Every finding on record at Saugus Center

Based on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for four Residents (#4, #5, #62 and #68) out of a total sample of 21 residents. Specifically: 1. For Resident #4 the facility failed to implement physician's orders to monitor and evaluate orthostatic blood pressures (orthostatic blood pressure is assessed to detect orthostatic hypotension, which is defined as a drop in systolic blood pressure of 20 mmHg (millimeters of mercury) or more or a stop in diastolic blood pressure of 10 mmHg or more within three minutes of standing from a supine position during a head-up tilt or at least 60 degrees. This drop can lead to symptoms such as dizziness, lightheadedness, fainting, headache, visual disturbances, and neck or shoulder discomfort due to inadequate blood flow to the brain and other organs) . 2. For Resident #5 the facility failed to implement physician's orders for vital signs twice daily. 3. For Resident #62, the facility failed to ensure that weekly weights were obtained per the physician order. 4. For Resident #68 the facility failed to ensure that nursing administered insulin based on a recent blood sugar (standard of care). Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1). Resident #4 was admitted to the facility in October 2024 with diagnoses that included schizophrenia, depression and adult failure to thrive. Review of the MDS dated [DATE] indicated a Brief Interview for Mental Status score of 9 out of 15. Review of Resident #4's active fall care plan indicated the following intervention, added 4/16/26: Orthostatic BP's (blood pressures) 2x a day for 3 days then re-evaluate. Review of Resident #4's physician orders indicated the following: Orthostatic BP's 2x daily post fall for 3 days then re-evaluate with PCP (primary care physician), dated 4/16/26. Review of the April Medication Administration Record (MAR) indicated that on 4/16/26, 4/17/26 and 4/18/26 orthostatic blood pressures were documented as obtained twice daily. Review of the vital signs tab in the medical record indicated the following: - The most recent blood pressure documented was from 4/15/26. - The most recent pulse documented was from 4/15/26. Review of progress notes failed to indicate that orthostatic blood pressures were assessed as per the care plan and physician's orders. During an interview on 4/22/26 at 2:18 P.M., Nurse #1 said that if orthostatic blood pressures were checked they would be documented in a progress note or in the vital signs tab of the electronic medical record. He said that Resident #4 had a recent fall and checking orthostatic blood pressures can help to determine the cause of the fall and determine if further medical intervention is required. He said that the care plan and physician orders should have been implemented. During an interview on 4/23/26 at 7:46 A.M., the Nursing Supervisor said that if something is not documented in the medical record then it is not done. The Nursing Supervisor reviewed the medical record and said that she could not find documentation that orthostatic blood pressures were completed. She said staff should be following and implementing the Resident's plan of care. During an interview on 4/23/26 at 10:13 A.M., the Director of Nurses said that the care plan and physician's orders should be implemented as indicated. She said that checking orthostatic blood pressures were a fall intervention that should have been completed. 2). Resident #5 was admitted to the facility in November 2020 with diagnoses that included dementia, adult failure to thrive and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/26, indicated a Brief Interview for Mental Status could not be completed, and the Resident was assessed by staff to exhibit severe cognitive impairment. The MDS failed to indicate that the Resident exhibited rejection of care. Review of physician's orders indicated the following: Check VS (vital signs) two times a day, dated 8/27/25. Review of April 2026 Medication Administration Record (MAR) indicated that twice daily vital signs were documented as obtained. Review of progress notes and vital signs tab in the electronic medical record (EMR) failed to indicate that vital signs were checked twice daily. Further review of the vital signs tab indicated that vital signs were last obtained as follows: -blood pressure: 2/11/26. -respirations: 2/11/26. -oxygen saturation: 2/11/26. -pulse: 2/11/26. -temperature 2/11/26. Further review of progress notes from 4/1/26 to 4/22/26 failed to indicate vital signs were obtained and failed to indicate that the Resident refused to have vital signs taken. During an interview on 4/22/26 at 10:19 A.M., Nurse Practitioner (NP) #1 said that she would expect that all physician's orders are implemented as indicated. During an interview on 4/22/26 at 2:14 P.M., Nurse #1 said that physician's orders should be implemented as written. He further said that nurses should not be signing off that orders are completed if they are not. He said that if any treatment is refused by the Resident, it should be documented in the medical record. During an interview on 4/23/26 at 7:38 A.M., the Nursing Supervisor said that nurses should be implementing physician's orders as indicated and should not be signing off orders that they are not completing. During an interview on 4/23/26 at 9:56 A.M., the Director of Nurses said that physician's orders should be implemented as indicated. She said that nurses should not be signing off that an order was completed if it was not. 3). Resident #62 was admitted to the facility in October 2021 with diagnoses including edema, essential primary hypertension, chronic kidney disease stage three, and anemia. Review of Resident #62's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief interview for Mental Status score of 13 out of 15 indicating intact cognition. Review of the physician's order dated 8/13/25, indicated the following order: - Weight Weekly on Weds (Wednesday) on 7-3 Shift, Unless Resident Refuses. Must Make Reattempts. One time a day every Wed. Review of the Treatment Administration Records (TAR) dated March and April 2026 indicated the following: 3/4/26: NA indicating Not Applicable. 3/11/26: Blank and contained no documentation. 3/18/26: NA indicating Not Applicable. 3/25/26: NA indicating Not Applicable. 4/1/26: NA indicating Not Applicable. 4/8/26: NA indicating Not Applicable. 4/22/26: 9 indicating Other / See Progress Note. Review of the order administration note indicated Resident spend all time in basement. Review of the progress notes dated 3/4/26, 3/11/26, 3/18/26, 3/25/26, 4/1/26, 4/8/26, and 4/22/26 failed to indicate that Resident #62 refused to be weighed. Review of the weights and vital tab in the electronic health record, indicated that on 2/18/26 and 4/10/26 facility staff obtained and documented Resident #62's weights. Further review indicated that there was no documentation to support that facility staff obtained Resident #62's order for weekly weight as ordered by the physician between 2/18/26 and 4/10/26 (six weeks). During an interview on 4/22/26 8:19 A.M., Certified Nursing Assistant (CNA) #3 said weights are obtained and given to the nurses to enter in the medical record and said if a resident refuses to be weighed she will notify the nurse. During an interview on 4/22/26 at 8:32 A.M., Nurse #5 said Resident #62 should have weights documented in the medical record and said the Resident has no documented refusals for weights. During an interview on 4/22/26 at 8:44 A.M., the Dietitian said she reviews the weights weekly and said Resident #62's weekly weights were not completed and said she notifies the nursing staff and Assistant Director of Nursing that weights needed to be obtained at the end of March and said she requested a reweigh on 4/1/26 and said it was not completed until 4/10/26. During an interview on 4/22/26 at 9:58 A.M., the Assistant Director of Nurses (ADON) said weights must be obtained as ordered and said he does not know why the weights were not obtained. The ADON said he was not aware of the weights not being obtained as ordered. During an interview on 4/22/26 at 10:13 A.M., the Director of Nurses said physician orders for weekly weights must be followed and said monthly weights are obtained between 1st and 7th of each month and no later than 10th. The DON said if a resident refuses to be weighed it must be documented in the medical record as refused and said the nursing supervisor must be notified to try and obtain the weight at another time. The DON said documenting NA is not a refusal and said if a resident refuses to be weighed a progress note must be documented. During an interview on 4/23/26 at 9:54 A.M., the Medical Director said he was not aware of Resident #62 not having a weight obtained during the month of March and said Nurses need to follow orders for weights, document any refusals in the medical record and notify the providers if weights are not obtained. 4). Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner, and as prescribed. -4. Medications are administered in accordance with prescriber orders, including and required time frames. -5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions. Review of the NOVOLOG manufacture's guidelines, dated March 2023, indicated the following: that adult patients start NovoLog, they must take their dose 5 to 10 minutes before eating. 2.3 Dosage Recommendations - Individualize the dosage of NOVOLOG based on the route of administration, the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. - Dosage adjustments may be needed with changes in physical activity, changes in meal patterns . Resident #68 was admitted to the facility in October 2022 with diagnoses including diabetes, glaucoma, and heart failure. Review of Resident #68's Minimum Data Set assessment, dated 4/16/26, indicated he/she had a moderate cognitive impairment as evidenced of a Brief Interview for Mental Status score of 11 out of a total possible 15. This MDS indicated Resident #68 received insulin injections 7 days, and hypoglycemic medications. Review of Resident #68's physician orders, dated 6/28/25, indicated: Check fingerstick 4x daily, before meals and at bedtime. Scheduled at 6:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of the meal delivery schedule indicated that meal trucks arrived on the unit at 7:45 A.M., 11:45 A.M., and 5:15 P.M. Review of Resident #68's physician's orders, dated 4/10/25, indicated: -NovoLOG Injection Solution 100 units per milliliter (Insulin Aspart) Inject as per sliding scale: if 0-150 = 0 units, 151-200= 2 units, 201-250= 5 units, 251-300= 8 units, 301-350= 12 units, and 351- greater than 400 call physician, subcutaneously four times a day for blood sugar monitoring/Notify physician if results less than 70. Review of Resident #68's blood glucose level in the electronic health record, dated 4/22/26 at 5:17 A.M., indicated a blood sugar of 195. On 4/22/26 at 8:28 A.M., the surveyor observed Nurse #1 prepare and administer Resident #68 two units of NovoLog insulin based on blood sugar of 195. Resident #68 had already eaten his/her breakfast. During an interview on 4/22/26 8:30 A.M., Nurse #1 said that the Night Nurse (11p-7a) obtains the blood sugars for the insulin administration, and he said he did not obtain a blood sugar for Resident #68 this morning. Nurse #1 reviewed the clinical record, and he said the blood sugar was from 5:17 A.M. (3 hours and 11 minutes prior). During an interview on 4/22/26 at 9:09 A.M., the Director of Nurses (DON) said that nurses should not be obtaining blood sugars three hours prior to administering the sliding scale insulin. The DON said that sliding scale insulin should be dosed based on a blood sugar that should be obtained 30 minutes prior to administering insulin. During an interview on 4/22/26 at 10:29 A.M., Nurse Practitioner (NP) #1 said that nursing should check Resident #68's blood sugars immediately before insulin administration. NP #1 said that getting a blood sugar three hours prior is not accurate and the Resident's blood sugar could have been higher or lower, and administering insulin based on a three-hour old value places the Resident at risk for hyperglycemia or hypoglycemia.

Based on observation, record review and interview, the facility failed to ensure referrals for outside services were implemented for three sampled Residents (#1, #33, and #2). Specifically:1.For Resident #1 the facility failed to ensure that Resident #1 attended a scheduled orthopedic appointment, and after the scheduled orthopedic appointment was missed the facility failed to reschedule the orthopedic appointment. 2. For Resident #33 the facility failed to set up an appointment with urology for a suprapubic (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow.) tube placement evaluation.3. For Resident #2 the facility failed to ensure a referral was replaced for neurology.Findings include: 1. Resident #1 was admitted to the facility in March 2026 with diagnoses including spinal stenosis, low back pain, pain in left leg, and difficulty walking. Review of the most recent Minimum Data Set assessment, dated 3/12/26, indicated Resident #1 was cognitively intact as evidenced of a Brief Interview for Mental Status score of 14 out of a possible 15. During an interview on 4/21/26 at 8:18 A.M., Resident #1 said that he/she was supposed to have an orthopedic appointment on 4/15/26 but he/she missed his/her appointment, and he/she didn't have any other appointments scheduled. Review of Resident #1's nursing note, dated 4/8/26, indicated: Resident #1 has an orthopedic appointment on 4/15/26 at 9:15 A.M. Review of the facility clinical communication dashboard, dated 4/8/26, indicated: Resident #1 Orthopedics appointment 4/15/26 at 9:00 A.M., please book transportation He/she needs his/her PT1 (insurance-based transportation) to be approved before booking. During an interview on 4/22/26 at 9:00 A.M., Nurse #1 said that he was aware that Resident #1 had an appointment for an orthopedic appointment and he placed the appointment on the clinical dashboard he said that it is the Receptionist's responsibility to book transportation. During an interview on 4/22/26 at 10:31 A.M., Nurse Practitioner #1 said she would want Resident #1 to attend his/her follow up orthopedic appointments. During an interview on 4/23/26 at 8:11 A.M., the Nursing Supervisor said she didn't recall Resident #1 missing an appointment, but she would look into it. During an interview on 4/23/26 at 8:12 A.M., the Administrator said that there were issues with booking transportation for appointments, and he said that the Receptionist was on leave and nobody had access to booking assessments. During a follow-up interview on 4/23/26 at 9:43 A.M., the Nursing Supervisor said that Resident #1 missed his/her orthopedic appointment on 4/15/26 and there was no follow up appointment booked. During an interview on 4/23/26 at 11:25 A.M., the Director of Nursing (DON) said she wasn't aware Resident had an orthopedic appointment. The DON said the facility process is for the nurse who obtains the order, puts the appointment on the dashboard, once on the dashboard Receptionist can see the appointment and book transport, and the overnight will complete the paperwork. 2. Resident #33 was admitted to the facility in February 2025 with diagnoses including heart failure, benign prostatic hyperplasia, diabetes, depression, and chronic pain. Review of the Minimum Data Set assessment, dated 2/12/26, indicated Resident #33 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of a possible 15. This MDS indicated Resident #33 required an indwelling catheter. During an interview on 4/21/26 at 7:44 A.M., Resident #33 said that he/she is supposed to see someone about getting a different type of catheter. Resident #33 said that he/she does not know why he/she had not seen anyone. Review of Resident #33's plan of care related to catheter, dated as revised 11/19/25, indicated that the resident will show no signs and symptoms of urinary infection through review date. Review of Resident #33's physician order, dated 3/14/26, indicated: Urology consult for SuperPubic [sic] Catheter need. Further review of the order indicated the order was transcribed by the Nurse Supervisor. During an interview on 4/22/26 at 10:26 A.M., Nurse Practitioner #1 said that based on the order written on 3/14/26, she would want the urology appointment booked. During an interview on 4/23/26 at 8:08 A.M., the Nurse Supervisor said the urology appointment was not booked yet. The Nurse Supervisor said that it would be the nurse who obtained the order to book the appointment and put the appointment on the clinical dashboard. During an interview on 4/23/26 at 11:12 A.M., the Director of Nursing (DON) said she wasn't aware of the appointment for suprapubic catheter referral with urology. The DON said nursing should have booked the appointment. 3. Resident #2 was admitted to the facility in December 2023 with diagnoses including peripheral vascular disease, dysphagia and muscle weakness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #2 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam. The MDS also indicated that Resident #2 has functional limitations in range of motion in his/her bilateral upper extremities. During an interview on 4/21/26 at 7:38 A.M., Resident #2 said that his/her fingers were contracted and it limited his/her mobility. Resident #2 said that he/she used to work with Occupational Therapy (OT) but they were not able to increase his/her range of motion. During an interview on 4/21/26 at 11:52 A.M., Certified Nurse Aide (CNA) #2 said that Resident #2's fingers have always been bent and contracted and he/she cannot move them. Review of Resident #2's active physicians orders indicated: - Patient should be seen by Neurology r/t (related to) Botox for bilateral contractures. 6/24/24-May refer to neurology for Botox due to b/l (bilateral) contractures. 6/27/24. During an interview on 4/22/26 at 8:01 A.M., Resident #2 said that he/she had not been offered a neurology appointment and would be interested in receiving Botox injections to help with his/her contractures. During an interview on 4/22/26 at 10:36 A.M., Nurse Practitioner #1 said that she was not aware of the current active orders for Resident #2 to be seen by neurology for Botox injections related to his/her contractures. Nurse Practitioner #1 said she would have expected staff to follow up and place the referral, and she would have approved of the referral. Nurse Practitioner #1 said that Botox is commonly used for contractures and it has the potential to decrease tone and improve range of motion. During an interview on 4/22/26 at 10:47 A.M., the Director of Rehab said that Resident #2 had worked with Occupational Therapy in the past, but they were not able to find a splint that would work form him/her. The Director of Rehab said that she thinks she heard something about Resident #2 going to neurology but wasn't sure if he/she had gone. The Director of Rehab said she was not aware of the active physician orders for Resident #2 to be seen for possible Botox injections for his/her contractures. The Rehab Director said that the goal of Botox is to help regain some movement and decrease tone for contractures. During interviews on 4/22/26 at 11:05 A.M., and 12:39 P.M., the Director of Nursing (DON) said she was unable to locate any evidence that Resident #2 was seen by neurology for Botox injections. The DON said that physician orders are reviewed monthly and someone should have picked up on the order and moved forward with the referral to neurology.

