a new activities director, and it has been a challenge. He said resident council meeting minutes/concerns are discussed with the interdisciplinary team (IDT) and the team decides to document as an individual grievance or as a whole for the resident council group. He said the food committee meetings started about two months to help separate food concerns from resident council meetings. He said the activities staff handwrites the resident council minutes, then the resident council minutes are discussed with IDT team before they are typed up. Regarding concerns voiced in resident council and food committee meetings, the NHA stated, It's been a challenge and lack of follow through.A review of the facility's policy titled Complaint/Grievance, revised 10/24/22, revealed the following, Policy: The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with whom grievances may be file (State agency, Ombudsman, Quality Improvement Organizations). Further review of the policy, under procedure, revealed the following, 1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. 2. Original grievance forms are then submitted to the Grievance Officer / designee for further 3. The Grievance Officer / designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint/Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance Official will log complaints/grievances in Monthly Grievance Log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care and services that is in accordance with professional standards of practice were provided related to: 1. ensuring oxygen was administered per physician orders for one resident (#10) out of two reviewed for oxygen therapy; 2. Failed to provide tracheostomy care according to professional standards of practice for two residents (#10, #12) out of two residents reviewed for tracheostomy care.Findings included:1.On 4/13/26 at 09:53 a.m., Resident #10 was observed in bed with a trach mask, delivering 2 liters per minute of oxygen at 28% humidity. There were red specks appearing to be dried blood in the trach mask. There were large amounts of tannish white secretions leaking out of trach mask onto a wash cloth which was under the trach mask. There was free water observed in lower portion of tubing prior to a water collection bag. The collection bag was placed on its side next to Resident #10 in bed. There were no dates on the oxygen tubing and trach tubing. Condensation was present on compressor and water was present on the table below equipment. [Photographic Evidence Obtained]On 4/13/26 at 10:58 a.m. and at 11:58 a.m., Resident #10 was observed in the room, there were no changes from prior observation. On 4/13/26 at 12:57 p.m., an interview and observation were conducted with Staff B, Registered Nurse (RN), at Resident #10's bedside. There were still no dates present on oxygen or trach tubing. Staff B, RN, reported that suction and care is given every shift and as needed, he stated The Resident [#10] has a lot of secretions and will need another suction before I leave. Staff B, RN, verified Resident #10 was receiving 2 liters per minute of oxygen at 28% humidity. Staff B, RN, reviewed the record and was unable to identify a physician order. Staff B, RN, stated, there should be an order. Staff B, RN, reported that trach suctioning and care would be charted in a progress note or in the treatment administration record (TAR). Staff B, RN, confirmed that all emergency trach supplies should be at the bedside to include trach tube, inner cannula, sterile catheters for suctioning, and an artificial manual breathing unit.An interview and observation were conducted on 4/13/26 at 2:35 p.m., Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM), was unable to locate a trach tube in Resident #10's room and stated, We must have run out in here, but they are in central supply. Staff A, LPN, verified Resident #10 was on 2 liters per minute of 28% humidified oxygen. Staff A, LPN, confirmed oxygen is administered with a physician order. Staff A, LPN, was unable to locate a physician order for oxygen and humidity via trach mask in the orders for Resident #10. Review of Resident #10's admission record showed an admission date of 4/8/26 with a primary diagnosis of chronic respiratory failure with hypoxia. Other diagnoses included dysphagia, aphagia, unspecified dementia, and tracheostomy status. Review of Resident #10's orders on the Medication Administration Record (MAR), effective as of 4/13/26, included but was not limited to: Head of bed maintained 30 degrees or more; every shiftChange trach ties daily and PRN (as needed) if soiled; as neededSuction tracheostomy tube as needed to clear airway. Document results in PN (progress note); as neededObserve for changes in skin integrity of stoma site, i.e., redness, excoriation, signs/symptoms of infection during care; every shiftChange trach tubing and circuit tubing (label and date all tubing); every night shift every FridayTracheostomy site dressing change; every shift and as needed if soiledTrach: (Artificial manual breathing unit) bag and extra trach same size (6) and one size smaller (4) to be kept at bedside; every shiftReview of Resident #10's medical record revealed there was no order for humidified oxygen via trach mask.Review of Resident #10's Treatment Administration Record (TAR) from 4/8/26 to 4/13/26 revealed: Change trach ties daily and PRN if soiled every day shift; started 4/10/26: No entries for 4/10/26, 4/12/26, 4/13/26Change trach tubing and circuit tubing (label and date all tubing) every night shift every Friday; started 4/10/26: Charted 4/10/26Suction tracheostomy tube as needed to clear airway. Document results in PN as needed; started 4/9/26: No entries chartedTracheostomy site dressing change every shift: No entries charted on day shift 4/10/26, 4/12/26Review of Resident #10's care plan, initiated on 4/9/26, showed: Focus: exhibits or is at risk for respiratory complications related to dx (diagnosis) of: Tracheostomy. Goal: will be free of s/s (signs/symptoms) of respiratory distress, and maintain optimal functioning within limitations imposed by disease process through review date. Interventions include but not limited to administer oxygen as ordered (Refer to MAR for current order).2. On 4/13/26 12:20 p.m. Resident #12 was observed in bed with tracheostomy mask delivering 5 liters per minute of oxygen at 28% humidity. Trach and oxygen tubing were not dated. A bag hung from side table was dated 3/28/26. There was no drainage observed at trach site or in the trach mask. The replacement trach tube was not readily accessible during observation. On 4/13/26 at 3:45 p.m. an observation and interview were conducted. Resident #12 was observed in bed with clear to white drainage at the trach site. Staff D, LPN, stated, Dates on the tubing are a night shift responsibility. Staff D, LPN, verified there were no dates on Resident #12's oxygen and trach tubing and pointed to a bag with a date of 3/28/26. Staff D, LPN, confirmed the expectation that emergency supplies should be at the bedside. Staff D, LPN, was unable to locate the trach tube at the bedside and stated, The trach tube is kept in central supply.Review of Resident #12's admission records showed an admission date of 3/26/26 with a primary diagnosis of acute and chronic respiratory failure with hypoxia and additional diagnoses to include anoxic brain damage, other specified chronic obstructive pulmonary disease, dysphagia, tracheostomy status, and dependence on supplemental oxygen. Review of Resident #12's TAR for 4/1/26 to 4/13/26 revealed:- Change O2 (oxygen) tubing (label and dating tubing) and bag cover every week every night shift every Sunday for maintenance - start date 3/29/26- Oxygen @ 5 liters per minute via trach mask with 28% humidified air continuously every shift for Acute on Chronic Hypoxic Respiratory Failure - start date 3/27/26Review of Resident #12's medical record revealed there were no orders or treatments for trach tubing, care, suctioning, and emergency supplies at the bedside Review of Resident #12's care plan, initiated on 3/27/26, showed: Focus: has a tracheostomy and is at risk for complications related to artificial airway device. Goal: will maintain effective airway through the next review date. Interventions include suction resident as needed and trach care every shift and PRN.On 4/13/26 at 2:35 p.m. an interview was conducted. Staff A, LPN, stated Trach care and suction should be provided every shift and as needed. Staff A, LPN, confirmed expectations that trach tubing and oxygen tubing were to be dated when changed. Staff A, LPN, confirmed expectations that all emergency trach supplies be at the bedside to include a trach tube. Staff A, LPN, stated trach care, suctioning, and drainage amount be charted in a progress note or treatment administration record. On 4/13/26 at 2:55 p.m., an interview was conducted. The Director of Nursing (DON) stated, the expectation is that clinical staff are following a physician order for tracheostomy care and the orders are specific to each resident. The DON confirmed a physician order was required for a resident on oxygen therapy. The DON confirmed all trach care performed by the nursing staff should be documented in the medical record. Review of a facility policy titled, Tracheostomy Care Policy, document RT-525, effective 11/30/2014, revised 1/29/2026 revealed, Tracheostomy care is a skilled respiratory therapy intervention performed to maintain airway patency, prevent infection, ensure proper function of the tracheostomy tube, and promote resident safety and comfort. All tracheostomy care, including the cleaning of reusable inner cannulas and stoma care, shall be performed only with a physician or authorized provider order and in accordance with the resident's individualized plan of care.

Based on interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies related to intravenous (IV) therapy for two residents (#20, #21) of three sampled for IV therapy and failed to ensure tracheostomy care was completed competently for two residents (#10, #12) of two sampled residents.Cross reference F695Findings included:Review of an employee list of IV certifications, provided by Human Resources (HR), showed 15 out of 19 LPNs with IV certification expired on [DATE].Interview on [DATE] at 6:55 p.m. Human Resources (HR) stated, The person before me may have had a list of all the LPN certifications, however I was only able to verify the IV therapy certifications that I could put my eyes on for four LPNs on the list I gave you. HR stated, The list includes all the licensed practical nurses, and I entered [DATE] as an expiration date because I don't have documentation of their IV therapy certification.During an interview on [DATE] at 7:01 p.m., the Director of Nursing (DON) stated, The previous DON did an audit to confirm (IV therapy) certification, but I don't have access to it. The DON confirmed that the HR Department tracks and audits IV therapy certifications for the LPNs. The DON confirmed that the expectation was for LPNs to have IV therapy certification. During an interview on [DATE] at 4:58 p.m., Staff A, LPN, stated, Only a few LPNs don't have IV certification, and I will be assisting with the skills checkoffs. Staff A, LPN, stated, I am not sure why they don't have my IV certification.During an interview on [DATE] at 6:50 p.m., Staff C, LPN stated, I am IV certified. If I wasn't certified, I would have to get a certified LPN or RN.During an interview on [DATE] at 6:52 p.m., Staff D, LPN stated, I am IV certified. Staff D, LPN confirmed that if she was not certified she would need to get a certified licensed practical nurse or registered nurse to perform IV therapy.Review of the HR employee list, Staff C, LPN, and Staff D, LPN are listed with expired IV therapy certifications as of [DATE].1.Review of Resident's #20 admission record showed an admission date of [DATE] with a primary diagnosis of unspecified cerebral palsy and additional diagnosis included left hand other acute osteomyelitis.Review of Resident's #20 Medication Administration Record (MAR) from [DATE] to [DATE] revealed:-Cefazolin (antibiotic) sodium injection (started [DATE]): 2 grams intravenously (IV) every 8 hours: 24 out of 35 opportunities charted by Licensed Practice Nurse (LPN) (Staff F, G, H, I, J, K) without facility documentation of IV competency.-Heparin lock flush solution 10u/mL use 5mL intravenously every 8 hours for flush of lumens after med admin; flush with 10mL of normal saline before med; flush with 10mL of normal saline after med; followed by heparin: 24 out of 35 opportunities administered by LPN (Staff F, G, H, I, J, K) with no documentation of IV competency.2. Review of Resident #21's admission record showed an admission date of [DATE] with a primary diagnosis of quadriplegia, C1-C4 incomplete and additional diagnoses included unspecified local infection of the skin and subcutaneous tissue, unspecified organism sepsis, carrier or suspected carrier of methicillin resistant staphylococcus aureus, and personal history of urinary (tract) infections.Review of Resident #21's MAR from [DATE] to [DATE] revealed:-Cefepime (antibiotic) HCL Intravenous Solution Reconstituted 2 grams (Effective [DATE] to [DATE]): Use 2 grams intravenously every 8 hours for infection: 8/10 opportunities administered by LPN (Staff F, H, K) with no documentation of IV competency.3. 1.On [DATE] at 09:53 a.m., Resident #10 was observed in bed with a trach mask, delivering 2 liters per minute of oxygen at 28% humidity. There were red specks appearing to be dried blood in the trach mask. There were large amounts of tannish white secretions leaking out of trach mask onto a wash cloth which was under the trach mask. There was free water observed in lower portion of tubing prior to a water collection bag. The collection bag was placed on its side next to Resident #10 in bed. There were no dates on the oxygen tubing and trach tubing. Condensation was present on compressor and water was present on the table below equipment. [Photographic Evidence Obtained]On [DATE] at 10:58 a.m. and at 11:58 a.m., Resident #10 was observed in the room, there were no changes from prior observation.On [DATE] at 12:57 p.m., an interview and observation were conducted with Staff B, Registered Nurse (RN), at Resident #10's bedside. There were still no dates present on oxygen or trach tubing. Staff B, RN, reported that suction and care is given every shift and as needed, he stated The Resident [#10] has a lot of secretions and will need another suction before I leave. Staff B, RN, verified Resident #10 was receiving 2 liters per minute of oxygen at 28% humidity. Staff B, RN, reviewed the record and was unable to identify a physician order. Staff B, RN, stated, there should be an order. Staff B, RN, reported that trach suctioning and care would be charted in a progress note or in the treatment administration record (TAR). Staff B, RN, confirmed that all emergency trach supplies should be at the bedside to include trach tube, inner cannula, sterile catheters for suctioning, and an artificial manual breathing unit.An interview and observation were conducted on [DATE] at 2:35 p.m., Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM), was unable to locate a trach tube in Resident #10's room and stated, We must have run out in here, but they are in central supply. Staff A, LPN, verified Resident #10 was on 2 liters per minute of 28% humidified oxygen. Staff A, LPN, confirmed oxygen is administered with a physician order. Staff A, LPN, was unable to locate a physician order for oxygen and humidity via trach mask in the orders for Resident #10.Review of Resident #10's admission record showed an admission date of [DATE] with a primary diagnosis of chronic respiratory failure with hypoxia. Other diagnoses included dysphagia, aphagia, unspecified dementia, and tracheostomy status.Review of Resident #10's orders on the Medication Administration Record (MAR), effective as of [DATE], included but was not limited to:Head of bed maintained 30 degrees or more; every shiftChange trach ties daily and PRN (as needed) if soiled; as neededSuction tracheostomy tube as needed to clear airway. Document results in PN (progress note); as neededObserve for changes in skin integrity of stoma site, i.e., redness, excoriation, signs/symptoms of infection during care; every shiftChange trach tubing and circuit tubing (label and date all tubing); every night shift every FridayTracheostomy site dressing change; every shift and as needed if soiledTrach: (Artificial manual breathing unit) bag and extra trach same size (6) and one size smaller (4) to be kept at bedside; every shiftReview of Resident #10's medical record revealed there was no order for humidified oxygen via trach mask.Review of Resident #10's Treatment Administration Record (TAR) from [DATE] to [DATE] revealed:Change trach ties daily and PRN if soiled every day shift; started [DATE]: No entries for [DATE], [DATE], [DATE]Change trach tubing and circuit tubing (label and date all tubing) every night shift every Friday; started [DATE]: Charted [DATE]Suction tracheostomy tube as needed to clear airway. Document results in PN as needed; started [DATE]: No entries chartedTracheostomy site dressing change every shift: No entries charted on day shift [DATE], [DATE]Review of Resident #10's care plan, initiated on [DATE], showed: Focus: exhibits or is at risk for respiratory complications related to dx (diagnosis) of: Tracheostomy. Goal: will be free of s/s (signs/symptoms) of respiratory distress, and maintain optimal functioning within limitations imposed by disease process through review date. Interventions include but not limited to administer oxygen as ordered (Refer to MAR for current order).4. 2. On [DATE] 12:20 p.m. Resident #12 was observed in bed with tracheostomy mask delivering 5 liters per minute of oxygen at 28% humidity. Trach and oxygen tubing were not dated. A bag hung from side table was dated [DATE]. There was no drainage observed at trach site or in the trach mask. The replacement trach tube was not readily accessible during observation. On [DATE] at 3:45 p.m. an observation and interview were conducted. Resident #12 was observed in bed with clear to white drainage at the trach site. Staff D, LPN, stated, Dates on the tubing are a night shift responsibility. Staff D, LPN, verified there were no dates on Resident #12's oxygen and trach tubing and pointed to a bag with a date of [DATE]. Staff D, LPN, confirmed the expectation that emergency supplies should be at the bedside. Staff D, LPN, was unable to locate the trach tube at the bedside and stated, The trach tube is kept in central supply.Review of Resident #12's admission records showed an admission date of [DATE] with a primary diagnosis of acute and chronic respiratory failure with hypoxia and additional diagnoses to include anoxic brain damage, other specified chronic obstructive pulmonary disease, dysphagia, tracheostomy status, and dependence on supplemental oxygen.Review of Resident #12's TAR for [DATE] to [DATE] revealed:- Change O2 (oxygen) tubing (label and dating tubing) and bag cover every week every night shift every Sunday for maintenance - start date [DATE]- Oxygen @ 5 liters per minute via trach mask with 28% humidified air continuously every shift for Acute on Chronic Hypoxic Respiratory Failure - start date [DATE]Review of Resident #12's medical record revealed there were no orders or treatments for trach tubing, care, suctioning, and emergency supplies at the bedsideReview of Resident #12's care plan, initiated on [DATE], showed: Focus: has a tracheostomy and is at risk for complications related to artificial airway device. Goal: will maintain effective airway through the next review date. Interventions include suction resident as needed and trach care every shift and PRN.On [DATE] at 2:35 p.m. an interview was conducted. Staff A, LPN, stated Trach care and suction should be provided every shift and as needed. Staff A, LPN, confirmed expectations that trach tubing and oxygen tubing were to be dated when changed. Staff A, LPN, confirmed expectations that all emergency trach supplies be at the bedside to include a trach tube. Staff A, LPN, stated trach care, suctioning, and drainage amount be charted in a progress note or treatment administration record.On [DATE] at 2:55 p.m., an interview was conducted. The Director of Nursing (DON) stated, the expectation is that clinical staff are following a physician order for tracheostomy care and the orders are specific to each resident. The DON confirmed a physician order was required for a resident on oxygen therapy. The DON confirmed all trach care performed by the nursing staff should be documented in the medical record.Interview on [DATE] at 2:45 p.m. with the HR personnel revealed, I don't have that in reference to documentation for nursing competency assessments for tracheostomy care and suctioning.Interview on [DATE] at 2:55 p.m. with DON confirmed the expectation of documented nursing assessments showing competency for tracheostomy care and suctioning. The DON stated, I have only been here for a couple weeks, but I am working on the staff competencies.On [DATE] at 3:17 p.m., the DON failed to provide a list of documented competencies for tracheostomy care and suctioning for nursing staff as requested.Review of a facility policy titled, Tracheostomy Care Policy, document RT-525, effective [DATE], revised [DATE] revealed, Tracheostomy care is a skilled respiratory therapy intervention performed to maintain airway patency, prevent infection, ensure proper function of the tracheostomy tube, and promote resident safety and comfort. All tracheostomy care, including the cleaning of reusable inner cannulas and stoma care, shall be performed only with a physician or authorized provider order and in accordance with the resident's individualized plan of care.The facility did not provide IV therapy policy.

Based on observations and interviews, the facility failed to ensure Activities of Daily Living (ADL) were provided to maintain grooming and personal hygiene for one (#19) resident of one resident reviewed for ADL care. Findings include:On 4/13/2026 at 3:38 PM an observation was made of Resident #19 sitting in their wheelchair with a blanket pulled over their head/face. The resident was wearing sweatpants that were soaked through from the briefs being overly wet and not changed from the 7-3 shift or the start of the 3-11 shift. In Resident #19's lap area were paper towels soaked in a yellow body fluid. Resident #19 was unable to communicate their needs.A review of Resident #19's admission record revealed an admission date of 4/10/2024 with diagnoses to include unspecified dementia, cognitive communication deficit, need for assistance with personal care, persistent mood (affective) disorder, anxiety disorder, and stage 3 chronic kidney disease.A review of Resident #19's Quarterly Minimum Data Set (MDS) assessment, dated 3/25/26, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 99, indicating Resident #19 has severe cognitive impairment. In Section GG- Functional Abilities revealed that Resident #19 scored a 1, Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Resident #19 for toilet transfer scored a 88-Not attempted due to medical condition or safety concerns. In Section H- Bladder and Bowel scored a 3-Always incontinent for both bladder and bowel continence. A review of Resident #19's progress notes dated 3/30/26-4/13/26 revealed the following the resident is alert with confusion and is dependent for most ADLs related to decreased cognitive function and decreased mobility. The resident is incontinent of bowel and bladder and wears briefs that are changed by staff as needed. Nursing reported Resident #19 has been cooperative with caregiving and taking his medications without reported side effects.A review of Resident #19's Care Plan revealed the resident is at risk for decreased ability to perform ADL in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to cognitive and physical decline. Further review revealed Resident #19 has a communication problem due to a brain injury, cognitive impairment, expressive aphasia, and receptive aphasia, with interventions to include: Anticipating and meeting the resident's needs per physical/non-verbal indications of discomfort/distress and follow up as needed. Resident #19's care plan revealed the resident has bowel incontinence with interventions to include to check on the resident routinely/frequently and assist with toileting as needed.On 4/13/2026 at 3:39 PM an interview was conducted with Staff P, Certified Nursing Assistant (CNA) for Resident #19. This aide was observed at the nurses station conversing with fellow care staff. The CNA was unaware of Resident #19's condition due to admitting she did not do her initial rounds by going into each room and checking on the residents as of yet. The CNA stated she had not completed her rounds when she clocked in, even though she is supposed to do rounds the moment she clocks in. Staff P, CNA stated prior shift must not have changed the resident either, nor did they make her aware of Resident #19 needing to be changed.On 4/13/2026 at 3:41 PM an interview was conducted with Staff Q, Licensed Practical Nurse (LPN), for Resident #19. Staff Q, LPN stated the CNAs are supposed to do bed side rounds at the start of the shift to ensure that all residents have water and are changed as needed. When asked if Staff Q, LPN was aware of the condition of the resident at the start of her shift, she stated she was unaware at the time. Staff Q, LPN stated they speak to mostly everybody when they start their shift. With Resident #19 being left in a soaked brief, Staff Q, LPN said it means the 7-3 CNA did not check on the resident all day, and that they have had these same issues with that CNA before as this was not the first time this has happened with this CNA.On 4/13/2026 at 3:44 PM an interview was conducted with the Director of Nursing (DON). The DON stated the CNAs should be checking on residents who are incontinent at least every 2-hours and more frequent for those residents who are unable to communicate. The DON stated Resident #19 should have been changed by now, even if the 7-3 shift CNA did not change the resident, the 3-11 shift CNA should have completed the task at start of their shift.A review of the facility's Diarrhea and Fecal Incontinence policy revealed the following: Residents must be cleaned after each episode of incontinence.A Bladder Incontinence and/or ADL Policy was requested from the facility, but was not provided by the facility.

Based on record review and interviews, the facility failed to ensure the physician was notified of blood sugar levels (BSLs) that were outside parameters for one (Resident #2) of two residents sampled.Findings included:Resident #2 was readmitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes with diabetic peripheral angiopathy without gangrene and long-term use of insulin.Review of Resident #2's Medication Administration Record (MAR) for January 2026 revealed Novolog FlexPen subcutaneous solution pen-injector 100 UNIT/ML (milliliters) (insulin Aspart). Inject per sliding scale: 150-200 + 4 Units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 units = 12 units. Notify MD (medical doctor) if BS (blood sugar) less than 70 or greater than 400; 401-450 = 14 units subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with hyperglycemia. Start date 10/29/25. D/C (discontinued) date 1/26/26.The order revealed the physician was to be notified for any BS readings above 400.Review of Resident #2's MAR for January 2026 revealed the following BS readings:On 1/1 at 9:00 p.m. = 420On 1/ 2 at 9:00 p.m. = 423On 1/4 at 9:00 p.m. = 409On 1/6 at 4:30 p.m. = 440On 1/8 at 9:00 p.m. = 450On 1/11 at 9:00 p.m. = 412On 1/18 at 9:00 p.m. = 408On 1/21 at 11:30 a.m. = 413On 1/23 at 4:30 p.m. = 436Review of Resident #2's MAR for December 2025 revealed Resident #2 had BS readings above 400 19 out of 120 tested times.Review of Resident #2's MAR for November 2025 revealed Resident #2 had BS readings above 400 32 out of 120 tested times.Review of Resident #2's medical record from November 2025 to January 2026 did not revealed documentation the physician being notified of BS readings above 400 per orders.On 2/23/2026 at 5:20 p.m. an interview was conducted with the Director of Nursing (DON). The DON reviewed the MARs for Resident #2 and stated the nurses should have been documenting notification of the BS levels that were above 400. She stated sometime in October the physician changed the sliding scale to include higher numbers because the resident was at baseline with the higher numbers. She stated when they changed the order to increase the sliding scale to 450, he did not change the instructions. The DON stated given the way the current orders read, They should have documentation. The DON stated if the numbers were above or below parameters, the physician should be notified.Review of a facility policy titled, Notification of Change, revised 12/16/2020, showed, policy - The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition.Procedure: The nurse to notify the attending physician and Resident Representative when there is a(n):o Accidentso Significant change in the patient/resident's physical, mental, or psychosocial statuso Need to alter treatment significantly New treatment Discontinuation of a current treatment due to but not limited to: Adverse consequences, Acute condition, Exacerbation of a chronic condition.o A transfer or discharge of the Patient/Resident from the Centero Patient/Resident consecutively refuses medication and/or treatment ( i.e. two or more times)o Patient/Resident is discharged without proper medical authority In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible. The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. If the Medical Director does not respond, call 911 and document in the medical record. Notify the patient/resident and the resident representative of the change in condition. Document notification in the medical record. Document resident/patient change in condition on 24 Hour Report Complete SBAR as indicated.

Based on observation, record review and interviews, the facility failed to ensure a resident with contractures received care and services to prevent on-going decline in physical abilities and deconditioning for one (Resident # 1) of one resident observed. Findings include:On 02/23/2026 at 9:45 AM Resident #1 was observed lying in bed right hand was observed with fingers touching palm, no splint or support. On 02/23/2026 at 12:14 PM Resident #1 was observed lying in bed. He was unable to verbally communicate but able to shake his head when asked questions. His right hand was observed with fingers touching palm, with no splint or support.On 02/23/2026 at 2:00 PM Resident #1 was observed lying in bed. His neck pillow was observed lying on top of the sheet over the stomach. The right hand was observed with fingers touching palm with no splint or support.Review of Resident #1's admission Record revealed an admission to the facility initially on 10/09/2025 and readmitted on [DATE] with diagnoses to included but not limited to unspecified displaced fracture of surgical neck of right humerus, subsequent encounter fracture with routine healing, Type 2 Diabetes Mellitus without complications, affecting right dominant side, functional quadriplegia.Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 has impairments on one side of his upper and lower extremity and has no mobility devices.Review of Resident #1's Therapy Funding Verification Form, dated 2/23/2026, revealed Resident #1 was approved minutes for Physical and Occupational Therapy, per discipline for 30 minutes times, three visit for four weeks.On 02/23/2026 at 2:15 PM an interview was conducted with Staff A, License Practical Nurse, (LPN), Staff A stated Resident #1 is not receiving range of motion or routine care from nursing for his contracted hand, therapy is usually responsible for contractures. Staff A stated to her knowledge when a resident has any kind of contracture therapy screens the residents first. Then therapy will either continue the resident on therapy services or refer them to restorative therapy.On 02/23/2026 at 2:30 PM an interview was conducted with Staff B, Restorative Therapy. Staff B stated Resident #1 is not on her case load for restorative therapy. Staff B stated when therapy refers a resident for restorative, therapy will put the information in the electronic medical record. Staff B, Restorative Therapy stated checking the system daily for any changes to the schedule. Staff B stated Resident #1 was never referred to restorative therapy.On 2/23/2026 at 2:40 PM an interview was conducted with the Rehab Director. The Rehab Director stated he has not screened resident #1 for his contracted hand. The Rehab Director stated nursing is responsible for managing Resident #1 contracted hand.On 02/23/2026 at 4:04 PM an interview was conducted with the Director of Nurses, (DON). The DON said Resident #1 was admitted with right hand contracture. The DON stated nursing cannot do anything for a resident's contracted hand. Nursing would only take over splint management once therapy has done an evaluation and provides education to nurses on how to safely manage the resident's hand.Review of the facility policy titled, Contractures, Prevention dated 11/30/2014, revealed: Policy: Each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Procedure. RANGE of Motion: Resident with inactive extremities should have range of motion done to those extremities as part of their daily care.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to be free from neglect for one resident (#3) out of two residents reviewed for neglect and abuse. The facility neglected to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and supervision as needed. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings Included: 1. On 11/17/25 at 11:39 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60-65 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Further observations of Resident #3 revealed he ate his meal without assistance from staff. On 11/18/25 at 11:50 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Staff were observed setting up the meal tray in front of him. Resident #3 began consuming his meal unassisted by staff. He was observed having difficulty getting food onto the fork. After four attempts, Resident #3 was able to get a dime-sized amount of food on the fork. Staff E, Certified Nursing Assistant (CNA) stated to Staff F, CNA, He [Resident #3] keeps doing that because he can't see his food. Staff F, CNA was observed looking at Resident #3's meal tray and stated, Well, he's almost done.A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation.A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: - Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section GG - Functional Abilities, . A. Eating: . 05. Setup or clean-up assistance .- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes .A review of Resident #3's current diet orders revealed the following: - Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25.A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24. - CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24. - CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24. - CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following: - [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP). - 11/10/25 health status note 12:05, Note Text: Late Entry: At time of assessing the resident after chocking his bilateral lungs were clear, Resp [respiratory] even and nonlabored, O2 [oxygen] sat [saturation] at 98% on r.a. [room air] Res. [resident] was taken back to his room and was sitting up in chair without s/s [signs and symptoms] of distress, created by Staff D, Nurse Supervisor. - 11/10/25 health status note 13:04, Note Text: At the time of assessment of patient, vitals taken: B/P [blood pressure] 126/80, pulse 98, temp 97.9, respirations 18, and O2 95 on room air. Patient alert and in no apparent distress. Lung sounds clear and patient observed to have normal respiratory effort, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 health status note 13:32, CXR reviewed: IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. 1) Vitals every shift for 3 days 2) CBC/CMP in AM.- 11/11/25 health status note, Labs reviewed, stable without any leukocytosis. Stable anemia and DM II [diabetes mellitus two] are noted. No new orders.- 11/11/25 health status note 21:12, LATE ENTRY Note Text: Resident is alert with confusion and is assisted totally with ADL's [activities of daily living]. Transfers to and from Geri chair with Hoyer lift and 2 assist [two person assist]. Resident is assisted with meals, encouraged to eat meal. Incontinent of B&B [bladder and bowel]. No s/s of acute distress and no c/o [complaints of] pain voiced at this time. - 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.- 11/13/25 health status note, V/S [vital signs] taken on 11/9/2025 s/p [status post] incident in MDR 126/89, 98, 18, 97.9 with O2 sat 95 on RA, created by the Director of Nursing (DON). A review of Resident #3's assessments revealed the following: - 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25. - 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 . Review of Resident #3's x-ray results revealed the following:- 4/21/25 chest, single view, Clinical Information: follow up left infiltrate Test Procedure: . CHEST, SINGLE VIEW Findings: Comparison: 03/15/2025 The cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. No pleural fluid or masses are noted. No pneumothorax is present. Impressions: No acute intrathoracic disease process. - 11/10/25 chest, 2 views, Date of Service: 11/10/2025 Clinical Information: . Pneumonitis due to inhalation of food and vomit possible aspiration Test Procedure: . CHEST, 2 VIEWS Findings: . No acute osseous or soft tissue abnormality. Cardiac and mediastinal contours are within normal limits. Normal pulmonary vasculature. No pneumothorax. Bilateral intrapillar airspace opacity is present. Peribranchial distention with peribranchial cuffing is present. This nonspecific finding indicates chronic or acute perihilar inflammation. IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. A review of a resource from the American Lung Association revealed the following, Atelectasis happens when the tiny air sacs or alveoli in your lungs are blocked, and it causes a partial or full collapse of one or more lobes or sections of the lungs. Other causes may include A small object blocking the airways (like food or toy) . Lung infection like pneumonia . Your healthcare provider will discuss treatment options if atelectasis is caused by a tumor, an aspirated foreign body, or other chronic lung conditions. Serious complications may occur if atelectasis remains untreated. Complications can include low oxygen levels, pneumonia, or lung failure. The reference was reviewed on the following website https://www.lung.org/lung-health-diseases/lung-disease-lookup/atelectasis. A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning of 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. He confirmed there was no nurse present in the dining room during the lunch meal on 11/9/25. Resident #10 said a nurse never came to assess Resident #3. He said staff took Resident #3 to his room after the lunch meal was completed. Resident #10 confirmed he stayed for the duration of the lunch. He said other departments are now helping in the dining room and a nurse is present. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said he had been in this position since August 2025. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident, but he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet, such as mechanical or regular. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said he could not provide the residents meal ticket for that day, as he did not have access to do that, but he could provide an example meal ticket of a dysphagia, mechanical texture for the meal that day. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. The Food Service Director said he did not have documentation of in-services or training regarding meal ticket accuracy for dietary staff prior to August 2025. He said since he has been at the facility he has not needed to provide an in-service on meal ticket accuracy. The Food Service Director said he completed audits and an in-service on meal ticket accuracy to all the dietary staff on 11/10/25. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as the, The double checker. She said she called out every ticket and made sure it is the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray, and she made sure it had the correct beverage, condiments, diet, and the meal matches. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aids were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her, she immediately called the Food Service Director and told him the resident choked and staff were blaming her for the incident. Staff G, Dietary Aide stated the Food Service Director told her no one had called him and, They would see about it on Monday when he comes in. She confirmed that the Nursing Home Administrator (NHA) asked her what happened and she provided a statement. She confirmed she had meal ticket accuracy education, before 11/9/25, from the Food Service Director. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. She said when she first started, at the end of June 2025, she was educated on the tray line and meal ticket accuracy process by the former food service director and one of the dietary aides. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said the day of the incident, Resident #3 was feeding himself and she heard him gasping for air. Staff J, CNA said she looked over and saw he was choking. She said his eyes were watering and demonstrated he had his hands on the chest/neck area while gasping. Staff J, CNA and Staff K, receptionist both went to assist him and yelled out for reception to get a nurse. Staff J, CNA said she leaned him forward to pat him on the back. She said it was difficult because he was reclined and leaning back in a Geri chair. She confirmed Staff K, receptionist performed the Heimlich maneuver on Resident #3. She said she assisted with twisting the resident to the side that way Staff K, receptionist could get behind him. Staff J, CNA said she is not cardiopulmonary resuscitation (CPR) certified. She said by the time Staff D, Nurse Supervisor arrived the food had been dislodged, and the resident was breathing. Staff J, CNA said Staff D, Nurse Supervisor asked what happened and said they should not have done anything because only a nurse should do the Heimlich. She said Staff D, Nurse Supervisor asked them if the resident was ok and said she had to go back to the unit to finish what she was doing, then left. Staff J, CNA said she did not observe an assessment completed on Resident #3 in the dining room and no vital signs were taken at that time. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. She said meals in the dining room started around 11:15 a.m. to 11:30 a.m., and Resident #3 choked around 11:45 a.m. Staff J, CNA said he did not leave the dining room until after 12:45 p.m.On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 2:03 p.m., a phone interview was conducted with Staff D, Nurse Supervisor. She stated, That day [11/9/25] I was the only supervisor in building, which is normal. Staff D, Nurse Supervisor said she was on the south wing assessing a patient who was complaining of chest pain. She stated while she was, Getting that under control, she heard yelling that a nurse was needed for an assessment. She said she ran to the dining room and confirmed the incident happened during lunch time. Staff D, Nurse Supervisor said Resident #3 was sitting up in the chair, there were approximately four staff members there, and she heard he choked. She stated, Whatever they did it was already taken care of, by the time she got to the dining room. Staff D, Nurse Supervisor confirmed the staff present said they did the Heimlich. She stated, He was calm, peaceful, nothing wrong with him. Staff D, Nurse Supervisor confirmed she assessed Resident #3 to include listening to his lungs and looking at him. She stated it was a Quick look, listen, and go, as she had another emergency she was handling. She said she saw he was okay; then went to the kitchen and asked what and how the incident happened. Staff D, Nurse Supervisor said, The head person in the kitchen stated someone was on their phone while fixing the tray. She said she told the kitchen staff they needed to be careful, and Resident #3 could have died. She did not recall the names of the kitchen staff present. She said the resident went back to his room but could not confirm who took him there. She said she called and let her manager know about the incident. Staff D, Nurse Supervisor confirmed Staff B, LPN was his assigned nurse. She stated, She [Staff B, LPN] was on the floor, not in the dining room. She said she does not know Resident #3 well but knows he was on a pureed diet and assumed he had a swallowing difficulty. She confirmed she assisted with educating staff after the incident. She said immediately after the incident, they started making sure a nurse and/or management is in the dining room during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating. On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds. She confirmed she documented her assessment in the electronic health record. Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed. Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when she was told about what happened. She confirmed she would have expected to be notified and would have evaluated him sooner since she was his assigned nurse. Staff B, LPN said lunch in the dining room is around 11:00 am. When asked what time she assessed Resident #3 she stated, Pretty much whatever time I documented is when I evaluated him, it was probably a few minutes before. Staff B,

