Every finding on record at Eldorado Rehab & Healthcare

Based on interview, and record review, the facility failed to ensure staff treated a resident with dignity and respect by not interacting in a manner that enhanced self-worth and quality of life for 1 (R1) of 4 residents reviewed for Resident Rights in the sample of 4.Findings Include: R1's, admission Record, documented R1 admitted to the facility on [DATE]. R1's diagnoses listed include cerebral ischemia, other speech and language deficits following cerebral infarction, cognitive communication deficit, aphasia, dysphonia, Parkinsonism, weakness, and transient cerebral ischemic attack. R1's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 14, indicating R1 is cognitively intact. R1's document titled, Summary of Daily Skilled Service, dated 04/03/2026, documented implemented functional transfer training with V3 (Family Member) using V3's vehicle. R1 required max assist with sit to stand transfers, stand pivot transfers, and was dependent with sitting on the very edge of seat in the car. R1 would fall back into a severe posterior lean and would not attempt to move herself in any direction and would not assist with transfer. V8 (Physical Therapy Assistant) provided max assist to hold patient in upright posture. R1 relied on V8 to place R1's lower extremities into the vehicle. R1 was slouched downward in the seat and received max encouragement and prompts. R1 refused to participate two times with V8 and one time with V3. R1 continued to rely on the physical assistance and demonstrated that she is not able to perform a car transfer safely. V8 recommended to V3 that family travel with R1 in a lower vehicle to prevent fall risk. R1 was not cooperative or motivated to participate in car transfers despite encouragement from V8 and V3. It was discussed with V3 and R1 that R1 has reached her plateau in progress with physical therapy services at this time due to noncompliance with exercising and increasing activity during the day as R1 sits in the recliner all day. On 07/07/2026 at 3:31 PM, V3 (Family Member) stated the incident occurred on 04/03/2026 and R1 was working with V8. V3 stated V8 sat down on the bed and was discussing that V8 thought R1 would have gotten more movement back after her stroke. V3 stated V8 asked R1 if she was doing the exercises she was given to be done when not in therapy. V3 stated V8 asked R1 what she did when she was not in therapy. V3 stated V8 was raising her voice to R1. V3 stated V8 said to R1, Look at me, I am talking to you. V3 stated throughout the interaction she was patting R1 on the back. V3 stated V8 was eye level with R1 and was talking to her. V3 stated that V8 had a nosebleed because she was so upset. V3 stated V8 asked R1, Do you remember me giving you therapy? and R1 replied, No. V3 stated this upset V8, and V8 loudly said, I am not going to be accused of Medicaid fraud. V3 stated V8 continued to be loud saying. You can't tell people that I am not here when I am here. V3 stated you could tell this upset V8 a lot. V3 stated V8 then raised her voice and yelled, You could get me fired for saying that. V3 stated she tried to calm V8 down. V3 stated R1 did not realize when she was receiving therapy from someone other than V8, that she was still receiving therapy. V3 stated R1 identifies therapy as V8 only. V3 stated that V8 kept saying she does not want to be accused of fraud, and she doesn't want to get fired. V3 stated V8 stormed out the door and did not come back. V3 stated before V8 left the room she kept telling V8 she has been a blessing to R1 and has got more movement back than anyone else had. V3 stated V8 did a good job working with R1 and that day was the only day there was an issue. V3 stated throughout the interaction R1 did not respond to V8 and kept gazing off. V3 stated R1 has a processing delay, is having transient ischemia strokes and has Parkinson's. V3 stated she did not want to tell on V8. V3 stated V1 (Administrator) called her to discuss the incident. V3 stated she told V1 what had happened and that she still wanted V8 to provide therapy for R1. V3 stated she was never made aware of the outcome of the situation with V8. V3 stated they were never apologized to, and it was brought up in the care plan meeting before R1 was discharged . V3 stated during the care plan meeting, she was told the matter was confidential. On 07/07/2026 at 2:11 PM, V5 (Business Office Manager) stated she was walking from the administrator's office back towards her office down the 100 hall, when she heard V8 saying to R1 in a loud tone, You're going to get me in trouble for Medicaid fraud. V5 stated V8 was sitting down and was close to R1's face. V5 stated V8 sounded very stern and emotional. V5 stated she went and got V9 (Therapy Director). V5 stated herself and V9 went to tell V1 (Administrator). V5 stated she was shocked because she had never heard V8 speak to anyone that way. V5 stated she believes this occurred around April to the First part of May 2026. On 07/07/2026 at 2:45 PM, V8 (Physical Therapy Assistant) stated she was the therapist who was providing care for R1. V8 stated she was working with R1 on the Friday before Easter. V3 stated R1, V3 and herself were working on car transfers, as this was one of the goals that needed to be achieved before R1 could be discharged and it did not go well. V8 stated R1 was blaming V8 for R1 not being able to complete the car transfer. V8 stated this whole situation has been very uncomfortable for her. V8 stated she worked with R1 for many months to get her strong enough to go back home. Originally V3 wanted me to continue seeing R1 after this incident, then changed her mind. V8 stated R1 was accusing her of not seeing her when V8 said she was. V8 stated, I did ask R1 to quit saying that I was not treating her when I was because that could be considered Medicaid Fraud. V8 stated V3 was in the room when this occurred. V8 stated she has never verbally abused any resident she has taken care of. V8 stated she feels the family is blaming her for R1 not getting more movement back from the stroke she had. V8 stated she never yelled at R1. V8 stated that she tries to be a cheerleader and encourage R1 to get better. V8 stated that she was never trying to be negative with R1. V8 stated she sat on the bed, so she was eye level and was trying to be encouraging. V8 stated she asked her to look at her so she could continue encouraging R1. V8 stated R1 stated that V8 was not providing therapy for her and that upset V8. V8 stated V3 kept saying that isn't what R1 means and apologizing for it. On 07/07/2026 at 3:04 PM, V9 (Therapy Director) stated she did not hear V8 yell at R1. V9 stated V3 was talking about it in the hallway. V9 stated she asked V3 about the alleged incident. V9 stated that V3 told her it was a miscommunication and that the car transfer went bad. V9 stated V3 told her that R1 said she wasn't being seen by V8, and that upset V8. V9 stated V3 went on to say that R1 says she doesn't receive therapy when V8 is not there, even if another therapist treats R1. V3 reported to V9 that V8 kept saying you cannot accuse me of Medicaid fraud. V9 stated V3 did not want to report anything at that time, that V3 really felt like it was all a big misunderstanding. V9 stated she went to V1and discussed the situation with her. V9 stated V3 had already left the building so V1 and herself called V3 on the phone. V9 stated that V3 had positive remarks to make about V8 and even called her a blessing. V9 stated during the phone call V3 kept saying V8 was the only therapist that has been able to show this much improvement with R1. On 07/07/2026 at 9:27 AM, V1 (Administrator) stated she was made aware, around lunch time on 04/03/2026, that V8 was in R1's room and was talking very loudly. V1 stated she found it odd that V3 did not come tell her this as she is in her office at least daily. V1 stated she immediately went to R1's room and V3 had already left. V1 stated she spoke to R1 and R1 was only concerned about not receiving therapy. V1 stated she went back to her office and called V3 on the phone. V1 stated V3 kept saying it was water under the bridge, and it was a miscommunication. V3 told V1 that R1 only associates V8 with therapy. V1 stated V3 explained when any other staff member would provide therapy, R1 would not realize that she was receiving therapy. V1 stated V3 said V8 was very worried about losing her job over the accusations R1 was saying. V1 stated V3 gave praise for how good V8 was with R1 and that she did not want a new therapist to see R1. She stated that V3 never told her that V8 was loud, threatening, or abusive. V1 stated V3 just kept saying it was just a miscommunication. V1 stated herself and V9 consulted human resources and V9's boss and agreed that V8 should be written up as customer service. V1 stated V8 was educated about not saying works like Medicaid Fraud to residents and tone. V1 stated last week V3 was in the facility so she could help her with a hearing for a denial on her therapy. On 07/08/2026 at 1:59 PM, V5 stated R1 was in room [ROOM NUMBER] when the incident happened. V5 stated she wouldn't consider it yelling and V8 was being stern and loud. V5 stated when she heard the interaction she stopped at the door. V5 stated as soon as she realized what happened she went to the Administrator about it. On 07/09/2026 at 9:17 AM, V1 stated V8 is a louder person and she was educated on understanding how loud she is and how others can perceive it. V1 stated V8 was also educated on using the words Medicaid fraud. V1 stated those were not words that R1 would have been able to understand. V1 stated after the conversation she had with V3, she did not feel that V8 had abused R1. V1 stated while she was on the phone with V3, V3 kept repeating that it was all a misunderstanding from her mom not understanding that V8 was there every day to provide therapy. V1 stated she investigated the incident as soon as V5 and V9 brought it to her attention. V1 stated she immediately went to R1's room and V3 was already gone. V1 stated herself and V9 called V3 on the phone at 1:39 PM. V1 stated this phone call lasted roughly 18 minutes. During this phone call V3 was praising V8 and did not want the facility to change out physical therapists when she offered that. V1 stated she did not see it as abuse. V1 stated if at any time during the conversation with V3, if she had even suggested any key words that would have made her think it was abuse, she would have investigated it as abuse. On 07/09/2026 at 9:26 AM, V3 stated, R1 is helpless and when V8 was eye level I was scared because I had never witnessed her act that way. V3 stated she was under the impression that it was reported to state by the facility. V3 stated she was told by a facility staff member that nothing ever happened with the incident between R1 and V8. V3 stated when she asked about the outcome in the care plan meeting and was told it was confidential, she realized nothing was probably done, so she decided to report it. On 07/09/2026 at 11:37 AM, V5 stated she does not feel the incident with V8 and R1 was abuse. V5 stated she felt it was inappropriate as it was a heated, emotional, defense to being accused of something. V5 stated she did not see it as abuse. The initial report was received at the State Survey Agency on 07/07/2026 at 3:54 PM via email. It documented:An allegation of verbal abuse was reported by a State Surveyor. Surveyor reports an allegation against V8 (Physical Therapy Assistant). Surveyor states that the allegation is that V8 raised her voice, got in R1's face and said, don't turn your head when I'm talking to you, and made accusation of Medicaid fraud. R1 was discharged home on May 31, 2026. V8 has been suspended pending investigation. Attending Physician, Power of Attorney, Local Police and Ombudsman have been notified. Final report within 5 days. The final report was reported to IDPH on 07/08/2026 at 4:59 PM via email, documenting: Interviewable residents were interviewed, including those that are on therapy case load, with no one reporting that V8 had mistreated or spoken inappropriately to them. Facility staff were interviewed with no one reporting that they have witnessed V8 being abusive in any way. This issue was previously reviewed, and V8 was disciplined according to facility policy for unprofessionalism on 4/6/2026. After a thorough investigation we do not substantiate verbal abuse with this incident. Attending Physician, POA, and Ombudsman will be notified of the investigation findings. V8's Employee counseling form documented on 04/06/2026 that V8 was counseled/educated on professionalism, tone of voice and late documentation. Under the section titled, Action to be Taken to Improve Performance, it stated V8 will be mindful of tone of voice and use motivation tools that remain positive in presentation. V8 will remain professional in all treatment approaches and family interactions. The facility policy titled, Quality of Life - Dignity, documented, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity and respect means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice.

Based on interview and record review the facility failed to report an allegation of staff to resident verbal abuse timely to the State Survey Agency and local law enforcement for 1 (R1) of 4 residents reviewed for abuse in the sample of 4.Findings include:R1's, admission Record, documented that R1 admitted to the facility on [DATE]. R1's diagnoses include cerebral ischemia, other speech and language deficits following cerebral infarction, cognitive communication deficit, aphasia, dysphonia, Parkinsonism, weakness, and transient cerebral ischemic attack. R1's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 14, indicating that R1 is cognitively intact. On 07/07/2026 at 9:27 AM, V1 (Administrator) stated she was made aware, around lunch time on 04/03/2026, that V8 was in R1's room and was talking very loudly. V1 stated she immediately went to R1's room and V3 (Family Member) had already left. V1 stated she spoke to R1 and R1 was only concerned about not receiving therapy. V1 stated she went back to her office and called V3 on the phone. V1 stated during the conversation with V3, V3 never once said anything about abuse. V1 stated the conversation that she had with V3 did not lead her to believe V3 was making an abuse accusation. V1 stated if she had been told an abuse allegation, she would have handled the situation differently. V1 stated V3 never told her that V8 was loud, threatening, or abusive. V1 stated V3 just kept saying it was just a miscommunication. On 07/07/2026 at 1:05 PM, V4 (Chief Operating Officer) stated the facility has no verbal abuse allegations that have been reported. The initial report was received at the State Survey Agency on 07/07/2026 at 3:54 PM via email. It documented:An allegation of verbal abuse was reported by a State Agency Surveyor. Surveyor reports an allegation against V8 (Physical Therapy Assistant). Surveyor states that the allegation is that V8 raised her voice, got in R1's face and said, don't turn your head when I'm talking to you, and made accusation of Medicaid fraud. R1 was discharged home on May 31, 2026. V8 has been suspended pending investigation. Attending Physician, Power of Attorney, Local Police and Ombudsman have been notified. Final report within 5 days. The final report was reported to the State Survey Agency on 07/08/2026 at 4:59 PM via email, documenting: Interviewable residents were interviewed, including those that are on therapy case load, with no one reporting that V8 had mistreated or spoken inappropriately to them. Facility staff were interviewed with no one reporting that they have witnessed V8 being abusive in any way. This issue was previously reviewed, and V8 was disciplined according to facility policy for unprofessionalism on 4/6/2026. After a thorough investigation we do not substantiate verbal abuse with this incident. Attending Physician, POA, and Ombudsman will be notified of the investigation findings. On 07/09/2026 at 9:05 AM, V9 (Director of Therapy) stated at no point in the conversation with V3 did V3 ever mention any words that would have made me think it was abuse. V9 stated V3 just kept saying it was a miscommunication and that she thought V8 was a blessing to R1. V9 stated V3 said it was water under the bridge and wanted V8 to continue seeing R1. V9 stated if V3 thought it was abuse, why would she want V8 to continue seeing R1. On 07/09/2026 at 9:17 AM, V1 stated after the conversation she had with V3, she did not feel that V8 had abused R1. V1 stated while she was on the phone with V3, V3 kept repeating that it was all a misunderstanding from her mom not understanding that V8 was there every day to provide therapy. The facility Policy titled, Abuse Prevention, dated 08-16-2025, documented: VII. External Reporting of Potential Crime and Abuse1. Reporting of allegations. Upon report of any allegation of a crime, suspicion of a crime, potential abuse, neglect, mistreatment or exploitation, the administrator is required to notify the Illinois Department of Public Health, the local police, and the ombudsman immediately or within 1 hour of the alleged violation.

Based on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for 1 (R1) of 4 residents reviewed for abuse in the sample of 4. Findings include:R1's, admission Record, documented that R1 admitted to the facility on [DATE]. R1's diagnoses include cerebral ischemia, other speech and language deficits following cerebral infarction, cognitive communication deficit, aphasia, dysphonia, Parkinsonism, weakness, and transient cerebral ischemic attack. R1's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 14, indicating that R1 is cognitively intact. The initial report was received at the State Survey Agency on 07/07/2026 at 3:54 PM, via email. It documented:An allegation of verbal abuse was reported by a State Agency Surveyor. Surveyor reports an allegation against V8 (Physical Therapy Assistant). Surveyor states that the allegation is that V8 raised her voice, got in R1's face and said, don't turn your head when I'm talking to you, and made accusation of Medicaid fraud. R1 was discharged home on May 31, 2026. V8 has been suspended pending investigation. Attending Physician, Power of Attorney, Local Police and Ombudsman have been notified. Final report within 5 days. The final report was reported to the State Survey Agency on 07/08/2026 at 4:59 PM, via email, documenting: Interviewable residents were interviewed, including those that are on therapy case load, with no one reporting that V8 had mistreated or spoken inappropriately to them. Facility staff were interviewed with no one reporting that they have witnessed V8 being abusive in any way. This issue was previously reviewed, and V8 was disciplined according to facility policy for unprofessionalism on 4/6/2026. After a thorough investigation we do not substantiate verbal abuse with this incident. Attending Physician, POA, and Ombudsman will be notified of the investigation findings. R1's electronic medical record was reviewed and there was no documentation of the incident. On 07/07/2026 at 2:11 PM, V5 (Business Office Manager) stated she was walking from the administrator's office back towards hers when she heard V8 (Physical Therapy Assistant) saying to R1 in a loud tone, You're going to get me in trouble for Medicaid fraud. V5 stated she went and got V9 (Therapy Director). V5 stated herself and V9 went to tell V1 (Administrator). On 07/07/2026 at 3:04 PM, V9 (Therapy Director) stated she did not hear V8 yell at R1. V9 stated V3 was talking about it in the hallway. V9 stated she asked V3 about the alleged incident. V9 stated she went to V1 (Administrator) and discussed the situation with her. V9 stated V3 had already left the building so V1 and herself called V3 on the phone V9 stated at no time during the conversation did V3 allege any allegations of abuse. On 07/07/2026 at 9:27 AM, V1 (Administrator) stated she was made aware, around lunch time on 04/03/2026, that V8 was in R1's room and was talking very loudly. V1 stated she immediately went to R1's room and V3 had already left. V1 stated she spoke to R1 and R1 was only concerned about not receiving therapy. V1 stated she went back to her office and called V3 on the phone. V1 stated during the conversation with V3, V3 never once said anything about abuse. V1 stated the conversation that she had with V3 did not lead her to believe V3 was making an abuse accusation. V1 stated if she had been told an abuse allegation, she would have handled the situation differently. V1 stated V3 never told her that V8 was loud, threatening, or abusive. V1 stated V3 just kept saying it was just a miscommunication. On 07/09/2026 at 9:17 AM, V1 stated after the conversation she had with V3, she did not feel that V8 had abused R1. V1 stated she investigated the incident as soon as V5 and V9 brought it to her attention. V1 stated she immediately went to R1's room and V3 was already gone. V1 stated she and V9 called V3 on the phone at 1:39 PM. V1 stated this phone call lasted roughly 18 minutes. V1 stated she did not see it as abuse. V1 stated if at any time during the conversation with V3, if she had even suggested any key words that would have made her think it was abuse, she would have investigated it as abuse. The facility Policy titled, Abuse Prevention, dated 08-16-2025, documented: VI. Internal Investigation of Abuse, Neglect, or Misappropriation Allegations and Response 1. All incidents will be documented, whether or not abuse occurred, was alleged or suspected.2. Any incident or allegation involving abuse, neglect or misappropriation will result in an abuse investigation.

