Every finding on record at Valencia Hills Health and Rehabilitation Center

Based on record review and interviews, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices related to completing required Daily Medicare/Managed Care nursing notes and weekly skin assessments needed for ongoing monitoring for one resident (#1) out of three sampled residents. These failures resulted in an incomplete medical record documenting the resident's condition and care.Findings included: Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including, but not limited to, fracture of an unspecified part of the neck of the left femur, subsequent encounter for closed fracture with routine healing; unspecified peripheral vascular disease; and a non pressure chronic ulcer of the left heel and mid foot with fat layer exposed. The resident was transferred to the hospital on 8/16/26, after 44 days in the facility, and did not return.Review of Resident #1's transfer form dated 7/2/26 showed the resident had a left heel pressure injury, was not ambulatory, and was receiving antibiotics for a wound infection.Review of the Nursing Admission/readmission Screening/History dated 7/3/26 at 3:32 p.m. showed the reason for admission was hip fracture (fx). The screening showed the resident was alert and oriented to person, place, time, and situation, with intact cognition. The resident appeared well nourished; range of motion was within normal limits in bilateral upper and lower extremities; and the resident required assistance from staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. The resident utilized a wheelchair for mobility, voiced no pain, and exhibited discoloration in both arms/hands and both legs. No treatment was ordered or required. The admission detail note instructed nursing staff to Note all skin issues, but the section was blank, and Treatment ordered or required: 0 was documented.Review of Resident #1's weekly skin sweeps showed two of six weekly opportunities were completed. Skin Sweep Weekly forms dated 7/6 and 7/29 were present, but no skin sweeps were completed during the weeks of 7/13, 7/20, 8/3, and 8/10/26, despite identified risk to the resident's skin integrity.Review of Resident #1's record showed that on 7/6/26 (three days after admission), a left heel wound was identified during a skin sweep. The treatment record showed no wound care to the resident's left heel was completed from 7/3 to 7/6/26.Review of Resident #1's treatment record showed daily wound care on 7/6 and 7/7, followed by every other day wound treatments to the left heel until discharge on [DATE]. The treatment record instructed staff to wrap rolled gauze around an inner dressing and an abdominal (ABD) pad every other day from 7/9 through 8/16/26.Review of Resident #1's treatment record also showed an order in place from 7/8 to 7/17/26 instructing staff to apply a skin barrier to bilateral heels every day and evening shift for ten (10) days. Documentation showed staff applied skin barrier to the right and left heels twice daily for ten days.Review of the Daily Medicare A/Managed Care Nursing Notes showed daily evaluations were completed thirteen times during the resident's 44 day stay. Evaluations were not completed on 7/6-7/18, 7/20-7/24, 7/28, 8/1-8/5, 8/7, and 8/10-8/14/26.An interview was conducted on 8/31/26 at 3:06 p.m. with the Director of Nursing (DON). The DON stated residents receiving skilled care, including Resident #1, required Daily Medicare A/Managed Care clinical notes every day, along with documentation supporting the care provided. The DON reviewed Resident #1's chart and agreed daily notes should have been present but were not reflected in the medical record. The DON also reviewed treatment documentation related to the application of skin barrier to both heels and stated staff would not have been able to apply skin barrier to the left heel twice daily due to the wound dressing in place.Review of the policy Skin Care and Wound Management - Regular Skin Inspections and Prompt Interventions to Address Changes, undated, revealed: The facility will inspect the resident's skin on a regular and ongoing basis to provide documentation and prompt interventions for any changes noted.1.Skin inspections will be conducted by the licensed nurse using the skin sweep form for documentation at the time of admission and weekly.2.Any identified skin impairment will be documented by the nurse at the time of discovery and weekly thereafter until healed, using the appropriate Skin Grid form. Pressure related impairments require the Skin Grid - Pressure form; all non pressure impairments such as surgical wounds, skin tears, bruises, etc. should be documented.Review of the policy Clinical Documentation, undated, revealed: 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. The policy stated the medical record should provide:1.A complete account of the resident's care, treatment, and response.2.Information for the physician when prescribing and managing care.3.A description of care and services used for measuring quality of care.4.An ongoing record of the resident's physical and mental status.5.Information for developing a plan of care.6.Elements supporting quality medical care.7.Documentation protecting physicians and the facility.8.Documentation required to support reimbursement.Guidelines included: All records must be accurate, legible, dated, and timed. Documentation should be completed as soon as possible following any event, evaluation, assessment, or change in condition.Documentation required at admission includes, but is not limited to, a Complete Body Audit (birthmarks, ostomy site, pacemaker/defibrillator presence, site and size of scars, rashes, burns, reddened areas, dry skin lesions, pressure ulcers, burns, general cleanliness of the body, hair, nails, etc.).

Based on record reviews and interviews, the facility failed to provide necessary wound care services to one resident ( #1) out of three residents reviewed, failed to assess and document an existing arterial wound on admission, failed to obtain wound care orders for three days, and failed to maintain dressing integrity, resulting in conditions that allowed larvae to hatch in the resident's wound.Findings included: Review of Resident #1's admission Record showed the resident was admitted from an acute care hospital on 7/3/26. Diagnoses included fracture of unspecified part of the neck of the left femur, subsequent encounter for closed fracture with routine healing; unspecified peripheral vascular disease; non pressure chronic ulcer of the left heel and mid foot with fat layer exposed; and arteriosclerosis of native arteries of the left leg with ulceration of the heel and mid foot. The resident was admitted for a short term stay.Review of Resident #1's Agency for Health Care Administration (AHCA) Form 5000 3008, dated 7/2/26, showed the resident's primary diagnosis was hip fracture, and another diagnosis was a left (L) heel ulcer. The skin care assessment documented a left heel pressure injury. The risk alert included pressure ulcers, and further information showed the resident was receiving antibiotics for an unspecified wound infection.Review of the Nursing Admission/readmission Screening/History, dated 7/3/26 at 3:32 p.m., showed the reason for admission was hip fracture (fx). The screening showed the resident was alert and oriented to person, place, time, and situation, with intact cognition. The resident appeared well nourished; range of motion was within normal limits in bilateral upper and lower extremities; and the resident required assistance from staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. The resident used a wheelchair for mobility, voiced no pain, and exhibited discoloration in both arms/hands and both legs. No treatment was ordered or required. The admission detail note instructed nursing staff to Note all skin issues, but the section was left blank, and Treatment ordered or required: 0 was documented.Review of Resident #1's Daily Medicare/Managed Care note dated 7/3/26 at 3:52 p.m. revealed Skin/Wounds: No new changes to skin integrity noted, and the wound description field was blank. The note documented No signs/symptoms of infection and Skin/Wound Treatments: None of the above. No new orders were received, including wound care orders. The note showed the resident did not have an infection.Review of Resident #1's Daily Medicare/Managed Care note dated 7/4/26 at 8:54 a.m. revealed the resident rated pain as hurts a little bit, without documentation of pain location. No new orders were received, and no treatments were initiated. No infections were documented, and no new changes to skin integrity were noted. The wound description showed no signs/symptoms of infection, and Skin/Wound Treatments: none of the above.Review of Resident #1's nursing notes dated 7/4/26 at 2:52 p.m. revealed the resident complained of left foot pain rated 8 out of 10 and stated acetaminophen did not relieve the pain. A nursing note dated 7/5/26 at 11:31 a.m. revealed the resident continued on oral antibiotics with no adverse reactions.Review of Resident #1's Daily Medicare/Managed Care note dated 7/5/26 at 7:39 p.m. showed the resident was alert and oriented to person and place, required assistance with turning and positioning in bed/chair, and required assistance with transferring in/out of bed/chair. The resident's pain level was 3/10, no new changes to skin integrity were noted, there continued to be no signs/symptoms of infection, and no skin/wound treatments were documented. The note showed the resident did not have any infections and was receiving physical, occupational, and speech therapies and had no nursing services.Review of a Situation, Background, Appearance, Recommendations (SBAR) dated 7/6/26 at 4:24 p.m. showed Resident #1 had a change in skin color or condition. The note stated, While doing a skin sweep noticed a wound on resident's left (L) heel, wound on top of L ankle, skin tear on right outer lower leg, and redness around groin and peri area. Cleaned wounds with normal saline (NS), applied an abdominal (ABD) pad on L heel, applied gauze on L ankle wound, then both wounds wrapped and taped. Barrier cream applied to groin and peri area. MD and family notified.Review of nursing notes dated 7/6/26 at 4:36 p.m. showed staff spoke with Resident #1's family member, who informed staff of an upcoming vein and vascular appointment to determine need for amputation.Review of the nurse practitioner (NP) note dated 7/6/26 at 1:00 a.m. (signed on 7/13/26 at 8:20 p.m.) revealed Resident #1 was seen for follow up on antibiotic therapy for a left leg wound infection. The resident continued on oral antibiotics. The assessment of the arterial wound on the left heel showed the wound measured approximately 12.5 x 7.0 x 0.5 centimeters (cm), with the wound bed presenting 10% slough, 80% necrosis, 10% granulation tissue, and moderate serous drainage. The NP documented instructions to Assess the wound site daily for signs of healing, worsening infection, or systemic symptoms, and monitor for adverse effects including gastrointestinal upset, rash or photosensitivity.Review of Resident #1's weekly skin sweep record showed two sweeps (7/6 and 7/29) were conducted during the resident's stay from 7/3 to 8/16/26, indicating four of six weekly sweeps were not completed. The skin/wound weekly evaluation record showed only 3 of 6 opportunities were completed.Review of Resident #1's Skin/Wound Note dated 7/7/26 at 8:44 p.m. showed a skin integrity evaluation completed by the wound physician. The left heel wound measured 12.5 x 7.0 x 0.5 cm, with 10% slough, 80% necrosis, 10% granulation tissue, and moderate serous drainage. The area was cleansed with Dakin's solution, silver alginate was applied, and a silicone dressing was placed. The note did not include wound care frequency instructions.Review of Resident #1's Treatment Administration Record (TAR) showed the first wound care was scheduled for 5:00 p.m. on 7/6/26, three days after admission. The order stated, Wound care to open area on left heel every evening and as needed (PRN). The order was administered on 7/6 and 7/7/26. The order did not specify required supplies. The TAR showed new orders beginning 7/9/26 instructing day shift to cleanse the left heel with sodium hypochlorite antiseptic solution, pat dry, apply silver alginate, cover with ABD pad, and wrap with rolled gauze every other day, with a PRN order. The TAR documented only every other day dressing changes and no PRN wound care. The order was discontinued 7/28/26. An order starting on 7/29/26 instructed staff to cleanse the left heel with sodium hypochlorite solution, pat dry, apply honey fiber, cover with ABD pad, and wrap with rolled gauze every other day. The order was discontinued 8/18/26 and was completed through 8/16/26. The August TAR showed one PRN dressing change on 8/5/26.Review of the wound care vendor note dated 8/11/26 showed the left heel arterial ulcer had no change in progression. The wound measured 12 x 7 x 1 cm with an area of 84 square centimeters. The wound had exposed necrotic bone and moderate serous drainage. The wound bed had 11-20% granulation, 41-50% slough, and 30% necrosis. A debridement was completed with resulting measurement of 12 x 7 x 1.5 cm. The provider instructed staff to cleanse the wound with sodium hypochlorite solution, apply honey fiber dressing, cover with ABD pad, and secure with rolled gauze daily and as needed. The TAR continued to show every other day dressing changes. The provider discussed the treatment plan with nursing staff and instructed routine skin inspections. Osteomyelitis was not suspected.Review of the SBAR (Situation, Background, Appearance, and Recommendation) form, dated 8/16/26 at 7:01 p.m. showed Resident #1 had a skin wound or ulcer that began on 8/16 and remained the same. The resident's pain was not clinically applicable to the change in condition. No additional information was documented. The clinician was notified, and the resident was sent to the hospital per family request.Review of Resident #1's progress notes on 8/16/26 did not contain information regarding the skin wound or ulcer noted in the SBAR.Review of Resident #1's August nursing notes on dates wound care was received showed the following: 8/16/26: SBAR completed without description of the wound or larvae. 8/14/26: no documentation related to the wound. 8/12/26: note related to upcoming surgery on 8/17 and Hibiclens instructions; no information related to the left heel wound. 8/10/26: no wound documentation. 8/8/26 at 7:19 p.m.: Daily Medicare/Managed Care note documented no new changes to skin integrity, no signs/symptoms of infection, and none of the above under skin/wound treatments.An interview with Staff A, Certified Nursing Assistant (CNA), conducted on 8/31/26 at 12:54 p.m., revealed the staff member did not know the required dressing change frequency and reported dressings are changed only when dirty, dislodged, or soiled. Staff A recalled a smell coming from Resident #1's room on the day of the incident and informed the assigned aide to notify the nurse. An interview with Staff B, Transportation Aide, conducted on 8/31/26 at 1:00 p.m., revealed the aide took Resident #1 to the orthopedic surgeon on or around 8/11. Staff B reported the wound was bleeding, and office personnel cleaned and re wrapped it. The person wrapping the wound stated the wound had good tissue and the physician had scraped the wound. The TAR did not document a dressing change on 8/11 but did show a change on 8/12.An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) conducted on 8/31/26 at 1:32 p.m. revealed Staff C, LPN, observed a saturated dressing on 8/17/26, and another RN (Registered Nurse) performed wound care and found larvae in the wound. The DON stated the primary care provider was notified and commented it might be beneficial. The wound care physician reported not seeing larvae during the last visit on 8/11/26. The DON stated nursing staff reported the wound was fine. The resident had not refused any wound care. The DON stated wound care was ordered every other day and PRN. The DON stated Staff E, LPN, completed wound care on 8/14 and told the resident the dressing was okay when asked.Another interview with the DON on 8/31/26 at 3:06 p.m. revealed the DON agreed that if the wound had moderate serous drainage, the dressing would likely require more frequent changes. The DON stated the resident frequently smoked outdoors and agreed the dressing integrity would require additional assessment.Review of a scientific resource from scienceinsights.org titled, How Fast Do Maggots Form? The Timeline Explained, dated November 15, 2025, retrieved on 8/31/26 showed: The rapid appearance of maggots often creates the illusion of spontaneous generation, but these organisms are simply the larval stage in the life cycle of flies. Maggot formation is the biological process defined by the hatching of a family egg into a larvae, known as the first instar. This transformation is a swift and predictable event, driven by the need for the Organism to quickly access a food source. The entire process, from egg deposition to the emergence of the larval stage, is a precise biological sequence determined by the insects internal clock in the surrounding environment. Female flies, such as house flies and blowflies, seek out decaying organic matter, [NAME] animal waste, or garbage. They are guided by their sense of smell, which detects volatile organic compounds (VOCs) released as the material breaks down. The information showed a female housefly could lay up to 150 eggs in a single laying and clustering ensured the larvae had an available food source. The maggot formation (transition from egg to larvae) is quick with favorable conditions. The process occurs within 8 to 48 hours after deposit and as little as 8 to 24 hours with favorable conditions such as warm temperatures and high moisture. The three stages of larval feeding lasts 3 to 5 days, which the larvae grow from 2 millimeters to 15 millimeters. The timeline is influenced by factors including warmer temperatures which speeds up the eggs metabolic processes and a high-moisture environment promotes egg hatching and prevents the first stage larvae from drying out. The large amount of larvae can produce heat increasing the mass to 50-68 degrees Fahrenheit (10-20 Celsius) warmer than the air around it. Source: (https://scienceinsights.org/how-fast-do-maggots-form-the-timeline-explained ).Review of the undated facility Abuse, Neglect, Exploitation, and Misappropriation policy defined neglect as the failure to provide goods and services necessary to avoid physical harm.Review of the undated facility Wound Care policy showed wound care documentation must include type of care, date/time, resident position, staff performing care, changes in condition, assessment data, resident tolerance, complaints, refusals, and name/title of the person documenting.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent resident to resident altercation for five (Residents: #20, #51, #126, #185, #192) of five residents reviewed. This failure resulted in three resident-to-resident physical altercations on one (500-unit) of five units. Findings Include:1. On 04/27/2026 at 10:52 AM, an observation was made of two residents yelling at each other in the dining room of the 500 units. An activities aid was sitting at the table with the two residents. A nurse and the medical records coordinator responded to the situation, after two minutes of the argument. At the same time, Resident #20 had walked over to resident #185, who was sitting in a wheelchair and watching television (TV). Resident #185 was in the middle of the dining room, and Resident #20 poked and shoved the right side of Resident #185's head near the ear. Staff continued to assist the other two residents, who were continuing to argue. Resident #20 then walked from the middle of the dining room to the far right of the dining room. Resident #20 walked around other residents and went over to resident #126. Resident #126 had been sitting in a chair on the far right of the room. Resident #20 began speaking unintelligible words, while looking and pointing at Resident #126. Resident #126 yelled go back, go back, go back, while having his arms up in front of his face and pointing away from Resident #20. Staff then began to walk over to Resident #20 and stood next to the resident while Resident #20 was pointing at Resident #126. Resident #20 then slapped Resident #126 on the right arm. During an interview on 04/27/2026 at 11:08 AM, Staff Z, Certified Nursing Assistant (CNA), stated sometimes Resident #20 gets aggravated. Staff Z stated having seen Resident #20 go over to Resident #126 and try to engage in conversation. Staff Z stated Resident #126 hollered at Resident #20 to go away, and Resident #20 hit Resident #126. Staff Z stated after sundown, residents get more aggressive. During an interview on 04/28/2026 at 2:17 PM, Staff CC Nurse Practitioner, stated Resident #20 was always confused and anxious. During an interview on 04/29/2026 at 09:57 AM, the Recreational Director stated, no I do not think so, when asked if one staff member is enough to keep 24 residents engaged. During an interview on 04/29/2026 at 10:24 AM, Staff EE, CNA, stated definitely having a hard time meeting job duty task. Staff EE stated, there is not enough staff. Staff EE stated she can't provide the level of care to a resident that she would like to, due to being pulled into the dining room. Staff EE stated Resident #20 is very caring and likes to touch people. Staff EE stated resident #126 is very vocal and stated, she retaliated against that. During an interview on 04/29/2026 at 11:11 AM, Staff FF, CNA, stated it's hard, there have been times when we have been short. During an interview on 04/29/2026 at 11:26 AM, Staff V, Registered Nurse (RN), stated if the residents aren't engaged in activities, they may begin to wander, and some may become aggressive due to an unknown reason. During an interview on 04/29/2026 at 5:16 PM, Staff GG, Licensed Practical Nurse (LPN), stated residents wander into each other's rooms often on this unit. During an interview on 04/29/2026 at 5:23 PM, Staff O LPN, Unit Manager, stated all she knew was that Resident #126 yelled at Resident #20, which is what he does all the time. Staff O stated, no there is not enough supervision. During an interview on 04/30/2026 at 8:40 AM, Staff HH, LPN, stated the staff members were told to make sure residents don't go into each other's room. Staff H stated the residents wander into each other's rooms, frequently. Staff H stated activities help keep residents from wandering into each other's rooms. Staff H stated sometimes they need more assistance and sometimes not. Sometimes we're short-staffed. During an interview on 04/30/2026 at 9:38 AM, Staff EE, CNA, stated Resident #20 touches other residents quite often, like quite often. Staff EE explained believing that wandering poses no safety risk to residents. During an interview on 04/30/2026 at 9:49 AM, Staff II, CNA, stated when residents wander, they could get hit, they could get pushed out. Staff II stated wandering does happen quite often down here. During an interview on 04/30/2026 at 10:354 AM, Staff JJ, Activities, stated there were two residents having a verbal interaction leading up to the time Resident #20 hit Resident #126. Staff JJ stated this is the reason she did not attempt to assist Resident #20, prior to Resident #20 slapping Resident #126. Record review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. Medical diagnosis included: unspecified dementia, unspecified severity, without behavioral, disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, and brief psychotic disorder. Review of Resident #20's physician orders revealed the resident had been ordered Rivastigmine Tartrate Oral Capsule 3 milligram (MG), one capsule was to be given two times a day for dementia, dated 01/03/2026. Seroquel oral tablet 50 MG, one tablet, was to be given by mouth at bedtime for brief psychotic disorder, dated 04/21/2026. Review of Resident #20's Minimum Data Set, dated [DATE], revealed a Brief Interview Minimum Status (BIMS) of 00, which meant severe impairment in cognition. Review of Resident #20's progress note revealed the resident had been seen on 04/28/2026 by psychiatry. The resident had a resident-to-resident altercation as the aggressor. Resident #20 was unstable, requiring psychiatric assessment. Review of resident #20's care plan revealed a focus: Resident #20 is on a secured unit related to impaired cognitive function/dementia or impaired thought processes related to diagnosis of dementia. The goal was for the resident to be able to communicate basic needs on a daily basis through next review date. Interventions included: cue, orient, and supervise as needed. Review of Resident #126's medical records revealed the resident was admitted to the facility on [DATE]. Medical diagnosis included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and vascular dementia, moderate with agitation. Review of orders for Resident #126 revealed, an order for Seroquel oral tablet, (Quetiapine Fumarate) give 12.5 mg by mouth at bedtime for brief psychosis, dated 04/22/2026. Review of Resident #126's Minimum Data Set, dated [DATE], BIMS of 11, which means moderate cognitive impairment. Review of resident #126's care plan revealed a focus: Resident #126 is on the secured unit due to his impaired cognitive function/dementia or impaired thought processes related to diagnosis of dementia, without disturbance. The goal was for the resident to maintain current level of cognitive function through next review date. Interventions included: cue, orient, and supervise as needed, and the resident needs assistance with all decision making. During an interview on 04/30/2026 at 1:10 PM, the interim Director of Nursing, (DON), stated there was an interaction between Resident #20 and Resident #126. The DON stated Resident #126 yelled at Resident #20 and Resident #20 then hit Resident #126. The DON stated in a memory care unit there will be residents with mental conditions and behaviors. The DON stated the expectation is for staff to ask for help if they need it. Stated staff should be able to monitor those residents. The DON stated, it could have been preventable, I wouldn't feel great if someone smacked me or slapped me. The DON stated there are some residents who cannot say whether they are alright with being touched or not. During an interview on 04/30/2026 at 1:30 PM, the Nursing Home Administrator (NHA), stated the residents in the 500-unit need to be observed by staff. The NHA stated resident safety is ensured by staff observations. 2. On 04/29/2026 at 4:55 PM, an observation was made of Resident #51 wondering near B hall door at end of the 500-unit. On 04/29/2026 at 4:59 PM, an observation was made of Resident #51 attempting to go into room [ROOM NUMBER], which was not the resident's room. Resident #51 then went to the end of the hall and began to speak to the other residents and continued to wander. On 04/29/2026 at 10:47 AM an interview was conducted with Resident #51's family member. The family member stated there have been many incidents that occurred since Resident #51 was admitted to the facility from a lack of supervision in the unit. The family member stated they noticed Resident #192 trying to call Resident #51 into their room, so the family member had asked staff to keep an eye on Resident #192 because of this and Resident #192 repeating to attempt to enter Resident #51's room. Resident #51's family member said Resident #192 would always search out Resident #51. Resident #51's family member stated the assault occurred at nighttime, and at the time aides were observed changing residents and providing care but could not recall where the nurses were. During an interview on 04/29/2026 at 4:41 PM, Staff KK, CNA, stated we are all responsible for watching the residents, most residents stay around the dining room. Staff KK stated she would periodically check on residents who are elsewhere. Staff KK stated, I don't know, how often I check on the residents. Staff KK stated normally has 20 or more residents to supervise in the dining room. Staff KK stated television is the main activity. Staff KK stated day to day, residents wander into each other's room. Staff KK stated recalling Resident #51's family reported the incident where the family member found Resident #51 in another resident's room, to the nurse in charge. Staff KK stated it is not dangerous for residents to go into each other's rooms. Staff KK explained not knowing what is being done to prevent the situation from happening again, although the Resident #192 is no longer at the facility. Staff KK stated if it were her, she would fight like hell. During an interview on 04/29/2026 at 5:23 PM, Staff O, Licensed Practical Nurse, Unit Manager, stated having been told by Resident #51's family member in 03/2026, that Resident #51's family member was looking for Resident #51 and walked into Resident #192's room and saw Resident #192 groping Resident #51's breast. Staff O stated, he was feeling up her breast. Staff O stated earlier in the year, Resident #192 had a similar situation in which he had touched another resident sexually and inappropriately. Staff O stated after each incident, Resident #192 had not remembered what he had done. Staff O stated after the first incident we thought it was a one-time incident. Staff O stated the facility staff had hoped it was a one-time incident. Staff O stated she would have been upset, had this happened to a loved one. We placed Resident #192 on 1:1 for everyone's safety after each incident. Then reevaluated as appropriate. During an interview on 04/30/2026 at 8:54 AM, Staff V, RN stated having been told to keep an eye on Resident #192. Staff V stated Resident #192 had a habit of touching himself. Staff V stated the facility was aware of Resident #192's sexual desires. Staff V stated this happened in February or March. During an interview on 04/30/2026 at 9:02 AM, Staff FF, CNA, stated residents typically go at each other during the 3:00 PM to 11:00 PM shift. Staff FF stated, I would not feel safe with my parents on this unit. Staff FF stated, I don't think they (the staff) are fully watching the residents like they (the staff) are supposed to. Staff F stated wandering is dangerous for residents. Staff FF stated, if a resident is in another room with the doors closed you don't know what is going on. Staff F stated of supervision, They could use more, I mean I only have two eyes. During an interview on 04/30/2026 at 9:12 AM, Staff F, CNA, stated Resident #192 had been touching himself from the beginning of being placed in the 500-unit. Staff F stated, not believing they are providing enough supervision to prevent residents from going into each other rooms. During an interview on 04/30/2026 at 9:38 AM, Staff EE, CNA stated, anything can happen when you allow a resident to wander. During an interview on 04/30/2026 at 9:59 AM, Staff O, LPN, UM stated for both incidents involving Resident #192, the female residents wondered into Resident #192's room. Staff O stated, they will go into another room, it does happen sometimes. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE]. Medical diagnosis included, heart failure, senile degeneration of the brain, dementia without behavioral disturbance, and anxiety. Review of Resident #51's physician orders revealed an order for the resident to be admitted to hospice, dated 01/22/2026. There was an order for a wander management bracelet, dated 03/22/2026. Review of Resident #51's Minimum Data Set, dated [DATE], revealed BIMS was 00, which meant the resident did not have the ability to answer the questions. This showed the resident did not have the ability to recall season, location, names, and faces and the resident has a long-term memory problem. Review of resident #51's care plan revealed a focus: Resident #51 is an elopement risk/wanderer related to impaired safety awareness. Resident #51 has diagnosis of dementia. The goal was for Resident #51 to not leave the facility unattended. Interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. A focus showed: Resident #51 has an alteration in neurological status related to senile degeneration of brain, dementia, dysphagia, anxiety, history of cerebrovascular accident. On 4/29/2026 at 5:06 PM an interview was conducted with the facility's psychiatric provider over the phone. The psychiatric provider revealed that the incident that occurred has a high potential of negatively affecting and being a trigger if Resident #51 had been sound of mind and not consenting to the act. A review of Resident #192's admission record revealed an admission date of 01/14/2025 with diagnoses to include Alzheimer's disease, major depressive disorder, unspecified dementia, anxiety disorders, and cognitive communication deficit. Resident #192 had a discharge date of 04/08/2026. A review of Resident #192's Quarterly Minimum Data Set (MDS) assessment, dated 4/8/26, revealed a BIMS of 6/15, indicating Resident #192 has severe impairment. Behaviors section revealed that Resident #192 scored a 2 for wandering, presence and frequency, meaning behavior of this type occurred 4 to 6 days during the seven day look back period. A review of Resident #192's Care Plan revealed the resident can be sexually inappropriate at times related to a diagnosis of dementia. Staff is to redirect, distract and provide alternative activities. Resident #192 is also care planned for being an elopement risk and wanderer related to impaired safety awareness. On 04/29/2026 at 10:39 AM an interview was conducted with Staff F, CNA for Resident #192. Staff F, CNA stated she would hear about Resident #192's inappropriate sexual behaviors but never witnessed them. On 4/30/2026 at 11:39 AM an interview was conducted with Staff I, LPN. Staff I, LPN stated Resident #192 had a habit of touching themselves, and she knew to knock loudly on the door before entering. Staff I, LPN stated it depended on the time of the day and the nature of the residents to determine if there was enough staff to provide supervision in the locked unit. Staff I, LPN said the care staff does what they can with the staff they have on a regular basis, but to have additional staff would be a relief to help provide additional supervision of residents. On 4/30/2026 at 1:45 PM an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that despite Resident #192 having the same type of incident three weeks prior, the resident was not seen as the aggressor. Resident #192 was not displaying any abnormal behaviors, and it was determined the resident could be removed from 1:1 care. This decision was made by the psychiatric provider and primary care provider (PCP). The NHA stated even though Resident #192 was not displaying sexual behaviors after the first incident, the facility still should have been monitoring Resident #192. The NHA stated the care staff should have been checking on Resident #192 more often than the usual rounds, due to his behaviors. The NHA said at the time of the incident with Resident #51, the staff on duty did not know how Resident #51 got into Resident #192's room, and there is no staff who were able to say they saw the two residents in the room together. The NHA stated one nurse was down Hall A charting but does not know where the nurse for Hall B was at the time of the incident. The NHA stated the care staff were responsible for supervising the halls of the unit. A review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revealed the following: It is the policy of the 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 Services Director, and the Director of Nursing. 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. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. 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 ware 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. Person centered care: For purposes of this subpart, person centered-care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Sexual abuse: Sexual abuse is non-consensual sexual contact of any type with a resident. The facility must determine whether the resident(s) have the capacity to consent to sexual activity.

Based on observations, interviews and record review, the facility failed to serve food in accordance with professional standards for food service safety related to one of one dish washing machines was not operated per its specifications. Findings included: On 4/27/2026 at 9:45 a.m. the kitchen was toured with the Certified Dietary Manager (CDM), and the Regional Dietary Manager. The CDM stated the kitchen operates a low temperature dishwashing machine. The CDM further stated the machine's operation includes wash temperatures to reach at least 140 degrees Fahrenheit (F), and the final rinse temperature to reach at least 120 degrees F. The CDM continued to state the machine provides a chemical sanitizer and with a litmus test strip for chemical sanitizer testing to reach 50 - 100 parts per million (ppm). On 4/27/2026 at 10:02 a.m. an observation of the dishwashing machine room occurred with the CDM. Staff were already utilizing the machine and were running soiled crates of dishes through the dishwashing machine. On 4/27/2026 at 10:03 a.m. an interview and observation with a Staff J, Dietary Aide (DA) occurred. Staff J, DA stated they have been operating the machine since 9:30 a.m. and have run many crates of dishes through the machine. Staff J was observed spraying soiled dishes with a water hose and setting up dishes and trays in crates. He then was observed to run the crates of soiled dishes and trays through the machine to be cleaned. On the other side of the machine, Staff K, DA was observed receiving the crates of dishes/trays from the clean side of the dish machine. Staff J and K confirmed the dish machine wash temperatures should reach 140 degrees F., and the rinse temperatures should reach 120 degrees F. On 4/27/2026 at 10:04 a.m. a crate of meal trays was put through the machine. The wash temp reached above 140 degrees, and the rinse temp reached above 130 degrees. Staff K conducted the sanitizer testing utilizing litmus paper test strip. Staff K placed the test strip in an area of pooled water, on one of the trays that was just washed. The white colored test strip did not change color and remained white. Staff K, DA proceeded to get another strip, repeated the process and the same outcome occurred. Staff J, DA pushed a priming button on the sanitizer dispenser and ran another crate of trays through the dish machine. On 4/27/2026 at 10:08 a.m. Staff J, DA put a crate of dishes through the dish machine. The wash temp reached above 140 degrees F, and the rinse temp reached above 120 degrees F. [NAME] this demonstration, there was a crate of bowls and plates that ran through the entire wash and rinse cycle, and the dishes were observed with food debris remaining. Staff K, DA picked out the soiled dishes and placed them in a soiled rack but took the rest of the plates and put them in the clean area. A chemical sanitizing test was not demonstrated since dishes came out of the machine still soiled. On 4/27/2026 at 10:12 a.m. a crate of meal trays was put through the dish machine. The wash temp reached above 140 degrees F., and the rinse temp reached above 130 degrees F. Staff K and Staff U, Assistant Dietary Manager (ADM) both placed a separate litmus test paper strip on a wet side of the washed meal trays. The strips did not change color and remained white. This indicated there was no chemical sanitizer getting into the machine, and the dishes. The CDM stated the litmus paper chemical sanitizer test strip should have turned a medium to dark purple color which would indicate PPM of 50 -100. The color grid could be verified on the test strip bottle. On 4/30/2026 at 4:00 p.m. the Nursing Home Administrator provided the Dish Machine Use policy and procedure with a date of 6/2025 for review. The policy revealed; Dishware, eating utensils, and meal trays are washed and sanitized by use of the mechanical dish machine. The policy interpretive and implementation section revealed;The following guidelines will be followed when dishwashing:Wash hands before and after running dishwashing machine, and frequently during the process.Flatware:Presoak the flatware.Run the flatware through the dishwashing machine in a pallet.Wash the flatware in the utensil holder with eating end pointed upward.Presoak dishes or pots that contain dried or burnt food.Do not overcrowd racks.Use overhead spray to remove loose food particles.After running items through entire cycle, allow to air-dry.Clean dish machine after each meal.Dish machine chemical sanitizer temperature and concentration will be as follows: Type of solution = Chlorine, Minimum concentration = 50-100 ppm, Minimum temperature = 120 degrees F. or as per manufacturers recommendation.

