Every finding on record at Fireside House of Centralia

Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 1 (R1) of 3 residents reviewed for medication administration in the sample of 8. This failure resulted in R1 receiving an intermittent access (INT) needle placed in her left hand, after unsuccessful attempt to right forearm, two doses of Meropenem 500 MG (milligrams) IV (intravenous), and sent to the local emergency room for treatment of nausea.This past non-compliance occurred between 7/27/2026 and 7/28/2026. Findings included:R1's admission Record documented an admission date of 7/2/2026 with diagnoses including non-st elevation (nstemi) myocardial infarction, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease, stage 3 unspecified, and resistance to vancomycin. R1's Minimum Data Set (MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, meaning R1 is cognitively intact. R1's Care Plan documented a focus area of urinary tract infection for vancomycin-resistant enterococci of urine with a date initiated of 7/13/2026 with an intervention of give medications as ordered. On 8/15/2026 at 8:15 AM, R1 stated she had been given an intravenous antibiotic a few weeks ago that she was not supposed to have received. R1 stated, she has a history of urinary tract infections that she sees a physician for and is in the process of getting scheduled for surgery on her bladder. R1 stated, she had not been feeling well around 7/26/2026 with symptoms from a urinary tract infection. R1 stated, the facility did place an intravenous needle in her left hand on 7/27/2026 after trying to place one in her right forearm. R1 stated, then she received 2 doses of IV medication before the facility realized she was not supposed to be getting it. R1 stated, she did have nausea and vomiting and ended up going to the local emergency room on 7/29/2026 where she was told her symptoms were related to the antibiotic she had been given in the facility. On 8/15/2026 at 9:24 AM, V3 (Licensed Practical Nurse/LPN) stated she had been working as the floor nurse on 7/27/2026 in the afternoon on R1's hallway when V2 (Director of Nursing/DON) brought her 3 orders from the fax machine. V3 stated, V2 told her R1 had an antibiotic order from V9 (Physician) for Meropenem 500 MG intravenously (IV) every 8 hours. V3 stated, V2 notified her that V5 (Registered Nurse/RN) had been notified to start R1's INT and the order needed entered. V3 stated, she did enter Meropenem Intravenous Solution Reconstituted 500 MG (Meropenem) use 500 mg intravenously every 8 hours for ESBL (extended-spectrum beta-lactamase) of wound until 08/03/2026 into R1's electronic health record (EHR) and did not review the paperwork. V3 stated, the facility does have a process in place of triple checking new orders which included the nurse entering the order to make sure the order is for the right resident, right medication with results, the nurse administering the first dose is supposed to check right resident, right medication with cultures results, then V10 (Assistant Director of Nursing/ADON) will be the third check on the next morning. V3 stated it appears that another resident's order had been mixed up with R1's orders and she did not verify the name. V3 stated, R1 did go to the local emergency room on 7/29/2026 but is unaware if it was related to the medication error. On 8/15/2026 at 11:21 AM, V4 (LPN) stated she had worked from 6:00 AM to 4:00 PM on 7/27/2026 with direct patient care to R1. V4 stated, she came in on 7/28/2026 and was given report by V6 (RN) on R1 having an IV placed on 7/27/2026 with Meropenem Intravenous Solution Reconstituted 500 MG given on 7/27/2026 at 6:00 PM and 7/28/2026 at 2:00 AM related to a wound culture result. V4 stated, she asked V6 what wound R1 had, because she had been taking care of R1 the day prior and she did not have any wounds. V4 stated, V6 blew her off with her questions, so she contacted V2 (DON) to notify and clarify with her why R1 had been getting an IV antibiotic and V2 told her she did not know anything about it that V3 had been the nurse on the floor the day prior. V4 stated, she contacted V3 to clarify why R1 had an order for IV antibiotic for wounds when V3 hung up the phone with no explanation. V4 stated, in the process of calling V9 (physician) to clarify orders on R1, she reviewed the faxed orders and discovered they had another resident's name on them. V4 stated, she had been notified on 7/29/2026 during her shift that R1 had some nausea and vomiting. V4 stated, she did notify V9 of R1's complaints. V4 stated, R1 did get sent to the local emergency room for further evaluation to make sure it was not due to the IV antibiotic. V4 stated, all new medication should be checked prior to administration, especially new orders with the resident's results. On 8/15/2026 at 12:16 PM, V6 (RN) stated she did work the night of 7/27/2026 with direct patient care for R1. V6 stated, when she reported for her shift, V3 reported to her that R1 had an IV placed and was to start Meropenem Intravenous Solution Reconstituted 500 MG (Meropenem) use 500 mg intravenously every 8 hours for ESBL (extended-spectrum beta-lactamase) related to a wound culture result. V6 stated, she did administer Meropenem IV on 7/27/2026 at 6:00 PM and 7/28/2026 at 2:00 AM to R1. V6 stated, she was not aware of R1 having a wound. V6 stated, she was to verify the new antibiotic order for R1 with her culture results prior to administering the medication, however, the report was not at the nurse's station for her to verify. V6 stated, since V3 reported to her that she was to get an IV antibiotic during report, she administered the medicine. V6 stated, when V4 arrived on 7/28/2026 for her shift, she reported to her about R1 having an IV placed and antibiotics administered. On 8/15/2026 at 12:33 PM, V2 (DON) stated on 7/27/2026 she took 3 faxed orders from V9 on R1 and another resident and handed them to V3 for review and then entered them into resident's EHR (electronic health record). V2 stated, V3 had been the nurse on R1's floor that afternoon. V2 stated, V3 entered Meropenem 500 MG: use 500 mg intravenously every 8 hours for ESBL (extended- spectrum beta-lactamase) related to a wound culture result in R1's EHR. V2 stated, she did notify V5 (RN) that there was an IV that needed placed but did not tell her who the resident was that needed the INT placed. V2 stated, on 7/28/2026 during morning meeting, V4 notified her via phone that R1 should not be administered IV antibiotics and was supposed to be given Bactrim by mouth. V2 stated, she did clarify orders with V9 on 7/28/2026. V2 stated, V3 should have reviewed orders to verify correct resident, correct order, etc. prior to entering order into R1's EHR. V2 stated, V6 should have verified R1's new medication order with R1's culture results at the nurse's station and should not have administered the medication if she could not find the results. V2 stated, the facility process has a triple check in place for all new medications that start with the nurse entering the new order is to review and verify all information, the nurse administering the first dose is to review and verify all information, and V10 will review the next morning. V2 stated, upon review of the faxed orders R1 did not have ESBL from her umbilicus culture, her results were VRE (vancomycin-resistant enterococci). V2 stated, her expectations are that all nursing staff follow standard practices of medication administration that included verify medication orders with correct name, culture results, etc. On 8/15/2026 at 12:50 PM, V5 stated V2 notified her that R1 needed an INT started on 7/27/2026. V5 stated, she did come into the facility and placed R1's INT in left hand around 5:58 PM. On 8/15/2026 at 1:00 PM, V1 (Administrator) stated it is her expectation that all nursing staff follow standards of medication administration that include reviewing and verifying resident medications prior to entering them in the EHR and administering to residents. On 8/15/2026 at 1:21 PM, V9 (Physician) stated he had been notified about a medication error with R1 by V2 on 7/28/2026. V9 stated, V2 notified him R1 had received 2 doses of Meropenem 500 mg intravenously for ESBL (extended-spectrum beta-lactamase) in error. V9 stated, his expectations are nursing staff review and verify all orders prior to entering them into a resident's EHR and administering them to a resident. R1's Progress Note dated 7/27/2026 at 5:07 PM by V3 (LPN) documented new orders received to start meropenem 500mg IV every 8 hours for 7 days and start Bactrim DS 1-tab po BID (twice a day) for 10 days related to uti (urinary tract infection) and ESBL of wound. R1's Progress Note dated 7/27/2026 at 5:09 PM by V2 (DON) documented V11 (Family) declined the need for R1 to be transported to the local hospital and wanted R1 to receive IV medication at the facility. R1's Progress Note dated 7/27/26 at 5:58 PM by V5 (RN) documented attempted IV to right forearm with 1 attempt. Obtained IV access to left hand with one attempt, good blood return and flushed well.R1's Progress Note dated 7/27/2026 at 9:31 PM by V6 (LPN) documented R1 resting in bed with eyes closed, voices no complaints at this time. No bowel movement reported so far this shift, call in reach, INT (intermittent) to left arm IV antibiotic ran tolerating well no adverse effects noted. R1's Progress note dated 7/28/2026 at 9:29 AM by V7 (LPN) documented while reviewing the paperwork, it was noted that the culture report was for another resident who was scheduled to receive IV antibiotics. This resident received two doses of IV meropenem, the Director of Nursing (DON), was notified and made aware of the issue for follow-up and appropriate corrective action. R1's Progress Note dated 7/29/2026 at 6:54 AM by V4 documented staff came to this nurse stated resident told her she has been throwing up all night. This nurse went in to assess resident. R1 stated she has thrown up 3/4 times throughout the night appearance each time was white and frothy or brown. Resident says she feels sick to her stomach. Resident had a wet washcloth on head that staff applied. VS: BP:159/60 which is higher than her normal. R1's Progress Note dated 7/29/2026 at 7:17 AM by V4 documented local ambulance services called for transport to local emergency room. R1's Local Emergency Report dated 7/29/2026 documented under Chief Complaint: R1 sent in from nursing home, she received another resident's IV meropenem.says she doesn't feel well.complaints of nausea. This same document under Progress Notes: documented clinical impressions as of 7/29/2026 with nausea without vomiting, accidental medication error, chronic anemia. Medical Decision Making: concern for side effect of medication. R1's Urinary Culture report dated 7/27/2026 with fax transmittal time of 2:54 PM documented V9's order for R1 to start Bactrim DS 1 tablet by mouth twice a day for 10 days with no order to start Meropenem 500 MG IV every 8 hours for 7 days. R1's July 2026 Medication Administration Record documented Meropenem Intravenous Solution Reconstituted 500 MG (Meropenem) use 500 mg intravenously every 8 hours for ESBL of wound until 08/03/2026, with a start date 07/27/2026 and discontinued date of 07/28/2026 and 2 doses documented by V6 on 7/27/2026 at 6:00 PM and 7/28/2026 at 2:00 AM administered. The facility's Medication Administration policy (revised December 2012) documented under Policy Statement: Medications shall be administered safe and timely manner, and as prescribed. The facility's Specific Medication Administration Procedures (effective date May 2018) documented under Purpose: to provide for safe, accurate, and effective administration of parenteral medication directly into the vascular system. This same document documented under Procedures: Review and confirm medication orders for each individual resident on the Medication Administration Record or Treatment Record PRIOR to administering medications to each resident. Prior to the survey date, the facility took the following actions to correct the non-compliance:Education to all nursing staff to call for transcribing all orders that are given orally completed on 7/28/2026Director of Nursing and Assistant Director of Nursing to complete audit on all orders 5 days a week for 4 weeks for compliance.QAPI (Quality Assurance and Performance Improvement) meeting with the Medical Director was held on 7/28/2026.Medication Error Report completed on 7/28/2026.

Based on observation, interview and record review the facility failed to ensure that the food storage area was kept clean and swept and failed to ensure that policies and procedures were followed to prevent cross contamination. This failure has the potential to affect all 60 residents who reside in the facility. The Findings Include:On 02/17/2026 at 9:23 AM during the initial tour of the kitchen, the following items were observed:Dry storage room floor was littered with hair restraints, food crumbs, and spilled cereal.The lid on the cereal storage container for the corn flakes was broken not allowing it to have an air tight seal and potential for pests to enter and become stale.A handled scoop was found in the bulk flour bin.The ice machine interior flap had a pink substance found on it indicating that it needed sanitized.The brown sugar bowl on the serving steam table was open with a spoon in it and no staff present.On 2/17/26 at 11:00 AM, V4 (Cook) was observed preparing the pureed and mechanical soft food items. During this time, V4 opened the oven door, opened a drawer for utensils, assembled the blender to modify the food and then used the same gloved hands to put the meatloaf in the blender. As V4 was using a spatula to cut the meatloaf pieces, he would then use his gloved hand that had touched multiple surfaces to dump the portions of food into the blender. On 2/17/26 at 10:15 AM, V3 (Dietary Manager) stated that they had not had a chance to sweep the dry storage room and she would have that done along with removing the scoop from the flour and replacing the cereal bin lid. At this time, V3 also stated that V4 should not touch foods with his gloved hands, especially after touching other surfaces. A Handwashing and Glove use policy, with a revision date of 4/15/20, documents that: Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the Food and Nutrition Services Department must be followed Gloves: 1. Gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching any ready to eat food. 2. When gloves are used, handwashing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, see above. Gloves may be used for one task only. 3.It is important to remember that gloves can often give a false sense of security and can carry germs the same as our hands The Long-Term Care Facility Application for Medicare and Medicaid dated 2/17/26, documents that 60 residents reside in the facility.

Based on observation, interview and record review the facility failed to ensure resident diet orders were provided as ordered for 4 of 4 (R8, R22, R23, and R26) residents reviewed for diet order accuracy in a sample of 44.The Findings Include:R8's admission Profile documents an admission date of 7/30/24. This same document includes the following diagnoses: dementia, type 2 diabetes, and dysphagia. The Order Listing Report documents that R8's diet order is easy to chew texture and regular/thin liquids. R22's admission Profile documents an admission date of 10/7/25. This same document includes the following diagnoses: Type 2 diabetes, depression and hypertension. The Order Listing Report documents R22's diet order is regular diet, regular/thin liquids and double protein with all meals, no double entrée. R23's admission Profile documents an admission date of 5/23/24. This same document includes the following diagnoses: parkinsonism, pressure of the sacral region, and hypertension. The Order Listing Report documents R23's diet order as: Regular diet, regular/thin liquids, hand cut meat and double protein at meals. R26's admission Record documented an admission date of 1/15/26 with diagnoses including major depressive disorder, need for assistance with personal care, muscle weakness, abnormalities of gait and mobility, lack of coordination. R26's 1/21/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R26 was cognitively intact. R26's Order Summary Report printed 2/20/26 documented a 11/4/25 order for regular diet, regular texture, regular/ thin liquids consistency, double protein at meals no double entrée. On 2/17/26 during the lunch meal service at 12:30PM, R8 was observed to have a small amount of protein on his lunch plate. At this time, V6 (Assistant Dietary Manager) stated that was all the mechanical soft meat that she had left and he is not a big eater, so she just gave him what she had. On 2/17/26 at 3:00 PM, V4 (Dietary Manager) stated that there was meatloaf left that could have been ground up to make more mechanical soft meat and that is what should have been done. V4 stated that the staff know if they run out of mechanically altered foods, they know to ask for more to be made. On 2/18/26 during the lunch meal service at 12:00 PM, it was observed that R22, R23 and R26 did not get the double protein portions served to them on their plate. On 2/18/26 at 12:10 PM, R23 who is alert to person, place and time stated that she only gets one serving of the meat option at the meal. R23 stated that she only had one slice of meatloaf on 2/17/26 and only has the one corndog on 2/18/26. On 2/18/26 at 12:15 PM, R22 who is alert to person, place and time stated that he only had the one corndog but would like another. On 2/18/26 at 1:45PM, V3 (Dietary Manager) stated that the staff serving the trays and staff delivering trays should check the tickets prior to delivering to the resident. V3 went on to state that they are trying to change those diet orders to be an extra ounce of protein rather than double. On 2/18/2026 12:35pm, V5 (Cook) stated that double protein means that residents should have received 6 tenders instead of 3 or the alternate corn dog should have gotten 2 instead of one. On 2/18/2026 12:36 PM, V6 (Assistant Dietary Manager) stated when residents have an order for double protein the staff on tray line should be adding double amounts of the protein option. On 2/17/26 at 11:42 AM, R26's noon time meal tray was delivered and contained one regular portion of meat loaf, mashed potatoes with gravy, corn, pie, tea, water, and juice. On 2/19/26 at 12:01 PM, R26's noon time meal tray contained a bowl of ham and potatoes, breadstick, an apple turnover, tea, water, and apple juice. R26 said she never got a meal tray with double protein portions or a meal with a peanut butter sandwich. On 2/19/26 at 1:04 PM, V3 (Dietary Manager) said residents with an order for double protein should receive 1 extra ounce of protein with meals. V3 said the new dietitian started recommending double protein for residents and the facility had made an addendum to the policy for double protein orders. V3 said on 2/19/26 at the noontime meal the residents with double protein orders should have received the regular entrée and half of a peanut butter sandwich. On 2/19/26 at 1:41 PM, V10 (Registered Dietitian) said when a resident has an order for double protein, she would expect the facility to give 2 portions of the meal's protein to the resident. V10 said if the protein of the entrée was a mixed dish she would expect the facility to give the regular portion to the resident and supplement with something like an ounce of peanut butter or some other form of protein. R26's Registered Dietitian progress note dated 2/9/26 documented in part . Res (resident) with 5% Wt (weight) loss/ 1mo (month) per HT (height): 69 2/9 WT: 310# (pounds/lbs) BMI (Body Mass Index): 46 Class III obesity. Jan WT: 325# (January weight 325 pounds). WT fluctuating R/T (related to) Dx (diagnosis): CHF (Congestive Heart Failure)/ Lasix use/ edema/ on daily WT's. Continue Reg (regular), double protein portions/ meals, no double entrée. The facility's 1/26/26 Addendum to policy for Therapeutic Diets documented in part . 12. Those residents that have physician order for double protein will have extra protein added to designated meal through addition of 1 ounce of protein rich food added to meal.

Based on interview and record review the facility failed to ensure that significant change assessments were completed timely for 1 of 1 (R63) residents reviewed for significant changes in a sample of 44.The Findings Include:R63's admission Profile sheet documents an admission date of 7/2/2022. This same document includes the following diagnoses: Hemiplegia and Hemiparesis, Type 3 Diabetes and Dysphagia.R63's current physician order sheet shows that Hospice was started on 10/29/2025. R63 did not have a significant change Minimum Data Set Assessment completed at this time.A Minimum Data Set submission report documents that R63's target date for her significant change assessment was 11/4/2025 and was submitted on 2/16/2026. There is a message documenting that the assessment completed late: is more than 14 days after assessment reference date.On 2/19/26 at 2:00 PM, V2 (Director of Nursing) stated that she did not complete the significant change assessment for R63 at the time of the Hospice order. V2 stated that she will get started on submitting this.

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precaution (EBP) infection control precautions for 1 of 6 residents (R11) residents reviewed for infection control in the sample of 44.The findings include:R11's admission Record documented an admission Date of 8/4/25 and listed Diagnoses including Diabetes Type 2, Chronic Obstructive Pulmonary Disease, Hypertension, and Gastrostomy Status. R11's Minimum Data Set, dated [DATE] documented that R11 was receiving enteral feeding. R11's Care Plan dated 1/29/26 documented a problem area, (R11) On EBP due to gastrostomy tube.On 02/18/2026 at 10:50am, V7 (Licensed Practical Nurse) was observed administering G (Gastrostomy) Tube medications to R11. A sign on R11's door read: (EBP) Enhanced Barrier Precautions. Hanging on the door were PPE (Personal Protective Equipment) supplies including gowns, gloves, and N95 masks. After handwashing, V7 donned gloves, but no gown, and entered the room. Following the procedure, the Surveyor asked V7 about the EBP sign and what it meant. V7 stated R11 had no infection in the gastrostomy and was not on isolation. The Surveyor asked V7 what PPE should be donned for EBP, and V7 stated she was not normally working on this hall, and this was only her second time working on this hall, and forgot R11 was on EBP, and stated there were no gowns available, but gowns were observed in the PPE supplies on the door.On 02/20/2026 at 8:07am, V2 (Director of Nurses) stated the PPE to be donned for EBP is gown and gloves.An Enhanced Barrier Precautions Policy dated 2001 documented, 2. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: G. Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.)

