Every finding on record at Timberridge Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to ensure residents were free from medical neglect when the facility staff failed to provide adequate supervision and failed to take necessary actions to meet the residents' needs for 1 of 4 reviewed residents, Resident #1. On 7/24/2026 at 1:55 PM, Resident #1 was found unresponsive on the bench in the courtyard. Resident #1 was brought to her room. Staff applied packed ice and cool blankets. At 2:55 PM, Emergency Medical Service (EMS) was contacted. Resident #1 was transported to a local hospital, being admitted with diagnoses of heat exhaustion, hyperthermia, and altered mental status.Findings include:Review of Resident #1's admission record showed the resident was admitted on [DATE] with diagnoses to include wedge compression fracture of first lumbar vertebra, history of falling, major depressive disorder, primary insomnia, muscle weakness, difficulty in walking, anxiety disorder, essential (primary) hypertension, hydronephrosis with renal and ureteral calculous obstruction (kidney stone is stuck in the kidney or tube to the bladder), epilepsy, and chronic systolic (congestive) heart failure.Review of Resident #1's change in condition evaluation dated 7/24/2026 read, Change in Condition: Altered Mental Status. Temperature 98.4 ( F) [Fahrenheit] on 7/24/2026 at 14:57 [2:57 PM]; Route: Forehead (non-contact). Most Recent O2 sats [oxygen saturation] was 88% on 7/24/2026 at 14:57; Method: Room Air. Short of breath. BP [blood pressure] 88/40; Pulse: 55 - regular; R [respirations] 16. Symptoms reported to the PCP [Primary Care Physician] on 7/24/2026 at 3:00 PM. The Recommendation of Primary Clinician was: Send to ER [Emergency Room] for further eval [evaluation] and treat. The Name of family/resident representative notified: Emergency Contact on 7/24/2026 at 3:01 PM.Review of Resident #1's physician order dated 7/24/2026 read, Send to eval for further eval and treat.Review of the EMS run report read, 07/24/2026 at 14:55:51 [2:55 PM] EMS Call received. 07/24/2026 at 14:57:44 [2:57 PM] EMS dispatched. 07/24/2026 at 15:02:23 [3:02 PM] EMS on scene. 07/24/2026 at 15:04:00 [3:04 PM] EMS at patient. 07/24/2026 at 15:14:27 [3:15 PM] EMS depart scene. 'Incident' Onset Time 13:00 [1:00 PM] 07/24/2026 (estimated). Last Known Well: 13:00 [1:00 PM] 07/24/2026. Secondary Complaint: AMS [altered mental status]. Patient level of distress: Severe. Signs & Symptoms: Heatstroke and sunstroke (primary). Altered mental status. Heat exhaustion. History: aneurysm, anxiety, chronic obstructive pulmonary disease (COPD), depression, hypertension (HTN), lung cancer, seizures. Vital Signs: 15:06 [3:06 PM] BP [blood pressure] 109/63, Pulse 122, RR [respiratory rate] 18, SPO2 [peripheral capillary oxygen saturation] 92 RM [room], Temp [temperature] 104.4 F. 15:17 [2:17 PM] BP [blood pressure] 113/57, Pulse 114, RR 28, SPO2 93 ox [oxygen], F. Mental Status: Heat illness, possible heat stroke, pt [patient] was left outside in the direct sun for over an hour heat stroke symptoms. Mental Status: confused, disorientation, unspecified, slowness, and poor responsiveness, stupor. Skin: Dry, Hot. EMS was dispatched for a [AGE] year-old female with a primary complaint of heat-related illness, possibly heat stroke, and a secondary complaint of altered mental status (AMS). The onset of symptoms was reported to have occurred at approximately 13:00 [1:00 PM] on July 24, 2026. The patient's level of distress was documented as severe. The patient denies pain, as indicated by an initial pain score of 0. Medical history was obtained from health care personnel and includes chronic obstructive pulmonary disease (COPD), hypertension (HTN), seizures, lung cancer, depression, anxiety, and aneurysm. The patient is currently prescribed Keppra, Trazodone, Losartan, and Aspirin. There is no indication of injury associated with this event. The patient is responsive to pain. Vital signs are as follows: blood pressure 109/63 mmHg [millimeters of mercury], glucose 217 mg/dl [milligrams per deciliter], oxygen saturation 92% on room air, pulse regular and strong, respiration quality normal with a regular rhythm, and temperature 104.4 F. Glasgow Coma Scale (GCS) score is 8 [severe brain injury], with eye opening response 2 (opens eyes to painful stimulation), motor response 5 (localizing pain), and verbal response 1 (no verbal/vocal response. ECG [electrocardiogram] 4-lead shows sinus tachycardia [heartbeat faster than normal], and myocardial infarction is not suspected. Assessment findings: Extremities: motor function abnormal/weakness noted in the left arm, left leg, right arm, and right leg. Radial pulse in left arm 2+ easily palpable normal. Stroke: Patient was reportedly left outside in direct sun for over an hour. Skin: Hot and dry. Comments indicate heat stroke symptoms. Supporting signs and symptoms include altered mental status, heat exhaustion, and primary heatstroke/sun stroke. Patient was left sitting outside in the sun for a prolonged period of time. Staff found patient sitting outside on the bench, w/AMS [with altered mental status], and brought her back inside. The patient presents with heat stroke and sunstroke as the primary impression, accompanied by altered mental status as the secondary impression. Patient had stopped sweating, and had a temp of 104.4 [Fahrenheit].Review of Resident #1's transfer form dated 7/24/2026 read, Transfer/Discharge Details: Sent To: [Name of local hospital]; Date: 7/24/2026 at 15:05 [3:05 PM]; Sent From: Timberridge Nursing and Rehab Unit: West; Reason(s) for Transfer: Altered Mental Status; the reason for transfer: Unplanned. Her mental status was: Alert, disoriented, but can follow simple instructions. Her functional ability was: Ambulates with assistive device. Her bladder function was: Incontinent. Skin/Wound: [blank].Review of Resident #1's nursing progress note dated 7/24/2026 read, Resident was observed in a slouch position, breathing but hard to arouse. Resident was assessed, vital signs taken. Call placed to [Name of the attending physician] and new order received to send resident to ER for further eval and treat due to altered mental status. Call placed to 911, EMS arrived and resident transferred to [Name of local hospital] via stretcher. Call was placed by this writer to [Name and telephone number of Resident #1's Responsible Party] and notified her of resident [Resident #1's name] transfer to ER. Safety Maintained.Review of the local hospital's clinical impression for Resident #1 dated 7/24/2026 at 4:10 PM read, Clinical Impression: heat exhaustion, acute kidney injury [a sudden loss of kidney function that happens over a few hours or day], pyelonephritis [serious kidney infection]. Disposition Decision: Admit. Second degree sunburn [painful blisters, very red or discolored skin]: Problem Specific Plan: Second degree burns to legs, neck and upper extremities. Consulted wound care.Review of the local hospital's record titled Admit Order Medical Reason for Resident #1 dated 7/24/2026 at 5:52 PM read, Patient is a [AGE] year-old female who presents to the emergency department after she was found outside of her nursing facility. The facility states patient was left outside for at least 1 hour. Tympanic temperature taken by EMS was 104.8. Patient's initial GCS was six [Glasgow Coma Scale total score of 6 indicates a severe brain injury or deep coma]. EMS gave 1 L [liter] of fluids, and patient became more alert and arousable. She moves all extremities. Patient is alert and oriented to person and place at this time. She denies headache, sore throat, numbness/tingling, fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, dizziness, syncope, dysuria, hematuria, melena, or hematochezia. Abnormal labs: UA [urinalysis] positive for UTI [urinary tract infection]. Vital signs on arrival: Blood pressure 110/56, heart rate 133, respirations 47, temperature 39.7 Celsius [103.46 Fahrenheit], O2 sats [oxygen saturation] 93%. Patient will be admitted for heat exhaustion and sepsis secondary to UTI.During an interview on 7/30/2026 at approximately 12:00 PM, the Administrator stated they do not have a policy regarding residents who went outside other than the smoking policy. The expectation was that staff checked on residents who were outside frequently, every 15 to 20 minutes. The main patio is not secure, so residents who are alert are able to go outside and have a right to do so. There are buttons outside the doors the residents can push to automatically open the doors. If a resident wanted to go outside and was not able to get there independently, a staff member would assist them. When asked if there were additional statements from staff regarding the incident with Resident #1, the Administrator stated, I gave you the statements that I had. A request was made for documentation Resident #1 was checked every 15 to 20 minutes. None was provided.During an interview on 7/30/2026 at 3:11 PM, Staff D, Certified Nursing Assistant (CNA), stated she had worked on 7/24/2026. She had been asked to come in early at 11:00 AM. She worked with Resident #1 that day and had worked with her maybe twice before. When she arrived, Resident #1 had been in bed. She received report at bedside. She had checked on her other residents. Around lunchtime, she had seen Resident #1 walking up the hall to go outside. She had observed Resident #1 sitting outside not long after that; she was sitting on the bench in the sun. She passed lunch trays, including one for Resident #1. When she picked up lunch trays, she noticed Resident #1 had not eaten and she told the nurse. It had been about 12:30 PM. Later they brought Resident #1 in, maybe around 1 or 1:30 PM. She (Staff D) had run to get ice. They had stripped Resident #1 down. Resident #1 had foam at the corner of her mouth, and she was out of it. Resident #1 felt hot. They had put ice all over her, around her neck and arm pits. She had helped taking off Resident #1's clothes. When EMS arrived, EMS asked what was happening, and EMS said they thought she may have had a stroke. She charted that Resident #1 wasn't available for her lunch; she couldn't document she refused it, because she was not in her room.During an interview on 7/30/2026 at approximately 3:13 PM, Staff A, Licensed Practical Nurse (LPN), stated, I saw her [Resident #1] walking toward the courtyard using her walker around 11:45 AM. After I finished the med pass, I went to check on her and that was about 1:15 PM. [Resident #1's name] stated she was doing fine and she was not ready to come inside. She was on the bench. I went on break and I returned from the break, and I saw her sitting outside in the same spot, but she was slumped over on the bench. We brought her to her room and [Name of Staff C, LPN/Unit Manager] packed ice and cool blankets around her body. She was placed on oxygen because she was struggling with her breathing. I did not get the vital signs, another nurse did.During an interview on 7/30/2026 at 3:50 PM, Staff E, Receptionist, stated, for those residents who went outside she checked on them every 10 to 15 minutes. She would offer them water or encourage them to come inside. There were four or five residents who liked to go outside. She did not recall Resident #1 being outside on Friday [7/24/2026], but if she had been outside, she would have checked on her. She always asks the residents if they are okay and looks at them to see that they are okay. When asked where the checks are documented, Staff E stated she did not document.During an interview on 7/30/2026 at 4:24 PM, Staff C, LPN/Unit Manager, stated that approximately between 2:00 PM to 2:15 PM, she saw Resident #1 being wheeled down the hall on her rollator walker. Resident #1 was being assisted by Staff A, LPN, and Staff E, CNA. They brought Resident #1 into her room. She was wearing long, thin sweatpants, a zipped-up jacket/hoodie and a shirt. The jacket had been zipped up but the hoodie was not up. They assessed her; her skin was warm to the touch. Staff C, LPN, applied a cold compress to Resident #1 and removed her jacket, socks and sneakers. They tried to keep her alert and awake. She was alert by opening her eyes, not verbal. When EMS arrived, I told EMS her (Resident #1) baseline was alert and oriented. I checked on her while rounding. She was lethargic and not responding as normal. The report (to EMS) was brief and quick. We let them know she was warm to touch. She was slightly hypotensive SBP (systolic blood pressure) within 90s, altered LOC (level of consciousness). EMS left the facility around 3:00 PM.During an interview on 7/31/2026 at 11:09 AM with the Administrator, Assistant Administrator, the Director of Nursing (DON), and the Staff Educator, a request was made for progress notes, physician notes, any and all documentation related to the incident involving Resident #1. The Staff Educator stated, I put ice on her. I put it under her arms and around her. I put a cold cloth on her head. When asked for the documentation to verify the time and date, the Staff Educator stated, I didn't document, because she was not my patient. Her attending nurse can document. When asked why there was a delay in contacting EMS after Resident #1 was returned to her room, no answer was provided. When asked if taking a resident's temperature using a scan thermometer that does not make contact with the resident's skin and after placing ice on the resident and/or placing ice or a cold cloth on the resident's forehead would provide an accurate reading, no answer was provided. When asked what time Resident #1 was found in a slumped position in the courtyard the Administrator stated, We don't know the exact time. When asked what time EMS was called, the Administrator stated, We don't know the time. When asked what time the resident left the facility via EMS, the Administrator stated, We don't know the time. When asked where it was documented, the Administrator stated, There is no documentation. When asked how long Resident #1 was in the courtyard, the Administrator stated, It was just over an hour. When asked where this is documented, the Administrator stated, There is no documentation. No additional documentation was provided.During an interview on 8/1/2026 at 9:30 AM, when asked about being notified of Resident #1 being in the hospital, the Administrator stated that he was told on Monday (July 27, 2026). He was told by the Risk Manager that Resident #1's Responsible Party came in and said that Resident #1 was still in the hospital, and she had sunburn and blisters on her from being left outside. When asked if she had contacted the hospital and requested an update for Resident #1, the Administrator stated, I was going to ask for her hospital record. I haven't asked for it. When asked why she had not called the hospital, the Administrator stated, They will usually give us information, but I didn't call. When asked how an investigation was conducted with no documentation available to review, the Administrator stated, We got statements from the staff. When asked why the lack of documentation was not discussed in QAPI (Quality Assurance and Performance Improvement) meeting, the Administrator did not answer. The Administrator further stated, The resident has the right to go outside if she wants to and if she doesn't want to come in, she has the right to stay outside if she wants to. When asked regarding the residents' safety and understanding to make the decision to remain outside, consequences and education provided regarding the effects of inclement weather, the Administrator stated, No, that wasn't done. When asked if Resident #1 was care planned for wanting to stay outside during inclement weather, the Administrator stated, No. When asked if the responsible party for Resident #1 was made aware when the resident doesn't want to come inside during inclement weather and request the responsible party to encourage the resident to come inside, the Administrator stated, No. When asked if Resident #1 would often go outside and not want to return back inside the facility was documented on her care plan, the Administrator stated, No.Review of the grievance filed on 7/27/2026 by Resident #1's Responsible Party read, [Resident #1's Responsible Party's name] reported [Resident #1] was left outside in the courtyard and not checked on in a timely manner. The resident [Resident #1's name] had a blister on the thigh and back of neck.During an interview on 8/1/2026 at 12:42 PM, when asked regarding the lack of documentation to verify when Resident #1 was checked, the Administrator stated, What we have is an interview with [Staff A's name] and she says she checked on the resident. When asked regarding Resident #1's responsible party stating the resident was sunburned and had blisters on her legs and neck, how this occurred if the resident was wearing thin sweatpants, and a hoodie jacket that was zipped up, but the hoodie was down, the Administrator stated, I don't know. We may have been a little neglectful in all of this.During an interview on 8/1/2026 at 1:32 PM, the Administrator stated, [Resident #1's name] has rights and if she wants to be outside, she can be outside that is her right. When asked if someone went out and explained to Resident #1 the consequences of being out during inclement weather conditions and the possibility of suffering from sunburn, heat exhaustion, heat stroke, and death, the Administrator stated, No, that wasn't done. When asked if anyone contacted Resident #1's Responsible Party and communicated that Resident #1 didn't want to come inside, the Administrator stated, No, no one did that. When asked how Resident #1 was safe in her environment if no one determined if she understood the environment she was in, and if this met the definition of neglect per the policy and procedure for Resident #1, the Administrator did not respond.During an interview on 8/1/2026 at 2:18 PM, when asked how the DON, Registered Nurse (RN), and LPN did not know Resident #1 had signs and symptoms beyond altered mental status that should be reported, the Administrator stated, I don't know what the symptoms were. I was told that [Resident #1's name] was fine when she left from the facility, her temperature was around 99 and she had altered mental status. The care provided by the staff, per interviews, was reviewed. When asked how the staff with the actions taken, did not know this was a reportable incident, the Administrator stated, I can't really say. When asked what EMS told the staff on arrival and their findings, the Administrator stated, As far as I know, they didn't tell them anything.Review of the facility policy and procedure titled Skilled Nursing: Nursing - Routine Resident Checks read, Policy: Routine resident checks shall be made to assure that the resident's safety and well-being are maintained. Procedure: 1. To ensure the safety and well-being of our residents, a resident check will be made regularly and frequently by nursing service personnel. 2. Changes in the resident's condition must be reported to the charge nurse at once. The policy and procedure was not dated.Review of the facility policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation the last review date of 1/26/2026 read, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental) neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and The Director of Nursing. 2. Training: Upon hire, each new employee shall be informed of what constitutes ANE [Abuse, Neglect, Exploitation] and the reporting requirements, including their obligation to report and how to report. Training shall include definitions of abuse (verbal, sexual, physical, and mental), neglect, exploitation, injuries of unknown source, and our policy and procedure regarding ANE. Every employee shall receive training, no less frequently than annually, on the requirements of the facility's policy and procedure on ANE and the requirements of the Federal and State laws. Prevention: 3. The facility encourages residents and families, and requires staff to report concerns, incidents, and grievances without fear or retaliation and is provided feedback, when possible, on these reports. The facility identifies, corrects and intervenes in situations of alleged abuse, neglect, and exploitation and focuses on the following areas of prevention: e. Maintenance of an open system of communication and encouraging the submission of complaints. Definitions: Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm.The Immediate Jeopardy (IJ) was removed onsite on 7/31/2026 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 7/27/2026, the facility held an Ad Hoc (Latin meaning for this- a group formed to look into one specific issue) QAPI meeting and completed a root cause analysis (RCA) related to neglect for Resident #1. The RCA yielded the facility failed to act upon Resident #1 remaining outdoors for an undetermined amount of time during midafternoon hours increasing the potential for heat-related exposure. On 7/27/2026 a list of residents who frequented the courtyard was complied. On 7/27/2026, the Director of Nursing/designee provided information for those residents who frequent the courtyard on signs and symptoms of heat exhaustion and encouraged them to notify staff should they experience any of these conditions or related changes. On 7/29/2026, the Director of Nursing/designee completed assessments of all residents in the facility with a BIMS (Brief Interview for Mental Status) Score of less than 12 to ensure no heat related illness or skin impairments. On 7/31/2026, the Director of Nursing/designee completed interviews with all resident with a BIMS score greater than 12 to ensure they had not experienced a heat related injury. On 7/29/2026, a Resident Council Meeting was conducted by the Director of Nursing/designee with education to the residents who attended on heat related illness, signs/symptoms, and hydrations, to include the use of sunscreen during outside exposure. Beginning on 7/27/2026, the Director of Nursing/designee equipped the courtyard with a hydration station and signage to read, Protect Yourself From Heat and Sun. On 7/31/2026, the Director of Nursing/designee completed staff education on abuse, neglect, and exploitation, with emphasis on neglect with 143 of 157 nursing staff, for a total of 91% of staff. The facility held Ad Hoc QAPI meetings on 7/27/2026, 7/29/2026, and 7/31/2026 to verify the completion and effectiveness of the removal plan.During staff interviews conducted on 7/30/2026 through 7/31/2026, five LPNs, 2 RNs, 8 CNAs, and 2 receptionists confirmed they received education on abuse, neglect, and exploitation.