Based on observations, record reviews, and interviews the facility failed to implement and maintain an effective infection control program related to 1) cleanliness and maintenance of the laundry room, 2) educate staff on hand hygiene and personal protective equipment required for the prevention of spreading Clostridioides difficile (C. diff) after two (#41 and #91) of two residents tested positive for the highly contagious bacteria and two (#1 and #39) of two sampled residents were actively being tested for the bacteria and 3) provide Pneumococcal immunization for one (R#20) of five residents sampled for the administration of vaccinations.Findings included: On 4/29/26 at 10:13 a.m. the facility laundry room was observed with the Housekeeping Director (HD) and the Nursing Home Administrator (NHA). The observers entered the clean area of the laundry area. The HD stated the area was swept multiple times a day. The observation revealed wire shelving units to the right of the doorway (facing from door into area) with miscellaneous bed linens folded and plastic bags filled with unknown objects. The bottom shelf appeared to be fuzzy with gray dust/lint-like material, under the unit was wadded up paper and dust, in front of the unit was a piece of blue plastic. An opened personal-sized bottle of purified water was observed sitting amongst folded linens. The HD observed the bottle and stated it should not be there. The area to the left of the door revealed a folded piece of white terry cloth with 2 pieces of dust/lint like substance attached to it. The HD took the item down, unfolded it and stated the pieces were part of the writing on the material. A continued observation with the HD showed the 2 pieces of substance continued to be attached to the material and was not part of the writing in black marker. Several flakes of a white/cream colored material littered the floor under the air duct. On the ceiling next to air duct were 2 areas showing previous repairs had been completed and the seams of the repair appeared wet and joint tape was hanging down from the ceiling. The HD stated the area had started leaking yesterday from the [NAME] fixing the roof. A dusty slipper and bits of plastic were observed under a white plastic shelving unit parked against the wall. The HD reported folding occurred on the 2 metal tables in the area, one to the right of door and the other to the left. On the left table inside a crate sitting on a dark colored dusty towel was a bottle of peach air fragrance. The HD stated the bottle should not be on the table.Observation was conducted of a room containing two washing machines. The outside of both washers was covered with fuzzy gray dust/lint material. On the floor between the wall and first washer was dusty terra [NAME] tiles with a blue rubber-type glove and remnants of white paper-like material. The conduit beside and behind the washers had the same fuzzy gray material attached to them. A fan attached to the wall behind the washers had a piece of opaque plastic inside the cage and the cage was covered with the gray fuzzy material. Next to the second washer on the floor was plastic hangers, a bag of pillows, and wadded up white linens. The HD stated they had used the blankets to soak up the water leaking from the roof in the folding area and confirmed the items should not be left on the floor next to the washer. The conduit running from electrical boxes to the ceiling had dust attached to them. The HD stated staff swept the floor every shift but did not wipe down the outside of washers. The third room of the laundry area contained one washer, metal lockers, and a sink. The gasket between the frame and drum of washer had white paper and brown crumbs of an unknown substance. On the floor next to the washer and in front of the lockers was a black plastic comb, on the other side of the washer behind an overflowing trash bin was a wadded-up blanket, and between the bin and sink on the floor was pieced of white wadded-up pieces of paper. The exhaust fan above the area was covered with the fuzzy gray material and had an opaque piece of plastic inside the cage. The sorting area contained multiple large plastic black bags stacked along the back wall and on top of a linen cart. Staff Q, laundry aide (LA) reported not knowing what was in the bags. Staff Q open one and stated pillows were in them. The staff member was asked to demonstrate how to fold a blanket. The staff member obtained an unfolded blanket, dragged a corner of it on the floor, held the blanket against self, and folded it into a neat square. Immediately following Staff Q, LA demonstration, the NHA informed the HD the staff member would need further education on how to fold the blanket, to include not dragging it on ground nor touching the staff members unprotected clothing. On 4/30/26 at 11:12 a.m. an observation was made of the laundry area containing one washer, metal lockers, and sink. The fan on wall near sink continued to be covered with gray fuzzy material and opaque plastic was still located within the blade cage. The facility failed to provide a policy regarding cleanliness of laundry room. 2.During an interview on 4/30/26 at 12:00 p.m. the Interim Director of Nursing/Infection Preventionist (DON/IP) reported the facility had two (R#91 and R#41) confirmed cases of Clostridioides difficile (C. diff) and one (R#1) resident was currently being tested for it. The line listing for April showed two residents were positive for C. diff and did not include information related to the third resident (R#1). The IP stated hand hygiene was to be done with soap and water instead of alcohol-based hand rub (ABHR) for C. diff. The IP reported no re-education on hand hygiene had been started for staff regarding the use of soap and water for C. diff but would start. The IP stated not knowing what constituted as an outbreak. Review of the April 2026 Infection Control Log did not reveal Resident #1 and Resident #39's information. Review of Resident #41's clinical record showed a stool sample had been obtained on 4/20/26. On 4/23/26 the results showed positive for the bacteria C. difficile. Review of monthly infection control log for the 300-hall showed Resident #41 was admitted on [DATE] with an onset of C. diff on 4/20/26 and the antibiotic Vancomycin (Vanco) started 4/22/26. Review of Resident #91's clinical record showed the resident was admitted to the secured unit on 10/14/25. The record showed a stool sample had been obtained on 4/16/26 and the sample tested positive for C. Diff Toxins A& B. The results were reported on 4/18/26 to the facility. Review of the monthly infection control log for the 500-hall (Resident #91's unit) showed the onset of infection was 4/14, culture was taken on 4/16 and the antibiotic vancomycin (Vanco) was started on 4/19/26. Review of Resident #1's clinical record showed the resident was admitted on [DATE] and moved to the secure unit on 1/8/26. Review of Resident #1's laboratory results showed the resident had tested positive for the bacteria, C. Difficile. Review of the monthly infection control log for the 500- hall showed Resident #1's information had been added after the interview with the IP on 4/30/26. The log showed Resident #1 had been tested on [DATE] with positive results. The resident started on the antibiotic Vanco on 4/30/26. Review of Resident #39's progress note dated 4/28/26 at 12:49 p.m. showed Resident #39 was alert and oriented. A note dated 4/28/26 at 2:27 p.m. revealed the resident had complaints of diarrhea, and an as needed (prn) dose of anti-diarrheal medication had been administered and the physician ordered STAT (to be completed immediately) blood work to include complete blood count (CBC) and comprehensive metabolic panel (CMP). The notes showed on 4/29/26 at 11:03 a.m. the physician had ordered the facility to check stool for C. Diff. The notes showed Resident #39 received another dose of anti-diarrheal medication on 4/29/26 at 8:45 p.m. A note on 4/30/25 at 7:05 a.m. revealed staff had been unable to collect a stool sample overnight due to no bowel movements. The notes showed on 4/30/26 at 10:16 am., Resident #39 was moved to the 300-hall without a documented reason. Review of Resident #39's clinical record showed the resident resided on the 400-hall since 1/31/25 and had moved to the 300-hall on 4/30/26. Review of the monthly infection control log for 300 and/or 400-hall, dated 4/15 - 4/30/26 did not reveal Resident #39 was being tested for an infection and if a culture had been obtained. 3.Review of Resident #20's vaccine consent form, dated 1/3/26 showed the legal representative had chosen for the resident to receive the pneumococcal, respiratory syncytial virus (RSV), and shingles vaccinations. Review of Resident #20's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, moderate recurrent major depressive disorder, and brief psychotic disorder. Review of Resident #20's January 2026 Medication Administration Record (MAR) did not show the consented vaccinations had been ordered and/or administered. Review of Resident #20's progress notes, dated 1/3 to 1/5/26 did not reveal the resident refused the vaccinations and/or the legal representative had rescinded the consent. During an interview on 4/30/26 at 12:00 p.m. the Interim Director of Nursing/Infection Preventionist (DON/IP) reported the facility does not offer RSV or shingles vaccinations. The IP reported not knowing why the resident did not get vaccinated (at time of consent) with pneumococcal vaccine. The DON/IP said if a resident refuse (staff) should retry, contact the family and physician, and document (the refusal). Review of the policy - Pneumococcal Vaccine, revised August 2016, showed All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The interpretation and implementation revealed the following:1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contradicted or the resident has already been vaccinated.2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission.4. Pneumococcal vaccines will be administered to residents (unless medically contradicted, already given, or refused) per our facilities physician-approved Pneumococcal vaccination protocol.5. Residents/ representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each residence medical record indicating the date of the refusal of the pneumococcal vaccination.6. For residents who received the vaccines, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the residence medical record. Review of the policy - Infection Prevention and Control Program, undated, revealed And in infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.1. The IPCP is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.2. The program is based on accepted national infection prevention and control standards.The elements of the IPCP included but not limited to:1. Coordination and Oversight d. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include:3. Surveillance and reporting b. Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and dictating unusual pathogens with infection control implications.4. Antibiotic Stewardshipa. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities.b. Medical criteria in standardized definitions of infections are used to help recognize and manage infections.6. Outbreak Management a. Outbreak management is a process that consists of: (1) determining the presence of an outbreak; (3) preventing the spread to other residents; (6) educating the staff and the public;7. Prevention of Infection a. Important facets of infection prevention include:(3) Educating staff and ensuring that they adhere to proper techniques and procedures;9. Monitoring Employee Health and Safetya. The facility has established policies and procedures regarding infection preventions and control among employees, contractors, vendors, visitors, and volunteers, including:b. Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment.(1) The facility provides personal protective equipment, checks for its proper use, and provides appropriate means for needle disposal.

Based on observations, record reviews, and interviews the facility failed to provide life enriching activities and assistance with activities for cognitively impaired residents residing on the secured unit of one cognitively impaired unit reviewed, failed to provide activities to one (Resident #7) of one bedridden residents, and failed to facilitate and assist one (Resident #120) of one residents with outside activities.Findings included: On 4/27/26 at 11:30 a.m. twelve of the forty-one residents residing in the 500-hall secure unit were sitting in dining room during a sensory activity with eyes closed and heads bowed. Staff Y, Activity Aide (AA), was observed sitting at a corner table occupied by one resident assisting with a jigsaw puzzle. The observation did not show the aide interacted or encouraged other residents. Review of the monthly 500-unit calendar showed Sensory Club was scheduled on 4/27/26 at 11:00 a.m. On 4/27/26 at 4:20 p.m., Staff Z, Certified Nursing Assistant (CNA) was observed sitting at table in the 500- hall dining room with Staff Y, AA. Twenty residents were observed in the room and a television was playing. On 4/27/26 at 4:26 p.m. an unknown female resident was observed at the end of the low 500 hall opening and shutting the window blinds. On 4/27/26 at 4:33 p.m. Staff Y, AA was observed escorting three female residents to the back patio of the 500-hall (did not include the unknown female seen at 4:26 p.m.). Staff T, Licensed Practical Nurse (LPN) was observed unlocking the patio door. At the time of the observation 24 residents were sitting in the dining room with Staff S, Licensed Practical Nurse/Unit Manager (LPN/UM) tossing beach ball, nine of the residents were interacting with one resident refusing, leaving 14 residents unencouraged to participate. An interview was conducted on 4/27/26 at 4:47 p.m. with Staff S, LPN/UM. Staff S stated usually the Activity Aide can take five residents outside for Patio Chat. The AA can take more if additional staff are able to go outside, as well. Staff S, states she even takes them out but can't remember the last time she did. Staff S reported not knowing how many residents usually went out because she was not normally at the facility this late. On 4/27/26 at 4:49 p.m. the patio door was opened by Staff T, LPN for this writer. Staff T stated they don't take residents outside, they do activities in the dining room. Staff Y, AA was observed sitting under a covered porch directly outside of the exit door with three female residents. Resident #186 stated always enjoying being outside. Staff Y stated coming outside was based on who was available as there isn't always coverage in the dining room but they are able to come outside about once a week. Staff Y stated being able to take up to five residents out, and tries to bring a couple in wheelchairs and a couple of residents with walkers. The staff member put code into keypad, which did not work, saying there was usually a key hanging next to the door. An observation was made of the courtyard area revealed a covered gazebo in the middle with pathways leading to it. Staff Y, AA stated they don't go any further than this covered porch. The three female residents were escorted back inside at 4:59 p.m. as the door was unlocked by Staff S and spending 26 minutes outside sitting under a covered porch. The female resident who was earlier seen opening and shutting the blinds (at 4:26 p.m.) attempted to exit the door. Staff S, LPN/UM informed Staff T, LPN she would take the resident outside. Staff T asked when Staff S wanted to come back in, Staff S stated, 5 minutes. On 4/27/26 at 5:04 p.m. Staff AA, CNA was observed in the 500-hall with 26 residents. The staff member wrinkled up nose and stated she doesn't go outside with the residents. On 4/27/26 at 5:09 p.m. Staff S, LPN/UM and the unknown female resident who was taken outside were at the nursing station. Review of the 500-unit Activity Calendar revealed at 4:30 p.m. every day, seven days a week the activity of Patio Chat was scheduled. On 4/28/26 at 10:18 a.m. an observation of the 500-hall dining room revealed the daily 10:00 a.m. scheduled refreshment activity had not occurred. Staff S, LPN/UM was observed entering the room with a bag of packaged cookies and crackers and exited with the bag. On 4/28/26 at 10:20 a.m. an observation of two CNA's entered the room with the bag of cookies and crackers. Staff BB, AA entered and asked for drinks which one of the CNA's stated they could get from the dining room. On 4/29/26 at 2:08 p.m. the door to the 500-hall dining room was shut. Staff S, LPN/UM stated, they're in there cleaning and staff were taking resident's outside for activities. An observation was made of the fenced courtyard with gazebo where 13 residents were sitting under and around the gazebo smiling and interacting with each other, only one resident appeared to have eyes closed. A family member who wished not to be identified stated this was the first time they had seen residents outside and visits regularly at different times of the day. An interview was conducted on 4/30/26 at 1:51 p.m. with the Recreation Director (Activity Director, AD). The AD reported the activity department was fully staffed with one person on each unit. The AD reported doing an in-room form for bedridden residents, it asked them what they enjoyed doing, if they wanted in-room visits. The activities included music, sensory, tactile, hand massages, socialization, reminiscing, playing cards, reading to them, and whatever they want us to do. The bedridden residents are visited 2-3 times a week per the AD. The AD stated residents are allowed to go outside if they are not smokers, the area outside of the 100 and 300 halls are available. They have a gardening area and one of the activity staff had a green thumb. The AD stated one resident from the 400-hall went out often, residents did need a staff or family escort, and usually is on the calendar for outside time, in-room residents are sometimes taken out, but there is not a schedule. The AD reported activities for the cognitive impaired residents were tactile, magnetic building blocks, hand massages, singalongs, read to them, and (wrinkled nose) outside time. The AD stated we try to do weekly. With cognitively impaired residents once or twice a week. The AD stated we try to do our best regarding interacting with the cognitively impaired residents, staff should interact during a planned activity. The AD stated staff are to assist residents with different activities, for example: puzzle, sing during the singalong, guide them to do building blocks, hand them balloon to toss, and move around the room. The AD stated she encourages staff to interact. The AD reported Patio Chat was outside time. During Patio Chat different activities can be completed for example: reminiscing, socializing, snacks, whatever the residents would like. The AD re-stated the cognitively impaired outside time was mostly daily as it was on the calendar for daily. Regarding the 500-hall the AD stated most of the time 5-10 residents go outside, the other day it was 3-5, we don't want to limit them being outside. The AD stated if activity staff are outside she doesn't know what the other staff are doing with the residents who remain inside. The AD stated outside time is usually for 20-30 minutes per day, it's supposed to happen daily. On 4/27/26 at 12:57 p.m., an interview occurred with Resident #120. Resident #120 stated the staff used to take them outside, but they no longer do. Resident #120 stated enjoying the activities within the facility but would like the opportunity to be outside and enjoy the fresh air and sunshine more frequently. Resident #120 stated they feel confined in their room and need to be able to get outside to make their stay at the facility more enjoyable. A review of Resident #120's admission record revealed an initial admission date of 4/11/2025, and a readmission date of 8/20/25 with diagnoses to include unspecified dementia, major depressive disorder and generalized anxiety disorder. A review of Resident #120's Quarterly Minimum Data Set (MDS) assessment, dated 4/7/26, revealed a Brief Interview Mental Score (BIMS) of 11/15, indicating Resident #120 is moderately impaired. Preferences revealed that Resident #120 scored a 1, indicating going outside to get fresh air when the weather is good is very important to them. A review of Resident #120's Activities task revealed that the resident participated in activities for the last 30 days, no activities were provided or offered outside. A review of Resident #120's current Care Plan revealed the resident enjoys being outside. On 4/29/26 at 2:15 p.m., an interview was conducted with Staff H, CNA. Staff H, CNA stated they do not ask Resident #120 to go outside, and they would not take the resident outside if they asked because they have to be able to complete their assignments/tasks with other residents, there is not enough time. On 4/27/26 at 1:47 p.m., an interview occurred with Resident #7 laying in their bed watching TV with the privacy curtain pulled around the resident's bed. Resident #7 stated the activities department does not come and visit in the room. Resident #7 stated not being able to get up and is the room all the time. Resident #7 stated they feel forgotten because no one comes to do activities with them, and is very bored saying watching television is not enough for an activity. A review of Resident #7's admission record revealed an initial admission date of 1/5/22, and a readmission date of 6/21/22 with diagnoses to include bipolar disorder, major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and schizoaffective disorder. A review of Resident #7's Quarterly Minimum Data Set (MDS) assessment, dated 2/5/26, revealed a BIMS of 15/15, indicating Resident #7 is cognitively intact. Preferences revealed that Resident #7 scored a 2, indicating it is somewhat important for Resident #7 to do their favorite activities. A review of Resident #7's current Care Plan revealed the resident will maintain involvement in cognitive stimulation, social activities as desired; and to invite Resident #7 to activities. A review of Resident #7's activities task for the last 30 days revealed Resident #7 was offered/attended activities 3 of the 30 days. Review of Resident #7's chart did not reveal any In Room Visit Forms for activities on file. These documents were requested from the facility and were unable to be provided for Resident #7 during the time of the survey. On 4/29/26 at 2:10 p.m., an interview was conducted with Staff G, CNA. Staff G, CNA stated Resident #7 rarely gets out of bed to participate in facility activities, and due to their chronic back pain they do not stay long in the activity before wanting to be put back in bed. Staff G, CNA stated Resident #7 had not participated or been offered to go to an activity since last week at least. Staff G, CNA said Resident #7 should be offered alternative activities for in bed more often than they are now. On 4/30/26 at 3:00 p.m., an interview was conducted with the AD. The AD stated for residents who are bedridden, activities is to go into the resident's room [ROOM NUMBER]-3 times per week, but they have not yet gone to Resident #7's room to provide activities. The AD explained the activities and care staff are expected to take the residents outside if they are not smokers. The AD said refusals to participate in activities should be documented by staff. The AD stated each resident is provided with a form for in room one to one (1:1) activities for each attempt, and that there should be documents for Resident #7's in-room activities being provided. The AD said television is not a sufficient form of activity, and the resident should be offered to play cards, reminisce and talk about their past, do puzzles, and color. On 4/30/26 at 4:15 p.m., an interview was conducted with the AD. The AD stated based on the documentation, neither resident had been offered and/or provided with in-room activities, or with the option of going outside. The AD stated she was not the one who provided these activities to these residents, so they cannot confirm if they were provided; but according to the documentation, Resident #7 was not provided activities and Resident #120 was not taken outside. Review of the facility policy and procedure titled Activity Department Planning and Programming not dated revealed: POLICY Activities should be provided for each resident according to an individualized therapeutic plan which is based on the needs and interests identified within the Interest Survey and Assessment.

Based on observations, interviews and record review, the facility failed to ensure a comfortable, homelike and clean environment to include; 1. Resident room water temperatures not hot; 2. Shower room bathing equipment with bio-growth in two of six community shower rooms, and 3. Loud alarm noises during meal services during four of four days observed (4/27/2026, 4/28/2026, 4/29/2026, and 4/30/2026). Findings included: On 4/27/2026 at 10:45 a.m., 4/28/2026 at 10:15 a.m., and again on 4/30/2026 at 8:30 a.m., the following was observed by turning on the sink hot water, letting it run for over three minutes and using the back of the hand to feel the actual water temperature:1. Resident room [ROOM NUMBER] bathroom sink had no water pressure. There was only air spraying out from spigot after turning both hot and cold turn knobs.2. Resident room [ROOM NUMBER] bathroom sink hot water was not hot, it was less than lukewarm. 3. Resident room [ROOM NUMBER] room sink hot water was not hot, it was less than lukewarm almost cold. 4. Resident room [ROOM NUMBER]/118 bathroom sink hot water was less than lukewarm. 5. Resident room [ROOM NUMBER] room bathroom sink hot water was not hot, it was less than lukewarm. 6. Resident room [ROOM NUMBER] room sink hot water was less than lukewarm.7. Resident room [ROOM NUMBER] room sink hot water was less than lukewarm.8. Resident room [ROOM NUMBER]/106 room sink hot water was less than lukewarm.9. Resident #194's bathroom sink hot water was not hot, it was cold. Resident #194 confirmed the hot water in the room never gets hot. Resident #194 stated he has spoken to staff about it in the past but things never change10. Resident room [ROOM NUMBER] room sink hot water was cold. Bathroom sink hot water tested as cold11. Resident #182's bathroom sink hot water was cold. An interview with Resident #182, confirmed there is usually never any hot water, and he does turn it on for a long period of time with it still not getting hot. He had complained about shower water temperatures not getting hot as well. The resident stated he has spoken to staff repeatedly about this concern with no changes12. Resident room [ROOM NUMBER] bathroom sink hot water was cold. 13. Resident room [ROOM NUMBER] bathroom sink hot water was cold. 14. Resident room [ROOM NUMBER] bathroom sink hot water was cold. Also, the room sink hot water was less than lukewarm.15. Resident room [ROOM NUMBER] room sink did not get hot. The bathroom water did not get hot, it was cold.16. Resident room [ROOM NUMBER] room sink and bathroom sink did not get hot, it was cold.17. Resident #3's room and bathroom sink water did not get hot, it was cold. An interview with the Resident #3, revealed the room and bathroom never get hot enough and in the shower room, the water takes, forever to get even warm. She had complained about this to staff but things have not changed. 18. Resident #4's room and bathroom sink hot water did not get hot, it was cold to lukewarm. Interview with Resident #4, confirmed the water in his room and bathroom sink never get hot, and is always less than lukewarm. He stated he has brought this up to the attention of staff for months, but there has not been any changes. An attempt to interview the maintenance director on 4/29/2026 at 3:00 p.m. revealed he terminated his services that day and was not able to be interviewed with relation to how water temperatures were audited and maintained to a comfortable level for residents. An interview with the Nursing Home Administrator (NHA) on 4/30/2026 at 4:00 p.m. confirmed the Maintenance Director had terminated his employment on 4/29/2026. The NHA would not be able to show how the water heater water temperatures are set, as well as not able to show how the temperatures are audited in each resident room. The NHA did find past water temperature logs dated 4/23/2026. The NHA confirmed she did not have water temperature logs for resident rooms the week of 4/27/2026 – 4/30/2026. She was not able to show what resident room water temperatures were held at. On 4/28/2026 at 11:30 a.m., 4/30/2026 at 8:30 a.m. the following was observed in community shower rooms. 1. The community shower room in hallway 200 - 209 was observed with; 1. Water to the shower did not turn on. There was a small plastic trash can in the shower stall with a plastic bag almost full of water; 2. One of one plastic shower chair was observed with black and pink bio-growth on each of the legs near the wheel castors; There was a shelf with various items to include open and used plastic straight razors, used combs and brushes which were not labeled 2. The Community shower room across from the 200 hall unit station was observed with; 1. 2 of 2 plastic shower chairs with black bio-growth on all four chair legs near the wheel castors. 2. The wall mounted shower sprayer was turned on and turned on to hot. After three minutes and with use of the back of the hand, the water was less than lukewarm. On 4/30/2026 at 2:45 p.m. the Housekeeping Director was interviewed related to cleaning protocols in community shower rooms and with resident shower/bathing equipment. The Housekeeping Director revealed the shower chairs are to be cleaned by nursing staff if there are any observations of matter and to clean and sanitize in between each use. She continued to say housekeeping will start to develop a plan for deep pressure wash treatment for shower chairs. She said she is developing a plan but had not implemented it just yet. She also confirmed she did not have any type of documentation to support the shower chairs are routinely cleaned. On 4/28/2026 at 3:00 p.m. the 400 main dining room was entered. There were no residents in the room at the time, but the room was identified as used for residents to dine in during meal services. While seated in the chair at a table, the dining room layout revealed twelve tables with red tablecloths on them. The room was very large, and one end of the room led into a hallway that goes to the 400 unit, the other end of the dining room had a windowed alarmed door that led outside. It was observed staff were using this door to either come in from outside or were coming from the 400 hall to use the dining room windowed door to go outside. It was found staff use the door from this dining room as a short cut to get to another part of the building. The door was observed with a code key lock and a screamer alarm affixed to the top corner. It appeared when staff used the door to come inside or to go outside, staff needed to press the Screamer alarm button prior to it triggering/alarming, and disarming when alarming. It appeared this door was being used at least fifteen times during a time period of 3:00 p.m. to 3:10 p.m. It was found that some staff did not press the Screamer button fast enough, and therefore the alarm sounded very loudly. There were no residents in this dining room at the time. A dining observation will be made on 4/29/2026. On 4/29/2026 at 12:20 p.m. the 400-unit main dining room was entered and there were two residents seated at a table and talking with one another. Each had what appeared to be a hydration drink. They were both awaiting the lunch meal service. At 12:22 p.m. a staff member opened the windowed alarmed door from the outside and did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 12:32 p.m. a staff member opened the windowed alarmed door from the outside and did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 12:34 p.m. a staff member was observed to walk from the 400 unit down the hallway and into the main dining room and proceeded to walk to the windowed alarmed door and walked outside. The staff member did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 12:35 p.m. a staff member was observed walking from the 400 unit down the hallway and into the main dining room and proceeded to walk to the windowed alarmed door and walked outside. The staff member did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 12:45 p.m. the dining room was observed with 12 residents seated at tables and awaiting their lunch meal tray. The kitchen staff brought in meal tray carts for the dining room. There were three staff members in the room and they began to pull trays from the cart and placed them on the table in front of residents. At 12:49 p.m. a staff member opened the windowed alarmed door from the outside and did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 12:52 p.m. a staff member was observed to walk from the 400 unit down the hallway and into the main dining room and proceeded to walk to the windowed alarmed door and walked outside. The staff member did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. Every time the alarm sounded, there were at least two residents who would place their hands over their ears due to the very loud noise. At 12:59 p.m. two staff members were observed walking from the 400 unit down the hallway and into the main dining room and proceeded to walk to the windowed alarmed door and walked outside. The staff members did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 1:00 p.m. the 400-unit dining/activity room was observed with ten residents who were still eating and enjoying their meal. At 1:02 p.m. a staff member opened the window alarmed door from outside and did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 1:12 p.m. a staff member opened the windowed alarm door from the outside and did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 1:15 p.m. the 400-unit dining/activity room was observed with three residents, who were still eating and enjoying their meal. At 1:22 p.m. a staff member was observed to walk from the 400 unit down the hallway and into the main dining room and proceeded to walk to the windowed alarmed door and walked outside. The staff member did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. At 1:35 p.m. one resident remained eating in the dining room with staff supervision and a staff member had opened the windowed alarm door from the outside and did not press the Screamer alarm prior to the alarm sounding. The alarm sounded for approximately five seconds before the alarm was turned off. Interview with over five various staff members (unknown names and position titles), all confirmed they use the door to go to another unit, and they try to press the screamer alarm disarm button before it alarms. The staff also confirmed the alarm sounds pretty quickly and they used the door during meal services when residents were in the room. On 4/30/2026 at 9:30 a.m. an interview with the Dietary Manager confirmed staff do use the door leading out and in from the 400-dining room, which is next to the kitchen. She confirmed she hears the alarm from the door sounding all day including when residents are in the room eating for all three meal services. She confirmed staff use this door to go to another side of the building and vice versa. The Dietary Manager stated she will tell staff not to use the door while residents are dining, but there is just too much staff traffic going in and out, that it's impossible to catch them all. The Dietary Manager was not aware if the Nursing [NAME] Administrator was aware of staff using this door as means as a short cut. On 4/30/2026 at 2:00 p.m. an interview with the Nursing Home Administrator stated she had just found out that staff were using the 400-unit dining room door to go outside to another unit, or staff coming on to the 400 unit from other parts of the building. She confirmed that when residents dine in that area, staff should not be using that door to go in and out. She did say there is a Screamer alarm attached but residents should be kept with a homelike dining experience when eating. On 4/27/2026 at 9:58 a.m., an observation of room [ROOM NUMBER] the vanity top material was not attached to the wood underneath it. The laundry basket under the sink contained 2 used gloves and appeared to have crumbs of unknown substances in it. On 4/27/2026 at 10:19 a.m. an observation of room [ROOM NUMBER] showed on the bathroom wall above the door appeared black and brown bio-growth. On 4/27/2026 at 10:20 a.m. an observation of room [ROOM NUMBER] showed the area surrounding the Packaged Terminal Air Conditioner (PTAC) had crumbling wallboard in the area between the unit and the decorative molding. The baseboards in the area were covered with a brownish-gray substance and the wall above the PTAC unit had an area of splitting paint. On 4/27/2026 at 10:30 a.m. an observation of room of the 400-hall unit nurses' station showed pieces of tiling missing in the doorway of one of two 400 hall and the nursing station area of the unit. The missing pieces were approximately 5 inches by 4 inches. The hole was off centered in the hallway and left an indentation of the depth of a floor tile. A smaller hole was observed in the doorway nearer the hinges. On 4/27/2026 at 10:55 a.m. an observation of room Resident 12's low air loss control unit hanging from footboard of bed frame. A black substance was noted within the indented of the weight selector dial. On 4/29/2026 at 11:35 a.m. another observation of the weight selector dial showed the black substance continued to surround the dial. On 4/27/2026 at approximately 11:10 a.m. an observation was made of room [ROOM NUMBER]. The privacy curtain to the left of doorway had a dried brown substance attached to it. The Packaged Terminal Air Conditioner (PTAC) had yellow duct tape attached to the molding and surrounding the unit on three sides. The tape was loosening on one corner. The sink vanity in the room had chipped and flaking paint. On 4/29/2026 at 11:00 a.m. an observation of the 500-hall dining room showed a package of crackers had fallen on floor, 10 crackers had spilled from the package. The baseboard near the package had staining of previously spilled liquids, the tiles next to the baseboards were discolored a tannish-yellow color with black/gray/brown unknown material. The observation showed areas of patching with unmatched wall coloring, the corners of the baseboards showed black attached unknown substances, the chair rail in the room was stained with dried splattering of unknown substances, the wall to the right of fish aquarium near the baseboard was an area of cracked wallboard approximately 2 foot in length. The cracked wallboard appeared to have been previously repaired. A square table next to the aquarium without anyone sitting at it, was unclean with a liquid on it. The 500-hall dining room was also used as the activity room for the secured unit. During the observation Staff S, Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed the observations and stated she had not noticed the cracked wallboard but would report it now. The staff member stated housekeeping was responsible for wiping down tables after meals. An interview was conducted on 4/29/2026 at 11:20 a.m. with Staff W, Housekeeper. Staff W reported not mopping the 500-hall dining room as she doesn't want people to fall, she just sweeps it. The staff member reported the facility doesn't have floor technicians and night shift was supposed to mop it. The staff member stated the stains on walls aren't able to be cleaned, they need to be bleached. An interview on 4/30/2026 at 8:55 a.m. was conducted with Staff S, LPN/UM. Staff S reports the floors in the building were being redone but the 500 hall is last on the list and portions of the dining room had been repainted on 4/29/2026. Staff S was shown the area where the breakfast cart had been pushed into the nearly repaired area next to the aquarium. An interview on 4/30/2026 at 10:47 a.m. was conducted with the Nursing Home Administrator (NHA). The NHA reported being Maintenance Director as the previous one had left on 4/29/26. Review of the policy – Cleaning and Disinfecting Residents' Rooms, revised August 2013, revealed it's purpose was to provide guidelines for cleaning and disinfecting residents' rooms. The general guidelines included:1. Housekeeping surfaces (e.g. Floors, table tops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.2. Environmental services will be disinfected (or cleaned) on a regular basis (e Daily, three times per week) and when surfaces are visibly saw failed.4. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Review of the facility policy and procedure titled Environmental Services – Safe Environment not dated. The policy stated; IN accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions: Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or hyperthermia or and is comfortable for the residents. Comfortable sound levels means levels that do not interfere with the resident's hearing, levels that enhance privacy when privacy is desired, and levels that encourage interaction when social participation is desired. Environment – refers to any environment int the facility that is frequented by residents and visitors, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. Sanitary includes, but not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but not limited to, equipment used in completion of activities of daily living. The procedure section of the policy revealed;1. The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. E . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.I . The facility will provide and maintain comfortable and safe temperature levels in all areas.a. The facility should strive to keep the temperature in common resident areas within a range established by regulation.1. The facility will maintain comfortable sound levels in the facility. 2. General Considerations:C . Maintain minimal use of alarms, using alternative interventions, unless otherwise indicated by the care plan.

