Every finding on record at Serenity Estates of Lincolnshire

Based on observation, interview and record review the facility failed to ensure food was served at a palatable temperature. This applies to all 125 residents who reside at the facility. The findings include:The Resident Census Report printed on 8/12/26 shows that there are 125 residents who reside at the facility.On 8/12/26 at 12:01 PM, the noon meal was brought to the 500 unit and placed on a steam table. This serving area plates meals for the 400, 500, and 600 unit. The plate warmer on the unit was not on and was not warm. At 12:10 PM, the 400 unit trays were prepared. The food was plated and placed on an open rolling cart. Some of the plates were covered with plastic (non-insulated) covers. At 12:21 PM, the 500 unit trays were prepared and placed on an open rolling cart. Some of the plates were covered with plastic (non-insulated) covers and five of the trays were left uncovered due to running out of covers on the unit. At 12:28 PM, the 600 unit trays were prepared and place on an open rolling cart. A test tray was plated at that time. The tray was placed on the rolling cart and covered with an insulated cover. The first meal tray for the 600 unit cart was delivered at 12:45 PM and the last tray was delivered at 12:51 PM. At 12:53 PM, temperatures of the test tray were taken and the pasta was 109 degrees Fahrenheit and the vegetables were 108 degrees Fahrenheit. The food tasted luke warm and was not an appetizing temperature. On 8/12/26 at 10:00 AM, R2 said that the food is always cold when it is served. On 8/12/26 at 9:40 AM, R4 said that the food is cold 95% of the time. At 12:31 PM, R4's tray was delivered to her room and was covered with a plastic (non-insulated) cover. R4 said that the food was warmer than usual but still cold. On 8/12/26 at 12 :38 PM, V6 (Dietary Aide) that was serving the noon meal) said that the plate warmer is broken and won't turn on. V6 said that it has been that way for at least a year. V6 said that the other plate warmer on the other unit gets too hot so she is unable to use that one as well. On 8/12/26 at 1:47 PM, V7 (Dietary Manager) said that to ensure food is kept at an appetizing temperature, they utilize warm plates and cover the food with an insulated lid and the food should be served within 20 minutes of being plated. V7 said that that they have 3 units that they serve from. V7 said that he is aware of the issues with the two plate warmers. V7 said that he is going to be purchasing additional insulated covers because currently they do not have enough insulated covers to serve all of the residents. V7 said that he has had 1-2 residents complain about cold food. V7 said that by the time they transfer the food to the rooms, it is sometimes room temperature. A Concern Form dated 6/6/26 in regards to R1 shows, Several occasions, meal trays are delivered ice cold rather than appropriate temperatures.The facility's Food Preparation Guidelines Policy shows, Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature.Serve hot foods/drinks hot.

Based on interview and record review the facility failed to have sufficient staff on a nursing unit to provide care for residents on 7/12/26. This applies to 14 of 17 residents (R1, R4-R16) reviewed for staffing in the sample of 17. The finding including:On 7/17/26 R1 stated, On that day (7/12/26) I was laying here and there was no one around. I was trying to call the front desk, and no one was answering the phone. So, I called the police, 911. The police came to my room. I always give them my name and my room number so they can find me. He came in and said, How can I help you? I told him I want to get up but I can't get out of my bed by myself. I think he then went out the door, and I am not sure who showed up after that. (Surveyor explained that the police report states 2 staff came to assist her) R1 stated, That is very unusual because it is hard enough to get one. R1 could not remember any more details regarding this situation and began complaining about other things. The Police Report dated 7/12/26 states, On July 12, 2026, at approximately 7:19 AM, I was dispatched to a check wellbeing at (Facility) (Resident's Room Number). The caller (R1) told dispatch she was unable to get out of bed, called for help, and no one was coming to help her. Dispatch called the main number and the after- hour number for (Facility) with no answer from staff. Upon arrival I went to (R1's) unit and arrived as approximately 7:30AM. I went to room (R1's room number) and contact with (R1). (R1) stated she pushed her call button for help several times and so staff member came to help her get out of bed. (R1) needs assistance to get out of bed. I checked the area and was unable to find any medical staff member in (R1's) unit. I made contact with a staff member in another unit who called twice for staff to assist (R1) but no one came. At approximately 7:35AM (V8-LPN) arrived in (R1's) unit. (V8) stated he was scheduled to start work at 7:00AM but arrived late to work today. The previous staff's shift ended at 7:00AM. There was a certified nursing assistant (CNA) who was also assigned to the unit, but she was also late to work and did not arrive by the time I left . On 7/17/26 the timecards were reviewed for the staff who worked on the R1's unit on 7/12/26. This review showed the following:V11 (Night shift LPN) working on R1's Unit from 7/11/26-7/12/26 punched out at 7:06AMV8 (Day Shift LPN) working on R1's Unit on 7/12/26 punched in at 7:33AM (showing there was no nurse on the unit for 27 minutes)V10 (Night Shift CNA) working on R1's unit on 7/11/26- 7/12/26 punched out at 7:10AM V9 (Day Shift CNA) working on the R1's unit on 7/12/26 punched in at 8:06AM (showing there was no CNA on the unit for 56 minutes)On 7/17/25 at 2:00PM Surveyor explained the above information and V1 (Administrator) stated she was not aware that staff left early and came in late. V1 stated she was aware that R1 had called the police and that the police had come to the facility because R1 needed help to get out of bed, but she did not realize that there were no staff on the floor. V1 stated that when calls are made to the facility and there is no receptionist then the calls are forwarded to the nurse's station, and the nurses should be answering the phone. V1 also stated that R1 has called the police many times since being at the facility and it is a behavior of hers. On 7/17/26 at 12:00PM V6 (Human Resources) stated, The staff from one shift is not supposed to leave until the next shift staff arrives.The Facility Census/Roster shows that R1 and R4-R16 were residing on the affected unit on 7/12/26.

Based on observation, interview and record review the facility failed to ensure timely administration of medications prescribed to control symptoms related to Parkinson's disease, and failed to ensure a resident's medication for restless leg syndrome was administered as ordered for 2 of 3 residents (R2 and R3) reviewed for care and services in the sample of 17.The findings include:1. R2's Physician Order Sheet (POS) dated 7/2026 show R2 has diagnoses that include Parkinson's Disease. The same POS show R2 has an order of Sinemet (Carbidopa/Levodopa) extended release 25/100 milligram (mg) give 2 tablet four times a day to be given at 10AM, 2PM, 6PM and 10 PM. Give Sinemet with Acetaminophen (Tylenol) 325 mg 2 tablets to be given at the same time- 10AM, 2PM, 6PM and 10PM.R2's facility assessment dated [DATE] shows R2 has no cognitive impairment.On 7/17/26 at 9:20 AM, R2 was in bed alert and pleasant. R2 stated her biggest concern was that her Parkinson's medication and acetaminophen (Tylenol) were being given to her late. R2 said she had waited for hours for her Parkinsons medication and Tylenol when it was due. R2 said she has had Parkinson's disease for many years and that her doctors have told her how important it is to receive her medications on time to help manage her Parkinson's symptoms. R2 said when her medications were given late, she can feel the effects- including increased tremors, her muscles get stiff, she moves slower, she can feel more pain, and it was harder to swallow. R2 said when she receives her medications as scheduled, it helps her function better, less pain and manage her Parkinsons symptoms better. R2 also showed this surveyor a document that was given to her years ago when she was newly diagnosed with Parkinsons that R2 keeps in her overbed table. The document shows, I have Parkinson's Disease. I need my medications on time, every time, otherwise my Parkinson's symptoms may become severe and uncontrollable.R2 medications as ordered: Sinemet 25-100(Carbidopa Levodopa) 2 tablet 4x a day to be given at 10AM, 2PM, 6PM and 10PM. Acetaminophen (Tylenol) 325 mg 2 tablet four times a day to be given with Sinemet (10AM, 2PM, 6PM and 10PM)R2's medication audit report shows:On 7/3/26, R2's Sinemet 25-100 (Carbidopa Levodopa) and Tylenol 325 mg 2 tablet, the 10 am dose was given at 12:21 PM (more than 2 hours late)On 7/6/26, R2's Sinemet 25-100 (Carbidopa Levodopa) and Tylenol 325 mg 2 tablet, the 10 am dose was given at 11:39 AM (1 hour and 30 minutes late)On 7/9/26, R2's Sinemet 25-100 (Carbidopa Levodopa) and Tylenol 325 mg 2 tablet, the 10 PM dose was given at 23:36 [11:36 AM] (1 hour and 36 minutes late)On 7/12/26, R2's Sinemet 25-100 (Carbidopa Levodopa) and Tylenol 325 mg 2 tablet, the 10 am dose was given at 11:23 AM (1 hour and 23 minutes late)On 7/13/26, R2's Sinemet 25-100(Carbidopa Levodopa) and Tylenol 325 mg 2 tablet, the 2PM dose was given at 15:38 [3:38 PM] (1 hour and 38 minutes late)On 7/16/26, R2's Sinemet 25-100(Carbidopa Levodopa) and Tylenol 325 mg 2 tablet, the 10 AM dose was given at 13:25 [1:25 PM] 3 hour and 25 minutes late)On 7/16/26, R2's Sinemet 25-100(Carbidopa Levodopa) and Tylenol 325 mg 2 tablet, the 6PM dose was given at 23:39 (11:39 PM) (5 hours and 39 minutes late)On 7/17/26 at 12:34 PM, V5 (Nurse Practitioner) said Parkinson's medications are time sensitive and should be administered to the resident at the exact time ordered to help control the resident's Parkinson's symptoms. [R2's] Parkinson's medication is given with acetaminophen to help manage pain and support the residents comfort and function and overall quality of life.R2's care plan dated 4/5/26 show R2 has diagnosis of Parkinson's Disease with intervention to give medications as ordered. 2. R3's POS show R3 has diagnoses that include restless legs syndrome. On 7/17/26 at 10:10 AM, R3 was in bed alert and was able to verbalize her needs. R3 said she has neuropathy affecting her legs and experiences restless leg syndrome. R3 stated that she has been taking restless leg medication for 4-5 years now-Pramipexole Dihydrochloride 0.5 mg twice a day. When she was admitted to this facility, her restless leg medication was only given to her once a day, this has caused her discomfort and difficulty sleeping at night.On 7/17/26 at 11AM, V2 (Director of Nursing) said R3 was a transfer from another facility. R3's medication orders were carried over upon admission. This surveyor and V2 (DON) reviewed the R3's previous medication orders and noted that the Pramipexole Dihydrochloride 0.5 was ordered to be administered twice daily. However, when the medication was transcribed into R3's POS upon admit last 7/10/26, it was transcribed as once a day. V2 said she would follow up with R3's NP (V7) regarding the medication, the need to adjust the dosage to better control R3's restless leg symptoms to promote relief and improve her ability to rest and function.

Based on interview and record review the facility failed to ensure daily weight was performed as ordered for a resident with congestive heart failure (CHF). This failure resulted in R1's worsening heart failure condition causing fluid retention and shortness of breath requiring hospitalization for 1 of 3 residents (R1) reviewed for care and services in the sample of 3.The findings include:R1's electronic face sheet shows R1 was admitted to the facility with diagnosis that includes congestive heart failure.R1's Physician Order Sheet dated 5/20/26 show, monitor weight daily before breakfast. Notify MD of a 2 pounds (lbs.) weight gain in one day or 5 lbs. weight gain in one week.R1's Physician Order Sheet dated 5/20/26 shows, R1 was also on diuretics related to acute and chronic congestive heart failure. Spironolactone Oral Tablet 25 milligrams (mg) Give 1 tablet by mouth one time a day. Bumetanide Tablet 2 mg, Give 1 tablet by mouth two times a day. Furosemide Tablet 20 mg, Give 1 tablet by mouth one time a day. R1's Medication Administration Record for May and June 2026 showed he received all ordered diuretics.R1's medical record showed R1 was admitted on [DATE] and discharged to the hospital on 6/9/2026. (R1 resided at the facility for 26 days.)R1's weight record shows R1 was weighed one time (5/21/26) while at the facility. R1's weight was 420.5 lbs. (R1 was weighed only one time during his 26 day stay.)R1's weight record did not show an admission weight 5/15/26. R1 was not also weighed on 5/22, 5/23, 5/24, 5/25. 5/26, 5/27, 5/28, 5/29, 5/30,5/31, 6/1, 6/2, 6/3, 6/4, 6/5, 6/6, 6/7, 6/8 and 6/9.R1's facility assessment dated [DATE] did not show any behavior of R1 refusing to be weighed.R1's Emergency Department (ED) Hospital records dated 6/9/26 show [R1] presents to emergency department complaining of progressive weight gain, leg swelling and shortness of breath. Patients require 6 liters (l) of oxygen (upon arrival at the hospital). In the ED, chest x-ray shows cardiomegaly and pulmonary edema. R1 was given IV diuretics and admitted for further care. R1's admitting diagnosis of volume overload, c/f (concern for) heart failure exacerbation (worsening of CHF.) Treatments; diuretics and daily weights.The same hospital records documents that R1 was discharged to the skilled nursing facility after treatment of CHF last 5/15/26 with a weight of 389 lbs. R1 was readmitted from the skilled facility to the hospital last 6/9/26 with a weight of 439 lbs. now returns with 50 lbs. weight gain since discharge to the skilled facility last 5/15/26. The hospital records also show, per [R1] they mismanaged his care and the weight he lost prior to going to the skilled nursing, reaccumulated over the last several weeks. R1 with abdominal distention, lower extremities edema and shortness of breath.On 6/23/26 at 9:50 AM, V3 (License Practical Nurse-LPN) said she was one of R1's nurses. R1 was alert and able to verbalize his needs. Last 6/9/26, R1 requested to be sent out due to complaints of discomfort. R1 was still at the hospital at this time. R1 has CHF, he was supposed to be weighted daily, R1 was on water pills. On 6/23/26 at 11:32 AM, V2 (Director of Nursing) said R1 was admitted in May, coming from the hospital after being treated with CHF. On 6/9/26 R1 requested to go to the hospital. R1's SBAR (change of condition documentation) was incomplete because it was R1 who insisted on going (to the hospital). R1 was admitted and still at the hospital at this time due to heart failure decompensation. (Heart failure had gotten worse.) R1 was on diuretics. This surveyor and V2 DON reviewed R1's weight record while at the facility. V2 confirmed that while R1 was at the facility, R1 was weighed only once (5/21/26) when R1 was supposed to be weighed daily. V2 said weight monitoring is very important for residents with CHF on diuretics to detect fluid retention that may lead to worsening heart failure.On 6/23/26 at 1:30 PM, V4 (Physician Assistant) said residents with CHF especially on diuretics (water pills) require ongoing monitoring including daily weights measurements to identify fluid retention, changes in condition that may indicate worsening of heart failure that requires timely intervention.On 6/23/26 at 1:45 PM, V7 (R1's family) said R1 was still hospitalized and undergoing treatment to stabilize his condition (CHF).On 6/23/26 at 2PM, V1 (Administrator) said the facility has no policy addressing CHF care.

Based on interview and record review the facility failed to ensure a resident was free from significant medication errors for 1 of 4 residents (R1) reviewed for medications in the sample of 7. This failure resulted in R2 receiving a double dose of an antipsychotic medication for 33 days.The findings include:On 5/12/26 at 1:10 PM, V21 (R2's daughter) said she was visiting R2 one evening around 7:00 PM and the nurse on duty was giving R2 his evening medications. V21 said she inquired about the medications being given and found out that R2 was receiving 200mg of quetiapine fumarate instead of 100mg. V21 said she asked the nurse who authorized the change to 200 mg at night and the nurse did not know. V21 said she went to V2's Director of Nursing office and asked why her dad's medication dose was changed. V21 said V2 told her she had no idea and looked in the computer. V21 said V2 told her that he must have come from the previous facility on that dose. V21 said that there was no way he was on that dose at that facility and she had gone over the medications with the nurse upon admission. V21 said V2 told her she would have to contact the hospital and see if they had changed the dose. V21 said she had reached out to R2's neurologist via my chart and the neurologist reported he had not made a change to R2's dose of quetiapine fumarate. V21 said she reported this information back to the facility. V21 said she felt like her dad was declining during his stay there and they even had to move him into the secured dementia unit due to his increased wandering. V21 said toward the end of R2's stay, she would find R2 just sitting by himself staring off into the distance.R2's admission Medication List from R2's previous facility dated 3/20/26 shows quetiapine fumarate 50 mg 1 tablet in daytime; 2 tablets at bedtime.R2's Physician Orders shows R2 was admitted on [DATE] and shows order quetiapine fumarate 50 mg Give 1 tablet by mouth one time a day and quetiapine fumarate 100 mg Give 2 tablets by mouth at bedtime (total dose 200 mg).R2's Medication Administration Record (MAR) for March 2026 shows R2 received 200 mg of quetiapine fumarate at bedtime from 3/25/26 to 3/31/26 (7 days).R2's MAR for April 2026 shows R2 received 200 mg of quetiapine fumarate at bedtime from 4/1/26 to 4/26/26 (26 days).On 5/13/26 at 11:42 AM, V20 Nurse Practitioner said she did not give any orders to increase quetiapine fumarte which is an antipsychotic. V20 said she would have consulted with psychology before making a change in that medication and there was nothing in her notes about changing that medication. V20 said it is important to ensure admitting medications are correct for the resident to make sure the resident is cared for appropriately, make sure the resident's medical diseases are treated, and to prevent re-admission to the hospital. V20 said doubling a dose of an antipsychotic could increase the risk for side effects such as sleepiness, lethargy, confusion, and increase the risk for extrapyramidal side effects. On 5/12/26 at 12:30 PM, V2 Director of Nursing said she never met R2's daughter and did not have any conversations regarding R2's medications. V2 said upon admission the nurse reviews the admitting order from the hospital or facility and then calls the doctor. V2 said the nurse does a read back going over the medications and gets orders to continue or discontinue the medications. V2 said the next day the clinical team reviews the new admission admitting orders for errors. V2, when asked how this error was missed said human error.The facility's Medication Administration Policy dated 9/1/24 shows Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure that the six rights of medication administration are followed: Right resident, right drug, right dosage, right route, right time, right documentation.

Based on interview and record review the facility failed to notify a resident's family of a room change for 1 of 4 residents (R1) reviewed for notification in the sample of 7.The findings include:On 5/12/26 at 1:01 PM, V21 (R1's daughter) said she came in on a Sunday and R2 had been moved into a different room (room [ROOM NUMBER]-B). V21 said the nurse told her R2 had an argument with his roommate Friday night and they moved him to the new room. V21 said she had gone to R2's old room (room [ROOM NUMBER]-B) and R2's personal items were still in that room. V21 said she was upset that no one had called her and they hadn't even moved all of R2's things to the new room, she had to do it. R2's Census List dated 5/13/26 shows on 4/10/26, R2 moved into room [ROOM NUMBER]-B.R2's Progress Notes do not contain documentation on or before 4/10/26 that V21 was notified or the reason for the room change.On 5/13/26 at 10:00 AM, V16 Social Service Director said R2 was moved to room [ROOM NUMBER]-B because of an issue with the roommate and R2 not getting along. V16 said the nurse asked for an available room and she told them the room that was available. V16 said that was all of the involvement she had with the move. V16 said the nurse should have called R2's daughter and let her know about the room change. V16 said there should have been a progress note charted as well regarding the details of the move. On 5/13/26 at 12:30 PM, V2 Director of Nursing said she was not involved with R2's room change on 4/10/26 and was not aware of the reason for the change. V2 said family should be notified of a resident's room change.The facility's Change of Room or Roommate Policy dated 9/1/24 shows Prior to making a room change or roommate assignment, all person involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible.

Based on observation, interview, and record review the facility failed to thoroughly investigate an allegation of abuse for 1 of 7 residents (R3) reviewed for abuse in the sample of 7. The findings include: On 5/11/26 at 1:40 PM, R3 was sitting on the bench seat of her rolling walker in the hall outside of her room. R3 said about a week ago on a Friday she was in the dining area before breakfast with a cup in her hand. R3 said V7 Certified Nursing Assistant took the cup out of her hand and accidently scratched the top of her hand with his fingernail. R3 said it was bleeding and she was upset. R3 said V8 Registered Nurse took care of the cut and put a band aid on it. R3 showed this surveyor the top of her right hand which had a band-aid still in place. R3 said it was healed and removed the band aid. R3's right hand had a healed skin tear in the shape of a half circle approximately the size of a half of quarter. On 5/11/26 at 3:08 PM, V7 said he had come in early for his 7:00 AM shift and was preparing the breakfast trays in the dining room. V7 said R3 was heading out of the unit doors with her walker and set off the alarms. V7 said V8 told him to get R3 back into the unit and he went to the unit entry door and called for R3 to come back that V8 needed to see her. V7 said R3 came back to the unit, and he went back to preparing trays. V7 said R3 told V8 that he scratched her and R3 said she was going to have me fired. V7 said he didn't even touch R3, he just held open the door to the unit for her to come back in. V7 said he was interviewed about what happened, but they didn't ask him about taking a cup out of R3's hand.On 5/12/26 at 9:31 AM, V8 said V7 was in the dining room fixing meal trays when the alarm went off for the unit door. V7 said she saw that R3 was in the hall and asked V7 to get her. V8 said she stepped away and when she came back, R3 was crying about a skin tear on her right hand. V7 said she was not interviewed about what happened with R3.On 5/12/26 at 10:51 AM, V3 Regional Nurse Consultant said V1 Administrator did the investigation and should have interviewed R3 and the staff involved. V3 said she interviewed R3 and R3 had told her the same story regarding the cup taken out of her hand by V7 and being scratched. V3 said R3 said the scratch was bleeding and V8 had taken care of it. On 5/12/26 at 9:20 AM, V2 Director of Nursing said V1 is no longer working at the facility, and she doesn't know anything about the investigation.The facility's Abuse Investigation for R3's allegation does not contain an interview with V8 or any other staff working at that time. V7's interview does not include any information about R3's story with the cup being taken out of her hand when the scratch occurred. On 5/12/26 at 12:15 PM, V4 Corporate Administrator said an Abuse Investigation should include an interview with the person making the allegation, anyone mentioned in the allegation (staff or residents) and anyone that would have information about the allegation. The facility's Abuse, Neglect, and Exploitation Policy dated 10/24/24 shows Investigation of Alleged Abuse, Neglect, and Exploitation: Identifying and interviewing all involved persons, including alleged victim, alleged, perpetrator, witnesses, and others who might have knowledge of the allegation.

Based on interview and record review the facility failed to conduct a post fall analysis to ensure fall interventions were appropriate for a resident's self-reported fall for 1 of 3 residents (R1) reviewed for safety in the sample of 7.The findings include: On 5/12/26 at 1:10 PM, V21 (R1's daughter) said she came in to visit her dad, and he told her he had fallen and his back hurt. V21 said she lifted her dad's shirt, and he had a bruise on the left lower side of his back and a scrape on his left elbow. V21 said she went to the nurse on duty V17 Licensed Practical Nurse and asked her why no one called her about her dad falling. V21 said V17 had no idea that her dad fell and then asked R2 why he didn't tell her he fell. V21 said V17 told her she would get someone to send R2 to the emergency room, but V21 declined. V21 said approximately 10 minutes or so later, R2's dinner tray arrived and R2 began eating. V21 said V17 came and wanted to do an assessment on R2. V21 said she told V17 to wait until after R2 finished eating. V21 said V17 never came back to assess R2 so she went to talk to V2 Director of Nursing. V21 said she reported to V2 that R2 said he had fallen and no one knew about it. V21 said V2 offered to send R2 to the emergency room but she declined the need for an emergency room visit. V21 said V2 made her feel like she was bothering her with this concern. V21 said she then took her dad outside to enjoy the weather and V13 Certified Nursing Assistant (CNA) came out to say hello. V21 said she told V13 that R2 had fallen and showed her R2's bruise on his back. V21 said no one spoke to her about the fall, what happened, or what they were going to do about it.On 5/12/26 at 3:05 PM, V13 CNA said she had taken care of R2 when he was on another unit and knew V21 as well. V13 said V21 was visiting with R2 on the patio, and she had gone out to say hello. V13 said V21 told her about R2 falling and said he had a bruise on his back. V13 said V21 lifted R2's shirt and R2 had a greenish bruise on the left side of his back. V12 said R2 told her he fell. V13 said V21 was upset that no one knew about it.On 5/13/26 at 10:37 AM, V17 said R2 had been in the unit for a few days, when V21 approached her and said something about R2 falling. V17 said she asked R2 how he fell and he didn't know and was not able to answer how he got up or if anyone helped him. V17 said V21 refused for her to do anything. V17 said she should have charted the fall and the events. V17 said she didn't look at R2's back or elbow and could not remember if she told anyone about the fall.On 5/13/26 at 10:40 AM, V23 CNA (regular CNA for R2's unit) said he didn't know anything about R2's fall, but R2 had been complaining about back pain. V23 said he didn't see any bruise on R2, but R2 didn't require too much assist to dress his upper body, and he had not given R2 a shower during his shifts.On 5/13/26 at 12:30 PM, V2 said she never met V21. V2 said she didn't know anything about R2's fall and V17 had never talked to her about it. V2 said if a resident falls the nurse does a full body assessment with vital, skin check, and a pain assessment. V2 said the doctor is notified for orders and the family is called. V2 said the nurse does a risk management form which documents the events of the fall and the assessment findings. V2 said if family refuses to be sent out or refuses an assessment than that should be documented as well. R2's Progress Notes or Assessments do not contain documentation regarding R2 having a fall or sustaining any injury. R2's Care Plan dated 3/26/26 shows R2 is a high risk for falls related to vascular dementia with behavioral disturbances, anxiety disorder, frontotemporal neurocognitive disorder, and gait abnormality. Benefits from staff assistance with transfers, toileting assistance, and activities of daily living cares. History of fall incidents related to poor safety awareness and cognitive impairments. This same Care Plan was not updated during R2's stay (3/25/26-4/27/26).The facility's April 2026 Incident List does not contain any incidents involving R2.The facility's Incidents and Accidents Policy dated 9/1/24 shows It is the policy of this facility for staff to utilize the computer risk management to report, investigate, and review any accidents or incident that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care.

Based on observation, interview, and record review the facility failed to be administered in a manner to ensure supplies were available for dependent residents for 1 of 3 residents (R2) reviewed for administration in the sample of 7. The findings include: On 5/11/26 at 1:15 PM, R2 was in bed dressed in a t-shirt and an incontinence brief. R2 said the facility has no briefs and has been out for a couple days. R2 said he wears the green XL size which is the most comfortable for him. R2 said he had a few in his closet but has been wearing them wet to make them last longer. R2 said they are uncomfortable to wear wet, but he has to make them last. R2 said they told him they were waiting on a delivery. R2's closet did not contain any incontinence briefs. On 5/11/26 at 1:35 PM, V5 Certified Nursing Assistant (CNA) said they are out of the green incontinence (XL) brief. V5 said he worked the weekend and they were out then as well. V5 said they have a few pull up briefs but not the ones R2 uses. V5 showed this surveyor the unit supply closet which contained a few pull up incontinence briefs, and three white incontinence briefs (small size). V5 said when they need supplies, he tells the nurse who tells the Director of Nursing.On 5/11/26 at 1:55 PM, V2 Director of Nursing said there was a supply order in, and it should be delivered Wednesday. V2 said they order supplies based on the census and the need. V2 said if they run out of something they can run to a local store and get supplies. V2, with this surveyor, went into the central supply room of the facility. V2 pointed to several empty pallets against one wall and said this is where the briefs are kept. There was one opened box of pull up incontinence briefs containing 3-4 pulls ups on one of the pallets, the rest were completely empty. V2 said she thought they went to the store on Friday, but she was not aware they were out. V2 said the Nurses or CNAs let her know. When asked who is in charge of ordering supplies, V2 said it is supposed to be the Scheduling Coordinator, but they don't have one, so it falls on her. V2 said residents should have the size incontinent briefs that fit and are comfortable for them. On 5/11/26 at 2:30 PM, V4 Regional Administrator said the facility should not run out of supplies, the administrator should make sure there is supplies and get some from local stores if needed. The facility's Central Supply Policy dated 9/1/24 shows It is the policy of the facility to ensure adequate quantities of supplies are provided to ensure ongoing care of the residents.

Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident with a known history of elopement while at home did not elope from the facility for 1 of 3 residents (R1). This failure resulted in R1 exiting a secured unit and the facility unsupervised, walking approximately 1,000 feet and crossing a four-lane road in the dark until found by staff approximately 45 minutes later. The Immediate Jeopardy began on 4/19/26 at approximately 3:30 AM, when R1 exited from a secured unit, walked to a different unattended unit and past a nurse's station, down a hallway, and exited the facility unsupervised through a fire exit door. R1 then walked through the rear courtyard for approximately 350 feet, through the facility parking lot another approximate 200 feet, across a four-lane street in the dark, and was found by facility staff around 4:15 AM walking in a nearby shopping center parking lot approximately 1000 feet from where R1 exited the building. V1 (Administrator) was notified of the Immediate Jeopardy on 4/28/26 at 4:23 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 4/28/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training, and dedicated staffing pattern.The findings include:R1's Facesheet dated 4/27/26 shows R1 admitted to the facility on [DATE] with diagnoses including, but not limited to, anxiety disorder, unspecified dementia with psychotic disturbance, major depressive disorder, paranoid personality disorder, and altered mental status. On 4/27/26 at 10:56 AM, R1 was sitting at a table in the dining room on the locked 700 unit. R1 was wearing a medium heavy jacket and tight-fitting walking shoes. R1 was unable to recall the events on 4/19/26 but quickly began experiencing both auditory and visual hallucinations including seeing a vehicle she stated was V6 (R1's Granddaughter) who was attempting to enter the facility and could not get in. R1 would also state that V6, who is pregnant, was telling R1 that V6 was going to lose the baby and didn't have any food. This increased R1's anxiety and aggression at attempting to exit the facility and make contact with V6. V8 (Business Office Manager) called V6 to have V6 speak to R1 to calm R1, but R1 went right back to experiencing auditory and visual hallucinations regarding V6 just minutes after getting off the phone with V6. On 4/27/26 at 9:58 AM, V1 (Administrator) said she was most concerned at the amount of distance R1 could travel away from the facility because R1 is a really good power walker. On 4/27/26 at 11:30 AM, V9 (Maintenance Director) said per the state building code, fire doors are required to remain locked for fifteen seconds once the door is attempted to be opened while the door alarm is armed. When the door is attempted to be opened, the alarm will sound immediately and remain on until staff disarm the alarm.On 4/27/26 at 11:30 AM, this surveyor noted R1 would have passed the 400 unit nurse's station in order to get to the fire exit door at the end of the hall. On 4/27/26 at 12:58 PM, V13 (Certified Nursing Assistant- CNA) said at the time the exit door fire alarm went off, V13 was on the 300 unit providing care to a resident and not on the 400 unit that R1 exited the building from.On 4/27/26 at 2:06 PM, V14 (Regional Director of Operations) said the facility will now add an additional CNA to the overnight shift. On 4/28/26 at 8:55 AM, V3 (Licensed Practical Nurse-LPN) said for the overnight shift, V3 covers multiple units, including the locked 700 unit that R1 resides on. On the overnight shift from 4/18/26 to 4/19/26, V3 was scheduled to cover the 700 unit, the 100 unit, and half of the 200 unit. The 100 and 200 units are on the west side of the facility, and the 700 unit is on East side of the North hallway of the facility. V3 said at the beginning of her shift, V3 did initial rounds on R1's unit and noted R1 to be sleeping. V3 then went onto the other units to do rounds. V3 returned to R1's unit around 2:00 AM. Around 3:30 AM when the 700 unit's door alarm went off, V3 was exiting another resident's room. V3 immediately checked R1's room knowing R1 is an elopement risk and noted R1 was missing. V3 then returned to the unit door where the alarm was sounding, exited, and continued down the hall and adjacent rooms searching for R1. V3 continued down the hall towards the main entrance and exited the main entrance, sounding the facility door alarm, alerting other staff. While out the main entrance, V3 called V11 (Registered Nurse- RN) to notify her that R1 was missing then proceeded to walk to the street. V3 went East about halfway down the building, then went [NAME] all the way to the traffic light and back to the main entrance without finding R1. At this time, the other staff were on their units conducting headcounts and looking room to room to try and locate R1. V3 and V11 looked through the facility together including checking the basement with no success. After finishing the first round of searching the facility V3 and V11 called V1 (Administrator) to notify her of the situation. V3 and V11 began going unit to unit again, conducting a second round search when they noted a door alarm going off on the non-locked 400 unit on the South-East side of the building. V3 stated the fire exit door in the back hall was open and V3 and V11 used flashlights from their phones to navigate the dark rear courtyard. First, V3 and V11 took a left out of the fire exit door, heading East, and searched that portion of the courtyard with no success. V3 and V11 then proceeded West, towards the parking lot. V3 said when they made it to the gate to the rear courtyard, the gate was ajar and R1 was nowhere to be seen. V3 and V11 headed towards the front of the building to take V3's car and search for R1. V11 sent a text message to V13 (CNA) and instructed V13 to take V13's car, head South of the facility and search the East side of the main busy four-way road (Route 21) while V3 and V11 would search the East side of the main busy four-way road (Route 21). V3 and V11 exited the parking lot to the facility and initially took a right and went all the way to the other end of the building. When not finding R1, V3 and V11 turned around, drove to the stop light, and took a left, heading South, onto the main, busy four-way road (Route 21). V3 and V11 then took the first right into a strip mall, located on the North-West corner of the intersection of the two main roads (Route 21 and Route 45), which includes a bank and restaurants. At approximately 4:15 AM, while driving past the bank, V3 noted R1 was walking by the entrance of the building adjacent to the bank. R1 was wearing a black jacket, pants and shoes. When V3 and V11 approached R1, R1 said, Oh my God, thank God you're here! Are you taking me home? R1 then told V3 and V11 that R1 wanted to go to V6's (R1's Granddaughter) birthday party. V3 and V11 assessed R1 after returning to the facility with no injuries or concerns.On 4/28/26 at 10:02 AM, V10 (RN) said at the time the main door alarm was activated by V3, V10 was on the 200 unit on the [NAME] side of the facility and not on the 400 unit R1 exited the building from. On 4/28/26 at 1:28 PM, V12 (CNA) said she worked the overnight shift from 4/18/26 into 4/19/26 on the locked 700 unit. V12 said R1's demeanor on the evening of 4/18/26 was actually pretty good. The last time V12 saw R1 was around 12:45 AM to 1:00 AM when V12 provided R1's roommate with a bedpan and R1 was sleeping in R1's bed. V12 said prior to the door alarm going off, V12 recalls V3 (LPN) sitting at the nurse's station on the locked unit. When the unit door alarm went off around 3:30 AM, V12 was in R7's room providing care and couldn't immediately respond to the door alarm. When V12 went to the door to see what was going on, V12 saw V3 running out the door. After finishing providing R7 care, V12 proceeded to conduct a head count on the unit. On 4/28/26 at 2:06 PM, V14 (Regional Director of Operations) said R1's hallucinations are family focused and early in the day on 4/18/26, R1's family had visited with R1 for an extended period of time which may have increased R1's agitation. R1's hospital documents from 3/30/26 show R1 was admitted to the local hospital for worsening agitation and paranoia delusions for several months. R1 was also exhibiting a behavior of fleeing and escaping from R1's home. V5 (R1's Husband) had to monitor R1 at all times to prevent R1 from escaping.R1's psychiatric hospital documents from 3/30/26 shows R1 escaped from R1's home on 3/28/26 and was alone for several hours before the police found R1 and called V5.R1's progress note from 4/8/26 at 9:58 PM shows R1 is able to walk without assistive devices. R1's Elopement Risk assessment dated [DATE] shows R1 is at high risk of elopement stating Recent hx (history) wandering outside her room, paranoid delusions that someone is out to get her. Placed on elopement life for safety.R1's Care Plan initiated 4/12/26 shows R1 is an elopement risk and the only intervention is from 4/8/26 stating, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.R1's Progress Note from 4/14/26 at 9:12 PM states, Resident left unit and was redirected in the hallway by staff where she [R1] displayed physical aggression .Facility nursing schedule for 4/18/26 shows V13 and V10 were the only two staff scheduled to cover the 400 unit. Neither V13 nor V10 were on the 400 unit when R1 exited the facility. An online measuring tool was used to calculate the approximate distance that R1 traveled showing R1 traveled an approximate 1,000 feet from the fire exit door of the 400 unit, across a known busy four-lane road (Route 21), and into the parking lot that R1 was found. The Facility Elopements and Wandering Residents policy revised 9/5/25 states, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk.The facility presented an abatement plan to remove the immediacy on 4/29/26 at 8:30 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 4/29/26 at 10:59 AM. The survey team reviewed the revised abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 4/29/26 at 11:34 AM. The survey team reviewed the revised abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 4/29/26 at 11:59 AM. The survey team reviewed the revised abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 4/29/26 at 12:20 PM, and the survey team accepted the abatement plan on 4/29/26 at 12:20 PM.The Immediate Jeopardy that began on 4/19/26 was removed on 4/28/26 when the facility took the following actions to remove the immediacy:All resident elopement assessments reviewed and up to date as of 4/20/26, and reviewed again on 4/28/26. All residents identified as a high risk for elopement had care plans reviewed for accuracy by 4/20/26, and reviewed again on 4/28/26. Elopement binder reviewed and up to date to reflect high risk residents by 4/20/26 and reviewed again on 4/28/26. An emergency QAPI was held to review policies/procedures, and final investigation notes, on 4/20/26. Daily door alarm audits completed beginning 4/20/26. An in-service education process was initiate on April 19, 2026. The Administrator is responsible for providing education and expectations to all managers and supervisors. In collaboration, the Administrator, managers, and supervisors will ensure re-education on the elopement policy is provided to all department staff as they return to work to verify understanding and ongoing compliance with facility policies and procedures. R1 provided with 1:1 staff and/or increased supervision as needed effective 4/19/2026.Ensure a dedicated staff is scheduled on each unit. The HR (Human Resources) director will ensure there will be a dedicated staff on each unit. The administrator or DON (Director of Nursing) will audit compliance.

Based on interview and record review the facility failed to adequately schedule staff to ensure all units were attended during the overnight shift. This has the potential to effect all 128 residents residing in the facility during the overnight shift. The findings include: Facility Data Sheet shows there are 128 residents residing in the facility as of 4/27/26. Facility provided nursing schedule from 2/27/26 to 4/27/26 shows the facility staffs the overnight shift with three nurses and six certified nursing assistants (CNAs) to cover seven units. Facility nursing schedule from 4/18/26 shows the 700 unit had a census of 23, the 100 unit had a census of 11, and the 200 unit had census of 16. V3 (Licensed Practical Nurse- LPN) was scheduled to cover the 700 unit, the 100 unit, and half of the 200 unit totaling 42 residents. This is a nurse to resident ratio of one to 42.Facility nursing schedule from 4/18/26 shows the 300 unit had a census of 20, the 400 unit had a census of 13, and the 200 unit had census of 16. V10 (Registered Nurse- RN) was scheduled to cover the 300 unit, the 400 unit, and half of the 200 unit totaling 41 residents. This is a nurse to resident ratio of one to 41.Facility nursing schedule from 4/18/26 shows the 500 unit had a census of 21 and the 600 unit had census of 16. V11 (RN) was scheduled to cover the 500 and 600 units totaling 44 residents. This is a nurse to resident ratio of one to 44.Facility nursing schedule from 4/18/26 shows the 100 unit had a census of 11, the 200 unit had a census of 16, the 300 unit had a census of 20, and the 400 unit had a census of 13. The schedule shows three CNAs are scheduled to cover those four units, providing each CNA with a staff to resident ratio of approximately one to 20. Facility nursing schedule from 4/18/26 shows the 500, 600, and 700 units each have their own scheduled CNA with unit census of 20 or more on each unit. On 4/27/26 at 12:58 PM, V13 (CNA) said it is normal to split the four units with only three CNAs and they try and split it so each CNA has 20 residents each. V13 said it would be better to have one CNA per unit because there is a lot of distance between some of the units. When you are on one unit, you can't see what's going on with the other unit.On 4/28/26 at 11:10 AM, V15 (Human Resources Director) said the current staffing pattern is the same staffing pattern the facility has followed for a while. V15 did say the 400 unit could use a full time nurse on all shifts, seven days a week, but it's not V15's decision to make. The Facility Assessment updated 4/1/26 states, 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 care 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. The assessment also shows direct care staffing ratios for licensed staff should not exceed a ratio of one staff member to 30 residents for the overnight shift and it shows for certified staff the ratio should not exceed a ratio of one staff member to 18 residents for the overnight shift.

Based on observation, interview and record review, the facility failed to ensure staff reported an allegation of verbal abuse to the abuse coordinator for 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings include:R1's admission Record showed she was admitted to the facility on [DATE] with diagnoses including, but not limited to chronic kidney disease stage 3, unsteadiness on feet, abnormal posture, abnormalities of gait and mobility, depression, insomnia, anxiety disorder, cognitive communication deficit, primary generalized osteoarthritis, morbid (severe) obesity, type II diabetes mellitus, anemia, and chronic peripheral venous insufficiency. R1's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R1 had no range of motion impairment to her bilateral upper and lower extremities and used a walker and wheelchair for mobility. Set up/clean up assist for meals. The assessment showed R1 required substantial/maximal assist for toilet hygiene, bathing, upper and lower body dressing, putting shoes on/off, bed mobility including rolling and going from a sitting to lying and lying to sitting on the side of the bed position, sit to stand position, transfers, and walking.On 3/20/26 at 8:31 AM, V19 (Insurance Case Manager) said she was in the facility talking with R1. V19 said she is R1's case manager for her insurance. R1 said V5 had verbally abused her by calling her fat and big. V19 said R1 is overweight and sensitive about her weight. R1 told V19 it happened several times and she was upset. No further information to provide. On 3/20/2026 at 10:11 AM, R1 was sitting in a wheelchair in her room. R1 was alert and oriented. R1 said the first day she was in the facility V5 (CNA) said You're so big to her. R1 said on days 3, 4 and 5, V5 said You're so fat. R1 said she told V10 and V18 (Certified Nursing Assistants (CNAs) and V9 (Licensed Practical Nurse-LPN) about what V5 said to her. R1 said she does not recall if she said anything to anyone else. R1 said she is sensitive about her weight. R1 said she does not see V5 anymore and she is not aware if he was fired or reassigned somewhere else. On 3/20/26 at 10:52 AM, This surveyor spoke with V1 (Administrator) about R1's allegations. V1 said she gave R1 her phone number and they have been communicating back and forth since 2/26/26. V1 said neither R1, nor have any staff said anything to her about V5 saying something about R1's weight. At 11:12 AM, V1 said R1 was recently admitted to the facility. V1 said she had not received any reports of verbal abuse. On 3/20/25 at 3:25 PM, V10 (CNA) said R1 never said anything to her about V5 calling her big or fat. V18 could not be interviewed as she was out of the country for a family member's funeral. On 3/24/26 at 2:02 PM, V9 (LPN) said R1 never said anything to her about V5 calling her big or fat. On 3/24/26 at 2:58 PM, V16 (CNA) said R1 told her a couple weeks prior that V5 was calling her fat. She did not say when it happened. V16 said it was a while ago that she told me that. A couple of weeks ago. I asked her if (V5) had apologized after he said that and she said no. She said she felt abused. V16 said she did not report it to anybody. V16 said if someone says they are being abused I should absolutely report it. I did not report it. I was just listening to her story. V16 said she remembers that R1 said that she had already told someone about it already, that is why she (V16) did not report it. V16 said it may have been a good idea to follow up with the (V1 Administrator) or (V4-Director of Nursing) to make sure they were aware.The facility's Abuse, Neglect, and Exploitation Investigation policy and procedure, with a review date of 2/27/2026, showed the facility is committed to ensuring all residents are free from abuse, neglect, exploitation, and misappropriation of property. All allegations, regardless of source or perceived severity, will be immediately reported, thoroughly investigated, and addressed.Ensure immediate resident safety and separate alleged victim and accused individual. Place accused staff member on administrative leave pending investigation. Notify Administrator, DON (Director of Nursing), RNC (Regional Nurse Consultant), and RDO (Regional Director of Operations) immediately.

Based on observation, interview and record review, the facility failed to suspend a staff member accused of abuse when an allegation was reported for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 6. The findings include:1. R1's admission Record showed she was admitted to the facility on [DATE] with diagnoses including, but not limited to chronic kidney disease stage 3, unsteadiness on feet, abnormal posture, abnormalities of gait and mobility, depression, insomnia, anxiety disorder, cognitive communication deficit, primary generalized osteoarthritis, morbid (severe) obesity, type II diabetes mellitus, anemia, and chronic peripheral venous insufficiency. R1's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R1 had no range of motion impairment to her bilateral upper and lower extremities and used a walker and wheelchair for mobility. Set up/clean up assist for meals. The assessment showed R1 required substantial/maximal assist for toilet hygiene, bathing, upper and lower body dressing, putting shoes on/off, bed mobility including rolling and going from a sitting to lying and lying to sitting on the side of the bed position, sit to stand position, transfers, and walking.On 3/20/26 at 8:31 AM, V19 (Insurance Case Manager) said she was in the facility talking with R1. V19 said she is R1's case manager for her insurance. R1 said V5 had verbally abused her by calling her fat and big. V19 said R1 is overweight and sensitive about her weight. R1 told V19 it happened several times and she was upset. No further information to provide. On 3/20/2026 at 10:11 AM, R1 was sitting in a wheelchair in her room. R1 was alert and oriented. R1 said some of the staff don't want to lift my legs and swing them around to help me get in position to lie down, they complain about their back. R1 identified V6 and V7 as two of the staff that complain about their back when they have to help swing her legs around. R1 said the first day she was in the facility V5 (CNA) said You're so big to her. R1 said on days 3, 4 and 5, V5 said You're so fat.2. R2's admission record showed he was admitted to the facility on [DATE] with diagnoses including, but not limited to Parkinson's disease, type II diabetes mellitus. unsteadiness on feet, abnormal posture. Muscle weakness, cognitive communication deficit, Asperger's syndrome, obstructive sleep apnea, a personal history of malignant neoplasm of testis, a history of falling, anxiety disorder, depression, spasmodic torticollis (painful, chronic neurological movement disorder causing involuntary muscle contractions in the neck, resulting in abnormal head twisting tilting and jerking), restless leg syndrome, and chronic kidney disease stage 3A. R2's care plans showed he is a fall risk and needs staff assist for transfers. R2's progress notes showed R1 needs staff assistance for toilet hygiene, bathing, and lower body dressing, and transfers. On 3/19/26 at 4:49 PM, V20 (EMT) said he is an EMT that was called to transport R2 back to the facility from the ER. V20 said R2 had mentioned something in the ER about abuse at the facility. V20 said on the way back to the facility R2 said a female CNA was aggressive, and rough with care. He did not say who the female CNA was. He did not say when the incident occurred.On 3/20/26 at 9:27 AM, R2 said one of the female CNAs from the midnight shift is very aggressive, and rough with care. R2 described the female CNA as a large full-figured African American woman. R2 said when he is incontinent, she comes in and says what do you want. R2 said the unknown aide is jostling him around like a piece of meat. R2 said the unknown female CNA told him to go to sleep and quit using the call light. She said I was abusing call-light privileges. She was very abrasive. R2 said V5 (CNA) confiscated his remote and said he could only eat in his room. R2 said it happened in the afternoon on the previous Sunday. R2 said V5 was rough with helping him too. On 3/20/26 at 10:52 AM, This surveyor spoke with V1 (Administrator) about R1 and R2's allegations. V1 said she gave R1 her phone number and they have been communicating back and forth since 2/26/26. V1 said neither R1, nor any staff have said anything to her about V5 (CNA) saying something about R1's weight. V1 said no staff have reported to her that R1 voiced concerns about staff saying it hurts their back to lift her legs and swing them onto the bed for her to lay down. V1 said she has not had any reports of verbal abuse or of staff being rough. On 3/24/26 at 10:30 AM, V5 was sitting up at the nurses' station on the unit R2 resides. On 3/24/26 at 12:18 PM, V2 (Regional Director of Operations) said V5 is suspended until the investigation is completed. V2 said V1 (Administrator) misunderstood and did not realize the new allegations included V5. On 3/24/26 this surveyor was provided with V5's time clock entries. The document showed V5 worked a double shift on Saturday 3/21/26 and a double shift on Sunday 3/22/26. The document showed V5 worked on 3/24/26 from 6:42 AM - 11:10 AM before he was suspended. The facility's Abuse, Neglect, and Exploitation Investigation policy and procedure, with a review date of 2/27/2026, showed the facility is committed to ensuring all residents are free from abuse, neglect, exploitation, and misappropriation of property. All allegations, regardless of source or perceived severity, will be immediately reported, thoroughly investigated, and addressed.Ensure immediate resident safety and separate alleged victim and accused individual. Place accused staff member on administrative leave pending investigation. Notify Administrator, DON (Director of Nursing), RNC (Regional Nurse Consultant), and RDO (Regional Director of Operations) immediately.

Based on interview and record review the facility failed to ensure a resident with cognitive impairment did not elope the facility and failed to ensure all residents were accounted for one of three residents (R1) reviewed for safety/supervision in the sample of seven.The Immediate Jeopardy began on February 4, 2026, at 5:43 AM when R1 was found sitting outside in the cold in her wheelchair by herself, a block away from the facility and was transferred to the local hospital for cold exposure. V1 Administrator was notified of the Immediate Jeopardy on February 9, 2026, at 3:45 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on February 10, 2026, at 10:34 AM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1's admission Record shows she was admitted to the facility on [DATE], with diagnoses including left femur fracture, urinary tract infection, unsteadiness on feet, anxiety disorder, malnutrition, dementia, alcohol abuse, pulmonary fibrosis, and altered mental status.R1 Elopement Risk assessment dated [DATE], shows R1 has a high risk of elopement.R1's Minimum Data Set, dated [DATE], shows that R1 is not cognitively intact.On February 5, 2026, at 1:01 PM, V6 Certified Nursing Assistant (CNA) said R1 is able to wheel herself in the wheelchair. V6 said R1 likes to wander the facility.On February 5, 2026, at 2:21 PM, V8 Licensed Practical Nurse (LPN) said R1 wanders the building by self propelling in her wheelchair.The facility's Walkers binder that is left near the receptionist desk and includes pictures and face sheets of residents that wander, was reviewed on February 9, 2025. R1's picture was not included in this binder.R1's Care Plan initiated October 1, 2025, shows R1 demonstrates cognitive impairment and R1 is at risk for falls related to current medication use, poor safety awareness, unsteady gait, decline in functional status, dementia, hip fracture, history of falls, and poor safety awareness.R1's Certified Nursing Assistant task documentation dated January 13, 2026, and January 14, 2026, shows R1 had behaviors of elopement.R1's Chronic Care Management note entered by V11 Nurse Practitioner (NP) dated January 29, 2026, shows R1 has severe impairment of cognitive status.R1's Acute Care Note dated February 1, 2026, entered by V11 NP shows that R1 was disoriented.R1's Incident Note dated February 4, 2026, at 9:07 AM entered by V3 Registered Nurse (RN) shows R1 was seen in bed asleep at 4:00 AM. V3 was notified by the police around 6:00 AM that R1 was taken to the local emergency room. R1 was observed by the police outside of the facility.On February 5, 2026, at 1:21 PM, V9 Police Officer said the previous day (February 4, 2026) a concerned passerby called 911 and reported a person sitting in a wheelchair in the cold. V9 said they originally received the call at 5:42 AM and V9 got there at 5:43 AM. V9 said he was nearby to the area. V9 said when he got there, there was a sweater on the ground near R1. V9 said R1 was disoriented and very cold and smelled like urine. V9 said R1's pants were wet in the groin area presumably with urine due to the strong urine smell. V9 said R1 had a thin sweater on. V9 said he did not know where R1 came from. V9 said R1 was sitting in a wheelchair about a block away from the facility. V9 said R1 had no winter gear on. V9 said R1 told him she was outside all night. V9 said R1 was shivering and had a shaky voice because it was cold outside. V9 said that R1 did not know where she lived nor did R1 say where she was going. V9 said he gave R1 his coat when R1 got into his police car to warm her up. V9 said the fire department came quickly and brought R1 to the hospital to be evaluated. V9 said he went to the facility after the fire department took R1 to the hospital. V9 said he talked to V3 Registered Nurse (RN), V4 RN, and V5 Certified Nursing Assistant (CNA). V9 said V4 RN was his first contact when he got to the facility. V9 said the facility did not know that R1 left the facility. V9 said that an exit door alarm went off about 3:30 AM, but the staff was unable to confirm the cause or origin of the alarm. V9 said that V3 RN reported to him that she turned off an exit door alarm but did not see anything. V9 said he went back by the facility to see if he could figure out what direction R1 took when she left the facility. V9 says he believes R1 left near the employee exit door because the sidewalk was not shoveled. V9 said he saw R1's wheelchair markings in the snow. V9 said the outside temperature was 17 degrees (Fahrenheit/F) because he looked it up when they picked up R1.An observation was made of the sidewalk that R1 potentially took. There were a couple of broken areas of concrete and also unlevel concrete. The sidewalk goes around the facility to the back of it which leads into a parking lot of a shopping plaza.On February 9, 2026, at 9:21 AM, V4 Registered Nurse (RN) said one of the staff members in the facility called her and reported that there was a police officer (V9) at the facility. (On February 4, 2026) V4 said she was the nursing supervisor on that shift. V4 said the police officer got to the facility around 6:00 AM. V4 said the police officer was asking about R1. V4 said she was not aware of the resident, so she looked up the resident's name in the computer and saw that R1 was a resident in the facility. V4 said she called R1's nurse which was V3 RN. V3 came to talk to V9 police officer. V4 said the staff did not know that R1 was gone out of the facility until the police officer came to the facility nor does anyone know what time R1 got out of the facility. V4 said all of the exit doors have alarms on them for when someone exits the facility. V4 said she did not hear any alarms going off. V4 said if a door alarm goes off, then all staff perform a head count on the residents to make sure they are all there. V4 said she was never notified that an alarm went off, nor did she perform a head count on the units she was responsible for.On February 9, 2026, at 9:07 AM, V3 Registered Nurse (RN) said that R1 self propels herself in her wheelchair. V3 said a police officer arrived to the facility around 5:30 AM and said a resident had gotten out of the facility and was taken to the hospital. V3 said she made her last rounds at 4:00 AM, and R1 was asleep in her bed. V3 said no staff knew that R1 had gotten out of the facility. V3 said she did not know what door R1 left out of. V3 said all exit doors are alarmed. V3 said the main exit door alarmed at about 3:00 AM/3:20 AM. V3 said she shut the alarm off, looked outside, and did not see anyone. V3 said it was very cold outside. V3 said all the residents were counted after the alarm went off but she did not report the alarm to the nurse on the other units. V3 said she called the local hospital after she was made aware that R1 had exited the facility. V3 said the hospital told her that R1's body temperature was low. V3 said the typical procedure for when an alarm goes off is to let all the staff know so that a head count can be performed.On February 5, 2026, at 2:02 PM, V5 Certified Nursing Assistant (CNA) said she last checked on her residents around 3:45 AM and R1 was in her bed asleep. R1's door was closed. V5 said they were made aware that a resident left the facility when the police officer (V9) came to the facility. V5 said they do not know how R1 got out of the facility. V5 said she did not recall any exit door alarms going off. V5 said an exit door would alarm if a resident got out. V5 said if an alarm goes off, the nursing supervisor will go to the door. V5 said the facility staff perform a head count of all of the residents. V5 said she was made aware of a door alarm that had sounded about 3:45 AM (conflicting statement) and the staff performed a head count. V5 said all the residents were there. V5 said that R1 is able to get in and out of bed on her own and self propels in her wheelchair. V5 said R1 cannot walk and R1 is disoriented and confused at times.R1's Emergency Medical Service (EMS) Report dated February 4, 2026, shows that EMS arrived on the scene with R1 at 5:55 AM. Patient condition: Complaint: Cold exposure, primary symptoms: Chills. R1 was confused. Assessment Summary: Skin cold. Narrative: Dispatched for a check for wellbeing. Upon arrival, crew made contact with the patient who was awake and alert, talking with cops. The patient informed the crew that she had been outside all night. The patient informed the crew that she had been living outside for a couple of months. Patient informed crew she felt cold. Provider Impression: Primary: Hypothermia-Initial Patient Acuity: Emergent.R1's emergency room Department Notes dated February 4, 2026, at 6:19 AM shows R1 presented to the emergency department for cold exposure. At 9:07 AM, a repeat temperature was taken and it was continuing to improve. There was no temperature values located in this document.R1's Discharge paperwork dated February 4, 2026, shows R1's rectal temperature upon discharge was 95.9 degrees F. (Rectal temperature=most accurate body temperature location. Normal rectal temperature=99.6-100.4 F)On February 9, 2026, at 12:03 PM, V10 Business Office Manager said V1 Administrator notified her that R1 was in the emergency room and V1 asked V10 if she could go to the emergency room to check on R1. V10 said she got to the emergency room a few minutes before 7:00 AM. V10 said R1 had been at the emergency room for about 54 minutes by the time she arrived. V10 said R1 slept after she ate breakfast while in the emergency department. V10 said R1 was hooked up to a heart monitor, and the hospital staff were monitoring R1's body temperature. V10 said hospital staff did an oral temperature which read 93 degrees F. The hospital staff were unsure if R1 had the thermometer under her tongue, so they took a rectal temperature which was 95.9 degrees F (an hour or more after resident arrived to the emergency department). V10 said R1 had 2-3 blankets on top of her and the hospital staff also placed a special blanket on top of R1 that blew warm air.On February 9, 2026, at 12:23 PM, V11 Nurse Practitioner said she heard that R1 exited the facility. V11 said that R1 used to be homeless before she became a resident of the facility. V11 said R1 would not be able to be on her own safely due to R1's cognition. V11 said residents should not be able to go out of a facility if the facility is secured. V11 said R1 was able to leave the facility with an escort: family or friend. V11 said residents with cognitive issues have an escort when they leave the facility for safety reasons. V11 said if a resident is found outside in temperatures less than 20 (degrees F), hypothermia would be a concern for her. V11 said a body temperature below 95 degrees (F) is considered hypothermia.On February 9, 2026, at 11:25 AM, R1 said she has been at the facility for Two weeks, I think. But I don't even have a room anymore. They took it away from me. When R1 was asked if she remembered when she went outside in the cold the other day, R1 said, I have no idea what you are talking about. R1 was asked if she ever goes outside, and R1 said, I go smoke a couple times a day. I just go out the front door when I want. R1 has not smoked since she has been a resident of the facility. When R1 was asked if she remembered going to the hospital, she said yes and that the hospital checked her out and sent her to the facility. R1 did not remember where she was picked up. R1 did not remember speaking with a police officer nor did R1 remember where she slept the night prior.The facility's Elopement and Wandering Residents Policy revised September 5, 2025, shows, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Adequate supervision will be provided to help prevent accident or elopements.The Immediate Jeopardy that began on February 4, 2026, was removed on February 10, 2026, at 12:34 PM, when the facility took the following actions to remove the immediacy:All residents were reassessed for the elopement risks.All residents identified as high risk for elopement had care plans reviewed for accuracy. Elopement binder reviewed and updated to reflect high risk residents.An emergency QAPI was held on February 6, 2026, to review policies/procedures.Daily door alarm audits began February 4, 2026.Door alarm added to interior door leading to staff entrance on February 6, 2026.Second door alarms added to reception door as well as the exit between two units in order to double alarm all exits on February 6, 2026.Additional speakers added so alarms are more audible on February 6, 2026.In-Service/Education was initiated on February 5, 2026, on facility's door alarm protocol, responding to alarms, and completing head counts.R1 was moved to a secured unit on February 4, 2026.The Administrator or designee will perform elopement risk assessment audits five times per week for two weeks, then three times weekly for two weeks, then weekly for four weeks to ensure compliance with transfer protocols. Findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly. Noncompliance will result in immediate corrective action and additional staff training. Monitoring will continue until the QAPI committee determines sustained compliance has been achieved.The Administrator or designee will perform door alarm response audits five times per week for two weeks, then three times weekly for two weeks, then weekly for four weeks to ensure compliance with transfer protocols. Findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly. Noncompliance will result in immediate corrective action and additional staff training. Monitoring will continue until the QAPI committee determines sustained compliance has been achieved.