Based on observations, interviews, and record review, the facility failed to ensure residents were free from avoidable accidents for two residents (#3 and #2) out of three residents reviewed for accidents.The facility failed to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and one to one supervision. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. On 11/17/25 at 11:39 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60-65 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Further observations of Resident #3 revealed he ate his meal without assistance from staff.On 11/18/25 at 11:50 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Staff were observed setting up the meal tray in front of him. Resident #3 began consuming his meal unassisted by staff. He was observed having difficulty getting food onto the fork. After four attempts, Resident #3 was able to get a dime-sized amount of food on the fork. Staff E, Certified Nursing Assistant (CNA) stated to Staff F, CNA, He [Resident #3] keeps doing that because he can't see his food. Staff F, CNA was observed looking at Resident #3's meal tray and stated, Well, he's almost done.A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation. A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following:- Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section GG - Functional Abilities, . A. Eating: . 05. Setup or clean-up assistance .- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes . A review of Resident #3's current diet orders revealed the following:- Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25. A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24.- CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24.- CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24.- CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following:- [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP).- 11/10/25 health status note 12:05, Note Text: Late Entry: At time of assessing the resident after chocking his bilateral lungs were clear, Resp [respiratory] even and nonlabored, O2 [oxygen] sat [saturation] at 98% on r.a. [room air] Res. [resident] was taken back to his room and was sitting up in chair without s/s [signs and symptoms] of distress, created by Staff D, Nurse Supervisor.- 11/10/25 health status note 13:04, Note Text: At the time of assessment of patient, vitals taken: B/P [blood pressure] 126/80, pulse 98, temp 97.9, respirations 18, and O2 95 on room air. Patient alert and in no apparent distress. Lung sounds clear and patient observed to have normal respiratory effort, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 health status note 13:32, CXR reviewed: IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. 1) Vitals every shift for 3 days 2) CBC/CMP in AM.- 11/11/25 health status note, Labs reviewed, stable without any leukocytosis. Stable anemia and DM II [diabetes mellitus two] are noted. No new orders.- 11/11/25 health status note 21:12, LATE ENTRY Note Text: Resident is alert with confusion and is assisted totally with ADL's [activities of daily living]. Transfers to and from Geri chair with Hoyer lift and 2 assist [two person assist]. Resident is assisted with meals, encouraged to eat meal. Incontinent of B&B [bladder and bowel]. No s/s of acute distress and no c/o [complaints of] pain voiced at this time.- 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.- 11/13/25 health status note, V/S [vital signs] taken on 11/9/2025 s/p [status post] incident in MDR 126/89, 98, 18, 97.9 with O2 sat 95 on RA, created by the Director of Nursing (DON).A review of Resident #3's assessments revealed the following:- 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25.- 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 .Review of Resident #3's x-ray results revealed the following:- 4/21/25 chest, single view, Clinical Information: follow up left infiltrate Test Procedure: . CHEST, SINGLE VIEW Findings: Comparison: 03/15/2025 The cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. No pleural fluid or masses are noted. No pneumothorax is present. Impressions: No acute intrathoracic disease process.- 11/10/25 chest, 2 views, Date of Service: 11/10/2025 Clinical Information: . Pneumonitis due to inhalation of food and vomit possible aspiration Test Procedure: . CHEST, 2 VIEWS Findings: . No acute osseous or soft tissue abnormality. Cardiac and mediastinal contours are within normal limits. Normal pulmonary vasculature. No pneumothorax. Bilateral intrapillar airspace opacity is present. Peribranchial distention with peribranchial cuffing is present. This nonspecific finding indicates chronic or acute perihilar inflammation. IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025.A review of a resource from the American Lung Association revealed the following, Atelectasis happens when the tiny air sacs or alveoli in your lungs are blocked, and it causes a partial or full collapse of one or more lobes or sections of the lungs. Other causes may include A small object blocking the airways (like food or toy) . Lung infection like pneumonia . Your healthcare provider will discuss treatment options if atelectasis is caused by a tumor, an aspirated foreign body, or other chronic lung conditions. Serious complications may occur if atelectasis remains untreated. Complications can include low oxygen levels, pneumonia, or lung failure. The reference was reviewed on the following website https://www.lung.org/lung-health-diseases/lung-disease-lookup/atelectasis. A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning at 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. He confirmed there was no nurse present in the dining room during the lunch meal on 11/9/25. Resident #10 said a nurse never came to assess Resident #3. He said staff took Resident #3 to his room after the lunch meal was completed. Resident #10 confirmed he stayed for the duration of the lunch. He said other departments are now helping in the dining room and a nurse is present. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray for Resident #3 in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident and he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray to assure it was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as The double checker. She said she called out every ticket and made sure it was the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aides were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her she immediately called the Food Service Director. Staff G, Dietary Aide stated the Food Service Director told her, They would see about it on Monday when he comes in. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember the person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said the day of the incident, Resident #3 was feeding himself and she heard him gasping for air. Staff J, CNA said she looked over and saw he was choking. She said his eyes were watering and demonstrated he had his hands on the chest/neck area while gasping. Staff J, CNA and Staff K, receptionist both went to assist him and yelled out for reception to get a nurse. Staff J, CNA said she leaned him forward to pat him on the back. She said it was difficult because he was reclined and leaning back in a Geri chair. She confirmed Staff K, receptionist performed the Heimlich maneuver on Resident #3. She said she assisted with twisting the resident to the side that way Staff K, receptionist could get behind him. Staff J, CNA said she is not cardiopulmonary resuscitation (CPR) certified. She said by the time Staff D, Nurse Supervisor arrived the food had been dislodged, and the resident was breathing. Staff J, CNA said Staff D, Nurse Supervisor asked what happened and said they should not have done anything because only a nurse should do the Heimlich. She said Staff D, Nurse Supervisor asked them if the resident was ok and said she had to go back to the unit to finish what she was doing, then left. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 2:03 p.m., a phone interview was conducted with Staff D, Nurse Supervisor. She stated, That day [11/9/25] I was the only supervisor in building, which is normal. Staff D, Nurse Supervisor said she was on the south wing assessing a patient who was complaining of chest pain. She stated while she was, Getting that under control, she heard yelling that a nurse was needed for an assessment. She said she ran to the dining room and confirmed the incident happened during lunch time. Staff D, Nurse Supervisor said Resident #3 was sitting up in the chair, there were approximately four staff members there, and she heard he choked. She stated, Whatever they did it was already taken care of, by the time she got to the dining room. Staff D, Nurse Supervisor confirmed the staff present said they did the Heimlich. She stated, He was calm, peaceful, nothing wrong with him. Staff D, Nurse Supervisor confirmed she assessed Resident #3 to include listening to his lungs and looking at him. She stated it was a, Quick look, listen, and go, as she had another emergency she was handling. She said she saw he was okay; then went to the kitchen and asked what and how the incident happened. Staff D, Nurse Supervisor said, The head person in the kitchen stated someone was on their phone while fixing the tray. She said she told the kitchen staff they needed to be careful, and Resident #3 could have died. She did not recall the names of the kitchen staff present. She said the resident went back to his room but could not confirm who took him there. She said she called and let her manager know about the incident. Staff D, Nurse Supervisor confirmed Staff B, LPN was his assigned nurse. She stated, She [Staff B, LPN] was on the floor, not in the dining room. She said she does not know Resident #3 well but knows he was on a pureed diet and assumed he had a swallowing difficulty. She said immediately after the incident, they started making sure a nurse and/or management is in the dining room during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating. On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds. Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed. Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when she was told about what happened. She confirmed she would have expected to be notified and would have evaluated him sooner since she was his assigned nurse. Staff B, LPN said nurses are checking meal tickets to make sure they match with the meal on the tray. She stated, They are stricter now, but the process was the same before. On 11/18/25 at 3:45 p.m., an interview was conducted with the DON and NHA to review their response to the incident with Resident #3. The NHA said the incident happened on 11/9/25. She said she was made aware during the morning meeting on 11/10/25 that Resident #3 choked in the dining room. The NHA said Staff D, Nurse Supervisor notified her Resident #3 had the wrong lunch tray and choked on a small piece of ham. The NHA said Resident #3 was fine, he had no change in condition, was at baseline, and the physician was notified who ordered a chest x-ray. She said Staff K, receptionist who was assisting with passing meal trays gave the resident the tray. The NHA said Staff D, Nurse Supervisor told her she did not see the tray provided to Resident #3 due to her being with two other resident emergencies. The NHA said she asked the dietary team about Resident #3's meal ticket that day and she was advised it was the right ticket on the tray. She said the dietary staff confirmed they provided the right tray, meal, and verified the meal before the tray exited the kitchen area. She said through her interview with Staff K, receptionist she confirmed she did not verify the meal before giving it to Resident #3. The NHA said after the Heimlich was performed, Resident #3's tray was taken back to the kitchen and confirmed he had the wrong tray. The NHA said he was provided a regular diet to include regular consistency of ham, black eyed peas, and greens. She said through their investigation they are not sure if it was the dietary staff or the staff passing trays that provided the wrong meal to Resident #3. The NHA stated it is, Still unknown where the error and confusion happened. She said Resident #3 was assessed again on 11/10/25 and had no signs of distress and labs completed showed he did n

Based on observations, interviews, and record review, the facility failed to ensure residents were provided the correct physician ordered therapeutic diet for one resident (#3) out of twenty-three residents sampled with texture-modified diets. The facility failed to provide Resident #3 with the correct physician ordered diet which resulted in the resident choking, and required staff to execute the Heimlich maneuver. Resident #3's physician ordered diet on 11/9/25 was a controlled carbohydrates (CCHO) diet, pureed texture, and regular/thin consistency due to advanced dementia and swallowing difficulties. The resident was provided a regular consistency meal for lunch. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation.A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: - Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes .A review of Resident #3's current diet orders revealed the following: - Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25.A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24.- CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24.- CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24.- CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following:- [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP).- 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.A review of Resident #3's assessments revealed the following:- 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25.- 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 .A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning at 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said he had been in this position since August 2025. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident, but he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet, such as mechanical or regular. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said he could not provide the residents meal ticket for that day, as he did not have access to do that, but he could provide an example meal ticket of a dysphagia, mechanical texture for the meal that day. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. The Food Service Director said he did not have documentation of in-services or training regarding meal ticket accuracy for dietary staff prior to August 2025. He said since he has been at the facility he has not needed to provide an in-service on meal ticket accuracy. The Food Service Director said he completed audits and an in-service on meal ticket accuracy to all the dietary staff on 11/10/25. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as the, The double checker. She said she called out every ticket and made sure it is the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray, and she made sure it had the correct beverage, condiments, diet, and the meal matches. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aids were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her, she immediately called the Food Service Director and told him the resident choked and staff were blaming her for the incident. Staff G, Dietary Aide stated the Food Service Director told her no one had called him and, They would see about it on Monday when he comes in. She confirmed that the Nursing Home Administrator (NHA) asked her what happened and she provided a statement. She confirmed she had meal ticket accuracy education, before 11/9/25, from the Food Service Director. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. She said when she first started, at the end of June 2025, she was educated on the tray line and meal ticket accuracy process by the former food service director and one of the dietary aides. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. She said meals in the dining room started around 11:15 a.m. to 11:30 a.m., and Resident #3 choked around 11:45 a.m. Staff J, CNA said he did not leave the dining room until after 12:45 p.m.On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 3:45 p.m., an interview was conducted with the DON and NHA to review their response to the incident with Resident #3. The NHA said the incident happened on 11/9/25. She said she was made aware during the morning meeting on 11/10/25 that Resident #3 choked in the dining room. The NHA said Staff D, Nurse Supervisor notified her Resident #3 had the wrong lunch tray and choked on a small piece of ham. She said Staff D, Nurse Supervisor obtained statements from the dietary staff, CNA and receptionist who were in the dining area at the time of the incident. The NHA said Resident #3 was fine, he had no change in condition, was at baseline, and the physician was notified who ordered a chest x-ray. She said Staff K, receptionist who was assisting with passing meal trays gave the resident the tray. The NHA said Staff D, Nurse Supervisor told her she did not see the tray provided to Resident #3 due to her being with two other resident emergencies. The NHA said she asked the dietary team about Resident #3's meal ticket that day and she was advised it was the right ticket on the tray. The NHA said the dietary staff confirmed what meals went out to the dining room and what Resident #3 received, which was a pureed diet. She said the dietary staff confirmed they provided the right tray, meal, and verified the meal before the tray exited the kitchen area. She said through her interview with Staff K, receptionist she confirmed she did not verify the meal before giving it to Resident #3. The NHA said after the Heimlich was performed, Resident #3's tray was taken back to the kitchen and confirmed he had the wrong tray. She said the tray ticket showed he had a pureed diet to include puree ham, mashed potato and puree black eyed peas. The NHA said he was provided a regular diet to include regular consistency of ham, black eyed peas, and greens. She said through their investigation they are not sure if it was the dietary staff or the staff passing trays that provided the wrong meal to Resident #3. The NHA stated it is, Still unknown where the error and confusion happened. When asked who can change a diet order, the NHA and DON said a nurse can downgrade, the speech therapist is the only one who can upgrade, the dietitian can upgrade and downgrade the diet, and kitchen managers cannot change the diets. The DON stated, They [kitchen managers] cannot touch the diets. The NHA and DON said there were no changes made to the tray line process. They said the kitchen staff will not provide the dining room trays unless a nurse is in the dining room. A review of the food consistency audits conducted in the dining room revealed the following:- On 11/10/25, an audit was completed for one meal, however, the meal time was not documented.- On 11/12/25, an audit was completed for two meals, however, the meal times were not documented.- On 11/14/25, a meal audit was not completed for dinner.- On 11/15/25, a meal audit was not completed for breakfast.- On 11/17/25, a meal audit was not completed for lunch.A review of Resident #3's Kardex revealed the following:- As of 11/18/25, .Eating/Nutrition Arrange meals in patients visual field, Offer food substitutions when meal is refused or an alternate is requested, Offer snacks prn, Offer/encourage fluids of choice, Provide diet as ordered, monitor and record intake - Dysphagia Puree Texture/thin liquids, Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided.- As of 11/19/25, .Eating/Nutrition Arrange meals in patients visual field, Offer food substitutions when meal is refused or an alternate is requested, Offer snacks prn Offer/encourage fluids of choice, Provide diet as ordered, monitor and record intake - Dysphagia Puree Texture/thin liquids, Set up meal tray allow to eat independently assist if needed, Set up trays adequate time to consume food/fluids provided.On 11/19/25 at 10:18 a.m., a phone interview was conducted with Staff L, SLP. Staff L, SLP said Resident #3 was referred to her because he had an episode of aspiration. She said he had been on a pureed diet due to advanced dementia and determined that was the safest consistency for him. Staff L, SLP said she was told Resident #3 was given a piece of ham and choked but did not know he was provided a regular tray in the dining room. She said she did not know Resident #3 until he was referred to her. Staff L, SLP said when she looked in the electronic health record she saw he was on a pureed diet and might have been on a mechanical texture at some point. She stated, Pureed is least restrictive and safer for him and because of his cognition. Staff L, SLP said when she made recommendations, she immediately lets the nurse on duty know what they are.On 11/19/25 at 11:20 a.m., an interview with Resident #9 was conducted. He was observed wheeling himself from the dining room, down the hall, and to his room. He said he was scared after the incident with Resident #3 and confirmed he was in the dining room when it happened. Resident #9 said there was no nurse that day, but now there is.A review of Resident #9's quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 12, indicating moderately impaired. On 11/19/25 at 11:33 a.m., a follow-up phone interview was conducted with Staff K, receptionist. She said she had no training on passing meal trays or reading meal tickets prior to 11/9/25. She confirmed it was not the first time she had helped in the dining room.On 11/19/25 at 11:44 a.m., an interview was conducted with Staff C, NP. He said Resident #3 was in the dining room and staff gave him the wrong tray or food consistency. Staff C, NP said to his understanding the resident is supposed to be on a mechanical soft, dysphagia diet. He stated, Mechanical soft dysphagia is basically puree consistency. He said staff did the Heimlich maneuver and the food dislodged. He confirmed he saw Resident #3 on 11/10/25. Staff C, NP said he presumed Resident #3 may have, Fear of choking, as it was an unpleasant experience, but he had no medical consequences. He said he looked at Resident #3's speech therapy evaluation and could not find diagnostic proof of dysphagia. Staff C, NP said the risks and concerns with receiving a regular diet is choking and aspiration. He said his expectation is for the right diet to be served to residents.On 11/19/25 at 2:53 p.m., a follow-up interview was conducted with Staff J, CNA. She said she knows the residents' diets because they provide food in activities. She said the kitchen manager provides her with the diet slip and allergy list. Staff J, CNA said she had no training or education prior to 11/9/25 to check the resident's food tray for meal ticket accuracy. She said the facility is now training staff about reviewing the food and checking the meal ticket before leaving the food tray, as well as a nurse being present during dining to check the meal tickets. She stated, Everything they should have been doing, they are doing now. On 11/20/25 at 10:03 a.m., an interview was conducted with Staff O, Cook, Staff G, Dietary Aide, and Staff P, Dietary Aide. They confirmed staff come to the kitchen door requesting something right away which interrupts them on the tray line. Staff O, [NAME] and Staff P, Dietary Aide said they tell staff to give them time as the residents need to receive their meals first. Staff P, Dietary Aide said staff sometimes stop them when they are taking the meal carts to the floor. Staff G, Dietary Aide confirmed there were distractions when she was on the lunch tray line on 11/9/25. Staff P, Dietary Aide said staff also call by phone requesting things. She stated, We can't step off the line to answer the phone. Staff O, Cook, Staff G, Dietary Aide and Staff P, Dietary Aide said there are less distractions now, but staff are still coming in or calling the kitchen during the meal service. (Photographic evidence obtained)A review of the facility's procedure and in-service documentation titled, Texture Modification Inservice, revealed the following: .Purpose: To educate all new hires and current employees on the importance of and guidelines for proper texture modification. Importance of Texture Modification . Proper preparation and delivery of texture-modified diets is critical for resident safety and wellness. Dysphagia Puree Consistency All foods (ex. meats, breads, starches, fruits, vegetables, and desserts) must be pureed to a mousse-like texture. Cannot receive hard, dry meats . or foods that cannot be pureed into a smooth mousse-like texture. A review of the facility's policy titled, Meal Distribution, with an original date of 5/2014 and a revised date of 2/2023, revealed the following: Procedures1. All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. 4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. 5. For point-of-service dining, the Dining Services Department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. The facility's immediate actions to remove the Immediate Jeopardy included:- On 11/10/2025, the Nursing Home Administrator, educated unlicensed staff that served the wrong diet consistency tray was suspended and educated on abuse and neglect.- On 11/10/25 dietary employee that prepared the wrong diet consistency tray was suspended and educated on abuse and neglect as well as tray accuracy by the CDM district dietary manager.- On 11/10/25 an ADHOC Quality Improvement Performance Committee meeting was held to review the recommendations made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing (via telephone), and management staff.- On 11/10/25, a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis (RCA) as determined by Quality Assurance Performance Improvement committee (QAPI). Root cause analysis identified as dietary staff prepared the incorrect diet consistency for Resident #3 and an unlicensed staff member served the incorrect meal tray.- On 11/10/25 The ADHOC QAPI Committee approved the following recommendations:1. Resident was assessed, MD was notified & chest x-ray was ordered.2. Current residents in the facility diet orders in [electronic health record vendor] were checked against meal tickets in the kitchen to ensure all were accurate.3. Education was completed for dietary employees on following the correct diet when preparing resident meal trays.4. Nursing staff were educated on checking the meal tickets with diet being served.5. Nursing staff completed competencies on meal tray serving.6. Current facility staff were

Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for three residents (#3, #11, and #2) out of eleven residents sampled related to: 1) failure to prevent accidents resulting in a choking and a fall incident; 2) failure to follow physician orders and care plan for therapeutic diets and positioning; and 3) failure to follow speech therapy recommendations for positioning and assistance when eating. The facility failed to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and one to one supervision. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. On 11/17/25 at 11:39 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60-65 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Further observations of Resident #3 revealed he ate his meal without assistance from staff. On 11/18/25 at 11:50 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Staff were observed setting up the meal tray in front of him. Resident #3 began consuming his meal unassisted by staff. He was observed having difficulty getting food onto the fork. After four attempts, Resident #3 was able to get a dime-sized amount of food on the fork. Staff E, Certified Nursing Assistant (CNA) stated to Staff F, CNA, He [Resident #3] keeps doing that because he can't see his food. Staff F, CNA was observed looking at Resident #3's meal tray and stated, Well, he's almost done.A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation.A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: - Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section GG - Functional Abilities, . A. Eating: . 05. Setup or clean-up assistance .- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes .A review of Resident #3's current diet orders revealed the following: - Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25.A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24.- CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24.- CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24.- CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following:- [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP).- 11/10/25 health status note 12:05, Note Text: Late Entry: At time of assessing the resident after chocking his bilateral lungs were clear, Resp [respiratory] even and nonlabored, O2 [oxygen] sat [saturation] at 98% on r.a. [room air] Res. [resident] was taken back to his room and was sitting up in chair without s/s [signs and symptoms] of distress, created by Staff D, Nurse Supervisor.- 11/10/25 health status note 13:04, Note Text: At the time of assessment of patient, vitals taken: B/P [blood pressure] 126/80, pulse 98, temp 97.9, respirations 18, and O2 95 on room air. Patient alert and in no apparent distress. Lung sounds clear and patient observed to have normal respiratory effort, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 health status note 13:32, CXR reviewed: IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. 1) Vitals every shift for 3 days 2) CBC/CMP in AM.- 11/11/25 health status note, Labs reviewed, stable without any leukocytosis. Stable anemia and DM II [diabetes mellitus two] are noted. No new orders.- 11/11/25 health status note 21:12, LATE ENTRY Note Text: Resident is alert with confusion and is assisted totally with ADL's [activities of daily living]. Transfers to and from Geri chair with Hoyer lift and 2 assist [two person assist]. Resident is assisted with meals, encouraged to eat meal. Incontinent of B&B [bladder and bowel]. No s/s of acute distress and no c/o [complaints of] pain voiced at this time.- 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.- 11/13/25 health status note, V/S [vital signs] taken on 11/9/2025 s/p [status post] incident in MDR 126/89, 98, 18, 97.9 with O2 sat 95 on RA, created by the Director of Nursing (DON).A review of Resident #3's assessments revealed the following:- 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25.- 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 .Review of Resident #3's x-ray results revealed the following:- 4/21/25 chest, single view, Clinical Information: follow up left infiltrate Test Procedure: . CHEST, SINGLE VIEW Findings: Comparison: 03/15/2025 The cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. No pleural fluid or masses are noted. No pneumothorax is present. Impressions: No acute intrathoracic disease process.- 11/10/25 chest, 2 views, Date of Service: 11/10/2025 Clinical Information: . Pneumonitis due to inhalation of food and vomit possible aspiration Test Procedure: . CHEST, 2 VIEWS Findings: . No acute osseous or soft tissue abnormality. Cardiac and mediastinal contours are within normal limits. Normal pulmonary vasculature. No pneumothorax. Bilateral intrapillar airspace opacity is present. Peribranchial distention with peribranchial cuffing is present. This nonspecific finding indicates chronic or acute perihilar inflammation. IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025.A review of a resource from the American Lung Association revealed the following, Atelectasis happens when the tiny air sacs or alveoli in your lungs are blocked, and it causes a partial or full collapse of one or more lobes or sections of the lungs. Other causes may include A small object blocking the airways (like food or toy) . Lung infection like pneumonia . Your healthcare provider will discuss treatment options if atelectasis is caused by a tumor, an aspirated foreign body, or other chronic lung conditions. Serious complications may occur if atelectasis remains untreated. Complications can include low oxygen levels, pneumonia, or lung failure. The reference was reviewed on the following website https://www.lung.org/lung-health-diseases/lung-disease-lookup/atelectasis.A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning at 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. He confirmed there was no nurse present in the dining room during the lunch meal on 11/9/25. Resident #10 said a nurse never came to assess Resident #3. He said staff took Resident #3 to his room after the lunch meal was completed. Resident #10 confirmed he stayed for the duration of the lunch. He said other departments are now helping in the dining room and a nurse is present. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said he had been in this position since August 2025. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident, but he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet, such as mechanical or regular. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said he could not provide the residents meal ticket for that day, as he did not have access to do that, but he could provide an example meal ticket of a dysphagia, mechanical texture for the meal that day. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. The Food Service Director said he did not have documentation of in-services or training regarding meal ticket accuracy for dietary staff prior to August 2025. He said since he has been at the facility he has not needed to provide an in-service on meal ticket accuracy. The Food Service Director said he completed audits and an in-service on meal ticket accuracy to all the dietary staff on 11/10/25. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as the, The double checker. She said she called out every ticket and made sure it is the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray, and she made sure it had the correct beverage, condiments, diet, and the meal matches. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aids were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her, she immediately called the Food Service Director and told him the resident choked and staff were blaming her for the incident. Staff G, Dietary Aide stated the Food Service Director told her no one had called him and, They would see about it on Monday when he comes in. She confirmed that the Nursing Home Administrator (NHA) asked her what happened and she provided a statement. She confirmed she had meal ticket accuracy education, before 11/9/25, from the Food Service Director. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. She said when she first started, at the end of June 2025, she was educated on the tray line and meal ticket accuracy process by the former food service director and one of the dietary aides. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said the day of the incident, Resident #3 was feeding himself and she heard him gasping for air. Staff J, CNA said she looked over and saw he was choking. She said his eyes were watering and demonstrated he had his hands on the chest/neck area while gasping. Staff J, CNA and Staff K, receptionist both went to assist him and yelled out for reception to get a nurse. Staff J, CNA said she leaned him forward to pat him on the back. She said it was difficult because he was reclined and leaning back in a Geri chair. She confirmed Staff K, receptionist performed the Heimlich maneuver on Resident #3. She said she assisted with twisting the resident to the side that way Staff K, receptionist could get behind him. Staff J, CNA said she is not cardiopulmonary resuscitation (CPR) certified. She said by the time Staff D, Nurse Supervisor arrived the food had been dislodged, and the resident was breathing. Staff J, CNA said Staff D, Nurse Supervisor asked what happened and said they should not have done anything because only a nurse should do the Heimlich. She said Staff D, Nurse Supervisor asked them if the resident was ok and said she had to go back to the unit to finish what she was doing, then left. Staff J, CNA said she did not observe an assessment completed on Resident #3 in the dining room and no vital signs were taken at that time. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. She said meals in the dining room started around 11:15 a.m. to 11:30 a.m., and Resident #3 choked around 11:45 a.m. Staff J, CNA said he did not leave the dining room until after 12:45 p.m.On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 2:03 p.m., a phone interview was conducted with Staff D, Nurse Supervisor. She stated, That day [11/9/25] I was the only supervisor in building, which is normal. Staff D, Nurse Supervisor said she was on the south wing assessing a patient who was complaining of chest pain. She stated while she was, Getting that under control, she heard yelling that a nurse was needed for an assessment. She said she ran to the dining room and confirmed the incident happened during lunch time. Staff D, Nurse Supervisor said Resident #3 was sitting up in the chair, there were approximately four staff members there, and she heard he choked. She stated, Whatever they did it was already taken care of, by the time she got to the dining room. Staff D, Nurse Supervisor confirmed the staff present said they did the Heimlich. She stated, He was calm, peaceful, nothing wrong with him. Staff D, Nurse Supervisor confirmed she assessed Resident #3 to include listening to his lungs and looking at him. She stated it was a Quick look, listen, and go, as she had another emergency she was handling. She said she saw he was okay; then went to the kitchen and asked what and how the incident happened. Staff D, Nurse Supervisor said, The head person in the kitchen stated someone was on their phone while fixing the tray. She said she told the kitchen staff they needed to be careful, and Resident #3 could have died. She did not recall the names of the kitchen staff present. She said the resident went back to his room but could not confirm who took him there. She said she called and let her manager know about the incident. Staff D, Nurse Supervisor confirmed Staff B, LPN was his assigned nurse. She stated, She [Staff B, LPN] was on the floor, not in the dining room. She said she does not know Resident #3 well but knows he was on a pureed diet and assumed he had a swallowing difficulty. She confirmed she assisted with educating staff after the incident. She said immediately after the incident, they started making sure a nurse and/or management is in the dining room during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating.On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds. She confirmed she documented her assessment in the electronic health record. Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed. Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when she was told about what happened. She confirmed she would have expected to be notified and w