Based on interview and record review the facility failed to ensure Preadmission Screen and Annual Review (PASRR) was accurate for one (Resident #81) of two residents reviewed for PASRR. Findings Include: Review of Resident #81's admission record revealed she was admitted to the facility on [DATE] with diagnoses to include anxiety, major depressive disorder, bipolar disorder, and dementia. Review of Resident #81's admission Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 14/15, which reflected intact cognition; and acknowledged Feeling down, depressed or hopeless 7-11 days a week. Review of the psychiatry progress note dated 4/10/26 revealed . Depression: Little interest in doing things, Feeling down/depressed/hopeless, Trouble falling or staying asleep, Feeling tired, Appetite problems, Feeling bad about self, Trouble concentrating, Moving or speaking slowly. Review of the medical records revealed no evidence of a Level II PASRR (Preadmission Screening and Resident Review) for a secondary diagnosis of dementia with a diagnosis of major depressive disorder was submitted to the State Mental Health Authority for review for evaluation and determination of whether the individual required specialized services for Resident #81. During an interview on 04/30/2026 at 4:42 PM the Nursing Home Administrator (NHA) confirmed that a Level IIPASRR evaluation had been submitted to the State Mental Health Authority for Resident #81.The NHA stated they had started a performance improvement plan (PIP) and a previous member of her administrative team was trying to fix the PASRR's. For Resident #81, the NHA asked what specifically was incorrect on the Level I PASRR form. The NHA confirmed question 6 in section II; dementia was not marked as a secondary diagnosis therefore no level 2 was submitted. Review of the PASRR Policy with no revision date revealed the following. Policy: The Admissions Coordinator/Designee is responsible for ensuring that the Level I PASRR Screen and Level II PASRR Evaluation and Determination, if applicable, are completed prior to admission. Procedure: 2. A Level I PASRR must be fully and accurately completed . Upon or prior to admission, if the facility finds the Level I to be incomplete or inaccurate, a corrected Level I PASRR must be completed by the hospital staff or appropriate Nursing Facility staff . 4. When applicable, a request for a PASRR Level II evaluation must be made .

Based on observations, interviews and record review, the facility failed to ensure access to vision services for one (Resident #73) of one resident reviewed for communication and sensory problems.Findings included: On 4/27/2026 at 1:13 p.m., an interview was conducted with Resident #73 in her room. Resident #73 stated she would like to visit an ophthalmologist (eye doctor). She said staff told her she was placed on a list months ago. She does not know why they have not followed up with her on this request. She said she can see with her current glasses but due to her glaucoma she would like an examination. A review of Resident #73's admission Record showed Resident #73 was admitted to the facility on [DATE] with a diagnosis including but not limited to glaucoma. A review of Resident #73's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition and showed she uses corrective lenses. Review of Resident #73's active Care Plan dated 7/25/25 revealed Resident #73 has impaired visual function related to Glaucoma. The interventions for this care plan state to observe, document and report as needed any signs or symptoms of acute eye problems. On 4/29/2026 at 12:46 p.m., an interview was conducted with Staff A, Certified nursing assistant (CNA). Staff A, remembers there was an eye doctor that would see the residents here, and she is not sure if they currently still have this process in place. She said, if a resident reported they needed to see an eye doctor, she would report this to her nurse. Staff A said, if she recalls accurately the Unit Manager would handle the arrangements to see an eye doctor. On 4/29/2026 at 12:54 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B said, Resident #73 did request a couple months ago that she would like to see an ophthalmologist. Staff B looked for a logbook to report this, could not find the logbook for vision care needs. Staff B said they didn't have a Unit Manager at the time, so she reported this to the previous Director of Nursing (DON). On 4/29/2026 at 12:54 p.m., an interview was conducted with the interim Director of Nursing (DON). The DON stated the process for a vision exam is to notify the nurse or supervisor first. Then determine if the resident would prefer the in-house optometrist, or if an outpatient appointment is needed. The DON stated they have two staff members that will handle appointment arrangements and transportation. The DON said, she is not aware of Resident #73 requesting to have a vision appointment for over two months. The DON acknowledged the process did not get the outcome expected for Resident #73. Review of the Resident Rights Policy with no revision date revealed the following. Policy: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote the rights of the resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, and reprisal from the facility.

Based on observations, interviews and record reviews, the facility failed to ensure call light accessibility for one (Resident #94) of 10 residents reviewed.Findings included: During an observation on 4/27/2026 at 9:57 a.m. Resident #94 's call light was seen tangled with the roommate's call light, located under the roommate's bed.Review of Resident #94 admission record revealed an admission date of 2/9/2023 and a readmission date of 5/13/2023. Resident #94 was admitted to the facility with diagnosis to include but not limited to gastritis, atherosclerotic heart disease of native coronary artery without angina pectoris, persistent mood disorders, hyperlipidemia, major depressive disorder, insomnia, hemorrhage of anus and rectum. During an interview with the Director of Nursing (DON) on 4/27/2026 at 10:00 a.m. the DON stated Resident #94's call light was not within reach and was located under the bed.During an interview on 4/29/2026 at 1:57 p.m. Staff N, Certified Nursing Assistant (CNA) said call lights should be located next to residents. Staff N always checked call light accessibility during the morning rounds. During an interview on 4/29/2026 at 2:01 p.m. Staff M, Registered Nurse (RN) said call lights were to be located within reach. Staff M checked call light accessibility when providing care, and every now and then. When a call light was on, there was a machine located at the nurse's station which would indicate this. The light above each of the residents' rooms also indicated a call light was on. Review of a facility policy and procedures titled Call light, Answering with no revision date showed Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Key procedural points: .4. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. (Photographic evidence was obtained)

Based on observations, staff interviews, and record review, the facility failed to develop and implement care plan problem areas related to oxygen therapy for one (Resident #11) of six sampled residents. Findings included:On 4/27/2026 at 10:30 a.m., 4/28/2026 at 8:45 a.m., 10:45 a.m., 2:00 p.m. and on 4/29/2026 at 8:10 a.m. Resident #11 was observed with oxygen being delivered by the way of a nasal canula with a flow rate of 1.5 liters per minute (lpm). Resident #11 was not able to answer questions related to his medical care and services. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #11 had a Power of Attorney to make his medical and financial decisions. Review of the diagnosis list revealed no specific diagnosis related to respiratory functions.Review of the current month 4/2026 Physician's Order Sheet revealed orders to include but not limited to: Oxygen (O2) at 2 lpm, as need for Shortness Of Breath (SOB), (Order date 4/16/2026).Review of the Medication Administration Record (MAR)/Treatment Administration Record (TAR) for month of 4/2026 revealed daily O2 saturation rates were documented as 92% and above each shift. The MAR revealed order 4/16/2026 - Titrate Oxygen to keep above 92% as needed to support labored breathing Titrate to keep above 92%. Documentation started on 4/17 - current 4/30/2026 as provided.Also, the MAR revealed Oxygen 2L as need for SOB and checked as completed from 4/1/2026 - 4/15/2026. Revie of the current Minimum Data Set (MDS) Significant Change assessment dated [DATE], revealed; (Cognition/Brief Interview Mental Status or BIMS score - 3 of 15, which revealed Resident #11 would not have been able to speak related to his medical care and service); (Activities of Daily Living ADL - Impairment both sides lower extremity, Dependent on staff with most to all ADLS); (Treatment - not checked for use of oxygen.) Review of the current care plans with a next review date 7/2/2026 revealed no care plan problem areas, goals and interventions related to use of oxygen. It was found resident #11 was receiving oxygen therapy routinely since 4/16/2026 and there had not been any care plans developed for the use of.On 4/29/2026 at 10:05 a.m. an interview with the MDS/Care Plan Coordinator revealed she is responsible for care planning development, along with the Interdisciplinary Team (IDT). She confirmed Resident #11 was ordered for Oxygen therapy at 2 liters per minute and with an order date of 4/16/2026. The Care Plan Coordinator reviewed Resident #11's current care plans with a next review date 7/2/2026 and confirmed there were no care plans with problem area, goals and interventions related to oxygen therapy. The Care Plan Coordinator also stated the care plan should have been developed by now. She stated she had received reports of residents who needed to have care plans updated, and Resident #11 for some reason was not on that report.On 4/30/2026 at 12:25 p.m. an interview with the 200 Unit Manager Staff E, revealed she was just made aware Resident #11 was now using oxygen routinely and that was something hospice services had changed but never brought to their attention to make the change. She confirmed Resident #11 should have by now been developed with a care plan to reflect the use of oxygen therapy. On 4/30/2026 at 3:20 p.m. an interview with the Director of Nursing and Nursing Home Administrator confirmed Resident #11 who utilized oxygen therapy, whether routinely or as need, should have been developed with a care plan problem area to identify oxygen therapy, and with goals and interventions related to it.On 4/30/2026 at 4:00 p.m. the Nursing Home Administrator provided the Resident Assessment Instrument Comprehensive Care Plan Policy, with an effective date of September 2024 for review. The policy stated; To ensure 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.The Policy Statement revealed; 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.The Procedure section of the policy #3 revealed;Developing the care Plan;An individualized care plan will be created for each resident within 7 days after completing the comprehensive MDS,The care plan will address physical, emotional, social, and cognitive needs, as well as any other relevant areas (e.g. nutritional, safety, mobility, medication management),The care plan will specify measurable objectives and timelines and include input from the residents and family where appropriate. #5 of the procedure revealed;The care plan will be reviewed quarterly and revised as necessary,The care plan must be updated in response to changes in the resident's condition, new assessments, or input from the resident/family,Significant changes in the residents' condition will trigger a new MDS assessment, guiding further revisions to the care plan.

Based on observations, interviews and record review the facility failed to ensure medication error rate was not greater than 5%. A total of 27 opportunities were observed with 2 errors constituting an error rate of 7.41%. Findings included:1. On 04/29/2026 at 8:34 AM a medication observation was conducted with Staff C, Licensed Practical Nurse (LPN) for Resident #131. Staff C dispensed the following medications:-Amlodipine 2.5 mg (milligram) -1 tablet-Aspirin 81mg chewable -1 tablet-Zyrtec 10mg -1 tablet-donepezil 5 mg -1tablet-Famotidine 10mg -4 tablets-Losartan 25 mg -1 tabletStaff C, LPN confirmed the tablets prior to administration.Review of Resident #131's admission Record showed she was admitted to the facility on [DATE] with diagnoses to include: cerebral atherosclerosis, vascular dementia, dementia, and hypertension. Review of Resident #131's active orders showed:-Donepezil HCl (hydrochloride) Tablet 5 mg; Give 10 mg by mouth one time a day for dementia.2. On 04/29/2026 at 4:30 PM a medication observation was conducted for with Staff D, LPN for Resident #194.Staff D obtained a blood glucose level of 234. Staff D then dispensed the Humalog KwikPen and turned the dial to show 3 units. Staff D, LPN stated she does not prime the pen prior to administration. Staff D administered the dose in the left lower abdomen and held dose knob for approximately 2 seconds.Review of Resident #194's admission Record showed he was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus type 2.Review of Resident #194 active orders showed: -HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Lispro) Inject as per sliding scale: if 0 - 110 = 0 units for blood sugar less than 70 notify physician; 111 - 149 = 1 units; 150 - 199 = 2 units; 200 - 249 = 3 units; 250 - 299 = 4 units; 300 - 349 = 5 units; 350 - 399 = 6 units ; 400+ = 6 units for blood sugar greater than 399 give 6 units and notify physician, subcutaneously before meals and at bedtime for DM (diabetes mellitus).On 04/30/2026 at 1:00 PM an interview was conducted with the Interim Director of Nursing (DON). She said she has not provided education to staff regarding insulin pen priming. She was not able to provide a proper demonstration of how to prime an insulin pen. DON said it was necessary to prime an insulin pen to provide the resident with the correct dose of insulin. Reviewed with DON regarding findings of the medication administration observations. The DON confirmed the correct dose of milligrams should have been administered, and the nurse should have primed the insulin-pen.Review of the manufacturer's KwikPen U-100 instructions for use 3mL single-patient-use pen found on the manufacturer's website at: https://uspl.lilly.com/humalog/humalog.htm#ug1 showed the following:Step 5: Priming your Pen. Prime before each injection.-Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly.-If you do not prime before each injection, you may get too much or too little insulin.Giving your injectionStep 11:-Insert the needle into your skin.-Push the dose knob all the way in.-Continue to hold the dose knob in and slowly count to 5 (5 seconds) before removing the needle.Review of the Policy Administering Medications with a revision date of April 2019 showed: Medications are administered in a safe and timely manner, and as prescribed. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on record reviews and interviews, the facility failed to provide timely laboratory services for one (Resident #130) of three residents reviewed.Findings included: Review of Resident #130's admission record revealed an admission date of 5/2/2024. Diagnosis includes but not limited to fracture of the lower end of right radius, nondisplaced fracture of right ulna styloid, chronic diastolic heart failure, and convulsions. Review of Resident #130's progress notes revealed a nursing note on 3/13/2026 at 10:11 p.m. showing Resident #130 had swelling of the right arm and right hand, felt hard and a little warm to touch. The resident's cast was removed from this arm on 2/19/2026 from a previous fracture. The note also said Resident #130 had range of motion within normal limits (ROM WNL), hospice and facility physician were notified. Review of Resident #130's progress notes revealed a nursing note on 3/14/2026 at 6:15 a.m. that a new order was placed for a venous ultrasound of the right upper extremity. Review of Resident #130's progress notes revealed a nursing note on 3/15/2026 at 9:56 p.m. that stated a call was placed to a mobile radiology vendor regarding Resident #130's doppler that was ordered. The facility was told someone would visit that same day however they had not come to do the venous doppler. Review of the procedure results showed on 3/17/2026 at 11:01 a.m. Resident #130 had an occlusive radial deep venous thrombosis. Review of Resident #130's care plan showed Resident #130 was at risk of cardiac complications. There was an intervention to notify physician of significant abnormalities and observe/document/report any color/warmth of extremities. During an interview on 4/30/2026 at 1:40 p.m. Staff Q, Certified Nursing Assistant (CNA) stated swelling was to be reported to the nurses right away who will then check on the resident. During an interview on 4/30/2026 at 1:42 p.m. Staff P, Licensed Practical Nurse (LPN) stated change in condition, such as swelling, was to be reported immediately. This included night shift nurses as there is an on call physician. Staff P did not know why there was a delay in testing after swelling was found on Resident #130's arm. Staff P said if radiology was ordered through a vendor and they did not show up, the facility would follow up with the vendor within that same shift. During an interview on 4/30/2026 at 12:48 p.m. the Director of Nursing (DON) stated swelling in residents with a history of chronic heart failure was to be reported right away. If this occurred during night shift, staff should not wait until morning to report it. The DON said if an outside vendors was to conduct a procedure but had not shown up yet, staff must call again to find out, what happened. Nurses are to confirm with the doctor and ensure the test(s) are ordered stat. The DON said she was unsure why there was a delay in care especially if there was swelling involved. Review of the facility's LPN position description revealed a Basic function: To deliver nursing care to residents of this facility. Essential Function: .3. Makes observations and reports pertinent information related to the care of the resident. The Coordination of Care: 1. Co-workers are informed of changes in residents conditions or of any other changes occurring on the unit. 2. Information is relayed to other members of the health care team (LE., physicians.)Review of the facility's Registered Nurse (RN) position description revealed a Basic Function: To plan and deliver nursing care to patients/residents requiring long-term of rehabilitative care. Essential Functions:.7. Maintains knowledge of necessary documentation requirements. The Coordination of Care: 1. Co-workers are informed of changes in residents conditions or of any other changes occurring on the unit. 2. Information is relayed to other members of the health care team (LE., physicians.)

Based on observation, interviews and record review, the facility failed to ensure one (Resident #13) received meals prior to going to dialysis out of one resident reviewed for dialysis.Findings included: On 04/29/2026 at 8:30 AM observed Resident #13 at the nurses' station in wheelchair. He stated he was going for dialysis and would talk with me when he got back from dialysis. He did not have any belongings or food with him. On 04/29/2026 at 4:00 PM an interview with Resident #13 was conducted. He stated he does not get his meal before he leaves for dialysis. He stated he used to, but it has been like this for about the past month. He stated he goes to dialysis on the Monday, Wednesday, Friday (MWF) schedule. Review of Resident #13's admission Record revealed he was admitted to the facility on [DATE] with a re-admission on [DATE]. He had diagnoses to include end-stage renal disease (ESRD), hypertension, diabetes mellitus type 2, major depressive disorder and generalized anxiety disorder. Review of Resident #13's Quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition; it also showed no behaviors and a special treatment of Dialysis. Review of Resident #13 active physician orders showed:-Patient (Pt) to go to (Dialysis Center Name and phone number) Monday, Wednesday and Friday, up in wheelchair by 9:00 AM. Chair time is 10:15 AM. Pt must have Hoyer pad underneath him in wheelchair.-Low Concentrated Sweets/NAS (No Added Salt) diet, Regular texture, thin consistency for diet Review of Resident #13's active Care Plan showed:-(Resident #13) has dehydration or potential fluid deficit related to (r/t) ESRD/dialysis; With interventions to include: ., recent/sudden weight loss, .-(Resident #13) is at risk of malnutrition and altered nutrition status r/t (related to) Dx (Diagnoses): ESRD on dialysis, DM2 (diabetes mellitus type 2), anemia, dementia, depression, obesity, Bilateral amputee, . Triggers for a significant weight loss for 30 days. With interventions: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, ESRD/obesity/malnutrition risk factors. Observe/record/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of malnutrition: . significant weight loss: 3 pounds (lbs) in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide, serve diet as ordered. Review of Resident #13's Progress Notes showed:-4/16/2026 Nutrition/Dietary Note -(Dietician)Note Text: Following resident due to significant weight loss of approximately 5.9% over 30 days (-11 lbs from 188 lbs on 03/06/2026 to 176.8 lbs on 04/14/2026). Current BMI (Body Mass Index) 51.8 (obese). Most of the weight loss occurred between 03/06/2026 and 04/14/2026. Resident on a Low Concentrated Sweets/NAS diet, Regular texture, thin consistency, with intake ranging 26-100%, mostly 76-100%. Resident is independent for feeding. No current swallowing concerns noted. On 04/30/2026 at 10:37 AM an interview with the Certified Dietary Manager was conducted. She stated Resident #13 frequently comes to the kitchen to ask for more milk and cereal. She is not aware if he does not get his tray prior to leaving for dialysis. She stated the trays go up at 7:30 AM, and he would be one of the first to receive it. She stated he should be getting his breakfast before he leaves for dialysis. On 04/30/2026 at 10:41 AM an interview with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) was conducted. She stated he should get his breakfast tray before dialysis. On 04/30/2026 at 10:43 AM an interview with Resident #13 was conducted. He confirmed he does not get his breakfast tray most days before dialysis. He said once in a while he will get it, just depends on if the kitchen is backed up. On 04/30/2026 at 1:00 PM an interview was conducted with the Interim Director of Nursing (DON). She said dialysis residents should be getting their breakfast tray prior to going to dialysis.

Based on observations, interviews, record review, and manufacturer specification review the facility failed to maintain the settings of a low air loss mattress for one (#12) of two residents investigated for the worsening and/or development of pressure ulcers. Findings included: On 4/27/26 at 10:55 a.m. Resident #12 was observed lying in bed atop of a low-air mattress, the resident refused to have staff and writer observe surgical area on lateral right leg. The elderly resident appeared to be of a weight consistent with age. The pump for the mattress was hanging from the foot board end of the bed, was set for static, low pressure and the weight (pounds) setting revealed 350 pounds, the highest setting possible. The dial for setting the weight was manual, requiring staff to turn the knob to then correct weight of the resident. On 4/29/26 at 11:35 a.m. Resident #12's air mattress was observed; the resident was out of bed. The pump settings continued to be set for static, low pressure and 350 pounds. During an interview and observation on 4/29/26 at 11:42 a.m. Staff V, Registered Nurse (RN) stated Resident #12 was tiny. The staff member observed the resident's mattress setting and confirmed it was set for 350 pounds (#). Staff V reported a setting set high would make the mattress full firm and a firm mattress could cause pressure injuries. The staff member readjusted the mattress to an approximate weight of the resident. An observation and interview was conducted with Staff S, Licensed Practical Nurse/Unit Manager (LPN/UM) on 4/29/26 at 11:46 a.m. Staff S stated an air mattress should be set per weight of the resident. Staff S said an incorrect weight setting of 350# was too firm and could cause pressure injuries. The staff member reported staff should be checking the weight setting. An interview was conducted on 4/30/26 at 1:41 p.m. Staff P, Licensed Practical Nurse (LPN) reported an air mattress should be set per resident's weight and Resident #12 did not weigh 350#. Review of Resident #12's admission Record showed the resident was admitted on [DATE] and 2/20/26. The record included diagnoses not limited to pressure-induced deep tissue damage of right heel (onset 3/4/26), unspecified protein-calorie malnutrition, and unspecified dementia unspecified severity with other behavioral disturbance. Review of Resident #12's active physician orders revealed an order dated 2/25/26 at 5:19 p.m. for Device: Mattress Air. every shift for off-loading. The order was to be included on the resident's Treatment Administration Record (TAR) and did not include specific settings for the mattress. Review of Resident #12's wound care physician notes revealed the following:4/7/26. The note revealed a history on 3/4/26 of an initial evaluation of a right heel deep tissue injury. The evaluation on 4/7/26 was for follow-up and management of an unstageable pressure injury to the right heel which showed no change. The note showed the resident weight was 110.99 #'s, the unstageable pressure injury measurements were 3-centimeter (cm) length x 4 cm width with no measurable depth with 100% necrosis. The interventions included daily dressing change per treatment plan and a pressure redistribution mattress.4/14/26. The patient was seen today for follow-up and management of an unstageable pressure injury of the right heel which shows deterioration. The measurements were 5 cm in length x 5 cm in width with no measurable depth. The wound bed showed 50% slough and 50% necrosis with the periwound exhibiting callus. The note revealed a mechanical debridement was performed and 100% of the wound was debrided. The post-debridement measurements were 5 cm x 5 cm x 0.3 cm depth and staged as unstageable. The barriers to healing was dementia, impaired mobility, incontinence, inevitable effect(s) of aging, and malnutrition.4/21/26. The note showed improvement with the right heel pressure ulcer. The wound measured 5 cm x 5 cm with no measurable depth, 80% slough, and 20% necrosis. The healing was expected to be delayed due to the identified barriers of healing. The pressure redistribution mattress was to be continued.4/28/26. The wound showed improvement with measurements of 4.8 cm x 4.7 cm with no measurable depth. The resident weight continued to be 110.99#. The goals included to promote epithelial wound edge advancement and reduce or control modifiable risk factors. Review of Resident #12's significant change in condition Minimum Data Set (MDS) dated [DATE] revealed Resident #12 required substantial/maximum assist with bed mobility and transfers. Review of Resident #12's care plan showed the resident did have an unstageable pressure ulcer on right heel related to (r/t) reduced mobility. The interventions included but were not limited to the use of a low air loss mattress. The intervention did not include information related to setting the mattress per weight of the resident. Review of the facility policy - Skin care and Wound Management, identification and early intervention plans, undated, revealed the facility would identify residents a risk for developing pressure ulcers and will initiate early prevention plans. The procedure showed the facility would: complete the Braden Scale (pressure ulcer risk) at admission/readmission, change in condition, and no less than quarterly.Identify areas of concern by completing either Section L of the Nursing Admission/readmission Screening History or the weekly skin sweepDevelop the care plan for skin care (preventative and wound management using the baseline care plan at admission/readmission and the Interdisciplinary Care Plan Tea would develop a comprehensive care plan.The policy did not reveal any specific early prevention plans, the procedure for pressure ulcer treatments, or reveal staff would be educated on the management of pressure ulcers including the use of low air loss mattresses. The manufacturer advertisement for the alternating pressure low air loss mattress, provided by the facility, showed alternating Pressure low air loss pump and mattress system facilitates the prevention of wounds for individuals at minimum to moderate risk and provides treatment for wounds at various stages. Through alternating pressure, the mattress can dynamically change to accommodate the patients preferred pressure points and improve patient circulation. The features included: static mode for easy resident transfer, 10-minute cycle for alternating pressure, and adjustable setting allows for customized pressure by resident weight. The advertisement was not for the same mattress system (observed pump) utilized by Resident #12. According to the mattress control unit (for a labeled model) operating instructions (located athttps://proactivemedical.com/wp-content/uploads/2018/06/Protekt-Aire-2000-Manual-1.pdf) utilized by Resident #12. The steps included:Step 3: press the static button for a quicker inflationStep 6: Determine the patient's weight and set the control knob to that weight setting on the control unit.Step 7: Press the static button to shift between alternating mode and static mode.Note! In Static mode, the overlay provides a firm service that makes it easier for the patient to transfer or reposition. The static mode will help ensure the patient does not bottom out when in a sitting position.

