Every finding on record at Achieve Rehabilitation and Nursing Center

Based on record review and staff interview, the facility failed to ensure the Baseline Care Plan included required information related to the resident's tracheostomy status for 1 of 1 residents,(R)1 reviewed for baseline care planning. In addition, the facility did not have a policy or procedure addressing the development of baseline care plans. This failure had the potential to result in unmet care needs.Findings include:Review of R1's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: acute and chronic respiratory failure with hypoxia, tracheostomy status, dysphagia, gastrostomy status, and dementia.Review of R1's order summary report revealed physician orders for an NPO [nothing by mouth] diet with a start date of 03/17/26; a Size 8 cuffed tracheostomy; and oxygen at 10 L [liters] via tracheostomy continuously every shift.Review of R1's progress note dated 03/17/26 at 22:18 [10:18 PM] revealed the following documentation: Skin only. Skin Evaluation: Skin warm and dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time. Note/Notification/Education: Skin note: resident has a trach and PEG tube; he also has a red area to the buttock. Nursing.Review of R1's Baseline Care Plan dated 03/17/26, which was marked as completed in the EHR [electronic health record] Assessments tab, revealed R1 was cognitively impaired and contained no documentation of the resident's tracheostomy care needs, suctioning requirements, respiratory monitoring, or admission interventions.On 05/06/26 at 1:52 PM, an interview was conducted with the Director of Nursing (DON), who reported she had been in her role for over one year. She stated she was familiar with R1 during the short time he was in the facility. The DON reported the resident was admitted with both a tracheostomy and a PEG [Percutaneous Endoscopic Gastrostomy] tube following a hospital stay of over one month. The DON stated the Baseline Care Plan should have addressed the resident's tracheostomy prior to being marked as completed. On 05/06/26 at 3:30 PM, an interview was conducted with the Facility Administrator in the presence of the nurse consultant. The Administrator stated there had been re education provided to all clinical staff, including admitting nurses, regarding the importance of ensuring Baseline Care Plans are accurately completed.

Based on observations and interviews the facility failed to ensure the daily staffing was posted over the weekend so the public and residents had access to this information. This deficient practice has the potential to affect all residents and visitors. Findings include:During an observation on 04/13/26 at 8:30 AM, the daily nursing staff report posted in the main lobby was dated 04/10/26. During an interview on 04/15/26 at 10:16 AM the Staffing Coordinator (SC) stated she completes the daily nurse staffing posting Monday through Friday, and the weekend posting was completed by the Director of Nursing (DON) or the unit managers. During an interview on 04/15/26 at 10:30 AM the Regional [NAME] President stated the facility follows the .state guidelines. and the facility does not have a policy.During an interview on 04/15/26 at 1:25 PM the DON stated the weekend posting of the daily nurse staffing was the responsibility of the staffing coordinator as .I'm not here on the weekends.During a second interview on 04/15/26 at 1:44 PM the DON stated the Manager on Duty (MOD) for each weekend was responsible for checking the midnight census, making changes and then posting the daily nurse staffing report. The DON stated the Laundry/Housekeeping Director was the MOD for 04/11/26 and 04/12/26 and was responsible for posting the weekend nurse staffing report.

Based on review of facility policy, observations and interviews, the facility failed to ensure stored food was dated when opened or when placed in refrigeration to thaw and failed to discard expired items in one of one kitchen and in one of four nursing unit resident refrigerators. The facility also failed to keep the kitchen's two ovens, two stove top spill pans, large manual can opener and its base, two drawers housing food preparation equipment, two food preparation tables, and floors clean and/or sanitized in one of one kitchen. These failures had the potential to create an environment for food-borne illnesses which could affect 166 residents who consumed food prepared from the facility's kitchens.Findings include:Review of the facility's undated policy titled, Food Safety: Labeling & Dating, specified, . Dating for Food Storage In addition to labeling, dating items requires special attention. All foods that require time and temperature control (TCS) should be labeled with the following: Common name of food (ex: macaroni and cheese) , Date the food was made, Use by date .Review of the facility's policy titled, Kitchen Equipment, with a revision date of 01/31/24, indicated, Policy: Foodservice equipment will be clean, sanitary, and in proper working order. Procedure: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's instructions. 2. Kitchen staff will be properly trained in the cleaning and maintenance of equipment. 3. Food contact equipment will be cleaned and sanitized after every use or per manufacturer instructions. 4. Non-food contact equipment will be clean and free of debris .1. Observation during the initial kitchen inspection on 04/13/26 from 10:20 AM to 11:10 AM, with the Dietary Manager (DM), revealed the following concerns with food storage:a. The kitchen's walk-in refrigerator contained one undated large storage container of apple sauce which had been removed from its original packaging, one opened and undated 135-ounce container of enchilada sauce, and one opened and undated 128-ounce container of salad dressing. Additionally, there was one package of thawed diced raw pork that was stored in a box which contained a manufacturer's instruction to freeze by 02/03/26, there was no date to indicate when the raw pork was placed in refrigeration to thaw.During an interview on 04/13/26 at 10:30 AM, the DM confirmed the food storage concerns observed in the kitchen's walk-in refrigerator. The DM stated staff were expected to date opened foods when they were placed into storage. Additionally, the DM stated staff had removed the raw diced pork from the freezer to thaw in the refrigerator, but he was unable to determine when this occurred because staff failed to date the product to specify when it was placed in the refrigerator to thaw.b. In the kitchen, a large storage container, which housed sugar, had a scoop stored in the product. The scoop's handle was observed to be in direct contact with the sugar stored in the container.During an observation and interview on 04/13/26 at 11:05 AM, the DM was observed removing the scoop from the storage container of sugar. The DM stated staff should not store scoops in stored food.2. Further observations during the initial kitchen inspection on 04/13/26 from 10:20 AM to 11:10 AM, with the DM present, revealed the following unclean food preparation and service equipment, and areas:a. The kitchen's two ovens were unclean with a heavy accumulation of dried and burned food substances on their inner cooking compartments and doors.b. The kitchen's two stove top spill pans were unclean with a heavy accumulation of dried food and burned food spills.c. The kitchen's large manual can opener was unclean with dried and sticky substances on its blade and table base attachment.d. The inner storage compartment of two kitchen drawers, which had food preparation and service equipment stored in them, including scoops, ladles, serving spoons, and spatulas were unclean with dried substances and accumulated food debris.e. The bottom shelves of two food preparation tables were unclean with dried food spills and food debris.f. The floors behind the kitchen's fryer, two ovens, and three compartment sink were very unclean with accumulated food debris and dried substances.During an interview on 04/13/26 at 11:15 AM, the DM confirmed the observed concerns with unclean food preparation equipment and areas that were identified during the initial inspection of the kitchen. The DM stated dietary staff were expected to follow the kitchen's cleaning schedule and keep all kitchen equipment and areas clean.3. During an observation on 04/14/26 at 12:37 PM, of items stored inside the 200 unit's resident refrigerator revealed, one opened 46 ounce container of honey consistency thickened water with an expired best if used by date of 12/29/25, one opened and undated 46 ounce container of nectar thickened orange juice with an expired best if used by date of 04/10/26, one opened and undated 32 ounce container of thickened orange juice, one opened and undated 32 ounce container of a fortified nutritional shake, and one opened and undated two pound and 14 ounce container of apple sauce. The refrigerator also contained five four-ounce cartons of nutritional supplements that were completely thawed. The containers were not dated to indicate the date they were thawed. The Manufacturer's instructions on the outside or the cartons specified to use within 14 days of thawing.During an observation and interview on 04/14/26 at 1:10 PM, the Director of Nursing (DON) observed and confirmed the opened and undated items and thawed and undated nutritional supplements that were stored inside the 200 unit's resident refrigerator. The DON stated food and beverages should be dated by staff when they are open and should be discarded when they have expired dates. The DON stated the housekeeping, dietary, and nursing staff were responsible for checking the resident refrigerators on the hallways.

Based on record review, observations, interviews, and testing and tasting of food served on a requested test tray, the facility failed to ensure food was palatable and served hot to seven of nine residents (Resident (R)8, R9, R23, R59, R70, R104, and R185) reviewed for food palatability out of a total sample of 31 residents. The failure had the potential to negatively affect 166 residents who consumed food prepared from the facility's kitchen by experiencing dissatisfaction with the meals, not eating the meals, and/or experiencing nutritional concerns. Findings include:1. Review of R8's quarterly Minimum Data Set (MDS) located under the MDS tab in the Electronic Medical Record (EMR), with an Assessment Reference Date (ARD) of 02/23/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 was cognitively intact.During an interview on 04/13/26 at 3:49 PM, R8 stated the food at the facility was always served cold. R8 specified at breakfast the eggs and grits were cold, and the food lacked flavor because it was not seasoned.2. Review of R9's quarterly MDS located under the MDS tab in the EMR, with an ARD of 03/06/26, revealed a BIMS score of 15 out of 15 which indicated R9 was cognitively intact.During an interview on 04/13/26 at 12:09 PM, R9 stated the food served at the facility did not taste good and was not hot. R9 specified she was served cold coffee at breakfast, and she would like for her food and coffee to be hot when served at meals.3. Review of R23's quarterly MDS located under the MDS tab in the EMR, with an ARD of 04/01/26, revealed a BIMS score of 14 out of 15 which indicated R23 was cognitively intact.During an interview on 04/13/26 at 1:30 PM, R23 stated he did not eat his lunch today because the food at the facility was not any good. R23 specified the food did not taste good and was not always hot. 4. Review of R59's quarterly MDS located under the MDS tab in the EMR, with an ARD of 02/04/26, revealed a BIMS score of 14 out of 15 which indicated R59 was cognitively intact.During an interview on 04/13/26 at 12:22 PM, R59 stated previously the facility's food was really good, but it had gotten worse and worse. R59 specified the facility's food was of poor quality, did not taste good and was not always hot when served. R59 also stated she was not always served cream and sweetener with her coffee.5. Review of R70's quarterly MDS located under the MDS tab in the EMR, with an ARD of 04/08/26, revealed a BIMS score of 15 out of 15 which indicated R70 was cognitively intact.During an interview on 04/13/26 at 12:55 PM, R70 stated the food at the facility frequently did not taste good and was served cold. R70 specified the hot cereal and eggs served at breakfast were not hot.6. Review of R104's quarterly MDS located under the MDS tab in the EMR, with an ARD of 04/07/26, revealed a BIMS score of 13 out of 15 which indicated R104 was cognitively intact.7. A review of R185's admission MDS found under the MDS tab in the EMR, with an ARD of 03/16/26, revealed the resident had a BIMS score of 13 out of 15, indicating the resident was cognitively intact. An interview with R185, on 04/13/26 at 11:33 AM, revealed the food is cold and offers no flavor. R185 stated the food is horrible.Review of the Resident Council Minutes provided by the facility from April 2025 until present revealed the following:04/29/25: Trays are coming out cold.05/27/25: Trays are coming out cold.12/30/25: Grilled cheese- burned for dinner Potato salad- not appetizing . Veggies- no flavor/mushy.01/27/26: Burgers are dry.During an interview on 04/13/26 at 11:54 AM, R104 stated the food served at the facility did not taste good and was not hot at most meals. R104 stated she would like her food to be hot at meals.In response to resident complaints about food, a test tray was requested to be sent to the facility's 100 hallway during the breakfast meal on 04/15/26. Review of the facility's 04/15/26 breakfast menu revealed scrambled eggs with cheese, choice of hot cereal or cold cereal, and hash browns were to be served at this meal. On 04/15/26 at 8:35 AM revealed a requested test tray was placed on an opened and unheated three shelf metal cart, with six other resident meal trays for the 100 hallway. Food temperatures monitored on the kitchen tray line prior to the test tray being prepared were at acceptable levels of 135 degrees Fahrenheit (F) and above for the hot foods. The food on the test tray was placed on an unheated plate and covered with an insulated dome lid prior to being placed on the open meal delivery cart. The meal delivery cart arrived at the 100 hallway at 8:37 AM. The last resident's breakfast tray was observed to be served on the 100 hallway at 8:54 AM. At this time, the food on the test tray was sampled in the presence of the facility's [NAME] President of Operations (VPO). A calibrated facility thermometer was utilized to obtain the temperatures of the food served on the test tray. The VPO also tasted the food served on the requested test tray with this surveyor. Temperature checks and tasting of the food served on the test tray revealed the following: a. The scrambled eggs on the test tray registered 105.6 degrees F. This surveyor tasted the scrambled eggs, and they were barely warm and tasted bland. The VPO tasted the scrambled eggs and agreed they were barely warm, needed to be hotter, and tasted bland. b. The grits on the test tray had begun to congeal and registered 116.3 degrees F. This surveyor tasted the grits, and they were slightly warm. The VPO tasted the grits and agreed they were slightly warm and needed to be hotter.c. The hash browns on the test tray registered 115.5 degrees F. This surveyor tasted the hash browns, and they tasted slightly warm. The VPO tasted the hash browns and agreed they were slightly warm and needed to be hotter.During an interview on 04/15/26 at 9:15 AM, [NAME] (C)1 stated he had been employed at the facility for eight months and prepared the food for the breakfast meal of 04/15/26. C1 confirmed scrambled eggs with cheese was on the facility's menu to be served during the breakfast meal of 04/15/26. C1 stated he did not add any cheese to the scrambled eggs served at the breakfast meal because no shredded cheese was available. C1 also stated during his employment at the facility resident meals had always been served on unheated plates because the kitchen did not have a plate warmer.During an interview on 04/15/26 at 4:00 PM, the facility's VPO stated the facility did not have a policy in relation to food palatability.

Based on observation, interview, record review, and facility policy review, the facility failed to protect residents right to privacy for two of three residents (Resident (R)24 and R122) who want engage in sexual relations. This failure had the potential to affect the current facility census of 173 residents. Cross reference to F550.Review of the facility policy titled, Residents Rights stated It is the policy of the company to ensure residents' rights are honored.Review of R24's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R24 was admitted to the facility on [DATE] with diagnosis of cerebral palsy and depression. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/26, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R24's care plan, dated 02/07/26, located under the Care Plan tab of the EMR, revealed that R24 was engaged in voluntary consensual sexual activities with another resident. Intervention in place included providing a private, non-confrontational environment for the two residents.Review of R140's Face Sheet located in the Profile tab of the EMR revealed R140 was admitted to the facility on [DATE] with diagnosis of absolute glaucoma, type 1 diabetes, and bilateral diabetic retinopathy.Review of R140's quarterly MDS with an ARD of 01/12/26, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R140's care plan, dated 02/07/26, located under the Care Plan tab of the EMR, revealed that R140 was engaged in voluntary consensual sexual activities with another resident. Intervention in place included providing a private, non-confrontational environment for the two residents.During an observation on 04/13/26 at 11:37 AM R24 and R140 were engaged in a sexual activity in R140's room where R140's roommate (R122) was present at the time. When Licensed Practical Nurse (LPN) 4 was called to R140's and R122's room, she stated, .R24 and R140 have signed consents that they can engage in sexual activity. LPN4 stated when resident requested a private moment staff would just close the door to give them privacy because they were supposed to have a designated area but they didn't know exactly where.During an interview on 04/13/26 at 12:08 PM, the Administrator and the Director of Nursing (DON) stated, .We heard about what you witnessed. This has been a problem for a while now. The staff has in-service training about this. R24 and R140 are care planned for this sexual activity. No additional information was relayed during the interview. During an interview on 04/13/26 at 2:38PM Certified Nursing Assistant (CNA) 4 stated, About three weeks ago, I found them [R24 and R140] having sex, the roommate was in the room at the time and she was alert. This happens all the time, this is not the first time, and everybody is aware, I have reported it to the nurse. We don't know what is right or what the instructions are because not everybody is on the same page. The roommates have told other staff and other residents that they are not ok with this. The facility has not told us about a designated area for them to be. They were doing it in any room. This designated place has not been set in place until state showed up today.During an interview on 04/14/26 at 12:36 PM, R24 stated .We only had a room when there was an empty room, but when that room gets filled, we don't have a room to be intimate or have sex.During an interview on 04/14/26 at 12:41 PM, R140 stated .They only gave us an empty room and that makes me mad because they said they were going to give us a room when we want to do something like be intimate.

Based on observation, interview, record review, and facility policy review, the facility failed to protect the resident's rights to dignity and respect for one of three residents (Resident (R)122) when they failed to ensure the resident's roommate did not have sexual relations in his presence. This failure had the potential to affect the current facility census of 173 residents. Findings Include:Review of the facility policy titled, Residents Rights stated It is the policy of the company to ensure residents' rights are honored.Review of R122's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R122 was admitted to the facility on [DATE] with diagnosis of cerebral infarction affecting right dominant side, dysphagia, and tracheostomy status. Review of R122's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/26/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) scored a 12 out of 15 indicating the resident was moderately impaired R122's seems or appears to recall after five minutes which indicated the resident was cognitively intact. Review of R122's care plan, located under the Care Plan tab of the EMR, dated 03/01/24 indicated, the resident is able to communicate by: using communication board, gestures, and uses his toes to communicate. On 08/01/24, the care plan, revealed that R122 had a communication problem related to stroke with intervention in place included to monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed.During an observation on 04/13/26 at 11:37 AM, R24 and R140 were engaged in a sexual activity in R122 and R140's room. R24 had her head down in R140's genital area while doing oral sex. When Licensed Practical Nurse (LPN) 4 was called to R140's and R122's room, she stated, .R24 and R140 have signed consents that they can engage in sexual activity.During an interview on 04/13/26 at 12:08 PM, the Administrator and the Director of Nursing (DON) stated, .We heard about what you witnessed. This has been a problem for a while now. The staff has in-service training about this. R24 and R140 are care planned for this sexual activity.During an interview on 04/13/26 at 2:38PM Certified Nursing Assistant (CNA) 4 stated, . There was a time when I was working unit one about three weeks ago, I found them [R24 and R140] having sex, the roommate was in the room and she was alert. This happens all the time, this is not the first time, and everybody is aware. I have reported it to the nurse. We have told the management, and we do not know what is right or what the instructions are because everybody is not on the same page. The roommates have told other staff and other residents that they are not ok with this. The facility has not told us about a designated area for them to be. They were doing it in any room. This designated place has not been set in place until the survey team showed up today. During an interview on 04/13/26 at 6:24 PM, R122 nodded yes when asked the following questions, when asked if he felt disrespected, did he feel his dignity and respect was violated, and when the presence and sounds of sexual activity were happening bothered him. The interview ended by R122 was asked to press his call bell to indicate understanding and they were able to.