Based on observation, interview, and record review the facility failed to maintain the desirable water temperature in the facility shower for 1 (R26) of 5 residents reviewed for environment in a sample of 44.Findings include:R26's admission Record documented an admission date of 1/15/26 with diagnoses including major depressive disorder, need for assistance with personal care, muscle weakness, abnormalities of gait and mobility, lack of coordination. R26's 1/21/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R26 was cognitively intact. On 2/17/26 at 2:08 PM, R26 said the facility shower's water temperature did not get hot enough for her liking.On 2/18/26 at 1:53 PM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit (F).On 2/18/26 at 2:50 PM, the west hall's shower room's shower water temperature was 90.6 degrees F and the sink's water temperature was 94.8 degrees F.On 2/18/26 at 3:06 PM, V8 (Maintenance Director) said the resident's hot water heater was set at 117 degrees F that went to a mixing valve that was set at 106 degrees F. V8 said the mixing valve did not have a gauge to determine what it was set at. V8 said when the plumbing company had to replace the mixing valve, they determined what water temperature it was set at by taking the temperature of the water in the resident shower room. V8 said the water then went to a holding tank that did not have a heating element before going to a recirculation pump to the resident shower room and resident rooms. V8 said there was no way to know what the temperature of the water was in the holding tank. V8 said he thought the recirculation pumps were working. V8 said he tested the water temperatures in resident rooms and shower rooms weekly.On 2/18/26 at 2:58 PM, V9 (Certified Nursing Assistant/ CNA) said she would turn the hot water on in the shower and let it run for 5 to 10 minutes prior to assisting a resident to shower so the water would be warm enough. V9 turned on the shower and left it running.On 2/18/26 at 3:06 PM, the west hall's shower room's water temperature measured 97.8 degrees F and did not feel warm enough to shower in.The facility's water temperature logs from 10/27/25 through 2/16/26 documented all resident rooms and shower rooms water temperatures measured 106 degrees F. The facility's 2/19/26 plumbing company's receipt documented in part .Replaced recirc (recirculation) pump for west wing. Was only getting 98 (degrees) water now getting 104 (degrees).The facility's revised 2009 'Water Temperatures, Safety policy documented in part .1. Water heaters that service resident rooms, bathrooms, common areas, and tub/ shower areas shall be set to temperatures on no more than 110 (degrees F) . or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log.

Based on observation, interview, and record review the facility failed to maintain a functioning call light system for 2 (R15 and R54) of 5 residents reviewed for environment in a sample of 44.Findings include:1. R15's admission Record documented an admission date of 3/3/25 with diagnoses including pneumonia, sepsis, and anemia. R15's 12/25/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating R15 was moderately cognitively impaired.On 2/17/26 at 11:11 AM, R15 and R54's room was observed to have a call light box on the wall with capped off wires with no cord call lights present. R15 was resting in bed with his eyes closed with an analog call bell sitting on his bedside table. On 2/17/26 at 1:57 PM, R15 was very hard of hearing and did not answer some questions appropriately. R15 was asked if he had a call light and R15 said no. R15 was asked what the analog call bell sitting on his bedside table was for and R15 said it was his bell, but he didn't really use it. R15's analog call bell was rung once, and staff did come to R15's room.On 2/20/26 at 11:43 AM, V1 (Administrator) said R15 could have a pendent call light if R15 wanted but wanted to keep the analog call bell.2. R54's admission Record documented an admission date of 12/18/25 with diagnoses including fracture of neck of right femur, presence of right artificial hip joint, Alzheimer's disease, seizures, and need for assistance with personal care. R54's 12/24/25 MDS documented a BIMS score of 5, indicating R54 was severely cognitively impaired.On 2/17/26 at 1:51 PM, R54 was slightly confused during this interview and was alert to person. R54 said he did not have a call light. R54 was asked how he alerted staff if he needed something and R54 said staff would just come in and check on me, so it's OK. On 2/20/26 at 11:43 AM, V1 was asked what R54 used as a call light and V1 said R54 had a pendent call light that hung from a lanyard that rang to a box at the nurse's station.On 2/20/26 at 11:50 AM, R54 was sitting in his wheelchair in his room and was alert to person and place at the time of this interview. R54 was asked if he had a call light and R54 responded no. R54 was asked if he had a call light that hung from a lanyard that he could wear and R54 answered yes. R54 was asked where his pendent call light was and R54 said he thought it was on his bedside table, but it was not able to be found. R54 was asked if he was wearing it and R54 answered no. R54 said he was not sure where his pendent call light could be.On 2/20/26 at 11:32 AM, V13 (Certified Nursing Assistant/ CNA) said she had never heard R15 use his analog call bell and was not sure if R15 was aware of what the analog call bell was for. V13 said on 2/17/26 when R15's analog call bell was tested was the first time V13 had heard it. V13 said she was not sure if R54 had a call light or not.On 2/20/26 at 11:28 AM, V12 (CNA) said she usually worked nightshift. V12 said during the night R15 and R54 were checked on at least every 2 hours to see if they needed anything. V12 said she had never heard R15 use his analog call bell. V12 said during the day R54 is usually up in his wheelchair and if he needed something he would come out into the hallway to get staff's attention. V12 said she did not think R54 had a call light, but staff were always on the hall if he needed something.On 2/18/26 at 2:09 PM, V8 (Maintenance Director) said R15 and R54's call light system could not be fixed. V8 said due to the system being so old parts to fix it could not be obtained. V8 said the facility had an outside electrical company come to the facility but they were also unable to obtain parts to fix the call light system.On 2/20/26 at 11:28 AM, V1 (Administrator) said the facility did not have a call light policy.

Based on interview and record review the facility failed to timely submit quarterly assessments for 1 of 1 (R45) residents reviewed for timely submission of assessments in a sample of 44.The Findings Include: R45's admission Record documents an admission date of 7/11/2024. This same document includes the following diagnoses: heart failure, anxiety disorder and chronic kidney disease.R45's quarterly Minimum Data Set (MDS) Assessment with a target due date of 1/13/2026 did not document that it was transmitted.A Final Validation Report documents that R45's MDS with a target date of 1/13/2026 was submitted on 2/19/2026 with a warning that the assessment was completed late due to being more than 14 days after the assessment reference date.On 2/19/2026 at 2:00 PM, V2 (Director of Nursing) stated that MDS was in progress and not completed and would work on getting that completed today and submitted.

Based on interview and record review the facility failed to timely submit discharge assessments for 1 of 1 (R36) residents reviewed for discharge assessments in a sample of 44.The Findings Include:R36's admission Record documents an admission of 9/2/25. The same document includes the following diagnoses: Type 2 Diabetes, Hypertension, Cognitive Communication Deficit, and anemia.R36's discharge Minimum Data Set (MDS) Assessment documented it was completed but not submitted on 9/30/2025.A Final Validation Report documents that R36's discharge MDS with a target date of 9/30/2025 was transmitted on 2/19/2026 with the warning error: Record submitted late, the submission date is more than 14 days after the assessment reference date.On 2/19/2026 at 2:00 PM, V2 (Director of Nursing) confirmed that R36's discharge assessment had not been transmitted.

Based on observation, record review and interview the facility failed to provide assistive devices at meals as ordered for 3 of 3 residents (R3, R25 and R55) in a sample of 44 reviewed for assistive devices at meals. The Findings Include:R3's admission Profile documents an admission date of 11/24/25. This same document includes the following diagnoses: Type 2 Diabetes Mellitus, unspecified lack of coordination, and major depressive disorder. R3's diet listed on the Facility Order Listing Report is as follows: Regular texture, regular/thin liquids, 8 ounces of extra fluids and built-up silverware to assist while eating.R25's admission Profile documents an admission date of 8/6/25. This same document includes the following diagnoses: Major Depressive Disorder, Anxiety Disorder, and Alzheimer's Disease. R25's diet listed on the Facility Order Listing Report is as follows: easy to chew texture, regular/thin liquids and build up silverware and divided plate with all meals.R55's admission Profile documents an admission date of 8/14/25. This same document includes the following diagnoses: Major Depressive Disorder, Dementia and hypertension. R55's diet listed on the Facility Order Listing Report is as follows: Regular texture, regular/thin liquids, weighted utensils and whole milk and juice with all meals. On 2/17/2026 at 12:00 PM, R3, R25 and R55 were observed during lunch mealtime to not have special silverware. R3, R25 and R55 all had regular silverware.On 2/18/26 at 12:15 PM, R3, R25 and R55 were observed to be provided the same regular silverware as the rest of the residents in the dining room.On 2/18/26 at 1:45PM, V3 (Dietary Manager) stated that the staff serving the trays and delivering the trays should check the tickets prior to delivery. On 2/18/2026 at 12:36 PM, V6 (Assistant Dietary Manager) stated when residents are ordered adaptive utensils, dietary staff are to read the card and put them on the tray during tray line.

Based on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This has the potential to affect all 54 residents currently residing at the facility. Findings Include: The Midnight Census Report dated 7/2/25 documents there are 54 residents residing at the facility. R8's admission Record with a print date of 7/9/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include dementia, muscle weakness, and vision loss. R8's Minimum Data Set (MDS) dated [DATE] documents R8 has a BIMS score of 09, indicating a moderate cognitive deficit. This same MDS documents R8 is dependent on staff for transfers. R8's current Care Plan documents a Focus area of Risk for falls. This Focus area includes the intervention mechanical lift for transfers. There are no dates documented on this Care Plan. R8's Order Summary Report dated 7/9/25 includes the following physician order, Mechanical Lift for transfers every shift, with a start date of 10/05/2019. On 7/8/25 at 7:05 PM, V4 (Certified Nursing Assistant/CNA) was in R8's room transferring R8 from chair to bed using a mechanical lift. V4 was attempting the transfer without assistance of another staff. V4 had R8 in the lift and in the air when this surveyor started the observation. V4 wheeled the lift to the bed and started to lower R8 onto the bed. V4 had to stop and raise R8 up again because she was high enough her head was too close to the head of the bed. V4 adjusted the lift and began lowering R8 to the bed again. V4 stopped the lift and had to adjust R8 to the center of the bed because she was too close to the edge. V4 then lowered R8 to the bed. V20 (Licensed Practical Nurse/LPN) was in the hallway preparing medications to administer to other residents, throughout this observation. On 7/8/25 at 7:16 PM, V4 (CNA) stated she came to work at 6 am and was supposed to leave at 6 PM. V4 stated they had other CNA's not show up for work tonight and she would be leaving as soon as she got the residents settled for the night. V4 stated there were two other CNA's working on her hall and one CNA working on the other hall. V4 stated three CNA's is enough to meet the needs of the residents after they are all in bed. V4 stated she transferred R8 using a mechanical lift without the assistance of another CNA. V4 stated she did that because the other CNA's were providing care to other residents and they didn't have enough staff to meet the needs of the residents right now. On 7/9/25 at 2:58 PM, R8 stated she guessed they used a mechanical lift to transfer her. R8 stated she wasn't sure how many staff were present when they did it. R8 stated she had never been [NAME] or fallen during a transfer. On 7/8/25 at 7:08 PM, V20 (LPN) stated she had three CNA's working with her. V20 stated that is enough to meet the needs of the residents, sometimes. On 7/8/25 at 6:27 PM, V29 (Anonymous) stated three CNA's didn't show up for work for evening/night shift on 7/8/25. V29 stated they have two CNA's and a nurse on one unit with 35 residents and two CNA's and a nurse on the other unit with 17 residents. V29 stated they typically have three to four CNA's on the unit with 35 residents. On 7/9/25 at 11:29 AM, V23 (CNA) stated she worked on the evening of 7/8/25 from 2 to 10 PM. V23 stated they had three people who didn't show up for work. V23 stated they pulled a CNA off the side she works on to cover the other side. V23 stated that left one nurse and one CNA for her side. When asked if that was enough to meet the needs of the residents, V23 stated it wasn't. V23 stated call lights didn't get answered timely, incontinence care wasn't provided timely, and behavior monitoring is also affected. On 7/9/25 at 3:05 PM, V3 (Assistant Director of Nursing) stated they have enough staff as long as they don't call in. After this surveyor reviewed the observation of V4 transferring R8 without assistance of another staff, V3 stated she would expect the nurse to stop administering medications and assist with the transfer. On 7/9/25 at 3:31 PM, V1 (Administrator) stated she was not made aware they were short staffed last night. V1 stated three to four CNA's in the facility on night shift is enough to meet the needs of the residents. The facility Staffing Policy dated October 2017 documents, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on interview and record review the facility failed to ensure supplements were available for 4 of 6 (R1, R2, R10, and R14) residents reviewed for nutrition in the sample of 14. Findings Include: 1. R1's admission Record with a print date of 7/9/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, dementia, and vitamin deficiency. R1's MDS (Minimum Data Set) dated 3/26/25 documents a BIMS score of 05, indicating R1 has a severe cognitive deficit. R1's current Care Plan documents a Focus area of, Actual alteration in nutrition or hydration status r/t (related to) Vitamin D deficiency, hypomagnesium, n/v (nausea/vomiting), GERD (gastroesophageal reflux disease). 3/2025 weight loss. This same Focus area include the intervention of, Supplements as ordered: 7/4/2025- Boost 90 ml (milliliters) TID (three times daily). R1's Order Summary Report dated 7/9/25 includes a physician order for, Boost three times a day for weight loss give 90 cc (cubic centimeters), with a start date of 7/4/25. R1's Medication Administration Record (MAR) dated 6/1/25 to 6/30/25 documents a physician order for Boost three times a day for weight loss give 90 cc Start Date 04/08/2025. This same MAR indicates the Boost was not administered as ordered on 6/15, 6/16, 6/17, 6/23, and 6/24/25. 2. R2's admission Record with a print date of 7/9/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include diabetes, dementia, vitamin deficiency, and GERD. R2's current undated Care Plan documents a Focus area of, Potential for/actual alteration in nutrition or hydration status r/t (related to) COPD (chronic obstructive pulmonary disease), dehydration risk, low protein, magnesium deficit, heartburn, vitamin deficiency, hyperlipidemia, GERD. This same Focus area includes the intervention, Supplements as ordered 5/19/25 House supplement 2.0 4 x (times) day for weight loss, give 120 cc QID (4 times daily). R2's Order Audit Report dated 7/10/25 documents a physician order for, House 2.0 Supplement four times a day for weight loss give 120 cc qid, with a start date of 5/19/25. R2's MAR dated 6/1/25 to 6/30/25 includes a physician order for House 2.0 Supplement four times a day for weight loss give 120 cc qid (four times daily). This same MAR indicates the house supplement was not administered three times on 6/14 and 6/15, four times on 6/16, 6/23, and 6/24 and twice on 6/17 and 6/26/25. 3. R10's admission Record with a print date of 7/9/25 documents R10 was admitted to the facility on [DATE] with diagnoses that include muscle weakness, vitamin deficiency, GERD, and major depressive disorder. R10's Order Summary Report dated 7/9/25 documents a physician order for, House 2.0 Supplement four times a day for wt (weight) loss give 120 cc po (by mouth) qid, with a start date of 8/6/24. R10's MAR dated 6/1/25 to 6/30/25 documents a physician order for, House 2.0 Supplement four times a day for wt loss give 120 cc po qid. Start Date 08/08/2024. This same MAR indicates R10 was not administered the house supplement four times on 6/15, 6/16, 6/23, 6/24, twice on 6/17, 6/26, and once on 6/25/25. 4. R14's admission Record with a print date of 7/9/25 documents R14 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart disease, muscle weakness, and vitamin deficiency. R14's Order Summary Report dated 7/9/25 documents a physician order for, House 2.0 Supplement two times a day for Weight loss Give 120 cc, with a start date of 3/8/25. R14's MAR dated 6/1/25 to 6/30/25 documents a physician order for House 2.0 supplement two times a day for Weight loss Give 120 cc. Start Date 03/09/2025. This MAR indicates R14 was not administered the supplement on 6/14, 6/15, 6/16, 6/23, and 6/24/25; and was only administered the supplement once on 6/17 and 6/26/25. On 7/8/25 at 2:52 PM, V9 (LPN/Licensed Practical Nurse) stated they have dietary supplements right now but they were out of them a while back. V9 stated the MAR's will reflect when the residents didn't get the supplements as ordered. V9 stated she wasn't aware of any significant weight loss. On 7/8/25 at 6:27 PM, V29 (anonymous) stated they didn't have dietary supplements a few weeks ago for about a week. V29 stated there were no significant weight loss issues related to not having the supplements. On 7/9/25 at 3:17 PM, V24 (LPN) stated she was the interim Assistant Director until this week. V24 stated in June she made an order for the supplements and it didn't get delivered. V24 stated she called the supplier and they said it didn't get shipped due to a billing issue and they were dealing with the owner on it. V24 stated they bought the boost at a local store but couldn't get the House Supplement locally. V24 stated it was resolved at this time. On 7/9/25 at 3:31 PM, V1 (Administrator) stated she knew they were out of the supplement but it was only a short time.