Based on observation, interviews, and record review, the facility failed to ensure supervision was provided to residents identified as requiring enhanced monitoring (EM), one to one (1:1) supervision, and/or continuous monitoring (CM) for six residents (#1, #3, #4, #6, #22, and #24) out of six residents sampled. Findings included:1. A review of Resident #1's admission record revealed an admission date of 4/15/25, with diagnoses to include unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate, unspecified psychosis not due to a substance or known physiological condition, and adjustment disorder with anxiety.A review of Resident #1's physician orders revealed the following:- Device: Wander Management Bracelet - Check Function with machine every night shift for elopement risk, with a start date of 9/1/25.A review of the facility's reportable incident log showed the following:- Date of Incident 2/23/26 [Resident #1] + [and] [Resident name] Type of Allegation * Physical .A review of the facility's incident log showed Resident #1 had a behavioral occurrence incident, on 2/23/26.A review of Resident #1's progress notes revealed the following:-2/23/26, Resident stated that she pushed another resident down to the ground whom entered her room and placed hands on her first. No new skin issues noted to resident. Resident placed on 1:1 after incident. All appropriate parties notified of incident with no further behaviors noted.- 2/23/26, Date of Service: 2026-02-24 . Psychiatry Subsequent Note . As per collected information, the patient is reported unstable and requires an evaluation. Staff reports speech was involved in a resident to resident altercation as the aggressor. Its reported the patient pushed an another patient. While meeting with the patient. She does show confusion at times during the visit. She denies any incident occurring between her and a peer. Patient reports she would never replace her hands on anybody else. She expresses she watched her peer go into the bathroom, but says she never goes in the bathroom with her. She waits until she comes out before going in there. Mental Status Exam: . Insight and Judgement: Impaired. Orientation: Oriented x 2 [oriented to person and place] . Summaries: A) Summaries of past notes: 2/24/26: [name of provider]: Pt [patient] has mood d/o [disorder]. Meds [medications]: Donepezil, Namenda, & [and] Trazodone. No meds changed. Removed 1:1 Supervision. Plan of Action: .Based on the patient interview and collected information, it appears that the patient is safer and one on one observation is not the least restrictive option to ensure safety. So, I recommend discontinuing one on one sitter.- 2/23/26, The Change In Condition/s reported on this CIC [change in condition] Evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis) . Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: Placed on 1:1 monitoring Primary Care Provider Feedback: . A. Recommendations: monitor.- 2/27/26, Resident currently not displaying any behavior. Removed one by one for the time being.A review of the 500-unit Certified Nursing Assistant (CNA) assignment sheets and the schedule provided by the staffing coordinator revealed the following:- On 2/23/26, the 3:00 p.m. to 11:00 p.m. shift had no resident documented or staff assigned for 1:1 supervision. - On 2/24/26, there was no resident documented or staff assigned for 1:1 supervision on all three shifts.- On 2/25/26, the 7:00 a.m. to 3:00 p.m. shift had no resident documented or staff assigned for 1:1 supervision.- On 2/26/26, the 7:00 a.m. to 3:00 p.m. shift had a CNA assigned to 1:1 supervision with no room number or resident name documented. The 11:00 p.m. to 7:00 am shift had no resident documented or staff assigned for 1:1 supervision. 2. A review of Resident #3's admission record revealed an admission date of 2/19/26, with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified psychosis not due to a substance or known physiological condition, and depression, unspecified.A review of Resident #3's physician orders revealed the following:- Continuous Observation for Elopement every shift, with a start date of 2/24/26 and end date of 2/25/26.A review of Resident #3's progress notes revealed the following:- 2/19/26, Date of Service: 2026-02-20 . Psychiatry Evaluation Note . Chief Complaint: Psychosis, depression and dementia. Reason for Encounter: . I was consulted for psychiatric evaluation and treatment of depressed mood and disorganized and confused thinking. As per collected information, the patient is new and requires any evaluation. Patient's BIMS [brief interview for mental status] score 7 and PHQ9 [patient health questionnaire measuring severity of depression] score 12 as patient has severe impairment and moderate depression. Patient is at the facility for a rehab services. It's reported last night the patient was restless and observed wandering into other resident's rooms. Prior to coming to the facility the patient was living at home with her spouse. Patient has some depression and sleep issue.- 2/21/26, Called and spoke with [family member] stated that he had someone with her at home all time as she was trying to leave at home also. He stated that he is okay with this and that if we need to permanently moved her to the secure unit he is fine with that and that he understands.- 2/21/26, . MOOD AND BEHAVIOR Mood and behavior patterns: Agitated (repeated vocalizations, screaming, shouting, complaining, moaning, cursing, fidgeting, etc.) .- 2/24/26, Resident is laying in her bed room [room number]. This writer given in report resident has order for continuous observation due to elopement. This writer visualizes resident in her room. Plan of care ongoing.- 2/24/26, Room Change: Resident and [family member] given advanced notification of room change. [Family member] agreed and [Resident #3] will move from [room number] to [room number].- 2/24/26, Resident laying in bed resting talking with [family member] who is at bedside room [room number]. During this writer's shift [family member] was there to visit. Resident continues on increased supervision due to risk for elopement. During this writer's shift no active exit seeking behaviors were noted. Plan of care ongoing.- 2/25/26, Resident continues with wandering and get combative when redirected.A review of the 300-unit CNA assignment sheets and the schedule provided by the staffing coordinator revealed the following:- On 2/24/26, the 7:00 a.m. to 3:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts had no resident documented or staff assigned for 1:1 supervision. The 3:00 p.m. to 11:00 p.m. shift had Staff C, CNA assigned to 1:1 supervision for Resident #1 and Resident #4, who resided in the same room.3. A review of Resident #4's admission record revealed an admission date of 1/28/26 with diagnoses to include metabolic encephalopathy, Alzheimer's disease, unspecified, cognitive communication deficit, and depression, unspecified.A review of Resident #4's physician orders revealed the following:- Psych [psychiatry] consult due to verbal suicidal ideations, with an order date of 2/17/26.- Resident to be on increased supervision with staff one on one, due to verbal suicidal ideations, with an order date of 2/17/26 and end date of 2/18/26.- Continuous Observation for Suicide Ideation every shift, with an order date of 2/18/26 and end date of 3/2/26.A review of the facility's incident log showed Resident #4 had a behavioral occurrence incident, on 2/17/26.A review of Resident #4's progress notes revealed the following:- 2/17/26, The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition . Nursing observations, evaluation, and recommendations are: Resident stated suicidal ideations to the CNA. CNA reported this to myself. I spoke with resident and resident continued to verbalize suicidal ideations. Resident then went to therapy. This writer notified supervisor and adon [assistant director of nursing] of resident's statements. Primary Care Provider responded with the following feedback: A. Recommendations: [primary physician] notified awaiting further response/direction.- 2/17/26, [Primary physician] ordered resident to be on increased supervision one on one status due to verbal suicidal ideations. (ADON notified). Psych consult. Still awaiting return call from next of kin.- 2/17/26, This writer followed up and repeated a phone call to next of kin [family member] who answered and stated Yes she done that all the time even before she came to y'all. This writer notified next of kin that resident will be on increased supervision one on one with staff per the doctor's orders. Next of kin verbalized thankfulness for care provided. Along with psych consult. Plan of care ongoing.- 2/17/26, The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition . Nursing observations, evaluation, and recommendations are: Resident stated to me that she was suicidal. I stayed with the resident to make sure she did not do anything to harm herself. Resident stated she had a plan and wanted to shoot herself. CNA came and stayed with resident for constant observation. I notified [primary care physician], ADON, and [family member]. I called [psych provider] mental health and notified of resident's statement. I passed this info [information] onto 3-11 [3:00 p.m. to 11:00 p.m.] nurse. Resident is on 1:1 observation with staff. Primary Care Provider responded with the following feedback: A. Recommendations: To put resident on 1:1 constant observation (completed). To notify [psych provider] mental health (completed).- 2/17/26, Resident sitting in the day room talking with aide. Resident is on increased supervision with staff one to one due to previously voiced ideations. This writer gave report to oncoming nurse that [psych provider] will call back with further direction.- 2/18/26, . History and Physical Exam . Apparently patient had suicidal Thoughts. Psychiatry was consulted. Close supervision, on 1:1.- 2/18/26, Resident laying in her bed watching tv [television]. She is refusing to eat. Resident is on increased supervision with staff one on one due to previously voiced suicidal ideations. - 2/19/26, Resident is on close observation with staff one on one due to previously voiced suicidal ideations.- 2/19/26, patient remains on 1:1 observation for safety.- 2/19/26, Care plan meeting held c [with] Resident's [family member] and Interdisciplinary team. Discussed resident's plan of care. [Resident #4] currently has decreased motivation to participate c Rehab Therapy and has decreased appetite. She was referred for psych consult and is also on Enhanced monitoring by staff for safety measures.- 2/19/26, Date of Service: 2026-02-20 . Psychiatry Subsequent Note . Reason for Encounter: . As per collected information, patient is unstable and requires an evaluation. Recently, the patient expressed thoughts of wanting to harm herself. Currently, she remains on one-to-one supervision with staff. Patient one to one staff reports she is doing well today. Based on the patient interview and collected information, it appears that the patient is safer and one on one observation is not the least restrictive option to ensure safety. So, I recommend discontinuing one on one sitter. A) Summaries of the past notes: 2/20/26: [provider name]: Pt [patient] has depression. Pt felt down. Started Trazodone 25 mg [milligrams] PO [by mouth] BID [twice a day] for depression. Removed 1:1 sitter.- 2/20/26, patient remains on 1:1 observation for safety. will continue close monitoring and document any changed or mental status.- 2/20/26, Resident seen by [psych provider] recommendation is remove continuous observation and start Trazodone 25mg PO BID for depression.- 2/21/26, Resident continues to be monitored for suicidal ideations.- 2/21/26, Resident continues on 1:1 monitoring for suicidal ideations, no suicidal ideations voiced during this shift.- 2/21/26, Resident continues to be monitored for suicidal ideations.- 2/23/26, . Visit Type: Psychotherapy . History of Present Illness: . Patient is currently on one-to-one supervision due to reportedly expressing thoughts of wanting to die.- 2/23/26, Patient is alert and orientedx2 [to person and place], 1:1 observation on continues by protocol.- 2/24/26, .Resident has active order for continuous observation. Resident is currently on enhanced monitoring continuous monitoring due to history of suicidal ideations.- 2/25/26, Enhanced monitoring with 1:1 continues by protocol.- 2/27/26, . Psychiatry Subsequent Note . Currently, she remains on one to one supervision with staff. A) Summaries of the past notes: 2/27/26: [provider name]: Pt at baseline. Removed 1:1 sitter.- 2/28/26, Continuous Observation for Suicide Ideation every shift. Per Report patient is no longer on 1:1 suicidal observation.- 3/1/26, Continuous Observation for Suicide Ideation every shift. Per Report patient is no longer on 1:1 suicidal observation.- 3/2/26, Continuous Observation for Safety .A review of the 300-unit CNA assignment sheets and the schedule provided by the staffing coordinator revealed the following:- On 2/23/26, the 11:00 p.m. to 7:00 a.m. shift had Staff D, CNA assigned to 1:1 supervision for Resident #4, as well as rooms 312-324 in her assignment.- On 2/24/26, the 3:00 p.m. to 11:00 p.m. shift had Staff C, CNA assigned to 1:1 supervision for Resident #1 and Resident #4, who resided in the same room.- On 2/28/26 and 3/1/26, there was no resident documented or staff assigned for 1:1 supervision on all three shifts. 4. A review of Resident #6's admission record revealed an admission date of 12/1/25 with diagnoses to include other specified anxiety disorders, major depressive disorder, recurrent, moderate, and weakness.A review of Resident #6's physician orders revealed the following:- 1:1 Observation every shift, with a start and end date of 2/13/26.- 1:1 Observation for suicidal behaviors every shift, with a start and end date of 2/13/26.- 1:1 Observation for Suicidal Ideation every shift, with a start date of 2/13/26 and an end date of 2/25/26.- Continuous observation for Suicidal Ideation every shift, with an order date of 2/13/26 and an end date of 2/25/26.A review of the facility's incident log showed Resident #6 had a behavioral occurrence incident, on 2/13/26.A review of Resident #6's progress notes revealed the following:- 2/13/26, Date of Service: 02/13/2026 . Psychiatry Subsequent Note . As per collected information, as part of the patient is unstable requires any evaluation. Patient recently lost a good friend and expressed as he has increased symptoms of depression. Patient reports he has no family members left. At this time, patient is visibly upset throughout the visit. Patient shows symptoms of increasing anxiety and agitation. Patient reports he just wants to go be with his family. When it asked to elaborate the patient reports all of his family is dead, so if he has to harm himself to go be with them, he will. When asked if he had a plan, patient reports he would walk out in front of traffic or go get drugs to overdose such as fentanyl. Mental Status Examination . Abnormal thought processes: Has thoughts of self harm . Orientation: Alert, Oriented X 3 (oriented to person, place, time) . A) Summaries of the past notes: . 2/13/26: [provider name] . Initiated 1:1 sitter: . Based on the collected information and patient interview, the patient is not safe. For safety purposes, initiating the one on-one sitter for close observation is the only least restrictive treatment option available. Therefore, I ordered one on one sitter. Our team will follow up closely and will recommend removal of a one-on-one sitter when the patient is safe.- 2/13/26, Writer was told from psychiatrist and from resident that he did not want to live . Writer was told he had a plan to either harm himself or walk out. New meds ordered ,and resident aware.- 2/14/26, .resident cont. [continue] to be 1/1 [one to one supervision] and received his shower as well today.- 2/15/26, . Sitter at bedside, 24 hr. [hour] sitter. Plan ongoing.- 2/15/26 09:43, Resident tolerated medication and conts [continues] on 1/1 with no speaking of hurting himself this shift.- 2/16/26, Resident noted to be upset with one on one this this shift per CNA. Resident was advised that he will need to remain on 1:1 until he has been cleared. Resident was noted to be upset and then laughing.- 2/16/26, Resident seen by psych via [by] Tele [telehealth] visit, Psych recommend to D/C [discontinue] continuous observation and have resident seen by psychotherapist.- 2/19/26, .Resident continues on close observation.- 2/21/26, Resident continues on 1:1 monitoring for suicidal ideations.- 2/22/26, Resident continues 1:1 per orders.- 2/25/26, IDT [interdisciplinary] team review resident being on continuous observation. Resident evaluated by [psych provider], new order received to D/C continuous observation.A review of the 300-unit CNA assignment sheets and the schedule provided by the staffing coordinator revealed the following:- On 2/17/26, the 3:00 p.m. to 11:00 p.m. and 11:00 to 7:00 p.m. shifts had no resident documented or staff assigned for 1:1 supervision.- On 2/18/26, the 11:00 p.m. to 7:00 a.m. shifts had no staff assigned to Resident #6 for 1:1- On 2/24/26, there was no staff assigned for 1:1 supervision for Resident #6 on all three shifts.- On 2/25/26, there was no staff assigned for 1:1 supervision for Resident #6 on all three shifts.5. On 3/9/26 at 6:30 a.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She said Resident #22 was on one-to-one supervision at this time. An observation of Resident #22's room showed he was alone with no staff present.A review of Resident #22's admission record showed an admission date of 9/18/25 with diagnoses to include cerebral atherosclerosis, vascular dementia, severe, with agitation, unspecified mood (affective) disorder, restlessness and agitation, major depressive disorder, recurrent, moderate, other specified anxiety disorders, brief psychotic disorder, and other specified persistent mood disorders.A review of Resident #22's physician orders revealed no active or discontinued orders related to enhanced monitoring or one-to-one supervision.A review of the facility's reportable incident log showed the following:- Date of Incident 2/3/26 [Resident #22]/[Resident name] Type of Allegation * Physical .A review of Resident #22's progress notes revealed the following:- 2/2/26, Writer located at the nurse's station when I observed resident being escorted out of [room number] by CNA. Resident in [room number] came out of room with bruise present to forehead, stating resident hit her. 3-11 [3:00 p.m. to 11:00 p.m.] supervisor notified on unit at 10:33PM. Resident's [family member] notified of incident at 10:41 PM, [primary care provider] notified at 10:44 PM and hospice notified at 10:45PM.- 2/2/26, The Change In Condition/s reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis) . Behavioral Status Evaluation: Physical aggression . Nursing observations, evaluation, and recommendations are: Resident has a hx [history] of going into other resident's rooms.- 2/3/26, Chief Complaint: Psychosis, mood disorder, depression, anxiety, dementia, insomnia. Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. As per collected information, it reported the patient was involved in a resident to resident altercation as the aggressor. Patient has history of dementia. Patient does not remember the incident occurring. Staff report the patient does have increased anxiety and agitation at times. Patient has a history of wandering around the unit and goes in and out of his peers rooms. Patient remains on one to one supervision at this time.- 2/3/26, Resident seen by psych new order received to increase Seroquel from 50 mg to 75 mg at bedtime. Resident continue enhance monitoring r/t [related to] behaviors. Agitation observed.- 2/3/26, Res [resident] remains alert with confusion. Wandering/exit seeking behaviors present. Remains on enhanced monitoring for previous aggressive behaviors.- 2/7/26, . Wandering/exit seeking behaviors present. Res [resident] remains 1:1 r/t behavior.- 2/9/26, . Remains on enhanced monitoring for aggressive behaviors, none noted during shift.- 2/11/26, Per psych. services can discontinue 1:1 due to medication changes resident has improved with no further behaviors noted.- 2/11/26, IDT met and spoke with PCP [primary care provider] in regard to discontinuation of 1:1 which he was in agreement with.- 2/16/26, . Wandering/exit seeking behaviors witnessed.- 2/18/26, . Wandering/exit seeking behaviors present.- 2/27/26, The resident is seen opening and closing all doors. The resident enters women's rooms on several occasions and becomes aggressive with CNA [Staff I, CNA] when she tries to remove him from the situation. The resident is taken to his room but refuses to stay in his bed.- 2/28/26 and 3/1/26, . Wandering behaviors present, keeps going in and out of other resident's rooms without permission, very difficult to redirect this behaviors.- 3/2/26, . Resident ambulates independently throughout unit, frequently entering other resident's rooms.- 3/6/26, . Date of Service : 2026-03-06 . As per collected information, its reported the patient is unstable and require an evaluation. It's Reported the patient was involved in a physical altercation with a peer. The patient is confused at baseline. Patient has a behavior of going into the wrong room on the unit. It was in the wrong room that he was involved in an altercation. Patient is not able to express why he went into the wrong room. Patient does not remember anything occurring between him and his peer. Currently the patient is on one-to-one supervision with staff.A review of the 500-unit CNA assignment sheets and the schedule provided by the staffing coordinator revealed the following- On 3/6/26, the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts had no staff assigned for 1:1 supervision for Resident #22.- On 3/7/26, the 3:00 p.m. to 11:00 p.m. shift had a staff member assigned to enhanced monitoring (EM) for Resident #22 and Resident #24 who resided in different rooms. On the 11:00 p.m. to 7:00 a.m. shift, there was no staff member assigned to Resident #22.- On 3/8/26, the 7:00 a.m. to 3:00 p.m. shift had a staff member assigned to Resident #22 and Resident #24. The assignment sheet for the 7:00 a.m. to 3:00 p.m. shift did not indicate if the assigned staff was to provide 1:1 supervision, EM, or continuous monitoring. The 3:00 p.m. to 11:00 p.m. shift had a staff member assigned to EM for Resident #22 and Resident #24. A review of the 11:00 p.m. to 7:00 a.m. shift CNA assignment sheet had no staff assigned for 1:1 supervision for Resident #22. A review of the staffing sheet provided by the staffing coordinator showed on the 11:00 to 7:00 a.m. shift, Staff I, CNA was assigned EM for Resident #22 and Resident #24.6. A review of Resident #24's admission record revealed an admission date of 1/14/25 with diagnoses to include cerebral atherosclerosis, Alzheimer's disease, vascular dementia, severe, with anxiety, major depressive disorder, recurrent, moderate, unspecified dementia, unspecified severity, with other behavioral disturbances, restlessness and agitation, and other specified anxiety disorders.A review of Resident #24's physician orders revealed there were no orders for 1:1 supervision, EM, or continuous monitoring.A review of the facility's reportable incident log showed the following:- Date of Incident 3/3/26 [Resident #24] /+ [Resident name] Type of Allegation * Sexual .A review of Resident #24's care plan revealed the following: - [Resident #24] can be sexually inappropriate at times r/t dx [diagnosis] of Dementia. Date Initiated: 03/10/2026, with interventions to include, Enhanced monitoring by staff as necessary. Revision on: 3/11/2026.A review of Resident #24's progress notes, dated 3/2/26 to 3/11/26, revealed the following:- 3/6/26, Date of Service : 2026-03-06 . As per collected information, patient reported the patient was recently observed in his bed with a female peer, touching her in an inappropriate manner. When question about the incident, the patient denies any incident happening. Patient is confused at baseline. When phrase multiple times, the patient continues to deny any inappropriate touch between him and a peer. No mood swings are observed during the visit. Patient has no depression and anxiety. Patient has fair appetite and improved sleep patterns. No signs of mania, psychosis and agitation are reported. No other psychiatric symptoms observed. Dementia is persisting, but no other behaviors noted.Further review of the progress notes revealed no documentation about 1:1 supervision, enhanced monitoring, or continuous monitoring.A review of the 500-unit CNA assignment sheets and the schedule provided by the staffing coordinator revealed the following:- On 3/7/26, the 7:00 a.m. to 3:00 p.m. shift showed no staff member was assigned to Resident #24 for 1:1 supervision or EM. The 3:00 p.m. to 11:00 p.m. shift had a staff member assigned to enhanced monitoring (EM) for Resident #22 and Resident #24 who resided in different rooms.- On 3/8/26, the 7:00 a.m. to 3:00 p.m. shift had a staff member assigned to Resident #22 and Resident #24. The assignment sheet for the 7:00 a.m. to 3:00 p.m. shift did not indicate if the assigned staff was to provide 1:1 supervision, EM, or continuous monitoring. The 3:00 p.m. to 11:00 p.m. shift had a staff member assigned to EM for Resident #22 and Resident #24. A review of the CNA assignment sheet, for the 11:00 p.m. to 7:00 a.m. shift, showed no staff assigned for 1:1 supervision for Resident #24. A review of the staffing sheet provided by the staffing coordinator showed on the 11:00 to 7:00 a.m. shift, Staff I, CNA was assigned EM for Resident #22 and Resident #24.- On 3/9/26, the 11:00 p.m. to 7:00 a.m. shift showed no staff member was assigned to Resident #24 for 1:1 supervision or EM.On 3/9/26, the facility provided a list of residents who required one-to-one supervision. A review of the list revealed one resident was documented.On 3/10/26 at 9:31 a.m., an interview was conducted with the Director of Nursing (DON). She said enhanced supervision is documented by the nursing staff in progress notes. The DON stated, Enhanced supervision is not really the same as one to one. She said 1:1 supervision meant one resident to one CNA. She said enhanced supervision is a CNA providing close supervision. She said enhanced supervision and 1:1 supervision is documented in the resident's care plan and did not require a physician order. The DON said when a resident is on enhanced monitoring, it is communicated through verbal reporting from nurse to nurse.On 3/9/26 at 11:00 a.m., an interview was conducted with Staff B, LPN. He said he had not seen one staff member providing supervision for two residents. He stated it, Would be hard to control both residents if need be. Staff B, LPN said staff are not supposed to have an assignment and supervise a resident who required 1:1. He stated it, Would be a safety concern, if staff had an assignment in addition to supervising a resident who required 1:1.On 3/9/26 at 12:33 p.m., an interview was conducted with Staff C, CNA. She confirmed she had been assigned 1:1 supervision for two residents in the same room on one occasion. Staff C, CNA said she would stay at the door to watch both residents. She said she tried to keep both residents in their room. Staff C, CNA said if one of the residents, that was supposed to be supervised, wandered outside of their room she assumed other staff were watching the resident who wandered. She said she documented on the residents at the end of the shift to include the care she provided to them. Staff C, CNA said the documentation is not specific to 1:1 supervision.On 3/9/26 at 1:53 p.m., a telephone interview was conducted with Staff D, CNA. She stated she was often instructed by one of the supervisors to provide 1:1 supervision, as well as patient care for other assigned residents. She said she had to bring a resident in the hallway with her, and take them room to room in their Geri chair while she provided care to other residents. Staff D, CNA said the supervisor would inform the staff a resident required 1:1 supervision because they felt they needed it. She said she would be informed by the staff member responsible for staffing of the resident who required 1:1 supervision. Staff D, CNA said in the past couple weeks the staff would rotate the 1:1 supervision assignment during their shift. She stated when they rotated the 1:1 assignment, You were still responsible for your own residents. She stated, Charting on the 1:1 is supposed to be done, but was not sure who was responsible for the documentation, especially when they rotated 1:1 supervision. She said she thought the task section is where 1:1 supervision would be charted in the electronic health system.On 3/10/26 at 11:27 a.m., an interview was conducted with Staff E, LPN/Unit Manager (UM). She said 1:1 supervision and enhanced monitoring was the same. She said 1:1 supervision is one staff member with the resident at all times. She said 1:1 supervision is initiated for behaviors such as resident-to-resident altercations, suicidal ideations, and elopement risk. She said on the unit there were currently three residents on 1:1 supervision to include Resident #22 and Resident #24. She said the risk manager (RM) would decide if a resident is placed on 1:1 supervision. Staff E, LPN/UM said the RM would let her know, as well as the staffing coordinator. She said the staffing coordinator would work on getting a staff member to provide 1:1 supervision. Staff E, LPN/UM said they would not have a staff member providing 1:1 supervision and be responsible for their assigned set of residents. When asked about one staff member assigned to two residents in different rooms she stated, Not on this unit. She said staff are made aware of the assignment through the staffing sheet. Staff E, LPN/UM said there would be EM or 1:1 by the staff member's name. She said one of the nurses could also assign a staff member to do enhanced monitoring. She stated, Anyone can do enhanced monitoring, it's not always a CNA. She said there was no required documentation specific to enhanced monitoring and usually there was no physician order.On 3/10/26 at 12:04 p.m., an interview was conducted with Staff F, Registered Nurse (RN)/UM. She said 1:1 supervision and enhanced monitoring was the same. She said a resident would require EM due to increased fall risk and no other interventions to put in place, as well as behavioral reasons such as suicidal ideation or persistent attempts to elope. She stated 1:1 supervision is a, Last resort, intervention for residents who fall or are considered an elopement risk. Staff F, RN/UM said the nurse assessed the resident and based on their assessment they would communicate with the nursing home administrator (NHA) to approve the 1:1 supervision/EM. She said 1:1 supervision/EM is a physician order. She said continuous monitoring or enhanced monitoring may be used, but they were the same. She said there would be an order in place for the nurses to document and 1:1/EM would be on the c

Based on interviews and record reviews, the facility failed to notify the physician of abnormal laboratory (lab) values for three residents (#7, #18 and #26) out of eight residents sampled. Findings Included:During an interview on 3/10/26 at 12:58 p.m. the Director of Nursing (DON) said for abnormal laboratory test values the nursing staff are expected to notify the doctor as soon as possible and the notification should be documented in the medical records.1) A review of Resident #7's admission record showed an admission date 2/4/26 with a primary diagnosis of left ilium (pelvic) fractureA review of Resident #7's lab report results revealed on 3/7/26 reported at 5:55 p.m. a TSH (thyroid stimulating hormone) level was 26.99, reference range 0.45-5.33 uI/ml (units/milliliter).A review of Resident #7's nursing note, dated 3/9/26 at 3:32 p.m. showed Received order to increase Levothyroxine to 200 mcg (micrograms) daily and repeat lab in a week.A review of Resident #7's nursing note dated 3/9/26 at 6:53 p.m. showed son made aware of increase on Levothyroxine and lab to be repeated in a week.Review of Resident #7's care plan revealed the following focus- [Resident #7] has hypothyroidism, initiated on 2/17/26. The care plan's goal is [Resident #7] will be compliant with thyroid replacement therapy through the next review date. The interventions include obtain and monitor lab/diagnostics work as ordered. Report results to medical doctor (MD) and follow up as indicated.A review of Resident #7's order summary report dated 3/11/26 showed an order 3/9/26 for Levothyroxine 200 mcg give 1 tablet by mouth daily was ordered.A review of the Resident #7's Medication Administration Record (MAR) showed on 3/9/26 Levothyroxine 200 mcg one tablet administration started.2) A review of Resident #18's admission record showed an admission date of 1/3/26 with a primary diagnosis of hypothyroidism.A review of Resident #18's nursing note, dated 2/19/26 at 11:57 a.m. showed Resident observed to have increased confusion. Advanced Registered Nurse Practitioner (ARNP) notified and requested labs to be ordered .A review of resident #18's order summary report, dated 3/9/26 showed an order for urinalysis with microscopic examination (UA with micro) dated 2/25/26.A review of resident #18's lab results report, reported 2/25/26 at 1:33 p.m. showed abnormal results for urine blood, urine protein, urine mucous and calcium oxalate crystals.A review of Resident #18's nursing note, dated 2/26/26 at 1:53 p.m. showed Urine results sent to ARNP .3) A review of Resident #26's admission record showed an initial admission date 1/3/26 diagnosis of idiopathic gout, right ankle and foot. A review of Resident #26's physician note, dated 3/5/26 at 11:02 a.m. showed admission labs reviewedA review of Resident #26's labs reported on 3/5/26 at 12:20 p.m. showed the following abnormal test results RBC (red blood count) 3.19 M/uL- reference range (RR) 4.20-5.40, Hgb (hemoglobin) 10.2 g/dL- RR 12.0-16.0, HCT (hematocrit) 30.9%- RR 37.0-47.0, and Hemoglobin A1c 6.2% -RR 4.0-6.0 and BUN (blood urea nitrogen) 33 mg/dL-reference range (RR) 6-20A review of Resident #26's nursing note, dated 3/6/26 at 6:42 a.m. showed Results was sent to [doctor].A review of Resident #26's labs reported on 3/7/26 at 4:53 p.m. showed BUN 36 mg/dL and at 5:03 p.m. RBC 3.38 M/uL, Hgb 10.9 g/dL, HCT 33.0% and Hemoglobin A1c 6.1%.A review of Resident #26's daily Medicare Managed care note, dated 3/7/26 at 8:57 p.m. the space to document any new lab: .is empty. During an interview on 3/11/26 at 9:05 a.m. Staff F, Registered Nurse (RN), Unit Manager said the doctor is notified of laboratory tests results as soon as possible.During an interview on 3/9/26 at 7:22 a.m. Staff B, Licensed Practical Nurse (LPN) said nurses can review lab results on the dashboard. He notifies the doctor when lab results are received and if new orders are given a change in condition note is completed During an interview on 3/10/26 at 12:58 p.m., the Director of Nursing (DON) said staff are expected to notify the physician as soon as abnormal test results are received. Review of a facility policy titled Nursing-Clinical Documentation, undated showed the following: Policy -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. Documentation in the medical record of each resident should provide:1. A complete account of the resident's care treatment and response to the care. 2.-Information for the physician when prescribing medications and managing care and treatments.3.-A description of care and services that can be used for measuring the quality of care provided to the resident .6.-Elements to support quality medical care. Documentation Guidelines: 5. Documentation should be done as soon as possible following any event, evaluation, assessment or change in condition.

Based on observations, interviews and record review, the facility failed to provide incontinence care for one resident (#12) out of three sampled for activities of daily living. Findings includedAn interview conducted on 3/10/26 at 12:13 PM with Resident #12 revealed the resident had many concerns with staff coming timely to provide incontinence and toileting care. The resident stated there had been many instances where the resident had a bowel movement (BM) and no staff would come timely to provide care when it was needed.A review of Resident #12's admission record revealed an admission date of 7/31/25 with diagnoses to include: Type 2 Diabetes Mellitus, anemia, paroxysmal atrial fibrillation, legal blindness, gastrointestinal hemorrhage, and adjustment disorder with anxiety.A review of Resident #12's Bowel and Bladder- Bowel Elimination Task documentation revealed the following:March no care marked on:Shift 11 PM-7 AM: 3/3Shift 3 PM-11 PM: 3/9February no care marked on:Shift 11 PM-7 AM: 2/28Shift 7 AM-3 PM: 2/3, 2/19January no care marked on:Shift 11 PM-7 AM: 1/10, 1/31Shift 3 PM-11 PM: 1/2, 1/5-7, 1/10, 1/12, 1/17, 1/22Shift 7 AM-3 PM: 1/6-9, 1/14, 1/24, 1/31A review of Resident #12's Quarterly Minimum Data Set (MDS) assessment, dated 2/9/26, revealed a Brief Interview Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #12's section GG- Functional abilities revealed the resident uses a wheelchair for mobility and scored a 02-Impairment on both sides for lower extremality range of motion. Resident #12 scored a 01-Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene. For toilet transfer, Resident #12 scored a 02-Substantial/maximal assistance- Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Resident #12's section H- Bladder and Bowel revealed Resident #12 is rated as a 3, Always incontinent (no episodes of continent bowel movements) for bowel continence.A review of Resident #12's Order Summary revealed no orders pertaining to incontinence care.A review of Resident #12's progress notes, dated from 1/1/26 to 3/11/26, revealed no documentation of the resident refusing incontinence care.A review of Resident #12's Care Plan revealed Resident #12 has impaired physical mobility and self-care deficit related to deconditioning, decreased endurance, depression, limited ROM (Range of Motion) lower extremity, pain infection, constipation, blindness, multiple diagnoses with multiple medications. The facility has planned interventions including the resident is totally dependent on staff to meet toileting needs toileted in bed with the assistance of staff. Further review revealed Resident #12 has constipation related to the use of opioids causing bowel defunction, decreased mobility and fear of pain. Interventions include encouraging the resident to sit on the toilet to evacuate bowel, and to follow facility bowel protocol for bowel management.An interview conducted on 3/11/26 at 9:33 AM with Staff F, Registered Nurse/Unit Manager (RN/UM) revealed it is the expectation of care staff to document whether a resident voided or not. Staff F, RN/UM stated it is the responsibility of the unit managers to ensure all documentation related to incontinence care is being done, and there is no way to know if a task was completed if it was not charted, if its not documented, its not done.On 3/11/26 at 9:43 AM with Staff R, Licensed Practical Nurse (LPN) revealed aides should be documenting resident toileting care by at least the end of their shift, and there is no way to verify if a task was completed if it was not seen or documented.On 3/11/26 at 2:46 PM and 3:03 PM an interview was conducted with the Director of Nursing (DON) revealed it is expected for aides to document in the system whether a resident voids or not. The DON stated if incontinence and toileting care is not documented, then it did not happen.A review of the facility's Charge Nurse-RN Position Description revealed the following: Minimum Performance Standards include Reports changes in residents' condition or deviation from prescribed treatments promptly to the physician and supervisor. Assists in the maintenance of the medical record as a legal document of the patient/resident. Monitors direct care given by Nursing Assistants to ensure compliance with nursing care plan interventions and facility policies.A review of the facility's Charge Nurse-LPN Position Description revealed the following: Responsible and accountable for the effective overall management of a nursing unit and the provision of quality nursing care to all residents. Reports changes in residents' condition or deviation from prescribed treatments promptly to the physician and supervisor. Assists in the maintenance of the medical record as a legal document of the patient/resident. Monitors direct care given by Nursing Assistants to ensure compliance with nursing care plan interventions and facility policies. Supervises and educates Nursing Assistants in safe procedures and enforcing compliance.A review of the facility's Certified Nursing Assistant (CNA) Position Description revealed the following: Essential functions include Provides care as directed by the professional nurse to patients/residents requiring long-term, rehabilitative care or restorative care. Reports observations and other pertinent information related to the care of the patient/resident. Provides services that support the care delivered to the patient/resident. Assistance with restorative programs as-Bowel and Bladder. All entries on charts, notes, flow sheets, etc., are recorded in an informative and descriptive manner. All changes in a patients/residents condition are reported as soon as possible to the Charge/Staff Nurse.A review of the facility's Nursing-Bowel and Bladder/Incontinence Care Policy revealed the following: Purpose-To maximize our resident's/patient's opportunities to remain continent, presume their independence, skin integrity, and dignity. Policy-Residents/patients who have had any episodes of incontinence will be provided assistance for the need of bowel and bladder toileting. Residents will be assisted to the bathroom or checked for incontinence and assisted with or provided incontinence care at least upon rising; before and/or after meals, activities, and therapy; before bedtime; and as needed or as identified per the individual resident plan of care. The C.N.A. will ask the resident to toilet or check for incontinence at the specified times. If the resident requests to be toileted at different times or they were incontinent, toileting and/or incontinence care will be completed as indicated based on the resident plan of care. The CNA will document resident toileting as part of ADL care.

