Every finding on record at Woodside Health and Rehabilitation Center

Based on observation, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to respond timely to residents' request for assistance for 2 (Residents #750 and #799) of 3 residents observed.The findings included:On 11/12/25 at 5:52 a.m., during a tour of the [NAME] Hall the call light of room [ROOM NUMBER] was observed on. Licensed Practical Nurse (LPN) Staff A and LPN Staff B were observed in the hallway passing medications. A Certified Nursing Assistant (CNA) walked past the room and entered another resident's room. The call light remained on and unanswered until the Social Service Director was observed answering the call light at 6:09 a.m.On 11/12/25 at 6:20 a.m., Resident #750 was heard yelling out loudly for help for approximately 15 minutes. The call light was not on. No staff were observed in the hallway.Review of the clinical record revealed Resident #750 had an admission date of 8/11/24. Diagnoses included history of falling, and benign prostatic hyperplasia with lower urinary tract symptoms.Review of the Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 8/2/25 revealed the resident was dependent on staff for toilet hygiene and transfers. The MDS specified the resident was frequently incontinent of urine and always incontinent of bowels. Resident #750 scored 15 on the Brief Interview for Mental Status, indicative of intact cognition.On 11/12/25 at 9:40 a.m., in an interview Resident #750 said at night no one comes to help, that is why he yells for help. The resident said he pushes the call light button, and it can take hours for staff to answer. He said he could not get out of bed on his own and did not walk. Resident #750 said he keeps his urinal on the table here and it fills up quickly. If he tries to use it the urine will spill, so he calls the staff to empty it. The resident said when he has a bowel movement, they don't come. Last night no one came and he was yelling because he needed the urinal to be emptied so the urine did not spill on him when he tried to use it. He said, No one ever comes in when I push the red button.On 11/12/25 at 9:12 a.m., Resident #799's emergency call light was observed on and beeping. Staff were observed walk past the resident's room.On 11/12/25 at 9:15 a.m., with the resident's permission, Resident #799 was observed in front of the toilet sitting in his wheelchair. The resident had no clothes on and was holding a soiled incontinent brief. Resident #799 said he needed help.On 11/12/25 at 9:25 a.m., the resident's call light was off. Resident #799 was observed sitting in the wheelchair. He was still not wearing any clothes and said no one had come to help him. He said he had been waiting for a long time and was yelling loudly for help.On 11/12/25 at 9:30 a.m., Registered Nurse (RN) Staff C was observed right next door from Resident #799's room with the medication cart. In an interview RN Staff C said, I turned the call light off because he is in the bathroom and needs help. I told the CNA. She was busy but knows and will come and take care of him because I told her.On 11/12/25 at 9:37 a.m., Resident #799 remained in the bathroom, yelling out for help.On 11/13/25 at 8:02 a.m., in an interview Resident #799 said, The call light is never answered and it happens just about every day. They just come in turn the light off and don't say anything. Yesterday was terrible, it was pretty bad. I had to go so badly to have a bowel movement and I went in my pants because no one came. They did not come for about an hour. The service here is terrible and it is worse on the night shift. I always wait over an hour. It makes me feel sad. I don't like to be like that, like I was yesterday, with stool on me.Review of the clinical record revealed Resident #799 was an [AGE] year-old male admitted on [DATE] with diagnoses including chronic kidney disease stage 3, type 2 diabetes mellitus, and hypertensive heart disease.Review of the admission MDS dated [DATE], documented that the resident was frequently incontinent of bowel and bladder and was not on a training program. The MDS specified the resident required substantial to maximum assistance with transfers to the toilet. The MDS documented a BIMS score of 08 indicating the resident's cognition was moderately impaired.The care plan initiated 10/23/25 identified Resident #799 had an activities of daily living (ADL) selfcare deficit related to fatigue, and chronic medical conditions.The goal for the resident specified he would not have a decline in ADL functioning through next review date.The interventions instructed staff to encourage and educate resident with increased independence as tolerated and assist with all ADL tasks as indicated, including transfers, toileting tasks, and personal/oral hygiene. Toileting: the resident will need extensive help of one or two staff. The resident will probably need you to wipe, redress, and wash their hands. Be prepared with 2 people to assist for resident safety during the transfer.On 11/13/25 at 8:30 a.m., in an interview RN Staff C said the call lights are to be answered as soon as you realize it is on. As soon as possible, take care of the resident.On 11/13/25 at 8:50 a.m., in an interview the Administrator said the call light response is a no pass zone, meaning everyone was to answer the call lights and not walk past them. He said, We have provided education, and the Leadership Staff are to be out on the floor making sure call lights are answered. It continues to be a problem, and we are working on it.A review of the training provided by the facility on 11/3/25 on call lights and customer service, documented it was very important that you must answer all call lights in a timely manner. Please knock on the door and wait for answer, enter room with a smile, a smile goes a long way, even if it's not your section, they are all our residents.A total of 23 employees received the training.

Based on review of the Resident Council Meeting Minutes and resident and staff interviews, the facility failed to act promptly upon the grievances expressed by the residents and the Resident Council group.The findings included:A review of the Resident Council meeting minutes for August 2025 through November 2025 revealed ongoing concerns related to call light response time.On 8/19/25 the Resident Council New Business documented Staff need to make sure call lights are always in reach. CNA's (Certified Nursing Assistants) need education on call light answering. Residents would like quicker call light response on weekends.There was no documentation to address the concerns with the call light response time.On 9/16/25 the Council meeting minutes documented expressed under new business Regarding weekend CNA's some residents cannot get as quick of a response to call lights; more mobile residents will help locate them. Is this appropriate?There was no documented response from the facility to address the concerns.On 10/7/25 the Resident Council meeting minutes documented under New Business, CNA's are turning off call lights and not coming back or following through with what they said they would do. Wait times for CNA's are up to 30 to 45 minutes, especially if they are doing showers. Weekends are worse.There was no documented response from the facility to address the concerns.On 10/21/25 the Resident Council minutes documented Review of previous meeting, outstanding issues. Nursing still needs to answer, waiting for responses.There was no documented response from the facility to address the concerns.On 11/4/25 the Resident Council meeting minutes documented under New Business, Education for all staff on reminding them to make sure call light is within reach. Some residents complained that the customer service overnight is not what they would like, and call lights are not answered promptly.There was no documented response from the facility to address the concerns.On 11/12/25 at 8:50 a.m., in an interview Resident #850 (Resident Council President) said the staff do not even come in the room to answer the call light. They just reach their hand in the door and turn it off. The Resident demonstrated how the call system light was located inside of the door on the left side of the wall. She said, They just reach in and shut it off. If I really need something, I just go to the nurse's station and look for help because I can walk.On 11/13/25 at 11:00 a.m., in an interview, the Social Service Director said she knew call lights were a concern and they were working on it. The Social Service Director did not have documentation of how the facility addressed the repeated concerns related to call light response voiced by the Resident Council from August through November 2025. She said, If I hear of a concern from the Council, then I write a grievance for it and deliver it to the appropriate person to resolve it.

Based on review of the facility nursing assignments and staff interviews, the facility failed to have a designated Licensed Nurse to serve as a charge nurse on the 11:00 p.m., to 7:00 a.m. shift as required.The findings included:On 11/12/25 at 5:35 a.m., Licensed Practical (LPN) Nurse Staff A answered the door upon arrival to the facility. A request was made to speak with the designated charge nurse. In an interview, LPN Staff A said there was no charge nurse assigned to the 11:00 p.m., to 7:00 a.m., shift. LPN Staff A said there has never been an assigned charge nurse on the night shift. She said if an emergency occurred the staff were to contact the Director of Nursing (DON).On 11/12/25 at 5:50 a.m., in an interview LPN Staff B confirmed there was no designated charge nurse on duty for the shift. She said there never is a designated licensed nurse to serve as a charge nurse for the night shift. Staff B said, If we have a problem we call the DON.On 11/12/25 at 6:45 a.m., in an interview LPN Staff E said there was no charge nurse assigned on the night shift. She said they call the DON for emergencies. Review of the 11-7 shift nurse assignments from 11/5/25 through 11/12/25 revealed there was no designated charge nurse assigned for the night shift.On 11/13/25 at 1:23 p.m., in an interview the DON said the facility did not have an assigned charge nurse as required on the 11:00 p.m. - 7 a.m., shift, the staff just call the DON.

Based on resident and staff interviews, policy review and record review, the facility failed to ensure that 2 (Residents #800 and #900) of 4 residents sampled were free of significant medication errors.The findings included:1. Review of facility Policy 5.0 Reordering, Changing, and Discontinued Medication Orders (Effective Date blank) revealed Policy: The facility will communicate any medication reorders, changes, or discontinuations to the pharmacy in accordance with pharmacy guidelines and state/federal regulations; thus ensuring standardized process of communication. Procedure: A. All orders must clearly be communicated to the pharmacy by the facility. This includes resident's full name (first and last). B. Reorder/Refill orders. 3. Verbal Orders: Refill orders can be submitted verbally. The following information must be communicated to the pharmacy: Facility, unit, physician, customer's full name, room number, prescription number to be refilled, medication name, medication strength, name of person placing the call to Specialty Rx, Inc. 4. Electronic Orders: Refill orders can be submitted electronically from a prescriber through their escribing software or through the facilities electronic medication administration record (EMAR) system. A clinical record review revealed that Resident #900 was admitted to the facility on [DATE] with diagnoses of primary generalized osteoarthritis (also known as arthritis, a breakdown of the joints which causes pain), presence of right artificial hip joint (also known as hip replacement), chronic obstructive pulmonary disease (a chronic lung disease), and generalized anxiety disorder. Review of the Quarterly Minimum Data Set (standardized assessment tool that measures health status in nursing home residents) dated 9/30/25 revealed the resident was cognitively intact. On 11/12/25 at 7:45 a.m., in an interview Resident #900 said the facility did not have her eye ointment for several days. A clinical record review revealed that resident #900 had an order on 9/15/25 for Pataday Opthalmic Solution 0.7%, instill one drop in both eyes in the morning (eye allergy itch relief medication). The start date was 9/16/25. Review of the medication administration record (MAR) revealed the Pataday Opthalmic Solution was not given because it was on order from pharmacy on 9/16, 9/17, 9/19, 9/20, 9/23, 9/25, 9/26, 9/28-30, 10/3, 10/4, 10/7 and 10/9. The medication was discontinued on 10/10/25. A clinical record review revealed that resident #900 had an order on 9/26/25 for Pataday Opthalmic Solution 0.7%, instill one drop in both eyes in the morning (eye allergy itch relief medication). The start date was 9/27/25. Review of the MAR revealed that the Pataday Opthalmic Solution was not given because it was on order from pharmacy 9/27-9/30,10/3, 10/4, 10/7, 10/9-12, 10/23, 10/24, 10/28, 10/31, 11/2, 11/4, and 11/7-11/9. The medication was discontinued on 11/10/25. On 11/13/25 at 9:50am, Staff H, RN said medications were often missing when she first started working at the facility 3 months ago. 2.On 11/12/25 at 9:00 a.m., in an interview Resident #800 said I am on intravenous (IV) antibiotics, and they never have the medication. I receive it every other day and I don't get it because it has not come in from Pharmacy and then my cycle has to start over. I don't know why they don't order it a day in advance because they know I get it every other day, but they don't have it here. Review of the physician orders documented an order dated 10/18/25 for Cubicin Solution (an antibiotic) Reconstituted 500 milligrams (mg). Use 500 mg intravenously every 48 hours for osteomyelitis until 11/11/2025. A review of the medication administration record (MAR) for October 2025 revealed on 10/19/25 the documentation indicated the medication was not administered and was reordered on 10/24/25. Further review of the MAR revealed the Cubicin Solution was not administered on 10/26/25, 10/28/25 and 10/30/25. Review of the nursing progress note dated 10/26/25 documented the Cubicin was not administered, awaiting pharmacy delivery. There was no documentation the physician was notified of the missed dose. The nursing progress note dated 10/28/25 documented patient refused, stated that the last dose was administered yesterday at 6 a.m. Nurse Practitioner notified and okay to reschedule start on 10/29/25 at 6:00 a.m. Resident aware and agreed with the changes. The nursing progress note dated 10/30/25 documented Cuibcin Solution Reconstituted 500 mg was not administer as the medication was completed on 10/29/25. A review of the November MAR documented a start dated of 10/31/25 for Cuibcin Solution Reconstituted 500 mg IV every 48 hours with a discontinue date of 11/3/25. On 11/2/25 the MAR indicated the medication was not administered. A review of the nursing progress note dated 11/2/25 documented the medication was not administered, awaiting Cubicin from pharmacy. The medication was reordered on 11/5/25 to continue until 11/11/25.

Based on observation, review of facility policy and procedure and staff interviews, the facility failed to ensure medications were stored in locked compartments when not in use in 1 ([NAME] Hallway) of 3 hallways observed to prevent unauthorized access to medications.The findings included:Review of the facility policy and procedure titled, Medication Storage and Labeling revised 1/2024 revealed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Procedure: Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications.On 11/12/25 at 5:40 a.m., during the initial tour of the facility, observation of the [NAME] Unit Hallway revealed two medication carts:The first cart had two prefilled syringes of Normal Saline Solution 0.9%, a bottle of powdered Cefazolin (antibiotic) 2 grams for Resident #700, and an intravenous bag of 50 milliliters normal saline that were unlocked and unattended on top of the medication cart. Photographic evidence obtained.On 11/12/25 at 5:44 a.m., Licensed Practical Nurse (LPN) Staff A was observed coming out of a resident's room. In an interview LPN Staff A verified the 2 prefilled syringes of Normal Saline Solution 0.9%, the bottle of powdered Cefazolin 2 grams and the 50 milliliters bag of normal saline were left unattended and unlocked on top of the medication cart. She said she should have locked them in the medication cart.A second medication cart located approximately 10 feet from the first cart was observed unlocked and unattended. Photographic evidence obtained.On 11/12/25 at 5:45 a.m., observation of the medication cart with LPN Staff A revealed the cart contained residents' medications. In an interview, LPN Staff A verified the medication cart was unlocked and unattended and said, Other nurses use the cart too. LPN Staff A walked away, left the cart unlocked and unattended. On 11/13/25 at 5:50 a.m., LPN Staff B verified the medication cart remained unlocked and unattended. In an interview, LPN Staff B said the medication cart should always be locked when not in use.On 11/12/25 at 1:57 p.m., during an interview, the Assistant Director of Nursing and the Administrator were informed of the observation of the medications left unsecured and unattended on the [NAME] Unit Hallway. The ADON and Administrator did not provide additional information or explanation related to the unsecured medications observed on the [NAME] Hall Unit.