Based on observation, record review and interview, the facility failed to ensure medical records were accurate for five Residents (#3, #5, #55, #62 and #10) out of a total of 21 sampled Residents. Specifically,1. For Resident #3 the facility failed to ensure that advance directives were consistently and accurately documented throughout the medical record.2. For Resident #5 the facility failed to ensure that only medical information related to Resident #5 was in the medical record. Specifically, another resident's MOLST (Medical Orders for Life-Sustaining Treatment- a medical form that documents a patient's preferences for life-sustaining treatments and translates them into actionable medical orders signed by a licensed healthcare professional) form was located in his/her medical record.3. For Resident #55, the facility documented that treatment orders for warm compress to the Right Axilla were administered as ordered when they were not.4. For Resident #62, the facility documented that Covid precautions were in place as ordered when they were not.5. For Resident #10, the facility failed to ensure contradicting orders for nothing by mouth (NPO) and by mouth (PO) were documented in the active physician orders.Findings include:1. Resident #3 was admitted to the facility in [DATE] with diagnoses that included diabetes, depression and anemia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Further Review of the MDS indicated that the Resident is a full code. Review of physician orders indicated the following: Full code/CPR (cardiopulmonary resuscitation), dated [DATE]. Review of the active advance directives care plan indicated the following: [Resident] has an established advanced directive; he/she is a Full Code status, updated [DATE]. Review of paper record indicated a MOLST form indicating: - Do Not Resuscitate, Do Not Intubate, Use Non-invasive ventilation, Transfer to hospital, signed and dated by the Resident's health care proxy [DATE]. During an interview and record review on [DATE] at 2:06 P.M., Nurse #1 said that the orders in the electronic medical record do not reflect the orders on the MOLST form. Nurse #1 said that the MOLST, physician's orders and care plan should all be consistently documented throughout the medical record. During an interview and record review on [DATE] at 2:09 P.M., the Nursing Supervisor reviewed the medical record and said that the physician's orders, care plan and Resident's wishes as indicated on the MOLST form should be consistently documented in the medical record, but they were not. During an interview on [DATE] at 10:07 A.M., the Director of Nurses said that the Resident's wishes as indicated on the MOLST form should be consistently and accurately documented in the medical record in a physician's order and in the care plan. During a phone interview on [DATE] at 9:55 A.M., the Medical Director said that he would expect that medical records are accurate and a resident's advance directives are consistently documented in the medical record to avoid confusion in an emergency. 2. Resident #5 was admitted to the facility in [DATE] with diagnoses that included dementia, adult failure to thrive and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status could not be completed, and the Resident was assessed by staff to exhibit severe cognitive impairment. The MDS further indicated that the Resident is a full code. Review of physician orders indicated the following: Full code/CPR, dated [DATE]. Review of the Resident's active care plan indicated the following: Resident #5 has an established advanced directive: HCP in place, invoked. Has a Full Code, updated [DATE]. Review of the paper chart indicated a MOLST form indicating Do Not Resuscitate (DNR) and Do Not Intubate (DNI). Further review of the MOLST form in Resident #5's paper chart indicated that the MOLST form belonged to another resident in the facility. Further review of the electronic and paper record failed to indicate a MOLST form for Resident #5. During an interview on [DATE] at 1:59 P.M., Nurse #1 said that if a Resident is found without a pulse or not breathing, he would check the physician's order for code status and ask someone else to verify the order by checking for the MOLST form in the paper record. He said Resident #5 has an order to be a full code. He checked the paper record and found a MOLST form that indicated DNR/ DNI. The surveyor alerted Nurse #1 that the MOLST form belonged to another Resident. Nurse #1 said that another resident's MOLST form should not be in Resident #5's chart because in an emergency it could cause a problem. He further said only medical records pertaining to Resident #5 should be kept in his/her medical record. He said there is no MOLST for Resident #5 so he/she would default to a full code. During an interview on [DATE] at 2:09 P.M., The Nursing Supervisor reviewed Resident #5's medical record and said that another resident's MOLST form should not have been in another resident's chart. During an interview on [DATE] at 10:02 A.M., the Director of Nurses said that another residents' health information should not have been in Resident #5's medical record. During a phone interview on [DATE] at 9:55 A.M., the Medical Director said that another resident's MOLST form should not have been in Resident #5's medical record. He said in an emergency, staff may not realize that it does not belong to Resident #5. 3. Resident #55 was admitted to the facility in [DATE] with diagnoses including morbid severe obesity, acute diastolic congestive heart failure, interstitial pulmonary disease, and asthma. Review of Resident #55's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief interview for Mental Status score of 15 out of 15 indicating no cognitive impairment. Review of Resident #55's active physician orders indicated the following: Apply Warm compress to R (right) axilla (armpit) for 15-20 min every shift for swelling. Start Date: [DATE]. On [DATE] at 7:45 A.M., and 10:48 A.M., the surveyor observed Resident #55 sitting up in bed. The Resident did not have a warm compress applied to his/her right axilla area. On [DATE] at 10:45 A.M., the surveyor observed Resident #55 sitting up in bed. The Resident did not have a warm compress applied to his/her right axilla area. During an interview on [DATE] at 12:48 P.M., Resident #55 said he/she has not used the warm compress to the area in weeks and said, that swelling was gone weeks ago when I was first admitted . The surveyor observed Resident #55's right armpit area and no swelling or warm compress was observed. During an interview on [DATE] at 8:412 A.M., Nurse #5 said Resident #55 does not have any swelling to his or her right arm and that he/she has not needed warm compresses. Nurse #5 said Nurses should not document that the warm compress is in place when it is not being used. During a telephone interview on [DATE] 9:57 A.M., the Medical Director said if the resident no longer needs the warm compress treatment, then nurses should not be documenting they are applying the warm compress when they are not and said he would expect the nurses to contact the providers to discontinue the order. During an interview on [DATE] at 1:11 P.M., the Director of Nursing (DON) said the nurses should not be documenting that the warm compress is being applied to the right armpit if it is not and said the physicians order should be discontinued if no longer needed. The DON said nurses should document treatments that are completed in the medical record and contact the provider if the resident no longer needs a treatment. 4. Resident #62 was admitted to the facility in [DATE] with diagnoses including essential primary hypertension, chronic kidney disease stage three and Parkinson's disease. Review of Resident #62's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief interview for Mental Status score of 13 out of 15 indicating no cognitive impairment. On [DATE] at 7:55 A.M., and 10:32 A.M., the surveyor observed Resident #62's room. There was no precaution sign or personal protective equipment located outside of Resident #62's room. The surveyor observed a staff member walking into Resident #62's room without wearing PPE. On [DATE] at 8:19 A.M., the surveyor observed Resident #62's room. There was no precaution sign or personal protective equipment (PPE) located outside of Resident #62's room. Review of Resident #62's active physician orders indicated the following: Covid precaution in place every shift three times a day. Start Date:[DATE]. Review of the Medication Administration Record dated [DATE] indicated that the nurse documented Covid precautions in place per the physician order on [DATE], [DATE] and [DATE]. During an interview on [DATE] at 8:23 A.M., Certified Nursing Assistant (CNA) #3 said Resident #62 does not have Covid and is not on precautions. CNA #3 said if the Resident was on precautions a precaution sign would be posted on the door and a cart with PPE would be outside the door. During an interview on [DATE] at 8:29 A.M., Nurse #5 said Resident #62 he is not sure why there is an order for Covid precautions and said the Resident does not have Covid. Nurse #5 said nurses should not document Covid precautions are in place when they are not. On [DATE] at 11:23 A.M., the surveyor observed Resident #62's room. There was no precaution sign or personal protective equipment located outside of Resident #62's room. Staff were observed walking in and out of the room without wearing PPE. During an interview on [DATE] at 12:39 P.M., the Assistant Director of Nurses said Resident #62 should not have an active order in place for Covid precautions and said the Resident does not have Covid and is not on precautions. The ADON said staff should not be signing off he/she is on precautions when the Resident is not on precautions. During an interview on [DATE] at 1:25 P.M., the Director of Nursing (DON) said the nurses should not be signing off that Resident #62 is on Covid precautions when he/she is not on precautions for Covid. The DON said she does not know why an order for Covid precautions is in place because the Resident has not tested positive for Covid. 5. Resident #10 was admitted to the facility in [DATE] with diagnoses including dysphagia, and epilepsy. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #10 is moderately cognitively impaired evidenced by a score of nine out of a possible 15 on the Brief Interview for Mental Status exam (BIMS). The MDS also indicated that Resident #10 receives nutrition through a feeding tube. During an interview on [DATE] at 12:13 P.M., Resident #10 said that he/she receives all his/her nutrition through a feeding tube and he/she cannot have anything by mouth. Review of Resident #10's physician orders indicated: - NPO (nothing by mouth): initiated [DATE] - Encourage PO (by mouth) fluids; initiated, [DATE] During an interview on [DATE] at 1:35 P.M., Nurse #2 said that Resident #10 cannot have anything by mouth. During an interview on [DATE] at 1:40 P.M. Certified Nurse Aide (CNA) #1 said that Resident #10 is NPO and cannot have anything to eat or drink. During an [DATE] at 2:07 P.M., the Director of Nursing said that if someone is NPO they should not have orders to encourage fluids by mouth.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically,1. The facility failed to establish an infection prevention and control program that includes a system for appropriate infection surveillance.2. For one Resident (#10) out of a total sample of 21 residents, the facility failed to implement Enhanced Barrier Precautions (EBP) during the administration of a tube feed. Findings include: Review of the facility assessment, dated 4/23/26, indicated the following: -Infection Prevention and Control: identification and containment of infections, prevention of infections. -Infection Control- Infection Prevention and Control Program. The facility must establish an infection prevention and control program that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon the facility assessment and following accepted national standards. 1. On 4/22/26 at 9:12 A.M., the surveyor requested to review the facility's line listings from the Director of Nurses. On 4/22/26 at 2:00 P.M., the Director of Nurse provided an Order Listing Report, dated 4/22/26 at 1:35 P.M. to the surveyor indicating the physician's orders for residents in the facility currently receiving antibiotic medications. The report contained only the physician's order for antibiotics and no symptom tracking or diagnostic testing completed to determine infections. On 4/23/26 at 10:25 A.M., the surveyor again requested line lists used for tracking infections and antibiotic use in the facility from the Director of Nurses. During an interview on 4/23/26 at 12:30 P.M., the Director of Nurses said that the Order Listing Report was not a line list. She said she is working on obtaining line lists from the Nursing Supervisor who maintains them. She said the line lists get submitted to the Department of Public Health and then disappear. She said copies of line lists should be maintained in the facility for trending and tracking purposes. On 4/23/26 at 1:00 P.M., the Director of Nurses provided another list to the surveyor that was undated, included a list of four antibiotics listed, but failed to indicate order dates, symptoms, specific residents, or any diagnostic testing. During an interview on 4/23/26 at 2:41 P.M., the Assistant Director of Nurses reviewed the Order Listing Report, and second list provided to the surveyor and said that it is not a sufficient line listing. He said that line lists should indicate resident, symptoms, diagnostic testing, dates of treatment and what the antibiotic is for. He said that these lists did not indicate that. During an interview on 4/23/26 at 3:15 P.M., the Director of Nurses said that she has no further line listings to provide to the surveyor. She said that she cannot locate any tracking or oversite for infection control in the facility. She said that she thought the Nursing Supervisor was keeping the line lists, but they could not be found. She said the entire infection control program needs a revamp at the facility. During a phone interview on 4/24/26 at 9:55 A.M., the Medical Director said that he would expect that the facility tracks and trends infections within the facility with line listings. 2. Review of the Centers for Disease Control Guidelines article titled Application of Enhanced Barrier Precautions indicated: Assuming Contact Precautions do not otherwise apply, Enhanced Barrier Precautions are recommended for residents with any of the following: 1) infection or colonization with a MDRO (Multidrug Resistant Organism), 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Resident #10 was admitted to the facility in January 2018 with diagnoses including dysphagia, and epilepsy. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #10 is moderately cognitively impaired evidenced by a score of nine out of a possible 15 on the Brief Interview for Mental Status exam (BIMS). The MDS also indicated that Resident #10 receives nutrition through a feeding tube. During an interview on 4/22/26 at 12:13 P.M., Resident #10 said that he/she receives all his/her nutrition through a feeding tube and he/she cannot have anything by mouth. Review of Resident #10's physician orders indicated: Enhanced barrier precautions for direct contact with care as per CDC guideline's, initiated 3/31/26. On 4/22/2026 at 1:30 P.M., Nurse #2 was observed wearing gloves without a gown while administering a feeding via Resident #10's enteral feeding tube. Nurse #2 said she should be wearing a gown. During an interview on 4/22/26 at 2:07 P.M., the Director of Nursing said Nurse #2 should have worn a gown while administering Resident #10's feed as he/she is on enhanced barrier precautions.

Based on observation, record review, and interview, the facility failed to ensure staff treated residents with dignity and respect for three Residents (#55, #14 and #16) out of a total of 21 sampled Residents. Specifically, the facility failed to ensure the Nurse Supervisor: 1. spoke appropriately about Resident #55 in a public setting, 2. responded appropriately to Resident #14's concerns, and 3. spoke appropriately about Resident #16 in a public setting. Findings include: Review of the facility policy titled Dignity, dated February 2021, indicated: 1. Residents are treated with dignity and respect at all times.10. Staff protect confidential clinical information. Examples include the following: B. A verbal staff to staff communication are conducted outside the hearing range or residents and the public.13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: A. addressing the underlying motives or root causes for behavior; and B. not challenging or contradicting the resident's beliefs or statements. 1. Resident #55 was admitted to the facility in January 2026 with diagnosis including arthritis and Sjogren syndrome. Review of the Minimum Data Set Assessment (MDS) assessment, dated 4/16/26, indicated Resident #55 is cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. During an interview on 4/22/26 at 6:58 A.M., the surveyor was inquiring about background information on Resident #55. The Nurse Supervisor said Resident #55 is a big problem and rolled her eyes while standing at the nurse's station. Staff members and other residents were also in the area and could have overheard the Nurse Supervisor's comments regarding Resident #55. During an interview on 4/23/26 at 12:21 P.M., the Director of Nursing said that the Nurse Supervisor should not be making comments about residents in that manner, especially in a public area. 2. Resident #14 was admitted to the facility in December 2024 with diagnoses including Parkinsons disease, dementia and anxiety disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #14 is severely cognitively impaired evidenced by a score of five out of a possible 15. On 4/22/26 at 8:30 A.M., Resident #14 was approaching the second-floor nursing station in his/her wheelchair stating he/she wanted to call his/her mother. Resident #14 appeared anxious and worried and said that he/she had not spoken to his/her mother in weeks. The Nurse Supervisor approached the Resident and sighed loudly and said, We've been over this, we've talked about this remember? We had this conversation. Your [spouse] controls this. We've sat down and talked about it. Resident #14 continued to be anxious about contacting his/her mother. On 4/22/26 at approximately 8:40 A.M., Resident #14 was seated in his/her wheelchair asking to call his/her mother. The Administrator approached and told Resident #14 that he would find out the information for him/her and Resident #14 appeared to be at ease after speaking with the Administrator. During an interview on 4/22/26 at approximately 2:10 P.M., the Director of Nursing said that the Nurse Supervisor should have responded to Resident #14 in a supportive manner. 3. Resident #16 was admitted to the facility in March 2020 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder and major depressive disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she has moderate cognitive impairment as evidenced by a score of 12 out of a possible 15 on the BIMS. On 4/23/26 at 9:49 A.M., the surveyor inquired about Resident #16 with the Nurse Supervisor in front of the first-floor nursing station. The Nurse Supervisor said she would have to follow up with the Resident and said He/she is nasty! He/she swears at people. When asked if Resident #14 swears at everyone, the Nure Supervisor said, A lot of people yes. The last time I tried to talk to him/her it wasn't pleasant. The last time I talked to him/her it didn't go well. There were staff and residents in the hallways of the unit who could have heard the Nurse Supervisors comments. During an interview on 4/23/26 at 12:21 P.M., the Director of Nursing said that the Nurse Supervisor should not speak about residents that way, especially in a public area.