Based on interviews, and record review, the facility failed to ensure the comprehensive care plan was implemented related to one to one supervision/enhanced monitoring for one resident (#24) out of ten residents sampled. Findings included: A review of Resident #24's admission record revealed an admission date of 1/14/25 with diagnoses to include cerebral atherosclerosis, Alzheimer's disease, vascular dementia, severe, with anxiety, major depressive disorder, recurrent, moderate, unspecified dementia, unspecified severity, with other behavioral disturbances, restlessness and agitation, and other specified anxiety disorders.A review of the facility's reportable incident log showed the following:- Date of Incident 3/3/26 [Resident #24] /+ [Resident name] Type of Allegation * Sexual .A review of Resident #24's comprehensive care plan revealed the following: - [Resident #24] can be sexually inappropriate at times r/t dx [diagnosis] of Dementia. Date Initiated: 03/10/2026, with interventions to include, Enhanced monitoring by staff as necessary. Revision on: 3/11/2026. A review of Resident #24's progress notes, dated 3/2/26 to 3/11/26, revealed the following:- 3/6/26, Date of Service : 2026-03-06 . As per collected information, patient reported the patient was recently observed in his bed with a female peer, touching her in an inappropriate manner. When question about the incident, the patient denies any incident happening. Patient is confused at baseline. When phrase multiple times, the patient continues to deny any inappropriate touch between him and a peer. No mood swings are observed during the visit. Patient has no depression and anxiety. Patient has fair appetite and improved sleep patterns. No signs of mania, psychosis and agitation are reported. No other psychiatric symptoms observed. Dementia is persisting, but no other behaviors noted.Further review of the progress notes revealed no documentation about 1:1 supervision, enhanced monitoring, or continuous monitoring. On 3/10/26 at 9:31 a.m., an interview was conducted with the Director of Nursing (DON). She said enhanced supervision is documented by the nursing staff in progress notes. The DON stated, Enhanced supervision is not really the same as one to one. She said 1:1 supervision meant one resident to one Certified Nursing Assistant (CNA). She said enhanced supervision is a CNA providing close supervision. She said enhanced supervision and 1:1 supervision is documented in the resident's care plan and did not require a physician order. The DON said when a resident is on enhanced monitoring, it is communicated through verbal reporting from nurse to nurse. On 3/10/26 at 12:04 p.m., an interview was conducted with Staff F, Registered Nurse (RN)/UM. She said 1:1 supervision and enhanced monitoring was the same. She said continuous monitoring or enhanced monitoring (EM) may be used, but they were the same. She said there would be an order in place for the nurses to document and 1:1/EM would be on the care plan which reflected on the Kardex. On 3/11/26 at 9:13 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). She said a physician order was needed for 1:1 supervision. The ADON said the expectation for residents on 1:1 or EM is an implementation of a care plan and documentation in the progress notes.On 3/11/26 at 2:20 p.m., an interview with the Risk Manager (RM) who revealed Resident #24 was placed on 1:1 as soon as the event occurred on 3/3/26. She said his care plan had been updated on 3/10/26 to reflect the incident. The RM stated his care plan showed, Enhanced monitoring by staff as necessary, that was added on 3/11/26. A review of the facility's policy titled Resident Assessment Instrument Comprehensive Care Plan Policy, with an effective date of September 2024, revealed the following: 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. Care Plan Review and Revision: - The care plan will be reviewed quarterly and revised as necessary. - The care plan must be updated in response to changes in the resident's condition, new assessments, or input from the resident/family. - Significant changes in the residents' condition will trigger a new MDS assessment, guiding further revisions to the care plan.

Based on observations, interviews and record review of the facility's Shift to Shift Controlled Medication count sheets, the facility did not ensure accurate documentation of controlled substances count logs for three carts (200-A, 100A - and100-B) out of ten medication carts. On 02/03/2026 at 9:25 a.m., an observation was made of the medication cart identified as cart 200-A. A review of cart 200 -A's narcotic book showed the Shift-to-Shift Controlled Medication Count with no entry for this morning's count. Staff G, Licensed Practical Nurse (LPN) who was assigned to the 200-A medication cart stated she forgot to mark the number of total narcotic cards, but the count was correct. On 02/03/2026 at 9:59 a.m., an interview was conducted with Staff C, LPN. Staff C, LPN, stated during shift change, two nurses, the off coming shift nurse and the oncoming nurse, must count the narcotic cards in the Shift-to-Shift Controlled Medication Count as well as each individual residents' narcotic medication. Both nurses will sign the Shift-to-Shift Controlled Medication Count. Staff C, LPN, stated if a resident was discharged or a medication was discharged , the medication card (s) would stay in the narcotic box in the medication cart until the Director of Nursing (DON) would remove the card after verifying with another nurse as a witness. Staff C, LPN, stated there have been times when she was asked to bring discharged narcotics to the DON's office located on the 400 hallway. Staff C, LPN was able to state there was a previous concern about a missing narcotic pill but could not recall when. Staff C, LPN stated the supervisor was involved but they were able to figure out the nurse forgot to sign it out and the event was confirmed by the resident involved.On 02/03/2026 at 10:28 a.m., an interview was conducted with Staff A , Registered Nurse (RN). Staff A, RN stated the narcotic count was correct this morning during shift change and stated he would not have taken over the medication cart if the count was wrong. Staff A, RN stated usually if the count is off, it is because the shift before nurse forgot to document when removing a medication or if pharmacy delivers narcotics, she/he forgot to add them to the Shift-to-Shift Medication Count. Staff A, RN stated he had heard about a narcotic pill missing from a resident a few months ago on the 300-hallway side. Staff A, RN stated he had heard the supervisor was involved but could not state he knew the outcome.On 02/03/2026 at 10:40 a.m., after the interview with Staff A, RN an observation was made of Staff A, RN walking to Staff B, LPN at the end of the 100 B hallway. Staff B, LPN was in the process of medication administration when Staff A, RN was observed in a brief conversation and then walked away from Staff B, LPN. A brief interview was conducted with Staff B, LPN, where Staff B acknowledged Staff A, RN, gave her his medication cart keys while Staff A,RN, went on break. On 02/03/2026 at 11:40 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when the pharmacy delivers narcotics, the nurse who received the medication will verify the prescription with the delivery person, sign their yellow copy and sign the delivery individual's phone confirming delivery. The nurse will place the prescription with another nurse acting as a witness in the narcotic book for the individual resident and adjust the Shift-to-Shift Controlled Medication Count. The ADON stated narcotics discontinued for various reasons will remain in the locked narcotic box in the medication cart until the DON will remove with verification from another nurse acting as a witness. The ADON stated if a nurse leaves for a break and relinquishes keys to their co-worker, the expectation would be for the nurses to count the narcotics before and after the nurse returns to their cart. The ADON stated she was not aware of any diversion for narcotics since her five months tenure. The ADON stated there was one minor incident in which the morning count was off, but the situation was resolved as soon as the investigation began. The ADON stated the Shift-to-Shift Controlled Medication Count were reviewed by the ADON and the former DON. The ADON stated there are ten medication carts. The ADON stated with the new DON, the unit managers are reviewing count sheets daily. On 02/03/2026 at 12:00 p.m., the interview with the ADON continued with review of the 100/A and 100/B narcotic binders. A review was conducted with the ADON for the 100/B Shift to Shift Controlled Medication Count. The following entries were noted: An entry was made on 11/28/25 for the evening shift of 27 narcotic medication cards counted and witnessed by two signatures. The following shift count the count went to 25 with no explanation on how the two cards were accounted for not being present. An entry was made on 12/01/25 for the night shift of 25 narcotic medication cards, followed by +1 card, -1 card, -1 card followed by a count of 27 next shift. An entry was made on 12/01/25 for the day shift of 27 narcotic medication cards (carried over ) followed by -1 card, +3 cards -1 card, -1 card for a total count of 25. An entry was made on 12/19/25 for the night shift of 30 narcotic medication cards, followed by +3 card, the count for the next shift (day) the total count was 32. An entry was made on 01/17/26 for the evening shift of 23 narcotic medication cards, followed by -1 card but the count remained at 23. An entry was made on 01/20/26 for the night shift of a beginning count for the shift before for 28 with -1 card and -1 card for a total 27. An entry was made on 01/21/26 following day shift the beginning count was 26 with +4 cards followed by the next shift -2 or -3 cards (illegible) for a total of 31 followed by the next shift with a beginning count of 27 or 29 (illegible) with illegible comment in the comment column. An entry was made on 01/27/26 for the night shift of a beginning count of 25 followed by the next shift (day) of a count of 27 with no entry on why the count went up. An entry was made on 01/30/26 for the night shift into the day shift the beginning count went from 29 to 28 without a reason for the count to be down by one. A review was conducted with the ADON for the 100/A Shift to Shift Controlled Medication Count. The following entries were noted: An entry was made on 11/19/25 during the top of the ledger for a total count of 21 narcotic cards, the ledger remained the same throughout the evening and night shift with +1 card entry, followed by -1 card entry; however, on the 11/20/25 day shift, the total cards ledger went to 20 with no comments. The count was corrected back to 21 on the evening shift with no comments made. An entry was made on 12/05/25 during the day shift of 21 narcotic cards with -2 cards followed by the next shift (evening) for a total of 18 cards. An entry was made on 12/16/25 for the night shift into the day shift with a starting count of 17 with illegible writing with -1 card and the total amount went up to 19. An entry was made on 12/30/25 during the evening shift of a total of 21 narcotic cards with -1 and -1 cards for a total of 19 for the next shift but +2 cards and -1 card but the total was documented as 22 total number of narcotic cards instead of 20. The narcotic total number of cards continued on 12/31/25 with the count at 22 on the evening shift -1 for a total of 21 cards followed by the next shift (night) with +1 card for 22 written not in the total number of cards but in the comments section. The narcotic total number of cards continued into 01/01/26 with the day shift crossed out no total entry and in the comment section was YD-moved followed by the evening shift with an entry for 23 narcotic cards total, followed by the night shift with an entry for total cards at 25 total narcotic cards with no entries in the comment section. An entry was made on a new Shift to Shift Controlled Medication Count with the date of 01/01/26 day shift for a total of 22 narcotic cards. An entry was made on the 01/12/26 evening shift of the total narcotic count at 19, followed by the next entry on 01/13/26 day shift of a total count of 18 with no comment entries. There was no count for the night shift into the day shift for 01/13/26. The count continued at 18 through 01/16/26. An entry was made on 01/16/25 on the day shift for a total of 18 followed by the evening shift with a total count of 19 with no comment entry.A review was conducted for the 200/A Shift to Shift Controlled Medication Count. The review was conducted with Staff D, LPN/Unit Manager. The following entries were noted: An entry was made on 11/23/25 of the night shift total narcotic count of 30 followed by an entry of the day shift on 11/24/25 with an entry of 29 with no entry in the comment section. Followed by the same day 11/24/25 night shift for a total count of 32 with no entry in the comment section. An entry was made on 11/30/25 on the night shift for a total narcotic count of 37 followed by the next shift (day) for a total narcotic count of 36 with no entry in the comment section. An entry was made on 12/05/25 of the evening shift for a total of 38, followed by no total entry for the night shift, followed by the day shift for 12/06/25 for a total of 34 with no comments on how the total went from 38 to 34. The count continued as 34 until 12/07/25 when -1 card was removed for a total of 33 evening shift followed by the next entry 12/07/25 night shift the count went to 37 with no entry in the comment section. An entry was made on 12/20/25 of the evening shift for a total of 31 narcotic cards, followed by the night shift for a total of 29 after a comment of -1 card, -1 card; however, count went to 27 the following day shift for a total of 27 with no entry in the comment section. An entry was made on 12/23/25 of the day shift for a total of 30 narcotic cards followed by the evening shift for a total of 29 with no entry in the comment section. An entry was made on 12/25/25 of the day shift for a total of 32 narcotic cards followed by the evening shift on 12/25/25 for a total of 31 narcotic cards with no entry in the comment section. An entry was made on 1/04/26 of the day shift for a total of 38 narcotic cards followed by the evening shift removing a card documented in the comment section for a total of 37 narcotic cards, the count continues as 37 through the night shift and a new Shift to Shift Controlled Medication Count was started. The count of 37 was not reviewed as continued to the next page. Instead on 01/5/26 on the day shift the count was documented as a start of 36 and a comment made of a removal of one card followed by the next shift (evening) of a count of 35 with no entry in the comment section. The evening shift documented the removal of one card for a total of 34 narcotic cards followed by the next shift (day) for 1/6/26 day shift with illegible documentation of a number and multiple scratched out entries for total narcotic cards. Finally, the next shift (evening) had the number 35 entered for total number of narcotic cards.On 02/03/2026 at 11:40 a.m., an interview was conducted with the ADON related to the observations made of narcotic book 100/A and 100/B. The ADON stated she has not had any concerns with narcotics. The ADON stated if there was a concern the pharmacy would bring it to their attention due to increased demand for delivery of narcotic prescriptions. The ADON stated there was one incident she could recall of a missing narcotic pill but was quickly resolved by the two nurses and the Risk Manager. The ADON acknowledged the areas of concern when the narcotic binders were reviewed but the ADON stated if a concern was present, the pharmacy would bring to the administration, and an investigation would start immediately with notification to include law enforcement. The ADON stated she had not received any complaints from residents regarding not getting their medication or increased pain. On 02/03/2026 at 12: 03 p.m., an interview was conducted with Staff A, RN. Staff A, RN stated he knew the count was correct before he went on a break and gave his keys to the other nurse, but he stated he counted when he returned, the count was correct, but the binder was in the ADON's office to document. He stated he did not document.On 02/03/2026 at 1:35 p.m., a telephone interview was conducted with the pharmacist account manager. The pharmacy account manager stated [pharmacy ] will make sure their [automatic pharmacy medication dispenser] is working properly and medication carts are functioning.On 02/03/2026 at 3:20 p.m., an interview was conducted with Staff D, LPN/UM related to the observations made of narcotic book 200/A. Staff D, LPN/UM viewed ledgers and stated there were areas for improvement. Staff D, LPN/UM stated the ledgers have narrow entry space and stated this could be part of the problem. Staff D, LPN/UM stated she will review the Shift-to-Shift Controlled Medication Count in the mornings for her designated units. Staff D, LPN/UM agreed today's ledger was not completed and asked Staff G, LPN the oncoming day shift nurse why the ledger was incomplete. Staff G, LPN stated she had forgotten. Staff D, LPN/UM completed the Shift-to-Shift Controlled Medication Count with this surveyor. On 02/03/2026 at 6:15 p.m., an interview was conducted with the ADON, DON, Nursing Home Administrator (NHA) and the Risk Manager related to concerns reviewed with the ADON and Staff D, LPN/UM for three narcotic books. The NHA stated concerns may be from not adding or subtracting accurately but added she was not clinical. The ADON present stated she agreed with observations of the narcotic books with inaccuracies but stated if there were truly narcotic cards missing the pharmacy would alert the facility. On 02/03/2026 at 6:30 p.m., a telephone interview was conducted with the pharmaceutical consultant. The consultant stated the facility has independently hired the consultant pharmacy to fulfill the requirements from a federal and state standpoint. The consultant stated job functions included monthly medication review for all residents, checking medications for expiration dates, verify destruction of medication, but they do not check narcotics other than to ensure the process of destroying them.A review of the facility's undated policy titled, 4.0 Schedule II Controlled Substance Medication, revealed a general information statement:To provide guidelines for facilities to follow relating to the handling of controlled substances within the facility. Controlled substances or handled by the facility and [pharmacy] in a manner that promotes proper storage and compliance with state and federal guidelines.H. Dispensing of Controlled Dangerous Substances (CDS) 5. When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/ her initials.6. And inventory count of all CDS medications stored on each nursing unit shall be performed at each change of each shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form.I. Storage of Controlled Dangerous Substance1. All CDS medications will be stored under double lock, separate from all other medications. 2. The keys to locked areas that store CDS medications must always be in the possession of a licensed nurse that meets the criteria for handling CDS medications as per facility policy and procedure. A review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation, with no effective or revision date, showed the following policy statement: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.If the alleged violation involves neglect, misappropriation of resident property, exploitation, or injuries of unknown source and involves no serious bodily injury, it must be reported no later than 24 hours. 2. Training: Upon hire, each new employee shall be informed of what constitutes ANE 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 procedures on ANE and the requirements of their Federal and State laws.3. Prevention: The facility encourages residents and families, and requires staff to report concerns, incidents, and grievances without fear of 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 for prevention: g. maintenance of inventory of resident's property4. Identification: Reporting suspected maltreatment is required of all staff. All incidents will be reviewed by the facility's Quality Assurance Committee for detection of patterns and/ or trendsIf the alleged violation involves neglect, misappropriation of resident property, exploitation of injuries of an unknown source and involves no serious bodily injury, it must be reported no later than 24 hours.

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Risk Manager, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one (#1) of 58 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility staff failed to ensure the safety of Resident #1; between approximately 2:45 PM on 11/27/2023 and 5:30 PM on 11/27/2023, Resident #1 ambulated from the dementia care unit, followed behind a staff member through a door equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and into an outdoor enclosed porch area. Resident #1 opened a wooden gate in the outdoor enclosed porch area, which was left unlatched and unlocked by staff, and walked into an enclosed courtyard. Resident #1 walked into the courtyard and exited the facility grounds unsupervised and without staff knowledge through a vinyl fence door equipped with an electromagnetic locking device, which was left propped open by staff. Resident #1 walked approximately 0.8 miles on a sidewalk along a 6 lane highway to a bus stop. The facility failed to take action to prevent the resident from exiting the secured dementia care unit by not providing supervision for the resident, not ensuring doors were properly closed to prevent the resident from following behind them as they exited the secured dementia care unit, and not accounting for the resident for approximately 1 hour and 45 minutes. Resident #1 was discovered by facility staff on 11/27/2023 at approximately 5:30 PM at a bus stop, sitting on a bench. Resident #1 was returned to the facility by facility staff at approximately 5:40 PM. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 11/27/2023. The findings of Immediate Jeopardy were determined to be corrected on 12/5/2023. Findings included: A review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 11/27/2023 at 9:28 PM revealed the following under the section titled Nursing Notes: [Resident #1] was noted missing from the unit. The unit was searched without success. Code silver [was] paged and all departments came to assist. [Local police department] was called to assist as well. Outside perimeter of the facility was searched and resident was located at a nearby establishment. [Resident #1] denies pain or discomfort. No new skin issues noted. VSS (vital signs stable). New order for [electronic elopement device] place[d] on resident and enhanced monitoring. A telephone interview was conducted on 12/19/2023 at 10:40 AM with Resident #1's responsible party (RP). The RP stated Resident #1 was initially admitted to the facility for a short term respite stay of 5 days and required placement on the dementia care unit due to his history of dementia and poor short term memory. The resident had a 5-day respite stay at the facility sometime in October, then again in November. The RP also stated Resident #1 required assistance at home with finding the bedroom and the bathroom and the doors in the house were deadbolted due to the resident wanting to exit the house and stating he needed to go to work. The RP stated Resident #1 had poor safety awareness and would often walk in the middle of the parking lot when they would go to the store together and required frequent redirection and reorientation to his surroundings. The RP stated on 11/27/2023 a staff member from the facility arrived at her house and told her Resident #1 was missing from the facility. The staff member asked if the resident was at the house and the RP told her Resident #1 was not at the house. The RP drove to the facility shortly after the interaction and spoke with local law enforcement at the facility. The RP stated Resident #1 was found around 5:30 PM by facility staff and was brought back to the facility. The RP also stated Resident #1 had an electronic elopement device placed on his body and was provided with increased supervision until he was discharged on [DATE]. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral atherosclerosis, vascular dementia, severe, without behavioral disturbance, and depression. Resident #1 was discharged home on 10/25/2023. Resident #1 was readmitted to the facility on [DATE] and was discharged home on 12/1/2023. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 11/24/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section E: Medical Condition, primary discharge diagnoses of cerebral atherosclerosis and dementia. The transfer form revealed under Section G: Patient Risk Alerts, Resident #1 was at risk for elopement. A review of Resident #1's physician's orders revealed the following: - An order dated 11/27/2023 for an electronic elopement device to the right ankle for safety. - An order dated 11/27/2023 to verify placement of the electronic elopement device to the resident's right ankle every shift for safety. - An order dated 11/27/2023 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. A review of Resident #1's Pre-Admission Care Needs assessment, dated 11/25/2023, revealed under the section titled Mental Status, Resident #1 was confused and an Elopement Risk. The assessment also revealed, under the section titled Behavior Patterns Resident #1 had a history of elopement. A review of Resident #1's Pre/Post Admission Elopement Risk Evaluation, dated 11/25/2023, revealed Resident #1 had a history of wandering or elopement, exit seeking behavior, confusion/dementia, and a resident or family home nearby. A review of the facility policy titled Risk Management/Nursing Policies - Elopement Risk, with no effective date, revealed under the section titled Policy an elopement risk evaluation is completed as a part of screening upon admission. All residents will be evaluated for elopement risk upon admission, quarterly, and with a change in condition. The policy also stated under the section titled Procedure if the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Facility staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behavior according to the plan of care. A review of Resident #1's baseline care plan, dated 11/26/2023, revealed Resident #1 was an elopement risk with a goal for Resident #1 to remain in a safe, supervised, and supportive environment. Interventions included to initiate elopement risk protocol, involve in activities, and redirect and/or distract as needed. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. A review of Resident #1's Progress Notes dated 10/21/2023 at 12:14 PM and authored by Staff F, Licensed Practical Nurse (LPN) and Unit Manager (UM), [Resident #1] has expressed the desire to leave on multiple occasions and is constantly looking for an exit. Redirected without much success. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. A review of the facility policy titled Abuse, Neglect, Exploitation, & Misappropriation, with no effective date, revealed under the section titled Policy it is the policy of this facility to take appropriate steps to prevent abuse, neglect, exploitation, and misappropriation and the occurrence of an injury of unknown source, and to ensure all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Services, Director, and the Director of Nursing. The policy defines neglect as .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. An observation was conducted on 12/18/2023 at 11:54 AM of the facility's dementia care unit. A doorbell was observed on the left wall outside of the entrance to the unit with a small gold colored sign underneath, which stated For entrance to the dementia unit, please ring this bell and then step to the door. A nurse at the station will press the key pad to let you in. Thanks for your help as we ensure the safety of our residents. A small contact alarm (an alarm with a magnetic piece and a sensor body that adhere to doors which activate when separated from their sensors and the sensor's magnetic field is broken) was observed on the entrance door of the unit, which sounded an audible alarm when opened by staff. The facility's Nursing Home Administrator (NHA) entered the hallway to silence the alarm after entering the unit. Facility staff were observed at the unit nurse's station, which is positioned next to the unit entrance. A small, enclosed patio was observed in the back of the unit, separated by a glass door exiting to the outside. The door was observed to be locked with an electromagnetic locking device and a red colored contact alarm was observed on the door. The Director of Nursing (DON) and Risk Manager (RM) were observed on the dementia care unit. The DON stated the contact alarm can be disengaged using a key to position the alarm from on to off and keys are kept by the nursing staff on the unit. The DON opened the magnetically locked door using a keypad to the left side of the door. Upon opening the door, the contact alarm engaged, and an audible alarming sound was heard. The alarm was disengaged by nursing staff and reengaged after exiting the unit to the enclosed porch. The outdoor porch was observed to be enclosed with a vinyl white lattice fence and a large wooden door leading out to a courtyard behind the unit. The wooden gate was observed to be latched with a metal latching device and locked with a small padlock. A white sign was observed on the wooden door, which stated gate to remain locked when not in use. A key box with a numbered combination lock was observed mounted to a post next to the wooden door. The RM entered the combination for the key box, which opened the box and revealed a key for the lock on the wooden gate. The RM unlocked the lock and unlatched the wooden door, leading to a large courtyard area behind the dementia care unit. The courtyard was observed enclosed by a white vinyl fence approximately 8 feet tall. Several exit signs were observed along the vinyl fence with signs pointing to an exit door, which lead to a small parking area, a sidewalk, and 4 lane street outside of the facility grounds. The RM stated the fence door is secured with an electromagnetic locking device and can be opened with the keypad. The keypad was moved from the inside of the courtyard to the outside of the courtyard, so staff do not have to go through the dementia care unit to gain access to the courtyard behind the dementia care unit. An interview was conducted on 12/18/2023 at 1:13 PM with the NHA, DON, and RM. The RM stated on 11/27/2023 around 4:30 PM, Resident #1 was not able to be located on the dementia care unit. Staff E, Certified Nursing Assistant (CNA) was working as Eagle Eye staff on the unit for the 3 PM to 11 PM shift and reported to Staff F, LPN UM she was not able to locate Resident #1 on the unit. The RM stated Eagle Eye staff are assigned to the dementia care unit to ensure the safety of the residents on the unit by visualizing the location of the resident every 15 minutes for the duration of their shift. The RM stated per Staff E, CNA's statement, Staff E, CNA noticed around 3:45 PM on 11/27/2023 Resident #1 was not located on the unit and began searching for the resident on the unit. After reporting the missing resident to Staff F, LPN UM, the dementia care unit was searched by the CNA staff and nursing staff on the unit. After not being able to locate Resident #1 on the unit, staff called a code silver, which is the code to indicate a missing resident from the facility, between 4:40 and 4:45 PM. The DON stated she reported to the dementia care unit to coordinate the code and several staff began to search for Resident #1 both inside the facility and outside of the facility as assigned by the DON. The DON also informed local law enforcement around 5:05 PM of Resident #1 missing from the facility. The DON assigned Staff F, LPN UM to search around the local shopping mall area and drove to Resident #1's house since it was near the facility. The DON was on the phone with Staff F, LPN UM when she arrived at Resident #1's house and Resident #1's RP answered the door. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and the RP stated Resident #1 was not at the house. Staff F, LPN UM continued to search the local area for Resident #1 and located the resident at a bus stop sitting on a bench around 5:30 PM. Resident #1 was brought back to the facility by Staff F, LPN UM and did not have any injuries. Resident #1 was wearing grey colored khaki pants, a grey short sleeved shirt, a blue jacket, and black shoes when he arrived back to the facility. The RM stated Resident #1 was placed on one to one supervision and an electronic elopement device was applied to the resident's right ankle. The RM stated Resident #1 did not have an electronic elopement device previously because he was housed on the locked dementia care unit. Resident #1 had one to one supervision until his scheduled discharge on 12/1/2023. The following day on 11/28/2023, the RM, NHA, and maintenance staff did walking rounds on dementia care unit to assess how Resident #1 eloped from the facility. The RM stated the wooden gate for the enclosed porch outside of the dementia care unit was observed to be open and unlocked. The RM also stated their investigation revealed a correlation between the time Resident #1 eloped and the time outside lawn workers performed lawn care for the courtyard behind the dementia care unit, which was typically on Mondays between 3:00 PM and 3:30 PM. The RM stated per interview with Staff G, Maintenance, the staff member went through the dementia care unit around 3:15 PM to the back courtyard area and through the locked glass door. Staff G, Maintenance unlocked the wooden gate to the enclosed porch behind the dementia care unit and left it open due to the not being able to lock the door from the outside. Staff G, Maintenance opened the white vinyl gate to allow lawn care workers into the courtyard behind the dementia care unit and left the door propped open for approximately 30 minutes. The RM stated the investigation revealed Resident #1 followed Staff G, Maintenance off the unit and onto the enclosed porch without the staff member's knowledge, before exiting the porch and exiting the courtyard to the sidewalk outside of the facility. The RM stated since the elopement occurred, the facility removed the button behind the nurse's station on the dementia care unit which allowed nursing staff to open the door to the unit. Nursing staff must enter a code on the keypad to deactivate the magnetic lock on the door to allow visitors and staff to exit the unit. A contact alarm was added to the exit doors on the unit, which were previously located inside of the unit. This was implemented to ensure staff turn around to deactivate the alarm, which will further ensure no resident is trailing behind them when they exit the unit. The RM stated contact alarms, or stop alarms, were added to the exit doors on the dementia care unit leading out to the enclosed patio and courtyard behind the unit. The DON stated all residents in the facility were re-evaluated for elopement risk and those residents determined at risk for elopement will have an electronic elopement device, including those residents on the dementia care unit. The DON also stated facility staff have been educated on the proper procedure for shift-to-shift walking rounds and staff must visualize the resident at the time of their report, which is also verified by the nurse. The DON stated all codes for the doors in the facility equipped with an electromagnetic lock were changed to ensure no residents have access to the codes. A review of the facility policy titled Risk Management - Missing Resident and Elopement, with no effective date, revealed under the section titled Policy elopement occurs when a resident who needs supervision leaves a safe area without supervision. If any resident should leave the premises at any time without following the facility procedure for voluntary leave, the missing resident/elopement procedure should begin immediately. The policy also revealed under the section titled Procedure it is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as possible. An interview was conducted on 12/18/2023 at 2:03 PM with Staff F, LPN UM, who was Resident #1's assigned nurse for the 7 AM to 7 PM shift on 11/27/2023. Staff F, LPN UM stated she was Resident #1's assigned nurse on 11/27/2023 for the 7:00 AM to 7:00 PM shift. Staff F, LPN UM also stated Resident #1 often expressed he wanted to go home, told staff his brother was waiting outside for him, and asked staff how he could get out of the facility, but was easily re-directed by staff on the dementia care unit. Staff F, LPN UM stated Resident #1 was an elopement risk before being admitted to the facility and his RP placed several locks on the doors of his home to prevent him from eloping from the house. Staff F, LPN UM stated prior to Resident #1's elopement, she saw the resident between 2:15 PM and 2:30 PM by the unit nurse's station walking in the unit halls. Staff F, LPN UM also stated around 4:00 PM, Staff E, CNA and Staff H, CNA told her Resident #1 was missing from the unit and the staff members already searched the unit for the resident. Staff F, LPN UM and the dementia care unit staff searched the unit one more time for Resident #1, including the courtyard and activity areas, without success. Staff F, LPN UM called a code silver and other facility staff reported to the unit to assist in locating Resident #1. Facility staff searched throughout the facility and surrounding areas. Staff F, LPN UM stated she went toward Resident #1's home because he previously stated he wanted to go home, and the resident lived close to the facility. Staff F, LPN UM arrived at Resident #1's home and spoke with the RP, who stated the resident was not at the house. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and local law enforcement was aware. After leaving Resident #1's home, Staff F, LPN UM got into her car and searched areas closer to the facility grounds. Staff F, LPN UM found Resident #1 sitting at a bus stop in front of a local restaurant. Staff F, LPN UM took Resident #1 by the hand and assisted him into her vehicle before driving him back to the facility. Resident #1 was assessed and had no injuries because of the elopement. Resident #1 was taken by staff to the unit dining room for dinner. Resident #1 was placed on one to one supervision until he was discharged on [DATE]. Staff F, LPN UM stated the CNA staff were not conducting shift to shift reporting properly and they have since reinforced the requirement of conducting a head count of the residents before and after each shift. An interview was conducted on 12/18/2023 at 2:33 PM with Staff C, CNA, who was Resident #1's assigned CNA on 11/27/2023 during the 7 AM to 3 PM shift. Staff C, CNA stated 11/27/2023 was the first day she was assigned care for Resident #1, and she was not very familiar with his behaviors. Staff C, CNA also stated Resident #1 had expressed a desire to leave during the 7 AM to 3 PM shift because his brother was waiting for him by the back door. Resident #1 was also pushing on the door but was easily re-directed to another area of the unit. Staff C, CNA stated she informed the Eagle Eye staff of Resident #1's attempts and desires to leave the unit but did not inform the nurse on duty, Staff F, LPN UM. Staff C, CNA stated the last time she saw Resident #1 on the unit on 11/27/2023 was around 3:00 PM while he was walking back and forth through the unit hallways. Staff C, CNA stated upon ending her shift, she gave a verbal report to Staff I, CNA for the 3 PM to 11 PM shift but did walking rounds to ensure all the assigned residents were present on the unit. Staff C, CNA also stated she had not been working as a CNA for very long and she was not aware they needed to visually check on the residents as part of her shift to shift rounds and she did not visualize the residents before leaving the unit around 3:35 PM. Staff C, CNA stated she did not include Resident #1's desire to leave the unit or attempts to open the doors to the unit in her report to Staff I, CNA and only stated to keep an eye on him. Staff C, CNA stated they must complete a form during their shift to shift rounds to verify the presence of the residents on the unit and verify placement of any electronic elopement devices on the residents, which is a process they did not have in place prior to Resident #1's elopement. An interview was conducted on 12/18/2023 at 3:23 PM with Staff E, CNA and Staff J, CNA. Staff J, CNA stated she worked as an Eagle Eye on the dementia care unit on 11/27/2023 during the 7 AM to 3 PM shift. Staff J, CNA also stated the Eagle Eye's role is to check every resident on the unit every 15 minutes to ensure the resident is safe and care needs are met. Staff J, CNA stated Resident #1 would normally wander around the unit hallways throughout the day and at one point told her he needed to leave because his brother was waiting for him outside. Resident #1 was easily re-directed by staff. Staff J, CNA stated she last saw Resident #1 on the unit around 2:45 PM while the resident was wandering the unit hallways. Staff E, CNA relieved Staff J, CNA for the 3 PM to 11 PM shift. Staff H, CNA was also supposed to work as an Eagle Eye for the 3 PM to 11 PM shift but was about 30 minutes late for her shift, leaving only Staff E, CNA. Staff E, CNA stated on 11/27/2023 she was assigned the opposite side of the hallway and Staff H, CNA was assigned the other side of the hallway where Resident #1 resided. Staff E, CNA also stated she conducted a report with Staff J, CNA, but did not conduct a head count or visualize all the residents on the unit as part of her shift to shift report. Staff E, CNA stated when she came on the unit around 3 PM, she conducted safety rounds on her assigned residents, which took about 10 or 15 minutes. Staff E, CNA then conducted rounds on the side of the hall Resident #1 was on and did not see the resident on the unit. Staff E, CNA stated a Bingo activity was being conducted on another unit of the facility and she assumed Resident #1 was at the activity, but she did not verify Resident #1 was at the activity. Staff E, CNA continued to look for Resident #1 on the unit until Staff H, CNA came to the unit around 3:30 PM and assisted in locating Resident #1. Staff E, CNA stated around 3:30 or 4 PM, she went to another unit where the Bingo activity was taking place to see if Resident #1 was at the activity. After verifying Resident #1 was not at the activity, Staff E, CNA informed Staff F, LPN UM around 4:00 PM, Resident #1 was missing. Staff F, LPN UM called a code silver and facility staff searched around the facility and facility ground attempting to find Resident #1. Staff E, CNA stated she searched the entire outside perimeter of the facility but was not able to locate Resident #1. Resident #1 was located by Staff F, LPN UM and was placed on one to one supervision upon his return. Staff E, CNA and Staff J, CNA were not able to state why they did not perform a head count of the residents on the dementia care unit during their shift to shift report. A review of the facility procedure titled Eagle Eye Observation Program, with no effective date, revealed there will be a CNA observer for the whole unit on 7:00 AM to 3:00 PM, 2 CNA observers, one for each hallway on 3:00 PM to 11:00 PM, and one CNA observer for the whole unit for the 11 PM to 7 AM shift. The procedure also revealed during those periods, the staff member will be responsible for the following monitoring: - Walk the halls, checking each room and common areas to include the solarium. This will occur throughout the eight-hour shift every 15 minutes. - During this time the staff members will be observing the following potential occurrences to promote proactive intervention and ensures resident safety: Preventing unusual occurrences, assist residents with activities, prevent residents from falling, prevent conflict between residents, redirects residents out of another resident's room, check each room for patient needs every 15 minutes, and prevent potential elopement. - Any unusual situation or significant change that this staff member observes will be immediately reported to the resident's assigned nurse. A telephone interview was conducted on 12/19/2023 at 9:15 AM with Staff I, CNA, who was Resident #1's assigned CNA for the 3 PM to 11 PM shift on 11/27/2023. Staff I, CNA stated she arrived at the dementia care unit on 11/27/2023 around 3:00 PM and received a verbal report from Staff C, CNA. Staff I, CNA assisted Staff C, CNA with changing another resident in the unit shower room and continued to check on other resident's in her assignment. Staff I, CNA stated she had never seen Resident #1 before and did not know to look for him on the unit because she did not know he was a resident of the facility. Staff I, CNA stated Staff E, CNA asked her where Resident #1 was and she replied, who's that? Staff I, CNA stated Staff E, CNA informed Staff F, LPN UM Resident #1 was missing from the facility and a code silver was called. Staff I, CNA stated she looked at a photo to see what Resident #1 looked like and began to assist in searching for him throughout the facility. Staff I, CNA stated Resident #1 was brought back to the facility around 5:40 PM and was brought into the facility dining room for dinner. A telephone interview was attempted on 12/19/2023 at 9:36 AM with Staff H, CNA. The phone call was not answered, and a message was left for a return call. Staff H, CNA did not return the phone call. A telephone interview was attempted on 12/19/2023 at 11:53 AM with Staff G, Maintenance. The phone call was not answered, and a message was left for a return call. Staff G, Maintenance did not return the phone call. A telephone interview was conducted on 12/19/2023 at 4:20 PM with the facility's Medical Director (MD). The MD stated Resident #1 was at the facility for a short term respite stay and resided on the dementia care unit. The MD also stated Resident #1 was not well known by the facility staff because he was only there for a short time, and he was informed of Resident #1's elopement on 11/27/2023 by the RM. The MD stated he was not very familiar with Resident #1 but did discuss the resident's elopement with the Interdisciplinary Team (IDT) to discuss elopement prevention, keeping track of the resident head count more frequently, and having every resident always accounted for. Facility's immediate actions to remove the Immediate Jeopardy included: - Full body sweep and evaluation for injury on Resident #1, completed on 11/27/2023 upon return to the facility. - CNA's assigned to resident for 7:00 AM - 5:30 PM on 11/27/2023 were suspended 11/27/2023. - Completed new elopement evaluations on all residents starting with Resident #1, update care plans and care guide as needed, completed on 11/28/2023. - All staff working on the dementia care unit on 11/27/23 from 7:00 AM to 5:30 PM were interviewed on 11/30/2023. - Complete elopement drills on each shift one to include the weekend and then twice a month on rotating shifts and including the weekend. Elopement drills were completed on 11/28/2023, 11/30/2023, and 12/3/2023. - Have all doors and alarm system devices were checked for functioning. Batteries to all alarm systems checked and a system of routine changing was put into place to prevent battery issues. On 11/27/2023 the NHA, Maintenance, and RM verified all doors were functioning as they should. Locks were replaced on the dementia care unit dining room, key entry, and key exit. Alarms on the dementia care unit doors removed from inside of the unit and placed on the outside of the unit. The door latch release behind the unit nurse's station was removed. Red exit door alarms placed on all exit doors for added notification. Completed on 11/28/2023. - 100% of all staff were educated on elopement response expectations, process/responsibilities, and reporting. Education completed on 12/5/2023. - Competency for all nurses on checking wander management device functioning. Education was conducted on responsibility to apply, notify, and care plan when evaluating residents who are at risk. Completed 12/15/2023. - 100% of all nursing staff were educated on walking rounds for report from shift to shift and rounding on their assigned residents at least every 2 hours. Completed 12/5/2023. - 100% of nurses were educated on completing the elopement evaluation and putting interventions into place. If a resident is cognitively impaired, staff should attempt to attain information from the family related to the elopement evaluation. Completed on 11/30/2023. - Nurse management or designee audited shift to shift walking reports being completed randomly between each shift one time a week. Audits began 11/28/2023, and were completed on 11/30/2023, 12/4/2023, 12/5/2023, 12/6/2023, 12/8/2023, 12/12/2023, 12/14/2023, 12/15/2023, and 12/18/2023. - All elopement books were audited for accuracy and maintenance on 11/28/2023. Verification of the facility's removal actions was conducted by the survey team on 12/20/2023. Review of facility education was conducted. Staff roster provided by NHA and DON. 306 total staff members, 1 on administrative leave. 305 total staff members were educated related to abuse, neglect, and exploitation, elopement response expectations, process/responsibilities[TRUNCATED]