Based on interview and record review, the facility failed to ensure a physician's order was documented for insertion of a size 20 French urinary catheter for 1 (Resident #3) of 3 residents reviewed for urinary catheters (tube inserted in the bladder to drain urine). The findings included: Review of the facility policy for Standards and Guidelines: Physician Orders, revised 1/2024: 5.) Verbal orders should be recorded in the resident's chart by the authorized person receiving the order and should include the prescriber's name, credentials, the date and the time of the order. Review of the Admission Minimum Data Set (MDS) assessment with a target date of 3/12/25 revealed Resident #3 was admitted on [DATE]. Diagnoses included neurogenic bladder (Bladder dysfunction). Resident #3 had an indwelling urinary catheter Review of the hospital discharge record form 3008 dated 3/5/25 revealed Resident #3 had an indwelling urinary catheter size 16 French (fr). Review of the progress notes revealed on 3/14/25 at 8:58 a.m., a Change in Condition note revealed Resident #3 had new abdominal pain and bleeding. The attending physician was notified and ordered a STAT (immediate) KUB (Kidney, ureter, and bladder X-ray), flushing, irrigation of the urinary catheter, and an ultrasound of the abdomen. Review of the nursing progress note effective 3/14/25 at 10:11 a.m., revealed Resident #3 presented this morning with a gross amount of clots in his urinary catheter drainage bag and severe spasm at his supra pubic area. The resident stated he was experiencing pain (10 out of 10). The progress note documented, A 16 fr. Foley (urinary catheter) was replaced with a size 20 fr. On 5/28/25, a review of the physician's orders failed to reveal an order to replace the 16 fr. urinary catheter with the 20 fr. urinary catheter. On 5/28/25 at 4:27 p.m., in an interview Registered Nurse (RN) Staff A said on 3/14/25 he replaced the 16 fr. catheter with the 20 fr. catheter. He said he thought he texted or called the physician to request the order for the 20 fr. urinary catheter. RN Staff A verified there was no order for the 20 fr. urinary catheter he inserted on 3/14/25. On 5/28/25 at 5:46 p.m., in an interview the Director of Nursing said there should be an order from the physician for the 20 fr. catheter. The DON verified there was no order for the 20 fr. catheter.

Based on observation, record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect each Residents' right to be free from abuse and neglect when they failed to accurately evaluate the risk for elopement and develop a individualized care plan to address wandering behaviors for Resident #53, and failed to immediately investigate an incident of staff to resident verbal abuse for Resident #5. Resident #53 was admitted to the facility on [DATE] and exhibited behaviors such as yelling out, combativeness and disrobing in the hallways. Resident #53 required continuous use of oxygen for Chronic Obstructive Pulmonary Disease (COPD). Staff interviews revealed Resident #53 was confused, constantly wandered and required close supervision. On 5/2/25, sometime between 6:00 p.m., and 6:55 p.m., Resident #53, who was cognitively impaired, with a history of dementia, unsafe wandering behaviors, and oxygen dependent, was able to exit the building unsupervised and without staff knowledge. The resident crossed a busy four lane highway, to a gas station that was approximately 0.1 miles from the facility. When the resident was located she was being tended to by Emergency Medical Services. She was brought back to the facility-by-facility staff. Staff were unable to determine the exact time of the resident ' s return but report it was sometime after 7:00 p.m. Resident #53 crossed a busy four lane road to get to the gas station located on a major eight lane highway creating a likelihood for serious injury, serious harm or death. Resident #53 could have sustained a fall traveling uneven ground or could have been hit by a car while crossing the busy four lane road. Resident #53 could have sustained life-threatening complications from the lack of necessary supplemental oxygen, such as low blood oxygen and respiratory failure. This failure resulted in the determination of Immediate Jeopardy. The findings included: Cross Reference to F689 and F835. 1. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI), revised 3/2025 revealed, Neglect . means 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 . Review of the clinical record revealed Resident #53 was admitted to the facility from a local hospital on 4/26/25. Diagnoses included but were not limited to acute respiratory failure with hypoxia (lack of sufficient oxygen in the tissues), Chronic Obstructive Pulmonary Disease (COPD), Dementia, symptoms and signs involving cognitive functions and awareness. Review of the hospital discharge summary dated 4/26/25 revealed the main problem during the hospital stay had been active delirium, agitation. The discharge summary noted, We do suspect this patient has Alzheimer dementia. She was treated with Seroquel [antipsychotic] while here, at discharge she will be on Seroquel 12.5 mg [milligrams] 3 times daily . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on . She is going today to SNF [Skilled Nursing Facility] . Review of the physician's orders dated 4/26/25 revealed to encourage and assist the resident to use oxygen at 4 liters via nasal cannula continuously for COPD. Review of the Admission Nursing Evaluation dated 4/26/25 revealed an elopement risk evaluation was completed. The nurse completing the evaluation entered No for the questions: Resident has cognitive status impairment (i.e. short term memory loss, BIMS score, diagnosis, etc.), Does the resident have the ability to ambulate independently (with or without use of assistive device/wheelchair)?, Does the resident exhibit exit-seeking behavior (e.g. walk towards exits, manipulate doors, handles etc.). The elopement evaluation determined Resident #53 was not at risk for elopement. The interventions included: Increased staff observation. Review of the progress notes revealed on 4/27/25 at 6:37 a.m., Resident #53 was sitting on the floor next to her bed. Her oxygen was off. Resident #53 was yelling at the nurse, You're trying to murder me, you're in love with my husband, you're having an affair with him. The nurse documented the resident was very confused and became more lucid with the oxygen on at 3 liters. On 4/29/25 at 1:27 a.m., a nursing progress note documented Resident #53 was standing naked in the hallway yelling, calling this nurse a witch and refusing to put O2 (oxygen) on. On 4/29/25 at 2:30 a.m., a nursing progress note documented the resident continued to yell at staff; sat on the floor from the wheelchair trying to hit and kick staff. The resident kicked and scratched the nurse. When the oxygen was put on, the resident became calmer. On 4/30/25 at 6:22 a.m., a Social Service progress note documented the resident's son did not feel she could return to independent living and was looking into memory care. The son shared his mother has had paranoid behaviors for some time now. On 5/1/25, an initial psychiatric evaluation noted the resident scored 05 on the Brief Interview for Mental Status, which indicated severely impaired cognition. The evaluation noted the resident was difficult to redirect, and verbally inappropriate making the assessment difficult. On 5/1/25, a statement signed by the attending physician noted in his opinion, Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient explanation without coercion or undue influence. On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including fighting, pulling off her oxygen, and not staying in one spot. LPN Staff A said on 5/2/25, Resident #53 got out of the building and was found at the gas station across the street. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A said they looked for the resident all around the building. Resident #53 was eventually located at the gas station across the street. Staff A said when they found Resident #53, she said she didn't want to be there, and she hated her son. Staff A said Resident #53 explained how she went out the back door and pushed the egress bar for 15 seconds to be let out. LPN Staff A said the door alarm did go off. Staff A said she notified the Director of Nursing (DON), the Administrator, and called the family. LPN Staff A verified the lack of documentation of Resident #53's wandering behavior and elopement incident in the clinical record. LPN Staff A said she had no explanation for the lack of documentation. She said, It was all just verbal. On 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 but was not directly working with Resident #53 when the resident left the building. LPN Staff B said she was on a different hallway. Someone said an Emergency Medical Services (EMS)/deputy was at the front door. She went to the front door. EMS told her they found someone at the gas station down the street and were trying to find where the person belonged. Staff B said EMS provided a last name that was different than Resident #53's last name. She said apparently Resident #53 had given EMS her [NAME] name. LPN Staff A looked in the computer and couldn't find a resident with the last name given by EMS. EMS left since they did not recognize the last name. LPN Staff B said a little after that LPN Staff A was going down the hall looking for Resident #53. When she told her the resident's last name, LPN Staff B said the resident that could not be located was probably the lady at the gas station EMS enquired about. She said she and Staff A went to the gas station. They asked EMS if the lady was still there so they could look at her and identify her. LPN Staff B said, I recognized her, I had seen her in the building. LPN Staff A said yes, that was who we were looking for. Resident #53 was a bit resistant to coming back. They called Resident #53's son from the gas station. He was able to persuade her to go back to the facility. LPN Staff B said Resident #53 was sitting on a milk crate at the gas station and didn't appear to have any harm. LPN Staff B said the Director of Nursing (DON) knew about the incident. The DON and the Administrator showed up to help. When asked about documentation of the incident, LPN Staff B said she wrote a witness statement. She did not do an incident report as she was not assigned to the resident. Staff B said she assumed LPN Staff A completed the incident report. LPN Staff B said earlier that day, before they knew Resident #53 was gone, she had heard the alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. She said they noticed Resident #53 was missing at around 6:55 p.m., since she printed the face sheet at that time. Further review of Resident #53's clinical record failed to reveal documentation of the resident's elopement, assessment for injuries upon return to the facility, physician, DON, Administrator and legal representative notification. There was no documentation, the care plan was updated and supervision implemented to prevent further incident of unsafe wandering and elopement. On 5/12/25 at 12:32 p.m., in an interview, the interim DON said Resident #53 went out the back door on 5/2/25. The interim DON said Resident #53 was alert and oriented and wanted to go to the store. She said they did a reenactment with the resident. Resident #53 was able to describe it all, including walking to the door, reading the sign that says the door will release after 15 seconds, went out, looked both ways, crossed the street and walked to the gas station on the corner. The interim DON said staff had been up front dealing with another resident who wanted to leave and go to the store. She said LPN Staff A, Resident #53's nurse, was up front assisting with the other resident. She said the alarm sounded; they discovered Resident #53 was not in building. She was found at the gas station on the corner. She said if a resident wants to go to the store, the normal process was to sign out on a leave of absence. She said Resident #53 scored 13 on a Brief Interview for Mental Status she performed upon the resident's return to the facility. (A BIMS score of 13-15 indicates intact cognition). The DON said Resident #53 had been very behavioral and declined when she took her oxygen off. The DON said Resident #53 did not have her oxygen when she was found at the gas station. She said the police were at the gas station, but she did not know if they did a report. The interim DON said Resident #53 was cognitively intact and was able to describe how she left the facility that day and again the next day. Therefore, they did not consider Resident #53 leaving the facility without staff knowledge or supervision an elopement but rather a near miss. On 5/12/25 at 3:10 p.m., in an interview, the Administrator said on 5/2/25 staff called and notified him saying they couldn't find Resident #53 and had called an elopement code. He came to the building and so did the interim DON. He said after the fact, they did a reenactment with Resident #53. He said at first Resident #53 said she didn't do it. Then she walked us through what she did. She was able to do it again the next day. He said they investigated and completed a head to toe assessment. Resident #53 had behaviors, but the interim DON completed a BIMS and the resident scored 13. He said Resident #53 was someone who did what she wanted to do. The Administrator said staff reported that EMS came to the building to enquire about someone, but EMS asked about someone with a last name different then Resident #53's last name. The Administrator said Resident #53 leaving the facility without staff knowledge and supervision was not considered an elopement. He said it was a near miss since the resident was cognitively intact and knew where she was going. The Administrator said Resident #53 had not been incapacitated. When asked about the incapacity statement the attending physician signed and dated 5/1/25, the Administrator said Had I known Resident #53 was incapacitated, I would have considered the incident an elopement without a doubt. On 5/12/25 at 3:32 p.m., in an interview, the interim DON said she did not know on 5/1/25 the attending physician had signed an incapacity statement for Resident #53. She said Definitely, the incident would have been considered an elopement and would have been reported for sure. On 5/13/25 at 1:02 p.m., the Interim DON said all residents were assessed for elopement, on admission, quarterly or with any change in condition. When asked about Resident #53's hospital discharge documentation indicating she needed constant supervision, the interim DON said that didn't mean resident was exit seeking but meant she needed a skilled nursing facility. She said if a resident is exhibiting behaviors, it would have to be exit seeking behavior for an elopement re-screen. She said it all depended on how a resident presented. On 5/13/25 at 2:08 p.m., in an interview the Attending Physician verified on 5/1/25 he signed the letter of incapacity for Resident #53. When asked if it was safe for Resident #53 to be at the gas station on a busy road alone, he said it was a tricky case, as the resident's BIMS fluctuated. He said when she first came, she was more confused, was up and down. Her mentation waxed and waned. He explained when tricky like that, the long-term plan would be further evaluation, maybe to a neuropsychologist. He said with the waxing and waning, bouts of confusion/mentation, it could be confusing, and it was quite a complicated case. 52388 2. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) Policy (last revised on 3/2025) revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 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 including abuse facilitated or enabled through the use of technology . Staff are required to report any allegation of ANEMMI to the facility risk manager, direct supervisor, and/or abuse coordinator immediately upon knowledge of the allegation . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily harm . Review of the facility's policy and procedure titled, Resident Rights last revised on 1/2024 revealed, Employees shall treat all residents with kindness, respect, and dignity. Review of the facility's Abuse Reporting education revealed verbal abuse is, Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. The education also noted, Any verbal, physical, sexual; neglect; exploitation or injury of unknown source must be reported immediately, and All licensed staff (RN (Registered Nurse), LPN (Licensed Practical Nurse), CNA (Certified Nursing Assistant) ) are REQUIRED by law to report abuse, neglect or exploitation. Record review for Resident #5 revealed diagnoses of depression, generalized anxiety disorder and an unspecified mood disorder. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 4/15/25 revealed Resident #5 scored 15 on the BIMS test, indicating intact cognition. Review of the progress notes revealed a psychology note dated 4/17/2025 which noted, Patient was visible irritable when I approached her in the hallways prior to our session. Patient shared that she had a negative interaction with an aide last night. She reports that she did not threaten the aide in any way, but she did request to speak to her night nurse to express her needs. Patient had a meeting this morning to discuss concerns with the aide's behavior and dissatisfaction with care. Behavior management techniques were used to address and modify patient's behavior. On 5/12/2025 at 12:04 p.m., in an interview, Resident #5 said a couple of weeks ago she was on the phone with her sister. She heard the CNAs arguing in the hallway. Her sister asked what was going on. She told her sister, I think the aides are fighting. Resident #5 said a CNA then came in her room, slammed her meal tray on the table and then slammed the door. She went out in the hallway to confront the CNA. Resident #5 said the CNA falsely accused her of using a racial slur. She said the CNA began cursing at her. It made her angry, so she cursed back at the CNA. The resident said, It was a yelling match in the hall, and they had to be separated. Resident #5 said LPN Staff C witnessed the incident. Resident #5 said the Administrator and Social Services met with her. She was not sure who the CNA was and had not seen her since that day. On 5/12/2025 at 1:57 p.m., in an interview, the Administrator said he and Social Service met with the resident that day. Resident #5 reported the incident and said she had used a racial slur, the N word. The Administrator said Resident #5 curses an awful lot. On 5/12/2025 at 3:33 p.m., in an interview, Resident #5 said Social Services came to talk to her today and asked how long ago the altercation happened. She told the Social Worker, You should know, you were there. Resident #5 said the Administrator and the Social Worker were both there the day of the altercation. They said they would get the CNA's name, but they never did. Resident #5 said there was no investigation done that she knew about. On 5/13/2025 at 11:35 a.m., in a joint interview, the Administrator and Director of Nursing (DON) said there was no prior investigation of the incident. On 5/14/2025 at 3:18 p.m., in an interview, LPN Staff C said he remembered the altercation. Resident #5 was upset that day that a CNA slammed the tray. He could not remember the name of the CNA and said the Administrator and Social Services talked to Resident #5. On 5/14/2025 at 3:21 p.m., in an interview, the Social Worker said the CNA was no longer employed at the facility. She said the incident happened over a month ago. The Social Worker said Resident #5 reported she was on the phone with her sister and went out in the hall after the CNA slammed the tray. The Social Worker said Resident #5 said the CNA called her a white bitch under her breath. On 5/14/2025 at 3:36 p.m., in a follow up interview, LPN Staff C confirmed witnessing the verbal altercation between Resident #5 and the CNA. When asked about reporting the incident and if anyone came to see Resident #5 that day, LPN Staff C replied, I don't know. On 5/14/2025 at 3:33 p.m., in a follow up interview, the Administrator said he was not aware of the verbal altercation. On 5/15/2025 at 11:44 a.m., in an interview, the Administrator said any staff who witnesses an altercation between a resident and staff member immediately separates them. The person who witnesses the altercation notifies the DON who in turn will notify him. The staff member involved in the altercation is immediately suspended pending investigation. The Administrator said a staff member yelling at a resident would be considered abuse and would be reported. The Administrator said, If they witnessed it, they have a licensed obligation to report it.