Based on a review of facility policy, record review, observations and interviews, the facility failed to ensure the call light was within reach for one of eight residents Resident (R)180, resulting in an unsafe environment with the potential for delayed assistance. Findings include:A review of the facility policy titled, Call Lights, effective 09/01/24, stated call lights are to be always kept within reach of residents.A review of the admission Record found under the Profile tab in the electronic medical record (EMR), revealed R180 was admitted on [DATE] with diagnoses including morbid obesity, obstructive sleep apnea, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and acquired absence of the right leg below the knee.A review of R180's admission Minimum Data Set (MDS) found under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 03/20/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The resident was also assessed as being dependent on staff for toileting, hygiene, showers/baths, dressing, and bed/chair transfers.A review of R180's Care Plan found under the Care Plan tab in the EMR, dated 03/17/26, revealed the focus of risk for falls related to medications that may cause dizziness, loss of balance, or impaired judgment, and physical impairments affecting balance and ambulation. Interventions included ensuring the call light was within reach and encouraging the resident to use it.An observation, on 04/13/26 at 9:35 AM, revealed R180 in bed with the call light on the floor beside the bed. An interview with R180 on 04/13/26 at 9:36 AM, revealed the call light is unable to be reached when it falls on the floor. R180 stated the call light is on the floor every morning when she wakes up.An interview with Licensed Practical Nurse (LPN)2 on 04/13/26 at 9:37 AM, confirmed the call light should always be within reach of the resident. The nurse verified the call light was on the floor and placed it on the resident's bed.An observation of R180 on 04/13/26 at 1:35 PM, revealed the resident was in bed with the call light on the floor.An interview with LPN2 on 04/13/26 at 1:38 PM, revealed the call light was not within reach and stated she would investigate alternative methods to secure it to the bed.An observation and interview with R180 on 04/14/26 at 7:38 AM, revealed the resident was in bed with the call light on the floor. R180, confirmed she could not reach the call light.An interview with Certified Nursing Assistant (CNA)1 on 04/14/26 at 7:41 AM, revealed the call light should always be within reach of the resident. CNA1 verified the call light was on the floor and placed it in the resident's bed.An interview with the Director of Nursing (DON)on 04/15/26 at 9:41 AM, revealed call lights should always be within reach. The DON stated R180 frequently uses the call light for assistance. The DON stated further measures would be taken to ensure the call light remains secure and accessible.

Based on review of facility policy, observation, record review and interview, the facility failed to ensure Resident (R)1 was free from misappropriation of a narcotic medication for 1 of 4 residents reviewed for misappropriation. Findings include: Review of the facility policy dated 11/26/24, titled, Abuse, Neglect and Exploitation revealed under the policy, Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a residents belongings or money without the residents consent. Review of R1's Facesheet revealed she was admitted to the facility on [DATE], with diagnoses that include, but not limited to: polyneuropathy, paraplegia, and anxiety. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact. Review of R1's Medication Monitoring/Control Record revealed, Percocet 10/325 milligrams (mg) take one by mouth twice daily. The date received was 01/23/25, and amount received was 30 tablets. Two of the Percocet were signed off as administered by Licensed Practical Nurse (LPN)1 on 01/22/25, the first entry time was 9:10 AM, and the second entry time was 9:00 PM. The remaining amount of Percocet was 28 tablets. Further review of the Medication Monitoring/Control Record dated 01/23/25, recorded Percocet was also signed off as administered by LPN1 at 9:15 AM, and by LPN2 at 8:35 PM. Review of R1's Medication Administration Record (MAR) dated 01/22/25, revealed Percocet was signed as administered by LPN1 on 01/21-23/25 at 9:00 AM. Review of the MAR on 01/21/25 and 01/22/25, revealed Percocet was signed as given by LPN2 at 9:00 PM. Additionally, the MAR revealed at 9:00 PM on 01/21/25 and 01/22/25, was coded with a 2. The chart codes for 2 revealed Drug Refused. Review of a Pharmacy Packing Slip Proof of Delivery revealed R1's Percocet was delivered to the facility on [DATE] at 1:06 AM. Review of an undated statement from LPN1 revealed R1 had zero tablets left on 01/21/25. Her medication came in on 01/22/25. It also stated she could not understand why LPN2 didn't understand, but the count was correct. Review of a Disciplinary Action Form dated 01/29/25, revealed LPN1 was terminated due to failure to follow Medication Administration Policy. During an interview on 03/05/25 at 1:30 PM, the Administrator stated she had to investigate this and stated she relied on nursing because she didn't understand the nursing aspect of nurses passing medication and had to keep asking questions. The Administrator stated what LPN1 said didn't make sense because her story changed a few times, she originally reported to the Nurse Practitioner (NP) that she made a medication error and gave R1's medications to another resident. LPN1 told me that as well, then she said it was the other resident that she accidentally gave the medication to. The Administrator further stated, I terminated her because her story kept changing. I don't think it was a medication error. She confirmed 2 Percocet were missing and could not be accounted for. During an interview on 03/05/25 at 2:01 PM, LPN2 stated, When I came on shift, I asked [LPN1] if [R1's] medication Percocet had come in. She said yes. I looked at the narcotic sheet. I pointed out to [LPN1] that two of the medications were signed as given on 01/22/25 and I asked her why. LPN1 said she made a med error. Her story changed several times and then said it was a different nurse. I said we need to speak to the Director of Nurses (DON). She then said she made a medication error and had to call the NP. So she called her. After, the conversation, I called my DON. She told me LPN1 called the NP and said she made a med error. The NP had already called the DON, supposedly about a med error. Looking at the narcotic sheets, she confirmed the last time the Percocet was given was dated 01/20/25 x2 that day. She confirmed the Percocet ran out. She said, We've been told in the past that we cannot document 8 - Medication Not Available. So, I didn't, that's why I coded the 2, which I should not have coded it that way. An attempted phone interview on 03/05/25 at 2:03 PM, with LPN1 was unsuccessful. During an interview on 03/05/25 at 2:33 PM, R1 stated, I take Percocet twice a day, 9 PM and 9 PM. R1 further stated, I remember being out of my Percocet in January, it was for a couple days. I told the nurses I was in pain. They gave me Tylenol. Tylenol only takes away a headache, it doesn't relieve my pain, I have nerve damage on my right side, back and front.

Based on interview, record review, and review of facility policy, the facility failed to accurately document Resident (R)110's wishes to be a full code; and failed to periodically review code statuses for R110, for 1 of 36 sampled residents reviewed for code status. This failure placed the resident at risk of not receiving life saving measures. On [DATE] at 8:56 PM, the Administrator was notified that the failure to accurately reflect a residents code status in the medical record, in accordance with the resident's wishes, constituted Immediate Jeopardy at F578. On [DATE] at 8:56 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.10 - Resident Rights. On [DATE] at 6:39 PM, the facility provided an acceptable plan for removal of the IJ. The survey team validated the IJ was removed on [DATE] at 1:00 PM, following the facility's implementation of the plan for removal of the IJ. The facility remained out of compliance at F578 at a lower scope and severity of D. Findings include: Review of the facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, with a copyright date of 2024, documented it was the facility policy to support and facilitate a resident's right to formulate an advanced directive. Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process. Any decisions will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of the Admission record located under the Profile tab of the EMR revealed R110 was admitted to the facility on [DATE]. Review of R110's quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of [DATE], identified R110 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he was cognitively intact and capable of making his own decisions. Review of R110's electronic medical record (EMR) revealed his code status on the dashboard of the EMR was marked as a Do Not Resuscitate (DNR). Review of R110's Physician Orders located in the Orders tab of the EMR, revealed an order for DNR with an order start date of [DATE]. Review of a document titled [Facility Name] located in the Documents tab of the EMR, documented, Please indicate your choice by checking the appropriate statement the choices were Full Code or Do Not Resuscitate. The resident check marked Full Code and next to the words full code it revealed I request that if (Resident's Name) has sudden failure of a vital function that emergency medical measure be used to restore the function. The form was signed by the resident and a facility representative with signature dates of [DATE]. Review of R110's Plan of Care located in the Care Plan tab of the EMR, revealed R110 had a Focus area of Advanced Directives which revealed he was a DNR with an initiation date of [DATE] and a revision date of [DATE]. During an interview on [DATE] at 5:37 PM, Licensed Practical Nurse (LPN)7 was asked what she would do if R110 was found without vital signs. LPN7 stated she would check the EMR for his code status. LPN7 checked the EMR and stated he was a DNR and therefore she would not start cardiopulmonary resuscitation (CPR). During an interview on [DATE] at 5:38 PM, LPN3 was asked what she would do if R110 was found without vital signs. LPN3 stated she would check the EMR for his code status. She checked the EMR and stated he was a DNR and therefore she would not start CPR. During an interview on [DATE] at 5:41 PM, R110 stated he wanted to be resuscitated and he stated he wanted to be Full Code and he wanted to be resuscitated. When asked, he also stated he would want to be sent to the hospital if needed. During an interview on [DATE] at 2:52 PM, the Administrator stated this resident had the order in place since [DATE] and confirmed it had been incorrect since [DATE]. On [DATE] at 6:39 PM, the facility provided an acceptable plan for removal, which included the following: 1. Immediately upon notification resident #110 Code Status medical record was updated to reflect their Advance Directive Form. 2. All residents have the potential to be affected by this alleged deficient practice. 3. On admissions all residents will be listed as full code unless documented is provided. The Interdisciplinary team will review advance directives quarterly and annually. All new admissions will be reviewed daily x 4 weeks, then weekly x4 weeks, then x1 month thereafter, in effort to ensure substantial compliance. Random audits will be reviewed daily x 4 weeks, then weekly x 4 weeks, then 1 month thereafter. 4. Director of Nursing (DON)/Designee conducted a facility-wide assessment to determine if any other residents were affected by this alleged deficient practice. Any identified concerns were immediately corrected. The DON/Designee reeducated all licensed practical nurses and registered nurses to review code status order entry on the third shift. Any staff not currently working will be educated prior to the start of next shift. All Licensed Nursing staff were educated by the Director of Nursing/Designee on [DATE], the outcome of the Immediate Jeopardy ensuring that Residents have the right to formulate advanced directives. Any staff not currently working will be educated prior to the start of the next shift until all staff have been educated. 5. DON/Designee will complete random audits using a Advance Directive audit tool for all new admissions. Random audits to be conducted daily x4 weeks, then weekly x4 weeks, then x1 month thereafter, in effort to ensure substantial compliance. Any negative findings will be corrected immediately, and this will be discussed at the Facility monthly Facility Quality Assessment and Performance Improvement (QAPI) meeting. Plan of removal date: [DATE], 9:00 am.

Based on observation, interviews, and facility policy review, the facility failed to ensure sanitizer was at a strength to sanitize the counters; ensure pans, utensils, equipment, and food preparation counters were clean and sanitized; ensure food was labeled and dated and disposed of by the use by date; ensure food was refrigerated after opening in accordance with the manufacturer's instructions; ensure hand washing between touching soiled objects and returning to serving; and ensure the outside of food and spice containers were clean with the potential to affect 151 of 157 census residents consuming food out of 1 of 1 kitchen. Failure to store, prepare, and distribute under sanitary conditions had the potential to result in cross contamination of food and food borne illness. Findings include: Review of the facility's policy titled, Use and Storage of Food Brought in by Family or visitors with a revised date of 01/01/25, revealed food placed in the resident refrigerators must by labeled and dated and consumed within three days and any foods older than three days would be discarded. Review of the facility's policy titled, Handwashing Guidelines for Dietary Employees with a copyright date of 2024, revealed employees must wash their hands after touching anything unsanitary. Review of the facility's policy titled, Sanitation Inspection with a copyright date of 2024, revealed all areas of the kitchen would be kept clean and sanitary. Review of the facility's policy titled, Date Marking for Food Safety with an implementation date of 12/13/24, revealed refrigerated ready to eat food shall be held at a temperature of 41 degrees or less for a maximum of seven days; food shall be clearly marked with the date the food should be consumed or discarded; and food should not exceed the manufacturer's use-by date or four days which ever is earliest. Review of the facility's policy titled, Food Safety Requirements with an implementation date of 12/01/24, revealed food will be stored, prepared, and distributed and served in accordance with professional standards for food service safety. The policy stated food should be stored in a manner that helps prevent deterioration or contamination of the food, including the growth of microorganisms. Staff should wash hands between contact with soiled objects and food. The policy stated all equipment used in the handling of food should be cleaned and sanitized and handled in a manner to prevent contamination. 1. During an observation of the kitchen on 01/08/25 with the Dietary Manager (DM) from 10:08 AM through 10:54 AM the following food service equipment/areas were observed to be soiled and in need of cleaning: a) The shelf under the coffee pot and the shelf under the sheet pan racks were covered with aluminum foil. The foil was visibly soiled with dust and what appeared to be dried food residue. b) A Robo coupe food processor and a five-gallon container of Clear Canola Salad Oil were stored on a soiled shelf below a food preparation counter located next to the food storage room. The outside of the oil container was visibly soiled with what appeared to be spilled oil; the food processor was soiled with what appeared to be dust and food crumbs; and the shelf was soiled with oil and what appeared to be food crumbs. The DM stated they did not use the food processor anymore and verified the observation. c) The bottom of two drawers containing food utensils was visibly rusty and soiled with food particles. The drawer contained two food scoops that had visibly dried food on them. The DM verified the observation and verified the utensils were not properly cleaned prior to being placed in the drawer. 2. During an observation of the kitchen and interview on 01/08/25 at 10:24 AM, the red containers of sanitizing solution with a wiping cloth in it tested at zero (0) parts per million (ppm). [NAME] (C)1 stated she was using it to clean off the food preparation counters. The Registered Dietitian (RD) assisted with obtaining the sanitizer level of the solution and verified it was zero ppm. During an observation and interview on 01/10/25 at 10:54 AM, two red containers of sanitizing solution located under the food preparation counter located across from the 3-compartment sink were tested by the DM. They both tested to be zero parts per million. [NAME] 3 stated they were using it to clean the counter. One of the containers had a cloth in it. [NAME] 3 stated he thought he put the sanitizer in the container at 9:15 AM that morning. The DM stated the solution should be good for at least four hours. Review of the manufacturer's instructions located on the Oasis 146 Multi-Quat Sanitizer revealed the sanitizer should be 150 to 400 ppm to sanitize food contact surfaces. 3. During an observation on 01/08/25 at 10:29 AM, the dry food storage room located off the main kitchen was inspected with the DM and the RD. The storage room contained the following items: a) Two open unsealed boxes of kosher salt were not dated to indicate when they were opened and one of the boxes was visibly soiled on the outside of the box with what appeared to be an oily substance. The DM stated the boxes should have had an open date and should have been sealed closed once they were opened. b) Sixteen (16) 16-ounce containers of spices that had been opened and partially used revealed the outside of each of the containers were visibly soiled with what appeared to be dried food substance and five of the containers felt greasy to the touch. c) Two-16 ounce open and partially used containers of paprika had a use by date of 07/12/23. The containers were not labeled with the date they were opened and one of the containers had the lid open exposing it to potential cross contamination. d) Two-one gallon open and partially used containers of Kens Home Style Ranch dressing revealed the outside of both containers was heavily soiled with spilled salad dressing and the date of 12/05/24 was marked on the containers with a black marker. The DM stated the 12/05/24 date was the date the containers were opened and placed in the food storage room. The manufacturer's instructions stated to keep refrigerated after opening. The RD and DM verified the salad dressing should have been refrigerated after it was opened, and the outside of the container should have been cleaned prior to storing it. e) One - one gallon opened partially used container of Kikkoman Teriyaki sauce had an open date of 01/18/24 marked on it with a black marker. The manufacturer's instructions on the label stated refrigerate after opening. f) A 16-ounce box of Peace Mining Belgian Waffle mix had an opened date of 12/28/24. The box was open to the air and not sealed shut. 4. During an observation of the 300-unit and interview on 01/08/25 at 10:54 AM, the resident food storage refrigerator located behind the nursing station on the 300 unit was inspected with the RD. The refrigerator did not have a thermometer in it therefore it was not possible to determine if it was maintained at a safe temperature level. The refrigerator contained three-two (2) ounce bags of sliced apples with expiration dates of 12/29/24; an undated/unlabeled plastic grocery store bag containing bread and chips; and an undated unlabeled pizza box. 5. During an observation of the 200-unit and interview on 01/08/25 at 10:56 AM, the resident food storage freezer and refrigerator located behind the nursing station on the 200 unit was inspected with the RD. The refrigerator contained an undated bag with three restaurant style food containers and a quart of open tomato juice. The tomato juice was one quarter full; did not have an open date; and had an expiration date of 12/21/24. The refrigerator also contained 18 four-ounce cartons of Mighty Shake nutritional supplements. The shakes were completely thawed. The containers were not dated to indicate the date they were thawed. The manufacturer's instructions on the outside of the containers stated to use within 14 days of thawing. 6. During an observation of the 400-unit and interview on 01/08/25 at 11:10 AM, the resident food storage freezer and refrigerator located behind the nursing station on the 400-unit was inspected with the RD. The refrigerator contained one four-ounce carton of Mighty Shake nutritional supplement. The shake was completely thawed. The container was not dated to indicate the date they were thawed. The manufacturer's instructions on the outside of the container stated to use within 14 days of thawing. 7. During an observation of the 100-unit and interview on 01/08/25 at 11:10 AM, the resident food storage freezer and refrigerator located behind the nursing station on the 100 unit was inspected with the RD. The refrigerator contained 24 completely thawed Mighty Shakes with no thaw dates on the containers; an open 32-ounce jar of apple sauce with an open date of 11/25/24; and an undated unlabeled KFC bag containing chicken. 8. During an observation of the kitchen and interview on 01/10/25 at 11:10 AM there was a tray with cups of ice sitting on top of a three-shelf chart. The DM stated they were prepared for the noon meal. The shelves of the cart were soiled with dried residue and the bottom shelf had a black build up. He verified the cart should have been cleaned and sanitized prior to use. 9. During an observation of the kitchen and interview on 01/10/25 at 11:12 AM, the large metal cart next to the three-compartment sink and across from the dishwasher had Clean steam table pans stacked together on it. Four of the six pans checked where stacked together wet and soiled with a white wet residue resembling food. The DM verified this and stated the pans on the rack should have been clean and allowed to dry prior to stacking them. 10. During an observation of the kitchen and interview on 01/10/25 at 12:11 PM, [NAME] 1 took a plate to the soiled end of the dishwasher and rinsed the plate off using the water sprayer with her gloved hands. She placed the plate on the counter at the soiled end of the dishwasher and then returned to the steam table and continued serving the noon meal touching the plates and the utensils without changing her gloves. On 01/10/25 at 12:14 PM the DM stated he would have expected [NAME] 1 to remove her soiled gloves and put on clean gloves after touching the soiled sprayer and prior to returning to serving. 11. During an observation of the 400-unit and interview on 01/10/25 at 12:24 PM the closed metal food cart containing residents' noon meal trays arrived at the 400 unit. The 400-unit cart containing the resident's meal trays was visibly soiled on the rungs and on the bottom were the rungs attached to the cart. The black substance was sticky to the touch. The DM verified the cart contained the meal trays that the kitchen had just prepared and that it was not clean prior to the staff placing the residents' trays in it. He stated he would have expected the carts to be cleaned and sanitized between meals. He stated they use the carts to deliver the trays to the unit and then the soiled trays are placed back in the cart after the residents are finished eating.