Based on observation, interview, and record review, the facility failed to ensure three (#147, #47 and #68 ) of four residents reviewed had dressings changed appropriately and per physician orders. The facility failed to ensure one (#37) of one resident had a splint applied and documented as ordered. Findings included: 1. During an interview on 08/06/24 at 10:46 a.m., Resident #147 stated he had a wound on his hand and arm. Resident #147 stated the dressing was dirty because the facility had not changed it. Resident #147 stated the facility changed it when he was first admitted to the facility but then did not. An observation on 08/06/24 at 10:46 a.m., revealed Resident #147 had dressings on his right hand/wrist area and another on the upper right arm that was visibly soiled and not dated. The dressing on his right-hand/wrist area had a brown dirty looking substance on the dressing and was not dated. Resident #147 gave (State Agency) SA Surveyor verbal permission to take a picture of the right hand/wrist and arm dressings. Photographic evidence obtained. A review of the Admission Record showed Resident #147 was admitted to the facility on [DATE] with diagnoses that included but not limited to Other specified sepsis, metabolic encephalopathy, bacteremia, thrombocytopenia and pemphigus vulgaris. A review of the Brief Interview for Mental Status (BIMS) evaluation dated 08/06/24 showed Resident #147 had a BIMS score of 15 which indicated intact cognition. Photographic evidence obtained. A review of the Order Summary Report showed the following physician orders related to dressing changes: - A physician order dated 08/02/24 showed, cleanse 3 small open areas on Left lower back with NS, apply Triamcinolone/bacitracin mixture to all open areas and leave open to air- every night shift for wound healing. - A physician order dated 08/02/24 showed, Paint left posterior pinky toe area with betadine daily leave open to air- every day shift for wound healing, - A physician order dated 08/02/24 showed, Cleanse right shoulder with NS, apply Triamcinolone/bacitracin and leave open to air- every day shift for wound healing. - A physician order dated 08/02/24 showed, Cleanse right elbow with NS, apply Triamcinolone/bacitracin mixture to area, cover with xeroform and wrap with kerlix daily and as needed if soiled or dislodged- every day shift for wound healing. - A physician order dated 08/02/24 showed, Cleanse left inner thigh with ns, pat dry , apply collagen and leave open to air- every day shift. - A physician order dated 08/02/24 showed, Cleanse left groin area with ns, pat dry apply collagen to wound and leave open to air- every day shift for wound healing. -Cleanse right shoulder with NS, apply Triamcinolone/bacitracin and leave open to air- every day shift for wound healing. - A physician order dated 08/02/24 showed, Cleanse right arm with ns, pat dry apply mixture of Triamcinolone /bacitracin to all open areas on arm cover with xeroform and wrap with kerlix- every day shift for wound healing. - A physician order dated 08/02/24 showed, Cleanse left scrotum area with ns, apply collagen and leave open to air daily- every day shift for wound healing. - A physician order dated 08/02/24 showed, Cleanse right hand and wrist with ns, apply xeroform and wrap with kerlix daily and prn if soiled or dislodged- every day shift for wound healing. - A physician order dated 08/02/24 showed, Cleanse right hip with ns, pat dry, mix bacitracin with Triamcinolone a ND apply cover with abd- every day shift for wound healing related to Pemphigus Vulgaris. Review of the August 2024 Treatment Administration Record (TAR) showed Resident #147 did not receive the following dressing changes on 08/05/24. - Cleanse left groin area with ns, pat dry apply collagen to wound and leave open to air- every day shift for wound healing - Cleanse left inner thigh with ns, pat dry, apply collagen and leave open to air- every day shift - Cleanse left scrotum area with ns, apply collagen and leave open to air daily- every day shift for wound healing - Cleanse right arm with ns, pat dry apply mixture of Triamcinolone /bacitracin to all open areas on arm cover with xeroform and wrap with kerlix- every day shift for wound healing. - Cleanse right elbow with NS, apply Triamcinolone/bacitracin mixture to area, cover with xeroform and wrap with kerlix daily and as needed if soiled or dislodged- every day shift for wound healing. - Cleanse right elbow with NS, apply Triamcinolone/bacitracin mixture to area, cover with xeroform and wrap with kerlix daily and as needed if soiled or dislodged- every day shift for wound healing. - Cleanse right hand and wrist with ns, apply xeroform and wrap with kerlix daily and prn if soiled or dislodged- every day shift for wound healing - Cleanse right hip with ns, pat dry, mix bacitracin with Triamcinolone a ND apply cover with abd- every day shift for wound healing related to Pemphigus Vulgaris. - Cleanse right ankle with NS, apply collagen cover with xeroform to the area and cover with border dressing- every day shift for wound healing. - Cleanse right shoulder with NS, apply Triamcinolone/bacitracin and leave open to air- every day shift for wound healing. - Paint left posterior pinky toe area with betadine daily leave open to air- every day shift for wound healing. 2. An observation on 08/06/24 on 10:58 a.m. revealed Resident #47 was sitting in a wheelchair beside his bed. Resident #47 had a soiled dressing on his right lower leg not dated. Resident #47 had blankets under his foot. During an interview on 08/06/24 on 10:58 a.m., Resident #47 stated he had been dealing with the swelling in his right lower leg for over a month. Resident #47 stated he put the blankets were under his right foot because sometimes his leg would drain a small pool of fluids out of it. A review of the Admission Record showed Resident #47 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral, low back pain, unspecified osteoarthritis, type 2 diabetes and hereditary and idiopathy neuropathy. A review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C-Cognitive Patterns showed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. A review of the Order Summary Report showed the following physician orders related to dressing changes: - A physician order dated 08/03/24 showed, Cleanse right lower leg with NS pat dry apply medical grade honey, add silver calcium alginate and wrap with kerlix. - every day shift. A review of the August 2024 Treatment Administration Record (TAR) showed Resident #47 did not receive the following dressing change on 08/05/24: -Cleanse right lower leg with NS pat dry apply medical grade honey, add silver calcium alginate and wrap with kerlix. - every day shift. During an interview on 08/07/24 at 4:49 p.m., Staff F, Regional Nurse Consultant (RNC) stated she expected staff to date all dressings and to document the treatment in the TAR. Review of the facility's policy Dressing Change revised date 12/06/17 stated, Policy: A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Sterile dressing will be used only if specifically ordered. Procedure: .Document in medical record. 37999 3. On 8/6/24 at 10:22 a.m., Resident #68 was observed sitting in a wheelchair in the hallway directly outside of doorway to the resident's room. The observation revealed the resident's right lower extremity was extremely edematous and had a bumpy rough surface. On top of the resident's right foot was a white patch of dry-looking skin. Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM) asked if the resident had a shoe to put on and the resident replied that a shoe would have to be specially made. The staff member asked if the resident had a sock to be put on and the resident responded they told her to keep it off due to cutting circulation off. During an interview on 8/6/24 at 10:40 a.m., Resident #68 revealed her right leg had an infection in it. The resident's right leg was observed without a dressing and in an area directly above the anterior ankle was a scant amount of a bright red wet-looking substance appearing to be coming from a crease in between the numerous bumpy areas. The area was mentioned to and acknowledged by Staff J, who was on other side of hallway administering medications. The staff member stated she would get to it. An observation was made on 8/6/24 at 3:10 p.m. of Resident #68 sitting outside of her room in a wheelchair, yelling down hallway to Staff J as the staff member was walking toward the nursing station. The resident yelled that the staff member had to dress the right leg. The observation revealed a dressing had not been applied to the resident's leg. A review of Resident #68's Admission Record showed the resident had been originally admitted on [DATE] and readmitted on [DATE]. The record included the diagnoses but was not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, need for assistance with personal care, and skin transplant status. A review of the [name of wound care vendor] Nurse Practitioner (NP) note, dated 7/30/24, showed the right lower extremity had a partial thickness venous wound, which measured 17-centimeter (cm) x 6 cm x 0.1 cm and covered a area of 102 cm2. The wound had been acquired on 2/5/24, had reopened, and had a moderate amount of serosanguineous exudate. The treatment instructed staff to cleanse with normal saline, cover with silver alginate and rolled gauze daily. A review of Resident #68's July 2024 Treatment Administration Record (TAR) revealed the following physician order: - Clean anterior RLE with normal saline, pat dry, apply skin prep and abdominal (abd) pad, and wrap with (rolled gauze) every shift for weeping. The order started on 7/29/24, discontinued on 8/1/24, and the TAR documentation revealed the order had been administered during the night shift on 7/29 and both day and night shifts on 7/30 and 7/31/24. Review of Resident #68's August TAR revealed the following physician order: - Clean anterior RLE with normal saline, pat dry, apply skin prep and abd pad, and wrap with (rolled gauze) every night shift for weeping. The order was started on 8/1/24 at 7:00 p.m. and was discontinued on 8/8/24 at 11:57 a.m. The TAR documentation showed staff had administered this dressing during the night shift except for 8/3/24 and was Held on 8/7/24. Review of Resident #68's July and August TAR's did not show the Wound NP's treatment order, dated 7/30/24, had been implemented. The NP skin and wound note, date of service 8/6/24 at 9:46 a.m., revealed Resident #68 was seen due to follow up for a right lower extremity (RLE) venous ulcer. The exam showed the resident had bilateral lower extremity (BLE) edema with a thickened texture. The assessment was the wound measured 17 cm x 6 cm x 0.1 cm with a surface area of 102 square cm's and a moderate amount of serosanguineous exudate. The treatment recommendations were to cleanse with normal saline, apply collagen to base of wound, secure with rolled gauze, and change daily. The note was signed on 8/6/24 at 9:51 a.m. by the NP. On 8/8/24 at 9:50 a.m., Resident #68 was observed sitting on her bed with lower her extremities dangling from the side of bed. The RLE was wrapped with rolled gauze and dated 8/7/24. The resident stated they don't usually wrap it. An interview was conducted with Staff H, LPN on 8/8/24 at 11:42 a.m., the staff member reported the wound care team came in on Tuesday, the Unit Manager received the wound care orders from the provider and put them into the computer. The staff member stated if the wound was new, staff would call the primary care provider. An interview was conducted with Staff D, LPN/North wing UM on 8/8/24 at 11:43 a.m., the staff member reported the UM's do rounds with the wound Advanced Practitioner Registered Nurse (APRN). The staff member reported the APRN type up their report and the order would come from it. Staff D stated the primary care provider deferred orders to the wound care providers. The staff member reviewed the NP Wound assessment dated [DATE] and confirmed the order was for silver alginate and cover with rolled gauze. Reviewing the TAR she confirmed the order was for skin prep to be applied. Staff D reviewed the wound care NP note on 8/6/24 and confirmed the order for Resident #68's RLE had not been changed, still read for skin prep and rolled gauze to be applied. The staff member reviewed the discontinued orders and confirmed the order for silver alginate and collagen had not been implemented. During an interview on 8/8/24 at 12:00 p.m. Staff H reported working 3 - 12 hour shifts during the week and Resident #68 did not refuse treatments and did not remove dressings. Review of Resident #68's August TAR showed the Wound Care NP order regarding the application of collagen and wrapping with rolled gauze had not been implemented until 8/8/24 and the resident did not have an order for an as needed (prn) dressing change from 7/30 until 8/8/24. An interview was conducted with the Director of Nursing (DON) on 8/8/24 at 12:04 p.m., the DON stated Staff D had started in the position on Tuesday (8/6/24). The DON stated the wound report gets emailed to herself and the Assistant DON, the UM's round with the Wound APRN and any changes would be verbally communicated to the UM. The UM should have made the changes and the orders should have been implemented. The DON stated typically there should be a prn order in case the dressing got dirty or wet. The observation of Resident #68 was discussed and the DON stated the nurse should have dressed the wound and if there was not a prn order the nurse should have obtained one from the physician. Review of the policy - Dressing Change, revised on 12/6/17, revealed A clean dressing will applied by a nurse to a wound as ordered to promote healing. The policy described the procedure for applying a dressing. Review of the policy - Physician Orders, revised on 3/3/21, revealed The center will ensure that Physician orders are appropriately and timely documented in the medical record. The procedure for routine orders showed: - A nurse may accept a telephone order from the Physician, Physician Assistant, or Nurse Practitioner (as permitted by state law). - The order will be repeated back to the physician, PA, or ARNP for his/ her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR/eTAR). - For pharmacy orders the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing, or completing the order electronically. - The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders require that the physician sign and date the order as soon as practicable after it is provided to maintain an accurate medical record. 4. On 8/6/24 at 11:31 a.m., a wrist splint was observed on the bedside dresser of Resident #37 while the resident laid in bed. The resident was non-verbal but did show staff put it on by nodding her head, the resident shook head in response to liking to wear it. On 8/7/24 at 9:53 a.m., the wrist splint of Resident #37 was shown to be lying on the bedside dresser next to the resident's bed. On 8/8/24 at 4:00 p.m. an observation was made of Resident #37's wrist splint lying near the front of the bedside dresser next to the resident's bed. On 8/9/24 at 8:49 a.m. an observation was made of Resident #37's wrist splint lying near the front of the bedside dresser next to the resident's bed. Review of Resident #37's Admission Record showed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to left hand contracture, functional quadriplegia, and aphasia. Review of Resident #37's physician orders revealed the resident to wear left (L) hand splint on and off daily or as tolerated by patient every day and night shift, on in a.m./off in p.m., this order was dated 8/3/24. Review of Resident #37's June 2024 Treatment Administration Record (TAR) showed a order for Patient (Pt) to wear left (L) hand splint on and off daily or as tolerated by patient every day and night shift, on in am/off in pm. The order started on 5/7/23 and was discontinued on 8/3/24. The nursing documentation showed the resident's splint was off 21 times, on eight times, and Y one time out of 30 opportunities during the day shift. The night shift documented the resident's splint was on three times and off twenty-seven times during the night shift. The TAR did not reveal the amount of time the resident tolerated the splint being on during the eight times it had been applied. The TAR did have an area for staff to document on and off during the day and night shifts. Review of Resident #37's July 2024 TAR showed an order for Patient (Pt) to wear L hand splint on and off daily or as tolerated by patient every day and night shift, on in am/off in pm. The order started on 5/7/23 and was discontinued on 8/3/24. The documentation showed the splint was off during the day shift 21 times out of 31 opportunities, y was documented twice during the day shift, and on 8 times during the day shift. The night shift documentation revealed the resident's splint was off twenty-nine times, on once, and no revealing documentation on 7/11/24. The TAR did not reveal the amount of time the resident tolerated the splint being on. The TAR did have an area for staff to document on and off during the day and night shifts. Review of Resident #37's August 2024 TAR showed an order, dated 5/7/23 for Pt to wear L hand splint on and off daily or as tolerated by patient every day and night shift, ON in am/off in pm. The record had an area for staff to document whether on or off during each shift. The TAR revealed the splint was off during the three available day shifts and twice on the night shift prior to the discontinuation of the order at 9:38 p.m. on 8/3/24. An order, Pt to wear L hand splint on and off daily as tolerated by patient every day and night shift, ON in am/off in pm was started at 7:00 a.m. on 8/4/24. The order did not allow for documentation of on and/or off during either day or night shifts. The TAR revealed a checkmark had been documented on the day and night shifts of 8/4 - 8/8/24. Per the TAR chart code legend a checkmark revealed the item had been administered. Review of Resident #37's progress notes, including eMAR notes, from 6/9/to 8/9/24 did not reveal documentation of how long the resident tolerated wearing the splint, how the resident tolerated wearing the splint or any behavior associated with the wearing of the splint. Review of the Certified Nursing Assistant (CNA) Tasks for Applying splints device(s) per order, apply splint to left hand as pt will allow. showed Resident #37's splint was on on 7/16, 7/18, 7/27, 7/28, 7/30, 7/31, 8/3, and 8/8/24. The tasks did not reveal the resident refused application of the splint from 7/16 to 8/8/24. The task documentation did not show how long the resident tolerated wearing the splint. Review of Resident #37's care plan showed the Registered Nurse (RN) and CNA were responsible for apply splint as tolerated as ordered related to the resident having contractures of left hand and was at risk for impaired skin integrity, pain and injuries related to cerebrovascular accident (CVA) (and) quadriplegia/paraplegia. The RN was to refer to restorative nursing and therapy as needed. The resident's goal was to remain free from complications of impaired Range of Motion (ROM) through next review date. The care plan showed the resident had a potential for pain/discomfort related to diagnosis of functional quadriplegia, left hand contracture, gout, very limited mobility, history of chronic pain syndrome, and abdominal cramps. The interventions instructed nursing to assess/monitor for non-verbal indicators of pain (pacing, agitation, anxiety, facial grimacing, tearfulness/crying, sad/distant facial expression, gasping/groaning, yelling out) and left hand splinting related to contractures as tolerated. An interview was conducted with Staff G, Restorative Aide, on 8/9/24 at 8:40 a.m., the staff member reported responsibilities of the restorative department was assisting with showers, ROM, exercises, Walk to Dine program, and when resident's did not have a payor source for therapy we pick them up, and put splints/braces on. Staff G said she used to put Resident #37's splint on but did not anymore because it caused the resident a lot of pain. The staff member reported the last time putting the resident's splint on was last week, did not have any documentation of the application, and the resident was not on the restorative program and had not been since approximately the beginning of the year. Staff G stated it would be therapy's responsibility to put the splint/brace on. The staff member stated she had been asked by the previous Unit Manager to put splint on so it was about 2 weeks ago, from what the staff member could see the splint caused pain, the resident would yell out and only time that occurred was due to pain. An interview was conducted with Staff I, CNA, on 8/9/4 at 8:50 a.m., the staff member reported not putting Resident #37's splint on, restorative put it on. During the interview with Staff I, on 8/9/24 at 8:50 a.m., Staff G reported being mistaken, therapy did not put Resident #37's splint on, nursing did. The staff member clarified nursing was not the aides but the nurses. An interview was conducted with the Director of Nursing (DON) on 8/9/24 at 9:35 a.m., the DON reported Resident #37 was not on restorative so it was on the TAR for nursing to put it on, the order was to wear as tolerated but it did cause the resident pain. The DON confirmed there were more off's then on's on the June and July TAR's and wasn't any documentation either in the progress notes or TAR of how long the resident tolerated the brace/splint. The DON stated she understood the findings. An interview was conducted with the DON on 8/9/24 at 11:21 a.m., the DON stated per Resident #37's therapy notes, the splint had been tolerated up to 3 hours and the resident had been discharged from therapy on 6/28/24. The DON stated the facility had a communication error related to who was responsible for putting on the splint, therapy and the nursing electronic documentation systems were not integrated so they needed to work on communication. Review of the Occupational Therapy Discharge Summary date 6/28/24, showed at the time of OT discharge Resident #37 tolerated wearing the orthotic device 3.5 hours and 5 minutes of passive ROM to left hand prior to donning the orthotic device. Review of the policy - Prevention Contractures, revised on 8/22/17, revealed To prevent contracture of extremities where those residents who no longer have full use of their extremities. All contracture prevention devices should be removed at least daily for hygiene and observation of skin conditions. Each resident must be evaluated for need of contracture prevention procedures on admission, readmission, and as needed. Residents with inactive extermination should have range of motion exercises done to those extremities as part of their daily care. Some residents may have braces or splints to prevent or help release contractures- be sure to follow the physician's order regarding the schedule of when to put these on and when to remove them.

Based on record review and interview, the facility failed to ensure one Dietary Manager out of one Dietary Manager met at least one of the minimum qualifications for the position. Findings included: During an interview on 08/06/24 at 9:00 a.m., Staff B, Dietary Manager (DM) identified as the facility's Dietary Manager. Review of the dietary staff credentials, provided by the facility, showed a Servsafe Certification for Staff A, Corporate Area Support Manager (CASM) with an expiration date 11/12/26. During an interview on 08/06/24 at 1:41 p.m., the Administrator stated Staff A, CASM was not full time and goes between two facilities. The Administrator stated Staff A, CASM was not on the employee list because he was a Traveler and worked for a contracting company. A review of the Nursing Home Key Staffing Form identified Staff B, Dietary Manager as the Dietary Manager for the facility. A review of the Active Employee Report provided by the facility, showed Staff A, CASM was not an employee listed for the facility. During an interview on 08/06/24 at 1:55 p.m., Staff B, Dietary Manager (DM) stated that she was not a Certified Dietary Manager (CDM). Staff B stated she started as the Dietary Manager in the facility around November 2023. Staff B stated that Staff A, CASM goes between his facility and this facility to help. Staff B stated that she was not Servsafe certified but planned to get that certification soon. During an interview on 08/08/24 at 11:00 a.m., Staff A, CASM stated he came to the facility every now and then and was not present in the facility daily. Staff A, CASM stated that he was more like the Problem Solver for the facility. During an interview on 08/08/24 at 4:08 p.m., Staff C, Human Service Director (HSD) stated when she first started working at the facility on 06/06/22 Staff B was a Cook. Staff C was unable to verify what date Staff B became the designated Dietary Manager for the facility.

Based on observation, record review, and interview, the facility failed to ensure one resident (#81) out of three residents reviewed for resident rights had their choices honored. Findings included: An observation on 08/06/24 at 10:26 a.m. revealed Resident #81 was in his room laying in bed with a hospital gown on. During an interview on 08/06/24 at 10:26 a.m., Resident #81 stated, no one was assisting him out of bed when he asked to get up. Resident #81 stated he asked for assistance to get out of bed daily, but no one would assist him. Resident #81 stated staff seemed too busy and I'm getting tired of being put off with no help. Resident #81 stated he even requested to talk with the Director of Nursing (DON) and had not had that request honored . An observation on 08/06/24 at 1:37 p.m., Resident # 81 remained in his bed with the same hospital gown. During an interview on 08/06/24 at 3:37 p.m., Resident # 81 stated he informed his nurse earlier that he would like assistance getting out of bed and into his wheelchair today. Resident # 81 stated the nurse informed him that she would be back, and no one had come back so he continued to lay in bed. An observation on 08/06/24 at 3:37 p.m., revealed Resident #81 remained in bed. Review of the Admission Record showed Resident #81 was admitted to the facility on [DATE] with diagnoses that included but not limited to Venous insufficiency (chronic) (peripheral), Unspecified atrial fibrillation, Chronic obstructive pulmonary disease, weakness, unsteady on feet and muscle weakness (generalized). Review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C-Cognitive Patterns showed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Review of the Care plan showed Resident #81 had a Focus- [Resident #81] is at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to chronic disease process, COPD, Lymphedema, recent hospitalization . Goal- Will maintain highest capable level of ADL ability throughout the next review period as evidenced by his/her ability to perform ADL'S. Interventions: -1/4 side rails for bed mobility -Assist of 2 or more with bed mobility. -Assist of 2 with transfers. - Enablers for positioning and bed mobility -Monitor laboratory test results and report abnormal results to MD/ARNP - Observe for decline in ADL function. Refer to rehab therapy if decline in ADL'S is noted. - Provide cueing for safety and sequencing to maximize current level of function - PT/OT/SP treatment as ordered by MD/ARNP An observation on 08/07/24 at 10:28 a.m., revealed Resident # 81 was in bed. An observation on 08/07/24 at 2:03 p.m., revealed Resident # 81 remained in bed. During an interview on 08/07/24 at 2:18 p.m., Staff D, Unit Manager (UM), Licensed Practical Nurse (LPN) stated she talked with Resident #81 yesterday about getting up out of bed. Staff D stated she went to the therapy department and made sure he was able to get up. Staff D stated therapy informed her Resident #81 was able to get out of bed with a Hoyer lift. Staff D stated the plan was to get him out of bed today. She said Resident #81 was waiting for his wounds to heal before getting up out of bed and he only wanted out of bed an hour at a time, so it would need to be coordinated. Review of the Weekly Non-Pressure Wound Evaluation dated 07/23/24 showed the venous wound on Resident #81's right lower extremities (RLE) was healed. An addition review of a second Weekly Non-Pressure Wound Evaluation dated 07/23/24 showed the venous wound on Resident #81's left lower extremities (LLE) was healed. Review of the Order Summary Report revealed no current wound treatment. During an interview on 08/07/24 at 2:24 p.m., Resident #81 stated that he was not assisted out of bed yet today however the nurse came back into his room a few minutes ago and said staff were going to assist him out of bed today. During an interview on 08/07/24 at 2:44 p.m., Staff E, Regional Director of Operations (RDO) stated I got the back story. Resident # 81 had not been getting out bed lately because the big guy with non-normal human strength [the Physical Therapy Assistant (PTA)] could assist Resident # 81 out of bed by himself but had been out for surgery. The RDO stated the nursing staff was having trouble coordinating the Hoyer lift to get Resident #81 out of bed for the 20 to 30 minutes that he tolerated, so Resident #81 had not been getting out of bed lately. Review of the Task tab titled Transfers on 08/07/24 at 3:13 p.m., revealed Resident #81 had only been assisted out of bed on 07/31/24 with a two persons physical assist with no Resident refusals during the 14-day look back period from 07/25/24 to 08/07/24. An observation on 08/08/24 at 10:40 a.m., revealed a Resident Rights sign posted on the hallway near the Director of Nursing (DON) Office. The sign posted stated Quality of Life .(b) Self-determination and participation The resident has the right to . (1) choose activities, schedules and healthcare consistent with his or her interests, assessments or plan of care; (3) Make choices about aspects of his or her life in the facility that are significant to the resident. Photographic evidence obtained.

Based on interview and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a current copy of the Advance Directive was in the resident's medical record for one resident (#55) of five sampled residents. During an interview on 8/6/2024 at 4:55 p.m., Resident #55 stated, I have spoken to several nurses when I returned from the hospital as I want to be a Full Code and change my Health Care Surrogate (HCS). I know this conversation occurred prior to 7/2/2024. I met with the Director of Social Services (DSS), discussed the [HCS] and request of being a full code. The DSS came back and told me everything was taken care of. Resident #55 continued to state never receiving the requested copies from the DSS and kept checking with the nurses regarding the changes and wanting to be a Full Code. Resident #55 stated, On [7/2/2024] the physician stated I was capable of making my own decisions. Still, I was not changed to a Full Code. I've seen the DSS at the nurses' cart, while the cart was at my door. Although, the DSS would state she didn't have time right now. Review of a progress note from the Resident's Advanced Practice Registered Nurse (APRN), 6/30/2024 at 21:18 revealed CODE STATUS: Full Code. Review of the Order Summary dated 8/7/2024 reveals Resident #55 was a DNR. Review of Resident #55's plan of care revealed resident was a DNR. An interview was conducted with Staff O, Licensed Practical Nurse (LPN) on 8/7/2024 at 1:40 p.m. Staff O stated caring on a regular basis for Resident #55. Staff O confirmed Resident #55 had been asking to be a Full Code since return from the hospital earlier this summer. I told the DSS on a couple occasions that Resident #55 wanted to be Full Code. I don't know why it has taken so long to complete. An interview was conducted with the Director Social Service (DSS) on 8/7/2024 at 2:04 p.m. The DSS stated Resident #55 requested to see her regarding wanting to be a DNR, this was completed. The DSS continued to state the resident did request to change her HCS and this was completed. The DSS stated not having any knowledge Resident #55 wanted to change her code status. An interview was conducted with the Director of Nursing (DON) on 8/7/2024 at 2:15 p.m. The DON said the process for a code change for a resident who was alert and oriented should be followed. The nurse would contact the physician and receive the order change and ensure all documents were in order. Review of the facility policy and procedure titled Advanced Directives with a revision date of 11/14/2018, revealed: Policy: The center will abide by state and federal laws regarding Advanced Directives. The center will honor all properly executed advanced directives that have been provided by the resident and/or representative. Process: . 2. Social Service Director and/or Business Development Coordinator/designee will assist the resident/resident representative to complete the Advanced Directives Discussion Document. If an advanced directive exists, the Social Services and/or Business Development Coordinator/designee will obtain a copy and place it in the resident's medical record. 5. Advanced directives will be reviewed: *quarterly *Hospice Admission . Request for a Do Not Resuscitated Policy and Procedure was requested and not provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure a clean and home like environment in two (#311 and #405 B) of sixty-one rooms observed. Findings included: 1. A review of the facility's work order #7384 for room [ROOM NUMBER], created on 7/27/24 at 12:42 p.m. showed ac leaking. A review of the facility's work order #7374 for room [ROOM NUMBER] B, created on 7/25/24 at 1:29 p.m., showed air conditioner running water on the floor. On 8/6/24 at 10:08 a.m., wet linen was observed piled under the Packaged Terminal Air Conditioner (PTAC) in room [ROOM NUMBER]. The resident in the room said the PTAC had been leaking for about a month. The room was muggy with a musty odor. (Photographic Evidence Obtained.) On 8/7/24 at 9:45 a.m., the same observation was made in room [ROOM NUMBER] (Photographic Evidence Obtained). On 8/8/24 at 9:52 a.m., the same observation was made in room [ROOM NUMBER] (Photographic Evidence Obtained).) 2. On 8/6/24 at 10:46 a.m., a blanket with a yellow ring and appeared dry was observed under the PTAC unit in room [ROOM NUMBER] (Photographic Evidence Obtained). On 8/7/24 at 2:34 p.m., the same observation was made in room [ROOM NUMBER] B. (Photographic Evidence Obtained). On 8/8/24 at 10:54 a.m., the same observation was made in room [ROOM NUMBER] B. On 8/7/24 at 9:54 a.m., during an interview Staff K, Certified Nursing Assistant (CNA) said maintenance related issues were reported through the facility's electronic building maintenance system. On 8/8/24 at 9:50 a.m., an interview and observation of room [ROOM NUMBER] was conducted with the Nursing Home Administrator (NHA). The NHA said he was not aware of the issue, and he would get the maintenance staff to address the issue. The NHA said all the facility's staff know how to report issues in the facility's electronic building maintenance system. He said maintenance needed to remove the unit and clean the drain. The NHA said the issue would be addressed today. On 8/8/24 at 10:26 a.m., during an interview, Staff L, Licensed Practical Nurse (LPN) said maintenance issues were reported in the facility's electronic building maintenance system. On 8/8/24 at 4:46 p.m., during an observation and interview in room [ROOM NUMBER] B, the NHA immediately called the maintenance director. The NHA said the maintenance director would address the issue. The NHA removed wet linen from under the PTAC and piled the linen in front of the unit. On 8/8/24 at 5:59 p.m., the NHA said staff should be checking resident rooms daily. A review of the facility's policy and procedure, subject Maintenance, effective date 11/30/2014 showed: Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify/areas items in need of repair. Procedure: all items needed maintenance assistance will be reported to maintenance using the maintenance repair request form. Environmental services personnel will check for completed forms throughout the day. The requests will be prioritized and completed according to need.