Based on observation, record review, resident representative and staff interviews, the facility failed to ensure processes were in place to ensure the safety of cognitively impaired residents at risk for elopement. The facility failed to accurately assess the risk for elopement and adequately supervise to prevent elopement of 1 (Resident #53) of 1 cognitively impaired, mobile and confused resident with known wandering behavior. Resident #53 was a vulnerable adult with severe cognitive impairment, confusion and multiple behaviors such as yelling out, disrobing in the hallway and constant wandering. On 5/2/25 at an unknown time after 6:00 p.m., staff failed to adequately supervise Resident #53. Resident #53 exited the facility without staff knowledge and necessary supervision. Staff were not aware of the resident's exit until 5/2/25 at approximately 7:00 p.m. On 5/2/25 at an unknown time after 7:00 p.m., Resident #53 was found at a gas station located approximately 0.1 mile from the facility. Resident #53 crossed a busy four lane road to get to the gas station located on a busy eight lane highway. The facility failure to ensure adequate supervision to prevent unsafe wandering and elopement of cognitively impaired, and confused residents created a likelihood of avoidable accidents for Resident #53 and other cognitively impaired and confused residents at risk for elopement which could result in serious harm, serious injury, serious impairment or death of the residents. This failure resulted in the determination of Immediate Jeopardy. The findings included: Cross Reference to F600 and F835. Review of the clinical record revealed Resident #53 was admitted to the facility from an acute care hospital on 4/26/25. Review of the hospital physician discharge summary dated 4/26/25 revealed Resident #53's main problem during the hospital admission has been delirium (serious changes in mental abilities resulting in confused thinking and lack of awareness of surroundings), active delirium and agitation. The practitioner documented, We do suspect this patient has Alzheimer [sic] dementia. She was treated with Seroquel (antipsychotic) while here . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on . The patient transfer form (Agency for Health Care Administration Form 3008) dated 4/26/25 noted Resident #53 was alert, disoriented but could follow simple instructions. Resident #53 ambulated with assistance. The Admission Nursing Evaluation note dated 4/26/25 at 9:35 p.m., noted Resident #53 has no weight bearing restrictions. The resident utilizes the following mobility devices: Walker, Wheelchair. Review of the elopement risk evaluation dated 4/26/25 at 9:35 p.m. revealed the nurse completing the form entered No for the following questions: Resident has cognitive status impairment (i.e. short-term memory loss, BIMS (Brief Interview for Mental Status) score, diagnosis, etc.), Does the resident have the ability to ambulate independently (with or without use of assistive device/wheelchair)?, Does the resident exhibit exit-seeking behavior (e.g. walk towards exits, manipulate doors, handles etc.). The facility determined Resident #53 was not an elopement risk but checked Increased staff observation in the Interventions/Approaches section of the elopement evaluation. Review of the behavior monitoring on the Medication Administration Record (MAR) for April 2025 revealed Resident #53's documented behaviors did not include wandering. Review of the progress notes revealed on 4/27/25 at 6:37 a.m., Resident #53 was sitting on the floor next to her bed. Her oxygen was off. Resident #53 was yelling at the nurse, You're trying to murder me, you're in love with my husband, you're having an affair with him. The nurse documented the resident was very confused and became more lucid with the oxygen on at 3 liters. On 4/29/25 at 1:27 a.m., a nursing progress note documented Resident #53 was standing naked in the hallway yelling, calling this nurse a witch and refusing to put O2 (oxygen) on. On 4/29/25 at 2:30 a.m., a nursing progress note documented the resident continued to yell at staff; sat on the floor from the wheelchair trying to hit and kick staff. The resident kicked and scratched the nurse. When the oxygen was put on, the resident became calmer. On 4/30/25 at 6:22 a.m., a Social Service progress note documented speaking to the resident's son. The son said he did not feel his mother could return to independent living and was looking into memory care facilities. The son shared that Resident #53 has had paranoid behaviors for some time now. She would call the police and say her son was beating her and taking her money. On 5/1/25, an initial psychiatric evaluation progress note documented Resident #53 had a psychiatric history of dementia with other behavioral disturbances, delirium and insomnia. Resident #53 was observed sitting in her wheelchair. She was alert with severe cognitive impairment. Resident #53 scored a 5 on the BIMS which indicated severely impaired cognition. The resident was difficult to redirect. The practitioner documented Resident #53 was unstable. The symptoms were occurring daily and causing severe distress. The practitioner discontinued the Seroquel and ordered Depakote sprinkles 250 mg three times daily (Used to manage irritable mood and impulsivity). On 5/1/25, the attending physician signed a statement noting in his opinion Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient explanation without coercion or undue influence. On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including not staying in one spot. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. LPN Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A said they looked for the resident all around the building. She said Resident #53 got out of the building and was eventually located at the gas station across the street. She said Resident #53 explained how she went out the back door and pushed the egress bar for 15 seconds to be let out. LPN Staff A said the door alarm did go off. She notified the Director of Nursing (DON), the Administrator, and called the family. LPN Staff A verified Resident #53's wandering behavior and not staying in one spot were not documented in the clinical record. She verified the lack of documented individualized interventions, including necessary and adequate supervision to ensure Resident #53's safety and prevent elopement. LPN Staff A said she had no explanation for the lack of documentation. She said, It was all just verbal. On 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 but was not directly working with Resident #53 when she left the building. LPN Staff B said EMS (Emergency Medical Services) came to the facility and said they had found someone at the gas station and were trying to find out where that person belonged. They did not recognize the name provided by EMS. LPN Staff A searched in the computer and could not locate any resident with the last name EMS provided. LPN Staff B said a little bit after that LPN Staff A was going down the hall looking for Resident #53 but could not locate her. LPN Staff B said earlier that day, before they knew Resident #53 was gone, she had heard the door alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. The Administrator and Director of Nursing (DON) were notified and came to the facility. Staff B and Staff A went to the gas station recognized Resident #53 and brought her back to the facility. On 5/12/25 at 12:32 p.m., in an interview, the interim DON verified on 5/2/25 Resident #53 exited the facility through the back door and was found at the gas station across the street. She said upon the resident's return, she evaluated the resident's cognition. Resident #53 was alert and oriented and scored 13 on the Brief Interview for Mental Status which indicated intact cognition. She said she was not aware on 5/1/25 the psychiatrist noted Resident #53's cognition was severely impaired and scored a 5 on the BIMS. The DON said they conducted a soft investigation. They did not consider the incident an elopement but a near miss. The DON said Resident #53 knew what she was doing and was able to describe it that Friday and again the next day on Saturday. On 5/12/25 at 3:10 p.m., in an interview, the Administrator verified on 5/2/25 the staff called him, said they could not find Resident #53 and had called a code orange (Code used by the facility to alert staff of a missing resident). The Administrator said they did a reenactment with Resident #53. She took him to the exit door and was able to demonstrate how she opened the door. She was able to do it again the next day. The Administrator said they did not consider it an elopement. The Administrator said they did elopement drills the next day and retrained staff on elopement. They did a root cause analysis of the incident and determined it was not an elopement. The Administrator said the incident was discussed in the Quality Assurance and Performance Improvement meeting on 5/9/25 but no performance improvement plan was put in place since they did not consider it an elopement. On 5/13/25 at 1:02 p.m., the hospital discharge summary noting Resident #53 required constant supervision and a potential diagnosis of Alzheimer's disease was reviewed with the DON. She said constant supervision did not mean the resident was exit seeking. It meant she needed to be in a skilled nursing facility. On 5/15/25 at 10:14 a.m., in an interview, the Interim DON said if staff hear an alarm go off, they are supposed to go to the door, check the surrounding area outside to see if a resident exited, do a head count and call a code orange. On 5/16/25 at 3:34 p.m., in a telephone interview, Resident #53's son said the facility notified him of the elopement. He said it should never have happened, absolutely not. He said the facility called and told him they no longer could provide services for her. It's been an ongoing battle for two to three years. She did not have a place to go due to her behaviors. The son said his mother has always had wandering behaviors. She had the behavior when she was living with him. Review of the facility's Standards and Guidelines: Elopement and Wandering revised on 1/1/24 provided by the DON revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for incapacitated residents . Definition: A situation in which an incapacitated resident leaves the facility grounds or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement . Each incapacitated resident will be assessed for wandering upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified.