Based on observation, interview, and record review the facility failed to ensure two staff were available when using a mechanical lift for 1 of 3 (R8) residents reviewed for accidents in the sample of 14. Findings Include: R8's admission Record with a print date of 7/9/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include dementia, muscle weakness, and vision loss. R8's Minimum Data Set (MDS) dated [DATE] documents R8 has a BIMS score of 09, indicating a moderate cognitive deficit. This same MDS documents R8 is dependent on staff for transfers. R8's current Care Plan documents a Focus area of Risk for falls. This Focus area includes the intervention mechanical lift for transfers. There are no dates documented on this Care Plan. R8's Order Summary Report dated 7/9/25 includes the following physician order, Mechanical Lift for transfers every shift, with a start date of 10/05/2019. On 7/8/25 at 7:05 PM, V4 (Certified Nursing Assistant/CNA) was in R8's room transferring R8 from chair to bed using a mechanical lift. V4 was attempting the transfer without assistance of another staff. V4 had R8 in the lift and in the air when this surveyor started the observation. V4 wheeled the lift to the bed and started to lower R8 onto the bed. V4 had to stop and raise R8 up again because she was high enough her head was too close to the head of the bed. V4 adjusted the lift and began lowering R8 to the bed again. V4 stopped the lift and had to adjust R8 to the center of the bed because she was too close to the edge. V4 then lowered R8 to the bed. V20 (Licensed Practical Nurse/LPN) was in the hallway preparing medications to administer to other residents, throughout this observation. On 7/8/25 at 7:16 PM, V4 (CNA) stated she came to work at 6 am and was supposed to leave at 6 PM. V4 stated they had other CNA's not show up for work tonight and she would be leaving as soon as she got the residents settled for the night. V4 stated there were two other CNA's working on her hall and one CNA working on the other hall. V4 stated three CNA's is enough to meet the needs of the residents after they are all in bed. V4 stated she transferred R8 using a mechanical lift without the assistance of another CNA. V4 stated she did that because the other CNA's were providing care to other residents and they didn't have enough staff to meet the needs of the residents right now. On 7/8/25 at 7:08 PM, V20 (LPN) stated she had three CNA's working with her. V20 stated that is enough to meet the needs of the residents, sometimes. On 7/9/25 at 2:58 PM, R8 stated she guessed they used a mechanical lift to transfer her. R8 stated she wasn't sure how many staff were present when they did it. R8 stated she had never been hurt or fallen during a transfer. On 7/9/25 at 3:05 PM, V3 (Assistant Director of Nursing) stated they have enough staff as long as they don't call in. After this surveyor reviewed the observation of V4 transferring R8 without assistance of another staff, V3 stated she would expect the nurse to stop administering medications and assist with the transfer. The facility Safe Lifting and Movement of Residents policy dated July 2017 documents, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was adequately supervised to prevent her exiting the facility without staff knowledge for 1 (R1) of 3 residents reviewed for accidents and supervision in the sample of 3. This failure resulted in R1, who has a diagnosis of dementia and was already on 15-minute visual checks for previous exit seeking behavior, exiting the facility at an unknown time without staff knowledge or supervision, walking approximately 1.3 miles away from the facility and was found by two unknown teenage female citizens who took R1 to the local emergency room. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 5/15/2025 at approximately 7:45pm when R1 exited the facility and was found by two teenage girls approximately 1.3 miles from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 5/21/2025 at 4:30pm. The surveyor confirmed by observation, record review and interview that the immediacy was removed on 5/22/2025. Findings include: R1's Facility admission Record documented R1 was admitted to this facility on 4/13/2025 with diagnoses of Parkinsonism and unspecified dementia among others. R1's MDS (minimum data set) dated 4/19/2025 documented R1 with a BIMS (brief interview for mental status) score of 6 out of 15 total which indicates R1 has severe cognitive impairment. R1's admission elopement evaluation (dated 4/13/2025) documented R1 with an elopement risk score of 0.0 which indicated no elopement risk. A progress note dated 5/13/2025 in R1's electronic health record documented R1 had attempted to leave the facility multiple times and was placed on 15-minute visual checks. On 5/21/2025, V18 (Licensed Practical Nurse/LPN) said she was the nurse caring for R1 on 5/13/2025 when R1 attempted to leave the facility without staff. V18 said R1 may use a wheelchair to get about the facility but R1 can walk well. V18 said R1 was attempting to leave the facility via the front door and was spotted by V17 (LPN) and brought back inside the facility and placed on 15-minute visual checks. V18 said at this facility the nurses are responsible for performing and documenting the 15-minute visual checks. On 5/13/2025, R1 was re-evaluated for elopement risk and scored a 3 which indicates R1 is an elopement risk. R1's care plan was updated 5/13/2025, to include 15-minute visual checks for attempted elopements from the facility. A form titled Long Term Care Facility Serious Injury Incident and Communicable Disease Report dated 5/16/2025 documented on 5/15/2025 at 8:15pm, R1 had exited the facility without staff knowledge even though R1 was on 15-minute visual checks. The report documented R1 became upset with another resident and decided to go home, left the facility, and was assisted by two juveniles and taken to the local hospital. On 5/16/2025 at 12:05pm, V13 (Hospital Registered Nurse) said on 5/15/2025 around 8:00pm, two unknown teenage females brought R1 into the local emergency room for help. V13 said the teenagers found R1 lying in the ditch next to the cemetery. V13 said the teenagers did not know R1 and she did not get the teenagers names. V13 said R1 was not injured and thus was not actually registered as a patient that evening. V13 said the local police were called to assist in identifying where R1 belonged but a policeman did not come to the hospital and a report was not completed as far as she knew. V13 said R1 eventually told them her name and birthday and they were able to look R1 up in the hospital's computer system. V13 said she was able to find R1 in the computer system and located a working phone number for R1's son (V15/Family). V13 said she called V15 around 9:15pm and learned R1 lived at the local nursing home. V13 said she called the nursing home at 9:20pm and requested them to come pick up R1. V13 said when R1 was brought into the hospital that evening, R1 was wearing a turtleneck sweater, jeans, and a coat, but the weather was very warm that night. On 5/21/2025 at 10:15am, V15 (Family) said on 5/15/2025 at 9:15pm, he received a call from V13 (Hospital Registered Nurse) to report R1 had been brought into the local hospital by two teenage girls after being found in a ditch near the local cemetery about a mile away from the nursing home. V15 said R1 was not hurt. V15 said R1's previous home is next to the cemetery where she was found. V15 said he told V13 that R1 lived at the nursing home. V15 said V13 called the nursing home, and the nursing home staff came to the hospital and picked up R1. On 5/21/2025 at 10:00am, V14 (Licensed Practical Nurse/LPN) said she was the nurse providing care for R1 during the day on 5/15/2025. V14 said she did not know R1 had previously attempted to leave the facility without staff on 5/13/2025 and was placed on 15-minute visual checks. V14 said this information was not passed on to her in shift report and she had been off for a few days. V14 said since she did not know R1 was on 15-minute visual checks, she did not perform the checks and did not pass this information on to the next nurse on duty which was V3 (Registered Nurse/RN). On 5/21/2025 at 10:30am, V3 said she, V6 (Certified Nursing Assistant/CNA) and V8 (CNA) were the staff providing care for R1 on the evening of 5/15/2025. V3 said she did not know R1 was on 15-minute visual checks as this information was not passed on to her in shift report. V3 said since she did not know R1 was on 15-minute visual checks, she was not performing the checks on the evening of 5/15/2025 when R1 left the facility without staff knowledge. V3 said she last remembered seeing R1 in her room around 7:30pm. V3 said she did not know R1 was missing from the facility until the hospital called the nursing home about 9:15pm to report R1 was at the hospital, needed picked up and was not injured. V3 said she sent V6 over to the hospital to pick up R1 and return her to the nursing home. V3 said after R1 returned to the facility she discovered R1 was already supposed to be on 15-minute visual checks and completed the 15-minute visual check sheet at that time. On 5/21/2025 at 2:15pm, V6 said she worked on R1's unit the evening of 5/15/2025. V6 said she had not worked for a few days and did not know R1 had attempted to leave the facility without staff on 5/13/2025 and was placed on 15-minute visual checks. V6 said this information was not passed on to her in shift report. V6 said the nurses are responsible for performing and documenting the 15-minute visual checks so she did not know anything about it. V6 said on 5/15/2025 the last time she remembered seeing R1 at the facility was around 7:30pm and R1 was in her room. V6 said she did not know R1 was missing from the facility until V3 (RN) received a call from the hospital around 9:15pm. V6 said she was sent to the hospital to get R1 and bring her back to the facility. On 5/21/2025 at 2:45pm, V8 said she worked R1's unit the evening of 5/15/2025. V8 said she had been off for a few days and did not know R1 had attempted to leave the facility without staff on 5/13/2025 and was placed on 15-minute visual checks. V8 said the nurses perform the 15-minute checks so she had no knowledge of R1 being on 15-minute visual checks. V8 said on 5/15/2025, she returned from her lunch break around 7:45pm and she seen R1 in her room. V8 said she did not know R1 was missing from the facility until 9:15pm when V3 (RN) received a phone call from the hospital reporting R1 was there without staff. On 5/21/2025 at 2:20pm, V5 (CNA) said she was working the evening of 5/15/2025 but was not on R1's unit. V5 said she did not know R1 was on 15-minute visual checks for elopement attempts. V5 said every evening between 6:00pm and 8:30pm the facility's door alarm is constantly alarming due to family members coming in and out of the facility. V5 said on 5/15/2025 around 7:30pm, she noticed the facility's front door alarm sounding and no one was around. V5 said she looked outside of the front door and did not see anyone. V5 said she reset the alarm and returned to work without telling any other staff about the alarming door. V5 said she feels this could be when R1 left the facility. V5 said she found out later that night around 9:30pm that R1 was missing from the facility after the hospital called to report R1 was at the hospital without staff. On 5/22/2025 at 1:45pm, R1 was observed walking with a wheeled walker with V16 (Physical Therapy Assistant) around the facility. R1 easily walked with a steady gait and lifted up and carried the wheeled walker when going over thresholds without losing her balance. V16 said R1 can walk very well and doesn't really need to use a wheelchair. V16 said on good days, R1 walks me instead of me walking R1. The facility's 24-Hour Report sheet for R1's unit dated 5/13/2025 documented R1 was started on 15-minute visual checks and the dressing to R1's left thumb was changed. The facility's 24-Hour Report sheet for R1's unit dated 5/14/2025 documented R1's dressing to the left thumb was changed and did not include any information about R1 being on 15-minute visual checks. The facility's 24-Hour Report sheet for R1's unit dated 5/15/2025 documented R1 had a new medication order and did not include any information about R1 being on 15-minute visual checks. R1's 15-minute visual check sheets dated 5/15/2025 documented V3 observed R1 in her room at 8:00pm. At 8:15pm, a question mark was documented for R1's location by V3. At 8:30pm, hosp (hospital) was documented for R1's location by V3. At 8:45pm, hosp was documented for R1's location by V3. At 9:00pm, hosp was documented for R1's location by V3. At 9:15pm, hosp was documented for R1's location by V3. At 9:30pm, R1 was documented in her room by V3. An undated facility policy titled Facility Door Alarms under the section titled Procedure For Response To Sounding Door Alarm documented Nurse or designee will identify the location of the door alarm triggered. The nurse or designee will notify the appropriate nursing station. The nurse or designee will go to identify the exit and verify reason for the triggered alarm. If the reason for the sounding alarm is not identified, the location of all residents known as a Wander/Elopement Risk will be verified. At no time will the sounding door alarm be canceled before verification is confirmed. An undated facility policy titled Wandering and Elopements documented the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident and if on 15-minute visual (checks) put on 24-hour report (sheet) until d/c'd (discontinued). The Immediate Jeopardy that began on 5/15/2025 was removed on 5/22/2025 when the facility took the following actions to remove the immediacy and correct the noncompliance. On 5/15/2025 at 9:30pm, R1 returned to the facility and was placed on 1:1 monitoring which continued until 5/16/2025 at 7:45am when an exiting alarm device was placed on R1's wrist. R1 continues on 15-minute visual checks. All staff, including department heads, have been educated to ensure that they are aware of policy related to resident elopement, wandering and 15-minute visual checks. Education was provided by V11 (Assistant Director of Nursing) and was completed on 5/15/2025 and 5/22/2025, with education on-going. On 5/22/2025 a Quality Assurance and Performance Improvement meeting was held and the plan of correction and implementation was documented as follows: 1. The facility reviewed the policy and procedures for door alarms, 15-minute visual checks. Missing residents, and elopements. (Staff) to make sure anyone on 15-minute visual checks is placed on the 24-hour report sheets daily. All reviewed with staff. 2. All residents at risk for elopement were reassessed. 3. All residents who are elopement risk will be reassessed as necessary. 4. Monitor door alarms for staff properly following protocol. 5. V1 (Administrator) in-serviced staff, Assistant Director of Nursing, and all department managers. 6. V1 ensured residents, who are identified as high elopement risk, have updated and correct information about them in the facility's elopement book at both nurses' stations. 7. Monitor staff for compliance with door alarm procedure. 8. Review nursing for completing assessments on high elopement risk residents. 9. Director of Nursing or Designee to monitor all for compliance weekly for two weeks.

Based on, interview, observation and record review, the facility failed to provide a sufficient number of staff to ensure residents timely and safe assistance with care and transfers. The failure has the potential to affect all 60 residents living in the facility. Findings include: On 03/04/25 at 9:56am, V1 (Administrator) stated the facility is short of staff, but that she could assure that everyone pitches in to help. V1 stated that they haven't had agency in the building for about 6 weeks or more. On 03/04/25 at 10:38am, R4 who was alert to person, place and time, stated her care here is fair, there aren't enough girls here to take care of everyone all at once. R4 stated there are times when there is just one girl taking care of everyone in the building. On 03/04/25 at 10:55am, R5 who was alert to person, place and time, stated she felt there's mostly enough staff, but that people do call in all the time and they do need more help. On 03/04/25 at 10:57am, R2 who was alert to person, place and time, stated her care here is all right. Sometimes they don't get to me for a long time. On 03/04/25 at 10:58am, R6 who was alert to person, place and time, stated he does not think they have enough staff to operate this facility period. R6 stated he does not think he always gets his shower on time, but they do their best to keep him clean. R6 stated sometimes there just aren't enough staff to get you taken care of quick enough, but the ones that are here try to get it done best they can. On 03/04/25 at 11:00am, R7 who was alert to person, place and time, stated they don't have enough staff here, but he does well taking care of himself and doesn't need much assistance. On 03/04/25 at 02:23pm, V4 (Licensed Practical Nurse/LPN) stated staffing is not great, but it really depends on the day of the week how bad it is. V4 stated the weekends are terrible. V4 stated some of the management are helpful and some are not. V4 stated she feels like the CNA's (Certified Nursing Assistants) work very hard to prioritize and tend to their resident's needs the best they can. V4 stated she knows showers are not able to be done timely. V4 stated nursing staff tries to help as much they can, sometimes medications are late because the nurses are trying to help the CNA's get everyone up and cleaned up. V4 stated none of the management staff on call on the weekends will answer their phones, sometimes they will go as far as turning them off. V4 stated V1 (Administrator) will come in and help, she's even left her groceries in the middle of the store to come in and assist with breakfast. V4 stated there are only 4 CNA's on the floor right now. On 03/04/25 at 2:26pm, V5 (LPN) stated most of the management will not help, there are very few who will. V5 stated and if they help, it's the nurse duties, they wouldn't dare be caught doing CNA work. V5 stated V1 (Administrator) is the only one who will answer her phone on the weekends, and will come in. V5 stated sometimes there is one CNA for both sides. V5 stated there are times when things are not done timely because everyone is trying to pitch in and make sure the residents are getting taken care of, med passes and Meals are a few of the things that run late. On 03/05/25 at 10:16am, V10 (CNA) stated staffing for CNAs is terrible, especially on the weekend that she works. V10 stated there have been weekends recently that it is just two CNAs for the whole building, herself and one other person. V10 stated there is a fair amount of people who require the assistance of two people. V10 stated it's a lot to expect of two people to do. V10 stated it takes them working constantly all day to get everyone up, changed and cleaned up and then to keep them clean and repositioned all day. V10 stated showers do not get done as they are supposed to, but we work very hard to keep everyone clean. V10 stated breakfast is supposed to start around 7:45am, sometimes it's 8:30am or later before they can get dependent residents to breakfast, and even then, they don't have anyone to assist with feeding. On 03/05/25 at 10:21am, V8 (Registered Nurse/RN) stated staffing is terrible, especially for the CNAs, weekends, evenings and nights are the worst. V8 stated too many times there are only 2 CNAs for the entire building, occasionally there is only one. V8 stated management will not answer their phones or turn it off on weekends, even if they are on call. V8 stated management will help with medication pass and nursing duties, but wouldn't do CNA work, beyond helping in the dining room. V8 stated she tries to help the best that she can, but sometimes that means her work is not completed timely, and everyone gets behind. On 03/05/25 at 12:25pm, V10 (CNA) stated she had worked the weekend of February 22 and remembered it was just herself and one other CNA. V10 stated showers were not able to be given as scheduled, but everyone who should have been showered received a bed bath. V10 stated that transfers and care requiring 2 staff members could not always be done with 2 staff members, so they must prioritize the things that they can do safely with one. V10 stated most nurses will step in when they can, but they have their own job duties and just barely enough of them to complete them. V10 stated management does not come in to assist, they won't even answer their phones. On 03/05/25 at 12:32pm, V11 (CNA) stated she specifically remembered Monday February 17, she was on the east side by herself and there were two CNAs on the west side. V11 stated the working schedule is not always an accurate representation of how staffing went for the day. V11 stated not all nurses are helpful on those days, but there are some that are. V11 stated she also understands they have their own tasks they have to complete as well and it's not like there is a bunch of them either. V11 stated management is not helpful at all. V11 stated on really short days, showers do not get done as scheduled, but we do try to give them a thorough bed bath when getting them up. V11 stated they have to make sure everyone stays clean enough and fed. V11 stated when there are only 2-3 CNAs total in the building, they have to figure out what 2 assists they can manage alone so that they can get residents taken care of until someone is available to assist with the others. V11 stated they do have discipline in place for calling in, but it only applies to certain people and a lot of times everyone gets in trouble, not just the people who are the problem. On 03/05/25 at 2:23pm, V12 (CNA) confirmed today there were only two CNAs on west hallway for 2-10 shift. V12 stated it happens this way sometimes, more staff would be ideal, but they manage the best that they can. On 03/05/25 at 2:25pm, R8 who was alert to person, place and time, stated she used to be the president of resident council and still participates. R8 stated they do not ask anything about staffing at resident council other than if they have a problem with any of the CNAs. R8 stated there would be enough staff to go around if they would just show up. R8 stated there are ones that frequently do not show up and no one replaces them. R8 stated her care is pretty good but she doesn't ask for much. R8 stated she feels sorry for the ones who need assistance, not that staff don't try, but they can only be expected to do so much. On 03/05/25 at 2:28pm, R9 who was alert to person, place and time, stated they do not discuss staffing issues at resident council much. R9 stated they do not have enough people on the floor to get things done for sure. R9 stated her care is fine, but sometimes it takes the girls a while to get to her. On 03/05/25 at 2:32pm, V13 (CNA) confirmed today there was only 3 CNA staff present on east hallway for 2-10 shift. V13 stated rarely does she feel they have enough staff to safely and effectively complete their jobs timely. V13 stated they can't keep people; they hire people, and they see what they have to deal with and quit. V13 stated they will ask people that are off if they want to work when they are short, but people can't always work, they are tired and have their own lives. V13 stated there are some nurses that will help, and then there are some that will come get you in the middle of a transfer to get someone ice water. V13 stated management will help the nurses at times and maybe assist with the dining room. V13 stated they just do not have enough staff with everyone who is a 2 assist or a mechanical lift, to always do it with two people. V13 stated over half of the people in the building require assistance and there are a lot of residents on both sides that use mechanical lifts. V13 stated they have to figure out how they can safely manage to do as much as they can with one person, otherwise they would not be able to get everything done. V13 stated sometimes they are not able to get everyone up for supper, they may have 15 people eating on the hall, especially when they only have one person for each side. On 03/05/25 at 3:38pm, V1 stated she did not have a specific plan in place for times when they may have had only 1-3 CNAs that were scheduled show up, but she can assure that everyone that isn't scheduled on the floor pitches in, but they don't count for the numbers. V1 stated she will always answer her phone on the weekends, because no one else does, and she will come in if she can. On 03/04/25 at 10:56am, it was observed that there were 2 CNA staff on west hallway. On 03/04/25 at 10:59am, it was observed that there were 2 CNA staff on east hallway. On 03/05/25 at 2:22pm, it was observed that there were 2 CNA staff on the west hallway. On 03/05/25 at 2:24pm, it was observed that there were 3 CNA staff on east hallway. A document titled Facility assessment tool with an assessment date of 08/06/25 was provided by V1 as the facility's current assessment tool. This document states on page 6 in Example 3, there are 32 residents that require an assist of 1-2 staff and 26 residents that are dependent for Assistance with Activities of Daily Living. On page 9 of this document under staffing plan example 1; it documents that licensed nurse providing direct care work 12-hour shift and the total number needed is 4 for 6a-6p and 2 for 6p-6a. Also documented in this section is Nurse aides work 8 hour shifts and the total number needed for first shift is 7, second shift is 7, and third shift is 4. Undated facility document titled, February 2025 1st shift, documents on Monday 02/17 there were 4 CNAs scheduled to work the first shift. On Saturday 02/22 there were 3 CNAs scheduled to work the first shift and two worked 6a-2p and one worked 5a-9a. Undated facility document titled, February 2025 3rd shift, documents on Wednesday 02/05 there were 4 CNAs scheduled to work and 3 called in, leaving one to work. Undated facility document titled, March 2025 1st shift, documents on 03/04 there were 4 CNAs scheduled for the whole shift and 1 scheduled for 5-9. Undated facility document titled, March 2025 2nd shift, documents on 03/05 there are 7/6 CNAs scheduled. On 03/05/25 at 10:33am, V1 stated they do not have a policy specific to staffing, they follow federal guidelines. Resident Room Roster dated 3/3/25 documents there are currently 60 residents living in the facility. According to the Food and Drug Administration (FDA) guide, found on their website at www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf, it documents under preparing environment, Most lifts require two or more caregivers to safely operate lift and handle patient. Facility Policy titled Safe Lifting and moving of Residents with a revision date of July 2017, documents under policy statement, In order to promote safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.