Based on interview, observation and record review, the facility failed to provide nutritional supplements as ordered for 2 of 3 residents (R1 and R13) reviewed for nutrition in the sample of 17.Findings include:1. R1's admission record dated 11/25/25 documents an admission date of 10/18/21. The same admission record documents diagnosis including but not limited to muscle weakness, vitamin deficiency, vitamin D deficiency, constipation, thrombocytosis, hyperlipidemia, osteoporosis, reduced mobility, and unsteadiness on feet.R1's physician order sheet dated 11/25/25 documents the following current orders including but not limited to health shake to be administered one time per day at lunch with a start date of 12/11/24, power pudding at lunch and supper, and ice cream at lunch both with a start date of 7/31/25.R1's current care plan documents a focus area indicating R1 is at risk for weight loss dated 10/18/21. Interventions for that focus area include but are not limited to antidepression medication as ordered for appetite dated 7/29/25, and diet as ordered dated 10/18/21. Another focus area on the same care plan documents R1 is at risk for alteration in skin integrity dated 10/18/21. Interventions for this focus area include but aren't limited to provide supplements as ordered dated 10/18/21.R1's Minimum Data Set (MDS) dated [DATE] documents in section GG that R1 requires at least supervision or touching assistance for eating. R1's dietary notes by V6 on Nutritional Care Form dated 8/29/25 documents R1 should have a nutritional supplement of ice cream with lunch.R1's dietary notes by V6 on the Nutrition Care Report dated 11/19/25 documents R1's health shakes to be increased to three times daily with meals.On 11/24/25 at 1:06 P.M., observed R1's lunch tray not to contain her health shake and ice cream on tray that was ordered. R1's meal ticket lying on tray documents R1 was to have a health shake and ice cream at lunch with her regular meal.On 11/24/25 at 2:00 P.M., V17, Dietary Aide stated he would expect residents' ordered supplements to be on the residents' trays when they leave the kitchen. V17 stated the reason R1's ice cream supplement at lunch time wasn't on her tray was because the facility ran out of ice cream yesterday and haven't gotten any in lately. V17 stated the facility is supposed to get a shipment of ice cream in tomorrow. V17 stated the facility runs out of ice cream frequently due to using ice cream with fruit as a frequent dessert for meals. V17 stated he thought he had put R1's ordered health shake on her lunch tray but possibly could have forgotten. On 11/24/25 at 2:05 P.M., V12, CNA (Certified Nurse Aide) stated she does not remember seeing R1's ordered health shake on her tray at lunch time meal.On 11/25/25 at 1:04 P.M., V5, Dietary Manager stated any ordered nutritional supplements should go out with the meal tray they are ordered to be administered with. V5 stated there is no reason they should not be included on the meal tray. V5 stated the reason the ice cream supplement wasn't included on R1's tray yesterday was because the facility was out of ice cream. V5 stated the supplements reportedly missing from R1's tray was unacceptable. V5 stated all supplements should be on the trays when they leave the kitchen. 2. R13's admission record dated 11/25/25 documents an admission date of 1/15/18. R13's admission record documents diagnosis including but not limited to hypothyroidism, anorexia, gastro-esophageal reflux disease with esophagitis, osteoporosis, and dysphagia.R13's physician's order sheet dated 11/25/25 documents orders including but not limited to regular diet with mechanical soft texture, regular liquid consistency, health shake three times per day with meals.R13's most recent care plan documents a focus area for the potential for a nutritional problem dated 11/24/23. Interventions for this focus area include but aren't limited to invite R13 to activities that promote additional intake dated 11/24/23 and provide and serve diet as ordered dated 11/24/23. Another focus area on same care plan documents R13 had potential for impairment to skin integrity dated 11/24/23. Interventions for this focus area include but aren't limited to encourage good nutrition and hydration to promote healthier skin dated 11/24/23. Another focus area for R13 documents R13 has osteoporosis dated 11/24/23. Interventions documented for this focus area include but aren't limited to encourage intake of dairy products, cereals enriched with calcium and vitamin D dated 11/24/23. R13's MDS dated [DATE] documents in section GG R13 is a set up/clean up assistance for eating.R13's dietary notes by V6, Registered Dietician dated 10/31/25 documents R13 had significant weight loss the past 2-3 months. Weight loss has slowed down. Current body mass index is low for age. R13 tolerates liquids better than solids. It is appropriate to add supplement with meals to provide nutrient dense liquid option for better tolerance related to pain with swallowing.On 11/24/25 at 1:00 P.M., observed R13's lunch tray not to contain the health shake on her tray. R13's meal ticket lying on her tray documents R13 was to have a health shake administered with her lunch time meal.On 11/24/25 at 2:00 P.M., V17, Dietary Aide stated he would expect residents' ordered supplements to be on the residents' trays when they leave the kitchen. V17 stated the reason R13's ordered health shake wasn't on her lunch tray was because V17 had simply forgotten to put it on the tray. On 11/24/25 at 3:16 P.M., V9, Registered Nurse stated she would expect any nutritional supplements ordered by the medical doctor to be on the tray when they go out of the kitchen. On 11/25/25 at 1:04 P.M., V5, Dietary Manager stated any ordered nutritional supplements should go out with the meal tray they are ordered to be administered with. V5 stated there is no reason they should not be included on the meal tray. V5 stated the supplements reportedly missing from R13's tray was unacceptable. V5 stated all supplements should be on the trays when they leave the kitchen. On 11/25/25 at 4:05 P.M., V1, Administrator stated she would expect the nutritional supplements to be administered as ordered to all residents. V1 agreed some of the possible adverse outcomes that could stem from residents not receiving their ordered nutritional supplements could include but not be limited to weight loss, loss of muscle mass affecting balance, strength, mobility, and prolonged or decreased ability to heal.On 11/25/25 at 2:32 P.M., V7, Medical Doctor stated she would expect the facility to administer or at least offer the nutritional supplements to R1 and R13 as they are ordered. V7 stated if nutritional supplements are not administered as ordered it could cause a decline in the affected resident's overall health, cause malnourishment if they are already prone to that, can increase the adverse effects of her chronic illnesses, affect her ability to heal, maintain weight and muscle mass.On 11/25/25 at 2:44 P.M., V6, Registered Dietician stated she would expect the facility to administer the ordered nutritional supplements as ordered by the medical doctor and recommended by her. V6 stated if nutritional supplements are not administered as ordered to the residents it could cause decrease in ability to heal, further weight loss, decrease in muscle mass, causing further weakness, and increased risk of falls.

Based on interview and record review, the facility failed to develop a comprehensive person centered Care Plan for 1 (R43) of 19 residents reviewed for comprehensive care plans in a sample of 33. Findings include: R43's Admission Record documents an admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's dementia, acute kidney failure, urinary tract infection, atrial flutter, diverticulosis, diabetes mellitus type 2 and general anxiety disorder. R43's Care Plan in the Electronic Health Record (EHR) documented only two focus areas that included: Advanced directives and long term residency. The Care Plan is undated but lists an admitted [DATE]. On 4/16/2025 at 9:15AM, V31 (Care Plan Coordinator) reviewed R43's EHR and said R43's Care Plan was never developed as far as she could tell. V31 said it only has two focus areas, advance directives and long term residency. V43 said it looks like R43's Care Plan was started but not finished. V43 said she was not the Care Plan Coordinator at the time R43's Care Plan was supposed to be developed. V31 said she might have a Baseline Care Plan for R43 in her desk drawer, but she would have to look. V31 agreed a Baseline Care Plan in her locked office in the drawer was not accessible to the staff for guiding R43's care. On 4/16/2025 at 9:05AM, V2 (Director of Nursing) said she did not know why, but R43's Care Plan had not been completed. V2 said R43's Care Plan should have more than advanced directives and long term residency as focus areas on it. V2 agreed R43 did not have a personalized comprehensive care plan developed after she was admitted to this facility. On 4/17/2025 at 10:30am, V21 (Corporate Nurse) said she could not find a Comprehensive Care Plan for R43.

Based on interview and record review, the facility failed to ensure residents who require assistance with bathing receive frequency of showers as scheduled/preferred for 3 (R35, R39, R7) of 4 residents reviewed for Activities of Daily Living assistance in a sample of 33. Findings include: 1. R35's Admission Record in the Electronic Health Record (EHR) document R35 was admitted to this facility on 11/22/2021 with diagnoses of cerebral infarction, muscle wasting, muscle atrophy, hemiplegia and hemiparesis. R35's Minimum Data Set (MDS) dated [DATE] documented R35 had a Brief Interview for Mental Status (BIMS) score of 12, indicating R35 is cognitively intact. This same MDS documented R35 has impairment of one side of his upper and lower extremities, needs set up/clean-up assistance for showering or bathing and does not reject care. On 4/14/2025 at 1:30PM, R35 said he is supposed to get two showers per week but does not get them. R35 said he wants his showers twice per week, but most of the time he only gets one shower per week and has to go 7 or 8 days in between showers. R35 said he was scheduled for showers on Tuesday and Friday evenings. R35's Skin Monitoring Comprehensive CNA (Certified Nursing Assistant) Shower Review received from V1 (Administrator) documented R35 received 12 of the 20 scheduled showers from February 1, 2025 through April 9, 2025. R35 received showers on 2/5, 2/11, 2/14, 2/21, 2/28, 3/7, 3/13, 3/18, 3/25, 4/2, 4/8, and 4/9 and refused showers on 2/18 and 3/28. 2. R39's Admission Record in the EHR documented R39 was admitted to this facility on 9/1/2024 with diagnoses of dementia and hemiplegia with right dominant side affected. R39's MDS dated [DATE] documented R39's cognitive impairment is too severe to participate in the testing. This same MDS documented R39 has physical impairment to both upper and lower extremities and is dependent on staff for all activities of daily living. On 4/14/2025 at 12:39PM, R39 was observed in the facility's dining room with very dry flaky skin noted to his scalp and face. On 4/15/2025 at 12:30PM, R39 was observed in the facility's dining room with the same dry flaky skin noted to his scalp and face. R39's Skin Monitoring Comprehensive CNA Shower Review documentation received from V1 from February 1, 2025 through April 9, 2025 documented that R39 received showers on 2/2, 2/8, 2/12, 2/19, 3/12, 3/19, 3/26, 3/31, 4/2 and 4/9 and received bed baths on 2/26, 3/5, and 3/15. The facility's shower schedule with revision date of 10/02/2024 documented R39's showers are scheduled on Wednesdays and Saturdays. On 4/16/2025 at 2:05pm, V22 (Certified Nursing Assistant/CNA) said R39 does not refuse showers and all the residents are supposed to be showered twice per week. On 4/16/2025 at 9:15AM, V9 (Licensed Practical Nurse/LPN) said residents are supposed to get showered twice per week according to the shower schedule which goes by room number. On 4/16/2025 at 9:25AM, V12 (CNA) said residents get two showers per week. If a resident refuses, then they are supposed to document the refusal on the shower sheet and turn it in to the nurse. On 4/16/2025 at 9:35AM, V2 (Director of Nursing/DON) said showers are to be given twice per week according to the shower schedule. V2 said she expects the residents to be showered as scheduled. 51792 3. R7's Admission Record documented R7 was admitted to the facility on [DATE] and include diagnoses of muscle weakness (generalized), unsteadiness on feet, and other reduced mobility. R7's MDS dated [DATE] documented a BIMS score of 14, indicating R7 was cognitively intact. In the section titled Functional Abilities under Self-Care, the MDS documented R7 requires substantial/maximal assist for showering/bathing, meaning the helper does more than half the effort . On 04/14/25 02:25PM, R7's hair appeared greasy and unkempt/uncombed. R7 stated We don't get our showers on time. We often only get a shower once a week. On 04/16/25 at 10:05 AM, R7 stated that her shower days are scheduled for Mondays and Thursdays. On 04/16/25 09:07AM, R7's Skin Monitoring Comprehensive CNA Shower Review documentation received from V1 from February 1, 2025 through April 12, 2025 documented that R7 received showers on printed shower sheets obtained from V1 documented R7 had showers on the following days: 2/2/25, 2/9/25, 2/14/25, 2/18/25, 2/24/25, 2/28/25, 3/5/25, 3/10/25, 3/13/25, 3/20/25, 3/27/25, 3/31/25, 4/7/25, 4/8/25, and 4/12/25. The facility policy titled Bath, Shower/Tub with a revision date of February 2018, documents the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Guideline #5 documents Each resident shall have at least one complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene.

Based on observation, interview, and record review, the facility failed to ensure bed rails/enablers were installed in accordance with manufacturer's recommendations and specifications for 1 (R7) of 1 resident reviewed for bed rails in the sample of 33. Findings include: R7's Admission Record documented R7 was admitted to the facility on [DATE] and included diagnoses of muscle weakness (generalized), unsteadiness on feet, other reduced mobility, cerebral infarction, unspecified, and hemiplegia, unspecified affecting left nondominant side. R7's Minimum Data Set (MDS) dated [DATE] lists her functional limitation in range of motion impairment as on one side for upper extremity and lower extremity. R7 MDS documented she uses a wheelchair as a mobility device, and requires substantial/maximal assistance in the following areas: upper and lower body dressing, roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed, and for lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support. R7's Care Plan dated 12/26/24 documented a Focus Area of the resident is at risk for falls deconditioning, gait/balance problems, incontinence. Corresponding interventions listed for this focus area are low bed and mobility bar to bed. On 04/14/25 at 10:00 AM, R7's bed was observed to have bed rails/enablers attached to the bed frame via zip ties. R7 stated that she was moved from her usual room, and unable to take her mattress and bed frame with her, but these rails were from her previous bed. R7 said that the staff told her that they could not bolt the bed rails/enablers she used to this specific bed frame in the new room, because it would void the warranty. R7 stated she was told the bed rails were not made for this bed frame, and the facility did not have the correct bed rails for that bed frame. R7 said that the bed rails/enablers are loose and do not assist her bed mobility as much as when they were bolted to the bed. At this time, surveyor grabbed a hold of the bed rails to check for stability and noted them to be wobbly/unstable. The rails were easily moved back and forth and up/down. On 04/15/25 at 01:26 PM, the bedrails/enablers on R7's bed were again observed to be attached to R7's bedframe via zip ties and were not anchored with nut and bolt or otherwise securely attached. On 04/15/25 at 01:32 PM, V10 (Licensed Practical Nurse/LPN) stated R7 does use the enablers to reposition herself. V10 stated that she has seen R7 use them frequently to reposition herself in bed and to pull herself up in bed. V10 further stated, if R7 did not have them, it would be more difficult for her to reposition herself without the assistance of staff. On 04/15/25 01:36 PM, V23 (Certified Nurse Aide/CNA) stated that R7 uses her bedrails/enablers every day to reposition and move herself around in bed. V23 said She (R7) needs them for her bed mobility. She uses it even when we get her up out of bed. She uses them to help her stand even when they are using the gait belt. On 04/15/25 at 01:48 PM, V24 (Maintenance Supervisor) stated that the enablers are attached to the bed using thick/wide zip ties. V24 said these are not the correct rails for this bed, and this was the only way to attach them to the bed until the correct bed rails/enablers come in that the facility has ordered. The facility is currently waiting on the rails designed for that bed. V24 said if he drills holes in the bed, it will void the warranty. V24 said that on R7's old bed, they were bolted on. This surveyor described the observation of R7's bed rails being unstable/loose to V24, and V24 stated he understood that, but this was the best solution the facility could come up with until the correct bed rails/enablers arrived and could be installed. V24 was asked for a user manual or manufacturer's instructions for R7's bed, and V24 stated they did not have one. On 04/16/25 at 10:05 AM, R7's bedrails/enablers were observed to be securely attached to the bed frame using nuts and bolts, two per bed rail/enabler. On 4/16/25 at 10:05 AM, R7 said that her bed rails/enablers had been attached with zip ties about 4 days ago from today and had been attached like that until this morning. The facility's Bed Safety Policy dated December 2007 states, Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit. When using side rails for any reason, the staff shall take measures to reduce related risks.

Based on interview and record review the facility failed to develop a plan for appropriate treatment and services for a resident with dementia for 1 (R43) of 19 residents reviewed for dementia care in a sample of 33. Findings include: R43's Admission Record document she was admitted to this facility on 1/18/2025 and include a diagnosis of Alzheimer's dementia. R43's Minimum Data Set (MDS) dated [DATE], documented R43 has severe cognitive impairment and could not participate in cognitive testing. This same MDS documented R43 needs maximum to total assistance for all activities of daily living. R43's Care Plan documented two focus areas that included: Advanced directives and long term residency. The Care Plan is undated but lists an admitted [DATE]. R43's Care Plan did not include a plan for R43's Alzheimer's dementia or cognitive decline. On 4/16/2025 at 9:15 AM, V31 (Care Plan Coordinator) reviewed R43's Care Plan in the EHR and said R43's Care Plan was never developed. V43 said it looks like R43's Care Plan was started but not finished and should have more than two focus areas on it. V31 said R43's Care Plan did not include a plan to treat or provide services for R43's dementia or cognitive decline. On 4/16/2025 at 9:05 AM, V2 (Director of Nursing) said she did not know why, but R43's Care Plan had not been completed. V2 said R43's Care Plan should have more than advanced directives and long term residency as focus areas on it. V2 agreed R43 did not have a comprehensive care plan developed after she was admitted to this facility. V2 said R43's Care Plan should have addressed R43's Alzheimer's dementia and included a plan for treatment and services. On 4/17/2025 at 10:30 AM, V21 (Corporate Nurse) said she could not find a comprehensive plan of care for R43's Alzheimer's dementia or cognitive decline.