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Risk Manager, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, facility failed to ensure one resident (#1) of 58 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility staff failed to ensure the safety of Resident #1; between approximately 2:45 PM on 11/27/2023 and 5:30 PM on 11/27/2023, Resident #1 ambulated from the dementia care unit, followed behind a staff member through a door equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and into an outdoor enclosed porch area. Resident #1 opened a wooden gate in the outdoor enclosed porch area, which was left unlatched and unlocked by staff, and walked into an enclosed courtyard. Resident #1 walked into the courtyard and exited the facility grounds unsupervised and without staff knowledge through a vinyl fence door equipped with an electromagnetic locking device, which was left propped open by staff. Resident #1 walked approximately 0.8 miles on a sidewalk along a 6-lane highway to a bus stop. The facility failed to take action to prevent the resident from exiting the secured dementia care unit by not providing supervision for the resident, not ensuring doors were properly closed to prevent the resident from following behind them as they exited the secured dementia care unit, and not accounting for the resident for approximately 1 hour and 45 minutes. Resident #1 was discovered by facility staff on 11/27/2023 at approximately 5:30 PM at a bus stop, sitting on a bench. Resident #1 was returned to the facility by facility staff at approximately 5:40 PM. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 11/27/2023. The findings of Immediate Jeopardy were determined to be corrected on 12/5/2023. Findings included: A review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 11/27/2023 at 9:28 PM revealed the following under the section titled Nursing Notes: [Resident #1] was noted missing from the unit. The unit was searched without success. Code silver [was] paged and all departments came to assist. [Local police department] was called to assist as well. Outside perimeter of the facility was searched and resident was located at a nearby establishment. [Resident #1] denies pain or discomfort. No new skin issues noted. VSS (vital signs stable). New order for [electronic elopement device] place[d] on resident and enhanced monitoring. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral atherosclerosis, vascular dementia, severe, without behavioral disturbance, and depression. Resident #1 was discharged home on 10/25/2023. Resident #1 was readmitted to the facility on [DATE] and was discharged home on 12/1/2023. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 11/24/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section E: Medical Condition, primary discharge diagnoses of cerebral atherosclerosis and dementia. The transfer form revealed under Section G: Patient Risk Alerts, Resident #1 was at risk for elopement. A review of Resident #1's physician's orders revealed the following: - An order dated 11/27/2023 for an electronic elopement device to the right ankle for safety. - An order dated 11/27/2023 to verify placement of the electronic elopement device to the resident's right ankle every shift for safety. - An order dated 11/27/2023 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. A review of Resident #1's baseline care plan, dated 11/26/2023, revealed Resident #1 was an elopement risk with a goal for Resident #1 to remain in a safe, supervised, and supportive environment. Interventions included to initiate elopement risk protocol, involve in activities, and redirect and/or distract as needed. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. An observation was conducted on 12/18/2023 at 11:54 AM of the facility's dementia care unit. A doorbell was observed on the left wall outside of the entrance to the unit with a small gold colored sign underneath, which stated For entrance to the dementia unit, please ring this bell and then step to the door. A nurse at the station will press the keypad to let you in. Thanks for your help as we ensure the safety of our residents. A small contact alarm (an alarm with a magnetic piece and a sensor body that adhere to doors which activate when separated from their sensors and the sensor's magnetic field is broken) was observed on the entrance door of the unit, which sounded an audible alarm when opened by staff. The facility's Nursing Home Administrator (NHA) entered the hallway to silence the alarm after entering the unit. Facility staff were observed at the unit nurse's station, which is positioned next to the unit entrance. A small, enclosed patio was observed in the back of the unit, separated by a glass door exiting to the outside. The door was observed to be locked with an electromagnetic locking device and a red colored contact alarm was observed on the door. The Director of Nursing (DON) and Risk Manager (RM) were observed in the dementia care unit. The DON stated the contact alarm can be disengaged using a key to position the alarm from on to off and keys are kept by the nursing staff on the unit. The DON opened the magnetically locked door using a keypad to the left side of the door. Upon opening the door, the contact alarm engaged, and an audible alarming sound was heard. The alarm was disengaged by nursing staff and reengaged after exiting the unit to the enclosed porch. The outdoor porch was observed to be enclosed with a vinyl white lattice fence and a large wooden door leading out to a courtyard behind the unit. The wooden gate was observed to be latched with a metal latching device and locked with a small padlock. A white sign was observed on the wooden door, which stated gate to remain locked when not in use. A key box with a numbered combination lock was observed mounted to a post next to the wooden door. The RM entered the combination for the key box, which opened the box and revealed a key for the lock on the wooden gate. The RM unlocked the lock and unlatched the wooden door, leading to a large courtyard area behind the dementia care unit. The courtyard was observed enclosed by a white vinyl fence approximately 8 feet tall. Several exit signs were observed along the vinyl fence with signs pointing to an exit door, which lead to a small parking area, a sidewalk, and 4 lane street outside of the facility grounds. The RM stated the fence door is secured with an electromagnetic locking device and can be opened with the keypad. The keypad was moved from the inside of the courtyard to the outside of the courtyard, so staff do not have to go through the dementia care unit to gain access to the courtyard behind the dementia care unit. An interview was conducted on 12/18/2023 at 1:13 PM with the NHA, DON, and RM. The RM stated on 11/27/2023 around 4:30 PM, Resident #1 was not able to be located on the dementia care unit. Staff E, Certified Nursing Assistant (CNA) was working as Eagle Eye staff on the unit for the 3 PM to 11 PM shift and reported to Staff F, LPN UM she was not able to locate Resident #1 on the unit. The RM stated Eagle Eye staff are assigned to the dementia care unit to ensure the safety of the residents on the unit by visualizing the location of the resident every 15 minutes for the duration of their shift. The RM stated per Staff E, CNA's statement, Staff E, CNA noticed around 3:45 PM on 11/27/2023 Resident #1 was not located on the unit and began searching for the resident on the unit. After reporting the missing resident to Staff F, LPN UM, the dementia care unit was searched by the CNA staff and nursing staff on the unit. After not being able to locate Resident #1 on the unit, staff called a code silver, which is the code to indicate a missing resident from the facility, between 4:40 and 4:45 PM. The DON stated she reported to the dementia care unit to coordinate the code and several staff began to search for Resident #1 both inside the facility and outside of the facility, as assigned by the DON. The DON also informed local law enforcement around 5:05 PM of Resident #1 missing from the facility. The DON assigned Staff F, LPN UM to search around the local shopping mall area and drove to Resident #1's house since it was near the facility. The DON was on the phone with Staff F, LPN UM when she arrived at Resident #1's house and Resident #1's RP answered the door. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and the RP stated Resident #1 was not at the house. Staff F, LPN UM continued to search the local area for Resident #1 and located the resident at a bus stop sitting on a bench around 5:30 PM. Resident #1 was brought back to the facility by Staff F, LPN UM and did not have any injuries. Resident #1 was wearing grey colored khaki pants, a grey short sleeved shirt, a blue jacket, and black shoes when he arrived back to the facility. The RM stated Resident #1 was placed on one-to-one supervision and an electronic elopement device was applied to the resident's right ankle. The RM stated Resident #1 did not have an electronic elopement device previously because he was housed on the locked dementia care unit. Resident #1 had one to one supervision until his scheduled discharge on 12/1/2023. The following day on 11/28/2023, the RM, NHA, and maintenance staff did walking rounds on dementia care unit to assess how Resident #1 eloped from the facility. The RM stated the wooden gate for the enclosed porch outside of the dementia care unit was observed to be open and unlocked. The RM also stated their investigation revealed a correlation between the time Resident #1 eloped and the time outside lawn workers performed lawn care for the courtyard behind the dementia care unit, which was typically on Mondays between 3:00 PM and 3:30 PM. The RM stated per interview with Staff G, Maintenance, the staff member went through the dementia care unit around 3:15 PM to the back courtyard area and through the locked glass door. Staff G, Maintenance unlocked the wooden gate to the enclosed porch behind the dementia care unit and left it open due to not being able to lock the door from the outside. Staff G, Maintenance opened the white vinyl gate to allow lawn care workers into the courtyard behind the dementia care unit and left the door propped open for approximately 30 minutes. The RM stated the investigation revealed Resident #1 followed Staff G, Maintenance off the unit and onto the enclosed porch without the staff member's knowledge, before exiting the porch and exiting the courtyard to the sidewalk outside of the facility. The RM stated since the elopement occurred, the facility removed the button behind the nurse's station on the dementia care unit which allowed nursing staff to open the door to the unit. Nursing staff must enter a code on the keypad to deactivate the magnetic lock on the door to allow visitors and staff to exit the unit. A contact alarm was added to the exit doors on the unit, which were previously located inside of the unit. This was implemented to ensure staff turn around to deactivate the alarm, which will further ensure no resident is trailing behind them when they exit the unit. The RM stated contact alarms, or stop alarms, were added to the exit doors on the dementia care unit leading out to the enclosed patio and courtyard behind the unit. The DON stated all residents in the facility were re-evaluated for elopement risk and those residents determined at risk for elopement will have an electronic elopement device, including those residents on the dementia care unit. The DON also stated facility staff have been educated on the proper procedure for shift-to-shift walking rounds and staff must visualize the resident at the time of their report, which is also verified by the nurse. The DON stated all codes for the doors in the facility equipped with an electromagnetic lock were changed to ensure no residents have access to the codes. A review of the facility policy titled Risk Management/Nursing Policies - Elopement Risk, with no effective date, revealed under the section titled Policy an elopement risk evaluation is completed as a part of screening upon admission. All residents will be evaluated for elopement risk upon admission, quarterly, and with a change in condition. The policy also stated under the section titled Procedure if the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Facility staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behavior according to the plan of care. A review of Resident #1's Pre-Admission Care Needs assessment, dated 11/25/2023, revealed under the section titled Mental Status, Resident #1 was confused and an Elopement Risk. The assessment also revealed, under the section titled Behavior Patterns Resident #1 had a history of elopement. A review of Resident #1's Pre/Post Admission Elopement Risk Evaluation, dated 11/25/2023, revealed Resident #1 had a history of wandering or elopement, exit seeking behavior, confusion/dementia, and a resident or family home nearby. A review of Resident #1's Progress Notes dated 10/21/2023 at 12:14 PM and authored by Staff F, Licensed Practical Nurse (LPN) and Unit Manager (UM), [Resident #1] has expressed the desire to leave on multiple occasions and was constantly looking for an exit. Redirected without much success. An interview was conducted on 12/18/2023 at 2:03 PM with Staff F, LPN UM, who was Resident #1's assigned nurse for the 7 AM to 7 PM shift on 11/27/2023. Staff F, LPN UM stated she was Resident #1's assigned nurse on 11/27/2023 for the 7:00 AM to 7:00 PM shift. Staff F, LPN UM also stated Resident #1 often expressed he wanted to go home, told staff his brother was waiting outside for him, and asked staff how he could get out of the facility, but was easily re-directed by staff on the dementia care unit. Staff F, LPN UM stated Resident #1 was an elopement risk before being admitted to the facility and his RP placed several locks on the doors of his home to prevent him from eloping from the house. Staff F, LPN UM stated prior to Resident #1's elopement, she saw the resident between 2:15 PM and 2:30 PM by the unit nurse's station walking in the unit halls. Staff F, LPN UM also stated around 4:00 PM, Staff E, CNA and Staff H, CNA told her Resident #1 was missing from the unit and the staff members already searched the unit for the resident. Staff F, LPN UM and the dementia care unit staff searched the unit one more time for Resident #1, including the courtyard and activity areas, without success. Staff F, LPN UM called a code silver and other facility staff reported to the unit to assist in locating Resident #1. Facility staff searched throughout the facility and surrounding areas. Staff F, LPN UM stated she went toward Resident #1's home because he previously stated he wanted to go home, and the resident lived close to the facility. Staff F, LPN UM arrived at Resident #1's home and spoke with the RP, who stated the resident was not at the house. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and local law enforcement was aware. After leaving Resident #1's home, Staff F, LPN UM got into her car and searched areas closer to the facility grounds. Staff F, LPN UM found Resident #1 sitting at a bus stop in front of a local restaurant. Staff F, LPN UM took Resident #1 by the hand and assisted him into her vehicle before driving him back to the facility. Resident #1 was assessed and had no injuries because of the elopement. Resident #1 was taken by staff to the unit dining room for dinner. Resident #1 was placed on one-to-one supervision until he was discharged on [DATE]. Staff F, LPN UM stated the CNA staff were not conducting shift to shift reporting properly and they have since reinforced the requirement of conducting a head count of the residents before and after each shift. An interview was conducted on 12/18/2023 at 2:33 PM with Staff C, CNA, who was Resident #1's assigned CNA on 11/27/2023 during the 7 AM to 3 PM shift. Staff C, CNA stated 11/27/2023 was the first day she was assigned care for Resident #1, and she was not very familiar with his behaviors. Staff C, CNA also stated Resident #1 had expressed a desire to leave during the 7 AM to 3 PM shift because his brother was waiting for him by the back door. Resident #1 was also pushing on the door but was easily re-directed to another area of the unit. Staff C, CNA stated she informed the Eagle Eye staff of Resident #1's attempts and desires to leave the unit but did not inform the nurse on duty, Staff F, LPN UM. Staff C, CNA stated the last time she saw Resident #1 on the unit on 11/27/2023 was around 3:00 PM while he was walking back and forth through the unit hallways. Staff C, CNA stated upon ending her shift, she gave a verbal report to Staff I, CNA for the 3 PM to 11 PM shift but did walking rounds to ensure all the assigned residents were present on the unit. Staff C, CNA also stated she had not been working as a CNA for very long and she was not aware they needed to visually check on the residents as part of her shift to shift rounds and she did not visualize the residents before leaving the unit around 3:35 PM. Staff C, CNA stated she did not include Resident #1's desire to leave the unit or attempts to open the doors to the unit in her report to Staff I, CNA and only stated to keep an eye on him. Staff C, CNA stated they must complete a form during their shift-to-shift rounds to verify the presence of the residents on the unit and verify placement of any electronic elopement devices on the residents, which is a process they did not have in place prior to Resident #1's elopement. A review of the facility policy titled Risk Management - Missing Resident and Elopement, with no effective date, revealed under the section titled Policy elopement occurs when a resident who needs supervision leaves a safe area without supervision. If any resident should leave the premises at any time without following the facility procedure for voluntary leave, the missing resident/elopement procedure should begin immediately. The policy also revealed under the section titled Procedure it is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as possible. An interview was conducted on 12/18/2023 at 3:23 PM with Staff E, CNA and Staff J, CNA. Staff J, CNA stated she worked as an Eagle Eye on the dementia care unit on 11/27/2023 during the 7 AM to 3 PM shift. Staff J, CNA also stated the Eagle Eye's role is to check every resident on the unit every 15 minutes to ensure the resident is safe and care needs are met. Staff J, CNA stated Resident #1 would normally wander around the unit hallways throughout the day and at one point told her he needed to leave because his brother was waiting for him outside. Resident #1 was easily re-directed by staff. Staff J, CNA stated she last saw Resident #1 on the unit around 2:45 PM while the resident was wandering the unit hallways. Staff E, CNA relieved Staff J, CNA for the 3 PM to 11 PM shift. Staff H, CNA was also supposed to work as an Eagle Eye for the 3 PM to 11 PM shift but was about 30 minutes late for her shift, leaving only Staff E, CNA. Staff E, CNA stated on 11/27/2023 she was assigned the opposite side of the hallway and Staff H, CNA was assigned the other side of the hallway where Resident #1 resided. Staff E, CNA also stated she conducted a report with Staff J, CNA, but did not conduct a head count or visualize all the residents on the unit as part of her shift-to-shift report. Staff E, CNA stated when she came on the unit around 3 PM, she conducted safety rounds on her assigned residents, which took about 10 or 15 minutes. Staff E, CNA then conducted rounds on the side of the hall Resident #1 was on and did not see the resident on the unit. Staff E, CNA stated a Bingo activity was being conducted on another unit of the facility and she assumed Resident #1 was at the activity, but she did not verify Resident #1 was at the activity. Staff E, CNA continued to look for Resident #1 on the unit until Staff H, CNA came to the unit around 3:30 PM and assisted in locating Resident #1. Staff E, CNA stated around 3:30 or 4 PM, she went to another unit where the Bingo activity was taking place to see if Resident #1 was at the activity. After verifying Resident #1 was not at the activity, Staff E, CNA informed Staff F, LPN UM around 4:00 PM, Resident #1 was missing. Staff F, LPN UM called a code silver and facility staff searched around the facility and facility ground attempting to find Resident #1. Staff E, CNA stated she searched the entire outside perimeter of the facility but was not able to locate Resident #1. Resident #1 was located by Staff F, LPN UM and was placed on one-to-one supervision upon his return. Staff E, CNA and Staff J, CNA were not able to state why they did not perform a head count of the residents on the dementia care unit during their shift-to-shift report. A review of the facility procedure titled Eagle Eye Observation Program, with no effective date, revealed there will be a CNA observer for the whole unit on 7:00 AM to 3:00 PM, 2 CNA observers, one for each hallway on 3:00 PM to 11:00 PM, and one CNA observer for the whole unit for the 11 PM to 7 AM shift. The procedure also revealed during those periods, the staff member will be responsible for the following monitoring: - Walk the halls, checking each room and common areas to include the solarium. This will occur throughout the eight-hour shift every 15 minutes. - During this time the staff members will be observing the following potential occurrences to promote proactive intervention and ensures resident safety: Preventing unusual occurrences, assist residents with activities, prevent residents from falling, prevent conflict between residents, redirects residents out of another resident's room, check each room for patient needs every 15 minutes, and prevent potential elopement. - Any unusual situation or significant change that this staff member observes will be immediately reported to the resident's assigned nurse. A telephone interview was conducted on 12/19/2023 at 9:15 AM with Staff I, CNA, who was Resident #1's assigned CNA for the 3 PM to 11 PM shift on 11/27/2023. Staff I, CNA stated she arrived at the dementia care unit on 11/27/2023 around 3:00 PM and received a verbal report from Staff C, CNA. Staff I, CNA assisted Staff C, CNA with changing another resident in the unit shower room and continued to check on other residents in her assignment. Staff I, CNA stated she had never seen Resident #1 before and did not know to look for him on the unit because she did not know he was a resident of the facility. Staff I, CNA stated Staff E, CNA asked her where Resident #1 was and she replied, who's that? Staff I, CNA stated Staff E, CNA informed Staff F, LPN UM Resident #1 was missing from the facility and a code silver was called. Staff I, CNA stated she looked at a photo to see what Resident #1 looked like and began to assist in searching for him throughout the facility. Staff I, CNA stated Resident #1 was brought back to the facility around 5:40 PM and was brought into the facility dining room for dinner. A telephone interview was attempted on 12/19/2023 at 9:36 AM with Staff H, CNA. The phone call was not answered, and a message was left for a return call. Staff H, CNA did not return the phone call. A telephone interview was conducted on 12/19/2023 at 10:40 AM with Resident #1's responsible party (RP). The RP stated Resident #1 was initially admitted to the facility for a short-term respite stay of 5 days and required placement on the dementia care unit due to his history of dementia and poor short-term memory. The resident had a 5-day respite stay at the facility sometime in October, then again in November. The RP also stated Resident #1 required assistance at home with finding the bedroom and the bathroom and the doors in the house were deadbolted due to the resident wanting to exit the house and stating he needed to go to work. The RP stated Resident #1 had poor safety awareness and would often walk in the middle of the parking lot when they would go to the store together and required frequent redirection and reorientation to his surroundings. The RP stated on 11/27/2023 a staff member from the facility arrived at her house and told her Resident #1 was missing from the facility. The staff member asked if the resident was at the house and the RP told her Resident #1 was not at the house. The RP drove to the facility shortly after the interaction and spoke with local law enforcement at the facility. The RP stated Resident #1 was found around 5:30 PM by facility staff and was brought back to the facility. The RP also stated Resident #1 had an electronic elopement device placed on his body and was provided with increased supervision until he was discharged on [DATE]. A telephone interview was attempted on 12/19/2023 at 11:53 AM with Staff G, Maintenance. The phone call was not answered, and a message was left for a return call. Staff G, Maintenance did not return the phone call. A telephone interview was conducted on 12/19/2023 at 4:20 PM with the facility's Medical Director (MD). The MD stated Resident #1 was at the facility for a short-term respite stay and resided on the dementia care unit. The MD also stated Resident #1 was not well known by the facility staff because he was only there for a short time, and he was informed of Resident #1's elopement on 11/27/2023 by the RM. The MD stated he was not very familiar with Resident #1 but did discuss the resident's elopement with the Interdisciplinary Team (IDT) to discuss elopement prevention, keeping track of the resident head count more frequently, and having every resident always accounted for. Facility's immediate actions to remove the Immediate Jeopardy included: - Full body sweep and evaluation for injury on Resident #1, completed on 11/27/2023 upon return to the facility. - CNAs assigned to resident for 7:00 AM - 5:30 PM on 11/27/2023 were suspended 11/27/2023. - Completed new elopement evaluations on all residents starting with Resident #1, update care plans and care guide as needed, completed on 11/28/2023. - All staff working on the dementia care unit on 11/27/23 from 7:00 AM to 5:30 PM were interviewed on 11/30/2023. - Complete elopement drills on each shift one to include the weekend and then twice a month on rotating shifts and including the weekend. Elopement drills were completed on 11/28/2023, 11/30/2023, and 12/3/2023. - Have all doors and alarm system devices were checked for functioning. Batteries to all alarm systems checked and a system of routine changing was put into place to prevent battery issues. On 11/27/2023 the NHA, Maintenance, and RM verified all doors were functioning as they should. Locks were replaced on the dementia care unit dining room, key entry, and key exit. Alarms on the dementia care unit doors removed from inside of the unit and placed on the outside of the unit. The door latch release behind the unit nurse's station was removed. Red exit door alarms placed on all exit doors for added notification. Completed on 11/28/2023. - 100% of all staff were educated on elopement response expectations, process/responsibilities, and reporting. Education completed on 12/5/2023. - Competency for all nurses on checking wander management device functioning. Education was conducted on responsibility to apply, notify, and care plan when evaluating residents who are at risk. Completed 12/15/2023. - 100% of all nursing staff were educated on walking rounds for report from shift to shift and rounding on their assigned residents at least every 2 hours. Completed 12/5/2023. - 100% of nurses were educated on completing the elopement evaluation and putting interventions into place. If a resident is cognitively impaired, staff should attempt to attain information from the family related to the elopement evaluation. Completed on 11/30/2023. - Nurse management or designee audited shift to shift walking reports being completed randomly between each shift one time a week. Audits began 11/28/2023, and were completed on 11/30/2023, 12/4/2023, 12/5/2023, 12/6/2023, 12/8/2023, 12/12/2023, 12/14/2023, 12/15/2023, and 12/18/2023. - All elopement books were audited for accuracy and maintenance on 11/28/2023. Verification of the facility's removal actions was conducted by the survey team on 12/20/2023. Review of facility education was conducted. Staff roster provided by NHA and DON. 306 total staff members, 1 on administrative leave. 305 total staff members were educated related to abuse, neglect, and exploitation, elopement response expectations, process/responsibilities, reporting, and walking rounds for report from shift to shift and rounding on their assigned residents at least every 2 hours. Education completed on 12/5/2023. All 69 nurses were educated on completing the elopement evaluation and putting interventions into place, responsibility to apply, notify, and care plan when evaluating residents who are at risk, and completed competency on checking wander management device functioning. Completed on 12/15/2023. A sample of three residents at risk for elopement, including Resident #1, were reviewed for verification of new orders related to electronic elopement devices and checks for presence and functioning every shift, care plan including elopement risk, and elopement risk evaluation. Review of the three residents revealed all residents had new orders related to electronic elopement devices and checks for presence and functioning every shift, care plan including elopement risk, and updated elopement risk evaluation. Interviews were conducted with 116 staff mem[TRUNCATED]