Based on record reviews and interviews, the facility failed to ensure one Resident (#12) was free from unnecessary psychotropic medications by ensuring a stop date was included in the physician's order for an as needed (PRN) dose of Ativan (medication used to treat anxiety) out of a total sample of 21 residents. Findings include:Review of the facility policy titled Antipsychotic Medication Use, undated, indicated the following:-The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Resident #12 was admitted to the facility in October 2024 with diagnoses that included Alzheimer's disease, dysphagia, conversion disorder, major depressive disorder and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 2/26/26, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. The MDS further indicated the use of antianxiety medications. Review of physician orders indicated the following: Ativan Oral Tablet 0.5 milligrams (mg) (Lorazepam), give one tablet by mouth as needed every 4 hours for anxiety, dated 2/24/26. Further review of physician's orders failed to indicate a stop date for the as needed dose of Ativan. Review of the March 2026 Medication Administration Record (MAR) indicated that the Resident received an as needed dose of Ativan on 3/16/26. Review of the April 2026 MAR indicated that the Resident received a dose of Ativan on 4/12/26 and 4/15/26. During an interview on 4/22/26 at 10:22 A.M., Nurse Practitioner #1 said that all as needed orders for psychotropic medications require a stop date and a reevaluation by a practitioner for continued use. She said after the initial 14-day use, if extended, the order still requires a stop and reevaluation date. During an interview on 4/22/26 at 2:22 P.M., Nurse #1 said that as needed psychotropic medications should have an initial 14 day stop date then providers will evaluate the use and they can extend it. Nurse #1 said that if extended beyond the initial 14 days of use, it is still required to have a stop and reevaluation date. During an interview on 4/23/26 at 10:18 A.M., the Director of Nurses said that an as needed dose of Ativan requires a stop date. During a phone interview on 4/24/26 at 9:55 A.M., the Medical Director said that all as needed psychotropic medications require a stop date and a reevaluation for continued use by a provider.

Based on observation, record review and interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#7) out of a total sample of 21 residents, after each assessment. Specifically, the facility failed to review and revise the care plan (eating status) after a quarterly assessment was completed to reflect the current status of the Resident. Findings include:Resident #7 was admitted to the facility in June 2018 with diagnoses that included type 2 diabetes mellitus, muscle weakness, post-traumatic stress disorder and obstructive sleep apnea. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/19/26, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderate cognitive impairment. The MDS further indicated that the Resident required set up or clean up assistance for meals. Review of the active activities of daily living (ADL) care plan indicated an intervention that indicated: Eating: Continual Supervision with tray set up and please assist him/her as needed when fatigued or behavioral, dated 7/19/23. Review of the most recent speech therapy (ST) discharge note, dated 11/2/25, indicated that Resident is safe to eat independently with a pureed diet. The discharge summary failed to indicate the need for or recommendation for assistance or supervision with meals. During an interview on 4/22/26 at 12:07 P.M., the Director of Rehab said that Resident #7 is able to eat independently after set-up of his/her tray. She said that therapy reports any changes in resident status to nursing staff. She said the current care plan does not accurately reflect the Resident's status. During an interview on 4/22/26 at 2:21 P.M., Nurse #1 said that the active care plan should reflect the current status of the resident. He said that if a resident has a change in status, whether it is an improvement or a decline, therapy communicates it with the staff so that the care plan can get updated. During an interview on 4/23/26 at 7:53 A.M., The Nursing Supervisor said that after an MDS or assessment is completed usually the MDS nurse would update the care plan. She said she was not sure who the MDS nurse was in the facility. She further said that the care plan should reflect the current status of the resident. During an interview on 4/23/26 at 10:14 A.M., the Director of Nurses said that the MDS nurse should review and update the care plan after each assessment to ensure that it is accurate and reflects the current status of the resident. During a phone interview on 4/23/26 at 11:52 A.M., the MDS nurse said that after quarterly meetings and assessments the plan of care should be updated. She said the team meets collaboratively and usually therapy updated the ADL care plan. She said that the care plan should reflect the current status of the Resident.

Based on observations, record reviews, and interviews, the facility failed to ensure the environment remained free of accidental hazards and was safe for one Resident (#67), out of a total sample of 21 residents. Specifically, for Resident #67, the facility failed to ensure that nursing consistently implemented Resident #67's plan of care related to smoking. Findings include: Review of the facility policy and procedures titled, Smoking Policy - Residents, dated as revised July 2017, indicated the facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or nonsmoking preferences.2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building.6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include:a. Current level of tobacco consumption;b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.);c. Desire to quit smoking, if a current smoker; andd. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited 13. Residents are not permitted to give smoking articles to other residents. 14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. Resident #67 admitted to the facility in February 2026 with diagnoses including osteomyelitis, schizophrenia, post-traumatic stress disorder, and contractures of the left and right hand. Review of Resident #67's Minimum Data Set Assessment, dated 2/13/26, indicated he/she had a memory problem, and was assessed as being moderately impaired for cognitive skills for daily decision making. On 4/21/26 at 6:56 A.M., the surveyors observed Resident #67 outside independently smoking a cigarette with another Resident. There were no staff outside the building providing supervision. Resident #67 was smoking a cigarette and there was approximately one inch of ash at the end of the cigarette. During an interview on 4/21/26 at 7:36 A.M., Resident #67 said that he/she can smoke whenever he/she wants and he/she has his/her cigarettes on him/herself. Resident #67 said he/she needs help lighting a cigarette. The surveyor observed ash on Resident #67's shirt. Review of Resident #67's care plan related to tobacco use, indicated that Resident #67 will adhere to the tobacco/smoking policies of the facility, including the following individualized interventions: - Resident requires supervision while smoking, initiated 3/9/26- Instruct Resident not to keep lighters and cigarettes in room, along with not smoking in room, initiated on 3/9/26. - Recommend use of apron when smoking for safety, created 4/15/26. On 4/21/26 at 8:58 A.M., the surveyor observed Resident #67 self-propelling in an electric wheelchair down the hallway from his/her room. Resident #67 had one cigarette and one lighter on his/her lap. Resident #67 did not have any staff supervision. On 4/21/26 at 4:01 P.M., the surveyor while exiting the facility with the Administrator observed Resident #67 outside smoking a cigarette unattended by staff and the Administrator said, you know you're not supposed to smoke on this side of the patio. Review of Resident #67's assessment titled N Adv - Smoking and Safety dated 4/22/26, indicated: Smoking status: Resident uses tobacco products. - Resident has limited or no range of motion in arms or hands.- Resident has burned skin, clothing, furniture, or other.- Resident drops ashes on self. - Resident unable to light tobacco or other smoking products safely. During an interview on 4/22/26 at 6:17 A.M., Nurse #4 said she just completed a smoking assessment for Resident #67 because there wasn't one done during admission. Nurse #4 said that Resident #67 can smoke by himself/herself and needs help lighting the cigarette. On 4/23/26 at 6:28 A.M., the surveyor observed Resident #67 outside smoking unattended, the surveyor observed Resident #67 sharing a cigarette with another Resident. During an interview on 4/22/26 at 10:51 A.M., the Director of Rehabilitation (DOR, Occupational Therapist) said that Resident #67 is supposed to wear a smoking apron while smoking but he/she doesn't want to wear the apron and the DOR said that staff should supervise him/her. The DOR said Resident #67 needs help lighting his/her cigarette. During an interview on 4/23/26 at 7:33 A.M., the Director of Nursing (DON) said smoking assessments and smoking agreements need to be completed on all new admissions. The surveyor was unable to locate these documents in the electronic health record or the paper medical record. The DON said she would look for them. During a follow up interview on 4/23/26 at 11:08 A.M., the DON said she was unable to find an initial smoking assessment and a smoking agreement. The DON said Resident #67 needs someone to light his/her cigarette and should wear a smoking apron, but he/she will not wear it. The DON reviewed the smoking care plan and said that it should be followed, and the DON said Resident #67 makes poor choices.

Based on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of a urinary catheter for one Resident (#33) out of a total sample of 21 residents. Specifically, for Resident #33 the facility failed to change a urinary drainage bag and failed to document urinary output as ordered by the physician.Findings include: Review of the facility policy titled, Catheter Care, Urinary, dated as revised September 2014, indicated the purpose of this procedure is to prevent catheter-associated urinary tract infections. 2. Maintain an accurate record of the resident's daily output.Resident #33 admitted to the facility in February 2025 with diagnoses including heart failure, gastroesophageal reflux disease, benign prostatic hyperplasia (BPH), diabetes, depression, and chronic pain.Review of the Minimum Data Set assessment, dated 2/12/26, indicated Resident #33 was cognitively intact as evidenced by a Brief Interview of Mental Status score of 14 out of a possible 15. This MDS indicated Resident #33 required an indwelling catheter. Review of Resident #33's plan of care related to catheter, dated as revised 11/19/25, indicated that the Resident will show no signs and symptoms of urinary infection through review date, the care plan indicated the following intervention: Monitor/record/report to physician for signs and symptoms urinary tract infection (UTI): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Review of Resident #33's physician orders, included: - Foley catheter: change catheter down drain bag weekly, one time a day every Thursday for BPH, dated 2/27/25. [sic]- Record foley output every shift, every shift for BPH, dated 6/25/25.Review of the Treatment Administration Record (TAR), dated 4/16/26 and 4/23/26, indicated nursing changed Resident #33's urinary drainage bag. Review of the TAR, dated April 2026, indicated nursing documented they recorded the foley output every shift but there was no documentation to support the values of the urinary output in the electronic health record.Review of Resident #33's Nurse Practitioner note, dated 3/13/26, indicated the following:Assessment and Plan: 8. Chronic urinary retention with Foley catheter- Maintain Foley catheter careReview of the nursing note, dated 4/15/26, indicated: Returned from hospital via stretcher at 4:00 A.M. No new orders. Catheter changed in hospital. Review of the nursing note, dated 4/19/26, indicated: Received a call form hospital, follow up on patient recent visit. This writer was informed that patient has urinalysis and its was positive for UTI. Order for antibiotic for 10 days. The hospital will fax the script to pharmacy. [sic] On 4/21/26 at 7:42 A.M., the surveyor observed Resident #33 in bed, there was a urinary drainage bag attached to electric wheelchair. The bag was a urometer style drainage bag (urometer is a specialized urine collection system with a built-in measurement chamber for accurate monitoring of urine output. It is widely used in critical care, and post-surgical patients where precise urine measurement is essential. The device combines a urine collection bag and a calibrated measuring chamber, ensuring both storage and accurate output recording) and the urinary drainage bag tubing was affixed with to the catheter with a red securement seal. During an interview on 4/22/26 at 10:25 A.M., Nurse Practitioner #1 said that Resident #33 receives a diuretic medication for his/her heart failure, and it is important for nursing staff to document the Resident's urinary output. On 4/23/26 at 9:34 A.M., the surveyor observed with Nurse #3 Resident #33's a urometer urinary drainage bag. Nurse #3 said that facility does not have that style drainage bag. Nurse #3 said that both nurses and Certified Nursing Assistants empty urine output and she said she sometimes documents it in her nursing note and there are not paper records of urinary output. During an interview on 4/23/26 at 10:00 A.M., Resident #33 said that nobody has changed his/her urinary drainage bag since he/she returned from the hospital. During an interview on 4/23/26 at 11:14 A.M., the Director of Nursing (DON) said catheter drainage bags are changed based on the physician's order to ensure that urinary sedimentation is not built up in the bags. The DON said that nursing should be documenting urinary out in the medical record since Resident #33 has congestive heart failure. On 4/23/26 at 11:37 A.M., the surveyor and the DON observed Resident #33's urometer style drainage bag and the tubing was affixed to the catheter with a red securement seal. The DON said that the facility does not carry that type of bag and the bag was still affixed to the catheter the way they are done in the hospital. The DON said there was no way that the bag was changed this morning on the 11-7 shift. On 4/23/26 at 5:15 P.M., and on 4/24/26 at 9:55 A.M., the surveyor made outreach to Nurse #4 (nurse who documented the drainage bag was changed on 4/23/26) but Nurse #4 was unavailable for interview.

Based on observations, record review, and interviews, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#33) out of sample of 21 residents. Specifically, for Resident #33, the facility failed to have a physician's order for oxygen administration and failed to maintain Resident #33's oxygen level in accordance with the plan of care. Findings include: Review of the facility policy titled, Oxygen Administration, dated as revised October 2010, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure.2. Review the resident's care plan to assess for any special needs of the residents. Resident #33 was admitted to the facility in February 2025 with diagnoses including chronic obstructive pulmonary disease (COPD), asthma, sleep apnea, and heart failure. Review of the Minimum Data Set assessment, dated 2/12/26, indicated Resident #33 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of a possible 15. This MDS indicated Resident #33 received oxygen administration. Review of Resident #33's physician orders, dated 7/8/25, indicated: oxygen via nasal cannula skin check and concentrator functioning: check for skin integrity and the nasal site and oxygen concentrator functioning every shift and as needed. Further review of the physician order failed to include a flow rate. Review of Resident #33's plan of care related to oxygen therapy, dated 3/4/25, indicated: Administer oxygen at 2 liters per minute (LPM) to maintain oxygen level 89%-90%. Review of Resident #33's weights and vitals tab in the electronic health record indicated that nursing documented an oxygen saturation greater than 90% 42 times between 4/1/26 through 4/23/26. During an interview on 4/21/26 at 7:44 A.M., Resident #33 said he/she always wears oxygen. The surveyor observed the flow rate at 2 liters per minute. On 4/21/26 at 9:54 A.M., 4/21/26 at 3:39 P.M., 4/22/26 at 3:03 A.M., 4/22/26 9:04 AM and on 4/23/26 at 6:45 A.M., the surveyor observed Resident #33 being administered oxygen at 2 LPM. During an interview on 4/22/26 at 6:29 A.M., Nurse # 4 said that oxygen is based on physician's orders and the results are documented in the treatment administration record. Nurse #4 said that there are orders for a flow rate for oxygen administration so that you don't dry out the person. During an interview on 4/22/26 at 10:23 A.M., Nurse Practitioner #1 said that Resident #33 has COPD and his/her goal range for oxygen level is 88-89% at night. The NP said that there should be a flow rate as part of the order. NP #1 said that Resident #33 is a chronic CO2 retainer (is a person whose lungs do not effectively remove carbon dioxide, leading to elevated CO2 levels in the blood, a condition known as hypercapnia). NP #1 said too much oxygen administration can raise the CO2 in the blood. During an interview on 4/23/26 at 11:21 A.M., the Director of Nursing (DON) said that all orders for oxygen administration require an oxygen flow rate. The DON said the care plan for oxygen administration should be followed as written or revised if inaccurate.

Based on record review and interview the facility failed to ensure for one Resident (#3), out of five applicable residents, out of a total sample of 21 residents, that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician/nurse practitioner response to the recommendations. Findings include: Resident #3 was admitted to the facility in December 2023 with diagnoses that included anxiety disorder, diabetes, hyperlipidemia and depression. Review of the Minimum Data Set (MDS) assessment, dated 2/19/26, indicated a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Review of the clinical progress note, dated 4/2/26, indicated: Medication Regimen Reviewed. Recommendations Made to Prescriber: See Medication Regime Review Report. [sic] Review of the medical record failed to indicate a Medication Regime Review Report. On 4/22/26 at 1:00 P.M., the surveyor requested a copy of the Medication Regime Review Report. Review of the Drug Regimen Review, dated 4/2/26, indicated the following:-Currently receiving Levothyroxine, Unable to locate recent TSH (Thyroid stimulating hormone, a blood test) in chart. Recommend 6-8 weeks after starting, then annually. Please consider ordering.-Currently receiving Atorvastatin (lipitor) 80 mg (milligrams) daily for dyslipidemia. Most recent lipid profile noted as well within normal limits. Please evaluate continued need, consider taper to 40 mg once daily and follow up lipid profile in 3 months. Review of the medical record indicated the following orders:-Lab: Repeat Lipid profile in 3 months July 21, 2026, dated 4/23/26.-Atorvastatin Calcium Oral Tabley 40 mg once tablet by mouth once daily for hyperlipidemia, dated 4/23/26.-Lab: May do TSH level next scheduled lab day then annually, dated 4/23/26. Review of the medical record indicated that the recommendations from the pharmacist were not implemented until the surveyor requested the Drug Regimen Review from the facility on 4/22/26; approximately 20 days later after the recommendation was made. During an interview on 4/23/26 at 7:27 A.M., Nurse #2 said that monthly pharmacy recommendations are sent to the Director of Nurses and she forwards them onto the Nurse Practitioners for review and approval. Nurse #2 said that if orders need to be entered into the Resident's medical record, sometimes the nurses will be asked to do that, but in general the nurses on the floor do not play a big role in the process. During an interview on 4/23/26 at 10:10 A.M., the Director of Nurses (DON) said that she is the one who receives the Monthly Medication reviews from the pharmacist and she reviews and addresses them with the providers as needed. The DON said the recommendations should be addressed within five days. She said that the 4/2/26 monthly review for Resident #3 was not addressed until today (22 days after the initial recommendation was made) with the physician when she saw that it had not been addressed yet. The DON said they are working in the facility on improving the process.