Based on observation, interview, and record review the facility failed to ensure medications were administered safely for 2 of 5 residents (R2 and R3) reviewed for medication administration in sample of 7. The findings include: R2's Admission Record documents an admitted [DATE] and includes diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Reduced Mobility, Anxiety, and Major Depressive Disorder. R2's Minimum Data Set (MDS) dated [DATE] documents in Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 is cognitively intact. The same MDS documents in section E, Behaviors, is coded 0 for behaviors. R2's Order Summary Report dated 8/28/2024 does not include orders for Nystatin Powder. R2's Care Plan with a revision date of 7/27/24 does not include focus area or interventions addressing behaviors or R2's ability for self-administration of medications. On 8/28/2024 at 11:10 AM, R2 was observed sitting in her room. A bottle labeled Nystatin Powder was observed sitting on the bedside table next to R2. The bottle was 1/2 full and contained powder. The pharmacy label on the bottle documented R2's name and instructions to apply Nystatin powder 4 times a day for 10 days with order date of 4/3/2024. R2 was alert and oriented to person, place, and time. R2 stated she applied the medication (Nystatin Powder) herself and she still applies the powder under her breast at times. R2 stated she normally keeps it in her bin, but she has been using it, so she sat it on her bedside table. R3's Face Admission Record documents an admitted [DATE] with diagnoses including Major Depression Disorder, Anxiety, Ulcerative Colitis, and Parkinson's Disease with Dyskinesia. R3's MDS dated [DATE] includes a BIMS score of 9, indicating R3 has moderate cognitive impairment. R3's Order Summary Report Physician dated 8/28/2024 documents current orders for Sulfasalazine 500 mg (milligrams) oral tablet, give 2 tablets by mouth three times a day related to ulcerative colitis, and Carbidopa-Levodopa tablet 25-250mg, give 1 tablet by mouth three times a day for Parkinson's disease related to Tremors. On 8/28/2024 at 11:35 AM, R3 was observed in her room lying in bed asleep. A medication cup containing 1 blue pill and 2 orange pills were observed sitting on bedside table in R3's room. At this time, V6 (Registered Nurse) walked by R3's room. V6 was asked about the medication cup that contained the 3 pills and V6 stated this is not my hall so I didn't leave the pills there, those shouldn't be there. V6 identified the resident lying in the bed as R3 and stated that she is confused. On 8/28/2024 at 11:40AM, V2 (Director of Nursing) entered R3's room. R3 was then sitting up on the side of the bed. R3 noted to be confused. R3 was asked if those were her medications sitting on the bedside table and R3 stated I guess they are. V2 stated well (R3) is very slow at taking her medications, it takes a long time, and she won't take her medications until she is ready to take them. V2 was asked if it is their policy to leave medications at bedside and V2 replied no, it isn't. V2 was asked who the medication nurse that was working the hall and she stated V8 (Registered Nurse). V2 then took the medications and left the room. V2 was asked if R3 could make her own decisions, V2 stated No. V2 then took the medications and left the room. On 8/28/2024 at 12:30 PM, V8 (Registered Nurse) was asked if she was the medication nurse for R3 and V8 stated yes, I am. V8 was asked is R3 was confused, V8 stated yes, she is confused most of the time. V8 was asked if she left medications sitting on the bedside table in R3's room, V8 stated (R3) has this funny thing about wanting to keep them in her room, sometimes she refuses to take them until she eats her cereal, so you just have to go along with her because she is confused, I do it all the time. V8 was asked if she leaves medications in R3's room frequently and she stated, yes because she wants us to. V8 was asked if she knows what the facility policy is on medication administration, V8 stated Our policy says we should not do that. We should probably stand there until she takes them. V8 was asked to pull R3's medication cards from the medication cart to identify what medications were in the medicine cup on R3's bedside table. V8 pulled R3's medication cards and identified that the medications were the 12 PM doses Sulfasalazine 500 mg 2 tablets and Carbidopa-Levodopa 25/250 mg one tablet per the pharmacy label on the medication cards. V8 stated yes, these are the medications that were left in R3's room. On 8/28/2024 at 1:15PM, V2 DON (Director of Nursing) stated her expectation is that medications are not left at the bedside unless ordered by the physician. V2 was asked if R2 and R3 had assessments done to be able to self-administer medications, V2 stated I am not sure and I don't know if those type of assessments are in PCC (Point Click Care). V2 stated she recently did education to the nurses on narcotic counts and medications. V2 stated, she can't say she has never seen medications left at bedside, but she hasn't seen any medications at the bedside lately, at lease the last several months except creams and powders. V2 was asked about R2's Nystatin Powder left at bedside. V2 stated (R2) has behaviors and will not let us take the powder. V2 stated R2 is alert and oriented and knows everything going on and she will not let us remove the medicated powder from her room. V2 was asked if she felt Nystatin powder was a prescribed medication, V2 stated yes, it is. V2 was asked if she realized the order was dated for 4/3/2024 and was for 10 days, she stated she would have to check. V2 wasn't sure if the physician was aware R2 was still using the medication. V2 was asked if R2 had an assessment for self-administration of medications and she stated she didn't know because she doesn't know if (name of electronic health record system) has those assessments. Documentation of an assessment to determine R2's ability to self-administer medications were requested at this time for review and none were provided during the survey. The facility policy titled Medication Administration (revision date December 2012) documents a Policy Statement of Medications shall be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation step #24 documents Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. results were observed and the person administering the drug. The facility policy titled Self-Administration of Medications (revision date December 2016) documents a Policy Statement of Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The Policy Interpretation and Implementation documents the following: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 9. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.