Based on observation, record review and staff interviews, the facility administration failed to utilize its resources effectively to ensure processes were in place and implemented to prevent neglect and maintain the safety of cognitively impaired and confused residents to prevent unsafe wandering and elopement. Resident #53 was a vulnerable adult with severe cognitive impairment, confusion and multiple behaviors such as yelling out, disrobing in the hallway and constant wandering. On 5/2/25 at an unknown time after 6:00 p.m., staff failed to adequately supervise Resident #53. Resident #53 exited the facility without staff knowledge and necessary supervision. Staff were not aware of the resident's exit until 5/2/25 at approximately 7:00 p.m. On 5/2/25 at an unknown time after 7:00 p.m., Resident #53 was found at a gas station located approximately 0.1 mile from the facility. Resident #53 crossed a busy four lane road to get to the gas station located on a busy eight lane highway. The facility administration failed to recognize the neglect of Resident #53 and called the resident's elopement a near miss. The facility administration failed to complete a thorough investigation and failed to implement immediate and appropriate action to prevent the neglect of other cognitively impaired, confused and mobile residents to prevent further incidents of unsafe wandering and elopement. The facility administration failure to use its resources effectively to maintain residents' safety created a likelihood of serious harm, serious injury or death of Resident #53 and other cognitively impaired residents who exit the facility without staff knowledge. The residents could cross the nearby busy four lane road or nearby eight lane highway, get hit by a car, or sustain a fall resulting in serious injury from walking the uneven ground around the facility. This failure resulted in the determination of Immediate Jeopardy. The findings included: Cross reference F600 and F689. Review of the Administrator's job description revealed, The Administrator administers, directs, and coordinated all functions of the facility to assure that the highest degree of quality of care is consistently provided to the patients . Responsibilities: . Understand the facility's care regulations and support the patient care program by regularly meeting with the Patient Services Director to discuss and address concerns of the department . Ensure adherence to the Patient's [NAME] of Rights . Operate the facility in accordance with (name) Care Center policies and federal, state and local regulations . Assist in the Quality Assurance and Performance Improvement (QAPI) process. The form noted, Employee signature below constitutes employees understanding of the requirements, essential functions and duties of the position. The Administrator signed the job description on 12/9/24. Review of the Director of Nursing job description revealed, Overview: Executes the goals and objectives of the nursing department in regard to patient/resident rights, patient/resident care and reflects the mission statement of the facility . Provides leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. Responsibilities: . Ensure compliance with government and accrediting agency standards and regulations pertaining to Nursing. Directs systems and programs within the department designed to meet regulatory standards. Assess, coordinate, plan and implement the systems required to deliver a high standard of care to patients/residents . Participate in QA/PI Programs by providing for the collection and analysis of data for the continuous quality improvement program . Ensure residents' safety in accordance with resident safety program . The form noted, Employee signature below constitutes employees understanding of the requirements, essential functions and duties of the position. The interim DON signed the form on 5/5/25. Review of the clinical record revealed Resident #53 was admitted to the facility from an acute care hospital on 4/26/25. Review of the hospital physician discharge summary dated 4/26/25 revealed Resident #53's main problem during the hospital admission had been delirium [serious changes in mental abilities resulting in confused thinking and lack of awareness of surroundings], active delirium and agitation. The practitioner documented, We do suspect this patient has Alzheimer [sic] dementia. She was treated with Seroquel [antipsychotic] while here . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on . On 5/1/25 the attending physician signed a statement noting in his opinion Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient explanation without coercion or undue influence. On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including not staying in one spot. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. LPN Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A said they looked for the resident all around the building. She said Resident #53 got out of the building and was eventually located at the gas station across the street. The clinical record lacked documentation of Resident #53's wandering behavior and the elopement incident. LPN Staff A said, It was all just verbal. On 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 when Resident #53 exited the facility. She said earlier that day, before they knew Resident #53 was gone, she heard the door alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS (Emergency Medical Services) showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. A little bit after that LPN Staff A was going down the hall looking for Resident #53 but could not locate her. The Administrator and Director of Nursing (DON) were notified and came to the facility. Staff B and Staff A went to the gas station recognized Resident #53 and brought her back to the facility. On 5/12/25 at 12:32 p.m., in an interview, the interim DON verified on 5/2/25 Resident #53 exited the facility through the back door and was found at the gas station across the street. She said upon the resident's return, she evaluated the resident's cognition. Resident #53 was alert and oriented and scored 13 on the Brief Interview for Mental Status, indicative of intact cognition. The DON said they conducted a soft investigation. They did not consider the incident an elopement but a near miss. The interim DON said Resident #53 knew what she was doing and was able to describe that Friday and again the next day on Saturday how she left the facility. The facility's soft investigation determined the incident did not meet criteria for elopement as the resident was able to demonstrate how she left the facility and was taught as a child to look both ways to cross the street. The DON said as part of elopement prevention, the facility's front door, the 200 hall door and the 400 hall exit door are equipped with a wander alarm system. The wander alert bracelets would set off the alarm if a resident attempted to go through the doors. She said the other doors have an egress bar that alarms if opened and can only be shut off with a key. On 5/12/25 at 3:10 p.m., in an interview, the Administrator verified on 5/2/25 the staff called him, said they could not find Resident #53 and had called a code orange. They did a root cause analysis of the incident and determined it was not an elopement. The Administrator said it was a near miss since the resident was cognitively intact, knew where she was going, and had not been incapacitated. The near miss incident was discussed in the Quality Assurance and Performance Improvement meeting on 5/9/25 but no performance improvement plan was put in place since they did not consider the incident an elopement. The Administrator said Resident #53 simply failed to follow the facility's leave of absence policy. She wanted to go to the store per her normal routine. When asked about the incapacity statement signed by the attending physician on 5/1/25, the Administrator said, Had I known Resident #53 was incapacitated, I would have considered the incident an elopement without a doubt. The Administrator said they conducted elopement drills the next day and retrained staff on the elopement policy. He said at least 75% of the staff were reeducated on the elopement policy. Review of the facility's Standards and Guidelines: Elopement and Wandering revised on 1/1/24 provided by the DON on 5/12/25 revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for incapacitated residents . Definition: A situation in which an incapacitated resident leaves the facility grounds or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement . Each incapacitated resident will be assessed for wandering upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified. If an incapacitated resident is missing who is considered at risk, initiate the elopement/missing resident emergency procedure . Announce Code Orange [facility's code to alert staff of a missing resident]. Note the time that the resident was discovered missing, or the door alarmed. On 5/12/25 at 3:32 p.m., in an interview, the interim DON said she did not know on 5/1/25 the attending physician had signed an incapacity statement for Resident #53. She said definitely the incident would have been considered an elopement and would have been reported for sure. On 5/13/25 at 1:42 p.m., in an interview, the interim DON reviewed part of the soft file investigation. It included a near miss/missing resident checklist, elopement drills, elopement in-services, and door alarm testing. On 5/14/25 at 10:40 a.m., the DON provided a Standards and Guidelines: Elopement and Wandering policy revised 1/1/2025. She said she did not realize the policy had been updated. The policy read, A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement and the situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle. The procedure only considered incapacitated residents and read in part, If identified at risk for wandering, elopement, or other safety issues, the incapacitated resident's care plan will include strategies and interventions to maintain the incapacitated resident's safety. Each incapacitated resident will be assessed for wandering and elopement upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified. On 5/15/25 at 10:14 a.m., in an interview, the interim DON said if staff hear an alarm go off, they are supposed to go to the door, check the surrounding area outside to see if a resident exited, do a head count and call a code orange. The DON said the function of the wander alert bracelets is checked daily. On 5/16/25 at 12:22 p.m., during a review of the facility's Quality Assurance and Performance Improvement program, the Administrator reviewed the facility's Performance Improvement Plans (PIPs). He verified there was no current PIP related to elopement prevention. Review of the facility's neglect investigation initiated on 5/12/25 related to Resident #53's elopement revealed Resident #53's incapacity statement completed and signed by the attending physician on 5/1/25 was not uploaded to the resident's chart until 5/8/25 after the resident's discharge. The investigation also noted all the exit doors were checked for proper functioning. On 5/16/25 at 2:20 p.m., the DON demonstrated the function of the wander alert bracelets for the six current residents identified at risk of elopement. Resident #24 was identified at risk for elopement and wore a wander alert bracelet. When checked, the light verifying the wander alert bracelet was functioning properly did not come on, indicating the wander alert bracelet would not set off the alarm if the resident went through a door equipped with a wander alert system. The DON verified the wander alert bracelet was not functioning and said she would place the resident on 1 to 1 supervision until the wander alert bracelet could be replaced. Resident #59 was identified at risk for elopement and wore a wander alert bracelet. When the DON checked the resident's wander alert bracelet, a red light came on. The DON said the red light meant the wander alert battery was low. She said she would have it replaced immediately. On 5/16/25 at 2:45 p.m., a tour of the facility was completed with the Maintenance Director and the Maintenance Assistant to check the alarm system and function of the egress doors. The Maintenance Director explained when an egress door is pushed open, a very loud alarm will sound. The Maintenance Director pressed on the Heritage Hall East egress door bar. The door made a beeping sound. The Maintenance Director opened the door fully. The door alarm did not come on. The Maintenance Director then checked the Heritage Hall [NAME] egress door. The door made a beeping sound when pressed. The Maintenance Director pushed the door open. The alarm did not come on. On 5/16/2025 at 2:55 p.m., the Maintenance Director said the two egress doors should have sounded loudly when opened. He instructed the Maintenance Assistant to fix both doors. On 5/16/25 at 3:00 p.m., observation of the dining room with the Maintenance Director revealed an exit door that led to a screened porch. The Maintenance Director said the door was a mag locked door and could not be pushed open. The Maintenance Director demonstrated by pushing the door. The door easily opened and did not alarm. The Maintenance Director said, The door should not be able to be opened. My guy was out here power washing earlier. As of the exit date of 5/16/25 the facility's Administration failed to have documentation of a thorough investigation of Resident #53's elopement incident and effective use of resources to ensure processes were implemented to maintain the safety of cognitively impaired and confused residents to prevent unsafe wandering and elopement.

Based on observation, residents and staff interviews, the facility failed to provide maintenance services to maintain a home-like environment and failed to store residents' care items in a safe and sanitary manner for 5 (Residents #57, #36, #56, #81, and #32) of 20 sampled residents, and in 1 (room [ROOM NUMBER]) of 10 rooms observed for environment. The findings included: 1. On 5/12/25 at 9:21 a.m., observation of the bathroom shared by Resident #57 and Resident #36 revealed: Two uncovered gray wash basins, two uncovered gray bed pans, and an uncovered urine measuring hat stored in a pile on the floor under the sink, next to the trash container. Photographic evidence obtained. In an interview during the observation, Resident #57 said staff use a basin to wash her in bed. In an interview during the observation, Resident #36 said she saw the wash basins, bed pans and the measuring hat on the floor under the sink but did not know who put them there. On 5/15/25 at approximately 9:50 a.m., the two uncovered gray wash basins, two uncovered gray bed pans, and the uncovered urine measuring hat remained stored in a pile on the floor under the sink, next to the trash container. On 5/15/25 at 9:52 a.m., Certified Nursing Assistant (CNA) Staff F verified the observation of the two uncovered gray wash basins, two uncovered bed pans, and the uncovered urine measuring hat stored in a pile on the floor under the sink, next to the trash container. CNA Staff F said they were trash should have been discarded. 2. On 5/12/25 at 9:33 a.m., Resident #56 was observed lying in bed, watching television. The picture was blurry on the television set. In an interview, Resident #56 said she does not leave her room and watches television every day. She said the picture has been blurry since she's been in this room. She has told several staff she wanted someone to fix the television but no one has done it. Photographic evidence obtained. On 5/15/25 at 9:24 a.m., observation of Resident #56's room revealed the picture on the television set remained blurry. In an interview Resident #56 said no one came to repair the television. 3. On 5/12/25 at 12:30 p.m., observation of the dining room revealed the picture on the television was blurry. 4. On 5/15/25 at 12:45 p.m., observation of the shared bathroom of room [ROOM NUMBER] revealed an uncovered bedpan stored on the floor under the sink. On 5/15/25 at 1:14 p.m., Occupational Therapist Staff H verified a bedpan was stored uncovered on the floor of room [ROOM NUMBER]'s shared bathroom. 5. On 5/15/25 at 12:48 p.m., observation of Resident #81's shared bathroom revealed an unlabeled, uncovered urinal hanging on the right arm rest of the raised toilet seat and an uncovered urinary catheter leg bag hanging from the left arm rest of the raised toilet seat. Photographic evidence obtained. On 5/16/25 at 12:25 p.m., in an interview Resident #81 said his electric wheelchair does not fit into the bathroom and he did not hang the urinal or the leg bag over the raised toilet. On 5/15/25 at 1:11 p.m., CNA Staff F verified an unlabeled, uncovered urinal and an uncovered urinary catheter leg bag were stored hanging from the arm rests of the raised toilet seat. She said she observed the uncovered and unlabeled urinal and urinary catheter leg bag this morning when she took care of Resident #81 and knew they were supposed to be labeled and covered but left them hanging from the arm rests of the raised toilet seat. 6. On 5/15/25 at 12:53 p.m., observation of Resident #32's bathroom revealed the raised toilet seat was rusty with peeling paint. Photographic evidence obtained. On 5/15/25 at 1:05 p.m., CNA Staff F verified the raised toilet seat in Resident #32's bathroom was rusty and the paint was peeling. She said she was not assigned to Resident #32 but the rusty toilet seat was not appropriate for resident use and should be thrown away. On 5/15/25 at 1:19 p.m., in an interview the Maintenance Director said the raised toilet seat in Resident #32's room was rusty and not appropriate for residents' use. He said he did not know about it, or he would have removed it. On 5/16/25 at 10:59 a.m., in a follow up interview the Maintenance Director said he conducts environmental rounds every day to make sure the environment is in good working order. He observed the blurry picture of Resident #56's television and said no one told him about it. Resident #56 told the Maintenance Director the television has been blurry for two years.

Based on record review and interview, the facility failed to report alleged violations related to abuse and neglect to the proper authorities within prescribed timeframe for 2 (Residents #53 and #5) of 2 residents reviewed for abuse and neglect. The findings included: Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin (ANEMMI) with a revised date of 03/2025 revealed, Reporting: . Staff are required to report any allegation of ANEMMI to the facility risk manager, direct supervisor, and/or abuse coordinator immediately upon knowledge of the allegation . The facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment . are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 1. Review of the clinical record for Resident #53 revealed an admitted [DATE]. Diagnoses included but were not limited to Dementia and symptoms and signs involving cognitive functions and awareness. Review of the hospital discharge summary dated 4/26/25 revealed the main problem during the hospital stay had been active delirium, agitation. The discharge summary noted, We do suspect this patient has Alzheimer [sic] dementia. She was treated with Seroquel (antipsychotic) while here, at discharge she will be on Seroquel 12.5 mg (milligrams) 3 times daily . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on . She is going today to SNF (Skilled Nursing Facility) . On 5/1/25, an initial psychiatric evaluation noted the resident scored 05 on the Brief Interview for Mental Status, indicative of severely impaired cognition. The evaluation noted the resident was difficult to redirect, and verbally inappropriate making the assessment difficult. On 5/1/25, a statement signed by the attending physician noted in his opinion, Resident #53 no longer has the capacity to make knowing health care decisions for herself or provided informed consent after a sufficient explanation without coercion or undo influence. On 5/12/25 at 12:08 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including fighting, pulling off her oxygen, and not staying in one spot. LPN Staff A said on 5/2/25, Resident #53 got out of the building and was found at the gas station across the street. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. On 5/2/25, she had been with a different resident when she noticed Resident #53 was gone. LPN Staff A said they looked for the resident all around the building. Resident #53 was eventually located at the gas station across the street. LPN Staff A said when they found Resident #53, she said she didn't want to be there, and she hated her son. Staff A said Resident #53 explained how she went out the back door, and pushing the egress bar for 15 seconds to be let out. LPN Staff A said the door alarm did go off. She notified the Director of Nursing (DON), the Administrator, and called the family. LPN Staff A verified the lack of documentation of Resident #53's wandering behavior and elopement incident in the clinical record. LPN Staff A said she had no explanation for the lack of documentation. She said, It was all just verbal. On 5/12/25 at 12:32 p.m., in an interview the interim DON said Resident #53 went out the back door on 5/2/25. The interim DON said Resident #53 was alert and oriented and wanted to go to the store. She said they did a reenactment with the resident. Resident #53 was able to describe it all, including walking to the door, reading the sign that says the door will release after 15 seconds, went out, looked both ways, crossed the street and walked to the gas station at the corner. The interim DON said staff had been up front dealing with another resident who wanted to leave and go to the store. She said LPN Staff A, Resident #53's nurse, was up front assisting with the other resident. She said the alarm sounded, they discovered Resident #53 was not in the building. She was found at the gas station at the corner. She said if a resident wants to go to the store, the normal process is to sign out on a leave of absence form. She said upon the resident's return to the facility she performed a Brief Interview for Mental Status test on Resident #53. The resident scored 13 on the test, indicative of intact cognition. The DON said Resident #53 had been very behavioral and declined when she took her oxygen off. The interim DON said Resident #53 was cognitively intact. She was able to describe how she left the facility that day and again the next day. Therefore, they did not consider Resident #53 leaving the facility without staff knowledge or supervision an elopement but rather a near miss. They did not filed a report the incident the Agency for Health Care Administration. On 5/12/25 at 3:10 p.m., in an interview the Administrator said on 5/2/25 staff called and notified him said they couldn't find Resident #53 and had called an elopement code. He came to the building and so did the interim DON. He said after the fact, they did a reenactment with Resident #53. At first, Resident #53 said she didn't do it. Then she walked them through what she did. She was able to walk them through what she did again the next day. He said they investigated and completed a head to toe assessment. Resident #53 had behaviors, but the interim DON completed a BIMS and the resident scored 13, indicative of intact cognition. He said Resident #53 was someone who did what she wanted to do. The Administrator said staff reported EMS came to the building to enquire about someone, but EMS asked about someone with a last name different than Resident #53's last name. The Administrator said Resident #53 leaving the facility without staff knowledge and supervision was not considered an elopement. He said it was a near miss since the resident was cognitively intact and knew where she was going. He verified he did not report the incident to the proper authorities, including the State Survey Agency, the Agency for Health Care Administration. 52388 2. Record review for Resident #5 revealed diagnoses of depression, generalized anxiety disorder and an unspecified mood disorder. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 4/15/25 revealed Resident #5 scored 15 on the BIMS test, indicating intact cognition. Review of the progress notes revealed a psychology note dated 4/17/2025 which noted, Patient was visibly irritable when I approached her in the hallways prior to our session. Patient shared that she had a negative interaction with an aide last night. She reports that she did not threaten the aide in any way but she did request to speak to her night nurse to express her needs. Patient had a meeting this morning to discuss concerns with the aides behavior and dissatisfaction with care. Behavior management techniques were used to address and modify patient's behavior. On 5/12/2025 at 12:04 p.m., in an interview Resident #5 said a couple of weeks ago she was on the phone with her sister. She heard the CNAs arguing in the hallway. Her sister asked what was going on. She told her sister, I think the aides are fighting. Resident #5 said a CNA then came in her room, slammed her meal tray on the table and then slammed the door. She went out in the hallway to confront the CNA. Resident #5 said the CNA falsely accused her of using a racial slur. She said the CNA began cursing at her. It made her angry so she cursed back at the CNA. The resident said, It was a yelling match in the hall and they had to be separated. Resident #5 said LPN Staff C witnessed the incident. Resident #5 said the Administrator and Social Services met with her. She was not sure who the CNA was and has not seen her since that day. On 5/13/2025 at 11:35 a.m., in a joint interview the Administrator and Director of Nursing (DON) said there was no prior investigation of the incident. On 5/14/2025 at 3:18 p.m., in an interview LPN Staff C said he remembered the altercation. Resident #5 was upset that day that a CNA slammed the tray. He could not remember the name of the CNA and said the Administrator and Social Services talked to Resident #5. On 5/14/2025 at 3:21 p.m., in an interview the Social Worker said the CNA involved in the altercation was no longer employed at the facility. She said the incident happened over a month ago. The Social Worker said Resident #5 reported she was on the phone with her sister and went out in the hall after the CNA slammed the tray. Resident #5 said the CNA called her a white bitch under her breath. On 5/14/2025 at 3:36 p.m., in a follow up interview LPN Staff C confirmed witnessing the verbal altercation between Resident #5 and the CNA. When asked about reporting the incident and if anyone came to see Resident #5 that day, LPN Staff C replied, I don't know. On 5/14/2025 at 3:33 p.m., in a follow up interview the Administrator said he was not aware of the verbal altercation and did not report the incident to the proper authorities, including the Agency for Health Care Administration. On 5/15/2025 at 11:44 a.m., in an interview the Administrator said any staff who witnesses an altercation between a resident and staff member must immediately separate them. The person who witnesses the altercation notifies the DON who in turn notifies him. The staff member involved in the altercation is immediately suspended pending investigation. The Administrator said a staff member yelling at a resident would be considered abuse and would be reported. The Administrator said, If they witnessed it, they have a license and obligation to report it.