46234 Based on record review, interviews, hospital record review, facility documentation and policy review the facility failed to ensure one (Resident #2) of three residents reviewed for diabetic management was free from neglect regarding neglecting to provide insulin to a Resident admitted to the facility with a diagnosis of insulin dependent Type II Diabetes. Resident #2 had been using an insulin pump for just under a year and their blood glucose levels were controlled with the insulin pump. Prior to the insulin pump Resident #2 was on daily insulin injections. After admission to the facility, Resident #2 was not provided insulin and showed signs of hyperglycemia (high blood glucose levels) including lethargy, excessive thirst and coma. On [DATE] Resident #2 was found unresponsive and sent to the hospital where her blood glucose was measured to be above 500 (normal ,d+[DATE]); she required hospitalization and intensive care treatment. Additionally, based on observations, interviews, and record review, the facility failed to ensure pain was managed effectively for three residents (#3, #8, and #13) out of three that were reviewed for pain. Resident #3 was admitted to the facility from the hospital on [DATE] after being diagnosed with gas gangrene and osteomyelitis of the left ankle and foot. At 6:10 p.m. on [DATE] the resident's pain medication had not been delivered to the facility. On [DATE] at 12:06 a.m. a nurse obtained access to the automated medication dispensing machine to provide Resident #3 with pain medication. Documentation showed the medication was ineffective and the resident screamed and yelled out. Over a six-day period the resident's PRN (as needed) pain medication, Hydrocodone-Acetaminophen, was documented as being ineffective four different times and nine times no pain level or re-evaluation of effectiveness was documented at all. There were no documented attempts to inform the resident's provider about the ineffective pain medication. Multiple staff members interviewed said over the six-day period Resident #3 was in the facility, they overheard her crying out due to her pain. Resident #3 took the last dose of her PRN pain medication, Hydrocodone-Acetaminophen on [DATE] at 5:46 p.m. The resident had a reported pain level of 6 out of 10 on [DATE] at 1:33 a.m. There was no documentation showing a provider or the pharmacy was called to reorder medication or access the automated medication dispensing machine for Resident #3. Interviews with staff showed the resident was in pain on the morning of [DATE] prior to going to a follow-up doctor's appointment with her Cardiologist. The resident was not given pain medication and screamed in pain on the way to the appointment. Upon arriving at the Cardiologist office, the office staff called 911 due to Resident #3 screaming in pain from the moment of her arrival. Residents #8 was showing signs of pain on interview, stated she frequently had to wait to get pain medication and said, I just want to die not in pain. Resident #13 stated she had to wait four hours for her PRN pain medication on [DATE], said it was typical to wait hours after requesting pain medication and reported staff disbelief of her reports of pain. These failures created a situation that resulted in serious harm to Resident #2 and #3, and the likelihood of serious harm or injury to Residents #8, and #13 and resulted in the determination of Immediate Jeopardy beginning on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to a D. Findings included: 1. A review of Resident #2's medical record showed an admitted [DATE] with diagnoses that included Type II Diabetes with hyperglycemia, Type II Diabetes with Diabetic Neuropathy and Wedge Compression fracture of second lumbar vertebra, subsequent encounter for fracture with routine healing (primary). A review of Resident #2's physician orders related to diabetic management revealed: [DATE] Trulicity Subcutaneous Solution Pen- injector 0.75 MG[milligram]/0.5 ML[milliliter] (Dulaglutide) Inject 1.5 mg subcutaneously one time a day every Thursday for Diabetes Mellitus and remove per schedule. [DATE] Metformin HCI Oral Tablet 1000 MG give 1 tablet by mouth one time a day for Diabetes Mellitus Type II. [DATE] Steglatro 15 MG Tablet give 1 tablet by mouth one time a day for diabetes mellitus. [DATE] Farxiga Oral Tablet 10 MG (Dapagliflozin) give 1 tablet by mouth one time a day for heart failure. [DATE] Accuchecks (blood glucose checks) AC/HS (before meals and at bedtime) for Diabetes Mellitus II if below 70 or above 400 please call (Medical Director/Admitting Physician(MDir/AP) for Resident #2]). Review of the medication Trulicity on www.Trulicity.com showed, Trulicity is for adults with type 2 diabetes to improve blood sugars (glucose). Trulicity is also used in adults with type 2 diabetes to reduce the risk of a major cardiovascular events (problems having to do with heart and blood vessels) such as death, heart attack, or stroke in people who have heart disease. Trulicity is not an insulin. Trulicity acts like the natural human hormone, GLP-1, helping the body do what it's supposed to do naturally, stimulating the body's (pancreas) natural production of insulin. Consider insulin as the first injectable when: Symptoms of hyperglycemia are present and when A1C (>10%) or blood glucose levels (>=300 mg/dL) are very high. Review of the medication Steglatro on www.Steglatro.com showed, Steglatro is a prescription pill used in adults with type 2 diabetes to improve blood sugar (glucose) control along with diet and exercise. It may increase the risk of diabetic ketoacidosis in these people. STEGLATRO may cause serious side effects including Ketoacidosis (increased ketones in the blood or urine) has happened in people with type 1 or type 2 diabetes during treatment and also in people with diabetes who were sick or who had surgery during treatment with STEGLATRO. Ketoacidosis is a serious condition, which may need to be treated in a hospital and may lead to death. Review of the medication Farxiga on www.Farxiga.com showed, Farxiga is a prescription medicine used to: -improve blood sugar control along with diet and exercise in adults with type 2 diabetes -reduce the risk of hospitalization for heart failure in adults with type 2 diabetes and known cardiovascular disease or multiple cardiovascular risk factors -reduce the risk of cardiovascular death and hospitalization for heart failure in adults with symptomatic heart failure. Review of Resident #2's record showed no physician orders for insulin. The resident's care plan did not show a focus, goal or interventions related to diabetes management. Review of Resident #2's medical record revealed a document titled, Internal Medicine Note dated [DATE]. The Internal Medicine Note showed Resident #2's medical history that included Type II diabetes mellitus treated with insulin. The list of medications on the Internal Medicine Note showed: Farxiga 10mg oral tablet Freestyle test strips Gabapentin 300 mg Humulin ,d+[DATE] Kwik Pen Macrobid 100mg Metformin 1000mg oral tablet Tramadol 50mg oral tablet Trulicity Pen 0.75mg/0.5ml Tylenol 325mg oral tablet The admission paperwork located in Resident #2's medical record showed a Medical Certification for Medicaid Long-Term Care Services for Patient Transfer Form 3008 with section L Time sensitive condition specific information: Insulin- [DATE] AM insulin signed by the DON. A review of the Medication Administration Review (MAR) showed Resident #2 never received a dose of the ordered Trulicity or Farxiga medications. Insulin was never ordered. Resident #2 received oral medications of Metformin and Steglatro as ordered. Review of the Accuchecks showed Resident #2's blood sugars for the following days: [DATE]: 6:30 AM- 263 11:30 AM- 200 4:30 PM- 374 9:00 PM- 220 [DATE]: 6:30 AM- 285 11:30 AM- N/A 4:30 PM- 272 9:00 PM- 341 [DATE]: 6:30 AM- 291 11:30 AM- 389 4:30 PM- 299 9:00 PM-236 [DATE]: 6:30 AM- 197 11:30 AM- 150 4:30 PM- 378 9:00 PM- 350 [DATE]: 6:30 AM- 302 11:30 AM- 398 4:30 PM- 312 9:00 PM- 356 [DATE]: 6:30 AM- 301 11:30 AM- 374 4:30 PM- 241 9:00 PM- 352 [DATE]: 6:30 AM- 289 11:30 AM- 332 4:30 PM- 319 9:00 PM- 358 [DATE]: 6:30 AM- 384 Review of Resident #2's medical record showed the following progress notes: A General Note dated [DATE] at 7:48 a.m., stated Resident found unresponsive even with sternum rub, vital signs. Doctor [Partnering doctor to the resident's MD] at bedside and gave orders to send resident to ER. Son at bedside and made aware of resident's condition. An Administration Note dated [DATE] at 8:06 a.m., showed that Resident #2 was unresponsive. A Narrative Note dated [DATE] at 8:42 a.m. showed, Resident presents with altered status and change of condition. Resident unresponsive, shallow respirations. Family at bedside. MD assessed the resident and ordered to send to the emergency room . EMS called to transfer resident to hospital. Resident received a dose of Rocephin Intramuscular [IM] Son will meet resident in hospital. (Note - Rocephine is an antibiotic.) During an interview on [DATE] at 10:00 a.m., the Director of Nursing (DON) stated that Resident # 2 was not on insulin when she came into the facility. When asked about the Medical Certification for Medicaid Long-Term Care Services for Patient Transfer Form 3008 that showed Resident #2 received insulin on the morning of [DATE] the DON replied, Oh Yes, that was the Trulicity. When the DON was questioned about Trulicity being a GLP-1 drug and not insulin the DON replied that she would have to go review the medical record again. DON stated that she was the person who completed Resident# 2's Medical Certification for Medicaid Long-Term Care Services for Patient Transfer Form 3008 on admission and it was completed at bedside with the doctor after meeting with the family to discuss medications and the care plan. The DON stated she reviewed the medications listed on the Internal Medicine Note dated [DATE] with the doctor and family and everyone agreed on the physician orders and all orders were put in point click care (PCC, electronic medical record) during the meeting. The DON was asked if diabetic management would be a focus put on a Residents baseline and comprehensive care plan and she stated, yes. During an interview on [DATE] at 10:27 a.m, a family member of Resident #2 stated Resident #2 had been receiving three insulin shots a day then was switched to the (Brand Name 30) Insulin Pump, while at home. They said Resident #2 had a continuous glucose monitor in place. The family member said upon admission the Director of Nursing (DON) informed them insulin pumps and continuous glucose monitors were not used in the facility. The family was concerned about Resident #2's blood sugar and insulin without using the monitor and insulin pump. The family member said they had an extensive three-hour long conversation with the DON and Medical Director (MD) about their concerns and were assured Resident #2 would have her blood sugar checked three times a day and would be given insulin accordingly. The family member said the DON promised it would be handled. The family member said the DON swore and promised us and looked us in the eye and she promised this was going to be taken care of. The family member also stated the MD said, he was on top of it. The family member said they didn't know how the process worked for admission, so they brought all of Resident #2's medication, pump supplies and insulin in a bag with them to the facility. They said the DON told them they don't use any of that and they could throw it out. They said they were told the facility had their own plan. The family member said the resident's insulin pump was still attached to her for several days after admission, even though the cartridge was empty. The family member said, after a few days in the facility Resident #2 was moved to a different room; the Family Member was speaking with Resident #2's nurse and the nurse said, oh she is diabetic? The family was shocked that the nurse was surprised to learn Resident #2 was a diabetic. The Family Member said the clinical staff would always pass things off on someone else and say, they don't have it in their notes, I got called away or they were just coming on shift. The family started getting concerned because the resident was getting dopey. The family member said they mentioned it to the nurse and the nurse said Resident #2 was just grumpy that day. The family member said the resident was very thirsty all the time and it would take hours to get her water, so they went out and purchased drinks to keep in her room. They said at one point they went to visit Resident #2 and she had not eaten in two days. They notified the nurse and the nurse said, she has sepsis. The family member said when they went to visit on [DATE] the resident couldn't speak or keep her head up. They spoke to the nurse, and she said the resident had an infection, had just received antibiotics and would be doing better the next day. On [DATE] the family said the resident was still unresponsive and they spoke with the nurse again. The nurse again told them she was septic she was going to be out of it. The family said Resident #2's roommate told them the resident had been asleep the entire time they were gone. They spoke with the nurse who then had another partnering doctor from the Medical Director's practice stop by the room. The family said the doctor did not examine her; he asked about the vitals, which the nurse told him, and the doctor said she needs oxygen then left the room. The family said it took the nurse approximately 10 minutes to get oxygen on the resident. The family said they personally rubbed the resident's sternal notch, and she still wouldn't respond; they told the nurse she had to call 911. The family said they had no idea Resident #2 was not receiving insulin until they arrived at the emergency room and were told there was no record of the resident receiving insulin. The family member stated Resident #2 never woke up from the coma and she died in the Intensive Care Unit (ICU) of cardiac arrest with blood sugars of 590 and sepsis. The family member said afterwards he spoke with the NHA who said, its agency people and the Medical Director said, agency people are the cancer of this place. The family member said after Resident #2 passed away in the hospital, they came to pick up Resident #2's belongings and they spoke with the DON. They said the DON wouldn't give them a reason why Resident #2 was not given insulin. The family member said when Resident #2 was admitted to the facility she was able to talk, move around, and walk; after being in the facility she deteriorated and went into a coma. On [DATE] at 11:40 a.m. an interview was conducted with Staff C, Admissions Director (AD). She stated Resident #2 was originally going to be admitted over the weekend but since the resident had the glucose monitor and insulin pump, she spoke with the DON and they decided to defer admission until Monday when the DON and Medical Director would be there to go over medications. Staff C AD said Monday the family came in and met with the DON and Medical Director as planned. Staff C AD said when the resident came in she was able to self-propel in her wheelchair and was able to make her needs known. She said the resident was alert with some confusion but was alert enough to crack jokes. During an interview on [DATE] at 11:54 a.m., the DON said when Resident #2 came into the facility on e family member went with the resident and Medical Director to the room and another family member stayed with the DON in her office to review the resident's medical history. The DON said next the two family members, Medical Director and herself sat down and went over the resident's history and physical, medications, how medications best helped her, and what the resident needed. She said they discussed gabapentin, Tramadol, cranberry, and Colace, but she can't remember every single med [medication] we talked about. She said they also spoke about the resident's Urinary Tract Infection (UTI) fractures, and the way she took her medication. The DON said while they were meeting the Medical Director gave orders for the medications and blood glucose checks and she put the orders in the computer. She said she told the family they could not utilize the continuous glucose monitor in the resident's arm and the family would have to discontinue that because the facility did not put it in. The DON said after the resident's death, the family chose to blame her. When asked about the resident having an insulin pump, she said, not that they made me aware of and not that was accessed. She said the resident's skin was beautiful and didn't have any open areas or anything. She said the family did not make anyone aware at any time during their conversation about an insulin pump. The DON was asked again about the Medical Certification for Medicaid Long-Term care Services and Patient Transfer Form 3008 and was asked why it showed insulin was scheduled to be given. She said the form listed insulin because the family had given the resident ,d+[DATE] that morning. The DON said the family said they were not doctors and they were turning to the medical director to prescribe the medications. She said they discussed insulin, but she didn't know if the family didn't want to continue to stick her with shots. She said they wanted to make sure Metformin was doing its job. She said the order for blood glucose checks had the parameter in place to call the doctor for blood sugars less than 70 or greater than 400. She added normal blood glucose is from ,d+[DATE]; they don't like to see blood glucose over 250, but when it is this to this you follow that. The DON also added the resident was on Metformin. She said she remembered talking about Metformin and accuchecks but not specifically about insulin in the meeting with the family. She stated they wanted to see if the Metformin was working on the resident and if she needed insulin. The DON reviewed Resident #11's (another resident) blood glucose levels throughout her stay. She said when the resident's blood glucose levels become unstable, the nurse asked the nurse practitioner about adding a sliding scale (varying the dose of insulin based on blood glucose level). During an interview on [DATE] at 12:20 p.m., Staff E Nurse Practitioner (NP) who saw Resident #2 on [DATE] stated that I was not aware she was ever on insulin. If I knew that I would have put her back on insulin. The NP stated, I was never told by staff that she was insulin dependent prior to entering the facility. The NP said she noticed a change in condition in Resident #2 with more confusion on [DATE] so she immediately ordered Rocephin (an antibiotic), but the NP stated Resident #2 probably should have gone out to the hospital when the change of condition was noticed. NP stated that the professional standard of care was usually not to take Residents off of insulin once blood sugar was controlled with insulin. During a phone interview on [DATE] at 12:44 p.m., the Medical Director/Admitting Physician (MDir/AP) for Resident #2 stated that he does not usually take people off insulin once being dependent on insulin. The MDir/AP stated, I can tell you I am not against insulin pumps. The MDir/AP stated both family members were in the facility and discussed Resident #2's medications. During an additional phone interview on [DATE] at 3:00 p.m., the Medical Director/Admitting Physician (MDir/AP) reviewed Resident #2's initial note. The MDir/AP stated he had written that Duloxetine was added for depression and Gabapentin was going to be tapered off. The MDir/AP had not mentioned anything about insulin in his physician note. The MDir/AP stated he remembered speaking with Resident #2's sons and advised the Survey Team to speak with the family as he was sure they would remember better what was discussed. The MDir/AP stated that Resident #2 was not obese. The MDir/AP stated the facility did not manage insulin pumps because insulin pumps are surgically implanted under the skin and only an Endocrinologist can refill it each time. Review of the MDir/AP's initial note dated [DATE] showed This is a medically complex [AGE] year-old cachectic white female with a long-standing history of numerous comorbidities include a known history of chronic constipation, osteoporosis, with compression fractures, COPD, diabetes mellitus type 2 with neuropathy, recurrent UTIs, recurrent falls, history of small bowel obstruction, hypertension, mild dementia and osteoarthritis. She normally resides at home with her son. The initial note revealed a section case reviewed that showed, I had a lengthy discussion about the patient's care with [2 family members]. We will start duloxetine 30 milligrams (mg) daily for depression and chronic pain. Taper off Gabapentin down to 300 mg for seven days then discontinue altogether. There was no mention of insulin therapy revealed in the MD's initial note. During an interview on [DATE] at 1:30 p.m., Resident #2's primary care provider (PCP), prior to admission confirmed it was her Internal Medicine Note dated [DATE] the family brought to the facility with them upon admission. The Internal Medicine Note listed the following medication: Cranberry docusate sodium 100mg, 2 capsules twice a day, Farxiga 10 mg oral tablet, Freestyle test strips, ,Humulin ,d+[DATE] Kwik pen 70 units- 30 units/ml subcutaneous suspension sliding scale, Gabapentin 300 mg oral capsules 1 time a day, Macrobid 100mg oral capsule twice a day, Metformin 1000mg oral tablet 1 time a day, Tramadol 50mg oral tablet, Trulicity Pen 0.75mg/0.5ml subcutaneous solution and Tylenol 325mg oral tablet, 650mg as needed. The PCP stated she managed the resident's medical conditions except for her diabetes; that was done by her Endocrinologist. The provider said she reviewed pharmacy records, and they indicated the resident was on a sliding scale, had an insulin pump, was on Trulicity, and Farxiga for diabetes as well. The provider added Humalog 100U was used in the insulin pump. Review of Resident #2's Insulin Delivery System, she was using prior to admission, at www.go-vgo.com revealed the user's manual for the (Brand name) series insulin pump. The manufacturer's user manual steps to applying and using the (Brand name) system included: A. (Brand name) can be worn any place where insulin can be injected or infused. Insulin is injected or infused into the subcutaneous tissue. You may apply (Brand name): - On the abdomen. The abdomen has ample flat surface area and is an accessible and comfortable location. Insulin absorption is fast, predictable, and less affected by exercise when administered through the abdomen. E. Hold (brand name) in place for ,d+[DATE] seconds. Run your finger around the entire edge of the adhesive pad to make sure it is firmly attached to your body. Step 5: Start the 24-hour flow of insulin with (brand name) Press down on the raised bump of the Start Button with one firm quick motion. The Start Button needs to be pressed completely down into (brand name) until you hear a click and the button locks in place. This begins the flow of insulin. (Brand name) delivers a continuous preset basal rate of insulin over 24 hours. During an interview on [DATE] at 4:20 p.m., Staff A Certified Nursing Assistant (CNA) stated that she remembered she gave Resident #2 a shower and Resident #2 did have an insulin pump access in her belly at shower time. Staff A CNA stated she noticed Resident #2 was declining and had a change of condition and was getting weaker on [DATE]. A review of Resident #2's electronic medical record revealed under the ADL section that Resident #2 received a shower by Staff A CNA on [DATE]. Further review of Resident #2's medical record revealed a Narrative Note dated [DATE], This nurse reports to Staff E NP that resident fasting blood sugars have been in 300 range consistently, Staff E NP gave new order to increase Trulicity. This nurse questioned Staff E NP about possibly putting resident on fast acting insulin. Staff E NP declines and stated Trulicity should cover resident. Narrative note was signed by Staff B Registered Nurse (RN). During an interview on [DATE] at 4:35 p.m., Staff B Registered Nurse (RN) discussed the Narrative note dated [DATE]. Staff B RN stated she remembered the conversation and asked Staff E NP about putting Resident #2 on some fast-acting insulin. Staff B RN stated, I explained to the NP that I didn't know what insulin was in the pump but did inform NP Resident #2 was on insulin prior to being admitted to the facility. Staff B RN stated that she also remembered the NP informed her that she was going to talk to the family about the specific insulin that was used in the pump and then Staff E NP proceeded into Resident #2's room to talk with the family about insulin. A review of the local hospital ER notes showed Resident #2 was admitted on [DATE] and The patient presents with Altered Mental Status (AMS) 2 days? Arrival by EMS from the local skilled nursing facility for evaluation of altered mental status hyperglycemia. Patient is a recent admit to the skilled nursing facility history of dementia previously living at home history of type 2 diabetes on Metformin Trulicity and Steglatro unable to obtain history from patient. Also receiving IV antibiotics for UTI. Full code per nursing home sheets reviewed by me. Additional history from son at bedside yesterday awake talking jibberish but not talking above a whisper, dec loc (decreased loss of consciousness) later that day. Son found her this morning unresponsive. Per son supposed to be on insulin 3 x a day previously on an insulin pump with continuous blood glucose monitor (CBG) but when patient moved into this facility a few days ago the pump was discontinued, and they were supposed to start her on insulin shots there is no daily insulin shots indicated on the MAR reviewed by me. The ER Rapid Triage noted patient presented with AMS/fever, from the facility, EMS stated hyperglycemia with CBG greater than 500. The ER Impression and Plan showed Resident #2 was diagnosed with Acute Diabetic Ketoacidosis (DKA) and Sepsis with a plan that Patient MUST be in a Critical Care unit or have telemetry monitoring in place and an order in place for insulin regular Additive 100 unit(s) + Sodium Chloride 0.9% intravenous solution 100 mL: UNIT/HR (hour), IV. Review of Diabetic Ketoacidosis (DKA) on www.mayoclinic.org showed, Diabetic ketoacidosis is a serious complication of diabetes. The condition develops when the body can't produce enough insulin. Insulin plays a key role in helping sugar enter cells in the body. Without enough insulin, the body begins to break down fat as fuel. This causes a buildup of acids in the bloodstream called ketones. If it's left untreated, the buildup can lead to diabetic ketoacidosis. Symptoms of DKA include Being very thirsty, being weak or tired, being short of breath and being confused. Seek emergency care if your blood sugar level is higher than 300 milligrams per deciliter, or 16.7 millimoles per liter for more than one test. Remember, untreated diabetic ketoacidosis can lead to death. During an interview on [DATE] at 8:13 a.m., Resident #2's Nurse from her established endocrinology office called and stated Resident #2 was last seen on [DATE]. She said the resident had a (brand name) insulin pump with Humalog (insulin). Resident #2 was also on Trulicity once weekly, Farxiga once a day, and Metformin twice per day. She said the resident had the pump for just under one year. She said Resident #2 was previously on ,d+[DATE] (insulin) but that was stopped on ,d+[DATE]. During a phone interview on [DATE] at 8:31 a.m., Resident #2's established Endocrinologist stated Resident #2 was on the (Brand name 30) pump then in December was decreased to a (Brand name 20). Endocrinologist said Resident #2 was not on a sliding scale. Endocrinologist said when she began seeing Resident #2 on [DATE] Resident #2 was on ,d+[DATE] insulin. Endocrinology said Resident #2 did not have controlled blood glucose levels, so she was put on the (brand name) insulin pump due to her dementia and to gain better control. Endocrinologist stated on the (brand name 30) the resident was having some low blood glucose readings at night, so they decided to decrease to (Brand name 20) in [DATE]. Endocrinologist said she told the son the only time the pump should be off was when they were decreasing from 30 to 20 but other than that the pump should have remained running 24 hours. Endocrinologist stated the facility never reached out to her to discuss what Resident #2 was taking for Diabetes. People don't reach out, they should have called Endocrinologist said some Type 2 Diabetics do not require insulin, but Resident #2's blood sugar was controlled with insulin, it wouldn't have made sense to take her off insulin. Endocrinologist said she knows some facilities don't use insulin pumps, but it would have been prudent to figure out what insulin to put her on. Endocrinologist stated Resident #2 was not always compliant, but her dementia was not to the point she would refuse, even though she didn't like fingerstick. Endocrinologist stated, If you take a pump off you have to start insulin. During an interview on [DATE] at 10:25 a.m., Resident #2's family member stated the family had three bags of Resident #2's current medications, pump equipment and insulin present in the facility when Resident #2 was admitted . The family member stated that both the DON and MD would not even look into Resident #2's medication bags. The family member stated the DON and MD kept saying because the medications were from the outside, the facility couldn't use the medications so advised the family to take the medications all back home. The family member stated that all of Resident #2's current medications were in the bags brought with Resident #2 on admission. During an interview on [DATE] at 10:37 a.m., a second Family Member stated that the family were told by the facility that insulin and everything Resident #2 would need was available at the facility. The second family member stated that the facility talked about pain medications, medications for a UTI and the Medical Director (MD) and the Director of Nursing (DON), basically just put us at ease. The second family member recalled the MD and DON kept saying we have everything in house. We have the facilities, we have the doctors, we have the medical staff. The second family member stated the MD and DON wouldn't look at anything in the bag of medications because they said they couldn't use it because it was from outside. The MD and DON told the family to just take it home. The MD and DON were adamant about doing things their own way. The second family member stated the family and MD and DON talked about putting Resident #2 on insulin. The MD and DON said the facility had everything Resident #2 needed. The second family member stated the MD and DON didn't go into detail about the exact plan to provide Resident #2 insulin but stated the facility knew Resident #2 was insulin dependent. The second family member stated that insulin was Absolutely 100% the main thing. Prior to admitting Resident #2 in the facility, the family made sure the MD and DON knew Resident #2 was insulin dependent and that was the reason for the delay in admission to a Monday. The second family member stated he told the MD and DON that Resident #2 was cared for by the family at home for 5 years and made sure the MD and DON knew Resident #2 needed her insulin. The second family member stated that the facility never mentioned they would take Resident #2 off insulin and stated had the family been told they would have just taken Resident #2 back home beca [TRUNCATED]