Based on observations, interviews, and record reviews for two Residents (#68 and #38) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of three nurses observed made two errors out of 28 opportunities resulting in a medication error rate of 7.14%. Specifically,1. For Resident #68 the facility failed to ensure Nurse #1 primed an insulin pen prior to administering the medication resulting in the incorrect dose. 2. For Resident #38 the facility failed to ensure Nurse #2 administered the correct dose of cholecalciferol (vitamin d). Findings include:Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including and required time frames. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors include:a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions. 1. Review of the glargine pen manufacture's guidelines, dated August 2022, indicated to always perform the safety test before each injection.STEP 3. PERFORM A SAFETY TEST - Dial a test dose of 2 Units (priming the pen).- Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. - Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.- If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. On 4/22/26 at 8:18 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #68 including glargine insulin (long-acting insulin). Nurse #1 did not prime the pen prior to administering the dose of glargine insulin resulting in the incorrect dose. Review of Resident #68's physician order, dated 12/11/24, indicated: Insulin Glargine Solution 100 units per milliliter, inject 30 units subcutaneously one time a day for diabetes. During an interview on 4/22/26 8:21 AM Nurse #1 said that he does not need to prime the glargine insulin pen because there is no air in the pen. During an interview on 4/22/26 at 9:07 A.M., the Director of Nursing (DON) said Nurse #1 should have primed the glargine insulin pen prior to administration to ensure the correct dose of the medication was given. During an interview on 4/22/26 10:28 A.M., Nurse Practitioner (NP) #1 said that Nurse #1 should prime the insulin pen prior to administration to ensure the correct dose of the medication is administered. NP #1 said that incorrect insulin administration can result in uncontrolled blood sugars. 2. On 4/22/26 at 8:31 A.M., the surveyor observed Nurse #2 prepare and administer Resident #38's medications, including vitamin d 400 international units (iu). Review of Resident #38's physician order, dated 4/16/25, indicated: cholecalciferol (vitamin d) tablet 1000 unit, give 1 tablet by mouth one time a day for bones. During an interview on 4/22/26 at 8:34 A.M., Nurse #2 said she was not aware she administered Resident #38 the incorrect dose of vitamin d. Nurse #2 opened up the medication cart, and she said that she had different doses of vitamin d in the medication cart and she administered the incorrect dose of vitamin d. During an interview on 4/22/26 at 9:06 A.M., the DON said that Nurse #2 should have administered the correct dose of vitamin d. During an interview on 4/22/26 at 10:27 A.M., Nurse Practitioner #1 said that nursing should administer Resident #38 the correct dose of vitamin d.

Based on observation, interviews, and record review, the facility failed to ensure one Residents (#68) was free from a significant medication error, out of a total sample of 21 residents. Specifically, for Resident #68, the facility failed to ensure insulin (an injectable hormone that lowers the level sugar in the blood) was administered in accordance with professional standards of practice (did not perform a safety test/ prime the insulin pen) resulting in Resident #68 not getting an incorrect dose of insulin. Findings include: Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including and required time frames. Review of the glargine pen manufacture's guidelines, dated August 2022, indicated to always perform the safety test before each injection.STEP 3. PERFORM A SAFETY TEST - Dial a test dose of 2 Units (priming the pen).- Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. - Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.- If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Resident #68 admitted to the facility in October 2022 with diagnoses including diabetes, glaucoma, and heart failure. Review of Resident #68's Minimum Data Set assessment, dated 4/16/26, indicated he/she had a moderate cognitive impairment as evidenced of a Brief Interview of Mental Status score of 11 out of a total possible 15. This MDS indicated Resident #68 received insulin injections 7 days and received hypoglycemic medications. On 4/22/26 at 8:18 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #68 including glargine insulin (long-acting insulin). Nurse #1 did not prime the pen prior to administering the dose of glargine insulin resulting in the incorrect dose. Review of Resident #68's physician order, dated 12/11/24, indicated: Insulin Glargine Solution 100 units per milliliter, inject 30 units subcutaneously one time a day for diabetes. During an interview on 4/22/26 8:21 AM Nurse #1 said that he does not need to prime the glargine insulin pen, because there is no air in the pen. During an interview on 4/22/26 at 10:28 A.M., Nurse Practitioner #1 said that Nurse #1 should have primed the insulin pen to ensure Resident #68 received the correct dose of insulin to prevent a medication error. During an interview on 4/23/26 at 11:27 A.M., the Director of Nursing said that Nurse #1 should have primed the insulin pen to prevent the medication error. During a phone interview on 4/24/26 at 9:55 A.M., the Medical Director said that he would expect that the correct dosing of medications are administered. He further said that he would expect the proper use of an insulin pen to ensure that the Resident is receiving the proper dose.

Based on observations and interview the facility failed to store drugs and biologicals in accordance with currently accepted professional principles on one of two units. Specifically,The facility failed to ensure unattended medication carts were locked on one of two units.The facility failed to ensure over the counter medications were not left out and unsecured at the nurse's station accessible to residents. Findings include:Review of facility policy titled Storage of Medications, undated, indicated the following:-The facility stores all drugs and biologicals in a safe, secure and orderly manner.-Drugs and Biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.-Compartments containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 1. On 4/21/26 at 8:29 A.M., the surveyor observed a medication cart unlocked and unsupervised on the second-floor unit, low end of hallway. There were residents ambulating in the hallway and the surveyor was able to gain access to the medication cart. During an interview on 4/21/26 at 8:30 A.M., Nurse #5 said the medication cart should be locked when it was unattended. 2. On 4/21/26 at 9:23 A.M., the surveyor observed unsecured medications at the second-floor nurse's station. On the counter of the nurse's station was one bottle of multivitamin with minerals, one bottle of melatonin, one bottle of vitamin D and one bottle of allergy tablets. There was also one bottle of nystatin powder. During an interview on 4/21/26 at 9:36 A.M., the surveyor and the Assistant Director of Nurses observed the medications at the nurse's station. The Assistant Director of Nurses said that the bottles of medications should not have been left at the nurse's station and should be securely stored in a medication room or medication cart. During an interview on 4/23/26 at 7:36 A.M., The Nursing Supervisor said that medication carts should be locked when unattended and medications should not be left unsecured at the nurse's station.

Based on interview and record review, the facility failed to ensure laboratory services were provided timely for one sampled Resident (#5), out of a total sample of 21 residents. Specifically, the facility failed to obtain a urine for urinalysis and culture as indicated in physician's orders. Findings include:Resident #5 was admitted to the facility in November 2020 with diagnoses that included dementia, adult failure to thrive and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/26, indicated a Brief Interview for Mental Status could not be completed, and the Resident was assessed by staff to exhibit severe cognitive impairment. The MDS failed to indicate that the Resident exhibited rejection of care. Review of Resident #5's active the physician orders indicated the following: UA (urinalysis) and culture, completed blood count (cbc), basic metabolic panel (bmp) to be drawn 3/31, dated 3/25/26. Review of the lab results tab in the electronic medical record failed to indicate a UA and culture were obtained as indicated in physician's orders. Review of the paper record failed to indicate any UA results for the Resident from 3/31/26. Review of progress notes failed to indicate that the Resident refused to or was unable to provide a urine sample for testing. Further review of the progress notes failed to indicate that a physician or nurse practitioner was made aware that a urine was not obtained. During an interview on 4/22/26 at 10:19 A.M., Nurse Practitioner #1 said that she would expect that all physician's orders are implemented as indicated. She said that physician services were last contacted on 3/20/26 regarding Resident #5. She said that staff reported that the Resident was experiencing altered mental status with orders given to obtain a urine and check other blood work. She said that she was not made aware of any urine results. She further said she was not aware that a urine was never obtained for the Resident. She said if she was notified that she would have suggested attempting to obtain a urine via straight catheterization, or depending on the blood work results, discontinuing the order all together. During an interview on 4/22/26 at 2:14 P.M., Nurse #1 said that if staff did not or could not obtain a urine on Resident #5, they should have contacted the physician or nurse practitioner to notify them. He reviewed the Resident's record and said that there were no urine results for UA and culture available because they were not obtained. He said that physician's orders should be followed as written. During an interview on 4/23/26 at 7:38 AM., the Nursing Supervisor said that physician's orders to obtain a urine were not implemented by nursing. She said that a urine should have been obtained and if staff were unable to, then the provider should have been contacted and updated. During an interview on 4/23/26 at 9:56 A.M., the Director of Nurses said that physician's orders should be implemented as written. She said that if staff could not obtain a urine the provider should have been contacted. She said there is a process concern with how orders are written in the facility and ensuring that nurses are aware of the orders. During a phone interview on 4/24/26 at 9:55 A.M., the Medical Director said that he would expect that orders to obtain a urine or any other lab requests are implemented.

Based on observation, interview and test trays, the facility failed to provide meals at a palatable temperature on two of two nursing units. Findings include: Review of the facility policy titled Food Temperatures, undated, indicated: Policy: Foods will be maintained at proper temperature to ensure food safety. Procedures: 1. The point of service temperature to residents will be within the range of 120-140 degrees based on the residents preferences. 2. The temperature of potentially hazardous cold foods will be not greater than 40 degrees F (Fahrenheit) when served to the resident. On 4/22/26 at 8:01 A.M. the surveyor observed Resident #2 in bed with his/her breakfast meal covered and left on his/her bedside table. Resident #2 said his/her meal was delivered 15 minutes ago but he/she needs assistance with being fed. Resident #2 said that he/she waits a long time and he/she has gotten used to eating cold meals. Resident #2 said that staff do not offer to re-heat his/her meal if it's been sitting for a while. On 4/22/26 at 8:09 A.M., the surveyor observed Nurse #2 enter Resident #2's room and say, I thought they were feeding you. Nurse #2 cut food on Resident #2's plate without offering re-heat the meal. The surveyor then entered the room and Resident #2 said the food was cold. Resident #2 gave the surveyor permission to take the temperature of his/her meal. The pancakes and eggs both reached 95 degrees F (farenheit). The surveyor then asked Nurse #2 if staff ever offer to re-heat resident meals and she responded by asking Resident #2 if he/she wanted his/her meal heated up. During Resident group meeting on 4/22/26 at 11:15 A.M., 7 out of 11 residents expressed that meals are not served at desired temperatures. A test tray was conducted on the second floor on 4/22/26 at 11:47 A.M:chicken drum stick 128 degrees F - Tasted lukewarmgreen beans 128 degrees F - Tasted lukewarmpudding cool 66 degrees F - Tasted coolmilk 53 degrees F - Tasted cool not cold A test tray was conducted on the first floor on 4/22/26 at 12:08 P.M:chicken drum stick 140 degrees F - Tasted hotgreen beans 108 degrees F - Tasted lukewarmpotato salad 72 degrees F - Tasted lukewarmpudding 49 degrees F - Tasted coolmilk 50 degrees- Warm The Food Service Director (FSD) was present during first floor test tray and said that the milk and potato salad should be at 39 degrees F. During an interview on 4/22/26 at 12:27 P.M., the Administrator said he expects food to be served at appropriate temperatures.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring for Infection Control.Findings Include:Review of the facility policy titled Quality Assurance and Performance Improvement ( QAPI) Policy and Procedure, dated 2024, indicated but was not limited to the following: It is the policy of the Facility to develop, implement and maintain and effective, comprehensive, data driven QAPI program that focuses on indicator of the outcomes of care and quality of life. -Role of the Infection Preventionist on the QAA (Quality Assessment and Assurance) Committee.A. The IP (Infection Preventionist) shall report to the Facility's governing body on the Facility infection prevention and control program, and on incidents such as healthcare-associated infections on a regular basis. B. The IP shall attend each QAPI meeting in order to be considered an active participant. C. The Facility shall demonstrate compliance with the federal regulations governing QAPI programs and QAA committees through: a. Evidence of systems, and reports demonstrating identification, reporting, investigation, analysis and prevention of adverse events;b. Data collection and analysis at regular intervals; andc. Documentation demonstrating development, implementation and evaluation of corrective actions or performance improvement activities. Review of the QAPI program for the year 2026, failed to indicate that an Infection Control program was reviewed and monitored and failed to include a system for appropriate infection control surveillance. Review of the last documented QAPI Team Meeting Agenda dated 2/20/26 and 3/23/26, indicated:Clinical Metrics 3.Infection RateInfection Control & Safety1.Infection Surveillance Report2.Antibiotic Stewardship Review3. Outbreak Monitoring4.Environmental Rounds summaryReview of the QAPI monthly meeting documentation failed to include any Infection Control information or program monitoring data.During the survey period it was identified that the facility failed to maintain an effective infection control monitoring program as evidenced by:-Failure to administer influenza and covid vaccines as indicated.-Failure to implement an appropriate infection control surveillance system including line listings to track potential and actual infections in the facility.-Failure to ensure that enhanced barrier precautions were utilized as appropriate. During an interview on 4/23/26 at 2:40 P.M., the Director of Nurses who is also the designated Infection Preventionist, said she does not track or report infection control information in the facility and said Infection Control has not been part of the monthly QAPI meetings since she started back in January 2026. The DON said she has not been monitoring the program or providing any data reports for immunizations or infection control rates within the facility since she started.During an interview on 4/23/26, at 2:44 P.M., the Administrator said the facility should have implemented a QAPI to track infections and systems in place for monitoring of the infection control program to ensure the program is being followed. The Administrator said infection control has not been discussed during QAPI and said he does not have any infection control program information. Refer to: F880, F883, and F887

Based on record review and interview, the facility failed to administer the Influenza vaccine during influenza season to one Resident (#55) who consented to receive the flu vaccine out of a sample of five residents. Specifically, the facility failed to administer the influenza vaccine to a resident who consented to receiving it.Findings include:Review of the Centers for Disease Control and Prevention (CDC) recommendations for Who Needs a Flu Vaccine, dated September 18, 2025, indicated the following:-Everyone 6 months and older should get a flu vaccine every season with rare exceptions. Vaccination is particularly important for people who are at higher risk of serious complications from influenza. Resident #55 was admitted to the facility in January 2026 with diagnosis that included aseptic necrosis of the right femur and asthma. Review of the Minimum Data Set (MDS) assessment, dated 4/16/26, indicated a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Further review of the MDS indicated that the Resident's flu vaccine was not up to date and that the vaccine was offered and declined. Review of the immunization tab in the electronic medical record (EMR) failed to indicate any vaccination information for Resident #55. Review of the miscellaneous tab in the EMR failed to indicate any vaccination information. Review of the paper record indicated a consent to receive the influenza vaccine, signed and dated by Resident #55 on 1/12/26. The consent indicted that the Resident wished to receive the influenza vaccine. Review of active, discontinued and completed orders failed to indicate that the influenza vaccine had been ordered or administered to the Resident. During an interview on 4/22/26 at 12:02 P.M., Resident #55 said that he/she was offered the influenza vaccine on admission to the facility but never received it. The Resident said that he/she would have liked to receive it, especially being admitted to a facility, he/she felt like they were at higher risk for the flu but feels like it is too late now. During an interview on 4/22/26 at 10:36 A.M., Nurse Practitioner #1 said that the expectation is that all residents are provided information and offered vaccines on admission, especially during flu season. During an interview on 4/23/26 at 10:23 A.M., the Director of Nurses said that she just started looking at vaccines last month in the facility, as she has only been in the facility for three months. She said that flu vaccines should be offered and administered to residents in the facility during flu season. She said if a resident consented to the flu vaccine during the flu season, they should have received the vaccine. During a phone interview on 4/24/26 at 9:55 A.M., the Medical Director said that he would expect that all residents are offered the appropriate vaccines when admitted to the facility, or when new up to date vaccines are available. He said that if a resident consents to receive a vaccine, the provider should be notified so that orders can be entered.