Based on observation, interview and record review, the facility failed to protect a resident's right to be free from neglect when they failed to: 1. appropriately assess a resident at risk for wandering, 2. ensure wandering and elopement behavior attempts were immediately reported to nursing staff, 3. ensure residents who elope were provided care and services in a manner to confirm safety, 4. immediately and thoroughly investigate an incident of elopement, 5. revise and individualize a resident's plan of care to prevent further attempts of elopement, and 6. conduct a physical assessment to ensure wellbeing immediately following an elopement for 1 (R59) of 2 residents reviewed for abuse in the sample of 40. This failure resulted in R59, who has a diagnosis of dementia with severe cognitive impairment, eloping from the facility on 12/29/23. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 12/29/23 when R59 walked to his previous home location approximately 2 blocks from the facility in 33-34 degree Fahrenheit temperatures with precipitation. R59 was followed by staff to this home location where V20 (Family Member) currently resided. At the time of this occurrence, there was an active Adult Protective Services case involving V20 and R59. Facility staff then left R59 at the home with V20 and returned to the facility, only for R59 to be later observed ambulating in the community alone. R59 later walked back to the facility, remaining alone, with no physical assessment conducted to observe for injuries immediately upon his return. R59's Clinical Record documented continuing wandering behavior with attempts of elopement following this incident with no facility-initiated revisions documented to R59's care plan. V1 (Administrator), V2 (Director of Nursing/DON), V19 (Director of Clinical Operations), and V23 (Chief Executive Officer/CEO) were notified of the Immediate Jeopardy on 2/9/24 at 3:13PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 2/9/24 but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member & Power of Attorney/POA) and V22 (Family Member). R59's Minimum Data Set with an assessment reference date of 1/4/24 documented a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section E0900 documents 0, indicating the behavior was not exhibited to the question has the resident wandered. R59's (Name of town) Primary Care record found in R59's Electronic Health Record, documented a visit on 12/7/23 with a chief complaint being to establish care. This document stated, Patient has been here in the past. It has been over 4 years since he was last seen in this clinic. He is here today with his sister to reestablish care. Over the past 2 years, she has noted a decrease in his mental status. He seems to be having problems with short-term memory. There is a family history of dementia in their father. The history of stroke is uncertain. He was hit by a semi several years ago in front of the (Store Name) here in town. He did sustain a significant head injury at that time .He does have some problems with his vision. This seems to be a problem when trying to watch TV as he cannot use his remote. He also likes to walk around town. He reports almost being hit by a semi couple days ago. According to his sister, approximately 18 months ago she became involved with his care when he showed up at her house and was quite disheveled. Since then she has worked on getting him help set up He does tend to sleep from 5 or 6:00 PM until 4:30 in the morning. At that time he does like to get up and walk around town . Local hospital Emergency Department (ED) notes dated 12/28/23 at 10:38 AM, documented R59 was seen for chief complaints of altered mental status and hallucinations. This document stated R59 was brought to the ED by family members and friends who stated R59's complaint symptoms had been going on for the last 18 months but worsened over the last 2 weeks. After workup, the Clinical Impression listed is Thoracic aortic aneurysm, unspecified part, unspecified whether ruptured; and Cardiac arrhythmia, unspecified cardiac arrhythmia type. A case management note documented report included family concerns with R59's current living apartment arrangements which state R59 has been found outside his apartment multiple times, locked out, and ultimately confused how to operate a key fob to get into the apartment. Not eating as he should and suspected hallucinations. Both R59's (Name of Town) Primary Care document and Local hospital ED documents as listed above were observed to be scanned into R59's Electronic Health Record in a folder titled, Referral Documents. R59's Elopement Risk Tool, documented as being completed by V2 (Director of Nursing/DON) on 12/28/23 at 8:14 PM, stated R59's Elopement Risk Summary was determined to be, Resident has not been found to be at risk for elopement at this time. Entries included on this same tool documented: Yes for the question, Has the family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? Yes, Additional Details: Early onset of dementia for the question, Does the resident display cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills? No for the question, Does the resident's wandering behavior affect his/her safety and well-being? R59's Departmental Notes notations include the following entries: -12/28/23 6:03 PM, Resident arrived per private auto with sister (V22). Resident went to dining room for pm meal. Alert and oriented x3 with intermittent confusion. Resident is independent in his care. Denies pain, no home meds. Was in ER today at (local hospital) and DX (diagnosis) of Afib (atrial fibrillation) but no new meds. Resident is cooperative at this time. Signed by V2 (DON) -12/29/23 6:21 AM, Resident awake and alert at 4 AM walking around asking about the exits. Approximately 5:30 during med pass got a phone call from staff stating that resident went out of backhall door. Staff (initials) (V26, Licensed Practical Nurse/LPN) stayed beside resident encouraging him to return to facility at this time resident kept walking down the street, 2nd staff (initials) (V27, Certified Nurse Assistant/CNA) ran out and assisted other staff with encouraging resident to return to facility. This point this nurse got into personal vehicle and drove down road to assist and pick up resident and other staff at which time, resident was already to his house and still refusing to return. Son (name of V20 - Family member) came outside and confirmed it was residents' home, this nurse contacted DON and returned to facility to call son (name of V21 - Family Member/POA) and inform him of residents' elopement. Signed by V28 (Licensed Practical Nurse/LPN). -12/29/23 7:23 AM, Resident returned to facility through side exit. Signed by V33 (LPN). -12/29/23 8:29 AM, Son (Name of V21) and Sister (Name of V22-Family Member) in the facility this am and discussed residents leaving the facility this AM, both agree that if he continues this behavior to leave facility they will need to consider a lock down unit and residents house is only 2 block away from the facility and he is use to walking 6 miles a day in the community. Resident voices remorse for leaving this AM and states he will not leave the facility unless one of his family members is here to sign him out. Signed by V2 (DON). -12/29/23 12:22 PM, Resident frequently up walking. Pleasant and cooperative. Alert to person and place, reorienting often. Family has been visiting and bringing belongings in throughout the day. Vital signs obtained 98% (room air), 166/82 bp (blood pressure), 97.3 F (Fahrenheit), 70 bpm (beats per minute), 19 rr (respirator rate). Resident often goes to bed early and gets up early. The resident can go out on leave with (name of V21) or (name of V22). (Name of V21) requests to be called in the morning to prevent elopements and reorient the resident. No c/o (complaints of) pain or discomfort. Continuing with the plan of care. Signed by V33 (LPN). -12/31/23 2:38 PM, .This morning he did well with adjusting to facility however became slightly restless towards the afternoon. He did not make any attempts to leave the facility but did gesture towards leaving the facility stating he was getting his warm clothes on . Signed by V35 (Registered Nurse/RN). -1/3/24 10:28 AM, Was able to speak with (Name of V21) today for resident's initial care plan meeting. Signed by V7 (LPN/MDS and Care Plan Coordinator/CPC). -1/3/24 10:40 AM, Resident has been pacing in hallways. Asking to go outside did show him the courtyard which he only walked through and returned. Is thinking that the facility is kicking him out and he has to pack his belongings. Was reassured that he is to stay here . Signed by V36 (LPN). -1/3/24 11:56 AM, Resident continues to walk in hallway and go into other residents' room. Is redirected and he states you just don't understand. Signed by V36 (LPN). -1/7/24 3:59 AM, Resident in coat and hat made 1 exit attempt within past hour, out front door facility, approached by staff redirected back into facility with 1 to 1 interaction. Signed by V37 (RN). -1/22/24 2:57 PM, Resident has been up and down hallway looking and entering other resident's room. Did explain that he does not need to be going into others rooms stated I was just looking around. Signed by V36 (LPN). -1/22/24 3:43 PM, Door alarm sounding resident was leaving building staff did approach immediately and resident did agree to re-enter the building. Was given lemonade and did sit with other residents in dining room. Signed by V36 (LPN). -1/23/24 5:30 PM, Resident was seen going out old side door alarm sounding was redirected and assisted to his room where he then watch (sic) tv. Has been pacing up and down hallway looking into other residents' room. Encouraged not to enter these rooms. Did attempt to help another resident stand was asked not to help him due to possible hurting himself or other resident. Signed by V36 (LPN). -1/26/24 11:46 AM, This DON (V2) spoke with (name of V22) residents sister. (Name of V22) and (Name of V21) who is health care POA continue to request all concerns for residents care while here at (facility initials) go through (Name of V21) or (Name of V22). Resident can speak and visit with other family members however (Name of V21) request that his father only leave the facility with (V22 or V21) . Signed by V2 (DON). -1/27/24 11:11 AM, Resident has been on and off exit seeking this morning and has been redirected multiple times by staff. Resident has not found his way outside of building. Signed by V38 (LPN). The National Weather Service documented the temperature on 12/29/23 between 4-8am was 33-34 degrees Fahrenheit with precipitation of snow. On 2/7/24 at 10:11 PM, V29 (Certified Nurse Assistant/CNA) stated that R59's cognition varies. V29 confirmed she was working the night (shift) when R59 eloped. V29 stated that herself and V30 (CNA) were doing bed checks when they heard the door alarm going off. V29 stated both herself and V30 went to the door, and saw R59 outside wearing a heavy coat, beanie, jeans, and shoes. V29 stated it was snowing, cold outside and the time they first viewed R59, he was approximately 15 feet from the facility. V29 stated herself and V30 both were trying to talk R59 into coming back into the facility, but he refused and just kept walking, stating he was going home. V29 stated staff could not get to him as R59 had squeezed through a gap and was on the other side of a fence, which they could not fit through. V29 stated she went back in the building and exited out the door near the staff time clock. V29 stated by that point R59 was halfway across the parking lot, so she ran to catch up with him. V29 stated she just kept trying to convince R59 to come back to the facility, telling him it was cold, and she was out of shape, in which R59 responded by laughing that he wasn't cold and to keep up, he was used to walking 6 miles a day. V29 stated she stayed with R59 who was not combative, but just kept walking and refusing to go back to the facility. V29 stated she had hollered at V30 as they were walking away to call V28 (LPN) and tell her to come help. V29 stated that V27 (CNA) had also ran to help and walked with herself and R59, also trying to convince R59 to return. V29 stated she is familiar with R59's family, as she went to school with them, so knows the home R59 was going to. V29 stated it was R59's home, who V20 (Family Member) now resides at, which is 2-3 blocks from the facility. V29 stated as they were approaching the house, V28 pulled up in her car and R59 walked right in the front door of the home. V29 stated V20 didn't seem upset and tried to convince R59 to return with staff, but finally stated it was fine if he stayed. V29 stated she believed that V28 (LPN) called V2 (DON) who said staff couldn't force him back, so they left R59 with V20, in the home and returned to the facility. V29 stated prior to this, also the morning of 12/29/23 around 5 AM, she witnessed R59 dressed in his coat and hat, exiting out the front door. V29 stated the alarm was sounding and R59 went out the door, stated it was cold, and came right back in the facility without redirection. When questioned about actions taken after, V29 stated she did not go report this occurrence to anyone and continued working. V29 stated R59 made a comment to her about there being all these exit signs and nowhere to go. V29 stated it was probably 10-15 minutes after she had witnessed R59 go out the front door and come back in, when the back door alarm was going off and R59 was out and walking away from the facility. V29 stated also later that morning, following R59's elopement (12/29/23), at approximately 6:15 AM, she was leaving work from her shift and saw R59 walking alone, down the road heading back towards the facility. V29 stated R59 was wearing the same attire he had left the facility in. V29 stated she called the facility and cannot recall who she spoke with but told them it looked like R59 was headed back, and they said they would go out to keep an eye out for him, so she left. On 2/7/24 at 10:29 PM, V30 (CNA) stated that she was working the front hall the night R59 eloped but was helping V29 (CNA) with her bed checks when they heard the back hall door alarm go off. V30 stated that herself and V29 went to check and R59 was observed outside, a few steps away from the door, on the other side of the fence, which staff could not fit through the tight area. V30 stated they were attempting to talk R59 back into the facility but R59 continued walking away stating 'the door says exit .that means someone can exit.' V30 stated R59 was wearing a sock hat, black winter coat, boots, and jeans. V30 stated it was cold outside that day. V30 stated she went back in the building to watch the halls and V29 ran to go out another door and catch up with R59 telling V30 to call V28 (LPN) and tell her what was going on, which she did. V30 stated she stayed outside the door watching R59 until V29 got out the other door of the facility and could catch up to R59. On 2/7/24 at 9:58 PM, V28 (LPN) described R59 as being confused when admitted , with some intermittent improvement to his cognition since being at the facility. V28 stated she was a nurse on duty when R59 eloped from the facility. V28 stated she believed R59 eloped the first night he was admitted . V28 stated she did not witness R59 leave, but from her understanding, R59 exited through the back hall door. V28 stated there is an alarm on that door and although she wasn't there to witness it sounding herself, assumes it was, since staff were with R59 outside. V28 stated she believed R59 had slept good that night (12/28/23), until he woke up around 4am (12/29/23). V28 stated R59 was walking around the facility saying things like there's a whole lot of exit's and nowhere to go. V28 said she believed it wasn't abnormal for R59 to wake up around 4am though, and that was his normal time to rise for the day. V28 stated she believes R59 was admitted to the facility with a diagnosis of a heart condition and his sister (V22) and son (V21) wanted him in a facility for his health with his diagnoses and history of walking the streets of (town name). V28 stated the night R59 eloped, she believes she received a call from V29 who stated to hurry up and get out here, that R59 had left and they couldn't get him to come back to the facility. V28 stated it was cold, so she got in her car to go try and coax him back. V28 stated V29 and V27 were both with him at the time she caught up to them and described R59 as definitely having some place he wanted to go. V28 stated V20's (Family Member) house was approximately 2 blocks behind the facility and that is where R59 went. On 2/7/24 at 11:23 PM, V28 (LPN) clarified that the V26's initials in her progress note dated 12/29/23 at 6:21 AM should have read V29's initials. V28 also stated that by the time she drove to meet R59 and staff, they were already by the house which sits on a corner. V28 stated that by the time she parked, R59 was already in the house. V28 stated that staff, along with V20 (Family Member), who was present at the time R59 entered the house were unable to coax R59 back to the facility. V28 stated she called V2 (DON) to find out what to do. V28 stated V2 called V32 (Former Administrator). V28 stated she was told they could not force R59 to come back, and it was (family) V20 he was with. V28 stated at that time, she did not reach out to R59's resident representative (V21) and is unsure if V2 or V32 reached out to (V21) to get permission for R59 to stay with V20, as V20 was not the representative for R59. V28 stated she was not present when R59 returned to the facility, but believed he walked back himself before 7 AM the same day that he had eloped. On 2/7/24 at 10:21 PM, V27 (CNA) stated that R59's cognition varies. V27 described R59's normal status as being that he will wander into other resident's rooms, bathrooms, and we will find him sleeping in other's recliners, etc. V27 stated R59 had eloped the first night he was at the facility she believes. V27 does not recall being told that R59 was any sort of elopement risk at that time. V27 stated residents are viewed at least every 2 hours during bed checks, but if (she) is walking down the halls, she looks in rooms while walking by too. V27 stated she was alerted of a resident outside by V31 (Laundry), who was coming in for her shift and saw a man she didn't recognize outside walking and wasn't sure if it was a resident. V27 stated she went to check and saw R59 and V29 halfway up the road, walking away from the facility, so she ran to them to try and help. V27 stated R59 was not being combative, was just saying over and over that he wasn't coming back. V27 stated R59 walked directly to (V20's) house which was a couple blocks from the facility. V27 stated (V20) said it was ok if R59 stayed there with him since he was refusing to return. V27 stated that R59 had been up and down a few times that night prior to eloping but was re-directable until 4am when he was wide awake and got himself dressed. On 2/08/24 at 11:54 AM, V31 (Laundry) stated that she recalls coming into work early one morning in which she observed a man outside the building that she didn't recognize. V31 stated she thought he was a predator, so she came in the facility and was talking to a co-worker about the man when she then saw two staff following behind him, making her realize it was a resident and not a predator. On 2/08/24 at 11:11 AM, V20 (Family Member) stated he believed it was approximately 3 AM when he heard a knock at his front door. V20 stated he answered the door and observed R59 standing there appearing anxious. V20 stated he saw 3 staff also with him. V20 stated he didn't know who the staff were, as he didn't realize R59 had been admitted to the facility. V20 stated that R59 used to live with him, which was originally R59's house. V20 stated that R59 had recently moved to an apartment 2-3 weeks prior to him showing up at his door with staff. V20 stated that R59 had been moved to the apartment due to his increased confusion. V20 stated that he doesn't know if R59 was experiencing any problems while residing at the apartment. V20 stated he had been told by (V22) that R59 was having continued confusion at the apartments as V20 had been told R59 was going into other people's apartments that were not his. V20 stated the morning R59 had left from the facility, R59 stayed with V20, as he was refusing to return to the facility with staff. V20 stated that he talked to R59 and reminded him of past family members who had lived at the facility and coaxed him to return. V20 stated he did not accompany R59 back to the facility or call the facility to let them know R59 was leaving his home. V20 stated that R59 walked out the front door and headed in the direction back toward the facility and he saw or heard nothing further. V20 stated he had called V22 to let her know what had happened and that he had talked R59 into heading back towards the facility. On 2/08/24 at 10:27 AM, V21 (Family Member/POA) stated that he is the Power of Attorney for R59. V21 stated that R59 was admitted to the facility after having a decline in mental status, which causes R59 anxiety. V21 stated that R59 responds to anxiety by walking and walking and walking. V21 stated R59 was continuously walking all over town which causes worry for R59's safety. V21 stated he was notified via phone that R59 had eloped from the facility. V21 cannot recall the time he was notified or by who, he just recalls the facility telling him that R59 had left and staff stayed with him the whole time. V21 stated he was told R59 walked to V20's house. V21 stated he cannot recall if the facility asked him if it was ok that R59 was left with V20 at the home, he just knows that they said they were unable to get him to come back to the facility. V21 stated he wasn't surprised knowing R59's stubbornness and assumes it would have taken physical restraint or a familiar voice to coax him back. V21 stated once he was notified of the elopement, he jumped in his car to head towards the facility, which was about an hour away to try and assist with the situation. V21 stated he believes he was close to the facility when he had received a call that R59 had returned to the facility on his own. V21 stated that he would assume knowing V20 that V20 was probably not aware that R59 had left the house and returned to the facility. V21 stated he considers the elopement an accident since he knows it was R59's first night at the facility, R59's anxiety would have been high and R59 has his normal routine history of walking. On 2/8/24 at 9:47 AM, V33 (LPN) stated that she was the nurse on duty and was also the staff member who witnessed R59 return to the facility. V33 stated R59 entered back into the facility through the side door. V33 stated she was passing medications on the hall near the door he came in. V33 stated she saw R59 walking towards the facility, alone to the door, in which he opened the door and came back in the facility. V33 stated R59 did not appear to be in any physical or emotional distress but was upset apologizing for leaving. V33 stated she believes it was around 7:15 AM, when R59 arrived back. V33 stated she notified the DON (V2) that R59 was back. V33 stated she did not notify the POA of R59's return. V33 confirmed that she is not aware of what the facility's protocol is for elopement returns, as she is newer to nursing. V33 stated that she did not conduct any head-to-toe assessment or notify the physician of R59's elopement return. During this interview, V33 stated she had not received any training or direction following R59's elopement on areas to be trained or improve on. On 2/8/24 at 12:09 PM, V22 (family member) stated she is involved in R59's care routinely. V22 stated that she previously initiated an Adult Protective Service against V20. V22 stated that V20, along with his girlfriend and kids had moved into R59's home and were financially abusing R59 as the utilities to the house were being shut off and R59's monthly income being spent very quickly. V22 stated R59 would vent to her as R59 and V20 were fighting and to cope, R59 would take off walking and just walk around town. V22 stated that V20 was struggling with an addiction to meth and ended up incarcerated after having possession of meth with prior felony charges. V22 stated that problems seemed to escalate with V20 as R59's cognition declined. V22 stated that she determined the best option she felt at that point was to reach out to Adult Protective Services in which V24 (Adult Protective Services Caseworker) was the staff member assigned to R59's case. V22 stated that V24 got an apartment set up for R59 to get him out of the environment with V20, but that living situation also didn't work. V22 stated that R59's cognition was too poor and R59 was leaving the apartment, locking himself out, going into wrong apartments, etc. V22 stated that 4 AM seems to be R59's worst time of the day for cognition as he becomes anxious and just wants to walk. V22 stated that she became scared to death that R59 was going to get hit as he would walk around town and across busy roads. V22 stated herself and V21 met with V32, who was the administrator at the facility during that time, which was approximately 1-2 weeks prior to R59's admission to the facility. V22 stated they wanted to meet with the facility to express concerns and a plan for R59 as his cognition varied, he was walking all over and expressed the history with R59 and V20. V22 stated that V32 was informed that R59 was not to leave the facility with V20 as R59 has a history being made upset by V20. V22 stated V21 also expressed that although he is the POA, information may be shared with V22. V22 verified that she was notified of R59's elopement from the facility, in which R59 went to V20's house. V22 stated she cannot recall what time she was notified or who it was that notified her by, just remembers it was the morning. V22 stated that since R59's elopement, she has not received any meeting or conference with the facility to discuss any changes in R59's plan of care. V22 stated that she did have a phone conversation with V1 (Administrator) who stated activities such as karaoke were available and maybe an activity R59 would like to participate in. On 2/8/24 at 2:45 PM, V2 (DON) described R59 as being confused intermittently with short term memory loss, easy to redirect, ambulates constantly. V2 stated that prior to R59 admitting to the facility, he walked around town a lot. V2 stated she was also told by V21 and V22 that they were to be R59's only contacts for medical information and the only contacts that R59 could leave the facility with. V2 stated that R59 has another son (V20), who lives close to the facility who they said could visit R59 at the facility or call. V2 stated approximately 1 1/2 months prior to R59 being admitted to the facility, she believes R59 had been removed from living in his home with V20 by Adult Protective Services due to financial exploitation with V20 using R59's money and not paying for utilities. V2 stated that after R59 was admitted to the facility, she slowly found out more from V22 (Family Member) that R59 did not like strangers in his house, which were frequently there with V20. This would cause R59 anxiety, so he would leave the home and just walk around town. V2 stated prior to R59 admitting to the facility, V22 and V21 had come to the facility to talk with V32 and herself about wanting to put R59 in the facility. V2 stated R59's chore girl infrequently was able to provide care services for R59 who was living in an apartment at the time, due to R59 being out walking. V2 described the chore girl as someone who had been set up to provide R59 assistance in the apartment. V2 stated the family was afraid he was not getting meals, being kept clean, and confusion was increasing which caused worry for them of him being out walking. V2 stated the family felt like if he was in the facility, he would be less lonely and respond better to care offered. V2 stated at the time of R59's admission, the family placed signs on R59's door and in his room, telling him not to leave the facility, which they thought would help remind him not to leave. V2 stated the family stated they had also placed signs such as these posted in his apartment where he lived prior to admitting the facility. V2 stated that she had approved R59's admission to the facility off of her prior conversations with R59's family (V21 & V22) along with reviewing the ER (emergency room ) documents that R59 admitted with. V2 stated that these documents didn't say much and diagnosed R59 with A-fib. V2 stated that she completed the Elopement risk tool upon R59's admission to the facility and deemed him not to be an elopement risk, because it wasn't like he had daily routines of running or hiding. V2 confirmed she was notified of R59's elopement by V28 (LPN), who was R59's nurse that night. V2 stated that R59 had just been admitted to the facility. V2 stated an investigation of the incident was complete with all staff interviewed and stated there was no fence where he left the facility at. V2 stated that she would expect any time a resident was viewed leaving the facility, despite if they immediately returned back in, she would expect the nurse to be notified and the incident documented in the resident's record. V2 stated it would give the staff a heads up that the resident maybe trying to leave. A specific example was given to V2, which included a resident is viewed independently leaving out of the facility, but once through the door, turns around and comes back in due to reported cold temperatures. V2 confirmed the resident should be redirected back inside the facility and the nurse immediately notified. V2 stated in the incident with R59, 2 staff members, a nurse and V20 could all not convince R59 to return to the facility with staff. V2 stated she can't really say she made the call to allow R59 to stay with V20 in the home at that time and have the staff return to the facility, but V20 did say R59 could stay there and we just knew where he was at. V2 stated in reviewing her phone log, she had called V32 (Former Administrator) at 5:54 AM, which she assumes was the call where she informed V32 that R59 was at the house with V20, and again at 7:20 AM, which she assumes was the call she made to V32 that R59 was back in the facility. V2 stated that she cannot say if R59 returned to the facility alone, as she didn't see him come back, a CNA just reported to her that R59 had come back in a side door. V2 stated V33 (LPN) was R59's nurse upon his return to the facility and a head-to-toe assessment should have been conducted and assumes V33 probably did one. V2 stated that R59 came to her right away upon his arrival back to the facility and apologized for leaving. V2 stated that shortly after R59's return to the facility V21 and V22 also arrived at the facility and assumes they had come to the facility that quickly due to R59 being reported at V20's house. V2 described there being poor family dynamics. V2 stated facility staff met with V21 and V22 in which they were apologetic for what had happened. V2 stated at the time R59 returned to the facility, a 1:1 staffing status was implemented, with herself being the 1:1 until the behaviors were determined to have ceased, which would