Based on observations, interviews, and record review the facility failed to provide care and services according to accepted standards of clinical practice for four residents (#2, #3, #8, and #13) out of thirteen residents sampled. Based on record review, interviews, hospital record review, facility documentation and policy review the facility failed to ensure one (Resident #2) of three residents reviewed for diabetic management was free from neglect regarding neglecting to provide insulin to a Resident admitted to the facility with a diagnosis of insulin dependent Type II Diabetes. Additionally, based on observations, interviews, and record review, the facility failed to ensure pain was managed effectively for three residents (#3, #8, and #13) out of three that were reviewed for pain. These failures created a situation that resulted in the likelihood of serious injury or harm to Resident #2, #3, #8, and #13 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to a D. Findings included: 1. A review of Resident #2's medical record showed an admitted [DATE] with diagnoses that included Type II Diabetes with hyperglycemia, Type II Diabetes with Diabetic Neuropathy and Wedge Compression fracture of second lumbar vertebra, subsequent encounter for fracture with routine healing (primary). A review of Resident #2's physician orders related to diabetic management revealed: [DATE] Trulicity Subcutaneous Solution Pen- injector 0.75 MG[milligram]/0.5 ML[milliliter] (Dulaglutide) Inject 1.5 mg subcutaneously one time a day every Thursday for Diabetes Mellitus and remove per schedule. [DATE] Metformin HCI Oral Tablet 1000 MG give 1 tablet by mouth one time a day for Diabetes Mellitus Type II. [DATE] Steglatro 15 MG Tablet give 1 tablet by mouth one time a day for diabetes mellitus. [DATE] Farxiga Oral Tablet 10 MG (Dapagliflozin) give 1 tablet by mouth one time a day for heart failure. [DATE] Accuchecks (blood glucose checks) AC/HS (before meals and at bedtime) for Diabetes Mellitus II if below 70 or above 400 please call [MDir/AP - (Medical Director/Admitting Physician for Resident #2]). Review of the medication Trulicity on www.Trulicity.com showed, Trulicity is for adults with type 2 diabetes to improve blood sugars (glucose). Trulicity is also used in adults with type 2 diabetes to reduce the risk of a major cardiovascular events (problems having to do with heart and blood vessels) such as death, heart attack, or stroke in people who have heart disease. Trulicity is not an insulin. Trulicity acts like the natural human hormone, GLP-1, helping the body do what it's supposed to do naturally, stimulating the body's (pancreas) natural production of insulin. Consider insulin as the first injectable when: Symptoms of hyperglycemia are present and when A1C (>10%) or blood glucose levels (>=300 mg/dL) are very high. Review of the medication Steglatro on www.Steglatro.com showed, Steglatro is a prescription pill used in adults with type 2 diabetes to improve blood sugar (glucose) control along with diet and exercise. It may increase the risk of diabetic ketoacidosis in these people. STEGLATRO may cause serious side effects including Ketoacidosis (increased ketones in the blood or urine) has happened in people with type 1 or type 2 diabetes during treatment and also in people with diabetes who were sick or who had surgery during treatment with STEGLATRO. Ketoacidosis is a serious condition, which may need to be treated in a hospital and may lead to death. Review of the medication Farxiga on www.Farxiga.com showed, Farxiga is a prescription medicine used to: -improve blood sugar control along with diet and exercise in adults with type 2 diabetes -reduce the risk of hospitalization for heart failure in adults with type 2 diabetes and known cardiovascular disease or multiple cardiovascular risk factors -reduce the risk of cardiovascular death and hospitalization for heart failure in adults with symptomatic heart failure. Review of Resident #2's record showed no physician orders for insulin. The resident's care plan did not show a focus, goal or interventions related to diabetes management. Review of Resident #2's medical record revealed a document titled, Internal Medicine Note dated [DATE]. The Internal Medicine Note showed Resident #2's medical history that included Type II diabetes mellitus treated with insulin. The list of medications on the Internal Medicine Note showed: Farxiga 10mg oral tablet Freestyle test strips Gabapentin 300 mg Humulin ,d+[DATE] Kwik Pen Macrobid 100mg Metformin 1000mg oral tablet Tramadol 50mg oral tablet Trulicity Pen 0.75mg/0.5ml Tylenol 325mg oral tablet The admission paperwork located in Resident #2's medical record showed a Medical Certification for Medicaid Long-Term Care Services for Patient Transfer Form 3008 with section L Time sensitive condition specific information: Insulin- [DATE] AM insulin signed by the DON. A review of the Medication Administration Review (MAR) showed Resident #2 never received a dose of the ordered Trulicity or Farxiga medications. Insulin was never ordered. Resident #2 received oral medications of Metformin and Steglatro as ordered. Review of the Accuchecks showed Resident #2's blood sugars for the following days: [DATE]: 6:30 AM- 263 11:30 AM- 200 4:30 PM- 374 9:00 PM- 220 [DATE]: 6:30 AM- 285 11:30 AM- N/A 4:30 PM- 272 9:00 PM- 341 [DATE]: 6:30 AM- 291 11:30 AM- 389 4:30 PM- 299 9:00 PM-236 [DATE]: 6:30 AM- 197 11:30 AM- 150 4:30 PM- 378 9:00 PM- 350 [DATE]: 6:30 AM- 302 11:30 AM- 398 4:30 PM- 312 9:00 PM- 356 [DATE]: 6:30 AM- 301 11:30 AM- 374 4:30 PM- 241 9:00 PM- 352 [DATE]: 6:30 AM- 289 11:30 AM- 332 4:30 PM- 319 9:00 PM- 358 [DATE]: 6:30 AM- 384 Review of Resident #2's medical record showed the following progress notes: A General Note dated [DATE] at 7:48 a.m., stated Resident found unresponsive even with sternum rub, vital signs. Doctor [Partnering doctor to the resident's MD] at bedside and gave orders to send resident to ER. Son at bedside and made aware of resident's condition. An Administration Note dated [DATE] at 8:06 a.m., showed that Resident #2 was unresponsive. A Narrative Note dated [DATE] at 8:42 a.m. showed, Resident presents with altered status and change of condition. Resident unresponsive, shallow respirations. Family at bedside. MD assessed the resident and ordered to send to the emergency room . EMS called to transfer resident to hospital. Resident received a dose of Rocephin Intramuscular [IM] Son will meet resident in hospital. (Note - Rocephin an antibiotic.) During an interview on [DATE] at 10:00 a.m., the Director of Nursing (DON) stated that Resident # 2 was not on insulin when she came into the facility. When asked about the Medical Certification for Medicaid Long-Term Care Services for Patient Transfer Form 3008 that showed Resident #2 received insulin on the morning of [DATE] the DON replied, Oh Yes, that was the Trulicity. When the DON was questioned about Trulicity being a GLP-1 drug and not insulin the DON replied that she would have to go review the medical record again. DON stated that she was the person who completed Resident# 2's Medical Certification for Medicaid Long-Term Care Services for Patient Transfer Form 3008 on admission and it was completed at bedside with the doctor after meeting with the family to discuss medications and the care plan. The DON stated she reviewed the medications listed on the Internal Medicine Note dated [DATE] with the doctor and family and everyone agreed on the physician orders and all orders were put in point click care (PCC, electronic medical record) during the meeting. The DON was asked if diabetic management would be a focus put on a Residents baseline and comprehensive care plan and she stated, yes. During an interview on [DATE] at 10:27 a.m, a family member of Resident #2 stated Resident #2 had been receiving three insulin shots a day then was switched to the (Brand Name 30) Insulin Pump, while at home. They said Resident #2 had a continuous glucose monitor in place. The family member said upon admission the Director of Nursing (DON) informed them insulin pumps and continuous glucose monitors were not used in the facility. The family was concerned about Resident #2's blood sugar and insulin without using the monitor and insulin pump. The family member said they had an extensive three-hour long conversation with the DON and Medical Director (MD) about their concerns and were assured Resident #2 would have her blood sugar checked three times a day and would be given insulin accordingly. The family member said the DON promised it would be handled. The family member said the DON swore and promised us and looked us in the eye and she promised this was going to be taken care of. The family member stated the MD said, he was on top of it. The family member said they didn't know how the process worked for admission, so they brought all of Resident #2's medication, pump supplies and insulin in a bag with them to the facility. They said the DON told them they don't use any of that and they could throw it out. They said they were told the facility had their own plan. The family member said the resident's insulin pump was still attached to her for several days after admission, even though the cartridge was empty. The family member said, after a few days in the facility Resident #2 was moved to a different room; the Family Member was speaking with Resident #2's nurse and the nurse said, oh she is diabetic? The family was shocked that the nurse was surprised to learn Resident #2 was a diabetic. The Family Member said the clinical staff would always pass things off on someone else and say, they don't have it in their notes, I got called away or they were just coming on shift. The family started getting concerned because the resident was getting dopey. The family member said they mentioned it to the nurse and the nurse said Resident #2 was just grumpy that day. The family member said the resident was very thirsty all the time and it would take hours to get her water, so they went out and purchased drinks to keep in her room. They said at one point they went to visit Resident #2 and she had not eaten in two days. They notified the nurse and the nurse said, she has sepsis. The family member said when they went to visit on [DATE] the resident couldn't speak or keep her head up. They spoke to the nurse, and she said the resident had an infection, had just received antibiotics and would be doing better the next day. On [DATE] the family said the resident was still unresponsive and they spoke with the nurse again. The nurse again told them she was septic she was going to be out of it. The family said Resident #2's roommate told them the resident had been asleep the entire time they were gone. They spoke with the nurse who then had another partnering doctor from the Medical Director's practice stop by the room. The family said the doctor did not examine her; he asked about the vitals, which the nurse told him, and the doctor said she needs oxygen then left the room. The family said it took the nurse approximately 10 minutes to get oxygen on the resident. The family said they personally rubbed the resident's sternal notch, and she still wouldn't respond; they told the nurse she had to call 911. The family said they had no idea Resident #2 was not receiving insulin until they arrived at the emergency room and were told there was no record of the resident receiving insulin. The family member stated Resident #2 never woke up from the coma and she died in the Intensive Care Unit (ICU) of cardiac arrest with blood sugars of 590 and sepsis. The family member said afterwards he spoke with the NHA who said, its agency people and the Medical Director said, agency people are the cancer of this place. The family member said after Resident #2 passed away in the hospital, they came to pick up Resident #2's belongings and they spoke with the DON. They said the DON wouldn't give them a reason why Resident #2 was not given insulin. The family member said when Resident #2 was admitted to the facility she was able to talk, move around, and walk; after being in the facility she deteriorated and went into a coma. On [DATE] at 11:40 a.m. an interview was conducted with Staff C, Admissions Director (AD). She stated Resident #2 was originally going to be admitted over the weekend but since the resident had the glucose monitor and insulin pump, she spoke with the DON and they decided to defer admission until Monday when the DON and Medical Director would be there to go over medications. Staff C AD said Monday the family came in and met with the DON and Medical Director as planned. Staff C AD said when the resident came in she was able to self-propel in her wheelchair and was able to make her needs known. She said the resident was alert with some confusion but was alert enough to crack jokes. During an interview on [DATE] at 11:54 a.m., the DON said when Resident #2 came into the facility on e family member went with the resident and Medical Director to the room and another family member stayed with the DON in her office to review the resident's medical history. The DON said next the two family members, Medical Director and herself sat down and went over the resident's history and physical, medications, how medications best helped her, and what the resident needed. She said they discussed gabapentin, Tramadol, cranberry, and Colace, but she can't remember every single med [medication] we talked about. She said they spoke about the resident's Urinary Tract Infection (UTI) fractures, and the way she took her medication. The DON said while they were meeting the Medical Director gave orders for the medications and blood glucose checks and she put the orders in the computer. She said she told the family they could not utilize the continuous glucose monitor in the resident's arm and the family would have to discontinue that because the facility did not put it in. The DON said after the resident's death, the family chose to blame her. When asked about the resident having an insulin pump, she said, not that they made me aware of and not that was accessed. She said the resident's skin was beautiful and didn't have any open areas or anything. She said the family did not make anyone aware at any time during their conversation about an insulin pump. The DON was asked again about the Medical Certification for Medicaid Long-Term care Services and Patient Transfer Form 3008 and was asked why it showed insulin was scheduled to be given. She said the form listed insulin because the family had given the resident ,d+[DATE] that morning. The DON said the family said they were not doctors and they were turning to the medical director to prescribe the medications. She said they discussed insulin, but she didn't know if the family didn't want to continue to stick her with shots. She said they wanted to make sure Metformin was doing its job. She said the order for blood glucose checks had the parameter in place to call the doctor for blood sugars less than 70 or greater than 400. She added normal blood glucose is from ,d+[DATE]; they don't like to see blood glucose over 250, but when it is this to this you follow that. The DON aadded the resident was on Metformin. She said she remembered talking about Metformin and accuchecks but not specifically about insulin in the meeting with the family. She stated they wanted to see if the Metformin was working on the resident and if she needed insulin. The DON reviewed Resident #11's (another resident) blood glucose levels throughout her stay. She said when the resident's blood glucose levels become unstable, the nurse asked the nurse practitioner about adding a sliding scale (varying the dose of insulin based on blood glucose level). During an interview on [DATE] at 12:20 p.m., Staff E Nurse Practitioner (NP) who saw Resident #2 on [DATE] stated that I was not aware she was ever on insulin. If I knew that I would have put her back on insulin. The NP stated, I was never told by staff that she was insulin dependent prior to entering the facility. The NP said she noticed a change in condition in Resident #2 with more confusion on [DATE] so she immediately ordered Rocephin (an antibiotic), but the NP stated Resident #2 probably should have gone out to the hospital when the change of condition was noticed. NP stated that the professional standard of care was usually not to take Residents off of insulin once blood sugar was controlled with insulin. During a phone interview on [DATE] at 12:44 p.m., the Medical Director/Admitting Physician (MDir/AP) for Resident #2 stated that he does not usually take people off insulin once being dependent on insulin. The MDir/AP stated, I can tell you I am not against insulin pumps. The MDir/AP stated both family members were in the facility and discussed Resident #2's medications. During an additional phone interview on [DATE] at 3:00 p.m., the Medical Director/Admitting Physician (MDir/AP) reviewed Resident #2's initial note. The MDir/AP stated he had written that Duloxetine was added for depression and Gabapentin was going to be tapered off. The MDir/AP had not mentioned anything about insulin in his physician note. The MDir/AP stated that Resident #2 was not obese. The MD stated the facility did not manage insulin pumps because insulin pumps are surgically implanted under the skin and only an Endocrinologist can refill it each time. Review of the MDir/AP's initial note dated [DATE] showed This is a medically complex [AGE] year-old cachectic white female with a long-standing history of numerous comorbidities include a known history of chronic constipation, osteoporosis, with compression fractures, COPD, diabetes mellitus type 2 with neuropathy, recurrent UTIs, recurrent falls, history of small bowel obstruction, hypertension, mild dementia and osteoarthritis. She normally resides at home with her son. The initial note revealed a section case reviewed that showed, I had a lengthy discussion about the patient's care with [2 family members]. We will start duloxetine 30 milligrams (mg) daily for depression and chronic pain. Taper off Gabapentin down to 300 mg for seven days then discontinue altogether. There was no mention of insulin therapy revealed in the MD's initial note. During an interview on [DATE] at 1:30 p.m., Resident #2's primary care provider (PCP), prior to admission confirmed it was her Internal Medicine Note dated [DATE] the family brought to the facility with them upon admission. The Internal Medicine Note listed the following medication: Cranberry docusate sodium 100mg, 2 capsules twice a day, Farxiga 10 mg oral tablet, Freestyle test strips, ,Humulin ,d+[DATE] Kwik pen 70 units- 30 units/ml subcutaneous suspension sliding scale, Gabapentin 300 mg oral capsules 1 time a day, Macrobid 100mg oral capsule twice a day, Metformin 1000mg oral tablet 1 time a day, Tramadol 50mg oral tablet, Trulicity Pen 0.75mg/0.5ml subcutaneous solution and Tylenol 325mg oral tablet, 650mg as needed. The PCP stated she managed the resident's medical conditions except for her diabetes; that was done by her Endocrinologist. The provider said she reviewed pharmacy records, and they indicated the resident was on a sliding scale, had an insulin pump, was on Trulicity, and Farxiga for diabetes as well. The provider added Humalog 100U was used in the insulin pump. During an interview on [DATE] at 4:20 p.m., Staff A Certified Nursing Assistant (CNA) stated that she remembered she gave Resident #2 a shower and Resident #2 did have an insulin pump access in her belly at shower time. Staff A CNA stated she noticed Resident #2 was declining and had a change of condition and was getting weaker on [DATE]. Further review of Resident #2's medical record revealed a Narrative Note dated [DATE], This nurse reports to Staff E NP that resident fasting blood sugars have been in 300 range consistently, Staff E NP gave new order to increase Trulicity. This nurse questioned Staff E NP about possibly putting resident on fast acting insulin. Staff E NP declines and stated Trulicity should cover resident. Narrative note was signed by Staff B Registered Nurse (RN). During an interview on [DATE] at 4:35 p.m., Staff B Registered Nurse (RN) discussed the Narrative note dated [DATE]. Staff B RN stated she remembered the conversation and asked Staff E NP about putting Resident #2 on some fast-acting insulin. Staff B RN stated, I explained to the NP that I didn't know what insulin was in the pump but did inform NP Resident #2 was on insulin prior to being admitted to the facility. Staff B RN stated that she remembered the NP informed her that she was going to talk to the family about the specific insulin that was used in the pump and then Staff E NP proceeded into Resident #2's room to talk with the family about insulin. A review of the local hospital ER notes showed Resident #2 was admitted on [DATE] and The patient presents with Altered Mental Status (AMS) 2 days? Arrival by EMS from the local skilled nursing facility for evaluation of altered mental status hyperglycemia. Patient is a recent admit to the skilled nursing facility history of dementia previously living at home history of type 2 diabetes on Metformin Trulicity and Steglatro unable to obtain history from patient. Also receiving IV antibiotics for UTI. Full code per nursing home sheets reviewed by me. Additional history from son at bedside yesterday awake talking jibberish but not talking above a whisper, dec loc (decreased loss of consciousness) later that day. Son found her this morning unresponsive. Per son supposed to be on insulin 3 x a day previously on an insulin pump with continuous blood glucose monitor (CBG) but when patient moved into this facility a few days ago the pump was discontinued, and they were supposed to start her on insulin shots there is no daily insulin shots indicated on the MAR reviewed by me. The ER Rapid Triage noted patient presented with AMS/fever, from the facility, EMS stated hyperglycemia with CBG greater than 500. The ER Impression and Plan showed Resident #2 was diagnosed with Acute Diabetic Ketoacidosis (DKA) and Sepsis with a plan that Patient MUST be in a Critical Care unit or have telemetry monitoring in place and an order in place for insulin regular Additive 100 unit(s) + Sodium Chloride 0.9% intravenous solution 100 mL: UNIT/HR (hour), IV. Review of Diabetic Ketoacidosis (DKA) on www.mayoclinic.org showed, Diabetic ketoacidosis is a serious complication of diabetes. If it's left untreated, the buildup can lead to diabetic ketoacidosis. Symptoms of DKA include Being very thirsty, being weak or tired, being short of breath and being confused. Seek emergency care if your blood sugar level is higher than 300 milligrams per deciliter, or 16.7 millimoles per liter for more than one test. Remember, untreated diabetic ketoacidosis can lead to death. During a phone interview on [DATE] at 8:31 a.m., Resident #2's established Endocrinologist stated Resident #2 was on the (Brand name 30) pump then in December was decreased to a (Brand name 20). Endocrinologist said Resident #2 was not on a sliding scale. Endocrinologist said when she began seeing Resident #2 on [DATE] Resident #2 was on ,d+[DATE] insulin. Endocrinology said Resident #2 did not have controlled blood glucose levels, so she was put on the (brand name) insulin pump due to her dementia and to gain better control. Endocrinologist stated on the (brand name 30) the resident was having some low blood glucose readings at night, so they decided to decrease to (Brand name 20) in [DATE]. Endocrinologist said she told the son the only time the pump should be off was when they were decreasing from 30 to 20 but other than that the pump should have remained running 24 hours. Endocrinologist stated the facility never reached out to her to discuss what Resident #2 was taking for Diabetes. People don't reach out, they should have called Endocrinologist said some Type 2 Diabetics do not require insulin, but Resident #2's blood sugar was controlled with insulin, it wouldn't have made sense to take her off insulin. Endocrinologist said she knows some facilities don't use insulin pumps, but it would have been prudent to figure out what insulin to put her on. Endocrinologist stated Resident #2 was not always compliant, but her dementia was not to the point she would refuse, even though she didn't like fingerstick. Endocrinologist stated, If you take a pump off you have to start insulin. During an interview on [DATE] at 10:25 a.m., Resident #2's family member stated the family had three bags of Resident #2's current medications, pump equipment and insulin present in the facility when Resident #2 was admitted . The family member stated that both the DON and MD would not even look into Resident #2's medication bags. The family member stated the DON and MD kept saying because the medications were from the outside, the facility couldn't use the medications so advised the family to take the medications all back home. The family member stated that all of Resident #2's current medications were in the bags brought with Resident #2 on admission. During an interview on [DATE] at 10:37 a.m., a second Family Member stated that the family were told by the facility that insulin and everything Resident #2 would need was available at the facility. The second family member stated that the facility talked about pain medications, medications for a UTI and the Medical Director (MD) and the Director of Nursing (DON), basically just put us at ease. The second family member recalled the MD and DON kept saying we have everything in house. We have the facilities, we have the doctors, we have the medical staff. The second family member stated the MD and DON wouldn't look at anything in the bag of medications because they said they couldn't use it because it was from outside. The MD and DON told the family to just take it home. The MD and DON were adamant about doing things their own way. The second family member stated the family and MD and DON talked about putting Resident #2 on insulin. The MD and DON said the facility had everything Resident #2 needed. The second family member stated the MD and DON didn't go into detail about the exact plan to provide Resident #2 insulin but stated the facility knew Resident #2 was insulin dependent. The second family member stated that insulin was Absolutely 100% the main thing. Prior to admitting Resident #2 in the facility, the family made sure the MD and DON knew Resident #2 was insulin dependent and that was the reason for the delay in admission to a Monday. The second family member stated he told the MD and DON that Resident #2 was cared for by the family at home for 5 years and made sure the MD and DON knew Resident #2 needed her insulin. The second family member stated that the facility never mentioned they would take Resident #2 off insulin and stated had the family been told they would have just taken Resident #2 back home because she needed her insulin. The second family member stated that the MD and DON never looked at the (current) medications the family brought into the facility with Resident #2 at admission. The second family member stated that he would come in daily and noticed Resident #2's face was a little drawn and she looked dehydrated. The staff told him their ice/water machine was down so he brought water for Resident #2 to drink and asked staff to please give her the water when she wanted it. The second family member stated that over the next two days, the facility never gave her the water and Resident #2's water cup was always empty. The second family member stated that Resident #2 was excessively thirsty and when he would ask the staff for water, they would reply we just gave her water. The second family member stated he would tell staff Resident #2's cup was empty and if she drank it all then she needed more. The second family member stated that he told staff that Resident #2 was extremely thirsty. The second family member stated that Resident #2 was in a little bit of a fog and would forget to eat. The second family member informed the staff that Resident #2 needed help eating but no one ever helped her. Resident #2 didn't eat while in the facility the family helped her eat when visiting. The second family member stated that on Valentines Day Resident #2 was laughing and then the next morning on [DATE], she was covered in feces and sat in feces for hours. A family member came in the morning of [DATE] around 8:00AM and Resident #2 was covered in feces then when I came in at 2:00 pm she still had feces under her nails and on some items on her tray. The next morning when the family came into the facility to visit Resident #2 and she was unresponsive. The staff said Resident #2 was nonresponsive because she had an infection and was fine. The family called 911 to send Resident #2 to the hospital. During an interview on [DATE] at 2:07 p.m. Staff G Certified Nursing Assistant (CNA) stated that Resident #2 was not responsive when passing breakfast trays, the morning of [DATE]. Staff G CNA stated that Resident #2 did not seem to be ok and reported it to the nurse. Staff G CNA stated that he remembered Resident #2 did not move and did not respond to good morning. Staff G CNA stated most of the time information such as a Resident is a diabetic is passed down verbally by the nurse to the CNA. During an interview on [DATE] at 2:17 p.m., Staff H Certified Nursing Assistant (CNA) stated he did assist Resident #2 outside for smoke breaks. Staff H CNA stated that Resident #2 was able to talk, was alert and oriented and family would come smoke with her. During a follow-up interview on [DATE] at 9:26 a.m., The Medical Director/Admitting Physician for Resident #2 (MDir/AP) stated, typically I set the highest parameter at 400. The MDir/AP stated that at the point a Residents blood sugar is above 400 a nurse is expected to contact me. The MDir/AP stated that a typical parameter is set for all diabetics and blood sugars. The MDir/AP stated that he was aware Resident #2 had an insulin pump however she was not alert enough to care for her pump such as refilling and monitoring it with dementia. The MDir/AP stated that he remembered there was a discrepancy between the ,d+[DATE] insulin and the insulin pump and that Resident #2 could not manage her own insulin pump. The MDir/AP stated that with no insulin dosage amount to refer to, it was best to just monitor Resident #2's blood sugars. The MDir/AP stated if Resident #2's blood sugar had gotten high, he would have known he needed to start her on some kind of long-acting insulin. The MDir/AP stated that Resident #2's blood sugar never went above 400 while in the facility so no one was required to contact him about high blood sugars. The MDir/AP stated that this facility does not allow the use of insulin pumps. During an interview on [DATE] at 9:48 a.m., Staff I Licensed Practical Nurse (LPN) stated that parameters depend on MD orders. The MD will say to follow facility protocol or give a direct order. Staff I LPN stated that generally any blood sugar under 70 or over 400 the nurse would notify the doctor. Staff I LPN stated that she would consider anything out of the Residents normal blood sugar range to be abnormal or high. Staff I LPN stated that if a Resident consistently showed high blood glucose levels in the 200 to 300 range and that was abnormal for the Resident then she would notify MD. Staff I LPN stated that blood sugar monitoring was very individualized. Staff I LPN stated she would look for signs and symptoms to accompany high blood glucose levels which may include excessive thirst, excessive hunger, altered mental status (AMS). Staff I LPN stated a nurse should notify the MD when blood sugar or