Based on interview and record review, the facility failed to ensure an environment free of accident hazards for 1 of 4 reviewed residents, Resident #1. On 7/24/2026 at 11:45 AM, Resident #1 was seen with her walker heading toward the outside courtyard. At 1:55 PM, Resident #1 was found unresponsive on the bench in the courtyard. Resident #1 was brought to her room. Staff applied packed ice and cool blankets. At 2:55 PM, Emergency Medical Service (EMS) was contacted. Resident #1 was transported to a local hospital, being admitted with diagnoses of heat exhaustion, hyperthermia, and altered mental status.Findings include:Review of Resident #1's admission record showed the resident was admitted on [DATE] with diagnoses to include wedge compression fracture of first lumbar vertebra, history of falling, major depressive disorder, primary insomnia, muscle weakness, difficulty in walking, anxiety disorder, essential (primary) hypertension, hydronephrosis with renal and ureteral calculous obstruction (kidney stone is stuck in the kidney or tube to the bladder), epilepsy, and chronic systolic (congestive) heart failure.Review of Resident #1's change in condition evaluation dated 7/24/2026 read, Change in Condition: Altered Mental Status. Temperature 98.4 ( F) [Fahrenheit] on 7/24/2026 at 14:57 [2:57 PM]; Route: Forehead (non-contact). Most Recent O2 sats [oxygen saturation] was 88% on 7/24/2026 at 14:57; Method: Room Air. Short of breath. BP [blood pressure] 88/40; Pulse: 55 - regular; R [respirations] 16. Symptoms reported to the PCP [Primary Care Physician] on 7/24/2026 at 3:00 PM. The Recommendation of Primary Clinician was: Send to ER [Emergency Room] for further eval [evaluation] and treat. The Name of family/resident representative notified: Emergency Contact on 7/24/2026 at 3:01 PM.Review of Resident #1's physician order dated 7/24/2026 read, Send to eval for further eval and treat.Review of the EMS run report read, 07/24/2026 at 14:55:51 [2:55 PM] EMS Call received. 07/24/2026 at 14:57:44 [2:57 PM] EMS dispatched. 07/24/2026 at 15:02:23 [3:02 PM] EMS on scene. 07/24/2026 at 15:04:00 [3:04 PM] EMS at patient. 07/24/2026 at 15:14:27 [3:15 PM] EMS depart scene. 'Incident' Onset Time 13:00 [1:00 PM] 07/24/2026 (estimated). Last Known Well: 13:00 [1:00 PM] 07/24/2026. Secondary Complaint: AMS [altered mental status]. Patient level of distress: Severe. Signs & Symptoms: Heatstroke and sunstroke (primary). Altered mental status. Heat exhaustion. History: aneurysm, anxiety, chronic obstructive pulmonary disease (COPD), depression, hypertension (HTN), lung cancer, seizures. Vital Signs: 15:06 [3:06 PM] BP [blood pressure] 109/63, Pulse 122, RR [respiratory rate] 18, SPO2 [peripheral capillary oxygen saturation] 92 RM [room], Temp [temperature] 104.4 F. 15:17 [2:17 PM] BP [blood pressure] 113/57, Pulse 114, RR 28, SPO2 93 ox [oxygen], F. Mental Status: Heat illness, possible heat stroke, pt [patient] was left outside in the direct sun for over an hour heat stroke symptoms. Mental Status: confused, disorientation, unspecified, slowness, and poor responsiveness, stupor. Skin: Dry, Hot. EMS was dispatched for a [AGE] year-old female with a primary complaint of heat-related illness, possibly heat stroke, and a secondary complaint of altered mental status (AMS). The onset of symptoms was reported to have occurred at approximately 13:00 [1:00 PM] on July 24, 2026. The patient's level of distress was documented as severe. The patient denies pain, as indicated by an initial pain score of 0. Medical history was obtained from health care personnel and includes chronic obstructive pulmonary disease (COPD), hypertension (HTN), seizures, lung cancer, depression, anxiety, and aneurysm. The patient is currently prescribed Keppra, Trazodone, Losartan, and Aspirin. There is no indication of injury associated with this event. The patient is responsive to pain. Vital signs are as follows: blood pressure 109/63 mmHg [millimeters of mercury], glucose 217 mg/dl [milligrams per deciliter], oxygen saturation 92% on room air, pulse regular and strong, respiration quality normal with a regular rhythm, and temperature 104.4 F. Glasgow Coma Scale (GCS) score is 8 [severe brain injury], with eye opening response 2 (opens eyes to painful stimulation), motor response 5 (localizing pain), and verbal response 1 (no verbal/vocal response. ECG [electrocardiogram] 4-lead shows sinus tachycardia [heartbeat faster than normal], and myocardial infarction is not suspected. Assessment findings: Extremities: motor function abnormal/weakness noted in the left arm, left leg, right arm, and right leg. Radial pulse in left arm 2+ easily palpable normal. Stroke: Patient was reportedly left outside in direct sun for over an hour. Skin: Hot and dry. Comments indicate heat stroke symptoms. Supporting signs and symptoms include altered mental status, heat exhaustion, and primary heatstroke/sun stroke. Patient was left sitting outside in the sun for a prolonged period of time. Staff found patient sitting outside on the bench, w/AMS [with altered mental status], and brought her back inside. The patient presents with heat stroke and sunstroke as the primary impression, accompanied by altered mental status as the secondary impression. Patient had stopped sweating, and had a temp of 104.4 [Fahrenheit].Review of Resident #1's transfer form dated 7/24/2026 read, Transfer/Discharge Details: Sent To: [Name of local hospital]; Date: 7/24/2026 at 15:05 [3:05 PM]; Sent From: Timberridge Nursing and Rehab Unit: West; Reason(s) for Transfer: Altered Mental Status; the reason for transfer: Unplanned. Her mental status was: Alert, disoriented, but can follow simple instructions. Her functional ability was: Ambulates with assistive device. Her bladder function was: Incontinent. Skin/Wound: [blank].Review of Resident #1's nursing progress note dated 7/24/2026 read, Resident was observed in a slouch position, breathing but hard to arouse. Resident was assessed, vital signs taken. Call placed to [Name of the attending physician] and new order received to send resident to ER for further eval and treat due to altered mental status. Call placed to 911, EMS arrived and resident transferred to [Name of local hospital] via stretcher. Call was placed by this writer to [Name and telephone number of Resident #1's Responsible Party] and notified her of resident [Resident #1's name] transfer to ER. Safety Maintained.Review of the local hospital's clinical impression for Resident #1 dated 7/24/2026 at 4:10 PM read, Clinical Impression: heat exhaustion, acute kidney injury [a sudden loss of kidney function that happens over a few hours or day], pyelonephritis [serious kidney infection]. Disposition Decision: Admit. Second degree sunburn [painful blisters, very red or discolored skin]: Problem Specific Plan: Second degree burns to legs, neck and upper extremities. Consulted wound care.Review of the local hospital's record titled Admit Order Medical Reason for Resident #1 dated 7/24/2026 at 5:52 PM read, Patient is a [AGE] year-old female who presents to the emergency department after she was found outside of her nursing facility. The facility states patient was left outside for at least 1 hour. Tympanic temperature taken by EMS was 104.8. Patient's initial GCS was six [Glasgow Coma Scale total score of 6 indicates a severe brain injury or deep coma]. EMS gave 1 L [liter] of fluids, and patient became more alert and arousable. She moves all extremities. Patient is alert and oriented to person and place at this time. She denies headache, sore throat, numbness/tingling, fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, dizziness, syncope, dysuria, hematuria, melena, or hematochezia. Abnormal labs: UA [urinalysis] positive for UTI [urinary tract infection]. Vital signs on arrival: Blood pressure 110/56, heart rate 133, respirations 47, temperature 39.7 Celsius [103.46 Fahrenheit], O2 sats [oxygen saturation] 93%. Patient will be admitted for heat exhaustion and sepsis secondary to UTI.During an interview on 7/30/2026 at approximately 10:00 AM, Resident #2, the roommate of Resident #1, stated, The date she [Resident #1] left [7/24/2026] she went outside after her shower to dry her hair. I'm not sure of the time but it was approximately 11:20 AM. She used her walker. I did not see when she came back in. I could only hear the staff working with her.During an interview on 7/30/2026 at approximately 12:00 PM, the Administrator stated they do not have a policy regarding residents who went outside other than the smoking policy. The expectation was that staff checked on residents who were outside frequently, every 15 to 20 minutes. The main patio is not secure, so residents who are alert are able to go outside and have a right to do so. There are buttons outside the doors the residents can push to automatically open the doors. If a resident wanted to go outside and was not able to get there independently, a staff member would assist them. When asked if there were additional statements from staff regarding the incident with Resident #1, the Administrator stated, I gave you the statements that I had.During an interview on 7/30/2026 at 12:35 PM, the Director of Nursing (DON) stated that on 7/24/2026 she had not seen Resident #1 sitting outside, she had been on a conference call until about 2:00 PM. A prn (as needed) CNA (Certified Nursing Assistant) had come to get her and when she got to Resident #1's room, she [Resident #1] was in bed with her eyes open, but she was slouched over her pillow. They had assessed her, called the doctor, and got orders to send her out (to hospital). They called EMS and they had transported her to the hospital. She had completed the change in condition documentation in (the name of computer program) and had called Resident #1's Responsible Party. Her O2 sat had been low, but her temperature was within normal limits. The DON didn't know what Resident #1's vital signs were. They did a head-to-toe assessment, and they put a cooling rag on her forehead because she had come in from outside. Resident #1 was not red or flushed.During an interview on 7/30/2026 at 3:11 PM, Staff D, Certified Nursing Assistant (CNA), stated she had worked on 7/24/2026. She had been asked to come in early at 11:00 AM. She worked with Resident #1 that day and had worked with her maybe twice before. When she arrived, Resident #1 had been in bed. She received report at bedside. She had checked on her other residents. Around lunchtime, she had seen Resident #1 walking up the hall to go outside. She had observed Resident #1 sitting outside not long after that; she was sitting on the bench in the sun. She passed lunch trays, including one for Resident #1. When she picked up lunch trays, she noticed Resident #1 had not eaten and she told the nurse. It had been about 12:30 PM. Later they brought Resident #1 in, maybe around 1 or 1:30 PM. She (Staff D) had run to get ice. They had stripped Resident #1 down. Resident #1 had foam at the corner of her mouth, and she was out of it. Resident #1 felt hot. They had put ice all over her, around her neck and arm pits. She had helped taking off Resident #1's clothes. When EMS arrived, EMS asked what was happening, and EMS said they thought she may have had a stroke. She charted that Resident #1 wasn't available for her lunch; she couldn't document she refused it, because she was not in her room.Review of the meal delivery schedule displayed on the hall where Resident #1 resided showed lunch trays were delivered between 11:15 AM and 11:30 AM. During an interview on 7/30/2026 at approximately 3:13 PM, Staff A, Licensed Practical Nurse (LPN), stated, I saw her [Resident #1] walking toward the courtyard using her walker around 11:45 AM. After I finished the med pass, I went to check on her and that was about 1:15 PM. [Resident #1's name] stated she was doing fine and she was not ready to come inside. She was on the bench. I went on break and I returned from the break, and I saw her sitting outside in the same spot, but she was slumped over on the bench. We brought her to her room and [Name of Staff C, LPN/Unit Manager] packed ice and cool blankets around her body. She was placed on oxygen because she was struggling with her breathing. I did not get the vital signs, another nurse did.During an interview on 7/30/2026 at approximately 3:20 PM, the DON stated her expectation for checking on residents was that staff visually observe the resident. For Resident #1, she would check every 30 minutes. Both of the receptionists also help check on the residents when they are on the main courtyard.During an interview on 7/30/2026 at 3:40 PM, Staff F, Receptionist, stated she did not recall Resident #1 being outside on Friday (7/24/2026), but if she had been outside, she would have checked on her. She was familiar with Resident #1's name because she answered the phone and greeted visitors, but she was not familiar with Resident #1.During an interview on 7/30/2026 at 3:50 PM, Staff E, Receptionist, stated, for those residents who went outside she checked on them every 10 to 15 minutes. She would offer them water or encourage them to come inside. There were four or five residents who liked to go outside. She did not recall Resident #1 being outside on Friday [7/24/2026], but if she had been outside, she would have checked on her. She always asks the residents if they are okay and looks at them to see that they are okay. When asked where the checks are documented, Staff E stated she did not document.During an interview on 7/30/2026 at 4:24 PM, Staff C, LPN/Unit Manager, stated that approximately between 2:00 PM to 2:15 PM, she saw Resident #1 being wheeled down the hall on her rollator walker. Resident #1 was being assisted by Staff A, LPN, and Staff E, CNA. They brought Resident #1 into her room. She was wearing long, thin sweatpants, a zipped-up jacket/hoodie and a shirt. The jacket had been zipped up but the hoodie was not up. They assessed her; her skin was warm to the touch. Staff C, LPN, applied a cold compress to Resident #1 and removed her jacket, socks and sneakers. They tried to keep her alert and awake. She was alert by opening her eyes, not verbal. When EMS arrived, I told EMS her (Resident #1) baseline was alert and oriented. I checked on her while rounding. She was lethargic and not responding as normal. We included the blood sugar, BP, and O2. The report (to EMS) was brief and quick. We let them know she was warm to touch. She was slightly hypotensive SBP (systolic blood pressure) within 90s, altered LOC (level of consciousness). EMS left the facility around 3:00 PM. Staff C stated she (Staff C) had experienced heat injury before and knew right away the resident was experiencing something very similar. Normally she (Resident #1) is alert and oriented X (times) 4 (person, place, time, and situation). They (facility staff) told them (EMS) what Resident #1's baseline was and that they had brought her inside because she had been outside. They reported to EMS that her skin was warm to touch and what her vitals were. She had been hypotensive. Her level of consciousness was different (than her baseline). Staff C, LPN stated her first thought was that Resident #1 had suffered a heat injury. The cold compresses had been applied to Resident #1 between her and the Staff Educator.During an interview on 7/30/2026 at 4:27 PM, Staff B, Registered Nurse (RN), stated she worked last Friday and had gotten Resident #1's blood pressure and put her on oxygen. When she spoke to Resident #1, she (Resident #1) had opened her eyes. Resident #1 had been able to open her eyes, but was not talking. Resident #1 liked to go outside often and sit on a bench or on her walker. When they assessed Resident #1, they thought that maybe she had a seizure, and that's what they told EMS. Resident #1's temperature had been 99 something. She had used the thermometer to scan her forehead, and she thought it had been 99.7. She did not document the vital signs; there were a lot of nurses in Resident #1's room and everyone was doing something to help. Resident #1 was picked up by EMS around 2:45 PM.During an interview on 7/31/2026 at 10:10 AM, the Medical Director stated, They told me the patient was sitting outside and developed heat exhaustion. Basically, if the patient is competent, they have a right to go outside. We periodically check on them. The nurses should check on them because it is summer. If they want to stay [outside], they need to hydrate. The expectation is that they are going every 30 minutes and ask them if they are okay or want to come inside. Unless the patient calls them [to come inside sooner]. The fluids should be around. This is the general instruction for the staff. If they [the residents] are not competent, the staff should assist and make sure the family is aware. They should never be in the direct sun. Basically, the increased risk; it depends on the medicine they are on. Anybody needs to be checked. Anybody can get heat exhaustion. Basically, heat exhaustion is the issue. The number [frequency] of checking should be every half hour. One thing is the patient could say they want to stay there. There should be checks and balances. Death is possible if a resident is exposed to heat and sun. Within an hour, a resident should be brought inside. For a patient with a UTI [urinary tract infection], if the resident is not drinking enough or is dehydrated, that would increase their risk or make the outcome more severe. If there is fever, there is an increased risk of heat exhaustion. If a resident has a kidney infection or pyelonephritis that is worse.During an interview on 7/31/2026 at 11:09 AM with the Administrator, Assistant Administrator, the DON, and the Staff Educator, when asked why there was a delay in contacting EMS after Resident #1 was returned to her room, no answer was provided. When asked if taking a resident's temperature using a scan thermometer that does not make contact with the resident's skin and after placing ice on the resident and/or placing ice or a cold cloth on the resident's forehead would provide an accurate reading, no answer was provided. When asked what time Resident #1 was found in a slumped position in the courtyard, the Administrator stated, We don't know the exact time. When asked what time EMS was called, the Administrator stated, We don't know the time. When asked what time the resident left the facility via EMS, the Administrator stated, We don't know the time. When asked how long Resident #1 was in the courtyard the Administrator stated, It was just over an hour.During an interview on 8/1/2026 at 9:30 AM, when asked about being notified of Resident #1 being in the hospital, the Administrator stated that he was told on Monday (July 27, 2026). He was told by the Risk Manager that Resident #1's Responsible Party came in and said that Resident #1 was still in the hospital, and she had sunburn and blisters on her from being left outside. When asked if she had contacted the hospital and requested an update for Resident #1, the Administrator stated, I was going to ask for her hospital record. I haven't asked for it. When asked why she had not called the hospital, the Administrator stated, They will usually give us information, but I didn't call. When asked how an investigation was conducted with no documentation available to review, the Administrator stated, We got statements from the staff. When asked why the lack of documentation was not discussed in QAPI (Quality Assurance and Performance Improvement) meeting, the Administrator did not answer. The Administrator further stated, The resident has the right to go outside if she wants to and if she doesn't want to come in, she has the right to stay outside if she wants to. When asked regarding the residents' safety and understanding to make the decision to remain outside, consequences and education provided regarding the effects of inclement weather, the Administrator stated, No, that wasn't done. When asked if Resident #1 was care planned for wanting to stay outside during inclement weather, the Administrator stated, No. When asked if the responsible party for Resident #1 was made aware when the resident doesn't want to come inside during inclement weather and request the responsible party to encourage the resident to come inside, the Administrator stated, No. When asked if Resident #1 would often go outside and not want to return back inside the facility was documented on her care plan, the Administrator stated, No.Review of Weather Underground at https://[NAME]-next-prod.wunderground.com/history/daily/us/fl/ocala/KFLOCALA480/date/2026-7-25 documented the temperature in Ocala, FL on 7/24/2026 at 11:51, 92 degrees Fahrenheit (F), 12:51 94 F, 1:51 95 F, and at 2:51 95 F.Review of the statements provided by the facility regarding the incident occurred to Resident #1 read, Statement obtained on 07/27/2026 by [Name of the DON], name of person supplying the statement is [Name of Resident #1's Responsible Party]. [Resident #1's Responsible Party] came to speak with DON, [Name of the DON] regarding [Resident #1] transfer to ER [Emergency Room]. [Resident #1's Responsible Party] stated after speaking with [Resident #1], the patient told Resident #1's Responsible Party] that she wanted to sit in the sunlight because she was cold.Review of the statement made by Staff A, LPN, on 7/27/2026, through interview by the Assistant Administrator read, [Staff A's name] was patient [Resident #1's name] nurse and she stated that patient went outside around lunch time. [Staff A's name] stated doing routine checks on patient while she was outside. Upon checking patient outside during her routine checks she saw patient in a slouched position and brought patient back inside. [Staff A's name] stated when checking on patent she would go outside to check resident.Review of the statement made by Staff C, LPN/Unit Manager on 7/27/2026, read, Seen the patient [Resident #1] making her way to the courtyard around lunch time.Review of the statement made by Staff F, Receptionist, on 7/28/2026 read, [Name of Staff F, Receptionist] did not recognize patient and stated she did not see the patient outside and had no interaction with the patient.Review of the statement made by Staff E, CNA/Receptionist, on 7/28/2026 read, Employee stated not seeing the patient [Resident #1] outside and stated she did not have any interaction with the patient.Review of the statement made by Staff H, CNA, on 7/30/2026 read, I did not see or interact with [Resident #1's name] on Friday 07/24/2026.Review of mayoclinic.org/diseases-conditions/heat-exhaustion/symptoms-causes/syc-20373250 read, Heat exhaustion is a condition that happens when your body overheats. Symptoms may include heavy sweating and rapid pulse. Heat exhaustion is one of the here heat illness. Causes of heat illness include exposure to high temperatures, particularly when there also is high humidity, and strenuous physical activity. Without prompt treatment, heat exhaustion can lead to heatstroke, a life-threatening condition. Fortunately, heat exhaustion is preventable. Causes: The body's heat combined with environmental heat affects your body's core temperature. This is your body's inner temperature. Your body needs to regulate heat gain in hot weather and heat loss in cold weather to keep a core temperature that's typical for you. The average core temperature is about 98.6 degrees Fahrenheit (37 degrees Celsius). Risk factors: Anyone can get heat illness, but certain factors increase your sensitivity to heat. They include: Young age or old age. Infants, children younger than 4 and adults older than 65 are at higher risk of heat exhaustion. The body's ability to regulate its temperature isn't fully developed in children. Older audits, illness, medicines or other factors can affect eh body's ability to control temperature. Complications: If heat exhaustion isn't treated, it can lead to heatstroke. Heatstroke is a life-threatening condition. It happens when our core body temperature reaches 104 degrees Fahrenheit (40 degrees Celsius) or higher. Heatstroke needs immediate medical attention to prevent permanent damage to your brain and other vital organs that can result in death.Review of the facility policy and procedure titled Skilled Nursing: Nursing - Routine Resident Checks read, Policy: Routine resident checks shall be made to assure that the resident's safety and well-being are maintained. Procedure: 1. To ensure the safety and well-being of our residents, a resident check will be made regularly and frequently by nursing service personnel. 2. Changes in the resident's condition must be reported to the charge nurse at once. The policy and procedure was not dated.The Immediate Jeopardy (IJ) was removed onsite on 7/31/2026 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 7/27/2026, the facility held an Ad Hoc (Latin meaning for this- a group formed to look into one specific issue) QAPI meeting and completed a root cause analysis (RCA) related to neglect for Resident #1. The RCA yielded the facility failed to act upon Resident #1 remaining outdoors for an undetermined amount of time during midafternoon hours increasing the potential for heat-related exposure. On 7/27/2026 a list of residents who frequented the courtyard was complied. On 7/27/2026, the Director of Nursing/designee provided information for those residents who frequent the courtyard on signs and symptoms of heat exhaustion and encouraged them to notify staff should they experience any of these conditions or related changes. On 7/29/2026, the Director of Nursing/designee completed assessments of all residents in the facility with a BIMS (Brief Interview for Mental Status) Score of less than 12 to ensure no hear related illness or skin impairments. On 7/31/2026, the Director of Nursing/designee completed interviews with all resident with a BIMS score greater than 12 to ensure they had not experienced a heat related injury. On 7/29/2026, a Resident Council Meeting was conducted by the Director of Nursing/designee with education to the residents who attended on heat related illness, signs/symptoms, and hydrations, to include the use of sunscreen during outside exposure. Beginning on 7/27/2026, the Director of Nursing/designee equipped the courtyard with a hydration station and signage to read, Protect Yourself From Heat and Sun. On 7/31/2026, the Director of Nursing/designee completed staff education on abuse, neglect, and exploitation, with emphasis on neglect with 143 of 157 nursing staff, for a total of 91% of staff. The facility held Ad Hoc QAPI meetings on 7/27/2026, 7/29/2026, and 7/31/2026 to verify the completion and effectiveness of the removal plan.During staff interviews conducted on 7/30/2026 through 7/31/2026, five LPNs, 2 RNs, 8 CNAs, and 2 receptionists confirmed they received education on abuse, neglect, and exploitation.