Based on interview, observation and record review the facility failed to provide the correct textured diet as ordered for 4 of 17 residents (R8, R20, R41, and R47) reviewed for meal texture in the sample of 35. Findings include: The facility document titled, Daily Spreadsheet dated Monday 12/09/2024 documents: regular diet: spaghetti with meat sauce 1/2 cup/6 oz (ounces), Caesar salad 1 cup, garlic bread 1 slice, and ambrosia #8 scoop. The easy to chew diet documents: spaghetti with meat sauce 1/2 cup/6 oz (ounces), chilled steamed vegetables 1/2 cup, soft and buttered bread, and mandarin oranges #8 scoop. 1. R47's Admission record documents: an admitted [DATE] with diagnoses including: chronic kidney disease, vitamin D deficiency, Vitamin B12 deficiency, anemia, and muscle weakness. R47's MDS dated [DATE] documents a BIMS score of 10 indicating R47 is moderately impaired. R47's Physicians order sheet documents a dietary order of: regular diet, easy to chew (mechanical soft) texture, regular/thin liquids consistency, no straws, HFBP (high fiber bowel program) 8 oz (ounces) extra fluids TID (three times a day) with meals, ice cream 1 x (time) daily with meal with an active date of 07/11/2024 at 12:28 PM. On 12/09/24 at 11:40 AM, R47 received spaghetti with meat sauce 1/2 cup/6 oz (ounces), beets 1/2 cup, toasted garlic bread 1 slice and ambrosia #8 scoop. 2. R8's admission sheet documents an admitted [DATE] and diagnoses including: type 2 diabetes mellitus, dementia, vitamin D deficiency, magnesium deficiency, muscle wasting and atrophy, and muscle weakness. R8's Physicians order sheet documents a diet order of: regular diet, easy to chew (mech soft) texture, regular/thin liquids consistency, 8 oz extra fluids TID (three times a day)with meals, HS (evening) snack, High Fiber, double protein with meals for nutrition with an active date of 07/11/2024 at 2:30 PM. On 12/09/24 at 11:40 AM, R8 received spaghetti with meat sauce 1/2 cup/6 oz (ounces), beets 1/2 cup, toasted garlic bread 1 slice and ambrosia #8 scoop. 3. R20's Admission Sheet documents an admitted [DATE] with diagnoses including: Parkinson's disease, multiple fractures of ribs, vitamin B12 deficiency, anemia, muscle weakness and dysphagia. R20's Physician's order sheet documents an dietary order dated 08/06/24 for regular diet, easy to chew (mech soft) texture with regular/thin liquid consistency. On 12/09/24 at 11:40 AM, R20 received spaghetti with meat sauce 1/2 cup/6 oz (ounces), beets 1/2 cup, toasted garlic bread 1 slice and ambrosia #8 scoop. 4. R41's Admission Record documents an admitted [DATE] with diagnoses including: muscle wasting and atrophy, dysphagia, and Parkinsonism. R41's Physicians order sheet documents a dietary order dated 10/01/24 for regular diet, easy to chew texture, regular/thin liquid consistency with double protein at meals. On 12/09/24 at 11:40 AM, R41 received spaghetti with meat sauce 1/2 cup/6 oz (ounces), beets 1/2 cup, toasted garlic bread 1 slice and ambrosia #8 scoop. On 12/12/24 at 1:05 PM, V14 (Dietary Manager) V14 stated the diets should be followed as directed by the spreadsheet. The mechanical soft diets should not have received the ambrosia salad or the toasted garlic bread. The facility policy titled, Diet Descriptions dated 04/26/2023 documents 3. Texture modified diets and thickened liquids - texture modified diets are prepared and served as prescribed by the physician or community speech language pathologist when a resident has difficulty chewing and/ or swallowing.

Based on interview, observation, and record review the facility failed to provide extra supplementation as ordered for 4 of 17 residents (R8, R45, R47, and R56) reviewed for dietary supplementation in the sample of 35. Findings include: 1. R47's Admission record documents: an admitted [DATE] with diagnoses including: chronic kidney disease, vitamin D deficiency, Vitamin B12 deficiency, anemia, and muscle weakness. R47's minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 10 indicating R47 is moderately impaired. R47's Physician's order sheet documents a dietary order with an active date of 07/11/2024 at 12:28 PM of: regular diet, easy to chew (mechanical soft) texture, regular/thin liquids consistency, no straws, HFBP (high fiber bowel program) 8 oz (ounces) extra fluids TID (tree times a day) with meals, ice cream 1 x (time) daily with meal. On 12/09/24 at 11:40 AM, R47 received her lunch in her room with no ice cream given. On 12/10/24 at 11:45 AM, R47 received her lunch in her room with no ice cream given. On 12/11/24 at 11:48 AM, R47 received her lunch in her room with no ice cream given. On 12/11/24 at 12:20 PM, R47 stated, she receives ice cream a few times a week but not every day. R47's care plan documents a focus area documenting in part: R47 has actual/potential alteration in nutritional or hydration status with an intervention listed as ice cream one time daily with meal dated 04/22/24. 2. R56's admission record documents an admitted [DATE] with diagnoses including: muscle weakness, dementia, and dysphagia. R56's MDS dated [DATE] documents no BIMS assessment was performed due to resident is rarely to never understood. R56's Physician order sheet documents a dietary order with an active date of 07/11/24 at 12:43 PM of: regular diet, pureed texture, mildly thick (nectar) consistency, HFBP, nutritional ice cream with lunch, 8 oz. cranberry juice with all meals, and prune juice with breakfast. On 12/09/24 at 11:40 AM, R56 received her lunch in the dining room with no nutritional ice cream given. On 12/10/24 at 11:45 AM, R56 received her lunch in the dining room with no nutritional ice cream given. On 12/11/24 at 11:48 AM, R56 received her lunch in the dining room with no nutritional ice cream given. R56's care plan documents a focus area documenting in part: R56 has actual/potential alteration in nutritional or hydration status with an intervention listed as nutritional ice cream with lunch dated 04/01/24. 3. R45's Admission Record documents an admitted [DATE] with diagnoses including: type 2 diabetes mellitus with diabetic neuropathy, muscle weakness, and dementia. R45's MDS dated [DATE] documents a BIMS score of 07, indicating resident's cognition is severely impaired. R45's Physician order sheet documents a dietary order of: regular diet, regular texture, regular/thin liquids consistency with juice and milk at all meals and ice cream daily with active date of 03/20/2024. On 12/09/24 at 11:40 AM, R45 received his lunch in the dining room with no ice cream given. On 12/10/24 at 11:45 AM, R45 received his lunch in the dining room with no ice cream given. On 12/11/24 at 11:48 AM, R45 received his lunch in the dining room with no ice cream given. On 12/11/24 at 1:15 PM, R45 stated he gets ice cream sometimes. 4. R8's admission sheet documents an admitted [DATE] and diagnoses including: type 2 diabetes mellitus, dementia, vitamin D deficiency, magnesium deficiency, muscle wasting and atrophy, and muscle weakness. R8's MDS dated [DATE] documents a BIMS score of 09 indicating moderately impaired. R8's Physician order sheet documents a diet order of: regular diet, easy to chew (mech soft) texture, regular/thin liquids consistency, 8 oz extra fluids TID (three times a day) with meals, HS (evening) snack, High Fiber, double protein with meals for nutrition with an active date of 07/11/2024 at 2:30 PM. R8's care plan documents a focus area documenting in part: R8 has actual/potential alteration in nutritional or hydration status with an intervention listed as double protein with meals dated 04/04/24. The facility document titled, Daily Spreadsheet dated Monday 12/09/2024 documents: regular diet: spaghetti with meat sauce 1/2 cup/6 oz (ounces), Caesar salad 1 cup, garlic bread 1 slice, and ambrosia #8 scoop, the easy to chew diet documents: spaghetti with meat sauce 1/2 cup/6 oz (ounces), chilled steamed vegetables 1/2 cup, soft and buttered bread, and mandarin oranges #8 scoop. On 12/09/24 at 11:40 AM, while in the dining room R8 received spaghetti with meat sauce 1/2 cup/6 oz (ounces), beets 1/2 cup, toasted garlic bread 1 slice, and ambrosia #8 scoop. There was no double protein placed on R8's lunch tray. The facility document titled, Daily Spreadsheet dated Tuesday 12/10/2024 documents: easy to chew diet: breaded pork chop 3oz, au gratin potatoes #8 scoop, honey glazed baby carrots (soft) #8 scoop, bread or roll with butter or margarine 1 each (soft and buttered), and frosted brownie 3x2 soft. On 12/10/24 at 11:45 AM, R8 received breaded pork chop 3oz, au gratin potatoes #8 scoop, honey glazed baby carrots (soft) #8 scoop, bread or roll with butter or margarine 1 each (soft and buttered), and frosted brownie 3x2 soft. R8 received his lunch without a double protein given. The facility document titled, Daily Spreadsheet dated Wednesday 12/11/2024 documents: easy to chew diet: fried chicken (remove bone) 3oz, mashed potatoes #8 scoop, gravy 1 oz, chilled steamed vegetables soft #8 scoop, bread or roll with butter or margarine 1 each (soft and buttered), vanilla butter cake 3x2. On 12/11/24 at 11:48 AM, R8 received fried chicken (remove bone) 3oz, mashed potatoes #8 scoop, gravy 1 oz, chilled steamed vegetables soft #8 scoop, bread or roll with butter or margarine 1 each (soft and buttered), vanilla butter cake 3x2. R8 received his lunch without a double protein given. On 12/11/24 at 1:05 PM, R8 stated he does not know if he receives double protein. On 12/12/24 at 1:05 PM, V14 (Dietary Manager) stated R47 is supposed to receive ice cream with lunch as a supplement for weight, she does have a BMI below normal limits and she does not remember when her last intervention was. R56 is supposed to receive a nutritional ice cream with lunch, R45 is suppose to receive ice cream with lunch. R8 is supposed to receive double protein and he should have received it. V14 stated she does not know why they did not receive those items. All residents that have an order for additional protein, food item, or supplement should receive it. The facility policy dated 09/16/2018 titled, Nourishments documents: policy: nourishments or additional snacks should be provided to offer therapeutic nutritional support.

Based on observation, interview and record review, the facility failed to maintain infection control practices in accordance with current standards of practice during patient care for 8 of 8 residents (R8, R16, R24, R28, R32, R41, R64, R65) reviewed for infection control in the sample of 35. Findings include: 1. On 12/10/2024 at 7:40am, V4 (Registered Nurse) was observed sanitizing her hands before preparing R64's morning medications. V4 placed R64's pills in pudding and fed them to R64. R64 spit out the pills and V4 collected them in a drinking cup. V4 returned to the medication cart and began preparing R64's medications again. V4 did not wash her hands or perform hand sanitation. After administering R64's pills a second time, V4 went to the medication cart to prepare medications for R32 and did not wash her hands or perform hand sanitation. V4 administered R32's medications. V4 returned to her medication cart to prepare the next resident's medications and did not wash her hands or perform hand sanitation. V4 noticed the bandage to R64's left elbow needed to be changed and was hanging half off. V4 gathered the needed supplies from the nearby treatment cart and laid them on a bedside table located next to the medication cart and near R64. V4 did not wash her hands or perform hand sanitation and did not sanitize the table or place a clean barrier on the table before laying her supplies down. V4 donned gloves, removed R64's old dressing, cleansed the wound and applied the clean dressing. V4 then placed the bedside table in front of R64. At 8:15am, R64 was served his breakfast tray on the same bedside table that had not been cleansed since being used for the dressing change. V4 returned to the medication cart, did not wash her hands or perform hand sanitation and prepared R24's morning medications. V4 administered R24's medications, returned to the medication cart and did not wash her hands or perform hand sanitation. On 12/12/2024 at 7:45am, V2 (Director of Nursing) said V4 should have washed her hands or performed hand sanitation before and after administering medications. V2 said V4 should have cleansed the bedside table or placed a clean barrier down before using the table for dressing change purposes. V2 said the bedside table should have been cleansed and sanitized before R64 was served his breakfast on it. On 12/12/2024 at 8:00am, V6 (Licensed Practical Nurse) said hand sanitation before and after patient medication administration is not only the facility's policy she considered it to be standard of care for all healthcare workers. Facility policy titled Administering Medications, revision date of December 2012, documented the follow: Staff shall follow established facility infection control procedures of handwashing, antiseptic technique, gloves, isolation precautions for the administration of medications. Facility policy titled Dressings, Dry/Clean, revision date of February 2014, documented the following: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Under steps in procedure: Clean bedside table. Establish a clean field. Place clean equipment on the clean field. Wash and dry your hands thoroughly. Put on clean gloves and remove soiled dressing. Remove gloves and wash and dry your hands thoroughly. Put on clean gloves. Cleanse wound and apply clean dressing. Remove gloves and wash your hands thoroughly. Facility policy titled Handwashing/Hand Hygiene, revision date of August 2015, documented the following: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub or soap and water . before preparing or handling medications, before handling clean or soiled dressings, After handling used dressings or contaminated equipment, before and after entering isolation precaution settings. The use of gloves does not replace hand washing/hand hygiene. 49907 2. R28's admission record documents an admitted [DATE] with the following diagnoses in part; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and Neuromuscular dysfunction of the bladder. R28's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 08, indicating R28 is moderately cognitively impaired. Section H-bladder and bowel documents that R28 has an indwelling catheter. R28's current care plan documents that R28 is at risk for urinary tract infection (UTI) with a history of UTI with extended-spectrum beta-lactamase (ESBL). On 12/11/24 at 1:13pm, peritoneal care and catheter care was performed on R28 by V12 (CNA/Certified Nursing Assistant). V12 donned a gown for enhanced barrier precautions. V12 closed the door and pulled the curtain to provide privacy, she washed her hands and applied gloves. V12's supplies were already placed on the resident's bedside table with a clean barrier. V12 uncovered part of R28 and positioned legs, she then pulled the string for the light above R28's bed and then moved the biohazard container from one side of the bed to the other. V12 did not change gloves or perform hand hygiene prior providing peri care/catheter care. V12 Performed peritoneal care and catheter care on R28. No gloves changes or hand hygiene was observed throughout the course of the care. V12 completed care and removed soiled gloves. V12 did not perform hand hygiene and then applied a new pair of gloves to reposition R28. V12 did not clean bedside table after providing care. Facility policy titled Catheter Care, Urinary with a revision date of October 2010 was reviewed. In the section titled Steps in the procedure it documents in part that gloves should be removed, and hand hygiene performed before moving between internal and external areas of the genitalia. This document further states that the bedside table should be cleaned after providing care. 3. R8's admission record documents an admitted [DATE] with the following diagnoses in part; generalized muscle weakness and cognitive communication deficit. R8's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 09, indicating R8 is moderately cognitively impaired. R8's Order Summary Report documents an active order to Cleanse area to scrotum with soap and water pat dry, apply skin protectant with cooling menthol to area q (once a shift) shift, every shift for excoriation. On 12/12/24 at 1:36pm, V13 (Licensed Practical Nurse/LPN) was observed administering a treatment to R8 and was assisted by V12 (CNA). V13 had supplies set up on R8's bed side table with a clean barrier in place. V13 and V12 both washed their hands and applied gloves. V12 assisted in positioning R18, V13 began cleansing R8's scrotum with a clean washcloth with soap and water. V13 noted that R8 had a bowel movement but continued to clean R8's scrotum only. V13 then removed her soiled gloves, did not perform hand hygiene before applying new gloves. V13 applied skin protectant cream to area of excoriation. V13 removed soiled gloves, no hand hygiene was observed before applying new gloves. V13 then began cleaning resident's buttocks where bowel movement was. V13 then changed gloves, repositioned resident with V12's assistance and then cleaned up her workspace. 48356 4. R16's admission record dated 12/11/24 documents an admitted [DATE] with a diagnosis of hemiplegia and hemiparesis, gastrostomy status, dysphagia, and heart failure. R16's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental status (BIMS) score of 03 which indicates that R16 has severely impaired cognition. Section GG documents that R16 is dependent with toileting, eating, and transfers. R16's Care Plan with a revision date of 11/08/24 documents under focus: Potential for alteration in nutrition r/t (related to) requires tube feeding, dehydration risk, GERD (Gastroesophageal reflux disease), dyslipidemia, dysphagia, NPO (Nothing by mouth), Enhanced Barrier Precautions with a date initiated 09/05/24. Another focus area is potential for alteration in skin integrity r/t decreased mobility, fragile skin, gastrostomy site, edema, skin lesion, split behind ear, incontinence, re-occurring rash to neck fold, end of life process with comfort care measures. On 12/11/24 at 1:15PM, V9 (Registered Nurse) walked into R16's room which had enhanced barrier precaution signage on door along with PPE (Personal Protective Equipment) hanging on door which was easily accessible to staff. V9 had used hand sanitizer prior to walking into room. V9 did place gloves on prior to cleaning area around g-tube (gastrostomy) and then did hand hygiene prior to doing treatment to g-tube. V9 never donned a gown before or during care. 5. R41's admission record dated 12/12/24 documents an admitted [DATE] with a diagnoses of pressure ulcer of sacral region stage III, pressure ulcer of left buttock stage II and personal history of other diseases of the respiratory system. R41's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental status (BIMS) score of 13 which indicates that R41 is cognitively intact. Section GG documents that R41 is dependent with toileting. R41 requires set-up and clean up assistance with personal hygiene. R65 requires partial/moderate assistance with transfers. R41's Care Plan with a revision date of 10/17/24 documents under focus Potential for/actual alteration in skin integrity decreased mobility, edema, wound, incontinence enhanced Barrier Precautions 05/23/24 stage III coccyx, 05/23/24 SDTI (Suspected deep tissue injury) to right buttock, stage II. R41's interventions for this focus include enhanced barrier precautions with a date initiated 09/16/24. On 12/11/24 at 2:11PM, V9 and V3 (Assistant Director of Nursing/ADON) went into R41's room to perform a treatment on R41's. There was enhanced barrier precaution signage on door along with PPE (Personal Protective Equipment) which was easily accessible to staff. V9 (Registered Nurse) was observed providing wound care to R41 assisted by V3. R41's wounds were located to the coccyx and right buttock. V9 and V3 performed hand hygiene prior to treatment. R41's old dressing was removed by V3 and both wounds were cleansed by V3 who only had gloves on at the time care was performed. V3 never donned a gown before cleaning R41's coccyx and right buttock. V9 performed hand hygiene then donned new gloves, but never donned a gown while applying the new treatment to R41. On 12/12/24 at 10:44AM, V3 (ADON) stated that she should of donned a gown and gloves when she removed and cleaned R41's wound. V3 stated that she doesn't know why she didn't do it, she said that the enhanced barrier precautions is so new and she just forgets what all they are suppose to do. 6. R65's admission record documents an admitted [DATE] with a diagnosis of acute infarction of intestine, perforation of esophagus, and encounter for surgical aftercare following surgery on the digestive tract, R65's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental status (BIMS) score of 15 which indicates that R65 is cognitively intact. Section GG documents that R65 is dependent with toileting. R65 requires substantial/Maximal assistance with transfers. R65's Care Plan with a revision date of 07/11/2024 documents under focus R65 requires tube feeding r/t (related to) cervical esophagostomy G-tube (gastrostomy tube) for drainage, J-tube (Jejunostomy tube) for feeding proximal gastrectomy and reduction of abdominal content form chest surgical incision neck ostomy with ostomy bag for drainage interventions include in part Enhanced Barrier Precautions initiated on 09/05/2024. On 12/11/24 at 12:42PM, V9 (Registered Nurse) walked into R65's room which had enhanced barrier precaution signage on door along with PPE (Personal Protective Equipment) hanging on door which was easily accessible to staff. V9 washed her hands while in the room. V9 applied gloves and cleaned area around J-tube and G-tube. V9 then changed gloved and performed hand hygiene and placed a new pair of gloves on and then performed treatment to J-tube and G-tube. V9 never donned a gown during cleaning or when performing treatment to J-tube or G-tube. On 12/12/24 at 9:45AM, R65 stated when nursing staff comes in to do her treatments they don't wear a gown they only wear gloves when performing her treatment to J-tube and G-tube. On 12/11/24 at 3:20PM, V10 (Infection Preventionist) stated that any staff that does treatments or direct care activities to a resident that is on a enhanced barrier precautions should always don a gown and gloves before providing care. V10 said that staff should especially don gloves and gowns with working on open wound areas such as g-tube and j-tube. V10 said they do education on the enhance barrier precautions for all staff. V10 did not know that last time they had training on enhanced barrier precautions, but she does know that staff has had training on the enhanced barrier precautions. On 12/11/24 at 3:26PM, V9 stated she does not know if she is supposed to wear a gown or not when doing treatments on resident who are on enhanced barrier precautions. V9 stated that she knows that staff that are caring for the resident who provide direct care such as the certified nurse assistants should wear a gown and gloves on any resident that is on enhanced barrier precautions, but she doesn't think that she had to when doing treatment. V9 said that she might be wrong and she might need to be wearing a gown, but she hasn't been. V9 said that she does remember getting some training on enhanced barrier precautions but can't remember what all she was suppose to do. On 12/12/24 at 1:35PM, V2 (Director of Nursing/DON) stated that V9 and V3 should have donned gloves and a gown while performing treatments on R16, R41, and R65 along with all resident who are on enhanced barrier precautions. V2 said that staff was just educated on the enhanced barrier precautions, but that they are still confused on what all they need to have on while providing care to a resident that is on a enhanced barrier precautions. V2 said they will be doing more education on the EBP. The facilities policy titled Enhanced Barrier Precautions with a revision date of August 2022, documents under policy statement Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organism (MDRO's) to residents. The policy interpretation and implementation documents in part under 2. EBP (enhanced barrier precautions) employ targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Section 3 documents in part Examples of high contact resident care activities requiring the use of gown and gloves for EBP's Include H. wound care (any skin opening requiring a dressing).