Based on observations, interviews, and record review, the facility did not provide supervision or hydration offerings for one (Resident #1) of three residents sampled for accident hazards. The facility allowed a resident who was at risk for dehydration related to diuretic use, hypertension, and diabetes and at risk for skin breakdown related to fragile skin to remain outside on a day with a temperature of 93 degrees Fahrenheit. Resident #1 was found in his wheelchair slumped over in an area behind the back patio, out of direct supervision, in direct sunlight and assessed as being unresponsive with an elevated body temperature of 104.8 degrees Fahrenheit with blisters to the right arm and neck area requiring a two-day hospital stay. Findings included: On 09/17/19 at 01:53 PM, in Tampa Florida, the temperature was 93 degrees Fahrenheit and the humidity was 50%. (wunderground.com) An interview was conducted on 09/20/19 at 10:06 AM with Staff Member A, Licensed Practical Nurse (LPN) regarding when Resident #1 was discovered outside. Staff Member A reported that she was doing eagle eye rounds during lunch time, and that the first time she walked down the hall she did not see Resident #1 by the 100 hall back door. It was between 1:45 PM - 2:00 PM when the incident happened. It was a Tuesday or Wednesday. Staff Member A stated she went down and pushed on the door at the end of the 100 hallway. When discovered by Staff Member A, Resident #1 was leaned over in the wheelchair and Staff Member A called on a Certified Nurse Assistant (CNA) for help. Staff Member E, Advance Registered Nurse Practitioner (ARNP) was in the facility when Resident #1 was brought inside and informed his nurse Staff Member D, LPN. Staff Member A stated that there was a sidewalk that ran along the outside area behind the 100 hall, but it was fenced in (photographic evidence available). Observation on 09/20/19 at 12:13 PM of the enclosed outside gazebo/sitting area where Resident #1 was discovered (between the 100 hall and 200 hall dining room and the rear of the 100 hallway). The door leading outside from the 100 and 200 dining room was able to be opened without staff assistance or keypad entry. A sidewalk led from the 100 and 200 dining room to the front of a large, covered gazebo in the middle of the outside area (photographic evidence available). A wooden gate with a sliding lock was present at the back side of the gazebo to prevent residents from entering the sidewalk area leading to the back of the 100 hallway (photographic evidence available). The sliding lock on the gate was easily opened, which made the sidewalk leading to the back of the 100 hallway accessible. The sidewalk leading from the back of the gazebo to the back of the 100 hallway was L shaped, which led to a secluded area which had large bushes on the left side and a fence on the right side (photographic evidence available). The sidewalk further led to a locked door in the back of the 100 hallway (photographic evidence available). An interview at the time of observation with Staff Member B, Risk Manager, revealed Resident #1 had wheeled himself to the back door of the 100 hallway, where a key code was needed for access, and this was where he was found on 09/17/19. Staff Member B stated that the gate was put up following the incident with Resident #1 to prevent residents from accessing the area behind the 100 hallway. Further observation found that the area where the resident's wheel got stuck and he was found could not easily be seen without looking directly to the right side of the door. Interviews were conducted with Resident #1 on 09/20/19 at 10:10 AM and on 09/22/19 at 4:55 PM regarding his hospitalization on [DATE]. Resident appeared dressed and well-groomed and was alert and oriented during both interviews. Resident #1 stated I had a heat stroke, but he was feeling much better now. Resident #1 stated that he enjoyed sitting outside every morning with his coffee and a cigarette and periodically, he sits outside throughout the day. Resident #1 stated that he went to the back door of the 100 hallway because he wanted to know what it looked like back there and that he didn't normally go to that area to sit. Resident #1 stated that he saw several staff members inside while he was outside, but no staff members checked on him or offered hydration while he was outside that afternoon. Resident #1 stated that at one point, his wheelchair wheel became stuck between the sidewalk and the grass and that he didn't remember very much after that. An observation of Resident #1 during the interview revealed five intact, fluid filled blisters on the right upper arm, as well as one open blister on the back of Resident #1's neck. Resident #1 stated that the blisters on his arm were from being out in the sun too long. An interview was conducted on 09/20/19 at 10:21 AM with Staff Member D, LPN, who was Resident #1's assigned nurse on 09/17/19 during the 7 AM to 3 PM shift. Staff Member D stated that Resident #1 was fine the morning of 09/17/19 and that she saw him between 12:15 PM and 12:35 PM. Staff member D stated that Resident #1 was allowed to go out to smoke by himself. Staff Member D was assigned to the dining room and was in the dining room from 12:30 PM to 1:40 PM. Staff Member D stated that she returned to the 200 unit to give Resident #1 his medications, but he was not on the unit. Staff Member D was then tasked with admitting a new resident and was called into another room between 1:45 PM and 2:00 PM. While Staff Member D was in the other resident's room, Staff Member A knocked on the door and told her to check on Resident #1, who was in his room after they found him outside. Other staff members had already put Resident #1 in bed and put cold compresses on the resident because he was hot. The ARNP also came into the room and started an ice bath to bring Resident #1's temperature down, which was 104.8 degrees Fahrenheit, and started IV therapy. Staff Member D stated that she thinks Resident #1's high temperature was due to the heat and that she was not sure how long Resident #1 was outside before he was discovered. An interview was conducted on 09/20/19 at 2:41 PM with Staff Member C, LPN Unit Manager for the 100 unit regarding Resident #1. Staff Member C stated that she was not that familiar with Resident #1 but will see him propelling himself around hallways and has seen Resident #1 outside many times. Staff Member C stated that the outside patio area behind the 100- and 200-unit dining rooms were well monitored, and that staff was frequently in and out of the dining room area to monitor residents. Staff Member C stated that activity staff was in the gazebo area frequently to assist residents that require smoking assistance. Staff Member C stated that she saw Resident #1 outside between 12:50 PM and 1:00 PM and that the resident smiled and waved at her but did not see him outside after that. Staff Member C stated that there was no system currently in place to keep track of residents who were outside and that every nurse and CNA was accountable for their residents. A follow up interview was conducted with Staff Member B on 09/20/19 at 12:20 PM regarding Resident #1. Staff Member B stated that Resident #1 regularly roamed the facility independently and was able to navigate the building without staff assistance. Staff Member B stated that Resident #1 was seen outside by Staff Member D, LPN around the timeframe of 12:30 PM and 12:45 PM and that Resident #1 told Staff Member D that he was going outside. Resident #1 was witnessed outside by Staff Member C, LPN Unit Manager between 12:50 PM and 1:00 PM and Resident #1 waved at her through the 100-hallway door. Around 1:50 PM, Staff Member A saw Resident #1 slumped over and brought him inside. Staff Member E, ARNP was in the building and assessed Resident #1. Staff Member [NAME] then started treatment for [REDACTED]. Resident #1 was started on intravenous (IV) fluids and cooled using cold wash cloths and ice packs. Staff Member [NAME] re-assessed Resident #1's temperature at 101.7 degrees Fahrenheit using a forehead thermometer and recorded a pulse rate of 138 beats per minute (bpm). Resident #1 was also started on oxygen therapy. Resident #1's primary care physician was contact at 3:30 PM and an order was received to send him to the hospital. Resident #1 was transported to the hospital at 3:50 PM. Resident #1 was in the hospital for 2 days and was treated for [REDACTED]. Staff Member B stated that Resident #1 did not have an elevated temperature or any UTI symptoms prior to being discovered on the outside patio on 09/17/19. Staff Member B stated that Resident #1's elevated temperature was a result of being outside, but that having a UTI also contributed to the elevated temperature. Staff Member B stated that CNA's and nurses perform 2-hour rounds to check on residents, but that Resident #1 may have been behind a bush and not in direct supervision. Staff Member B stated that Resident #1 was dehydrated from being outside and also stated that hydration carts do not go outside. Independent smokers were able to go outside in the gazebo area and smoke unsupervised because the door was always left open. Staff Member B stated that she did not feel like further instances could be prevented currently and that they are still working on a solution to the problem. A review of Resident #1's clinical record revealed a Facesheet with an original admitted in (YEAR) and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident #1's Minimum Data Set (MDS) assessment, completed on 07/12/19, under Section C - Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident #1 was cognitively intact. A review of Section G - Functional Status, revealed that Resident #1 required extensive assistance of one staff member for locomotion on and off the unit. A review of Resident #1's care plan revealed the following information: Problem Onset 1/18/19: Resident #1 has impaired cognitive skills related to decision making problems, long term memory problems, a history of dementia, and exhibiting behavior of being forgetful at times with interventions to report changes in cognition to the physician, provide orientation and validation, and explain care before providing it. Problem Onset 8/26/19: Resident #1 is at risk for fluid and electrolyte imbalances related to use of diuretics and [DIAGNOSES REDACTED]. Problem Onset 1/22/19: Resident #1 is at risk for skin breakdown related to fragile skin, [DIAGNOSES REDACTED]. Problem Onset 1/22/19: Resident #1 requires assistance with ADLs related to muscle weakness, limited mobility, dementia, [MEDICAL CONDITION], anxiety, depression, [MEDICAL CONDITION], and refusing medications and treatments at times with interventions to assist resident with ADLs as needed, re-direct resident as needed, reinforce safety awareness as needed, staff to offer and encourage to receive medication, care, and treatment and notify the physician and family as needed. An interview was conducted on 9/20/19 at 10:34 AM with Staff Member E, ARNP, regarding Resident #1. The ARNP stated that Resident #1 was a regular patient of hers. She stated that around 2:30 PM on 09/17/19 she was getting ready to go see another resident when she heard a nurse say that they found Resident #1 outside. The ARNP stated that Resident #1 was assessed in his room and his temperature was 104.8 degrees Fahrenheit, heart rate was 138 bpm (beats per minute), respirations were 40 breathes per minute, and blood pressure was around 110/59. Oxygen saturation started at 89% and dropped to 85%. Staff soaked towels in ice water and placed them on Resident #1's body after removing his clothing. Staff Member E, ARNP, stated that she did not know how long Resident #1 was outside. The ARNP stated that they were able to get Resident #1's temperature down to 101.7 degrees Fahrenheit and the primary care physician was notified. IV therapy was started and Resident #1's urine looked concentrated. The ARNP stated that according to what she saw it was heat exhaustion, dehydration, and UTI and that when he gets a UTI and goes outside, his blood pressure drops really low. She stated that being in the heat did not help the UTI and that a lot of it is from the UTI. The ARNP stated that Resident #1 can be difficult at times and if he does not want to come back inside, he won't come back in. She stated that his family supported his ability to make his own decisions. Resident #1 has a psychiatric background, but he was usually alert and oriented. Resident #1 has a catheter and gets frequent UTI's. The ARNP stated he gets more stubborn when he has UTI's and that he was treated for [REDACTED]. A review of Staff Member E, ARNP's, Acute Assessment Data, performed on 09/17/19 and signed at 7:21 PM found under the section titled Physical Exam Additional Notes that Resident #1 was unresponsive to verbal cues and non-responsive to sternal rub. The assessment stated that after approximately 30 minutes, Resident #1 began to open his eyes, groan and mutter nonsensically and initially had a flaccid muscle tone. Under the section titled Assessment & Plan under the Diagnostic Statement was documented Heatstroke and sunstroke. A review of Resident #1's vital signs record documents vital signs on 09/17/19 on the 11 PM to 7 AM shift revealed: temperature - 98.3 degrees Fahrenheit, heart rate - 74 bpm, respiration rate - 18 breathes per minute, and blood pressure of 137/67. A review of Resident #1's hospital History and Physical Report for an admitted [DATE] revealed a chief complaint of being found outside in his wheelchair unresponsive and that staff was not sure how long the resident was outside for. Resident #1 had an elevated temperature and staff used cooling measures to cool him down. Under the section History of Present Illness, Resident #1 was not in acute distress and was only oriented to person at the time of the assessment. Resident #1 was diagnosed with [REDACTED]. A review of Resident #1's Hospital Transfer Form dated 9/19/19 revealed the following information: Section C: Decision Making Capacity - Requires a surrogate. Section E: Medical Condition - Primary Diagnosis: [REDACTED]. An interview was conducted on 09/20/19 at 2:57 PM with Staff Member G, LPN regarding Resident #1. Staff Member G stated that she saw Resident #1 around 11:30 AM, sometime before noon. Resident #1 was inside at the time by clean utility room on the 200 unit and did not see Resident #1 until they were bringing him back into his room. Staff Member G stated that Resident #1 was alert and oriented to a point but will have episodes of seeing things that aren't there and delusions. Staff Member G stated that Resident #1 required an assist of 1 staff member with ADL's and can transfer himself in and out of his wheelchair. Staff Member G stated that Resident #1 would usually inform staff if he was going outside and that she was not sure if Resident #1 can open the outside doors by himself because she had never seen him do so. Staff Member G was performing medication pass on the other side of the hall when staff brought Resident #1 inside around 2:00 PM on 09/17/19. Staff Member G stated that Resident #1 was not responding well and that the ARNP, along with other staff members, had wrapped the resident in cool towels and started IV therapy. Resident #1 was sent to the hospital around the timeframe of 3:30 PM and 3:45 PM. Staff Member G stated that CNAs perform 1-hour safety checks to verify a resident's location and that nurses and CNAs should know where residents were at all times. An interview was conducted on 09/21/19 at 11:46 AM with Staff Member F, CNA, who was Resident #1's assigned CNA on 09/17/19. Staff Member F stated that she saw Resident #1 outside behind the glass door between 12:00 PM and 12:10 PM and saw Resident #1 around 2:00 PM unresponsive. Staff Member F also stated that she may have seen Resident #1 in the 100 and 200 hall dining room around 12:30 PM. Resident #1 will usually let staff know when he goes outside to sit, but not always. Staff Member F stated that she usually offered fluids to residents every 30 minutes, but Resident #1 usually drinks soda instead of water. Staff Member F stated that Resident #1 did not mention feeling any different on 09/17/19 before going outside. Staff Member F stated that she usually takes Resident #1's vital signs, but they were not due that day and that Resident #1 did not have an increased temperature prior to 09/17/19.

Based on staff interviews, family interview, hospital record review, facility record review, and policy review it was determined that the facility failed to ensure one (Resident #3) of three residents reviewed for supervision, was free from neglect. The facility failed to follow the structures and processes in place for meal preparation, delivery, and supervision. Resident #3, was a vulnerable [AGE] year-old with a [DIAGNOSES REDACTED]. As a result of the neglect, Resident #3 received the incorrect food consistency and choked on a hot dog. The failure to follow Resident #3's care plan related to supervision during dining, resulted in Resident #3 requiring emergency medical care including back blows and abdominal thrusts (the [MEDICATION NAME] maneuver), cardiopulmonary resuscitation, transport to a higher level of care, life support, and ultimately, and led to his death. The neglect of facility staff to provide the appropriate food consistency and supervision resulted in findings of immediate jeopardy beginning on [DATE]. The immediate jeopardy was determined to be removed on [DATE]. Findings included: 1. An interview was conducted with the facility Risk Manager at 10:30 a.m. on [DATE]. The Administrator was present during the interview. The Risk Manager said she lived 3 minutes from the facility, so when staff called her and reported what had happened, she came in that evening, right away, to start an investigation. The resident was already out of the building when she arrived, around 6:20 or 6:30 p.m. She said Resident #3 was found to be choking and the nursing staff came in response to a code. They did abdominal thrusts and they did get some meat out of his mouth. They called 911. It was a short period after that EMS (emergency medical services) showed up. When EMS got here, they took over care. They intubated him, and when they did, they got another piece of meat out of the airway. Resident #3 lost pulse at that point, and they put him on a compression machine and transported him to the hospital after that. I started to get statements from everybody. None of the CNAs (Certified Nursing Assistants) admitted to passing the tray. Staff F, CNA was assigned to him, but she was giving care to somebody else at the time. She came out to assist with tray pass and realized the trays were already passed. She went to check on Resident #3 and noticed he was choking and screamed for the nurse. The nurse was at the desk. He came running down the hall and tried some back blows. He went to call 911, and Staff C, RN from the other unit came to help. I think someone told me he had vomited when EMS put the ET (endotracheal) tube down. He was supposed to be supervised with his meals. Resident #3 sat down there a lot because that's where he liked to be. The staff were around because they were passing trays. The one CNA said she came by and removed the lid from his tray. Staff F, his CNA, would always go over and check on him because that was her usual practice. He didn't need any assistance. The family came in a couple days after that and told us he was on a respirator. They said they brought him hamburgers. He would eat better with fast food, finger food. It looked like he was supposed to be on mechanical meats. It appeared to be a hot dog. The surveyor asked if hot dogs were served to residents on mechanical soft diets. She replied, not that I am aware of, no. But if they were, they would be chopped. The surveyor asked if the hot dog on Resident #3's tray was mechanically altered. She said the hot dog on the tray appeared to be whole according to staff. It appeared to have a couple bites out of it they said. The surveyor inquired about the resident's condition. She said after a while I think he died . Ten days later or something like that. I looked up his obituary when I heard it. I want to say it was the 27th (of July). We don't know what happened during the hospital stay. He had a lot of comorbidities. I think we knew Resident #3 had some issues, and staff did check on him because they knew that. He couldn't have been down for long or he would have been passed out from a clinical perspective. But somewhere the process broke down. It wasn't just one piece. Something fell through the cracks. Most of our CNAs have been here for some time. They know the residents pretty well. I believe Staff E, CNA was the one who picked up the lid off the tray. She was just walking around making sure everyone was eating. She said the tray was already in front of him. She just assumed it had been checked before she got there. 2. At 11:26 a.m. on [DATE], a telephone interview was conducted with Resident #3's family member. He said, They lied to me a lot. I just left picking up his death certificate a half hour ago. I know they said he choked on a hot dog, and they were taking him to the hospital for precautions. That's what they told my brother. Come to find out it was a little more serious than that. When we got to the hospital the doctors asked me a bunch of questions I couldn't answer. So, we went and had a little meeting with the Risk Manager and the Administrator on (MONTH) 22nd. The Risk Manager and Administrator, they told me he had a pulse and heartbeat the whole time and they never had to resuscitate him. The resident's family member indicated he was told staff were able to get a portion (of the food) out. When EMS got there, the nurse had been doing resuscitation, because he wasn't breathing. EMS had to do the same thing. Bottom line, they left him by himself, and he wasn't supposed to be alone when he was eating. They told us a long time ago he couldn't be left alone with food. They said, don't leave food with him. We brought him food, but we stayed with him. The resident's family member said he and another family member came in just about every day, at least four or five days a week. He loved hamburgers from McDonalds. If dinner was late, we would give him the cheeseburger. We would stay there the whole time, because they told us that when he was eating somebody had to. The doctors at the hospital said they were unsure about how long he was without oxygen. They did an EKG (electrocardiogram)and a 24-hour EEG (electroencephalogram), and he was pretty much brain dead, is what the doctors told me. When he came out of the hospital a year ago, he was on a pureed diet for a while. He finally got back to where he could eat solid food. They never said he couldn't have anything. But we never brought him hot dogs. We brought him hamburgers and Hershey's chocolate. It's hard to say, I didn't know what he was allowed to have. With his eating habits I wouldn't have given him a hot dog. You wouldn't give a 3 or 5-year-old a hot dog and leave them alone. He was like a 5-year-old. He had signs of dementia, but he knew who his family was. It wasn't like he lost his mind or anything. He could feed himself. But he would put too much food in his mouth at a time. It was messy. We tried to give him as much independence as we could. He had trouble eating with a spoon or fork, but a hamburger, he could pick it and eat it with no problem. He didn't have a perfect life there, but he could sit up every day and watch tv. We couldn't care for him at home. If he was not left alone, he would still be alive today. 3. Hospital record review of the Emergency Department (ED) records included the following information: [DATE] at 18:23 by RN Information given by EMS: Chief complaint: pt (patient) was reported to be eating a hotdog when he started choking. [MEDICATION NAME] was unsuccessful, pt went into asystole. Information from ED (Emergency Department): Level of Consciousness: Comatose Oxygen Therapy: Ventilator ED RN at [DATE] 18:39 pm ESI/GSC (emergency severity index/Glascow Coma Scale) Is this pt dying? YES. ED RN at [DATE] 18:45 pm Cardio comment: patient is in sinus [MEDICAL CONDITION]/p code in asystole. Respiratory comment: pt is vented. Diagnostic chest portable [DATE] 1830 perihilar interstitial opacities and ground glass airspace opacities within right upper lobe represent [MEDICAL CONDITIONS]. 19:44 reexamination/reevaluation Patient has been treated for [REDACTED]. Lactic acidosis is likely secondary to [MEDICAL CONDITION]. Currently on vasopressor support. Patient has been admitted to ICU (intensive care unit). Critical Care Critical care condition (s) assessed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, renal, hepatic. Associated risk factors: [MEDICAL CONDITIONS], metabolic changes, acidosis. From (hospital) History and Physical, dated [DATE] by physician: Chief complaint: status [REDACTED]. Patient is a [AGE] year-old with prior stroke and advanced dementia who resides in a nursing home and is wheel-chair bound. He had an episode of choking on some hot dog. The [MEDICATION NAME] maneuver was administered, but the patient still appeared to be in distress. EMS was called. They were able to remove the aspirated hot dog particle and intubated the patient. The patient subsequently had lost pulse and arrested. He apparently had aspirated after vomiting around that time. Initial rhythm is unknown, but he received 2 boluses of epi ([MEDICATION NAME]) and CPR (cardiopulmonary resuscitation) with return of spontaneous circulation. He was brought to the emergency room intubated for further care. Risk factors include aspiration with asphyxiation secondary to hot dog that was aspirated. The patient was noted to have a right upper lobe infiltrate on chest x-ray and was started on [MEDICATION NAME] in the emergency room . Hospital Assessment/Plan: Pt is a [AGE] year-old with prior stroke and advanced dementia who resides in a nursing home and is wheel chair bound. He had an episode of aspiration of a hot dog and bun with subsequent hypoxic respiratory arrest and associated [MEDICAL CONDITION]. [DATE] CT (computed tomography) head Impression: Poor gray-white matter differentiation diffusely suggestive of global [MEDICAL CONDITION] injury in regard to the stated injury. Plan The patient currently does not have evidence of cortical or brainstem activity, but he is on sedation and therefore I cannot make the [DIAGNOSES REDACTED]. I asked the nurse to let me know when the family arrive so I can discuss with them the prognosis. [DATE] Social Worker note at 13:01 (1:00 p.m.) Patient was admitted to MICU (medical intensive care unit) with aspiration, [MEDICAL CONDITION] and a [MEDICAL CONDITION]. SW spoke to RN who reported that pts prognosis is very poor, and the family is realistic.It was discussed in rounds that she plans to place an order for [REDACTED].>Impression and Plan: [MEDICAL CONDITION] actively dying ([DATE]) D/C disposition: Expired. Dated on [DATE] 7:42 EDT. Physician's progress notes [DATE] (palliative care). Discharge/death: Patient with advanced dementia at SNF (skilled nursing facility) Patient was reported to be eating a hot dog when he started choking. [MEDICATION NAME] maneuver was unsuccessful, patient went into asystole. ROSC (return of spontaneous circulation) be EMS (emergency medical system) after epi and CPR. HPI (history of present illness) Chief complaint: status [REDACTED]. Patient did not improve due to [MEDICAL CONDITIONS], was transferred to palliative care for CMO (comfort measures only). Patient died [DATE]. 4. Resident #3, a [AGE] year-old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Activities Progress note, dated [DATE], found Resident #3 was alert and capable of choosing activities he would like to attend, at that time. The progress note indicated Resident #3 preferred to stay in his room watching tv and doing puzzles. Review of the Readmission Observation dated [DATE] showed Mobility/Activity: the box next to 'assist' under ADLS (activities of daily living) was checked. Review of a readmission to the facility on [DATE] revealed the resident was on a pureed diet during the hospitalization , according to the AHCA form ,[DATE], Medical Certification for Medicaid Long-Term Care Service Patient Transfer Form. Review of the ST (speech therapy)-Therapist Progress and Discharge Summary dated [DATE] reflected the following information: Analysis of Functional outcome/Clinical Impression: Actively participating in tx (treatment). Patient responds well to therapeutic cues for safe swallow strategies. The use of compensatory strategies has improved toleration of upgraded diet with regular solids. Frequent monitoring during meals is recommended to provide appropriate supervision to provide cues as needed for safe swallow. Skilled Services Provided since last report Skilled ST services to address dysphagia include: provide dietary analysis/feedback strategies to reduce risk of aspiration; provided education re: aspiration/diet recommendations. Patient/Caregiver training since last report Instruction and education provided to patient, caregivers to reduce risk of aspiration and ensure proper nutrition, hydration and safe swallow. Review of Resident #3's care plan in the medical record, dated [DATE], reflected a Problem/Need: Resident #3 is at risk for choking and/or aspiration R/T (related to) dx (diagnosis) dysphagia. Goal: Resident #3 will tolerate the less restricted diet without any S/S (signs/symptoms) of aspiration and/or choking through next review. Approaches: Provide diet per orders and monitor tolerance of diet. Review of the Nutrition Care Plan, most recently reviewed on [DATE], identified: Problem--Has a risk for nutrition or hydration deficit R/T (related to): the box was checked next to mechanically altered diet. The words were crossed out. The date '[DATE]' was hand written next to them, and the word ok, indicating the resident was getting a mechanical soft diet. Interventions included Diet as ordered by MD. Review of Resident #3's initial, admission Medical Nutritional Therapy Assessment, dated [DATE], signed by the RD (Registered Dietician), revealed the following: Diet order: Puree NAS (no added salt). The note also reflected that Resident #3 was on speech therapy caseload for a [DIAGNOSES REDACTED]. Review of a nutrition assessment dated [DATE] indicated Resident #3 was on a regular diet with large meat portions, at that time. Review of the Medical Nutritional Therapy Assessment signed by the RD, dated [DATE], reflected the following: Diet order: Mechanical soft, large meat portions. A review of the physician's orders [REDACTED]. [DATE] ST (speech therapy) eval and tx (evaluation and treatment) for diet upgrade if tolerated. [DATE] ST clarification: dysphagia tx 5x (times) week for 1 week for increased swallow function, safe swallow strategies and diet texture analysis. Additional review showed an order, Change diet from puree to regular also dated [DATE]. Upon further review of Resident #3's physician orders, dated [DATE], a written order reflected: Diet order-dc (discontinue) regular diet. mechanical soft diet. Indication/Dx (diagnosis) -difficulty swallowing. Furthermore, review of Resident #3's physician's orders [REDACTED]. Review of Resident #3's medical record showed the following nurse's note, dated [DATE]: At 1 pm resident was choking on a piece of meat at meal time. Swallow eval submitted. New order for mechanical soft foods for difficulty swallowing. Review of the Change of Diet notification, dated [DATE], provided by the Registered Dietician (RD), revealed: current diet order: regular; new diet order: mechanical, indicating the dietary services department was aware of Resident #3's diet change. Review of Resident #3's meal ticket that kitchen staff would have referred to when preparing Resident #3's meal, printed by the RD on [DATE], included the following information: (Upper left-hand corner): Resident #3's name and room number. Diet: MS (mechanical soft), Lg (large) meat portion. The lower right corner had mech soft on it. Review of the MDS (Minimum Data Set) assessment, dated [DATE], revealed the following information: Section C, Cognitive patterns C0500. BIMS (Brief interview for mental status) summary score 4, indicating severe cognitive impairment. Section G, Functional status G0110H1. Eating-1. Supervision-oversight, encouragement, or cuing. G0110H2. Eating: support provided 1. Set up help only G0400A. ROM limitation: upper extremity 0. No impairment Review of the Care Card-Resident Information Sheet (CNA instructions for care), undated, revealed: Nutrition Regular, NAS (no added salt), mechanical soft. Dining location: 'Wing dining room', 'in room' were circled. Type assistance needed: set up. Cognition/behaviors: Alert, confused. Review of nurse's notes, dated [DATE], revealed the following information: Nurse responded to Staff F, CNA calling for help from 200-day room/sunroom. This nurse observed Resident #3 in respiratory distress with s/s of choking. Resident was alert, eyes open coughing at approximately 5:35 p.m. This nurse was able to open mouth with verbal request from this nurse. Some food was removed. Resident flushed, breathing shallow. This nurse ran to desk yelled for help. Nurse Staff C, RN responded, and I called 911 after paging code. Supervisor on site after code called. She notified responsible party/family. Signed by Staff H, LPN. Staff C, RN wrote: Staff H, the nurse called out for help. I responded, ran down to 200-unit solarium where I found resident hunched over in wheel chair, a shade of blue visibly noted. I told Staff H, LPN to call 911 and performed 3 back thrusts with no results. I had the aides assist the resident to the floor. I then gave multiple abdominal thrusts, turned patient to the side with no results. I then laid the resident back on his back and performed multiple abdominal thrusts. Turned resident on side. A piece of meat with phlegm and blood came from resident's mouth. Staff D, RN the supervisor applied oxygen via a non-rebreather mask, But I could not auscultate any lung sounds or oxygen exchange. At this time EMS arrived and took over treatment. The solarium was observed to be a room located at the far end of the 200 Unit A hall, where Resident #3 resided. The nurse's station was at the opposite end of the hall, and the main dining room was further away than the nurse's station. The solarium area had comfortable seating, a television, a small table with chairs and multiple windows. Staff D, RN Supervisor wrote: I heard code blue was paged overhead. Staff C, RN was doing the abdominal thrust and a small piece of sausage came out of resident's mouth. He opened his eyes and was having labored breathing. Non-rebreather mask was put on at 15L O2. By then EMS came and took over. They prepared to intubate him and was able to retrieve another piece of sausage with a forcep (size of a quarter) then intubated him as well as CPR was initiated. Resident was transferred out at 6:35 p.m. I called and spoke with the resident's family member. An IDT (interdisciplinary team) note, dated [DATE], was reviewed and the following was discovered: Met with Resident #3's family. They admitted to bringing hamburgers and they are aware of choking hazards. Appreciative of the care but they are now faced with hard decisions. At a later time regarding the Resident's advance directives, family member stated the resident is hooked up on a machine and 24-hour EEG (electroencephalogram). At this time no brain activity. Another family member added it is what it is and thanked IDT for the meeting. Review of the [DATE] Nursing Home to Hospital Transfer form revealed the reason for the transfer was respiratory distress. Review of the SBAR (situation, background, assessment, recommendation) dated [DATE] revealed situation: the change of condition was respiratory distress choking s/s (signs and symptoms). A review of a physician's orders [REDACTED]. EMS with BLS (basic life support) as medically necessary. Indication/dx: choking episode. 5. On [DATE] at 2:13 p.m. an interview was conducted with Staff Q, OT (Occupational Therapist). Staff Q, OT said Resident #3 was last on her caseload ,[DATE] of this year. He was on case load for wheel chair positioning and needing a pummel cushion because he would slide forward. He was pretty dependent. As of [DATE] he was minimum assist for upper body dressing, and maximum assist for lower body dressing. He was very impulsive. He had decreased safety awareness. He was a high fall risk. He would try to get up on his own. So, feeding was supervision as of (MONTH) of last year. Supervision means someone is with him to make sure he is able to do hand to mouth, and to take the cup and bring it to his mouth. He could wheel himself along. He would pull himself along the railings. I don't know if he was with people when he was feeding himself, but he could pull himself along the rail. The last thing I have for him was feeding supervision. The Speech Therapists (ST) are very new and have been here about a month. One was just hired a week ago. The other was maybe a month. Staff R, SLP (Speech Language Pathologist) was the one who saw him. The last time she saw him was [DATE]. Staff Q, OT said Staff R, SLP was no longer employed at the facility. On [DATE] at 11:32 a.m. an interview was conducted with Staff T, SLP (Speech Language Pathologist). Staff T, SLP said she started in (MONTH) of this year, and didn't know the resident. The surveyor asked what 'supervision' on the Speech Therapist note meant. Staff T, SLP said, That would mean while he was consuming his meal, he would need someone to sit with him or be checking in on him. The surveyor asked what 'frequent monitoring during meals' meant. Staff T, SLP said, that means someone does need to sit with him the whole time. Someone should be checking in on him the whole time to make sure they provide him the cues he needs to safely swallow. The surveyor asked what 'cueing' meant. Staff S, SLP said, so cuing means, prompts that you give the person to ensure they are taking small bites and small sips, and going back and forth between solids and liquids. Those are the main ones we would talk to caregivers about. On [DATE] at 7:40 p.m. a telephone interview was conducted with Staff R, SLP, (former employee at the facility who wrote the ST discharge summary). Staff R, SLP said, Cuing and supervision would be to monitor his intake, to instruct him to slow down, and monitor his amount that he takes in at one time, because he was a little impulsive. Ideally, it would be nice for him to be in the dining room, but he did not want to go there. Often times, CNAs were feeding other residents down there, so he was being supervised. Eating in his room by himself was not ideal. On [DATE] at 5:02 p.m. an interview was conducted with Staff F, CNA. Staff F, CNA said she worked the 3 to 11 p.m. shift and Resident #3 was part of her regular assignment. Staff F, CNA said, I didn't pass trays that day. I was busy with a patient in the room doing patient care. She didn't hear anything because the door was closed. Staff F, CNA said she usually passes trays. She was asked what kind of diet Resident #3 was receiving. She said Resident #3 was on a mechanical diet. The surveyor asked what that meant. Staff F, CNA said It means ground meat. Chopped food. It's not regular. The surveyor asked if Resident #3 could feed himself. Staff F, CNA said, He fed himself, but you had to be there with him. If he was not eating right, you had to help him. Staff F, CNA said when she passes the trays, his tray was after everybody else's. That day, she doesn't know what happened, because she wasn't passing trays. I was the one who found him choking. Staff F, CNA said when she came out of another resident's room, she went to Resident #3 to help him, and she saw him choke. Then she called for help. I tried to help him, but he was in the chair. I couldn't stand him up, so I called for help. The nurse came right away. She did not remember the exact time. She said she thought it was 6 something. Staff F, CNA said she didn't notice anything else. She said, I just saw him choke and called for help. Staff F, CNA said she didn't know what was on his tray. I was just shocked, and I called 'help, help'. Everybody came. There was 3 or 4 or 5 nurses working on him. Staff F, CNA said she didn't help with any of it because there were so many nurses. She continued, explaining the CNAs were just there if the nurses asked for something. The nurses were doing CPR on him, trying to help him. He spit something out. Staff A, CNA said she doesn't know what came out. It was food. She thinks it was a hot dog. It was a little piece, not a big piece. The surveyor asked if a resident was on a mechanically altered diet, could they have a hot dog. Staff F, CNA replied, No. Staff F, CNA said she doesn't know who gave Resident #3 the tray. An interview was conducted with Staff A, CNA, on [DATE], at 3:13 p.m. She said Resident #3 was part of her regular assignment. She regularly cared for him. She said she worked double shifts twice a week (7a.m. to 3 p.m., and 3 p.m. to 11 p.m.). She was asked if she worked on [DATE], and she said she did; 7 to 3. When Staff A, CNA returned to work Saturday morning, the next day, she said she checked Resident#3's room. He wasn't in there. She asked coworkers where he was. They told her he was in the hospital. They said he choked last night. Staff A, CNA said she asked staff how he choked. Her coworkers said they didn't know how. That's what they heard. A nurse had a 24-hour report that he was in the hospital for choking. Staff A, CNA said she saw Resident#3's family member. She asked him if Resident #3 was ok. He just shook his head. He said he wasn't upset with staff. They took care of his daddy. Then he said there are some questions he needed to ask. Since it was Saturday, administration wasn't at the facility. The family came in another day and told the nurse the family pulled the plug. It may have been a week or two after his first visit. Staff A, CNA said Resident #3 was on a regular diet with mechanical meat and regular liquids. Some days he needed assistance, some days he didn't. If he was tired, he needed assistance. That was usually in the morning. In the afternoon and evening he could handle the spoon. Staff A was asked where to find Resident #3's diet orders and care instructions. She said they were in his chart; a nurse's note and dietary. That's where the nurse will find the information and tell us. Any changes are put on the 24-hour report, and then it is reported to the next shift. She heard he choked on a hotdog. She said she didn't ask if it was the wrong diet, because she was upset. Resident #3 was her buddy. Staff A, CNA was asked about the meal delivery process. She replied, first we check the tray. If it's not correct we let the nurse know, and she calls dietary. Then, they will bring out the correct tray. On [DATE] at 3:53 p.m. an interview was conducted with Staff B, CNA. She said she usually worked the 3 to 11 shift. Staff B, CNA said she was working on (MONTH) 19. She also said she passed trays for dinner that evening. She was asked about the process and Staff B said, You pass the trays to all the residents until there are no more trays on the cart. You check the ticket. You lift the lid and make sure the diet matches. Then you check the name on the door to make sure it matches the ticket and the person in the room. Staff B, CNA said she knew the resident because he used to be in her assignment. She said she was on the other hallway (B) so no, she didn't pass his dinner tray. She said she passed two trays on her hall, when she heard the nurse call code blue. It was around 5:30 p.m. She said trays come on the other hallway a little earlier. When Staff B, CNA heard the code, she ran to the solarium on the other hallway (A hallway). When Staff B, CNA saw his color, she said she ran up the hall to get the crash cart. Then she ran back down A hall with the crash cart and the board. Staff B, CNA said when she arrived with the crash cart Resident #3 was already on the floor and staff were working on him. Staff B was asked who was working on him. She said Staff C, RN and Staff D, Supervisor. Resident #3 was blue. There was chunks on the floor that they had got out. It was a hot dog or a sausage. Staff B, CNA was asked if it was a whole hot dog. She said, yes, it was. The hot dog was probably about an inch long, like if you cut the hot dog or took one bite. It was just the meat. She didn't see any bread. She said she did not notice his tray. On [DATE] at 4:15 p.m. an interview was conducted with Staff E, CNA. Staff E, CNA said she worked on both A and B of the 200 hallways. She floats. She said she worked 7 to 3 on (MONTH) 19th, and she stayed until 7:00 p.m. that day. She said she didn't pass any trays for the dinner meal. She was giving a resident a bed bath at the time. Staff E, CNA said when she came out after giving the bed bath, the dinner trays were already delivered to the other hallway. Staff E, CNA said she took the soiled linens from the bed bath into the soiled utility room. When she came out of the soiled utility room, the trays had already been given out. Staff E, CNA added that after she had given the bed bath, she changed the resident's roommate and put her to bed. That was around 5:00 p.m. Staff E, CNA said when she finished and dropped off the linen, another CNA told her to go help on the other side. They had already finished passing trays on her side (A hall). Staff E, CNA said when she went to help on the other side (B hall), she saw the dining cart standing there. She pushed the cart to the A hall. Then she went to the back of the hallway to pick up a chair. She saw Resident #3 sitting in his wheel chair. The table was in front of him about two feet away. Staff E, CNA said she saw Resident #3 trying to move to get to the table to his dinner tray. The tray was covered. She didn't want him to fall so she pushed him closer to the table and opened the tray for him. She had removed the lid from the plate for him. Then she left. Staff E, CNA said the tray had baked beans, sauerkraut, and a hot dog. It was a whole hot dog. It was on a bun. Staff E, CNA said she knew the resident. He could feed himself. Sometimes, when she had him if she had time, she helped him, because he messes up the whole floor. Then you have to clean it up. But he could feed himself. Staff E, CNA said she was not very sure about his diet. Sometimes his children brought him a hamburger. He could eat a cheeseburger. When she fed him, sometimes, he had rice or vegetables. In the morning when she gave him his breakfast, he had bread, scrambled egg, and sausage. Staff E, CNA said she just cut it up for him. She said she didn't know if he needed his hot dog cut up. She left him and went in a room to feed another resident. She said when code blue was called, she was in the resident's room with the door closed so she didn't hear it. Before that, she heard somebody calling help. One of the other staff members were calling help, help. Staff E, CNA said she saw Resident #3 trying to swallow something. The CNA was yelling for help. The nurse came down the hall and took over from there. He took over, and staff were doing CPR (cardiopulmonary [MEDICAL CONDITION] resuscitation). Staff E, CNA said Resident #3 was still conscious when she saw him trying to swallow. Staff E, CNA was asked about Resident #3's ability to communicate and understand. She said he didn't talk cl