Based on interview and record review, the facility administration failed to ensure they were aware of the incident occurred to 1 of 4 reviewed residents, Resident #1, who was found unresponsive in the courtyard during inclement weather, had foam at the side of her mouth, was unresponsive, was applied ice/ice packs, and was transferred to a higher level of care. The facility's inactions and decisions of administering the facility contributed to the deficient practice and the deficient practice was not acted upon until a grievance was completed by Resident #1's Responsible Party three days post the incident.Findings include:Review of the Medical Director Services Agreement dated 3/9/2021 read, 3. Medical Director of Facility: During the Term, Physician agrees to serve as Medical Director for Facility. Physician agrees to perform the services identified on Exhibit A attached hereto and incorporated herein by reference. Exhibit A Medical Director Services: 2. Develop, implement, and evaluate resident care policies, procedures and guidelines, based on the current standards of practice, and collaborate with Facility leadership, staff, and other practitioners and consultants, regarding the following: b. accidents and incidents, use of medications, use and release of clinical information, ancillary services such as laboratory, radiology, and pharmacy and overall quality of care. C. providing a continuity of care and an adequate medical record system. K. medical and clinical concerns and issues that affect resident care, medical care, or quality of life, or are related to the provision of services by physicians or other licensed health care practitioners. Participate in Facility's Resident Care Management System, which will include attendance and active participation in Facility's monthly Quality Assessment and Assurance/Risk Management Committee. 6. Direct and coordinate: A. the medical care in Facility and ensure that Facility is providing appropriate care as required; e. in-service education by providing information for Facility personnel as may be required by accrediting bodies and Facility, including pertinent education regarding existing and proposed procedures within Facility.Review of the Position Description Administrator read, Basic Function: Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Characteristic Duties and Responsibilities - Essential Functions: 1. Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. (Includes personnel policies, patient/resident care policies, procedure manuals, position descriptions, etc.). 3. Ensure that all personnel, patients/residents, visitors and the general public follow established policies and procedures. 6. Ensure that patients'/residents' rights to fair and equitable treatment, self determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times. Marginal Functions: 1. Responsible for the overall quality assessment and improvement program and the coordination of quality assessment and improvement activities. 7. Participate in quality assessment and improvement activities. Supervision Exercised: The Administrator exigencies administrative and functional supervision over the entire facility. Working Conditions: 4. Involved with patients/residents, family members, personnel, visitors, government agencies/personnel, etc. under all conditions/circumstances. Specific Requirements: 6. Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations and guidelines pertaining to hospital and skilled nursing facility operation. 8. Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality patient/resident care and maintaining a sound operation. Signature-Administrator [signed by the Administrator. Date: 7/27/26]. Review of the Position Description Assistant Administrator read, Basic Function: Responsible for assisting in the directing the overall operation of the facility's activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Characteristic Duties and Responsibilities - Essential Functions: 1. Assist in establishing and directing the implementation of written policies and procedures that reflect the foals and objectives of the facility. (Includes personnel policies., patient/resident care policies, procedure manuals, position descriptions, etc.) 3. Ensure that all personnel, patients/residents, visitors and the general public follow established policies and procedures. 4. Interpret the facility's polices and procedures to personnel, patients/residents, family members, visitors, etc., as directed by the Administrator. 6.Ensure that patients'/residents' rights to fair and equitable treatment, self determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times. 18. In the absence of the Administrator, assume the authority, responsibility, and accountability of directing the facility's operations. Working Conditions: 4. Involved with patients/residents, family members, personnel, visitors, government agencies/personnel, etc., under all conditions/circumstances. Specific Requirements: 5. Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations and guidelines pertaining to hospital and skilled nursing facility operation. [signed by the Assistant Administrator and dated 7/27/2026].Review of the Position Description Director Of Nursing (DON) read, Basic Function: Responsible for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all patient/residents. Characteristic Duties and Responsibilities - Essential Functions: 1. Supports and practices the philosophy, objectives, and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. 2. Coordinates interdisciplinary patient/resident care management efforts. 4. Ensures that nursing interventions meet the personal, physical and cognitive needs of each patient/resident as well as maximize his/her self care capacities, identity, independence, choice and opportunity for social interaction. 5. Monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees and monitoring the effective and efficient use of budgeted resources (personnel, supplies, equipment). 6. Ensures a safe and sanitary environment for patients/residents, employees and visitors. 8. Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator. Supervision Exercised: Exercises administrative and functional supervision over nursing personnel. Minimum Performance Standards: Supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. Coordinates interdisciplinary patient/resident care management efforts. 1. Provides direction as to format and approach to patient/resident care management. 2. Ensures implementation of resident care planning format to comply with patients/residents needs and various regulatory agency requirements. Ensures that nursing interventions meet the personal, physical and cognitive needs of each patient/resident as well as maximize his/her self care capacities, identity, independence, choice and opportunity for social interaction. 3. Ensures that nursing personnel assist in evaluating each patient's/resident's capability for participation in facility activity programs, in accordance with patient's resident's interest and needs. Monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees and monitoring the effective and efficient use of budgeted resources (personnel, supplies, equipment). 1. Visits nursing units on a daily basis and observes the care the patients/residents are receiving to ensure compliance with accepted facility nursing standards. 5. Discusses and implements plan of action to correct deficient areas identified on quality reviews. Ensures a safe and sanitary environment for patients/residents, employees and visitors. 1. Participates in ensuring a safe environment for patients/residents, staff and family. 3. Monitors and reviews patient/resident incidents to identify possible legal issues and to identify patterns that might require preventive intervention. Ensure that nursing interventions meet the personal, physical and cognitive needs of each patient/resident as well as maximize his/her self care capacities, identify, independence, choice and opportunity for social interaction. [signed by the Director of Nursing and dated 7/29/26].Review of Resident #1's admission record showed the resident was admitted on [DATE] with diagnoses to include wedge compression fracture of first lumbar vertebra, history of falling, major depressive disorder, primary insomnia, muscle weakness, difficulty in walking, anxiety disorder, essential (primary) hypertension, hydronephrosis with renal and ureteral calculous obstruction (kidney stone is stuck in the kidney or tube to the bladder), epilepsy, and chronic systolic (congestive) heart failure.Review of Resident #1's change in condition evaluation dated 7/24/2026 read, Change in Condition: Altered Mental Status. Temperature 98.4 ( F) [Fahrenheit] on 7/24/2026 at 14:57 [2:57 PM]; Route: Forehead (non-contact). Most Recent O2 sats [oxygen saturation] was 88% on 7/24/2026 at 14:57; Method: Room Air. Short of breath. BP [blood pressure] 88/40; Pulse: 55 - regular; R [respirations] 16. Symptoms reported to the PCP [Primary Care Physician] on 7/24/2026 at 3:00 PM. The Recommendation of Primary Clinician was: Send to ER [Emergency Room] for further eval [evaluation] and treat. The Name of family/resident representative notified: Emergency Contact on 7/24/2026 at 3:01 PM.Review of Resident #1's physician order dated 7/24/2026 read, Send to eval for further eval and treat.Review of the EMS (Emergency Medical Service) run report read, 07/24/2026 at 14:55:51 [2:55 PM] EMS Call received. 07/24/2026 at 14:57:44 [2:57 PM] EMS dispatched. 07/24/2026 at 15:02:23 [3:02 PM] EMS on scene. 07/24/2026 at 15:04:00 [3:04 PM] EMS at patient. 07/24/2026 at 15:14:27 [3:15 PM] EMS depart scene. 'Incident' Onset Time 13:00 [1:00 PM] 07/24/2026 (estimated). Last Known Well: 13:00 [1:00 PM] 07/24/2026. Secondary Complaint: AMS [altered mental status]. Patient level of distress: Severe. Signs & Symptoms: Heatstroke and sunstroke (primary). Altered mental status. Heat exhaustion. History: aneurysm, anxiety, chronic obstructive pulmonary disease (COPD), depression, hypertension (HTN), lung cancer, seizures. Vital Signs: 15:06 [3:06 PM] BP [blood pressure] 109/63, Pulse 122, RR [respiratory rate] 18, SPO2 [peripheral capillary oxygen saturation] 92 RM [room], Temp [temperature] 104.4 F. 15:17 [2:17 PM] BP [blood pressure] 113/57, Pulse 114, RR 28, SPO2 93 ox [oxygen], F. Mental Status: Heat illness, possible heat stroke, pt [patient] was left outside in the direct sun for over an hour heat stroke symptoms. Mental Status: confused, disorientation, unspecified, slowness, and poor responsiveness, stupor. Skin: Dry, Hot. EMS was dispatched for a [AGE] year-old female with a primary complaint of heat-related illness, possibly heat stroke, and a secondary complaint of altered mental status (AMS). The onset of symptoms was reported to have occurred at approximately 13:00 [1:00 PM] on July 24, 2026. The patient's level of distress was documented as severe. The patient denies pain, as indicated by an initial pain score of 0. Medical history was obtained from health care personnel and includes chronic obstructive pulmonary disease (COPD), hypertension (HTN), seizures, lung cancer, depression, anxiety, and aneurysm. The patient is currently prescribed Keppra, Trazodone, Losartan, and Aspirin. There is no indication of injury associated with this event. The patient is responsive to pain. Vital signs are as follows: blood pressure 109/63 mmHg [millimeters of mercury], glucose 217 mg/dl [milligrams per deciliter], oxygen saturation 92% on room air, pulse regular and strong, respiration quality normal with a regular rhythm, and temperature 104.4 F. Glasgow Coma Scale (GCS) score is 8 [severe brain injury], with eye opening response 2 (opens eyes to painful stimulation), motor response 5 (localizing pain), and verbal response 1 (no verbal/vocal response. ECG [electrocardiogram] 4-lead shows sinus tachycardia [heartbeat faster than normal], and myocardial infarction is not suspected. Assessment findings: Extremities: motor function abnormal/weakness noted in the left arm, left leg, right arm, and right leg. Radial pulse in left arm 2+ easily palpable normal. Stroke: Patient was reportedly left outside in direct sun for over an hour. Skin: Hot and dry. Comments indicate heat stroke symptoms. Supporting signs and symptoms include altered mental status, heat exhaustion, and primary heatstroke/sun stroke. Patient was left sitting outside in the sun for a prolonged period of time. Staff found patient sitting outside on the bench, w/AMS [with altered mental status], and brought her back inside. The patient presents with heat stroke and sunstroke as the primary impression, accompanied by altered mental status as the secondary impression. Patient had stopped sweating, and had a temp of 104.4 [Fahrenheit].Review of Resident #1's transfer form dated 7/24/2026 read, Transfer/Discharge Details: Sent To: [Name of local hospital]; Date: 7/24/2026 at 15:05 [3:05 PM]; Sent From: Timberridge Nursing and Rehab Unit: West; Reason(s) for Transfer: Altered Mental Status; the reason for transfer: Unplanned. Her mental status was: Alert, disoriented, but can follow simple instructions. Her functional ability was: Ambulates with assistive device. Her bladder function was: Incontinent. Skin/Wound: [blank].Review of Resident #1's nursing progress note dated 7/24/2026 read, Resident was observed in a slouch position, breathing but hard to arouse. Resident was assessed, vital signs taken. Call placed to [Name of the attending physician] and new order received to send resident to ER for further eval and treat due to altered mental status. Call placed to 911, EMS arrived and resident transferred to [Name of local hospital] via stretcher. Call was placed by this writer to [Name and telephone number of Resident #1's Responsible Party] and notified her of resident [Resident #1's name] transfer to ER. Safety Maintained.Review of the local hospital's clinical impression for Resident #1 dated 7/24/2026 at 4:10 PM read, Clinical Impression: heat exhaustion, acute kidney injury [a sudden loss of kidney function that happens over a few hours or day], pyelonephritis [serious kidney infection]. Disposition Decision: Admit. Second degree sunburn [painful blisters, very red or discolored skin]: Problem Specific Plan: Second degree burns to legs, neck and upper extremities. Consulted wound care.Review of the local hospital's record titled Admit Order Medical Reason for Resident #1 dated 7/24/2026 at 5:52 PM read, Patient is a [AGE] year-old female who presents to the emergency department after she was found outside of her nursing facility. The facility states patient was left outside for at least 1 hour. Tympanic temperature taken by EMS was 104.8. Patient's initial GCS was six [Glasgow Coma Scale total score of 6 indicates a severe brain injury or deep coma]. EMS gave 1 L [liter] of fluids, and patient became more alert and arousable. She moves all extremities. Patient is alert and oriented to person and place at this time. She denies headache, sore throat, numbness/tingling, fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, dizziness, syncope, dysuria, hematuria, melena, or hematochezia. Abnormal labs: UA [urinalysis] positive for UTI [urinary tract infection]. Vital signs on arrival: Blood pressure 110/56, heart rate 133, respirations 47, temperature 39.7 Celsius [103.46 Fahrenheit], O2 sats [oxygen saturation] 93%. Patient will be admitted for heat exhaustion and sepsis secondary to UTI.Review of the Root Cause Analysis conducted by the facility read, On Friday, 06/24/2026, [Sic.] [7/24/2026] resident [Name of Resident #1] was observed ambulating independently to the courtyard bench at approximately 12:00 PM. 12:30 PM: Nurse [Staff A, Licensed Practical Nurse (LPN)'s name] checked on resident in the courtyard. Resident was seated on the bench with no signs of distress. Hydration was within reach in the rollator basket. Nurse [Staff A, LPN's name] discussed lunch with the resident; resident expressed a desire to remain outside. 1:10 PM: Nurse [Staff A, LPN's name] passed through the courtyard on the way to lunch break and observed the resident alert and without distress. Resident stated she was doing okay. 1:40 PM: Nurse [Staff A, LPN's name] again observed and spoke with the resident. Resident continued to state she was doing okay. 2:15 PM - 2:25 PM: During another routine round, nurse [Staff A, LPN's name] observed the resident slouched over with altered mental status. Resident was immediately transported to her room while staff called for assistance. Four staff members responded, obtained vital signs, applied oxygen, removed excess clothing, and applied cold compresses. Mild facial redness was noted; no other acute changes were observed. Resident responded to sternal rub and physical touch and opened her eyes. The DON [Director of Nursing] notified EMS, the physician, and the resident's family. EMS arrived promptly, transferred the resident to a stretch, and transported her to the hospital. Why is this happening? 1. Why is that? Resident is alert and oriented with a BIMS [Brief Interview for Mental Status] score of 13 [indicating intact cognition], is capable of making her own decisions, and routinely chooses to spend time outdoors in the courtyard. 2. Why is that? Resident is independent with activities of daily living (ADLs) and ambulates independently, allowing her to access the courtyard without assistance. 3. Why is that? The resident chose to remain outdoors during midafternoon hours, increasing the potential for heat-related exposure, despite alertness and appearance of no distress during multiple staff observations. 4. Why is that? Staff conducted routine monitoring throughout the resident's time outdoors, assessed her condition on multiple occasions, ensured hydration was available, and offered lunch. At each interaction, the resident denied concerns and wished to remain outside. 5. Why: When a change in condition was identified, staff responded immediately by initiating assessment and first aid measures, applying oxygen and cooling interventions, notifying the DON, physician, and family and activating EMS without delay. Conclusion: The incident was determined to be related to environmental heat exposure rather than a failure to monitor the resident. Staff performed appropriate and frequent checks, recognized the change in condition promptly and responded immediately. Additional preventive measures have been implemented such as hydration stations, sunscreen availability, resident and staff education, weather announcements, to further reduce the risk heat related exposure, while continuing to respect residents rights, resident independence, resident personal choices, and fostering a homelike environment.During an interview on 7/31/2026 at 10:10 AM, the Medical Director stated, They told me the patient was sitting outside and developed heat exhaustion. Basically, if the patient is competent, they have a right to go outside. We periodically check on them. The nurses should check on them because it is summer. If they want to stay [outside], they need to hydrate. The expectation is that they are going every 30 minutes and ask them if they are okay or want to come inside. Unless the patient calls them [to come inside sooner]. The fluids should be around. This is the general instruction for the staff. If they [the residents] are not competent, the staff should assist and make sure the family is aware. They should never be in the direct sun. Basically, the increased risk; it depends on the medicine they are on. Anybody needs to be checked. Anybody can get heat exhaustion. Basically, heat exhaustion is the issue. The number [frequency] of checking should be every half hour. One thing is the patient could say they want to stay there. There should be checks and balances. Death is possible if a resident is exposed to heat and sun. Within an hour, a resident should be brought inside. For a patient with a UTI [urinary tract infection], if the resident is not drinking enough or is dehydrated, that would increase their risk or make the outcome more severe. If there is fever, there is an increased risk of heat exhaustion. If a resident has a kidney infection or pyelonephritis that is worse.During an interview on 7/30/2026 at approximately 12:00 PM, the Administrator stated they do not have a policy regarding residents who went outside other than the smoking policy. The expectation was that staff checked on residents who were outside frequently, every 15 to 20 minutes. The main patio is not secure, so residents who are alert are able to go outside and have a right to do so. There are buttons outside the doors the residents can push to automatically open the doors. If a resident wanted to go outside and was not able to get there independently, a staff member would assist them. When asked if there were additional statements from staff regarding the incident with Resident #1, the Administrator stated, I gave you the statements that I had. A request was made for documentation Resident #1 was checked every 15 to 20 minutes. None was provided.During an interview on 7/31/2026 at 11:09 AM with the Administrator, Assistant Administrator, the DON, and the Staff Educator, when asked why there was a delay in contacting EMS after Resident #1 was returned to her room, no answer was provided. When asked if taking a resident's temperature using a scan thermometer that does not make contact with the resident's skin and after placing ice on the resident and/or placing ice or a cold cloth on the resident's forehead would provide an accurate reading, no answer was provided. When asked what time Resident #1 was found in a slumped position in the courtyard, the Administrator stated, We don't know the exact time. When asked what time EMS was called, the Administrator stated, We don't know the time. When asked what time the resident left the facility via EMS, the Administrator stated, We don't know the time.During an interview on 7/31/2026 at 4:18 PM, when asked how the Administrator conducted a full investigation of the incident involving Resident #1, the Administrator stated, I took statements from the staff. When asked with the little information that was documented on the statements, how the Administrator conducted an investigation, the Administrator stated, I talked to everyone again and I have more information. The statements were reviewed and dated 7/31/2026. When asked why there is additional information on the statements dated 7/31/2026 then on the statements dated 7/27/2026 closer to when the incident occurred, why wasn't this documented in the beginning when the incident was new and why this information was not documented in the record, the Administrator stated, I don't know what to say to that. I don't know why it wasn't documented in the beginning.Review of the statements provided by the facility regarding the incident occurred to Resident #1 read, Statement obtained on 07/27/2026 by [Name of the DON], name of person supplying the statement is [Name of Resident #1's Responsible Party]. [Resident #1's Responsible Party] came to speak with DON, [Name of the DON] regarding [Resident #1] transfer to ER [Emergency Room]. [Resident #1's Responsible Party] stated after speaking with [Resident #1], the patient told Resident #1's Responsible Party] that she wanted to sit in the sunlight because she was cold.Review of the statement made by Staff A, LPN, on 7/27/2026, through interview by the Assistant Administrator read, [Staff A's name] was patient [Resident #1's name] nurse and she stated that patient went outside around lunch time. [Staff A's name] stated doing routine checks on patient while she was outside. Upon checking patient outside during her routine checks she saw patient in a slouched position and brought patient back inside. [Staff A's name] stated when checking on patent she would go outside to check resident.Review of the statement made by Staff C, LPN/Unit Manager on 7/27/2026, read, Seen the patient [Resident #1] making her way to the courtyard around lunch time.Review of the statement made by Staff F, Receptionist, on 7/28/2026 read, [Name of Staff F, Receptionist] did not recognize patient and stated she did not see the patient outside and had no interaction with the patient.Review of the statement made by Staff E, CNA/Receptionist, on 7/28/2026 read, Employee stated not seeing the patient [Resident #1] outside and stated she did not have any interaction with the patient.Review of the statement made by Staff H, CNA, on 7/30/2026 read, I did not see or interact with [Resident #1's name] on Friday 07/24/2026.During an interview on 8/1/2026 at 12:42 PM, when asked why the Administrator was not made aware of Resident #1 being sent out to the hospital on 7/24/2026, the Administrator stated, I wasn't told about it until her [Resident #1's Responsible Party] called and said we were neglectful, leaving [Resident #1] outside. I was at a conference and didn't get back until Thursday, [7/30/2026]. When asked why the Administrator was not made aware related to the signs and symptoms Resident #1 was experiencing, the Administrator stated, I was told she [Resident #1] was fine that all she had was altered mental status. Her temperature the highest was 99 something degrees [Fahrenheit]. When asked why staff would apply ice and cold packs to a resident whose signs and symptoms were altered mental status, the Administrator stated, I didn't know all that happened until Monday [7/27/2026]. When asked why the Administrator had not contacted the hospital to aid in the investigation to determine what happened to Resident #1, the Administrator stated, I was going to call and ask for the hospital records. I didn't do it. When asked who is responsible for the day-to-day operation of the facility, the Administrator stated, I am. When asked regarding the lack of documentation to verify when Resident #1 was checked, the Administrator stated, What we have is an interview with [Staff A's name] and she says she checked on the resident. When asked regarding Resident #1's Responsible Party stating the resident was sunburned and had blisters on her legs and neck, how did this occur if Resident #1 was wearing thin sweatpants, and a hoodie jacket that was zipped up, but the hood was down, the Administrator stated, I don't know. During an interview on 8/1/2026 at 1:32 PM, the Administrator stated, [Resident #1's name] has rights and if she wants to be outside, she can be outside that is her right. When asked if someone went out and explained to Resident #1 the consequences of being out during inclement weather conditions and the possibility of suffering from sunburn, heat exhaustion, heat stroke, and death, the Administrator stated, No, that wasn't done. When asked if anyone contacted Resident #1's Responsible Party and communicated that Resident #1 didn't want to come inside, the Administrator stated, No, no one did that. When asked how Resident #1 was safe in her environment if no one determined if she understood the environment she was in, and if this met the definition of neglect per the policy and procedure for Resident #1, the Administrator did not respond.The Immediate Jeopardy (IJ) was removed onsite on 7/31/2026 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 7/27/2026, the facility held an Ad Hoc (Latin meaning for this- a group formed to look into one specific issue) QAPI meeting and completed a root cause analysis (RCA) related to neglect for Resident #1. The RCA yielded the facility failed to act upon Resident #1 remaining outdoors for an undetermined amount of time during midafternoon hours increasing the potential for heat-related exposure. On 7/27/2026 a list of residents who frequented the courtyard was complied. On 7/27/2026, the Director of Nursing/designee provided information for those residents who frequent the courtyard on signs and symptoms of heat exhaustion and encouraged them to notify staff should they experience any of these conditions or related changes. On 7/29/2026, the Director of Nursing/designee completed assessments of all residents in the facility with a BIMS Score of less than 12 to ensure no hear related illness or skin impairments. On 7/31/2026, the Director of Nursing/designee completed interviews with all resident with a BIMS score greater than 12 to ensure they had not experienced a heat related injury. On 7/29/2026, a Resident Council Meeting was conducted by the Director of Nursing/designee with education to the residents who attended on heat related illness, signs/symptoms, and hydrations, to include the use of sunscreen during outside exposure. Beginning on 7/27/2026, the Director of Nursing/designee equipped the courtyard with a hydration station and signage to read, Protect Yourself From Heat and Sun. On 7/31/2026, the Director of Nursing/designee completed staff education on abuse, neglect, and exploitation, with emphasis on neglect with 143 of 157 nursing staff, for a total of 91% of staff. The facility held Ad Hoc QAPI meetings on 7/27/2026, 7/29/2026, and 7/31/2026 to verify the completion and effectiveness of the removal plan.During staff interviews conducted on 7/30/2026 through 7/31/2026, five LPNs, 2 RNs, 8 CNAs, and 2 receptionists confirmed they received education on abuse, neglect, and exploitation.During interviews conducted on 7/30/2026 through 7/31/2026, the Administrator, the Director of Nursing, and the Assistant Administrator confirmed the education and content verified the completion of the education related to QAPI, supervision, root cause analysis, abuse and neglect.

Based on interview and record review, the facility failed to develop and implement a performance improvement plan following the identification an incident occurred to 1 of 4 reviewed residents, Resident #1, when the facility staff failed to provide adequate supervision and failed to take necessary actions to meet the resident's needs. On 7/24/2026 at 11:45 AM, Resident #1 was seen with her walker heading toward the outside courtyard. At 1:55 PM, Resident #1 was found unresponsive on the bench in the courtyard. Resident #1 was brought to her room. Staff applied packed ice and cool blankets. At 2:55 PM, Emergency Medical Service (EMS) was contacted. Resident #1 was transported to a local hospital, being admitted with diagnoses of heat exhaustion, hyperthermia, and altered mental status.Findings include:Review of the facility policy and procedure titled Quality Management with the last review date of 1/22/2026 read, Vision Statement: The facility will create a caring and nurturing environment, focused on professionalism and excellence in service delivery. The facility strives to be the provider of choice as well as the employer of choice in our community. Mission Statement: This facility's mission statement is to provide Quality Focused Care, One Resident at a Time. To that end we will: Recognize each resident as an individual with unique needs and preferences; Honor and respect each resident's dignity and rights; Provide a supportive environment that promotes comfort. Purpose: Through Quality Assurance and performance Improvement (QAPI), the facility will take a proactive approach to continually improving care and services for our residents. Guiding Principles: The facility will use QAPI to make decisions and improve day-to-day operations; The facility will support performance improvement by encouraging our staff to support each other as well as to be accountable for their own performance and practice; The desired outcome of QAPI in the facility is the improved quality of care and the enhanced quality of life for our residents. Scope: The broad types of care and services provided by the facility that have an impact on clinical care, quality of life, resident choice, and care transitions: Activities and Leisure Pursuits; Nursing Services. Policy: The Administrator is responsible for the Quality Assessment and Assurance Committee for the facility. The facility will have an internal Quality Assurance and Performance Improvement Program designed to provide a comprehensive approach to ensuring high quality care and services. The QA&A Committee, referred to as the QAPI Committee, will meet at least monthly and will utilize the 5 Elements of QAPI which are: 1. Design and Scope; 2. Governance and Leadership; 3. Feedback, Data Systems and Monitoring; 5. Systemic Analysis and Systemic Action. Composition and Duties of the QAPI Committee: The facility Administrator and Department Leaders will create an environment that promotes quality improvement and involves all caregivers. 2. The Committee will identify opportunities for improvement as well as recommend, implement, monitor and evaluate changes. The Committee will address all systems of care and management practices, aiming for safety and health equity while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 4. The committee will charter Performance Improvement Projects (PIPs) to provide concentrated efforts to address a particular problem areas identified in one part of the facility or facility wide. The facility conducts PIPs to examine and improve care or services by gathering information systematically to clarify issues and intervening for improvement. 5. The facility will be proficient in the use of Root Cause Analysis to determine how identified problems may be caused or exacerbated and will look across all involved systems to prevent future events and promote sustained improvement programs. 6. Once the root cause has been established, changes or corrective actions tightly linked to the root cause will be implemented. These changes or corrective measures should offer long term solutions to the problem, and must be achievable, objective, and measurable.Review of Resident #1's change in condition evaluation dated 7/24/2026 read, Change in Condition: Altered Mental Status. Temperature 98.4 ( F) [Fahrenheit] on 7/24/2026 at 14:57 [2:57 PM]; Route: Forehead (non-contact). Most Recent O2 sats [oxygen saturation] was 88% on 7/24/2026 at 14:57; Method: Room Air. Short of breath. BP [blood pressure] 88/40; Pulse: 55 - regular; R [respirations] 16. Symptoms reported to the PCP [Primary Care Physician] on 7/24/2026 at 3:00 PM. The Recommendation of Primary Clinician was: Send to ER [Emergency Room] for further eval [evaluation] and treat. The Name of family/resident representative notified: Emergency Contact on 7/24/2026 at 3:01 PM.Review of the EMS run report read, 07/24/2026 at 14:55:51 [2:55 PM] EMS Call received. 07/24/2026 at 14:57:44 [2:57 PM] EMS dispatched. 07/24/2026 at 15:02:23 [3:02 PM] EMS on scene. 07/24/2026 at 15:04:00 [3:04 PM] EMS at patient. 07/24/2026 at 15:14:27 [3:15 PM] EMS depart scene. 'Incident' Onset Time 13:00 [1:00 PM] 07/24/2026 (estimated). Last Known Well: 13:00 [1:00 PM] 07/24/2026. Secondary Complaint: AMS [altered mental status]. Patient level of distress: Severe. Signs & Symptoms: Heatstroke and sunstroke (primary). Altered mental status. Heat exhaustion. History: aneurysm, anxiety, chronic obstructive pulmonary disease (COPD), depression, hypertension (HTN), lung cancer, seizures. Vital Signs: 15:06 [3:06 PM] BP [blood pressure] 109/63, Pulse 122, RR [respiratory rate] 18, SPO2 [peripheral capillary oxygen saturation] 92 RM [room], Temp [temperature] 104.4 F. 15:17 [2:17 PM] BP [blood pressure] 113/57, Pulse 114, RR 28, SPO2 93 ox [oxygen], F. Mental Status: Heat illness, possible heat stroke, pt [patient] was left outside in the direct sun for over an hour heat stroke symptoms. Mental Status: confused, disorientation, unspecified, slowness, and poor responsiveness, stupor. Skin: Dry, Hot. EMS was dispatched for a [AGE] year-old female with a primary complaint of heat-related illness, possibly heat stroke, and a secondary complaint of altered mental status (AMS). The onset of symptoms was reported to have occurred at approximately 13:00 [1:00 PM] on July 24, 2026. The patient's level of distress was documented as severe. The patient denies pain, as indicated by an initial pain score of 0. Medical history was obtained from health care personnel and includes chronic obstructive pulmonary disease (COPD), hypertension (HTN), seizures, lung cancer, depression, anxiety, and aneurysm. The patient is currently prescribed Keppra, Trazodone, Losartan, and Aspirin. There is no indication of injury associated with this event. The patient is responsive to pain. Vital signs are as follows: blood pressure 109/63 mmHg [millimeters of mercury], glucose 217 mg/dl [milligrams per deciliter], oxygen saturation 92% on room air, pulse regular and strong, respiration quality normal with a regular rhythm, and temperature 104.4 F. Glasgow Coma Scale (GCS) score is 8 [severe brain injury], with eye opening response 2 (opens eyes to painful stimulation), motor response 5 (localizing pain), and verbal response 1 (no verbal/vocal response. ECG [electrocardiogram] 4-lead shows sinus tachycardia [heartbeat faster than normal], and myocardial infarction is not suspected. Assessment findings: Extremities: motor function abnormal/weakness noted in the left arm, left leg, right arm, and right leg. Radial pulse in left arm 2+ easily palpable normal. Stroke: Patient was reportedly left outside in direct sun for over an hour. Skin: Hot and dry. Comments indicate heat stroke symptoms. Supporting signs and symptoms include altered mental status, heat exhaustion, and primary heatstroke/sun stroke. Patient was left sitting outside in the sun for a prolonged period of time. Staff found patient sitting outside on the bench, w/AMS [with altered mental status], and brought her back inside. The patient presents with heat stroke and sunstroke as the primary impression, accompanied by altered mental status as the secondary impression. Patient had stopped sweating, and had a temp of 104.4 [Fahrenheit].Review of Resident #1's transfer form dated 7/24/2026 read, Transfer/Discharge Details: Sent To: [Name of local hospital]; Date: 7/24/2026 at 15:05 [3:05 PM]; Sent From: Timberridge Nursing and Rehab Unit: West; Reason(s) for Transfer: Altered Mental Status; the reason for transfer: Unplanned. Her mental status was: Alert, disoriented, but can follow simple instructions. Her functional ability was: Ambulates with assistive device. Her bladder function was: Incontinent. Skin/Wound: [blank].Review of Resident #1's nursing progress note dated 7/24/2026 read, Resident was observed in a slouch position, breathing but hard to arouse. Resident was assessed, vital signs taken. Call placed to [Name of the attending physician] and new order received to send resident to ER for further eval and treat due to altered mental status. Call placed to 911, EMS arrived and resident transferred to [Name of local hospital] via stretcher. Call was placed by this writer to [Name and telephone number of Resident #1's Responsible Party] and notified her of resident [Resident #1's name] transfer to ER. Safety Maintained.Review of the local hospital's clinical impression for Resident #1 dated 7/24/2026 at 4:10 PM read, Clinical Impression: heat exhaustion, acute kidney injury [a sudden loss of kidney function that happens over a few hours or day], pyelonephritis [serious kidney infection]. Disposition Decision: Admit. Second degree sunburn [painful blisters, very red or discolored skin]: Problem Specific Plan: Second degree burns to legs, neck and upper extremities. Consulted wound care.Review of the local hospital's record titled Admit Order Medical Reason for Resident #1 dated 7/24/2026 at 5:52 PM read, Patient is a [AGE] year-old female who presents to the emergency department after she was found outside of her nursing facility. The facility states patient was left outside for at least 1 hour. Tympanic temperature taken by EMS was 104.8. Patient's initial GCS was six [Glasgow Coma Scale total score of 6 indicates a severe brain injury or deep coma]. EMS gave 1 L [liter] of fluids, and patient became more alert and arousable. She moves all extremities. Patient is alert and oriented to person and place at this time. She denies headache, sore throat, numbness/tingling, fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, dizziness, syncope, dysuria, hematuria, melena, or hematochezia. Abnormal labs: UA [urinalysis] positive for UTI [urinary tract infection]. Vital signs on arrival: Blood pressure 110/56, heart rate 133, respirations 47, temperature 39.7 Celsius [103.46 Fahrenheit], O2 sats [oxygen saturation] 93%. Patient will be admitted for heat exhaustion and sepsis secondary to UTI.Review of the Root Cause Analysis conducted by the facility read, On Friday, 06/24/2026, [Sic.] [7/24/2026] resident [Name of Resident #1] was observed ambulating independently to the courtyard bench at approximately 12:00 PM. 12:30 PM: Nurse [Staff A, Licensed Practical Nurse (LPN)'s name] checked on resident in the courtyard. Resident was seated on the bench with no signs of distress. Hydration was within reach in the rollator basket. Nurse [Staff A, LPN's name] discussed lunch with the resident; resident expressed a desire to remain outside. 1:10 PM: Nurse [Staff A, LPN's name] passed through the courtyard on the way to lunch break and observed the resident alert and without distress. Resident stated she was doing okay. 1:40 PM: Nurse [Staff A, LPN's name] again observed and spoke with the resident. Resident continued to state she was doing okay. 2:15 PM - 2:25 PM: During another routine round, nurse [Staff A, LPN's name] observed the resident slouched over with altered mental status. Resident was immediately transported to her room while staff called for assistance. Four staff members responded, obtained vital signs, applied oxygen, removed excess clothing, and applied cold compresses. Mild facial redness was noted; no other acute changes were observed. Resident responded to sternal rub and physical touch and opened her eyes. The DON [Director of Nursing] notified EMS, the physician, and the resident's family. EMS arrived promptly, transferred the resident to a stretch, and transported her to the hospital. Why is this happening? 1. Why is that? Resident is alert and oriented with a BIMS [Brief Interview for Mental Status] score of 13 [indicating intact cognition], is capable of making her own decisions, and routinely chooses to spend time outdoors in the courtyard. 2. Why is that? Resident is independent with activities of daily living (ADLs) and ambulates independently, allowing her to access the courtyard without assistance. 3. Why is that? The resident chose to remain outdoors during midafternoon hours, increasing the potential for heat-related exposure, despite alertness and appearance of no distress during multiple staff observations. 4. Why is that? Staff conducted routine monitoring throughout the resident's time outdoors, assessed her condition on multiple occasions, ensured hydration was available, and offered lunch. At each interaction, the resident denied concerns and wished to remain outside. 5. Why: When a change in condition was identified, staff responded immediately by initiating assessment and first aid measures, applying oxygen and cooling interventions, notifying the DON, physician, and family and activating EMS without delay. Conclusion: The incident was determined to be related to environmental heat exposure rather than a failure to monitor the resident. Staff performed appropriate and frequent checks, recognized the change in condition promptly and responded immediately. Additional preventive measures have been implemented such as hydration stations, sunscreen availability, resident and staff education, weather announcements, to further reduce the risk heat related exposure, while continuing to respect residents rights, resident independence, resident personal choices, and fostering a homelike environment.During an interview on 7/30/2026 at approximately 3:13 PM, Staff A, Licensed Practical Nurse (LPN), stated, I saw her [Resident #1] walking toward the courtyard using her walker around 11:45 AM. After I finished the med pass, I went to check on her and that was about 1:15 PM. [Resident #1's name] stated she was doing fine and she was not ready to come inside. She was on the bench. I went on break and I returned from the break, and I saw her sitting outside in the same spot, but she was slumped over on the bench. We brought her to her room and [Name of Staff C, LPN/Unit Manager] packed ice and cool blankets around her body. She was placed on oxygen because she was struggling with her breathing. I did not get the vital signs, another nurse did.During an interview on 7/31/2026 at 11:09 AM with the Administrator, Assistant Administrator, the DON, and the Staff Educator, a request was made for progress notes, physician notes, any and all documentation related to the incident involving Resident #1. The Staffing Educator stated, I put ice on her. I put it under her arms and around her. I put a cold cloth on her head. When asked for the documentation to verify the time and date, the Staff Educator stated, I didn't document, because she was not my patient. Her attending nurse can document. When asked why there was a delay in contacting EMS after Resident #1 was returned to her room, no answer was provided. When asked if taking a resident's temperature using a scan thermometer that does not make contact with the resident's skin and after placing ice on the resident and/or placing ice or a cold cloth on the resident's forehead would provide an accurate reading, no answer was provided. When asked what time Resident #1 was found in a slumped position in the courtyard, the Administrator stated, We don't know the exact time. When asked what time EMS was called, the Administrator stated, We don't know the time. When asked what time the resident left the facility via EMS, the Administrator stated, We don't know the time. When asked where it was documented, the Administrator stated, There is no documentation. When asked how long Resident #1 was in the courtyard the Administrator stated, It was just over an hour. When asked where this is documented, the Administrator stated, There is no documentation. When asked if the lack of documentation resulting in an incomplete inaccurate record was discussed during the QAPI (Quality Assurance Performance Improvement) meeting. The Administrator stated, No. No additional documentation was provided.During an interview on 8/1/2026 at 9:30 AM, when asked about being notified of Resident #1 being in the hospital, the Administrator stated that he was told on Monday (July 27, 2026). He was told by the Risk Manager that Resident #1's Responsible Party came in and said that Resident #1 was still in the hospital, and she had sunburn and blisters on her from being left outside. When asked if she had contacted the hospital and requested an update for Resident #1, the Administrator stated, I was going to ask for her hospital record. I haven't asked for it. When asked why she had not called the hospital, the Administrator stated, They will usually give us information, but I didn't call. When asked how an investigation was conducted with no documentation available to review, the Administrator stated, We got statements from the staff. When asked why the lack of documentation was not discussed in QAPI meeting, the Administrator did not answer. The Administrator further stated, The resident has the right to go outside if she wants to and if she doesn't want to come in, she has the right to stay outside if she wants to. When asked regarding the residents' safety and understanding to make the decision to remain outside, consequences and education provided regarding the effects of inclement weather, the Administrator stated, No, that wasn't done. When asked if Resident #1 was care planned for wanting to stay outside during inclement weather, the Administrator stated, No. When asked if the responsible party for Resident #1 was made aware when the resident doesn't want to come inside during inclement weather and request the responsible party to encourage the resident to come inside, the Administrator stated, No. When asked if Resident #1 would often go outside and not want to return back inside the facility was documented on her care plan, the Administrator stated, No.During an interview on 8/1/2026 at 12:42 PM, when asked why the Administrator was not made aware of Resident #1 being sent out to the hospital on 7/24/2026, the Administrator stated, I wasn't told about it until her [Resident #1's Responsible Party] called and said we were neglectful, leaving [Resident #1] outside. I was at a conference and didn't get back until Thursday, [7/30/2026]. When asked why the Administrator was not made aware related to the signs and symptoms Resident #1 was experiencing, the Administrator stated, I was told she [Resident #1] was fine that all she had was altered mental status. Her temperature the highest was 99 something degrees [Fahrenheit]. When asked why staff would apply ice and cold packs to a resident whose signs and symptoms were altered mental status, the Administrator stated, I didn't know all that happened until Monday [7/27/2026]. When asked why the Administrator had not contacted the hospital to aid in the investigation to determine what happened to Resident #1, the Administrator stated, I was going to call and ask for the hospital records. I didn't do it. When asked who is responsible for the day-to-day operation of the facility, the Administrator stated, I am.Review of the Ad Hoc Ad Hoc (Latin meaning for this- a group formed to look into one specific issue) QAA [Quality Assurance and Assessment] Meeting Performance Improvement Plan and/or Root Cause Analysis dated 7/24/2026, 7/27/2026, and 7/29/2026 did not show a performance improvement plan following the identification of the change in status and lack of documentation for Resident #1. The Immediate Jeopardy (IJ) was removed onsite on 7/31/2026 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 7/27/2026, the facility held an Ad Hoc QAPI meeting and completed a root cause analysis (RCA) related to neglect for Resident #1. The RCA yielded the facility failed to act upon Resident #1 remaining outdoors for an undetermined amount of time during midafternoon hours increasing the potential for heat-related exposure. On 7/27/2026 a list of residents who frequented the courtyard was complied. On 7/27/2026, the Director of Nursing/designee provided information for those residents who frequent the courtyard on signs and symptoms of heat exhaustion and encouraged them to notify staff should they experience any of these conditions or related changes. On 7/29/2026, the Director of Nursing/designee completed assessments of all residents in the facility with a BIMS Score of less than 12 to ensure no hear related illness or skin impairments. On 7/31/2026, the Director of Nursing/designee completed interviews with all resident with a BIMS score greater than 12 to ensure they had not experienced a heat related injury. On 7/29/2026, a Resident Council Meeting was conducted by the Director of Nursing/designee with education to the residents who attended on heat related illness, signs/symptoms, and hydrations, to include the use of sunscreen during outside exposure. Beginning on 7/27/2026, the Director of Nursing/designee equipped the courtyard with a hydration station and signage to read, Protect Yourself From Heat and Sun. On 7/31/2026, the Director of Nursing/designee completed staff education on abuse, neglect, and exploitation, with emphasis on neglect with 143 of 157 nursing staff, for a total of 91% of staff.QAPI meeting was held to discuss a resident [Resident #1] change in status while out on the courtyard for an undetermined amount of time. The facility provided a completed a root cause analysis (RCA) related to neglect and supervision for Resident #1. The RCA yielded the facility failed to act upon Resident #1 remaining outdoors for an undetermined amount of time during midafternoon hours increasing the potential for heat-related exposure. On 7/31/2026, education was completed by the Regional Director of Operations with the Administrator, Assistant Administrator, Director of Nursing, and Assistant Director of Nursing on QAPI, Supervision, Root Cause Analysis, and Abuse/Neglect. The facility held Ad Hoc QAPI meetings on 7/27/2026, 7/29/2026, and 7/31/2026 to verify the completion and effectiveness of the removal plan.During interviews conducted on 7/30/2026 through 7/31/2026, the Administrator, the Director of Nursing, and the Assistant Administrator confirmed the education and content verified the completion of the education related to QAPI, supervision, root cause analysis, abuse and neglect.