Based on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to one (#55) out of five sampled Residents. Specifically, the facility failed to offer a COVID-19 vaccination upon admission or seasonally for residents. Findings include:Review of the Centers for Disease Control and Prevention 2025-2026 Covid -19 Vaccination Guidance, dated as November 4, 2025, indicated the following:- The 2025-2026 COVID-19 vaccine is recommended for people ages 6 months and older based on individual-based decision-making (also known as shared clinical decision making).-Additionally, some people may be at increased risk for SARS-CoV-2 infection including healthcare workers and residents and employees in long-term care facilities and other residential congregate settings. Resident #55 was admitted to the facility in January 2026 with diagnoses that included aseptic necrosis of the right femur and asthma. Review of the Minimum Data Set (MDS) assessment, dated 4/16/26, indicated a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. The MDS further indicated that the Resident was not up to date with his/her Covid vaccination. Review of the immunization tab in the electronic medical record (EMR) failed to indicate any documented vaccines. Review of the miscellaneous tab of the EMR failed to indicate any vaccine information or vaccine consents. Review of the paper record failed to indicate that the Covid vaccine was offered to the Resident on admission to the facility. Review of active, discontinued and completed orders failed to indicate any orders for the Resident to receive a Covid vaccination. During an interview on 4/22/26 at 12:02 P.M., Resident #55 said that he/she was never offered the opportunity to receive the most recently recommended Covid vaccination but that he/she would be interested in receiving it to stay up to date with recommendations. During an interview on 4/22/26 at 10:36 A.M., Nurse Practitioner #1 said that the expectation is that all residents are offered the most up to date Covid vaccination on admission to the facility. If the resident declines, she would expect education to be provided and documented in the medical record. During an interview on 4/23/26 at 10:23 A.M., the Director of Nurses said that she just started looking at vaccines last month in the facility, as she has only been in the facility for three months. She said that Covid vaccines should be offered and administered to residents in accordance with the current guidelines from the Centers for Disease Control and Prevention (CDC). During a phone interview on 4/24/26 at 9:55 A.M., the Medical Director said that he would expect that all residents are offered the most up to date Covid vaccination, and any consent or declination be documented in the medical record.

Based on observations, record review and interviews, the facility failed to notify one Resident's (#172) physician and legal guardian of a change in condition out of a total sample of 27 residents. Specifically, the facility failed to notify the physician of Resident #172's refusing medication, exit seeking behavior, an elopement from the facility and multiple other attempts of elopements from the facility, including through a second story window, resulting in Resident #172 from falling out of a second-floor window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Findings include: Review of the facility policy titled, Notification of Changes, dated 2024, indicated the following: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. -Circumstances requiring notification include: 1. Accidents a. resulting in injury b. potential to require physician intervention 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. 3. A change of room or roommate assignment. 4. Notice of Rome changes. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) assessment completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on the Resident's bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor the Resident said he/she went out the window because he/she was trying to get out of the building. The facility nursing staff called 911 and the Resident was taken to the hospital. During an interview on 6/8/25 at 6:52 A.M., Certified Nursing Assistant (CNA) #1 said she worked the overnight shift and Resident #172 was wandering up and down the hallways since 5:00 A.M., and at one point was attempting to go near the dining room window. CNA #1 said she had been told by other staff that the Resident had attempted to jump out of the dining room window previously and the staff had to barricade the window with tables and chairs to prevent access to the window. CNA #1 said at approximately 6:30 a.m., she left the Resident alone so she could go into the hallway and complete her paperwork. CNA #1 said it was at this point the Resident must have walked down to his/her bedroom and jumped out the window. On 6/8/25 at 6:56 A.M., the surveyor observed Resident #172's bedroom window. The window was open, with the opening measuring 24.5 inches wide and 4 feet 2 inches high. The surveyor observed nothing in the window to secure the opening of the window to prevent it from opening to that distance. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get out a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated the day of admission to the facility, that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of the elopement assessment dated [DATE] indicated Resident #172 was wandering and that his/her wandering was both goal-directed and aimless and not goal-oriented. Review of the nursing note dated 6/5/25 and written by the Director of Nursing indicated the following: -At 0845 writer and the Administrator were called to the second floor. The resident was observed using a very loud tone of voice and swearing at staff members. The Director of Nursing (writer) was able to escalate (sic) the resident's behavior and redirect the resident. The resident responded very well to the Director of Nursing, with a calm, soft voice, and apologized for yelling. While the writer was assessing the resident, it was noted that the resident was very confused, did not know where they were, and was using word salad when speaking. The writer was able to calm the resident to the point that they were able to leave the resident safely with the nursing staff. Nursing staff will continue to monitor the resident for the remainder of the shift. The medical record failed to indicate the medical provider or guardian was notified of these escalating behaviors. Review of the social services note dated 6/5/25 indicated the following: -Resident was transferred from (first-floor room) to (second-floor room) for safety reasons with prior authorization from Guardian and the agreement of roommate. Social worker will continue to monitor for changes in mood and behavior. Social services continues to remain available as needed for ongoing psychological support and reassurance. The medical record failed to indicate the medical provider was notified of the room change. Review of the nursing note dated 6/7/25 and time stamped 7:11 A.M., indicated the following: -Resident attempt (sic) to elope twice by opening the window in the dinner room. Cont. (continue) to monitor for safety. The medical record failed to indicate the medical provider or guardian was notified of the attempts of elopement. Review of the nursing note dated 6/7/25 and time stamped 12:53 P.M., indicated the following: -Pt. (patient) is alert, oriented and confused at baseline. Refused all am (morning) scheduled medications, ate 50% of breakfast and 100% of lunch. The medical record failed to indicate the medical provider or guardian was notified of the Resident's refusal of medications. Review of Resident #172's mood care plan created on 6/4/25, indicated the following intervention: -Monitor/document/report any risk for harm to self: suicidal plan, past attempted suicide, risky actions (stocking pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. During interviews on 6/8/25 at 6:56 A.M., and 6/10/25 at 6:52 A.M., Nurse #1 said he was aware Resident #172 had a history of attempting to jump out windows and while at this facility, the Resident had attempted to open and exit the second-floor dining room window on 6/6/25 and 6/7/25. Nurse #1 said the Resident had also opened the balcony door off the dining room on 6/6/25 and had gone over to the edge of the balcony and needed to be pulled from the edge. Nurse #1 said he did not notify the provider or management of these behaviors and incidents. During an interview on 6/8/25 at 6:59 A.M., CNA #1 said the staff were aware that Resident #172 had been attempting to exit seek through windows and was unaware if anyone contacted administration or the medical providers to report this. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said she did not notify the physician or nurse practitioner of the wandering and exit seeking behavior. During an interview on 6/9/25 at 10:12 A.M., CNA #5 said Resident #172 eloped from the building when he/she was first admitted and made it two miles down the road. CNA #5 said on the second day at the facility, Resident #172 attempted to jump off the second-floor balcony. CNA #5 said the administration blamed the nurse for agitating the Resident and said the nurse was overreacting to the situation. CNA #5 was unaware if the physician was notified after these two events. On 6/8/25 at 9:09 A.M., the surveyor interviewed the Administrator and Director of Nursing. During the interview, the Administrator said he received a call at 7:00 A.M. that Resident #172 had fallen out of his/her bedroom window. The Administrator said Resident #172 was a new admit to the facility and had dementia and was confused with a history of behaviors. The Administrator said the Resident recently displayed behaviors of yelling, swinging arms and banging on the walls and said the Resident wanted out and was assessed as being high risk for elopement. The Administrator said he was unaware of Resident #172's previous elopement history, including his/her attempt to elope from a third-floor window at a previous facility as he did not read the Resident's pre-admission paperwork. The Administrator said that the Resident did elope from the first floor on 6/4/25 and made it around the building to the back parking lot and was then moved to the second floor. He said he was also aware that on 6/6/25, Resident #172 was able to exit the second-floor dining room onto the balcony through a door that is supposed to be always locked. The Administrator said he had not received any calls over the weekend regarding Resident #172's increased behavior and attempt to elope from the second-floor dining room windows twice on 6/7/25. The Administrator said he was unaware if the physician was notified regarding Resident #172's elopement, elopement attempts, increased behaviors or history of elopement. During an interview on 6/9/25 at 2:03 P.M., the Director of Nursing said he read the nursing note dated 6/4/24 indicating Resident #172 was attempting to open windows, was aware he/she eloped out the front door on 6/4/25, and attempted to go out a window on 6/6/25 but was unaware the Resident had refused medications and did not notify the physician of any of these incidents. During an interview on 6/9/25 at 9:54 A.M., Resident #172's Guardian said she was never notified of the Resident's escalating behaviors, elopement, refusal of medications and attempted elopements out a window. The Guardian said she would have expected to be notified of all of these. During an interview on 6/9/25 at 8:44 A.M., Physician #1 said he had not yet assessed Resident #172 since his/her admission into the facility. Physician #1 said he was unaware of Resident #172's elopement history and the facility did not notify him or his nurse practitioner of Resident #172's behaviors, refusal of medications, room change, elopement and elopement attempts and that all of those examples are indicative of a call to the provider. Physician #1 said he is also the medical director of the facility and would have expected the facility to have a plan to ensure safety for residents admitted with a high risk and history of elopement. During an interview on 6/9/25 at 8:49 A.M., Nurse Practitioner (NP) #1 said she completed Resident #172's admission assessment. NP #1 said Resident #1 was wandering when she met him/her and was incoherent. NP #1 said she was unaware of Resident #172's elopement history and the facility did not make her aware of this on the day she was in the building. NP #1 said she expects the facility to notify her if a resident refuses medication, has escalating behaviors, attempts to elope and actually elopes from the facility. NP#1 said she was never notified with any of these when they occurred with Resident #172. NP#1 then checked the call log for the medical office and said no phone calls were made over the weekend on 6/7/25 to notify the physician's group that Resident #172 had attempted to elope out the window twice.