Based on observation and interview, the facility failed to ensure the laundry room equipment was clean, which included two large washing machines, six dryers, one fan, the windowsill, items lying directly on the floor or in a plastic bag on the floor, and a dusty laundry chute for 1 of 1 laundry room. Findings include: Observations on 01/09/25 at 11:57 AM, in the laundry room revealed the following: 1. The designated dirty area revealed: -The two large washing machines, which were next to each other had white dried material, gray grime, and dust on the outside of the machines. -There was a fan that was positioned directly on the floor, which was caked with dust and grime. -There was a blue bin directly on the floor that had dust and black material inside the bin and a glove. -There was one large plastic bag that was partially ripped with pillows partially in the bags, and the bag was lying directly on the floor. There were three pillows not in plastic bags, two were lying directly on the floor. -There were a few paper towels and two gloves lying on the floor. -There were six blankets that were stacked on top of each other and the bottom blanket was lying directly on the floor. -The outside of the laundry dispenser that contained the detergents was located on the wall near the drain and was caked with dust and grime. -There was a large plastic bag filled with clean wash cloths lying directly on the floor in the dirty laundry room. 2. The designated clean area revealed: -The six dryers had a moderate amount of dust on the top of the dryers. -There was a silver cart in the clean area of the laundry room that had a microwave and coffee pot on top of the cart, coffee and coffee filters and other items on the second shelf of the cart. --The top and second shelf on the cart were very dusty. -The refrigerator and hot water heater were very dusty. -The one windowsill in the laundry room was caked with dust. 3. The laundry chute that was located in another area and was filled with a large amount of dust with dust strings hanging from the inside of the chute. During an interview on 01/09/25 at 11:57 AM, Laundry Aide (LA)1 confirmed the above findings. LA1 stated there was not enough space between the two washing machines to clean the machines properly. She stated the staff cleaned the outside of the washing machines and dryers when they had time. LA1 stated none of them were tall and they could not reach on top of the machines where a lot of dust accumulated and could not reach the upper sides of the machines. She stated the laundry staff were responsible for keeping the cart clean and stated she did not know when the cart was last cleaned. LA1 stated the other two fans that were mounted on the walls were cleaned by maintenance and he had not cleaned the fan on the floor. She stated the blankets that were lying on the floor were used by the ambulance staff when transporting residents to the facility; they cleaned the blankets, and the ambulance staff periodically picked them up. LA1 stated the staff were not able to clean the laundry dispenser machine because they could not get adequate access to the area due to the area around the drain had partially deteriorated and it was not safe to step on. LA1 stated the bag of clean wash cloths was an emergency supply for the upcoming storm in case of electrical issues. LA1 stated clean items, such as the washcloths and ambulance blankets, were not to be stored in the dirty laundry area. She stated the last time there was a deep cleaning in the laundry was the summer of 2024, which included the laundry chute. LA1 stated the laundry room was dusty, dirty, and needed to be deep cleaned. During an interview on 01/09/25 at 12:32 PM, the Housekeeping Supervisor (HS) stated there was no set schedule for the cleaning of the laundry room. He stated three weeks ago that one of the laundry staff told him the laundry chute needed to be cleaned. The Housekeeping Supervisor stated he had observed the laundry chute and confirmed it needed to be cleaned with compressed air. He stated the laundry chute was to be checked weekly and cleaned monthly. The HS stated he did not know when the laundry chute had been last cleaned. He stated nothing was to be stored directly on the floor and the clean blankets used by the ambulance staff and the washcloths were to be kept in the clean part of the laundry room. The HS stated fans, carts, dryers, washing machines, and other equipment were to be kept clean. He stated the area around the drain needed to be safe for staff to step on to replace the cleaning agents in the dispenser.

Based on observation, interviews, and facility policy review, the facility failed to ensure a clean, comfortable, homelike environment related to the rooms and common areas not being maintained in clean conditions for 3 of 4 units (100 unit, 200 unit, and 300 unit). Failure to maintain a clean homelike environment has the potential to result in resident dissatisfaction with their living conditions and increased depression. Findings include: Review of the facility's policy titled, Cycle Cleaning with a copyright date of 2024, revealed it was the facility policy to identify the functional areas in the facility that require cleaning and to use the cleaning schedules to maintain regularly scheduled environmental service tasks and it was the responsibility of the Environmental Services Manager to ensure cleaning was maintained. 1. During intermittent observations conducted over four days of the survey (01/08/25 through 01/11/25) the bottom portions of the walls on the 300 unit were soiled with scuffs up and down the length of the corridors and there was a dark brown build up on the floor along the baseboards; there was heavy dirt build up on the floor around the door frames to the kitchen and the employee lounge. 2. During an observation on 01/08/25 at 3:14 PM, and on 01/10/25 at 10:05 AM, there was a water stained and drooping ceiling tile in the corridor leading to the shower room across from room [ROOM NUMBER]. The stain was brown and appeared to be from a leaking pipe or leaking roof. 3. During an observation on 01/08/25 at 12:43 PM, and on 01/10/25 at 10:05 AM, resident room [ROOM NUMBER] had dirt built up along the walls, vents, and under the closets. The top of the baseboard type heater had a build up of dust and debris. 4. During an observation on 01/08/25 at 12:34 PM, and on 01/10/25 at 10:09 AM, the bathroom off of room [ROOM NUMBER] had a buildup of dirt along the walls and behind the toilet. 5. During an observation on 01/08/25 at 11:11 AM, and on 01/10/25 at 10:12 AM, the floor in front of the refrigerator located behind the nursing station on the 200 unit had a heavy build up of black dirt in front of it. 6. During an observation on 01/08/25 at 11:17 AM, and on 01/10/25 at 10:12 AM, the floor under and on the side of the ice maker and in front of the refrigerator on the 100 unit had a build-up of dirt. The wall to the side of the refrigerator was soiled with what appeared to be dried spilled residue. During observation and interview on 01/10/25 from 9:50 AM through 10:15 AM, the units were toured with the Maintenance Director and the Housekeeping Supervisor (HS). They verified each of the above observations. The HS verified the areas described above were soiled and in need of cleaning and stated it would be his expectation that the areas be clean and well maintained.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the menu was followed for 2 of 2 residents, who wish to remain anonymous, of 36 sample residents. Failure to follow the menu had the potential to result in weight loss, resident dissatisfaction, and resident hunger with the potential to affect 151 of 157 residents consuming food in the facility. Findings include: Review of the facility's policy titled, Menus and Adequate Nutrition with a revised date of 01/01/25, revealed menus must be posted in the kitchen and in an area accessible to all residents at least one week in advance. The policy stated the menus will be followed as posted. Review of the menu titled, 2022-23 F/W [Fall/Winter] Menus .Week: 2 revealed the facility was supposed to serve the residents on regular diets, low concentrated sweets diets, and liberal renal diets three ounces of buttered corn and two hushpuppies along with their lunch meal. Residents on the mechanical soft diet were supposed to receive four ounces of seasoned carrots and a dinner roll. Residents on puree diets were to receive two ounces of puree bread with the noon meal on 01/10/25. During an interview on 01/08/25 at 11:49 AM, a resident wishing to remain confidential, stated the food was not appetizing, she did not get the food on the menu or what she requested, and the food was often cold. During an interview on 01/08/25 at 12:47 PM, a resident wishing to remain confidential, stated the menu was not followed and the food was not hot about 75% of the time. During an observation and interview on 01/10/25 at 11:36 AM, [NAME] 2 placed the serving utensils in the food items on the steam table. She placed a 3-ounce scoop in the corn, a 3-ounce scoop in the lima beans, and a 3-ounce scoop in the puree lima beans. She did not have carrots on the steam table and when queried about why she gave the mechanical soft and purees lima bean and not carrots she stated she just decided to make the change without any additional explanation. At 11:59 AM, she began serving the noon meal using the above scoops. On 01/10/25 at 12:14 PM after she completed serving the unit 300 cart and the first cart to unit 400, the Dietary Manager (DM) was asked to check the scoop sizes. He verified the scoop in the corn, lima beans, and puree lima beans were 3-ounce scoops and should have been a 4-ounce scoop. After he was asked about the scoop sizes, he switched the 3-ounce scoop into the corn with a 4-ounce scoop and left the 3-ounce scoop in the lima beans. During the meal service, no rolls or hushpuppies were observed on the tray line and were not on the residents' trays. During an interview on 01/10/25 at 12:24 PM, [NAME] 2 was asked if she was supposed to serve bread with the meal and she stated she was supposed to give the residents two hushpuppies or a roll and she stated she forgot to prepare the hushpuppies and rolls and stated she did not give them to any of the residents.

Based on observations, record review, interviews, and facility policy review, the facility failed to maintain all electrical outlets in safe operating conditions for 4 of 4 resident rooms and 7 of 7 residents (Resident (R)68, R39, R54, R15, R82, R11, and R7) reviewed of 36 sample residents. Failure to ensure residents had functioning outlets in their rooms resulted in the residents not being able to watch their televisions, charge their devices, or run their refrigerators. Failure to ensure the outlet covers are not in disrepair exposing the wires had the potential to result in shock of a resident or employee. Findings include: Review of the facility's policy titled, Electrical Safety implementation date of 01/01/25, revealed it was the facility policy for the Maintenance Director (MD) or designee to inspect and test electrical components. The policy stated hazards or other conditions that could develop into a hazard must be reported to a supervisor or MD as soon as practical. 1. During observations on 01/08/25 at 12:43 PM and 3:16 PM, on 01/09/25 at 12:12 PM, and on 01/10/25 at 10:02 PM, the outlet cover over R68's bed was observed to be broken with a fourth of the cover missing exposing the outlet. During an interview on 01/10/25 at 10:02 AM, the MD verified the outlet cover was broken. 2. During an observation and interview on 01/08/25 at 5:47 PM, R39's family member (FM)1 was interviewed. During the interview it was noted the cords to the tube feeding pump and the electric bed were strung across the room. FM1 stated that it was the only outlet that worked in the room. She stated that because the other outlets did not work R39 was not able to have his television (TV), or his refrigerator plugged in. She stated the outlets had been messed up about a month or more. She stated they used to watch TV together in the room but now they go to the lounge to watch TV. She stated the room next door also had outlet problems and at times they would have an extension cord plugged into an outlet in the hall for the room. The bed and the tube feeding pump were also observed plugged into the outlet over the TV on 01/09/25 at 12:05 PM and at 5:00 PM. During an interview on 01/09/25 at 3:31 PM, the Ombudsman stated there was a concern in the facility related to the electric outlets not working in some of the residents' rooms. During an interview on 01/10/25 at 9:39 AM, the MD was interviewed about the outlets. He stated he was just notified on Monday 01/06/25 of the outlets not working and he checked all the rooms and found the outlets did not work in three rooms. He stated an electrician came in on 01/07/25 and verified the outlets did not work. He provided a letter titled Accu-Mechanical which revealed the technician came to the facility on [DATE] and was trying to find the cause of the electrical problem. According to the letter they were preparing an estimate to update the wires and the receptacles. Review of the Daily Census report, dated 01/08/25, revealed R39, R54, R15, R82, R11, and R7 resided in the three rooms with the non-functioning outlets. During an interview on 01/10/25 at 10:05 AM, R54 was sitting in the dining room watching TV. She stated none of the outlets in her room have worked for over a month. She stated as a result she had to watch TV and charge her phone in the dining room. She stated if the outlets worked, she would watch TV in her room. She stated she had informed several employees of the outlets not working but did not provide any specific employee names. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 10/02/24 and located in the MDS tab of the electronic medical record (EMR) identified her as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating she was cognitively intact. During an interview on 01/11/25 at 10:50 AM, Licensed Practical Nurse (LPN)9 stated the electrical outlets in the affected rooms had not functioned for at least a couple of weeks. She stated when it first occurred it involved the rooms, the hallway, and the dietary department. She stated they got the power working in the hallway and the dietary department, however the outlets in three of the rooms continued to not work. She stated, she called the MD and left a message on his cell phone about the issue a couple of weeks ago. During an interview on 01/11/25 at 11:02 AM, R15 stated the outlets in her room have not functioned for the past three to four weeks. She stated she liked to watch TV and if they did work, she would watch TV in her room at times. Review of R15's quarterly MDS located in the MDS tab of the EMR with an ARD of 08/14/24, identified her as having a BIMS score of 15 out of 15 indicating she was cognitively intact. During a telephone interview on 01/11/25 at 12:45 PM, LPN10 was asked if she was aware of any electrical outlets that did not work. She stated she was, and she stated the problem had started about a month ago and when asked if it was reported she stated it had been and stated R45 had told numerous staff members about it.

26190 Based on record review, interview and facility policy review, the facility failed to provide appropriate Activities of Daily Living (ADLs) for residents to maintain adequate personnel hygiene for 2 of 2 residents (Resident (R)145 and R115) reviewed for ADLs of 36 sample residents. Findings include: Review of the facility's undated policy titled, Activities of Daily Living (ADLs) documented, .Care and services will be provided for the following activities of daily living: 1. Bathing . Policy Explanation and Compliance Guidelines .2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .personal .hygiene . Review of the facility's undated policy titled, Resident Showers documented, Policy: It is the practice of this facility to assist residents with bathing to maintain proper hygiene .Policy Explanation and Compliance Guidelines: 1. Residents will be provided showers as per request or as per facility schedule protocols . Review of the facility's policy titled, Nail Care, dated 2023, documented Routine cleaning and inspection of nails will be provided during Activities of Daily Living (ADL) care on an ongoing basis. Routine nail care to include trimming and filing will be provided on a regular schedule .Nail care will be provided between scheduled occasions as the need arises. The resident's care will identify: the frequency of nail care to be provided, the person responsible for providing nail care .Nails should be kept smooth to avoid skin injury. Only licensed nurse shall trim or file fingernails of residents with diabetes. 1. Review of R145's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R145 was admitted to the facility on [DATE], with diagnoses including but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, heart failure, chronic obstructive pulmonary disease, bipolar disorder, and major depressive disorder. Review of R145's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/09/24, located under the Resident Assessment Instrument (RAI) tab indicated R145 was set up assist with eating; dependent for lower body dressing; substantial/maximum assist for upper body dressing and showering/bathing; and partial/moderate assist for bed mobility. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R145 was cognitively intact. Review of Unit 1's Shower Sheet binder, provided by the facility, indicated R145, since her admission on 12/02/24, received a shower/bath on the following dates: 12/13/24 and 12/30/24. Review of the shower schedule that was posted in the binder revealed room [ROOM NUMBER] (R145's room) was to receive a shower on Monday/Wednesday/Friday during the second shift. During an interview on 01/08/25 at 4:00 PM, R145 stated she had not been receiving a bath/shower on a regular basis. R145 said since her admission to the facility she had gone 13 days without a shower, then received a shower only to go another 11 days without a shower. During an interview on 01/09/25 at 2:10 PM, Certified Nursing Assistant (CNA)7 stated there should be a shower sheet in the binder for every bath/shower completed. During an interview on 01/09/25 at 2:20 PM, Occupational Therapy Assistant (OTA)1 confirmed they assisted with showers for some of the residents. OTA1 explained their showers were part of the resident's therapy session and they did set up for the resident, but the resident did the rest. OTA1 reviewed the Occupational Therapy (OT) notes in their computer system and located additional showers for R145 on the following dates: 12/04/24, 12/13/24, 12/19/24, and 01/09/25. OTA1 stated R145 had complained to her, previously, about not getting enough showers/baths. During an interview on 01/09/25 at 3:30 PM, a request was made with the Administrator to provide any additional completed shower sheets for R145. No additional shower sheets were located. During an interview on 01/10/25 at 9:55 AM, CNA8 and CNA12 stated the shower sheets were to be filled out for every bath/shower that was completed for a resident and placed in the shower sheet binder located at the nurse's station. CNA8 confirmed that the OTA assisted with resident's bathing/showering as part of their therapy session. During an interview on 01/10/25 at 11:00 AM, the Director of Nursing (DON) stated showers were supposed to be consistently three times a week for all residents. The DON stated shower sheets were to be filled out when the resident's shower was given. The DON said she felt there were times when the CNAs were not completing the shower sheets but were providing the showers for residents. During an interview on 01/11/25 at 11:10 AM, Registered Nurse (RN)1 stated R145 had not brought it to her attention that she was missing showers. 2. Review of R115's Face Sheet located under the Profile tab in the EMR documented R115 was admitted to the facility on [DATE], with diagnoses including but not limited to: type two diabetes mellitus and the history of a stroke with hemiparesis. Review of the quarterly MDS located under the MDS tab in the EMR with an ARD of 10/10/24, documented R115 had a BIMS of 99 out of 15, which indicated R115 was severely cognitively impaired, required maximum assistance from the staff for personal care and personal hygiene that included nail care, and had no rejection of care. Review of the Care Plan, dated 11/06/23 and located under the Care Plan tab in the EMR related to Activities of Daily Living (ADL)/self-care performance deficit revealed dependent one assist for personal hygiene and bathing. Observations on 01/08/25 at 10:45 AM, 01/09/25 at 3:08 PM, and 01/10/25 at 10:15 AM, revealed R115 had long fingernails, black material under all of her fingernails, an offensive odor from her left contracted hand, and needed hand and nail care. During an interview on 01/11/25 at 10:15 AM, Certified Nursing Assistant (CNA)9 stated R115 was confused, cooperative with care, and the staff provided her personal care and nail care during personal care and as needed. She stated the nurses trimmed R115's nails and she was only allowed to clean the nails. CNA9 stated sometimes there were not enough staff to provide nail care to residents. CNA9 stated although she provided range of motion (ROM) exercises to R115, R115 had three fingers on her left hand that did not open and close all the way, and she did not provide ROM to the left hand. She stated she washed R115's left hand carefully as best she could and had not noticed any odors. During an interview on 01/10/25 at 10:20 AM, Licensed Practical Nurse (LPN)3 stated R115 was compliant with care and the licensed staff trimmed her fingernails as she had diabetes mellitus, and the CNAs cleaned her nails. LPN3 stated it was the responsibility of the CNAs to wash R115's left hand and report any issues. During an interview on 01/10/25 at 10:25 AM, LPN3 assessed R115's fingernails and left hand. She confirmed R115's left hand had an odor and stated her nails were long, dirty, and her hand and nails needed cleaning and trimming. During an interview on 01/10/25 at 9:39 AM, the Director of Nursing Service (DON) stated the CNAs provided fingernail care to residents during their shower, during a full bed bath, and as needed. She stated R115's left hand was to be cleaned and dried during personal care, and issues such as an odor to the hand were to be reported to the nurse.