Based on observation, interview and record review the facility failed to provide feeding assistance for dependent residents in a way that promoted dignity for 2 out of 2 residents (R11, R23) reviewed for dignity in a sample of 35. Findings include: 1. R11's admission record documents an admitted [DATE] with the following diagnoses in part; Alzheimer's disease, unspecified and dysphagia, oropharyngeal stage. R11's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 04, indicating R11 is severely cognitively impaired. Section GG- functional abilities documents that R11 requires assistance with eating. On 12/09/24 at 12:31pm, V16 (Certified Nurse Aide/CNA) was observed standing over R11 while providing eating assistance. On 12/09/24 at 12:37pm, V16 was observed using R11's clothing protector to clean food off R11's mouth. On 12/10/24 at 12:28pm, V16 was observed standing over R11 while providing eating assistance. 2. R23's admission record documents an admitted [DATE] with the following diagnosis in part; vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R23's Minimum Data Set (MDS) dated [DATE] documents a BIMS was not completed, because resident is rarely/never understood. Section GG- functional abilities documents that R23 is dependent on staff for eating. On 12/09/24 at 12:30pm, V7 (CNA) was observed standing over R23 while trying to provide eating assistance. On 12/09/24 at 12:37am, V7, V15, V16, V17 (CNA's) were assisting residents with their meals, and were talking amongst themselves and not engaging residents. V7 (CNA) had earbuds in. On 12/12/24 1:34pm, V2 (DON) stated she would expect CNA's to be seated next to residents they are providing assistance for meals, not standing. V2 also stated it was her expectation that staff would be engaging residents in conversation, not other staff.

Based on interview and record review, the facility failed to ensure an individual admitted with a mental illness diagnosis was referred to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination of need for any specialized service for 2 of 3 residents (R32 and R35) reviewed for PASARR requirements in a sample of 35. Findings include: 1. R32's Admission Record dated 12/11/24 documents an admitted [DATE]. R32's diagnosis report dated 12/12/24 documents Bipolar II disorder with a onset date 07/15/20 and Major Depressive Disorder recurrent with a onset of 07/15/20. R32's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 13 which indicates that R32 is cognitively intact. Section I under Active diagnoses list anxiety disorder, depression, and bipolar disorder. R32'S OBRA (Omnibus Budget Reconciliation Act) I Initial Screen/Interagency Certification of Screening Results, dated 03/29/2021, documents the following under Reasonable Basis to Suspect a Mental Illness The individual has been formally diagnosed with a mental illness which substantially impairs the person's cognitive, emotional and/or behavioral functioning is checked No. The individual has a history of psychiatric hospitalization is checked No The individual has a history of outpatient mental health services No There are other indicators of mental illness No. Specify other indication is blank. On 12/11/2024 at 3:30pm, V8 (Business Office Manager) said he reached out to the agency that performs PASARR (pre-admission screening and resident review) assessments and requested the agency perform another assessment on R32 since the previous one was incorrect. V8 said R32 does have qualifying diagnosis of bipolar, however the screening agency was not aware of this information. V8 said the facility missed notifying the screening agency but should have. 41610 2. R35's Admission Record documents an original admitted [DATE]. R35's Minimum Data Set (MDS) dated [DATE] documents: an active diagnosis of schizophrenia. R35's medical record contains no documentation of a Level II PASARR. R35's Preadmission Screening and Resident Review dated 04/28/22 documents: screening indicated nursing facility services are appropriate. This document does not contain a diagnosis of schizophrenia. On 12/12/24 at 10:45 V8 (Business Office Manger) stated the PASSAR Level 1 is all they have for R35, he has not been in this position long, so R35 does not have a Level II PASARR. The Facility policy titled Admission Criteria with a revision date of December 2016 documents under policy interpretation and implementations 8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordinator with the Medicaid Pre-Admission Screening and Resident Review program (PASARR) to the extent practicable. 9. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility.

Based on interview and record review the facility failed to keep a resident's environment free of accident hazards and failed to implement new interventions to reduce falls for 7 of 10 residents (R2, R3, R9, R41, R49, R51, R54) reviewed for falls in a sample of 40. This failure resulted in R2 falling out of bed on 11/29/2023 due to a loose bed enabler and suffering a fractured left acetabular medial wall, a fractured iliopubic junction fracture and a fractured pubic rami. Findings include: 1. According to R2's face sheet, R2 was admitted on [DATE] with diagnosis of Parkinson's, Muscle Weakness, Muscle wasting and Atrophy, Alzheimer's, Osteoporosis and Convulsions among others. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 needs substantial assistance for dressing, showering and bed mobility. This same MDS documents R2 is dependent on staff for toileting and transferring. R2's MDS dated [DATE] documents R2 was assessed with the BIMS (Brief Interview for Mental Status) in which R2 scored 7 out of 15 indicating R2 has severe cognitive impairment. R2's care plan documents R2 is high risk for falls and planned interventions to prevent falls include anticipate R2's needs, call light within reach, encourage R2 to use call light and staff to promptly respond to R2's call light. This same care plan documents R2 uses bilateral bed enabler bars on her bed for bed mobility and due to seizure disorder. R2's Fall Risk Evaluation, dated 11/29/2023, documented R2 requires the use of assistive devices for gait/balance, has had a change in condition within the past 14 days, is chair bound with incontinence, has had medication changes within the past 5 days, and is a high risk for falls. On 12/3/2023, the state agency was notified of R2 having a fall with serious injury in which R2 fell out of bed on 11/29/23. This Long-Term Care Facility-Serious Injury Incident Report dated 12/3/2023 documented R2 fell out of bed on 11/29/23 at 2:30am due to loose bed enabler and was sent to the ER (emergency room ) for evaluation of left hip pain. This report documented R2's X-rays were negative at the time of her fall, but R2 continued to have left hip pain and was sent to the ER again on 12/3/23 and CT scan (computed tomography) revealed R2 had fracture of the left medial acetabular wall and admitted to the hospital for treatment. Hospital records for R2 dated 12/3/2023 documented R2 was admitted due to multiple fractures found after falling at the nursing home on 11/29/23. The multiple fractures were documented as a fractured left acetabular medial wall, iliopubic junction fracture and pubic rami Fracture. The Long Term Care Facility-Serious Injury Report (dated 12/3/2023) documented R2 returned to the nursing home on 12/4/23, was non-weight bearing on her left lower leg and R2's bed enabler was re-secured to her bed for bed mobility. R2's hospital discharge records dated 12/4/2023 documents the following in part, (R2) who is mostly wheelchair bound presented with hip pain after fall at NH (nursing home). She was found to have multiple fractures. She was evaluated by orthopedics and recommended to be managed conservatively given predominately non ambulatory status. She was discharged back to skilled nursing facility one pain controlled. She was recommended to be non-weight bearing and following up with orthopedics. On 2/28/2024 at 12:51pm, V11 (Registered Nurse/RN) said she, V9 and V10 (both Certified Nursing Assistants/CNA) were providing care for R2 on 11/29/23 at 2:30am when R2 fell out of bed. V11(RN) said V10 (CNA) yelled for her to come to R2's room where she saw R2 sitting on the floor by her bed. V11 said R2 is very difficult to understand verbally but was able to indicate that she was reaching for her call light and fell out of bed. V11 said one of R2's bed enabler bars were not attached to the bed and was laying on the floor by R2. V11 said R2 had just returned from the hospital on 11/18/2023 and staff removed R2's bed enablers for the ambulance to transfer R2 from her bed to their gurney because the bed enablers are in the way. V11 said she feels R2's bed enabler was not securely re-attached when R2 returned for the hospital on 11/18/2023. V11 said she had no knowledge of the facility having a protocol/policy for ensuring resident's bed enablers are re-attached securely after being removed for ambulance transferring purposes. On 2/29/2024 at 9:00am, V10 (CNA) said she went to answer R2's call light and found R2 sitting on the floor next to her bed. V10 said she did not remember if R2's bed enabler was attached to the bed or on the floor as reported by V11. V10 said R2 had returned from a hospital admission on 11/18/2023 due to seizure disorder. V10 said staff have to remove the bed enablers from the resident's bed when the ambulance comes to get the residents for transfer to the hospital because the enablers are in the way of transferring the resident from the bed to the gurney. V10 said she feels R2's enabler was not securely re-attached when R2 returned from the hospital on 11/18/2023. V10 said she has no knowledge of the facility having a protocol/policy for ensuring resident's bed enablers are reattached securely after being removed for ambulance transferring purposes. On 2/27/2024 at 12:06pm, V6 (Maintenance) said he applies bed enablers when he is told to do it. V6 said after he attaches the bed enablers, he does not perform any routine checks or maintenance on the enablers. V6 said staff will complete a work order ticket if they notice anything broken or in need of repair about the facility and this included bed enablers. V6 said after R2 fell on [DATE], he re-secured R2's bed enabler, but has not re-checked the bed enabler since that time. On 2/27/2024 at 12:50pm, V1 (Administrator) said V6 is supposed to do quarterly checks of resident's beds. V1 said R2's bed enabler had been rechecked since being re-secured by maintenance, but she could not produce any documentation of them being checked. V1 said she could not produce any documentation of any other resident's bed enablers being checked for looseness since R2 fell on [DATE]. On 2/28/2024 at 8:00am, V1 said on the evening of 2/27/2024 she personally checked all residents bed enablers and can ensure all were securely attached. R2's care plan documents R2 had a fall on 11/29/2023 but did not have any new interventions in place to prevent R2 from having future falls until 2/27/2024 and was added by V8 (Licensed Practical Nurse/LPN Care Plan Coordinator/CPC). R2's care plan documented the intervention of Enabler re-secured to bed by maintenance staff to assist with bed mobility initiated on 11/29/2023 but was created on 2/27/2024. On 2/27/2024 at 10:30am, V8 said no interventions were developed and put into place for R2's fall on 11/29/2023 until the morning of 2/27/2024 when V2 (Director of Nursing) approached her and told her to update R2's care plan with the intervention of re-securing the bed enabler with the initiation date of 11/29/2024. On 2/28/2024 at 2:30pm, V2 (Director of Nursing/DON) said R2 fell on Wednesday, 11/29/2023, but R2's fall was not investigated until Sunday, 12/3/2023 after R2 was found to have multiple fractures from falling in 11/29/2023. V2 said V17 (RN) is the one who investigates incidents, but she has been on medical leave and no other staff member was assigned to investigate incidences in her absence. On 2/28/2024 at 2:19pm, V8 (LPN/CPC) said she does not normally do fall interventions and that is usually done by V17 (RN) but V17 has been out on medical leave. 2. R51's Face Sheet documents R51 was admitted to this facility on 9/3/2021 with diagnosis of Congestive Heart Failure, Chronic Kidney Disease, Dementia, Unsteady on Feet, Muscle Wasting and Muscle Atrophy among others. R51's MDS assessment dated [DATE] documents R2 needs substantial/maximum assistance with toileting, showers, dressing and transferring. This same MDS documents R51 was assessed with the BIMS in which R51 scored a 10 out of 15 total, indicating R51 has moderate cognitive impairment. R51's care plan documents R51 is at risk for falls due to Dementia, Gait and balance problems and incontinence and was initiated on 9/20/2021. R51's Fall Risk Evaluation, dated 12/9/2023 documents R51 is chair bound with incontinence, has problems with balance while standing and walking, has decreased muscular coordination, requires use of assistive devices and is a high fall risk. A facility incident report dated 1/16/2024 documented at approximately 8:30am R51 had a witnessed fall that resulted in injury. According to the incident report, R51 was walking with V12 (Certified Nursing assistant/CNA) to his recliner, V12 (CNA) let go of R51 to grab R51's wheelchair when R51 lost his balance and fell backwards hitting his head on his dresser causing laceration and was sent to the local ER for evaluation. ER discharge report dated 1/16/2024 documented R51 had a laceration to the back of his head and received 6 staples and returned to the facility. On 2/26/2024 at 2:00pm, R51 was interviewed about his recent fall. R51 said, I was walking with a girl and fell backwards and hit my head. R51 could not remember much else about the fall. On 2/26/2024, R51's care plan was reviewed for his fall on 1/16/2024 and no interventions were found in place to prevent R51 from future falls. On 2/27/2024, R51's care plan had been updated by V8 (LPN/CPC) with the intervention of CNA verbally warned not to turn back on resident when resident is in an upright position. On 2/27/2024 at 10:30am, V8 said no interventions were developed or put into place after R51 fell on [DATE] and R51's care plan was not updated with a new intervention for falling on 1/16/2024 until 2/27/2024 when V2 (DON) had instructed her to update the care plan. 3. R9's face sheet documents R9 was admitted to this facility on 1/30/2024 with diagnosis of Orthostatic Hypotension, Acute Osteomyelitis of right foot and ankle, Gangrene of right leg with surgical amputation or right toes, Diabetes Mellitus type 2 and Peripheral Vascular Disease among others. R9's MDS dated [DATE] document R9 needs Substantial/Maximum assistance for toileting and dressing and is dependent on staff for transferring. This same MDS documents R9 was assessed with the BIMS and scored 4 out of 15 which indicates R9 has severe cognitive impairment. R9's care plan, with revision date of 2/13/2024, documents R9 is at risk for falls due to gait and balance problems, amputation of right toes and history of falls and R9 had an actual fall on 2/10/2024, however no fall interventions were put into place to prevent future falls according to the care plan. Fall interventions documented on R9's care plan are as follows: Initiated dated on 9/1/2023 anticipate resident's needs, assess fall risk and provide appropriate interventions to reduce fall related injuries, assess level of need for ambulation and transfers and assist as necessary, ensure call light and frequently used items are within reach and educate on importance of call light utilization, fall risk assessment upon admission, quarterly and with significant changes, keep room free of clutter, notify doctor as needed and therapy to evaluate as needed. R9's Fall Risk Assessment, dated 8/28/2023 and done prior to his re-admitted [DATE], documented R9 is alert and oriented to person, place, and time, has had no falls in the past 3 months, requires the use of assistive devices and is a low fall risk. R9's incident report, dated 2/10/2024 documented R9 was found sitting on the floor in front of the toilet, Floor was dry. Lights were on. Pants were down. ROM WNL (range of motion were within normal limits) R9 noted with abrasion to left shoulder. No other signs or symptoms of injuries. Assisted up to toilet per 2 staff. Stated (he) was trying to wipe himself and slid to the floor. On 2/28/2024 at 2:19pm V8 (LPN/CPC) said she could not find any documented interventions developed and put into place to prevent R9 from future falls for R9's fall on 2/10/2024. V8 said she does not usually do the care plans for falls and that V17 (RN) does, but V17 has been out on medical leave. On 2/28/2024 at 2:23pm, V2 (DON) said V17 (RN) usually does the investigating for incidents, but she has been out for a long time due to medical reasons and no other employee was assigned to perform these duties in her absence and the facility definitely needs to revamp how they do things. 