Based on observations, interviews, and record review, the facility failed to ensure pain was managed effectively for three residents (#3, #8, and #13) out of three that were reviewed for pain. Resident #3 was admitted to the facility from the hospital on 2/2/23 after being diagnosed with gas gangrene and osteomyelitis of the left ankle and foot. At 6:10 p.m. on 2/2/23 the resident's pain medication had not been delivered to the facility. On 2/3/23 at 12:06 a.m. a nurse obtained access to the automated medication dispensing machine to provide Resident #3 with pain medication. Documentation showed the medication was ineffective and the resident screamed and yelled out. Over a six-day period the resident's PRN (as needed) pain medication, Hydrocodone-Acetaminophen, was documented as being ineffective four different times and nine times no pain level or re-evaluation of effectiveness was documented. There were no documented attempts to inform the resident's provider about the ineffective pain medication. Multiple staff members interviewed said over the six-day period Resident #3 was in the facility, they overheard her crying out due to her pain. Resident #3 took the last dose of her PRN pain medication, Hydrocodone-Acetaminophen on 2/8/23 at 5:46 p.m. The resident had a reported pain level of 6 out of 10 on 2/9/23 at 1:33 a.m. There was no documentation showing a provider or the pharmacy was called to reorder medication or access the automated medication dispensing machine for Resident #3. Interviews with staff showed the resident was in pain on the morning of 2/9/23 prior to going to a follow-up doctor's appointment with her Cardiologist. The resident was not given pain medication and screamed in pain on the way to the appointment. Upon arriving at the Cardiologist office, the office staff called 911 due to Resident #3 screaming in pain from the moment of her arrival. Residents #8 was showing signs of pain on interview, stated she frequently had to wait to get pain medication and said, I just want to die not in pain. Resident #13 stated she had to wait four hours for her PRN pain medication on 3/10/23, said it was typical to wait hours after requesting pain medication and reported staff disbelief of her reports of pain. This failure created a situation that resulted in serious harm to Resident #3, and the likelihood of serious harm or injury to Residents #8, and #13 and resulted in the determination of Immediate Jeopardy beginning on 2/2/23. The findings of Immediate Jeopardy were determined to be removed on 3/23/23 and the scope and severity was reduced to a D. Findings included: A review of the Cardiovascular Office Visit notes for Resident #3, dated 2/10/23, showed Vitals could not be obtained due to her writhing in pain. The person that is accompanying her is stating that for the last few days she has been crying in pain and nothing has been done about this. The notes revealed the resident was being sent to the emergency department. A review of records showed Resident #3 was admitted to the facility from the hospital on 2/2/23 with diagnoses including acute osteomyelitis of ankle and foot, cellulitis of left lower limb, type 2 diabetes mellitus with diabetic neuropathy, gas gangrene, pressure ulcer of left heel, stage 3, non-pressure chronic ulcer of other part of left foot with unspecified severity, cognitive communication deficit, idiopathic gout in left ankle and foot, other idiopathic peripheral autonomic neuropathy, peripheral vascular disease, pain in left foot, and acquired absence of right leg below the knee. A review of Resident #3's orders showed an order for Hydrocodone-Acetaminophen Oral tablets 5-325 mg (milligrams.) Give 1 tablet by mouth every 4 hours as needed for pain for 14 days, dated 2/2/23. No additional pain medication was ordered. Resident #3 also had an order in place for Seroquel Oral tablet 50 mg. Give 1 tablet by mouth at bedtime for anxiety and insomnia, dated 2/6/23. A review of Resident #3's care plan did not show any care plans in place related to pain. A review of Resident #3's Minimum Data Set (MDS) Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 6, showing severely impaired cognition. A review of progress notes for Resident #3 showed the following: 2/2/23 at 6:10 p.m. new admit, medication was not delivered yet. 2/3/23 at 12:06 a.m. Pharmacy gave code to pull 2 doses of Hydrocodone-Acetaminophen 5-325 mg from the automated medication dispensing machine. One administered and one put in lock box on the medication cart. The pain level charting showed the resident rated pain 10 out of 10. 2/3/23 at 1:12 a.m. Patient assignment acquired at 2300 (11:00 p.m.) Patient was loudly calling out repeatedly and escalating. Xanax and Norco (Hydrocodone-Acetaminophen) prescriptions had been faxed to the pharmacy. Nursing staff with automated medication dispensing machine access secured. The pharmacy was called for codes as patient's behavior and screaming continued to escalate, resulting in her sliding from her bed to the floor. She did not suffer any injuries. Bed was in lowest position. She was placed in a gerichair and brought out to the nurses station for close monitoring due to repeated attempts to climb out of bed. She kept calling for someone to bring her a phone, call her neighbor, call her daughter, call her son He will bring us all breakfast. Finally, after one dose of Xanax and Norco with one-on-one attention for an hour, she quieted down. 2/3/23 at 2:00 a.m. showed the patient rested quietly for about 30 minutes and then was up yelling at the top of her lungs again. A review of the Medication Administration Record (eMAR,) Medication Monitoring/Control Record, and progress notes was completed. The eMAR is where all medication given should be documented along with pain levels, and effectiveness for PRN pain medication. The Medication Monitoring/Control Record is a log kept on the medication cart and tracks the tablet counts for narcotics/controlled medications. The eMAR and Medication Monitoring/Control log combined showed Hydrocodone-Acetaminophen 5-325 mg was given as follows: 2/3/23 12:06 a.m. A pain scale of 10. Re-evaluation of pain: ineffective 4:57 a.m. A pain scale of 10. Re-evaluation of pain: ineffective 8:15 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 1:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 5:20 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. A progress note on 2/3/23 at 5:58 a.m. Did not appear to provide any relief-patient continued yelling out repeatedly. There was no documentation to show a provider was notified of the ineffective pain medication for Resident #3 on 2/3/23. 2/4/23 2:51 a.m. A pain scale of 7. Re-evaluation of pian: effective. 8:00 a.m. A pain scale of 10. Re-evaluation of pain: effective 12:00 p.m. A pain scale of 10. Re-evaluation of pain: effective 4:00 p.m. A pain scale of 10. Re-evaluation of pain: effective 8:00 p.m. A pain scale of 10. Re-evaluation of pain: effective A progress note on 2/4/23 at 4:17 a.m. Resident complained of pain and discomfort all night. Resident very restless and getting little to no sleep due to pain and anxiousness asking for her children all night. 2/5/23 12:27 a.m. A pain scale of 7. Re-evaluation of pain: effective 4:30 a.m. A pain scale of 7. Re-evaluation of pain: effective 8:30 a.m. A pain scale of 10. Re-evaluation of pain: effective 2:20 p.m. A pain scale of 10. Re-evaluation of pain: effective 11:08 p.m. A pain scale of 10. Re-evaluation of pain: ineffective A progress note on 2/5/23 at 23:08. Screaming could be heard down the hall at the nurses station. 2/6/23 3:11 a.m. A pain scale of 10. Re-evaluation of pain: effective 9:33 p.m. A pain scale of 6. Re-evaluation of pain: effective A progress note on 2/6/23 at 12:03 a.m. showed the follow-up pain scale was 10 out of 10. PRN medication was ineffective. Unable to determine whether her screaming is pain or behavior-Xanax and Norco did nothing to quiet her yelling. A progress note on 2/6/23 at 12:32 a.m. showed Patient was yelling at the start of my shift-could be heard down the hall-gave scheduled Xanax and PRN Norco to no avail. -+Keeping entire hall away [sic]-removed from room-taken to tv room so as not to disturb the other residents trying to sleep. There was no documentation to show a provider was notified of the ineffective pain medication or continued yelling of Resident #3 on 2/6/23. 2/7/23 3:31 a.m. A pain scale of 10. Re-evaluation of pain: effective 9:00 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 2:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 7:51 p.m. A pain scale of 5. Re-evaluation of pain: effective A progress note on 2/7/23 at 3:31 a.m. showed Resident #3 was yelling out ow. ow! 2/8/23 3:08 a.m. A pain scale of 5. Re-evaluation of pain: ineffective 8:07 a.m. A pain scale of 8. Re-evaluation of pain: effective 2:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 5:46 p.m. A pain scale of 10. Re-evaluation of pain: effective A progress note on 2/8/23 at 3:08 a.m. at showed the resident was moaning in pain. There was no documentation to show a provider was notified of the ineffective pain medication on 2/8/23 at 3:08 a.m. 2/9/23 1:33 a.m. A pain scale of 6. Re-evaluation of pain: effective 6:00 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 10:00 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 2:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 5:40 p.m. A pain scale of 6. Re-evaluation of pain: effective The Medication Monitoring/Control Record showed the dose given on 2/9/23 at 5:40 p.m. left 0 remaining doses available to Resident #3. A review of Resident #3's Weights and Vitals Summary showed a pain scale of 6 was entered by Staff N, RN on 2/10/23 at 2:36 a.m. There was no documentation that a provider or the pharmacy were called due to the resident being out of pain medication and continuing to be in pain. A review of the Medical Director's notes, dated 2/6/23, showed the reason for appointment was admission/history and physical for Resident #3. It said on exam, the patient's foot is gangrenous and in definite need of amputation. Nursing was instructed to get resident back to podiatry this week, if unable, may need to be readmitted to the hospital. Pain was not mentioned in the provider's note. A provider note from a facility doctor that partners with the Medical Director, dated 2/9/23 said the reason for the appointment was acute care visit and risk of hospitalization due to complications of cardiovascular disease, diabetes, and risk of falls with injury. It said the resident was in bed, nonverbal but moans often, I am told it stops a little bit after her pain medication is administered which was just given prior to my visit today. Ineffective pain medication was not mentioned in the provider's note. A review of a Pain Evaluation, dated 2/9/23, showed a pain assessment interview could be conducted due to the resident being able to communicate appropriately. The resident was unable to answer questions regarding pain presence, frequency, effect on function, or intensity. It noted there were non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) present. The evaluation noted the resident complained or showed evidence of pain daily. The evaluation was completed and signed by Staff B, RN. An interview was conducted on 3/9/23 at 4:18 p.m. with Staff A, Certified Nursing Assistant (CNA). Staff A said she took Resident #3 to her doctor's appointment on 2/10/23 with Staff D, Director of Transportation. Staff A said the resident was crying out and screaming in pain. She said the doctor's office called 911. An interview was conducted on 3/9/23 at 2:40 p.m. with Staff D, Director of Transportation. Staff D confirmed she drove Resident #3 and Staff A, CNA to a doctor's appointment on 2/10/23. She said they left the building around 12:45-1:00 p.m. Staff D said the resident was upset because her foot was hurting her. An interview was conducted on 3/15/23 at 3:25 p.m. with the Office Manager of the Cardiovascular office Resident #3 visited on 2/10/23. The Office Manager said Resident #3 was crying out in pain from the minute she came off the elevator. She said the resident's appointment was at 3:15 p.m. and the resident and her CNA arrived around 3:35 p.m. due to going to the wrong location initially. She said the CNA that was with Resident #3 was yelling at the resident to stop screaming and shut up. The Office Manager said it was very obvious she was in pain. She said the staff at the doctor's office called 911 to have Resident #3 taken to the emergency room . The Office Manager provided statements written by the cardiovascular registered nurse (RN), cardiovascular medical assistant (MA) 1, and cardiovascular MA 2. A written statement provided by the cardiology MA 1 revealed Resident #3 could be heard crying from the waiting room. She said when she attempted to take Resident #3's vital signs, she screamed in pain. The CNA with the resident told the resident to stop crying. The cardiovascular MA 1 said she removed the pulse oximeter and blood pressure cuff and informed the aide the resident needed critical care. MA 1 said she excused herself from the triage room and went to speak with the doctor and call emergency medical services (EMS.) MA 1 said while waiting for EMS the aide could be heard multiple times telling Resident #3 to be quiet and stop yelling. A written statement provided by the cardiology RN revealed Resident #3 came into the office for a hospital follow-up and she could be heard screaming for help from the triage room. She said the resident was overheard screaming ouch my back, I have a sore on my back while being moved to the stretcher. A written statement provided by the cardiology MA 2 revealed Resident #3 and her CNA arrived late to the appointment because they went to the hospital prior to appointment and found out they were at the wrong location. MA 2 said the resident's CNA didn't seem to care much about her resident and was yelling at her to be quiet. MA 2 said for some reason the CNA wasn't aware her resident needed urgent medical attention. MA 2 said Resident #3 was in excruciating pain, yelling help me, help me, since she came to the office. A review of the (Local) Medical Transportation Run Report showed the reason for transport was acute pain. The resident's pain scale was 10 on a scale of 1-10. It said upon arrival patient was found in a wheelchair in obvious distress. Emergency Medical Services arrived for the resident on 2/10/23 at 3:20 p.m. and arrival at the hospital was shown to be at 3:37 p.m. A review of the Emergency Department records showed the reason for Resident #3's visit was complaints of pain associated with a left foot wound. It stated her pain level was 10/10 and she was anxious, crying, restless. The records show Resident #3 was given Dilaudid 1 mg (milligram) in the Emergency Department and after was noted to be resting comfortably in no acute distress. The record showed Resident #3's x-ray did not definitively show any osteomyelitis, however, did show subcutaneous gas, which consistent with patient's physical exam of crepitus along plantar surface. It revealed that was concerning for necrotizing fasciitis. The diagnosis is listed as necrotizing fasciitis left foot with a condition of guarded. Patient admitted inpatient. A review of the hospital discharge summary showed Resident #3 had a below-the-knee amputation due to sepsis in the infected leg. The resident was discharged on [DATE] to a second long term care facility. A review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) from the second long-term care facility showed Resident #3 had a left below the knee amputation on 2/12/23. An observation was conducted of Resident #3 in the second long-term care facility on 3/14/23. Throughout the day the resident was resting comfortably, showing no signs of pain and no behaviors of yelling out. A follow-up interview was conducted on 3/21/23 at 12:18 p.m. with Staff A, CNA. Staff A said prior to leaving the facility for the doctor's appointment with Resident #3 on 2/10/12, the resident was in pain. Staff A said the nurse, Staff B, RN told her she was going to give the resident pain medication before they left. Staff A said she knew they had a one-hour drive to the appointment, the time there, and the one-hour drive back. Staff A said Resident #3 was screaming the whole ride. She said she didn't know why the resident was screaming because she was under the impression the nurse had given the resident her pain medication. Staff A said the resident had been crying out in pain daily since she was admitted . Staff A said the resident would be quiet and get some rest for a little bit after getting pain medication, but she would wake up and start crying out again. Staff A said she doesn't understand, because if a resident is in pain and needs medication, they should get it. She stated Resident #3 cried out in pain probably 15 hours out of every day. An interview was conducted on 3/10/23 at 6:00 p.m. with Staff O, Staffing Coordinator/Central Supply. Staff O said she was familiar with Resident #3. She said when she walked around the facility daily, Resident #3 was typically in pain and would always cry out. An interview was conducted on 3/10/12 at 6:10 p.m. with Staff P, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff P said Resident #3 was not comfortable because of the pain in her foot. She said she just wanted to lay here because of the pain. When asked about the resident not receiving pain medication prior to her appointment on 2/10/23 she said, I would have assumed the nurse would have given it to her. Staff P said they typically give pain medication before therapy and before going to appointments. She said when she gave the resident a shower, she was not in pain. Staff P said Resident #3 was in pain as soon as she got here. She said if someone talked to the resident, she would not scream but she would always say she was in pain. An interview was conducted on 3/21/23 at 1:07 p.m. with Staff Q, CNA. She stated she was familiar with Resident #3. She said the resident was always in pain and was always crying out. She said she thinks pain medications helped the resident because they would put her to sleep, but she would wake up and cry in pain again. An interview was conducted on 3/21/23 at 2:11 p.m. with Staff H, CNA. He stated he remembered Resident #3. He said she would tell him she was in pain and other times she could not talk because of her pain. An interview was conducted on 3/21/23 at 2:16 p.m. with Staff L, LPN. She said she remembers Resident #3 sitting in the dining area crying and moaning in pain. An interview was conducted on 3/21/23 at 3:05 p.m. with the Director of Nursing (DON). The DON was observed reviewing Resident #3's medical records. The DON said she did not know the resident very well and cannot speak to her pain on a day-to-day basis. The DON stated she was looking at the resident's record to see if the screaming had to do with behaviors, psychiatric medication, or history of drug use. She said they are always looking at psych (psychiatric issues) versus pain. She said they followed up with the resident's pain and gave her pain medication. She said they had the resident followed by psychiatry (psych) as well. There was an order for psych to evaluate and follow-up as needed. She said she did not see any provider notes in the record for psychiatry. The DON confirmed there were no notes in the record where the doctor was called and notified about Resident #3's ineffective pain medication. She said she would expect the nurse to follow physician orders and if the medication is not effective, they should notify the doctor. When asked if a resident cries and reports pain should the nurse call the physician, she said, I don't know. I was not down there and cannot speak to that. The DON said if a pain medication is not effective, the nurse can try non-pharmacological approaches for pain relief. She said if the nurse did that, it would be documented in the progress notes. The DON reviewed the progress notes and confirmed nothing was documented showing other approaches to pain management were attempted. On 3/21/23 at 5:00 p.m. the DON said she was unable to find anything showing psychiatry had evaluated Resident #3 during her stay. An interview was conducted on 3/21/23 at 3:38 p.m. with Staff B, RN, who confirmed she had cared for Resident #3 a few times, including the morning she went to her follow-up Cardiology appointment. Staff B said Resident #3 would yell out a lot, even after having her pain medication. She said sometimes the medication helped with the resident's pain and sometimes it did not. She said if pain medication is ineffective, typical practice would be to call the doctor to get something different. Staff B said she never had to call the provider for Resident #3 about ineffective pain medication. She said on 2/10/23 prior to Resident #3's doctor's appointment, she doesn't remember her being in excessive pain, but she had her normal foot pain and was complaining about leg pain. She said typical practice is to try to medicate a resident prior to transporting to an appointment. She said if the resident reported a pain level of 6 out of 10, she would have given her Hydrocodone-Acetaminophen. When asked about her not giving the pain medication to Resident #3 on the morning of 2/10/23 she said she didn't remember anything specific about the morning of her appointment. An interview was conducted on 3/21/23 at 4:05 p.m. with Resident #3's provider/facility Medical Director. The doctor stated he vaguely remembers Resident #3. He recalled she had a gangrenous foot and was demented. As for behaviors, he said he believed the resident would sometimes yell out, but pain can make anyone with confusion do that. The doctor said if a resident had out of control pain, the staff would normally talk to him. He said if it was brought to his attention, there would be a progress note indicating that. He said if a pain medication was ineffective after being administered to a resident, he would expect the nurse to call him because that is the protocol. He said if he doesn't know the pain medications aren't effective, then he cannot treat them. The doctor said for a resident going out to an appointment, being jostled around he would expect the nurse to give the resident pain medication. The doctor confirmed there is an on-call provider 24 hours a day 7 days a week and staff have his direct number that he always answers. An interview was conducted on 3/22/23 at 9:55 a.m. with Staff N, RN, who took care of Resident #3 on multiple shifts including the shift beginning 2/2/23 11:00 p.m. to 2/3/23 7:00 a.m. Staff N said she remembers Resident #3. She said the resident had a lot of pain. She said one night the resident was crying out a lot one night, so she put her in a gerichair she borrowed from another resident and moved her to the TV room. She said the resident would not settle down, even with pain medication. Staff N said, if you have a gangrenous foot you are going to be in pain. She said if the resident had a pain level of 6 she would have given her medication if it was available. She said she did not have access to the automated medication dispensing machine because she is an agency nurse, she said a staff person would have had to access it. When asked about documenting the pain scale and Hydrocodone-Acetaminophen as given then striking it out on 2/9/23 she said she could not remember why she did that or if the medication was available. An interview was conducted on 3/22/23 at 10:11 a.m. with Resident #3's family member. The family member stated Resident #3 had a lot of pain in her left foot. She said she felt like the pain medication the resident was getting never really helped. The family member said the medication knocked the resident out for a little bit and made her sleep for a sort time but didn't really do anything for the pain. She said the resident would scream out while she was visiting her, and the pain medication was not helping. The family member said she never spoke with the provider directly but did speak with two different nurses. She said she could not remember the nurses' name; one was male and one was female and they were both agency nurses. The family member said they never called the provider they would tell her, Let's just see if it works. She said the facility could never get her comfortable because of the pain and infection. The family member said when her mother got to the emergency room , they gave her something and it controlled the resident's pain without issue. She said Resident #3 was admitted to the hospital and had a left leg amputation. She said the resident is doing much better now and no longer yells out. The family member said on 2/10/23 she was in the facility with Resident #3 from 9:00 a.m. to 12:00 p.m. She said she left just prior to the resident going out to the doctor's appointment. She said the resident was yelling out in pain while she was there. She did not recall the nurse bringing Resident #3 any pain medication. An interview was conducted on 3/22/23 at 11:01 a.m. with the DON. The DON said she contacted the pharmacy and was told the only time the staff requested a code to access the automated medication dispensing machine for Resident #3 was on 2/3/23. She said they confirmed they sent 28 tablets of Hydrocodone-Acetaminophen that was received by the facility on 2/3/23. They said that was the only time Hydrocodone-Acetaminophen was sent for Resident #3. The pharmacy told the DON they did not have an order for additional doses. The DON confirmed no orders or refill requests were sent to the pharmacy. She said when a resident is down to the last few remaining tablets, the nurse should have called the doctor to get a new prescription sent to the pharmacy. She said Hydrocodone-Acetaminophen is available in the facility's Emergency Drug Kit and the nurse could have called pharmacy for a code to access it. The DON confirmed agency nurses can be put in as a one-timer user that is good for three days. Two additional residents (#8 and #13) were sampled for pain management. A review of records showed Resident #8 was admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis, urinary tract infection, surgical wound, acquired absence of other specified parts of the digestive tract and diverticulosis. A review of Resident #8's MDS (Minimum Data Set) Section C, Cognitive Patterns, showed a (Brief Interview of Mental Status) BIMS score of 15, showing she was cognitively intact. A review of orders showed the following orders related to pain: Lidoderm patch 5%. Apply topically in the morning for low back pain/shoulder pain. Remove at bedtime, rotate sites. Order date: 2/2/23. Oxycodone HCL 10mg. Give 10 mg by mouth every 4 hours as needed for severe pain. Order date: 1/24/23. Tylenol 325 mg. Give 2 by mouth every 6 hours as needed for pain. Order date: 10/29/22. A review of records showed a Care Plan in place for risk of experiencing pain associated with decreased mobility, surgical procedure and wound, morbid obesity, gastroesophageal reflux disease, diverticulosis and chronic lymphedema of bilateral lower extremities. The interventions included administer and monitor for effectiveness and for possible side effects of routine and PRN pain medication and assess/monitor for non-verbal indicators of pain (pacing, agitation, anxiety, facial grimacing, tearfulness/crying, sad/distant facial expressions, gasping/groaning, yelling out.) On 3/10/23 at 3:50 p.m. Resident #8 was observed to be lying in bed. The resident was agitated, grimacing, gagging, and having difficulty speaking. When asked if the resident is able to get pain medication when she needed it, the resident said she always has to wait. Resident #8 then stated, I just want to die not in pain. The resident was unable to continue the interview due to coughing/gagging. A staff member was called into the room to check on the resident. A review of Resident #8's Pain Evaluation, dated 2/2/23, revealed the resident has pain in the last five days that made it hard for her to sleep at night and limited her day-to-day activities. An interview was conducted on 3/10/23 at 3:55 p.m. with Resident #13, who was the roommate of Resident #8. Resident #13 said staff ignore Resident #8. She said Resident #8 has a lot of wounds and is in pain often and staff don't pay any attention to her. She said Resident #8 isn't always the nicest person and staff don't like her, but it doesn't mean she should have to be in pain. A review of records showed Resident #13 was admitted on [DATE] with diagnoses including moderate protein-calorie malnutrition, chronic gastritis, disorders involving the immune mechanism not classified elsewhere, systemic involvement of connective tissue, hypertrophic pylori stenosis, rheumatoid arthritis, epigastric pain, and pain in unspecified joint. A review of Resident #13's MDS, Section C, Cognitive Patterns, showed a BIMS score of 15, showing she was cognitively intact. A review of Resident #13's Pain Evaluation, dated 2/3/23, showed the resident frequently experienced pain or hurting over the last 5 days, making it hard to sleep at night, and limiting her day-to-day activities. A review of orders showed the following orders related to pain: Gabapentin 100 mg. Give 1 capsule by mouth at bedtime for neuropathy. Order date, 3/3/23. Norco (Hydrocodone-Acetaminophen) oral tablet 7.5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain. Order date, 2/8/23. MS (Morphine Sulfate) Contin Extended Release 30 mg. Give 1 tablet by mouth every 12 hours related to pain in unspecified joint. Order date, 2/6/23. A review of records showed a Care Plan in place for pain related to diagnosis of chronic gastric ulcers, delayed gastric emptying, abdominal pain. Interventions included administer and monitor for effectiveness and possible side effects from routine and PRN pain medications, monitor for change in mood or mental status, and give medications per order. An interview was conducted on 3/10/23 at 3:55 p.m. with Resident #13. The resident said on the morning of 3/10/23 she asked for a pain pill at 8:40 a.m. She said the last dose of her PRN pain medication she had was at 2:00 a.m. that morning. She said at 9:45 a.m. she still had not received her medication, so she found the nurse and asked again. The nurse told her she was on her way. Resident #13 said she got the same response from the nurse at 10:10 a.m. The resident said she went to the unit manager at 11:50 a.m. because the unit manager knows she needs her pain medication to keep it controlled or she starts having issues. The resident said the unit manager told her she would take care of it, but never came. Resident #13 said at 12:35 p.m. she asked the nurse again for her pain medication and was told other residents were in front of her and she needed to be patient, wait her turn and go back to her room. The resident said she let the nurse know her pain level was 10 out of 10 and the nurse told her if it was a 10 you wouldn't be walking. Resident #13 said she finally received her pain medication at 12:45 p.m. A review of Resident #13's eMAR showed PRN pain medication was administered on 3/10/23 at 1:46 a.m. and 4:37 p.m. A follow-up interview was conducted on 3/22/23 at 11:40 a.m. with Resident #13. She s[TRUNCATED]

Based on record review, interviews, hospital record review, facility documentation and policy review the facility failed to ensure Residents were assessed for a change of condition. The facility failed to ensure the physician was notified and assessed for a change of condition for one (Resident #2) of three Residents reviewed for diabetic management. The facility failed to notify a physician when pain medications were ineffective for uncontrolled pain for one (Resident #3) of three Residents reviewed for pain. These failures created a situation that resulted in serious harm to Resident #2 and #3, and the likelihood of serious harm or injury to other residents resulted in the determination of Immediate Jeopardy beginning on 2/2/23. The findings of Immediate Jeopardy were determined to be removed on 3/23/23 and the scope and severity was reduced to a D. Findings included: Reference citation F600 1. A review of Resident #2's medical record showed an admitted [DATE] with diagnoses that included Type II Diabetes with hyperglycemia, Type II Diabetes with Diabetic Neuropathy and Wedge Compression fracture of second lumbar vertebra, subsequent encounter for fracture with routine healing (primary). A review of Resident #2's physician orders related to diabetic management revealed: 02/06/23 Trulicity Subcutaneous Solution Pen- injector 0.75 MG[milligram]/0.5 ML[milliliter] (Dulaglutide) Inject 1.5 mg subcutaneously one time a day every Thursday for Diabetes Mellitus and remove per schedule. 02/06/23 Metformin HCI Oral Tablet 1000 MG give 1 tablet by mouth one time a day for Diabetes Mellitus Type II. 02/06/23 Steglatro 15 MG Tablet give 1 tablet by mouth one time a day for diabetes mellitus. 02/06/23 Farxiga Oral Tablet 10 MG (Dapagliflozin) give 1 tablet by mouth one time a day for heart failure. 02/06/23 Accuchecks (blood glucose checks) AC/HS (before meals and at bedtime) for Diabetes Mellitus II if below 70 or above 400 please call [MDir/AP - (Medical Director/Admitting Physician for Resident #2]). Review of Resident #2's record showed no physician orders for insulin. The resident's care plan did not show a focus, goal or interventions related to diabetes management. A review of the Medication Administration Review (MAR) showed Resident #2 never received a dose of the ordered Trulicity or Farxiga medications. Insulin was never ordered. Resident #2 received oral medications of Metformin and Steglatro as ordered. Review of the Accuchecks showed Resident #2's blood sugars for the following days: 02/09/23: 6:30 AM- 263 11:30 AM- 200 4:30 PM- 374 9:00 PM- 220 02/10/23: 6:30 AM- 285 11:30 AM- N/A 4:30 PM- 272 9:00 PM- 341 02/11/23: 6:30 AM- 291 11:30 AM- 389 4:30 PM- 299 9:00 PM-236 02/12/23: 6:30 AM- 197 11:30 AM- 150 4:30 PM- 378 9:00 PM- 350 02/13/23: 6:30 AM- 302 11:30 AM- 398 4:30 PM- 312 9:00 PM- 356 02/14/23: 6:30 AM- 301 11:30 AM- 374 4:30 PM- 241 9:00 PM- 352 02/15/23: 6:30 AM- 289 11:30 AM- 332 4:30 PM- 319 9:00 PM- 358 02/16/23: 6:30 AM- 384 Review of Residents #2's medical record showed a Skilled Nursing Note dated 02/09/23. The note showed Resident #2 was alert and oriented times three (oriented to person, place, and time). Resident #2 had a bed mobility self-performance of guided with one person assist. Resident #2's ability to transfer, walk in facility corridor, and have locomotion on unit all with a one person assist. Resident #2 was able to use toilet independently and eat with set up assistance only. The assessment was signed by Staff B RN showed, Alert and Oriented times three. No complaints of pain or discomfort. Takes meds whole without difficulty. Review of Resident #2's medical record showed a Skilled Nursing Note dated 02/12/23. The note showed Resident #2 was alert and oriented times three. Resident #2 has bed mobility self-performance of independent. Resident #2's ability to transfer was a one person assist. Resident #2's ability to walk in the facility's corridors did not occur and locomotion on the unit was total dependence. Resident #2's ability to use the toilet was one person assist, eating at independent with set up help only. The assessment showed, Resident was observed sleeping in bed with no signs of acute distress when exiting the room. Review of Resident #2's medical record showed a Skilled Nursing Note dated 02/15/23. The note showed Resident #2 was oriented to person only. Resident #2 had bed mobility self-performance of extensive assistance. Resident #2's ability to transfer was total dependance and needed two-person physical assistance. Resident #2's ability to walk in the facility's corridor and locomotion on the unit did not occur. Resident #2's ability to eat changed to one-person physical assist and toileting activity did not occur. The assessment signed by Staff R Licensed Practical Nurse (LPN) and showed Resident moved to room (room #) this afternoon. Received Rocephin [an antibiotic] injection per doctors' orders related to urine cloudy pale yellow and thick. Resident's appetite is poor, has drank fluids without difficulty. Staff encouraging Resident to eat and drink. During an interview on 03/10/23 at 4:20 p.m., Staff A Certified Nursing Assistant (CNA) stated that she remembered she gave Resident #2 a shower and Resident #2 did have an insulin pump access in her belly at shower time. Staff A CNA stated that she did recall an insulin pump access in Resident #2's belly during the shower provided on 02/09/23. Staff A CNA also stated she noticed Resident #2 was declining and had a change of condition and was getting weaker on 02/09/23. Further review of Resident #2's medical record revealed a Narrative Note dated 02/15/23, This nurse reports to Staff E NP that resident fasting blood sugars have been in 300 range consistently, Staff E NP gave new order to increase Trulicity. This nurse questioned Staff E NP about possibly putting resident on fast acting insulin. Staff E NP declines and stated Trulicity should cover resident. Narrative note was signed by Staff B Registered Nurse (RN). During an interview on 03/10/23 at 4:35 p.m., Staff B Registered Nurse (RN) discussed Narrative note dated 02/15/23. Staff B RN stated she remembered the conversation and asked Staff E NP about putting Resident #2 on some fast-acting insulin. Staff B RN stated, I explained to the NP that I didn't know what insulin was in the pump but did inform Staff E NP that Resident #2 was on insulin prior to being admitted to the facility. Staff B RN stated that she also remembered Staff E NP informed her that she was going to talk to the family about the specific insulin that was used in the pump and then NP proceeded into Resident #2's room to talk with the family about insulin. During an interview on 03/20/23 at 10:37 a.m., a second family member stated that he would come in daily and noticed Resident #2's face was a little drawn and she looked dehydrated. The staff told him their ice/water machine was down so he brought water for Resident #2 to drink and asked staff to please give her the water when she wanted it. The second family member stated that over the next two days, the facility never gave her the water and Resident #2's water cup was always empty. The second family member stated that Resident #2 was excessively thirsty and when he would ask the staff for water, they would reply we just gave her water. The second family member stated he would tell staff Resident #2's cup was empty and if she drank it all then she needed more. The second family member stated that he told staff that Resident #2 was extremely thirsty. The second family member stated that Resident #2 was in a little bit of a fog and would forget to eat. The second family member informed the staff that Resident #2 needed help eating but no one ever helped her. Resident #2 didn't eat while in the facility the family helped her eat when visiting. The second family member stated that on Valentines Day Resident #2 was laughing and then the next morning on 02/15/23, she was covered in feces and sat in feces for hours. A family member came in the morning of 02/15/23 around 8:00AM and Resident #2 was covered in feces then when the second family member came in at 2:00pm she still had feces under her nails and on some items on her tray. The next morning on 02/16/23 when the family came into the facility to visit Resident #2 and she was unresponsive. The staff said Resident #2 was nonresponsive because she had an infection and was fine. The family called 911 to send Resident #2 to the hospital. During an interview on 03/20/23 at 2:07 p.m. Staff G Certified Nursing Assistant (CNA) stated he did remember that Resident # 2 was not responsive when passing breakfast trays, the morning of 02/16/23. Staff G CNA stated that Resident #2 did not seem to be ok and reported it to the nurse. Staff G CNA stated that he remembered Resident #2 did not move and did not respond when he said good morning. During an interview on 03/20/23 at 2:17 p.m., Staff H Certified Nursing Assistant (CNA) stated he did assist Resident #2 outside for smoke breaks. Staff H CNA stated that Resident #2 was able to talk, was alert and oriented and family would come smoke with her. During a follow up interview on 03/20/23 at 2:42 p.m., Staff B Registered Nurse (RN) stated that when Resident #2 was admitted to the facility she was confused at baseline, but she was oriented to person, place, and time. Staff B RN stated that Resident #2 was confused on basic things such as getting up by herself although she was a one person assist with her walker. Staff B RN stated that Resident #2 would try to transfer by herself, and the facility would educate her about self-transfers. Staff B RN stated that when Resident #2 showed weakness, the change of condition was reported to Staff E NP immediately. Staff B RN stated that was when Staff E NP ordered labs, UA Rocephin IM and Staff B talked to Staff E NP about Resident #2's baseline blood sugars being in the 300s which was high. Staff B RN stated she asked Staff E NP about Resident #2 getting short acting insulin and a sliding scale and the only orders were to increase Trulicity. Staff B RN stated that Staff E NP was informed Resident #2 was on insulin prior to being admitted to the facility and Staff E NP said that she would talk to the family about this. Staff B RN stated she told Staff E NP that the family told Staff B RN that Resident #2 was on the pump prior to admission. During an interview on 03/21/23 at 11:23 a.m., the Director of Nursing (DON) stated once a resident showed a change of condition, staff would be required to call a physician, get vitals, complete a Change of Condition form in the computer and notify family. The DON stated that some things that would be considered a change of condition would be a change in mental status, lethargy, abnormal behavior, and infections. The DON stated that once a change of condition is revealed the nurse should report the change of condition to the doctor immediately. During a follow-up interview on 03/21/23 at 12:00 p.m., Staff A CNA stated when assisting Resident #2 with a shower on 02/09/23 she observed Resident #2 with an insulin pump access in her lower right abdomen. Staff A CNA stated that she noticed a change of condition with Resident #2 as she was getting weaker and showing less energy. Staff A CNA stated that she reported Resident #2's change of condition immediately to Staff B RN after the shower. During a follow-up interview on 03/21/23 at 3:36 p.m., Staff B Registered Nurse (RN) stated the only changes of condition for Resident #2 that she was aware of was the day she had Staff E NP come in to assess Resident #2 and discussed with Staff E NP Resident #2's high fasting blood sugars. Staff B RN stated that was the day Rocephin was ordered on 02/15/23. Staff B RN was asked where the change of condition form was in the medical record and she said a change of condition form is usually completed but, stated if there was not one in the medical record it probably did not get done because Resident #2 was immediately taken off the unit and transferred to the other unit immediately. Staff B RN stated if the change of condition form is not in the medical record, then the Change of Condition form was not completed for 02/15/23. Staff B RN stated a change of condition form was expected to be completed but must have been missed. During an interview on 03/22/23 at 10:26 a.m., the Director of Nursing (DON) reviewed Resident #2's medical record and said there was no change of condition form in Resident #2's medical record for 02/15/23. The DON stated there was only a progress note on 02/15/23 about the change of condition and transfer to the other unit in the facility. The DON confirmed there was no change of condition form available on 02/09/23 when Staff A CNA reported to Staff B RN a change of condition observed during shower. The DON stated there was no change of condition assessment forms completed for 02/09/23 or 02/15/23 however there was a change of condition assessment form completed at Resident #2's discharge on 02/16/23. During an interview on 03/22/23 at 11:10 a.m., the DON provided a notification of change policy for review. The DON was asked about the protocol and steps for staff to follow when a change a of condition was identified. The DON stated that the facility did not have a protocol written down or in document form that discussed steps outlined for staff to follow when a change of condition was identified for a Resident. 2. A review of the Cardiovascular Office Visit notes for Resident #3, dated 2/10/23, showed Vitals could not be obtained due to her writhing in pain. The person that is accompanying her is stating that for the last few days she has been crying in pain and nothing has been done about this. The notes revealed the resident was being sent to the emergency department. A review of records showed Resident #3 was admitted to the facility from the hospital on 2/2/23 with diagnoses including acute osteomyelitis of ankle and foot, cellulitis of left lower limb, type 2 diabetes mellitus with diabetic neuropathy, gas gangrene, pressure ulcer of left heel, stage 3, non-pressure chronic ulcer of other part of left foot with unspecified severity, cognitive communication deficit, idiopathic gout in left ankle and foot, other idiopathic peripheral autonomic neuropathy, peripheral vascular disease, pain in left foot, and acquired absence of right leg below the knee. A review of Resident #3's orders showed an order for Hydrocodone-Acetaminophen Oral tablets 5-325 mg (milligrams.) Give 1 tablet by mouth every 4 hours as needed for pain for 14 days, dated 2/2/23. No additional pain medication was ordered. Resident #3 also had an order in place for Seroquel Oral tablet 50 mg. Give 1 tablet by mouth at bedtime for anxiety and insomnia, dated 2/6/23. A review of Resident #3's care plan did not show any care plans in place related to pain. A review of Resident #3's Minimum Data Set (MDS) Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 6, showing severely impaired cognition. A review of progress notes for Resident #3 showed the following: 2/2/23 at 6:10 p.m. new admit, medication was not delivered yet. 2/3/23 at 12:06 a.m. Pharmacy gave code to pull 2 doses of Hydrocodone-Acetaminophen 5-325 mg from the automated medication dispensing machine. One administered and one put in lock box on the medication cart. The pain level charting showed the resident rated pain 10 out of 10. 2/3/23 at 1:12 a.m. Patient assignment acquired at 2300 (11:00 p.m.) Patient was loudly calling out repeatedly and escalating. Xanax and Norco (Hydrocodone-Acetaminophen) prescriptions had been faxed to the pharmacy. Nursing staff with automated medication dispensing machine access secured. The pharmacy was called for codes as patient's behavior and screaming continued to escalate, resulting in her sliding from her bed to the floor. She did not suffer any injuries. Bed was in lowest position. She was placed in a gerichair and brought out to the nurses station for close monitoring due to repeated attempts to climb out of bed. She kept calling for someone to bring her a phone, call her neighbor, call her daughter, call her son He will bring us all breakfast. Finally, after one dose of Xanax and Norco with one-on-one attention for an hour, she quieted down. 2/3/23 at 2:00 a.m. showed the patient rested quietly for about 30 minutes and then was up yelling at the top of her lungs again. A review of the Medication Administration Record (eMAR,) Medication Monitoring/Control Record, and progress notes was completed. The eMAR is where all medication given should be documented along with pain levels, and effectiveness for PRN pain medication. The Medication Monitoring/Control Record is a log kept on the medication cart and tracks the tablet counts for narcotics/controlled medications. The eMAR and Medication Monitoring/Control log combined showed Hydrocodone-Acetaminophen 5-325 mg was given as follows: 2/3/23 12:06 a.m. A pain scale of 10. Re-evaluation of pain: ineffective 4:57 a.m. A pain scale of 10. Re-evaluation of pain: ineffective 8:15 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 1:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 5:20 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. A progress note on 2/3/23 at 5:58 a.m. Did not appear to provide any relief-patient continued yelling out repeatedly. There was no documentation to show a provider was notified of the ineffective pain medication for Resident #3 on 2/3/23. 2/4/23 2:51 a.m. A pain scale of 7. Re-evaluation of pian: effective. 8:00 a.m. A pain scale of 10. Re-evaluation of pain: effective 12:00 p.m. A pain scale of 10. Re-evaluation of pain: effective 4:00 p.m. A pain scale of 10. Re-evaluation of pain: effective 8:00 p.m. A pain scale of 10. Re-evaluation of pain: effective A progress note on 2/4/23 at 4:17 a.m. Resident complained of pain and discomfort all night. Resident very restless and getting little to no sleep due to pain and anxiousness asking for her children all night. 2/5/23 12:27 a.m. A pain scale of 7. Re-evaluation of pain: effective 4:30 a.m. A pain scale of 7. Re-evaluation of pain: effective 8:30 a.m. A pain scale of 10. Re-evaluation of pain: effective 2:20 p.m. A pain scale of 10. Re-evaluation of pain: effective 11:08 p.m. A pain scale of 10. Re-evaluation of pain: ineffective A progress note on 2/5/23 at 23:08. Screaming could be heard down the hall at the nurses station. 2/6/23 3:11 a.m. A pain scale of 10. Re-evaluation of pain: effective 9:33 p.m. A pain scale of 6. Re-evaluation of pain: effective A progress note on 2/6/23 at 12:03 a.m. showed the follow-up pain scale was 10 out of 10. PRN medication was ineffective. Unable to determine whether her screaming is pain or behavior-Xanax and Norco did nothing to quiet her yelling. A progress note on 2/6/23 at 12:32 a.m. showed Patient was yelling at the start of my shift-could be heard down the hall-gave scheduled Xanax and PRN Norco to no avail. -+Keeping entire hall away [sic]-removed from room-taken to tv room so as not to disturb the other residents trying to sleep. There was no documentation to show a provider was notified of the ineffective pain medication or continued yelling of Resident #3 on 2/6/23. 2/7/23 3:31 a.m. A pain scale of 10. Re-evaluation of pain: effective 9:00 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 2:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 7:51 p.m. A pain scale of 5. Re-evaluation of pain: effective A progress note on 2/7/23 at 3:31 a.m. showed Resident #3 was yelling out ow. ow! 2/8/23 3:08 a.m. A pain scale of 5. Re-evaluation of pain: ineffective 8:07 a.m. A pain scale of 8. Re-evaluation of pain: effective 2:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 5:46 p.m. A pain scale of 10. Re-evaluation of pain: effective A progress note on 2/8/23 at 3:08 a.m. at showed the resident was moaning in pain. There was no documentation to show a provider was notified of the ineffective pain medication on 2/8/23 at 3:08 a.m. 2/9/23 1:33 a.m. A pain scale of 6. Re-evaluation of pain: effective 6:00 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 10:00 a.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 2:00 p.m. Not documented on eMAR. No documented pain scale and no documented re-evaluation. 5:40 p.m. A pain scale of 6. Re-evaluation of pain: effective The Medication Monitoring/Control Record showed the dose given on 2/9/23 at 5:40 p.m. left 0 remaining doses available to Resident #3. A review of Resident #3's Weights and Vitals Summary showed a pain scale of 6 was entered by Staff N, RN on 2/10/23 at 2:36 a.m. There was no documentation that a provider or the pharmacy were called due to the resident being out of pain medication and continuing to be in pain. A review of the Medical Director's notes, dated 2/6/23, showed the reason for appointment was admission/history and physical for Resident #3. It said on exam, the patient's foot is gangrenous and in definite need of amputation. Nursing was instructed to get resident back to podiatry this week, if unable, may need to be readmitted to the hospital. Pain was not mentioned in the provider's note. A provider note from a facility doctor that partners with the Medical Director, dated 2/9/23 said the reason for the appointment was acute care visit and risk of hospitalization due to complications of cardiovascular disease, diabetes, and risk of falls with injury. It said the resident was in bed, nonverbal but moans often, I am told it stops a little bit after her pain medication is administered which was just given prior to my visit today. Ineffective pain medication was not mentioned in the provider's note. A review of a Pain Evaluation, dated 2/9/23, showed a pain assessment interview could be conducted due to the resident being able to communicate appropriately. The resident was unable to answer questions regarding pain presence, frequency, effect on function, or intensity. It noted there were non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) present. The evaluation also noted the resident complained or showed evidence of pain daily. The evaluation was completed and signed by Staff B, RN. An interview was conducted on 3/9/23 at 4:18 p.m. with Staff A, Certified Nursing Assistant (CNA). Staff A said she took Resident #3 to her doctor's appointment on 2/10/23 with Staff D, Director of Transportation. Staff A said the resident was crying out and screaming in pain. She said the doctor's office called 911. An interview was conducted on 3/9/23 at 2:40 p.m. with Staff D, Director of Transportation. Staff D confirmed she drove Resident #3 and Staff A, CNA to a doctor's appointment on 2/10/23. She said they left the building around 12:45-1:00 p.m. Staff D said the resident was upset because her foot was hurting her. An interview was conducted on 3/15/23 at 3:25 p.m. with the Office Manager of the Cardiovascular office Resident #3 visited on 2/10/23. The Office Manager said Resident #3 was crying out in pain from the minute she came off the elevator. She said the resident's appointment was at 3:15 p.m. and the resident and her CNA arrived around 3:35 p.m. due to going to the wrong location initially. She said the CNA that was with Resident #3 was yelling at the resident to stop screaming and shut up. The Office Manager said it was very obvious she was in pain. She said the staff at the doctor's office called 911 to have Resident #3 taken to the emergency room . The Office Manager provided statements written by the cardiovascular registered nurse (RN), cardiovascular medical assistant (MA) 1, and cardiovascular MA 2. A written statement provided by the cardiology MA 1 revealed Resident #3 could be heard crying from the waiting room. She said when she attempted to take Resident #3's vital signs, she screamed in pain. The CNA with the resident told the resident to stop crying. The cardiovascular MA 1 said she removed the pulse oximeter and blood pressure cuff and informed the aide the resident needed critical care. MA 1 said she excused herself from the triage room and went to speak with the doctor and call emergency medical services (EMS.) MA 1 said while waiting for EMS the aide could be heard multiple times telling Resident #3 to be quiet and stop yelling. A written statement provided by the cardiology RN revealed Resident #3 came into the office for a hospital follow-up and she could be heard screaming for help from the triage room. She said the resident was overheard screaming ouch my back, I have a sore on my back while being moved to the stretcher. A written statement provided by the cardiology MA 2 revealed Resident #3 and her CNA arrived late to the appointment because they went to the hospital prior to appointment and found out they were at the wrong location. MA 2 said the resident's CNA didn't seem to care much about her resident and was yelling at her to be quiet. MA 2 said for some reason the CNA wasn't aware her resident needed urgent medical attention. MA 2 said Resident #3 was in excruciating pain, yelling help me, help me, since she came to the office. A review of the (Local) Medical Transportation Run Report showed the reason for transport was acute pain. The resident's pain scale was 10 on a scale of 1-10. It said upon arrival patient was found in a wheelchair in obvious distress. Emergency Medical Services arrived for the resident on 2/10/23 at 3:20 p.m. and arrival at the hospital was shown to be at 3:37 p.m. A review of the Emergency Department records showed the reason for Resident #3's visit was complaints of pain associated with a left foot wound. It stated her pain level was 10/10 and she was anxious, crying, restless. The records show Resident #3 was given Dilaudid 1 mg in the Emergency Department and after was noted to be resting comfortably in no acute distress. The record showed Resident #3's x-ray did not definitively show any osteomyelitis, however, did show subcutaneous gas, which consistent with patient's physical exam of crepitus along plantar surface. It revealed that was concerning for necrotizing fasciitis. The diagnosis is listed as necrotizing fasciitis left foot with a condition of guarded. Patient admitted inpatient. A review of the hospital discharge summary showed Resident #3 had a below-the-knee amputation due to sepsis in the infected leg. The resident was discharged on [DATE] to a second long term care facility. A review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) from the second long-term care facility showed Resident #3 had a left below the knee amputation on 2/12/23. An observation was conducted of Resident #3 in the second long-term care facility on 3/14/23. Throughout the day the resident was resting comfortably, showing no signs of pain and no behaviors of yelling out. A follow-up interview was conducted on 3/21/23 at 12:18 p.m. with Staff A, CNA. Staff A said prior to leaving the facility for the doctor's appointment with Resident #3 on 2/10/12, the resident was in pain. Staff A said the nurse, Staff B, RN told her she was going to give the resident pain medication before they left. Staff A said she knew they had a one-hour drive to the appointment, the time there, and the one-hour drive back. Staff A said Resident #3 was screaming the whole ride. She said she didn't know why the resident was screaming because she was under the impression the nurse had given the resident her pain medication. Staff A said the resident had been crying out in pain daily since she was admitted . Staff A said the resident would be quiet and get some rest for a little bit after getting pain medication, but she would wake up and start crying out again. Staff A said she doesn't understand, because if a resident is in pain and needs medication, they should get it. She stated Resident #3 cried out in pain probably 15 hours out of every day. An interview was conducted on 3/10/23 at 6:00 p.m. with Staff O, Staffing Coordinator/Central Supply. Staff O said she was familiar with Resident #3. She said when she walked around the facility daily, Resident #3 was typically in pain and would always cry out. An interview was conducted on 3/10/12 at 6:10 p.m. with Staff P, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff P said Resident #3 was not comfortable because of the pain in her foot. She said she just wanted to lay here because of the pain. When asked about the resident not receiving pain medication prior to her appointment on 2/10/23 she said, I would have assumed the nurse would have given it to her. Staff P said they typically give pain medication before therapy and before going to appointments. She said when she gave the resident a shower, she was not in pain. Staff P said Resident #3 was in pain as soon as she got here. She said if someone talked to the resident, she would not scream but she would always say she was in pain. An interview was conducted on 3/21/23 at 1:07 p.m. with Staff Q, CNA. She stated she was familiar with Resident #3. She said the resident was always in pain and was always crying out. She said she thinks pain medications helped the resident because they would put her to sleep, but she would wake up and cry in pain again. An interview was conducted on 3/21/23 at 2:11 p.m. with Staff H, CNA. He stated he remembered Resident #3. He said she would tell him she was in pain and other times she could not talk because of her pain. An interview was conducted on 3/21/23 at 2:16 p.m. with Staff L, LPN. She stated she remembers Resident #3 sitting in the dining area crying and moaning in pain. An interview was conducted on 3/21/23 at 3:05 p.m. with the Director of Nursing (DON). The DON was observed reviewing Resident #3's medical records. The DON said she did not know the resident very well and cannot speak to her pain on a day-to-day basis. The DON stated she was looking at the resident's record to see if the screaming had to do with behaviors, psychiatric medication, or history of drug use. She said they are always looking at psych (psychiatric issues) versus pain. She said they followed up with the resident's pain and gave her pain medication. She said they had the resident followed by psychiatry (psych) as well. There was an order for psych to evaluate and follow-up as needed. She said she did not see any provider notes in the record for psychiatry. The DON confirmed there were no notes in the record where the doctor was called and notified about Resident #3's ineffective pain medication. She said she would expect the nurse to follow physician orders and if the medication is not effective, they should notify the doctor. When asked if a resident cries and reports pain should the nurse call the physician, she said, I don't know. I was not down there and cannot speak to that. The DON said if a pain medication is not effective, the nurse can try non-pharmacological approaches for pain relief. She said if the nurse did that, it would be documented in the progress notes. The DON reviewed the progress notes and confirmed nothing was documented showing other approaches to pain management were attempted. On 3/21/23 at 5:00 p.m. the DON said she was unable to find anything showing psychiatry had evaluated Resident #3 during her stay. An interview was conducted on 3/21/23 at 3:38 p.m. with Staff B, RN, who confirmed she had cared for [TRUNCATED]