Based on observations, interviews, and record review, the facility failed to follow physician's orders for compression wrap for 1 of 1 resident (Resident (R)33) reviewed for edema of 36 sample residents. This failure had the potential to negatively affect R33's diagnosed undated circulatory deficits. Findings include: Review of R33's undated Face Sheet found in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia with behaviors, anxiety disorder, and Alzheimer's disease. Review of R33's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/24, located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R33 was moderately cognitively impaired. During observations on 01/09/25 at 3:30 PM and on 01/11/25 at 12:45 PM, R33 had notable edema (condition where excess fluid accumulates in the body's tissues, causing swelling) to her feet and legs. R33 rarely sat to elevate her legs, so the edema worsened during the day as she stood and waited for her ride home every day. There were no observations of R33 wearing the compression hose as ordered. Review of R33's Order Summary Report and found under the Orders tab of the EMR, revealed a physician's order, dated 11/16/24 at 7:00 AM, Please have supply person order: Tubular compression wraps: Tubular compression size G to BLE (bilateral lower extremities) and size J to thighs. To be applied daily for chronic lymphedema BLE. May be removed at bedtime to give rest. Review of R33's Medication Administration Record (MAR) and her Treatment Administration Record (TAR) found in the EMR under Orders, then Reports tabs from 11/15/24 through 01/11/25, revealed no entries related to the application or removal of the compression wraps. Review of the EMR progress notes in the Progress Notes tab, revealed on 11/24/24, Medication Administration Note: Please have supply person order tubular compression wraps: Tubular compression size G to BLE and J to thighs to be applied daily for chronic lymphedema BLE. May be removed at bedtime to rest. This note was repeated on 12/07/24; on 12/29/24; on 01/04/25; and again on 01/05/25. During an interview on 01/10/25 at 9:30 AM, the Regional Director of Clinical Services (RDCS) stated she entered the multiple Administrative Notes, . because the contracted DME (Durable Medical Equipment) provider had not filled the order. She confirmed that seven weeks was excessive, and the facility needed another way to ensure the physician's orders got implemented timely. During an interview on 01/11/25 at 10:30 AM, the Director of Nursing (DON) stated it was absolutely her expectation that treatment orders were processed and carried out timely. She stated this delay in treatment was unacceptable and she would correct immediately.

Based on facility policy review, observations, interviews, and record review, the facility failed to provide a consistent activities program for residents on the secure/dementia care unit for 1 of 4 residents (Resident (R)116) and failed to provide activities of choice for 1 of 1 resident (R75) reviewed for activities of 36 sample residents. The failure to provide an activities program in a behavioral health unit can exacerbate behaviors due to boredom and negatively impact their psychosocial well-being. Findings include: Review of the facility's policy titled, Activities and dated as implemented on 12/01/24, documented, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored and individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interactions within the community. Definitions: Activities refer to any endeavor, other than routine ADLs (activities of daily living), in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health .9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: Residents who exhibit unusual amounts of energy or walking without purpose, Residents who engage in behaviors not conducive with a therapeutic home. Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomed by other residents sharing a social space. Residents who go through others' belongings. Residents who have withdrawn from previous activity interest/customary routines and spend time alone in room/bed most of the day. Residents who excessively seek attention from staff and/or peers, Residents who lack awareness of personal safety, Residents who have delusional and hallucinatory behavior that is stressful to themselves . 1. Review of R116's undated Face Sheet found in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: paranoid schizophrenia, history of a traumatic brain injury (TBI) with intellectual disabilities and aggressive behaviors, as well as psychosis with auditory hallucinations. Review of R116's EMR revealed, a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/24, located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated R116 was severely cognitively impaired. During an observation on 01/09/25 at 3:30 PM and on 01/11/25 at 12:45 PM, R116 was observed to be independently ambulatory with the use of a wheelchair. R116 could stand and ambulate short distances in his room without devices. R116 was rarely found in his room during the survey. He spent much of his time in the dayroom of the secure unit, or in front of the nurse's station engaging with staff and other residents. Review of R116's Care Plan located in the Care Plan tab of the EMR and dated as implemented on 11/23/23, revealed quarterly reviews and revised interventions updated prn (as needed). The care plan included R116's behaviors of wandering, walking without assistance, placing himself on the floor intentionally, physical aggression towards staff, other residents and self when delusional and/or hallucinating. The interventions included .Present just one thought, idea, question or command at a time; Cue, reorient and supervise as needed; Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity; Distract resident from wandering or aggressive behaviors by offering pleasant diversions, structured activities, food, conversation, television, books; and intervene as necessary to protect the rights and safety of others . During an interview on 01/09/25 at 10:00 AM, Licensed Practical Nurse (LPN)1 and Certified Nursing Assistant (CNA)1 stated, We are supposed to have activities, but it hasn't happened in a while. There was a COVID outbreak last month and the activity person for back here (secure unit) has been out for knee surgery. When asked who was covering for the activity person, both staff members confirmed no-one was providing organized activities for the cognitively impaired residents on the secure unit and hadn't for several weeks . During an interview on 01/10/25 at 9:30 AM, The Regional Director of Clinical Services (RDCS) stated she was unaware that no-one was providing activities on the dementia unit and stated she would make sure that was addressed. She confirmed the facility policy was not followed if organized activities were not being provided on the secure unit. During an interview on 01/10/25 at 2:30 PM, Registered Nurse (RN)2 stated she was the secure unit manager. RN2 was asked about activities for the residents, and she confirmed, .the activity person assigned back here has been out for medical, so my staff has to do it . When advised that no activities, except supervised smoking, had been observed on the unit during the survey, RN2 stated, .well we are supposed to do it if there's time . During a phone interview on 01/11/25 at 11:30 AM, the Activity Director (AD) stated she was now fully staffed and had an activity person for each unit. When asked about the secure unit she stated that the specific staff member had been out on medical leave, but someone else was covering for her. When advised no activities had been observed during the four on-site days, the AD stated she would take care of it when she returned the following week. 2. Review of R75's activity note, dated 10/06/23 and timed 3:55 PM, located under the Progress Notes tab of the EMR, revealed the resident was nonverbal and spoke with her son to obtain information. According to the note, R75 liked to watch crime shows. Review of the plan of care under the Care Plan tab of the EMR, revealed she had an activity plan of care (POC) with a last reviewed date of 01/07/25, revealed she was non-verbal and once liked watching crime shows and horror movies. The interventions included continuing one-on-one visits at least twice a week and encouraging her to get up and go to the day room to watch television. The diagnosis listed on the POC included but was not limited to muscle weakness, vascular dementia with psychotic disturbance, aphasia, hemiplegia, and hemiparesis following a cerebral infarction, and cognitive communication deficit. Review of the annual MDS with an ARD of 10/09/24, and located under the MDS tab of the EMR revealed she had a BIMS score of 99 out of 15 which revealed the resident was severely cognitively impaired. Under the activity portion of the MDS it was marked that it was somewhat important for her to listen to music she liked and to do her favorite activities. The MDS identified her as being dependent on staff for transfers, dressing, and locomotion in the wheelchair. Review of a handwritten progress note, provided by the facility, dated 12/31/24, and signed by the AD revealed the resident was no longer being set up in the day room and she was placed on one-on-ones on Monday, Wednesday, and Friday. The note revealed activities would listen to music and enjoy snacks with her. During observations on 01/08/25 at 2:34 PM and 3:22 PM, 01/09/25 at 12:08 PM, 12:26 PM, 2:58 PM, 3:29 PM, and 5:21 PM; on 01/10/25 at 8:03 AM, 9:29 AM, and 12:24 PM; and 01/11/25 at 10:35 AM; R75 was observed laying in her bed on her back either sleeping or awake. The curtain was pulled in front of her bed, and she did not have a television or radio playing during the observations. During an interview on 01/11/25 at 10:41 AM, Certified Nursing Assistant (CNA)11 stated she had cared for the resident for the past year. She stated the resident was kept in her room and liked to stay in bed. She stated when they got her up and took her to the dining room to watch television (TV) she screamed out baby baby. She stated the resident liked to watch television and she used to watch her roommate's TV however the roommate moved out a while back. She stated other than activity visiting her about twice a week the resident was not engaged in any activities. She verified the resident did not have access to a radio or TV in her room. During an interview on 01/11/25 at 10:50 AM, LPN9 stated R75 did not like to leave her room. She stated she liked to watch TV, and she used to watch her roommates' TV, and the roommate would get upset because she would have it on when she did not want it on, and she spoke to the son about getting earphones for her. She stated her roommate moved sometime before Thanksgiving and the resident had no access to a TV since. She stated if R75 had a TV or radio it would give her more stimulation. During an interview via telephone on 01/11/25 at 12:45 PM, LPN10 was asked about R75's activities and she stated the resident liked staying in her room. She stated when they got her up, she screamed or verbalized. She stated R75 liked to watch TV, and they would put her in a geriatric chair to watch TV, but she tended to scream when they took her out to the dining room where the TV was located. She stated she used to watch her roommates' TV, but her roommate moved out a month or two ago and she has not had a TV since then. She stated the resident could benefit from having a TV in her room. During a telephone interview on 01/11/25 at 11:29 AM, the AD stated R75 was just added to the one-on-one list on 12/31/24 but she has not been started on one-on-ones yet because they had covid in the building and were not fully staffed. She stated R75 screamed when she was put in the geriatric chair and taken to the dining room where the television was located. She stated R75 liked to watch television and listen to music. She stated she used to watch her roommate's television however the roommate moved some time ago and she has not had access to a television since she moved. She stated they did have a radio on the unit for all the residents to share, however she was not sure where the radio was. She stated the resident would benefit from having a television and radio in her room since she preferred to stay in her room, and she enjoyed watching television. 30067

Based on record review and interview, the facility failed to provide the Advanced Beneficiary Notice of Non-Coverage (ABN) and the Notice of Medicare Non-Coverage (NOMNC) to 1 of 2 residents (Resident (R)136) reviewed for Beneficiary Notification of 36 sample residents. This failure had the possibility to negatively impact residents due to them not being aware that they no longer had coverage for their stay under Medicare Part A. Findings include: Review of R136's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R136 was admitted to the facility on [DATE], with diagnoses including but not limited to: other neurological conditions, urinary tract infection, diabetes, and depression. Review of R136's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/28/24, located under the Resident Assessment Instrument (RAI) tab, indicated R136 was set up assist for oral hygiene; supervision for showering; dependent for lower body dressing; partial/moderate assistance for upper body dressing, transfers, and bed mobility. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R136 was cognitively intact. Review of the SNF (Skilled Nursing Facility) Beneficiary Notification Review forms that were provided to the facility for completion, indicated R136's forms were incomplete and the ABN and NOMNC had not been provided to R136 when Medicare Part A Services ended on 12/22/24. During an interview on 01/11/25 at 11:20 AM, the Administrator confirmed that the beneficiary notices had not been provided to R136. The Administrator explained that the Social Service Director may not have understood the necessity of the forms being completed and notification made to the residents since they had so few residents that were covered by Medicare Part A.

Based on observation, record review, interview, and facility policy review, the facility failed to provide care and services in a manner that maintained and promoted dignity which included ensuring the privacy curtain was pulled closed, for 1 of 1 resident, (Resident (R)123), reviewed for resident rights. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment. Findings include: Review of the facility's policy titled, Resident Rights, dated 2024, documented, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . Maintain resident privacy. Review of R123's Admission Record located under the Profile tab in the electronic medical record (EMR) documented, R123 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/25/24, revealed R123 had a Brief Interview for Mental Status (BIMS) of 99 out of 15 which indicated R123 was severely cognitively impaired, was incontinent of bowel and bladder functions, and was dependent on one staff for personal care and dressing. During an observation on 01/08/25 at 10:19 AM, a staff member stated a resident was receiving personal care. The curtain between R123 and her roommate's bed was not pulled. The roommate was sitting in her wheelchair and R123 was lying in her bed, which was visible to the roommate. R123 was wearing a shirt and a brief. Certified Nursing Assistant (CNA)3 was providing incontinent care to R123. CNA3 proceeded to remove R123's brief, exposing the lower half of her body, provided incontinence care, placed a clean brief on R123, and finished dressing her with the privacy curtain still not pulled. During an interview on 01/08/25 at 10:25 AM, CNA3 stated she usually worked the second shift, was behind in her assignment, R123 needed to be washed, dressed, and out of bed, she was distracted, and forgot to pull the privacy curtain. CNA3 stated the roommate, who was alert and oriented, was able to observe her care to R123. During an interview on 01/10/25 at 10:02 AM, Licensed Practical Nurse (LPN) 3 stated the staff were to ensure a resident's privacy with clothing/blanket and pull the privacy curtains whenever providing personal care to a resident. During an interview on 01/09/25 at 1:16 PM, the Director of Nurses (DON) stated all staff were educated regarding the facility's dignity policy during orientation and as needed. She stated when staff were assisting residents, they were to ensure a resident's body parts were not exposed to others and privacy curtains were to be pulled to ensure residents' dignity.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that residents who were dependent on staff for restorative nursing received range of motion, a carrot to the left hand, and/or a wedge to the leg for positioning, as ordered by the Physician for 2 of 3 residents (Resident (R)115 and R71) reviewed for restorative services of 36 sample residents. This failure has the potential for other residents to be at risk for decreased range of motion, worsening of their contracture, and/or increased edema. Findings include: Review of the facility's policy titled, Restorative Nursing Programs, dated 2023, documented, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .Restorative aides will implement the plan for a designated length of time, performing the activities and documenting on the Restorative Aide Documentation Form .The Restorative Nurse, or designated licensed nurse will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan. 1. Review of R115's Face Sheet, located under the Admissions tab in the electronic medical record (EMR) documented R115 was admitted to the facility on [DATE], with diagnoses including but not limited to: type two diabetes mellitus and history of a stroke with hemiparesis. Review of R115's Physician Orders located under the Orders tab in the EMR, dated 04/14/24, revealed, Resident may participate in Restorative Nursing Programs 5 times a week for ROM upper and lower extremities. Review of R115's Physician Orders located under the Orders tab of the EMR, dated 05/24/24, revealed, Resident may participate in Restorative Nursing Program as per MD [Medical Doctor] order: Place carrot to left hand five times a week, place wedge to left leg five days per week for positioning. Review of R115's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 10/10/24, revealed a Brief Interview for Mental Status (BIMS) of 99 out of 15 which indicated R115 was severely cognitively impaired, had a functional limitation of range of motion on the upper and lower body on one side, required maximum assistance on the staff for personal care, and had no rejection of care. During observations on 01/08/25 at 10:46 AM, 01/09/25 at 3:06 PM, and 01/10/25 at 10:15 AM, revealed R115 had no wedge to her left leg and no carrot in her left hand. During an interview on 01/11/25 at 10:15 AM, Certified Nursing Assistant (CNA)9 stated R115 was confused, cooperative with care, and the staff provided her with personal care. CNA9 stated although she provided range of motion (ROM) exercises to R115, R115 had three fingers on her left hand that did not open and close all the way, and she did not provide ROM to the left hand. During an interview on 01/10/25 at 10:25 AM, Licensed Practical Nurse (LPN)3 stated she was not aware R115 was to have a carrot placed in her left hand. She stated she was not sure R115 used a wedge on her left leg for positioning and said she had not observed a wedge in her bed. During an interview on 01/10/25 at 11:37 AM, the Restorative Aide (RA)1 stated she met with the Rehabilitation Director weekly, and they discussed the restorative program for each resident. She said she was educated on any changes in the resident's restorative program and any new residents added to the restorative program. RA1 stated that for the past several months, she worked as a CNA, had a CNA assignment, did not meet with the Rehabilitation Director, and did not provide restorative services to residents on the restorative program. RA1 stated she was assigned to work as a RA on 01/09/25 and 01/10/25. She stated she provided range of motion exercises to R115's upper and lower body. RA1 stated she was not aware R115 was to have a carrot in her left hand and there was no wedge in R115's room. RA1 stated she told the Rehabilitation Director about the missing wedge. During an interview on 01/10/25 at 12:01 PM, the Therapy Director stated for the past several months she had not met with RA1 to discuss the residents on the restorative program as RA1 was assigned to work as a CNA on the nursing units. The Therapy Director stated the CNAs were expected to provide ROM during personal care. She stated she was not aware that R115 needed a carrot and wedge. The Therapy Director said although R115's orders were for five days a week; they should have been for seven days a week. During an interview on 01/11/25 at 3:30 PM, the Regional Director of Clinical Services (RDCS) confirmed there were no RA notes in the clinical record for R115 from 11/01/25 to 01/10/25. During an interview on 01/10/25 at 9:39 AM, the Director of Nurses (DON) stated although restorative nursing had not been provided by the RA for several months, the CNAs could provide ROM during care, could place carrots etc. and use wedges or positioning devices as ordered. She stated she was not aware R115 did not have a wedge and carrot available for use. The DON stated R115 did not receive her restorative program from 11/01/24 to 01/09/25. 2. Review of R71's Face Sheet, located in the EMR under the Admissions tab documented R71 was admitted to the facility on [DATE], with diagnoses including but not limited to: history of a stroke with hemiparesis (partial weakness on one side of the body) and hemiplegia (paralysis on one side of the body). Review of the Physician Orders located in R71's EMR under the Orders tab, dated 01/06/25, revealed Restorative Nursing for left hand brace. To be worn six hours per day. Review of the quarterly MDS located under the MDS tab in the EMR with an ARD of 08/22/24, documented R71 had a BIMS of 15 out of 15 which indicated R71 had intact cognition, functional limitation of range of motion on the upper and lower body on one side, was dependent on staff for personal care, and had no rejection of care. During an observation and interview on 01/08/25 at 11:21 AM, R71 stated he had not seen any rehabilitation staff in several days and no one had applied the splint to his left hand in several days. Although R71 had a left-hand splint in his room, it was not observed on his left hand. During an observation and interview on 01/10/25 at 10:05 AM, R71 stated no one applied the left-hand splint to his left hand yesterday or today and there was no left-hand splint observed on his left hand. Review of the Adaptive Rehab In-Service /Staff Meeting Acknowledgement and Attendance Record, dated 01/30/24, revealed R71 was to use a splint on his left hand six hours per day. The record revealed that four staff on R71's unit had received education, including one nurse. The record revealed that RA1 was not listed on the form. During an interview on 01/10/25 at 11:37 AM, RA1 stated she worked as a CNA on the nursing unit and not as an RA for several months. She stated that on 01/06/25 to 01/08/25, she worked as a CNA and not a RA. RA1 stated that on 01/09/25 and 01/10/25, although she was assigned to work as a RA, she was not educated that R71 was on restorative program that included a left hand splint, and therefore did not apply the splint on 01/09/25 and 01/10/25. RA1 stated R71 had not had the left-hand splint placed between 01/06/25 and 01/11/25. During an interview on 01/10/25 at 12:01 PM, the Therapy Director stated she had not met with the RA for several months. The Therapy Director stated R71 was on occupational therapy from 11/08/24 to 01/02/25, (Thursday). She stated the splint was to be worn seven days a week for six hours. She stated she notified the DON prior to 01/02/25 that R71's occupational therapy ended, and they needed a physician order for the splint to be done by the RA. The Therapy Director stated she was not aware the order for R71's splint was not obtained until 01/06/25. She stated the orders for restorative nursing were usually obtained as soon as she emailed or gave them to the DON. She stated on 01/03/25, the staff on R71's unit, which included the nurse and CNAs assigned to the unit that day were educated about the splint and the splint was applied to R71's left hand. She stated her staff did not apply the splint to R71 after 01/03/25 as it was not the responsibility of nursing to apply the splint. She stated after the education was completed; the nurses were to continue the education with the other staff. The Therapy Director stated RA1 was not usually assigned to R71's floor and would have been educated by the nurse when RA1 was assigned to work as a RA again and not assigned as a CNA on a unit. During an interview on 01/11/25 at 3:30 PM, the RDCS confirmed there were no RA notes in the clinical record for R71 from 01/04/25 to 01/11/25. During an interview on 01/10/25 at 9:24 AM, the Director of Nurses (DON) stated R71 completed his occupational therapy and when notified on 01/05/25 or 01/06/25, she obtained an order for a restorative splint program for R71. She confirmed the RA had not worked as an RA for several months. When asked who was responsible for placing the splint on R71, she stated if RA1 was not assigned to work as an RA, the DON stated the nurse would assume the responsibility. The DON stated R71 had not had the left-hand splint applied from 01/06/25 to 01/11/25.