Based on interview and record review, the facility failed to ensure accurate and complete documentation following the identification of a change in condition for 1 of 4 residents, Resident #1.Findings include:Review of Resident #1's change in condition evaluation dated 7/24/2026 read, Change in Condition: Altered Mental Status. Temperature 98.4 ( F) [Fahrenheit] on 7/24/2026 at 14:57 [2:57 PM]; Route: Forehead (non-contact). Most Recent O2 sats [oxygen saturation] was 88% on 7/24/2026 at 14:57; Method: Room Air. Short of breath. BP [blood pressure] 88/40; Pulse: 55 - regular; R [respirations] 16. Symptoms reported to the PCP [Primary Care Physician] on 7/24/2026 at 3:00 PM. The Recommendation of Primary Clinician was: Send to ER [Emergency Room] for further eval [evaluation] and treat. The Name of family/resident representative notified: Emergency Contact on 7/24/2026 at 3:01 PM.Review of Resident #1's nursing progress note dated 7/24/2026 read, Resident was observed in a slouch position, breathing but hard to arouse. Resident was assessed, vital signs taken. Call placed to [Name of the attending physician] and new order received to send resident to ER for further eval and treat due to altered mental status. Call placed to 911, EMS arrived and resident transferred to [Name of local hospital] via stretcher. Call was placed by this writer to [Name and telephone number of Resident #1's Responsible Party] and notified her of resident [Resident #1's name] transfer to ER. Safety Maintained.During an interview on 7/31/2026 at 11:09 AM with the Administrator, Assistant Administrator, the Director of Nursing (DON), and the Staff Educator, a request was made for progress notes, physician notes, any and all documentation related to the incident involving Resident #1. The Staff Educator stated, I put ice on her. I put it under her arms and around her. I put a cold cloth on her head. When asked for the documentation to verify the time and date, the Staff Educator stated, I didn't document, because she was not my patient. Her attending nurse can document. When asked how long Resident #1 was in the courtyard, the Administrator stated, It was just over an hour. When asked where this is documented, the Administrator stated, There is no documentation. No additional documentation was provided.Review of the facility policy and procedure titled Skilled Nursing: Nursing - Routine Resident Checks read, Policy: Routine resident checks shall be made to assure that the resident's safety and well-being are maintained. Procedure: 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The policy and procedure was not dated.

Based on interview and record review the facility failed to ensure physician ordered parameters were followed for 6 of 8 residents, Residents #15, #88, #23, #6, #94 and #179, reviewed for unnecessary medications. Findings include: 1. Review of Resident #15's admission record documented diagnosis that include unspecified sequala of cerebral infarction (a stroke), major depressive disorder, recurrent moderate, depression unspecified, and essential (primary) hypertension. Review of Resident #15's physician orders dated 7/22/2025 read, Losartan Potassium Oral Tablet 25 MG [milligrams] (Losartan Potassium) Give 1 tablet by mouth two times a day for HTN [hypertension] HOLD FOR SBP [systolic blood pressure] BELOW 130. Review of Resident #15's medication administration record (MAR) for January 2026 documented Losartan was administered outside of physician ordered parameters at 0900 (9:00 AM) on 1/9/2026 for a blood pressure (B/P) of 116/53, on 1/10/2026 with a B/P of 123/49, on 1/11/2026 with a B/P of 116/64, on 1/18/2026 with a B/P of 116/71, on 1/23/2026 with a B/P of 118/66, on 1/24/2026 with a B/P of 127/54, on 1/25/2026 with a B/P of 95/55, and at 1700 (5:00 PM) on 1/3/2026 with a B/P of 124/71, on 1/4/2026 with a B/P of 114/71, on 1/10/2026 with a B/P of 101/72, on 1/11/2026 with a B/P of 121/60, on 1/16/2026 with a B/P of 110/65, on 1/18/2026 with a B/P of 124/68, on 1/24/2026 with a B/P of 124/75, on 1/25/2026 with a B/P of 102/71 and on 1/30/2026 with a B/P of 116/71. Review of Resident #15's MAR for February 2026 documented Losartan was administered outside of physician ordered parameters on 2/1/2026 at 1700 (5:00 PM) with a B/P of 92/54. During an interview on 2/4/2026 at 10:23 AM Staff L, Licensed Practical Nurse (LPN) stated If there is a check mark, I probably administered this medication. We should follow the orders to hold if there are parameters. 2. Review of Resident #179's admission record documented diagnosis to include encounter for orthopedic aftercare following surgical amputation, difficulty in walking not elsewhere classified, muscle weakness generalized, type 2 diabetes mellitus with hyperglycemia, essential primary hypertension, hyperlipidemia unspecified, polyneuropathy unspecified, depression unspecified, gastroesophageal reflux disease without esophagitis, radiculopathy, lumbar region, peripheral vascular angioplasty, gangrene not elsewhere classified, peripheral vascular disease unspecified, acquired absence of right great toe, atherosclerosis of arteries of extremities with gangrene right leg, and anemia unspecified. Review of Resident #179's physician order dated 12/26/2025 read, Oxycodone-Acetaminophen Tablet 10-325 MG Give 1 tablet by mouth every 4 hours as needed for Non acute Moderate Pain 6-10. Review of Resident #179's MAR for January 2026 document Oxycodone-Acetaminophen was administered on 1/5/2026 at 0205 (2:05 AM) with a documented pain assessment of 5 out of 10, on 1/7/2026 at 0600 (6:00 AM) with a documented pain scale of 5, at 2038 with a documented pain scale of 5, on 1/25/2026 with a documented pain scale of 4, and on 1/31/2026 at 0501(5:01 AM) with a documented pain scale of 5. During an interview on 2/4/2026 at 8:44 AM Staff M, LPN stated, I did give the pain medication. I guess I should have followed the doctor's orders for the parameter. I should have called the doctor if it was not in the parameters. 3. Review of Resident #6's admission record documented an admission date of 12/21/2021 with diagnosis that include cerebral infarction unspecified, major depressive disorder, schizoaffective disorder bipolar type, type 2 diabetes mellitus with unspecified complications, essential hypertension, and generalized anxiety disorder. Review of Resident #6's physician orders dated 8/13/2025 read, Enalapril Maleate Oral Tablet 20 MG (Enalapril Maleate) Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP less than 110. Review of Resident #6's MAR for December 2025 read, Enalapril Maleate Oral Tablet 20 mg Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP less than 110. On 12/28/2025, Resident #6's blood pressure was documented as 108/50 and signed as administered with a code 13 = WNL (within normal limits). Review of Resident #6's MAR for January 2026 read, Enalapril Maleate Oral Tablet 20 mg (milligrams) Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP less than 110. On 1/18/2026, Resident #6's blood pressure was documented as 101/55 and signed as administered with a code 13 = WNL. On 1/21/2026, Resident #6's blood pressure was documented as 102/44 and signed as administered. During an interview on 02/04/2026 at 1:08 PM, Staff B, LPN stated that the check mark on the MAR on 12/21/2025 meant she administered the medication. The medication was administered outside of the physician's ordered parameters. 4. Review of Resident #23's admission record documented the resident was first admitted on [DATE] with diagnosis not limited to essential hypertension, chronic diastolic heart failure and hypertensive heart disease with heart failure. Review of Resident #23's physician order dated 5/20/2023 read, Midodrine HCI [Hydrochloride] Oral Tablet 10 MG (Midodrine HCI) give 1 tablet by mouth three times a day for hypotension HOLD FOR SBP > [greater than] 110. Review of Resident #23's MAR for the month of January 2026 documented Midodrine 10 mg was administered given on 1/2/2026 at 0900 [9:00 AM] blood pressure was 124/59, on 1/2/2026 at 1300 [1:00 PM] blood pressure was 124/59, on 1/4/2026 at 1700 [5:00 PM] blood pressure was 144/82, on 1/5/2026 at 0900 blood pressure was 138/75, on 1/6/2026 at 0900 blood pressure was 122/51, at 1300 blood pressure was 122/51, on 1/17/2026 at 1700 blood pressure was 115/67, on 1/18/2026 at 0900 blood pressure was 120/56, on 1/19/2026 at 1300 blood pressure was 112/59, on 1/30/2026 at 0900 blood pressure was 120/72, and at 1300 blood pressure was 117/59. Review of Resident #23's Medication Administration Record for the month of December 2025 documented Midodrine 10 mg was administered on12/1/2025 at 0900 blood pressure was 131/73, on 12/11/2025 at 0900 blood pressure was 122/58, on 12/19/2025 at 0900 blood pressure was 113/70, on 12/22/2025 at 1300 blood pressure was 115/63, on 12/29/2025 at 0900 blood pressure was 120/78, and on 12/31/2025 at 0900 blood pressure was 121/59. During an interview on 2/03/2026 at 3:46 PM Staff A, LPN, stated, I don't recall those dated for [Resident #23's name] but if there is a check mark that means I have given the medication. 5. Review of Resident #88's admission record documented the resident was first admitted on [DATE] with diagnosis including but not limited to essential hypertension, paroxysmal atrial fibrillation, chronic combined systolic and diastolic heart failure, and type 2 diabetes mellitus without complications. Review of Resident #88's physician order dated 10/11/2025 read, Sacubitril-Valsartan Oral Tablet 24-28 MG (Sacubitril Valsartan) Give 1 tablet by mouth two times a day for HTN Hold for SBP less than 110. Review of Resident #88's MAR for the month of January 2026 documented Sacubitril-Valsartan Oral Tablet 24-26 MG was administered on 1/4/2026 at 1700 blood pressure was 101/61, on 1/10/2026 at 0900 blood pressure was 105/69, at 1700 blood pressure was 103/67, on 1/14/2026 at 1700 blood pressure was 106/66, on 1/17/2026 at 1700 blood pressure was 100/73, on 1/19/2026 at 0900 blood pressure was 102/64, on 1/21/2026 at 1700 blood pressure was 106/64, on 1/24/2026 at 0900 blood pressure was 100/60 and on 1/30/2026 at 1700 blood pressure was 106/60. Review of Resident #88's MAR for the month of December 2025 documented Sacubitril-Valsartan Oral Tablet 24-26 MG was administered on 12/12/2025 at 1700 blood pressure was 101/64, on 12/16/2025 at 1700 blood pressure was 102/73, on 12/18/2025 at 1700 blood pressure was 101/64, on 12/23/2025 at 1700 blood pressure was 104/57, on 12/26/2025 at 1700 blood pressure was 108/71, and on 12/28/2025 at 1700 blood pressure was 108/75. During an interview on 2/03/2026 at 3:46 PM Staff A, LPN, stated, I don't recall those dates for [Resident #88's name] but if there is a check mark that means I have given the medication. During an interview on 2/04/2026 at 1:40 PM Staff J, LPN, stated, If the medication has a check mark in the medication administration record it means that the medication was given. I am always supposed to follow the parameters. I really don't recall those residents [Resident #23 and Resident #88's names]. I see over 30 residents. During an interview on 2/04/2026 at 10:04 AM the Director of Nursing stated, Nurses should follow the parameters that are ordered by the provider. During an interview on 2/04/2026 at 11:29 AM Medical Doctor #1 stated, I expect staff to follow parameters strictly as ordered. 6. Review of #94's medical record documented diagnoses to include essential hypertension and atrial flutter. Review of Resident #94's physician order dated 5/30/2023 read, Carvedilol Tablet 3.125 MG, Give 1 tablet by mouth two times a day for HTN, Hold if SBP < [less than] 110. Review of Resident #94's physician order dated 10/31/2022 read, Diltiazem HCl [hydrochloric acid] 120 MG, Give 1 capsule by mouth two times a day for a fib [atrial fibrillation] Hold if SBP < 110. During review of Resident #94's MAR for December 2025 documented Carvedilol was administered on 12/14/2025 at 9:00 AM with the blood pressure documented as 105/60, 12/18/2025 at 9:00 AM with the blood pressure documented as 102/59, and on 12/21/2025 at 9:00 AM with the blood pressure documented as 102/70. Review of Resident #94's MAR for January 2026 documented Carvedilol was administered on 01/02/2026 at 9:00 AM with the blood pressure documented as 109/68 and on 01/09/2026 at 9:00 with a blood pressure documented as 100/60. Review of Resident #94's MAR for December 2025 documented Diltiazem was administered on 12/14/2025 at 5:00 PM with the blood pressure documented as 105/60 and on 12/21/2025 at 9:00 AM with the blood pressure documented as 102/70. Review of Resident #94's MAR for January 2026 documented Diltiazem was administered on 01/02/2026 at 9:00 AM with a blood pressure documented as 109/68 and on 01/09/2026 at 9:00 AM with a blood pressure documented as 100/60. Review of the facility policy and procedure titled Medication Administration General Guidelines with a last review date of 1/22/2026 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedure: B. Administration: 2) Medications are administered in accordance with written orders of the prescriber.

Based on record review and interview, the facility failed to coordinate assessments for the residents with newly evident or possible serious mental disorder for Level II PASRR (Pre-admission Screening and Resident Review) for 1 of 3 residents reviewed for PASRR, Resident #2.Findings include:Review of Resident #2's admission record documented the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (onset date of 1/12/2026), other specified anxiety disorders (onset date of 1/12/2026), and schizophrenia (onset date of 8/21/2024).Review of Resident #2's PASRR dated 7/22/2025 documented schizophrenia as the only mental illness or suspected mental illness under Section I. PASRR Screen Decision-Making.Review of Resident #2's psychiatry subsequent note dated 1/12/2026 read, Chief complaint: Depression, anxiety and insomnia. Diagnostic assessment and plan: Major depressive disorder recurrent moderate, other specified anxiety disorders, primary insomnia.During an interview on 2/4/2026 at 9:33 AM, the Director of Nursing stated, We should have rescreened the resident [Resident #2] to see if he required Level II services.During an interview on 2/4/2026 at 9:50 AM, the Assistant Director of Nursing stated, I should have gone in and updated the Level 1 PASSR to ensure he [Resident #2] did not require evaluation for Level II PASSR.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for residents who had language preferences for 1 of 3 residents reviewed for communication services, Resident #122.Findings include:During an interview (conducted in Spanish) on 2/2/2026 at 9:53 AM, Resident #122 stated she preferred to talk in Spanish and she had difficulty at times communicating with the staff and would prefer to speak in Spanish with the staff.During an observation on 2/3/2026 at 11:40 AM, Staff H, Certified Nursing Assistant (CNA), was assisting Resident #122, who was speaking in Spanish. Staff H was answering with a couple of words in Spanish.During an observation on 2/3/2026 at 1:12 PM, Staff E, CNA, was accommodating Resident #122 in her bed and speaking to resident in Spanish.Review of Resident #122's care plan did not document a focus for communication for Resident #122's Spanish speaking preference.During an interview on 2/3/2026 at 11:33 AM, Staff F, Registered Nurse (RN), stated, I can understand her [Resident #122] a little, but she is strictly a Spanish-speaking resident. I have had her [Resident #122] for some time now and gotten used to her and I can understand her, but she is [NAME] [Spanish] only. If I am not able to understand what she is saying, I will get a staff member to translate for me, so I can understand what she needs. During an interview on 2/3/2026 at 11:41 AM, Staff H, CNA, stated, I don't speak Spanish, but I can understand a little. I am learning with her [Resident #122]. If she gets very agitated, she only speaks in Spanish. I will get another staff member to translate for her to make sure we get anything she needs.During an interview on 2/3/2026 at 2:15 PM, the Minimum Data Set Coordinator stated, I was not aware that [Resident #122's name] preferred Spanish. Maybe, due to her age, she has reverted back to her native language. The care plan does not have a focus for Spanish language communication. It will need to be added.During an interview on 2/4/2026 at 10:11 AM, the Director of Nursing stated, Normally when I do my rounds, [Resident #122's name] is resting. Her [Resident #122] language preferences should be part of the care plan.Review of the facility policy and procedure titled Resident Assessment Instrument Comprehensive Care Plan Policy with the last review date of 1/22/2026 read, Purpose: To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI), and to comply with state and federal regulations. Policy Statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary team members and be revised to reflect resident condition changes.