Based Based on observation, interview, and record review, the facility failed to ensure residents at risk for elopement were accurately assessed and incidents of elopement were appropriately identified and thoroughly investigated for 2 (R59 and R24) of 6 reviewed for accidents and supervision in the sample of 40. This failure resulted in R59, who has a diagnosis of dementia with severe cognitive impairment, eloping from the facility on 12/29/23. Findings Include: 1. R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member & Power of Attorney/POA) and V22 (Family Member). R59's Minimum Data Set with an assessment reference date of 1/4/24 documented a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section E0900 documents 0, indicating the behavior was not exhibited to the question has the resident wandered. R59's (Name of town) Primary Care record found in R59's Electronic Health Record, documented a visit on 12/7/23 with a chief complaint being to establish care. This document stated, Patient has been here in the past. It has been over 4 years since he was last seen in this clinic. He is here today with his sister to reestablish care. Over the past 2 years, she has noted a decrease in his mental status. He seems to be having problems with short-term memory. There is a family history of dementia in their father. The history of stroke is uncertain. He was hit by a semi several years ago in front of the (Store Name) here in town. He did sustain a significant head injury at that time .He does have some problems with his vision. This seems to be a problem when trying to watch TV as he cannot use his remote. He also likes to walk around town. He reports almost being hit by a semi couple days ago. According to his sister, approximately 18 months ago she became involved with his care when he showed up at her house and was quite disheveled. Since then she has worked on getting him help set up He does tend to sleep from 5 or 6:00 PM until 4:30 in the morning. At that time he does like to get up and walk around town . Local hospital Emergency Department (ED) notes dated 12/28/23 at 10:38 AM, documented R59 was seen for chief complaints of altered mental status and hallucinations. This document stated R59 was brought to the ED by family members and friends who stated R59's complaint symptoms had been going on for the last 18 months but worsened over the last 2 weeks. After workup, the Clinical Impression listed is Thoracic aortic aneurysm, unspecified part, unspecified whether ruptured; and Cardiac arrhythmia, unspecified cardiac arrhythmia type. A case management note documented report included family concerns with R59's current living apartment arrangements which state R59 has been found outside his apartment multiple times, locked out, and ultimately confused how to operate a key fob to get into the apartment. Not eating as he should and suspected hallucinations. Both R59's (Name of Town) Primary Care document and Local hospital ED documents as listed above were observed to be scanned into R59's Electronic Health Record in a folder titled, Referral Documents. R59's Elopement Risk Tool, documented as being completed by V2 (Director of Nursing/DON) on 12/28/23 at 8:14 PM, stated R59's Elopement Risk Summary was determined to be, Resident has not been found to be at risk for elopement at this time. Entries included on this same tool documented: Yes for the question, Has the family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? Yes, Additional Details: Early onset of dementia for the question, Does the resident display cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills? No for the question, Does the resident's wandering behavior affect his/her safety and well-being? R59's Departmental Notes notations include the following entries: -12/28/23 6:03 PM, Resident arrived per private auto with sister (V22). Resident went to dining room for pm meal. Alert and oriented x3 with intermittent confusion. Resident is independent in his care. Denies pain, no home meds. Was in ER today at (local hospital) and DX (diagnosis) of Afib (atrial fibrillation) but no new meds. Resident is cooperative at this time. Signed by V2 (DON) -12/29/23 6:21 AM, Resident awake and alert at 4 AM walking around asking about the exits. Approximately 5:30 during med pass got a phone call from staff stating that resident went out of backhall door. Staff (initials) (V26, Licensed Practical Nurse/LPN) stayed beside resident encouraging him to return to facility at this time resident kept walking down the street, 2nd staff (initials) (V27, Certified Nurse Assistant/CNA) ran out and assisted other staff with encouraging resident to return to facility. This point this nurse got into personal vehicle and drove down road to assist and pick up resident and other staff at which time, resident was already to his house and still refusing to return. Son (name of V20 - Family member) came outside and confirmed it was residents' home, this nurse contacted DON and returned to facility to call son (name of V21 - Family Member/POA) and inform him of residents' elopement. Signed by V28 (Licensed Practical Nurse/LPN). -12/29/23 7:23 AM, Resident returned to facility through side exit. Signed by V33 (LPN). -12/29/23 8:29 AM, Son (Name of V21) and Sister (Name of V22-Family Member) in the facility this am and discussed residents leaving the facility this AM, both agree that if he continues this behavior to leave facility they will need to consider a lock down unit and residents house is only 2 block away from the facility and he is use to walking 6 miles a day in the community. Resident voices remorse for leaving this AM and states he will not leave the facility unless one of his family members is here to sign him out. Signed by V2 (DON). -12/29/23 12:22 PM, Resident frequently up walking. Pleasant and cooperative. Alert to person and place, reorienting often. Family has been visiting and bringing belongings in throughout the day. Vital signs obtained 98% (room air), 166/82 bp (blood pressure), 97.3 F (Fahrenheit), 70 bpm (beats per minute), 19 rr (respirator rate). Resident often goes to bed early and gets up early. The resident can go out on leave with (name of V21) or (name of V22). (Name of V21) requests to be called in the morning to prevent elopements and reorient the resident. No c/o (complaints of) pain or discomfort. Continuing with the plan of care. Signed by V33 (LPN). -12/31/23 2:38 PM, .This morning he did well with adjusting to facility however became slightly restless towards the afternoon. He did not make any attempts to leave the facility but did gesture towards leaving the facility stating he was getting his warm clothes on . Signed by V35 (Registered Nurse/RN). -1/3/24 10:28 AM, Was able to speak with (Name of V21) today for resident's initial care plan meeting. Signed by V7 (LPN/MDS and Care Plan Coordinator/CPC). -1/3/24 10:40 AM, Resident has been pacing in hallways. Asking to go outside did show him the courtyard which he only walked through and returned. Is thinking that the facility is kicking him out and he has to pack his belongings. Was reassured that he is to stay here . Signed by V36 (LPN). -1/3/24 11:56 AM, Resident continues to walk in hallway and go into other residents' room. Is redirected and he states you just don't understand. Signed by V36 (LPN). -1/7/24 3:59 AM, Resident in coat and hat made 1 exit attempt within past hour, out front door facility, approached by staff redirected back into facility with 1 to 1 interaction. Signed by V37 (RN). -1/22/24 2:57 PM, Resident has been up and down hallway looking and entering other resident's room. Did explain that he does not need to be going into others rooms stated I was just looking around. Signed by V36 (LPN). -1/22/24 3:43 PM, Door alarm sounding resident was leaving building staff did approach immediately and resident did agree to re-enter the building. Was given lemonade and did sit with other residents in dining room. Signed by V36 (LPN). -1/23/24 5:30 PM, Resident was seen going out old side door alarm sounding was redirected and assisted to his room where he then watch (sic) tv. Has been pacing up and down hallway looking into other residents' room. Encouraged not to enter these rooms. Did attempt to help another resident stand was asked not to help him due to possible hurting himself or other resident. Signed by V36 (LPN). -1/26/24 11:46 AM, This DON (V2) spoke with (name of V22) residents sister. (Name of V22) and (Name of V21) who is health care POA continue to request all concerns for residents care while here at (facility initials) go through (Name of V21) or (Name of V22). Resident can speak and visit with other family members however (Name of V21) request that his father only leave the facility with (V22 or V21) . Signed by V2 (DON). -1/27/24 11:11 AM, Resident has been on and off exit seeking this morning and has been redirected multiple times by staff. Resident has not found his way outside of building. Signed by V38 (LPN). The National Weather Service documented the temperature on 12/29/23 between 4-8am was 33-34 degrees Fahrenheit with precipitation of snow. On 2/7/24 at 10:11 PM, V29 (Certified Nurse Assistant/CNA) stated that R59's cognition varies. V29 confirmed she was working the night (shift) when R59 eloped. V29 stated that herself and V30 (CNA) were doing bed checks when they heard the door alarm going off. V29 stated both herself and V30 went to the door, and saw R59 outside wearing a heavy coat, beanie, jeans, and shoes. V29 stated it was snowing, cold outside and the time they first viewed R59, he was approximately 15 feet from the facility. V29 stated herself and V30 both were trying to talk R59 into coming back into the facility, but he refused and just kept walking, stating he was going home. V29 stated staff could not get to him as R59 had squeezed through a gap and was on the other side of a fence, which they could not fit through. V29 stated she went back in the building and exited out the door near the staff time clock. V29 stated by that point R59 was halfway across the parking lot, so she ran to catch up with him. V29 stated she just kept trying to convince R59 to come back to the facility, telling him it was cold, and she was out of shape, in which R59 responded by laughing that he wasn't cold and to keep up, he was used to walking 6 miles a day. V29 stated she stayed with R59 who was not combative, but just kept walking and refusing to go back to the facility. V29 stated she had hollered at V30 as they were walking away to call V28 (LPN) and tell her to come help. V29 stated that V27 (CNA) had also ran to help and walked with herself and R59, also trying to convince R59 to return. V29 stated she is familiar with R59's family, as she went to school with them, so knows the home R59 was going to. V29 stated it was R59's home, who V20 (Family Member) now resides at, which is 2-3 blocks from the facility. V29 stated as they were approaching the house, V28 pulled up in her car and R59 walked right in the front door of the home. V29 stated V20 didn't seem upset and tried to convince R59 to return with staff, but finally stated it was fine if he stayed. V29 stated she believed that V28 (LPN) called V2 (DON) who said staff couldn't force him back, so they left R59 with V20, in the home and returned to the facility. V29 stated prior to this, also the morning of 12/29/23 around 5 AM, she witnessed R59 dressed in his coat and hat, exiting out the front door. V29 stated the alarm was sounding and R59 went out the door, stated it was cold, and came right back in the facility without redirection. When questioned about actions taken after, V29 stated she did not go report this occurrence to anyone and continued working. V29 stated R59 made a comment to her about there being all these exit signs and nowhere to go. V29 stated it was probably 10-15 minutes after she had witnessed R59 go out the front door and come back in, when the back door alarm was going off and R59 was out and walking away from the facility. V29 stated also later that morning, following R59's elopement (12/29/23), at approximately 6:15 AM, she was leaving work from her shift and saw R59 walking alone, down the road heading back towards the facility. V29 stated R59 was wearing the same attire he had left the facility in. V29 stated she called the facility and cannot recall who she spoke with but told them it looked like R59 was headed back, and they said they would go out to keep an eye out for him, so she left. On 2/7/24 at 10:29 PM, V30 (CNA) stated that she was working the front hall the night R59 eloped but was helping V29 (CNA) with her bed checks when they heard the back hall door alarm go off. V30 stated that herself and V29 went to check and R59 was observed outside, a few steps away from the door, on the other side of the fence, which staff could not fit through the tight area. V30 stated they were attempting to talk R59 back into the facility but R59 continued walking away stating 'the door says exit .that means someone can exit.' V30 stated R59 was wearing a sock hat, black winter coat, boots, and jeans. V30 stated it was cold outside that day. V30 stated she went back in the building to watch the halls and V29 ran to go out another door and catch up with R59 telling V30 to call V28 (LPN) and tell her what was going on, which she did. V30 stated she stayed outside the door watching R59 until V29 got out the other door of the facility and could catch up to R59. On 2/7/24 at 9:58 PM, V28 (LPN) described R59 as being confused when admitted , with some intermittent improvement to his cognition since being at the facility. V28 stated she was a nurse on duty when R59 eloped from the facility. V28 stated she believed R59 eloped the first night he was admitted . V28 stated she did not witness R59 leave, but from her understanding, R59 exited through the back hall door. V28 stated there is an alarm on that door and although she wasn't there to witness it sounding herself, assumes it was, since staff were with R59 outside. V28 stated she believed R59 had slept good that night (12/28/23), until he woke up around 4am (12/29/23). V28 stated R59 was walking around the facility saying things like there's a whole lot of exit's and nowhere to go. V28 said she believed it wasn't abnormal for R59 to wake up around 4am though, and that was his normal time to rise for the day. V28 stated she believes R59 was admitted to the facility with a diagnosis of a heart condition and his sister (V22) and son (V21) wanted him in a facility for his health with his diagnoses and history of walking the streets of (town name). V28 stated the night R59 eloped, she believes she received a call from V29 who stated to hurry up and get out here, that R59 had left and they couldn't get him to come back to the facility. V28 stated it was cold, so she got in her car to go try and coax him back. V28 stated V29 and V27 were both with him at the time she caught up to them and described R59 as definitely having some place he wanted to go. V28 stated V20's (Family Member) house was approximately 2 blocks behind the facility and that is where R59 went. On 2/7/24 at 11:23 PM, V28 (LPN) clarified that the V26's initials in her progress note dated 12/29/23 at 6:21 AM should have read V29's initials. V28 also stated that by the time she drove to meet R59 and staff, they were already by the house which sits on a corner. V28 stated that by the time she parked, R59 was already in the house. V28 stated that staff, along with V20 (Family Member), who was present at the time R59 entered the house were unable to coax R59 back to the facility. V28 stated she called V2 (DON) to find out what to do. V28 stated V2 called V32 (Former Administrator). V28 stated she was told they could not force R59 to come back, and it was (family) V20 he was with. V28 stated at that time, she did not reach out to R59's resident representative (V21) and is unsure if V2 or V32 reached out to (V21) to get permission for R59 to stay with V20, as V20 was not the representative for R59. V28 stated she was not present when R59 returned to the facility, but believed he walked back himself before 7 AM the same day that he had eloped. On 2/7/24 at 10:21 PM, V27 (CNA) stated that R59's cognition varies. V27 described R59's normal status as being that he will wander into other resident's rooms, bathrooms, and we will find him sleeping in other's recliners, etc. V27 stated R59 had eloped the first night he was at the facility she believes. V27 does not recall being told that R59 was any sort of elopement risk at that time. V27 stated residents are viewed at least every 2 hours during bed checks, but if (she) is walking down the halls, she looks in rooms while walking by too. V27 stated she was alerted of a resident outside by V31 (Laundry), who was coming in for her shift and saw a man she didn't recognize outside walking and wasn't sure if it was a resident. V27 stated she went to check and saw R59 and V29 halfway up the road, walking away from the facility, so she ran to them to try and help. V27 stated R59 was not being combative, was just saying over and over that he wasn't coming back. V27 stated R59 walked directly to (V20's) house which was a couple blocks from the facility. V27 stated (V20) said it was ok if R59 stayed there with him since he was refusing to return. V27 stated that R59 had been up and down a few times that night prior to eloping but was re-directable until 4am when he was wide awake and got himself dressed. On 02/08/24 at 11:54 AM, V31 (Laundry) stated that she recalls coming into work early one morning in which she observed a man outside the building that she didn't recognize. V31 stated she thought he was a predator, so she came in the facility and was talking to a co-worker about the man when she then saw two staff following behind him, making her realize it was a resident and not a predator. On 02/08/24 at 11:11 AM, V20 (Family Member) stated he believed it was approximately 3 AM when he heard a knock at his front door. V20 stated he answered the door and observed R59 standing there appearing anxious. V20 stated he saw 3 staff also with him. V20 stated he didn't know who the staff were, as he didn't realize R59 had been admitted to the facility. V20 stated that R59 used to live with him, which was originally R59's house. V20 stated that R59 had recently moved to an apartment 2-3 weeks prior to him showing up at his door with staff. V20 stated that R59 had been moved to the apartment due to his increased confusion. V20 stated that he doesn't know if R59 was experiencing any problems while residing at the apartment. V20 stated he had been told by (V22) that R59 was having continued confusion at the apartments as V20 had been told R59 was going into other people's apartments that were not his. V20 stated the morning R59 had left from the facility, R59 stayed with V20, as he was refusing to return to the facility with staff. V20 stated that he talked to R59 and reminded him of past family members who had lived at the facility and coaxed him to return. V20 stated he did not accompany R59 back to the facility or call the facility to let them know R59 was leaving his home. V20 stated that R59 walked out the front door and headed in the direction back toward the facility and he saw or heard nothing further. V20 stated he had called V22 to let her know what had happened and that he had talked R59 into heading back towards the facility. On 02/08/24 at 10:27 AM, V21 (Family Member/POA) stated that he is the Power of Attorney for R59. V21 stated that R59 was admitted to the facility after having a decline in mental status, which causes R59 anxiety. V21 stated that R59 responds to anxiety by walking and walking and walking. V21 stated R59 was continuously walking all over town which causes worry for R59's safety. V21 stated he was notified via phone that R59 had eloped from the facility. V21 cannot recall the time he was notified or by who, he just recalls the facility telling him that R59 had left and staff stayed with him the whole time. V21 stated he was told R59 walked to V20's house. V21 stated he cannot recall if the facility asked him if it was ok that R59 was left with V20 at the home, he just knows that they said they were unable to get him to come back to the facility. V21 stated he wasn't surprised knowing R59's stubbornness and assumes it would have taken physical restraint or a familiar voice to coax him back. V21 stated once he was notified of the elopement, he jumped in his car to head towards the facility, which was about an hour away to try and assist with the situation. V21 stated he believes he was close to the facility when he had received a call that R59 had returned to the facility on his own. V21 stated that he would assume knowing V20 that V20 was probably not aware that R59 had left the house and returned to the facility. V21 stated he considers the elopement an accident since he knows it was R59's first night at the facility, R59's anxiety would have been high and R59 has his normal routine history of walking. On 2/8/24 at 9:47 AM, V33 (LPN) stated that she was the nurse on duty and was also the staff member who witnessed R59 return to the facility. V33 stated R59 entered back into the facility through the side door. V33 stated she was passing medications on the hall near the door he came in. V33 stated she saw R59 walking towards the facility, alone to the door, in which he opened the door and came back in the facility. V33 stated R59 did not appear to be in any physical or emotional distress but was upset apologizing for leaving. V33 stated she believes it was around 7:15 AM, when R59 arrived back. V33 stated she notified the DON (V2) that R59 was back. V33 stated she did not notify the POA of R59's return. V33 confirmed that she is not aware of what the facility's protocol is for elopement returns, as she is newer to nursing. V33 stated that she did not conduct any head-to-toe assessment or notify the physician of R59's elopement return. During this interview, V33 stated she had not received any training or direction following R59's elopement on areas to be trained or improve on. On 2/8/24 at 12:09 PM, V22 (Family member) stated she is involved in R59's care routinely. V22 stated R59 would vent to her as R59 and V20 were fighting and to cope, R59 would take off walking and just walk around town. V22 stated that V20 was struggling with an addiction to meth and ended up incarcerated after having possession of meth with prior felony charges. V22 stated that problems seemed to escalate with V20 as R59's cognition declined. V22 stated that she determined the best option she felt at that point was to reach out to Adult Protective Services in which V24 (Adult Protective Services Caseworker) was the staff member assigned to R59's case. V22 stated that V24 got an apartment set up for R59 to get him out of the environment with V20, but that living situation also didn't work. V22 stated that R59's cognition was too poor and R59 was leaving the apartment, locking himself out, going into wrong apartments, etc. V22 stated that 4 AM seems to be R59's worst time of the day for cognition as he becomes anxious and just wants to walk. V22 stated that she became scared to death that R59 was going to get hit as he would walk around town and across busy roads. V22 stated herself and V21 met with V32, who was the administrator at the facility during that time, which was approximately 1-2 weeks prior to R59's admission to the facility. V22 stated they wanted to meet with the facility to express concerns and a plan for R59 as his cognition varied, he was walking all over and also express the history with R59 and V20. V22 stated that V32 was instructed that R59 was not to leave the facility with V20 as R59 has a history being made upset by V20. V22 stated V21 also expressed that although he is the POA, information may be shared with V22. V22 verified that she was notified of R59's elopement from the facility, in which R59 went to V20's house. V22 stated she cannot recall what time she was notified or who it was that notified her but just remembers it was the morning. V22 stated that since R59's elopement, she has not received any meeting or conference with the facility to discuss any changes in R59's plan of care. V22 stated that she did have a phone conversation with V1 (Administrator) who stated activities such as karaoke were available and maybe an activity R59 would like to participate in. On 2/8/24 at 2:45 PM, V2 (DON) described R59 as being confused intermittently with short term memory loss, easy to redirect, ambulates constantly. V2 stated that prior to R59 admitting to the facility, he walked around town a lot. V2 stated she was also told by V21 and V22 that they were to be R59's only contacts for medical information and the only contacts that R59 could leave the facility with. V2 stated that R59 has another son (V20), who lives close to the facility who they said could visit R59 at the facility or call. V2 stated approximately 1 1/2 months prior to R59 being admitted to the facility, she believes R59 had been removed from living in his home with V20 by Adult Protective Services due to financial exploitation with V20 using R59's money and not paying for utilities. V2 stated that after R59 was admitted to the facility, she slowly found out more from V22 (Family Member) that R59 did not like strangers in his house, which were frequently there with V20. This would cause R59 anxiety, so he would leave the home and just walk around town. V2 stated prior to R59 admitting to the facility, V22 and V21 had come to the facility to talk with V32 and herself about wanting to put R59 in the facility. V2 stated R59's chore girl infrequently was able to provide care services for R59 who was living in an apartment at the time, due to R59 being out walking. V2 described the chore girl as someone who had been set up to provide R59 assistance in the apartment. V2 stated the family was afraid he was not getting meals, being kept clean, and confusion was increasing which caused worry for them of him being out walking. V2 stated the family felt like if he was in the facility, he would be less lonely and respond better to care offered. V2 stated at the time of R59's admission, the family placed signs on R59's door and in his room, telling him not to leave the facility, which they thought would help remind him not to leave. V2 stated the family stated they had also placed signs such as these posted in his apartment where he lived prior to admitting the facility. V2 stated that she had approved R59's admission to the facility off of her prior conversations with R59's family (V21 & V22) along with reviewing the ER (emergency room ) documents that R59 admitted with. V2 stated that these documents didn't say much and diagnosed R59 with A-fib. V2 stated that she completed the Elopement risk tool upon R59's admission to the facility and deemed him not to be an elopement risk, because it wasn't like he had daily routines of running or hiding. V2 confirmed she was notified of R59's elopement by V28 (LPN), who was R59's nurse that night. V2 stated that R59 had just been admitted to the facility. V2 stated an investigation of the incident was complete with all staff interviewed and stated there was no fence where he left the facility at. V2 stated that she would expect any time a resident was viewed leaving the facility, despite if they immediately returned back in, she would expect the nurse to be notified and the incident documented in the resident's record. V2 stated it would give the staff a heads up that the resident maybe trying to leave. A specific example was given to V2, which included a resident is viewed independently leaving out of the facility, but once through the door, turns around and comes back in due to reported cold temperatures. V2 confirmed the resident should be redirected back inside the facility and the nurse immediately notified. V2 stated in the incident with R59, 2 staff members, a nurse and V20 could all not convince R59 to return to the facility with staff. V2 stated she can't really say she made the call to allow R59 to stay with V20 in the home at that time and have the staff return to the facility, but V20 did say R59 could stay there and we just knew where he was at. V2 stated in reviewing her phone log, she had called V32 (Former Administrator) at 5:54 AM, which she assumes was the call where she informed V32 that R59 was at the house with V20, and again at 7:20 AM, which she assumes was the call she made to V32 that R59 was back in the facility. V2 stated that she cannot say if R59 returned to the facility alone, as she didn't see him come back, a CNA just reported to her that R59 had come back in a side door. V2 stated V33 (LPN) was R59's nurse upon his return to the facility and a head-to-toe assessment should have been conducted and assumes V33 probably did one. V2 stated that R59 came to her right away upon his arrival back to the facility and apologized for leaving. V2 stated that shortly after R59's return to the facility V21 and V22 also arrived at the facility and assumes they had come to the facility that quickly due to R59 being reported at V20's house. V2 described there being poor family dynamics. V2 stated facility staff met with V21 and V22 in which they were apologetic for what had happened. V2 stated at the time R59 returned to the facility, a 1:1 staffing status was implemented, with herself being the 1:1 until the behaviors were determined to have ceased, which would have been about 5:30 PM - 6 PM that night when she left the facility. V2 stated that elopement would have been triggered on R59's baseline care plan at the time of admission due to wandering. V2 also stated that the Minimum Data Set personnel were notified of R59's elopement on 12/29/23 as the facility holds a daily meeting with all department heads to discuss incidents which have occurred or concerns. V2 stated that Section E of R59's MDS would be a section completed by social services. On 2/8/24 at 3:25 PM, V2 (DON) was asked to show the door of the facility in which R59 exited from on 12/29/23. V2 led surveyors to a door at the end of 600 hall, which R59 resides on. The door was observed as opening into a parking lot area, butting up to two roads with no fence in the very immediate vicinity visualized. V2 was asked what door would be described as the back hall door, in which she stated oh and took surveyors to another door which is also near the employee entrance door. V2 stated that some staff refer to a hallway in the facility as the back hall. Upon exiting the back hall door from inside the building, a chain link fence was to the immediate right of the door. The fence ended at an area which adjoins to an area with concrete blocks, broken concrete, trash, down tree debris, lumber and a creek bed. There was a matted down pathway between the end of the fence post and tall weeds with a wire welded fence slanted on its side creating an uneven surface. On the other side of the slanted wire fence was the creek bed. Once on the other side of this fence you could see the employee entrance door, storage buildings, and parking lot which runs adjacent to the road which V2 stated takes you to R59's house. On 2/9/24 at 10:08 AM, V11 (Regional Maintenance) observed the fence outside of the 400 hallway. V11 stated that the sidewalk outside the door at the fence gate measures 5 feet wide. The fence was observed as having a gate with a chain encircling the gate and stationary fence post connected by a hooking mechanism[TRUNCATED]