Based on review of the facility policy, record review, and interviews, the facility failed to administer medications according to medication practices for 1 of 1 Resident, Resident (R)2. R2 was given his medications whole versus crushed and the nurse did not observe the resident while administering the medications. On [DATE] at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 4:11 PM, the survey team provided the Administrator and Interim Director Of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template notifying that the failure to administer medications according to medication practices for Resident (R)2 constituted Immediate Jeopardy (IJ) at F760, related to 42 CFR 483.45 Pharmacy Services and informed the facility the IJ existed as of [DATE]. On [DATE] at 3:30 PM, the survey team exited the facility. The facility failed to provide an acceptable IJ Removal Plan. IJ is ongoing. Findings include: Review of the facility policy entitled Medication Administration reviewed ,d+[DATE] revealed, 14c states Crush medication as ordered. Additionall number 15 states, Observe resident consumption of medication. Record review of R2 revealed a new diagnosis of Gastrointestinal (GI) bleed with acute Esophageal Necrosis and Distal Esophageal Stricture and Dysphagia. R2's physician orders included an order dated [DATE], May change medication form as condition warrants (solid, liquid, crush). R2 also had a diet order dated [DATE] for Puree texture, Honey/Moderately thick consistency, for Dysphagia Pureed, honey thickened liquids. Resident expired on [DATE]. An interview with R3 on [DATE] at 11:57 AM, whom has a Brief Interview of Mental Status (BIMS) score of 15, indicating full capacity stated, I was there when R2 began choking. Licensed Practical Nurse (LPN)2 came back with a cup of regular water, not thickened and a little cup of pills and left them at the corner of our table and she left. They weren't crushed. His liquids were supposed to be thickened and his medication crushed. She, (LPN)2, left and he took the medication as it was. I watched him, he started to jerk a minute, then I noticed starting from his head, his color started to leave him, to that early death color. His head fell forward on his chest, liquid started running from his nose. They brought the crash cart. The oxygen tank was empty, I heard them say it. R2 and I were very close, we were boyfriend and girlfriend, everyone here knew it. An interview with R4 on [DATE] at 12:26 PM revealed, I was in the dining room when R2 died . The staff did Cardiopulmonary resuscitation (CPR) and didn't have any oxygen. She confirmed she told the staff they can use her oxygen since she had her tank on and it was working. An interview on [DATE] at 12:31 PM with the former Director of Nursing (DON) revealed, I got a call from LPN2 to tell me R2 had expired. She said he choked. I caught wind of the oxygen tank that was empty, the next morning. We started an investigation and crash cart checks. R3 called me and told me everything that happened. I had him the day before and I gave him his medications crushed and in thickened water. He had no difficulty swallowing them that way. An interview on [DATE] at 1:20 PM with LPN2 revealed she gave R2 his medication whole, but gave him thickened liquid. She also confirmed the crash cart oxygen was empty. She confirmed she did not watch him take the medications. An interview on [DATE] at 2:23 PM with Certified Nurse Assistant (CNA)2 revealed, I heard someone say, help, help, help, it was R3. I saw vomit coming from R2's nose and mouth, he was sitting in his wheelchair at the dinner table with R3. I went to get the nurse on B Cart. She came and we pulled him to the floor in the corner. I got another CNA and asked her to call on the intercom for CPR. Unit 4's nurse came and we got the crash cart, but there was nothing on it. The oxygen tank was there, but it was empty. I looked for the suction machine and it wasn't on the crash cart either. I knew his roommate used one and knew it was in there. I first went down the hall towards the oxygen room, when I saw his nurse coming from another Unit. I asked her to get the oxygen, so I went back to get the suction machine. CNA1 began chest compressions while LPN3, was using the Ambu Bag. On [DATE] a phone interview with CNA2 at 2:23 PM, revealed,I was the one who had picked up his meal tray. He didn't eat his dinner, he told me he didn't want it. On [DATE] at 2:20 PM, an interview with LPN2 revealed, I worked over that day, I worked on Unit 2. I've been over there several times before. R3 approached me saying R2 needed to go to the hospital. LPN3 was also working on the Unit. I spoke with R2 and I asked him what was going on. He said he was having hoarseness. He had a cup beside him with mucous. He said his chest was hurting, when he coughed, a soreness. He said no, I don't want to go to the hospital. He asked for as needed pain meds. It was 5:,d+[DATE] PM, when I gave him the medicine with his routine meds in the dining room on the Unit. R3 asked me to crush his meds, but he took them whole. R2 had an order that they may be crushed, not that they should be crushed. I gave him his medication whole. He coded about 7 pm. An interview on [DATE] at 3:25 pm with LPN3 revealed His meds should have been crushed. He also got thickened liquid and he was on puree foods. His regular nurse remarked on this when he returned from the hospital. It was a complete change for him. The nurse that had him that day was not his routine nurse. I believe he choked. During an interivew on [DATE] at 10:10 AM with the Interim DON, she stated, My expectation would be to call the doctor to clarify the order and inform the family. Nurses learn in school and common sense would tell you if a resident is on a puree diet with thickened liquids, you would just crush the meds. She should have called the doctor. You never leave the medications; you must ensure the residents are taking them. Record review of R2's progress note dated [DATE] at 19:06 stated, 2 was found unresponsive, CPR unsuccessful, EMS arrived and was unable to revive.

Based on the review of the facility policy, observations, and interview, the facility failed to ensure that Resident (R)1 was free from elopement from the facility on February 27th, 2024, at approximately 5 PM. On 03/06/2024 at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/06/2024 at 4:11 PM, the survey team provided the Administrator and Interim Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template at F689 related to 42 CFR 483.25 - Quality of Care, Informing the facility IJ existed as of 02/27/2024 for failure to ensure that Resident (R)1 was free from elopement from the facility on February 27th, 2024, at approximately 5 PM. On 03/07/2024 at 3:30 PM, the survey team exited the facility. The facility failed to provide an acceptable IJ Removal Plan. IJ is ongoing. Findings include: A review of facility policy titled, Elopements and Wandering Residents revealed Residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Under policy and explanation and compliance guidelines, states under section D- Adequate supervision will be provided to help prevent accidents or elopements. R1 was admitted to the facility on [DATE] with diagnoses including but not limited to Dementia, Cognitive Communication Deficit, Muscle Weakness, and Altered Mental Status. According to the Significant change in status, Minimal Data Set with an Assessment Reference date of 1/30/2024, R1 has a Brief Interview of Mental Status (BIMS) score of 99, which indicates he is not cognitively intact/ severely impaired. Further review of the MDS revealed that R1 had wandering behaviors during the assessment period. E0900. Wandering - Presence & Frequency- Behavior of this type occurred for 4 to 6 days. A review of the Elopement/Wandering Risk Evaluation dated 1/30/2024 revealed the resident is at high risk for elopement. The evaluation indicated, The resident orientation is Disoriented (x3 spheres), Behavior/Mood is Combative/severely agitated, Exhibits/expresses fear and/or anxiety, and does not understand his surroundings. No recent changes/ experiences. The resident's mobility is independent, with no assistance. The resident's diagnosis is dementia with psychosis. The resident's medications taking antipsychotics, anti-anxiety/hypnotics, and documented as taking narcotics as well. The resident has a history of wandering/exit seeking as well as wandering aimlessly without purpose. A review of R1's progress notes revealed a note dated, 2/27/2024 22:36 Behavior Note- Resident (R)1 remains on 1 to 1 related to wandering and exit seeking at present time accepts medications without difficulty fair po/fluid intake observed vitals stable 1 to 1 at bedside vitals stable remains safe and monitored. An interview with Licensed Practical Nurse (LPN)1 on 03/05/2024 at 12:30 PM revealed that she worked on February 27th, 2024. LPN1 stated, She was unsure how, but the resident made it out of the facility with the housekeeper. LPN1 stated that alarms went off and she got nervous because it was her first day in the locked unit. LPN1 stated that all she knows is that the resident made it back in with a staff member and does not remember who the staff member was. LPN1 also stated that she is unsure how far the resident went because she didn't go outside. An interview with the facility housekeeper on 03/05/2024 at 12:33 PM revealed she confirmed she is the housekeeper for unit 4, which is a locked unit. The Housekeeper stated that on February 27th, 2024, she heard the alarms going off. She stated she then called LPN1, who told her to turn the alarm off, while she, (LPN)1, remained seated while charting. The housekeeper saw staff searching for the resident in the parking lot, while she was turning off the alarm. The housekeeper stated a nurse was yelling The resident got out. The housekeeper stated that she didn't remember who the staff members were that were looking for the resident. She stated that the resident is known for this behavior, he knows how to get out and to wait 15 seconds and push the door. During a second interview on 03/05/2024 at 2:17 PM, the Housekeeper stated the staff walked the resident to the front of the building because they did not come in through the exit door located on unit 4, which is the door the resident was able to exit from. The housekeeper stated staff gets tired of chasing after the resident and that she was trained to tell the nurse if a resident was having wandering behaviors. Staff was not able to confirm how the resident was dressed or the exact temperature. Continued review of the medical record revealed no additional documentation related to the elopement. A telephone interview with R1's brother/emergency contact on 03/05/2024 at 2:33 PM revealed the facility called him and told him that they found R1, 1.2 miles away from the facility on [NAME] Drive. R1's brother stated the facility told him they would take him to the hospital to be checked out and the hospital called him asking for permission to treat the resident because it was cold outside at the time they found the resident. R1's brother stated that the resident is known for his wandering behaviors and is not sure why the staff was not supervising him, especially with his diagnosis. A telephone interview on 03/05/2024 at 3:52 PM with the Facility Administrator (FA) confirmed she was in the facility on the day of the incident. FA stated staff member, Human Resources (HR) was in the parking lot when she heard the alarm go off. HR told FA when the alarm went off she saw the resident come out of the building, unsure of what door. FA stated that HR called other staff to come outside and assist with redirecting the resident and that's when FA came outside along with the other staff. FA stated one staff member who happened to have a good rapport with the resident was able to hold his hand and walk back in the building. FA stated that the resident didn't make it out of the premises to her knowledge, just to the facility parking lot, and the resident was put on 1:1 as a precaution of his wandering behaviors. During an interview on 03/07/2024 at 10:45 AM, an interview with HR revealed, I was already outside on the phone when I heard the alarms go off and sounds coming from unit 4. I looked up and it was R1 wandering by the Security shed located across the kitchen area, in the facility parking lot. I ran to him, and he was upset. I texted the scheduler letting her know the resident made it out. The scheduler is one of the few people who can calm the resident down. After that, staff comes running out approximately a few minutes later. All staff surrounded the resident asking him if he wanted a drink or a snack, the resident then replied, yes, and the staff was able to bring him back into the building. HR stated, Trying to escape the facility is a normal pattern for the resident. She stated, Typically there is a code for the doors to open, so I'm unsure how he was able to make it out, but he made it out. An anonymous caller on 03/07/2024 at 2:08 PM indicated she wanted to call and relay information related to the resident and his elopements. The caller stated the resident has had multiple elopements and the facility often does not tell about it, but he has gotten out multiple times before.

Based on review of facility policy, interview and record review, the facility failed to provide adequate supervision to prevent an elopement. Specifically, on 12/12/23 at approximately 8:30 AM, Resident (R)1 was found by police at a gas station approximately 3.7 miles from the facility. This failure placed R1 at risk for severe harm and/or death due to cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. On 12/14/23 at 3:15 PM, the Administrator and the Director of Nursing were notified that the failure to prevent the elopement of Resident (R)1 constituted Immediate Jeopardy (IJ) at F689. On 12/14/23 at approximately 3:15 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 12/12/23. On 12/15/23 at 12:40 PM, the facility presented an acceptable IJ Removal Plan. On 12/15/23 at 1:50 PM, the survey team validated the facility's corrective actions and removed the IJ as of 12/14/23. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the undated facility policy titled Elopements and Wandering Residents documented, Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, muscle weakness, and cognitive communication deficit. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/08/23 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R1 suffered from severe cognitive impairment. Review of R1's Elopement/Wandering Risk Evaluation dated 12/08/23 revealed R1 scored 24, indicating R1 was at moderate risk for elopement/wandering due to being disoriented to person, place, and time; having early dementia; being independent with mobility; and demonstrating wandering behaviors. Review of R1's Care Plan revealed R1 was initiated as an elopement risk on 09/12/23 with interventions including distracting from wandering, identified the pattern of wandering, and providing structured activities. During an interview on 12/14/23 at approximately 10:45 AM, the Administrator revealed that R1 eloped from the facility on the morning of 12/12/23. The police notified the Administrator at approximately 8:30 AM that the resident was found at a local gas station. The resident was soiled and wet and the police took him to the emergency room . Though the facility had not been able to determine how the resident left, it was suspected that he followed someone leaving the locked unit. Review of Google Maps revealed R1 was found at an Exxon gas station that was 3.7 miles away from the facility. which was a 1 hour and 22 minute walk. Review of timeanddate.com revealed the weather in [NAME], SC on 12/12/23 from 6:00 AM - 12:00 PM was sunny and between 28 degrees Fahrenheit and 48 degrees Fahrenheit. During an interview on 12/14/23 at 11:13 AM, a Detective with the local police department confirmed R1 was found by the police at a gas station. However, the Detective did not discover the resident, and the deputy who did was unavailable. Review of an undated Statement to the facility written by Licensed Practical Nurse (LPN)1 revealed, LPN1 did not see R1 that morning. During shift change, the previous nurse reported R1 took medication at approximately 6:30 AM. R1 was noted missing at approximately 7:20 AM. During an interview on 12/14/23 at 11:40 AM, LPN1 confirmed her statement to the facility. LPN1 stated the previous nurse (LPN2) said she had given R1 PRN (as needed) Klonopin at 6:40 PM, and that he was currently asleep. They did not discover he was missing until breakfast was served at approximately 7:15 AM - 7:20 AM. LPN1 further stated, at that point they searched the unit/building for the resident and called a Code Pink (elopement code). The resident did have a history of wandering, and there were no further interventions other than being on a locked unit. On 12/14/23 at 11:45 AM attempted interview with LPN2 was unsuccessful. Review of LPN3's statement to the facility written on 12/12/23 revealed, LPN3 arrived at 7:10 AM. R1 was discovered missing during breakfast at approximately 7:30 AM and at that point they searched rooms and bathrooms before calling Code Pink. During an interview on 12/14/23 at 11:45 AM, LPN3 confirmed her statement to the facility. LPN3 stated, the local police department notified the facility of R1's discovery at approximately 8:00 AM - 8:30 AM. LPN3 further stated R1 had a history of pacing aimlessly around the facility but he had never previously verbalized a desire to leave the building. The resident did not have a wander guard at the time of the incident, though he was on the locked unit. Review of a picture provided by the facility of R1 at the gas station revealed R1 was wearing a plaid pajama bottom, a burgundy long-sleeved shirt, and slippers. Review of Certified Nursing Assistant (CNA)1's statement to the facility written on 12/12/23 at 9:22 AM, revealed she did not see the patient that morning. CNA1 overheard a conversation between the nurses that he was given medications at 6:45 AM and was in bed sleeping. CNA1 rounded at 7:20 AM and discovered the resident was not in bed. She began looking for him, and they called a Code Pink. During an interview on 12/14/23 at 12:06 PM, CNA1 confirmed her statement to the facility. CNA1 stated R1 went missing around shift change, and she did not actually see him before his elopement. CNA1 further stated she discovered he was missing when she was first rounding on her residents. Observation and interview with R1 on revealed he was dressed and groomed in the dining room with supervision. He did not recall the elopement. He had no concerns with facility care at the time of the interview. During an observation on 12/12/23 at 12:20 PM, revealed a sign posted at the locked unit doors which warned those leaving the unit not to allow residents to follow them. Review of the Maintenance Director's (MD) statement to the facility written on 12/12/23 revealed he was notified of R1's elopement at 7:35 AM. He checked all doors on the locked unit to ensure they were functioning, which they were. During an interview on 12/14/23 at 1:10 PM, the MD confirmed his statement to the facility. The MD stated all doors were functioning on the locked unit at the time of the incident. During an interview on 12/14/23 at approximately 2:06 PM, the Director of Nursing (DON) confirmed R1 was discovered 3.7 miles from the facility. The DON stated R1 was missing for about 1.5 hours or more. The last CNA to see him was the 3rd shift CNA assigned to the resident (CNA2). During an interview on 12/14/23 at 2:16 PM, the Administrator revealed there were no family or visitors in the facility at the time of the elopement. The Administrator further stated since R1 eloped around shift change, he could have followed any number of the employees leaving the building at that time, and the facility does not track exiting staff. On 12/14/23 at 2:32 PM, interview attempt with CNA2 was unsuccessful. On 12/15/23 the facility submitted a removal plan which included the following: Identification of Residents Affected or Likely to be Affected: (Completion Date: 12/14/23) Residents directly involved in the deficient practice had their care plans reviewed and updated by the DON to reflect current wandering and elopement risk. The Minimum Data Set (MDS) Coordinator reviewed section E of the MDS and associated care plans for all residents on Unit 4. Residents requiring additional care plan revision were identified. These residents will have new MDS assessments to ensure correct assessments and care plans. The DON, designee, and or MDS Coordinator re-evaluated residents on Unit 4 that were at risk for wandering/elopement using an elopement risk assessment tool. Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee. Any staff on leave will receive education on their next scheduled workday. Non-nursing employees will receive education on responding to door alarms. Actions to Prevent Occurrence/Recurrence: (Completion Date: 12/14/23) R1 had a history of removing his wander guard. A wander guard will be attached on the resident's belt buckle and the buckle will be on his backside. Th DON or designee will educate staff on the application of the resident's wander guard and there will be a return demonstration. His wander guard will be checked every shift. R1 will also have frequent checks by facility staff as to his location and whereabouts. When R1 was returned to the facility after the elopement he was placed on 1:1 observation and continues on 1:1 observation. His attending physician did not order any medication changes. Psych services is in the facility today and will be reviewing R1. Elopement and wandering residents' policy was reviewed/revised. The facility revised its pre-admission screening intake form to include a question about history and frequency of wandering / elopement. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. The DON or designee will audit completed MDS's to ensure the care plan reflects the needs/concerns identified in the Care Area Assessments (CAAs). New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s). A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. Unannounced Elopement drills will be conducted every shift on a weekly basis x 4 weeks, then monthly thereafter. Date Facility Asserts Likelihood for Serious Harm no Longer Exists: December 14, 2023.