Based on observations, record review of the Facility Assessment, policies and procedures, job descriptions, and clinical records, and interviews with facility staff, the Medical Director (MD), the facility Advanced Practice Registered Nurse (APRN), a Family Member, and a resident, the facility neglected to provide the care and services to prevent an unwitnessed exit from the facility for one (Resident #129) of 10 sampled residents reviewed for high risk elopement. The facility neglected to notify Resident #129's physician and family of escalating exit-seeking behaviors, failed to obtain physician orders for a wanderguard (electronic monitoring device), failed to assess the possible reason for exit seeking behaviors in order to put meaningful interventions in place, failed to provide one to one supervision as directed by the Director of Nursing (DON), failed to place Resident #129's picture and physical description information in the elopement books, failed to implement the person-centered care plan, and failed to identify risks in the physical environment of a faulty exit gate in the enclosed courtyard area. Resident #129 was a newly admitted resident who was unfamiliar with his environment. He was assessed as a high risk for elopement with multiple attempts to exit the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/16/22, Resident #129 exited the facility, unbeknownst to staff, through the courtyard area and was able to ambulate approximately 5 miles away from the facility, through heavy traffic alongside and across a highly traveled 8 lane divided highway with a speed limit of 55 mph. Resident #129 was last seen by facility staff around 3:00 PM on 04/16/22. Staff were unable to locate the resident and contacted the Police to assist in the search on 04/16/22 around 4 PM. The Police contacted the facility on 04/16/22 around 7 PM to let them know the resident was found and transferred to the hospital. Resident #129 was admitted to the hospital for 4 days and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The likelihood of serious physical harm or death to Resident #129 as a result of the facility's neglect resulted in findings of Immediate Jeopardy on 04/16/22, and removed on 04/22/22, with the scope and severity reduced to a D. Findings included: Cross Reference F689 Review of a facility report revealed the facility started an investigation for possible neglect on 04/16/22. The report indicated that Resident #129 was last seen in the facility on 04/16/22 around 3:00 PM. The Director of Nursing (DON) was notified of this around 4:00 PM on 04/16/22. A complete search of the facility and surrounding areas was completed and staff was sent out by car. The Pinellas County Sheriff's Office (PCSO) was notified and arrived at the facility at approximately 4:05 PM. The report stated the Resident had no Representative/Family on file. A review of the Facility Assessment reviewed by the Quality Assurance and Performance Improvement (QAPI) Committee on 3/21/22, revealed the facility accepts residents for admission that have psychiatric/mood disorders and neurological system diseases/conditions to include common diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility provides opportunities for social activities/life enrichment, preventing abuse and neglect, identifying hazards and risks for residents, and offering the resident and family caregivers to be involved in person-centered care planning and advance care planning. All residents complete a social history and evaluation on admission. Baseline assessments are completed for elopement to identify residents that could be at risk and care plans are developed to decrease risks/hazards. The staffing portion of the Facility Assessment revealed Staffing is adjusted based on specific resident needs. On occasion, we will have a need to place a resident on a one to one ratio. This is done when a resident has a difficult time transitioning, is and [sic] elopement risk, or a very significant fall risk . A review of a facility policy with a copyright date of 2021 titled, Abuse, Neglect and Exploitation revealed: Policy: 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, mistreatment including injuries of unknown origin and misappropriation of resident property. Facility policy is to report allegations and complete investigation of allegation. Definitions: . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; . c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: 1. Screening . B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. II. Employee Training . C. Training topics will include: . 6. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: . b. Wandering or elopement-type behaviors; . e. Difficulty in adjusting to new routines or staff. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents to prevent occurrences when appropriate; . E. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and F. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. B. Possible indicators of abuse include, but are not limited to: . 8. Failure to provide care needs . Review of a facility policy titled, Notification of changes revised 04/03/22 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. Circumstances requiring notification included: 1) Accidents with the potential to require physician intervention, 2) a significant change in the resident's mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: Life-threatening conditions. 3) Circumstances that require a need to alter treatment. Review of a facility job description titled, Director of Nursing (DON), dated August 2021, revealed Summary: To manage the overall operations of the Nursing Department in accordance with Company policies, standards, of nursing practices, and governmental regulations to maintain excellent care of all residents' needs . Duties and Responsibilities included: Direct the performance and delivery of nursing services and resident care services in compliance with corporate policies and State and Federal regulations. Review of a facility job description titled, Charge Nurse (LPN), dated July 2021 revealed a Summary: Provide direct nursing care to the residents and provide oversight of the day-to-day nursing activities performed by Certified Nursing Assistants .in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern facility. Duties and Responsibilities included: Ensure nursing personnel assigned to you comply with written policies and procedures; Obtain clinical guidance from the DON/designated RN as appropriate related to resident care; Meet with your assigned nursing staff, in planning the shifts services .; Cooperate with other resident services when coordinating nursing services and be certain that the resident's total regimen of care is maintained; Work with physicians .to review treatment plans .; Received telephone orders from physicians .; Document in electronic health record (EHR) in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care following established facility charting and documentation policies; Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices; . assist with other resident needs; Consult with the resident's physician in providing the resident's care, treatment . as necessary; Make periodic rounds to confirm that care and services are being properly administered by CNAs to evaluate the resident's physical and emotional status; Notify the resident's attending physician when the resident is involved in an accident or incident; Notify the resident's attending physician and responsible party when there is a change in the resident's condition; Review care plans to confirm that appropriate care is being rendered; Confirm that CNAs are aware of the resident care plans . Review of a facility job description titled, Registered nurse (RN), dated April 2020 revealed a Summary: Provide direct nursing care to the residents and provide clinical oversight of the day-to-day nursing activities performed by Licensed Practical Nurses and or Certified Nursing Assistants . in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern facility. Duties and Responsibilities included: Ensure nursing personnel assigned to you comply with written policies and procedures; Meet with your assigned nursing staff, . in planning the shifts services .; Cooperate with other resident services when coordinating nursing services and be certain that the resident's total regimen of care is maintained; Work with physicians .to review treatment plans .; Received telephone orders from physicians .; Document in electronic health record (EHR) in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care following established facility charting and documentation policies; . assist with other resident needs; Consult with the resident's physician in providing the resident's care, treatment .as necessary; Make periodic rounds to confirm that care and services are being properly administered by LPNs, CNAs . to evaluate the resident's physical and emotional status; Notify the resident's attending physician when the resident is involved in an accident or incident or when there is a change in the resident's condition; Review care plans to confirm that appropriate care is being rendered; Confirm that LPN's and CNA's are aware of the resident care plans . Review of a facility job description titled, Certified Nursing Assistant (CNA), dated April 2020 revealed Summary: Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting compassionate physical and psychosocial environment for the residents . Duties and Responsibilities included observe residents carefully and report changes in condition to Charge Nurse. An interview was conducted on 04/19/22 at 5:09 PM with the Admissions Director. The Admissions Director stated he first received the referral paperwork for Resident #129 in early March of 2022 from a hospital located in Jacksonville. The Admissions Director stated it took over a month to review and assess if Resident #129 was appropriate for admission. The Admissions Director reported his primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admissions Director said, they [the referring hospital] said he did not need a secure unit, but he would be okay with an electronic monitoring device. The Admissions Director stated the elopement risk did not present outside of the normal admission criteria. The Admissions Director stated an electronic monitoring device was put on Resident #129, on Friday, 4/15/22 (the day of admission), because he was observed wandering around and was exit seeking. The Admissions Director stated he sent out a notification to the Nursing Home Administrator (NHA), Director of Nursing (DON), all Department heads, and the nursing staff that he was a wander risk on Friday morning (04/15/22) prior to the resident's arrival. The Admissions Director provided a copy of the notification sent prior to admitting the resident, which indicated the resident might need a wanderguard. On 04/19/22 at 4:38 PM, the Social Services Director (SSD) stated he saw Resident #129 briefly when he assisted with smoke break supervision in the courtyard at 2 PM on Friday (4/15/22), the day the resident was admitted . The SSD stated Resident #129 presented confused and walked around looking for cigarette butts. The SSD stated Resident #129 was telling everyone that he didn't have any cigarettes. The SSD said, I did not address his anxiety. I know he wanted cigarettes. I should have gotten them for him. Normally when a resident does not have cigarettes, I'll go out and buy them cigarettes. The SSD stated he did not get a chance to establish a relationship with Resident #129. The SSD was observed to become tearful. The SSD stated he was emotional because he did not meet the resident's needs. The SSD stated he usually meets with new residents within the first couple of days they are admitted . The SSD stated his assessment of Resident #129 based on his observations was that he was coherent. He was telling people he just got out of prison. Resident #129 was able to make his needs known. Resident #129 did not show anger, just anxiety. The SSD stated Resident #129 was wandering around confused. The SSD stated he supervised him and other residents in the courtyard area for about 20 minutes and went back in the facility. The SSD confirmed he was aware Resident #129 was an elopement risk and the Admissions Director had stated that he probably needed an electronic monitoring device. The SSD confirmed that the Admissions Director had informed nurses on Friday, 4/15/22 and had also covered this with the department heads in several meetings prior to the resident's admission. The SSD stated if a resident was wandering and presenting elopement behaviors, the protocol was to call the physician and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #129's clinical record revealed no Social Service Assessment or Social Service notes were completed prior to the resident eloping on 04/16/22. An interview was conducted on 04/21/22 at 11:25 AM with Staff V, an Agency Registered Nurse (RN). Staff V stated that she admitted Resident #129 around 1:45 PM on Friday, 04/15/22. Staff V stated she did not get a report on Resident #129 prior to his arrival. Staff V stated she reviewed the paperwork the resident arrived with, completed the admission assessments and physician orders. Staff V stated Resident #129 started wandering instantly. Staff V stated Resident #129 wanted to smoke and kept walking out of the room. Staff V stated she did not have an assessment of Resident #129's mental status but figured we needed to keep him from exiting the facility. Staff V stated Staff N, LPN/Unit Manager told her to put an electronic monitoring device on Resident #129. Staff V stated she put the device on Resident #129 on 04/15/22 because he wanted to go out. Staff V said, I kept chasing him around. Staff V stated she did not know the facility policy on wandering residents or electronic device application. Staff V said, I figured the Unit Manager had the orders in place. A review of the admission elopement evaluation dated 04/15/22 at 1:38 PM completed by Staff V revealed the resident's elopement score was 12. The form noted that a score of 11 or above indicated High Risk to Wander. A review of the skilled nursing evaluation also completed on 04/15/22 at 1:38 PM revealed resident was alert with some forgetfulness, wanders at night, sleeps intermittently, no restraints, alarms, or sensors were in place, resident/responsible party concerns were noted as possible wandering. A neurologic and mental status note indicated within normal limits (WNL), although resident has history of confusion at times. Continued review of the clinical record revealed no presence of notes related to the resident's continuous wandering, his desire to leave the facility, and/or placement of the wanderguard device on 04/15/22, the day he was admitted . Additionally, there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/21/22 at 11:35 AM, Staff N, Licensed Practical Nurse (LPN)/Unit Manager confirmed she had worked on Friday 4/15/22 when Resident #129 was admitted . Staff N stated it was sometime early in the afternoon. Staff N stated she was covering both units that day and did not have any interaction with Resident #129. Staff N could not recall if she was notified the resident was an elopement risk. Staff N said, I might have. I was focused on another resident. Staff N said if a resident was displaying elopement behaviors, the expectation was to call the physician, get an order, and update the care plan. Staff N said, I should have made the call to the physician. I guess I should have. Friday was hectic. I was here until 4 or 5 PM. On 04/19/22 at 4:51 PM, Staff E, RN/Minimum Data Set (MDS) Coordinator revealed she reviewed Resident #129's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that Resident #129 had been hospitalized in Jacksonville since November of 2021, was noted as at risk for wandering, was ambulatory, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff E reported that she started Resident #129's baseline care plan but had no interaction with the resident that day. She stated that her counterpart, Staff D, RN/MDS Coordinator came in on Saturday, 04/16/22 to update the care plan for Resident #129. Staff E reported that she first heard about Resident #129's elopement when she returned to work on Monday, 04/18/22. Staff E stated in-servicing and mock elopement drills were started that Monday, 04/18/22. Staff E confirmed that there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 04/19/22 at 3:03 PM with Staff A, Certified Nursing Assistant (CNA). Staff A confirmed he was assigned to Resident #129 on 04/16/22 from 7 AM-3 PM. Staff A stated the first time he saw Resident #129. he noticed something was suspicious. Staff A reported he saw Resident #129 exit his bedroom around 1 PM, his body language was odd. When asked to describe what he meant by odd, Staff A stated, he was looking like he had a purpose or plan to escape. Staff A stated Resident #129 was carrying his personal bag, walking down hall 300 towards the front lobby exit door of the facility. Staff A stated he did not ask Resident #129 where he was going at first. Staff A indicated he wanted to see where Resident #129 was going and watched him for about 30 minutes while also attending to other residents. Staff A said, I assumed he was going to elope because he was hanging out by the front door. Staff A stated the resident kept going back and forth between the front lobby exit door and the 300 nurses' station. Staff A stated another CNA, Staff F, was about to let Resident #129 exit out the front of the building because Staff F thought Resident #129 was a guest. Staff A stopped Staff F from letting the resident out and redirected Resident #129 to his room. Staff A stated Resident #129 was high functioning and he presented as a guest even though he had slurred speech and was difficult to understand. Staff A stated Resident #129 repeatedly said he was just nervous and did not want to be at the facility. Staff A stated Resident #129 wanted to smoke, but did not have cigarettes. Staff A stated he attempted to find out why the resident wanted to leave, but the resident did not provide any specifics as to why or where he wanted to go but continued to verbalize wanting to leave. Staff A suggested to Resident #129 to wait till Monday to speak to the Social Services Director (SSD). Staff A stated he notified Staff B, the Agency Licensed Practical Nurse (LPN) assigned to Resident #129, and the Director of Nursing (DON), who was in the building, that Resident #129 was attempting to elope. Staff A stated the DON agreed Resident #129 was an elopement concern and told Staff A to keep an eye on the resident as they would probably put him on 1:1 supervision. Staff A reported he received a phone call on 04/16/22 around 1 PM from Staff L, the Staffing Coordinator, and was asked to tell Staff C, C.N.A., to provide 1:1 supervision for Resident #129. Staff A stated he continued to watch Resident #129 and tended to his other residents while Staff C was on her lunchbreak. Staff A stated he saw Resident #129 grab his bag and exit through the 400 hall door to the enclosed exterior courtyard/gazebo area. The resident walked through the courtyard and re-entered the facility through the dining room door and then went to the front lobby area around 1:30 PM. Staff A reported that he saw Staff D, Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator, stopping Resident #129 at the front lobby exit door attempting to leave, yet again. Staff A confirmed that Resident #129 was not listed in the elopement book (a binder maintained in the front lobby and at the nurses stations with photos and physical descriptions of residents assessed as high risk for wandering and elopement), but reported that the resident had an electronic monitoring device on that entire day. Staff A said, I did not check it [the electronic monitoring device]. I do not know if it was functioning. Staff A said he saw Resident #129 attempting to leave again about 20-25 minutes later. Staff A stated on 04/16/22 at about 2:45 PM, he checked on Resident #129 and found him just standing in his room. Staff A stated he last saw Resident #129 at the end of his shift (3 PM) in the courtyard picking up sticks. Staff A thought Resident #129 was just keeping busy. Staff A confirmed there was no staff with the resident in the courtyard. Staff A stated supervision was required for residents who are exit seeking. Staff A said, He should have had supervision, for sure from 1pm and 3pm. Staff A stated he could not confirm the exact time the DON established the 1:1 supervision. Staff A stated they did not have a 1:1 supervision log for that day. Staff A stated the expectation for 1:1 supervision was to visually keep an eye on the resident and to try to redirect. Staff A stated he did not speak to the on-coming shift about Resident #129's wandering concerns before he left at 3 PM on 04/16/22 because he thought Staff C was going to be providing 1:1 supervision. Staff A stated from his assessment, Resident #129 probably pulled himself over the gate in the courtyard. Staff A stated the gate was not alarmed and the electronic monitoring device would not activate on that gate. An observation was made of the courtyard/gazebo area with Staff A immediately following the interview. The 400 hall door and the Dining Room door both exit to the enclosed courtyard/gazebo area. These doors do not alarm or require keypad access in order to enter or exit. Black colored scuff marks were observed on the white courtyard exit gate. The marks were noted to be in the shape of a shoe print. The shoe print marks were also observed on a blue electrical box on the left side of the gate. Staff A stated Resident #129 most likely stepped on the electrical box and pulled himself up over the fence in order to exit the facility. Measurements of the gate revealed it was approximately 6 feet tall. Observation of the exterior of the gate revealed a facility parking lot that was adjacent to medical offices. This was approximately 300 ft away from US Highway 19, an 8 lane divided highway with additional lanes for turning, and a speed limit of 55 MPH. Photographic evidence was obtained. The facility was observed to have a staff member stationed in the courtyard area to supervise residents and observe the exit gate. Staff A stated this was put in place after Resident #129's elopement. An interview was conducted on 4/19/22 at 4:05 PM with Staff D, RN/MDS Coordinator. Staff D stated she came in to work on Saturday morning (04/16/22) and saw Resident #129 in the front lobby area around 10 AM. Staff D stated she had not met him prior to this as he was admitted the day before (04/15/22). She noticed he was carrying a reusable shopping bag and looked like a visitor. Staff D stated she asked Resident #129 if he was wanting to exit the facility. Staff D stated she was about to let the resident out of the building when, The Receptionist [Staff R] told me he was a resident. I redirected him to his room. Staff D stated Resident #129 was moderately built, steady, healthy, presented content but confused. Staff D stated Resident #129 looked confused as he headed to his room. Staff D stated she was notified that they had already placed an electronic monitoring device on the resident. Staff D stated she started the elopement care plan and in the special instructions section noted, wanders/elopement risk so everyone would know. Staff D stated Resident #129 was not in the elopement book. Staff D did not know who takes the photos and places them in the elopement book. Staff D said, In hindsight, I should have done it then. I should have put him in the elopement book and brought a copy to all units. Staff D stated throughout the day, Resident #129 was observed in the smoking courtyard area or the front lobby area. Staff D stated that was concerning because these areas are target exits. Staff D stated she last saw Resident #129 on 04/16/22 at 2 PM talking to another resident (Resident #74). Staff D stated the next thing she heard was the announcement that was made shortly after 4 PM on 04/16/22. Staff D stated Staff B announced, Attention staff, Mr. [Resident #129] report to your room. Staff D reported this was repeated three times. Staff D reported to the nurse's station and heard that Resident #129 was last seen on 04/16/22 at 3 PM. Staff D verified that the interior of the facility was searched, and she drove her car around the parameter of the facility, searched around a strip mall area and gas station approximately ½ a mile from the facility and could not locate the resident. Staff D stated she saw other staff looking for the resident, and they had traveled North on U.S. Highway 19. Staff D stated the Police, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were at the facility when she returned. Staff D stated the DON had her verify the electronic monitoring devices and care plans for Resident #129. Staff D stated as she reviewed Resident #129's physician orders, she noticed there was no order for an electronic monitoring device. Staff D stated the transcription for an order was to be done as soon as an order was given. Staff D stated she could not confirm if the nurse who placed the device on the resident had ever received a verbal physician's order. Staff D stated I should have looked at that and spoken to the nursing staff. Staff D stated she stayed at the facility and reviewed other residents at risk for elopements care plans and physician orders until the police officer came and let them know that Resident #129 had been located, which was probably between 7 PM and 7:30 PM on 04/16/22. Staff D stated she heard Resident #129 was found at a local supermarket somewhere off U.S. Highway 19 North. Staff D stated that on Monday, 04/18/22, there was follow-up education by nursing. The education consisted of reviewing the elopement policies, updating elopement books and how to print pictures of residents, and reviewing elopement scores. A review of Resident #129's clinical record revealed a care plan was developed by Staff D, MDS Coordinator on 04/16/22 for a risk of elopement/exit seeking aimlessly, wandering due to cognition and has the potential to approach exit doors. The goal, with a target date of 7/14/22, was Resident #129 will not leave the facility unattended. Interventions included: Approach in a calm manner. Assess for psychological causes. Check functioning/placement of wanderguard every shift. Evaluate unit for possible safety hazards. Facilitate resident to call close family/friend for reassurance when exit seeking behaviors occur. Monitor resident for tailgating when visitors are in the building. Reassure resident when distressed over placement. Refer to Social Services as needed. Seek a referral for a mental health evaluation from primary care physician as needed. Use diversional activities when exit-seeking behavior is occurring (i.e.: offer food, activities, one-on-one company). Review of Resident #129's clinical record revealed no evidence that these interventions were implemented prior to Resident #129's elopement on 04/16/22. On 04/20/22 at 1:41 PM, an interview was conducted with Resident #129's Family Member who was also listed as the Emergency Contact on Resident #129's Admission Record (face sheet) and also listed on two hospital patient transfer forms (Form 3008) dated 2/14/22 and 4/14/22. These transfer forms were in Resident #129's admission paperwork that accompanied him from the referring hospital in Jacksonville, FL on 04/15/22. The Family Member's name and telephone number were listed on all forms. Resident #129's Family Member stated she was not notified about the elopement by the facility nor had anyone from the facility made any attempts to contact her to discuss the resident's needs or history. She stated that the hospital called her on 04/19/22 to no [TRUNCATED]