Based on observation, interview and record review, the facility failed to keep resident care areas and equipment clean and in a good state of repair. This has the potential to affect all 60 residents living in the facility. Findings include: On 02/06/24 at 12:14 PM, Dining room observed having brown ceiling tiles around ceiling vent area. On 02/08/24 at approximately 9:59 A.M., V4 (Maintenance Supervisor) and V11 (Regional Maintenance) were asked about the vent in the dining room with discolored tiles around it. V4 stated that he was aware of the discoloration of the ceiling tiles around the vent. V4 stated that it was on his list to do he has just been busy and it hasn't been that way long. V11 asked V4 if he had tiles available and V4 replied yes. On 02/06/2024 at 09:00 AM, observation in R10's room revealed the following: cove base in the bathroom ripped, dry wall exposed and ripped, dust and debris noted where the cove based stopped. On 02/06/2024 at 09:04 AM, observation in R24 and R212's room revealed the following: bathroom sink dripping, mildew build up around faucet and chipped/bent fixture by hot water handle. On 02/06/2024 at 09:35 AM observation in R52's room revealed a quarter bed rail loose, able to be shaken. On 02/06/2024 at 09:38 AM observation in R11's room revealed the following: on the right side of the wheelchair, the arm rest is tattered and torn, and the personal fan in the room had a gray / brown debris noted on it. On 02/06/2024 at 10:11 AM observation in R34's room: the faucet in the resident bathroom dripped and had a mildew like substance built up around faucets, paint chips, and a toilet riser that appears to be a bed side commode place over the toilet, not affixed to anything. On 02/06/2024 at 10:21 AM observation in R6's room revealed the following: personal fan running with grey / brown dust debris observed to cover. Quarter rail observed to left upper side of bed, loose. On 02/06/2024 at 11:16 AM observation in R17's room revealed the following: Paint chips along with a small hole near the baseboard observed in room. Bathroom nonskid strip peeling in front of toilet. Mildew buildup observed on sink faucet. On 02/06/2024 at 11:41 AM observation in R44 and R12's room revealed the following: brown stained ceiling tiles x 6. On 02/08/2024 at approximately 10:00 A.M. an interview and tour with V4 and V11 was conducted. V4 stated that most of the items were on his list to do he has just been busy and hasn't gotten around to it. V11 stated that he expected all items to be corrected as soon as possible. V11 stated the fans with debris should be cleaned by housekeeping. V11 instructed V4 to start fixing the items immediately. Interview of V4 about the procedure of being notified of maintenance issues, V4 stated that when a maintenance issue arises there is a work order for that is filled out. After the work order form is filled out, V4 then puts them on a list to be completed. On 02/08/2024 at 11:13 AM, V12 (Housekeeping Manager) stated that housekeeping staff should be cleaning the personal fans. 43088 On 2/6/24 at 8:52 AM, the men's bathroom on the 600 hall had a crack in the floor between the sink and the urinal and another crack in the floor between the urinal and the toilet. The base boards around the urinal were peeling off the wall. The flooring below the urinal was stained yellowish. The sink had approximately 8 sharp edged areas where pieces of the front bottom edge of the sink was broken. Three ceiling tiles were discolored yellowish from water damage. On 2/6/24 at 8:55 AM, the 600 hallway walls had multiple vertical lines of wallpaper peeling up from the wall. Approximately 6 areas of peeling wall paper had a piece of clear tape at the bottom of the wall where the wall paper started. On 2/9/24 at 10:48 AM, V11 (Regional Maintenance) said he was not aware of the wall paper peeling off the wall on the 600 hallway. V11 said he was not aware of the men's bathroom on the 600 hall having a crack in the floor, the base boards peeling off the wall, the stained flooring under the urinal, or the water damaged ceiling tiles. The facility provided a list of male residents who were able to use the men's bathroom on the 600 hall indicating R28, R32, R49, R51, R57, and R59. The facility's Census List printed 2/6/24 documented residents residing on the 600 hall include: R13, R27, R32, R33, R45, R49, R51, R53, R56, R59, R262. The facility's revised May 2017 Quality of Life - Homelike Environment documented in part . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; The Long Term Care Facility application for Medicare and Medicaid dated 2/6/24, documents 60 residents reside in the facility.

Based on observation, interview and record review the facility failed to ensure that food items in the kitchen were properly stored/labeled and equipment was properly cleaned and maintained. This failure has the potential to affect all 60 residents residing in the facility. The Finings Include: During the initial tour of the facility on 2/6/24 at 8:40 AM the following concerns were noted: 1. A one gallon container of milk was in the refrigerator without a lid and not dated/labeled. 2. An open bag of shredded white and yellow cheese was found in the reach in refrigerator opened and not dated. The white shredded cheese was not sealed open to air in original bag. 3. A tray of drinks not labeled, not dated and uncovered were found in the reach in refrigerator. V40 (Corporate Director of Culinary Services) stated that they are drinks for the day for the residents. 4. The deep fryer located next to the oven was found to have food crumbs on the edges of it and floating in oil. 5. The walk-in freezer was found with the door not latched and ice accumulation on the floor under the bottom rack directly under the condenser unit approximately 12 inches deep and sloping out into the walking space. Ice was also found accumulating directly under the condenser unit forming a thick ice covering an electrical cord and outlet inside the walk in freezer unit. On 2/6/24 at 9:43 AM, V3 (Dietary Manager) stated, that he just started cooking last Wednesday and he noticed the ice then but did not report it to anyone. V3 stated that the ice looks the same as it did last Wednesday. V3 went on to state that the deep fryer is cleaned every couple weeks, but they do not keep a log of when it is to be cleaned. V3 thinks the deep fryer was cleaned at least a couple weeks ago. On 2/6/24 at 9:50 AM, V4 (Maintenance Supervisor) did not know of any issues with the freezer having ice buildup. V4 stated that he has not been notified of any issues with the freezer until now, but will start to work on it now. On 2/6/24 at 11:21 AM, V6 (Cook) stated that she is the afternoon cook and noticed the ice build up about 2 days ago, and it has been growing. V6 stated that she has not told anyone because she leaves after her shift about 8 PM and no one is around and she doesn't think about it when she gets here in the afternoon. On 2/8/24 at 1:32 PM, V11 (Regional Maintenance) stated that he has called a local heating and cooling company to verify that he has fixed the problem with the walk-in freezer. On 2/9/24 at 8:51AM, V11 stated that the local heating and cooling company found the unit had a leak in it and they filled it with freon. The Long Term Care Facility application for Medicare and Medicaid dated 2/6/24, documents 60 residents reside in the facility. The Labeling and Dating Foods (Date Marking) policy from contracted dietary company dated 2016 documents: All foods stored will be properly labeled according to the following guidelines .2. Date marking for refrigerated storage food items .once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date.

Based on record review and interview the facility failed to maintain documentation of holding quarterly Quality Assurance and Performance Improvement meetings (QAPI). This has the potential to affect all 60 residents residing in the facility. The Findings Include: During the investigation and review of facility records no evidence of quarterly QAPI meeting attendance or meeting information was found or produced by the facility. On 2/9/24 at 2:30 PM, V1 (Administrator) stated that he is not able to find any documentation of minutes or attendance sheets prior to January 2024 for the facility's quarterly QAPI meeting. V1 went on to state that he started his employment at this facility in January 2024 and no QA information is able to be accessed prior to that. The Long Term Care Facility application for Medicare and Medicaid dated 2/6/24, documents 60 residents reside in the facility.

Based on observation, interview, and record review the facility failed to provide activities that met resident goals and preferences for five (R7, R13, R14, R26, and R27) of five residents reviewed for activities out of a sample of 40. Findings include: 1. The facility's February 2024 activities calendar documented 2/8/24 10:00 AM sensory, 10:30 AM Valentine's Day crafting, and 11:00 AM social gathering. On 2/8/24 at 10:16 AM, V5 (Activities Director) was in the main dining room directing the sensory activity. 3 residents were in their wheelchairs around the table. 1 of the residents was asleep, 1 of the residents did not have an activity device but was scrolling on her phone, and 1 was using a fidget board. On 2/8/24 at 10:19 AM, another resident was wheeled into the dining room to participate in the activity and fell asleep in her wheelchair. On 2/8/24 at 10:22 AM, 5 residents were sitting around the table in the dining room with 3 of them asleep in their wheelchairs, 1 blankly staring at nothing, and 1 was with a fidget board in front of her. On 2/8/24 at 10:30 AM, V5 placed a plastic container of dry macaroni noodles with plastic ducks in it in front of R26. On 2/8/24 at 10:28 AM V5 (Activities Director) asked a resident if she would like to decorate a Valentine's Day box. 1 Valentine's Day box was presented and only 1 resident participated in decorating it. On 2/8/24 at 10:38 AM, R14 was sitting in his wheelchair in the dining room in front of the television and was asleep in his wheelchair. R13 was asleep in her wheelchair with a plastic football on the table in front of her. V5 gave R26 some paint on a paper plate, a paint brush, and piece of paper. R26 had difficulty holding the paint brush and attempted to put paint on the paper. On 2/8/24 at 10:55 AM, R14 was sitting in his wheelchair in the dining room watching television. 4 residents were sitting around a table in the dining room asleep in their wheelchairs and 2 were staring out the windows with no activity materials in front of them. On 2/8/24 at 11:04 AM V5 told the residents sitting in the dining room she was going to start putting any activity materials back in the closet because lunch would be coming soon. On 2/8/24 at 11:13 AM, V5 wheeled the sleeping residents to different tables in the dining room where they usually sat for meals. Several of the residents were asleep in their wheelchairs. 2. The facility's February 2024 activities calendar documented 2/9/24 10:00 AM sensory, 10:30 AM music circle, 11:00 AM daily delights. On 2/9/24 at 10:07 AM, V5 placed a container with dry macaroni noodles in it and plastic football on the table in the dining room with several residents sitting around it asleep in their wheelchairs. On 2/9/24 at 10:11 AM, V5 attempted to wake R13 by repeatedly asking if R13 could hear V5. V5 asked R13 if R13 would like to touch the macaroni or the football and R13 said no and closed her eyes. R7 was asleep in her wheelchair. On 2/9/24 at 10:15 AM, V5 turned the television in the dining room off and got out a purple speaker to play music. Several of the residents were asleep in their wheelchairs. On 2/9/24 at 11:08 AM, several residents were asleep in their wheelchairs in the dining room while V5 sorted through shirts preparing to iron on vinyl designs. V5 had very little interaction with the residents in the dining room. On 2/9/24 at 11:24 AM, three residents in the dining room were asleep in their wheelchairs. On 2/9/24 at 11:43 AM, V43 (Activity Aide) said the daily sensory activity was designed for residents who are wheelchair bound and can't get up to participate in activities. V43 said for this activity staff would have a fidget board or things with different textures for the residents to touch. V43 said Valentine's Day crafting was supposed to be for residents to paint Valentine's Day boxes if they wanted. V43 said social gathering was supposed to be residents gathering in the dining room to talk and listen to music. V43 said daily delights was a packet of papers contain news and puzzles. V43 said the facility was not able to print the daily delight packets because the activity's computer was not functioning. On 2/9/24 at 12:22 PM, V26 (Licensed Practical Nurse/ LPN) said bingo was the most attended activity with usually 10 to 13 residents attending. 3. R27's face sheet documented an admitted [DATE] with diagnoses including anxiety disorder, spinal stenosis, insomnia, anemia, gout. R27's 11/24/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating R27 was moderately cognitively impaired. R27's 5/26/23 annual MDS section F Preferences for Customary Routine and Activities documented it was very important to listen to music, be around animals, and do things with groups of people. R27's full care plan printed 2/13/24 documented no activity care plan. On 2/6/24 at 11:25 AM, R27 said the facility did not have activities every day. R27 said she thought the facility had an activity every other day. R27 said she was not sure if there was an activity calendar posted in the facility because she had never seen one. The facility's February 2024 activities calendar documented: 2/8/24 10:00 AM sensory, 10:30 AM Valentine's Day crafting, 11:00 AM social gathering. 2/9/24 10:00 AM sensory, 10:30 AM music circle, 11:00 AM daily delights. R27 was not seen participating in any activities on 2/8/24 or 2/9/24. 4. R7's face sheet documented an admitted [DATE] with diagnoses including: heart failure, major depressive disorder, anxiety disorder, Parkinson's disease. R7's full care plan printed 2/13/24 documented no activity care plan. R7's 1/12/24 MDS documented a BIMS score of 12, indicating R7 was moderately cognitively impaired. This same MDS documented it was very important to listen to music, keep up with the news, and do thing with groups of people. 5. R13's face sheet documented an admitted [DATE] with diagnoses including: malaise, major depressive disorder, anxiety disorder, Alzheimer's disease, mutism, dementia, dysphagia. R13's 12/1/23 MDS documented a BIMS score of 00, indicating R13 was not cognitively intact. R13's full care plan printed 2/13/24 documented a 7/18/23 care area for attention: has difficulty focusing on what is going on around her during meals and focus activities around her with interventions of provide smaller group activities to decrease distraction and give verbal cues to help prompt; but no activity care area. 6. R14's face sheet documented an admitted [DATE] with diagnoses including: major depressive disorder, chronic obstructive pulmonary disorder, hypertension, Parkinson's disease with dyskinesia. R14's full care plan printed 2/13/24 documented a 12/17/23 care area for behavior: physically aggressive behavior toward peers with a 12/17/23 intervention to provide diversional activities; but no activity care area. R14's 12/1/23 MDS documented a BIMS score of 7, indicating R14 was severely cognitively impaired. This same MDS documented it was very important to listen to music, be around animals such as pets, and somewhat important to do things with groups of people. 7. R26's face sheet documented an admitted [DATE] with diagnoses including: dementia, chronic obstructive pulmonary disease, abnormalities of gait and mobility, chronic kidney disease stage 3. R26's full care plan printed 2/13/24 documented no activity care plan. R26's 1/5/24 MDS documented a BIMS score of 11, indicating R26 was moderately cognitively impaired. This same MDS documented it was very important to listen to music, keep up with the news, and do things with groups of people. On 2/13/24 at 11:59 AM, V5 said the facility's morning activities were different every day. V5 said sometimes she would play music or just talk to the residents. V5 was asked why there were very few residents participating in the group activities and V5 said she did not know. V5 was asked what activity had the most participation by residents and V5 said bingo had the most resident interest and would usually have 10 to 15 residents in attendance. The facility's revised June 2018 Activity Evaluation policy documented in part .1. An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident. 2. The resident's activity evaluation is conducted by Activity Department personnel, in conjunction with other staff who evaluate related factors such as functional level, cognition and medical conditions that may affect activities participation . 6. The activity evaluation is used to develop an individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/ her choice and interest. 7. Each resident's activities care plan relates to his/ her comprehensive assessment and reflects his/ her individual needs. 8. Through the interdisciplinary process, the activity evaluation and activities care plan identify if a resident is capable of pursuing activities independently, or if supervision and assistance are needed .