Based on observation, record review, and interview, the facility failed to ensure residents received oxygen therapy as ordered by the physician for 3 of 5 residents reviewed for respiratory care, Residents #22, #151, and #11.Findings include: 1) During an observation on 2/2/2026 at 2:22 PM, Resident #22 was being administered oxygen at 4 liters per minute via nasal cannula. Review of Resident #22's physician order dated 6/7/2025 read, Oxygen @ [at] 3L [liters]/Min [minute] every shift related to chronic obstructive pulmonary disease. During an interview on 2/3/2026 at 11:55 AM, Staff N, Registered Nurse (RN), stated, We check on the amount of oxygen every time we have to take a resident on or off. I'm not sure why the oxygen was not at the right amount. We should follow the orders for what oxygen is running at. 2) During an observation on 2/2/2026 at 10:56 AM, Resident #151 was in bed with the head of bed elevated, with oxygen being administered at 3 liters per minute via nasal cannula. Review of Resident #151's physician order dated 2/2/2026 read, Oxygen @ 2 liters/min via N/C [nasal cannula] PRN [as needed]. During an interview on 2/2/2026 at 10:56 AM, Resident #151 stated, I do not change my oxygen level at all. During an interview on 2/3/2026 at 9:08 AM, Staff N, Registered Nurse (RN), stated, She [Resident #151] has oxygen and CPAP [Continuous Positive Airway Pressure] at night for her sleep apnea. We should be checking every shift to make sure it is correct. We should follow doctor's order for the rate. 3) Review of Resident #11's physician order dated 12/31/25 read, Oxygen @ 2 liters/minute continuous inhalation via nasal cannula every shift related to chronic obstructive pulmonary disease. During an observation on 02/02/2026 at 1:08 PM, Resident #11 was observed with oxygen being administered via nasal cannula through an oxygen concentrator at 3 liters per minute. During an interview on 02/01/2026 at 11:58 AM, Staff O, LPN stated, Nursing staff are responsible for setting and adjusting oxygen flow rates and that oxygen must be administered strictly according to physician orders. The nursing staff monitor the resident's oxygen use every shift and are required to communicate any changes in respiratory condition or oxygen needs to the physician. The facility has protocols in place for monitoring oxygen equipment and ensuring alarms are functioning. Review of the facility policy and procedures titled Oxygen Administration with the last review date of 1/22/2026 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure. 4. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on record review and staff interview, the facility failed to maintain complete and accurate medical records for 1 of 8 residents, Resident #11, reviewed for documentation. Findings Include: Review of Resident #11's Medication Administration Record (MAR) for January 2026, on 01/27/2026 for the scheduled 9:00 AM medication pass, the MAR was blank, no entries, for the physician ordered medications: Citalopram 0.5 tablet (10 mg) by mouth daily for depression, Fluticasone-Salmeterol one inhalation daily for COPD (chronic obstructive pulmonary disease), Tamsulosin HCl 0.4 mg one capsule by mouth daily, Thiamine HCl 100 mg one tablet by mouth daily, Doxycycline Hyclate 100 mg one tablet by mouth twice daily, Gabapentin 100 mg one tablet by mouth twice daily, Metoprolol Succinate ER (extended release) 25 mg one tablet by mouth twice daily with parameters to hold if heart rate less than 60, and Sennosides 8.6 mg one capsule by mouth twice daily. The MAR did not include staff initials, documentation codes, or narrative notes to indicate whether these medications were administered, refused, held, or unavailable on 01/27/2026. Review of the MAR for Resident #11 was not documented for Antidepressant side effect monitoring for the shift on 01/27/2026 from 7:00 AM through 3:00 PM, Behavioral monitoring on 01/01/2026 at 3:00 PM, Nursing care documentation related to respiratory support, including encouragement to elevate the head of the bed to assist breathing for 01/01/2026 at 3:00 PM and for 01/27/2026 during the 7:00 AM through 3:00 PM shift, Dietary documentation for fortified foods ordered three times daily there was no documentation for 01/23/2026, 01/24/2026, 01/25/2026, 01/27/2026, and 01/29/2026 at the scheduled 3:00 PM administration times, and there was no supporting nursing documentation corresponding to a nursing note time-stamped 01/27/2026 at 2:30 PM. During an interview on 02/04/2026 at 9:10 AM, Staff S, Registered Nurse (RN), stated that blank MAR entries are not acceptable and must include documentation explaining why the medication was not administered. She further stated that if medication administration is passed to another nurse, this should be documented in the progress notes and that staff are expected to follow facility documentation codes. During an interview on 2/03/2026 at 10:02 AM the Director of Nursing stated, The documentation in the resident record should be accurate and reflect the actual administration of the medication. Review of the facility policy and procedure titled Documentation with a last review date of 1/22/2026 read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. Review of the policy and procedure titled, Medication Administration General Guidelines last approval date of 1/22/2026 read, Procedure: D. Documentation (including electronic): 1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the documentation. 7) If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when failing to perform hand hygiene during medication administration and dining observations and failing to follow transmission-based precautions. Findings include: 1. During an observation of medication administration on 2/3/2026 beginning at 8:43 AM with Staff F, Registered Nurse (RN) for Resident #120, Staff F did not perform hand hygiene, unlocked the medication cart, activated the computer and prepared the medications for the resident. Staff F, RN, entered the resident's room, did not perform hand hygiene, administered the medications, did not perform hand hygiene, and exited the resident's room. Staff F returned to the medication cart, did not perform hand hygiene, unlocked the medication cart, activated the computer and began preparing medications for Resident #141. Staff F entered the resident's room, did not perform hand hygiene, administered the medications, did not perform hand hygiene, and exited the resident's room. Staff F returned to the medication cart, did not perform hand hygiene, unlocked the medication cart, activated the computer, and began to prepare medications for Resident #14. Staff F entered the resident's room, did not perform hand hygiene, administered the medications, did not perform hand hygiene, and exited the resident's room. Staff F returned to the medication cart, did not perform hand hygiene and began preparing medications for another resident. During an interview on 2/3/2026 at 1:13 PM Staff F, RN stated, I should have done that [hand hygiene] each time I left the room. Review of the policy and procedure titled, Medication Administration General Guidelines last approval date of 1/22/2026 read, Procedure: A, Preparation: 2). Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident. b. Hand sanitization is done with an approved sanitizer between hand washings when returning to the medication cart or preparation are, at regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. These procedures should be followed. 2. Review of Resident #68's physician order dated 2/02/2026 read, Contact isolation precautions for ESBL [Extended-spectrum beta lactamase] in urine until 2/13/2026. During an observation on 2/02/2026 at 12:25 PM with Staff E, Certified Nursing Assistant (CNA), the CNA entered Resident #68's room without donning a gown or gloves and delivered the lunch tray to Resident #68. Resident #68's room had a Contact Precaution sign and a bin with personal protective equipment outside of the resident's room. Staff E adjusted Resident #68's bed touching the bed linen and bed controller. Staff E assisted Resident #68 with setting up her lunch meal. Staff E exited Resident #68's room without performing hand hygiene and returned to the meal cart. Staff E removed another meal tray from the meal cart and entered Resident #145's room to deliver the lunch tray. During an observation on 2/02/2026 at 1:01 PM Staff E, CNA, entered Resident #68's room without donning a gown or gloves removed the meal tray. Staff E returned the meal tray to the meal cart, did not perform hand hygiene, and entered Resident #5's room. During an observation on 2/03/2026 at 10:55 AM Staff F, Registered Nurse (RN), entered Resident #68's room to administer medications to the resident without donning a gown or gloves. Staff F exited the room and began to pour medications for Resident #67 without performing hand hygiene. Resident #68 called Staff F to help her. Staff F entered Resident #68's room and opened a bottle of soda that Resident #68 had in her hand. Staff F without performing hand hygiene exited the room and continued to pour Resident #67's medications. Staff F entered the resident's room without performing hand hygiene and administered the medications to Resident #67. During an observation on 2/03/2026 at 11:31 AM Staff G, Licensed Practical Nurse Unit Manager, entered Resident #68's room without donning a gown or gloves and delivered a bowl of soup to Resident #68. During an interview on 2/03/2026 at 1:43 PM Staff F, RN, stated, When a patient is on contact you should always wear the ppe [personal protective equipment] when going into the room. I should have worn the ppe and washed my hand's when I was done with her [Resident #68]. During an interview on 2/03/2026 at 1:50 PM Staff G, LPN Unit Manager, stated, I should have worn a gown and gloves before entering the room [Resident #68's room]. During an interview on 2/03/2026 at 3:00 PM Staff E, CNA, stated, We were not trained to put on a gown and gloves to go into the room. Only when we are having physical contact with the resident. They spoke to me about it and when it is contact precautions you should always were the gown and gloves to go into the room. I forgot to perform hand hygiene I should have hand sanitized between each resident. During an interview on 2/03/2026 at 4:28 PM the Assistant Director of Nursing stated, Staff should follow the signage posted on the door and don personal protective equipment as listed on the sign. The staff should perform hand hygiene before exiting the room, upon meal delivery, and in between each resident. If a resident is on contact precautions personal protective equipment should be donned before entering the room at all times. During an interview on 2/4/2026 at 10:04 AM the Director of Nursing stated, The staff should utilize the sign posted outside of the room and don and doff ppe as instructed. For a contact precaution room, the staff should don before entering the resident's room with gown and gloves. Hand hygiene should be performed in between each resident and after each meal tray delivery. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with a last review date of 1/22/2026 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation. Administrative Practices to Promote Hand Hygiene: 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene. 1. Hand hygiene is indicated: a. immediately before touching a resident; d. after touching a resident; e. after touching the resident's environment; Review of the facility policy and procedure titled Isolation-Categories of Transmission-Based Precautions with a last review date 1/22/2026 read, Contact Precautions: 7. Staff and visitors wear gloves (clean, non-sterile) when entering room.8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on record review and interview the facility failed to ensure 1 resident, Resident #512, of 3 residents reviewed for insurance and payor source change was informed of co-pay obligations following a payor source change. Findings include: Review of Resident #512's admission record showed Resident #512 was initially admitted to the facility on [DATE] with diagnoses that included unspecified fracture of sacrum, subsequent encounter for fracture with routine healing. Review of Resident #512's pre-admission insurance/managed care verification form, dated 4/5/2024, [name of the managed care insurance company] was documented as Resident #512's primary payor source. A co-pay of $125.00 a day for days 21-100 was indicated on the form. During an interview on 8/27/2024 and 10:15 AM, Resident #512 stated she was told by the Business Manager that her insurance wouldn't cover services after 20 days and the facility was going to switch her over to Medicare for coverage. Resident #512 reported she asked the Business Manager if there would be a co-pay, and the Business Manager had told her there would not be a co-pay. Resident #512 stated that when she went to settle up at discharge she was told there had been a co-pay of $205.00 a day. Review of Resident #512's Managed Medicare Conversion Form and Medicare Part D Enrollment agreement showed Resident #512 had signed the coverage conversion form on 4/30/2024. The conversion form did not specify a daily co-pay cost. During interview on 8/27/2024 beginning at 12:50 PM, the Business Office Manager stated it was a team decision that Resident #512 be switched to Medicare due to Resident #512 needing more time under skilled care. The Business Office Manager reported she had spoken with Resident #512 and explained everything to her, however, she had not documented the conversation. Review of the policy and procedure titled Medicare Conversions, last reviewed 8/22/2024, read Procedure 1. Explain verbally and in writing the impact of changing coverage and that the beneficiary will be choosing another type of plan and losing the current plan coverage. Explain medical coverage will be billed to original Medicare and/or Medicaid if the beneficiary is disenrolled from Medicare health plan and what this means regarding deductibles ad co-pays/insurance and or loss of lack of supplemental coverage for the beneficiary. The name of the new drug plan will be discussed along with all co-pays and co-insurance.

Based on record review and interview the facility failed to ensure pain medication was administered within parameters for 1 of 10 residents, Resident #24, failed to ensure blood pressure medication was administered within parameters for 3 of 10 residents, Residents #42, #110, and #127, reviewed for medication administration, failed to administer medications in accordance with professional standards of practice when administering crushed medications via gastrostomy tube for 1 of 1 resident, Resident #27, and failed to ensure dressing changes were completed for peripherally inserted central catheters for 1 of 4 residents, Resident #264. Findings include: 1) Review of Resident #24's physician order dated 7/25/2024 read, Oxycodone HCI Tablet 10 mg [milligrams]. Give 1 tablet by mouth every 8 hours as needed for Pain Management > [greater than] 5. Review of Resident #24's Medication Administration Record for the month of August 2024 for Oxycodone HCI 10 mg documented the medication was given on 8/05/2024 at 5:51 PM for a pain level of 4, 8/08/2024 at 3:54 PM for pain level of 4, 8/09/2024 at 3:40 PM for a pain level of 4, 8/13/2024 at 12:27 PM for pain level 3, 8/15/2024 at 9:40 AM for a pain level of 3, 8/19/2024 at 4:03 PM for a pain level of 4, 8/20/2024 at 3:46 PM for a pain level of 4, 8/21/2024 at 9:23 PM for a pain level of 4, on 8/22/2024 at 3:52 PM for a pain level of 4, on 8/26/2024 at 4:03 PM for a pain level of 4, and 8/27/2024 at 4:12 PM for a pain level of 4. During an interview on 8/28/2024 at 2:00 PM the Director of Nursing (DON) stated, After reviewing the medication administration record for [Resident # 24's name] the order was to give oxycodone when pain level was higher than five and the nurses were giving the medication out of parameters. They are expected to follow the parameters put in place by the physician. 2) Review of Resident #42's physician order dated 7/24/2024 read, Valsartan Oral Tablet 80 mg give 1 tablet by mouth one time a day for HTN [hypertension] hold if SBP [systolic blood pressure] is less than 110 or HR [heart rate] less than 60. Review of Resident #42's MAR for the month of August 2024 documented Valsartan 80 mg on 8/2/2024 at 9:00 AM given with a heart rate of 58, 8/13/2024 at 9:00 AM given with a heart rate of 57, on 8/15/2024 at 9:00 AM given with a heart rate of 57, on 8/16/2024 at 9:00 AM given with a heart rate of 52, on 8/26/2024 at 9:00 AM given with a systolic blood pressure of 106, and on 8/28/2024 at 9:00 AM given with a heart rate of 52. During an interview on 8/29/2024 at 12:14 PM APRN [Advanced Practice Registered Nurse] #2 stated, Resident #42 has been very stable and had no adverse events. Sometimes parameters are a bit lower and different. I like to put higher parameters to be on the safe side so they will not drop [blood pressure]. The parameters should be followed at all times. 3) Review of Resident #110's physician order dated 8/12/2024 read, Hydralazine HCI Oral Tablet 25 mg give 50 mg by mouth three times a day for HTN hold for SBP less than 110 or HR less than 60. Review of Resident #110's MAR for the month of August 2024 for Hydralazine HCI documented medication given on 8/8/2024 at 8:00 PM with a heart rate of 54, on 8/20/2024 at 9:00 AM with a heart rate of 50, and 8/20/2024 at 8:00 PM with a heart rate of 59. During an interview on 8/29/2024 at 12:24 PM with ARNP #1 stated, [Resident #110's name] has not had any adverse effects. Hydralazine would not affect the heart rate it works more on the blood pressure. It would not cause any harm, but parameters should be followed. 4) Review of Resident #127's physician order dated 8/7/2024 read, Metoprolol Tartrate oral give by mouth two times a day for hypertension hold for SBP less than 110 & HR less than 60. Review of Resident #127's MAR for the month of August 2024 for Metoprolol Tartrate documented medication was given on 8/09/2024 at 9:00 AM with a heart rate of 58. During an interview on 8/28/2024 at 2:00 PM with the DON Residents #42, 110, and 127's medication records were reviewed. The DON stated, Nursing staff are expected to follow the parameters in place and contact the doctor if there are any questions. During an interview on 8/28/2024 at 2:04 PM the Assistant Director of Nursing (ADON) stated, Nurses were giving medications out of parameters. The nurses are expected to obtain vital signs and follow whatever the parameters may be. Review of the policy and procedure titled Administration of Drugs with a last review date of 8/22/2024 read, Policy: Residents shall receive their medications on a timely basis and in accordance with our established policies. Review of the policy and procedure titled Nursing-Medications, Oral with a last review date of 8/22/2204 read, Procedure: 2. Verify the physician's medication order for resident's name, drug name, dose, time, and route of administration. 5) During an observation on 8/28/2024 at 9:02 AM Resident #264 was lying in bed, a PICC line to the right upper arm with a single lumen was observed and the dressing was dated 8/21/2024. There was a dried dark red substance and a 2 X 2 gauze with a beige colored substance underneath the transparent dressing. Staff E proceeded to flush the IV (intravenous) line with normal saline and administered medication via the IV. During an interview on 8/28/2024 at 9:02 AM Resident #264 stated, I came in with the IV dressing from the hospital. It looks pretty disgusting, but I have no pain, it is not swollen, and it flushes without any issues. During an interview on 8/28/2024 at 9:26 AM Staff D, LPN, stated, If I would have done the admission I would have changed the dressing then. If the dressing is soiled, I would change it also. I told my relief nurse yesterday about changing the dressing due to the condition of the dressing. Today when I came in, I saw it [IV dressing] had not been changed. I was going to change the dressing, but it was breakfast time, and I was unable to change it at that time. Review of the facility policy and procedure titled Infusion Devices and Procedures with a last review date of 8/22/2024 read, Policy: .Central vascular access device (CVAD) and midline catheter site care and dressing changes are performed at established intervals, and immediately when integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment if site infection or inflammation is suspected . 39371 5) On 8/26/24 at 10:20 AM an observation of Resident #264 room door it had an enhance barrier precaution sign. Upon entering the room during the observation of the resident, her right upper arm was exposed. A peripherally inserted central catheter (PICC) had a dressing that was dated 8/21/24. The dressing site was visibly soiled with a dark red/blackish substance. (Photographic evidence was obtained). On 8/26/24 at 10:20 AM during an interview Resident 264 stated, That was put in at the hospital [PICC], I'm on a blood thinner. I know it does look bad; the bruising looked worst immediately after it was put in. Review of Pharmacy Policy title 005-O: Central Venous Catheter Dressing Changes. Policy. Central venous catheter dressing will be changed at specific intervals, or when needed, to prevent catheter related infections that are associated with contaminated, loosen, soiled, or wet dressings. Dressing must stay clean, dry, and intact. Change dressing if any contamination is suspected. Change gauze dressing or TSM [transparent semi-permeable membrane] over gauze dressings every 48 hours. General Guidelines 5. Change transparent semi-permeable (TSM) dressings every 5 to 7 days and PRN [as needed] (when wet, soiled, or not intact). 50123 6) During an observation on August 28, 2024, at 9:00 am, of Staff F, Licensed Practical Nurse (LPN), administering medication via gastrostomy tube (GT) for Resident #27, Staff F crushed the resident's medications and placed them in individual medications cups and brought the medication cups to the resident's bedside. Staff F flushed the GT with 15 milliliters of water, then the medication powder of one of the cups was poured directly into the syringe without first mixing it with water followed by 10 to 15 milliliters of water to be administered via the syringe connected to the GT by gravity. This was observed to be repeated nine times during the observation. The final medication was a powder medication that the instructions indicated to mix with 45 milliliters of water prior to administration. The medication powder was poured directly into the syringe by Staff F, followed by 15 milliliters of water, then 30 milliliters of water. During an observation on August 29, 2024, at 8:45 am, of Staff F, Licensed Practical Nurse (LPN), administering medication via GT for Resident #27, Staff F crushed the resident's medications and placed them in individual medications cups and brought the medication cups to the resident's bedside. Staff F mixed one of the powdered medications with 45 milliliters of water and administered via gravity through the syringe into the GT. A crushed powdered medication was then administered directly into the syringe by Staff F followed by 15 milliliters of water into the GT via gravity and this was repeated nine times. The syringe was observed to become clogged twice during this process and required assistance by Staff F with a plunger for administration of the medications. During an interview on August 28, 2024, at 9:30 am Staff F, LPN stated, I administered them [the medications] separately. I flushed in between. I thought I could choose to mix or not mix [the medications]. When asked why the syringe became clogged, Staff F stated, Because the medications got stuck. During an interview on August 28, 2024, at 10:30 am the Director of Nursing stated, Medications should be mixed with water prior to administration not in the tube. Review of the policy and procedure titled Enteral Tube Medication Administration read, All medication are used in accordance with the manufacturer's recommendations or the pharmacy's directions for storage, use and disposal. Procedures: 2. Prepare mediations for administration. Ensure orders to crush medications. If a tablet is appropriate to crush, do so and dissolve in at least 5 ml [milliliters] of water. Dilute liquids with at least 5 ml of water. Empty capsule content and dilute with at least 4 ml of water. 8. Remove plunger from the 60 ml syringe and connect the syringe to the clamped tubing. 9. Flush the tube with 30 ml of water prior to medication administration. 10. Medications are never added directly to the feeding solution. Keep in mind any possible fluid restrictions and appropriate fluid requirements the resident may have and adjust accordingly. Administer liquid medications first. Allow medication to flow down tube via gravity. Administer each medication one at a time and flush 10 cc [cubic centimeter] between each medication. Give gentle boosts with the plunger (approximately 1 inch down) if the medication will not flow by gravity. Repeat if necessary. Do not push medications through the tube. 11. Flush the tube with 30 ml of water.

Based on record review and interview, the facility failed to ensure each resident was provided an assessment which accurately reflects the resident's status for 1 of 3 residents, Resident #159, reviewed for discharge status. Findings include: Review of the Social Service's progress note for Resident #159 dated 6/7/24 read, Pt [patient] was DC [discharged ] home today. Review of the MDS (Minimum Data Set) signed and dated 6/10/24 at 12:55 PM read, Section A 12105, Discharge Status 04. Short - Term General Hospital (acute hospital). During an interview on August 27, 2024, at 1:50 PM the Lead MDS Coordinator stated, It [the MDS] should be coded for the resident going home, that was incorrect. During an interview on August 27, 2024, at 1:55 PM the Director of Nursing stated, My expectation is they [the MDS] should have been coded correctly. Review of the policy and procedure titled Resident Assessment Instrument (RAI) read, Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a residents Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with the time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each residents functional capacities and assist staff to identify health problems for care plan development. Procedure: Completion of Minimum Data Set: 1 Resident Assessment Instrument. A facility will complete a comprehensive assessment of residents needs, functional and health status, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS [Center for Medicare and Medicaid Services]. The assessment must include at least the following: . j) Disease diagnosis and health conditions.p) Discharge planning.

Based on observation, interview, and record review the facility failed to ensure 1 of 6 residents, Resident #136, reviewed for nutrition was offered a therapeutic diet as ordered by the physician and recommended by the Registered Dietician. Findings include: Review of Resident #136's admission record showed Resident #136 was admitted to the facility with diagnoses that included unspecified cirrhosis of liver, end stage renal disease, and mild protein-calorie malnutrition. Review of Resident #136's physician's orders read Liberal Renal diet Regular texture. Thin consistency. Add double protein portions. Add eggs w/ [with] breakfast when available. Review of Resident #136's care plan, revised on 4/1/2024, read [Resident #136's Name] has a nutritional problem r/t [related to] non-compliance with dialysis, CHF [congestive heart failure], ESRD [end stage renal disease], anemia in chronic disease, chronic viral Hepatitis C, therapeutic diet, abnormal nutrition related labs, fluid restriction, drug-nutrient interactions. Resident #136's care plan documented nutritional interventions that included Double protein at each meal. Review of Resident #136's complete blood count with auto differential/comprehensive metabolic profile, collection date, results showed Resident #136's hemoglobin at 6.9 and Resident #136's albumin level at 3.0. Review of Resident #136's nutrition note, dated 7/1/2024, read reports recent wt [weight] loss confirmed by nurse .would like to receive more protein portions and a supplement to complement PO [by mouth intake] .preferences are eggs for breakfast and meat for lunch/dinner. Rec: [Recommendations] Continue Liberal Renal diet, regular texture, thin consistency. Add double protein portions. On 8/27/2024 beginning at 8:13 AM, Resident #136's morning meal was observed. Resident #136 was served 1 sausage patty, 1 2-ounce scoop of eggs and one 8 ounce serving of milk. During an interview on 8/28/2024 at 12:49 PM, the Registered Dietician stated Resident #136 had requested large protein portions. He stated Resident #136 was nutritionally compromised, double protein, two scoops of eggs and two sausage patties should have been served to Resident #136.

Based on record review and interview the facility failed to accurately document blood pressure medication administration and vital signs for 2 of 10 residents, Residents #42 and #110 reviewed for medication administration. Findings include: 1) Review of Resident #42's physician order dated 7/24/2024 read, Valsartan Oral Tablet 80 mg (milligrams) give 1 tablet by mouth one time a day for HTN [hypertension] hold if SBP [systolic blood pressure] is less than 110 or HR [heart rate] less than 60. Review of Resident #42 Medication Administration Record (MAR) for the month of August 2024 for Valsartan 80 mg at 9:00 AM documented on 8/7/2024 coded 9 other/see progress note, on 8/12/2024 vital signs documented NA [not applicable], and on 8/20/2024 through 8/22/2024 coded 5 hold/ see progress notes. Review of Resident #42's progress notes did not provide documentation for the coded 9 and 5 entries on the MAR for 8/7/2024, and 8/20/2024 through 8/22/2024. During an interview on 8/29/2024 at 11:48 AM the Assistant Director of Nursing (ADON) stated, In reviewing [Resident #42's name] medication record I do not see any additional documentation for those entries on the progress notes. 2) Review of Resident #110's physician order dated 8/12/2024 read, Hydralazine HCI Oral Tablet 25 mg give 50 mg by mouth three times a day for HTN hold for SBP less than 110 or HR less than 60. Review of Resident #110's MAR for the month of August 2024 for Hydralazine HCI documented on 8/05/2024 at 1:00 PM coded 9 other/see nursing note, 8/12/2024 at 9:00 AM and 1:00 PM vital signs coded NA (not applicable), and on 8/20/2024 at 1:00 PM coded 5 hold/see progress notes. Review of Resident #110's progress note revealed no documentation for the coded entries on 8/5/2024, and 8/20/2024 on the medication record. During an interview on 8/29/2024 at 11:45 AM the ADON stated, I do not see any documentation for those entries on the MAR for [Resident #110's name]. During an interview on 8/29/2024 at 11:55 AM the Director of Nursing (DON) stated, Vital signs should be inputted into the MAR. If staff code to see nursing notes than there should be a note in the system. It is a documentation issue. Review of the policy and procedure titled Documentation with a last review date of 8/22/2024 read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members.

Based on observation, interview, and record review the facility failed to maintain enhance barrier precautions to prevent the possible spread of infection during direct catheter care and intravenous medication administration and failed to prevent the possible spread of infection in failing to provide intravenous dressing change for peripherally inserted central catheter line (PICC). Findings Include: 1) During an observation on 8/26/2024 at 9:40 AM Staff C, Certified Nursing Assistant (CNA), entered Resident #127's room without gowning and inspected the urinary catheter drainage bag to see if it was leaking. Staff C exited Resident #127's room and came back with towels to place on the wet floor. Staff C without wearing a gown emptied the urinary catheter drainage bag. During an observation on 8/26/2024 at 10:02 AM Staff C, CNA was observed to be providing incontinent care for Resident #127, who has an indwelling urinary catheter, without wearing a gown. During an interview on 8/29/2024 at 8:41 AM with Staff C, CNA, stated, I know I messed up. I should have gowned when I was emptying the catheter and providing incontinent care. 2) During an observation on 8/28/2024 at 6:00 AM Staff D, License Practical Nurse (LPN) entered Resident #151's room. Resident #151's door had an enhance barrier sign posted. Staff D donned gloves and no gown. Staff D without wearing a gown connected an antibiotic medication bag to intravenous tubing and primed the intravenous tubing. Staff D cleansed the needleless connector, inserted the needless syringe to the resident's peripherally inserted central catheter (PICC) line and flushed the line to verify patency with a 10-milliliter syringe of normal saline. Staff D then re-cleansed the needleless connector and inserted the intravenous (IV) tubing to the needleless connector and began to run the medication. During an interview on 8/29/2024 at 9:00 AM Staff D, LPN, stated, You are supposed to wear gloves and gowns sometimes. To be honest they moved all the personal protective equipment [PPE], and I did not know where to get a gown from. I should have had a gown since I was administering IV medication. During an interview on 8/29/2024 at 8:55 AM the Director of Nursing (DON) stated, We have educated on enhanced barrier precautions and the staff are expected to don and doff [PPE]. The staff should wear gloves, gown, and if dealing with a urinary catheter they should wear a face mask. Enhanced barrier precautions are applied for residents with intravenous catheters, foleys, gastric tubes and wounds. Review of the policy and procedure titled Enhanced Barrier Precautions with a last review date of 8/22/2024 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, ect.). 3) During an observation on 8/28/2024 at 9:02 AM Resident #264 was lying in bed, a PICC line to the right upper arm with a single lumen was observed and the dressing was dated 8/21/2024. There was a dried dark red substance and a 2 X 2 gauze with a beige colored substance underneath the transparent dressing. Staff E proceeded to flush the IV (intravenous) line with normal saline and administered medication via the IV. During an interview on 8/28/2024 at 9:02 AM Resident #264 stated, I came in with the IV dressing from the hospital. It looks pretty disgusting, but I have no pain, it is not swollen, and it flushes without any issues. During an interview on 8/28/2024 at 9:26 AM Staff D, LPN, stated, If I would have done the admission I would have changed the dressing then. If the dressing is soiled, I would change it also. I told my relief nurse yesterday about changing the dressing due to the condition of the dressing. Today when I came in, I saw it [IV dressing] had not been changed. I was going to change the dressing, but it was breakfast time, and I was unable to change it at that time. Review of the facility policy and procedure titled Infusion Devices and Procedures with a last review date of 8/22/2024 read, Policy: .Central vascular access device (CVAD) and midline catheter site care and dressing changes are performed at established intervals, and immediately when integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment if site infection or inflammation is suspected . 39371 3) On 8/26/24 at 10:20 AM an observation of Resident #264 room door it had an enhance barrier precaution sign. Upon entering the room during the observation of the resident, her right upper arm was exposed. A peripherally inserted central catheter (PICC) had a dressing that was dated 8/21/24. The dressing site was visibly soiled with a dark red/blackish substance. (Photographic evidence was obtained). On 8/26/24 at 10:20 AM during an interview Resident 264 stated, That was put in at the hospital [PICC], I'm on a blood thinner. I know it does look bad; the bruising looked worst immediately after it was put in. Review of Pharmacy Policy title 005-O: Central Venous Catheter Dressing Changes. Policy. Central venous catheter dressing will be changed at specific intervals, or when needed, to prevent catheter related infections that are associated with contaminated, loosen, soiled, or wet dressings. Dressing must stay clean, dry, and intact. Change dressing if any contamination is suspected. Change gauze dressing or TSM [transparent semi-permeable membrane] over gauze dressings every 48 hours. General Guidelines 5. Change transparent semi-permeable (TSM) dressings every 5 to 7 days and PRN [as needed] (when wet, soiled, or not intact).