Based on record review, resident and staff interviews the facility failed to have documentation of an investigation for an allegation of abuse for 1 (Resident #5) of 3 residents reviewed for allegation of abuse. The findings included: Review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) Policy (last revised on 3/2025) revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 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 including abuse facilitated or enabled through the use of technology . Staff are required to report any allegation of ANEMMI to the facility risk manager, direct supervisor, and/or abuse coordinator immediately upon knowledge of the allegation . Ensure that all alleged violations involving abuse, neglect . are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily harm. Review of the facility's policy titled, Resident Rights (last revised on 1/2024) revealed, Employees shall treat all residents with kindness, respect, and dignity. Review of the facility's Abuse Reporting education revealed verbal abuse is defined as Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. The education noted any verbal abuse must be reported immediately. All Licensed staff Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants are required by law to report abuse, neglect or exploitation. Review of the clinical record for Resident #5 revealed an admitted [DATE]. The Quarterly Minimum Data Set (MDS) assessment with a target date of 4/15/25 revealed Resident #5 scored 15 on the BIMS test, indicating intact cognition. Review of a psychology progress note dated 4/17/2025 revealed, Patient was visibly irritable when I approached her in the hallways prior to our session. Patient shared that she had a negative interaction with an aide last night. She reports that she did not threaten the aide in any way but she did request to speak to her night nurse to express her needs. Patient had a meeting this morning to discuss concerns with the aides behavior and dissatisfaction with care. Behavior management techniques were used to address and modify patient's behavior. On 5/12/2025 at 12:04 p.m., in an interview Resident #5 said a couple of weeks ago she was on the phone with her sister. She heard the Certified Nursing Assistants arguing in the hallway. Her sister asked what was going on. She told her sister, I think the aides are fighting. Resident #5 said a CNA then came in her room, slammed her meal tray on the table and then slammed the door. She went out in the hallway to confront the CNA. Resident #5 said the CNA falsely accused her of using a racial slur. She said the CNA began cursing at her. It made her angry so she cursed back at the CNA. The resident said, It was a yelling match in the hall and they had to be separated. Resident #5 said Licensed Practical Nurse (LPN) Staff C witnessed the incident. Resident #5 said the Administrator and Social Services met with her. She was not sure who the CNA was and has not seen her since that day. On 5/13/2025 at 11:35 a.m., in a joint interview the Administrator and the Director of Nursing (DON) said there was no prior investigation of the incident. On 5/14/2025 at 3:18 p.m., in an interview LPN Staff C said he remembered the altercation between Resident #5 and a CNA. Resident #5 was upset that day that a CNA slammed the tray. He could not remember the name of the CNA and said the Administrator and Social Services talked to Resident #5. On 5/14/2025 at 3:21 p.m., in an interview the Social Worker said the CNA was no longer employed at the facility. She said the incident happened over a month ago. The Social Worker said Resident #5 reported she was on the phone with her sister and went out in the hall after the CNA slammed the tray. The Social Worker said Resident #5 said the CNA called her a white bitch under her breath. On 5/14/2025 at 3:36 p.m., in a follow up interview LPN Staff C confirmed witnessing the verbal altercation between Resident #5 and the CNA. When asked about reporting the incident and if anyone came to see Resident #5 that day, LPN Staff C replied, I don't know. On 5/14/2025 at 3:33 p.m., in a follow up interview the Administrator said he was not aware of the verbal altercation. He verified the lack of an investigation into the resident's allegation of verbal abuse.

Based on observation, staff interview, and record review the facility failed to ensure 1 (Resident #12) of 2 residents reviewed for activities, attended activities of their choice to maintain and/or improve their psychosocial well-being and independence. The findings included: On 5/12/25 at 10:30 a.m., 11:16 a.m., 12:35 p.m., and 3:00 p.m., Resident #12 was observed in his room without the television or radio on. Resident #12 was not observed in any of the facility's activities during the day. On 5/13/25 at 8:30 a.m., 10:32 a.m., and 11:00 a.m., Resident #12 was observed in his room without the television or radio on. Resident #12 was not observed in any of the facility's activities during those observations. On 5/13/25 at 11:00 a.m., in an interview Resident #12 said he was blind and could not see but he would like to go outside and feel the sun and wind on his face. He said he didn't remember the last time a facility staff brought him outside to enjoy the sunlight and/or the last time he attended an out-of-room activity with other residents. Review of Resident #12's medical record revealed his initial admitted to the facility was on 11/26/24 with medical diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a cerebral infarction (stroke), legal blindness, major depressive disorder, generalized anxiety, and muscle weakness. Review of Resident #12's activity plan of care stated Resident #12 was dependent on staff for emotional, intellectual, physical, and social stimulation related to cognitive deficits. The activity goal was to increase Resident #12's involvement in cognitive stimulation with social activities as desired through the next care plan review date. Interventions put in place to achieve Resident #12's activity goals were to assist Resident #12 to activity functions and invite him to resident scheduled activities. The care plan noted that Resident #12's preferred activities were: family/friend visits, socials/parties, the love of 70's and 80's music, going outside when the weather was good, and one-on-one visits with Resident #12 by activity staff for reading the daily chronicle and/or the book Chicken Soup. Activities staff were to offer 1:1 bedside/in-room visits/activities if Resident #12 was unable to attend out of room events. Review of the Director of Activities (DOA) job description stated the Director of Activities was responsible for developing, implementing and supervising a full scope of recreation services in the nursing home to stimulate customers to have fuller and richer lives. The DOA was responsible for planning individual and group recreation services, both therapeutic and general, direct supervision of all activity staff and volunteers, and was responsible for all necessary activity documentation. On 5/15/25 at 11:00 a.m., in an interview Unit Manager (Staff J) said she knew Resident #12 very well as he was one of the residents on her unit. She said if Resident #12 didn't want to do something he would tell you. Staff J also said in the past three to four months he had been doing very well, and she could not remember the last time he had refused care. She said Resident #12 enjoyed going outside when the weather was good and attending group activities. She confirmed Resident #12 had remained in bed on 5/12/25 and 5/13/25 but didn't know why. She said she didn't remember the last time Resident #12 had been outside and/or attended a group activity. She said there was no medical reason why Resident #12 could not attend group activities. On 5/15/25 at 11:45 a.m., in an interview with the Director of Activity (DOA), she said she had been working as the DOA since January 2025. She confirmed as part of her job duties she was responsible for developing, implementing and supervising recreation services in the nursing home for each resident. She was also responsible for planning individual and group recreation services, both therapeutic and general, direct supervision of all activity assistants and volunteers, and was responsible for all necessary documentation to include which activity each resident attended to ensure each resident attended activities noted in their individual activity plan of care. The DOA confirmed Resident #12's personalized activity program stated Resident #12 was dependent on staff for emotional, intellectual, physical, and social stimulation related to cognitive deficits and his activity goal was to increase Resident #12's involvement in cognitive stimulation and social activities through the next care plan review. She said some of the interventions she had put in place to achieve those goals were to assist Resident #12 to activity functions and invite him to resident scheduled group activities. She said Resident #12 enjoyed social parties, 70's and 80's music, going outside when the weather was good, and one-on-one visits from the activity staff to read him the daily chronicle and books since he was legally blind. She said for Resident #12 to attend group activities and/or go outside the facility on good weather days she depended on the nursing staff or the therapy department to have Resident #12 in his wheelchair. She further said she didn't remember the last time the nursing staff had Resident #12 out of bed to get in his wheelchair so he could attend a group activity. The DOA reviewed Resident #12's activity attendance sheet for April and May 2025 which revealed no documentation Resident #12 had attended a group activity program and/or been outside of the facility as required in his activity plan of care. Review of the documentation the one-on-one documentation for Resident #12 for April and May 2025 revealed the activity department documented they had conducted one-on-one activities with Resident #12 for a total of 4 times, (2 times in April and 2 times in May). She said she was unable to find documentation Resident #12 had attended the activities outlined in his activity plan of care as required on a routine basis to ensure his overall psychosocial well-being and independence were maintained and/or improved as required.

Based on observation, staff and resident interviews, and medication record review, the facility failed to identify and monitor the safe and proper storage of medications for 1(Resident #48) of 1 resident observed with unsecured medications at the bedside. The findings included: Review of the facility Standards and Guidelines, Medication Storage and Labeling issued 03/2021 and revised 01/2024 stated, Drugs and biologicals used in the facility Must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Review of the clinical record for Resident #48 revealed an initial admitted [DATE]. Diagnoses included Hypertension, Diabetes, Dependence on Renal Dialysis, and CVA (Cerebral Vascular Accident). Her BIMS (Brief Interview for Mental Status) score was a 15 which indicates intact cognition. On 5/12/25 at 9:00 a.m., in an interview Resident #48 said she had been a resident at the facility for two years now. Several medications were observed in a plastic bin on her over bed table including: Melatonin 3 mg (milligrams) tablets (bottle of 90), (dietary supplement) Melatonin 5 mg gummies (bottle of 60) and Glucosamine & Chondroitin Complex, (dietary supplement), one bottle (160 tablets). Photographic Evidence obtained. Resident #48 was able to identify the medications. She said she has been taking the medications for sleep every night for the past two years. Resident #48 said her roommate has Alzheimer's and sometimes takes her belongings. On 5/13/25 at 10:00 a.m., Resident #48's room was observed from the doorway. The door was open. Resident #48 and her roommate were not in the room. The plastic bin of medications observed on 5/12/25 remained unsecured on the resident's over bed table. Photographic evidence obtained. On 5/14/25 at 9:45 a.m., a pack of Gentle Laxative Soft Chews (1200 mg Magnesium Hydroxide/Saline Laxative) was observed at the resident's bedside. In an interview Resident #48 said she took two of the Magnesium Hydroxide saline laxative this morning. The bottles of Melatonin and Glucosamine & Chondroitin Complex Dietary Supplement were still observed stored in the plastic bin at the bedside. The resident said, the nurses don't know that I have them. On 5/14/2024 at 9:50 a.m., in an interview Licensed Practical Nurse (LPN) Staff D said she has been employed at the facility since last July and has provided care for Resident #48. LPN Staff D said she has never noticed the medications at the resident's bedside. On 5/14/2025 at 9:55 a.m., the observation of the medications at Resident #48's bedside was shared with the Regional Director of Nursing (DON). In an interview the Regional DON said residents were not allowed to keep medications in their room.