Based on interview and record review the facility failed to provide person-centered care plan meetings for 1 (R11) of 17 residents reviewed for care planning in a sample of 40. Findings Include: On 2/8/2024 at 9:15 AM, R11 was alert and oriented and stated she has never been invited to a care plan meeting, verbally or in writing. R11 stated, being here almost 3 years and have not been to a meeting, and I do not have a primary medical representative. R11's electronic medical record care plan meeting for quarterly and annual conferences documents that care plan letters were mailed to the patient medical representative with no response. On 02/08/24 at 08:49 AM, V7 (Care Plan/ Minimum Data Set Coordinator) stated, R11 was verbally notified of care plan meetings but nothing was given to R11 on paper, but R11 was reminded of the date and time of meetings. V7 states, the care plan letters were mailed to family, but family never responded. R11's MDS (Minimum Data Set) with Assessment Reference Date of 11/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R11 has no cognitive impairment. Quarterly care plan conference notes document IDT (Interdisciplinary Team) members in attendance for meetings dated 4/20/23, 7/12/2023, 10/17/2023 and annual care plan conference dated 11/7/2023 with R11 not noted to be in attendance. The facility policy titled Care plans, Comprehensive Person-Centered Policy Statement documents 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning process; b. Identify individuals or roles to be included; c. Request meetings;d. Request revisions to the plan of care; e. Participate in establishing the expected goals and outcomes of care f. Participate in determining the type, amount frequency and duration of care; g. Receive the services and/or items included in the plan of care; and h. See the care plan and sign it after significant changes are made.

Based on observation, interview, and record review, the facility failed to provide unconflicted lunch meal and smoking schedules for one resident (R21) of 17 residents reviewed for accommodation of need in the sample of 40. Findings include: R21's Face Sheet documented an admitted [DATE], and listed diagnoses including History of Cerebral Infarction, Hypertension, and Nicotine Dependence. The facility's Meal Schedule documented the lunch meal service begins at 12:00pm. On 02/06/24 at 11:15am, R21 was alert and oriented to person, place, and time. R21 stated she always eats in her room, and her lunch meal is frequently cold by the time she eats it. R21 stated she gets her tray as late as 1:00pm, which interferes with the 1:00pm scheduled smoking time. On 02/06/24 at 12:52pm, R21 was observed waiting by the exit to go outside to smoke. R21 stated staff had just informed her they probably won't go out until about 1:30pm. On 02/06/24 at 1:03pm, R21's lunch tray was observed sitting on her overbed table. The plate was covered with a metal plate cover. On 02/06/24 at 01:28pm, R21 walked back into her room. R21 tasted her lunch, stated it is still a little warm and she will eat it as is. The Smoking Schedule documented resident smoking times as 9:00am, 1:00pm, and 6:00pm. The facility's Smoking/Tobacco Policy stated,The facility offers a structured smoking program for all residents who smoke. The facility will make all attempts to guard the rights of the smoker and non- smoker. On 02/13/24 at 11:02am, V1, Administrator, stated some of the residents have complained about feeling they need to rush through lunch so as not to miss their 1:00pm smoke break. V1 stated within the past two weeks, the facility had identified the need to re-evaluate the smoking schedule and have not yet done so.

Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for one (R58) of one residents reviewed for advanced directives in the sample of 40. Findings Include: R58's Face Sheet documented an admitted to the facility as [DATE]. This document also listed R58's diagnoses including, but not limited to: Acute kidney failure, Dysphagia, Parkinson's disorder without dyskinesia. R58's POLST form, scanned into R58's Electronic Health Record, with a [DATE] signature date by R58, documented a Do Not Resuscitate status. Review of the Advanced Directive tab, as well as the informational screen heading listed in R58's Electronic Record documented R58's status as being attempt CPR (Cardiopulmonary Resuscitation). On [DATE] at 2:59 PM, V1 (Administrator) verified that the Advanced Directive status listed for R58 do not correlate. V1 confirmed that the code status should match and consistently reflect the resident's POLST wishes throughout the Electronic Health Record. The Advance Directives policy with a revision date of [DATE] documented, Advanced directives will be respected in accordance with state law and facility policy 7. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record .10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

Based on observation, interview, and record review, the facility failed to identify and assess adaptive equipment in order to ensure safety and freedom for normal movement for one (R24) of one residents reviewed for physical restraints in the sample of 40. The Findings Include: Review of R24's Face Sheet documents an admitted to the facility as 6/1/22 and includes the diagnosis other reduced mobility, major depressive disorder, spinal stenosis, sciatica, and anxiety disorder. R24's current month of February 2024 Physician Orders does not have an order for the use of a self-releasing seatbelt. R24's Annual Minimum Data Set (MDS) with assessment reference date as 1/12/2024 documents a Brief Interview for Mental Status score of 3, indicating significant cognitive impairment. This same assessment documents R24 is dependent on staff for chair/bed transfer, sit to stand, and sit to lying position. Review of section GG0115 documents no range of motion impairment in her upper or lower extremities. R24's current care plan has a category for fall with the interventions as follows all with a start date of 6/2/22: introduce to call light, keep adaptive devices within reach, keep personal items in reach (call light, remote, water glasses, etc.), observe for unsafe actions and intervene, wheelchair for locomotion, bed in lowest position, ensure room is clutter free, remind resident not to ambulate without assistance, physical and occupational therapy to evaluate and assist with transfers. R24's current Care Plan does not include any reference to a self-releasing seat belt used as an intervention for falls On 2/6/24 at 9:05 AM, R24's wheelchair was observed to have a cord coming out of the back of the wheelchair not connected to anything. On 2/07/24 at 1:50 PM, V10 (Certified Nurse Assistant/CNA) stated that she is familiar with R24. V10 described R24 as being confused, which is her normal status. V10 went on to state that R24 utilizes a seatbelt as a fall prevention. V10 stated that R24 is able to release her seatbelt herself and that is usually connected to a box on the back of her chair, which alarms when undone. V10 stated that R24's box is broken, and she believes a new one has been ordered, so the seatbelt does not currently sound. On 2/8/24 at 12:15 PM, V2 (Director of Nursing) stated that the seatbelt for R24 is a fall prevention and not a restraint and that a little black bag should be on the wheelchair with an alarm box in it. V2 stated at this time that R24 has intermittent times of confusion, but she wouldn't call her confused all the time. On 2/8/24 at 12:30 PM in the dining room, R24 was observed sitting at a table with her lunch tray in front of her. R24 did not have a black bag with an alarm box in it, nor was it observed anywhere else on her chair. At this time, V2 confirmed there was not an alarm box, but that since it is not a restraint she does not need an alarm box and that R24 is able to remove the seatbelt at any time and on command. At this time, R24 was prompted by V2 (Director of Nursing) to release her seatbelt and she was unable to do so on her own accord. V2 attempted to assist her with removal of the seatbelt and then stated this is not adjusted properly on her. V2 confirmed at the time that R24 was unable to release her seatbelt. On 2/8/24 at 12:30 PM, V15 (Family Member) stated that R24 has not had an alarm box to her seatbelt for quite some time now, so she doesn't know why they have the seatbelt on her when up in the wheelchair. V15 went on to state that R24 can release it and they won't know when she is getting up, so if it is to help prevent falls it is useless. V15 stated that when they started using the seatbelt it was attached to an alarm. On 2/9/24 at 2:00 PM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) stated that the self-releasing seat belt is not on the care plan. A facility pre-restraining evaluation dated and completed on 9/26/22 by V19 (Director of Clinical Operations) documents under the recommendations that: 'the IDT (Interdisciplinary team) has reviewed with the input of the family and primary care physician and V45 (Power of Attorney) approved the use of a seat belt after discussion of risk/benefit and he approved and expressed wish for her to use. It was explained to his (sic) that she was able to demonstrate removal of seat belt at this time so it was not considered a restraint. He verbalized understanding.' The facility's physical restraint assessment for R24 has a start date of 2/7/24, a complete date of 2/7/24 and a print date of 2/8/24. This assessment documents that a device used is a self-releasing seat belt as a fall intervention. This assessment documents that R24 is confused all the time and that the resident is able to open the seat belt with no assistance from staff at this time. This assessment documents that the device is not a restraint. Review of the facility policy Resident Rights with a revision date of December 2016 documents in part .d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms. Review of the facility policy titled Use of Restraint with a revision date of February 2017 states, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. Review of an article titled, Use of physical restraint in nursing homes: clinical-ethical considerations dated March 2006 and found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564468/ states, Physical restraint can be defined as any device, material or equipment attached to or near a person's body and which cannot be controlled or easily removed by the person and which deliberately prevents or is deliberately intended to prevent a person's free body movement to a position of choice and/or a person's normal access to their body. Examples of physical restraint include vests, straps/belts, limb ties, wheelchair bars and brakes, chairs that tip backwards, tucking in sheets too tightly, and bedside rails. V1 (Administrator) when asked for the self-releasing seat belt guidelines provided the TL-2109 and TL 2109V Chair belt manufacturer guidelines on 2/8/24 at 3:00 PM. These guidelines document under the 'Quick Start Instructions' to 1. Install batteries, 2. Seat belt installation, 3. Mount the Fall Monitor, 4. Connect the seat belt to the fall monitor, and 5. Test the system.

Based on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) coding for one (R59) of 17 reviewed for Minimum Data Sets in the sample of 40. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family member/Power of Attorney/POA) and V22 (Family member). R59's (Name of town) Primary Care record found in R59's Electronic Health Record, documented a visit on 12/7/23 with a chief complaint being to establish care. This document stated, Patient has been here in the past. It has been over 4 years since he was last seen in this clinic. He is here today with his sister to reestablish care. Over the past 2 years, she has noted a decrease in his mental status. He seems to be having problems with short-term memory. There is a family history of dementia in their father. The history of stroke is uncertain. He was hit by a semi several years ago in front of the (Store Name) here in town. He did sustain a significant head injury at that time .He does have some problems with his vision. This seems to be a problem when trying to watch TV as he cannot use his remote. He also likes to walk around town. He reports almost being hit by a semi couple days ago. According to his sister, approximately 18 months ago she became involved with his care when he showed up at her house and was quite disheveled. Since then she has worked on getting him help set up He does tend to sleep from 5 or 6:00 PM until 4:30 in the morning. At that time he does like to get up and walk around town . Local hospital Emergency Department (ED) notes dated 12/28/23 at 10:38 AM, documented R59 was seen for chief complaints of altered mental status and hallucinations. This document stated R59 was brought to the ED by family members and friends who stated R59's complaint symptoms had been going on for the last 18 months but worsened over the last 2 weeks. After workup, the Clinical Impression listed is Thoracic aortic aneurysm, unspecified part, unspecified whether ruptured; and Cardiac arrhythmia, unspecified cardiac arrhythmia type. A case management note documented report included family concerns with R59's current living apartment arrangements which state R59 has been found outside his apartment multiple times, locked out, and ultimately confused how to operate a key fob to get into the apartment. Not eating as he should and suspected hallucinations. R59's Resident Incident Report dated 12/29/23 at 5:31 AM documented the incident type as, Wander from grounds. This report documented a narrative of incident and description of injuries: Resident left building out the Exit door on back hall to walk 2 blocks down the road to his house. Resident was full dressed with shoes and a heavy coat on. 2 CNA's escorted resident to his house on foot and a nurse followed in the car. Resident went to his home where his son (name of V20) also lived and (name of V20) agreed that resident could stay there at that time and he would try to get him to come back. V2 (DON) is documented as being notified on 12/29/23 at 5:30 AM, V21 (POA) on 12/29/23 at 5:45 AM, and V25 (Physician) at 8:00 AM. This report documented exam by physician as no. Immediate action taken is listed as, Escorted by staff to home. Alarm were checked on facility doors and the (sic) were working properly. frequent visual checks by all staff attempts will put 1:1 sitter with him until behavior ceases. The following Medical risk factors possibly related to incident are documented on this incident report as Confusion/Disorientation, and Other: Afib (atrial fibrillation). This form includes no printed names, signatures, or dates of completion for this report. The Incident Investigation, Narrative of investigation completed by V2 stated, IDT (Interdisciplinary Team) investigation resident left building escorted by staff to home 2 blocks down the street. Temp was 39 outside and he had on a heavy coat on. Alarms were checked on facility doors and they were working properly. Frequent visual checks by all staff. If resident attempts will put 1:1 sitter with him until the behavior ceases as resident did Returned (sic) to facility that same AM and apologized to DON and stated he would stay in the building and only leave with someone with him. Family also spoke with DON and Admin they also spoke with resident about leaving the building alone. Review of R59's Minimum Data Set with an assessment reference date of 1/4/24 documented a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section E0900 documents 0, indicating the behavior was not exhibited to the question has the resident wandered. On 02/09/24 at 09:56 AM, V34 (Social Services Director) stated that she did complete Section E of R59's Minimum Data Set care plan with the reference date of 1/4/24. V34 stated that she was not aware that R59 wandered or had exited the building when she completed the assessment, which is why she marked section E0900 as wandering behavior not exhibited. V34 stated due to her entry of 0 in this section, the system automatically disables further question entries in this section. V34 stated she is new to this job and acknowledges the coding error. V34 stated she would be notified of incidents with residents that have occurred in morning meeting or if she's just randomly looking in the charts.