Based on interviews, record reviews, and policy and procedure reviews, the facility failed to ensure residents were free from medical neglect by failing to implement policies and procedures for neglect, resident change in condition or status, and resident transportation safety for facility operated vehicles when the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. The transportation driver did not notify the facility licensed medical staff of the resident declining medical care and services and continued to transport Resident #1 back to the facility. Resident #1 suffered cardiac arrest and did not survive. The facility's failure to implement their policies and procedures for Resident #1 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on [DATE], at 12:13 PM. The Immediate Jeopardy began on [DATE], and was removed on site on [DATE]. Review of the Cleveland Clinic documentation titled, Hypoxia read, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER [emergency room ]. Hypoxia should be treated right away to prevent permanent organ damage. (My.clevelandclinic.org/health/diseases/23063-hypoxia accessed on [DATE]) Findings include: Review of the facility medical record for Resident #1 documented the resident was admitted with diagnoses of acute on chronic combined systolic congestive and diastolic congestive heart failure (with combined congestive heart failure in systolic, ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic the ventricles cannot relax, expand, or fill with enough blood), RSV (respiratory syncytial virus - is the most common cause of lower respiratory tract infections), pneumonia unspecified organism, dysphasia following cerebral infarction (an area of dead tissue in the cerebrum caused by an insufficiency for arterial or venous blood flow - resulting in an impairment in the production of speech resulting from brain disease or damage) paroxysmal atrial fibrillation (rapid, erratic heart rate begins suddenly and then stops on its own within seven days), acute myocardial infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting left nondominant side, repeated falls, ischemic cardiomyopathy (damaged heart muscle from a lack of blood flow), anemia, atherosclerotic heart disease of native coronary artery without angina pectoris (silent heart ischemia), presence of automatic implantable cardiac defibrillator (a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide an immediate treatment which can be in the form of shock therapy) presence of coronary angioplasty implant and graft (creates a new path for blood to flow around a blocked or partially blocked artery), retinal detachment left eye, occlusion and stenosis of unspecified carotid artery (the narrowing of the carotid arteries), major depressive disorder, idiopathic peripheral autonomic neuropathy (nerve damage when the cause can't be determined), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), essential primary hypertension (high blood pressure), hyperlipidemia, acquired absence of right leg above the knee, acquired absence of left leg below the knee, chronic obstructive pulmonary disease with acute exacerbation (sudden worsening in airway function and respiratory symptoms in people with COPD), non ST elevation myocardial infarction (a type of involving partial blockage of one of the heart arteries, causing reduced flow of oxygen-rich blood to the heart muscle), type 2 diabetes mellitus with other circulatory complications, and acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing a state in which oxygen is not available in sufficient amounts). Review of the physician orders dated [DATE] Oxygen 3 liters PRN [as needed]. Review of the nursing progress note dated [DATE] at 1430 [2:30 PM] read, Resident was being transported from an appointment when the transport driver witnessed resident having a medical event. She was lowered to the floor of the transport vehicle, lying sideways with her stumps facing the windshield and her head facing the wall. 911 was called, the facility director and MD [Medical Doctor] were notified. She was transferred into an ambulance to be transported to [name of a local hospital]. Multiple attempts made by staff via telephone to reach family. Review of the nursing progress note dated [DATE] at 1530 [3:30 PM] read, Resident transported via TR [Timberridge] transportation van to appointment at [name of the eye center] at the [location of the eye center that is 48.3 miles from the facility; approximately a one-hour drive] at Approx [approximately] 8:45 AM for a 9:30 AM appointment time. Accompanied by driver. Notification made by driver when enroute to return to the facility that resident c/o [complaint of] shortness of breath and chest pain, driver then pulled over to assist resident and called 911. Driver states that he assisted her into a rescue position to assure her comfort and safety until EMS [Emergency Medical Services] arrived. EMS arrived & escorted resident to [name of local hospital]. Call received from [name of local hospital] to make notification to the facility of the resident passing. Administration notified daughter of event and hospitalization . During an interview on [DATE] at 9:35 AM the Administrator stated, I'm not really sure about everything that happened, or what was done. I'm sorry I was on vacation and just need to get myself up to speed with everything that has been done. [The Administrator was notified of the event on [DATE] at 2:02 PM]. During an interview on [DATE] at 10:10 AM the Director of Nursing (DON) stated, I took [Staff A name's] statement the day of the event and it was that [Resident #1's name] told him that she was out of oxygen, and he pulled over and asked her if she wanted to go to the hospital and she said no she was fine. So, he came back to Ocala and when he saw her in the wheelchair, the wheelchair was tilted, and she was slumped to her left side. He immediately pulled over and called 911. He did follow the policy for transporting, when he recognized a medical emergency, he called 911. I don't think that he saw her lack of oxygen as an emergency. We don't know if the oxygen was out or not. He wouldn't know how to change an oxygen tank. We did not send any other tanks with her. But she is awake, alert and she stated she didn't want to go so that is what he did, he honored her right to refuse to go to the hospital. I don't know exactly what transport drivers have in education about emergencies. He is not able to assess a resident, he does not have medical training to do that. During an interview on [DATE] at 11:30 AM the Administrator, in the presence of the DON stated, [Staff A's name] was transporting [Resident #1's name] to her eye appointment, and she stated, I think I'm out of oxygen, he pulled over and asked her if she wanted to go to the hospital and she said no, because she has a BIMS [Brief Interview for Mental Status] of 15 [this score means cognition is intact], it was her right to refuse to go. We have no way of knowing whether the oxygen tank was empty or not. We don't know whether this contributed to the event. But once he did recognize an emergency, he did follow our policy for transportation and did call 911. [Staff A's name] was trained on transport, and he followed the training. He is not cardiopulmonary resuscitation [CPR] trained to my knowledge. We did not, after the investigation, think that we needed to QAPI [Quality Assurance and Performance Improvement] this, she was of sound mind and competent to make her decision not to get medical treatment. We did not do an Adhoc [from the Latin and means for this] QAPI related to this. We did not do a Root Cause Analysis [RCA] to determine if there were any other factors or breaks. She had the right to refuse treatment, it was her right to do that. We do plan on discussing this during our next QAPI on the 25th. During an interview on [DATE] at 2:00 PM the Assistant Director of Nursing (ADON) stated, I did not take care of her [Resident #1]. I was on the back end of the process, meaning I received the calls from the Driver and the hospital that there was a medical event during transportation of [Resident #1's name]. I did not speak with the nurse or the tech that took care of her before she left. All nurses should assess a resident before they leave. When we send a resident out with oxygen, we should assess the tank before they leave. I can't say that I know exactly how long the oxygen tanks are good for. I don't know if any other tanks went with the resident when she left. I'm not sure if the driver would even know how to change the oxygen tanks if they ran out of oxygen. During an interview on [DATE] at 2:40 PM Staff C, Certified Nursing Assistant (CNA) stated, Depending on how early the appointment is ,d+[DATE] [shift] will get a resident up and dressed and start getting them breakfast, if it's a later appointment I will do that. She [Resident #1] was already up and had eaten when I got in [at 7:00 AM], she was in her wheelchair. I just made sure her oxygen tank was full. She always used her oxygen, all the time, whether she was in bed or out of it. She would always pull the nasal cannula down on her chin because her nose would dry out and then put it back in. I did not provide any extra tanks for her transport that day. I actually didn't see her leave that morning, so I don't know what time she left out of the building that day. When residents go to an appointment the nurses see them and give them the paperwork to go to the appointment with them. I think they make sure the oxygen is full before transport takes them. She seemed fine that morning her usual self. During an interview on [DATE] at 3:07 PM, Staff B, Licensed Practical Nurse (LPN) stated, I was just coming on shift when I saw her [Resident #1]. I work starting at 7:00 [AM]. She was already dressed and up in her wheelchair. I gave her the envelope for the appointment. She was wearing the oxygen when I saw her. She always used oxygen, she didn't ever take off her oxygen, like she didn't use it PRN [as needed], she used it continuously. I did not assess her oxygen level when I saw her. I don't know how much was in the tank [oxygen]. Typically, I will check oxygen before residents go but I never saw her leave. I have no idea when she left the building. I saw her at 7:30 [AM] or so and that's the last time I saw her. I did not provide any further oxygen tanks for her to transport with. It is my usual habit to check and verify that the oxygen is full. We do sometimes send patients to Gainesville for appointments, most were in the area for her. I do not know how long oxygen tanks are good for. I should have made sure to see her oxygen tank. Not everyone that goes out to an appointment uses oxygen. During a telephone interview on [DATE] at 6:00 PM, Staff A, Transport Driver stated, I brought [Resident #1's name] up to her doctor's appointment in Gainesville and then she wanted to get something to eat so I brought her to the food court in the mall. [Name of mall] up there in Gainesville. That was where her doctor is, in the mall. We ate and then got in the van, we had just gotten on I [Interstate] 75 from [street location] where the mall is when she said, 'I think I'm out of oxygen. I need some oxygen' and I asked her if she were {sic} okay. She told me she was short of breath. I did pull off 75 and asked but she said she didn't want any medical help. She said 'No I'm okay' to me and so I just drove on down to Ocala. She was talking to me, and I would glance up into the mirror and she would be fidgeting with stuff. It was just after I got off 75 on 200 just before [name of a restaurant] that I saw her slumped in the wheelchair. She had not complained of any shortness of breath or chest pain, she was just slumped over, not conscious at all. I pulled off and called 911. I couldn't adjust her in the chair, so I unbuckled her and got her to the floor, after that the paramedics came. I am a floor technician, that's my job and I also drive residents to their appointments. Not everyone uses oxygen when they go. I really don't know nothing about that, nothing about oxygen. I don't know how to change an oxygen tank. I have been doing the driving for a few years now, I think, since 2008. I can't really remember what type of training I got then about it. I know I need to make sure the chairs are strapped in and that if I have any kind of a medical emergency that I pull over and call 911. I do not have any CPR training. I haven't gotten no additional training after this happened. I did not call any of the nurses about the oxygen being out. I just tried to bring her back. During an interview on [DATE] at 12:29 PM Staff D, Certified Nursing Assistant/Unit Secretary stated, I was assisting her because she was running late, so I called the doctor's office to see if it was okay to be there late. She wanted me to check. I went to get her at her doorway. I told her it was okay for her to be there later. I walked alongside her; she wanted me to pull up her blanket. I looked at her oxygen tank and it was at green when I saw her. I didn't truly know if it was completely full. I helped load her in the van. During an interview conducted on [DATE] at 1:22 PM the Medical Doctor/Medical Director, stated, I was under the understanding that she [Resident #1] was at an appointment and eating a [name of restaurant] sandwich. She told the driver she thought that she was out of oxygen, and he asked her if she wanted to go to the hospital and she said no. I do think she was stubborn, and I don't know if he could have convinced her to go. I don't think we could force her to go. The driver is not trained to assess residents. She was a sick lady with an EF [Ejection Fraction] of ,d+[DATE]% [an indicator of heart strength. It measures the amount of oxygen-rich blood pumped out to the body with each heartbeat. An EF of 20% is about one-third of the normal ejection fraction. The heart is not pumping all the oxygen-rich blood the body needs], had an ACB [aortocoronary bypass, a surgery that creates a new path for blood to flow around a blocked or partially blocked artery in the heart], AICD [automatic implanted cardioverter-defibrillator, a device that helps when there is a sudden loss of all heart activity, a condition called cardiac arrest], recent RSV [respiratory syncytial virus, inflammation partially or completely blocks the airways] and pneumonia, also very severe heart disease and peripheral vascular disease. She was using her oxygen and did need it all the time because of these things. She was hospitalized , I think, five times last year. Her oxygen was PRN because sometimes she was not compliant in wearing it. But she did need the oxygen based on her condition. But I understand that it was her right not to wear it if she didn't want to. Review of the nursing progress notes for the period of 9//2023 through [DATE] documented two occurrences of Resident #1 having concerns with oxygen. Dated [DATE] at 17:41 [5:41 PM] read, While assisting resident back to bed this afternoon. Resident oxygen released from the nose. When placing it back in nose resident took it out and placed in one nares. Attempted to place back explained to her that it wasn't in correctly. Resident replied 'I only keep it in one side because it makes me sneeze.' Explained to her that she is not receiving the correct amount of oxygen but continue to place in one nares. Dated [DATE] at 20:25 [8:25 PM] Patient has her O2 [oxygen] cannula out of her nose due to soreness in nostrils. Declines to wear a mask. During an interview on [DATE] at 4:05 PM the Administrator stated, I don't want to determine what [Staff A's name] perceived or did not perceive. He determined that she was fine, he stated that she did not want to go to the hospital, and he thought she was fine. I know that when she had an actual emergency, he did call 911. I can't say that her shortness of breath and chest pain was an emergency to [Staff A's name]. He offered and she stated she did not want to go to the hospital. It was her right to refuse. When asked the Administrator declined to answer if [Staff A's name] was able to assess the resident and able to determine if Resident #1's name was having a medical emergency. During an interview on [DATE] at 10:09 AM the DON stated, I was here when [the Administrator's name] got a phone call from [Staff A's name]. He was on the side of the road near [restaurant's name]. That is the only call we got from [Staff A's name] that I know about. [Resident #1's name] was transported to [local hospital name]. I was here when [Staff A's name] got back, and he was very upset, shook up. The oxygen tank, well, I didn't look at the regulator when [Staff A's name] returned. I just heard it running, it was making a sound. I did not photograph the oxygen tank and I did not look to see whether it was empty or not. I can't say the tank was empty because I wasn't there, but she refused care all the time. So, it's not unusual for her to refuse to do things. I don't know if she had capacity because I was not there with her. I was not in the van with [Staff A's name] so I can't say that I know that she had shortness of breath or chest pain. I wasn't there. But if she did per my Administrator's interview, then no one but [Staff A's name] was in the van with the resident. He is not able to notify her of the consequences of not getting assessed, he would not be able to explain to her that being without oxygen would or could have her in more problems or what the result of not getting medical help would be. But we can't say she was out of oxygen, we don't know that, and we did not look at the oxygen gauge when he returned. So, therefore I can't say that anything happened with her oxygen, or that she was in any distress during the ride. I only have the statement that he gave me, and he thought she was alright. I wasn't called by [Staff A's name] about any chest pain or shortness of breath, so I can't tell you what I would have said to him. If a resident is short of breath and having chest pain, I would tell them to get a nurse to evaluate the resident if they were in the building. During an interview on [DATE] at 10:20 AM the Administrator stated, All the information that I documented during my interview with [Staff A's name] was accurate, he did state that she complained of chest pain and shortness of breath the first time he pulled the van over. He did not call me, or anyone else about the resident at that time, he asked the resident who has the capacity to self-determine if she wanted to go to the hospital and she declined. So, he brought her back here. He told me she was fidgeting and conversing with him during the trip. He did not tell me that she complained of pain when getting off 75, he told me exactly what I wrote. It was around 2 o'clock when [Staff A's name] called me, it was so jumbled, he was frantic and upset. The information I understood at that time [Resident #1's name] required and was sent to the hospital. I can't say because I wasn't with her that she had a medical emergency any sooner than [Staff A's name] recognized it, I was not there. I think that he followed our policies and procedures. I don't think he is able to discuss the consequences of not going to the hospital. But according to [Staff A's name] she was fine during the transport, and he did what he was supposed to do when she was slumped in the chair. During an interview on [DATE] at 1:50 PM Staff A, Transportation Driver /Floor Technician stated, She [Resident #1] had chest pain and shortness of breath up in Gainesville and I asked but she said no she didn't want to go to the doctors, back to there at the doctors. I did not call anyone when she had that pain. I got no training on emergencies like that. I knew that I should call if we needed to call 911. I didn't know that this was a problem, that that might cause her to die. It's been terrible. I feel so badly about it all, it is just awful, every time I talk about this I just get feeling sad all over again. I never did ask her again if she wanted to go to the hospital, just that one time. I didn't talk much to her on the way home, but I would glance up and I would see that she was fidgeting in her chair, she was awake and when I glanced in Ocala, she was all slumped over and the chair was tilted a little, she was tilted to her side. I had a hard time after I pulled over getting her pulled in her seat, so I unbuckled her and moved her to the floor. She couldn't talk to me at all. She didn't tell me that she was short of breath or having any chest pain again after being in Gainesville. That's the only time she said that. She did not say it on the off ramp here in Ocala, she wasn't saying anything. Well, I did know that it was serious her having pain and feeling that way, but she just said she didn't want to go. I just wasn't trained to call for anything but an emergency. I didn't think this was that type of an emergency. I'm not wanting to be a driver anymore. Review of the facility time-line documented: 8:49 AM Resident observed by [Staff D's name, CNA/Unit Secretary prior to departing facility for her appointment. [Staff D's name] states she verified that [Resident #1's name's] oxygen e-tank was full at time of departure. 8:55 AM Resident was loaded into the Timberridge transportation van in her wheelchair. Both [Resident #1's name] and her chair were secured. 8:55 - 9:45 AM Resident enroute to her appointment, no signs and symptoms of distress noted. 12:50 PM resident requested to stop for lunch prior to returning to the transportation van and returning to the facility. At this time the driver states he did not notice any signs of distress. 1:00 PM resident is loaded back into the facility van and both she and her chair were secured prior to getting on to the Interstate. Resident stated she believed her oxygen may have been out. Driver immediately suggested that he return her to the health facility to be evaluated. Resident declined. Driver continued to monitor resident during transport. 1:40 PM: Resident complained of chest pain and shortness of breath. Driver immediately pulled over called 911 EMS arrived and assumed responsibility of resident's care. [Approximately 4 hours and 51 minutes after exit from the facility]. 2:02 PM Administrator notified. Review of a handwritten statement by Staff A, Transportation Driver/Floor Technician dated [DATE] as transcribed by the DON read, He stated that while transporting [Resident #1's name] back from her eye appointment [Resident #1's name] was fidgeting with her wheelchair and stated she was out of oxygen. He offered to return her to health facility and she declined. I looked back in the rearview mirror she was fidgeting again she was leaned over to the right side chair was tilted I pulled over and called 911. Review of the job description titled, Van Driver: General description: under general supervision, performs various tasks relating to the transport of residents and passenger vans. Typical duties/responsibilities: operates a passenger van safely and efficiently. Follows commonly scheduled routes or responds to requests from facility supervisor or management for unscheduled pickups or drop offs. Assist residents in boarding and exiting vehicle. Loads and unloads luggage, packages, or other items. Transmits and receives messages per cell phone. Monitors traffic and weather conditions and notifies facility supervisor of potential problems. Reports accidents or other safety situations to facility supervisor. Treats all residents and other persons in a courteous friendly and professional manner. Also, may be required to perform other related duties as requested. Essential functions: Must be able to perform other duties as necessary to ensure resident safety. Review of Resident #1's care plan read, Focus: [Resident #1's name] is at risk for return to hospital due to SOB [shortness of breath], falls, CHF [congestive heart failure], COPD, RSV, PNA [pneumonia]. Interventions: Monitor labs and diagnostic test, monitor/document/report PRN any signs and symptoms of CAD [coronary artery disease], chest pain or pressure especially with activity, heartburn, nausea, vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap [capillary] refill, color/warmth of extremities, new or worsening agitation/delusions, notify MD as indicated. Focus: [Resident #1's name] has congestive heart failure. Interventions: check breath sounds and monitor/document for labored breathing, monitor/document for use of accessory muscles while breathing, check vital signs every shift, notify MD of significant abnormalities, encourage adequate nutrition, offer small frequent feedings, give cardiac medications as ordered, incentives spirometer as ordered, Lasix 40 milligram every two days BID [twice a day] for CHF, monitor/document/report PRN any s/sx [signs and symptoms] of congestive heart failure, periorbital edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation, OXYGEN SETTINGS: per MD orders, weigh per MD orders/ facility policy. Focus: [Resident #1' name] is on diuretic therapy related to CHF. Interventions: Administer diuretic medications as ordered by physician. Focus: [Resident #1's name] is on anticoagulant therapy r/t a-fib [atrial fibrillation - an irregular heart rhythm], h/o [history of] cva [cerebral vascular accident], pvd [peripheral vascular disease. Interventions: Administer anticoagulant medications as ordered by physician. Review of the [Name of oxygen suppler] Standard Invoices dated [DATE] and [DATE] documented the number of cylinders delivered with a material number of OX USPEAWBPLUS [OX USPEAWBPLUS USP (United States Pharmacopeia) Medical Grade Oxygen, Size E High Pressure Aluminum Medical Cylinder With Walk-O2 [oxygen]-Bout(R) Regulator, VIPR 1 [valve with integrated pressure regulator]. Review of the document provided by the facility titled, Approximate Hours Of Service For Oxygen Tanks under E Tanks read, Liter flow per minute - 3. Full Cylinder 2,000 lbs. [pounds] 3 ,d+[DATE] hours. Review of the policy and procedure titled, Resident Transportation Safety (Facility Operated Vehicles) read, Policy: Facility operated vehicles used for the purpose of resident transportation will be operated in a manner that will minimize the risk of injury to residents and staff . 9. Each van/facility operated vehicle shall have a telecommunication (cell phone) available to the driver to ensure proper emergency communication. No driver shall use a telecommunication devise while the van is in motion. 10. The driver of the van facility operated vehicle is to report any accident or incident (even if there is no injury or property damage) to the facility administrator and to law enforcement as required by law. 11. If an accident or incident occurs involving a resident that results in suspected or confirmed injury to the resident or if there is a medical emergency involving a resident, emergency service should be requested by calling 911. The administrator is to be notified as soon as possible after requesting assistance for the resident. The administrator is to be notified as soon as possible after requesting assistance for the resident. The van/facility operated vehicle should wait at the location for emergency services to arrive. Review of the policy and procedure titled, Facility Operated Vehicle read, Policy: This policy is designed to maximize employee and resident safety and minimize risk of injuries and property damage. Procedure . 8. Facility operated vehicles shall have a telecommunication system available to the driver(s) to ensure proper emergency communications. Review of the policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation read, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical or mental), neglect, exploitation and misappropriation and the occurrence of an injury of unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. Procedure: The facility shall take steps to prevent, detect, and report suspected maltreatment: 7. Investigation: A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate the procedures for conducting the investigation. The investigation will include: a. They type of allegation, b. What occurred, when, where and to whom? By whom? Get a physical description or identify the alleged perpetrator if possible, c. Describe the injury and any treatment, d. Interview witnesses separately; interview caregivers, roommates; get statements; observe/document demeanor; include names, addresses, and phone numbers of actual witnesses .f. Obtain signed statement from alleged perpetrator, if possible .h. Describe action taken to protect resident .l. If neglect is alleged, identify staff, length of time, and outcome to resident .o. Review any meds that may cause resident to bruise easily or be R/T [related to] nature of the injury .q. Review nurse's notes and other records for information about the incident. Upon completion of the investigation, the facility should prepare a summary report of the findings and conclusions, including any actions taken by the facility. 8. Corrective action: The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. Definitions: Neglect: Neglect is failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the policy and procedure titled, Nursing - Change in a Residents Condition or Status read, Policy: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the residence medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's advanced directives. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated [DATE] documented the facility has initiated the following steps to ensure the safety of residents who require oxygen and are at risk for medical emergencies during transport: [DATE] A 30 day lookback was completed for residents requiring oxygen who were transported on the facility van. No identified concerns of oxygen administration [TRUNCATED]