Based on observations, record reviews and interviews, the facility failed to keep three Residents (#172, #56 and #35 free from accidents while at the facility. Specifically, 1. For Resident #172, with a known history of elopement from a window, the facility failed to ensure it provided appropriate supervision and safety resulting in the Resident falling from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs; 2. For Resident #56, the facility failed to ensure supervision was provided during a trialing of an upgraded diet texture resulting in a choking episode requiring the Heimlich Maneuver; and 3. For Resident #35, the facility failed to ensure smoking materials were not left unsupervised in the Resident's room. Findings include: Review of the facility policy titled, Elopement Prevention, dated 12/27/24, indicated the following: -The facility maintains a process to assess all residents for risk of elopement, implement prevention strategies for those identified as elopement risk, institute measures for resident identification at the time of admission. -The physical plant is secured to minimize the risk of elopement, such as: c. safety locks or keypad entry that restrict access to dangerous areas, d. restricted window openings 1. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing admission assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on his/her bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor he/she said he/she went out the window because he/she was trying to get out of the building. The facility nursing staff called 911 and the Resident was taken to the hospital. During an interview on 6/8/25 at 6:52 A.M., Certified Nursing Assistant (CNA) #1 said she worked the overnight shift and Resident #172 was wandering up and down the hallways since 5:00 A.M., and at one point was attempting to go near the dining room window. CNA #1 said she had been told by other staff that the Resident had attempted to jump out of the dining room window previously and the staff had to barricade the window with tables and chairs to prevent access to the window. CNA #1 said at approximately 6:30 a.m., she left the Resident alone so she could go into the hallway and complete her paperwork. CNA #1 said it was at this point the Resident must have walked down to his/her bedroom and jumped out the window. On 6/8/25 at 6:56 A.M., the surveyor observed Resident #172's bedroom window. The window was open, with the opening measuring 24.5 inches wide and 4 feet 2 inches high. There was nothing in the window to secure the opening of the window to prevent it from opening to that distance. On 6/8/25 at approximately 7:00 A.M., the surveyor observed the second-floor dining room window that CNA #1 said Resident #172 had been repeatedly approaching. The window was able to open from the left side with an opening measuring 22.5 inches wide and 4 feet 7 inches high. There was nothing in the window to secure the opening of the window to prevent it from opening to that distance. The right side of the window was secured with a device in the window ledge to prevent it from opening. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated the day of admission to the facility, that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of the elopement assessment dated [DATE] indicated Resident #172 was wandering and that his/her wandering was both goal-directed and aimless and not goal-oriented. Review of the nursing note dated 6/5/25 and written by the Director of Nursing indicated the following: -At 0845 writer and the Administrator were called to the second floor. The resident was observed using a very loud tone of voice and swearing at staff members. The Director of Nursing (writer) was able to escalate (sic) the resident's behavior and redirect the resident. The resident responded very well to the Director of Nursing, with a calm, soft voice, and apologized for yelling. While the writer was assessing the resident, it was noted that the resident was very confused, did not know where they were, and was using word salad when speaking. The writer was able to calm the resident to the point that they were able to leave the resident safely with the nursing staff. Nursing staff will continue to monitor the resident for the remainder of the shift. Review of the social services note dated 6/5/25 indicated the following: -Resident was transferred from (first-floor room) to (second-floor room) for safety reasons with prior authorization from Guardian and the agreement of roommate. Social worker will continue to monitor for changes in mood and behavior. Social services continues to remain available as needed for ongoing psychological support and reassurance. Review of the nursing note dated 6/7/25 and time stamped 7:11 A.M., indicated the following: -Resident attempt to elope twice by opening the window in the dinner room. Cont. (continue) to monitor for safety. Review of the nursing note dated 6/7/25 and time stamped 12:53 P.M., indicated the following: -Pt. (patient) is alert, oriented and confused at baseline. Refused all am (morning) scheduled medications, at 50% of breakfast and 100% of lunch. Review of Resident #172's elopement and wandering care plan created on 6/4/25, failed to indicate an individualized care plan for Resident #172's history of elopement through windows. Interventions that were included on the care plan, all initiated on 6/4/25, were: -Clearly identify Resident's room and bathroom. -Engage Resident in purposeful activity. -Identify if there are triggers for wandering/eloping. -Identify if there is a certain time of day wandering/elopement attempts occur. -Identify if there is a pattern and purpose of wandering. -Provide care in a calm and reassuring manner. -Provide clear, simple instructions. -Provide reorientation to surroundings. -Wander guard (a bracelet worn to activate an alarm if exiting through the doors or elevator of the unit) placed to left ankle. The care plan failed to include any interventions after actual elopement attempts by the Resident. Review of Resident #172's mood care plan created on 6/4/25, indicated the following intervention: -Monitor/document/report any risk for harm to self: suicidal plan, past attempted suicide, risky actions (stocking pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. During interviews on 6/8/25 at 6:56 A.M., and 6/10/25 at 6:52 A.M., Nurse #1 said he was aware Resident #172 had a history of attempting to jump out windows and while at this facility, the Resident had attempted to open and exit the second-floor dining room window on 6/6/25 and 6/7/25. Nurse #1 said the Resident had also opened the balcony door off the dining room on 6/6/25 and had gone over to the edge of the balcony and needed to be pulled from the edge. Nurse #1 said he did not notify the provider or management of these behaviors and incidents. During an interview on 6/8/25 at 6:59 A.M., CNA #1 said the staff were aware that Resident #172 had been attempting to exit seek through windows and was unaware if anyone contacted administration or the medical providers to report this. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said she did not notify the physician or nurse practitioner of the wandering and exit seeking behavior. During an interview on 6/9/25 at 10:12 A.M., CNA #5 said Resident #172 eloped from the building when he/she was first admitted and made it two miles down the road. CNA #5 said on the second day at the facility, Resident #172 attempted to jump off the second-floor balcony. CNA #5 said the administration blamed the nurse for agitating the Resident and said the nurse was overreacting to the situation. CNA #5 was unaware if the physician was notified after these two events. On 6/8/25 at 9:09 A.M., the surveyor interviewed the Administrator and Director of Nursing. During the interview, the Administrator said he received a call at 7:00 A.M. that Resident #172 had fallen out of his/her bedroom window. The Administrator said Resident #172 was a new admit to the facility and had dementia and was confused with a history of behaviors. Both the Administrator and Director of Nursing said they had not read Resident #172's admission paperwork and were unaware of his/her behaviors, elopement risk and previous attempt to elope out a third-floor window. The Administrator said that the Resident did elope from the first floor on 6/4/25 and made it around the building to the back parking lot and was then moved to the second floor. He said he was also aware that on 6/6/25, Resident #172 was able to exit the second-floor dining room onto the balcony through a door that is supposed to be always locked. The Administrator and Director of Nursing said they were aware Resident #172 displayed behaviors of yelling, swinging arms and banging on the walls and said the Resident wanted out and was assessed as being high risk for elopement. The Director of Nursing said he needed to be called to Resident #172's floor when his/her behavior escalated and needed to provide support to the Resident in order to deescalate the behaviors. The Administrator said he had not received any calls over the weekend regarding Resident #172's increased behavior and attempt to elope from the second-floor dining room windows twice on 6/7/25. The Administrator said he was unaware if the physician was notified regarding Resident #172's elopement, elopement attempts, increased behaviors or history of elopement. During an interview on 6/9/25 at 2:03 P.M., the Director of Nursing said he read the nursing note dated 6/4/24 indicating Resident #172 was attempting to open windows, was aware he/she eloped out the front door on 6/4/25, and attempted to go out a window on 6/6/25 but was unaware the Resident had refused medications and did not notify the physician of any of these incidents. The Director of Nursing said he attempted to secure the second-floor dining room window, and was successful in doing so on the right side of the window, but because I am not a carpenter he was unable to secure the left side. The Director of Nursing said after not being able to secure the left side of the window, he did not come up with a plan to secure that window further. During an interview on 6/9/25 at 9:54 A.M., Resident #172's Guardian said she was never notified of the Resident's escalating behaviors, elopement, refusal of medications and attempted elopements out a window. The Guardian said she would have expected to be notified of all of these. During an interview on 6/9/25 at 8:44 A.M., Physician #1 said as the medical director of the facility and would have expected the facility to have a plan to ensure safety for residents admitted with a high risk and history of elopement. During an interview on 6/9/25 at 8:49 A.M., Nurse Practitioner (NP) #1 said she completed Resident #172's admission assessment. NP #1 said Resident #1 was wandering when she met him/her and was incoherent. NP #1 said she was unaware of Resident #172's elopement history and the facility did not make her aware of this on the day she was in the building. NP #1 said she was unaware of Resident #172's actual elopement and elopement attempts at the facility. During an interview on 6/9/25 at 1:33 P.M., the Administrator said the clinical liaison who interacts with the hospital does the initial admission screening, then speaks with the admission coordinator at the facility. The Administrator said this screening process is in place to ensure the facility can clinically and safely take care of the residents. The Administrator says he has little involvement in looking at the preadmission screens as he trusts the Director of Nursing to do this. The Administrator said elopements are not something he has had a great deal of experience with as it has been many years since he has had a building with a locked unit. He said he believed the facility would be able to clinically care for Resident #172 at the time of his/her admission, however, he was not aware of the Resident's prior elopement attempts. The Administrator said he was aware Resident #172 had eloped from the building, had gotten out onto the second-floor balcony and had banged on windows; however, he said he was unaware the Resident had attempted to open and climb out a second-floor window on two other occasions. The Administrator said he would have expected any elopement attempts or safety concerns to be reported to him as it is his responsibility for all residents' safety. When asked about his system for ensuring the windows of the facility are secure, the Administrator said he had asked his maintenance director to complete an audit in March 2025 to check all windows and ensure they could not open more than four inches. The Administrator said he did not receive a formal audit from the maintenance director and took his word that it had been completed. During an interview on 6/10/25 at 7:35 A.M., the Case Manager in charge of admissions from the hospital was interviewed. The Case Manager said she helps coordinate Resident #172's admission to the facility and was aware that the Resident was in the hospital for psychiatric concerns and had attempted to elope from a window at a previous facility. The Case Manager said she sent all of the preadmission paperwork and the Resident's clinical history/information to the facility to ensure the facility would be able to handle the patient. During an interview on 6/10/25 at 9:01 A.M., the Admissions Coordinator said she was aware of Resident #172's prior attempt to elope from a window prior to his/her admission to the facility and did not tell the Administrator and did not have a conversation with anyone in the building to ensure the windows were secure. During an interview on 6/11/25 at 8:17 A.M., the Maintenance Director said he was asked to complete a window audit in March 2025, and he delegated his task to his assistant, asking him to ensure the windows could not open more than 4 inches. The Maintenance Director said he was never given a formal audit showing that his assistant completed this task, but he took his word for it. The Maintenance Director said he was never told to check the second-floor dining room door to the outside balcony, and he had never been told to add that door to his daily safety check. During an interview on 6/11/25 at 8:29 A.M., the Maintenance Assistant said he was assigned the task to audit all windows in March 2025, and he did this task but did not write down the results on a formal audit form. The Maintenance Assistant said he was aware that the window in Resident #172's room could open all the way, and he did not go back to ensure that it was secure. The Maintenance Assistant said the door to the second-floor dining room is not on a daily safety check list and he was never told to check the door after the fact. During an interview on 6/11/25 at 11:18 A.M., the Administrator said he was unaware the window in Resident #172's bedroom was able to open all the way and that the maintenance assistant was aware of this. 2. Resident #56 was admitted to the facility in April 2024 with diagnoses that included dysphagia, Huntington's Disease, adult failure to thrive, and severe protein-calorie malnutrition. Review of Resident #56's Minimum Data Set (MDS) assessment, Dated 7/27/24, indicated require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of Resident #56's Minimum Data Set (MDS) assessment, dated 4/2/25, indicated he/she scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive deficits. Further review of the MDS indicated mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of Resident #56's diet order from 8/4/24 to 1/14/25 indicated Regular diet, Liquid / No Texture texture, Nectar consistency. Review of Resident #56's Speech Evaluation, dated 8/2/24, indicated baseline mechanical soft nectar liquids. Swallowing abilities= Severe, Oral phase= Moderate. Diet Recs - Solids = Mechanical Soft Textures, Mechanical Soft/Ground Textures. Supervision for Oral Intake = Close supervision. Review of Resident #56's Speech Therapy note, dated 8/6/24, indicated Pt (patient) was trialed on soft meatballs during noon meal. Pt took an entire meatball and place in her mouth. SLP directed pt to take food out of her mouth. Review of Resident #56's Speech Therapy note, dated 8/29/24, indicated Pt presented with mechanical soft food. Review of Resident #56's nursing progress note, dated 9/3/24, indicated During the lunch service, the dietician provided a chicken sandwich to the patient. While eating, the patient began to choke. The nurse on duty quickly intervened by performing the Heimlich maneuver. It was successful, and patient expelled the pieces of the sandwich that were obstructing her airway. After the incident, the patient was assessed and found to be in stable condition. Review of Resident #56's Nurse Practitioner progress note, dated 9/5/24, indicated Patient seen today following an episode of choking on 9/3/2024. Patient was eating a sandwich and choked requiring the Heimlich maneuver, article fluid was expelled. Due to this episode patient continues to have nectar consistent, puréed texture. (sic) During an interview on 6/10/25 at 10:55 A.M., the Speech Therapist said she was working with Resident #56 on 9/3/25, gave the Resident a chicken salad sandwich and then left the Resident with the nurse to be supervised. The Speech Therapist said at that time there was not an order in place for the Resident to have mechanically altered foods with nursing staff but she was working with the Resident to try and upgrade his/her diet. The Speech Therapist said he/she was a puree diet at the time of the trial and was discharged to stay on a puree with thickened liquid diet. During an interview on 6/10/25 at 1:46 P.M., Nurse #3 said she is familiar with Resident #56 and the choking incident that happened on 9/3/24. Nurse # 3 said that speech should not have left the nurse alone with the Resident while trialing new food textures until a doctors order is in place for that food texture. Nurse #3 said the diet order at the time should have said puree texture and not no texture texture. During an interview on 6/12/25 at 10:24 A.M., the Director of Nursing (DON) said when a Resident is working with speech on trialing different foods the expectation is that the speech therapist stay for the whole duration of that meal. The DON said the speech therapist should have never left the nurse with the Resident with the chicken salad sandwich because there was not a doctors order in place for that texture of food and could be dangerous. The DON said he expects the Residents plan of care to be followed and the diet texture should have been clear in the order. During an interview on 6/12/25 at 10:28 A.M., Nurse Practitioner (NP) #1 said she knows Resident #56 well and he/she does have a history of choking at the facility. The NP said she would expect the speech therapist to have stayed until the Resident was done with that session of trialing the mechanically altered food as it is their job. The NP said the texture should have been clear in the doctors orders at that time as the Resident was on a puree diet and still is. 3. Review of the facility policy titled Smoking Policy, undated, indicated the following: - Each Resident should be individually assessed to determine whether he/she can safely smoke without supervision. The Facility shall conduct an assessment to determine whether the resident requires any safety devices such as a smoking apron and shall document this in the resident's care plan. - Supervised smokers are not permitted to have any smoking paraphernalia in their room or on their person. Resident #35 was admitted to the facility in May 2025 with diagnoses including muscle wasting, heart disease and nicotine dependence. Review of the Resident's most recent Minimum Data Set assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 11 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated the Resident requires partial/moderate assistance from staff with ADL care and currently uses tobacco. Review of the list of Residents who currently smoke in the facility provided by the facility failed to indicate that Resident #35 smokes. On 6/8/25 at 8:50 A.M., the surveyor observed Resident #35 lying in his/her bed. On Resident #35's bedside table next to his/her bed was one unlit cigarette and one cigarette that had been previously lit and stubbed out (burnt, black markings were on the end of it). Resident #35 told the surveyor that he/she smokes while living in the facility. Review of Resident #35's Nursing admission Evaluation dated 5/9/25, indicated the following under the smoking section: - Smoking: yes - Resident needs for adaptive equipment: supervision - Does the resident need facility to store lighter and cigarettes: yes - Decision: safe to smoke with supervision Review of Resident #35's active care plans failed to indicate that the facility developed a smoking care plan with individualized, resident-specific interventions. During an interview on 6/10/25 at 8:36 A.M., Nurse #5 said there is a lock box downstairs that contains all of the Residents' smoking materials after they finish smoking. Nurse #5 said Residents should not have any cigarettes or smoking material at the bedside. The surveyor showed Nurse #5 the photos of the cigarettes at Resident #35's bedside and he said they should not be there. During an interview on 6/10/25 at 9:19 A.M., Nurse #7 said cigarettes are kept in a lock box and staff who are in charge of supervising smoking ensure Residents put all smoking material back in the box after smoking. Nurse #7 said nursing has complained about this and residents are going outside without supervision and smoking. Nurse #7 said we have lost control of residents going out to smoke. During an observation on 6/10/25 at 9:41 A.M., as the surveyor was interviewing Nurse #7, Resident #35 was walking down the hallway coming from his/her room holding a cigarette in his/her right hand. Resident #35 told Nurse #7 that he/she had the cigarette with him/her and is trying to leave the building to smoke. During an interview on 6/10/25 at 10:33 A.M., the Director of Nursing (DON) said all residents who wish to smoke in the facility must have a smoking assessment and smoking care plan. The DON said if a resident is of sound mind and body then they can have smoking materials with them. During an interview on 6/10/25 at 12:30 P.M., the Administrator said residents who are alert and oriented and are safe smokers who do not need supervision are allowed to have smoking materials with them and he said he refers to the facility policy. The Surveyor reviewed the smoking policy with the Administrator, and he said Resident #35 should not have smoking materials with him/her and he/she should have a smoking care plan.

Based on observation, record review, and interviews, the facility failed to ensure licensed nursing staff were trained and competent in managing wandering behavior and elopement, subsequently, one Resident (#172) eloped and fell from a second-floor bedroom window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Findings include: Review of the Facility Assessment, most recently updated on 4/18/25, indicated the following: -The staff are provided with training/education which includes how to care for residents with a diagnosis of dementia. -The staff are provided with competency training on disaster planning and procedures, which includes competency on elopements. Review of the document titled, Round [NAME]: Annual Education, undated and provided by the Administrator indicated the following: -Round [NAME] Education (group education) is mandatory. -Stations for training included: elopement, dementia, how to deal with difficult behaviors, and safety training. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing admission assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on his/her bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor he/she said he/she went out the window because he/she was trying to get out of the building. The Facility nursing staff called 911 and the Resident was taken to the hospital. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated [DATE], that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -A referral sheet that indicated, From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of Resident #172's medical record indicated the following: -A daily skilled nursing note dated 6/4/25 indicating Resident #172 was attempting to push on doors and open windows. -A nursing note dated 6/7/25 indicating Resident #172 attempted to elope from the facility by the window twice. -Resident #172 was documented as having wandering behaviors on 6/5/25 and 6/7/25. -A social service note dated 6/6/25 indicating Resident #172 was admitted to the facility after a psychiatric hospitalization for irritability and altered mental status. The note failed to include the Resident's history of attempting to elope out of a window. Review of Resident #172's elopement and wandering care plan created on 6/4/25, failed to indicate an individualized care plan for Resident #172's history of elopement through windows. Interventions that were included on the care plan, all initiated on 6/4/25, were: -Clearly identify Resident's room and bathroom. -Engage Resident in purposeful activity. -Identify if there are triggers for wandering/eloping. -Identify if there is a certain time of day wandering/elopement attempts occur. -Identify if there is a pattern and purpose of wandering. -Provide care in a calm and reassuring manner. -Provide clear, simple instructions. -Provide reorientation to surroundings. -Wander guard (a bracelet worn to activate an alarm if exiting through the doors or elevator of the unit) placed to left ankle. The care plan failed to include any revisions/updates to interventions after actual elopement attempts by the Resident. Observations of the facility indicated the wander guard system was only located on the elevators and doors and not any window. During an interview on 6/10/25 6:52 A.M., Nurse #1 said the facility had never given the staff guidance or education on handling residents with a high elopement risk. Nurse #1 said the staff felt stuck because they didn't have guidance on how to manage extreme behaviors, such as residents who are attempting to elope from windows. During an interview on 6/10/25 at 8:02 A.M., Certified Nursing Assistant (CNA) #3 said he works at another facility that does annual competencies and education, so he is not required to do them here. CNA #3 said he was not familiar with Resident #172. During an interview on 6/10/25 at 8:06 A.M., CNA #4 said the staff have not been provided with any in-services or annual education since the new company bought the building in September 2024. CNA #4 said he was not familiar with Resident #172. During an interview on 6/10/25 at 8:14 A.M., Nurse #4 said she has worked at the building for about two and a half months and she had some competencies since starting work but has not finished them. Nurse #4 said she does not remember learning about elopement during her hiring process/orientation. During an interview on 6/10/25 at 8:36 A.M., CNA #9 said he worked over the previous weekend and was aware of Resident #172's attempts to elope from the building, but no one educated him that the Resident was attempting to get out the window. CNA #9 said Resident #172 is not like the typical person the staff had to take care of and the staff had to give him/her special attention. CNA #9 said they were not given any specific education or guidance from management on how to properly take care of Resident #172. During an interview on 6/10/25 at 8:44 A.M., CNA #6 said when she worked over the weekend, Resident #172 was attempting to elope and that the Resident was always in the dining room attempting to go out the window. CNA #6 said no one from the facility talked to her before her shift about the Resident trying to wander and elope and how to manage those behaviors. CNA #6 said she received education from the previous staff educator but cannot remember if managing elopement was part of that education. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said no one from the administration came to the unit to offer her or the other staff guidance or education on how to manage these behaviors and that this would have been very helpful. She said the staff provided constant supervision to the Resident for the entirety of the shift as the intervention of the exit seeking behavior. Review of ten employee records indicated the following: -Eight out of ten employees had no dementia training. Five of these employees were newly hired and did not have the required 8 hours of dementia training. Three out of the five employees had been employed at the facility for over a year and did not have the required four-hour yearly dementia training. -Four out of five employees who had been employed at the facility for more than a year had not completed annual education or competencies for caring for residents with dementia and a risk of elopement. During an interview on 6/8/25 at 9:09 A.M., the Administrator said all staff should have direct knowledge on how to manage residents with dementia who have a risk of elopement. The Administrator said nursing staff are expected to complete education upon hire, annually and as needed. The Administrator said the Assistant Director of Nursing is responsible for staff education. During an interview on 06/09/25 02:03 P.M., the Director of Nursing (DON) said he expects the staff to have education regarding elopement annually and at orientation. The DON said when Resident #172 had escalating behaviors and attempts at elopement, he did not provide staff with on the spot education regarding techniques to prevent elopement. During an interview on 6/10/25 at 11:50 A.M., the Assistant Director of Nursing (ADON) said he was hired within the last 30 days and did not have a chance to meet with the prior staff educator to understand the level of education previously provided to the staff. The ADON said that he is responsible for all new hire education and dementia training. The ADON said he was unaware the staff reviewed did not have annual competencies/education or dementia training. During an interview on 6/12/25 at 10:02 A.M., the Administrator said he was unaware that there was no annual education provided to the nursing staff last year. The Administrator said he had asked the previous nursing leadership to complete education and he had observed some ad hoc education occurring on the floor and assumed all education was being provided.