41610 4. R54's Face sheet documents diagnosis including: Dementia, History of falling, Muscle wasting and Atrophy, Unspecified lack of Coordination, and Cognitive Communication Deficit. R54's MDS dated [DATE] documents a BIMS of 4 indicating severe impairment. Section GG documents: substantial/maximal assistance is needed for transfers. R54's Care plan with a revision date of 02/08/24 documents: Focus: Risk for falls Dementia: document falls on 10/16/23 and 02/07/24. R54's Care plan does not document any intervention for the fall documented on 10/16/23. R54's Care plan documents a fall on 12/20/22 with an intervention of: Reeducate on importance of call light utilization and waiting for assistance PRN (as needed). R54's Fall Investigation dated 10/16/23 documents: Immediate action taken: Patient (R54) education to wait for staff for assistance with transfers. R54's Progress notes dated 10/16/23 at 5:15 PM document: R54 was on floor in an empty room. R54 was assisted back to her wheelchair. R54's wheelchair was unlocked pointing toward bathroom. R54 had shoes on and her clothing dry. R54 stated she was trying to sit in room chair. R54's Post Fall Evaluation with an Effective date of 02/07/24 at 3:14 PM documents: date of fall: 02/07/24 at 2:33 PM, Fall was not witnessed with the location of the fall as R54's room. Pre-Fall: Fall Risk Score: 10. (The facility document titled, Fall Risk Assessment documents a 10 or higher as high risk.) Did injury occur as a result of the fall: yes, bruise to left hand and pain to right hip. Did ER visit/hospitalization occur as a result of the fall: Yes. Has there been a recent change in resident's medications: No. Pain: Indicators of Pain: Vocal complaints of pain - New Issue. R54's progress notes dated 02/07/24 documents: Fall Details: Date/Time of Fall: 02/07/2024 at 2:33 PM. The fall was not witnessed. R54's fall occurred in the resident's room. R54 was reaching for item(s) at time of the fall. Reason for the fall was evident. Reason for the fall: Messing with stuff in her closet. R54 stated she was trying to get something out of her closet. R54's Fall Risk Score is documented as 10, (The facility document titled, Fall Risk Assessment documents a 10 or higher as high risk.) Did an injury occur as a result of the fall: Yes. Injury details: bruise to left hand and pain to right hip. Did fall result in an ER visit/hospitalization : Yes. R54's Physician Order Sheet dated 02/01/24 documents an order for Methocarbamol 500 mg with a start date of 02/07/24. R54's X-ray report dated 02/07/24 documents: minimally displaced fractures anterior aspect of right 9th, 10th, and 11th ribs. R54's Care plan documents an intervention for the fall on 02/07/24 as: Medication changes made. On 02/28/24 at 1:50 PM when R54 was asked about the fall, she pointed to her rib area, when asked if they hurt, she nodded yes. R54 was verbally unable to be understood. On 02/29/24 at 2:00 PM, V2 (Director of Nursing) stated, adding a muscle relaxer would not help prevent with future falls and R54 did not have any other medication changes. V2 stated interventions should not be duplicated. 5. R3's Care plan documents an admitted [DATE] with diagnosis including: Legal Blindness, Dementia, Unspecified Psychosis not due to a substance or known Physiological condition, Restless leg syndrome, Morbid Obesity, History of Falling, Repeated Falls, Unsteadiness on feet, Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, and Lack of Coordination. R3's MDS dated [DATE] documents a BIMS of 8 indicating R3 is moderately impaired. Section GG documents: substantial/maximal assistance is needed for transfers. R3's Care plan with a revision date of 01/25/24 documents: Risk for Falls Decreased safety awareness, Dementia, incontinence, Vision/hearing problems/ Non-compliant with fall interventions. R3's Care Plan documents R3 has had multiple falls with many interventions. R3's progress notes dated 01/24/2024 at 10:06 AM Post Fall Evaluation, Fall Details: Fall was witnessed. The fall location: shower room. The activity at the time of fall: R3 was transferring to shower chair without assistance. The reason for the fall was evident. The reason for fall: Transferring without assistance. Did an injury occur as a result of the fall: Yes. Injury details: 1.0 x 0.1 abrasion to left forearm below elbow. Did fall result in an ER visit/hospitalization : No. Fall Details Note: There was a loud noise coming from and shower room and help needed in shower room, R3 was sitting on the floor in shower stall. Contributing Factors: Was fluid spilled on floor: Yes. Clutter present on the floor: Yes. Contributing factors note: R3 was transferring self without assistance. R3 went into shower room for shower was told not to transfer until assistance got in there was another resident showering with staff in the stall next to R3 and R3 transferred herself to shower chair wheels not locked on shower chair and chair moved and resident went down onto the floor on her buttocks hitting her head on shower stall wall. There were no new fall interventions documented in R3's Clinical Records for this fall. R3's Fall Report dated 11/25/23 documents in part, CNA yelled for this nurse to come down the hall and assess resident due to her being on the floor. No witness for this fall. This nurse and second nurse went in to evaluate condition and resident was laying on her left side with legs extended. Left arm was underneath resident on the floor .Resident denies any pain and denies hitting her head or body .Resident wheelchair was in front of her and noted to be unlocked. Resident has had confusion throughout the day and is upset about current condition of having to stay in room due to being on isolation .Resident is confused and unable to state what happened . There were no new fall interventions documented in R3's Clinical Records for this fall. 6. R41's Face sheet documents an admitted [DATE] and diagnosis including: Parkinson's Disease, Dementia, Muscle Wasting and Atrophy, Lack of Coordination, and Cognitive Communication Deficit. R41's MDS dated [DATE] documents a BIMS of 04 indicating cogitation is severely impaired. Section GG documents: dependent for: roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, and toilet transfer. R41's Care Plan with a revision date of 02/14/24 documents: Risk for falls: with falls documented: on 08/25/23 and 02/13/24. R41's care plan does not document any intervention for the fall on 08/25/23. R41's Care plan documents an intervention of MD evaluation for the fall on 02/13/24. R41's Fall investigation dated 08/25/23 at 9:45 PM documents: Nursing Description - R41 laying on left side on floor mat beside bed, R41 is in a gown and barefoot incontinent of bowel bed in low position no clutter noted R41 assisted to bed per staff no red or bruised area noted. Immediate Action Taken - R41 was assisted to bed, floor mats to side of bed continued, bed in low position continued. Resident taken to the Hospital - No: Injuries Observed at Time of Incident - No injuries observed at time of incident. Level of Pain: Facial Expression - smiling or Inexpressive: body language - Relaxed; Consolability - no need to console. Mental status - oriented to person: Injuries Report Post Incident - no injuries observed post incident. Level of Pain: with nothing documented: Mental Status - with nothing checked: Predisposing Environmental Factors - with nothing checked: Predisposing Physiological Factors: with incontinent checked: Predisposing Situation Factors - with recent room change checked: Other info - with nothing documented: Witnesses - no witnesses found. No intervention was documented on this investigation report. R41's Nurse's notes dated 08/25/23 at 10:01 PM document: R41 laying on left side on floor mat beside bed, R41 is in a gown and barefoot incontinent of bowel bed in low position no clutter noted R41 assisted to bed per staff no red or bruised area noted. R41's Fall investigation dated 02/13/24 at 7:40 PM documents: Nursing Description: Staff called to hallway by nurse's station R41 laying on floor on right side in pajamas and nonskid socks hall lights on floor dry free of clutter asked res what happened with no response voiced R41 moves all extremities without difficulty. Immediate action taken assessment completed, sent to ER for evaluation. Resident taken to hospital: No. Level of Pain: Facial Expression - sad, frightened, frown: body language - tensed, distressed pacing; Consolability - no need to console. Mental status - oriented to person, Injuries Report Post Incident - no injuries observed post incident. Level of Pain: with nothing documented: Mental Status - with nothing checked: Predisposing Environmental Factors - with nothing checked: Predisposing Physiological Factors: with nothing checked: Predisposing Situation Factors - with nothing checked: Other info - fall from wheelchair: Witnesses - no witnesses found. No intervention was documented on this investigation report. R41's Nurse's note dated 02/13/24 at 9:53 PM document: Staff called to hallway by nurse's station R41 laying on floor on right side in pajamas and nonskid socks hall lights on floor dry free of clutter asked res what happened with no response voiced R41 moves all extremities without difficulty. R41's Nurse's note dated 02/13/24 at 9:55 PM document: Fall Details: Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: unknown. The reason for the fall was not evident. Did fall result in an ER visit/hospitalization : Yes. R41's Nurse's notes dated 02/16/24 at 1:23 PM document: Resident resting quietly in recliner at nurse's station at this time. Alert, pleasant and cooperative with staff. No further injuries noted r/t fall 2/13/24. Bruising continues to right front and back of shoulder, dark purple in appearance to back of shoulder and yellow in front. On 02/29/24 at 1:50 PM V2 (Director of Nursing) stated, she does not know why the fall investigation for R41's fall on 02/13/24 documents that she was not sent to the hospital, because she was sent out for X-rays, she does not know why it documents no need to console, because she was obviously in pain and was being consoled and she does not know why it documents she was pacing because she does not walk. She did have bruising, but the X-rays were negative. V2 stated she has talked to the nurses about correct documentation. On 02/29/24 at 2:00 PM, V2 (Director of Nursing) stated, sending to the emergency room does not help prevent future falls. 7. R49's Face sheet documents an admitted [DATE] with diagnosis including: Dementia, Muscle wasting and atrophy, Abnormalities of gait and mobility, and lack of Coordination. R49's MDS dated [DATE] documents a BIMS score of 09 indicating moderately impaired. Section GG documents Partial to Moderate Assistance is needed for: sit to lying, lying to sitting on side of bed, sit to stand, chair /bed to chair transfer, and toilet transfer and walk 10 feet - not attempted and resident did not perform this activity prior to the current illness, exacerbation, or injury. On 02/26/24 R49 stated he had falls, R49 would not give any further information. R49's Care plan dated 05/16/23 documents falls on: 10/10/23, 11/15/23, 11/25/23, 12/19/23, and 01/25/24 with no interventions documented. R49's fall investigation dated 10/10/23 documents: Immediate action taken - encouraged resident (R49) to use call light and ask for help. R49's Care plan documents an intervention dated 05/16/23 as: be sure R49's call light is within reach and encourage the resident to use it for assistance as needed. R49's fall investigation dated 11/15/23 at 11:20 AM documents: R49 was noted laying on the floor on his left side with his head rested against right wheelchair wheel. R49 was holding himself up on his left arm. Both lower extremities were extended but slightly bent. Right slipper noted to be hanging off foot. Wheelchair noted to be unlocked. The floor was dry, adequate lighting was noted. R49's roommate was attempting to help him get up, he stated R49 was walking back from the sink and lost his footing and he fell . Immediate Action Taken: assessment completed, neurological check initiated, R49 was assisted back into his wheelchair via two assist and gait belt and encouraged resident to use call light for assistance. R49's fall investigation dated 11/15/23 does not document any new intervention for this fall. R49's fall investigation dated 11/25/23 at 4:15 AM documents: R49 was found lying on the floor on his right side facing the recliner. R49 stated, he was sitting on the side of his bed and fell asleep and fell forward and hit his head on bedside table. Neurological assessments were done and within normal limits, R49 was able to more all extremities. R49 has a hematoma noted to top of head with minimal bleeding, skin tear to right knee measuring 0.3 x 0.3 cm (centimeter), small skin tear to left hand measuring 0.1 x 0.1 cm, small skin tear to left elbow measuring 0.2 x 0.1 cm. Small skin tear to left third knuckle. R49 stated he is just sore. R49 was re-educated on putting light on when needing help. R49's fall investigation dated 12/19/23 at 5:19 PM documents: R49 was found on his hands and knees. R49 moved to sitting on his buttocks, feet facing the bathroom door. When R49 was asked what he was doing, he stated, I don't know, trying to get out of bed. Immediate action taken - assessments done, no new areas to knees or hands. His shoes were on, the floor was dry and free of clutter. R49's wheelchair was locked. R49 has been very tired today. R49 denies any pain from the fall. R49's Fall Investigation dated 12/19/23 at 5:19 PM does not document any intervention for this fall. R49's fall investigation dated 01/25/24 at 4:50 PM documents: Nursing Description: R49 was sitting on his buttocks on the floor in his room facing his recliner with his wheelchair noted behind him in the unlocked position. R49 has his left leg extended and his right leg bent at the knee. The water pitcher was noted to be on the floor and the floor was wet. R49 stated I slid out on the floor and R49 stated he spilled his water and was trying to get up and he slipped out of wheelchair. R49 was brought to the nurse's station to finish his supper with supervision. Neurological checks were initiated. Immediate Action Taken - assessment and investigation completed, neurological checks initiated, R49 was brought to the nurse's station to be supervised while eating. R49's fall investigation dated 01/25/24 at 4:50 PM does not document any intervention for this fall. On 2/28/2024 at 2:19pm, V8 (LPN/CPC) said she does not normally do fall interventions and that is usually done by V17 (RN) but V17 has been out on medical leave. Facility policy titled Falls-Clinical Protocol (revision date of March 2018) documents in part, based on assessment the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling, and if underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature of category of falling, until falling is reduced or stops.