Based on interviews, resident record reviews, and review of the policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to implement policies and procedures for neglect, resident change in condition or status, and resident transportation safety for facility operated vehicles; the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. The transportation driver did not notify the facility licensed medical staff of the resident declining medical care and services and continued to transport Resident #1 back to the facility. Resident #1 suffered cardiac arrest and did not survive. The facility's failure to implement their policies and procedures for Resident #1 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on [DATE], at 12:13 PM. The Immediate Jeopardy began on [DATE], and was removed on site on [DATE]. Review of the Cleveland Clinic documentation titled, Hypoxia read, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER [emergency room ]. Hypoxia should be treated right away to prevent permanent organ damage. (My.clevelandclinic.org/health/diseases/23063-hypoxia accessed on [DATE]) Findings include: Review of the Position Description Administrator read, Basic Function: Responsible for directing the overall operation of the facilities activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Characteristic Duties and Responsibilities: Essential Functions: 1. Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. (Includes personnel policies, patient/resident care policies, procedure manuals, position descriptions, etc.) 2. Assist in the development and implementation of departmental policies and procedures, and establish a rapport in and between departments so that each can see the importance of teamwork. 3. Ensure that all personnel, patients/residents, visitors, and the general public follow established policies and procedures. 4. Interpret the facility's policies and procedures to personnel, patients/residents, family members, visitors, etc. as may become necessary. 5. Review policies and procedures periodically, at least annually, and make changes as necessary to ensure compliance with current regulations are being continually maintained. 6. Ensure that patients'/residents' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times .Marginal Functions: 1. Responsible for the overall quality assessment and improvement program and the coordination of quality assessment and improvement activities . 9. Review and check competence of the work force and make necessary adjustments/corrections as required or that may become necessary. Review of the Position Description Director of Nursing (DON) read, Basic Function: Responsible for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all patients/residents. Characteristic Duties and Responsibilities: Essential Functions: 1. Supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. 2. Coordinates interdisciplinary patient/resident care management efforts .6. Ensures a safe and sanitary environment for patients/residents, employees, and visitors .8. Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator .Coordinates interdisciplinary patient/resident care management efforts. 1. Provides direction as to format and approach to patient/resident care management. 2. Ensures implementation of resident care planning format to comply with patients/residents needs and various regulatory agency requirement. 3. Coordinate requirements and cooperates with all other departments in providing a favorable physical, social, and emotional environment for all patients/residents. Review of the Medical Director Services Agreement read, 3. Medical Director of Facility. During the Term, Physician agrees to serve as Medical Director for Facility: During the Term, Physician agrees to perform services identified on Exhibit A attached hereto and incorporated herein by reference. Review of Exhibit A, Medical Director Services read, 1. Visit facility as often as needed to effectively perform the services which shall be at least once monthly and document each visit in writing. 2. Develop, implement, and evaluate resident care policies, procedures and guidelines, based on the current standards of practice, and collaborate with Facility leadership, staff, and other practitioners and consultants regarding the following: a. admissions, discharges, infection control, safety, restraints, fall risks, pain management, significant weight loss or gain, psychotropic medications, physician privileges and practices, responsibilities of non-physician health care workers and other aspects of residence care to ensure adequate and comprehensive services. b. accidents and incidents, use of medications, use and release of clinical information, ancillary services such as laboratory, radiology, and pharmacy and overall quality of care. c. providing a continuity of care and an adequate medical record system. d. the safe and effective use of medications to meet the needs of residents; . k. medical and clinical concerns and issues that affect resident care, medical care, or quality of life, or are related to the provision of services by physicians or other licensed healthcare practitioners .5. Advise and consult with the Facility Administrator regarding: a. Facility's ability to meet the residents' needs and opportunities for future resident care programs .f. improving performance of medical services as an integral part of improving Facility's performance. 6. Direct and Coordinate: a. the medical care in Facility and ensure that Facility is providing appropriate care as required. Review of the Position Description Assistant Director of Nursing read, Basic Function: Assists the Director of Nursing in the overall management of the Department of Nursing .Characteristic Duties and Responsibilities: Essential Functions: 1. Assist in ensuring quality nursing care to all residents/patients. Supports and practice the philosophy nursing objectives and standards of the Department of Nursing .5. Assists in ensuring a safe and sanitary environment for patients/residents, employees and visitors . Minimum Performance Standards: Assist in ensuring quality nursing care to all patients/residents. Supports and practices the philosophy, nursing objectives and standards of the Department of Nursing. Performance in the following areas is acceptable when: 2. Participates in the implementation of the patient/resident care planning process to comply with patient/resident needs and regulatory agency requirements. Review of the facility medical record for Resident #1 documented the resident was admitted with diagnoses of acute on chronic combined systolic congestive and diastolic congestive heart failure (with combined congestive heart failure in systolic, ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic the ventricles cannot relax, expand, or fill with enough blood), RSV (respiratory syncytial virus - is the most common cause of lower respiratory tract infections), pneumonia unspecified organism, dysphasia following cerebral infarction (an area of dead tissue in the cerebrum caused by an insufficiency for arterial or venous blood flow - resulting in an impairment in the production of speech resulting from brain disease or damage) paroxysmal atrial fibrillation (rapid, erratic heart rate begins suddenly and then stops on its own within seven days), acute myocardial infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting left nondominant side, repeated falls, ischemic cardiomyopathy (damaged heart muscle from a lack of blood flow), anemia, atherosclerotic heart disease of native coronary artery without angina pectoris (silent heart ischemia), presence of automatic implantable cardiac defibrillator (a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide an immediate treatment which can be in the form of shock therapy) presence of coronary angioplasty implant and graft (creates a new path for blood to flow around a blocked or partially blocked artery), retinal detachment left eye, occlusion and stenosis of unspecified carotid artery (the narrowing of the carotid arteries), major depressive disorder, idiopathic peripheral autonomic neuropathy (nerve damage when the cause can't be determined), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), essential primary hypertension (high blood pressure), hyperlipidemia, acquired absence of right leg above the knee, acquired absence of left leg below the knee, chronic obstructive pulmonary disease with acute exacerbation (sudden worsening in airway function and respiratory symptoms in people with COPD), non ST elevation myocardial infarction (a type of involving partial blockage of one of the heart arteries, causing reduced flow of oxygen-rich blood to the heart muscle), type 2 diabetes mellitus with other circulatory complications, and acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing a state in which oxygen is not available in sufficient amounts). Review of the physician orders dated [DATE] Oxygen 3 liters PRN [as needed]. Review of the nursing progress note dated [DATE] at 1430 [2:30 PM] read, Resident was being transported from an appointment when the transport driver witnessed resident having a medical event. She was lowered to the floor of the transport vehicle, lying sideways with her stumps facing the windshield and her head facing the wall. 911 was called, the facility director and MD [Medical Doctor] were notified. She was transferred into an ambulance to be transported to [name of a local hospital]. Review of the nursing progress note dated [DATE] at 1530 [3:30 PM] read, Resident transported via TR [Timberridge] transportation van to appointment at [name of the eye center] at the [location of the eye center that is 48.3 miles from the facility; approximately a one-hour drive] at Approx [approximately] 8:45 AM for a 9:30 AM appointment time. Accompanied by driver. Notification made by driver when enroute to return to the facility that resident c/o [complaint of] shortness of breath and chest pain, driver then pulled over to assist resident and called 911. Driver states that he assisted her into a rescue position to assure her comfort and safety until EMS [Emergency Medical Services] arrived. EMS arrived & escorted resident to [name of local hospital]. Call received from [name of local hospital] to make notification to the facility of the resident passing. Administration notified daughter of event and hospitalization . During an interview on [DATE] at 9:35 AM the Administrator stated, I'm not really sure about everything that happened, or what was done. I'm sorry I was on vacation and just need to get myself up to speed with everything that has been done. [The Administrator was notified of the event on [DATE] at 2:02 PM]. During an interview on [DATE] at 10:10 AM the Director of Nursing (DON) stated, I took [Staff A name's] statement the day of the event and it was that [Resident #1's name] told him that she was out of oxygen, and he pulled over and asked her if she wanted to go to the hospital and she said no she was fine. So, he came back to Ocala and when he saw her in the wheelchair, the wheelchair was tilted, and she was slumped to her left side. He immediately pulled over and called 911. He did follow the policy for transporting, when he recognized a medical emergency, he called 911. I don't think that he saw her lack of oxygen as an emergency. We don't know if the oxygen was out or not. He wouldn't know how to change an oxygen tank. We did not send any other tanks with her. But she is awake, alert and she stated she didn't want to go so that is what he did, he honored her right to refuse to go to the hospital. I don't know exactly what transport drivers have in education about emergencies. He is not able to assess a resident, he does not have medical training to do that. During an interview on [DATE] at 11:30 AM the Administrator, in the presence of the DON, stated, [Staff A's name] was transporting [Resident #1's name]to her eye appointment, and she stated, I think I'm out of oxygen, he pulled over and asked her if she wanted to go to the hospital and she said no, because she has a BIMS [Brief Interview for Mental Status] of 15 [this score means cognition is intact], it was her right to refuse to go. We have no way of knowing whether the oxygen tank was empty or not. We don't know whether this contributed to the event. But once he did recognize an emergency, he did follow our policy for transportation and did call 911. [Staff A's name] was trained on transport, and he followed the training. He is not cardiopulmonary resuscitation [CPR] trained to my knowledge. During an interview on [DATE] at 2:00 PM the Assistant Director of Nursing (ADON) stated, I did not take care of her [Resident #1]. I was on the back end of the process, meaning I received the calls from the Driver and the hospital that there was a medical event during transportation of [Resident #1's name]. I can't say that I know exactly how long the oxygen tanks are good for. During an interview on [DATE] at 3:07 PM, Staff B, Licensed Practical Nurse (LPN) stated, I was just coming on shift when I saw her [Resident #1]. I work starting at 7:00 [AM]. She was already dressed and up in her wheelchair. She always used oxygen, she didn't ever take off her oxygen, like she didn't use it PRN, she used it continuously. I do not know how long oxygen tanks are good for. During a telephone interview on [DATE] at 6:00 PM, Staff A, Transport Driver stated, I brought [Resident #1's name] up to her doctor's appointment in Gainesville and then she wanted to get something to eat so I brought her to the food court in the mall. [Name of mall] up there in Gainesville. That was where her doctor is, in the mall. We ate and then got in the van, we had just gotten on I [Interstate] 75 from [street location] where the mall is when she said, 'I think I'm out of oxygen. I need some oxygen' and I asked her if she were {sic} okay. She told me she was short of breath. I did pull off 75 and asked but she said she didn't want any medical help. She said 'No, I'm okay' to me and so I just drove on down to Ocala. She was talking to me, and I would glance up into the mirror and she would be fidgeting with stuff. It was just after I got off 75 on 200 just before [name of a restaurant] that I saw her slumped in the wheelchair. She had not complained of any shortness of breath or chest pain, she was just slumped over, not conscious at all. I pulled off and called 911. I couldn't adjust her in the chair, so I unbuckled her and got her to the floor, after that the paramedics came. I am a floor technician, that's my job and I also drive residents to their appointments. Not everyone uses oxygen when they go. I really don't know nothing about that, nothing about oxygen. I don't know how to change an oxygen tank. I have been doing the driving for a few years now, I think, since 2008. I can't really remember what type of training I got then about it. I know I need to make sure the chairs are strapped in and that if I have any kind of a medical emergency, that I pull over and call 911. I do not have any CPR training. I haven't gotten no additional training after this happened. I did not call any of the nurses about the oxygen being out. I just tried to bring her back. During an interview conducted on [DATE] at 1:22 PM the Medical Doctor/Medical Director, stated, I was under the understanding that she [Resident #1] was at an appointment and eating a [name of restaurant] sandwich. She told the driver she thought that she was out of oxygen, and he asked her if she wanted to go to the hospital and she said no. I do think she was stubborn, and I don't know if he could have convinced her to go. I don't think we could force her to go. The driver is not trained to assess residents. She was a sick lady with an EF [Ejection Fraction] of ,d+[DATE]% [an indicator of heart strength. It measures the amount of oxygen-rich blood pumped out to the body with each heartbeat. An EF of 20% is about one-third of the normal ejection fraction. The heart is not pumping all the oxygen-rich blood the body needs], had an ACB [aortocoronary bypass, a surgery that creates a new path for blood to flow around a blocked or partially blocked artery in the heart], AICD [automatic implanted cardioverter-defibrillator, a device that helps when there is a sudden loss of all heart activity, a condition called cardiac arrest], recent RSV [respiratory syncytial virus, inflammation partially or completely blocks the airways] and pneumonia, also very severe heart disease and peripheral vascular disease. She was using her oxygen and did need it all the time because of these things. During an interview on [DATE] at 4:05 PM the Administrator stated, I don't want to determine what [Staff A's name] perceived or did not perceive. He determined that she was fine, he stated that she did not want to go to the hospital, and he thought she was fine. I know that when she had an actual emergency, he did call 911. I can't say that her shortness of breath and chest pain was an emergency to [Staff A's name]. He offered and she stated she did not want to go to the hospital. It was her right to refuse. When asked the Administrator declined to answer if [Staff A's name] was able to assess the resident and able to determine if Resident #1's name was having a medical emergency. During an interview on [DATE] at 10:09 AM the DON stated, I was here when [the Administrator's name] got a phone call from [Staff A's name]. He was on the side of the road near [restaurant's name]. That is the only call we got from [Staff A's name] that I know about. [Resident #1's name] was transported to [local hospital name]. I was here when [Staff A's name] got back, and he was very upset, shook up. The oxygen tank, well, I didn't look at the regulator when [Staff A's name] returned. I just heard it running, it was making a sound. I did not photograph the oxygen tank and I did not look to see whether it was empty or not. I can't say the tank was empty because I wasn't there, but she refused care all the time. So, it's not unusual for her to refuse to do things. I don't know if she had capacity because I was not there with her. I was not in the van with [Staff A's name] so I can't say that I know that she had shortness of breath or chest pain. I wasn't there. But if she did per my Administrator's interview, then no one but [Staff A's name] was in the van with the resident. He is not able to notify her of the consequences of not getting assessed, he would not be able to explain to her that being without oxygen would or could have her in more problems or what the result of not getting medical help would be. But we can't say she was out of oxygen, we don't know that, and we did not look at the oxygen gauge when he returned. So, therefore I can't say that anything happened with her oxygen, or that she was in any distress during the ride. I only have the statement that he gave me, and he thought she was alright. I wasn't called by [Staff A's name] about any chest pain or shortness of breath, so I can't tell you what I would have said to him. If a resident is short of breath and having chest pain, I would tell them to get a nurse to evaluate the resident if they were in the building. During an interview on [DATE] at 10:20 AM the Administrator stated, All the information that I documented during my interview with [Staff A's name] was accurate, he did state that she complained of chest pain and shortness of breath the first time he pulled the van over. He did not call me, or anyone else about the resident at that time, he asked the resident who has the capacity to self-determine if she wanted to go to the hospital and she declined. So, he brought her back here. He told me she was fidgeting and conversing with him during the trip. He did not tell me that she complained of pain when getting off 75, he told me exactly what I wrote. It was around 2 o'clock when [Staff A's name] called me, it was so jumbled, he was frantic and upset. The information I understood at that time [Resident #1's name] required and was sent to the hospital. I can't say because I wasn't with her that she had a medical emergency any sooner than [Staff A's name] recognized it, I was not there. I think that he followed our policies and procedures. I don't think he is able to discuss the consequences of not going to the hospital. But according to [Staff A's name] she was fine during the transport, and he did what he was supposed to do when she was slumped in the chair. During an interview on [DATE] at 1:50 PM Staff A, Transportation Driver /Floor Technician stated, She [Resident #1] had chest pain and shortness of breath up in Gainesville and I asked but she said no she didn't want to go to the doctors, back to there at the doctors. I did not call anyone when she had that pain. I got no training on emergencies like that. I knew that I should call if we needed to call 911. I didn't know that this was a problem, that that might cause her to die. I never did ask her again if she wanted to go to the hospital, just that one time. I didn't talk much to her on the way home, but I would glance up and I would see that she was fidgeting in her chair, she was awake and when I glanced in Ocala, she was all slumped over and the chair was tilted a little, she was tilted to her side. I had a hard time after I pulled over getting her pulled in her seat, so I unbuckled her and moved her to the floor. She couldn't talk to me at all. She didn't tell me that she was short of breath or having any chest pain again after being in Gainesville. That's the only time she said that. She did not say it on the off ramp here in Ocala, she wasn't saying anything. Well, I did know that it was serious her having pain and feeling that way, but she just said she didn't want to go. I just wasn't trained to call for anything but an emergency. I didn't think this was that type of an emergency. Review of the facility time-line documented: 8:49 AM Resident observed by [Staff D's name, CNA/Unit Secretary prior to departing facility for her appointment. [Staff D's name] states she verified that [Resident #1's name's] oxygen e-tank was full at time of departure. 8:55 AM Resident was loaded into the Timberridge transportation van in her wheelchair. Both [Resident #1's name] and her chair were secured. 8:55 - 9:45 AM Resident enroute to her appointment, no signs and symptoms of distress noted. 12:50 PM resident requested to stop for lunch prior to returning to the transportation van and returning to the facility. At this time the driver states he did not notice any signs of distress. 1:00 PM resident is loaded back into the facility van and both she and her chair were secured prior to getting on to the Interstate. Resident stated she believed her oxygen may have been out. Driver immediately suggested that he return her to the health facility to be evaluated. Resident declined. Driver continued to monitor resident during transport. 1:40 PM: Resident complained of chest pain and shortness of breath. Driver immediately pulled over called 911 EMS arrived and assumed responsibility of resident's care. [Approximately 4 hours and 51 minutes after exit from the facility]. 2:02 PM Administrator notified. Review of a handwritten statement by Staff A, Transportation Driver/Floor Technician dated [DATE] as transcribed by the DON read, He stated that while transporting [Resident #1's name] back from her eye appointment [Resident #1's name] was fidgeting with her wheelchair and stated she was out of oxygen. He offered to return her to health facility and she declined. I looked back in the rearview mirror she was fidgeting again she was leaned over to the right side chair was tilted I pulled over and called 911. Review of the job description titled, Van Driver: General description: under general supervision, performs various tasks relating to the transport of residents and passenger vans. Typical duties/responsibilities: Transmits and receives messages per cell phone. Reports accidents or other safety situations to facility supervisor . Review of Resident #1's care plan read, Focus: [Resident #1's name] is at risk for return to hospital due to SOB [shortness of breath], falls, CHF [congestive heart failure], COPD, RSV, PNA [pneumonia]. Interventions: Monitor labs and diagnostic test, monitor/document/report PRN any signs and symptoms of CAD [coronary artery disease], chest pain or pressure especially with activity, heartburn, nausea, vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap [capillary] refill, color/warmth of extremities, new or worsening agitation/delusions, notify MD as indicated. Focus: [Resident #1's name] has congestive heart failure. Interventions: check breath sounds and monitor/document for labored breathing, monitor/document for use of accessory muscles while breathing, check vital signs every shift, notify MD of significant abnormalities, encourage adequate nutrition, offer small frequent feedings, give cardiac medications as ordered, incentives spirometer as ordered, Lasix 40 milligram every two days BID [twice a day] for CHF, monitor/document/report PRN any s/sx [signs and symptoms] of congestive heart failure, periorbital edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation, OXYGEN SETTINGS: per MD orders, weigh per MD orders/ facility policy. Focus: [Resident #1' name] is on diuretic therapy related to CHF. Interventions: Administer diuretic medications as ordered by physician. Focus: [Resident #1's name] is on anticoagulant therapy r/t a-fib [atrial fibrillation - an irregular heart rhythm], h/o [history of] cva [cerebral vascular accident], pvd [peripheral vascular disease. Interventions: Administer anticoagulant medications as ordered by physician. Review of the [Name of oxygen suppler] Standard Invoices dated [DATE] and [DATE] documented the number of cylinders delivered with a material number of OX USPEAWBPLUS [OX USPEAWBPLUS USP (United States Pharmacopeia) Medical Grade Oxygen, Size E High Pressure Aluminum Medical Cylinder With Walk-O2 [oxygen]-Bout(R) Regulator, VIPR 1 [valve wiht integrated pressure regulator]. Review of the document provided by the facility titled, Approximate Hours Of Service For Oxygen Tanks under E Tanks read, Liter flow per minute - 3. Full Cylinder 2,000 lbs. [pounds] 3 ,d+[DATE] hours. Review of the policy and procedure titled, Resident Transportation Safety (Facility Operated Vehicles) read, Policy: Facility operated vehicles used for the purpose of resident transportation will be operated in a manner that will minimize the risk of injury to residents and staff . 9. Each van/facility operated vehicle shall have a telecommunication (cell phone) available to the driver to ensure proper emergency communication. No driver shall use a telecommunication devise while the van is in motion. 10. The driver of the van facility operated vehicle is to report any accident or incident (even if there is no injury or property damage) to the facility administrator and to law enforcement as required by law. 11. If an accident or incident occurs involving a resident that results in suspected or confirmed injury to the resident or if there is a medical emergency involving a resident, emergency service should be requested by calling 911. The administrator is to be notified as soon as possible after requesting assistance for the resident. The van/facility operated vehicle should wait at the location for emergency services to arrive. Review of the policy and procedure titled, Facility Operated Vehicle read, Policy: This policy is designed to maximize employee and resident safety and minimize risk of injuries and property damage. Procedure . 8. Facility operated vehicles shall have a telecommunication system available to the driver(s) to ensure proper emergency communications. Review of the policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation read, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical or mental), neglect, exploitation and misappropriation and the occurrence of an injury of unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. Procedure: The facility shall take steps to prevent, detect, and report suspected maltreatment: 7. Investigation: A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate the procedures for conducting the investigation. The investigation will include: a. They type of allegation, b. What occurred, when, where and to whom? By whom? Get a physical description or identify the alleged perpetrator if possible, c. Describe the injury and any treatment, d. Interview witnesses separately; interview caregivers, roommates; get statements; observe/document demeanor; include names, addresses, and phone numbers of actual witnesses .f. Obtain signed statement from alleged perpetrator, if possible .h. Describe action taken to protect resident .l. If neglect is alleged, identify staff, length of time, and outcome to resident .o. Review any meds that may cause resident to bruise easily or be R/T [related to] nature of the injury .q. Review nurse's notes and other records for information about the incident. Upon completion of the investigation, the facility should prepare a summary report of the findings and conclusions, including any actions taken by the facility. 8. Corrective action: The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. Definitions: Negl [TRUNCATED]