Based on observation, residents and staff interviews, the facility failed to provide maintenance services to maintain a clean, safe and comfortable environment in 15 (Rooms 314, 325, 418, 201, 203, 212, 307, 309, 314, 324, 328, 337, 407, 403, and 418) of 15 rooms observed and 3 ([NAME], Hibiscus and Heritage) of 4 hallways observed. The findings included: On 7/10/24 at 9:30 a.m., during a tour of the facility the following observations were made: Common hallways were being used as storage spaces for wheelchairs, walkers, supply carts, water carts, mechanical lifts, and mattresses. Photographic evidence obtained Common hallway floors with the tile cracked, missing or stained throughout the building. Photographic evidence obtained Common hallways with multiple areas of peeling wallpaper and warped/damaged cove base. Photographic evidence obtained Multiple resident bathrooms with black bio-growth on walls and/or ceiling including rooms 314, 324 and 418. Photographic evidence obtained Multiple resident rooms and bathrooms with peeled missing paint, holes in plaster, scrapes on wall, cove based damaged with ground in dirt, caulk missing around toilets, tile cracked and/or missing pieces and brown substances on toilets including rooms 201, 203, 212, 307, 309, 314, 324, 328, 337, 407 and 418. Photographic evidence obtained) In room [ROOM NUMBER], a corner where 2 walls meet was badly damaged with plaster missing and the corner bead exposed. The corner was duct taped together. Photographic evidence obtained On 7/10/24 at 12:39 p.m., in an interview the Administrator said they had hired a plumber to fix the plumbing, but discovered an issue with root intrusion which has been an ongoing issue with no repair date. The Administrator said the Maintenance Director did not stay long and they had just hired a new Maintenance Director who will begin at the end of the month. She said the facility staff had been trained to enter repair issues into the system. They had been bringing maintenance personnel from other facilities to help with drywall repair, ceiling repair and floor repair. On 7/10/24 at 3:16 p.m., Resident #5 said she was visually impaired. She said the clutter in the hallways causes her problems and she had bumped into some of it. She said it hadn't caused her any injury because she would feel her walker hit something and she would back off. She said she spoke with the Administrator, and she moved stuff, I think to the right side, but I still bump into stuff. I wish it could be cleared, but I don't think they have anyplace to put all the stuff. On 7/11/24 at 9:49 a.m., Resident #7 said her bedroom wall had been damaged for quite a while. She said there had been chips hanging out of the hole and she pulled them out. She said it bothered her. On 7/11/24 at 10:06 a.m., Resident #8 said they had been really good to her there and she didn't want to make any waves, but she had bumped into things in the hallways. She said luckily it didn't cause injury because I'm a tough old person. She said the building repairs were bad, and it was , almost as if they'd had a flood or something because what else could cause that? She said no one had discussed making repairs but figured staff would see the areas in disrepair and fix them. On 7/11/24 at 10:46 a.m., during a walk through with the Administrator, she agreed the broken surfaces could not be thoroughly cleaned and the building was in need of repairs. She said the Chief Executive Officer planned to visit the facility the following week to assess the situation.

Based on record review, residents and staff interviews, the facility failed to ensure resolution of residents grievances related to call lights for 2 (Residents #5 and #6) of 4 residents interviewed who complained of staff not promptly responding when the call light is activated to request assistance. The findings included: On 7/11/23 at 10: 01 a.m., in an interview Resident #6 said depending on who is working, when he calls for help, staff does not come right away and sometimes they never come. Resident #6 said he's had to get up and go to the nurses station to request assistance. On 7/ 11/24 at 10:15 a.m., in an interview Resident #5 said the call bell system has been broken for a while and there was a temporary system in place. She says getting assistance could take a bit. She said when she pressed the button, she will wait 15 minutes then press it again. She said after waiting for 45 minutes she has to get out of her bed and go to the nurses station for assistance. Resident #5 said she was lucky that she could walk and did not know how residents who could not walk went to the nurse for assistance. Record review of the grievance log revealed concerns with call lights and timely response in January 2024, February 2024, March 2024, and June 2024. Review of the Resident Council meeting minutes for 6/25/24 revealed concerns related to call lights not being answered and ignored. On 7/10/24 at 12:47 p.m., in an interview the Administrator said on the 300 hall they had a wireless call bell in place. The residents were given a red button they needed to carry with them. When the button is pressed, it alerts the nurses station. She said the residents needed to carry the button with them for it to work. If the resident went to the bathroom and did not bring the button, they would not be able to request assistance as the old system in the bathroom did not work. She said the enunciator panel from the old system broke, they sent it out for repair.

Based on record review and interview, the facility failed to ensure 1 (Resident #3) of 3 sampled residents was free from a significant medication error by failing to administer multiple doses of an ammonia reducing medication in accordance with the physician's order. The findings included: Facility policy titled Physicians Orders Revised 1/2024 indicated: 9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during the shift. The physician should be notified and the responsible party if indicated. 10. The resident will be informed of medication changes as they occur. If the resident is deemed incapable of making health care decisions, the residents responsible party will be informed of medication changes as they occur. Review of the clinical record for Resident #3 revealed an admitted [DATE] following a hospitalization for a liver workup and was on the waitlist for a liver transplant. The hospital discharge instructions included an order for: Lactulose 20 gram/30mL solution, Take 20g total (30mls) by mouth 4 (four) times daily. (Lactulose is used to reduce the amount of ammonia in the blood of patients with liver disease). Review of the Medication Administration Record (MAR) for May 2024 and June 2024 showed a start date of 6/1/24. The Lactulose was scheduled to be administered at 0000 (12:00 a.m.), 0600 (6:00 a.m.), 1200 (12:00 p.m.) and 1800 (6:00 p.m.). Review of Medication Administration Record (MAR) for May 2024 indicated the resident did not receive any medications at the facility on 5/31/2024. Review of the MAR for June 2024 revealed the 12:00 a.m., and 6:00 a.m., doses of Lactulose were not administered. On 6/1/24 at 7:01 a.m., the Licensed Nurse documented in a progress noteand documented in a progress note, New patient. Medication is being ordered and On order. The first dose of Lactulose was documented as given on 6/1/24 at 12:00 p.m. The MAR noted the Lactulose was discontinued on 6/1/24 at 12:53 p.m. Review of the orders and progress notes showed no documentation the physician had ordered the Lactulose to be discontinued on 6/1/24. Review of the progress note for 6/2/24 at 13:21 indicated the family was questioning the dosing of Lactulose and a call was made to the doctor. Progress note for 6/2/24 at 14:19 indicated the physician returned call and issued a new order to begin Lactulose 30 mg four times daily related to ammonia levels. Further Review of the MAR for June 2024 revealed on 6/2/24 the order to administer 30 mls of Laculose four time a day (12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.) was entered with a start date of 6/2/24 at 6:00 p.m. The MAR showed that between 6/1/24 and 6/2/24 Resident #3 had missed six out of eight doses of Lactulose. Review of progress notes for 6/3/24 at 9:30 a,m., indicated Resident #3 was lethargic and difficult to arouse. The physician was called and ordered a chest x-ray stat and labs, including an ammonia level. Results of the ammonia level drawn on 6/3/24 came back high at 134 with a reference range of 11 to 35. A nursing progress note dated 6/3/24 at 11:51 a.m., indicated the family was requesting for patient to leave and be transported to a [NAME] hospital. The facility suggested transport to a local hospital. The family declined feeling [NAME] hospitals knew the resident's situation best. The family took the resident out of facility against medical advice. On 7/10/24 at 4:06 p.m., in an interview the Administrator said they found out about the family's concerns when they found a negative online review. The Administrator said their investigation showed a few nurses worked with the resident during his short stay at the facility. Two nurses who are no longer employed at the facility were working to get clarification from the physician as they questioned the Lactulose order. The Administrator said ultimately they found the Lactulose order was correct at 20gm/30mL. The Administrator said the family had been asking for a larger dose. There was no order to change or stop the Lactulose and when clarified, the order was found to be correct. The Administrator said in her investigation she had not discovered the Lactulose had been discontinued and the resident had missed six out of of eight doses. On 7/10/24 at 4:17 p.m., in an interview the Director of Nursing (DON) said she had not been aware Resident #3 missed so many doses of the Lactulose while he was there. She said Lactulose is available in the PYXIS (electronic pharmacy system) and she had gotten it out before. She also said staff can call the pharmacy for an emergency order and she had done it before and had meds delivered at 2:00 a.m. The DON said nurses are not allowed to discontinue medications without a doctors' order and she was not aware a nurse had discontinued the Lactulose order. She said they can't just discontinue orders without a doctors' order. She said with newly admitted residents from the hospital they should always go by the discharge medication list. On 7/10/24 at 4:30 p.m., in a telephone interview the physician said he did not issue an order to discontinue the Laculose order for Resident #3. The Administrator and the Director of Nursing were present during the interview. The physician said he was not aware of the missed doses of Lactulose until the nurse called him to restart the medication. The physician said he did not know how high the resident's ammonia level was prior to the one obtained on 6/3/24. The physician said Resident #3 was also receiving XiXifan which helped with the ammonia level but the Lactulose probably would have helped decrease the ammonia to a normal level.

Based on observation, interview, and record review the facility failed to ensure 4 (Resident #12, #20, #42, and #55) of 5 sampled residents received care and services with respect and dignity. The finding included: 1. Resident #12 was admitted to the facility on [DATE] with a history of coronary artery disease, heart failure, peripheral vascular disease, renal insufficiency, chronic pain, anxiety disorder, and depression. The Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #12's cognition was mildly impaired with a Brief Interview for Mental Status score of 12. The MDS noted Resident #12 required supervision with transferring, ambulation, eating, and toileting and extensive assistance with dressing. On 8/29/23 at 9:07 a.m., Resident #12 said staff did not treat her respectfully. Resident #12 said staff have an attitude when they care for her. On 8/29/23 at 9:37 a.m., Resident #12 said staff will sometimes open her bathroom door without knocking when she is using the bathroom and it makes her feel indecent when it happens. While conducting the interview with Resident #12 in her room, Certified Nursing Assistant (CNA) Staff M was observed opening Resident #12's closed bedroom door without knocking and waiting for the resident's permission to enter the room. On 8/31/23 at approximately 11:00 a.m., Resident #12 said she walked out of her room in the morning and staff in the hallway told her to go to her room. Resident #12 could not identify the staff who told her to go to her room but said staff treat her as though she was a child. 2. Resident #20 was admitted to the facility on [DATE] with a history of anemia, coronary artery disease, hypertension, and depression. The Quarterly MDS dated [DATE] showed she had moderate cognitive impairment with a Brief Interview for Mental Status BIMS score of 7. The MDS showed Resident #20 required extensive assistance with transferring, bed mobility, dressing, toileting, and personal hygiene. On 8/29/23 at 10:48 a.m., Resident #20 was observed fully dressed and lying in bed. Resident #20 was asked if staff treated her with respect and dignity. Resident #20 said when staff at the facility speak with her they have an attitude and make her feel demeaned. Resident #20 said she had asked for the TV (television) remote control six times this morning and staff ignored her. Resident #20's call light was observed pinned to the left side of the bed, out of the resident's reach. Resident #20 said she could not reach the call light to request assistance. With the resident's permission the call light was engaged. CNA Staff M responded to the call light 10 minutes later and came in the room. Resident #20 asked CNA Staff M for her remote control. CNA Staff M looked for the remote control, was not able to find it and proceeded to provide incontinent care without addressing the resident's concern about the television remote control. 3. Resident #42 was admitted to the facility on [DATE] with a history of anxiety disorder and Schizophrenia. The Quarterly MDS dated [DATE] noted the resident's cognition was intact with a BIMS score of 15. Resident #42 required extensive assistance with transferring, dressing, toileting, and personal hygiene. On 8/29/23 at 12:00 p.m., during a resident council meeting Resident #42 said staff do not treat her with respect and dignity. Resident #42 said staff speak in a different language while they are providing her care and it offends her. Resident #42 said, I don't know if they're talking about me or not. Resident #42 said staff will act like they don't hear you, they pass right by you, and ignore you. On 9/1/23 2:09 p.m., Resident #42 said staff do not respond to call lights at night. Resident #42 said the majority of the staff have an attitude and disrespect her. They use their phone when they are giving her care. 4. Resident #55 was admitted to the facility on [DATE] with a history of hypertension, Multiple Sclerosis, Arthritis, and depression. The Annual MDS dated [DATE] showed Resident #55 has a BIMS of 15. Section G of the MDS shows Resident #55 needs extensive assistance from staff with mobility, transferring, toileting, and grooming. The Quarterly MDS dated [DATE] noted the resident's cognition was moderately impaired with a BIMS score of 10. On 8/28/23 at 9:55 a.m., Resident #55 was asked if staff treat her with respect and dignity. Resident #55 said, They treat me like a pile of [excrement]. I have been known to sit in my feces three to four hours at night. On the 25th of this month I called for help at 2:00 a.m., and did not get assistance until 6:45 a.m. The resident said when she reported it to the staff, they called her a liar. On 9/1/23 at approximately 2:30 p.m., the Social Service Director said residents had complained about staff using their phones while providing care and not speaking English. She verified the facility had identified residents were identified who felt staff were not treating them with respect. The Social Service Director said the facility started a performance improvement plan on 8/25/23 related to treating residents with dignity.