Based on interview and record review the facility failed to protect a resident's right to be free from neglect when they failed identify a change in condition as emergent and to ensure a system was in place to obtain timely emergency transport for 1 of 3 (R1) residents reviewed for neglect in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. This failure has the potential to affect all 37 residents residing at the facility. These failures resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to ensure R1 received timely medical care when they failed to recognize an emergent situation and call 911 after the ambulance provider they called was delayed. This failure resulted in R1 remaining at the facility from 6:39 AM until the ambulance arrived at 7:35 AM with worsening symptoms. R1 was subsequently transferred to the local hospital, went into cardiac arrest during transfer, and expired in the hospital emergency roiagnom on [DATE]. R1's cause of death is documented as a massive gastrointestinal (GI) bleed. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 9:14 AM. The surveyor confirmed by record review and interview, that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training. Findings Include: R1's Admission Record with a print date of [DATE] documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, malignant neoplasm of pancreas, atrial fibrillation, restless leg syndrome, neuromuscular dysfunction of bladder, major depressive disorder, cognitive communication deficit, and weakness. R1's MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 was cognitively intact. R1's Order Summary Report with active orders as of [DATE] documents a physician order that R1 was a full code and a physician order for Xarelto 20 milligrams (mg) one every afternoon. R1's Care Plan documents a Focus area with a created date of [DATE] documents, Usage of black box medications: .Xarelto . The interventions documented for this Focus area include, Monitor and assess for side effects of medications that contain black box warning PRN (as needed). R1's Care Plan documents a Focus area with a created date of [DATE] of, (R1) wishes to return home with (name of home health agencies). The intervention documented for this Focus area is, Evaluate and discuss with the (R1) and (V19) the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits, and needs for maximum independence. R1's Power of Attorney for Health Care dated [DATE] documents V19 (family member/spouse) was R1's agent to make decisions for her when she was not able to make them for herself. The form documents a check mark next to the following statement, Staying alive is more important to me, no matter how sick I am, how much I am suffering, the cost of the procedures, or how unlikely my chances for recovery are. I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical standards. R1's Social Services Assessment and Note dated [DATE] documents under Social Service Note, (R1) was admitted to (name of facility) for a short-term therapy stay following a long hospitalization . POLST (Physician Orders for Life Sustaining Treatment) FULL CODE per choice. HCPOA (Health Care Power of Attorney) husband (V19) [DATE] . R1's Progress Notes document the following: [DATE] 2:20 PM, resident (R1) is alert, verbal, oriented x 2, sleeps well at night. [DATE] 6:50 AM, AM ADL's (activities of daily living) to go get chemo (chemotherapy) port placement this am. Res (R1) has been NPO (nothing by mouth). CNA (Certified Nursing Assistant) called this writer (V14) to room. (R1) having difficulty with speech et (and) slow to respond. CNAs stated at oncome of shift at 0600 (6:00 AM) was talking fine. Pupils sluggish to response, dilated. Bilat (bilateral) upper ext. (extremity) edema. Unable to get O2 sat (saturation), pale but no discoloration. Blanches pink nail beds, flaccid strength per her norm, total assist, blankets applied to increase temp (temperature) skin cool, 95.7 ,d+[DATE], 84, 20 room air. Called (V24/NP-Nurse Practitioner) send to ER (emergency room ) for evaluation r/t (related to) condition change. (Name of ambulance service) called at 0655 (6:55 AM) called husband and made aware of. This writer staying by room to monitor. This progress note was signed by V14 (LPN/Licensed Practical Nurse). [DATE] 7:35 AM, (ambulance service) here. 0745 (7:45 AM) Exit with (R1) per transfer of 4 to stretcher. [DATE] 10:15 AM, husband here et made aware of wife expiring. Hugged this nurse et stated thank you for taking good care of her. Belongings taken at this time. Administrators present with facilities (sic) condolences. Called (V24) et made aware of (R1) expiring per notification from husband. R1's Ambulance Patient Care Report dated [DATE] documents under Response Information the Nature of Call as Medical Emergency and documents, Caller (Uncooperative) No EMS (Emergency Medical Service) Vehicles (Units) Available. Under Times the report documents, Injury: 0659 (AM) .Recvd (received) 06:59 (AM) .Dispatch: 07:35 (AM) . The Patient Care Report documents Altered Consciousness-Unresponsive as the chief complaint. Under Narrative the report documents, Responded emergent for a direct call to (name of facility) report of a female with flaccid, decline in responsiveness, and uneven pupils. Per dispatch nursing home refused to call 911 and wanted to wait for (name of ambulance service) ambulance knowing it (sic) we don't have any units available and will be a while. Delay to scene due to no units available. AOS (arrived on scene) to find pt (patient/R1) laying in nursing home bed. Per nursing home staff, staff noticed a change in (R1's) condition around 0600 (6:00 AM) this morning when they started their shift. Further, nurse states (R1's) temperature is 95.4 and they are attempting to warm her. (R1) is unresponsive, pale, cool, and clammy. (R1) moved to cot, secured, and loaded into ambulance. (R1) has a PICC (peripherally inserted central catheter) line to her left upper arm. (R1) placed on cardiac monitor showing sinus bradycardia, (R1) went into cardiac arrest. CPR (Cardiopulmonary Resuscitation) immediately started by (names of paramedics and emergency medical technician) contacted (name of local hospital) ED (Emergency Department) to given (sic) (R1) update upon arrival. Pads placed on (R1) showing asystole. ER (emergency room ) staff met this unit outside and assisted in taking (R1) into emergency room .(R1) care left with ER nursing staff R1's local hospital emergency department record dated [DATE] documents under History, Chief Complaint Patient (R1) presents with Cardiac Arrest. Pt (R1) per EMS (emergency medical services) has been told by NH (nursing home) staff unresponsive since 0600 (6:00 AM) . they were called just pta (prior to arrival) and found (R1) unresponsive hr (heart rate) 30's in route just across street full arrest they started CPR (cardiopulmonary resuscitation) large amt (amount) of black vomit on arrival asystole on arrival accu (sic) done by us 84 on arrival, CPR continued going thru epi (epinephrine) x (times) 3, attempted intubations very large vomit in airway clogging up many yankars with blood clots difficult to get clear site, unable to pass 7 tube ? (question) mass beyond tried 6.5 still unable getting video stylet unable to see, anesthesia called but placed lma (laryngeal mask airway) and b/l (bilateral) bs (breath sounds) after still asystole and (R1) pupils fixed dilated on arrival pale waxy color entire time and US (ultrasound) cardiac no activity no pulse called TOD (time of death) at 0808 (8:08 AM). Under Physical Exam R1's hospital record documents, BP (blood pressure) ,d+[DATE], SpO2 85% .fixed and dilated pupils .pulse with CPR then nothing .bagging after lma b/l bs. R1's hospital record documents Cardiac Arrest under ED (Emergency Department) Course, Clinical Impressions. R1's Certificate of Death Worksheet documents R1 expired on [DATE] and Cause of Death is documented as Massive Gastrointestinal Bleed. On [DATE] at 4:17 PM, V12 (CNA) stated she provided care to R1 on ,d+[DATE], ,d+[DATE], and [DATE]. V12 stated on ,d+[DATE] and [DATE], R1 refused to eat and didn't want to get out of bed on those days. V12 stated R1 wasn't talking as loud, she was kind of quiet and mumbly (sic). V12 stated she came to work on [DATE] and it was reported to her by night shift, R1 had complained of not feeling well through the night. V12 stated she went straight to R1's room after she got report at 6:00 AM. V12 stated she told V14 (LPN/Licensed Practical Nurse) to assess R1. V12 stated V14 first said she was going to send R1 out to the hospital for evaluation and then changed her mind and had them get R1 up to go to the appointment she had. V12 stated they got R1 up and took her to the nurse's station. V12 stated they took R1's temperature and it was around 95.0. V12 stated, V14 told them to put R1 back to bed they were calling the ambulance. V12 stated V14 told them it was going to be a little bit before the ambulance could get there because they had someone going out on a helicopter. V12 stated at that point R1 was cold and was still speaking and told them she was hurting all over. V12 stated then R1 was kind of hollering and yelling. V12 stated, V25 (PTA/Physical Therapy Assistant) went in to check on R1 and R1 told V25 she was hurting all over. V12 stated she checked on R1 around 7:00 AM and at that time R1 was not able to verbally communicate with words. V12 stated the ambulance got to the facility around 7:30 AM. V12 stated R1 was alert but they couldn't get her to speak at that point. V12 stated the ambulance crew asked V14 as soon they got in the room why she refused to call 911. V12 said V14 told the ambulance crew as far as she knew there were no ambulances. On [DATE] at 11:28 AM, V25 (PTA) stated she was walking another resident down the hall when she heard R1 screaming and yelling, help me, help me. V25 stated she finished walking the resident down the hall and went back to check on R1. V25 stated she asked R1 if she was ok and R1 didn't respond. V25 stated R1 was looking up at the ceiling so she asked R1 if she was hurting. V25 stated R1 said yes and when she asked her where she was hurting R1 screamed, everywhere. When asked if that was normal behavior for R1, V25 stated, no. V25 stated she had never heard R1 scream out like that. V25 stated R1 was definitely not a screamer. V25 stated R1 was hollering and V25 mimicked a continuous holler. V25 stated at first there were no words and then R1 yelled the word, everywhere. V25 stated she thought this was around 6:30 AM then stated it was between 7:15 and 7:30 AM. V25 stated she reported it to the V14 (LPN). V27 stated an unknown CNA told her they had already contacted the ambulance and they were just waiting on the ambulance to get free to come get R1. On [DATE] at 3:27 PM, V9 (CNA) stated she provided care to R1 in the days leading up to [DATE] and was working when R1 was sent to the hospital. V9 stated R1 had progressively gotten worse in the three days prior to [DATE]. V9 stated she got to work on the morning of [DATE] around 5:50 AM. V9 stated R1 had an appointment scheduled for that morning so she and another CNA (V12) went to R1's room around 6:10 AM. V9 stated R1 was really out of it. V9 stated they reported it to the nurse (V14). V9 stated V14 told them to get R1 up so she could go to her appointment, so they did. V9 stated they took R1 to the nurse's station and R1 was very cold. V9 stated V14 told them to put R1 back to bed and they were sending R1 to the hospital. When asked how long it took the ambulance to arrive, V9 stated she knew it was a whole big ordeal. V9 stated she knew they called the ambulance, and they said it was going to be awhile before they could get to the facility. V9 was not able to say when the ambulance arrived. V9 stated she remembered R1 yelling and just trying to talk while V9 was trying to get other residents up. V9 stated she kept going in R1's room to check on her. V9 stated R1 was trying to talk but couldn't get her words out, but she was yelling and mumbling. V9 stated R1 worsened because she was able to say her name when she first saw her around 6:10 AM. When asked if a nurse was with R1 during this time frame, V9 stated, not the whole time but she was in the room multiple times. On [DATE] at 9:38 AM, V14 (LPN) stated she provided care to R1 on [DATE]. V14 stated she started her shift at 6:00 AM and went to R1's room around 6:05 AM. V14 stated right after that V9 and V12 (CNAs) reported to her R1 was acting different. V14 stated she assessed R1 including checking her vital signs and R1's blood pressure was ,d+[DATE]. V14 stated R1 was sluggish to respond but was vocal at that time. V14 stated R1's temperature was 95.7 Fahrenheit and hypothermic measures were implemented such as extra blankets. V14 stated R1 was full of fluid but blanched pink when she blanched her. V14 stated she called the ambulance service direct around 6:15 AM and told them R1 was sluggish to respond and slurring her words, a change from 10 minutes prior. V14 stated the ambulance service told her they would send someone out. V14 stated she then went to R1's room and stayed with her. V14 then stated she passed medications to other residents on the same hallway. When asked if that meant she wasn't with R1 the whole time, V14 stated, No, not the whole time. V14 stated R1 looked as though she was resting. When asked when the ambulance service arrived, V14 stated, V20 (RN/Registered Nurse) hollered down and told her there were two helicopters and all the ambulance crews were tied up, so that delayed them from arriving at the facility. V14 stated she would guess they arrived at the facility around 7:15 or 7:20 AM. V14 stated she didn't call 911. V14 stated she didn't realize she had an emergent situation. V14 stated R1 had a condition change and she wanted her out of the facility as fast as she could go but didn't think she was going to pass away. V14 stated the normal procedure for sending a resident to the hospital is to call the ambulance service direct. V14 stated she thought calling them would be her fastest response. On [DATE] at 4:31 PM, V13 (EMT/Emergency Medical Technician, Basic) stated she transported R1 from the facility to the local hospital on [DATE]. V13 stated it was unusual because R1's call came while she was on another call. V13 stated she was on the helipad and the patient she was working with had a soft blood pressure so the helicopter couldn't leave. V13 stated when that happens the ground crew can't leave the helipad. V13 stated she got the call around 6:39 AM from the night shift dispatcher (V27) that there was a resident (R1) at the facility with uneven pupils, flaccid, unresponsive, and sitting at the nurse's station. V13 stated she responded to dispatch to call the facility and tell them to call another service because with those symptoms they needed immediate transport, and the other crew was in another city on a different transport. V13 stated she returned to the helipad, and she got another call from dispatch at around 7:00 AM. V13 stated dispatch told her the resident (R1) was still waiting for transport. V13 stated she explained to dispatch R1 couldn't wait. V13 stated they finished at the helipad around 7:35 AM and when they called in that the call, they were on was complete, they were told the resident (R1) was still waiting for transport at the facility. V13 stated they went in route to the facility and arrived within less than two minutes. V13 stated the nurse (V14) told them R1 was in bed, and they were trying to warm her since her temperature was 95.4. V13 stated they asked her why she didn't call 911 and V14 told them she was busy on the hall. V13 stated when they got to R1's room she was in bed laying under a blanket. V13 stated R1 was diaphoretic, cold to touch gray/blue around her lips and outside her mouth, both pupils were dilated, and the left pupil measured a 6 while the right pupil was an 8. V13 stated facility staff helped transfer R1 to the cot and they started oxygen immediately. V13 couldn't remember if oxygen had been applied by the facility staff prior to their arrival. V13 stated once in the ambulance her partner attempted to start an IV (intravenous access) and they were unable to get a blood pressure. V13 stated then R1 went loose and lost her pulse. V13 stated they started CPR and R1 was spewing coffee ground emesis with compressions. V13 stated they were in route to the hospital which is less than two minutes away and they turned her care over to the ER staff when they arrived. On [DATE] at 4:04 PM, V27 (Dispatcher, Ambulance Service) stated she works at the ambulance service as a dispatcher on the 11 PM to 7 AM shift. V27 stated she received a call from the facility around 6:39 AM on [DATE] and the nurse (V14) gave her the information on R1. V27 stated she told V14 there was no crew available because they had a crew going to a regional hospital and one on the helipad. V27 stated V14 said she guessed she would wait for them. V27 stated she called the crew to get an established time frame and they said it would be ,d+[DATE] minutes. V27 stated she called the facility back around 7:00 AM to make them aware of the time frame. V27 stated she didn't get the name of the nurse who answered the phone, but she told them the time frame and they said they would let the nurse know. V27 stated it took the crew approximately 30 minutes after that to get to the facility. On [DATE] at 12:02 PM, V5 (Ambulance Dispatcher) stated he came on duty on [DATE] at 7:00 AM. V5 stated the original call came from the facility at 6:39 AM. V5 stated they had one ambulance crew out of town doing a run and a second crew working on the helipad with a stroke victim. V5 stated the night shift dispatcher (V27) called the facility back at 7:02 AM and told them it was still going to be thirty minutes before they could arrive to the facility to transport R1 to the local hospital. V5 stated the facility said they would wait. V5 stated the crew arrived at the facility at 7:35 AM. On [DATE] at 11:22 AM, when asked why the time on R1's ambulance report is documented as 6:59 AM when all the interviews say the first call came from the facility at 6:39 AM, V5 (ambulance dispatcher) stated the original call came in at 6:39 AM but they didn't create the call in the system because they didn't know if they would be taking the call. V5 stated they didn't create the call in the system until they talked to the crew and called the facility back. V5 stated he took a picture of the time the calls came in and the original call's picture shows it was 6:3*, with the last number not visible. V5 stated the time stamp on the call logs shows the ambulance service called the facility back at 7:02 AM. On [DATE] at 11:19 AM, V17 (LPN) stated she was working the day R1 was sent to the hospital. V17 stated they were getting ready to start morning medication pass and the CNAs brought R1 up for breakfast. V17 stated V14 (LPN) said she was going to send R1 out to the hospital. V17 stated they took R1 to her room and V17 started passing medications. V17 stated the ambulance service called back and said they were ,d+[DATE] minutes out. V17 stated she remembered calling that information down to V14. V17 stated she talked to R1 on her way out the door and told her goodbye. When asked if R1 responded to her, V17 stated she couldn't remember. On [DATE] at 1:37 PM, V20 (RN) stated she works night shift and on the morning of [DATE] she gave report to the oncoming nurse (V14) at approximately 6:00 AM. V20 stated V14 brought R1 to the nurse's desk and V14 said something was wrong with R1. V20 stated it was a change in condition from when she had seen R1 around 2:30 AM, when R1 was talking and asking to be repositioned. V20 stated V14 was having trouble getting R1's vital signs so she helped her and V14 called the ambulance. V20 stated she was working on paperwork when the ambulance called back, and she answered the phone. V20 stated they told her they were going to be about 30 minutes. V20 stated she told the other nurse (V17) and V17 told V14. V20 stated she finished her work and left, and the ambulance had not arrived at the facility when she left. When asked if it was typical for the ambulance to take an extra 30 minutes, V20 stated, At times they do, When asked what they normally do in those situations V20 stated she would either call another ambulance service or call 911. On [DATE] at 2:33 PM, V23 (CNA) stated she worked the night before R1 was sent to the hospital. V23 stated R1 was talking to her when she left the facility the morning of [DATE] at 6:00 AM. V23 stated R1 was very restless through the night shift and said she just didn't feel good and couldn't get comfortable. V23 stated R1's hands were very swollen and R1 couldn't use them. On [DATE] at 3:24 PM, V26 (CNA) stated she worked night shift beginning on [DATE] and leaving on the morning of [DATE]. V26 stated R1 was very uncomfortable, R1's hands were swollen, and R1 seemed really nervous like she was scared or something. V26 stated R1 complained of a stomachache and so they gave her some tums and it helped. When asked how R1 was when she left the facility at 6:00 AM, V26 stated R1 had been up all night and was sleeping so she let her sleep. On [DATE] at 1:14 PM, V19 (family member) stated he saw R1 on [DATE] and [DATE]. V19 stated R1 couldn't swallow and seemed kind of groggy. V19 stated the facility called him on [DATE] and told him they were transferring R1 to the hospital and then the hospital called him a lot later with an update. When asked what time the facility called him V19 stated he told V22 (family member). On [DATE] at 1:22 PM, V22 (family member) stated the facility called V19 on [DATE] at 6:30 AM and told V19, R1 was not acting right. V22 stated around 7:45 AM, R1 arrived at the hospital in cardiac arrest. On [DATE] at 3:01 PM, V6 (LPN) stated the typical time to transfer a resident to the hospital is thirty minutes or so if the ambulance is backed up. V6 stated it has taken longer. V6 stated it has taken up to an hour. When asked if there was another option for an ambulance service V6 stated the name of another ambulance service provider and stated but sometimes they don't come this way. V6 then stated, Honestly, if it came down to it, I would push them to the hospital. It is right next door. When asked who she calls when they need an ambulance V6 stated, if they are unresponsive, I call 911. When asked if she was providing care to R1 when she was transferred to the hospital on [DATE], V6 stated she was not. V6 stated, She (R1) wasn't one to give up. I was kind of shocked when I found out she had passed away. On [DATE] at 3:39 PM, V10 (LPN) stated she didn't provide care for R1. When asked what the process was to send a resident to the hospital V10 stated, they assess the resident, call the physician, get the orders, call the power of attorney, ambulance, and hospital. When asked how long this process takes V10 stated ,d+[DATE] minutes or less if there are two nurses working on it. V10 stated it usually takes the ambulance ,d+[DATE] minutes to arrive. On [DATE] at 10:07 AM, V15 (RN) stated the normal procedure for sending a resident to the hospital would be to assess the resident, call the doctor, if emergent she would get another nurse to get the paperwork started and call the ambulance. V15 stated if not emergent she would call the doctor, get the paperwork printed and get them sent out. V15 stated unless there is a delay with the ambulance it is a pretty speedy process. When asked what would cause a delay V15 stated the ambulance service sometimes says they don't have any crews available. V15 stated they have more than one ambulance service they can call if that happens. When asked if she ever called 911, V15 stated she had many times. V15 stated she would call 911 if it was an emergent situation. When asked what the difference was in calling an ambulance service direct and calling 911, V15 stated she wasn't sure what it meant to them but to the facility it meant they needed someone at the facility now. On [DATE] at 3:35 PM, this surveyor reviewed R1's progress notes dated [DATE] with V3 (Assistant Director of Nursing/ADON). At that time V3 stated she would have called the doctor to see what they wanted her to do. On [DATE] at 10:36 AM, V3 (ADON) stated she worked the night shift beginning on [DATE] and didn't come to the facility on [DATE] until around 9:00 AM. V3 stated she was told R1 had died at that time. V3 stated she was told they couldn't get R1's body temperature up and they called the doctor and were told to send R1 to the hospital. V3 stated they told her R1 was talking to them when she left the facility. This surveyor reviewed the symptoms documented in R1's progress notes and asked V3 if she would consider them emergent. V3 stated, Yes, that could be signs of stroke. This surveyor reviewed with V3 the delay in an ambulance arriving to the facility and asked what her expectation would be and V3 stated she would have called all the ambulance services and if they weren't available, she would have called 911. On [DATE] at 10:24 AM, V2 (DON/Director of Nurses) stated it was not the facility's normal procedure to wait for an ambulance. V2 stated she would have called 911 if she had been at the facility. V2 stated it isn't uncommon for the ambulance service to say they don't have a crew available. V2 stated most people they send to the hospital are not in emergent situations. When asked what the normal process is, V2 stated the facility staff should call the ambulance listed on the resident chart and then call other services if the residents preference provider is not available. When asked why they didn't just call 911, V2 stated most of the time it is non-emergent, so she thinks staff are just used to calling the ambulance service direct. V2 stated she was not aware of the delay for R1. On [DATE] at 11:08 AM, V1 (Administrator) stated she wasn't involved in R1's transfer to the hospital on [DATE]. V1 stated she knew R1 was supposed to go out for a new chemotherapy line and had been without food and drink through the night for the procedure. V1 stated she knew R1 wasn't doing well and had been in a slow decline. V1 stated they wondered why the physician was putting her through the treatment when the outcome wasn't going to be good. V1 stated but she knew R1 wanted to fight. V1 stated she read the hospital medical records and that R1 had coded on her way to the hospital. V1 stated she got statements from V12 (CNA) and V25 (PTA) who was working. V1 stated V25 was walking another resident when she heard R1 holler out and said she was hurting everywhere. V1 stated this happened at 7:00 AM so she knew R1 was talking at that time. V1 stated she called the ambulance supervisor and talked with him. V1 stated she thought that ambulance service was their 911 ambulance. V1 stated the ambulance supervisor said they were the 911 ambulance service but there was also one in another nearby town. V1's investigation provided to this surveyor, included statements from V12 and V25, a copy of R1's hospital record that documented, From NH (nursing home) EMS states she was down since 6am when EMS arrived her pupils were fixed and dilated. CPR in process when EMS arrived (to hospital). This hospital record had handwritten at the bottom, Talked with (name of person) at (name of ambulance service) stated EMS denied statement that she was down since 06:00 (6:00 AM)- Last well time was 06 (6:00 AM). V1's investigation also included a copy of R1's progress notes from [DATE]. There was no outcome or interventions documented in investigation. On [DATE] at 10:19 AM, V1 (Administrator) was asked via email if she had provided this surveyor with her full investigation and if there were any interventions implemented after her investigation. V1 responded, That was my investigation at that time. V1 stated she also called the manager at the ambulance service and discussed R1's transfer and asked him if they were other 911 ambulance services and the manager replied they were. V1 stated in the email she asked him if they were not available who should they call, and the manager named another local ambulance service, and she asked if that service was unavailable who should they call. V1 stated he said if they called 911 it would be another close town's ambulance if no one else was available. V1 stated she shared the information with the team and plans were made to review charts. V1 stated they completed that review on [DATE]. V1 stated V2 (DON) scheduled a meeting with the nurses on [DATE] to explain to call 911 for emergencies and to call the resident ambulance choice for non-emergencies. On [DATE] at 11:49 AM, V5 (ambulance dispatcher) stated they notify the facility 100% of the time if they don't have a crew available. V5 stated they tell them they need to call for mutual aid. V5 stated they have two other options in the town that would be immediate responses. When asked what the difference was for someone to call 911 versus calling the ambulance direct, V5 stated if someone calls 911 that call goes to the police department dispatch and then they tone out this ambulance service. V5 stated if this ambulance service doesn't have a crew available, they tone out the next ambulance service and if they don't have a crew available, they tone out the next ambulance service. On [DATE] at 9:49 AM, V24 (Nurse Practitioner) stated she remembered getting the call on [DATE] related to R1's symptoms and she told them to send her to the emergency room for evaluation and treatment. V24 stated she got the call in the early morning but didn't have the time documented anywhere. This surveyor reviewed R1's progress notes and the staff interviews with V24 including the time frames. V24 stated she wasn't aware of the delay in treatment. V24 stated even if V14 didn't think it was emergent when the symptoms first started, she should have quickly realized it was. V24 stated based on what she read in R1's record it was a significant bleed that appeared to be spontaneous. V24 stated based on that she couldn't say the outcome for R1 would have been different if she had received timely care. V24 stated R1's symptoms were emergent, and she would have expected the facility to call 911. On [DATE] at 9:03 AM, V18 (Cancer Specialist) stated R1 had pancreatic cancer and her cancer treatment was palliative in nature, to help prevent pain and discomfort. V18 stated R1 was on Xarelto and that could increase her risk of bleeding. When asked if R1 had received treatment quicker if the outcome could have been different V18 stated, with a GI bleed the quicker the treatment the better. V18 stated he couldn't guarantee it would have made a difference in the outcome. V18 stated she couldn't be off the Xarelto due to her diagnosis, and he couldn't judge if quicker treatment would have altered the outcome. V18 stated R1 would have been at risk for complications but would hope that being in the facility it would lessen the risks. According to https://www.mayoclinic.org/di [TRUNCATED]