Based on interview and record review the facility failed to obtain a STAT (immediate) chest x-ray as ordered for 1 of 5 residents (R4) reviewed for radiology services in the sample of 12.The findings include:R4's Nurse Practitioner Progress Notes dated 2/5/26 shows, Acute Cough. Chest x-ray R4's Physician's Order Sheet shows an order dated 2/5/26 for a stat chest x-ray written by the prescriber. On 2/10/26 at 2:52 PM, V11 (Nurse Practitioner) said that R4 had a cough so she ordered a chest x-ray to make sure R4 did not have pneumonia due to his history of chronic bronchitis and pneumonia. V11 said that she put the order into the computer and told the nurse as well. V11 said that she has not seen the results of the x-ray and does not know if it was done or not. On 2/11/26 at 10:45 AM, V2 (Director of Nursing) said that if a provider orders a stat x-ray, the nurse calls the x-ray provider and orders the x-ray. V2 said that they typically come out and perform the x-ray within four hours. V2 said that the results are usually received that same day. V2 said that she could not find any evidence that a x-ray was performed. The facility's Laboratory and Diagnostic Services and Reporting Policy revised on 9/1/24 shows, The facility must provide or obtain laboratory and diagnostic services when ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory and diagnostic services to meet the needs of its residents.The nurse will carry out laboratory and radiology orders per facility protocol. Promptly notify the ordering physician, physician assistant, nurse practitioner of laboratory and radiology results that fall outside the clinical reference range for appropriate follow-up/orders.

Based on interview and record review the facility failed to ensure a respiratory viral panel was performed as ordered for 1 of 5 residents (R4) reviewed for laboratory services in the sample of 12.The findings include:R4's Nurse Practitioner Progress Notes dated 2/5/26 shows, Acute Cough. respiratory viral panel R4's Physician's Order Sheet shows an order dated 2/5/26 for a respiratory viral panel written by the prescriber. On 2/10/26 at 2:52 PM, V11 (Nurse Practitioner) said that R4 had a cough so she ordered a respiratory viral panel to make sure that he did not have a virus that was causing the cough. V11 said that she put the order into the computer and told the nurse as well. V11 said that she has not seen the results of the test and does not know if it was done or not. On 2/11/26 at 10:45 AM, V2 (Director of Nursing) said that if a provider orders a respiratory viral panel, the nurse should collect the specimen and notify the laboratory that the specimen needs to be picked up and fill out a laboratory requisition form. V2 said that she could not find any evidence that a specimen was collected and sent to the laboratory. The facility's Laboratory and Diagnostic Services and Reporting Policy revised on 9/1/24 shows, The facility must provide or obtain laboratory and diagnostic services when ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory and diagnostic services to meet the needs of its residents.The nurse will carry out laboratory and radiology orders per facility protocol. Promptly notify the ordering physician, physician assistant, nurse practitioner of laboratory and radiology results that fall outside the clinical reference range for appropriate follow-up/orders.

Based on interview and record review the facility failed to ensure significant medications were administered as ordered for 2 of 5 residents (R4 and R5) reviewed for medication administration in the sample of 12.The findings include:1.R5's Nurse Practitioner Note dated 2/5/26 shows that R5 was diagnosed with a pulmonary embolism (blood clot in the lung) on 11/4/25 and is to continue her Lovenox (Enoxaparin- an anticoagulant used to treat and prevent blood clots) 100 milligrams (mg) twice a day.On 2/5/26 at 1:07 PM, R5 said that she recently had a blood clot in her lung and was put on a blood thinner to prevent additional clots. R5 said that the facility is constantly running out of her medications. R1 said that she has missed multiple doses. R5's January Medication Administration Record (MAR) shows an order starting 1/2/26 for Enoxaparin Sodium Injection 100 mg/mL (milliliter)-Inject 100 mg subcutaneously two times a day for anticoagulant. R5's MAR shows that she did not receive a dose on 1/2/26 (PM dose), 1/19/26 (AM and PM dose), 1/20/26 (PM dose), and 1/26/26 (AM and PM dose). R5's Orders-Administration Notes for those dates document that the medication is on order.On 2/9/25 at 12:01 PM, V11 (Nurse Practitioner) said that R5 is on enoxaparin due to having a pulmonary embolism in November shortly after her motor vehicle accident. V11 said that she is on the medication to prevent any additional blood clots and to keep her previous one from getting worse. V11 said that it is important that she receives the doses as ordered. V11 said that R5 did tell her about the missing doses as well. 2.R4's January MAR shows that he receives levetiracetam 500 mg-3 tablets twice a day for anticonvulsant. R4's MAR shows that he did not receive his AM or PM does on 1/20/26 and his AM dose on 1/21. R4's Orders-Administration Note shows that the medication was not available. On 2/9/26 at 12:01 PM. V11 (Nurse Practitioner) said that R4 has a seizure disorder. V11 said that he is on levetiracetam to prevent seizures and should be given as ordered. V11 said that if he misses too many doses, he could have a seizure. V11 said that if a medication is not available, they should call her and let her know and she will direct them on what to do. V11 said that she was not aware that he missed any doses of his levetiracetam. On 2/9/26 at 2:09 PM, V2 (Director of Nursing) said that all medications should be administered as ordered. V2 said that all medication should be ordered when they have a 2-3 day supply remaining. V2 said that if a nurse goes to administer a medication and it is not available, they should call the pharmacy to see when it is expected to be delivered and if it is not going to be delivered by the time that the medication is due, they need to call the pharmacy for a STAT (immediate) delivery. V2 said that resident's should not have to go without their ordered medications. The facility's Medication Administration Policy revised on 9/1/24 shows, Reorder medications from the pharmacy when there is 2 to 3 day supply remaining.

Based on interview and record review the facility failed to administer medications as order for 3 of 5 residents (R1, R4 and R5) reviewed for pharmacy services in the sample of 12.The findings include:1.R4's January Medication Administration Record (MAR) shows an order dated 12/8/25 for, Muro 128 Ophthalmic Ointment 5%-Instill 1 application in right eye two times a day. The MAR shows that he did not receive it on 1/12 (PM dose) and 1/30 (AM dose) and 1/31 (AM dose). R4's February MAR shows that he didn't receive it on 2/1/26.R4's Order-Administration Note dated 1/12 shows, Solution available however responsible party/POA is awaiting the ointment as ordered. R4's Order-Administration Note dated 1/30, 1/31 and 2/1 shows, medication not available. On 2/9/26 at 10:41 AM, V12 (Registered Nurse) said that she has worked at the facility for two weeks and R4 has never had Muro ointment available to administer until just the other day. V12 said that she did call pharmacy but it never came. V12 said that she would just sign it out as administered even though she didn't have it because R4's mother had a supply of it. R4's January MAR shows an order dated 1/27/26 for Dextromethorphan-15 mg (milligrams)/5 ml (milliliters)-Give 5 ml by mouth three times a day for cough for 7 days. R4's MAR shows that he did not receive it on 1/28 for one dose and 1/29 for one dose. R4's Orders-Administration Notes for those dates shows, Medication not available.2.R1's Nursing Note dated 1/27/26 shows, Resident returned to facility at 1730 (5:30 PM), with new orders in stable condition.R1's January MAR shows and order dated 1/28/26 for, Magic Mouthwash (lidocaine/Maalox-give 15 ml by mouth four times a day for mouth sore ***Compounded by pharmacy-fax MD order to Pharmacy**. The MAR shows that she did not receive the medication for three doses on 1/28/26 and one dose on 1/29/26. R1's Pharmacy Proof of Delivery List from 1/1/26 to 2/5/26 shows that Magic Mouthwash was never delivered to the facility.On 2/9/26 at 12:01 PM, V11 (Nurse Practitioner) said that R1 was sent to the emergency room due to having blood all over in her mouth. V11 said the emergency room found out that she had bit her tongue and ordered the mouthwash for pain control. V11 said that she does not think that she ever received the mouth wash. V11 said that the mouth wash would have been ordered upon her return and delivered by the pharmacy. 3.R5's January and February Medication Administration Record shows that she receives Prazosin 2mg at bedtime for dreams. R5's MAR shows that she did not receive the medication on 1/2/26, 1/5/25 and 2/1/26. R5's Order-Administration notes for those dates show that it was on order. On 2/9/26 at 2:09 PM, V2 (Director of Nursing) said that all medications should be administered as ordered. V2 said that all medication should be ordered when they have a 2-3 day supply remaining. V2 said that if a nurse goes to administer a medication and it is not available, they should call the pharmacy to see when it is expected to be delivered and if it is not going to be delivered by the time that the medication is due, they need to call the pharmacy for a STAT delivery. V2 said that resident's should not have to go without their ordered medications. The facility's Medication Administration Policy revised on 9/1/24 shows, Reorder medications from the pharmacy when there is 2 to 3 day supply remaining.

Based on observation, interview, and record review the facility failed to provide necessary care, services, and translation services after a resident experienced a fall and subsequent hip and arm fractures. This failure resulted in R1 experiencing pain and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 5. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 5/13/25 with diagnoses to include but not limited to dementia, pubic fracture (onset date 6/27/25), osteoarthritis (joint cartilage breakdown), right shoulder bone density disorder, and spinal stenosis. R1's 11/19/25 Quarterly Minimum Data Set (MDS) showed Mandarin was her preferred language and she would like an interpreter to communicate with a doctor or health care staff. The MDS showed she was not able to complete a Brief Interview for Mental Status (BIMS) test and she had both short and long-term memory problems. The MDS showed she had no range of motion limitations to her upper or lower body extremities, and she used a wheelchair for mobility. The Functional Abilities section of R1's MDS showed she required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for eating, oral hygiene, toileting hygiene, dressing, putting on footwear, sit to stand, chair/bed transfers, and walking 10 feet. On 1/22/26 at 12:30 PM, R1 was in bed, asleep, and did not awaken to her name. R1 had bruising to the left side of her face; the remainder of her body was covered in a blanket. On 1/21/26 at 9:35 AM, V4 Lieutenant Firefighter/Paramedic with facility's local fire department stated he responded to a 911 call on Monday 1/20/26 at 1:30 AM for a fall. V4 stated when he got there R1 was asleep in bed and not on the floor. V4 stated The nurse said she fell on the 15th (1/15/26, Thursday) and we just got X-rays, and she has a broken hip. I asked, 'Why didn't you call on 15th and she said I don't know, I wasn't here when she fell. We went to take blood pressure on the left arm, and she immediately winced in pain. Nurse walks up and says she has a broken left hip and left forearm; that would have been nice to know beforehand. V4 said, R1 only spoke Chinese. V4 said, We tried Google translate and we were not having good luck. We asked the facility how they communicate, and they said they speak English to her and they said we just know what she wants based on her grunts and groans. They said they don't have a translator. V4 said, The nurse read us the fall report from the 15th, and they didn't call EMS at that time. two RNs (registered nurses) were with us. V4 reiterated, They (two nurses) both said they did not have translation services. They said we speak English to her and then we just know what she wants or needs based on her moans and groans. V4 was asked about any abnormal findings with R1, he replied, The first thing we noticed was bruising to left side of her face that looked old. Then once we took blood pressure of her left arm there was guarding (person protecting a body part by moving the body part when touched), so we moved her to a back board for stabilization. They (other paramedics) did look at the left leg, but I wasn't the one that assessed it, I was in charge . They (nursing staff) read me the assessment from the 15th but they said everything was normal on the 15th, which got me wondering, with the displaced fracture in the left arm and the broken hip, how did they move her and toilet her with broken bones? V4 stated, V5 Firefighter/Paramedic with the facility's local Fire Department was the paramedic who was most involved in R1's assessment. V4 stated he did not know the names of the nursing staff. On 1/21/26 at 11:03 AM, V5 stated When we got there, they informed us she had fallen 5 days ago, they just got Xrays, and they only told us about the hip fracture. She winced in pain when we tried to take her blood pressure on the left arm. V5 stated they tried a translation app on their phone but they were unsuccessful. V5 stated, when the paramedics placed her on the back board she winced in pain with movement. V5 said, when he got to the hospital with R1 the Emergency Department nurse removed her sweater and her left elbow was obviously swollen. V5 stated he spoke to nursing staff at the facility and they read the notes from the fall on the 15th and the notes said she was in no obvious pain. R1's Ambulance Run Report (Authored by V5) showed they were dispatched at 1:18 AM on 1/20/26 and arrived to the R1 at 1:31 AM. The report showed, .hip and left forearm fracture from a fall 5 days prior. Staff state they received report that the pt (patient) began moaning in pain in the morning and is why she was sent out for X-rays. Staff stated that the pt was acting to her norm and only speaks Chinese.Crew noted pt winced when examining her left forearm but could not feel any obvious deformity. R1's Nurses Notes from 1/15/26 (Thursday) at 7:17 PM, showed Resident with fall from bed at 1610 (4:10 PM) while attempted self-transfer and fell to floor on her left side and bumped the small dresser. Small bruise on left side of forehead, anxious, moving all extremities, and attempting to get up off the floor. (Note authored by V7 Registered Nurse, RN) On 1/21/26 at 1:57 PM, V7 RN stated (regarding R1's fall on 1/15/26) R1 rolled out of bed and hit her head on the bedside table. V7 said, She was very antsy and kept wanting to get up but nothing was broken. I saw her a couple of days later and she was walking with the wheelchair out in front of her.it must have been Saturday that I saw her walking. V7 stated she notified the Nurse Practitioner of the fall. On 1/21/26 at 12:11 PM, V6 R1's Daughter and Power of Attorney stated, I went and saw her over the weekend after the fall and she was walking, but she has to be supervised. Yeah, it was this last weekend. I was there from 11:00 AM to 4:00 PM on Saturday and she was walking and doing fine. She did walk a little bit, maybe 10 yards, then had to rest. Then Sunday my brother went there and tried to get her to move, and my brother said she walked a lot, and she was really strong. She was not having pain. V6 said R1 was walking and using both arms to stabilize herself without pain or discomfort. V6 said she did not notice any pain or guarding with R1's left arm. V6 said, Monday night I got a call.they said they were going to send her out for a fracture. I don't know why they did the Xray. She was fine over the weekend, I should try to figure that out. Monday night, when they called about sending her out, the nurse told me she fell several days ago. They always call me when she falls; no problems there. R1's EHR showed V13 RN entered an order for an X-Ray of the left forearm and left hip due to pain. The X-Ray order was entered on 1/19/26. The facility's schedule showed V13 RN was R1's day nurse (7:00 AM to 3:00 PM) on Friday, Saturday, Sunday, and Monday (1/16/26 through 1/19/26). On 1/22/26 at 11:57 AM, V13 stated R1 was fine over the weekend, and she had no pain. V13 stated R1 did not have a fall during her shift on 1/19/26 (Monday). V13 said, .the off-going night nurse (V16 Licensed Practical Nurse) told me that she (R1) was in pain. I'm pretty sure it was Monday, and she asked if I could get an order from the NP (Nurse Practitioner). She asked me to get an order for an Xray and for pain medication. When I asked the NP, I got a stat Xray order. It was [V16] and she said I should get an order for pain meds (medications) and an Xray. [V16] did not say that anything happened Sunday night, she didn't say anything about a fall. She said when she went in to check on her in the morning, she (R1) was having pain in her left arm and she (R1) was pointing to her hip. When I worked with her on Sunday, she (R1) was not having any pain. I did work a double on Sunday. If I knew about a fall, I would have told the NP about it when I got the order for the Xray. [R1], she does not have pain. She does not speak English. When I tried to touch her left arm on Monday, she retracted the left arm and she was not like that on Sunday. [R4, R1's roommate] did not say anything about what happened to [R1]. V13 said R4 is not known to make up allegations. On 1/22/26 at 10:08 AM, V10 Certified Nursing Assistant (CNA) stated she was R1's CNA when she fell on 1/15/26. V10 said after R1's fall she did not have any pain, and she was at her baseline. V10 said R1 was not her resident on Friday 1/16/26; however, she did assist R1 to the bathroom and R1 had no pain. V10 said, I did not have her on Monday (1/19/26), [V11 CNA] had her on Monday. It was mealtime and I asked [V11] where she was and he said she was in bed and I asked why and he said I don't know why. He told me her (R1) roommate said she had a fall on Sunday night. On 1/22/26 at 10:57 AM, V11 CNA stated .She (R1) did not get out of bed on Monday. She was sleepy that day. She usually eats in the dining room but that morning she ate in her room. When I would clean her up, she kept saying a word over and over again. The word was Iyo, Iyo, Iyo, over and over and over again. I don't know what it means. I did not get a report that she had a fall the night before. [R4] said she had a fall but, I think she was referring to a fall from the week before. I was emptying [R4's] catheter on Monday morning and [R4] asked how her roommate was doing because she had a fall but I don't remember when she said [R1] fell. I don't know if they have any translator services or not. Translator services would be beneficial then I would know what they are saying and what they need like the word that [R1] was saying. She just kept saying Iyo, Iyo, Iyo over and over again when I changed her brief on Monday. She did not get out of bed on Monday. I did not notice any swelling on her left arm. On 1/22/26 at 11:20 PM, V6 R1's Daughter stated Iyo it means ouch, like pain. On 1/22/26 at 10:25 AM, R4 (R1's roommate) said I think she (R1) had a fall Sunday night. She was over here, she was on my side of the room, touching my tv. The daughter said to me she doesn't speak English. I'm pretty sure it was Sunday, but it wasn't the 15th, I know it wasn't the 15th, because people were asking me about it. [V2 Director of Nursing, DON] came and talked to me about it. I heard her (R1) fall, and I knew it was a bad one. I knew it was bad because it was loud. She crawled over to my side, it was the middle of the night, so I pushed the button, and she had wedged herself by the door so they couldn't push the door open. They finally came in and pulled my curtain. The nurse brought her out to the nurses' station, and I think they called a gentleman to help or a male nurse. They took her out in the chair and then later put her back in the bed. I think it was just the CNA that put her back in bed and I could tell she was in pain. I knew she was in pain because she was moaning and yelling. I'm certain the fall was on the weekend.Then they did Xrays on Monday, so yes, the fall happened Sunday night because they did the Xrays the next day after the fall, that I do remember. The staff don't use any translator services. Sometimes I will try to communicate with her through google translate. I asked the daughter what some of the words mean that she says all the time and she told me they mean pain and bathroom. On 1/22/26 at 12:23 PM, R4 said Normally when they get her (R1) up she doesn't make any noise but on Monday she was complaining a lot. I knew she was in pain on Monday when they were moving her. Yes, she kept saying Iyo, Iyo, Iyo. Does that mean ow? R4's 12/11/25 Quarterly MDS showed she was cognitively intact with a BIMS score of 15 out of 15. On 1/21/26 at 10:36 AM, following R1's fall note on 1/15/26 at 7:17 PM, R1's Electronic Health Record (EHR) showed no other fall documentation in either the assessment section or the progress notes. R1's NP Note with a 1/15/26 Date of Service (Authored by V17 NP) showed, Patient had a fall from bed on 1/15/2026 while attempting self-transfer, resulting in a small bruise to the left forehead; no change in mental status, pain, or ADL (Activities of Daily Living) function reported post-event. (No similar NP assessment was completed on 1/19/26 per R1's EHR. This note was a PDF document and was electronically signed on 1/19/26 at 11:53 AM.) R1's 1/20/26 Orthopedic Physician Consult Note showed, [R1] is a [AGE] year old female presenting with a complaint of LEFT hip and LEFT elbow pain after a fall sustained apparently 5 days ago.Patient resides at [the facility] and staff reported patient started moaning last night and noticed bruising to the elbow and forehead so they performed Xrays at the facility which reported a left hip and left elbow fracture. The note showed she had a fractured left hip and a displaced (the bone has shifted at the fracture point) left elbow fracture. The note showed the family elected not to pursue surgical interventions and they are now contemplating palliative care services. (No mention of a fall on 1/19/26.) On 1/23/26 at 9:56 AM, V16 Licensed Practical Nurse (LPN) stated V12 LPN was originally scheduled to be R1's nurse for the third shift beginning on 1/18/26; however, herself and V16 switched assignments. (The facility's staff scheduled showed V12 was assigned R1 for that shift.) V16 said at approximately 12:30 AM on Monday 1/19/26, she was doing rounds and found R1 on the floor. V16 said the call light turned on as she was going into the room. V16 said, nothing seemed abnormal regarding her assessment of R1. V16 said, I did look at her entire body, she was in a brief, nothing was abnormal or out of range. V16 said R1 did not have pain during her shift. V16 said, she gave acetaminophen (over the counter pain medication) just in case. V16 said After a fall, in case there is any achiness, I just give them [acetaminophen]. V16 said after R1 fell she was brought out to the dining room adjacent to the nurses' station for approximately 3 hours. V16 said she was not in the room when R1 was put back to bed and she was not notified of R1 having pain when she was put back to bed. V16 said, I would want to be notified of the resident being put back to bed and if she was having pain. That creates a more serious issue; I may need to do further interventions. If I had been aware, I would have called the NP at that time to get orders. We did let the NP know because she gave the Okay for the testing. The oncoming nurse let her know. V16 said she documented the fall in R1's progress notes. V16 said the NP was not notified; however, V16 stated she did notify the oncoming nurse (V13). V16 was asked, why she requested an Xray, if per her assessment, nothing seemed abnormal or out of range? V16 stated, We do an Xray just in case. (During V13's interview, V13 denied being notified of a R1 falling; however, she stated she was notified, by V16, of R1's pain during V16's shift.) R1's progress notes showed a note was entered into R1's chart by V16 with an effective date of 1/19/26 at 6:10 AM; however, the note was created on 1/21/26 at 2:29 PM (2.5 days after the fall occurred and after the initiation of the survey.) The note showed, During routine rounds at 12:30 a.m., the resident was observed lying supine on the floor in her room. She was wearing non-skid socks and was gesturing to staff to get her up. She was not able to state what she was trying to do and was speaking Chinese. She did not have any complaints of pain or discomfort were observed. She did not have any bumps, redness, or new areas of skin discoloration to her head. She was assisted from the floor to the w/c (wheelchair) with the assistance of two staff members. Vital signs were assessed and stable. [Acetaminophen] was offered and given. This writer used a translator app, and stated she was hungry. We provided a peanut butter sandwich, a pudding, and a mighty shake, which was consumed. The resident was placed with the CNA for closer supervision. At around 4:00 a.m. the resident was sleeping in the w/c, so she was assisted to bed. The resident was quiet and sleeping the remainder of the shift. R1's Medication Administration Record showed an order for two 325 milligram acetaminophen tablets to be given for as needed every six hours for Mild to Moderate pain. V16 documented administration of acetaminophen at 12:30 AM on 1/19/26 for a Pain Level of zero. V15 CNA assigned to R1 third shift the evening beginning on Sunday 1/18/26 was called on 1/22/26 at 1:18 PM and 1/23/26 at 8:48 AM. V15 returned call on 1/23/26 after work hours. A third attempt was made on 1/27/26 at 1:20 PM. On 1/22/26 at 2:01 PM, V6 R1's Daughter stated she was notified of R1's fall by V2 Director of Nursing on 1/21/26. On 1/23/26 at 10:30 PM, V17 Nurse Practitioner stated, .on Monday the nurse said she was having pain, but nothing was abnormal, then they got the Xrays back way early in the morning and sent her (R1) out. I remember the nurse saying she had a fall, she didn't say the date of the fall, so I'm not actually sure of the specifics of the fall or when it happened, she could have been talking about the fall on the 15th.I did not see her on Monday (1/19/26), I think I was already gone, so probably sometime after noon. V17 stated the date of service is the date she saw R1. V17 said when she electronically signed R1's note it must have also entered a progress note. (R1's EHR showed a progress note authored by V17 on 1/19/26 at 11:53 AM. The note was identical to V17's PDF note from 1/15/26 which was electronically signed on 1/19/26 at 11:53 AM. This made it appear as if V17 had assessed R1 on 1/19/26.) V17 said, If I had been told that she was having pain and she had a fall I would have seen her while I was here and maybe done something different than an Xray. Those fractures can be painful with movement, especially the hip fracture. I would think the injury happened on the 19th. I do know [R4]. She is alert and oriented. She has MS (multiple sclerosis) and she is a good historian. If I had reviewed the chart (R1's chart), I would not have seen the fall note if it was not entered until 1/21/26. I was totally reliant on the day nurse (on 1/19/26), the information she had, and what she was telling me. If she (day nurse) didn't know about the fall on the 19th then I would not have known. I need to know all of the information, so I know what to do and what to prescribe, so I really rely on them as to what I need to do. [Acetaminophen] should not be given after a fall 'just in case.' It should be given for pain or fever, that is the indication. We don't order an Xray if the post fall assessment is fine and there is no pain. We don't order an Xray 'just in case.' One 1/21/26 at 11:02 AM, V4 stated, I'd say it does make assessment challenging (lack of translation services). We tried with our own translation services (phone translator) with minimal response. Only thing we have left would be a physical assessment. Being able to communicate with the patient makes things significantly better. On 1/23/26 at 10:56 AM, V2 Director of Nursing stated, following a fall the staff should assess the resident, do vital signs, assess for pain, document in the medical record and do an incident report. V2 said the oncoming shift should be notified as well as the nurse practitioner. V2 stated it is acceptable for nursing staff to give acetaminophen prophylactically (to prevent) for pain after a fall. V2 said shift-to-shift communication is important so the nurses are aware of the condition of their residents. The facility's Effective Communication and Language Assistance Services policy (Reviewed/revised 9/1/25) showed, Purpose: To ensure all residents receive clear, respectful, and understandable communication and have timely access to language assistance services necessary to participate fully in their care. Policy Statement: The facility will provide effective communication to all residents and language assistance services at no cost to residents with limited English proficiency and/or other communication needs, in accordance with federal and state regulations.Language Assistance Services: Oral interpretation, written translation, or other aids provided at no cost to ensure residents can understand and access health care services. The facility's Change in Resident's condition Policy (Reviewed 9/1/24) showed, Document the resident's assessment in the medical record as applicable. (Head-to-toe assessments, vital signs, diagnostic results, laboratory results, behaviors, etc.) The facility's Fall Prevention Program showed (Reviewed 9/1/24) showed when any resident experiences a fall, the facility will: Assess the resident, complete a post-fall assessment, complete an incident report, and document all assessments and actions.