Based on observations, record review, resident, and staff interviews, the facility failed to ensure the availability of sufficient nursing staffing to meet the needs of 5 (Residents #55, #12, #47, #330 and #383 ) of 31 sampled residents. The failure to ensure sufficient nursing staffing to provide timely care and services could prevent residents from attaining, or maintaining their highest practicable physical, mental, and psychosocial well-being. The findings included: The facility's assessment with a date reviewed by the Quality Assurance and Performance Improvement committee on July 20, 2023, noted Registered Nurses and the Licensed Practical Nurses were based on 1.0 per person per day state mandated requirements. Certified Nursing Assistants direct care staff is based on Day shift: (7a-3p): 8-9 CNA's Evening Shift:(3p-11p) 8-9 CNA's Night Shift:(11p-7p) 5-6 CNA's The hours were based upon the state mandatory requirement of 2 hours per person per day. The Facility Assessment showed 77 residents required the assistance of one to two staff members for toileting. 28 residents required one to two staff members for eating and 66 residents required one to two staff members for transferring, and eight residents were dependent on staff for transfers. 1. Resident #55 was admitted to the facility on [DATE] with a history of hypertension, Multiple Sclerosis, Arthritis, and depression. The Quarterly Minimum Data Set (MDS) showed Resident #55's cognition was intact with a Brief Interview for Mental Status score of 15. has a BIMS of 15. Resident #55 required extensive physical assistance from staff with mobility, transferring, toileting, and grooming. On 8/28/23 at 9:55 a.m., Resident #55 said she had to sit in her feces 3 to 4 hours at night. Resident #55 said, On the 25th of this month I called for help at 2:00 a.m., and did not get assistance until 6:45 a.m. When asked if she reported this to nursing staff she stated she was called a liar. Resident #55 said she uses a mechanical lift (total body lift) to transfer to her wheelchair and she always has to wait 30 minutes to an hour for the mechanical lift to be available. 3. Resident #12 was admitted to the facility on [DATE] with a history of coronary artery disease, heart failure, peripheral vascular disease, renal insufficiency, Diabetes Mellitus, chronic pain, anxiety disorder, and depression. The Quarterly MDS dated [DATE] showed Resident #12 required supervision with transferring, ambulation, eating, and toileting and extensive physical assistance with dressing. On 8/29/23 at 9:15 a.m., Resident #12 said staff do not respond to her call light at night. She said she complains but the staff ignore her. 4. On 8/28/23 at 4:22 p.m., Resident #47 said, Without a doubt they need more staff, both days and nights. At times it can take 45 minutes other times within minutes. Most of the time you wait a while. Sometimes you hear buzzers all night. 5. On 8/29/23 at 11:19 a.m., Resident #330 said he often has to wait thirty minutes to an hour for staff to respond to his call light. He stated that this happens often day and night. 6. On 8/28/23 at 3:54 p.m., Resident #383 said sometimes it can take up to two hours for someone to answer the call light. Resident #383 said it occurred more during the day. On 9/1/23 at approximately 2:30 p.m., the Social Service Director verified she had had complaints from several residents regarding call light response time. She said the facility had recently started a performance improvement plan due to call light response time.

Based on staff interviews, record review, facility policy review and reportable events review the facility failed to have documentation of a thorough investigation of an allegation of neglect for 1 (Resident #230) of 2 residents reviewed. The findings included: The facility's policy and procedure titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of Unknown Origin (ANEMMI) revised 10/2022 noted, Identification . Any resident event that is reported to any staff by resident, family, other staff or any other person will be considered as possible ANEMMI if it meets any of the following criteria: . Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well-being to include toileting issues . Any report to Adult Protective Services will trigger an internal investigation . Review of the clinical record for Resident #230 revealed documentation on 2/7/23 at 9:15 p.m., a police officer came to the facility to visit Resident #230. The resident told the police officer that she put the light on and nobody came. The nurse documented in the progress note two Certified Nursing Assistants had changed the resident at 8:45 p.m. Paramedics arrived at the facility and took the resident to the hospital. Review of the hospital records revealed documentation on 2/7/23 the resident presented to the Emergency Department with altered mental status and concerns for neglect. Review of the facility's Nursing Homes Federal Reporting to the Florida Agency for Health Care Administration revealed on 2/9/23 the facility submitted a report for an allegation of neglect. The report noted an investigator from the Department of Children and Families (DCF) came to the facility and spoke with the Administrator regarding Resident #230. The Administrator documented in the report, DCF arrived on 2/9/23 and it is still unclear why. DCF stated that they may have had facts misconstrued and that she would come back to the center. The center has not heard from her since that day. The Nursing Homes Federal Reporting noted the allegation of neglect was not substantiated. On 8/31/23 at 3:52 p.m., interviewed Facility Administrator about reported event alleging neglect involving Resident #230. The administrator said the facility was unable to provide information about the investigation. The Administrator said, If the event had occurred now we would submit the event as a reportable, interviewed staff and residents, keep the witness statements. I would have documented the DCF person who came to investigate and called back to obtain the DCF report. I know this investigation in the 5-day report is not complete. On 9/01/23 at 2:21 p.m., interviewed the administrator who confirmed that they have no documentation of a full investigation. The administrator could not explain how the allegation of neglect was unsubstantiated. Administrator confirmed the investigation process was outlined in the abuse and neglect policy and should have been followed.

Based on observation, review of facility's policies and procedures, resident and staff interview, the facility failed to provide the necessary supervision and assistance with dining resulting in a burn from hot coffee for 1 (Resident #2) of 3 sampled residents. The findings included: The facility's clinical insight titled Hot Beverage safety dated April 2022 noted, Hot beverages such as coffee, tea, and hot chocolate are prepared and brewed at high temperatures to maximize flavor and quality. However, injuries may occur when skin comes in contact with hot liquids or steam. This may happen with accidental spills or splashes of hot food and beverages. Patients are at increased risk because skin tends to be less sensitive, reaction times are reduced, and immobility may prevent the ability to remove contact with the hot liquid or cause a tendency not to pull away quickly enough. Dispensing of hot beverages in the kitchen . consider the temperature range of 150- 155 degrees F (Fahrenheit) as an approximate guide for hot beverages leaving the kitchen; record the temperature taken on the Food Temperature Log. Serving hot beverages to patients . Explain that a hot beverage is being served. Allow hot beverages to cool before serving. Review of the clinical record for Resident #2 revealed a date of admission of 4/6/22. Diagnoses included Diabetes, Dementia, and depression. The Significant change in status Minimum Data Set (MDS) assessment with a target date of 8/2/22 documented in the Care Area Assessment Summary Resident #2 triggered for Functional Activities of Daily Living (ADL) and was addressed in the care plan. The Quarterly MDS assessment with a target date of 11/2/22 noted Resident #2 had impaired cognition, had short term and long term memory problem. The MDS noted the resident required limited physical assistance (Resident is highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) of one person for eating. The care plan for ADL initiated on 4/7/22 and revised on 6/29/22 noted to assist with eating as needed. The progress notes with an effective date of 12/12/22 at 12:00 p.m., noted the nurse was notified by the Certified Nursing Assistant (CNA) assigned to the resident about spilling his coffee. The nurse documented assessing the resident and Resident #2 sustained burns measuring 8.0 centimeters (cm) by 4.0 cm to the right upper flank. On 12/12/22 the wound progress note documented the nurse referred this patient that looks like he spilled his coffee over him and complained of burning and pain to the right lateral chest. Resident #2 had pain, decreased range of motion. On assessment she found a second degree burn (involves the outer layer and part of the inner layer of the skin) to the right lateral chest with open blister 8 cm by 4 cm, with redness around. Review of the Nursing Home Five Day Federal reporting to the Florida Agency for Health Care Administration noted CNA (Staff A) taking care of the resident placed his tray with a cup of coffee by his bedside. She went to turn to retrieve a clothing protector, the resident grabbed the coffee and spilled it on his upper flank. The kitchen staff received an in service on ensuring that temperatures are taken right before the coffee hits the floor and that it cannot be greater than 155 degrees. On 12/19/22 at 9:35 a.m., Resident #2 said he didn't know what happened. He said, I know it burnt me, but I am fine. Resident #2 was not able to recall if anyone warned him that the coffee was hot. On 12/19/22 at 9:55 a.m., CNA Staff A, said, The kitchen takes the temperatures. If it is steamy, I tell the resident not to touch it and to let it cool down. On 12/19/22 at 11:30 a.m., the Kitchen Manager said the coffee is brewed at 200 degrees. He said they brew the coffee and let it cool down before going to the residents. The kitchen manager described the process as, Brew coffee, test temperature, allow to sit for 15 minutes, then seal thermos, and send out to floor. The Kitchen Manager said since Resident #2 got burned, he has been taking the temperature of the coffee on the individual halls. He said when not present his assistant is supposed to take the temperature, but it doesn't always get done. On 12/19/22 at 12:00 p.m., CNA Staff D was observed serving an uncovered steaming cup of coffee from a carafe to Resident #1 and #7 in the main dining room. The CNA said she knew the coffee was ok since they test it before it comes out, so I know it is safe. The Kitchen Manager measured the coffee temperature in the carafe at 157 degrees. The Kitchen Manager said, it should be below 150 degrees for safety. On 12/19/22 at 12:08 p.m., upon surveyor's request the temperature of the carafe of hot water for hot tea was measured and read 167 degrees on the 300 hall. The Kitchen Manager said, We haven't been testing the hot water for tea. We only test the coffee since that is what the issue was about. I know we need to test the hot water now too. The Kitchen Manager also said they had not been monitoring the temperature of the coffee or the hot water for tea in the dining room. He said they come out of the machine between 180 to 200 degrees. On 12/19/22 at 12:15 p.m., the Administrator said she heard the how water was 167 degrees. She said she asked the kitchen to monitor the hot water for tea as well, but it wasn't done. The Administrator also said they have not been taking the temperature of the hot beverages in the dining hall. Review of the temperature logs for December 2022, revealed missing documentation of temperatures including 12/1/22 entire dinner meal, 12/3/22 lunch meal coffee temperature, 12/4/22 lunch meal coffee temperature, 12/6/22 breakfast and lunch meals coffee temperatures, 12/7/22 dinner meal coffee temperature, 12/10/22 lunch meal coffee temperature, 12/11/22 dinner meal coffee temperature, 12/12/22 breakfast and lunch meals coffee temperatures dinner meal missing all temperatures, 12/13/22 breakfast and lunch meals coffee temperatures dinner meal missing all temperatures, 12/15/22 coffee temperatures for all meals, 12/16/22 and 12/18/22 all meals missing temperatures. On 12/19/22 at 12:30 p.m., the Kitchen Manager confirmed the lack of documentation the temperature was obtained for several meals. He said, They should be completed for each meal and the coffee temperatures should be done for each hall since we had the incident with the burn. He agreed it was a safety concern and there needed to be a process when he was not present to ensure meal temperatures are done and documented.

Based on observations, staff interviews, records review and facility policy review the facility failed to ensure reheated food and drink items are given to residents at an appropriate temperature for residents' safety which resulted in first and second degree [CONDITION(S)] for 1 (Resident #1) of 1 resident reviewed. The findings included: Facility policy titled, Food Temperatures at Point of Service, dated 11/2020 stated, Each patient receives, and facility provides: (1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and [CONDITION(S)]. On 4/4/22 at 9:45 a.m., interviewed Food Services Director about food reheating for residents. Food Services Director said, We have three nutrition rooms with microwaves for reheating resident's food or drink. Staff use T sticks (disposable thermometer when inserted into food/ drink which changes color at tip for temperature over 165 degrees) to check the temperature after reheating. Food Service Director showed nutrition room to surveyor with microwave for reheating, instructions for T stick use and reheating instructions. Food Services Director described the reheating process, They reheat and then put the stick tip in. When it turns orange, it has been heated enough. Asked how the staff knows if the item is too hot to be safely given to the resident. Food Services Director replied, I guess we don't. This shows that it has reheated to 165 degrees a safe temp for bacteria, but we don't actually see a number for the temperature to know if it is too hot. I guess if it spilled it might burn someone. I guess we should look at that again. On 4/4/22 at 10:15 a.m., interviewed Certified Nursing Assistant (CNA), Staff A, on reheating residents' food and drink on the unit. CNA, Staff A, replied, No that hasn't happened. CNA, Staff A, asked if someone did ask for food or drink to be reheated how would she complete that task. CNA, Staff A, replied I would bring it to the kitchen to get heated. If not, I would use the microwave in the nutrition room on the unit. I would warm for 1 minute but then stop warming after 50 seconds. I would tell the resident to be careful since it is hot, and I don't want them to hurt themselves. CNA, Staff A, did not say anything about using stick to check temperature of food or drink. On 4/4/22 at 10:30 a.m., interviewed CNA, Staff B, about reheating foods and drinks for residents. CNA, Staff B, said, If someone needed food or drink warmed, I would take it to the kitchen. If not going to the kitchen we have the microwave on the unit, and I would use that. We have temperature sticks to make sure whatever is heated is hot enough. Surveyor asked CNA, Staff B, how she would know if what had been reheated was too hot and unsafe for resident to drink/ eat. CNA, Staff B, replied I don't know. On 4/4/22 at 10:45 a.m., interviewed Registered Nurse (RN), Staff C, about reheating foods and drinks for residents. RN, Staff C, said, We don't do that too much but if I need to then I use the microwave here on the unit. I do 20 second intervals and use the dip sticks. They change color when what I am reheating has gotten to the temperature level hot enough. I wish they used the thermometer with the numbers. Where I worked before, we had those, so we knew if it was too hot. I think it could be a safety issue if the staff isn't paying attention since the sticks, we use will look the same whether 165 degrees or 200 degrees. On 4/4/22 at 11:00 a.m., interviewed Resident #1, whether she has the staff warm food and drink items for her. Resident #1 replied, Sometimes I do. Asked if she had ever had anything that was too hot. Resident #1 replied, I don't know what you are asking. When asked, have you ever spilled hot foods or drinks on yourself, and it be too hot for your skin. Resident #1 replied, Yes, that happened, but I am okay now. On 4/4/22 at 11:15 a.m., interviewed Director of Nursing (DON) about process for reheating food and drinks for residents on the unit. DON was asked how staff knows if the food or drink is too hot and could burn or scald resident after reheating using the process posted for staff to follow. DON replied, I don't know. I need to find out if the t stick gets darker or something if it is hotter. I don't think it does. It just lets you know it has reached 165 degrees. I guess we will need to fix the process because I can see how it could be a risk for the resident if food and/or drink was too hot, and they spilled on themselves. On 4/4/22 at 11:30 a.m., reviewed clinical record for Resident #1, documented in nursing alert progress note dated 11/26/21 at 1:45 a.m., stated This nurse was called to resident's room to assess after resident had spilled her hot cup of soup down her chest and abdomen. Areas are red and with some welting on the lower part of her abdomen. This nurse immediately cleaned all the areas with cool NS (normal saline) to remove remaining soup. Resident complained of the areas burning and rated her pain 4/10 on the numeric pain scale. Physician contacted at this time. She, the physician had this nurse ask the patient for permission to video chat so that she could see the areas. The physician instructed the nurse to apply [MEDICATION(S)] Gel to the affected areas once a day and apply cool compresses to the affected areas throughout the night. Monitor the areas closely to evaluate if getting worse/ better. Have patient's physician follow-up with patient as per facility protocol. VSS (Vital signs stable)- BP (Blood Pressure) 110/70, Pulse 76, respirations 18, oxygen sat 96 % on room air, temperature 97.4. Will continue to monitor. Telehealth note documented by physician dated 11/26/21 at 12:56 a.m., said, Patient was eating her own soup that had been heated in microwave, patient spilled the hot soup on her bare chest and abdomen, areas are very red with some welting. Diagnosis, assessment/ plan [CONDITION(S)] of first degree to other side of trunk Burn of second degree of abdominal wall. Nursing progress note 11/26/21 at 7:25 a.m., said, Re-assessed patient with morning medication pass as she was with eyes closed each time prior this nurse entering the room. [CONDITION(S)] remain unchanged. Patient states that it continues to burn will continue to monitor. Facility physician progress note dated 11/26/21 at 11:02a.m., said, Patient seen and examined, was requested to follow up from burn from hot soup last night, +ew vesicles (blisters) on right chest, pinkish skin on right posterior thoracic area continued plan of care telehealth provider had initiated. Reviewed Resident #1's care plan which did not indicate that she was an accident risk. Reviewed Resident #1 Minimum Data Set (MDS) assessment which documented a Brief Interview for Mental Status (BIMS) score of 15 indicating resident is cognitively intact. On 4/4/22 at 12:05 p.m., interviewed CNA, Staff D, about reheating food or drinks on unit. CNA, Staff D, said, We can put a resident's food for 3 days in nutrition room refrigerator with a name and date. When reheating I use the stick which shows it is an ok temperature. Asked what if food or drink is too hot. CNA, Staff D, replied, If it is steaming, then I wait to give it to them, I don't want them to get hurt. Asked how she knows it's too hot. CNA, Staff D, said, Well if it is steaming you know. Asked if she would bring anything steaming to a resident and tell them to wait for it to cool off. Replied, No, I wouldn't risk that, they might not listen and hurt themselves. If it is too hot, then I wait to bring it to them. Asked if she retakes temperature of food or drink before bringing it to resident. CNA, Staff D, replied, No, I just wait for it to cool down a bit. On 4/4/22 at 1:45p.m., interviewed Licensed Practical Nurse (LPN), Staff E, who cared for resident #1 when she had her burn injury 11/26/22. Asked if resident is prone to accidents and if she remembered the burn to her chest area. LPN, Staff E, replied, No she doesn't usually have accidents. She is with it. I remember the burn. I wasn't here when it happened, but I took care of her the next shift after, the soup was just too hot. It is all better now. On 4/4/22 at 3:15 p.m., interviewed DON who confirmed that the t- stick thermometers do not have a different color over 165 degrees. Confirmed they turn orange at 165 degrees Fahrenheit. DON said, I see where you are going with this and yes, I agree it is a danger to the residents. I personally have never used these temp sticks. I guess we will need to look at changing our process for resident safety. On 4/4/22 at 3:50 p.m., interviewed by phone facility administrator. Administrator confirmed she can see the concern for the t-stick thermometers not indicating what the temp is above 165, that some of the staff are not following the process fully and it could be a risk to the residents if food or drink heated to a very high temperature.