Based on interviews, resident record reviews, and review of policies and procedures, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP) when the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. The transportation driver did not notify the facility licensed medical staff of the resident declining medical care and services and continued to transport Resident #1 back to the facility. Resident #1 suffered cardiac arrest and did not survive. The facility's failure to develop and implement appropriate plans of action to identify and correct process failures of providing emergency care and services for Resident #1 led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on [DATE], at 12:13 PM. The Immediate Jeopardy began on [DATE], and was removed on site on [DATE]. Review of the Cleveland Clinic documentation titled, Hypoxia read, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER [emergency room ]. Hypoxia should be treated right away to prevent permanent organ damage. (My.clevelandclinic.org/health/diseases/23063-hypoxia accessed on [DATE]) Findings include: Review of the facility medical record for Resident #1 documented the resident was admitted with diagnoses of acute on chronic combined systolic congestive and diastolic congestive heart failure (with combined congestive heart failure in systolic, ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic the ventricles cannot relax, expand, or fill with enough blood), RSV (respiratory syncytial virus - is the most common cause of lower respiratory tract infections), pneumonia unspecified organism, dysphasia following cerebral infarction (an area of dead tissue in the cerebrum caused by an insufficiency for arterial or venous blood flow - resulting in an impairment in the production of speech resulting from brain disease or damage) paroxysmal atrial fibrillation (rapid, erratic heart rate begins suddenly and then stops on its own within seven days), acute myocardial infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting left nondominant side, repeated falls, ischemic cardiomyopathy (damaged heart muscle from a lack of blood flow), anemia, atherosclerotic heart disease of native coronary artery without angina pectoris (silent heart ischemia), presence of automatic implantable cardiac defibrillator (a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide an immediate treatment which can be in the form of shock therapy) presence of coronary angioplasty implant and graft (creates a new path for blood to flow around a blocked or partially blocked artery), retinal detachment left eye, occlusion and stenosis of unspecified carotid artery (the narrowing of the carotid arteries), major depressive disorder, idiopathic peripheral autonomic neuropathy (nerve damage when the cause can't be determined), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), essential primary hypertension (high blood pressure), hyperlipidemia, acquired absence of right leg above the knee, acquired absence of left leg below the knee, chronic obstructive pulmonary disease with acute exacerbation (sudden worsening in airway function and respiratory symptoms in people with COPD), non ST elevation myocardial infarction (a type of involving partial blockage of one of the heart arteries, causing reduced flow of oxygen-rich blood to the heart muscle), type 2 diabetes mellitus with other circulatory complications, and acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing a state in which oxygen is not available in sufficient amounts). On [DATE] at approximately 8:45 AM, Resident #1 was transported to a 9:30 AM appointment by a facility transport driver, Staff A, in the facility van to a medical appointment 48.3 miles from the facility. Resident #1 had one oxygen e-tank. Following the appointment, the Staff A and Resident #1 had lunch in the mall where the medical appointment was. On the return trip home, after just getting on the interstate, Resident #1 told Staff A that she thought she was out of oxygen. When Staff A asked if she was okay, Resident #1 said she was short of breath and had chest pain but did not want medical help. Staff A continued on toward the facility. The transport driver saw her fidgeting in her chair. When Staff A pulled off the interstate to go to the facility, he noticed Resident #1 was slumped in her chair. Staff A called 911 at approximately 1:40 PM. [Approximately 4 hours and 51 minutes after exit from the facility]. (Cross Reference F600) During an interview on [DATE] at 9:35 AM the Administrator stated, I'm not really sure about everything that happened, or what was done. I'm sorry I was on vacation and just need to get myself up to speed with everything that has been done. [The Administrator was notified of the event on [DATE] at 2:02 PM]. During an interview on [DATE] at 11:30 AM the Administrator, in the presence of the DON stated, [Staff A's name] was transporting [Resident #1's name]to her eye appointment, and she stated, I think I'm out of oxygen, he pulled over and asked her if she wanted to go to the hospital and she said no, because she has a BIMS [Brief Interview for Mental Status] of 15 [this score means cognition is intact], it was her right to refuse to go. We have no way of knowing whether the oxygen tank was empty or not. We don't know whether this contributed to the event. But once he did recognize an emergency, he did follow our policy for transportation and did call 911. [Staff A's name] was trained on transport, and he followed the training. He is not cardiopulmonary resuscitation [CPR] trained to my knowledge. We did not, after the investigation, think that we needed to QAPI [Quality Assurance and Performance Improvement] this, she was of sound mind and competent to make her decision not to get medical treatment. We did not do an Ad Hoc [from the Latin and means for this] QAPI related to this. We did not do a Root Cause Analysis [RCA] to determine if there were any other factors or breaks. She had the right to refuse treatment, it was her right to do that. We do plan on discussing this during our next QAPI on the 25th. Review of the policy and procedure titled, Quality Management read, Vision Statement: This facility will create a caring and nurturing environment, focused on professionalism and excellence in service delivery. The facility strives to be the provider of choice as well as the employer of choice in our community. Purpose: Through quality assurance and performance improvement (QAPI), the facility will take a proactive approach to continually improving care and services for our residents. The facility will involve residents, staff, and other partners to realize our vision of being both the provider and the employer of choice in this community. To do this, all employees will participate in ongoing QAPI efforts to support our mission of providing quality focused care, one resident at a time. Guiding Principles: The facility will use QAPI to make decisions and improve the day-to-day operations. QAPI will include all employees, every department, and all services provided. QAPI focuses on systems and processes, rather than individuals. The facility will have a culture that encourages, rather than punishes, staff who identify errors or system breakdowns . The facility will make decisions based on data, which will include the input and experiences of caregivers, residents, health care partners, families and other stakeholders. The facility will set goals for performance and measures progress toward those goals. The desired outcome of QAPI in the facility is to improve quality of care and the enhanced quality of life of our residents. Policy: The Administrator is responsible for the quality assessment and assurance committee for the facility. The facility will have an internal Quality Assurance and Performance Improvement Program designed to provide a comprehensive approach to ensuring high quality care and services. The QA&A [Quality Assurance & Assessment] Committee, referred to as the QAPI Committee, will meet at least monthly and will utilize the 5 Elements of QAPI which are: 1. Design and scope - ongoing program and is comprehensive, dealing with the full range of services offered by the facility. The QAPI program will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 2. Governance and Leadership - the governing body (administration of the facility) will develop a culture of seeking input from facility staff, residents, and families while assuring adequate resources to conduct QAPI efforts. QAPI will be a priority and will include setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. 3. Feedback, Data Systems and Monitoring - the facility will put systems in place to monitor care and services through the use of multiple sources. Feedback systems will incorporate input from staff, residents, families, and others. Performance Indicators will monitor a wide range of care and outcomes and findings will be compared to benchmarks or targets established for performance. 4. Performance Improvement Projects (PIP's) - involves gathering information systematically and intervening for improvement with a written work plan by the project team and a timeline. 5. Systematic Analysis and Systematic Action - the facility will model and promote systems thinking, practice root cause analysis and take action at the systems level. Composition and duties of the QAPI Committee: the facility administrator and Department Leaders will create an environment that promotes quality improvement and involves all caregivers. The residents, families and staff will be encouraged to bring quality concerns forward to the Committee without fear of reprisal. The committee will be expected to build effective teamwork among departments and caregivers, emphasizing effective communication across shifts and between departments. The Committee is comprised of: Medical Director, Administrator (serving as Chairperson), Director of Nursing, Risk Manager, Safety Committee Leader, Care Plan Coordinator, Activity Director, Social Service Director, Food Service Manager, Maintenance Supervisor, Laundry/Housekeeping Supervisor, Infection Control Preventionist, Other Facility Staff, Guests or Designees as indicated. 2. The Committee will identify opportunities for improvement as well as recommend, implement, monitor and evaluate changes. The Committee will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 3. The Committee will obtain data from multiple sources, including Performance Indicators which are benchmarked, and will incorporate input from staff, residents, families, and others as appropriate. 4. The Committee will charter Performance Improvement Projects (PIP's) to provide concentrated efforts to address a particular problem areas identified in one part of the facility or facility wide. The facility conducts PIPs to examine and improve care or services by gathering information systematically to clarify issues and intervening for improvement. 5. The facility will be proficient in the use of Root Cause Analysis to determine how identified problems may be caused or exacerbated and will look across all involved systems to prevent future events and promote sustained improvement programs. 6. Once the root cause has been established, changes or corrective actions tightly linked to the root cause will be implemented. These changes or corrective measures should offer long term solutions to the problem, and must be achievable, objective, and measurable. 7. The Committee will review Performance Improvement Projects each month to monitor and provide feedback to sustain continuous improvement. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated [DATE] documented the facility has initiated the following steps to ensure proper utilization of the QAPI process. [DATE] Ad Hoc QAPI meeting held to discuss a resident change in status while being transported from a Physician appointment. QAPI committee completed root cause analysis with the following findings: Facility did not ensure resident was supplied with sufficient oxygen (E tanks) for the duration of the trip. Facility failed to educate driver to notify the facility or emergency personnel of any changes in resident status at the time of the change. QAPI committee completed: All staff education on abuse and neglect. Oxygen Transportation Education for LPNs and RNs. Transport Driver education to call emergency personnel in the even {sic} of any resident change of status. Transportation Driver training in American Heart Association CPR, First Aide and Transportation Safety. Transportation Policies and Procedure update for RN, LPN, Drivers, Administrative Staff. An Ad Hoc QAPI meeting was held again on [DATE] to review the IJ template and approved the final remediation plan. The plan was approved as written. Facility alleges compliance with immediate jeopardy removal on [DATE]. Review of the Internal Risk Management and Quality Assurance Performance Improvement Program Meeting Minutes dated [DATE] documented the Administrator, DON, Medical Director, Care Plan Coordinator, Activity Director, Social Service Director, CDM/Food Service Director, Maintenance Supervisor, Laundry/HKPG [housekeeping], Infection Control Preventionist and four additional staff members signed as attending the meeting. On the agenda of the meeting was resident change in status while being transported from a physician's appointment. Review of the Root Cause Analysis (RCA): TR - Transport documented it was completed dated [DATE]. Review of the In-Service Record titled, Re-Education on Resident Transportation Safety Policies and Procedures documented five (5) staff signed as having attended the training completed on [DATE]. Three staff were transport drivers, the other two staff members consisted of the Human Resource Director and the Maintenance Director. During interviews it was stated they attended for the education of the required training. The Maintenance Director oversees the transport drivers. Review of the American CPR Care Association cards documented 3 of 3 transportation drivers completed AED, Adult, Child, Infant CPR & AED Training (BLS) on [DATE]. Review of the In-Service Record dated [DATE]-ongoing, completed [DATE], titled, Oxygen Safety, Ensure that residents leaving the facility with oxygen have a full tank per MD [Medical Doctor] orders documented 67 licensed staff, 32 CNAs [Certified Nursing Assistants], the Maintenance Director, and Human Resource Director signed as attending the training. Review of the In-Service Record documented the [NAME] Clerk signed attending training titled, Transportation Arrangements. Observations were conducted on [DATE] of two residents, being administered oxygen, being transported to physician appointments. A check list was completed for the residents and a licensed nurse attended with each transport. Review of the Internal Risk Management and Quality Assurance Performance Improvement Program Meeting Minutes dated [DATE] documented the Administrator, Director of Nursing, Medical Director, Infection Control Preventionist, and an additional staff person, was in attendance and the Removal Plan was approved. Interviews were conducted with two of three of the transportation drivers, the Maintenance Director, the Human Resources Director, regarding transportation safety policy and procedures and oxygen tanks and safety. Interviews were conducted with 24 CNAs, and 16 licensed who stated they had completed training on abuse, neglect, exploitation, oxygen safety, and the oxygen tanks.

Based on record review, interview, and policy and procedure review, the facility failed to ensure adequate supervision was provided to prevent accidents and/or injury when using a mechanical lift device during a resident transfer for 1 of 3 residents sampled for device-assisted transfers, Resident #1. The facility staff failed to implement proper transfer procedures when using a mechanical lift and failed to follow the facility's policy and procedure for using a mechanical lift with transfers. This had the potential to affect 36 out of total 144 residents in the facility who require mechanical lift transfer assistance. Findings include: Review of Resident #1's medical records revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. enough oxygen or has too much carbon [MEDICATION NAME]), status [REDACTED]. Review of the Minimum Data Set Comprehensive Admission assessment dated [DATE] revealed Resident #1 could not complete the Brief Interview for Mental Status (BIMS) assessment, and that Resident #1 required two-person physical assistance with total dependence on staff for transfers between surfaces from bed to the chair. Resident #1 was not steady during bed to chair transfers and required human assistance to stabilize during transfers due to functional impairment of upper and lower extremities. Review of the care plan for Resident #1 dated February 4, 2020 revealed the resident required total assistance with Activities of Daily Living (ADL) and full body mechanical lift for all transfers. Review of the Certified Nursing Assistant plan of care revealed Resident #1 required two-person assistance and mechanical lift (A battery-operated lift that safely transfers individuals) use. Review of the nursing progress note authored by the Assistant Director of Nursing dated 3/23/2020 at 9:45 AM read, Called to resident's room to assess for injury s/p (status [REDACTED]. Resident was wearing a gown, brief, left [MEDICAL CONDITION] glove and B/L (bilateral) knee braces. Wound vac and indwelling catheter were in place, G (gastrostomy) tube feeding was disconnected. Therapists and nursing staff had been transferring resident from bed to chair when resident fell forward and onto the floor. Staff removed the mechanical lift and log rolled resident to her back. Her eyes were opened, and she was mumbling incoherent words. resident sustained [REDACTED]. Small abrasion noted to right arm. Cleaned face with normal saline and 4x4 gauze than applied pressure to forehead and nose to stop the bleeding. Wound vac and bilateral braces were removed. 911 called to transfer resident to ER (emergency room ) for evaluation and treatment as ordered. Review of a written statement from Staff B, Physical Therapist (PT) dated 3/23/2020, 9:40 AM, read, Patient was assisted for Hoyer transfer room from bed to Broda chair with (Staff C's name) Certified Nursing Assistant (CNA), Staff A, Occupational Therapist (OT) and this writer in pt.'s (patient's) room. Hoyer pad was already placed under patient when this writer arrived in the room. CNA was standing on the right side of bed and put on right top and bottom straps. OT was standing to the left side head of bed and put on left top strap, this writer placed on the left bottom strap as this writer was standing left side foot of bed. As patient was cleared from bed, this writer went to retrieve the Broda chair from window side of the room, began to push Broda chair towards bed, this writer saw patient lost balance, forward falling out of pad face down on floor. Nursing was called immediately. Review of a written statement from Staff A, Occupational Therapist (OT) dated 3/23/2020, 9:40 AM, read, This writer and patient's Physical Therapist (PT) and CNA assisted patient with transfer out of bed. Hoyer pad was already placed under patient when writer arrived to room. CNA was standing on right side of bed and attached top and bottom Hoyer straps on right side. This writer attached top Hoyer strap and PT attached bottom strap. When all 4 straps were secured, CNA started to lift pt. (patient). This writer leaned over bed to reach bed control on right side of bed to lower bed further as CNA proceeded to operate Hoyer away from bed stating: I'm clear when coming back from reaching over bed, this writer observed pt. (patient) suspended on Hoyer pad facing this writer and fully cleared from bed as patient slowly lost balance forward falling out of the Hoyer pad. This writer went to notify nurse supervisor to room immediately. Review of Investigation Notes from the Risk Manager (RM) read, 03/23/2020 at 10:20 AM Risk Manager informed of fall with transfer to hospital. (Staff C's name) interviewed with Director of Nursing present. (Staff C's name) stated she was controlling the Hoyer. She stated she was on the right side of bed and therapist were on the left. Per (Staff C's name) she began to lift resident up and cleared the edge of bed. Per (Staff C's name) she began to turn lift slightly to prepare to get her to chair and suddenly resident slid out of pad. (Staff C's name) questioned regarding who placed pad, she stated she placed pad and also attached the front to lift sling hooks. (Staff C's name) stated (Staff A's name) placed the two leg sling hooks. (Staff C's name) was also given lift and asked to demonstrate how procedure occurred. (Staff C's name) stated she only put on resident shirt and brief and then prepared pad under resident with head cradled midway on pad. Return demonstration shown by (Staff C's name) using lift. 3/23/2020 at 1:00 PM: Risk Manager, DON (Director of Nursing) and Therapy Director present and (Staff A's name) interviewed. (Staff A's name) was asked to demonstrate transfer and show us team where she was positioned. Per (Staff A's name), she was on the left side of the bed, (Staff A's name) states she asked (Staff C's name) about straps and she placed them. (Staff A's name) stated that she also placed catheter tubing and wound vac (portable unit) on resident's lap in sling pad. Per (Staff A's name), (Staff C's name) began to lift resident up from bed and cleared bed and began to turn and resident slid out of sling. (Staff A's name) stated that she saw resident start to slide before she could get around to other side of bed. (Staff A's name) questioned regarding resident's position and stated that resident was facing her, and (Staff C's name) was at an angle toward room door controlling lift. (Staff A's name) was asked to write a statement and she said she would. 03/23/2020 at 1:25 PM: (Staff B's name) was interviewed in main conference room. DON, RM (Risk Manager), and Therapy Director present. (Staff B's name) was asked to explain events as she remembered. (Staff B's name) stated she was standing on left side of bed closer the foot of bed. Per (Staff B's name) she was applying knee braces and checking them. She stated she moved from bed to go retrieve chair which was located in room near window. (Staff B's name) stated that she turned to return chair nearer to bed when resident started to fall from sling, and she could not get to her quick enough. (Staff B's name) stated when asked about taking care of resident previously that she also assisted with transfers on Friday, herself and (Staff A's name) got (Resident #1's name) out of bed and aide was not in room. Aide was providing care to another resident at that time. RM and DON checked lift, lift inspected 2019 by Wings Healthcare. Sling also checked and in good condition. No frayed areas. DON notified Administrator. Administrator informed of events. DON and Administrator phoned significant other. Plan of Care was followed and checked. Assistant Director of Nursing was also interviewed. RM informed DON to err on side of caution, will report. A review of Investigation Review with no date or time, signed by the RM read, Risk Manager spoke with staff involved again. Therapist nor aide could state hands were on resident. All stated lift cleared bed. Identified need for mechanical lift re-education. Spoke with Staff Educator to schedule mandatory lift training for all nursing and therapist. A review of Investigational Review/Findings/Summary/Conclusion (Reasonable Cause) with no date or time, authored by the Risk Manager read, Risk manager spoke with staff present during the fall. Staff provided account of transfer via demonstration using mechanical lift. All involved stated resident had cleared the bed. CNA was operator of lift and demonstrated knowledge of use proficiently. Therapists both stated that they had resident on prior week and performed transfer using lift. Mechanical lifts evaluated and all were inspected December 2019 by Wing healthcare. Vanderpad/sling also inspected with no signs of frays noted. Random reviews of staff using lifts also completed and RM identified need for reeducation of mechanical lift use. Staff involved in fall stated loops used were black on bottom and green on top. This caused the resident to be in a more upright position when in the sling. RM also noted that staff are not always using specific colored loop, identified need to include this in reeducation. RM investigational findings have determined that reasonable cause is attributed to techniques use during mechanical lift transfers. Spoke with DON/Administrator and educator regarding need to schedule mandatory training on sling positioning. Loop application and body positioning during mechanical lift transfers. Staff retraining using lifts has been scheduled. During an interview with Staff C, CNA on 4/2/2020 at 8:50 AM, she stated, I am the CNA who was taking care of Resident #1 the morning that she fell . There were three of us, (Staff A's name) from OT and staff from PT. I was operating the Hoyer lift, (Staff B's name) was on one side and (Staff A's name) on the other side. (Staff B's name) went to get the chair and as I pulled out the machine, she just leaned forward in the sling pad and she was face down on the floor bleeding. I really can't tell you how it happened. I was on one side of the bed, (Staff A's name) was on the other side, no one was touching or guiding the sling when the patient fell . I know that when we use the mechanical lift we should be able to touch the resident or have our hand on the back of the sling or have the residents facing us, it happened so quickly that I didn't have time to turn her toward me and (Staff A's name) was still on the other side of the bed. We always have two people when using the lift. I didn't know everything about the patient, but I did get report and I knew that she was not able to move, and she needed full assistance. I had just cleaned her up and changed her brief and put the lift pad under her, so I knew that she couldn't move almost at all. During an interview with Staff A, Occupational Therapist (OT) on 4/2/2020 at 10:15 AM, she stated, We, PT and OT, were working with Resident #1 giving her passive range of motion while she was supine in bed with the Hoyer lift (Vander) pad already under her. The CNA was on one side of the bed operating the lift, after the hooks were positioned on the lift, I leaned over to get the bed control to lower the bed when the Aid stated I'm clear and pulled the machine out from under the bed. Before I could get to the other side of the bed, I saw the patient lean forward and I couldn't get there soon enough to stop the fall. She ended up on the floor face first and I went to get a nurse. Usually there are two people assisting with mechanical lifts and one person operates the machine and the other person guides the resident into the chair. The resident should not have at any time been hanging in the sling without staff holding the lift/sling pad. Someone should have been holding the sling/lift pad or have the resident facing the person who is operating the controls so they can have hands on the patient's knees/legs. I have worked with this resident before and have used the mechanical lift to get her out of bed without any problems. I do feel comfortable in using that piece of equipment. During an interview with Staff B, Physical Therapist (PT) on 4/2/2020 at 11:42 AM, she stated, When I came to the room (Resident #1's name) was already dressed, with the Hoyer sling pad under her, the CNA was operating the lift machine. I was splinting her extremities and placed the straps on the mechanical lift. I was on the right side of the bed and (Staff A's name) was on the left side. I stepped away to get the resident's chair and when I did the resident fell out of the sling face first onto the floor. The chair was about five feet away near the window in the room. I guess we had a failure to have hands on the resident during the transfer. (Staff A's name) was trying to lower the bed and (Staff C's name) said it's clear and she began moving the machine. I have been working with the resident and know that she has had [MEDICAL CONDITION] hemorrhagic stroke with no arm or leg use, no reflexes, no verbal expression and no trunk control which makes her a high risk for falls. She also has flexor tone in arms and legs. The leadership staff did have the three of us reenact the fall and what we were doing when it happened. It showed me that there was a lack of physical assistance for the resident during the transfer process. We should have had her within reach, holding the back of the sling or had her positioned to be facing whoever was operating the mechanical lift so hands can be on the sling or on the resident's knees to stabilize them. During an interview with the Director of Nursing on 4/2/2020 at 09:05 AM, she stated, Part of our thought was that the resident needed to be less upright during the transfer. There were two staff with (Resident #1's name) when she fell that had worked with her extensively and had just a week prior to the fall did a mechanical lift transfer on the resident. This occurred when staff broke contact with the resident and the sling pad and the resident had a sudden movement that propelled her out of the sling and onto the floor. Someone ideally will position the resident to face them if they are operating the mechanical lift, this will ensure that the knees or legs can be supported until the resident is safely in the chair. Also, if they don't reposition the resident to face them they should maintain hands on the lift pad either the loops on the back of the sling that assist in guiding patients into position or on the sides of the lift sling. These did not happen in this case; the aid did not turn the patient to face her and no one was in position to have hands on contact with the lift pad while the resident was in the air and not over the bed. During an interview with the Risk Manager on 4/2/2020 at 9:35 AM, she stated, I was notified that (Resident #1's name) sustained a fall. I began an immediate investigation and started to get interviews. No staff indicated that they were in contact with the resident or the lift pad sling. We had them demonstrate what they were doing at the time (Resident #1's name) fell . (Staff C's name) was operating the lift machine. (Staff A's name) was on the other side of the bed and (Staff B's name) was getting the residents Broda chair. During the investigation we determined that they had not followed procedure and have hands on the resident. We also found that there was no consistent usage of the loops on the sling that determine how upright residents are when they are being transferred in the sling. Review of the facility's Plan of Correction read, Proper and safe placement of resident on Hoyer lift sling. Follow up: Resident sent to local hospital Date: 3/23/20. Hoyer lift and sling involved immediately removed from unit and were checked by maintenance and housekeeping personnel to ensure lift was in proper working order and sling in good repair. Results of inspection were Hoyer lift and sling were in good working order and repair. PIP (Performance Improvement Plan) initiated 3/23/2000. Dates: 3/23/2020 All current residents requiring use of Hoyer lift were monitored during transfer to ensure safe positioning and contact guard was maintained. 3/24 -29/2020. All Hoyer lifts and slings were inspected by maintenance and housekeeping personnel and found to be in good working order and in good repair. QAPI (Quality Assurance Performance Improvement) meeting held on 3/24/2020 and 4/2/2020 to review, investigate and make changes as necessary to ensure proper and safe placement of residents in slings. Mandatory Hoyer lift skills training with return demonstration conducted for all licensed nursing staff, CNAs and therapy personnel with procedure changes made to use of sling. New audit tool implemented 4/4/2020. Audits tools were done for the immediate time frame for resident safety). The new tool also requires an auditory response as well. They have to tell what they are doing and why. Any nursing personnel or therapy personnel who have not received training will not be allowed to assist with Hoyer transfers until training is completed. Ongoing mechanical lift competency training will continue upon hire and annually for licensed staff, CNAs and therapy personnel. Daily audits will be conducted (to include all shifts) of residents requiring Hoyer lifts. DON/designees to conduct auditing daily and if indicated corrective measures will be taken immediately as concerns are identified. This plan of correction will be brought to the QAPI committee monthly and the committee will decide whether to continue the monitoring period or discontinue based on effectiveness of the plan. Fifty-eight Hoyer/Vander lift transfer audits have been completed to ensure that residents are properly positioned during transfers. Review of the Mechanical Lift Training sign in sheets revealed 89 of 120 staff completed training titled, Lifting and Positioning Training as of 4/2/2020 with repeat demonstration. During an interview with the Director of Nursing on 4/2/2020 at 09:05 AM, she stated, We have started facility wide education with all staff who could use the mechanical lift to transfer residents. These began on 3/30 and will end tomorrow and it is mandatory for all staff. Part of our thought was that the resident needed to be less upright during the transfer, so we are now positioning patients, so they are more cradled as opposed to upright sitting in the mechanical lift sling/pad. We did have the involved staff come to the conference room and demonstrate what they were doing at the time of the fall. We evaluated the Vander lift and determined that it had been serviced and checked in 12/2019 and evaluated the sling/pad for any signs of wear and fraying and it was in good condition. During a follow up interview with the Director of Nursing on 4/3/2020 at 11:46 AM, she stated, I believe there was a failure to follow the procedure due to a lack of knowledge and understanding. We reviewed the Process improvement Plan (PIP), have begun auditing and observing transfers to monitor the mechanical lift training education by observing transfers. I expect that all staff will follow the policy and procedures for mechanical lift use. During an interview with Staff C, CNA on 4/2/2020 at 8:50 AM she stated, I am the CNA who was taking care of (Resident #1's name) the morning that she fell . We have had training on how to use the mechanical lift in our annual competencies and I did go through the mandatory training we just had. I was required to demonstrate the proper use of the mechanical lift with the training I went through. During an interview with Staff G, LPN (Licensed Practical Nurse) on 4/2/20 at 9:01 AM she stated, I have been trained on how to use the mechanical lift and had to demonstrate how to use it. We always have two people operating the mechanical lift. We make sure the wheels are locked. One person operates the lift while the other person maintains hands on the resident for safety. During an interview with Staff F, CNA on 4/2/2020 at 09:10 AM she stated, I have received training related to the proper use and resident positioning in a mechanical lift sling. I was asked to do return demonstration also. To operate a mechanical lift we usually have two people or three people. We go in and ask the patient to roll. We tuck the pad under the person, then we place the lift under the bed and lock the lift. We hook the pad on the second hole. We position the chair and one person would come around, so we are both on the same side of the bed One person is operating the lift, the other person is assisting with the chair and holding the pad. The other person will lower the lift. We make sure the resident is situated in the chair. We should not let go and let the patient free dangle in the air and we should not let go of the Hoyer lift pad. During an interview with Staff I, LPN on 4/2/2020 at 9:32 AM she stated, I have received training on how to use the mechanical lift and I did have to do a repeat demonstration process during the in-service. During an interview with Staff N, CNA on 4/2/20 at 10:16 AM she stated, I have received the recent education and training on mechanical lift use and had to show them I could do it. To transfer a patient using a lift you can't' do it yourself. You have to have someone with you. One person operates the lift and the other person guides the resident to make sure they are safe to prevent falls or skin tears. Sometimes, I would have to hold on to their feet or their knees but usually I guide them by holding the straps until they are seated in the chair. During an interview with Staff J, CNA on 4/2/20 at 10:23 AM she stated, I was at the new training on how to use the mechanical lifts. I was required to repeat demonstrate how to use it properly. First you get a pad, you either have them roll over or roll them over. Tuck the pad under them making sure there are no wrinkles and have it cradling their head. You put the bottom part about the back of the knee. Once they are hooked to the lift, one person will operate the lift the other person will hold the resident. Usually, you hold the straps or the resident's legs. Do not let go of the person until they are securely in the seat. Usually, holding onto the pad this keeps their direction so there is not any swinging when they are in the sling. During an interview with Staff O, CNA on 4/2/20 at 10:40 AM she stated, I did receive education on how to use the mechanical lift and proper resident placement to prevent any falls. Depending on the care plan, we use two or three people. First, we put them on the pad properly, then hook the pad on the second hole from the top. We make sure that the lift is locked. One person operates the lift and another staff holds the pad on both sides guiding the patient. After the resident is in the chair and their bottom is seated then you can let go of the pad. Review of The (Manufacturer's name) Lift policy and procedures read, (Manufacturer's name) lift Effective date 1/2000 Policy: To be used to transfer patents who require high levels of care or are too heavy to handle (Patients up to 350 lbs. of weight). Prior to the use of the (Manufacturer's name) lift, the patient must be evaluated by a licensed nurse to determine the use of the lifter and the need for one or two employees. Procedure: #14. Use the stabilizer handles to guide the patient into the chair. Review of the hospital records for Resident #1 dated 03/23/2020 revealed, Patient presented as a Level 1 trauma alert on 03/23/2020 after she was dropped during patient transport at Timberridge Rehab Center. Per EMS (Emergency Medical Services) patient fell with direct impact to her pace. Patient is nonverbal at baseline and has a G (gastrostomy) tube. Per EMS, patient was GCS 8 (Glasgow Coma Scale - a tool used to assess patients in a coma. The initial score correlates with the severity of [MEDICAL CONDITION] and prognosis. Patients with scores of 3-8 are usually said to be in a coma). Patient was evaluated as per ATLS (Advance Trauma Life Support) guidelines: A (Airway) - not patent; B (Breathing) - no breath sounds heard; C (Circulation) - 2+ pulses throughout; D (Disability) - GCS 5; E (Exposure) - Patient exposed for secondary survey (is performed once a patient has been resuscitated and stabilized. It involves a more thorough head-to-toe examination, and the aim is to detect other significant but not immediately life-threatening injuries.) Secondary survey revealed: 6 cm (centimeter) laceration with hematoma in the R (right) frontal area. 1 cm laceration over nasal bridge - Obvious deformity of nose. Bruising of R knee. Sacral wound with disconnect wound vac. Review of the CT (Computed Tomography) Brain dated 03/23/2020 revealed: Large volume R hemispheric SDH (Subdural hematoma - a type of bleeding in which a collection of blood - usually associated with a [MEDICAL CONDITION] - gathers between the inner layer of the dura mater and the arachnoid mater of the meninges surrounding the brain) (25mm) (millimeters) R frontoparietal and temporal region with compression of the R lateral ventricle and effacement of the sulci throughout the right hemisphere. R-L (right to left) midline shift at least 12 mm. (A shift of the brain past its center line). Injuries/Problems: R sided SDH with midline shift. Surgeries/Procedures: Emergent OR (operating room) with (The physician's name). Neuro (neurology): GCS 3T (deep coma). R sided SDH with midline shift. {Physician's name} consulted: Taken to OR emergently.