Based on review of the facility policy titled, Abuse, Neglect and Exploitation record review, interviews, and observations, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for accidents related to wandering. Resident (R) 1 had a successful elopement from an unconfirmed door of the facility on 04/18/22 approximately between 2:30 PM and 3 PM. Failure to establish, maintain and implement written policies and procedures regarding abuse places an individual's health and safety at risk for serious injury, harm, impairment, or death. R1, with a history of exit seeking behaviors, was found roaming in the parking lot of the facility by Certified Nursing Assistant (CNA)10, adjacent to the highway, on 04/18/22 at approximately 2:55 PM. She was fully clothed but did not have on socks or shoes. She had a wanderguard on her ankle, which alarmed, however, staff did not immediately respond. The weather was reported to be fairly nice in the 70s. R1 had no injuries upon assessment. On 06/13/22 at 4:00 PM, the Administrator was provided with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F600 due to facility's neglect to provide adequate supervision to prevent the elopement of R1, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/14/22 at approximately 10:30 AM, the Administrator provided an acceptable IJ removal plan related to F600. The immediacy of the IJ was removed as of 06/14/22. The IJ was lowered to scope and severity of D, no actual harm with potential for more than minimal harm that is not IJ. Additionally, the failure constituted substandard quality of care, warranting the completion of an extended survey on 06/15/22. The facility's removal plan for F600 included: 1) The identified Resident suffered no serious injury, as a result of the incident. 2) All other residents have the potential to be affected by the deficient practice. An elopement risk assessment will be initiated by licensed nursing staff on 06/13/22 and completed by 06/14/22. 3) Immediate in-service initiated 6/13/22 by the Director of Nursing (DON) and/or the DON Designee to all staff to include nurses and CNAs to ensure that they respond to all alarm alerts. Also, to be aware of all residents that have elopement risks and to be on alert for potential elopements. Residents at risk of wandering are placed in an elopement notebook at each nursing unit as well as main reception area, to include a picture of the resident. The in-service will be conducted in person, telephone, email or text. Those staff that will have in-service that was not able to be conducted in person, will be acknowledged on the sign in sheet in-service communication by 06/14/22 and will have the in-person in-service prior to their working shift with signatures on the sign in sheet prior to them working their shift. All newly hired staff along with any agency staff will receive the information contained in the in-service prior to working with residents. 4) If any residents are identified to have increase in exit seeking behavior, the facility DON and/or Designee will notify the Primary Care Provider and Psych services immediately for immediate intervention which may include transfer to the closed unit of the facility and/or medication management and/or closer monitoring in the facility closed unit. 5) The facility will conduct weekly focus meetings with the Interdisciplinary team that includes the DON or DON designee, social service director, activity director, MDS/Care Plan Coordinator, Unit nurse and/or unit CNA to discuss any residents that are elopement risks and will discuss the interventions put in place and determine if the interventions are beneficial to eliminate the risk of elopement. These interventions will be placed on the resident's care plan. Implementation of the removal plan was verified by observations, interviews and record reviews. Upon implementation verification, the Administrator was notified the IJ was removed as of 06/14/22. Findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means 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. Under Section III. Prevention of Abuse, Neglect and Exploitation; Section D: The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Review of the facility's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/02/20 revealed she had a Brief Interview of Mental Status (BIMS) score of 04 out of 15, indicating she is cognitively impaired. Further review of the MDS assessment revealed R1 required supervision to limited assistance with activities of daily living (ADLs). She also was coded in Section E: Behaviors as exhibiting wandering daily. Review of R1's most recent Quarterly MDS with an ARD of 4/5/22 indicated a BIMS score of 00, indicating severe cognitive impairment. Review of Section E: Behaviors continued to be coded as wandering behaviors exhibited daily. Review of R1's Admission Elopement Risk Evaluation dated 11/02/20 indicated R1 scored an 11, which revealed above high risk to elope. Per the evaluation, R1's daughter had indicated she had gotten out of the home without anyone knowing, prior to admission to the facility. Review of R1's Quarterly Elopement Risk Evaluation dated 04/10/22 indicated R1 scored a 9, indicating at risk to elope. Comments indicate R1 wanders daily into other rooms and to the exit doors. Following her elopement on 04/18/22, an additional evaluation was completed with a score of 9 with comments to proceed with care plan updates. On 06/14/22, R1 had an additional evaluation that scored her as a 9, due to her previous elopement from the facility in April of '22. Review of R1's care plan with an initiation date of 10/31/20 and revised initiation date of 04/19/22 revealed a focus that stated, The resident is an elopement risk/wanderer as evidenced by aimlessly wandering throughout the unit and into other resident's rooms without invite. Also takes things that do not belong to her. She is exit seeking, pushes on the exit doors. Elopement on 4/18/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions put into place are distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book, identify pattern of wandering and intervene as appropriate, monitor location every 30 minutes and redirect as needed, document wandering behavior and wanderguard in place. Review of R1's Physician orders dated January 2022 through June 2022 revealed an order, which stated, Check wanderguard placement and function every shift and check skin integrity every shift. Review of R1's Treatment Administration Record (TAR) reviewed for January 2022 to June 2022 revealed adequate monitoring of the wanderguard placement and functioning. Review of the facility's investigation on 06/13/22 at 12:00 PM revealed a written statement from Licensed Practical Nurse (LPN)4 which stated, On 04/18/22, I was walking in the courtyard to go inside and clock in when I witnessed a 1st shift CNA escorting a resident inside the building. She stated, look who I found wandering around out here. This nurse immediately informed a second nurse as she was walking by then informed the 1st shift nurse, who was on duty. She notified the Responsible Party (RP) and Director of Nursing (DON) but not answer at first. So, she went on to do an incident report and note. DON was notified by this nurse after the meeting she was in. The RP then called back and was told about the elopement. The alarm box was off, but the wanderguard was sounding. The statement did not indicate an exact time of incident. Multiple attempts were made to contact LPN4 via telephone for an interview, with no success. During an observation of the secured unit on 06/13/22 at 12:30 PM, R1 was observed pacing up and down the halls, going from her room door to the dayroom. Upon approach, she allowed the surveyor to observe her leg. There was a wanderguard placed on her right ankle. An interview was attempted, however, R1 was unable to respond coherently to questions asked. During a tour and interview with the Administrator and Maintenance Director on 06/13/22 at 1:00 PM, the Administrator revealed R1 had possibly gotten out of the side door adjacent to the secured unit, however, it was fully unknown which door she eloped from. The Administrator stated R1 has a history of going to the service door at the end of the hall on Unit 4. The Maintenance Director stated all doors have been reset with new alarm codes, in which they are being consistently tested . All staff has also been educated on door alarms and the importance of ensuring all doors are alarmed when entering/exiting them. Review of CNA11's written statement included in the facility's investigation revealed, I worked on Unit 4 on 04/18/22. I don't know how R1 got out the door. When I was getting off, a lady was bringing her back in and said she had gotten out. During an interview with CNA11 on 06/13/22 at 2:45 PM, she revealed she last saw R1 on 04/18/22, a little after 2 PM walking up and down the hall of the secured unit. She appeared pleasant and was fully dressed but did not have on socks or shoes. Multiple attempts were made to contact the Responsible Party of R1 via telephone with no success. During a telephone interview with CNA10 on 06/13/22 at 3:25 PM, she stated, I was getting ready to leave a little after 2:30 PM and I heard a door alarm sounding. When I looked it appeared to be the side door that we used to come in to get screened. There was a receptionist sitting there on her phone. I asked if she knew where the alarm was coming from, and she stated she was unaware. I continued to leave for the day, when I got outside to the parking lot and noticed R1 outside walking across the parking lot towards the road. I yelled out her name and she did not respond. I then threw my belongings down that were in my hands and ran towards her. At that time, R1 began to walk more briskly. I finally caught up to her and linked arms with her as if I were a friend. I asked R1 where she was going and R1 responded, I'm just getting out of here. I was able to get her back into the building and back to her unit. When I got on the unit, I am unsure of what happened, but no one appeared to be looking for her. When asked how the weather was and if R1 was appropriately dressed, CNA10 responded R1 was fully dressed, but did not have on socks or shoes. She also stated the weather was nice. From what she saw, R1 had no injuries, however, she was upset when she realized she had been brought back into the building and became combative. During an interview with the DON on 06/13/22 at 3:45 PM, she stated CNA10 had found R1 out in the parking lot unattended and returned her to the facility. A body audit was completed with no injuries noted to R1. Staff was then educated on wandering residents and alarms; however, the DON was unable to provide the full documentation of trainings.