Based on hospital record review, facility interviews, family interview, medical record review, and policy review, the facility failed to ensure food was prepared and served in the form necessary to prevent aspiration, for one (Resident #3) of sixty-nine residents with physician's orders [REDACTED].#3's dinner tray. Direct care staff delivered the whole, unaltered hot dog to Resident #3. Resident #3, a [AGE] year-old with a [DIAGNOSES REDACTED]. As a result of the facility's actions, Resident #3 choked on the hot dog, requiring the need for emergency medical interventions, including the [MEDICATION NAME] maneuver (abdominal thrusts and back blows), EMS (emergency medical services) activation, cardiopulmonary resuscitation; paramedics inserting an artificial airway into his trachea and placing Resident #3 on an automatic chest compressor, transporting him to a higher level of care, life support, and ultimately his death. The facility failed to follow the structures and processes in place for meal preparation and delivery, resulting in findings of immediate jeopardy beginning [DATE]. The immediate jeopardy was determined to be removed on [DATE]. Findings included: 1. Hospital record review of the Emergency Department (ED) records included the following information: [DATE] at 18:23 by RN Information given by EMS: Chief complaint: pt (patient) was reported to be eating a hotdog when he started choking. [MEDICATION NAME] was unsuccessful, pt went into asystole. Information from ED (Emergency Department): Level of Consciousness: Comatose Oxygen Therapy: Ventilator ED RN at [DATE] 18:39 pm ESI/GSC (emergency severity index/Glascow Coma Scale) Is this pt dying? YES. ED RN at [DATE] 18:45 pm Cardio comment: patient is in sinus [MEDICAL CONDITION]/p code in asystole. Respiratory comment: pt is vented. Diagnostic chest portable [DATE] 1830 perihilar interstitial opacities and ground glass airspace opacities within right upper lobe represent [MEDICAL CONDITIONS]. 19:44 reexamination/reevaluation Patient has been treated for [REDACTED]. Lactic acidosis is likely secondary to [MEDICAL CONDITION]. Currently on vasopressor support. Patient has been admitted to ICU (intensive care unit). Critical Care Critical care condition (s) assessed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, renal, hepatic. Associated risk factors: [MEDICAL CONDITIONS], metabolic changes, acidosis. From (hospital) History and Physical, dated [DATE] by physician: Chief complaint: status [REDACTED]. Patient is a [AGE] year-old with prior stroke and advanced dementia who resides in a nursing home and is wheel-chair bound. He had an episode of choking on some hot dog. The [MEDICATION NAME] maneuver was administered, but the patient still appeared to be in distress. EMS was called. They were able to remove the aspirated hot dog particle and intubated the patient. The patient subsequently had lost pulse and arrested. He apparently had aspirated after vomiting around that time. Initial rhythm is unknown, but he received 2 boluses of epi ([MEDICATION NAME])n and CPR (cardiopulmonary resuscitation) with return of spontaneous circulation. He was brought to the emergency room intubated for further care. Risk factors include aspiration with asphyxiation secondary to hot dog that was aspirated. The patient was noted to have a right upper lobe infiltrate on chest x-ray and was started on [MEDICATION NAME] in the emergency room . Hospital Assessment/Plan: Pt is a [AGE] year-old with prior stroke and advanced dementia who resides in a nursing home and is wheel chair bound. He had an episode of aspiration of a hot dog and bun with subsequent hypoxic respiratory arrest and associated [MEDICAL CONDITION]. [DATE] CT (computed tomography) head Impression: Poor gray-white matter differentiation diffusely suggestive of global [MEDICAL CONDITION] injury in regard to the stated injury. Assessment: [AGE] year-old man status [REDACTED]. Head CT shows evidence of global [MEDICAL CONDITION] injury/ischemic [MEDICAL CONDITION]. Plan The patient currently does not have evidence of cortical or brainstem activity, but he is on sedation and therefore I cannot make the [DIAGNOSES REDACTED]. I asked the nurse to let me know when the family arrive so I can discuss with them the prognosis. [DATE] Social Worker note at 13:01 (1:00 p.m.) Patient was admitted to MICU (medical intensive care unit) with aspiration, [MEDICAL CONDITION] and a [MEDICAL CONDITION]. SW spoke to RN who reported that pts prognosis is very poor, and the family is realistic.It was discussed in rounds that she plans to place an order for [REDACTED].>Impression and Plan: [MEDICAL CONDITION] actively dying ([DATE]) D/C disposition: Expired. Dated on [DATE] 7:42 EDT. Physician's progress notes [DATE] (palliative care). Discharge/death: Patient with advanced dementia at SNF (skilled nursing facility) Patient was reported to be eating a hot dog when he started choking. [MEDICATION NAME] maneuver was unsuccessful, patient went into asystole. ROSC (return of spontaneous circulation) be EMS (emergency medical system) after epi and CPR. HPI (history of present illness) Chief complaint: status [REDACTED]. Patient did not improve due to [MEDICAL CONDITIONS], was transferred to palliative care for CMO (comfort measures only). Patient died [DATE]. 2. An interview was conducted with the facility Risk Manager at 10:30 a.m. on [DATE]. The Administrator was present during the interview. The Risk Manager said she lived 3 minutes from the facility, so when staff called her and reported what had happened, she came in that evening, right away, to start an investigation. The resident was already out of the building when she arrived, around 6:20 or 6:30 p.m. She said Resident #3 was found to be choking and the nursing staff came in response to a code. They did abdominal thrusts and they did get some meat out of his mouth. They called 911. It was a short period after that that EMS (emergency medical services) showed up. When EMS got here, they took over care. They intubated him, and when they did, they got another piece of meat out of the airway. Resident #3 lost pulse at that point, and they put him on a compression machine and transported him to the hospital after that. I started to get statements from everybody. None of the CNAs admitted to passing the tray. Staff F, CNA was assigned to him, but she was giving care to somebody else at the time. She came out to assist with tray pass and realized the trays were already passed. She went to check on Resident #3 and noticed he was choking and screamed for the nurse. The nurse was at the desk. He came running down the hall and tried some back blows. He went to call 911, and Staff C, RN from the other unit came to help. I think someone told me he had vomited when EMS put the ET (endotracheal) tube down. He was supposed to be supervised with his meals. Resident #3 sat down there a lot because that's where he liked to be. The staff were around because they were passing trays. The one CNA said she came by and removed the lid from his tray. Staff F, his CNA, would always go over and check on him because that was her usual practice. He didn't need any assistance. The family came in a couple days after that and told us he was on a respirator. They said they brought him hamburgers. He would eat better with fast food, finger food. It looked like he was supposed to be on mechanical meats. It appeared to be a hot dog. The surveyor asked if hot dogs were served to residents on mechanical soft diets. She replied, not that I am aware of, no. But if they were, they would be chopped. The surveyor asked if the hot dog on Resident #3's tray was mechanically altered. She said the hot dog on the tray appeared to be whole according to staff. It appeared to have a couple bites out of it they said. The surveyor inquired about the resident's condition. She said after a while I think he died . Ten days later or something like that. I looked up his obituary when I heard it. I want to say it was the 27th (of July). We don't know what happened during the hospital stay. He had a lot of comorbidities. I think we knew Resident #3 had some issues, and staff did check on him because they knew that. He couldn't have been down for long or he would have been passed out from a clinical perspective. But somewhere the process broke down. It wasn't just one piece. Something fell through the cracks. Most of our CNAs have been here for some time. They know the residents pretty well. I believe Staff E, CNA was the one who picked up the lid off the tray. She was just walking around making sure everyone was eating. She said the tray was already in front of him. She just assumed it had been checked before she got there. 3. At 11:26 a.m. on [DATE], a telephone interview was conducted with Resident #3's family member. He said, They lied to me a lot. I just left picking up his death certificate a half hour ago. I know they said he choked on a hot dog, and they were taking him to the hospital for precautions. That's what they told my brother. Come to find out it was a little more serious than that. When we got to the hospital the doctors asked me a bunch of questions I couldn't answer. So, we went and had a little meeting with the Risk Manager and the Administrator on (MONTH) 22nd. The Risk Manager and Administrator, they told me he had a pulse and heartbeat the whole time and they never had to resuscitate him. The resident's family member indicated he was told staff were able to get a portion (of the food) out. When EMS got there, the nurse had been doing resuscitation, because he wasn't breathing. EMS had to do the same thing. Bottom line, they left him by himself and he wasn't supposed to be alone when he was eating. They told us a long time ago he couldn't be left alone with food. They said, don't leave food with him. We brought him food, but we stayed with him. The resident's family member said he and another family member came in just about every day, at least 4 or 5 days a week. He loved hamburgers from McDonalds. If dinner was late, we would give him the cheeseburger. We would stay there the whole time, because they told us that when he was eating somebody had to. The doctors at the hospital said they were unsure about how long he was without oxygen. They did an EKG (electrocardiogram)and a 24-hour EEG (electroencephalogram), and he was pretty much brain dead, is what the doctors told me. When he came out of the hospital a year ago, he was on a pureed diet for a while. He finally got back to where he could eat solid food. They never said he couldn't have anything. But we never brought him hot dogs. We brought him hamburgers and Hershey's chocolate. It's hard to say, I didn't know what he was allowed to have. With his eating habits I wouldn't have given him a hot dog. You wouldn't give a 3 or 5-year-old a hot dog and leave them alone. He was like a 5-year-old. He had signs of dementia, but he knew who his family was. It wasn't like he lost his mind or anything. He could feed himself. But he would put too much food in his mouth at a time. It was messy. We tried to give him as much independence as we could. He had trouble eating with a spoon or fork, but a hamburger, he could pick it and eat it with no problem. He didn't have a perfect life there, but he could sit up every day and watch tv. We couldn't care for him at home. If he was not left alone, he would still be alive today. 4. Resident #3, a [AGE] year-old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Activities Progress note, dated [DATE], found Resident #3 was alert and capable of choosing activities he would like to attend, at that time. The progress note indicated Resident #3 preferred to stay in his room watching tv and doing puzzles. Review of the MDS (minimum data set) assessment, dated [DATE], revealed the following information: Section C, Cognitive patterns C0500. BIMS (Brief interview for mental status) summary score 4, indicating severe cognitive impairment. Section G, Functional status G0110H1. Eating-1. Supervision-oversight, encouragement, or cuing. G0110H2. Eating: support provided 1. Set up help only G0400A. ROM limitation: upper extremity 0. No impairment Review of Resident #3's care plan in the medical record, dated [DATE], reflected a Problem/Need: Resident #3 is at risk for choking and/or aspiration R/T dx (diagnosis) dysphagia. Goal: Resident #3 will tolerate the less restricted diet without any S/S of aspiration and/or choking through next review. Approaches: Provide diet per orders and monitor tolerance of diet. Review of the Nutrition Care Plan, most recently reviewed on [DATE], identified: Problem--Has a risk for nutrition or hydration deficit R/T: the box was checked next to mechanically altered diet. The diet was crossed out by the facility. There was a date '[DATE]' hand written in by the diet instructions, with ok, indicating they were the correct instructions. Interventions included Diet as ordered by MD. Review of Resident #3's initial, admission Medical Nutritional Therapy Assessment, dated [DATE], revealed the following: Diet order: Puree NAS (no added salt). The note signed by the RD (registered dietician) included with the assessment, reflected that Resident #3 was on speech therapy caseload for a [DIAGNOSES REDACTED]. Review of the nutrition assessment dated [DATE] indicated Resident #3 was on a regular diet with large meat portions, at that time. The Medical Nutritional Therapy Assessment, dated [DATE], was reviewed and reflected the following: Diet order: Mechanical soft, large meat portions. A review of the physician's orders [REDACTED]. [DATE] ST (speech therapy) eval and tx (evaluation and treatment) for diet upgrade if tolerated. [DATE] ST clarification: dysphagia tx 5x (times) week for 1 week for increased swallow function, safe swallow strategies and diet texture analysis. Additional review showed an order, Change diet from puree to regular also dated [DATE]. Upon further review of Resident #3's physician orders, dated [DATE], a written order reflected: Diet order-dc (discontinue) regular diet. mechanical soft diet. Indication/Dx (diagnosis) -difficulty swallowing. Furthermore, review of Resident #3's physician's orders [REDACTED]. Review of the Change of Diet notification, dated [DATE], provided by the Registered Dietician (RD), revealed: current diet order: regular; new diet order: mechanical, indicating the dietary services department was aware of Resident #3's diet change. Review of Resident #3's meal ticket that kitchen staff would have referred to when preparing Resident #3's meal, printed by the RD on [DATE], included the following information: (Upper left-hand corner): Resident #3's name and room number. Diet: MS (mechanical soft), Lg (large) meat portion. The lower right corner had mech soft on it. Review of the Care Card-Resident Information Sheet (CNA instructions for care), undated, revealed: Nutrition Regular, NAS (no added salt), mechanical soft. Dining location: 'Wing dining room', 'in room' were circled. Type assistance needed: set up. Cognition/behaviors: Alert, confused. Further review of Resident #3's medical record showed the following nurse's note, dated [DATE]: At 1 pm resident was choking on a piece of meat at meal time. Swallow eval submitted. New order for mechanical soft foods for difficulty swallowing. Further review of nurse's notes, dated [DATE], revealed the following information: Nurse responded to Staff F, CNA calling for help from 200-day room/sunroom. This nurse observed Resident #3 in respiratory distress with s/s of choking. Resident was alert, eyes open coughing at approximately 5:35 p.m. This nurse was able to open mouth with verbal request from this nurse. Some food was removed. Resident flushed, breathing shallow. This nurse ran to desk yelled for help. Nurse Staff C, RN responded, and I called 911 after paging code. Supervisor on site after code called. She notified responsible party/family. Signed by Staff H, LPN. Staff C, RN wrote: Staff H, the nurse called out for help. I responded, ran down to 200-unit solarium where I found resident hunched over in wheel chair, a shade of blue visibly noted. I told Staff H, LPN to call 911 and performed 3 back thrusts with no results. I had the aides assist the resident to the floor. I then gave multiple abdominal thrusts, turned patient to the side with no results. I then laid the resident back on his back and performed multiple abdominal thrusts. Turned resident on side. A piece of meat with phlegm and blood came from resident's mouth. Staff D, RN the supervisor applied oxygen via a non-rebreather mask, But I could not auscultate any lung sounds or oxygen exchange. At this time EMS arrived and took over treatment. The solarium was observed to be a room located at the far end of the 200 Unit A hall, where Resident #3 resided. The nurse's station was at the opposite end of the hall, and the main dining room was further away than the nurse's station. The solarium area had comfortable seating, a television, a small table with chairs and multiple windows. Staff D, RN Supervisor wrote: I heard code blue was paged overhead. Staff C, RN was doing the abdominal thrust and a small piece of sausage came out of resident's mouth. He opened his eyes and was having labored breathing. Non-rebreather mask was put on at 15L O2 (15 liters of oxygen). By then EMS came and took over. They prepared to intubate him and was able to retrieve another piece of sausage with a forcep (size of a quarter) then intubated him as well as CPR was initiated. Resident was transferred out at 6:35 p.m. I called and spoke with the resident's family member. An IDT (interdisciplinary team) note, dated [DATE], was reviewed and the following was discovered: met with Resident #3's family. They admitted to bringing hamburgers and they are aware of choking hazards. Appreciative of the care but they are now faced with hard decisions. At a later time regarding the Resident's advance directives, family member stated the resident is hooked up on a machine and 24-hour EEG (electroencephalogram). At this time no brain activity. Another family member added it is what it is and thanked IDT for the meeting. Review of the [DATE] Nursing Home to Hospital Transfer form revealed the reason for the transfer was respiratory distress. Review of the SBAR (situation, background, assessment, recommendation) dated [DATE] revealed situation: the change of condition was respiratory distress choking s/s (signs and symptoms). A review of a physician's orders [REDACTED]. EMS with BLS (basic life support) as medically necessary. Indication/dx: choking episode. Review of the ST (speech therapy)-Therapist Progress and Discharge Summary dated [DATE] reflected the following information: Analysis of Functional outcome/Clinical Impression: Actively participating in tx (treatment). Patient responds well to therapeutic cues for safe swallow strategies. The use of compensatory strategies has improved toleration of upgraded diet with regular solids. Frequent monitoring during meals is recommended to provide appropriate supervision to provide cues as needed for safe swallow. Skilled Services Provided since last report Skilled ST services to address dysphagia include: provide dietary analysis/feedback strategies to reduce risk of aspiration; provided education re: aspiration/diet recommendations. Patient/Caregiver training since last report Instruction and education provided to patient, caregivers to reduce risk of aspiration and ensure proper nutrition, hydration and safe swallow. 5. On [DATE] at 11:32 a.m. an interview was conducted with Staff T, SLP (Speech Language Pathologist). Staff T, SLP said she started in (MONTH) of this year, and didn't know the resident. The surveyor asked what 'supervision' on the Speech Therapist note meant. Staff T, SLP said, That would mean while he was consuming his meal, he would need someone to sit with him or be checking in on him. The surveyor asked what 'frequent monitoring during meals' meant. Staff T, SLP said, that means someone does need to sit with him the whole time. Someone should be checking in on him the whole time to make sure they provide him the cues he needs to safely swallow. The surveyor asked what 'cueing' meant. Staff S, SLP said, so cuing means, prompts that you give the person to ensure they are taking small bites and small sips, and going back and forth between solids and liquids. Those are the main ones we would talk to caregivers about. On [DATE] at 7:40 p.m. a telephone interview was conducted with Staff R, SLP, (former employee at the facility who wrote the ST discharge summary). Staff R, SLP said, Cuing and supervision would be to monitor his intake, to instruct him to slow down, and monitor his amount that he takes in at one time, because he was a little impulsive. Ideally, it would be nice for him to be in the dining room, but he did not want to go there. Often times, CNAs were feeding other residents down there, so he was being supervised. Eating in his room by himself was not ideal. On [DATE] at 5:02 p.m. an interview was conducted with Staff F, CNA. Staff F, CNA said she worked the 3 to 11 p.m. shift and Resident #3 was part of her regular assignment. Staff F, CNA said, I didn't pass trays that day. I was busy with a patient in the room doing patient care. She didn't hear anything because the door was closed. Staff F, CNA said she usually passes trays. She was asked what kind of diet Resident #3 was receiving. She said Resident #3 was on a mechanical diet. The surveyor asked what that meant. Staff F, CNA said It means ground meat. Chopped food. It's not regular. The surveyor asked if Resident #3 could feed himself. Staff F, CNA said, He fed himself, but you had to be there with him. If he was not eating right, you had to help him. Staff F, CNA said when she passes the trays, his tray was after everybody else's. That day, she doesn't know what happened, because she wasn't passing trays. I was the one who found him choking. Staff F, CNA said when she came out of another resident's room, she went to Resident #3 to help him, and she saw him choke. Then she called for help. I tried to help him, but he was in the chair. I couldn't stand him up, so I called for help. The nurse came right away. She did not remember the exact time. She said she thought it was 6 something. Staff F, CNA said she didn't notice anything else. She said, I just saw him choke and called for help. Staff F, CNA said she didn't know what was on his tray. I was just shocked, and I called 'help, help'. Everybody came. There was 3 or 4 or 5 nurses working on him. Staff F, CNA said she didn't help with any of it because there were so many nurses. She continued, explaining the CNAs were just there if the nurses asked for something. The nurses were doing CPR on him, trying to help him. He spit something out. Staff A, CNA said she doesn't know what came out. It was food. She thinks it was a hot dog. It was a little piece, not a big piece. The surveyor asked if a resident was on a mechanically altered diet, could they have a hot dog. Staff F, CNA replied, No. Staff F, CNA said she doesn't know who gave him the tray. An interview was conducted with Staff A, CNA, on [DATE], at 3:13 p.m. She said Resident #3 was part of her regular assignment. She regularly cared for him. She said she worked double shifts twice a week (7a.m. to 3 p.m., and 3 p.m. to 11 p.m.). She was asked if she worked on [DATE], and she said she did; 7 to 3. When Staff A, CNA returned to work Saturday morning, the next day, she said she checked Resident#3's room. He wasn't in there. She asked coworkers where he was. They told her he was in the hospital. They said he choked last night. Staff A, CNA said she asked staff how he choked. Her coworkers said they didn't know how. That's what they heard. A nurse had a 24-hour report that he was in the hospital for choking. Staff A, CNA said she saw Resident#3's family member. She asked him if Resident #3 was ok. He just shook his head. He said he wasn't upset with staff. They took care of his daddy. Then he said there are some questions he needed to ask. Since it was Saturday, administration wasn't at the facility. The family came in another day and told the nurse the family pulled the plug. It may have been a week or two after his first visit. Staff A, CNA said Resident #3 was on a regular diet with mechanical meat and regular liquids. Some days he needed assistance, some days he didn't. If he was tired, he needed assistance. That was usually in the morning. In the afternoon and evening he could handle the spoon. Staff A was asked where to find Resident #3's diet orders and care instructions. She said they were in his chart; a nurse's note and dietary. That's where the nurse will find the information and tell us. Any changes are put on the 24-hour report, and then it is reported to the next shift. She heard he choked on a hotdog. She said she didn't ask if it was the wrong diet, because she was upset. Resident #3 was her buddy. Staff A, CNA was asked about the meal delivery process. She replied, first we check the tray. If it's not correct we let the nurse know, and she calls dietary. Then, they will bring out the correct tray. On [DATE] at 3:53 p.m. an interview was conducted with Staff B, CNA. She said she usually worked the 3 to 11 shift. Staff B, CNA said she was working on (MONTH) 19. She also said she passed trays for dinner that evening. She was asked about the process and Staff B said, you pass the trays to all the residents until there are no more trays on the cart. You check the ticket. You lift the lid and make sure the diet matches. Then you check the name on the door to make sure it matches the ticket and the person in the room. Staff B, CNA said she knew the resident because he used to be in her assignment. She said she was on the other hallway (B) so no, she didn't pass his dinner tray. She said she passed two trays on her hall, when she heard the nurse call code blue. It was around 5:30 p.m. She said trays come on the other hallway a little earlier. When Staff B, CNA heard the code, she ran to the solarium on the other hallway (A hallway). When Staff B, CNA saw his color, she said she ran up the hall to get the crash cart. Then she ran back down A hall with the crash cart and the board. Staff B, CNA said when she arrived with the crash cart Resident #3 was already on the floor and staff were working on him. Staff B was asked who was working on him. She said Staff C, RN and Staff D, Supervisor. Resident #3 was blue. There was chunks on the floor that they had got out. It was a hot dog or a sausage. Staff B, CNA was asked if it was a whole hot dog. She said, yes, it was. The hot dog was probably about an inch long, like if you cut the hot dog or took one bite. It was just the meat. She didn't see any bread. She said she did not notice his tray. On [DATE] at 4:15 p.m. an interview was conducted with Staff E, CNA. Staff E, CNA said she worked on both A and B of the 200 hallways. She floats. She said she worked 7 to 3 on (MONTH) 19th, and she stayed until 7:00 p.m. that day. She said she didn't pass any trays for the dinner meal. She was giving a resident a bed bath at the time. Staff E, CNA said when she came out after giving the bed bath, the dinner trays were already delivered to the other hallway. Staff E, CNA said she took the soiled linens from the bed bath into the soiled utility room. When she came out of the soiled utility room, the trays had already been given out. Staff E, CNA added that after she had given the bed bath, she changed the resident's roommate and put her to bed. That was around 5:00 p.m. staff E, CNA said when she finished and dropped off the linen, another CNA told her to go help on the other side. They had already finished passing trays on her side (A hall). Staff E, CNA said when she went to help on the other side (B hall), she saw the dining cart standing there. She pushed the cart to the A hall. Then she went to the back of the hallway to pick up a chair. She saw Resident #3 sitting in his wheel chair. The table was in front of him about 2 feet away. Staff E, CNA said she saw Resident #3 trying to move to get to the table to his dinner tray. The tray was covered. She didn't want him to fall so she pushed him closer to the table and opened the tray for him. She had removed the lid from the plate for him. Then she left. Staff E, CNA said the tray had baked beans, sauerkraut, and a hot dog. It was a whole hot dog. It was on a bun. Staff E, CNA said she knew the resident. He could feed himself. Sometimes, when she had him if she had time, she helped him, because he messes up the whole floor. Then you have to clean it up. But he could feed himself. Staff E, CNA said she was not very sure about his diet. Sometimes his children brought him a hamburger. He could eat a cheeseburger. When she fed him, sometimes, he had rice or vegetables. In the morning when she gave him his breakfast, he had bread, scrambled egg, and sausage. Staff E, CNA said she just cut it up for him. She said she didn't know if he needed his hot dog cut up. She left him and went in a room to feed another resident. She said when code blue was called, she was in the resident's room with the door closed so she didn't hear it. Before that, she heard somebody calling help. One of the other staff members were calling help, help. Staff E, CNA said she saw Resident #3 trying to swallow something. The CNA was yelling for help. The nurse came down the hall and took over from there. He took over, and staff were doing CPR (cardiopulmonary [MEDICAL CONDITION] resuscitation). Staff E, CNA said Resident #3 was still conscious when she saw him trying to swallow. Staff E, CNA was asked about Resident #3's ability to communicate and understand. She said he didn't talk clearly but he could tell you if he needed to be changed. When the other staff came and started CPR, she went to finish feeding the resident she was helping. Staff E, CNA was asked where Resident #3 was when CPR was started. She replied he was on the floor. Staff E, CNA said she helped get him on the floor. Staff E, CNA was asked what Resident #3 looked like when she assisted him to the floor. She said his lips were a little bit blue. Staff E, CNA didn't recall if his eyes were still open. At 4:41 p.m., on [DATE], an interview was conducted with Staff D, RN Supervisor. She said she was the 3 to 11 supervisor. She worked Monday through Friday. She said she was on 300 wing when she heard code blue paged. She said she documented everything, but she couldn't remember the time. Staff D, RN said she ran over to 200 hall as soon as she heard the page to the solarium. Staff D, RN said she saw another nurse already doing abdominal thrusts on him. Resident #3 was already on the floor. He was a big guy so we couldn't put our arms around him, so we had to do abdominal thrusts on the floor. The nurse was Staff C, RN. She was from the 100 wing. The resident's nurse was calling 911. There were CNAs there. Sta