Based on interview, record review, and observation, the facility failed to provide a Dental Soft/Mechanical Soft diet to 2 of 4 residents (R2, R3) reviewed for mechanically altered diets in the sample of 4. This failure resulted in the wrong textured diet being provided to R2 which resulted in a choking incident and a trip to the emergency room . Findings include: 1.) R2's Face Sheet dated [DATE], documents R2 had diagnoses that included Dementia without Behavior Disturbance, Dysphagia, History of Transient Ishecmic Attacks, History of Cerebral Infarction and [CONDITION(S)], Hypertension and [CONDITION(S)]. R2's Minimum Data Set/MDS dated [DATE] under Section C, documents R2 had a Brief Interview for Mental Status of 2, indicating R2 had severely impaired cognition and impaired short term and long term memory. Under Section G of R2's MDS, it is documented that R2 required 100 % of staff assistance for eating. In Section K of R2's MDS, it is documented that R2 had a swallowing disorder and needed a Mechanical Soft diet. R2's Physician's Orders dated [DATE] document R2 was on a Mechanical Soft diet with thin liquids, and on [DATE] the Mechanical Soft diet was discontinued. R2's Physician's Orders dated [DATE] document that R2 was started on a Pureed, No Added Salt, Concentrated Sweets diet with double portions of protein. A facility report labeled Illinois Department of Public Health Initial Report dated [DATE] documents in part: Initial: It was reported that on [DATE] at 6:05p, resident (R2) was eating supper when he began to choke on a piece of meat. Nurse immediately assessed the resident and performed the [MEDICATION(S)] maneuver dislodging the piece of meat. Resident was reassessed and was coughing with coarse rattling sound. All vitals were within normal limits. Attending physician and POA (Power of Attorney) notified and orders received to send to ER for evaluation. 9:30p Resident returned from hospital . Final: Investigation revealed that resident was eating supper when he began to choke on a piece of meat and the [MEDICATION(S)] was performed by nurse dislodging the piece of meat. Resident was assessed and physician and POA notified. Resident was noted to be coughing with course rattling sounds. Vital signs were all within normal limits. Orders received to send resident to ER for evaluation. Xray was performed and was noted to be clear with no signs dyspnea. Physician ordered for resident to be placed on a puree diet with a speech evaluation to be performed. Resident tolerating pureed diet with no noted problems. Staff will assist with meals. Family is aware of new orders will update family once speech evaluation has been completed. The facility's Diet Spreadsheet/Menu for supper on [DATE] (Day 23) for Dental Soft (Mech Soft) documents; Ground meatball with sauce sandwich, Tater Tots drizzled with ketchup (dental soft), soft-cooked vegetables (dental soft), Strawberry shortcake, Milk/Beverage. The Dining RD Spring/Summer 2022 recipe documents, for Ground Meatball with Sauce Sandwich in line #3: Place needed number of cooked meatballs in a clean and sanitized food processor and grind to the size and texture of fine hamburger. Reheat to 165 degrees Fahrenheit for 15 seconds. Add just enough heated spaghetti sauce to the ground meat to hold the product moist but not soupy. Maintain 135 degrees Fahrenheit of above. Line #4: To assemble sandwich: Place #12 dipper of ground meatballs with sauce, 2 Tablespoons grilled onions and 1 ounce shredded cheese on each hot dog bun; Cut sandwich in half and serve immediately. On [DATE] at 2:30 PM, via telephone, V7 (Nursing Assistant) stated on [DATE] around 6:00 PM, V8 (Registered Nurse) asked her to feed R2 because he wasn't eating very well on his own. V7 stated dietary sent a sub sandwich that had very small meatballs on a bun. V7 stated she cut up 2 meatballs into bite sized pieces for R2 and he was chewing the meatballs but she wasn't sure if he was swallowing them. V7 stated R2 may have been pocketing the meat when he swallowed the meat and got choked. V7 stated R2 wasn't coughing and she ran to get V8. V7 stated V8 came quickly and did the [MEDICATION(S)] Maneuver on R2 and got the meat out. V7 stated she didn't usually work on that side and she just thought R2 was on a regular diet since that's what dietary sent. V7 stated she didn't look at the dietary card, or attempt to do the [MEDICATION(S)] Maneuver. On [DATE] at 1:35 PM, via telephone, V8 stated R2 had a stroke about 1 year ago and V10 (Physician) told her that R2 was having Transient Ischemic Attacks frequently. V8 stated she asked V7 to feed R2 because he wasn't trying to feed himself. V8 stated on [DATE] around 6:00 PM, V7 came and got her because R2 was choking. V8 stated when she got to R2 he couldn't speak, and he wasn't coughing. V8 stated it was apparent that he was choking, so she did the [MEDICATION(S)] Maneuver 4 times, and on the 4th try, a clump of meat came out of R2's mouth. V8 stated it looked like the meat was clumped together as though it had been pocketed, and there were also a few smaller pieces of meat. V8 stated the meatballs were small and on a bun, not ground per R2's Physician's Order. V8 stated they called for an ambulance immediately and then called V10 since R2 had choked. V8 stated once R2's airway was cleared, R2 was having stridor when breathing and continued to be raspy sounding when the ambulance arrived. On [DATE] at 11:00 AM, via telephone, V5 (Dietary Aide) stated the meatballs were very soft and were easily mashed with a fork. V5 stated she asked V3 (Dietary Manager) if it was ok to serve the meatball sub to R2 and V3 told her to serve them since the meat was soft. V5 also stated the meatball subs had Provolone cheese on them and she thought R2 was supposed to have ground meat, but since V3 said it was ok, she went ahead and served it to R2. On [DATE] at 10:15 AM, V3 stated R2 shouldn't have received the meatball sandwich with whole meatballs, but should have had the meat ground. V3 stated after the choking incident, R2 was assessed by speech therapy and his diet changed to pureed. On [DATE] at 10:15 AM, V3 stated he receives a diet slip from the nurse who received a physician's order for the diet. V3 stated he enters the dietary order into his computer, including the liquid consistency. V3 stated when a diet order changes, the nurses fill out the standard dietary form that has the physician's name and date of diet change. V3 said when he gets the dietary order changes, he enters the new diet order into his computer and informs the dietary staff about the diet order change. V3 said once he instructs the staff about the diet order change, he monitors the meal tray to make sure the diet is sent out correctly. V3 also stated when he gets an order change, it is not only entered into the computer, he prints it out along with the Spread Sheet and the recipes for all of the diets, including the specialized diets for the cooks to use. V3 stated they use DiningRD as guidance and that includes the correct size scoops, menus and recipes for all the diets that are to be used daily. On [DATE] at 11:50 AM, V6 (Registered Nurse/RN) stated when they receive a diet order change from the physician, they put the new order on the Medication Administration Record, make out a Dietary Order form and take it to the Dietary staff. V6 stated when V3 is there, they make sure he gets the order change. V6 also stated the nursing staff watch and monitor to see if the diet the resident received is the diet that the physician just ordered. V6 also stated when they get a recommendation from the Speech Therapist, they send that recommendation to the physician and he will send a telephone order for the diet change. On [DATE] at 12:05 PM, V4 (Dietician) was in the main dining room and when asked if R2 should have received the meatball sub on a Dental soft/Mechanical Soft diet, she stated no, the meat should have been ground up. V4 stated a Mechanical Soft diet should always have the meat ground up. On [DATE] at 12:42 PM, V13 (Speech Therapist) stated she hadn't done a swallowing evaluation on R2 prior to the choking incident because he hadn't had any problems with eating up to that point. V13 stated she did do a swallowing evaluation on R2 on [DATE] when R2 returned from the hospital. V13 stated R2's diet was down graded to a Pureed diet and V10 was sent the recommendation and he gave an order for the Pureed diet. On [DATE] from 9:30 AM to 9:55 AM, V12 (Certified Nurses Aide), V14 (Certified Nurses Aide), V15 (Certified Nurses Aide), and V16 (Certified Nurses Aide) all stated they are to check the resident's dietary card to verify the resident's name and what diet the resident is to be receiving and if the diet isn't correct, they take the tray back to the kitchen and ask for the right diet. All of these C.N.A.s stated they are trained on the [MEDICATION(S)] Maneuver and would know how to perform the [MEDICATION(S)] Maneuver if a resident is choking. On [DATE] at 8:34 AM, via telephone, V10 stated R2 was having multiple Transient Ischemic Attacks (TIAs) and he was in decline prior to the choking incident. V10 stated R2's decline related to the TIA's, may have been the reason R2 had the choking incident. V10 stated the Mechanical soft diet should have been given to R2 but the choking incident didn't cause his decline or eventually, his death. V10 stated R2 did go on hospice on [DATE] and R2 died on [DATE] at the nursing home. R2's Progress Notes dated [DATE] document: At 6:05 pm; V7 was feeding resident (R2) meat balls for dinner, called me to come quickly, he's choking. Arrived to find resident unable to speak, could not cough, [MEDICATION(S)] done immediately. Took 4 tries before 1 whole meat ball and several pieces came out. He refused to open mouth, has stridor resp (respirations), continue to try and sweep mouth was successful only once. Eventually did cough once. Upper chest with loud rhonchi sounds. Ambulance called and report given to ER nurse, (name of nurse). 6:25 pm, ambulance here for resident. He has recovered somewhat, 6:40 pm left with ambulance crew to a local ER. Signed by: V8 (RN). R2's Hospital Provider Notes dated [DATE] document under Chief Complaint: Choking- Aspiration into airway. Review of Systems, under Respiratory: No complaint of cough or shortness of breath. On [DATE] Chest x-ray Finding: The pulmonary vascularity is unremarkable. The lungs are clear. There is no consolidation, infiltrate, pleural effusion or pneumothorax. Impression: No evidence of active pulmonary disease. R2's Progress Note dated [DATE] at 4:47 AM, documents, resident returned to facility via ambulance at 9:30 PM. Vital Signs 97.5, 76, 18, ,d+[DATE], O2 Saturation 95% Room Air. Hospital Report Xray- Clear. Complete Blood Count and Comprehensive Metabolic Panel done. Reported 500cc from straight catheter and no Urinary Tract Infection, No new orders received. Resident speaking. No signs or symptoms of Dyspnea. V11 (Family) was notified after ambulance transferred him to the local hospital emergency room . R2's Progress Note on [DATE] at 9:56 AM, (late entry) Received report from LPN, evaluation shows resident is lethargic, drooling, but awake. Smiles readily at V6, speech remains garbled and slurred. Oral cavity clear except for spittal. T 98.4 p 90 R 18 b/p ,d+[DATE] p/o (Pulse Oximeter) 95% on ra (room air). Lungs with slight rhonchi heard left upper lobe. Other clear. Pulses adequate. Signed by: V6 (RN) 2.) R3's Physician's Orders dated September, 2022, document R3 is to have a Regular, Mechanical Soft diet with Super-cereal at breakfast. R3's Minimum Data Set, dated dated dated [DATE] documents under Section C that R3 has a Brief Interview of Mental Status of 5, indicating R3 is severely cognitively impaired. In Section G under Eating, R3 requires supervision and cueing during her meals and requires set up help. On [DATE], R3 was eating in her room at 12:25 PM. R3 was sitting in her recliner with a bedside table that had her meal of Spaghetti, whole corn, pineapple dessert, bread stick and butter, tea and water sitting in front of her. R3 stated she was hungry and the food was good. On [DATE] at 12:30 PM, R3 was sitting in her recliner with her bedside table in front of her and she received a mechanical soft diet of ground pork with brown gravy, mashed potatoes, soft [NAME] sprouts that were easily mashed with a fork, banana split pudding, tea and water. At 12:55 PM on [DATE], V4 was asked if whole corn and a bread stick were appropriate on a Dental Soft/Mechanical Soft Diet. V4 stated the spaghetti was fine on a Mechanical soft diet, but R3 should have had creamed corn not whole corn, and R3 shouldn't receive a bread stick because it would be too hard to chew and swallow. V4 stated the dietary staff need more training on the importance of getting the diets right before they go out to the residents. V4 stated she gave an in-service to the dietary staff on [DATE] about diet orders, Spread Sheets, Mechanical Soft and Pureed diets. The Dietary Spreadsheet for Spring/Summer 2022 documents under Dental Soft (Mechanical Soft) that R3 was to have Ground meatballs with spaghetti and sauce, creamed corn, pureed pineapple trifle, bread and margarine and a beverage. The facility's policy on Dental Soft (Mechanical Soft) Diets, dated 2022 documents under Indications for Use: The Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods. If a Mechanical Soft Diet is ordered, the Dental Soft (Mechanical Soft) Diet would be appropriate if there is a chewing/dentition problem. This diet may also be used by a Speech Language Pathologist (SLP) in the treatment of dysphagia with individualization per recommendations by the SLP. This diet may be used for those experiencing mouth irritation and dentition problems including lack of teeth or poor fitting dentures. Individualization for specific food tolerances is required. For individuals that have any swallowing problems or dysphagia, it is recommended that a SLP be consulted and one of the Dysphagia Level Diets may need to be implemented.

Based on observation, interview, and record review the facility failed to obtain physician's orders to treat a laceration injury to the right leg for 1 of 3 residents (R2) reviewed for improper nursing care in the sample of 3. This failure resulted in R2 being transported to the emergency room , and subsequently being admitted to the hospital for intravenous antibiotic treatment for 7 days with an admission [DIAGNOSES REDACTED]. Findings Include: R2's quarterly Minimum Data Sets ((MDS) dated [DATE] documents R2 was admitted to the facility 05/07/18 and has a BIMS (Brief Interview for Mental Status) score of 05 (Severe Impairment). R2's [DIAGNOSES REDACTED]. R2's MDS dated [DATE] continues to document R2 requires extensive assistance with transfer, dressing, toilet use, personal hygiene, and utilizes a wheel chair propelled by staff or family for locomotion on/off unit. R2's baseline care plan dated 05/07/18 documents weekly skin assessments to be completed, and that R2 requires assist of 2+ staff for bed mobility, transfer, and toileting, locomotion, grooming/hygiene, and bathing. A nursing note dated 08/12/18 at 11:46 PM signed by V16, Licensed Practical Nurse (LPN) documents in part, staff was assisting R2 when R2 took legs off foot pedals and outer right leg ,just below knee cap , bumped leg causing bruise and 12 centimeter cm skin tear. [MEDICAL CONDITION] area cleansed then steri-stripped and dry dressing applied. NO (new order) rec (received) cleanse skin tear to right outer leg just below knee cap Q (every) shift apply dry dressing till healed d/t (due to) [MEDICAL CONDITION]. NO (new order) monitor q (every) shift till healed. DR (doctor) notified will notify family in AM. R2's (MONTH) Physician Order sheet does not document an order for [REDACTED]. R2's Treatment Administration Records (TAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) have no documentation to show treatment for [REDACTED]. R2's most recent care plan (undated) does not include a focus problem, goal, or intervention related to R2's right leg laceration injury of 08/12/18. A nursing note dated 08/13/18 at 11:54 AM signed by V12, Licensed Practical Nurse (LPN) documents dressing change to right lower leg skin tear with clear drainage noted. A nursing note dated 08/19/18 at 6:29 PM signed by V17, LPN documents in part, Resident right leg redness with [MEDICAL CONDITION] and tenderness from right knee down to ankle. States it hurts. Has been having chills off and on all day. When attempting to move RLE (right lower extremity) R2 cries out in pain. R2's family member at this time called another family member who requested for resident to be sent to ER for eval . Hospital records document R2 was transferred to the emergency roiagnom on [DATE] where her acuity level was assessed at a level 3 - emergent. Summary of History and Physical and Hospital Course document R2 presented to the emergency room with complaint of bilateral lower leg pain and redness. Patient and family stated she (R2) suffered a cut to her right lower leg a week ago at the nursing home. Right leg [DIAGNOSES REDACTED], swelling, and tenderness. Right lower leg laceration dressed with sterile strips - appears infected. Hospital records document R2 was initially treated in the emergency room with an intravenous piggy back (IVPB) of Meropenem in 50 milliliters (ML) normal saline 1 gram (GM) used to treat bacterial infections, and an intravenous push (IVP) of [MEDICATION NAME] 1 GM for pain. Assessment and Plan dated 08/19/18 document intravenous antibiotic treatment of [REDACTED]. A complete blood count (CBC) dated 08/19/18 shows a white blood count (WBC) of 11.0. R2's hospital discharge date of [DATE] documents a [DIAGNOSES REDACTED]. R2 was subsequently admitted to the hospital on [DATE], where intravenous antibiotic treatment was continued. R2 remained in the hospital until 08/27/18, at which time she returned to the long-term care facility with discharge instructions to follow-up with her primary care physician in 3-5 days, and establish with a wound care clinic. A facility document titled Skin/Wound QI (quality improvement) Log dated 08/15/18 documents R2 sustained a facility acquired skin tear to the outer knee on 08/12/18 measuring 12 centimeters (cm) x 0.2 cm. Ointment/medication and a dressing was applied to the wound. This form documents the intervention was completed, and family and doctor were notified of R2's injury on 08/12/18. A nursing note dated 08/21/18 at 8:01 AM signed by V19 , Director of Nursing/RN (DON) documents local hospital phoned to inform facility that resident had been admitted with [DIAGNOSES REDACTED]. Nursing notes dated 08/14/18 through current date of 09/12/18 contain no documentation related to R2's right leg laceration on 08/12/18. The facility is unable to produce documentation of who V16 received orders from to treat R2 for the injury sustained on 08/12/18. R2's clinical records do not document the facility notified V20, primary care physician, or V14, wound specialist of R2's laceration injury sustained on 08/12/18. Wound Care Follow-Up Progress Note for R2 dated 08/28/18 signed by V14, Wound Specialist, document an Assessment of wounds both legs, venous with a plan to check in 2 days and continue with unna boots. Wound Care Follow-up Progress Note dated 09/04/18 documents an Assessment of wound both legs - vascular type resolved with a plan to discontinue unna boots. There was no documentation on either visit to note that V14 was aware of R2's right leg laceration or hospital discharge orders to follow-up with a wound clinic. The facility was unable to provide documentation a follow-up appointment for R2 was scheduled with her primary care physician. The facility was also unable to provide documentation V14 was ever made aware of R2's right leg laceration. A Nursing Home Visit Progress Note dated 09/10/18 signed by V21, Nurse Practioner (NP) for V20, primary care physician, documents this as the first follow-up with her primary care physician/provider. Again, no documentation was provided that V21 was aware of R2's injury. On 09/11/18 at 2:10 PM, R2 was observed to have a healing wound to the right lateral leg just below the knee. V10, Family Member and V11, Family Member, stated they don't know how R2 keeps getting injuries on her arms and legs and staff cannot explain it to them. V10 is unsure of the date, but stated she noticed R2's pants were wet. She stated staff took R2 to the bathroom and V10 saw a cut around R2's right knee that was bloody and oozing. She stated staff put steri strips over the wound. V10 stated the bottom half of the cut was not covered. V10 stated R2's cut got infected and caused R2 to be in the hospital from 08/19/18 to 08/27/18. On 09/12/18 at 10:40 AM V12, LPN, stated she does rounds with V14, wound doctor, when he comes to the facility to treat residents. V12 stated V14 was not made aware of R2's injury on 08/12/18. On 09/12/18 at 11:14 AM, V13, LPN for V14, Wound Physician stated she spoke with V14 regarding the facility nursing note from 08/12/18, which documents new orders were received to treat R2's right leg laceration. V13 stated V14 was not made aware of R2's injury and did not give orders to treat this wound. On 09/12/18 at 11:25 AM, V15, emergency room Nurse Practioner (ERNP) stated R2 presented to the ER with an obvious wound infection to her right lower extremity. The infection was not systematic yet, but her white blood count was 11.0 (normal range is 5.0 - 10.0) Her understanding is R2 caught her leg on her wheel chair. V15 is not sure how it was being treated at the facility the week prior to arrival, but R2 came in with steri-strips covering a portion of the wound. V15 stated she would not typically treat a wound this size with steri-strips. V15's discharge orders were to follow-up with primary care physician in 3-5 days, and follow-up with wound clinic. On 09/12/18 at 12:30 PM a call was placed to V16, LPN, who witnessed R2's injury and documented on 08/12/18 that she received new orders to treat what was described as a 12 cm skin tear. V16 did not answer and no message was left due to V16 not having a voice mailbox set up on her cell phone. On 09/12/18 at 12:35 PM V12 and V17, both LPNs, confirmed there was never an order or documentation to treat R2's right leg laceration prior to her going to the hospital on [DATE]. They stated the facility has standing orders in the computer system for skin tears, which are to apply triple antibiotic ointment (TAO) and dressing to cover the wound. This allows nursing staff to print the order so the doctor can sign it when they are in the facility. They stated there are no standing orders for applying steri-strips to skin tears or any other type of wound. V12 and V17 stated they could not produce any documentation for a telephone order, Physician's Order Sheet, or Treatment Administration Record documenting R2's right leg laceration. V17 stated she worked the evening R2 went to the emergency room . R2 complained of pain in her right leg and when V17 assessed R2's leg, she observed the laceration and stated it looked septic. On 09/12/18 at 1:44 PM, V20, primary care physician for R2 stated he doesn't recall receiving a phone call on 08/12/18 at 11:46 PM and has no corresponding documentation for this date regarding R2. V20 stated he never reviewed or signed an order to treat a laceration wound on 08/12/18 for R2.

Based on record review and interview the facility failed to ensure that residents remain free of significant medication errors for 1 of 3 (R1) residents reviewed for significant medication errors on the sample of 3. This failure resulted in hospitalization and [DIAGNOSES REDACTED]. The findings include: R1's admission record states R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/12 Nursing Notes at 9:30am state R1 had foul smelling coffee ground emesis, a distended abdomen and bowel signs times four. A 1:20pm nurses notes finds R1 was admitted to the hospital for observation with [DIAGNOSES REDACTED]. E3 found errors in [MEDICATION NAME] dosage changes, administration of wrong dosage and transcription errors. The 1/10/12 incident report prepared by E1 (Administrator) finds the medication errors began on 12/28 with an order for [REDACTED].'s orders [REDACTED]. breakdown in our system as the nurse receiving order failed to pull the 4mg [MEDICATION NAME] from med cart. From 12/28/11 until 01/04/12 (R1) received 3mg until an LPN noticed the MAR indicated [REDACTED]. She then pulled the 3mg [MEDICATION NAME] from cart and sent to pharmacy for return, assuming the order was 4mg. He then received 4mg daily until hospitalization on [DATE]. Upon arrival to ER (emergency room ), an INR (International Ratio) of 5.4 was determined." A review of R1's POS and MAR sheets from December and January confirms the confusion of the [MEDICATION NAME] orders and the administration of the incorrect dosage of [MEDICATION NAME] from 1/4/12 to the time R1 was hosptalized on [DATE] with the UGI bleed and the INR of 5.4.