Based on observation, interview, and record review the facility failed to notify a resident's family and nurse practitioner after the resident fell. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 5. The findings include:R1's admission Record (Face Sheet) showed an original admission date of 5/13/25 with diagnoses to include but not limited to dementia, pubic fracture (onset date 6/27/25), osteoarthritis (joint cartilage breakdown), right shoulder bone density disorder, and spinal stenosis. On 1/22/26 at 12:30 PM, R1 was in bed, asleep, and did not awaken to her name. R1 had faded bruising to the left side of her face; the remainder of her body was covered in a blanket. R1's 1/15/26 Nurse's Note from 7:17 PM showed, Resident with fall from bed at 1610 (4:10 PM) while attempted self-transfer and fell to floor on her left side and bumped the small dresser. Small bruise on left side of forehead. (note authored by V7 Registered Nurse) On 1/21/26 at 1:57 PM, V7 Registered Nurse stated she did not notify R1's family of the fall on 1/15/26 until the next day. V7 stated she should have notified the family of the fall the day it happened. V7 said R1 must have hit her head due to a mark and small bruise that was forming on the left side of her head. R1's Nurses Note from 1/19/26 at 6:10 AM, During routine rounds at around 12:30 a.m., the resident was observed lying supine on the floor in her room. She was wearing non-skid socks and was gesturing to staff to get her up. (Less than 24 hours after this fall R1 was diagnosed with a fractured left hip and left elbow. Note authored by V16 Licensed Practical Nurse.) On 1/23/26 at 8:55 AM, V16 stated she did not notify the family or the nurse practitioner after R1's fall on 1/16/26. On 1/22/26 at 2:01 PM, V6 R1's Daughter/Power of Attorney stated she was not notified of R1's fall on 1/15/26 until 1/16/26 at noon. V6 said she was not notified of R1's fall on 1/19/26 until 1/21/26 when V2 Director of Nursing told her. V6 said she expects the facility to call her right away. V6 said, I need to know what is going on. On 1/23/26 at 10:56 AM, V2 Director of Nursing stated staff are expected to notify the family and provider after a resident falls. V2 said notification is important so family and providers are notified of changes and can make informed decisions. On 1/23/26 at 10:30 AM, V17 Nurse Practitioner stated she did not round on R1 on 1/19/26. V17 said if she had been notified of a fall on 1/19/26 she would have seen the resident in the morning while she was at the facility. V17 said notification is important so she is aware of what is going on with her residents and so she can make fully informed decisions. The facility's Fall Prevention Program showed (Reviewed 9/1/24) when any resident experiences a fall, the facility will: assess the resident, complete a post-fall assessment, complete an incident report, notify physician, notify family, and document all assessments and actions.

Based on observation, interview, and record review the facility failed to ensure a resident who is a high risk for falls was supervised and failed to ensure fall interventions were individualized for a resident with poor safety awareness and cognitive deficits and failed to ensure bed rails were installed in manner to prevent entrapment. This failure resulted in R1 being found in her room kneeling on the floor with her right arm trapped between the side rail and the mattress sustaining a right comminuted humerus fracture. This applies to 1 of 3 resident (R1) reviewed for safety in the sample of 9. The findings include: R1's Final Incident Report dated 4/15/25 shows on 4/10/25 (R1) is a [AGE] year-old female with diagnoses including atrial fibrillation, type 2 diabetes, major depressive disorder, insomnia, hypertension, and dementia with agitation .(R1) usually transfers with partial to moderate one staff assist and can use call to alert staff when assistance is needed. (R1's) call light was activated, and the nurse (V3-Licensed Practical Nurse-LPN) responded to the light. (R1) was observed kneeling on the floor next to her bed with the wheelchair behind her. (R1's) right arm was between the side rail and the mattress and (R1) was complaining of pain to the right shoulder .(R1) was sent to the local hospital and admitted with diagnosis of right humerus fracture. On 4/16/25 at 9:45 AM, R1's bed was observed with two 1/2 side rails in an upright position. There was a gap (wide enough for her arm to fall through to get trapped) between the mattress and the side rail. On 4/16/25 at 11:53 AM, V3 (Licensed Practical Nurse-LPN) said on 4/10/25, she did not see R1 go back to her room after dinner. She heard R1 was yelling help me, help me and the call light alarming from the room. When she entered the room R1 was on her knees with her wheelchair behind her, her right arm was stuck between the mattress and the side rail. R1's 1/2 side rail was in the upright position, and she was complaining of pain to her right arm and she could not move her right arm. She asked R1 what happened and R1 could not tell her what happened. V3 said it looked like R1 slide from the bed or was transferring to the bed. R1 was having problems moving her right arm and she was transferred to the local hospital. We remind R1 to use her call light, but she likes to be independent. R1 does not need assistance with transfers and can transfer herself. R4 (R1's roommate) had activated the call light not R1, when she entered the room R4's call light was alarming. Frequent monitoring and supervision could have prevented the incident with R1. On 4/16/25 at 11:41 AM, V4 (Certified Nursing Assistant-CNA) said on 4/10/25, after passing the meal trays, she went to another resident's room to assist with feeding. V3 (LPN) reported she needed help with R1. When she entered R1's room she saw her kneeling on the floor, her right arm was stuck between the side rail and mattress, and she could not move her arm. She was saying, help me, help me. R1's call light was not activated, her roommate R4's call light was alarming. R1 never calls for help, she transfers herself, and does not staff assistance with transfers. She is not a fall risk. On 4/16/25 at 12:12 PM, R4 (R1's roommate) said on 4/10/25, she heard R1 fall but did not see what happened because the privacy curtain was pulled. R1 was yelling out so loud and she alerted the call light. On 4/16/25 at 10:18 AM, V5 (Registered Nurse-RN) said he is the nurse on this unit and splits between two units and so does the CNA. R1 is alert and forgetful, she self-propels in her wheelchair. We remind her to use her call light, but she does not remember to use it and he is not sure if R1 knows how to use the call light. She forgets where her room is and asks the same question over and over again. She tries to stand and self-transfer and forgets she needs assistance. She does not use her call light for assistance, she needs to be supervised. If she is left alone, she will attempt to get up. On 4/16/25 at 10:22 AM, V6 (CNA) said R1 is alert to self, but forgetful. We tell her to use her call light, but she does not use her light for assistance. R1 is one-person extensive assist, she is weak and does not ambulate. We toilet her after meals and lay her down. On 4/16/26 at 3:02 PM, V2 (Director of Nursing-DON) said R1 is high fall risk, she has alert and forgetful and reports her needs to staff. Staff reported R1 she can safely transfer herself and she is not sure if consents need to be obtained for the use of side rails. R1's X-ray report dated 4/10/25 shows comminuted fracture (a bone broken in at least two places) of the right humeral neck. R1's Fall Risk assessment dated [DATE] shows R1 is a High Risk for Falling, her gait is weak, and she overestimates or forgets her limits. R1's current care plan shows she has self-care performance deficit related to dementia .she requires partial/moderate assistance with transfers, toileting and bed mobility. R1 is non-complaint to ask for assistance for help to her ADLs (activities of daily living) related to her dementia and poor safety awareness. R1's care plan shows she is a HIGH fall risk related to dementia .prefers to do things herself then requesting for staff assistance, her interventions include encourage her to use her call light for assistance, items within reach and remind R1 to request staff for assistance with toileting and to use her call light to alert staff (same intervention listed twice). R1's current care plan shows R1 may need to use bilateral half side rails to enhance functional independence and promote skin integrity with interventions include side rails as assistive devices to help to turn and reposition for transfers and demonstrate her to take full advantage of the side rails for positioning, turning, and transfers. May need on-going education on the use of the side rails. The facility's Proper Use of Bed Rails policy dated 9/2024 states, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternatives are attempted prior to installing or using bed rails. If bed rails are used, the facility ensure the correct installation, use and maintenance of the rails .the resident assessment should assess the resident's risks of entrapment between the mattress and bed rail or in the bed rail itself Informed Consent form the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails the information that the facility should provide to the resident, or resident representative includes but is not limited .the residents benefits from the use of bed rails .the residents risks form the use of bed rails upon receiving informed consent, the facility will obtain a physician's order for he use of the specified bed rail and medical diagnosis, condition, symptom or functional reason for the use of the bed rails .Installation and Maintenance of Bed Rails the facility will assure the correct installation and maintenance of bed rails prior to use. This includes ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a residents head or body, regardless of mattress width, length or depth the facility will follow manufactures recommendations/instructions regarding disabling or tying rails down The Fall Prevention Program Policy revised 2024 states, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls High Risk Protocols the resident will be placed on the facility's fall prevention program .provide additional interventions that address unique risk factors measured by the risk assess mention tool .provide additional interventions as directed by the residents assessment, including but not limited to: assistive devices, increased frequency of rounds, sitter if needed, medication regime review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education, therapy services referral .interventions will be monitored for effectiveness. The plan of care will be revised as needed.

Based on observation, interview, and record review the facility failed to ensure a residents pain was managed for 1 of 4 residents (R1) reviewed for pain in the sample of 4. This failure resulted in R1 experiencing severe pain. Findings include: On 2/11/25 at 10:15 AM, R1 was walking in the hallway of the facility. R1 said she was looking for her nurse. R1 said she has problems getting her medicine especially her Norco (Narcotic Pain Reliever). R1 said she had stomach cancer and had part of her stomach removed. R1 said she has severe stomach pain and Norco is the only way she can eat solid foods without pain. R1 said the facility runs out of Norco all the time and there is always different excuses like the forgot to renew it, the medicine is not delivered yet, or a new doctor took over so they don't have it yet. R1 said they try to give her Tylenol which doesn't help the pain. R1 said she has been taking Norco for years. R1 stated I can take the Norco every 8 hours. It allows me to eat solid food. I have pain every single day of my life. Yesterday (2/10/25) I spent all day walking around from unit to unit looking for a nurse to give me my Norco. They didn't order it in time and I didn't have any left. The pain got so bad I was bawling. I didn't know what to do and a friend gave me a number to call the State so I did. The one nurse told me she would give it to me but she had 2 more places to go and then 30 minutes goes by and then an hour, and an hour and a half and still no medicine. They treat it like it's a cookie and if I do what they want, they will give it to me. I tried to go up the ladder and talk to the Director of Nursing and she said she would look into it. I don't know what to do. They did get my medicine delivered this morning so I got my Norco, but what happens when it runs out again? On 2/11/25 at 11:10 AM, V2 Director of Nursing said the pharmacy delivers medication two times per day. V2 said nurses can order medication refills directly from the electronic medical records. V2 said nurses should order medication refills when there is around 3 days of the medication left and should not wait until the medicine is completely depleted. V2 said pain medicine like Norco is available in the emergency medication system. V2 said as long as there is an active order, the nurses can get Norco from the medication system for the patient if their Norco has not been delivered yet. V2 said pain medications should be given as ordered. V2 said no one had come to her with pain medication concerns and there has been no issues with pharmacy deliveries that she is aware of. On 2/11/25 at 11:20 AM, V4 Licensed Practical Nurse (LPN) said R1 takes Norco in the AM and PM. V4 said yesterday R1 came to me and said she was in pain. V4 said she didn't have Norco to give to her, there was no medication card in the cart. V4 said R1 was upset and kept insisting that she give her Norco and was saying that V5 LPN always gives it to her. V4 stated I told R1 that I didn't know how and R1 kept saying V5 does, so I told her to go find V5 then. V4 said R1 left and came back with V5 who said she had given R1 Norco from the medication supply. V4 said she doesn't have a key or access to the back up medication supply, only the Supervisor does. V4 said she was not oriented on how to access the back up medication supply. V4 said she wasn't sure if the Norco got sent for a refill, but the doctor needs to sign a script in order to refill Norco. V4 said the script is then sent to pharmacy. V4 said she printed a script and had V6 Nurse Practitioner sign it and then sent it to pharmacy. V4 said R1's Norco was delivered this morning. On 2/11/25 at 12:07 PM, V5 said she was working on another unit yesterday and R1 came to her for a Norco. V5 said R1 told her the nurse wouldn't give her Norco. V5 said she gave R1 a Norco from the back up medication supply. V5 said the other day, even though she was not assigned to R1, she gave R1 her Norco twice that day from the back up medication supply. V5 said R1 takes Norco for stomach pain from stomach cancer. V5 said R1 knows when she can have it and writes down when she takes it, so she knows when 8 hours is up and she can have another. V5 said if R1 has any trouble getting her medication form the nurse on duty she will come try to find me. V5 said she will give R1 her medication when she can. V5 said some nurses have access to the back up medication supply, but not all. V5 said if the nurse doesn't have access, there is always a nurse supervisor on duty that can access the back up medication supply. On 2/11/25 at 1:07 PM, V6 Nurse Practitioner said R1 has chronic pain from stomach cancer and takes Norco for the pain. V6 said she is aware that R1 takes Norco everyday and it is effective at relieving R1's pain. V6 said R1 should get Norco to relieves R1's pain and make R1 comfortable. V6 said the expectation is for R1's Norco to be given as ordered which is every 8 hours as needed. R1's Electronic Medical Records contains a written prescription dated 1/27/25 for Hydrocodone - APAP (N-acetyl-para-aminophenol) 10-325 mg (milligrams) Give 1 tablet by mouth every 8 hours as needed for severe pain. This same prescription shows dispense 30, refills 3. R1's Controlled Drug Administration Record Tablet for Hydrocodone- APAP 10-325 mg (Norco) shows the order was dated 1/28/25 and contained 21 tablets. This same form shows R1 last tablet was on 2/7/25 at 2:00 PM. R1's Controlled Drug Administration Record Tablet for Hydrocodone- APAP 10-325 mg shows the order was dated 2/10/25 and contained 27 tablets. This same form shows the first does given was on 2/11/25 at 6:00 AM. R1's Medication Administration Record for February 2025 shows R1 did not receive Norco on 2/10/25 until 8:37 PM and was administered by V5. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has a diagnosis of personal history of other malignant neoplasm of the stomach, R1 is cognitively intact, and R1 receives scheduled and as needed pain medication for pain. The same MDS shows R1 has occasion pain, highest rated at a level of 7, and the pain occasionally limits day to day activities. R1's Care Plan dated 12/5/23 shows R1 is at risk for pain (Acute or Chronic) related to diagnosis of chronic pain syndrome with interventions to provide analgesic as ordered. The facility's Resident Council Minutes for 12/26/24 shows Issues waiting for pain meds-a few hours. Regular medications running out of stock. The facility's Resident Council Minutes for 1/31/25 shows Concerns with out of stock medications and how we follow up. The facility's Pain Management dated 10/23/24 shows In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated and Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences.

Based on interview and record review, the facility failed to ensure resident was assisted and supervised while ambulating to her room for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 6 residents. This failure resulted in R3 falling and sustaining subarachnoid and subdural hemorrhages. The findings include: On 12/2/24 at 10:16 AM, V14, Director of Nursing (DON) at the time of R3's fall, said V12, Licensed Practical Nurse (LPN), and V13, Nursing Supervisor, called her (on 11/14/24) and said R3 was found on the floor. V14 said V12 and V13 told her R3 was last seen walking toward her room after dinner. V14 said R3's fall was not witnessed, but the nurses had seen R3's drawers were still open, so they assumed she was trying to get something out of them and lost her balance and fell . On 12/2/24 at 11:10 AM, V11, LPN, said she came in to work at 11:00 PM on the night R3 fell . V11 said R3 was already gone to the hospital at that time. V11 said she called the hospital to follow up and see how R3 was doing, and the hospital staff told her R3 was being admitted to the ICU (Intensive Care Unit)with a subarachnoid hemorrhage and a subdural hematoma. V11 said staff know what level of care a resident requires by looking at the resident's care plan and by staff-to-staff report. V11 said R3 had cognitive problems. On 12/2/24 at 12:17 PM, V10, Restorative Director/LPN, said after a resident falls, he works with the DON to come up with interventions for the resident's care plan to prevent another fall/injury. V10 said R3 is a fall risk and needs supervision when ambulating. V10 said R3 previously fell on [DATE]th (2024) and her care plan was updated at that time to include assisting her to her bedroom before and after meals. V10 said staff should walk R3 to her room before and after meals, R3 needs supervision for transfers (moving from the chair to bed, bed to a chair), ambulation, and toileting hygiene. V10 said R3 is not independent; she needs supervision for most of her ADLs (activities of daily living). V10 said supervision is stand by assistance, then he pointed to number 4 on a sign on his office door and said that is supervision. The sign read as follows: Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The facility's Un-witnessed Fall report dated 11/14/24 at 7:00 PM shows R3 was seen walking towards her room with her rolling walker. R3 was later found lying flat on her back on the floor. R3 was assessed and a bump was found on the back of R3's head. The report noted predisposing physiological factors including confusion and impaired memory, and predisposing situation factors including ambulating without assist. The facility's Final Report dated 11/20/24 shows R3's fall was attributed to R3 suddenly losing her balance when she was ambulating. R3's current care plan provided by the facility shows R3 is a high risk for falls related to a history of falling, difficulty in walking, and lack of coordination. The goal is that she will not sustain serious injury. The following intervention was initiated on 7/22/24: Assist R3 to walk to her bedroom before and after meals. She is on supervision for toileting hygiene, transfers, and ambulation. R3's Minimum Data Set (MDS) dated [DATE] shows R3 requires Supervision or Touching assistance for sit to stand, chair/bed to chair transfer, toilet transfer, and walking 10, 50, or 150 feet. The MDS also shows R3 has severe cognitive impairment. R3's eInteract SBAR (Situation-Background-Assessment-Recommendation) Summary for Providers dated 11/14/24 at 10:48 PM shows R3's diagnoses include, but are not limited to, abnormalities of gait and mobility, unsteadiness on feet, and right and left knee arthritis. R3's ED (Emergency Department) to Hosp(Hospital)-admitted d 11/14/24 shows R3 presented to the ED after an unwitnessed fall where she was found lying on the floor beside her bed with her head near the foot of the bed around 7:00 PM. R3 has a history of dementia. R3's head CT shows a subdural hemorrhage and a subarachnoid hemorrhage.

Based on interview and record review, the facility failed to identify and assess a resident experiencing a change in condition. This failure resulted in a delay in treatment for R1, and R1 experiencing pain due to fractured hip for 1 of 3 residents (R1) reviewed for falls in the sample of 9. Findings include: R1's Admission Record, printed by the facility on 9/6/24, showed he had diagnoses including Alzheimer's disease, anxiety disorder, depression, osteoarthritis of knee, restlessness and agitation, weakness, and a history of falling. R1's facility assessment dated [DATE] showed he had wandering behaviors daily. The assessment showed R1 required supervision or touching assistance for walking 50 feet with two turns, and partial/moderate assistance for walking 150 feet. The assessment showed R1 was frequently incontinent of urine, and occasionally incontinent of bowel. The assessment showed R1 was unable to answer when asked if he had pain or hurting at any time in the last 5 days of the assessment. The assessment also showed R1 had a fall within two-to-six months prior to admission. R1's care plan initiated on 9/4/24 (after being discharged to a local hospital) showed he demonstrates having a cognitive impairment relate to diagnosis of Alzheimer's disease or other form of dementia. R1's care plan initiated on 8/26/24 showed he had an ADL (activities of daily living) self-care performance deficit related to Alzheimer's disease, restlessness and agitation, weakness, history of fall, and osteoarthritis. R1's care plan initiated on 9/4/24 (after admission to a local hospital) showed he had a behavior of wandering into other patients' rooms and taking others' belongings. The care plan showed R1 was usually easy to redirect but has in the past exhibited aggression and non-compliance with redirection. R1's Wandering care plan (initiated on 9/4/24-after being admitted to the hospital) showed R1 had current behaviors of pacing, roaming or wandering in and out of peers' rooms. R1's 8/20/24 care plan showed he is a high risk for falls. R1's Progress Note, written by V9 on 9/2/24 at 10:47 PM, showed Fall f/u (follow-up) . Resident is responsive and alert to baseline with no change of condition noted. All medication given as schedule. Neuro-check in progress. On 9/5/24 at 7:55 AM, V18 (R1's daughter) said R1 was admitted to the facility on [DATE]. V18 said R1 had a fall in the facility and was diagnosed with a hip fracture. V18 said R1 had hip surgery on 9/4/24. V18 said V19 was R1's Power of Attorney (POA) and she went into the facility often to see R1. On 9/5/24 at 6:28 PM, V19 said she had been in the facility literally every day to see R1 except on 9/2/24 because she was taking a family member to the airport. V19 said R1 had a fall on 8/30/24 and another fall on 9/2/24. V19 said she received the call on 9/2/24 that R1 had fallen. V19 said she called V4 (Hospice Registered Nurse-RN) and V4 said she would go in and check on R1. V19 said V4 went into the facility and did not see any apparent injury on R1 at the time of her assessment. V19 said early Tuesday morning, around 6:45 AM, she received a call from V10 (RN) saying that R1 was grimacing, and his knee may be swollen. V19 said she got to the facility around 7:15 AM and told the nurse to call an ambulance. V19 said R1 was in excruciating pain and kept saying Too much pain. Too much pain in his native tongue. On 9/6/24 at 11:38 AM, V4 (Hospice RN) said she was the on-call hospice nurse. V4 said she went into the facility around 11:30 AM to check on R1. V4 said R1 was standing up in the middle of the room when she got there. V4 said R1 was confused and weak so she helped him sit down in a chair. V4 said she and one of the CNAs transferred R1 into bed and provided incontinent care. V4 said she did not see R1 show any signs of pain or discomfort while they were providing care. On 9/6/24 at 11:42 AM, V7 (Licensed Practical Nurse-LPN) said she had just started her shift on 9/3/24 and she saw V19 in the facility. V7 said she asked V19 why she was there so early. V7 said V19 told her that she was called and told R1 was not doing well. V7 said she got shift report from V10 (RN) the overnight nurse. V7 said V10 informed her (V7) that R1 had fallen on 9/2/24 at 5:00 AM. V7 said V10 told her R1 was in a lot of pain, so she called V19 (R1's POA). V7 said V19 came out and told staff that R1 was wet so V7 said she called the CNA. V7 said V19 came back out of R1's room and said he cannot move. V7 said she and V19 both called hospice to let them know, then V7 said she went in to assess R1. V7 said she noticed one of R1's legs were shorter than the other. V7 said R1 was sent out to the hospital. V7 said V11 called her on Tuesday night and asked what happened with R1. V2 said she called V8 (Certified Nursing Assistant-CNA) and asked her how R1 was on second shift on 9/2/24. V2 said V8 told her that she informed V9 (LPN on duty on the second shift on 9/2/24) about R1's pain and that something was not right with R1. On 9/6/24 at 12:18 PM, V8 (CNA) said she worked from 3:00 PM-11:00 PM on 9/2/24. V8 said when she started her shift she asked where R1 was and was told he was in bed, and he slept a lot during first shift. V8 said when she went to take R1 his dinner tray, she saw him in a wheelchair. She asked V23 (CNA) about R1 being in a wheelchair and V23 told V8 she and V9 put R1 in the wheelchair. V8 said she saw R1 trying to get up out of the wheelchair around dinner, and he made a face like he was in pain. V8 said she told V9 that she needed to do something because R1 was in pain, and he was not acting like his normal self. V8 said V9 told her she had just given R1 his pain medications. V8 said around 8:00 PM she put R1 back in bed. Around 9:30 PM R1 was trying to get out of bed so she and V9 put him back in the wheelchair. V8 said she told the oncoming CNA during shift change that R1 had been in pain and V9 had given him something for pain. On 9/6/24 at 1:30 PM, V9 (LPN) said she worked from 3:00 PM-11:00 PM on 9/2/24. V9 said R1 was sleeping when she started her shift. V9 said some time before supper R1 got up and went into another resident's room. V9 said she told one of the CNAs to grab a wheelchair and put him in it because R1 was a fall risk, and had a fall that morning. V9 said staff had been monitoring R1 throughout the shift. V9 said staff would tell R1 to sit down when he tried to stand up from the wheelchair. V9 said R1 usually complained of pain to his knee. V9 said R1 just points to his area of pain, or you see it on his face, or he will touch his knee. V9 said R1 was showing signs of pain, so she gave him Tylenol. V9 said at one point after dinner, V8 told her that she thinks R1 was in pain. V9 said she told V8 that she had already given R1 some pain pills and she thinks he will be okay. V9 said she told V8 to just keep an eye on him. V9 said she did the neurological checks, level of consciousness and vitals on R1 per protocol. V9 said she informed the oncoming nurse (V10) that R1 had a fall, and he was being monitored and neurological checks were being done. V9 said she informed V10 that she had given R1 Tylenol for pain. V9 said she did not update R1's doctor because he was on hospice and the hospice nurse had evaluated him earlier that day. On 9/6/24 at 1:54 PM, V10 (RN) said she worked from 11:00 PM on 9/2/24-7:00 AM on 9/3/24. V10 said R1 was up in a wheelchair when her shift started. V10 said she was told that R1 did not want to stay in bed. V10 said she told V24 (CNA-agency staff) to stay with R1. V10 said R1 would stand up and then sit back down, then stand up. V10 said R1 really did not walk around on the overnight shift. V10 said R1 did not show any signs of pain at that time. V10 said about 4:30 AM, V24 said R1 was sleepy so V24 and V10 put R1 in bed. V10 said when they put R1 in bed he was grimacing, grabbing his left leg, and guarding it. V10 said she assessed R1's left leg and it was a little swollen at his knee. V10 said R1's left knee was bigger than his right. V10 said she gave R1 medicine for pain and about 45 minutes later, R1 was still grabbing his leg and grimacing so she called hospice and left a message to return her call. V10 said she called V19 and V19 said she was coming to the facility. V10 said she asked V19 if she wanted to send R1 out to the hospital and V19 said she was waiting for hospice to call her back and was going to talk to her sister. V10 said it was about shift change when V19 said she talked to hospice and wanted him to be sent out to the hospital. V10 said she did not notice any signs of increased pain prior to putting R1 in bed when he was grimacing and guarding his left leg. On 9/6/24 at 3:13 PM, V11 (LPN) said on 9/3/24 he worked 7:00 AM-11:00 PM. V11 said V7 (LPN) called him to let him know she was sending R1 out. V11 said he told her she would have to call the Nurse Supervisor. V11 said he told V9 that he would help her get the paperwork ready to send R1 out. V11 said V2 (DON) went to him and told him to write pain assessments and other documentation and he (V11) told V2 no that he cannot do that because he did not want to put his license on the line. V11 said Why should I lie because there wasn't a proper assessment. V11 said he did not observe R1 at all on the morning of 9/3/24. On 9/7/24 at 1:42 PM, V3 (Nurse Practitioner) said if a resident has a fall with no injuries, staff should do post-fall monitoring. V3 said if there are any changes in the resident's pain and behavior changes-not being themselves, she would expect the nurse to do a full assessment and update her right away so they can determine what to do moving forward. On 9/7/24 at 1:50 AM, V2 (DON) said if a resident has a change in condition, a change in behavior or shows signs of pain after a fall, the nurse on duty should do a thorough assessment and notify the resident's doctor or nurse practitioner to update them on the resident and see if they want the resident sent out to the emergency room for evaluation. At 2:28 PM, V2 denied asking any nurses to document assessments for R1 after he was sent out to the hospital. The facility's policy and procedure titled Falls Policy and Procedure, with a revision date of 2/2/24, showed Fall Management: Nursing administration reviews every fall that occurs within the last 24 hours during the morning report meeting. Assessments of resident who is on the floor to include neurological signs, vital signs, and range of motion. Any suspected injury: Do a complete assessment identifying any deficits, deformities, pain and notify MD (doctor). Follow MD order which may include sending to ER (emergency room ) or getting an in-house X-ray. Document findings. Protocol for any Unwitnessed Fall: Full assessment by the licensed nurse including vital signs and neurological vital signs for 72 hours, and range of motion assessment. The facility's policy and procedure titled Management of Pain, with a revision date of 3/20/24, showed Physician Communication and Involvement: Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan .Nursing Observation: Nursing observation is an important part of the pain assessment, especially in the non-verbal resident. Nursing will observe behaviors that may indicate pain in the non-verbal or cognitively impaired resident. Pain may be indicated when there are changes in the following: Facial expressions, vocal behaviors, body movements, routines, and mental status.

Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse. This failure resulted in R1 being struck in the face by R2. R1 was sent to the local hospital and sustained a closed fracture of the left zygomatic arch (cheek bone). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: The facility's Initial Report dated 7/6/24 documents Activity staff reported to the nurse two residents (R1, R2) had an altercation. R1's face sheet shows she is a [AGE] year-old female with diagnoses including zygomatic fracture left side, osteoarthritis, type 2 diabetes, heart failure, cerebrovascular disease, major depressive disorder, unspecified dementia. On 7/10/24 at 9:43 AM, R1 was observed lying in bed, she had a dark purple bruise under her left eye and greenish discoloration to her left cheekbone. The left side of her face had some mild swelling. R1 was alert to herself, she could recall her date of birth and said she was at a home. This surveyor asked what happened to her left eye, she said somebody must have hit me, I don't know. R1 touched her left side of the face and said, it's tender. On 7/10/24 at 9:50 AM, V8 (Certified Nursing Assistant/CNA) said R1 is alert and forgetful. She gets along with others and has no behaviors. R2 has dementia and behaviors of aggression. He usually sits near the nurse's station and needs to be supervised because he attempts to get out of his wheelchair. On 7/10/24 at 9:56 AM, V9 (CNA) said she was working on 7/6/24 with the wound nurse. She heard R2 punched R1. R1 is alert and forgetful with no behaviors. R2 usually sits at the table near the nurse's station. R2 has to be supervised because he is a fall risk. He gets irritated at times and gets combative with staff. On 7/10/24 at 11:43 AM, V7 (CNA) said she was working on 7/6/24. She said she told V11 (Agency CNA) she was going to answer a call light, and V11 said she would stay at the desk. V7 said she thinks it was agency staff because she had not seen her before. When she came back to the nurse's station V11 was not there. V6 (Activity Aide) was in the dining room, he reported R2 got up from his wheelchair and started hitting R1. She went to check on R1, R1's face was turning colors. R1 said he (R2) hit me, and she was pointing to the left side of her face. R2 said I'm in trouble now. R2 has behaviors, he's been combative with staff and he's very unpredictable. On 7/10/24 at 12:45 PM, V3 (Nurse Supervisor) said she was on duty on 7/6/24. She received a call from V4 (Manger on Duty) around 10:00 AM about an altercation on a unit. When she arrived at the unit, R1 was in the dining room. R1 had a huge hematoma to her left eye. R1 was sent out to the local hospital. On 7/10/24 at 1:00 PM, V5 (Licensed Practical Nurse/LPN) said she was working on 7/6/24. Sometime after 7:30 AM, she was told she had to pick four residents from a unit. V6 (Activity Aide) reported to me he was on the unit and witnessed R2 abuse R1. It happened. It was obvious R1 sustained a fracture to her face. On 7/10/24 at 1:10 PM, V4 (Manager on Duty) said around 10:00 AM, V6 reported an allegation of abuse with R1 and R2. V6 reported he was in the dining room because the CNA were providing care to other residents. R2 had struck R1 in the face. R2 did this unprovoked and out of the blue. Both residents were sent out to the local hospital. On 7/10/24 at 1:56 PM, V1 (Administrator) said it happened R2 stuck R1 in the face. V1 said he was still working on the final report. R1 sustained an injury to her face and R2 was admitted to behavioral health hospital. R1's Incident Note dated 7/6/24 documents received a call from the manager on duty there was an altercation between two residents. Upon entering the unit, (R1) was in the dining room in her wheelchair. The staff reported (R1) was hit. (R1) acquired a large hematoma under her left eye. R1's nurse's note dated 7/6/24 documents (R1) returned to the facility and per the hospital report (R1) has a closed fracture of the left zygomatic arch, swelling and discoloration to left side of face. R1's CT report dated 7/6/24 documents non-displaced fracture of the left zygomatic arch, overlying soft tissue swelling is noted. R2's face sheets shows he is a [AGE] year-old male with diagnoses including unspecified dementia, psychotic disorder with delusions due to physiological condition, anxiety, and Parkinson's. R2's Psychiatry Progress note dated 6/24/24 documents requiring redirection: often, not improved worse. Displays of inappropriate behavior: not improved, keeps standing up, agitated, restless, unable to redirected, poor safety awareness. Affect/Mood: anxious, irritable, poorly modulated, or labile. Patient report or observation of psychotic symptoms: delusions evident, (R2) not aware of psychotic symptoms, confabulated delusions are evident. R2's care plan dated 4/25/24 documents he has the potential to demonstrate physical behaviors related to dementia. Interventions include to assess and anticipate R2's needs, analyze key times, triggers, circumstances and what de-escalates behavior. The nurse's note dated 7/6/24 documents around 9:45 AM, staff were prompting residents to participate in activities. Another resident who was slowly wheeling herself (R1) towards the activity without any unusual occurrence. (R2) was observed standing up, approached (R1) and physically attacked her. The nurse's note dated 7/8/24 documents R2 was sent out to behavioral health hospital for aggressive behavior. The facilities undated Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures Policy states, polices are in that prohibit and prevent resident abuse .

Based on interview and record review the facility failed to supervise a cognitively impaired resident (R65), with a history of falls, in a dining room of the facility. This failure resulted in R65 sustaining an unwitnessed fall requiring R65 to be emergently transported to a local hospital where she was diagnosed with two brain bleeds as result of the fall. This failure applies to 1 of 17 residents (R65) reviewed for safety and supervision in the sample of 17. The findings include: R65's current care plan showed R65 was cognitively impaired related to her diagnosis of dementia. The plan showed R65 was at high risk for falls related to her history of previous falls and impaired cognition. The plan showed R65 exhibited poor safety awareness as evidenced by overestimating or forgetting her limits and forgetting to use her walker when ambulating. R65 required the assistance of one staff, a gait belt, and a walker when ambulating. R65 required staff assistance with toileting and bed mobility. She required staff supervision with transfers and attempting to stand. The facility's Fall incident report dated 1/4/24 showed facility staff (V5 Licensed Practical Nurse/LPN) found R65 lying on the floor, in a dining room, after hearing a thud sound coming from the room. R65 was found lying on her back. R65 stated she lost her balance while trying to reach her walker and fell backwards, striking her head on the floor. 911 was called. R65 was transferred to a local hospital. R65's hospital records dated 1/4/24 showed R65 was diagnosed with right frontal subarachnoid hemorrhage (brain bleed), left cerebellar subarachnoid hemorrhage (brain bleed), and a scalp hematoma (bruise) as a result of her fall. On 1/30/24 at 11:15 AM, V5 LPN stated, I didn't see (R65) fall. I was back in the nurse's room on the computer. (R65) was seated at a table in the dining room. No staff were around except a housekeeper and a CNA (certified nursing assistant). The CNA (V15) was down the hall, helping another resident. I heard a thud. I came out of the room I was in and found (R65) on the floor. We called 911 and sent her out. (R65) did have a history of falls. She was forgetful. She had no safety awareness. On 1/30/24 at 11:25 AM, V2 Director of Nursing stated R65 was confused related to her dementia with limited safety awareness. V2 stated R65 needed supervision when out in common areas of the facility due to her history of falls and trying to get up on her own. On 1/30/24 at 12:57 PM, V7 Nurse Practitioner stated R65 was forgetful, had poor safety awareness, had a history of previous falls, and could exhibit impulsive behaviors related to her diagnosis of dementia. V7 stated, (R65) needed to be supervised. I mean that's why she is in a skilled nursing facility. She usually walked with a walker but somebody should be around her to make sure she doesn't try to get up or walk on her own. On 1/31/24 at 10:17 AM, V15 CNA stated, I was down the hall, by the exit doors of the unit, in a resident room. As I was walking out of the resident's room, I looked down the hall towards the dining room to see (R65) falling on the floor. I ran down to her. V15 CNA stated there was no nursing staff present in the dining room at the time of R65's fall.

Based on interview and record review the facility neglected to have licensed nursing staff to assess and monitor a resident with low blood oxygen levels, neglected to have licensed nursing staff to assess, monitor, and provide medications, and neglected to assist with safe discharge planning. This failure resulted in R13 being sent out of the facility by emergency personnel related to no licensed nursing staff to monitor or assess R13. This failure resulted in no licensed nursing staff in the facility for approximately 2 hours to assess, monitor, and provide morning medications as ordered by a physician. This failure also resulted in R1 and R8 leaving the facility with no physician orders or medications. This applies to all 108 residents residing in the facility. The Immediate Jeopardy began on May 1, 2023, when the facility failed to ensure licensed nursing staff was available to monitor, assess, administer medications and plan discharges. V1 Administrator was notified of the Immediate Jeopardy on May 8, 2023 at 3:26 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on May 15, 2023 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and staffing levels. The findings include: The facility data sheet provided on May 1, 2023 shows, there are 108 residents residing in the facility. On May 1, 2023 at 12:51 PM, V9 Police Detective stated, V7 Former Medical Director and V8 Nurse Practitioner (NP) came in (on May 1, 2023) and there was only 8 Certified Nursing Assistants (CNAs) and 12 kitchen staff in the building. On May 4, 2023 at 2:50 PM, V7 Former Medical Director stated, he arrived at the facility around 8:00 AM on May 1, 2023 and did not see a nurse or any former administrative staff. He got concerned and called 911. On May 4, 2023 at 12:19 PM, V8 NP stated, she arrived to the facility at 8:45 AM on May 1, 2023. No one was really here besides me, V7 former Medical Director, 1 CNA for each unit and kitchen staff. On May 8, 2023, at 10:25 AM, V5 New Ownership Associate Manager stated, from approximately 8:30AM until approximately 11:00 AM there were no licensed nurses in the building. 1. On May 1, 2023 at 2:45 PM, V9 Police Detective stated, R13 was sent to the hospital for a low pulse oxygen saturation. R13's face sheet lists his diagnoses to include: Parkinson's disease, dementia & personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. On May 8, 2023 at 9:47 AM, V30 CNA/Dietary stated she was working the morning of May 1, 2023 in the kitchen. She was one of the 12 kitchen staff that was in the building. She was helping V22 CNA with breakfast when she went into R13's room. She stated, breakfast was late that morning and she wasn't sure what time she first went into R13's room. His breakfast tray was in front of him and he hadn't eaten anything yet. She stated, she woke him up and tried to get him to eat. She left the room while he was eating. She went back a little while later to check on him and take his breakfast tray. At that time, she checked his vital signs and his oxygen level was 90% on 3 LPM. He was not his usual self and pale. She left and found V8 NP. She made V8 NP aware of his pulse oxygen. V8 NP told her to call 911 and send him to the hospital because there was no one to monitor him. She called 911 at 10:46 AM from her personal cell phone. She did verify that there were no nurses to help R13. On May 4, 2023 at 12:19 PM, V8 NP stated, a CNA (V30 CNA/Dietary) told her that R13's oxygen was dropping. She was increasing his oxygen and his oxygen saturation was not going up. I said to discharge him to the hospital because there is no one here to take care of him. She stated, the CNAs were titrating his oxygen and that is typically done by the nurses. She also stated it was important to have nurses in the building for a million reasons, basic care, medications, in case of emergencies, they have good critical thinking skills, they are the backbone in healthcare. The facility's oxygen therapy and administration policy last revised July 28, 2022 shows, Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Purpose: To assure adequate oxygenation to all spontaneously breathing and ventilator dependent patients. Indications: .Hypoxia- oxygen saturation levels of <92% (less than) . Procedure: Confirm order from physician (this should include liter flow, FiO2 and delivery device) . Note: b. Oxygen rounds should be completed weekly by RN (registered Nurse) or RCP (Respiratory Care Person), depending on facility . The facility's general care policy last revised on July 28, 2022 shows, Policy Statement- It is the facility's policy to provide care for every resident to meet their needs. 2. On May 1, 2023, at 5:00 PM, R18 stated, after 8:00 AM there were no nurses to care for him until later when V43 came in on her day off to care for the residents and pass medications. R18 said he did not receive his morning medications until approximately 12:36 PM, which are normally given around 9-9:30 AM. R18 said he was not able to get out bed due to lack of staffing. R18 said he normally gets out of bed every day. On May 2, 2023 at 3:45 PM, V48 (R9's Son) stated, R9 did not receive her morning medications on May 1, 2023. On May 3, 2023, at 9:54 AM, R24 stated, he did not receive his morning medications on May 1, 2023, due to lack of nurses in the building in the morning. On May 4, 2023, at 10:20 AM, R29 stated he did not receive his morning medications on May 1, 2023 because there was no nurse until around lunch time. On May 2, 2023, at 10:45 AM, V13 (Registered Nurse) stated, she arrived to the facility on [DATE] around 11:00 AM. There was not a nurse on the unit. V13 stated, none of the residents received their morning medications on time because there was not a nurse on duty to administer the medications. V13 stated R29 received his medications late including his IV antibiotic. R31's May 2023 MAR shows R31 is to receive medications at 9:00 AM. On May 4, 2023, at 3:06 PM, V29 (LPN) stated she arrived to work around 10:20 AM and started passing medications around 11:00 AM. V29 confirmed there was not a nurse on the unit when she arrived and none of the morning medications were passed on the unit. On May 3, 2023 at 11:15 AM, R3 stated he originally did not see any nurses after 8:30 AM, then some of the old staff started coming in around 10:40 AM. R3 stated he was told they were trying to bring staff back to the building to take care of the residents. R3 stated he was not told if he was going to be seen by wound care or anyone else. R3 stated he did not receive his morning medications and was not updated about wound care. R3 stated he was not going to wait around so he had V13 help him get an ambulance to a local hospital. R3 stated it was a sinking ship, and I had to get out of there. V13 stated she arrived to the facility after 11:20 AM. V13 stated by the time she rounded on R3 it was around 11:45 AM when he received his morning medications. On May 3, 2023, at 10:00 AM, V49 (R1's family) stated he arrived to the facility after 11:30 AM. V49 stated V53 came into the room to give R1's morning medications. On May 4, 2023 at 10:15 AM, V54 (R6 family) stated she arrived to the facility around 12:30 PM on May 1, 2023. V54 stated V29 Licensed Practical Nurse came into R6's room after 1:00 PM to give R6 her morning medications. On May 4, 2023 at 1:10 PM, V55 (R2 family) stated on the morning of May 1, 2023, R2 was transported to a local hospital by ambulance due to the facility not having any nursing staff in the building. R2's MAR for May 2023 showed R2's medications to be given at 9:00 AM. None of the medications were signed off as given. On May 3, 2023 at 2:45 PM, R28 stated on May 1, 2023, there were no nurses in the facility to pass morning medications. R28 stated she did not receive her morning medications until 1:00 PM. V44 Licensed Practical Nurse stated she arrived to the facility around 11:00 AM on May 1, 2023. V44 stated she assisted with medication administration for residents. V44 stated R28 did not receive her morning medications until early afternoon. On May 1, 2023 at 1:00 PM, V45 R14's son stated, he arrived to the facility on [DATE] at 10:00 AM. They are under new management. At 10:00 AM, it was empty, no one was here. His dad finally received his morning medications an hour ago (approximately 12:00 PM). The facility's Medication Pass Policy revised on 3/28/23 showed It is the policy of the facility to adhere to all Federal and State regulations with mediation pass procedures. 3. On May 3, 2023 at 11:08 AM, V18, R8's daughter stated, she came in the facility on May 1, 2023 at 9:00 AM. She walked in and noticed there was no one there. All of the lights were out and offices were empty. She went to her mom's (R8) room. She found R8 sitting in bed. Her diaper was soaked, t-shirt was wet and the bed was wet. She left the room to find someone to help her change her mom. She couldn't find anyone. She wondered why the desks were clear and lights were off in offices. She finally found a young man on her mom's wing. She asked him (V21 CNA) what was going on and he said no one was at the facility and no one came to work. He told her they switched hands and the employees didn't want to work with the new owner so no one showed up to work. The Friday before (April 28, 2023) she had signed paperwork to keep her mom at the facility as a long term care resident. She ended up taking her mom (R8) home because there was no one to take care of her on May 1, 2023. V18 stated, she saw V5 Associate Manager and asked if she needed a doctor release or anything to take her mom home. He stated, I'm sorry I can't give it to you. V18 stated, they were the first people to leave. The facility did not send her with any medications or orders to care for her mom at home. I'm just giving her (medications) what I originally gave her before she went to the facility. On May 4, 2023 at 10:00 AM, V49 (R1 family) stated the facility had talked about referrals for hospice the week before we left, but none of the conversations were about discharging. V49 stated he was unable to reach anyone by phone at the facility and was fearful for R1's safety. V49 went to the facility to talk to the staff. V49 stated on May 1, 2023 he arrived to the facility around 12:30 PM. R1 was still in bed, and had not received any morning medications. V49 stated after finding out the new owners had no nursing staff show up he packed up R1's belongings and discharged R1 from the facility. V49 stated the facility did not give him any documentation pertaining to any orders, medication changes, therapy notes, or home health nursing referrals. V49 stated R1 was seen by her primary physician on May 1, 2023. R1's primary physician put through all of the medication and home health orders for R1. On May 1, 2023, R1 and R8 were discharged from the facility by family with no physician orders or medications. The facility's Transfer and Discharge Policy revised on July 28, 2022 showed under the Procedure heading: Obtain a physician order for transfers to other facilities or discharge to the community .Provide adequate preparation by giving resident or the responsible party education on the transfer/discharge procedure. Make referral as needed to the appropriate community agency to ensure continuity of services for the resident. Ensure safe transportation to the destination. 4. On May 2, 2023 at 10:48 AM, V43 Registered Nurse (RN) stated, she came in at approximately 10:30 AM on May 1, 2023. There were only CNAs on the unit when she arrived and no nurses. None of the resident's morning medications had been provided. V43 RN stated, she rounded on the residents right away. They said they were fearful and anxious. This has never happened before. On May 3, 2023 at 11:15 AM, R3 stated he originally did not see any nurses after 8:30 AM then some of the old staff started coming in around 10:40 AM. R3 stated he was told they were trying to bring staff back to the building to take care of the residents. R3 stated he was not told if he was going to be seen by wound care or anyone else. R3 stated he did not receive his morning medications and was not updated about wound care. R3 stated he was not going to wait around so he had V13 helped him get an ambulance to a local hospital. R3 stated it was a sinking ship, and I had to get out of there. On May 3, 2023 at 11:08 AM, V18 R8's daughter stated, This is neglect. How can the nurses leave her like this? The facility's abuse and neglect policy effective October 24, 2022 shows, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations Types of Abuse and Examples: 7. Neglect: Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware of should have been aware of the service the resident requires but fails to provide that service. The facility presented an abatement plan to remove the immediacy on May 10, 2023. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on May 11, 2023, and the survey team accepted the abatement plan on May 11, 2023. On May 12, 2023 surveyors were on site and were unable to remove immediacy due to no night nurses scheduled for May 12, 2023. The immediate Jeopardy that began on May 1, 2023 was removed on May 15, 2023 when the facility took the following actions to remove the immediacy. 1. Upon discharge on 5/1/23 R8 was stable and is no longer a resident of the facility. 2. Upon discharge on 5/1/23 R13 was stable and is no longer a resident of the facility. 3. R12 was discharged on [DATE] in stable condition and is no longer a resident of the facility. 4. All residents who missed Monday morning medications resumed medication administration as scheduled by licensed nurses at approximately 11:00am on Monday, May 1, 2023. Blood sugar checks were performed by nurses on all other residents as ordered by their attending physician by noon on 5/1/23 forward and ongoing with insulin administration as ordered. No adverse outcomes were noted or reported with any resident. 5. All residents requiring oxygen saturation monitoring have been assessed and documentation done by licensed nurses as ordered after 11:00am. This was done by licensed nurses. The physician will be notified within an hour for any acute status change and notify the Interim Director of Nursing. Completed May 9, 2023. 6. Nurse leadership recruitment continues by the facility Human Resource managers, including nursing supervisors for the off shifts. A DON and Infection Preventionist Nurse was hired. Two Nurse Consultants have been hired to support nursing operations and assist in onboarding the Director of Nursing. Nursing leadership is involved in ensuring operations per regulation. Managers of other departments are functioning in a supportive role to nursing leadership and nurse consultants. Completed May 15, 2023. 7. Social Work Director provides Assessment, interview and assistance in discharge planning. Completed May 10, 2023. 8. A scheduler has been hired. The scheduler creates the daily schedule of nursing staff comprised of the facility nursing staff and agency staff as contracted to fill nursing needs. The occupancy of the building has decreased substantially, and the need for labor has also decreased proportionately. Staffing schedules for the succeeding weeks are being drafted and finalized. Completed May 15, 2023.

Based on interview, and record review, the facility failed to ensure the facility had licensed nursing staff present in the facility after a change of ownership. This failure has the potential to affect 108 residents residing within the facility. This failure resulted in R13 being transferred to the hospital for low oxygen saturation, residents being removed from the facility by family due to lack of staff, and residents not receiving their prescribed medications as ordered. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 1, 2023 during a change of ownership. V1 Administrator was notified of the Immediate Jeopardy on May 8, 2023 at 3:26PM by the surveyor. The surveyor confirmed by observation, interview and record that the Immediate Jeopardy was removed on May 15, 2023 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and staffing levels. The findings include: The Facility Data Sheet dated (not dated) shows there were 108 residents. On May 1, 2023, at 12:51 PM, V9 Police Dectective stated, V7 Former Medical Director and V8 Nurse Practitioner (NP) came in (on May 1, 2023) and there were only 8 Certified Nursing Assistants (CNAs) and 12 kitchen staff in the building. On May 4, 2023, at 2:50 PM, V7 Former Medical Director stated, he arrived at the facility around 8:00 AM on May 1, 2023, and did not see a nurse or any former administrative staff. He got concerned and called 911. On May 4, 2023 at 12:19 PM, V8 NP stated, she arrived to the facility at 8:45 AM on May 1, 2023. No one was really here besides me, V7 former Medical Director, 1 CNA for each unit and kitchen staff. On May 3, 2023, at 3:01PM, V1 New Administrator said at 12:01AM on May 1, 2023, he took over ownership of the facility. He assumed all the staff would be coming over to work for him. 1. On May 8, 2023, at 10:25AM, V5 (New Ownership Associate Manager) said from approximately 8:30AM until approximately 11:00AM there were no licensed nurses in the building. The facility's nursing staff schedule April 30, 2023 - May 1, 2023 showed V32 Licensed Practical Nurse (LPN) and V33 LPN were in the facility until 8:20AM. This same list shows there were only 8 Certified Nursing Assistants CNAs working in the facility for day shift, V21 CNA, V37 CNA, V24 CNA, V23 CNA, V14 CNA, V16 CNA, V22 CNA, V38 CNA. There were no licensed nursing staff on this schedule for 8 AM. On May 2, 2023, at 2:03PM, V32 LPN said she worked night shift (11pm - 7am) from April 30 to May 1 and left at 8:20AM. V32 said nobody came in to give report to so I left. At 3:07PM, V35 RN said he worked night shift (11pm - 7am) from April 30 to May 1 and left at 8:15AM. V35 said no nurse came to relieve him. At 3:14PM, V34 RN said he worked night shift (11pm - 7am) from April 30 to May 1 and left at 8:30AM. V34 said there were no nurses to give report to when she left. V34 said no nurse came to relieve her. V34 said she left the building and there were no nurses to give report to. At 3:23PM, V36 RN said she worked night shift (11pm - 7am) from April 30 to May 1 and left at 8:00AM. V36 said staff were waiting for the new owner's team of nurses to come but they did not show up. At 3:36PM, V33 LPN said she worked night shift (11pm - 7am) from April 30 to May 1. V33 said she didn't feel right or safe about leaving. V33 said there were no nurses to give report to. On May 3, 2023, at 10:23AM, V19 RN said she worked night shift (11pm - 7am) from April 30 to May 1. V19 said she called V47 Former Director of Nursing on May 1, 2023 and said there were no nurses at 8:00AM in the facility, but there was a CNA on every unit. V19 said she talked to V6 Managing Director for New Owners and told V6 there were no nurses showing up from their team. V19 said she went with [V6] and collected the narcotic keys from the night shift nurses and gave those keys to [V6]. V19 said [V6] asked how many nurses the facility needed. V19 said she told [V6] the facility needed 7 nurses in the skilled area and 1 nurse in the assisted living portion. V19 said [V6] said she would take care of staffing. On May 3, 11:40AM, V20 LPN said she worked night shift (11pm - 7am) from April 30 to May 1, 2023. V20 said she was told by V47 Former DON all the nurses were to leave together on May 1, 2023 between 7:00AM - 8:00AM. V20 said she left around 8:00AM and saw V7 Former Medical Director in the parking lot and told V7 there were no nurses in the building. 2. A list of residents provided by the V26 (Lieutenant Local Fire Department) show R7 transferring to another facility, R8 going home with family, and R3 going home (On May 3, 2023, at 11:15 AM, R3 stated he went to the hospital). On May 3, 2023 at 11:08 AM, V18 R8's daughter stated, she came in the facility on May 1, 2023 at 9:00 AM. She walked in and noticed there was no one there. All of the lights were out and offices were empty. She went to her mom's (R8) room. She found R8 sitting in bed. Her diaper was soaked, t-shirt was wet and the bed was wet. She left the room to find someone to help her change her mom. She couldn't find anyone. She wondered why the desks were clear and lights were off in offices. She finally found a young man on her mom's wing. She asked him (V21 CNA) what was going on and he said no one was at the facility and no one came to work. He told her they switched hands and the employees didn't want to work with the new owner so no one showed up to work. The Friday before (April 28, 2023) she had signed paperwork to keep her mom at the facility as a long term care resident. She ended up taking her mom (R8) home because there was no one to take care of her on May 1, 2023. V18 stated, she saw V5 Associate Manager and asked if she needed a doctor release or anything to take her mom home. He stated, I'm sorry I can't give it to you. V18 stated, they were the first people to leave. The facility did not send her with any medications or orders to care for her mom at home. I'm just giving her (medications) what I originally gave her before she went to the facility. On May 4, 2023 at 10:00 AM, V49 (R1 family) stated the facility had talked about referrals for hospice the week before we left, but none of the conversations were about discharging. V49 stated he was unable to reach anyone by phone at the facility and was fearful for R1's safety. V49 went to the facility to talk to the staff. V49 stated on 5/1/23 he arrived to the facility around 12:30 PM. R1 was still in bed, and had not received any morning medications. V49 stated after finding out the new owners had no nursing staff show up he packed up R1's belongings and discharged R1 from the facility. V49 stated the facility did not give him any documentation pertaining to any orders, medication changes, therapy notes, or home health nursing referrals. V49 stated R1 was seen by her primary physician on 5/2/23. R1's primary physician put through all of the medication and home health orders for R1. 3. On May 1, 2023 at 2:45 PM, V9 Lincolnshire Police Detective stated, R13 was sent to the hospital for a low pulse oxygen saturation. R13's face sheet lists his diagnoses to include: Parkinson's disease, dementia & personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. On May 8, 2023 at 9:47 AM, V30 CNA/Dietary stated, she was working the morning of May 1, 2023 in the kitchen. She was one of the 12 kitchen staff that was in the building. She was helping V22 CNA with breakfast when she went into R13's room. She stated, breakfast was late that morning and she wasn't sure what time she first went into R13's room. His breakfast tray was in front of him and he hadn't eaten anything yet. She stated, she woke him up and tried to get him to eat. She left the room while he was eating. She went back a little while later to check on him and take his breakfast tray. At that time, she checked his vital signs and his oxygen level was 90% on 3 LPM. He was not his usual self and pale. She left and found V8 NP. She made V8 NP aware of his pulse oxygen. V8 NP told her to call 911 and send him to the hospital because there was no one to monitor him. She called 911 at 10:46 AM from her personal cell phone. She did verify that there were no nurses to help R13. On May 4, 2023 at 12:19 PM, V8 NP stated, a CNA (V30 CNA/Dietary) told her that R13's oxygen was dropping. She was increasing his oxygen and his oxygen saturation was not going up. I said to discharge him to the hospital because there is no one here to take care of him. She stated, the CNAs were titrating his oxygen and that is typically done by the nurses. She also stated it was important to have nurses in the building for a million reasons, basic care, medications, in case of emergencies, they have good critical thinking skills, they are the backbone in healthcare. 4. On May 5, 2023 at 11:00 AM, V43 (RN), stated she arrived to the unit around 10:30 AM and rounded the unit. She said the 8:00 AM and 9:00 AM meds were not passed on the unit. V43 stated she started passing the 11:00 AM meds after she rounded on the residents on the unit and did accuchecks. On May 2, 2023 at 3:45PM, V48 R9's Son said R9 did not receive her morning medications on May 1, 2023. On May 3, 2023, at 9:54AM, R24 stated he did not receive his morning medications on May 1, 2023, due to lack of nurses in the building in the morning. On May 1, 2023, at 5:00PM, R18 said after 8:00AM there were no nurses to care for him until later when V43 came in on her day off to care for the residents and pass medications. R18 said he did not receive his morning medications until approximately 12:36PM, which are normally given around 9-9:30AM. R18 said he was not able to get out bed due to lack of staffing. R18 said he normally gets out of bed every day. On May 4, 2023, at 10:20 AM, R29 stated he did not receive his morning medications because there was no nurse until around lunch time. On May 2, 2023, at 10:45 AM, V13 (Registered Nurse) stated she arrive to the facility on [DATE] around 11:00 AM. There was not a nurse on the unit. V13 stated none of the residents received their morning medications on time because there was not a nurse on duty to administer the medications. V13 stated R29 received his medications late including his IV antibiotic. On May 4, 2023, at 10:45 AM, R30 stated she did not receive her morning medications. R30's May 2023 MAR shows R30 is to receive the following medications at 9:00 AM. These medications were not signed off as given. R31's May 2023 MAR shows R31 is to receive medications at 9:00 AM. On May 4, 2023, at 3:06 PM, V29 (LPN) stated she arrived to work around 10:20 AM and started passing medications around 11:00 AM. V29 confirmed there was not a nurse on the unit when she arrived and none of the morning medications were passed on the unit. On May 3, 2023 at 11:15 AM, R3 stated he originally did not see any nurses after 8:30 AM then some of the old staff started coming in around 10:40 AM. R3 stated he was told they were trying to bring staff back to the building to take care of the residents. R3 stated he was not told if he was going to be seen by wound care or anyone else. R3 stated he did not receive his morning medications and was not updated about wound care. R3 stated he was not going to wait around so he had V13 help him get an ambulance to a local hospital. R3 stated it was a sinking ship, and I had to get out of there. On May 7, 2023, at 2:45 PM, V13 stated she arrived to the facility after 11:20 AM. V13 stated by the time she rounded on R3 it was around 11:45 AM when he received his morning medications. On May 3, 2023, at 10:00 AM, V49 (R1's family) stated he arrived to the facility after 11:30 AM. V49 stated V53 came into the room to give R1's morning medications. On May 4, 2023 at 10:15 AM, V54 (R6 family) stated she arrived to the facility around 12:30 PM on 5/1/23. V54 stated V29 Licensed Practical Nurse came into R6's room after 1 PM to give R6 her morning medications. On May 7, 2023 at 3:00 PM, V29 stated she arrived to the facility around 10:30 AM (May 1, 2023). V29 stated she administered R6's medications later on during the day. V29 could not recall the exact time she gave R6 her medications. On May 4, 2023 at 1:10 PM, V55 (R2 family) stated on the morning of May 1, 2023 R2 was transported to a local hospital by ambulance due to the facility not having any nursing staff in the building. R2's MAR for May 2023 showed R2's medications to be given at 9 AM. None of the medications were signed off as given. On May 3, 2023 at 2:45 PM, R28 stated on May 1, 2023, there were no nurses in the facility to pass morning medications. R28 stated she did not receive her morning medications until 1PM. On May 9, 2023, at 11:20 AM, V44 Licensed Practical Nurse stated she arrived to the facility around 11:00 AM on 5/1/23. V44 stated she assisted with medication administration for residents. V44 stated R28 did not receive her morning medications until early afternoon. R8's MAR for May 2023 shows she was to receive 9:00 AM medications. None of the medications were signed off. On May 1, 2023 at 1:00 PM, V45 R14's son stated, he to the facility on [DATE] at 10:00 AM. They are under new management. At 10:00 AM, it was empty, no one was here. His dad finally received his morning medications an hour ago. (approximately 12:00 PM). On May 4, 2023 at 3:06 PM, V29 Licensed Practical Nurse (LPN) stated, she came in around 10:00 AM to help out because no staff showed up to work. She verified there were no nurses working until she arrived. She passed R12, R8, R14 & R15's morning medications. On May 8, 2023 at 9:57 AM, V51 Registered Nurse (RN) stated, she came in at 11:00 AM on May 1, 2023. She started giving medications at 11:15 AM. She verified she passed R11's medications. The facility presented an abatement plan to remove the immediacy on May 10, 2023. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on May 11, 2023, and the survey team accepted the abatement plan on May 11, 2023. On May 12, 2023 surveyors were on site and were unable to remove immediacy due to no night nurses scheduled for May 12, 2023. The immediate Jeopardy that began on May 1, 2023 was removed on May 15, 2023 when the facility took the following actions to remove the immediacy. 1. Nurse leadership recruitment continues by Human Resource managers. A DON has been hired effective Monday, May 15, 2023, and Infection Preventionist Nurse was hired May 9, 2023. Two Nurse Consultants have been hired to support nursing operations and assist in onboarding the Director of Nursing. Nursing leadership involved in ensuring operations per regulation. Managers of other departments are functioning in a supportive role to nursing leadership and nurse consultants. Completed May 15, 2023. 2. A scheduler has been hired. The scheduler creates the daily schedule of nursing staff comprised of nursing staff and agency staff as contracted to fill nursing needs. The occupancy of the building has decreased substantially, the need for labor has also decreased proportionately. Staffing schedules for the succeeding weeks are being drafted and finalized. Completed May 15, 2023. 3. The Business Office Manager, Admissions/Marketing Manager, The Director of Accounting and the Social Services Director and Medical Director are hired. An on-site management meet daily to assess operations and delegate tasks as needed. Ads continue to run on social media for any unfilled positions, specifically Indeed. The departments of Therapy, Dietary and Housekeeping are all contracted services and remain stable. Completed May 15, 2023. 4. The Director of Nursing, Nurse Consultants and the Scheduler review the next day schedule daily to ensure it is adequate to meet minimum staffing requirements. This will continue until operations reach stability. Moreover, great effort is being devoted to creating a normal schedule through June 1, 2023. Completed May 15, 2023.