Based on observations, review of medical records and facility policies, and interviews with facility staff, the Medical Director (MD), a Family Member, and residents, the facility failed to provide supervision to prevent an unwitnessed exit from the facility for one (Resident #129) of 10 residents sampled for high risk elopement. Resident #129 was a newly admitted resident with diagnoses to include other [CONDITION(S)], [CONDITION(S)], generalized anxiety disorder, [CONDITION(S)], alcohol and psychoactive substance abuse in remission, and a history of falling. Resident #129 was identified as a high elopement risk with an electronic monitoring device (wanderguard) placed on him without notification or orders from the physician. Resident #129 could ambulate independently and presented as a visitor to those who did not know him. On 04/16/22 between 3pm and 4pm, Resident #129 was unaccounted for after multiple elopements attempts earlier that day in which the resident was seen carrying his belongings in a bag. Resident #129 was left unsupervised in an enclosed outdoor courtyard with a faulty exit gate. Resident #129 either jumped over the 6 foot gate or pushed the faulty gate open and was able to ambulate approximately 5 miles away from the facility, through heavy traffic alongside and across a highly traveled 8 lane divided highway with a speed limit of 55 mph. Facility staff drove around the neighborhood surrounding the facility and searched within the facility, but could not locate the resident and notified the authorities. Police contacted the facility around 7pm on 04/16/22 having located Resident #129 at a grocery store approximately 5 miles from the facility. Resident #129 was hospitalized post incident from 04/16/22 to 04/20/22 where he was treated for acute kidney injury, acute rhabdomyolysis, and acute generalized weakness all of which were secondary to dehydration. The likelihood of serious physical harm or death to Resident #129 as a result of the facility's failure to provide adequate supervision to prevent the elopement resulted in findings of Immediate Jeopardy on 04/16/22, and removed on 04/22/22, with the scope and severity reduced to a D. Findings included: Cross reference F600 Review of a Pinellas County Emergency Medical Services [EMS] Patient Care Report for Patient #129 revealed: EMS received a call on 4/16/22 at 18:07 (6:07 PM) EMS arrived at the scene on 4/16/22 at 18:29 (6:29 PM) The narrative section of the Patient Care Report revealed EMS was called to a parking lot for a male who was found wandering the streets and was sitting outside a grocery store in Tarpon Springs. Pinellas County Sheriff's Office (PCSO) said that the patient is confused and appears to have eloped from his assisted living facility this morning in Palm Harbor. Staff confirmed patient is from Orchid Cove and has been missing since lunchtime. Patient has not voiced complaints. Police Department (PD) said that patient's Heart Rate (HR) is in the 140's but his BP is normal. Per PD, patient at first didn't want any treatment. Per PD, patient appears to have a history of dementia. Patient says he is from Jacksonville, Florida and is currently homeless. Pt was found sitting on the curb in a parking lot with PD and PCSO. Patient was alert with a Glasgow Coma Scale (GCS) of 14 at this time. Patient is unsteady on his feet and is at risk of falling. Patient's HR was sustained at 120 during transport. Pt kept moving his arms and EMS was unable to obtain his blood pressure (BP) during the 2 minute transfer to the emergency room (ER). Patient has a strong radial post. All other findings as noted. Patient to local hospital for evaluation of dehydration. A review of the hospital emergency room record revealed the patient was seen on 04/16/22 at 7:05 PM. The history of present illness (HPI) revealed Patient is a [AGE] year-old male who presents to the emergency department by emergency medical services (EMS). Patient has reportedly eloped from a nursing home facility this afternoon where he is a known flight risk, is still wearing an ankle monitor. Patient has been reportedly missing since around 1530 [3:30 PM] . He has apparently been walking around the area all afternoon. Patient states that he intends to walk to Fort [NAME] and then to Jacksonville . Patient is confusional, appears to have underlying dementia, and although he is able to answer some questions appropriately, is not oriented to time or situation . Patient complains of his feet aching . A physical exam of his skin revealed Patient appears to have [CONDITION(S)] to his exposed forearms, neck, and face, consistent with sunburn . On physical examination, the patient's feet are cracked, appeared irritated and socks are very sweaty, but no indication of infection, no obvious injury . Review of Resident #129's hospital discharge summary dated 04/20/22, revealed a date of admission of 04/16/22 and date of discharge of 04/20/22. The discharge diagnosis revealed acute generalized weakness, suspect secondary to dehydration, acute rhabdomyolysis likely secondary to dehydration, acute kidney injury likely secondary to dehydration, Elevated CPK ([MEDICATION(S)] Phosphokinase) level secondary to rhabdomyolysis, cognitive impairment, history of [CONDITION(S)] brain injury, and history of alcohol and [MEDICATION(S)] use. Review of Google Maps revealed the location where the police and EMS located Resident #129 was approximately 4.9 miles from the facility. Observation of the most direct route to this location from the facility on Saturday, 04/23/22 at approximately 5:30 PM, revealed Resident #129 would have traveled approximately 0.1 miles along a 2 lane limited access road (Highlands Blvd North) in front of the facility with a speed limit of 30 miles per hour (MPH). The resident would have then traveled North on US Highway 19 for approximately 2.4 miles. US Highway 19 is a highly traveled 8 lane divided highway with additional turning lanes and a speed limit of 55 MPH. US Highway 19 was observed to have sidewalks along both sides of the highway. In order for the resident to get to the location where he was found, he would have needed to cross the 8 lane highway. It is unknown where Resident #129 crossed the highway and if he used a crosswalk when crossing. Continuing along this direct route, Resident #129 would have then traveled on [NAME] Road for approximately 1.3 miles. This is a 4 lane divided roadway with sidewalks and a speed limit of 40 MPH. The resident would have then traveled to Pinellas Avenue (also known as Alternate US-19). The resident would have likely traveled approximately 1 mile on this 2 lane road with turning lanes and sidewalks and speed limits ranging from 35-40 MPH. This road led to the grocery store parking lot and intersection where Resident #129 was located. Review of the weather (www.wunderground.com) on 04/16/22 revealed the temperatures were noted as: 2:53 PM: 83 degrees Fahrenheit (F) with Humidity (H) of 65% 3:53 PM: 85 F; H 61% 4:53 PM: 86 F; H 48% 5:53 PM: 83 F; H 60% 6:53 PM: 79 F; H 72% Observation of the facility front entrance/lobby area on 04/18/22 at approximately 9:00 a.m. revealed no residents or guests could enter or exit the facility through the front entrance without a staff member entering a code on a keypad located just inside of the exit/entry door. An interview was conducted on 4/19/22 at 4:05 PM with Staff D, Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator. Staff D stated she came in to work on Saturday morning (04/16/22) and saw Resident #129 in the front lobby area around 10 AM. Staff D stated she had not met him prior to this as he was admitted the day before (04/15/22). She noticed he was carrying a reusable shopping bag and looked like a visitor. Staff D stated she asked Resident #129 if he was wanting to exit the facility. Staff D stated she was about to let the resident out of the building when, The Receptionist [Staff R] told me he was a resident. I redirected him to his room. Staff D stated Resident #129 was moderately built, steady, healthy, presented content but confused. Staff D stated Resident #129 looked confused as he headed to his room. Staff D stated she was notified that they had already placed an electronic monitoring device on the resident. Staff D stated she started the elopement care plan and in the special instructions section noted, wanders/elopement risk so everyone would know. Staff D stated Resident #129 was not in the elopement book (a binder maintained in the front lobby and at the nurses stations with photos and physical descriptions of residents assessed as high risk for wandering and elopement). Staff D did not know who takes the photos and places them in the elopement book. Staff D said, In hindsight, I should have done it then. I should have put him in the elopement book and brought a copy to all units. Staff D stated throughout the day, Resident #129 was observed in the smoking courtyard area or the front lobby area. Staff D stated that was concerning because these areas are target exits. Staff D stated she last saw Resident #129 on 04/16/22 at 2 PM talking to another resident (Resident #74). Staff D stated the next thing she heard was the announcement that was made shortly after 4 PM on 04/16/22. Staff D stated Staff B announced, Attention staff, Mr. [Resident #129] report to your room. Staff D reported this was repeated three times. Staff D reported to the nurse's station and heard that Resident #129 was last seen on 04/16/22 at 3 PM. Staff D verified that the interior of the facility was searched, and she drove her car around the parameter of the facility, searched around a strip mall area and gas station approximately ½ a mile from the facility and could not locate the resident. Staff D stated she saw other staff looking for the resident, and they had traveled North on U.S. Highway 19. Staff D stated the Police, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were at the facility when she returned. Staff D stated the DON had her verify the electronic monitoring devices and care plans for Resident #129. Staff D stated as she reviewed Resident #129's physician orders, she noticed there was no order for an electronic monitoring device. Staff D stated the transcription for an order was to be done as soon as an order was given. Staff D stated she could not confirm if the nurse who placed the device on the resident had ever received a verbal physician's order. Staff D stated I should have looked at that and spoken to the nursing staff. Staff D stated she stayed at the facility and reviewed other residents at risk for elopements care plans and physician orders until the police officer came and let them know that Resident #129 had been located, which was probably between 7 PM and 7:30 PM on 04/16/22. Staff D stated she heard Resident #129 was found at a local supermarket somewhere off U.S. Highway 19 North. Staff D stated that on Monday, 04/18/22 there was follow-up education by nursing. The education consisted of reviewing the elopement policies, updating elopement books and how to print pictures of residents, and reviewing elopement scores. An interview was conducted on 04/19/22 at 3:03 PM with Staff A, Certified Nursing Assistant (CNA). Staff A confirmed he was assigned to Resident #129 on 04/16/22 from 7 AM - 3 PM. Staff A stated the first time he saw Resident #129 he noticed something was suspicious. Staff A reported he saw Resident #129 exit his bedroom around 1pm, his body language was odd. When asked to describe what he meant by odd, Staff A stated, he was looking like he had a purpose or plan to escape. Staff A stated Resident #129 was carrying his personal bag, walking down hall 300 towards the front lobby exit door of the facility. Staff A stated he did not ask Resident #129 where he was going at first. Staff A indicated he wanted to see where Resident #129 was going and watched him for about 30 minutes while also attending to other residents. Staff A said, I assumed he was going to elope because he was hanging out by the front door. Staff A stated the resident kept going back and forth between the front lobby exit door and the 300 nurses' station. Staff A stated another CNA, Staff F was about to let Resident #129 exit out the front of the building because Staff F thought Resident #129 was a guest. Staff A stopped Staff F from letting the resident out and redirected Resident #129 to his room. Staff A stated Resident #129 was high functioning and he presented as a guest even though he had slurred speech and was difficult to understand. Staff A stated Resident #129 repeatedly said he was just nervous and did not want to be at the facility. Staff A stated Resident #129 wanted to smoke, but did not have cigarettes. Staff A stated he attempted to find out why the resident wanted to leave but the resident did not provide any specifics as to why or where he wanted to go but continued to verbalize wanting to leave. Staff A suggested to Resident #129 to wait till Monday to speak to the Social Services Director (SSD). Staff A stated he notified Staff B, the Agency Licensed Practical Nurse (LPN) assigned to Resident #129 and the Director of Nursing (DON), who was in the building, that Resident #129 was attempting to elope. Staff A stated the DON agreed Resident #129 was an elopement concern and told Staff A to keep an eye on the resident as they would probably put him on 1:1 supervision. Staff A reported he received a phone call on 04/16/22 around 1 PM from Staff L, the Staffing Coordinator and was asked to tell Staff C, CNA, to provide 1:1 supervision for Resident #129. Staff A stated he continued to watch Resident #129 and tended to his other residents while Staff C was on her lunchbreak. Staff A stated he saw Resident #129 grab his bag and exit through the 400 hall door to the enclosed exterior courtyard/gazebo area. The resident walked through the courtyard and re-entered the facility through the dining room door and then went to the front lobby area around 1:30 PM. Staff A reported that he saw Staff D, Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator, stopping Resident #129 at the front lobby exit door attempting to leave, yet again. Staff A confirmed that Resident #129 was not listed in the elopement book, but reported that the resident had an electronic monitoring device on that entire day. Staff A said, I did not check it [the electronic monitoring device]. I do not know if it was functioning. Staff A said he saw Resident #129 attempting to leave again about 20-25 minutes later. Staff A stated on 04/16/22 at about 2:45 PM, he checked on Resident #129 and found him just standing in his room. Staff A stated he last saw Resident #129 at the end of his shift (3 PM) in the courtyard picking up sticks. Staff A thought Resident #129 was just keeping busy. Staff A confirmed there was no staff out in the courtyard at that time. Staff A stated supervision was required for residents who are exit seeking. Staff A said, He should have had supervision, for sure from 1pm and 3pm. Staff A stated he could not confirm the exact time the DON established the 1:1 supervision. Staff A stated they did not have a 1:1 supervision log for that day. Staff A stated the expectation for 1:1 supervision was to visually keep an eye on the resident and to try to redirect. Staff A stated he did not speak to the on-coming shift about Resident #129's wandering concerns before he left at 3 PM on 04/16/22 because he thought Staff C was going to be providing 1:1 supervision. Staff A stated from his assessment, Resident #129 probably pulled himself over the gate in the courtyard. Staff A stated the gate was not alarmed and the electronic monitoring device would not activate on that gate. An observation was made of the courtyard/gazebo area with Staff A immediately following the interview. The 400 hall door and the Dining Room door both exit to the enclosed courtyard/gazebo area. These doors do not alarm or require keypad access in order to enter or exit. Black colored scuff marks were observed on the white courtyard exit gate. The marks were noted to be in the shape of a shoe print. The shoe print marks were also observed on a blue electrical box on the left side of the gate. Staff A stated Resident #129 most likely stepped on the electrical box and pulled himself up over the fence in order to exit the facility. Photographic evidence was obtained. The facility had a staff member stationed in the courtyard area to supervise residents and observe the exit gate. Staff A stated this was put in place after Resident #129's elopement. On 04/19/22 at 2:34 PM, Staff C, CNA was observed seated in the courtyard area and stated she was watching the exit gate because they suspected Resident #129 eloped by going over the gate. Staff C confirmed staff have been watching the gate since Saturday night (04/16/22) because they don't know if it is secure. Staff C stated she first met Resident #129 on Saturday (4/16/22). Staff C was assigned light duty on 04/16/22, to include smoking supervision. Staff C reported that she was scheduled to work a double shift on 04/16/2022 (7AM-3PM and 3PM-11PM). Staff C stated she first saw Resident #129 during a smoke break on 04/16/22 around 11 AM. Staff C stated, Resident #129 was outside most of the afternoon and was in and out of the building with residents who smoke all day. Staff C stated she did not think Resident #129 had cigarettes even though he wanted to smoke. Staff C stated she last saw Resident #129 around 3 PM when obtaining his vitals and passing ice water. Staff C stated Resident #129 appeared restless and had an electronic monitoring device on. Staff C stated when a new resident comes in and they become actively exit seeking, they put an electronic device on them. Staff C stated that she heard from Staff A that Resident #129 had tried to get out and Staff B, LPN was notified. Staff C said, I was planning to do 1 to 1 supervision per [Staff A], then the nurse [Staff B] said that it was not necessary. The nurse [Staff B] asked me to pass ice instead of the 1 to 1 supervision. Staff C said, From my understanding, if the nurse felt it was necessary, she should have put him on a 1 to 1. Staff C stated Resident #129 was not put on 1:1 supervision because a receptionist (Staff R) was watching the front door. Staff C stated residents on electronic monitoring devices require supervision. We check equipment for placement and functionality and to know where the resident is throughout the day. Staff C stated it was the responsibility of the resident's assigned CNA along with the nurse and other staff. Staff C stated when Resident #129 was confirmed missing, it was around 4 PM. Staff C said, No one had seen him for about one hour or so. I went around the building and then got in the car and drove around, went up and down US Highway 19 and was looking at least an hour and half. Staff C stated Resident #129 was not found and she returned to the facility. A telephone interview was conducted on 04/20/22 at 10:02 AM with Staff B, Agency LPN. Staff B confirmed she had worked a double shift on 04/16/22, 7 AM-3 PM and 3 PM-11 PM. Staff B stated she was assigned to Resident #129 on both shifts. Staff B stated from the time she arrived that Saturday morning, Resident #129 kept wandering around and appeared forgetful. Staff B confirmed that a CNA almost let the resident out of the building because he thought the resident was a visitor. Staff B stated Resident #129 had an electronic monitoring device on and was hanging out by the front lobby exit door. Staff B said, The fear was that he would run out the door. Staff B stated at some point, Resident #129 had packed his stuff and was walking around with a bag. Staff B said, It concerned me that he was walking around with the bag. I feared he might escape. Staff B stated she spoke to the DON about Resident #129's wandering behaviors, and the DON had said to put Resident #129 on 1 to 1 supervision. Staff B stated Staff C, C.N.A., was on light duty and was to provide the 1:1 supervision. Staff B stated around 1:30 PM she asked Staff C to do vitals for the 300 and 400 hall residents. Staff B stated there was a receptionist (Staff R) in the building who was to keep an eye on Resident #129. Staff B did not report discussing supervision of Resident #129 with Staff R, Receptionist. Staff B stated she was concerned about the evening shift (3 PM-11 PM) because the Receptionist (Staff R) leaves at 4 PM. Staff B stated she last saw Resident #129 on 04/16/22 at 3 PM sitting on his bed. Staff B stated she took a break and when she returned at 4 PM, she did not see Resident #129. Staff B stated she expected Staff C to provide supervision while also attending to other duties. Staff B said, I should have just put him on the 1 to 1 supervision. Staff B said, I didn't expect the CNA not to supervise the resident. I should have never trusted the CNA. I should have made sure he was supervised. I know better. It could have been worse. I did not do the right thing. I take full responsibility. As the charge nurse I should have followed the DON's orders. I didn't expect him to jump the fence. Staff B repeatedly said, I take full responsibility. Staff B stated she did not check if the electronic monitoring device was functioning. Staff B stated she had not received elopement in-services at this facility. Staff B stated she was aware of the elopement protocol from experience. Staff B stated she grabbed the elopement book when she realized she could not locate Resident #129, but found that he was not in the book. Staff B stated she called the elopement code and had CNAs start looking for the resident. Staff B stated she called the DON and the police. Staff B stated that the supervision expectation for a wandering resident was to keep an eye on the resident. Staff B stated that she had been notified that Resident #129 was at risk for wandering by the previous shift. Staff B stated that when the DON came in to do the search, they questioned me and had me do a written statement. The facility's corporate representatives called me yesterday (4/19/22) to find out what I put in place when I found out he was a wanderer. Outside of this, there has been no follow-up after the incident. A review of the facility's written statements pertaining to the investigation of Resident #129's elopement on 04/16/22 revealed no written statement by Staff B. The only information provided by the facility relating to Staff B was an undated employee interview statement completed by the Regional Nurse. The statement indicated Staff B last saw Resident #129 at 3 PM on 04/16/22 in his room. The statement noted employee stated she went outside on break when she came in she asked C.N.A. where he [Resident #129] was and started elopement procedure looking for him. The statement indicated Resident #33 witnessed Resident #129 climbing the fence. The statement said Staff B didn't see the resident as a risk and was in the locked courtyard. The resident was not agitated, was easily redirected and the wander guard was on. On 04/20/22 at 4:43 PM and 5:15 PM, a telephone interview was conducted with the DON. The DON stated she was notified that Resident #129 was exit seeking while she was in the building on Saturday, 04/16/22 around 12:30 PM. The DON stated she had observed Resident #129 in the hallway. The DON stated Staff B, LPN had reported that Resident #129 had an electronic monitoring device on him, but she did not see it. The DON stated she reviewed her phone record and confirmed she spoke to the nurse on duty, Staff B (Agency LPN) on 04/16/22 at 1:16 PM, and she had texted Staff L, Staffing Coordinator at 2:33 PM. The DON stated she asked Staff L, Staffing Coordinator, to place Resident #129 on 1 to 1 with Staff C, CNA. The DON stated Staff B asked Staff C to go inside and pass water to residents instead of providing the 1 to 1 supervision. The DON stated that Staff C left her area of assignment. The DON stated that they have documentation for the 1 to 1 provided on Saturday. (Documentation was requested from facility staff but not provided). The DON stated physician orders were required before an electronic monitoring device was applied. The DON stated whoever puts the device on should have called the doctor to receive the order. The DON stated the nurse should notify the physician of exit seeking behaviors and obtain orders. The DON said, I don't believe the physician was notified. The DON stated on Saturday afternoon (04/16/22) she received a call at approximately 4 PM and was told Resident #129 was nowhere to be found. The DON stated she instructed Staff B to call the police and she responded to the facility immediately and assisted with the search. The DON stated 5 police officers responded to the facility, and they brought in a helicopter to assist with the search. The DON stated that Resident #33 witnessed the elopement in the courtyard and had pointed to the fence. The DON stated that this resident was aphasic and does not speak clearly. The DON stated that it was on 04/16/22 around 4:30 PM when the resident provided this information. The DON stated she called emergency room s in the area in an attempt to locate the resident. The DON stated she called the Assistant Director of Maintenance (ADOM) to come to the building on 04/16/22 to check all the doors to make sure they were functioning. The DON stated that the ADOM said the gate in the back of the gazebo/courtyard area was not locked. The DON said, [The ADOM] yanked on the gate, and it opened. He said it has been like that for months. I was not aware of that. The DON stated the gate had a keypad which she thought was functional. The DON stated she was made aware the gate was not secured at the time the resident eloped. The DON stated she put a staff member in the courtyard to monitor the gate 24 hours a day until a vendor could come in to repair the keypad. The DON stated she was notified Resident #129 was found around 7 PM around [NAME] Blvd and Alternate US-19 and was transferred to the hospital. The DON stated after the incident on 04/16/22 she initiated the investigation, got staff statements and started education. The DON stated the education consisted of reviewing who was at risk, reviewing orders and care plans and filing an immediate federal report. The DON stated that she called the State Agency hotline to report the incident and they did not accept it. The DON stated that on the day of the elopement (4/16/22) she provided the facility with her 30 day notice of resignation. The DON stated, I was too overwhelmed. The DON stated she was at the facility on Monday, 4/18/22 but did not get to fully investigate the incident because the survey started. The DON indicated that she decided to leave the facility before the 30 days and no longer was employed by the facility. (On 04/19/22 at 10:21 AM the Nursing Home Administrator [NHA] informed the survey team that the DON walked out and the ADON would take over as DON until the arrival of the Corporate Chief Nursing Officer who would then fill the role of DON temporarily). An attempt to interview Resident #33, who was said to have observed Resident #129's elopement by going over the courtyard exit gate was conducted immediately following the interview with the DON. The resident could not answer simple questions with words, vocalizations, writing or gestures. The resident was unable to provide any information related to the elopement. On 04/21/22 at 10:42 AM, Staff R, Receptionist stated she remembered Resident #129 because he was roaming the front of the building on Saturday, 04/16/22. Staff R said, He kept coming by the lobby. Staff R stated the door was locked and she thought Resident #129 had an electronic monitoring device, but she did not see the device. Staff R stated on 04/16/22 around 8:15 AM, Resident #129 had come to the lobby, carrying a bag. Staff R stated she did not speak to the resident, but she observed other staff speaking to him. Staff R stated she kept hearing Resident #129 saying he wanted to leave. Staff R stated that Resident #129 said this to a couple different staff members (Staff A and Staff F). Staff R stated she observed Resident #129 attempting to leave between 8:15 AM to 8:45 AM and between 1 PM and 1:30PM. Staff R stated she saw Resident #129 wander from the front lobby through the dining room and out to the courtyard/gazebo area several times. Staff R could not remember if there was staff present in the courtyard. Staff R said she checked on Resident #129 every so often until 2 PM. When asked if she was providing 1 to 1 supervision, Staff R indicated she was not told to provide 1 to 1 and doesn't even know what that means. She said, I don't know how they monitor. I did not see any staff following him around. Staff R confirmed that Resident #129 was not in the elopement book. Staff R stated around 4 PM just before her shift ended, the nurse (Staff B) had asked her to make an overhead page for Resident #129 through the facility's intercom system. Staff R stated after about 10 minutes she heard a second overhead page through the intercom system and realized Resident #129 had not been located. Staff R stated staff then initiated the search. An interview was conducted on 04/20/22 at 12:10 PM with Staff L, Staffing Coordinator. Staff L stated she was not in the building on Saturday, 04/16/22 but received a message from the DON about a resident needing 1 to 1 supervision around 12:45 PM on 01/16/22. Staff L stated she spoke to Staff A, C.N.A. and instructed him to have Staff C, C.N.A. provide the 1 to 1. Staff L stated she did not speak to Resident #129's assigned nurse (Staff B) about the 1 to 1. Staff L stated she received elopement training on Monday, 04/18/22. An interview was conducted with Staff F, CNA on 04/20/22 at 9:27 AM. Staff F stated he saw Resident #129 on Saturday, 04/16/22 around 11 AM - 11:30 AM. Staff F said, I thought he was a family member, and I was stopped by another staff from letting him out. He walked up to the front. He had a bag, like a plastic bag, like a family member would have. Staff F stated after that, he saw the resident a couple of hours later in the courtyard/gazebo area with no staff supervision. Staff F stated the last time he saw Resident #129 was between 1PM and 1:30 PM heading to the front lobby area. Staff F stated the Receptionist was at the door and Staff F along with another staff member, redirected Resident #129 to his room. Staff F stated that he assisted in the search for Resident #129 on 04/16/22 by looking around the doctor's offices across from the facility, but he did not locate the resident. An interview was conducted on 04/21/22 at 11:25 AM with Staff V, an Agency RN. Staff V stated that she admitted Resident #129 around 1:45 PM on Friday, 04/15/22. Staff V stated she did not get a report on Resident #129 prior to his arrival. Staff V stated she reviewed the paperwork the resident arrived with, completed the admission assessments and physician orders. Staff V stated Resident #129 started wandering instantly. Staff V stated Resident #129 wanted to smoke and kept walking out of the room. Staff V stated she did not have an assessment of Resident #129's mental status but figured we needed to keep him from exiting the facility. Staff V stated Staff N, LPN/Unit Manager told her to put an electronic monitoring device on Resident #129. Staff V stated she put the device on Resident #129 on 04/15/22 because he wanted to go out. Staff V said, I kept chasing him around. Staff V stated she did not know the facility policy on wandering residents or electronic device application. Staff V said, I figured the Unit Manager had the orders in place. On 04/21/22 at 11:35 AM, Staff N, LPN/Unit Manager confirmed she had worked on Friday 4/15/22 when Resident #129 was admitted . Staff N stated it was sometime early in the afternoon. Staff N stated she was covering both units that day and did not have any interaction with Resident #129. Staff N could not recall if she was notified the resident was an elopement risk. Staff N said, I might have. I was focused on another resident. Staff N said if a resident was displaying elopement behaviors, the expectation was to call the ph [TRUNCATED]

Based on observation, record review and interviews the facility failed to provide the ordered wound care treatments in a timely manner for one (Resident #3) of three residents reviewed (#1, #2, #3) denying Resident #3 of her right to appropriate health care. Resident #3 was admitted to the facility following a right hemicolectomy for a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The facility initiated the treatment, installed the wound vac, but did not change the dressing for 11 days. The physician was not notified that the dressing was not changed. Nurses recorded that the dressing was changed on 08/15/20 and 08/18/20. Ten days after admission a nurse attempted to change the dressing for the first time. The dressing material (sponge) at that time was adhered to the resident's wound and could not be removed. The resident required hospitalization for antibiotics, pain medication, and surgical debridement of the wound including skin, subcutaneous tissue, and fascia secondary to the adherent wound vac sponge that had not been changed in 11 days. This resulted in an unnecessary hospitalization for Resident #3. Findings included: A review of the record on 09/16/20 revealed that Resident # 3 was admitted to the facility on [DATE] following a stay at an acute care hospital. Pertinent [DIAGNOSES REDACTED]. Resident #3's physician orders [REDACTED]. Resident #3's physician admission orders [REDACTED]. On 08/20/20 an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Resident #3 also received [MEDICATION NAME]-[MEDICATION NAME] 5-325mg ordered to be given with the dressing changes, once on 08/15/20, 08/16/20, 08/18/20, 08/20/20, 08/21/20 and twice on 08/22/20. Review of the treatment administration record (TAR) on 09/16/20 revealed an entry by staff A, Licensed Practical Nurse (LPN) on 08/15/20 at 03:39 AM to record that the dressing change had been completed, as well as an entry by staff B on 08/18/20 at 0224 AM to record that the dressing change had been completed. Review of the nurse progress note showed on 8/11/20 Patient was admitted for the following reason: Wound Care, the pt. had been hospitalized for [REDACTED]. Pt has history [MEDICAL CONDITION] colon Review of the nurse progress notes on 09/16/20 in Resident #3's record revealed entries of an intact and draining wound VAC in place on 08/11/20, 08/12/20, 08/13/20, 08/17/20, and 08/18/20. On 08/20/20 at 18:30 PM a late entry from staff D, RN indicated an alarm from the wound VAC and unsuccessful attempts to change the dressing, a call to the physician for orders, and the application of a wet dressing. On the evening of 08/22/20 Resident #3 was transferred to an acute care hospital for evaluation of her wound. Review of the hospital Discharge Summary dated 8/25/20 for Resident #3 revealed Hospital Course: .female who presented from her rehabilitation facility with reports that the staff was unable to remove the wound VAC sponge from her abdominal wound. The wound had not been changed regularly. She came to the hospital, was admitted .taken to the OR yesterday and underwent debridement of the wound including skin, subcutaneous tissue, and fascia secondary to adherent wound VAC sponge.she can be discharge with home health. A review of the Resident's record on 09/16/20 revealed documented interviews with staff related to the ordered wound care. On 08/25/20 staff interviews were conducted by Staff F clinical regional nurse (CRN) with Staff E and Staff A, during the interview staff A stated that she did not perform wound care on Resident #3 on 08/15/20 and must have signed off the wound care accidentally. Another interview with Staff E and Staff B revealed that Staff B was not aware of any wound vac for Resident #3 and Staff B stated that she had no recollection of signing off on a dressing change for Resident #3 on 08/18/20. Staff E stated that on 08/20/20 she and Staff C tried unsuccessfully to change the wound vac dressing for Resident #3. Other staff interviews conducted by Staff F, CRN revealed that Resident #3's wound vac dressing was not changed after it was placed on 08/11/20 by Staff C, despite being signed off by Staff A on 08/15/20 and by Staff B on 08/18/20. An interview with the Director of Nursing (DON) on 09/16/20 at 17:30 revealed that she could not provide any documentation related to education for the nurses on dressing changes for the wound VAC. A subsequent interview with the Nursing Home Administrator (NHA) on 09/16/20 revealed that she was not the administrator during these events but had reported the allegation of neglect when a family member of Resident #3 later contacted the facility on 08/24/20. A telephone interview with Resident #3's physician on 09/16/20 at 6:10 pm revealed that the nurses did not contact him to tell him that the dressings had not been changed for 11 days. The physician stated that the nurses at the facility should be given an in-service education session by the manufacturer of the wound VAC or their representatives. A review of the hospital record on 09/18/20 revealed that Resident #3 was seen in the emergency room where they were unable to remove the wound vac dressing without possible sedation, and admitted Resident #3 to the hospital on [DATE] for a wound consult. The consulting physician noted Apparently the wound vac was not changed .for 10 days, and now it is too painful to perform with the patient awake .To OR (operating room) to remove wound vac foam . A telephone interview was conducted on 09/21/20 at 2:10 PM with Resident #3 who was recovering at home. Resident #3 stated that her original surgeon removed the sponge surgically on 08/24/20 and she was discharged home on[DATE] and sees the surgeon twice weekly for dressing changes at their offices. Resident #3 also stated that her treatment from the oncologist had to be postponed because of this second surgery. Review of How wound VAC therapy works on Healthline.com revealed, A VAC therapy system includes a vacuum pump, a special bandage, a canister to collect fluid, and tubing. A healthcare provider first fits a layer of foam dressing over the wound, which is sealed with a thin layer of film. The film has an opening that rubber tubing can fit through to connect to a vacuum pump. Once connected, the vacuum pump can remove fluids and infections from the wound while helping to pull the edges of the wound together. Wound VAC dressing change frequency, VAC bandages should be changed two to three times a week. https://www.healthline.com/health/wound-vac#candidates