Based on record review and interviews, the facility failed to ensure it provided appropriate administrative oversight, specific to clinical management and building safety, when one Resident (#172) fell from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Specifically, the facility administration failed to: 1. Ensure the facility's environment was safe for a Resident with a known risk of elopement from a window; 2. Ensure effective systems were in place for education and training for licensed staff to ensure competent, safe, and effective resident care related to residents with dementia and a risk of elopement; 3. Ensure the facility assessment indicated the facility cared for a population with the behaviors of elopement in order to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: Review of the facility policy titled, Elopement Prevention, dated 12/27/24, indicated the following: -The facility maintains a process to assess all residents for risk of elopement, implement prevention strategies for those identified as elopement risk, institute measures for resident identification at the time of admission. -The physical plant is secured to minimize the risk of elopement, such as: c. safety locks or keypad entry that restrict access to dangerous areas, d. restricted window openings Review of the facility policy titled, Dementia Treatment Plan, dated 9/2024, indicated the following: -For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. -Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on results of the reviews. -Progressive or persistent worsening of symptoms and increased need for staff support will be reported to the IDT. -The IDT will review the past and current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complication, and functional impairments. -The IDT will adjust interventions and the overall plan depending on he individual's response to those interventions, progression of dementia, development on new acute medical conditions or complications, changes in resident or family wishes, etc. 1. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing admission assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on his/her bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor he/she said he/she went out the window because he/she was trying to get out of the building. The facility nursing called 911 and the Resident was taken to the hospital. During an interview on 6/8/25 at 6:52 A.M., Certified Nursing Assistant (CNA) #1 said she worked the overnight shift and Resident #172 was wandering up and down the hallways since 5:00 A.M., and at one point was attempting to go near the dining room window. CNA #1 said she had been told by other staff that the Resident had attempted to jump out of the dining room window previously and the staff had to barricade the window with tables and chairs to prevent access to the window. CNA #1 said at approximately 6:30 a.m., she left the Resident alone so she could go into the hallway and complete her paperwork. CNA #1 said it was at this point the Resident must have walked down to his/her bedroom and jumped out the window. On 6/8/25 at 6:56 A.M., the surveyor observed Resident #172's bedroom window. The window was open, with the opening measuring 24.5 inches wide and 4 feet 2 inches high. There was nothing in the window to secure the opening of the window to prevent it from opening to that distance. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated [DATE], that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -A referral form that indicated: From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of Resident #172's medical record indicated the following: -A daily skilled nursing note dated 6/4/25 indicating Resident #172 was attempting to push on doors and open windows. -Resident #172 was documented as having wandering behaviors on 6/5/25 and 6/7/25. -A nursing note dated 6/7/25 indicating Resident #172 attempted to elope from the facility by the window twice. -A social service note dated 6/6/25 indicating Resident #172 was admitted to the facility after a psychiatric hospitalization for irritability and altered mental status. The note failed to include the Resident's history of attempting to elope out of a window. Review of Resident #172's elopement and wandering care plan created on 6/4/25, failed to indicate an individualized care plan for Resident #172's history of elopement through windows. Interventions that were included on the care plan, all initiated on 6/4/25, were: -Clearly identify Resident's room and bathroom. -Engage Resident in purposeful activity. -Identify if there are triggers for wandering/eloping. -Identify if there is a certain time of day wandering/elopement attempts occur. -Identify if there is a pattern and purpose of wandering. -Provide care in a calm and reassuring manner. -Provide clear, simple instructions. -Provide reorientation to surroundings. -Wander guard (a bracelet worn to activate an alarm if exiting through the doors or elevator of the unit) placed to left ankle. The care plan failed to include any revisions/updates for interventions after actual elopement attempts by the Resident. Observations of the facility indicated the wander guard system was only placed on doors and elevators and was not on any of the windows in the facility. During interviews on 6/8/25 at 6:56 A.M., and 6/10/25 at 6:52 A.M., Nurse #1 said he was aware Resident #172 had a history of attempting to jump out windows and while at this facility, the Resident had attempted to open and exit the second-floor dining room window on 6/6/25 and 6/7/25. Nurse #1 said the Resident had also opened the balcony door off the dining room on 6/6/25 and had gone over to the edge of the balcony and needed to be pulled from the edge. Nurse #1 said he did not notify the provider or management of these incidents. On 6/8/25 an observation of the second-floor dining room window at 7:50 A.M., the window was observed to be able to open 22.5 inches wide and 4 feet 7 inches high. During an interview on 6/8/25 at 6:59 A.M., CNA #1 said she had noticed that the second-floor dining room window was open from the left side so she barricaded the window with tables and chairs so Resident #172 could not have access to the window. CNA #1 said she did not know how else to secure the window from being able to open to the width a person would be able to get out of. During an interview on 6/8/25 at 7:17 A.M., a resident who was sitting in the second-floor hallway said he/she had witnessed Resident #172 exit the dining room and go onto the outside balcony on 6/6/25 and saw the nurse have to run out onto the balcony to grab the Resident. During an interview on 6/8/25 at 7:35 A.M., Nurse #1 said he was aware the Director of Nursing secured the second-floor window on the right side but failed to secure the left side of the window and that no one assessed Resident #172's window to see if it was secure and unable to open. During an interview on 6/8/25 at 7:32 A.M., when asked about the windows being secure on the second floor, Nurse #2 said there was a dining room window that could open all the way on the left side of the window. Nurse #2 said he was unsure why the full window was not secured. Nurse #2 also said he was unsure why Resident #172's bedroom window was not secured given his/her elopement history. Nurse #2 said he felt the facility was not prepared for this patient due to the high risk of elopement. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said no one from the administration came to the unit to offer her or the other staff guidance or education on how to manage these behaviors and that this would have been very helpful. She said the staff provided constant supervision to the Resident for the entirety of the shift as the intervention of the exit seeking behavior. During an interview on 6/8/25 at 9:09 A.M., the Administrator said he received a call at 7:00 A.M. that Resident #172 had fallen out of his/her bedroom window. The Administrator said Resident #172 was a new admit to the facility and had dementia and was confused with a history of behaviors. The Administrator said the Resident recently displayed behaviors of yelling, swinging arms and banging on the walls and said the Resident wanted out and was assessed as being high risk for elopement. The Administrator said he was unaware of Resident #172's previous elopement history, including his/her attempt to elope from a third-floor window at a previous facility as he did not read the Resident's pre-admission paperwork. The Administrator said that the Resident did elope from the first floor on 6/4/25 and made it around the building to the back parking lot and was then moved to the second floor. He said he was also aware that on 6/6/25, Resident #172 was able to exit the second-floor dining room onto the balcony through a door that is supposed to be always locked. The Administrator said he was unsure how the door was unlocked as that is a safety risk and asked maintenance to immediately lock it. The Administrator said he had not received any calls over the weekend regarding Resident #172's increased behavior and attempt to elope from the second-floor dining room windows twice on 6/7/25. The Administrator said maintenance should check all the windows and doors for safety and he believes there was a specific audit for window safety that had been completed, and he would look for that audit. During an interview on 6/9/25 at 1:33 P.M., the Administrator said the clinical liaison who interacts with the hospital does the initial admission screening, then speaks with the admission coordinator at the facility. The Administrator said this screening process is in place to ensure the facility can clinically and safely take care of the residents. The Administrator says he has little involvement in looking at the preadmission screens as he trusts the Director of Nursing to do this. The Administrator said elopements are not something he has had a great deal of experience with as it has been many years since he has had a building with a locked unit. He said he believed the facility would be able to clinically care for Resident #172 at the time of his/her admission; however, he was not aware of the Resident's prior elopement attempts. The Administrator said he was aware Resident #172 had eloped from the building, had gotten out onto the second-floor balcony and had banged on windows, however, he said he was unaware the Resident had attempted to open and climb out a second floor window on other occasions. The Administrator said he would have expected any elopement attempts or safety concerns to be reported to him as it is his responsibility for all residents' safety. When asked about his system for ensuring the windows of the facility are secure, the Administrator said he had asked his maintenance director to complete an audit in March 2025 to check all windows and ensure they could not open more than four inches. The Administrator said he did not receive a formal audit from the maintenance director and took his word that it had been completed. During an interview on 6/10/25 at 7:35 A.M., the Case Manager in charge of admissions from the hospital was interviewed. The Case Manager said she helps coordinate Resident #172's admission to the facility and was aware that the Resident was in the hospital for psychiatric concerns and had attempted to elope from a window at a previous facility. The Case Manager said she sent all of the preadmission paperwork and the Resident's clinical history/information to the facility to ensure the facility would be able to handle the patient. During an interview on 6/10/25 at 9:01 A.M., the Admissions Coordinator said she was aware of Resident #172's prior attempt to elope from a window prior to his/her admission to the facility and did not tell the Administrator and did not have a conversation with anyone in the building to ensure the windows were secure. During an interview on 6/11/25 at 8:17 A.M., the Maintenance Director said he was asked to complete a window audit in March 2025, and he delegated his task to his assistant, asking him to ensure the windows could not open more than 4 inches. The Maintenance Director said he was never given a formal audit showing that his assistant completed this task, but he took his word for it. The Maintenance Director said he was never told to check the second-floor dining room door to the outside balcony, and he had never been told to add that door to his daily safety check. During an interview on 6/11/25 at 8:29 A.M., the Maintenance Assistant said he was assigned the task to audit all windows in March 2025, and he did this task but did not write down the results on a formal audit form. The Maintenance Assistant said he was aware that the window in Resident #172's room could open all the way, and he did not go back to ensure that it was secure. The Maintenance Assistant said the door to second-floor dining room is not on a daily safety check list and he was never told to check the door after the fact. During an interview on 6/11/25 at 11:18 A.M., the Administrator said he was unaware the window in Resident #172's bedroom was able to open all the way and that the maintenance assistant was aware of this. During an interview on 6/9/25 at 8:44 A.M., Physician #1 said he is the medical director of the facility and would have expected the facility to have a plan to ensure safety for residents admitted with a high risk and history of elopement. 2. Review of ten employee records indicated the following: -Eight out of ten employees had no dementia training. Five of these employees were newly hired and did not have the required 8 hours of dementia training. Three out of the five employees had been employed at the facility for over a year and did not have the required four hour yearly dementia training. -Four out of five employees who had been employed at the facility for more than a year had not completed annual education or competencies for caring for residents with dementia and a risk of elopement. During an interview on 6/10/25 6:52 A.M., Nurse #1 said the facility had never given the staff guidance or education on handling residents with a high elopement risk. Nurse #1 said the staff felt stuck because they didn't have guidance on how to manage extreme behaviors, such as residents who are attempting to elope from windows. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the day of Resident #172's admission and that the Resident was constantly trying to elope from the building by pushing on door, elevators and windows. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said no one from administration came to the unit to offer her or the other staff guidance of education on how to manage these behaviors and that this would have been very helpful. During an interview on 6/8/25 at 9:09 A.M., the Administrator said all staff should have direct knowledge on how to manage residents with dementia who have a risk of elopement. The Administrator said nursing staff are expected to complete education upon hire, annually and as needed. The Administrator said the Assistant Director of Nursing is responsible for staff education. During an interview on 6/10/25 at 11:50 A.M., the Assistant Director of Nursing (ADON) said he was hired within the last 30 days and did not have a chance to meet with the prior staff educator to understand the level of education previously provided to the staff. The ADON said that he is responsible for all new hire education and dementia training. The ADON said he was unaware the staff reviewed did not have annual competencies/education or dementia training. During an interview on 6/12/25 at 10:02 A.M., the Administrator said he was unaware that there was no annual education provided to the nursing staff last year. The Administrator said he had asked the previous nursing leadership to complete education and he had observed some ad hoc education occurring on the floor and assumed all education was being provided. 3. Review of the Facility Assessment, most recently updated on 4/18/25, indicated the following: -The purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Use this assessment to make decisions about your direct staff needs (including those who provide services under contract and volunteers), as well as your capabilities to provide services to the residents in your facility, at least annually and as necessary, per the above requirement. Using evidence-based, data driven methods focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. - If the facility is less familiar with or has not previously provided care for diagnosis of potential admission, the IDT team will review the details of the referral's requirements for care prior to admission. The review will consist of matching the care needs of the residents to the current skill set of the staff. Any shortfalls in skill and knowledge sets will be identified. Educational opportunities for staff education and training to overcome the skill set lack will be identified and taken advantage of. Training will be provided by nursing management or by vendors of specific medical products the staff are not familiar with. -The facility created a grid of common diagnoses residents are admitted with. The list of diagnoses under the Mental and Behavioral Health sections listed behavior that needs interventions as a diagnosis the facility is able to admit. -The facility created a grid of resident care needs. Under the Mental Health and Behavior care area, the facility lists the following as areas of resident care provided by the facility: manage the medical conditions and medication-relates issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (post traumatic stress disorder), other psychiatric diagnoses, intellectual or developmental disabilities. -The staff are provided with training/education which includes how to care for residents with a diagnosis of dementia. -The staff are provided with competency training on disaster planning and procedures, which includes competency on elopements. The facility assessment failed to indicate the facility cared for a resident population with an increased risk of elopement. The assessment also failed to indicate caring for residents who are at risk for elopement was part of their staff training. During an interview on 6/10/25 at 12:37 P.M., the Administrator said he has written a lot of facility assessments over the years and did not think the elopement risk of the population was something that needed to be included in the assessment. The Administrator said every resident with dementia is at risk for elopement and the facility has a lot of residents with wander guards (a bracelet worn by the resident that triggers an alarm if a resident were to open a door or elevator) so that would indicate there is a risk for elopement. The Administrator said it was his responsibility to ensure the residents of the building were safe, including ensuring the windows are secure as listed in the facility assessment.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she required two staff members for assistance with bed mobility, which included turning and repositioning when in bed, and for incontinence care, the Facility failed to ensure staff implemented and followed interventions identified in his/her care plan, when on 03/11/24 Certified Nurse Aide (CNA) #1 provided care to Resident #1 unassisted by another staff member, Resident #1's upper body rolled off the bed, and his/her head hit the floor. Resident #1 was transferred to the Hospital Emergency Department and diagnosed with a sinus fracture and subdural hematoma (pool of blood between the brain and the outermost covering) Findings include: The Facility Policy, titled Comprehensive Care Plans, dated 07/2023, indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's needs would be developed for each resident, and each resident's care plan would be designed to incorporate identified problem areas, risk factors, and aid in preventing or reducing declines in the resident's functional status and functional levels. Resident #1 was admitted to the Facility in January 2018, diagnoses included colitis, encephalopathy, dementia, hematuria, and stroke. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as revised on 11/08/23, indicated he/she was totally dependent and required two staff members for bed mobility, to turn and reposition in bed, and for incontinence care. Review of Resident #1's Electronic Care Card (allows Facility staff nurses and CNAs to get a comprehensive picture of a resident's needs), in effect at the time of the incident, indicated Resident #1 was totally dependent and required assistance of two staff members for bed mobility, including being turned and repositioned in bed, and two staff members for assist with incontinence care. Review of the Nurse Progress Note, dated 03/11/24, indicated, at 10:28 A.M., Certified Nurse Aide (CNA) #1 requested that Nurse #1 assess Resident #1, that Resident #1 had an abrasion on the left side of his/her nose, and had vomited. The Progress Note indicated Resident #1 was transferred to the Hospital Emergency Department via 911. Review of the Facility's Internal Investigation, undated, indicated that on 03/11/24, CNA #1 did not follow Resident #1's plan of care for the need of two staff members to assist with bed mobility, and as a result Resident #1 sustained a fall from the bed, resulting in a sinus fracture and subdural hematoma. Review of the Hospital Discharge Summary, dated 03/13/24, indicated that Resident #1 was admitted to the Hospital via the Emergency Department on 03/11/24, and was diagnosed with a sinus fracture and subdural hematoma. During a telephone interview on 04/01/24 at 12:23 P.M., Certified Nurse Aide (CNA) #1 said that on 03/11/24 at 10:15 A.M., he was providing care for Resident #1 by himself, and when he rolled Resident #1, (who was in bed which did not have side rails), away from him, Resident #1's upper body slid off the side of the bed, which was about 3 feet from the ground. CNA #1 said he held Resident #1's legs and hips and pulled him/her back onto the bed, but said that Resident #1's head hit the floor during this event. CNA #1 said he knew how to access and review residents's electronic care cards, and that he regularly cared for Resident #1, and was familiar with his/her plan of care. CNA #1 said he knew that Resident #1's Plan of Care indicated he/she required two staff members be present to assist to move him/her in the bed, and said he did not have another staff member help him roll Resident #1 in bed that day. During a telephone interview on 04/05/24 at 12:05 P.M., Nurse #1 said that on 03/11/24, sometime between 10:20 A.M., and 10:27 A.M., CNA #1 told her Resident #1 did not feel well. Nurse #1 said she went immediately to assess Resident #1, who was in bed, and said he/she had a large bruise between his/her eyebrows, and was bleeding from his/her nose and mouth. Nurse #1 said Resident #1 was sent to the Hospital Emergency Department via 911. During an interview on 04/01/24 at 8:04 A.M., the Assistant Director of Nurses (ADON) said that on 03/11/24 sometime after 10:00 A.M., (exact time unknown) she was called to Resident #1's room, said Resident #1 had a bump in the middle of his/her forehead, and that Resident #1 said he/she fell . The ADON said Resident #1 had little to no use of his/her legs and required two staff members for bed mobility. The ADON said CNA #1 should have followed Resident #1's plan of care to have two staff members for bed mobility, and should have had another staff member with him to provide care for Resident #1, but did not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members for assistance with bed mobility which included turning and repositioning, and required assistance of two with incontinence care, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety, when on 03/11/24, Certified Nurses Aide (CNA) #1 provided care for and repositioned Resident #1 in bed without assistance from another staff member, Resident #1 rolled off the side of the bed, and his/her head struck the floor. Resident #1 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with a sinus fracture and subdural hematoma (pool of blood between the brain and outermost covering). Findings include: The Facility Policy, titled Supporting Activities of Daily Living, dated 09/2019, indicated appropriate care and services would be provided for residents who were unable to carry out Activities of Daily Living (ADLs) independently, in accordance with the plan of care, including appropriate support and assistance with hygiene and mobility. The Policy indicated interventions to improve or minimize a resident's functional abilities would be in accordance with the resident's assessed needs and recognized standards of practice. Resident #1 was admitted to the Facility in January 2018, diagnoses included colitis, encephalopathy, dementia, hematuria, and stroke. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as revised on 11/08/23, indicated he/she was totally dependent and required two staff members for bed mobility, which included turning and repositioning in bed, and an assist of two for incontinence care. Review of Resident #1's Electronic Care Card (allows Facility staff nurses and CNAs to get a comprehensive picture of a resident's needs), in effect at the time of the incident, indicated Resident #1 was totally dependent and required assistance of two staff members for bed mobility, including being turned and repositioned in bed, and required two staff members for assistance with incontinence care. Review of the Nurse Progress Note, dated 03/11/24, indicated, at 10:28 A.M., Certified Nurse Aide (CNA) #1 requested that Nurse #1 assess Resident #1, that Resident #1 had an abrasion on the left side of his/her nose, and had vomited. The Nurse Progress Note indicated Resident #1 was transferred to the Hospital Emergency Department via 911. Review of the Facility's Internal Investigation, undated, indicated that on 03/11/24, CNA #1 did not follow Resident #1's plan of care for two staff members for bed mobility, and as a result Resident #1 sustained a fall from the bed, resulting in a sinus fracture and subdural hematoma. Review of the Hospital Discharge Summary, dated 03/13/24, indicated that Resident #1 was admitted to the Hospital via the Emergency Department on 03/11/24, and was diagnosed with a sinus fracture and subdural hematoma. During a telephone interview on 04/01/24 at 12:23 P.M., Certified Nurse Aide (CNA) #1 said that on 03/11/24 at 10:15 A.M., he was providing care for Resident #1 by himself, and when he rolled Resident #1, (who was in bed which did not have side rails) away from him, Resident #1's upper body slid off the side of the bed, which was about 3 feet from the ground. CNA #1 said he held onto Resident #1's legs and hips and pulled him/her back onto the bed, but said Resident #1's head hit the floor during this event. CNA #1 said he regularly cared for Resident #1, and was familiar with his/her care needs. CNA #1 said he knew Resident #1 required two staff members to move him/her in the bed, but said he did not have any other staff member help him provide care to Resident #1 that day. During a telephone interview on 04/05/24 at 12:05 P.M., Nurse #1 said that on 03/11/24, sometime between 10:20 A.M., and 10:27 A.M., CNA #1 told her Resident #1 did not feel well. Nurse #1 said she went immediately to assess Resident #1, who was in bed, and noted he/she had a large bruise between his/her eyebrows, and was bleeding from his/her nose and mouth. Nurse #1 said Resident #1 was sent to the Hospital Emergency Department via 911. During an interview on 04/01/24 at 8:04 A.M., the Assistant Director of Nurses (ADON) said that on 03/11/24 sometime after 10:00 A.M., (exact time unknown) she was called to Resident #1's room, said Resident #1 had a bump in the middle of his/her forehead, and that Resident #1 said he/she fell . The ADON said Resident #1 had little to no use of his/her legs and required two staff members for bed mobility. The ADON said CNA #1 should have had another staff member with him to provide care for Resident #1, but did not.