Based on observations, interview, and record review the administration failed to ensure key personnel were hired prior to taking ownership of the facility, and failed to ensure nursing staff were hired to meet the needs of the residents. These failures have the potential to affect all 108 currently residing within the facility. The Immediate Jeopardy began on 5/1/2023 during a change of ownership when the administration failed to ensure a safe living environment for residents by not having licensed nursing staff present. V1 Administrator was notified of the Immediate Jeopardy on 5/8/2023 at 3:26 PM. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed on 5/15/23, but noncompliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of staff hiring and in services. The findings include: The Facility Data Sheet provided May 1, 2023 showed there were 108 residents. This same document listed V7 as the Medical Director and V41 as the Director of Nursing. On 5/1/23 at 5:30 PM during a group interview, V1 (Administrator) stated his Director of Nursing (DON) was going to be V58 (Corporate Nurse Consultant). Immediately, V58 stated she was not the DON. During this same interview V5(Associate Manager) confirmed there were no licensed nurses in the building that morning for a few hours from 8:00AM until around 11:00 AM. On 5/2/2023 at 8:40AM, V41 (First Interim Director of Nursing) stated he was hired today as the DON. On 5/2/23 at 2:30PM a staffing plan was presented to the surveyor showing the previous owner would help provide staffing for the new owner for seven days starting 5/1 and ending 5/8/23. Open shifts would be filled using agency staff hired by the previous owner. The new owner would provide daily updates to the staff hired to add to the daily schedules. The facility will consolidate residents to five units, 19 residents will need to be moved and appropriate notifications will be made. Any further discharges will allow the new owners to reduce units if needed. On 5/4/2023 at 2:52PM, V7 Former Medical Director said he was not the medical director for the new owners. V7 said he had not spoken with the new owners regarding a position as their medical director. V7 said on 5/1/2023 he arrived at the facility to find no licensed nurses or administrative staff present. On 5/5/2023 at 1:00 PM, V1 stated he hired V46 as his new DON. V1 confirmed the staff needed to reapply with his company by 6pm on 4/30/23 or they would not have a job with him. V1 was not able to state how many nurses he had hired by his deadline. He stated he met with the night shift nurse around 2:00 AM on Monday morning to see who was going to stay with him; only one nurse indicated he was staying on with him. V1 stated the change in ownership went too quickly and he was not ready to staff the building. I assumed everyone would be working for me. I was wrong. The facility's nursing staff schedule 4/30- 5/1/23 showed V32 Licensed Practical Nurse (LPN) and V33 LPN were in the facility until 8:20AM. This same list shows there were only 8 Certified Nursing Assistants CNAs working in the facility for day shift, V21 CNA, V37 CNA, V24 CNA, V23 CNA, V14 CNA, V16 CNA, V22 CNA, V38 CNA. There were no licensed staff (nurses) on this schedule for 8 AM. The facility presented a list of new hires on 5/5/23 showing they had hired 6 Lisenced Practical Nurses (LPN), 2 Registered Nurses (RN) and 1 DON. They were still unable to provide the number of CNAs and nurses whom were hired by 6PM on 4/30/23 (5 days after taking ownership). On 5/8/20023 at 3:26 PM, V6 Managing Director stated they had hired 5 LPNs and 1 RN and a DON since 5/1/23 (in a week). They have a nurse consultant but no other nursing managers. On 5/9/2023 at 1:30PM, V46 (2nd Interim DON New Ownership) said he was the DON and his first day of work was 5/8/23. The facility's staffing plan dated 5/10/23 shows the census is 65 residents there will be one nurse for each of the 4 open units and 2 CNAs for each of the four units on days and evenings, and there will be one nurse per unit and one CNA per unit for each of the four units on the night shift. The facility's staffing schedule for 5/12/23 shows there are no nurses scheduled for the night shift (there should have been 4) and one unit was short a nurse (there were 3 nurses and there should have been 4) on the PM shift. On 5/12/23 at 9:20 AM, V59 (Social Services) stated as of this morning they had hired a total of 4 LPNs, 1 RN, 1 DON, an Infection Preventionist and a MDS Coordinator (in the 12 days since the new owner took over). V46 stated the staffing scheduler would not be in until after 4PM because she had another job. She was not sure how the open spots on the schedule were going to be filled; maybe agency. On 5/12/23 at 9:55 AM, V1 stated he did not have a contract for a medical director. (12 days after taking ownership) He was going to reach out to V7 to see if he would be the medical director and if not he had another physician in mind. V1 stated he believed they had contracts with staffing agencies but he would have to check. On 5/15/23 at 12:06 V60 (Interim Administrator) stated they just hired a new DON (third DON in two weeks) and were working on getting a medical director. They were actively interviewing nursing staff. This place was a mess. V1 was not prepared to take over on 5/1/23. The facility presented an abatement plan to remove the immediacy on 5/10/23. The survey team reviewed the abatement plan and was unable to accept the plan to remove immediacy. The facility presented a revised abatement plan on 5/11/23, and the survey team accepted the abatement plan on 5/12/23. On 5/12/23, the survey team was unable to remove the immediacy due to the facility not having any nurses scheduled to work the night shift on 5/12/23. The Immediate Jeopardy that began on 5/1/23 was removed and the deficient practice was removed on 5/15/23 when the facility took the following actions to remove immediacy. 1. A director of nursing was hired on 5/15/2023. 2. A medical director was hired on 5/15/2023. 3. A business office manager/admissions/marketing director, director of accounting and social services directors were hired 5/12/2023 4. A nurse scheduler was hired and is working with the DON and Interim Administrator to ensure nursing schedules are completed utilizing hired staff and agency staff. 5/15/23 5. The facility is actively interviewing and hiring licensed nurses and CNAs. 5/15/2023

Based on interview and record review the facility failed to ensure licensed nursing staff monitored and assessed a resident exhibiting low oxygen saturations. This failure resulted in R13 being sent out of the facility by emergency personnel related to no licensed nursing staff to monitor or assess R13. The facility also failed to ensure a dressing change was done per physician orders. This applies to 1 of 33 residents (R13) reviewed for care and services in the sample of 33. The Immediate Jeopardy began on May 1, 2023, when the facility failed to ensure licensed nursing staff was available to monitor and assess R13's oxygen saturations/status which resulted in R13 being sent to the hospital by emergency personnel. V1 Administrator was notified of the Immediate Jeopardy on May 8, 2023. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on May 15, 2023 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and staffing levels. The findings include: 1. R13's face sheet lists his diagnoses to include: Parkinson's disease, dementia & personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. On May 4, 2023 at 2:50 PM, V7 (Former Medical Director) stated he arrived at the facility around 8:00 AM on May 1, 2023 and did not see a nurse or any former administrative staff. He got concerned and called 911. On May 1, 2023 at 12:51 PM, V9 Police Detective stated, V7 Former Medical Director and V8 Nurse Practitioner (NP) came in (on May 1, 2023) and there was only 8 Certified Nursing Assistants (CNAs) and 12 kitchen staff in the building. At 2:45 PM, V9 Police Detective stated, R13 was sent to the hospital for a low pulse oxygen saturation. On May 8, 2023 at 11:18 AM, V32 Licensed Practical Nurse (LPN) stated, she worked the night shift with R13. Around 2-3:00 AM (she was not sure exactly), she was told that R13's pulse oxygen saturation was 86-88% (normal is 90-100%). She put him on oxygen at 3 liters per minute (LPM) and raised the head of his bed. His oxygen saturations came up to 90-92%. She did not call the doctor (V7 former Medical Director) until 7:00 AM. On May 8, 2023 at 9:47 AM, V30 CNA/Dietary stated, she was working the morning of May 1, 2023 in the kitchen. She was one of the 12 kitchen staff that was in the building. She was helping V22 CNA with breakfast when she went into R13's room. She stated, breakfast was late that morning and she wasn't sure what time she first went into R13's room. His breakfast tray was in front of him and he hadn't eaten anything yet. She stated, she woke him up and tried to get him to eat. She left the room while he was eating. She went back a little while later to check on him and take his breakfast tray. At that time, she checked his vital signs and his oxygen level was 90% on 3 LPM. He was not his usual self and pale. She left and found V8 NP. She made V8 NP aware of his pulse oxygen. V8 NP told her to call 911 and send him to the hospital because there was no one to monitor him. She called 911 at 10:46 AM from her personal cell phone. She did verify that there were no nurses to help R13. On May 4, 2023 at 12:19 PM, V8 NP stated, a CNA (V30 CNA/Dietary) told her that R13's oxygen was dropping. She was increasing his oxygen and his oxygen saturation was not going up. I said to discharge him to the hospital because there is no one here to take care of him. She stated, the CNAs were titrating his oxygen and that is typically done by the nurses. She also stated it was important to have nurses in the building for a million reasons, basic care, medications, in case of emergencies, they have good critical thinking skills, they are the backbone in healthcare. On May 4, 2023 at 2:50 PM, V7 Former Medical Director stated, R13 does not usually wear oxygen and he wasn't aware he was sent out to the hospital. R13's electronic medical record (EMR) does not show any documentation about his condition the night of April 30, 2023, or May 1, 2023. On May 8, 2023 at 11:18 AM, V32 LPN stated, because there was a change of ownership at midnight and the computer system was no longer working. She did not chart anything on paper or in the computer regarding R13. R13's EMR also does not show a physician order for oxygen. On May 9, 2023 at 1:08 PM, V47 former Director of Nursing stated, R13 was discharged to the local hospital on May 1, 2023 and admitted with a diagnosis of Pneumonia. The facility's oxygen therapy and administration policy last revised July 28, 2022 shows, Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Purpose: To assure adequate oxygenation to all spontaneously breathing and ventilator dependent patients. Indications: .Hypoxia- oxygen saturation levels of <92% (less than) . Procedure: Confirm order from physician (this should include liter flow, FiO2 and delivery device) . Note: b. Oxygen rounds should be completed weekly by RN (registered Nurse) or RCP (Respiratory Care Person), depending on facility . The facility's general care policy last revised on July 28, 2022 shows, Policy Statement- It is the facility's policy to provide care for every resident to meet their needs. The facility presented an abatement plan to remove the immediacy on May 10, 2023. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on May 11, 2023 and the survey team accepted the abatement plan on May 11, 2023. On May 12, 2023 surveyors were on site and were unable to remove immediacy due to no night nurses scheduled for May 12, 2023. The immediate Jeopardy that began on May 1, 2023 was removed on May 15, 2023 when the facility took the following actions to remove the immediacy. 1. Upon learning of the building not having licensed staff on or about 8:30am on 5/1/23, the two managing directors walked the entire building to assess staffing throughout the building. All units were found to have at least 2 certified nurse assistants caring for residents. Upon the Medical Director's arrival with his nurse practitioner, R13 was assessed and 911 was called. First responders immediately transported resident to the hospital with no adverse outcomes. R13 is no longer a resident of the facility after discharge to the hospital. 2. As of 11:00 am on 5/1/23 licensed RN/LPN's, staff and agency nurses have been on site assessing and monitoring all existing residents including blood sugar and oxygen saturation monitoring. No further change in condition noted and reported. 3. Nurse leadership recruitment continues by the facility Human Resource managers. A DON and Infection Preventionist Nurse was hired. Two Nurse Consultants have been hired to support nursing operations and assist in onboarding the Director of Nursing. Nursing leadership involved in ensuring operations per regulation. Managers of other departments are functioning in a supportive role to nursing leadership and nurse consultants. Completed May 15, 2023. 4. The Interim Director of Nursing and/or other nurse leadership are making routine rounds every shift on all units to assess residents' condition. The Interim Director of Nursing will serve as a resource for all charge nurses (agency or staff) should any residents have any change in condition. In the off shifts and weekends, the Interim DON will be notified by the nurse on the unit for any change in condition, after notifying the attending physician. Completed May 15, 2023. 5. A scheduler has been hired. The scheduler has been creating the daily schedule of nursing staff comprised of the facility nursing staff and agency staff to fill needs in staffing currently open for hire. Since the occupancy of the building has decreased substantially, the need for labor has also decreased proportionately. Staffing schedules for the succeeding weeks are being drafted and finalized. Completed May 15, 2023 6. All units are now staffed with licensed nurses and certified nurse assistants, assessing and monitoring residents. Forty four CNA's, 4 LPN's and 1 RN. Each skilled unit has a patient ratio of 1 RN/LPN to 22 residents and 1 CNA to 8 residents. Staffing agencies [2] are in contract with the facility. Completed May 9, 2023.

Based on observation, interview, and record review, the facility failed to serve hot beverages in a safe manner resulting in full thickness burns to an extensive area of skin which have required advanced and continuing treatment for the past 11 weeks to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 10/29/22 when tea that was served to R1 used hot water from the facility's hot water dispenser (part of their coffee brewing system) on the unit on which R1 resides. R1 spilled tea on herself and sustained full thickness burns to her thighs bilaterally which have required advanced and ongoing wound treatment ever since. On 1/17/23 at 11:06 AM hot water dispensed from the facility's hot water dispenser on R1's unit was measured to be 180 degrees Fahrenheit (F). V1 (Administrator) was notified of the Immediate Jeopardy on 1/18/23 at 12:50 PM. The surveyor confirmed by observation interview, and record review that the Immediate Jeopardy was removed on 1/18/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 1/17/23 at 10:26 AM, V5 (Certified Nursing Assistant/CNA) said the staff take mugs to the hot water dispenser on the unit and get the hot water for tea and take the tea to the residents. V5 showed the coffee maker with the incorporated hot water dispenser (coffee brewing system) on the unit kitchenette which staff use to make hot tea. V5 said she does not check the temperature of the tea prior to serving it to the residents. On 1/17/23 at 10:56 AM, V6 (Registered Nurse/RN) said carafes of coffee are made in the kitchenette and the CNA comes and gets the carafe for their unit and the CNA also gets the hot water for the tea from the kitchenette hot water dispenser. On 1/17/23 at 11:06 AM, V4 (Maintenance Director) checked the hot water dispensed from the hot water dispenser on the brew machine located in the kitchenette on the unit where R1 resides, and it was steaming and measured 180 degrees F. V4 said, That's a problem, it should not exceed 120 degrees F. V4 said the kitchen director is responsible for these machines. V4 said he was not aware of anyone getting burned from the tea made from the water dispensed or he would have done something about it. V4 said if they can't turn down the temperature on the machine, he will remove the machines. On 1/17/23 at 2:09 PM, V4 measured the temperature of the water dispensed from the coffee brewing system on a different unit and it was 166.9 degrees F and on 1/17/23 at 2:23PM, V4 measured the temperature of the water dispensed from the coffee brewing system located in the kitchen and it was 176.5 degrees F. On 1/17/23 at 12:00 PM, V8 (Dietary Manager) said she was aware R1 had spilled some tea and burned herself. V8 said the facility has coffee machines on the units and dietary and the CNAs have access to the coffee machines. V8 said dietary or the CNA can make the coffee in the kitchenette, put it in the carafe, and take it to the units. V8 said there is a spout on the coffee machine for hot water to make tea. V8 said they don't make a carafe of tea because there are only a few residents who drink it. V8 said the CNA or dietary aide would put the tea bag in a cup and use the hot water dispenser on the coffee machine and add it to the mug for the residents who want tea. V8 said there is another coffee machine on another unit with a hot water dispenser and a main one in the kitchen. V8 said all three machines are the same except the kitchen one can brew larger quantities. V8 said the temperature on the machines cannot be changed or recalibrated. V8 said the hot water in the machine needs to be 155 degrees F or less. V8 said she believes she checked the water temperature on each of the three machines after R1 burned herself. V8 said she believes the temperature was safe but cannot be 100% sure if the hot water was less than 155 degrees F. V8 said she does not remember what the temperatures were when she checked them or if she recorded them anywhere. V8 said the CNA would need to check the temperature of the tea before giving it to the resident, same with the coffee. V8 said the CNAs know that and have all received competencies to check the hot beverage temperatures. V8 said there is no specific temperature log for the hot water dispensers on the units. On 1/17/23 at 12:12 PM, V9 (Licensed Practical Nurse/LPN) said she was the nurse for R1 when she spilled hot tea on her lap. V9 said R1 was in the dining room and no staff saw the incident. R1 told staff that she spilled tea on her lap. V9 said she assessed R1 and noticed redness to R1's inner thighs and on a thumb and a finger. V9 said if a resident requests hot tea, they were getting the hot water from the hot water dispenser on one of the units to make the tea. V9 said after R1 was burned she stopped using the hot water dispensers, but she is not sure why. V9 said the hot water dispensers were not removed from the units. On 1/17/23 at 1:03 PM, V10 (Wound Care Nurse) said she was in the facility on 10/29/22 and was called by V9 (LPN) and informed that R1 had a thermal wound. V10 said they had already pulled down R1's pants, and she noted that R1's upper inner thighs bilaterally and a couple of her fingers were pink, slightly red, and intact. V10 said R1's burns progressively worsened and R1 is still receiving wound care. On 1/17/23 at 2:42 PM, V11 (Family Nurse Practitioner/FNP) said R1 was having tea and she spilled it on herself. V11 said initially it was redness and she ordered more first aid, symptomatic care, labs and preventive care. V11 said she saw R1 a couple days later and blisters were forming so she initiated more treatments and dressing changes. V11 said R1's wound progressed from redness to blisters. V11 said the damage won't initially show up with how R1 sustained her burn. V11 said they got a wound specialist to optimize R1's care. V11 said burns can progress from first degree to full thickness. V11 said R1 did develop cellulitis during the first week from her burns, so she started antibiotics so it did not become systemic. V11 said the burn caused the cellulitis. On 1/17/23 at 11:46 AM, V1 (Administrator) said the investigation completed on the incident when R1 sustained burns after she spilled hot tea on herself concluded the root cause was that R1 spilled the tea on herself. V1 said he is not sure if there were any changes implemented as a result of the incident. On 1/18/23 at 11:07 AM, V1 said off meal on demand beverages should not be prepared by staff in the kitchenettes on the units. V1 said there are no temperature logs for the on demand hot beverages whether they come from the kitchen or were made on the units. On 1/18/23 at 12:20 PM, V1 said they do not have a specific policy on using the coffee brewing system, it would just fall under the Food Temperature Maintenance Policy. V1 said nursing staff is not supposed to use the brew machine at all. On 1/17/23 at 10:36 AM, R1 said she had a cup of hot tea and went to remove the teabag from the cup, and it snagged and the tea spilled all over her lap. R1 said she was burned between her thighs and was getting daily wound care. R1 said the tea is always hot, and she is still drinking it when she has a taste for it. R1's Admission Record dated 1/17/23 shows she was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, pulmonary embolism, diabetes mellitus type 2, pulmonary hypertension, atelectasis, respiratory failure, congestive heart failure, gastrointestinal hemorrhage, history of falling, abnormal posture, transient cerebral ischemic attack (TIA), hypertension, gastroesophageal reflux disease, hyperlipidemia, chronic obstructive pulmonary disease, osteoarthritis and osteoporosis. R1's Minimum Data Set (MDS) dated [DATE] shows she is cognitively intact and requires supervision with eating/drinking. R1's care plan initiated on 11/8/22 shows she is on antibiotic therapy for cellulitis to her thighs. R1's Wound Assessment Details Report shows she sustained burns acquired in the facility which were first identified on 10/29/22 to her right front thigh and her left front thigh. The burn injuries were both described as superficial on that day and R1' right thigh burn measured (Length x Width x Depth (L x W x D) 18.0 cm (centimeter) x 12.2 cm x unknown and her left thigh burn measured 17.0 cm x 25.0 cm x unknown. R1's Wound Assessment Details Report dated 11/5/22 shows R1's right and left front thigh burns had progressed to full thickness injuries and her right thigh burn measured 18.0 cm x 15.0 cm x 0.10 cm (L x W x D) and her left thigh burn measured 17.0 cm x 29.0 cm x 0.10 cm (L x W x D). R1's Progress Notes show an Incident Note written on 10/29/22 at 12:45 PM which describes that R1 told staff she had spilled hot tea on her lap. Staff took her to her bathroom, removed her clothes, and the nurse noted redness to R1's right and left thighs both front and inner, left thumb, right middle finger and her left lower quadrant. R1's provider was notified, and treatment orders were received for what was described as first degree burns. On 1/18/23 at 9:22 AM, V12 (Wound Care Specialist/Nurse Practitioner/NP) said R1 sustained full thickness (3rd degree) burns (thermal injury) to her right and left thighs after she spilled hot tea on herself. V12 said a thermal injury can progressively get worse after first presenting as a superficial injury. V12 said the damage is not immediately visible, but the damage has been done. V12 said R1's thigh burns began as superficial injuries, then blisters formed, then quickly became necrotic tissue. V12 said the higher the temperature of the tea, the deeper the damage. V12 said the patient will develop an infection 100 percent (%) of the time due to contaminated skin, and cellulitis development is part of the burn progression. V12 said he used very advanced treatment to treat (R1's) thermal wounds including use of a skin substitute which is like a skin graft. V12 said he began treating R1's burn wounds on 11/7/22 and her wounds were 75-100% necrotic tissue. V12 said R1 had an extensive, huge area of burns. V12 said he evaluates and treats R1's burn wounds every week and saw her last for continuing treatment two days ago. On 1/17/23 at 11:16 AM, V2 (Director of Nursing/DON) said the CNA gets hot water from the hot water dispenser on the resident unit to prepare tea for the residents when they request it. V2 said back in October (10/29/22) V9 (LPN) called to notify him that R1 spilled hot tea on herself and had redness to both of her thighs. V2 said he asked V9 if the tea was made with hot water from the unit's hot water dispenser, and she confirmed it was. V2 said he told V9 not to use the hot water dispenser until it was recalibrated so no one else would get burned. V2 said he remembers R1's burns progressed to blisters, then became full thickness burns on 11/5/22. On 1/18/23 at 1:57 PM, V13 (Restorative Nurse) said she helps V2 (DON) with some of the clinical type of investigations. V13 said she and V2 investigated R1's burn and it happened on a weekend. V13 said on the following Monday, 10/31/22, they spoke to R1 about what happened, and R1 told them she was in the dining room waiting for lunch, she was served the hot tea and she spilled it when she was pulling the tea bag out of the cup onto herself. V13 said she did a hot beverage evaluation of R1 and R1 did not want her hot beverage privilege taken away. V13 said R1 was found to be able to continue drinking hot beverages while supervised. V13 said the investigation included the incident report, the hot beverage evaluation, and the education she provided to R1 which she documented in an assessment in R1's chart. V13 said she is not aware of any other outcomes/changes following their investigation of R1's hot tea burn incident. The user guide for the facility's coffee brewing system (undated) provided by the facility documents .Temperature - sets the brewing temperature of the water held in the water tank (the factory default is 200 degrees F). The range is 170 degrees F to 206 degrees F .choose the desired temperature .to set and exit. The facility's Food Temperature Maintenance Policy (revised 7/11/22) documents .Hot beverage items will be served at 140-150 degrees F for safety . No documentation was provided to show the nursing staff received competencies on checking hot water beverage temperatures prior to serving them to the residents, and no documented in-services were provided regarding using the facility's coffee brewing system. The Immediate Jeopardy that began on 10/29/22 was removed on 1/18/23 when the facility took the follow steps to remove immediacy: 1. Removed hot water machine dispensers (coffee brewing system) from the units so that only dietary staff could have access to pouring hot beverages directly from the kitchen and recalibrated the coffee brewing system in the kitchen to the lowest temperature possible to brew at 170 degrees F. Drinks dispensed after brewing will sit until desired temperature is reached prior to serving on 1/18/23. 2. Reassessed all residents for who can be served hot beverages and updated their care plans to reflect the assessment results on 1/18/23 3. Created a list of residents who cannot be served hot beverages without supervision/assistance on 1/18/23. 4. Updated the Food Temperature Maintenance and Hot Beverage Guidelines to include naming a designated department/person responsible to check the hot water dispenser temperature prior to serving it directly to the resident and hours available for hot beverage service on 1/18/23. 5. In-serviced all nursing staff on duty regarding the new Food Temperature Maintenance and Hot Beverage Guidelines and plan to in service those staff on medical leave, vacation, or unavailable prior to returning to work. This in-service includes the list of residents who cannot be served hot beverages without supervision/assistance, the process to call down to the kitchen for any resident that wants a hot beverage, dietary staff taking temperatures of hot beverages to be served or delivered at 140-150 degrees F, dietary staff to log the temperature. Started on 1/18/23 6. Created a temperature log for the dietary staff to complete after brewing hot beverages and serving to residents during off-meal hours. This log is to be kept in the kitchen and completed by dietary staff. 7. Plans to include the facility's Food Temperature Maintenance and Hot Beverage Guidelines in all new employees' orientation. 8. Created and implemented an audit tool for the DON or Designee to ensure staff are able to identify who needs assistance with hot beverages on 1/18/23. (To be carried out daily for 4 weeks, then twice weekly for 4 weeks) 9. Created and implemented an audit tool for the dietary director or Designee to ensure dietary staff are taking temperatures of hot beverages before they are being served/delivered to the residents on 1/18/23. (To be carried out daily for 4 weeks, then twice weekly for 4 weeks.)