Based on interview and record review the facility failed to identify a decline in condition as an emergent situation and ensure a system was in place to obtain timely emergency transport for 3 of 6 (R1, R8, and R9) residents reviewed for hospital transfers in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. This failure has the potential to affect all 37 residents residing at the facility. These failures resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to ensure R1 received timely medical care when they failed to recognize an emergent situation and call 911 after the ambulance provider they called was delayed. This failure resulted in R1 remaining at the facility from 6:39 AM until the ambulance arrived at 7:35 AM with worsening symptoms. R1 was subsequently transferred to the local hospital, went into cardiac arrest during transfer, and expired in the hospital emergency roiagnom on [DATE]. R1's cause of death is documented as a massive gastrointestinal (GI) bleed. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 9:14 AM. The surveyor confirmed by record review and interview, that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training. Findings Include: 1. R1's Admission Record with a print date of [DATE] documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, malignant neoplasm of pancreas, atrial fibrillation, restless leg syndrome, neuromuscular dysfunction of bladder, major depressive disorder, cognitive communication deficit, and weakness. R1's MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 was cognitively intact. R1's Order Summary Report with active orders as of [DATE] documents a physician order that R1 was a full code and a physician order for Xarelto 20 milligrams (mg) one every afternoon. R1's Care Plan documents a Focus area with a created date of [DATE] documents, Usage of black box medications: .Xarelto . The interventions documented for this Focus area include, Monitor and assess for side effects of medications that contain black box warning PRN (as needed). R1's Care Plan documents a Focus area with a created date of [DATE] of, (R1) wishes to return home with (name of home health agencies). The intervention documented for this Focus area is, Evaluate and discuss with the (R1) and (V19) the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits, and needs for maximum independence. R1's Power of Attorney for Health Care dated [DATE] documents V19 (family member/spouse) was R1's agent to make decisions for her when she was not able to make them for herself. The form documents a check mark next to the following statement, Staying alive is more important to me, no matter how sick I am, how much I am suffering, the cost of the procedures, or how unlikely my chances for recovery are. I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical standards. R1's Social Services Assessment and Note dated [DATE] documents under Social Service Note, (R1) was admitted to (name of facility) for a short-term therapy stay following a long hospitalization . POLST (Physician Orders for Life Sustaining Treatment) FULL CODE per choice. HCPOA (Health Care Power of Attorney) husband (V19) [DATE] . R1's Progress Notes document the following: [DATE] 2:20 PM, resident (R1) is alert, verbal, oriented x 2, sleeps well at night. [DATE] 6:50 AM, AM ADL's (activities of daily living) to go get chemo (chemotherapy) port placement this am. Res (R1) has been NPO (nothing by mouth). CNA (Certified Nursing Assistant) called this writer (V14) to room. (R1) having difficulty with speech et (and) slow to respond. CNAs stated at oncome of shift at 0600 (6:00 AM) was talking fine. Pupils sluggish to response, dilated. Bilat (bilateral) upper ext. (extremity) edema. Unable to get O2 sat (saturation), pale but no discoloration. Blanches pink nail beds, flaccid strength per her norm, total assist, blankets applied to increase temp (temperature) skin cool, 95.7 ,d+[DATE], 84, 20 room air. Called (V24/NP-Nurse Practitioner) send to ER (emergency room ) for evaluation r/t (related to) condition change. (Name of ambulance service) called at 0655 (6:55 AM) called husband and made aware of. This writer staying by room to monitor. This progress note was signed by V14 (LPN/Licensed Practical Nurse). [DATE] 7:35 AM, (ambulance service) here. 0745 (7:45 AM) Exit with (R1) per transfer of 4 to stretcher. [DATE] 10:15 AM, husband here et made aware of wife expiring. Hugged this nurse et stated thank you for taking good care of her. Belongings taken at this time. Administrators present with facilities (sic) condolences. Called (V24) et made aware of (R1) expiring per notification from husband. R1's Ambulance Patient Care Report dated [DATE] documents under Response Information the Nature of Call as Medical Emergency and documents, Caller (Uncooperative) No EMS (Emergency Medical Service) Vehicles (Units) Available. Under Times the report documents, Injury: 0659 (AM) .Recvd (received) 06:59 (AM) .Dispatch: 07:35 (AM) . The Patient Care Report documents Altered Consciousness-Unresponsive as the chief complaint. Under Narrative the report documents, Responded emergent for a direct call to (name of facility) report of a female with flaccid, decline in responsiveness, and uneven pupils. Per dispatch nursing home refused to call 911 and wanted to wait for (name of ambulance service) ambulance knowing it (sic) we don't have any units available and will be a while. Delay to scene due to no units available. AOS (arrived on scene) to find pt (patient/R1) laying in nursing home bed. Per nursing home staff, staff noticed a change in (R1's) condition around 0600 (6:00 AM) this morning when they started their shift. Further, nurse states (R1's) temperature is 95.4 and they are attempting to warm her. (R1) is unresponsive, pale, cool, and clammy. (R1) moved to cot, secured, and loaded into ambulance. (R1) has a PICC (peripherally inserted central catheter) line to her left upper arm. (R1) placed on cardiac monitor showing sinus bradycardia, (R1) went into cardiac arrest. CPR (Cardiopulmonary Resuscitation) immediately started by (names of paramedics and emergency medical technician) contacted (name of local hospital) ED (Emergency Department) to given (sic) (R1) update upon arrival. Pads placed on (R1) showing asystole. ER (emergency room ) staff met this unit outside and assisted in taking (R1) into emergency room .(R1) care left with ER nursing staff R1's local hospital emergency department record dated [DATE] documents under History, Chief Complaint Patient (R1) presents with Cardiac Arrest. Pt (R1) per EMS (emergency medical services) has been told by NH (nursing home) staff unresponsive since 0600 (6:00 AM) . they were called just pta (prior to arrival) and found (R1) unresponsive hr (heart rate) 30's in route just across street full arrest they started cpr (cardiopulmonary resuscitation) large amt (amount) of black vomit on arrival asystole on arrival accu (sic) done by us 84 on arrival, cpr continued going thru epi (epinephrine) x (times) 3, attempted intubations very large vomit in airway clogging up many yankars with blood clots difficult to get clear site, unable to pass 7 tube ? (question) mass beyond tried 6.5 still unable getting video stylet unable to see, anesthesia called but placed lma (laryngeal mask airway) and b/l (bilateral) bs (breath sounds) after still asystole and (R1) pupils fixed dilated on arrival pale waxy color entire time and US (ultrasound) cardiac no activity no pulse called tod (time of death) at 0808 (8:08 AM). Under Physical Exam R1's hospital record documents, BP (blood pressure) ,d+[DATE], SpO2 85% .fixed and dilated pupils .pulse with cpr then nothing .bagging after lma b/l bs. R1's hospital record documents Cardiac Arrest under ED (Emergency Department) Course, Clinical Impressions. R1's Certificate of Death Worksheet documents R1 expired on [DATE] and Cause of Death is documented as Massive Gastrointestinal Bleed. On [DATE] at 4:17 PM, V12 (CNA) stated she provided care to R1 on ,d+[DATE], ,d+[DATE], and [DATE]. V12 stated on ,d+[DATE] and [DATE], R1 refused to eat and didn't want to get out of bed on those days. V12 stated R1 wasn't talking as loud, she was kind of quiet and mumbly (sic). V12 stated she came to work on [DATE] and it was reported to her by night shift, R1 had complained of not feeling well through the night. V12 stated she went straight to R1's room after she got report at 6:00 AM. V12 stated she told V14 (LPN/Licensed Practical Nurse) to assess R1. V12 stated V14 first said she was going to send R1 out to the hospital for evaluation and then changed her mind and had them get R1 up to go to the appointment she had. V12 stated they got R1 up and took her to the nurse's station. V12 stated they took R1's temperature and it was around 95.0. V12 stated, V14 told them to put R1 back to bed they were calling the ambulance. V12 stated V14 told them it was going to be a little bit before the ambulance could get there because they had someone going out on a helicopter. V12 stated at that point R1 was cold and was still speaking and told them she was hurting all over. V12 stated then R1 was kind of hollering and yelling. V12 stated, V25 (PTA/Physical Therapy Assistant) went in to check on R1 and R1 told V25 she was hurting all over. V12 stated she checked on R1 around 7:00 AM and at that time R1 was not able to verbally communicate with words. V12 stated the ambulance got to the facility around 7:30 AM. V12 stated R1 was alert but they couldn't get her to speak at that point. V12 stated the ambulance crew asked V14 as soon they got in the room why she refused to call 911. V12 said V14 told the ambulance crew as far as she knew there were no ambulances. On [DATE] at 11:28 AM, V25 (PTA) stated she was walking another resident down the hall when she heard R1 screaming and yelling, help me, help me. V25 stated she finished walking the resident down the hall and went back to check on R1. V25 stated she asked R1 if she was ok and R1 didn't respond. V25 stated R1 was looking up at the ceiling so she asked R1 if she was hurting. V25 stated R1 said yes and when she asked her where she was hurting R1 screamed, everywhere. When asked if that was normal behavior for R1, V25 stated, no. V25 stated she had never heard R1 scream out like that. V25 stated R1 was definitely not a screamer. V25 stated R1 was hollering and V25 mimicked a continuous holler. V25 stated at first there were no words and then R1 yelled the word, everywhere. V25 stated she thought this was around 6:30 AM then stated it was between 7:15 and 7:30 AM. V25 stated she reported it to the V14 (LPN). V27 stated an unknown CNA told her they had already contacted the ambulance and they were just waiting on the ambulance to get free to come get R1. On [DATE] at 3:27 PM, V9 (CNA) stated she provided care to R1 in the days leading up to [DATE] and was working when R1 was sent to the hospital. V9 stated R1 had progressively gotten worse in the three days prior to [DATE]. V9 stated she got to work on the morning of [DATE] around 5:50 AM. V9 stated R1 had an appointment scheduled for that morning so she and another CNA (V12) went to R1's room around 6:10 AM. V9 stated R1 was really out of it. V9 stated they reported it to the nurse (V14). V9 stated V14 told them to get R1 up so she could go to her appointment, so they did. V9 stated they took R1 to the nurse's station and R1 was very cold. V9 stated V14 told them to put R1 back to bed and they were sending R1 to the hospital. When asked how long it took the ambulance to arrive, V9 stated she knew it was a whole big ordeal. V9 stated she knew they called the ambulance, and they said it was going to be awhile before they could get to the facility. V9 was not able to say when the ambulance arrived. V9 stated she remembered R1 yelling and just trying to talk while V9 was trying to get other residents up. V9 stated she kept going in R1's room to check on her. V9 stated R1 was trying to talk but couldn't get her words out, but she was yelling and mumbling. V9 stated R1 worsened because she was able to say her name when she first saw her around 6:10 AM. When asked if a nurse was with R1 during this time frame, V9 stated, not the whole time but she was in the room multiple times. On [DATE] at 9:38 AM, V14 (LPN) stated she provided care to R1 on [DATE]. V14 stated she started her shift at 6:00 AM and went to R1's room around 6:05 AM. V14 stated right after that V9 and V12 (CNA's) reported to her R1 was acting different. V14 stated she assessed R1 including checking her vital signs and R1's blood pressure was ,d+[DATE]. V14 stated R1 was sluggish to respond but was vocal at that time. V14 stated R1's temperature was 95.7 Fahrenheit and hypothermic measures were implemented such as extra blankets. V14 stated R1 was full of fluid but blanched pink when she blanched her. V14 stated she called the ambulance service direct around 6:15 AM and told them R1 was sluggish to respond and slurring her words, a change from 10 minutes prior. V14 stated the ambulance service told her they would send someone out. V14 stated she then went to R1's room and stayed with her. V14 then stated she passed medications to other residents on the same hallway. When asked if that meant she wasn't with R1 the whole time, V14 stated, No, not the whole time. V14 stated R1 looked as though she was resting. When asked when the ambulance service arrived, V14 stated, V20 (RN/Registered Nurse) hollered down and told her there were two helicopters and all the ambulance crews were tied up, so that delayed them from arriving at the facility. V14 stated she would guess they arrived at the facility around 7:15 or 7:20 AM. V14 stated she didn't call 911. V14 stated she didn't realize she had an emergent situation. V14 stated R1 had a condition change and she wanted her out of the facility as fast as she could go but didn't think she was going to pass away. V14 stated the normal procedure for sending a resident to the hospital is to call the ambulance service direct. V14 stated she thought calling them would be her fastest response. On [DATE] at 4:31 PM, V13 (EMT/Emergency Medical Technician, Basic) stated she transported R1 from the facility to the local hospital on [DATE]. V13 stated it was unusual because R1's call came while she was on another call. V13 stated she was on the helipad and the patient she was working with had a soft blood pressure so the helicopter couldn't leave. V13 stated when that happens the ground crew can't leave the helipad. V13 stated she got the call around 6:39 AM from the night shift dispatcher (V27) that there was a resident (R1) at the facility with uneven pupils, flaccid, unresponsive, and sitting at the nurse's station. V13 stated she responded to dispatch to call the facility and tell them to call another service because with those symptoms they needed immediate transport, and the other crew was in another city on a different transport. V13 stated she returned to the helipad, and she got another call from dispatch at around 7:00 AM. V13 stated dispatch told her the resident (R1) was still waiting for transport. V13 stated she explained to dispatch R1 couldn't wait. V13 stated they finished at the helipad around 7:35 AM and when they called in that the call, they were on was complete, they were told the resident (R1) was still waiting for transport at the facility. V13 stated they went in route to the facility and arrived within less than two minutes. V13 stated the nurse (V14) told them R1 was in bed, and they were trying to warm her since her temperature was 95.4. V13 stated they asked her why she didn't call 911 and V14 told them she was busy on the hall. V13 stated when they got to R1's room she was in bed laying under a blanket. V13 stated R1 was diaphoretic, cold to touch gray/blue around her lips and outside her mouth, both pupils were dilated, and the left pupil measured a 6 while the right pupil was an 8. V13 stated facility staff helped transfer R1 to the cot and they started oxygen immediately. V13 couldn't remember if oxygen had been applied by the facility staff prior to their arrival. V13 stated once in the ambulance her partner attempted to start an IV (intravenous access) and they were unable to get a blood pressure. V13 stated then R1 went loose and lost her pulse. V13 stated they started CPR and R1 was spewing coffee ground emesis with compressions. V13 stated they were in route to the hospital which is less than two minutes away and they turned her care over to the ER staff when they arrived. On [DATE] at 4:04 PM, V27 (Dispatcher, Ambulance Service) stated she works at the ambulance service as a dispatcher on the 11 PM to 7 AM shift. V27 stated she received a call from the facility around 6:39 AM on [DATE] and the nurse (V14) gave her the information on R1. V27 stated she told V14 there was no crew available because they had a crew going to a regional hospital and one on the helipad. V27 stated V14 said she guessed she would wait for them. V27 stated she called the crew to get an established time frame and they said it would be ,d+[DATE] minutes. V27 stated she called the facility back around 7:00 AM to make them aware of the time frame. V27 stated she didn't get the name of the nurse who answered the phone, but she told them the time frame and they said they would let the nurse know. V27 stated it took the crew approximately 30 minutes after that to get to the facility. On [DATE] at 12:02 PM, V5 (Ambulance Dispatcher) stated he came on duty on [DATE] at 7:00 AM. V5 stated the original call came from the facility at 6:39 AM. V5 stated they had one ambulance crew out of town doing a run and a second crew working on the helipad with a stroke victim. V5 stated the night shift dispatcher (V27) called the facility back at 7:02 AM and told them it was still going to be thirty minutes before they could arrive to the facility to transport R1 to the local hospital. V5 stated the facility said they would wait. V5 stated the crew arrived at the facility at 7:35 AM. On [DATE] at 11:22 AM, when asked why the time on R1's ambulance report is documented as 6:59 AM when all the interviews say the first call came from the facility at 6:39 AM, V5 (ambulance dispatcher) stated the original call came in at 6:39 AM but they didn't create the call in the system because they didn't know if they would be taking the call. V5 stated they didn't create the call in the system until they talked to the crew and called the facility back. V5 stated he took a picture of the time the calls came in and the original call's picture shows it was 6:3*, with the last number not visible. V5 stated the time stamp on the call logs shows the ambulance service called the facility back at 7:02 AM. On [DATE] at 11:19 AM, V17 (LPN) stated she was working the day R1 was sent to the hospital. V17 stated they were getting ready to start morning medication pass, and the CNA's brought R1 up for breakfast. V17 stated V14 (LPN) said she was going to send R1 out to the hospital. V17 stated they took R1 to her room and V17 started passing medications. V17 stated the ambulance service called back and said they were ,d+[DATE] minutes out. V17 stated she remembered calling that information down to V14. V17 stated she talked to R1 on her way out the door and told her goodbye. When asked if R1 responded to her, V17 stated she couldn't remember. On [DATE] at 1:37 PM, V20 (RN) stated she works night shift and on the morning of [DATE] she gave report to the oncoming nurse (V14) at approximately 6:00 AM. V20 stated V14 brought R1 to the nurse's desk and V14 said something was wrong with R1. V20 stated it was a change in condition from when she had seen R1 around 2:30 AM, when R1 was talking and asking to be repositioned. V20 stated V14 was having trouble getting R1's vital signs so she helped her and V14 called the ambulance. V20 stated she was working on paperwork when the ambulance called back, and she answered the phone. V20 stated they told her they were going to be about 30 minutes. V20 stated she told the other nurse (V17) and V17 told V14. V20 stated she finished her work and left, and the ambulance had not arrived at the facility when she left. When asked if it was typical for the ambulance to take an extra 30 minutes, V20 stated, At times they do, When asked what they normally do in those situations V20 stated she would either call another ambulance service or call 911. On [DATE] at 2:33 PM, V23 (CNA) stated she worked the night before R1 was sent to the hospital. V23 stated R1 was talking to her when she left the facility the morning of [DATE] at 6:00 AM. V23 stated R1 was very restless through the night shift and said she just didn't feel good and couldn't get comfortable. V23 stated R1's hands were very swollen and R1 couldn't use them. On [DATE] at 3:24 PM, V26 (CNA) stated she worked night shift beginning on [DATE] and leaving on the morning of [DATE]. V26 stated R1 was very uncomfortable, R1's hands were swollen, and R1 seemed really nervous like she was scared or something. V26 stated R1 complained of a stomachache and so they gave her some tums and it helped. When asked how R1 was when she left the facility at 6:00 AM, V26 stated R1 had been up all night and was sleeping so she let her sleep. On [DATE] at 1:14 PM, V19 (family member) stated he saw R1 on [DATE] and [DATE]. V19 stated R1 couldn't swallow and seemed kind of groggy. V19 stated the facility called him on [DATE] and told him they were transferring R1 to the hospital and then the hospital called him a lot later with an update. When asked what time the facility called him V19 stated he told V22 (family member). On [DATE] at 1:22 PM, V22 (family member) stated the facility called V19 on [DATE] at 6:30 AM and told V19, R1 was not acting right. V22 stated around 7:45 AM, R1 arrived at the hospital in cardiac arrest. On [DATE] at 3:01 PM, V6 (LPN) stated the typical time to transfer a resident to the hospital is thirty minutes or so if the ambulance is backed up. V6 stated it has taken longer. V6 stated it has taken up to an hour. When asked if there was another option for an ambulance service V6 stated the name of another ambulance service provider and stated but sometimes they don't come this way. V6 then stated, Honestly, if it came down to it, I would push them to the hospital. It is right next door. When asked who she calls when they need an ambulance V6 stated, if they are unresponsive, I call 911. When asked if she was providing care to R1 when she was transferred to the hospital on [DATE], V6 stated she was not. V6 stated, She (R1) wasn't one to give up. I was kind of shocked when I found out she had passed away. On [DATE] at 3:39 PM, V10 (LPN) stated she didn't provide care for R1. When asked what the process was to send a resident to the hospital V10 stated, they assess the resident, call the physician, get the orders, call the power of attorney, ambulance, and hospital. When asked how long this process takes V10 stated ,d+[DATE] minutes or less if there are two nurses working on it. V10 stated it usually takes the ambulance ,d+[DATE] minutes to arrive. On [DATE] at 10:07 AM, V15 (RN) stated the normal procedure for sending a resident to the hospital would be to assess the resident, call the doctor, if emergent she would get another nurse to get the paperwork started and call the ambulance. V15 stated if not emergent she would call the doctor, get the paperwork printed and get them sent out. V15 stated unless there is a delay with the ambulance it is a pretty speedy process. When asked what would cause a delay V15 stated the ambulance service sometimes says they don't have any crews available. V15 stated they have more than one ambulance service they can call if that happens. When asked if she ever called 911, V15 stated she had many times. V15 stated she would call 911 if it was an emergent situation. When asked what the difference was in calling an ambulance service direct and calling 911, V15 stated she wasn't sure what it meant to them but to the facility it meant they needed someone at the facility now. On [DATE] at 3:35 PM, this surveyor reviewed R1's progress notes dated [DATE] with V3 (Assistant Director or Nurses/ADON). At that time V3 stated she would have called the doctor to see what they wanted her to do. On [DATE] at 10:36 AM, V3 (ADON) stated she worked the night shift beginning on [DATE] and didn't come to the facility on [DATE] until around 9:00 AM. V3 stated she was told R1 had died at that time. V3 stated she was told they couldn't get R1's body temperature up and they called the doctor and were told to send R1 to the hospital. V3 stated they told her R1 was talking to them when she left the facility. This surveyor reviewed the symptoms documented in R1's progress notes and asked V3 if she would consider them emergent. V3 stated, Yes, that could be signs of stroke. This surveyor reviewed with V3 the delay in an ambulance arriving to the facility and asked what her expectation would be and V3 stated she would have called all the ambulance services and if they weren't available, she would have called 911. On [DATE] at 10:24 AM, V2 (DON/Director of Nurses) stated it was not the facility's normal procedure to wait for an ambulance. V2 stated she would have called 911 if she had been at the facility. V2 stated it isn't uncommon for the ambulance service to say they don't have a crew available. V2 stated most people they send to the hospital are not in emergent situations. When asked what the normal process is, V2 stated the facility staff should call the ambulance listed on the resident chart and then call other services if the residents preference provider is not available. When asked why they didn't just call 911, V2 stated most of the time it is non-emergent, so she thinks staff are just used to calling the ambulance service direct. V2 stated she was not aware of the delay for R1. On [DATE] at 11:08 AM, V1 (Administrator) stated she wasn't involved in R1's transfer to the hospital on [DATE]. V1 stated she knew R1 was supposed to go out for a new chemotherapy line and had been without food and drink through the night for the procedure. V1 stated she knew R1 wasn't doing well and had been in a slow decline. V1 stated they wondered why the physician was putting her through the treatment when the outcome wasn't going to be good. V1 stated but she knew R1 wanted to fight. V1 stated she read the hospital medical records and that R1 had coded on her way to the hospital. V1 stated she got statements from V12 (CNA) and V25 (PTA) who was working. V1 stated V25 was walking another resident when she heard R1 holler out and said she was hurting everywhere. V1 stated this happened at 7:00 AM so she knew R1 was talking at that time. V1 stated she called the ambulance supervisor and talked with him. V1 stated she thought that ambulance service was their 911 ambulance. V1 stated the ambulance supervisor said they were the 911 ambulance service but there was also one in another nearby town. V1's investigation provided to this surveyor, included statements from V12 and V25, a copy of R1's hospital record that documented, From NH (nursing home) EMS states she was down since 6am when EMS arrived her pupils were fixed and dilated. CPR in process when EMS arrived (to hospital). This hospital record had handwritten at the bottom, Talked with (name of person) at (name of ambulance service) stated EMS denied statement that she was down since 06:00 (6:00 AM)- 'Last well time was 06 (6:00 AM). V1's investigation also included a copy of R1's progress notes from [DATE]. There was no outcome or interventions documented in investigation. On [DATE] at 10:19 AM, V1 (Administrator) was asked via email if she had provided this surveyor with her full investigation and if there were any interventions implemented after her investigation. V1 responded, That was my investigation at that time. V1 stated she also called the manager at the ambulance service and discussed R1's transfer and asked him if they were other 911 ambulance services and the manager replied they were. V1 stated in the email she asked him if they were not available who should they call, and the manager named another local ambulance service, and she asked if that service was unavailable who should they call. V1 stated he said if they called 911 it would be another close town's ambulance if no one else was available. V1 stated she shared the information with the team and plans were made to review charts. V1 stated they completed that review on [DATE]. V1 stated V2 (DON) scheduled a meeting with the nurses on [DATE] to explain to call 911 for emergencies and to call the resident ambulance choice for non-emergencies. On [DATE] at 11:49 AM, V5 (ambulance dispatcher) stated they notify the facility 100% of the time if they don't have a crew available. V5 stated they tell them they need to call for mutual aid. V5 stated they have two other options in the town that would be immediate responses. When asked what the difference was for someone to call 911 versus calling the ambulance direct, V5 stated if someone calls 911 that call goes to the police department dispatch and then they tone out this ambulance service. V5 stated if this ambulance service doesn't have a crew available, they tone out the next ambulance service and if they don't have a crew available, they tone out the next ambulance service. On [DATE] at 9:49 AM, V24 (Nurse Practitioner) stated she remembered getting the call on [DATE] related to R1's symptoms and she told them to send her to the emergency room for evaluation and treatment. V24 stated she got the call in the early morning but didn't have the time documented anywhere. This surveyor reviewed R1's progress notes and the staff interviews with V24 including the time frames. V24 stated she wasn't aware of the delay in treatment. V24 stated even if V14 didn't think it was emergent when the symptoms first started, she should have quickly realized it was. V24 stated based on what she read in R1's record it was a significant bleed that appeared to be spontaneous. V24 stated based on that she couldn't say the outcome for R1 would have been different if she had received timely care. V24 stated R1's symptoms were emergent, and she would have expected the facility to call 911. On [DATE] at 9:03 AM, V18 (Cancer Specialist) stated R1 had pancreatic cancer and her cancer treatment was palliative in nature, to help prevent pain and discomfort. V18 stated R1 was on Xarelto and that could increase her risk of bleeding. When asked if R1 had received treatment quicker if the outcome could have been different V18 stated, with a GI bleed the quicker the treatment the better. V18 stated he couldn't guarantee it would have made a difference in the outcome. V18 stated she couldn't be off the Xarelto due to her diagnosis, and he couldn't judge if quicker treatment would have altered the outcome. V18 stated R1 would have been at risk for complications but would hope that being in the facility it would lessen the risks. According to https://www.mayoclinic.org/diseases-conditions/gastrointe [TRUNCATED]