Based on record review, observation, and interview, the facility failed to prevent the development of 8 unstageable pressure ulcers that resulted in hospitalization , for one (Resident #53) of a sample of 3 residents reviewed for pressure ulcers. Splinting devices used by Resident #53 caused actual harm to the resident evidenced by pressure ulcer development and worsening without assessment. The resident was hospitalized and required extensive treatment. The resident lost her independent mobility. Cross reference F323 for devices. The findings included: Review of the medical record revealed that Resident #53 was originally admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. She was discharged to the hospital on [DATE] for 2 femur fractures that she sustained in the facility. She fell out of bed while receiving care from a Certified Nursing Assistant. She returned to the facility on [DATE] wearing a soft cast (on her) bilateral lower extremities. The MDS (Minimum Data Set) assessments of 6/28/15 (annual), 8/3/15 (discharge), 8/18/15 (significant change), and 8/23/15 (14 day) documented the resident had no pressure ulcers. She had a BIMS (Brief Interview for Mental Status) score of 15 (indicating no cognitive impairment). The MDS of 9/6/15 (30 day) and 9/13/15 documented one Stage II pressure ulcer. The resident was discharged from the facility on 9/19/15. The MDS dated [DATE] (discharge) documented the resident had 4 unstageable pressure ulcers due to non-removable pressure device and coverage of wound bed by slough and/or eschar. The medical record progress notes of 9/17/15 included a skin assessment. The assessment identified 3 unstageable pressure ulcers on the resident's left lower extremity demonstrating eschar and slough. The assessment also notes 4 unstageable pressure ulcers on the residents right lower extremity demonstrating eschar and slough. Interview of the Therapy Director on 11/5/15 at 11:00 p.m. revealed that a physical therapist looked at Resident #53 on 8/20/15. This was per nursing request because of the resident's complaint of pain. The physical therapist documented on 8/20/15 Skin Integrity = Bruises (significant mid lateral shin bruising secondary to improper brace placement. Nursing notified of bruising, bruising also reported in 24 hour report). [MEDICAL CONDITION] = 2+ [MEDICAL CONDITION] (indentation [MEDICATION NAME] 15-20 seconds) BLE (both lower extremities). The Therapy Director said, at this time, that the therapy department was not involved in any bilateral lower leg devices/splints/braces worn by Resident #53. She said the physical therapist removed the lower leg devices and reported to nursing that there was skin breakdown under the devices. A Wound Care Team assessment, dated 8/20/15 in the progress notes, stated right anterior ankle measured 3.5cm (centimeter) by 3cm, right outer calf skin intact dark purple 6cm by 7.5cm, left outer calf skin intact purple bruise 5cm by 5cm, back of right heel measured 1 cm by 1.5cm, left heel has a fluid filled blister measured 5cm by 7cm. Review of the nursing progress notes, for the time period 8/12/15 through 8/15/15, made no reference to soft cast to bilateral lower extremities or lower extremity bruising. Review of the nursing progress notes, for the time period 8/16/15 through 8/24/15 (10 days/30 shifts) demonstrated 10 references to the soft cast to lower extremities. Only one reference indicated that the soft cast had been removed (8/21/15) during a shift. Otherwise documentation stated in place, intact, adjusted, on, checked for positioning, with no skin evaluation identified. There was no indication during this time period that the resident refused to have the soft casts removed or that she refused repositioning. No reference was made to lower extremity bruising. Nurse Practitioner Progress Notes documented: On 8/21/15, (Resident #53) has formed blisters on bilateral heels, continue with immobilizer braces, elevate legs off of bed with pillows as patient does not want to wear foam boots. On 8/27/15, (Resident #53) is now remaining in bed until her follow-up in about a month with orthopedics. She has formed blisters on bilateral heels, and they continue to be closed. And now with a wound base exposed on the right lateral maleolus (ankle). She also has blisters under her immobilizers prompting removal of the metal 'stays' within the brace as they were causing pressure. Pressure ulcers plan: off load as much as possible, metal stays removed from brace and areas more off loaded, continue skin prep to all ulcers. On 9/3/15, Continue with immobilizers, Acute Pressure Ulcers, continue with current treatment of [REDACTED]. On 9/11/15, bilateral immobilizers in place, poor wound healing due to [MEDICATION NAME] (low plasma protein), CMP (a blood test) on Monday to evaluate nutritional status. Review of the primary physician notes dated 8/18/15, 8/25/15, and 9/8/15 revealed documentation that Resident #53 had extremities that were warm and dry, no rashes, ulcerations or [MEDICAL CONDITION]. These notes gave no indication that the resident was wearing bilateral leg braces and that pressure ulcers, on both her lower extremities, were identified 8/21/15. On 8/21/15 a phone order was given by the primary physician to Check bilateral leg brace for proper application and skin changes every shift, every shift for fractured femur. On 9/8/15 the primary physician wrote an order to Loosen brace briefly for care every shift related to fx (fractured femur). Resident #53 was sent to the emergency room for wound debridement on 9/19/15. A history and physical performed upon admission to the hospital on [DATE] noted August of this year, sustained bilateral femur fractures. According to the chart she declined surgery and was sent to rehab (rehabilitation). Patient states that at rehab she was fitted with some braces over both legs and these braces were not removed until a couple of days ago. When removed, fairly severe pressure wounds were revealed and she was ultimately sent to the emergency room for further evaluation. Patient has deep pressure wounds on both legs. On the left leg, she has one on the heel over the left lateral malleolus etc. The wounds are somewhat chronic looking, not clean and have some surrounding [DIAGNOSES REDACTED] (skin reddening, due to injury or irritation). On the right leg, she also has similar deep wounds. A Final Summary Report from the hospital dated 9/29/15 noted, bilateral lower extremity ulcers with gangrene and abscess collection, from braces placed as nonsurgical treatment for [REDACTED]. Wound culture and tissue culture came positive for Pseudomonas and Corynebacterium Striatum (bacteria). Patient treated with a broad spectrum antibiotic, s/p (status [REDACTED]. Observation of the resident, on 11/4/15 at 4:30 p.m., revealed intact bandages on her lower extremities, below her knees; and her left foot was a dark ashen color. A wire halo device was observed on her right foot with metal bars implanted in her foot to maintain positioning of the device. The resident stated she has pain in both of her lower extremities (below her knees); and the pain medication did not take it totally away, especially in the left lower leg. In addition, she stated she can no long use her electric wheelchair because of the wire halo device attached to her right foot. She continued to state, They better put me to sleep when they take that thing out (pointing to the wire halo device implanted in her right foot). The facility knew, or should have known, that the bilateral lower extremity splinting devices, being used by Resident #53, were causing pressure resulting in pressure ulcer development. Progress notes identify pressure sore development on 8/20/15 and documented further development of pressure ulcers and deterioration of skin integrity under the splinting devices being used. Some 30 days were allowed to pass as the pressure ulcers continued to develop and get worse on the resident's bilateral lower legs. This failure to reassess the use of the splinting devices resulted in the resident's subsequent hospitalization resulting in extensive treatment/intervention and the loss of her mobility to maintain independent locomotion. Review of Quality Assurance Committee documents found there were several important issues that were not addressed: The Nurse Practitioner noted the splints were causing pressure but did not discontinue. The Primary Physician continued to document intact skin. The Therapy Department made no recommendations regarding use of the splints after they were consulted.

Based on resident records reviews, resident and staff interviews, and observation, the facility failed to ensure the environment was free from hazards for one (Resident #53) of three residents reviewed concerning falls. The facility's practice resulted in actual harm of the resident falling out of bed and sustaining femur fractures. Cross reference F314. The findings included: 1. A review of a nursing assessment dated [DATE] showed Resident #53 has a history of falls. The resident had [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] showed Resident #53 was a risk for falls and had a major injury due to a fall. The MDS also showed Resident #53 required extensive assistance with most of the activities of daily living, including toileting, requiring two or more staff to provide this type of care. A review of the care plan showed Resident #53 was incontinent due to impaired mobility. She had a history of [REDACTED]. The interventions showed Resident #53 will be provided assistance with toileting, incontinent care as needed, skin care and report to nursing for any signs or symptoms of urinary tract infection. There was no information concerning the process for her incontinent needs or the amount of staff to perform this task. The care plan also showed she was at risk for falls. This portion of the care plan was developed on 6/19/13. The goal was to minimize the risk for falls. Resident #53 will be in a low bed, encourage to transfer and change positions slowly, and the staff will provide assistance for transfer and ambulation. The care plan was revised on 8/13/15 to show she was using a wide bed. An interview was conducted with Resident #53 on 11/3/15 at 3:05 p.m. She confirmed she had a fall in August. She was lying in bed on her left side and the staff was changing her brief. She said the process was she was to turn on her left side while lying in bed and the staff would be behind her on the right side of the bed. The staff then changed her brief. Since there was no side rails on the bed, she held on to a chair that was located next to her bed on the left side. She said she must have swung her right leg too much causing her to fall out of the bed. The staff grabbed on to her clothing and to gently set her down on the ground. She went to the hospital due to this fall. She said she broke her ankle from this fall. When she was readmitted to the facility, they gave her a wider bed and she now has a trapeze (a hanging bar above the bed). A review of Resident #53's progress notes revealed on 8/3/15 she was receiving care from a CNA (certified nursing assistant) and rolled out of bed and landed on her back. She complained of severe pain to her right lower leg. She suffered bilateral femur (thighbone) fractures due to this fall. A second interview was conducted with Resident #53 on 11/4/15 at 11:11 a.m. At that time, she said she needed staff to change her adult brief. The surveyor advised the resident to put her call light on, which she did. Observation at 11:12 a.m. included one CNA (Staff G) entered Resident #53's room and closed the bedroom door. Approximately 15 minutes later Resident #53's bedroom door opened. Staff G was standing at the sink washing her hands and then walked out of the room. The surveyor walked in Resident #53's room at this time. An interview was conducted with Resident #53. She said the CNA changed her adult brief. There was only one CNA conducting this task. Interviews were conducted with the Administrator, corporate staff, and the Director of Nursing on 11/4/15 at 1:15 p.m. The Administrator stated Resident #53 fell out of her bed while receiving care from a CNA. She did an incident report. This report showed Resident #53 rotated on the bed to hold on to the chair next to her bed during care. The CNA was on the other side of the bed (resident facing away from the CNA) to change her adult brief. This was the routine for the staff to change Resident #53's adult briefs. The CNAs always stayed on the opposite direction of where the resident rotated. Resident #53 over-rotated and started falling out of the bed. The CNA grabbed on to her clothing but could not hold on resulting in the resident falling on the floor. Resident #53 sustained bilateral femur fractures. At this time she did not know what caused both fractures. When Resident #53 came back to the facility, they gave her a wider bed. Therapy evaluated the resident for 1/4 side rails. Since Resident #53 was now on a wider bed, the 1/4 rails were discontinued and she was using a trapeze. Resident #53 now has two staff providing care for her at all times since this accident. The Administrator said they also reviewed the position of the chair showing it was in the correct position next to the bed. Observation of the chair located next to Resident #53's bed on 11/4/15 at 4:45 p.m. revealed there are no stoppers on the legs of this chair. The Administrator was not able to determined who or how this process was developed for the CNA to stand on the right side of Resident #53's bed while the resident turns on her left side (away from the CNA), the resident holds on to an unsecured chair next to her bed and then the CNA will change her adult brief. An interview was conducted with the Director of Therapy on 11/4/15 at 4:15 p.m. The process for changing Resident #53's adult briefs was explained to her as the way the Administrator had explained it. The Director of Therapy reviewed Resident #53's medical record and stated therapy did not determined this process for the staff to change Resident #53's adult briefs. She stated she was aware of this process after Resident #53 had her accident. The resident now has a trapeze on her bed to hold on to while staff conduct care.