Based on observation, interview, and record review, the facility failed to provide Physician ordered one to one supervision for a resident with a known risk for elopement. R1 left the facility, unknown to staff, on (MONTH) 22, (YEAR) and traveled over a mile from the facility. R1 was found wandering outside by the emergency medical services and taken to the hospital for evaluation. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 21, (YEAR) at 11:00 PM when the Certified Nursing Assistant (CNA) did not provide one on one supervision to a resident at risk for elopement. V1 (Administrator) was informed of the Immediate Jeopardy on Dcember 5, (YEAR) at 12:13 PM. The Immediate Jeopardy was removed on (MONTH) 6, (YEAR). While the immediacy was removed, the facility remains out of compliance at a severity level 2 as they are in the process of retraining staff regarding one on one supervision expectations. This applies to 1 of 3 residents (R1) reviewed for elopement in the sample of 4. The findings include: R1's physician's orders [REDACTED]. R1's 11/2/18 Minimum Data Set (MDS) assessment shows R1 had wandering behaviors and required supervision of staff for walking in his room or the corridor, dressing and personal hygiene. R1's 11/1/18 Progress notes show Resident continues to ask when he is going to be discharged . 11/8/18 Progress notes show (R1) noted to be restless and agitated after his brother left the facility. He was observed walking around frequently and changing position almost every 10-15 minutes. Patient was seen sitting in the Palm Beach (name of the unit R1 was on) TV area, then walked back in his room, walked out of his room back to the TV room, sitting on the couch in between the nurse stations. Patient was asked if we could help him with anything or if there is anything that bothers him tonight. He just smiled and did not say a single word and then he walked back to his room again. V14's (Licensed Clinical Psychologist) Neuro-psychological test report of 11/5/18 shows (R1) is slowly recovering neurologically and may have experienced long-term damage of some of his short-term memory skills as well as his hunger/saturation signals in his hypothalamus .It may be beneficial that (R1) be monitored to that end. The report shows His short-term memory was compromised as a result of his [MEDICAL CONDITION] and double craniotomy. The report also shows He mentioned on several occasions he wanted to return to home, return to work, exercise and his routine. When this writer discussed changes in his lifestyle and the importance of his having supportive monitoring, assistance initially with medication management and a safe discharge from residential, R1 seemed to avoid or discount his need and was focused on returning home as primary. The 11/14/2018 Social Services UDA (user defined assessment) shows R1 does not appear to be able to refrain from self-harmful and/or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding persons who constitute a bad influence and is not able to practice harm reduction strategies). The assessment shows R1 does not appear to be capable of unsupervised outside pass privileges at the time of assessment and supervision is recommended while in the community for safety purposes. The assessment shows R1 has attempted an actual elopement in the last year, roams or wanders throughout the facility, does not respond favorably to staff redirection and has verbalized a strong desire to leave the facility and has the ability to do so. The assessment also shows R1 has made comments asking about the nearest streets. He is at risk for elopement at this time for safety precautions and staff is aware of the residents who are a wander/elopement risk. On 11/15/2018 an order was written for 1:1 supervision. The 11/15/18 facility's Room Transfer Notification 1.2 shows R1 was transferred to another room in the facility due to elopement precaution. V3's (NP-C Nurse Practitioner) notes e-signed on 11/20/18 show Per staff, patient had an elopement risk on 11/15/18 where he threw his red suit case over the fence. At that time the patient was unable to be redirected. However, he was not able to elope due to not feeling well and having intermittent headaches leading him to be sent out to the ED (emergency department). Upon readmission to (the facility), the patient was moved to the locked unit. R1's 11/10/18 Progress notes show R1 was out of his room walking around. Agitated and not answering questions. R1's 11/11/18 at 8:15 AM Progress notes show Resident slow to respond. Agitated and not answering questions. Complained of pain to top of head 7 out of 10 on pain scale with nausea and blurred vision and photophobia. Blood pressure 178/98. At 11:10 AM Progress notes show a change in condition and documents R1 shows a decreased level of consciousness and increased confusion or disorientation. R1 keeping his eyes closed and refusing to answer questions. At 1:14 PM progress notes show R1 with episodes of anger, acting out and being verbally abusive with staff. Resident is unable to be directed at this time. The facility staff called V13 (R1's Power of Attorney) to inform her that R1 had returned from the hospital, where he had been sent out for evaluation after a change of condition (head pain, nausea, elevated blood pressure, decreased level of consciousness and increased confusion or disorientation). While speaking with V13, she voiced concerns about R1 not sleeping at night and calling/texting her at 4:00 AM. R1's 11/15/18 at 7:30 AM Progress notes show Resident awake and walking around. Periods of confusion. 11:40 AM notes show R1 was expressing that he is missing his red suit case. Resident stated that he did not leave the premises but threw his suitcase outside with an attempt to leave but he did not feel well. POA stated resident called her this morning about his suitcase but she thought it was just him being delusional given his cognition sometimes. The notes show He will also have a room change to a more secure unit and have 1:1 for supervision at this time. The 11/11/18 at 1:30 PM Progress notes show Administration aware that this resident needs continual 1 on 1 care. R1's 11/16/18 Progress notes show at 7:30 AM R1 needed redirecting and close monitoring and at 3:56 PM one on one CNA staff close supervision/safety ensured. R1's 11/20/18 Progress notes show R1 was still on one on one supervision. The notes show Noted resident ambulating from bed to toilet without clothes; resident reoriented to get dressed. R1's 11/21/18 Daily Evaluation form shows R1 is on one on one supervision. The evaluation shows R1 displaying agitation/restlessness and a depressed affect. V7's (Registered Nurse-RN) 11/22/18 ,8:53 AM Progress notes show that at 11:15 PM (on 11/21/18) V7 was informed that one on one supervision was arranged for R1. V7's 11/22/18 Progress notes show V7 spoke with CNA on duty specifically assigned to R1 for one on one at 1:00 AM, the CNA said R1 is asleep comfortably. R1's 11/22/18 at 6:00 AM Progress notes show around 6:00 AM V8 (Licensed Practical Nurse-LPN) was alerted by V4 (Certified Nursing Assistant-CNA/Sitter) that R1 was not in his room during routine monitoring rounds. Patient search conducted by staff immediately in unit and facility. V6( Registered Nurse- RN/Night Supervisor) was informed. Staff conducted further search in and around facility but unable to locate patient. The notes show the writer spoke with an RN at a local hospital and was informed R1 was being admitted due to mental status changes. The facility's Incident Report form shows V8, LPN, was notified by V4 (CNA) around 6:00 AM that R1 was not in his room. Patient search conducted by staff immediately in unit and facility. V6 informed. Staff conducted further search in and around facility premises but unable to locate patient. V1 (Administrator) and V2 (Don) were notified immediately by V6. Further search conducted in R1's room noted broken window screen. 911 and local police department called for assistance. The incident report shows one of the police officers from the local police department informed staff that R1 was transferred to a local hospital for evaluation. Interviews done by facility management staff show V4 said she did not go into R1's room during her one on one supervision to check on R1 until 6:00 AM on 11/22/2018. From 11:00 PM, 11/21/2018, through 6:00 AM 11/22/2018, V4 did not go into R1's room to check on him. At that time, she noticed that R1 was not in his room and she notified V8 , LPN on duty. The 11/22/18 Emergency Department Documentation shows R1 was alert to self, otherwise confused. The notes show Patient is a [AGE] year old with a history of two craniotomies secondary to subdural hematomas brought in by EMS (emergency medical services) for altered mental status .Patient had eloped from the facility sometime early this morning and was found by EMS wandering the streets. Upon EMS arrival, patient was alert and oriented times one (to person). The 11/22/18 notes from the local hospital show R1 presented to the hospital with a history of [MEDICAL CONDITION] and two prior subdural hemorrhages with craniotomies. The notes show R1 developed altered mental status and was found to have bilateral subdural hematomas which had worsened on the left side with some midline shift. R1 was taken to the operating room and bilateral craniotomies were performed. The (City) Police report shows on 11/22/18 at 6:22 AM, V17 (Police Officer) was dispatched to the facility for a public complaint after the County Sheriff's office had responded to an earlier call around 5:39 AM regarding a subject standing outside with his pants down at a location 1.2 miles away from the facility. The County Sheriff's office had responded to that call and learned the subject was supposed to be in a secured wing of (the facility) and was supposed to be with staff at all times because he was a flight risk patient. The report shows when V17 arrived at the facility, he was notified by his department that the facility was calling to report one of their residents missing. The same report shows V17 was taken to R1's room and shown the window screen which was cut/slit around the edges. The report shows V17 walked outside to look at the window. V17 observed the hedges were disturbed and obsderved a branch that appeared to be freshly broken. V17 observed shoeprints in the mud/mulch bed, facing west. V20 (Deputy Sheriff from the County Sheriff's office) arrived at the facility and informed V17 that R1 had been transported to the local hospital where he was currently being evaluated. The AccuWeather forecast for local weather conditions the morning of 11/22/18 show the temperatures on that day were a low of 33 degrees and a high of 39 degrees. On 11/28/18 at 11:43 AM, the screen on the right window in R1's room had a cut down both sides and at the bottom. The front door to the facility is visible from R1's window. At 11:45 AM the area from the facility to the location R1 was found was retraced by this surveyor. R1 would have had to cross 2 busy highways to get to that location. One highway is 4 lanes with a speed limit of 45 miles/hour. The other highway is a 2 lane highway with 2 turn lanes and a speed limit of 35 miles per hour. The speed limit at the location R1 was picked was 35 miles per hour. This was a 2 lane road with 1 turn lane. On 11/28/18 at 11:10 AM, V21 (Social Services Director) said she is familiar with R1. V21 said when R1 first got to the facility he did not have any behaviors. V21 said R1 attempted to elope when he was in the hospital. V21 said over time, R1 wanted to go home. He didn't understand his limitations. V21 said. R1's behaviors increased and he became agitated with staff. V21 said R1 wanted to go home independently, however, he could not do this due to his short term memory loss. V21 said R1 threw his suit case out of one of the doors. V21 said R1's head was hurting and that is why he never left the building after putting his suitcase outside. V21 said R1 was placed on one on one after that. On 11/28/18 at 3:33 PM, V18 (Police Officer) said he was one of the officers that went to the nursing facility to see if the subject that was picked up was a resident of the facility. V18 said upon arriving at the facility, he received notification from dispatch that the facility had just called the police department and was in the process of reporting a missing resident. V18 staed he did not see R1, however he remembers being told by the County Sheriff that R1 did not have any pants on. V18 said the individual that was supposed to be doing the one on one supervision informed him that she did not check on R1 when she began her shift. V18 said he saw the cut screen, a bush that was disturbed and footprints in the dirt near the window. V18 said R1 had to cross two major intersections to get to the location he was found wandering. On 11/28/18 at 5:45 AM, V2 (Director of Nursing-DON) said when a resident is on one on one supervision, staff are expected to have a visual of the resident they are watching. V2 said; ( R1) was a one on one supervision. He verbalized on and off that he wanted to go home. He supposedly was looking for belongings and threw them outside of our building so he could go home. It was the Thursday before Thanksgiving. He was put on 1:1 from that time on. Prior to that R1 was at risk for elopement when he was in Palm Beach because he would walk around a lot. V2 said she got a call at 6:30 AM on 11/22/2018, from V6 (RN, Night shift Supervisor), informing her that R1 was missing. V2 said around 6:00 AM V4 noticed R1 was missing. V2 stated, Prior to that the last time he was observed was on the 3-11 PM shift. V2 said one of the CNAs saw R1 close to 11:00 PM before she left. V2 said V4 did not go in and put eyes on R1 the whole time and that is why the facility had to let her go. At 10:31 AM, V2 said they are still trying to figure out how R1 got his suitcase out of the building. V2 said the neurosurgeon said R1 still needs to be supervised and he cannot function independently. V2 said R1 is impulsive . He is not able to make own meals or drive. R1 has short-term safety awareness. V2 said she was told that R1 was wearing shorts and a sweatshirt, and had socks and shoes on when he was last seen. V2 said R1's [DIAGNOSES REDACTED]. On 11/28/18 at 2:45 PM, V4 CNA said I worked the 11 PM-7AM shift on 11/21/18. My job duties that night were to watch over (R1). He was a one on one. That meant keeping an eye out for him. Making sure he did not exit the unit or the facility. The door to (R1's) room was cracked open a little bit. I did not physically see him. I talked to the CNA that worked the 3-11 PM shift. I worked with R1 three times. All three times were for a one on one. The other times he would come out of his room at 4:30 or 5:30 AM and sit in the TV area on the couch. I was sitting on the couch in the TV area, staring at his door, the whole shift. I don't know why they (the facility) are so upset with me. The other two times I did one on one with him I did the same thing. I guess I was supposed to be in the room with him. If they wanted me in the room with him, they should have told me that. V4 said R1 had brain surgery so she z guesses he (R1) had something wrong mentally. V4 said (R1) did not come out to sit on the couch like he usually does, so around 6:00 AM, I went into his room to check on him . He was not in there. I told the Nurse that had come in early (V8). We checked the bathroom and outside of the unit. V4 said another CNA went into R1's room and saw the screen to the window in R1's room was cut open. V4 said they saw footprints going out towards the road. On 11/28/18 at 5:10 AM, V5, CNA, said he worked the night shift on 11/21/18 the night R1 got out. V5 said he worked on the unit that R1's room was on, but he was not assigned to R1. V5 said V4 was assigned to R1. V5 said R1 was an elopement risk and V4 was assigned to do one on one supervision with R1. V5 said one on one means to focus on the resident assigned. Keep an eye on them and make sure they are alright. Sitting with them at all times. With R1, V4 should have been in the same room with him. V5 said he checked on R1 at the start of his shift between 11:00 and 11:15 PM and that was the only time he saw R1 during that shift. V5 said he was getting residents up in the morning and that is when V4 went in to check on R1 and realized he was not in there. I think it was about 5:30 AM. V5 stated, For the most part I just saw (V4) sitting in the TV room. I did not see her go into (R1's) room. On 11/28/18 at 7:50 AM, V7 (RN) said she was the Nurse working both the Melbourne (the unit R1 was located) and the Barcelona units on 11/21/18 into the morning of 11/22/18. V7 said she did not see R1 at all during the night. V7 said V4 was assigned to be a one on one with R1. V7 said at 1:00 AM, she asked V4 if she was checking on R1. V4 replied yes. V7 said V8, LPN, came in around 5:00 AM to help with the morning medication pass. V8 was passing medications on the unit R1's room was lcoated. V7 said one on one means direct supervision. Keeping the resident visible at all times. V7 said V4 was watching R1's door and did not have direct eye contact with R1. On 11/28/18 at 8:10 AM, V8 (LPN) said he went into work on 11/22/18 at 5:00 AM. V8 said he was passing medications on the wing that R1's room was located. V8 said during report from the night nurse, he was told that everything was good and that it had been a quiet night. V8 said V5 (CNA) told him that everything was good. V8 said V5 informed him that V4, CNA was doing one on one with R1. V8 said he did not talk to V4 until about 6:00 AM when V4 told him she could not find R1. V8 said the facility initiated the elopement protocol by searching the units and around the premises. V1 (Administrator) and V2 (DON) were notified. V8 said: One of the CNAs went into R1's room and noticed the screen was cut. We went outside and saw the footprints and notified the police. V8 said the facility was told that R1 had already been located and was at a local hospital. V8 said he called V13 (R1's Power of Attorney-POA) to inform her. V13 said she was already aware of the situation. V8 said one on one supervision means specifically assigning a staff member to physically be with the resident and have visual contact at all times. If that staff member needs to go somewhere, they need to let another staff member know so they can watch the patient. V8 said R1 has tried to leave the facility before and that is why he was put one on one. On 11/28/18 at 7:38 AM, V6 (RN, Night shift Supervisor) said she was working Wednesday,11/21/18. V6 said R1 was supposed to be a one on one the night he (R1) got out of the building. V6 said one on one supervision means a staff member should have eyes on the resident at all times. V6 said staff discovered at 6:00 AM that R1 was not in his room. V6 said staff reported it to her and the staff did a search of the facility. V6 said a staff member drove around the building because one of the CNAs showed her that R1's window screen was cut at the bottom. V6 said she called V2 and V1. V6 said when staff were not able to locate R1, they called the police. V6 said she did not see R1 at all on 11/21/18-11/22/18. On 11/29/18 at 10:10 AM, V2 (DON) said the investigation into R1's elopement is finished. The screen was damaged that night, we were not able to figure out how he cut the screen, the only thing I can think of is a bread knife. We searched the room. I don't know how he cut it, a new screen was ordered. 1:1 it depends on resident assessment-if a resident ambulates quick they are placed on 1:1, 1:1 you have to visually watch that person, if you have to go to the bathroom they have to get someone else to cover, the resident has to be visually seen all the time. There is not a policy regarding 1:1 definition. V4 just watched the door, not the resident. We let her go because she did not follow his plan of care. On 11/29/18 at 12:35 PM, V1 (Administrator) said one on one supervision means having an eye on the resident at all times. V1 said V4 was the staff member assigned to do the one on one supervision. V1 said R1 was last visualized at 11:00 PM on 11/21/18 and staff realized R1 was not in his room about 6:00 AM. V1 said V4 should have known what her task for one on one was, as far as visualizing the resident during the shift. On 11/28/18 at 6:40 AM, V9 (LPN) said; One on one means one person is responsible for just one resident. All of the time the staff member should be right by the resident with their eyes on the resident . It is important to keep an eye on them so they can't get out. Outside they are not safe due to cold weather, and cars out there. They could get hurt. They could fall and break something. R1's elopement care plan initiated on 10/29/18 shows R1 presents a potential elopement risk. He does not fully comprehend why he needs to be at the facility and he had attempted to leave the hospital twice before his admission. The care plan shows Resident verbalized he wants to leave today, but has not verbalized any intent to do so without permission. He is not responding well to discussions about needing long-term care support. He believes he is more capable than he is. R1's cognition care plan initiated on 11/19/18 shows he displays impaired cognitive function/dementia or impaired thought processes related to or as evidenced by current medical condition. He displays short-term memory loss in relation to medical history as well as history of substance abuse. The care plan shows R1 needs supervision with decision making. R1's Activities of Daily Living care plan initiated on 10/26/18 shows he has a self-care performance deficit and impaired mobility related to subdural hematoma. The care plan shows R1 requires supervision with transfers and supervision with toileting. R1's [MEDICAL CONDITION] disorder care plan initiated on 11/07/18 shows he has a [MEDICAL CONDITION] disorder related to a head injury. R1's care plan titled Presence of Abuse and Neglect Factors initiated on 10/27/18 shows R1 presents with behavioral symptoms including recent physically inappropriate behavior while hospitalized . When the resident was in the hospital, he knocked down two nurses in his attempt to elope from the hospital multiple times (during his hospital stay between 10/13/18 and 10/26/18 in which he had a craniotomy due to subdural hematoma). The facility policy and procedure titled Elopement Policy with a revision date of 2/20/17 shows It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. The policy shows Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement: 3. All residents who are at risk for possible elopement/wandering shall be accompanied by staff or responsible party when leaving the residents unit and/or facility grounds. On 11/29/ 18 at 6:50 AM, V20 (County Sheriff) said he was the officer that responded to the call regarding R1 on 11/22/2018. V20 said (R1) was not dressed appropriately for the weather. I cannot remember exactly what he was wearing because I answer so many calls but I do remember that he was not dressed appropriately. He did not appear to me, to be able to make good decisions or care for himself. The paramedics were asking him questions and he was not responding to their questions. V20 said R1 should not have been outside. At 10:42 AM V20 said the local ambulance were the ones that transported R1 to the hospital. V20 said R1 could have frozen to death. It was cold. On 12/3/18 at 3:10 PM, V22 (ER-emergency room Physician) said she saw R1 the morning of 11/22/18 in the ER. V22 said R1 was very confused, almost lethargic. V22 said in that state of mind R1 was in no conditions to make good decisions or care for himself. Through observation, interview and record review on 12/6/18 the surveyors confirmed that facility took the following steps to remove the immediacy: 1. All current residents were reassessed for elopement risk on 12/5/18 (using the updated Elopement Assessment Procedure) and care plans were updated to reflect the assessment results. A daily audit tool created 12/5/18 was put in place to reconcile resident elopement picture lists located in all nursing stations and front desk to ensure accuracy. The maintenance team will inspect these lists 7 days a week and will work with the IDT (iinterdisciplinary team) to update this list. 2. Safety committee updated the lists and picture boards in every nurses' station and reception area with the 4 identified residents. Melbourne unit list and pictures were updated 12/5/18 to match the lists on the other resident units. 3. All employees in all departments that were on duty 12/5/18 were in-serviced on the facility Elopement policy and new Direct Supervision Guidelines, except fo staff that were on medical leave, vacation, or unavailable. Included in the in-service was a list of those residents currently identified as elopement risks, and where the picture lists are located on each unit and the reception desk. These picture lists were updated on 12/5/18. This process was completed by 12/6/18. Those who were unavailable due to medical leave, vacation, or unavailability will be in-serviced prior to their return to work. 4. Competency tests were initiated on 12/5/18 and include the Elopement policy and t the new Direct Supervision Guidelines. This will be an ongoing process to educaate all staff and will continue until all staff have completed. 5. The facility's Elopement policy and Direct Supervision guidelines will continue to be included in all new employees' orientation training and competency testing. 6. Social Services initiated a QA (quality assurance) tool on 12/5/18. This tool will be utilized to gauge the staff's ability to identify elopement residents, what interventios are in place for these residents, knowledge of Elopement policy and Direct Supervision guidelines. This will be carried out daily for 30 days. 7. Issues related to the incident of 11/22/18 which included direct supervision were discussed with the Medical Director on 11/30/18 during the Quality Assurance and Performance Improvement Committee. The Medical Director stated any individual providing direct supervision should always have visual supervision of the resident. This was subsequently incorporated into the new Direct Supervisionn guidelines on 12/5/18.

Based on observation, interview and record review the facility failed to safely turn a resident in bed. This failure resulted in resident rolling out of bed and sustaining a laceration requiring six staples to her left lower extremity. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 5. The findings include: R1's Physician order [REDACTED]. R1's Minimum Data Set assessment dated (MONTH) 19, (YEAR) shows R1 needs extensive assist of 2 or more staff for bed mobility. R1's facility incident report dated (MONTH) 26, (YEAR) shows (R1) was assisted to turn, Certified Nursing Assistant-(CNA) wasn't able to hold her weight which caused her to slip out of bed. Laceration to the left lower extremity .resident sent to the hospital. R1's progress notes dated (MONTH) 26, (YEAR) at 9:50 PM shows per CNA, he was providing care to resident, while resident was turn on her side, resident slid out of the bed. Per resident, she hit her knee, sustained laceration. Pressure dressing applied to laceration to control bleeding. Resident was sent out to emergency room for evaluation. R1's Emergency visit summary dated (MONTH) 26, (YEAR) shows (R1) was evaluated after a fall, 6 staples applied to laceration to left knee. R1's home care instruction shows, for (R1) sutures and staples, to keep clean and dry. On (MONTH) 5, (YEAR) at 9:18 AM, R1 was lying in bed. R1 said more than a week ago, she fell out of bed and had to be sent to the emergency room . R1 said the CNA came to her room to change her after having a bowel movement. R1 said she told the CNA that he needed another staff to help him turn R1. R1 said the CNA told her he was able to assist her by himself. R1 stated, He pushed me to turn towards the window, my left leg moved forward and caused me to roll out of bed. R1 said if there were 2 staff, one on each of side of her, she would have not fallen. R1 stated I tried to tell him that he needed another staff but he didn't listen. R1 said she was sent to the hospital and had staples to her left knee. On (MONTH) 5, (YEAR) at 10:30 AM, V3 (CNA) said he was assigned to R1 on (MONTH) 26, (YEAR) at the time of the incident. V3 said he went to R1's room to answer R1's call light. R1 had a bowel movement. V3 said he asked R1 to turn to her right side to clean her up. V3 said as he rolled R1 towards the window, he asked R1 to lift her left leg so V3 can clean between R1's legs but R1 rolled out of bed. V3 said he tried to hold on to R1 but was not able to due to R1's weight. V3 said the weight of R1's unsupported left leg caused R1's entire body to roll out of the bed. R1's left knee hit the night stand as she was falling and immediately began bleeding. V3 said he informed the nurse that R1 was on the floor bleeding. R1 was sent to the hospital. V3 said he knew R1 was a 2 person assist when turning in bed, but the other staff were busy. V3 said he thought he was able to do it himself. On (MONTH) 5, (YEAR) at 1:45 PM, V4 (Registered Nurse-RN) said she was the nurse working on the day R1 fell . V4 said she was informed by V3 that R1 slid off the bed and ended on the floor. V4 said R1 sustained a laceration to her left knee. V4 said R1 was sent to the local hospital. On (MONTH) 5, (YEAR) at 10:00 AM, V5 (RN) said R1 needs an assist of 2 staff when rolling R1 side to side in bed. On (MONTH) 5, (YEAR) at 11:32 AM, V2 (Director Of Nursing) said R1 is a 2 person assist when being provided care in bed. V2 stated R1 definitely needs 2 person assist to be safely turned side to side in bed. R1's care plan dated (MONTH) 19, (YEAR) shows R1 is at high risk for falls related to impaired mobility. R1's care plan interventions include: bed mobility- requires 2 staff assist to reposition and turn in bed. Assist safely in bed to prevent sliding out of bed. The facility policy entitled Fall Occurrence shows, It is the policy of the facility to ensure residents are assessed and interventions are put in place to prevent them from falling.