Based on review of the facility policy titled, Elopements and Wandering Residents, record review, interviews, and observations, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for accidents related to wandering. Resident (R) 1 had a successful elopement from an unconfirmed door of the facility on 04/18/22 approximately between 2:30 and 3 PM. Failure to establish, maintain and implement written policies and procedures regarding Elopement places an individual's health and safety at risk for serious injury, harm, impairment, or death. R1, with a history of exit seeking behaviors, was found roaming in the parking lot of the facility by Certified Nursing Assistant (CNA)10, adjacent to the highway, on 04/18/22 at approximately 2:55 PM. She was fully clothed but did not have on socks or shoes. She had a wanderguard on her ankle, which alarmed, however, staff did not immediately respond. The weather was reported to be fairly nice in the 70s. R1 had no injuries upon assessment. On 06/13/22 at 4:00 PM, the Administrator was provided with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F689 due to facility's failure to provide adequate supervision to prevent the elopement of R1, who had a diagnosis of dementia, with an effective date of 04/18/22. On 06/14/22 at approximately 10:30 AM, the Administrator provided an acceptable IJ removal plan related to F689. The immediacy of the IJ was removed as of 06/14/22. The IJ was lowered to scope and severity of D, no actual harm with potential for more than minimal harm that is not IJ. Additionally, the failure constituted substandard quality of care, warranting the completion of an extended survey on 06/15/22. The facility's removal plan for F689 included: 1) The identified Resident suffered no serious injury, as a result of the incident. 2) All other residents have the potential to be affected by the deficient practice. An elopement risk assessment will be initiated by licensed nursing staff on 06/13/22 and completed by 06/14/22. 3) Immediate in-service initiated 6/13/22 by the Director of Nursing (DON) and/or the DON Designee to all staff to include nurses and CNAs to ensure that they respond to all alarm alerts and to ensure the wanderguard system is not to be disarmed. Anyone disarming the wanderguard system will be subject to disciplinary action. Also, any staff member that disregards alarm sounding will be subject to disciplinary action up to and may include termination. The in-service will be conducted in person, telephone, email, or text. Those that will have in-service that was not able to be conducted in person, will be acknowledged on the sign in sheet in-service sheet as to the method of communication conveyed. All staff will have evidence of in-service communication by 06/14/22 and will have the in-person in-service prior to their working shift with signatures on the sign-in sheet prior to them working their shift. All newly hired nurses along with any agency staff will receive the information contained in the in-service prior to working with residents. Implementation of the removal plan was verified by observations, interviews and record reviews. Upon implementation verification, the Administrator was notified the IJ was removed as of 06/14/22. In addition, based on record reviews, interviews and the policy title, Fall Prevention Program, the facility failed to ensure that interventions and proper supervision were in place to prevent or decrease falls for Resident (R)22 for 1 of 3 residents reviewed for falls. This failure placed the resident at an increased risk to suffer injuries from multiple falls. In addition, based on observation, record review, and interview, the facility failed to ensure residents were safe from potential incidents/accidents due to alcohol usage by a CNA on 1 of 1 unit, 1 of 1 incident reviewed for misappropriation of property. Findings include: Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Review of the facility's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder, vascular dementia with behavioral disturbances, [CONDITION(S)] disorder, and anxiety. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/02/20 revealed she had a Brief Interview of Mental Status (BIMS) score of 04 out of 15, indicating she is cognitively impaired. Further review of the MDS assessment revealed R1 required supervision to limited assistance with activities of daily living (ADLs). She also was coded in Section E: Behaviors as exhibiting wandering daily. Review of R1's most recent Quarterly MDS with an ARD of 4/5/22 indicated a BIMS score of 00, indicating severe cognitive impairment. Review of Section E: Behaviors continued to be coded as wandering behaviors exhibited daily. Review of R1's Admission Elopement Risk Evaluation dated 11/02/20 indicated R1 scored an 11, which revealed above high risk to elope. Per the evaluation, R1's daughter had indicated she had gotten out of the home without anyone knowing, prior to admission to the facility. Review of R1's Quarterly Elopement Risk Evaluation dated 04/10/22 indicated R1 scored a 9, indicating at risk to elope. Comments indicate R1 wanders daily into other rooms and to the exit doors. Following her elopement on 04/18/22, an additional evaluation was completed with a score of 9 with comments to proceed with care plan updates. On 06/14/22, R1 had an additional evaluation that scored her as a 9, due to her previous elopement from the facility in April of '22. Review of R1's care plan with an initiation date of 10/31/20 and revised initiation date of 04/19/22 revealed a focus that stated, The resident is an elopement risk/wanderer as evidenced by aimlessly wandering throughout the unit and into other resident's rooms without invite. Also takes things that do not belong to her. She is exit seeking, pushes on the exit doors. Elopement on 4/18/22 with a diagnosis of Dementia. Goal put in place is R1 will not leave facility unattended through the next review date and R1's safety will be maintained through the review date. Interventions put into place are distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book, identify pattern of wandering and intervene as appropriate, monitor location every 30 minutes and redirect as needed, document wandering behavior and wanderguard in place. Review of R1's Physician orders dated January 2022 through June 2022 revealed an order, which stated, Check wanderguard placement and function every shift and check skin integrity every shift. Review of R1's Treatment Administration Record (TAR) reviewed for January 2022 to June 2022 revealed adequate monitoring of the wanderguard placement and functioning. Review of the facility's investigation on 06/13/22 at 12:00 PM revealed a written statement from Licensed Practical Nurse (LPN)4 which stated, On 04/18/22, I was walking in the courtyard to go inside and clock in when I witnessed a 1st shift CNA escorting a resident inside the building. She stated, look who I found wandering around out here. This nurse immediately informed a second nurse as she was walking by then informed the 1st shift nurse, who was on duty. She notified the Responsible Party (RP) and Director of Nursing (DON) but not answer at first. So, she went on to do an incident report and note. DON was notified by this nurse after the meeting she was in. The RP then called back and was told about the elopement. The alarm box was off, but the wanderguard was sounding. The statement did not indicate an exact time of incident. Multiple attempts were made to contact LPN4 via telephone for an interview, with no success. During an observation of the secured unit on 06/13/22 at 12:30 PM, R1 was observed pacing up and down the halls, going from her room door to the dayroom. Upon approach, she allowed the surveyor to observe her leg. There was a wanderguard placed on her right ankle. An interview was attempted, however, R1 was unable to respond coherently to questions asked. During a tour and interview with the Administrator and Maintenance Director on 06/13/22 at 1:00 PM, the Administrator revealed R1 had possibly gotten out of the side door adjacent to the secured unit, however, it was fully unknown which door she eloped from. The Administrator stated R1 has a history of going to the service door at the end of the hall on Unit 4. The Maintenance Director stated all doors have been reset with new alarm codes, in which they are being consistently tested . All staff has also been educated on door alarms and the importance of ensuring all doors are alarmed when entering/exiting them. Review of CNA11's written statement included in the facility's investigation revealed, I worked on Unit 4 on 04/18/22. I don't know how R1 got out the door. When I was getting off, a lady was bringing her back in and said she had gotten out. During an interview with CNA11 on 06/13/22 at 2:45 PM, she revealed she last saw R1 on 04/18/22, a little after 2 PM walking up and down the hall of the secured unit. She appeared pleasant and was fully dressed but did not have on socks or shoes. Multiple attempts were made to contact the Responsible Party of R1 via telephone with no success. During a telephone interview with CNA10 on 06/13/22 at 3:25 PM, she stated, I was getting ready to leave a little after 2:30 PM and I heard a door alarm sounding. When I looked it appeared to be the side door that we used to come in to get screened. There was a receptionist sitting there on her phone. I asked if she knew where the alarm was coming from, and she stated she was unaware. I continued to leave for the day, when I got outside to the parking lot and noticed R1 outside walking across the parking lot towards the road. I yelled out her name and she did not respond. I then threw my belongings down that were in my hands and ran towards her. At that time, R1 began to walk more briskly. I finally caught up to her and linked arms with her as if I were a friend. I asked R1 where she was going and R1 responded, I'm just getting out of here. I was able to get her back into the building and back to her unit. When I got on the unit, I am unsure of what happened, but no one appeared to be looking for her. When asked how the weather was and if R1 was appropriately dressed, CNA10 responded R1 was fully dressed, but did not have on socks or shoes. She also stated the weather was nice. From what she saw, R1 had no injuries, however, she was upset when she realized she had been brought back into the building and became combative. During an interview with the DON on 06/13/22 at 3:45 PM, she stated CNA10 had found R1 out in the parking lot unattended and returned her to the facility. A body audit was completed with no injuries noted to R1. Staff was then educated on wandering residents and alarms; however, the DON was unable to provide the full documentation of trainings. 2) Findings include: Review on 6/13/22 at 10:30 AM of the facility's undated policy titled, Fall Prevention Program, states under policy, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Procedures include: The resident will be placed on the facility's Fall Prevention Program and will be recorded on the resident's care plan. Provide interventions that address the unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. The facility admitted R22 with diagnoses including, but not limited to alzheimer's disease, major depressive disorder, dementia with behavioral disturbance, and overactive bladder. Review of R22's MDS with an ARD of 10/21/22 revealed R22 had a BIMS score of 00, which indicated R22 was rarely/never understood. Further review of the MDS revealed R22 required supervision when: walk in room, walk in corridor, locomotion on unit, and locomotion off unit. Additionally, the MDS indicated R22 did not have any mobility devices and had 2 or more falls since admission or prior assessment with no injury. Review of R22's nurses notes dated 03/08/22, revealed, R22 was observed by staff laying on the floor in the dining room. Staff assisted resident up and into a chair. Upon assessment a laceration was noted near the resident's left eyebrow. The physician was called, and he gave an order to send resident to the emergency room (ER) for further evaluation. R22 was taken to the local hospital and treated for a laceration to the left eyebrow area which measured 4 centimeters (cm) in length with 5 staples in place. Further review of R22's progress notes, revealed multiple falls without injury. Review of the Post Fall Evaluation dated 03/09/22 revealed: Fall Details: Date / Time of Fall: 03/08/2022 11:50 AM Fall was not witnessed. Fall occurred elsewhere. Other fall location: Dining Room Activity at the time of fall: N/A The reason for the fall was not evident. Was a safety evaluation completed/documented prior to the fall: No. Safety teaching documented before the fall: No. Did an injury occur as a result of the fall: Yes. Injury details: Laceration to left eye brow Did fall result in an ER visit/hospitalization : Yes. ER Visit/hospitalization Details: 5 staples Fall Details Note: Resident observed on floor in dining room. Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair involved: No. Wearing glasses at the time of the fall: N/A. Footwear at time of fall: Shoes. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Incontinent at time of fall: Yes. Call light on when Resident was found: N/A. Bathroom call light on when Resident was found: N/A. Personal alarm sounding when Resident found: N/A. Other Residents involved in fall: No. Review of R22's Care Plan with an initiated date of 11/13/20 and target date of 08/02/22 revealed: Focus - I need out of room 1:1 visits due to my wandering about my unit and my diagnosis. Goal - I will try to interact with staff thru conversation when walking or sitting by me during 1:1. Actions - Continue to spend 1:1 time with me as I am walking up and down the halls. Also included in R22's Care Plan with an initiated date of 11/16/20 and target date of 08/02/22 revealed: Focus - I have had falls in the past. I am at risk for falls related to diagnosis of Dementia. I have poor safety awareness. I will lay in the floor at times. I need assistance with transferring and ambulation/locomotion. Goal - I want to be safe in my movements. I do not want to have any major injuries occur from falls. Actions - Fall risk assessment done per facility policy, Frequent checks, I need assist with transfers and ambulation, Monitor for gait instabilities, Staff to monitor resident's whereabouts on the unit, and Staff to provide frequent checks. Focus - I need assistance with transfers/bed mobility/ambulation. Goal - I would like not to decline in my physical function. Actions - I ambulate around unit with staff supervision. Monitor for gait instabilities and render assist if needed. An interview on 06/13/22 at approximately 3:30 PM with CNA1, confirmed the fall with injuries to R22. An interview on 6/13/22 at 3:58 PM with the DON confirmed the fall that took place on 03/08/22 and stated, He (R22) falls a lot due to his shuffled walk and I do not feel he has the cognitive ability to use a walker. An observation 6/14/22 at 4:26 PM, during a follow up interview with another resident, revealed R22 in the dining room of the 400 Unit, leaning on a dining room table. There were no facility staff present in the dining room, R22 was unsupervised. As this surveyor was exiting the dining room, there was a loud noise and it appeared that R22 had fallen. R22 was on the floor, laying in the fetal position on his side and the table was turned onto its side next to R22. Facility staff immediately responded and began to assess the resident. R22 was found to have no injuries from the fall and was monitored by staff. R22 was observed to be wearing sneakers with no mobility devices present. An interview on 06/14/22 at 4:40 PM with Unit Manager, confirmed R22's falls and stated, follow up to R22's fall would be to notify the physician, conduct Neuro checks and acute charting for the next 3 days, 30-minute checks on residents. An interview on 06/14/22 at 4:45 PM with LPN1, revealed she assisted R22 after the fall. LPN1 took vitals but stated she did not see the fall and she is not R22's nurse. LPN1 further stated follow up to the fall would be to, complete an incident report, conduct a post fall assessment, skin assessment, and notify doctor and family. Review of R22's Nursing Note dated 06/14/22 revealed, Resident was seen by staff lying on the floor beside overturned table in dining room (DR), alert and responsive. Staff assessed resident, did neurochecks and helped him to a chair. No apparent injuries noted-when this nurse asked resident, he mumbled, no to any discomfort. Neruochecks started, resident representative (RP), supervisor, physician, DON, Administrator notified. Review of the Post Fall Evaluation dated 06/14/22 revealed: Fall Details: Date / Time of Fall: 12/02/2021 4:50 PM Fall was not witnessed. Fall occurred elsewhere. Other fall location: dining room Activity at the time of fall: none The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization : No. Fall Details Note: Resident was on right side on the floor in dining room. Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair involved: No. Wearing glasses at the time of the fall: N/A. Footwear at time of fall: Shoes. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Incontinent at time of fall: No. Call light on when Resident was found: N/A. Bathroom call light on when Resident was found: N/A. Personal alarm sounding when Resident found: N/A. Other Residents involved in fall: No. Contributing Factors Note: Resident was in napping position when seen by staff. In a follow-up interview on 06/15/22 at 9:47 AM, CNA1 revealed she assisted R22 up from the fall that occurred on 06/14/22. She stated R22 woke up this morning and ate breakfast, he had no visible injuries from the fall. Other nurses at the nurses station reported there were no complaints or negative observations from the night shift. Review of Nursing Notes and Post Fall Evaluations revealed R22 had documentation of falls or being found on the floor, that occurred on: 05/04/21, 05/17/21, 08/10/21, 08/19/21, 09/23/21, 09/25/21, 11/29/21, 12/02/21, 03/08/22, 03/09/22, 03/11/22 and 06/14/22. 3) Additional findings include: Review of the facility's document titled, Responsibilities and Rules of Residency, states, 2. Alcohol and Drugs:(a) Alcohol and drugs, legal or illegal, can interfere with or enhance the effect of legally prescribed medications. Mixing these without the prescribed knowledge of your physician can have negative consequences up to and including death. Improperly consumed, the effects may cause an increase in negative or disruptive behaviors that interfere with the rights of others and the positive health-promoting mission of the facility. For this reason: Drugs or alcohol, other than those prescribed by your physician, are not allowed in the facility or on facility grounds. (c) .(ii) stop administering any and all prescribed medication, (iii)search the resident's room and personal belongings for contraband. Any alcohol, drug or medication not ordered by your physician will be confiscated by facility personnel. The facility submitted a 24-hour reportable to the State Agency on 06/06/22 at 10:15 AM, alleging R2 was observed sitting in his wheelchair in the hallway drinking from a can of beer on 06/05/22 at approximately 10:55 PM. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to [CONDITION(S)], hypertension, [CONDITION(S)], and convulsions. Review of his quarterly MDS with an ARD of 03/17/22 revealed he has a BIMS score of 15, indicating he is cognitively intact. Review of R2's progress notes dated 06/06/22 at 10:45 PM revealed: Social Services Director (SSD) spoke with R2 via phone on 06/05/22 related to having beer in his room and drinking beer without doctor's orders. R2 said his cardiologist can provide the needed orders and documentation. SSD explained that we have to have the documentation in place before the alcohol is brought in then it cannot be stored in his refrigerator. He said he understood and that he would not be asking anyone else to bring in beer. He said he talked to his friend on the phone, and she asked him what he wanted for his birthday. He said he didn't think his friend would actually bring it. He would not give his friend's name. SSD will speak to (R2) in person on 6/7/22. Additional review revealed a document from the SSD which read, Please notify a Nursing Supervisor or Social Services if R2 has a visitor. Also, he doesn't need any deliveries given to him unless someone checks it thoroughly first. Review of R2's Physician Orders dated March 2022- June 2022 did not contain orders related to allowing R2 to consume alcohol while in the facility. Additional review of the Physician's Progress Note dated 06/06/22 states, I was asked to evaluate patient due to ETOH abuse. Over the weekend, the patient had a birthday party and per report had a 12 pack of beer delivered. On questioning, R2 states he did not drink that much and only had 1 or 2. He denies any excessive intake of alcohol. Before questioning, he became defensive and states, who told you? Why can't I have alcohol, I was told by other doctors that I could have alcohol. R2 does not understand reasons for not being able to drink alcohol and states he has had alcohol for years without any issues. Denies withdrawal symptoms in the past. Denies excessive intake. Denies other acute issues at this time. Review of the Medication Administration Record (MAR) revealed medications were held due to alcohol usage and R2 was to be observed closely for monitoring. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to major depressive disorder, panic disorder, post-traumatic stress disorder, [CONDITION(S)], anxiety disorder, and hypertension. According to a Quarterly MDS completed on 04/18/22, R3 has a BIMS score of 15 out of 15, which indicated she is cognitively intact. Review of the facility's investigation revealed a written witness statement from CNA14 dated 06/10/22 that read, I, CNA14, was in the breakroom and witnessed CNA13 take one of R2's Budweiser's and mix it with a couple of juices. CNA13 mixed the beer and juice in a clear water pitcher liner and drank it in the breakroom. This statement was noted to be taken via telephone by the Administrator. Multiple attempts were made to contact CNA14 with no success. During an interview with the DON on 06/14/22 at 2:46 PM, she stated she was contacted by staff and told R2 was in the facility drinking beer. Also, a staff member had observed CNA13 consume one of the beers and continue working. She stated, when she returned to work, she immediately in-serviced only the staff involved on the importance of immediately reporting and use of alcohol, while in the facility. Additional review of the facility's investigation revealed an undated written document that reads, The nurse was verbally educated via phone conversation that if a circumstance arises like this situation with R2, the priority is to have the alcohol locked up immediately. It should not be delegated out to anyone. This document had the DON's name on it. During an interview with CNA12 on 06/14/22 at 2:51 PM, she stated she was not directly involved with R2, however, she did see him drinking in the hallway. When asked if she had seen or heard of anyone drinking beer while working, she stated she heard CNA13 drank one, but she did not see it herself. During an interview with the Administrator on 06/14/22 at 3:41 PM, she stated the facility replaced the 1 beer that was alleged to be drunken by CNA13. She said the 4 cans of beer are currently being held in the medroom because the Nurse Practitioner said R2 cannot have beer due to his comorbidities. However, the Cardiologist has said it was okay, pending approval from R2's Neurologist. When asked if staff is made aware of facility rules on alcohol usage, the Administrator stated only facility staff are given orientation, agency staff do not receive orientation. During a telephone interview with LPN9 on 06/14/22 at 4:12 PM, she stated R3 was in the hallway with a can of beer in her hands. When asked where she had gotten the beer, R3 stated R2 had given them to her, and he had more. LPN9 took the beer from R3 and went to R2. At that time, he was attempting to hide the beer can under his leg, and told her he was not drinking beer, although she could see the Budweiser label on the can. LPN9 then took the beer from R2 and entered his bedroom to find 2 additional cans in his refrigerator. LPN9 stated there was also a paper bag by his bed, in which contained empty beer cans. LPN9 attempted to ask R2 where the beer had come from, and he stated a friend had brought some in in a Pepsi box during the weekend. LPN9 then began the process of reporting to the officials and asked CNA14 if she would take the beer and put them in the breakroom, until she had a chance to lock them up, because she had fallen behind on her medication pass due to the reporting process. Upon completion of medication pass, LPN9 stated she went into the breakroom to retrieve the cans of beer and noticed that there were only 3 cans, when there were originally 4. When she inquired of CNA14, CNA14 told her she had observed CNA13 in the breakroom, drinking the beer after having mixed it with a carton of juice. LPN9 stated she did not physically see CNA13 consume the alcohol, but she did see the empty juice carton and beer can in the breakroom's trash can. When asked if CNA13 had any behaviors that night, LPN9 stated she had not worked with her before, however, she was joking all night about needing a beer. LPN9 stated she asked CNA14 why she didn't tell her that CNA13 had consumed the beer immediately and she stated, I thought you knew since she was joking and talking about it. LPN9 went on to say all residents on the unit were assessed and interviewed to ensure there was no harm or injuries related to CNA13 caring for them. During a telephone interview with CNA13 on 06/14/22 at 4:22 PM, she stated she was coming from R3's room to check R2's room after hearing he had beer in his room. After searching, she did not find any beer. Later that night, beer was found in his room. She finished her shift and went home. The next day, someone called her from the facility saying that she drunk the beer with juice, and she could not return to the building. When asked if she has worked or heard additional information from the facility since then, she stated she has not. An interview on 06/14/22 at 4:45 PM with R3 revealed I remember seeing him (R2) drinking a beer one night, I think he was a little drunk. I saw him in the doorway of his room drinking one, so I went up and asked him for one and he gave it to me. By the time I got back into my room, one of the nurses saw me with the beer and took it from me before I could drink it, which made me mad because I can drink Monster energy drinks because the Dr. approved me. When they asked me where I got it from, I told them, and I saw them take the rest of the beers that he had from him. I didn't see any of the nurses drinking it, I just saw when they put it away behind the nurse's station somewhere. During an interview with the DON and Executive Director on 06/14/22 at 4:50 PM, the DON stated she had completed an in-service with 4 CNAs related to alcohol usage. Upon review of the in-service sign in sheet dated 06/07/22, there was a signature that contained CNA13's name. During an additional phone interview with CNA13 on 06/14/22 at 4:55 PM, she stated she had not heard anything additional from the DON, nor had she received any in-services. Review of CNA13's timecard revealed her last shift worked was on 06/05/22 from 7 AM to 11 PM. During an interview with the Executive Director on 06/14/22 at 5:10 PM, he stated it was his expectation if staff were brought in for in-services, that they clock in. During an interview with R2 on 06/14/22 at 5:20 PM, when asked if he had consumed beer, or had beer in his possession at any time while in the facility, he stated, Maybe I did, Maybe I didn't. During an observation of the medroom on 06/14/22 at 5:25 PM, 4 Budweiser cans were noted to be on the counter, unopened. Both the Administrator and DON were asked to provide documentation related to staff orientation on alcohol usage. None had been provided by the end of the survey.