Based on observations, record review and interview the facility failed to ensure services to prevent a contracture from worsening were implemented for 1 Resident (#21) out of a total sample of 21 residents. Findings include: Resident #21 was admitted to the facility in September, 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Minimum Data Set Assessment, dated 3/16/22 indicated Resident #21 was cognitively intact, was dependent on staff for bed mobility, transfers, hygiene, toilet use, bathing, and had functional limitation of range of motion for the upper and lower extremities on one side. On 5/10/22 at 8:28 A.M., Resident #21 was observed resting in bed. His/her left hand was bent at the wrist and his/her fingers were in a fist with his/her thumb under the other fingers. Resident #21 used his/her right hand to gently open his/her fingers. His/her wrist did not open, and the fingers opened some and closed back up into a fist. Resident #21 said he/she had a splint before at the other place (nursing home), but they could not find it. Further interview on 5/10/22 at .11:42 A.M., Resident #21 said he/she had a device for his/her left hand but did not recall having it here. Resident #21's left wrist and hand were folded in tightly. No device was observed in the Resident's general area. On 5/11/22 at 2:36 P.M. review of Resident #21's medical orders did not indicate the use of any splint/device or orthotic. On 5/11/22 at 3:18 P.M., the surveyor observed Resident #21 resting in bed. His/her left hand was bent at the wrist and his/her fingers were folded in a fist. During an interview on 5/11/22 at 3:30 P.M., the Director of Rehabilitation (DOR) said that Resident #21 was on rehab services back in November 2021 and worked on wearing and met the goal of tolerating a resting hand splint for up to three hours a day. The DOR said the nursing staff and CNAs were provided education on how to don (put on) and doff (take off) and a schedule for the splint use. At this time, the DOR accompanied the surveyor to Resident #21's room. With the consent of Resident #21 the DOR looked for the resting hand splint. The DOR located the splint in the bedside table. Resident #21 said he/she had not seen that (the splint) in long time. The DOR asked Resident #21 if he could apply the splint. The splint was observed to have finger separators. After completing passive range of motion, the DOR was able to gently open Resident #21's fingers but his/her fingers would not stay in place between the finger separators and Resident #21's wrist remained bent at the wrist. When asked why the fingers did not stay in place the DOR said the Resident's fingers were tighter, and he would have the occupational therapist see Resident #21 and maybe a soft roll hand splint could be used instead. The DOR said the Occupational therapist and the Resident worked hard to have Resident #21 be able to tolerate the hand splint. Review of the Occupational Therapist (OT) Progress and Discharge Summary document dated 11/12/21 indicated the following: * Orthotic, caregiver will appropriately don and doff resting hand splint orthotic to left upper extremity and monitor skin for effective hand contracture prevention. *At the end of care, Resident #21 was able to tolerate a left hand orthotic for 3 hours. *A discharge recommendation to continue to wear the resting hand orthotic after discharge from OT. Review of all physician's s orders active and discontinued since 11/1/21 through present did not indicate the presence of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission assessment dated [DATE] did not indicate the use of a left-hand resting splint. Review of Resident #21's care plans indicated a care plan for [CONDITION(S)] due to [CONDITION(S)] disease, dated 9/29/21 did not indicate the use of the resting hand splint as an intervention. The Activities of Daily living care plan did not have the intervention of a resting hand splint as an intervention. On 5/12/22 at 7:44 A.M., Resident #21 was observed resting in bed. His/her left hand was bent at the wrist and his/her fingers were in a fist and held firmly to his/her side. During an interview on 5/12/22 at 7:47 A.M., CNA #4 said he has cared for the Resident since she was transferred from another nursing home. CNA #4 said Resident #21 left side is impaired and that he did not apply any devices to his/her left hand. CNA #4 said he did not receive education from therapy to apply a hand splint on the resident. During an interview on 5/12/22 at 10:01 A.M, the DOR said Resident #21 was admitted with elbow, shoulder, and left-hand contracture. He said the plan was for Resident #21 to wear the device during the day shift up to three hours a day and staff were to don and doff the splint. He said the purpose of the splint was to maintain the contracture and prevent it from getting worse. The DOR said the use of the splint should have been established as an order and that the use of the splint should have been on the contracture care plan. The DOR said Resident #21 does have anxiety and will not always accept treatment. The DOR said the non-use of the splint could result in worsened contractures. He said when he tried to put the splint on yesterday the wrist was at 90 degrees and he believe Resident #21 could range at 60 to 70 degrees before, which would indicate the contracture worsened.

Based on observation, record review and interviews, the facility failed to effectively manage pain for 1 Resident (#265) out of a total sample of 21 residents. Findings include: Review of the policy titled Pain management revised 4/18 indicated the following: *The pain management program is based on a facility-wide commitment to resident comfort. * Pain management is defined as the process of alleviating the resident's pain and is based on his or her clinical condition and established treatment goals. *Pain management is a multidisciplinary care process that includes the following: a) Assessing the potential for pain b) Effectively recognizing the presence of pain c) Identifying the characteristics of pain d) Addressing the underlying causes of pain e) Developing and implementing approaches to pain management f) Identifying and using specific strategies for different levels and sources of pain g) Monitoring for the effectiveness of interventions h) Modifying approaches as necessary *Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is an onset of new pain or worsening of existing pain. *Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. *Recognizing pain: a) Use pain scale and PAINAD for non-verbal signs of pain. b) Possible behavioral signs of pain, verbal expressions such as groaning, crying and screaming. c) Facial expressions such as grimacing, frowning, clenching of the jaw, etc. Resident #265 was admitted to the facility in May, 2022 with the following diagnoses, [CONDITION(S)] of right lower limb, [CONDITION(S)] of right ankle and foot, [CONDITION(S)] of right ankle and foot, person injured in unspecified motor vehicle accident, low back pain, and peripheral autonomic [CONDITION(S)]. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score (BIMS) score of 15 out of a possible 15 indicating intact cognition. On 5/10/22 at 9:18 A.M., Resident #265 told the surveyor he/she has a history of pain due to a car accident and other diagnoses. Resident #265 told the surveyor before he/she was discharged from the hospital, his/her discharge planner called the facility to make sure they had all his/her medication including pain medication prior to his/her arrival. The facility told the discharge planner they had all of Resident #265's pain medication. Resident #265 told the surveyor he/she had not been given any pain medication since he/she was admitted . He/she was wincing in pain while speaking to the surveyor. Resident #265 told the surveyor he/she had requested pain medication several times during the night. Review of Resident #265's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Gabapentin tablet 800 MG(milligrams)-give 1 tablet by mouth four times a day related to peripheral autonomic [CONDITION(S)]. *Tylenol tablet 325 MG (milligrams) (acetaminophen)-give 3 tablets by mouth 3 times a day for pain for 10 days. *[MEDICATION(S)] HCI tablet 5 MG (milligrams)- give 5 tablets by mouth every 4 hours as needed for severe pain. *[MEDICATION(S)] film 4-1 MG(milligrams) ([MEDICATION(S)] HCI([MEDICATION(S)])-[MEDICATION(S)] HCI([MEDICATION(S)]))-give 2 films sublingually two times a day for analgesics-opioid, place 2 films under the tongue. During an interview with Nurse #4 on 5/11/22 at 7:43 A.M., she said Resident #265's medication prescriptions were faxed to the pharmacy on 5/9/22. There was no response from the pharmacy. Another new set of pharmacy prescriptions were faxed to the pharmacy on 5/10/22 after the nurse practitioner met with Resident #256. During an interview with Nurse #5 on 5/11/22 08:07 A.M., Nurse #5 said that she tried to access the emergency kit on 5/9/22. She contacted the doctor, got the code to the emergency kit and tried to reach out to the pharmacy with no success. Review of the pain assessment interview completed on 5/9/22 indicated the following, Resident #265 had pain in the last 5 days, he/she had experienced pain constantly in the last 5 days, the pain has made it hard for him/her to sleep in the last 5 days, he/she has had to limit activity in the last 5 days due to pain, on a numeric rating scale of 1-10, Resident #265 indicated a 7 out of 10, he/she had a pain scale with a verbal descriptor of very severe and horrible pain. Review of the May 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *Gabapentin tablet 800 MG (milligrams), give 1 tablet by mouth four times a day, given on 5/10/22 at 8:00 AM (a delay of 16 hours) 12:00 PM, 4:00 PM and 10:00 PM. *Tylenol tablet 325 MG (milligrams) (acetaminophen), give 3 tablets by mouth three times a day for pain for 10 days, given on 5/10/22 at 8:00 AM (a delay of 16 hours), 2:00 PM with a pain level of 8 out of 10, and 9:00 PM. *[MEDICATION(S)] HCI tablet 5 MG(milligrams) by mouth every 5 hours as needed, given on 5/11/22 at 7:00 A.M., (a delay of 1 day, 15 hours) with a pain level of 8 out of 10. *[MEDICATION(S)] film 4-1 MG (milligrams) ([MEDICATION(S)] HCI ([MEDICATION(S)])-[MEDICATION(S)] HCI([MEDICATION(S)])), give 2 films sublingually two times a day for analgesics-opioid, given at a hospital emergency roiagnom on [DATE] at 5:00 P.M., (1 day, 1 hour delay) after Resident #265 was sent there after he/she started showing signs and symptoms of withdrawals, as noted in a nursing progress note dated 5/10/22 at 5:07 P.M. During an interview with Resident #265 on 5/11/22 at 7:26 A.M., he/she told the surveyor he/she was very upset that he/she was not getting the care he/she thought he/she would, he/she was sent to a hospital emergency room yesterday afternoon to get a dose of [MEDICATION(S)] because the facility pharmacy had not delivered his/her medication. During an interview with Resident #265 on 5/11/22 at 7:37 A.M., he/she told the surveyor he/she will be leaving the facility against medical advice to go see his/her primary care physician in the community, the facility pharmacy did not deliver all his/her pain medication this morning. Resident #265 was moaning off and on in pain during this conversation with the surveyor. During an interview with Nurse #4 on 5/11/22 at 7:43 A.M., she said the pharmacy delivered Resident # 265's [MEDICATION(S)] at 6:30 AM in the morning, the pharmacy did not deliver the rest of Resident #265's medication as requested. Resident # 265 did get a PRN dose of [MEDICATION(S)] at 7:00 A.M.,(as indicated in the medication administration record). On 5/11/22 at 8:00 A.M., Resident #265 signed out of the facility against medical advice. During an interview with the clinical assistant director of nursing (ADON) on 5/11/22 at 1:35 P.M., she acknowledged that Resident #265's pain was not managed effectively during his/her stay in the facility, the facility should have made sure all his/her pain medication was available at admission, or made sure staff were able to access the emergency kit.