Based on observation, interview, and record review the facility failed to identify a resident with a history of falls as high risk for falls and failed to implement safety interventions. The facility failed to supervise a resident with a history of falls during toileting. The facility failed to safely transfer a resident who is at risk for falls with a gait belt. The facility failed to ensure a personal safety alarm was in working order. This failure resulted in R1 sustaining C1 and C2 neck fractures and experiencing a decline in activities of daily living. This applies to 3 of 4 residents (R1, R3, R4) reviewed for falls in the sample of 8. The findings include: R1's most recent face sheet shows that R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R1's undated Interim Care Plan shows R1 is at risk for falls and has interventions to observe for changes in ability to ambulate or loco mote, side rails as ordered, observe residents gait for steadiness and balance, muscle coordination, and ability to turn and reposition self, keep call lights within reach when in bathroom or restroom, and use of wheelchair for assistive device. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively intact, requires extensive assistance of 1 for bed mobility, transfers, walking, locomotion, and toileting, and R1 is not steady when moving from seated to standing position or moving on and off the toilet. R1's Incident Report for R1's first fall dated June 16, 2016 shows R1 was found by a Certified Nursing Assistant (CNA) on the bathroom floor. R1 told the nurse writing the report I was on the toilet and got up to wash my hands and my legs gave out. R1's Nurses Note from June 17, 2016 states the call light was not going off when the resident was found. R1's Fall Risk assessment dated [DATE] (the day after the first fall) shows R1 is a low risk for falls and the section for recent falls is marked no. R1's Care Plan dated June 17, 2016 shows interventions added to risk for falls section of: frequently reorient the resident to surroundings, ensure resident is able to use the call light, and ask the resident every 2 hours if he needs to use the bathroom. R1's Incident Report for R1's second fall dated November 16, 2016 showed the CNA observed R1 leaning off of his motorized wheelchair. R1 reported he had fallen off his chair while reaching for his heater. R1's Fall Risk assessment dated [DATE] (the day after the second fall) shows R1 is a low risk for falls and the section for recent falls is marked unknown. R1's Care Plan dated November 17, 2016 shows interventions of be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The facility's incident report for R1's third fall dated February 19, 2017 shows on February 19, 2017 R1 was found by the activity aide on his bathroom floor yelling for help. R1 was transferred back to bed and complained of neck pain. The doctor was informed of the fall and an order was obtained to send R1 to the hospital. R1's Hospital Cervical/Spine Imaging Report dated February 20, 2017 shows an acute fractures of C1 and C2 (neck). R1 was admitted for further evaluation and management. R1's Final Incident Investigation report for the third fall dated February 24, 2017 shows based on various staff interviews and clinical record review that were conducted, the resident's fall was related to his leaning forward while he was removing feces out causing him to lose balance and fall. Resident is at risk for falls due to impaired balance, unsteady gait, impulsive behavior, and poor safety awareness. R1's Nurses Note dated February 22, 2017 shows R1 was readmitted to the facility from the hospital with a cervical collar in place. R1's MDS dated [DATE] (after the fall with neck fractures) shows R1 requires extensive assistance of 2 staff for bed mobility and transfers, walking, and locomotion did not occur. R1's Care Plan dated March 3, 2017 shows R1 is totally dependent on staff for repositioning and turning in bed, for dressing, requires total assistance to eat, and requires assist of 2 staff for activities of daily living. Prior to this fall, R1 was oriented, required assist of one staff to go to the bathroom and transfer to bed. R1 could stand and pivot with assistance and could propel his wheelchair around the unit. On May 30, 2017 at 2:00 PM, E5 Restorative Nurse stated the section for recent falls on the fall risk assessments done after R1's falls on June 16, 2016 and November 16, 2016 should have been marked yes which would have indicated R1 is at high risk for falls and interventions would have been put into place. After the second fall on November 16, 2016, the intervention of a personal alarm should have been added for R1. On May 30, 2017 at 1:40 PM, E2 Director of Nursing stated for residents who have had falls in the bathroom and who do not follow instructions to use call light, staff should remain with the residents while in the bathroom. If privacy is requested the bathroom curtain is pulled and the staff should remain in the resident room. For residents with poor safety awareness staff should have a visual of resident at all times. On May 31, 2017 at 10:00 AM, E8 CNA stated he assisted R1 to the bathroom and R1 asked him to step out for privacy. E8 stated he left the room and answered other residents' call lights. Another staff member, who was walking down the hall, heard R1 yelling out and found R1 on the bathroom floor. E8 stated the call light was not going off. If R1 was going to be fast in the bathroom I would pull the bathroom curtain and wait in the room with him, if R1 was going to be longer, R1 would tell me to step out. I'm not sure if he was a fall risk or if there were interventions in place. On May 30, 2017 at 2:50 PM, E2 Director of Nursing (DON) stated when R1 requested privacy the CNA should have pulled the curtain and stayed in the room. R1 fell after the CNA had left the room. On May 31, 2017 at 10:17 AM, E7 Licensed Practical Nurse stated before R1's fall on February 19, 2017, R1 was alert and oriented to person, place, and time, was able to take himself in his motorized wheelchair from his room to the dining and activity rooms. R1 needed help of one staff member with bathing, dressing, transferring, using the bathroom, and set up for meals. R1 was a fall risk and should be closely monitored by staff. After R1's fall in February R1 was in a neck brace for his broken neck, was only alert to self and could recognize familiar faces. R1 was bedbound and not able to get up into his wheelchair. On May 31, 2017 at 12:50 PM, E1 Administrator stated the facility doesn't have a fall prevention policy. Interventions are based on the resident's fall risk assessment and interdisciplinary team meeting. The facility's Fall Occurrence Policy dated February 20, 2017 shows It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. If a resident had fallen, the resident is automatically considered at high risk for falls .the nurse may immediately start interventions to address falls in the unit. 2. R3's Minimum Data Set (MDS) assessment dated [DATE] shows that his cognition is impaired, requires extensive assistance to use the toilet and is not steady with moving on and off of the toilet. Nursing Notes dated June, 15, 2106 show that R3 was found on the floor in the bathroom. R3 stated, I was trying to wipe myself. A new chair alarm was ordered. On May30, 2017 at 9:30 AM, R3 was in his wheelchair self-propelling himself down the hallway towards his room. The cord to R3's chair clip alarm was wrapped around his wheelchair handle instead of attached to the back of his shirt. R3 stated, I am headed to the bathroom. When asked if he needed help, R3 stated, No, I can do it myself. R3 got to his room and E3, Certified Nursing Assistant (CNA) was in the room with R3's roommate. E3 assisted R3 from his wheel chair to the toilet and back without using a gait belt. After R3 was assisted back to his wheelchair, E3 did not attach the resident's clip alarm to his shirt. At 10:30 AM, R3 was in the dining room in his wheelchair and the clip alarm was still wrapped around the handle of the wheel chair. At 12:19 PM, R3 was eating lunch and the clip alarm was still around R3's wheelchair handle. On May 30, 2017 at 12:19 PM, E4 (CNA) said that R3 is at risk for falls. R3 sometimes likes to try and take himself to the bathroom on his own. R3 has a chair clip alarm that should be on at all times. E4 also said that R3 requires extensive assistance of one person for transferring and a gait belt should be used for all transfers for a safe transfer. At 1:48 PM, E2 (Director of Nursing) stated, gait belts should be used for all resident transfers for the safety of the resident. E2 also said that wheelchair clip alarms should be on at all times when the resident is up in the wheel chair. R3's activities of daily living care plan initiated June 16, 2016 shows, TOILET USE: the resident requires extensive physical assist x 1 from staff. R3's fall care plan dated June 16, 2016 (one day after a fall in the bathroom) shows that he is at low risk for falls and the interventions put in place were, Floor mats/Floor pads at bedside, PT/OT (Physical Therapy/Occupational Therapy) consult for strength and mobility and anticipate and meet the resident's needs 3. R4's MDS dated [DATE] shows an admitted [DATE]. R4 is cognitively impaired, requires extensive assistance for transfers and has had one fall since admission. On May 30, 2017 at 9:30 AM, R4 was in his wheel chair in the dining room. R4's wheel chair sensor alarm cord was not attached to the sensor pad that he was sitting on. At 9:55 AM, E4 put R4 into bed. At 12:40 PM, R4 was sitting in his wheel chair in the dining room again with the sensor cord still unattached. At 12:45 PM, E4 said that R4 is at high risk for falls and should have a wheel chair sensor alarm on and attached at all times when he is up. At 1:48 PM, E2 said that wheel chair sensor alarms have a box that hangs on the handle of the wheel chair with a cord that comes out the bottom of the box and attaches to the wheel chair sensor pad. That needs to be plugged in for the alarm to work. The facility's Gait Belt Policy revised February 20, 2017 shows, Staff will use a gait belt/transfer belt on residents who need limited to total assistance with transfer or walking. The facility's Fall Occurrence Policy revised February 20, 2017 shows, If a resident had fallen, the resident is automatically considered as high risk for falls . the fall coordinator will add the intervention in the resident's care plan.

Based on interview and record review the facility failed to ensure the staff gave medications to the right resident. This failure contributed to (R1) being hospitalized for [REDACTED]. This applies to one of eleven residents (R1) in the sample reviewed for Medication Administration. The findings include: R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. R1's face sheet date March 17, 2016 does not show R1 having a medical [DIAGNOSES REDACTED]. R1's March 27, 2016 Physician orders [REDACTED]. On March 27, 2016 at 9:00 AM, E11 (Licensed Practical Nurse- L.P.N.) administered R1's morning medication per physician orders. On March 27, 2016 at 9:15 AM, E3 (L.P.N.) administered R2 ' s medications to R1. The medications were: [MEDICATION NAME] 500 mg, [MEDICATION NAME] 200 mg, Asprin 81 mg, [MEDICATION NAME] 50mg, [MEDICATION NAME] 5mg, Multivitamin, Vitamin C 500 mg, Vitamin D3 2,000 units, and [MEDICATION NAME] 300mg. R1's Nurses note dated March 27, 2016 shows E11 (L.P.N.) witnessed R1 getting additional medication. The medication given at 9:15 AM was found to be given in error. R1's pulse rate was 42 at 4:10 PM. R1 was sent to the hospital at 4:50 pm diagnosed with [REDACTED]. R1 returned to the facility on [DATE] with the additional admitting [DIAGNOSES REDACTED]. On April 12, 2016 at 12:15 PM, E3 (L.P.N.) stated she walked into R1's room and R1 stated Didn ' t I already get these? E3 (L.P.N.) stated, I completely ignored that red flag. E3 (L.P.N.) stated to R1, This is the first time I am giving you medications, the other time I just gave you water. E3 stated R1 took the medications at this time. E3 (L.P.N.) stated E11 (L.P.N.) walked by and asked me whose medication I gave? E3 (L.P.N.) stated at this time she realized it was the wrong resident. E3 (L.P.N.) stated she was not mentally prepared to handle the additional patients she received that morning. E3 (L.P.N.) stated she glanced at R2 ' s picture in the Electronic Medical Record but did not make the correlation or check R1's Identification wrist band before administering medications. E3 (L.P.N.) stated she did not follow the five rights of medication administration before administering medications. On April 12, 2016 at 12:30 PM, E4 (Nursing Supervisor) stated E3 (L.P.N.) was in a hurry and did not check the five rights of medication administration before administering medication and that is why the medication error occurred. On April 12, 2016 at 11:55 AM, Z3 (Nurse Practitioner - N.P.) stated she was called around 9:15 AM, E3 (L.P.N.) administered additional medications to R1. Z3 (N.P.) stated she gave orders to send R1 out to the hospital if her heart rate went below 50. Z3 (N.P.) stated her main concern for R1 was the anti-arrhythmic medication given. E3 (L.P.N.) stated around 4:00 PM, R1 ' s heart rate was between 42-47. Z3 (N.P.) stated R1 was admitted to a local hospital with a [DIAGNOSES REDACTED]. On April 12, 2016 at 10:00 AM, E1 (Administrator/Director of Nursing) stated E3 (L.P.N.) gave R2 ' s medication to R1 on March 27, 2016. On April 12, 2016 at 10:10 AM, E7 (Registered Nurse- R.N.) stated to make sure you have the proper medications for the proper resident, you use the picture, resident arm band with name and date of birth to verify who the resident is. The undated Facility Med Pass Policy and Procedure shows: It is the policy of the facility to adhere to federal regulations with medication pass procedure.

Based on observation, interview and record review the facility failed to provide a mechanical soft diet as ordered for a resident with swallowing precaution and [DIAGNOSES REDACTED]. This failure resulted in R1's choking incident on [DATE] that required assistance of the EMS (emergency medical service). R1 was hospitalized as a result of this incident and was diagnosed with [REDACTED]. This applies to one of three residents ( R1) reviewed for therapeutic diet. The findings include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 had an order of general mechanical soft diet. The Care plan initiated on [DATE] showed R1 demonstrates some risk to potentially choke or aspirate food or liquids. This problem is related to a [DIAGNOSES REDACTED]. R1 was observed coughing or choking during meals or while swallowing medication. R1's MDS ( minimum data set ) assessment dated [DATE] showed R1 was coded in eating meaning R1 needed supervision with set up help. An Incident report dated [DATE] showed R1 started coughing while eating lunch in the dining room. CNA attended to the resident immediately and observed the resident was continuing to cough and was unable to cough up one piece of steak. Resident was observed having difficulty in coughing anything else up and could not speak. [MEDICATION NAME] maneuver was immediately performed by the CNA until another piece of meat came out of patient's mouth. After second piece of meat was expelled, the patient slumped over in the wheelchair and was not responding to the staff questions. 911 called. [MEDICATION NAME] resident immediately and responded. 911 paramedics arrived and transported resident to hospital emergency room for evaluation. Resident was admitted with [DIAGNOSES REDACTED]. Hospital emergency department documentation dated [DATE] showed R1 was found choking on some steak in the nursing facility. EMS arrived and removed three more pieces of steak. R 1 was brought to the emergency room where R1 had another piece of steak that was removed from R1's trachea. R1 was admitted with [DIAGNOSES REDACTED]. R1's dysphagia evaluation/plan of treatment done by Z3 LSP dated [DATE] showed the clinical impressions for R1 present with mild/moderate oropharyngeal dysphagia characterized by decreased ROM ( range of motion) and slight muscle weakness oral/lingual dyscoordination. R1 demonstrates an ability to tolerate more challenging textures. R1 requires food to be cut up into pieces to decrease likelihood of choking secondary to decrease mastication thoroughness. Recommended diet mechanical soft. Speech therapy progress notes dated [DATE] showed R1 trialed regular texture meats. R1 presents with fast rate of intake with challenging textures and demonstrates increase coughing and nasal discharge when eating. R1 took large bites if meat item was not cut into smaller pieces. Attempted to cut items into smaller pieces for improved safety, however thin may not be available during actual meals as consistency may be probable. R1 displays difficulty with self regulation of meat items which increase R1's risk of choking. Will continue to provide controlled trials of thin to determine LRD ( least restrictive diet) and safety for quality of life. Regular trials should be supervised by licensed SLP ( Speech language pathologist) only. On [DATE] at 1:30 PM E3 ( nurse) stated on [DATE] at around 1 PM she was passing medications and heard R1 coughing. R1 usually sits by himself in the back table. E3 went to R1's table and saw R1 teary and coughing. E3 called the supervisor, who came right away. R1 was brought to his room and R1 still coughing and cough out a piece of meat an inch size. R1 turns cold and was not responding. E4 stands up R1 and did [MEDICATION NAME] maneuver and nothing came out. E3 said that they put R1 to bed and oxygen was applied and started responding. E3 further stated she called the code after applying the oxygen to R1. The nurses came and she went out of the room, called 911 and the physician. E3 said R1 was still having stridor, crackles in the lungs. E12 ( nurse) said when she left the room R1 coughed out another piece of meat about an inch size. The paramedic came after 5 minutes. On [DATE] at 11:35 AM E4 CNA ( certified nursing assistant) said he was serving lunch with E5 CNA for the residents. E4 said the kitchen always sent R1's tray because it was a special tray/mechanical soft diet and E5 gave R1's tray. R1 started eating and was finished and ready to go back to bed and that was R1's routine. Some of R1's food was left on the tray. There were beef chunks size of a nickel. E4 said R1 wanted to go to bed and was told to wait for 5 minutes because they were still serving lunch. R1 started coughing and looked like he wanted to vomit and told E3 (nurse). E3 told me to return him to his table and E3 said she was coming. When I returned him to his table, R1 did not look good. There was no more coughing. It looked like R1 was choking and his color was pale. E3 said to bring R1 to his room. E3 went to R1's room checked R1's mouth and found nothing. R1 was alert a little bit . E3 called the supervisor while we were at R1's room. E4 said he went to get oxygen. E3 and E5 were with R1. E3 said when he came back to R1's room R1 was choking and was not responding. R1 was really cold like a piece of ice and R1's color was white look like somebody died . E4 stated he did the [MEDICATION NAME] maneuver and R1 threw up a piece of meat the size of a nickel. E4 said the after the [MEDICATION NAME] Maneuver was initiated R1 became more responsive. E4 further stated when everybody came R1 was better and then 911 came after 5 minutes. On [DATE] 15 at 4:15 PM Z1 (ambulance crew member) stated on [DATE] they came to the facility and the facility staff told the crew they did [MEDICATION NAME] to R1 once and removed one steak. R1 was showing signs of respiratory distress, labor breathing and drooling. R1 was alert and awake but was not following commands. R1 was asked if he was having hard time breathing but R1 could answer. His airway was checked and a piece of steak was found. We used laryngeal scope and forceps to remove a piece of steak approximately one and one fourth inch by one and one fourth inch. It was big and for myself I would not take a bite. The ambulance comprehensive report dated [DATE] showed R1 was choking on a piece of meat and went unresponsive for 30 seconds prior to EMS arrival. Staff stated they did [MEDICATION NAME] maneuver to R1 and removed one piece of steak. The crew assessed R1 and he was still showing signs of respiratory distress, shallow breathing, low SPO2, pale drooling and stridor. The crew placed a NPA ( nasal pharynx airway) in R1's nose to support R1's airway. The crew assessed R1's airway with a laryngoscope and saw another piece of of steak in R1's trachea. The crew removed the piece of steak with a forceps. The crew took R1 to the hospital. On [DATE] at 12 PM E11 ( Food service director ) said the mechanical soft diet is more toward the pureed diet and the vegetables are cut fine as discussed with SLP. Based on facility's spread sheet for beef stroganoff the facility should serve ground beef. On [DATE] menu for this day was beef stroganoff for lunch as confirmed by E11. Review of beef stroganoff recipe showed to chop thawed beef into bite sized pieces. The facility's policy and procedure on mechanical soft diet dated 2010 showed: Policy: Food will be provided in a form designed to meet individual needs. The highest practicable level of eating will be provided. The texture of the food may be altered to mechanical soft consistency. Mechanical soft diets will be served as ordered by the physician. Procedure: The texture may be altered by one of the following methods: Unless otherwise indicated, meat and meat substitutes will be mechanically ground. On [DATE] at 1:25 PM Z2, R1's (Physician) said R1 was old and demented. Z2 said that R1 had problem with swallowing and ending up choking and it happened in the hospital. Z2 was asked why the mechanical diet was ordered. Z2 said it could be from a previous admission. R1 swallow evaluations a few times in the hospital. Z1 was informed the facility staff did not follow the diet order and R1 ending up getting wrong diet. Z2 said it is possible it was too much for him ( R1 ) and the cause him of choking.

Based on observation, record review and interview the facility failed to prevent avoidable pressure sores for 1 of 2 residents (R2), identified with pressure sores in a sample of 12. This resulted in R2 developing two new pressure areas. Findings Include: Review of R2's medical record indicates R2 developed an unstageable left buttock pressure sore on 8/16/11 and a stage 2 left hip pressure sore on 8/17/11. R2 has pressure sore assessments dating from admission in May 2011 indicating R2 is high risk for pressure sores. Review of R2's treatment sheet indicates R2 developed stage II pressure sore to the left hip on 8/17/11 and on 8/16/11 an unstageable pressure sore to the left buttock. The left hip pressure sore is documented as healed on 9/7/11 according to the treatment record and interview of E3. E3 stated, "Yesterday it was healed. " Observation of the treatment to the left hip from 2:10pm until 2:40pm shows that R2 has an unstageable pressure sore to this area ( .2 cm x .3 cm x .1 cm) . There is yellow slough in the center with a red periphery. Observation during the treatment showed that the area was covered by a thin [MEDICATION NAME] dressing prior to the treatment and when it was removed this was when the unstageable pressure area was found. The treatment record for the 7-3 shift skin check ,indicates that today 9/8/11 the area was healed. Observation of R2's dressing change in room [ROOM NUMBER] on 9/8/11 to the left buttock, shows R2 has an unstageable 1.0 cm. x1.0cm. x 0.4 cm. with yellow slough in the center and surrounded by a red x1.0cm. periphery. Comparison of the measurement of the wound during the 9/8/11 observation shows that the wound has increased in size since treatment measurement documented for 9/6/11. E3 stated that the area to the left buttock was the result of deep tissue injury (DTI). The facility pressure ulcer protocol defines DTI as "...damage to underlying soft tissue from pressure..." Interview with E3 stated R2 developed these pressure sores because R2 leans to the left. R2 was observed sitting a wheelchair with a pillow propped under his right arm. R2 was taken to his room for the dressing change and was leaning to his right when the pillow was removed. Although identified as high risk for pressure sores since July, there was no assessment as to the reason for R2 developing these pressure sores, no assessment to show whether these were avoidable or unavoidable, or no measures taken or in place to prevent R2 from developing these pressure sores.

A. Based on observation, interview and record review the facility failed to complete a competent and thorough assessment, and implement a timely care plan to address cognitive loss/dementia, communication, psychological well-being and behavioral symptoms. These failures resulted in R3 having an avoidable decline and an escalation in behaviors which resulted in R3 sustaining multiple bruises, a fractured nose and a fractured forearm. This is for 1 resident (R3) in the sample of 20. The findings include: R3 was admitted to the facility on [DATE] from a Behavioral Health Hospital with [DIAGNOSES REDACTED]. R3 triggered in the areas of Cognitive Loss/Dementia, Communication, Psychological Well-Being and Behavioral Symptoms according to the Care Area Assessment (CAA) trigger legend on page 33 of the Minimum Data Sets dated 3/9/11. Thorough assessments were not completed for these triggered areas. For example, the CAA summary for the triggered areas of Cognitive Loss/Dementia, Communication and Psychological Well-Being states "Dementia per physician's orders [REDACTED]. R3's care plans for Behavior, Communication and Cognitive Loss were not developed by the 21st day of stay as required and were not individualized. R3's Behavior care plan was not developed until 4/12/11. This was confirmed by E6 (MDS Coordinator) on 6/27/11 at 1:55 PM after reviewing all of R3's records. R3 displayed aggressive and exit seeking behaviors on multiple occasions according to documentation in the nursing notes (3/29, 3/30, 3/31, 4/12, 4/13 and 4/14). On 3/28/11 R3 was noted with a bruise under his left eye and a bruise on the right side of his face near his eye according to documentation in the nursing notes and on the Incident/Accident Report dated 3/28/11. The facility concluded that they were unable to determine the potential cause of the injury and that they believe the injury was related to "frequent agitation and physical aggression to staff" according to the Investigation of Injury of Known/Unknown Origin form dated 4/7/11. R3 also was noted with visible bruise and slight swelling on his left lower eye lid according to the 3/29/11 nursing notes. On 4/13/11 R3 was agitated and aggressive when staff attempted to change him and was striking out at staff according to the Incident Report dated 4/13/11. The 4/13/11 report states that when R3 was attempting to hit the CNA he "scratched his nose with his fingernail resulting in a laceration." On 4/14/11 R3 was found to have bruises and swelling on bilateral periorbital areas, swelling on the right lower lid and redness on the right eye according to the Incident Report dated 4/14/11. The facility concluded that they were unable to determine the potential cause of the injuries but believed the injuries occurred related to "physical aggression toward staff and other residents and resistive to care the night before, hitting staff members" according to documentation on the Investigation of Injury of Unknown Origin dated 4/14/11. R3 sustained a fractured nose according to the hospital report dated 4/16/11, and a "spiral, undisplaced fracture distal ulna" according to the Xray report dated 4/15/11. The facility's investigation dated 4/19/11 states that R3's fracture and facial bruises were a result of the resident's extreme agitation and behavioral symptoms of hitting staff, residents and other objects. On 6/27/11 at 2:00 PM E15 (Activity Director) stated that she was the person responsible for completing the Cognitive Loss/Dementia, Communication, Psychological Well-Being and Behavioral Symptoms sections of the CAA. E15 confirmed that no additional assessments were completed for R3 other than the statement of "Dementia per physician's orders [REDACTED]. E15 confirmed that no assessment was completed at all regarding R3's behavioral symptoms. On 6/16/11 E1 (Administrator) and E2 (DON) both confirmed that they were aware that R3 had a history of known aggressive behaviors upon his admission from the Behavioral Health Hospital. R3 was in his room on 6/16/11 sitting on a chair. R3 does not communicate verbally. R3's knuckles on his left hand were swollen and he was guarding his left arm. E9 (CNA) was in R3's room to assist in a skin check. E9 said that R3 does not like it when you touch him without asking his permission. This preference is not indicated on any of R3's care plans. B. Based on record review and interview the facility failed to ensure that pain assessments are complete,accurate and contain non-pharmacologic intervention. The facility failed to ensure that physician orders [REDACTED].. This is for 5 of 10 residents (R6, R12, R14, R13, R9) sampled for pain in a total sample of 20. Findings include; 1. The record of R13, admitted to the facility after a hip replacement, was reviewed. R13's record contains a physician's orders [REDACTED]." This order does not include a pain scale that differentiates when to give one tablet and when to give two tablets. R13's record contains a "PRN and PAIN MONITORING FORM" that contains the following documentation: On 6-14-11 at 9 AM one [MEDICATION NAME] 5/325 mg was administered for a pain scale of 5, the effectiveness was only documented as a + sign, no quantitative measure of effectiveness. On 6-20-11 at 8:45 PM two [MEDICATION NAME] 5/325 mg was administered for a pain scale of 5, the same number value for pain given when he received one [MEDICATION NAME] and the effectiveness was documented as a + sign.. The record contains documentation on several dates pain medication was administered without a pain scale, such as on 6/17/11 at 8:30 PM [MEDICATION NAME] 5/325 mg was given without a pain assessment prior to and after administration and no amount was documented (1 to 2 tabs) 2. The record of R6 contains a physician's orders [REDACTED]." This physician's orders [REDACTED]. R6's record contains a physician's orders [REDACTED]." This physician's orders [REDACTED]. 3. The record of R12 contains a physician's orders [REDACTED]. This physician's orders [REDACTED]. R12's record contains a" PRN and PIN MONITORING FORM" that states: On 6-8-11 R12 received one [MEDICATION NAME] tablet for a pain scale of 2. On 6-9-11 R12 received one [MEDICATION NAME] for a pain scale of 5. 4. The record of R14 contains a physician's orders [REDACTED]." This order does not include a pain scale for administration. R14's record also contains a physician's orders [REDACTED]." This ordered does not include a pain scale for administration. These pain medications do not explain when to give each medication. (pain scale) R14's record contains a "PRN and PAIN MONITORING FORM" that states on 6/23/11 she received "Tylenol 650 mg" for a pain scale of 5 and on 6/26/11 she received [MEDICATION NAME] 5/325 mg two tabs for a pain scale of 5. 5. R9 is an [AGE] year old resident who was originally admitted to the facility on [DATE] and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. R9 goes for [MEDICAL TREATMENT] three times a week according to POS. R9 has physician's orders [REDACTED]. R9 triggered in the CAA category of Pain according to the CAA trigger legend in the most current MDS dated [DATE]. The CAA summary states "resident will verbalize relief from pain after being medicated for pain." R9's Comprehensive Pain assessment dated [DATE] was incomplete and lacked vital information, e.g. pain site(s), pain intensity, pain duration, non-pharmaceutical approaches to relieving pain, etc. Several errors were noted in the administration of pain medication for R9. For example, R9 received 2 [MEDICATION NAME] pills on 6/27/11 according to documentation on the PRN and Pain Monitoring Form and on the Controlled Substance Proof of Use form for June 2011. E16 (Nurse) confirmed that R9 has an order to administer only 1 [MEDICATION NAME] pain tablet. Nursing notes dated 6/28/11 at 4:00 AM document, "no c/o pain or discomfort...Tylenol 650 mg given." The administration of Tylenol for 6/28/11 is not documented on the MAR or PRN ad Pain Monitoring Form for June 2011. Nursing notes also document that [MEDICATION NAME] was given on 6/28/11 5:45 AM. The Controlled Substances Proof of Use form shows that [MEDICATION NAME] was administered on 6/26/11 at 10:10; 6/26/11 5:10 PM, 6/28/11 at 5:30 AM. The administration of these pain medications is not documented in the Medication Administration Record or the PRN and Pain Monitoring Form and there was no documentation of quantitative pre and post pain assessments. This was confirmed by E16 on 6/28/11.