Based on observations, interviews, record review, and review of the facility's COVID-19 Policy/Plan for Facilities and Infection Prevention and Control policies, the facility failed to prevent the potential transmission of COVID-19 from the community and between facility residents. Specifically: 1. The facility failed to ensure all employees were adequately screened prior to entry for their shift, thus employees were allowed to work in the building with elevated temperature or without their temperature and/or signs and symptoms of COVID-19 being monitored. 2. The facility failed to ensure residents in the dining room and day rooms maintained at least six feet of separation between them to prevent the potential spread of COVID-19. 3. The facility failed to ensure one employee did not cross over from the dedicated isolation unit to the non-isolation resident areas. Additionally, the facility failed to ensure an adequate infection prevention and control surveillance program to determine trends or possible infection control breaches. These failures placed all 137 facility residents at high risk for potential transmission of COVID-19 and other infections. The facility Administrator was informed on 05/18/2020 at 3:15 PM that the Immediate Jeopardy began on 03/06/2020. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/19/2020 at 9:34 AM and the Immediate Jeopardy was removed on 05/19/2020 at 3:45 PM and lowered to the scope and severity of F. The findings included: 1. The facility's COVID-19 Policy/Plan for Facilities, implemented on 03/04/2020 and updated on 05/06/2020 indicated, Temperatures of staff will be taken with no person permitted to work with a temperature greater than 99.6. All staff will complete the Staff Log and be screened for potential concerns prior to reporting to resident areas. Staff logs now include temperatures at exit as well. On 05/18/2020 at 8:32 AM, the screening station at the front door was observed with only one pen, one thermometer, one alcohol wipe, hand sanitizer, and a clipboard containing screening forms. The station also contained approximately six screening forms from 05/16/2020 and 05/17/2020. The receptionist stated these were screening forms from the weekend that had not been looked at yet. The receptionist stated she/he would add the weekend's forms to the binder where all completed screening forms were kept. The receptionist stated that no one looked at these forms over the weekend and they just piled up until she/he picked them up on Monday mornings. On 05/18/2020 at 8:35 AM, the Activity Director (AD) entered the facility through the front door and approached the employee screening station. The AD took his/her own temperature without first sanitizing the thermometer and used the one pen to sign the screening form. She/he placed the pen down on the table without sanitizing it. There was no staff evaluating his/her temperature and responses on the screening form, and she/he entered the resident area to work. On 05/18/2020 at 8:40 AM, social work assistant (SWA) #1 entered the front door and approached the screening station. She/he used the same pen to complete the screening form without sanitizing it before or after. The receptionist told SWA#1 the thermometer had not yet been sanitized, so she/he would have to wait to take his/her temperature. SWA#1 reported to the receptionist that she/he had already taken his/her temperature at home and documented a temperature of 98.3 degrees Fahrenheit (F) on the form. SWA#1 was not observed to take his/her temperature, nor was it monitored by any staff. SWA#1 then entered the resident area without being asked to re-check her temperature. The receptionist did not view the screening form that SWA#1 completed. At 8:45 AM, the receptionist was asked whether SWA#1 completed the screening form before entering the resident area, and she/he stated she/he was not sure. The receptionist then called SWA#1, who confirmed she/he had completed the screening form. On 05/18/2020 at 9:20 AM, a second screening station was observed at the side courtyard entrance in the second-floor. The station had a clipboard with screening forms, one pen, one alcohol wipe, one thermometer, and hand sanitizer. There were no staff in the area. Several staff had completed the screening form at the side courtyard entrance at the beginning of their shift on 05/18/2020. On 05/18/2020 at 10:08 AM in the second-floor hallway, certified nurse aide (CNA) #1 stated this was his/her first day of orientation. She/he stated when she/he entered for his/her shift, she/he came in through the side courtyard door, used hand sanitizer, answered the screening questions on the form with the pen provided, and took his/her temperature. She/he stated there were no staff members at the screening station to monitor or assist with completing the screening. On 05/18/2020 at 10:10 AM in the second-floor hallway, Registered Nurse (RN) #1 stated when she/he entered the building for his/her shift, she/he was to sanitize his/her hands, check his/her temperature using the provided thermometer, and answer the screening questions. RN#1 stated, We check in on our own. RN#1 also stated staff was supposed to wipe down thermometer before and after use with the provided alcohol wipes. On 05/18/2020 at 10:15 AM in the second-floor hallway, CNA#3 stated when she/he first entered the facility for his/her shift, she/he was to check in at the screening station, take his/her temperature, and answer the screening questions on the form. She/he stated that staff did not review the screening form entries or his/her temperature before she/he could enter the resident area. On 05/18/2020 at 10:16 AM in the second-floor hallway, housekeeper (HK) #1 stated she/he typically entered through the front door and there was someone who took his/her temperature. She/he then completed the screening questions on the form before entering the resident area but was unsure whether any staff monitored the responses to the screening questions. On 05/18/2020 at 10:17 AM in the second-floor hallway, CNA#2 stated when she/he entered the facility at the beginning of the shift, she/he took his/her own temperature and completed the screening form. She/he stated she/he typically entered through the side courtyard door. CNA#2 stated there was typically no staff member present to assist or monitor the screening process. On 05/18/2020 at 10:25 AM in the second-floor hallway, HK #3 stated when she/he entered the building for his/her shift, she/he was to check in at the screening station, his/her temperature was monitored by staff, and she/he completed the screening questions. She/he did not know if the screening responses were reviewed by staff before she/he entered the resident area. On 05/18/2020 at 10:44 AM in the conference room, the Assistant Director of Nursing (ADON), who also served as the facility's Infection Preventionist, stated the receptionist or others at the front office were responsible to ensure all employees completed the screening, the thermometers worked appropriately, and the staff sanitized the pen and thermometers before and after each use. The ADON stated employees were not permitted to work if they had a temperature over 99.6 degrees F. When alerted to the screening observations of the AD and SWA#1, the ADON stated the AD was someone who helped with screening at times, so that is why she/he probably screened himself/herself. She/he stated SWA#1 should not have entered the building without monitoring his/her temperature at the screening station. The ADON stated, We made (SWA#1) come back and re-check (his/her) temperature with our thermometer. The ADON reported SWA#1's temperature was monitored at 98.1 degrees F. The ADON stated that she/he reviewed the completed screening forms the following morning, but there were no staff assigned to review the forms in real time in order to prevent unauthorized access to the resident areas. The ADON also stated she/he reviewed the forms for the weekends on the following Monday, and had not yet reviewed the forms from 05/15/2020, 05/16/2020, and 05/17/2020. She/he stated staff was supposed to use the front entrance only, as the front door screening station is monitored by several people. When asked who monitored the front door screening station, the ADON replied, It is random no one specific is assigned. Review of the May 2020 employee screening forms revealed on 05/15/2020, Licensed Practical Nurse (LPN) #7 documented a temperature of 100.1 degrees F on the entry screening form at 2:38 PM. Review of LPN#7's time punches indicated she/he proceeded to work her shift from 2:41 PM to 11:15 PM on 05/15/2020. Additionally, review of the employee screening forms from 05/01/2020 through 05/17/2020 revealed: -On 05/07/2020 at 6:50 AM, floor technician (FT) #2 answered the four screening questions on the entry screening form but did not document a temperature. -On 05/07/2020 at 6:57 AM, CNA#10 answered the four screening questions on the entry screening form but did not document a temperature. -On 05/07/2020 at 6:58 AM, CNA#3 documented a temperature on the entry screening form but did not answer the four screening questions. -On 05/07/2020 at 10:52 PM, CNA#7 and CNA#8 answered the four questions on the entry screening form but did not document their temperatures. -On 05/07/2020 at 10:55 PM, CNA#9 answered the four questions on the entry screening form but did not document a temperature. -On 05/08/2020 at 11:56 AM, dietary aide (DA) #3 signed the entry screening form and documented his/her temperature. However, she/he did not answer the four screening questions. -On 05/09/2020, the Medical Director (MD) signed the entry screening form and answered the four screening questions; however, she/he did not enter a temperature or the time of entry. -On 05/12/2020, hospice worker #1 signed the entry screening form, but did not enter a time of entry, temperature, or responses to the screening questions. -On 05/13/2020, the MD signed his/her name but did not document a time of entry, temperature, or answers to the four screening questions. -On 05/13/2020, DA#3 did not document the time or entry or answers to the four screening questions. -On 05/14/2020 at 6:50 AM, FT#2 documented answers to the four questions but did not document a temperature on the entry screening form. -On 05/14/2020 at 7:00 AM, LPN#8 documented answers to the four questions but did not document a temperature on the entry screening form. -On 05/14/2020 at 7:06 AM, CNA#12 documented answers to the four questions but did not document a temperature on the entry screening form. -On 05/14/2020 at 7:53 AM, HK#4 did not document answers to the four questions or a temperature on the entry screening form. -On 05/14/2020, LPN#9 and DA#4 documented answers to the four screening questions but did not document their times of entry or their temperatures. -On 05/14/2020 at 10:58 PM, CNA#9 documented answers to the four questions but did not document a temperature on the entry screening form. -On 05/14/2020, CNA#11 documented answers to the four screening questions but did not document a time of entry or a temperature. -On 05/15/2020 at 10:52 PM, CNA#7 answered the four questions on the entry screening form but did not document a temperature. On 05/18/2020 at 11:48 AM, an interview was conducted with the Administrator and Director of Nursing (DON) in the conference room. The Administrator stated all staff were provided with in-service training regarding the entry screening process and the facility completed handwashing and PPE use competency testing, as well as competency testing for temperature monitoring. The Administrator stated that the AD had been the person checking people in (at the entry screening station) when she/he was available, and the receptionist assisted. Both the Administrator and DON stated they were unaware staff were entering the side courtyard door at the beginning of the day shift, and the DON stated that door was to be used for exiting only. She/he stated the screening log and thermometer at that side door were for exit screening only. The Administrator added that staff were educated, and expected, to use only the front door for entry before the start of their shift. The DON stated the staff should be sanitizing the pens and thermometers after each use, and the front office staff were responsible for ensuring alcohol wipes were fully stocked. Both the Administrator and DON stated they were unaware LPN#7 worked on 05/15/2020 with a fever of 100.1 degrees F, and the DON stated LPN#7 should not have worked that day and should have left the building without entering the resident area. The DON stated she/he would implement an immediate fix for entry through the side courtyard door by having the entry codes changed. In a concurrent interview with the DON and the ADON on 05/18/2020 at 1:07 PM in the conference room, the ADON stated she/he was unaware LPN#7 worked in the building with a fever of 100.1 degrees F on 05/15/2020. The ADON added she/he had not reviewed the screening forms for 05/15/2020. The ADON stated she/he was unaware there were staff who had either failed to answer the screening questions and/or failed to document their temperature on the entry screening forms. She/he stated she/he did not know why that was happening, as all staff were educated on the screening process. The DON added that the MD had been a part of development of the facility's policies and screening procedures, so she/he could not explain why the MD was not completing the screening questions and documenting his/her temperature before entering the resident area. On 05/18/2020 at 4:00 PM in the conference room, the Administrator stated education regarding the screening process prior to starting work was covered in an in-service, held on 03/05/2020 and 03/06/2020, for all staff. The agenda for the in-service documented COVID-19 Plan as an agenda item. The accompanying 03/05/2020 and 03/06/2020 in-service materials documented, COVID-19 Plan 03/2020 - CNA responsibilities - s/s (signs and symptoms) of COVID-19; location of sanitizer and PPE (personal protective equipment); including having temperature taken before shift and what to do if there are concerns. 2. Review of the facility's COVID-19 Policy/Plan for Facilities, implemented on 03/04/2020 and updated on 05/06/2020, indicated, Prevent gatherings. Gatherings for meals and activities are banned at this time and until further notice unless the social distancing rules of 6' (six feet) of distance between persons and ample fresh air can be employed. On 05/18/2020 at 9:15 AM, two residents were observed seated at one table, with less than six feet of distance between them near the north wall in the Unit 2 dining room. There were 18 place settings with dirty dishes noted throughout the Unit 2 dining room where residents had eaten their morning meal. The place settings were less than six feet apart. On 05/18/2020 at 9:20 AM, three residents were observed seated in the Unit 3 day room together, two of whom were sitting closer than six feet apart. An unidentified staff member was in the day room conversing with the third resident. On 05/18/2020 at 12:07 PM, two residents were observed seated at the same table in the Unit 3 dining room, less than six feet apart from one another. On 05/18/2020 at 12:10 PM, in the Unit 2 dining room, eight residents were observed seated at several tables and tablemates were closer than six feet apart. At a setup of three tables pushed together, near the center of the room, Certified Occupational Therapy Assistant (COTA) #1 was seated at the south (left) end of the tables, between two residents that were closer than six feet apart. An unidentified staff member informed COTA#1 the residents were supposed to be six feet apart; COTA#1 stated, I'm sorry. I didn't know. COTA#1 then moved one resident to another table, near the west wall. During an interview on 05/18/2020 at 12:13 PM in the Unit 2 dining room, DA#2 was asked if the facility had been keeping the residents six feet apart in the dining rooms and she/he responded, I'm not going to lie to you. No. She/he stated Unit 3 staff did a good job in keeping their residents apart, but it was harder in Unit 2. On 05/18/2020 at 12:20 PM in the Unit 2 dining room, resident #3 and resident #4, who were not roommates, were observed seated together at a table, with less than six feet between them. Resident #4 stated the staff had not made residents stay in their rooms for meals. She/he stated a resident could get a room tray if they wanted, but it was not required. She/he stated, You can't physically do it (maintain six feet distance between residents) in this room. On 05/18/2020 at 12:50 PM in the Unit 4 dining room, 19 residents were observed eating their lunch meal. Two residents were seated less than six feet apart at the center table. Two additional residents were observed within six feet of one another near the south wall. On 05/18/2020 at 1:07 PM, the DON and ADON were interviewed concurrently in the conference room. The DON stated the facility limited communal dining to the extent possible, and those that ate meals in the dining room should be socially distanced. The DON stated that residents who were roommates could be closer together, since they shared a room, but we try to keep them as far apart as possible. The DON stated the facility talked to the residents about eating in their rooms, but a lot don't remember. She/he also stated there were signs posted throughout the building reminding staff and residents to maintain social distancing of at least six feet. The ADON stated she/he was not aware residents were eating their meals within six feet of one another and added that residents sitting side by side should be separated. The DON added that Unit 2 had the most alert and oriented residents, who wanted to sit together and socialize, so it was more difficult for the facility to ensure residents maintained appropriate social distancing in the Unit 2 dining room. The DON stated all staff had been educated on the COVID-19 policy on 03/05/2020 and 03/06/2020, which included limiting communal dining unless the residents could maintain a social distance of at least six feet. The 05/19/2020 Immediate Jeopardy Removal Plan included the following: Summary of Incident: . No residents were directly involved in the cited deficient practice, but all residents are at risk from the failure to adhere with correct and adequate infection control processes as guided by the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (Services) (CMS). The deficient practice occurred when 1) several employees identified not following infection screening process and 2) residents observed less than 6 (six) feet apart in the dining room during lunch services. Immediate Changes to Facility System: . 5/18/20 @ (at) 12:30 pm - Ad Hoc QA Meeting with IDT (inter-disciplinary team) to discuss immediate action plan to address alleged deficient practice 12:45 pm - The Activity Director immediately stationed at front door to screen. Activity director will only leave station for any reason when relieved by other designated screener. 12:50 pm - The Maintenance Director called Carolina Burglar Systems to change door access codes. 1:00 pm - Designated employees stationed at front door and all other doors until codes are changed by Maintenance Director. Facility policy for dining has been changed as per CMS social distancing guidelines. Education Plan: . 1:30 pm - The Staff Development (Coordinator) and Unit Manager began education to nursing, dietary, housekeeping, activities, social work, therapy, and administration on Screening process for staff, visitors, and other providers on the following: 1) Screening process for staff, visitors, and other providers 2) Exclusion from work and/or visiting process 3) Infection (control) practices when entering/exiting 4) Maintaining adequate supplies 5) Maintaining social distancing in dining area and/or other centralized settings All staff will receive education before next scheduled shift. New hires will receive this education as part of orientation. -Effective immediately, the Front Door will be used for entering and exiting the facility with the exception of the isolation unit which will continue to have a designated exit only door -All door codes will be changed and will only be provided to you if you are a door screener -The courtyard will have its own door code which will be provided to staff for the purpose of courtyard activity only. This is not an exit or entrance to/from work -You must check-in/out at the front door with the designated screener and the screener and the screener will take temperatures and will clean thermometer with alcohol before and after use. Facility will have a designated person by the door 7 (seven) days a week throughout the day to check all employee's (sic) and visitors prior to entry. -You will document on the sign-in/out log. You should use your own pen. If one is provided to you for use, it will be cleaned with alcohol before and after use -No one will be allowed to enter if answering yes to any questions on screening tool or if you have a temperature of 99.6 (degrees F) or greater. The Administrator/Director of Nursing will be notified. The return-to-work process will be followed. -Masks are to be worn at all times in the facility -Adequate cleaning supplies will be maintained by facility for entering/exiting process -Residents are to maintain 6 (six) foot social distancing at all times. It is all staff responsibility to remind residents of this -The dining room and other common settings such as the courtyard must maintain 6 (six) foot social distancing. 3:20 pm - IJ (Immediate Jeopardy) called 3:30 (PM) - (Administrator) education to screeners 4:10 (PM) all education completed for 1st (first) shift staff and 2nd (second) shift Education to continue to all oncoming shifts prior to starting work until all staff have been educated. No staff remember (sic) will be allowed until they have been educated. Monitor Removal Plan Outcomes: . Facility Administrator/Director of Nursing or Designee will review sign in logs each shift daily for compliance. Dining room tables will be marked off for 6 (six) feet of separation and checked prior to each meal. Administrator/Director of Nursing or Designee will monitor daily to ensure compliance. All changes will be QAPI (Quality Assurance/Performance Improvement committee) weekly for 3 (three) months to ensure compliance. QAPI committee will make any necessary adjustments as needed. Completion Date: . The facility alleges the removal of the immediate jeopardy on 5/18/2020. The Administrator is responsible for assuring corrective actions are sustained. On 05/19/2020 from 12:30 PM to 3:45 PM, the survey team validated the facility's implementation of the above Removal Plan through observations, staff and resident interviews, and facility record reviews.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of Resident #1's physician orders [REDACTED]. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the resident's Medication Administration Record [REDACTED]. The order indicated [MEDICATION NAME] sulfate 20 milligram/1 milliliter solution 0.25 milliliter oral every 2 hours as needed for pain. The nurse indicated the resident displayed signs of pain by yelling out when care was being given and holding head as if having a headache. The 9/7/17 dose at 5:49 AM was the first time the resident was administered the medication during the month of (MONTH) (YEAR). Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed [MEDICAL CONDITION] tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with [MEDICATION NAME]. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without help. The physician said it could have happened at any time because of her severe [MEDICAL CONDITION]. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect.

Based on review of facility files and interview, the facility failed to ensure services were provided in accordance with each resident's written plan of care. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed [MEDICAL CONDITION] tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with [MEDICATION NAME]. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without help. The physician said it could have happened at any time because of her severe [MEDICAL CONDITION]. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect.

Based on review of facility files and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of Resident #1's physician orders [REDACTED]. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the resident's Medication Administration Record for (MONTH) (YEAR) revealed the resident received 0.25 milliliters of morphine sulfate on 9/7/17 at 5:49 AM. The order indicated morphine sulfate 20 milligram/1 milliliter solution 0.25 milliliter oral every 2 hours as needed for pain. The nurse indicated the resident displayed signs of pain by yelling out when care was being given and holding head as if having a headache. The 9/7/17 dose at 5:49 AM was the first time the resident was administered the medication during the month of (MONTH) (YEAR). Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed fracture of the distal tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with morphine. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without anybody. The physician said it could have happened at any time because of her severe osteoporosis. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of Resident #1's physician orders [REDACTED]. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the resident's Medication Administration Record [REDACTED]. The order indicated [MEDICATION NAME] sulfate 20 milligram/1 milliliter solution 0.25 milliliter oral every 2 hours as needed for pain. The nurse indicated the resident displayed signs of pain by yelling out when care was being given and holding head as if having a headache. The 9/7/17 dose at 5:49 AM was the first time the resident was administered the medication during the month of (MONTH) (YEAR). Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed [MEDICAL CONDITION] tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with [MEDICATION NAME]. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without help. The physician said it could have happened at any time because of her severe [MEDICAL CONDITION]. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect. Review of the facility's Freedom from Abuse, Neglect, and Exploitation Policy revealed the resident has the right to be free from neglect. The policy defined neglect as the failure or omission of the facility or its employees or service providers to provide the care, goods, or services necessary to avoid physical harm, mental anguish, or mental illness or emotional distress.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents. Water temperatures were above accepted parameters on 3 of 4 units. Water temperatures exceeded 140 degrees Fahrenheit on the locked Alzheimer's Unit. The facility's Maintenance Director and Administrator were aware the water temperatures exceeded a safe range. The Maintenance Director did not have a system of recording water temperatures and was unaware of how to calibrate a thermometer. These findings resulted in Immediate Jeopardy existing in the facility at the time of discovery on 3/21/16. The facility Administrator was informed of the Immediate Jeopardy on 3/21/16 at 7:00 PM. Additionally, interventions were not implemented following falls to prevent recurrence for 1 of 4 residents reviewed for accidents (Resident #166). The findings included: Observation on Unit 1 in Room 113 on 3/21/2016 at 3:42 PM revealed the water temperature in the sink was 127 degrees Fahrenheit. Resident #190 indicated the water temperature gets hot sometimes. Random observation in other rooms on Unit 1 on 3/21/2016 at approximately 4:15 PM revealed the following water temperatures: 124 degrees Fahrenheit in Room 123, 124 degrees Fahrenheit in Room 124, and 125 degrees Fahrenheit in the Unit 1 shower room. Observation on Unit 4 in Room 119 on 3/21/2016 at approximately 4:30 PM revealed the water temperature at the sink was 147.6 degrees Fahrenheit. Observation on Unit 1 in Room 115 on 3/21/2016 at 4:39 PM revealed the water temperature was 126 degrees Fahrenheit. Interview with the Maintenance Director on 3/21/2016 at 5:05 PM revealed (s)he checked water temperatures on Mondays and Fridays. (S)he stated the water heaters/mixers were checked six days each week and were maintained at a setting of 120 degrees Fahrenheit. (S)he stated the water in Unit 3 had to run awhile before it would get warm. (S)he stated Units 1 and 2 had a circulating pump. The Maintenance Director then stated (s)he bet the Unit 4 room with the high water temperature was at the back of the hall because the last two rooms ran off the same water heater as the laundry below them. (S)he stated the two rooms at the end of the hall, including Room 119, needed to have a separate water heater. The Maintenance Director confirmed a water temperature of 126 degrees Fahrenheit on Unit 1 in Room 113 at this time and stated this room was near the water heater. The Maintenance Director stated (s)he used to record the water temperatures, but (s)he did not record them anymore. (S)he proceeded to Unit 4 where a water temperature of 144 degrees Fahrenheit was confirmed in Room 119. The Maintenance Director stated (s)he would turn the hot water valves off tightly on Unit 4 in Rooms 118 and 119. When asked about how to calibrate a thermometer, the Maintenance Director stated on 3/21/2016 at 6:18 PM that (s)he had an old thermometer with a round top and (s)he did not check it for accuracy other than looking at it with a magnifying glass for accurate readings. On 3/22/2016 at 9:40 AM the Administrator was asked for work orders related to any plumbing issues or repairs and none were available or provided. Interview with the Maintenance Director on 3/22/2016 at 9:49 AM revealed (s)he last checked the water temperature on Unit 4 in Rooms 118 and 119 on Friday 3/18/2016 during the morning. (S)he stated those rooms are usually fine during the day when the laundry was running. The Maintenance Director further stated that those rooms have used the same water heater as the laundry room since the 1980's when laundry service began. Interview with the Administrator on 3/22/2016 at 4:13 PM revealed the Maintenance Director stated several months ago that the rooms over the laundry needed their own water heater. Interview with the Maintenance Director on 3/22/2016 at 4:19 PM revealed (s)he had not reported any problems to the Administrator recently regarding the hot water because there was not anything wrong until this week. Interview with the Administrator on 3/23/2016 at 4:48 PM revealed (s)he could not confirm whether or not the Maintenance Director was recording the water temperatures. Record review of the Job Description Maintenance Department signed by the current Maintenance Director on 4/5/1983 revealed the following: Purpose: Maintenance must provide the necessary services to maintain a safe, sanitary and comfortable environment; and to meet the local, state and federal requirements. Responsibility: Regular inspection of property and equipment for compliance with safety regulations. Job Description: Minor repairs for electrical and plumbing. During an interview on 3-21-16 at 3 PM, the Director of Nurses (DON) stated no resident had been injured by hot water in the facility. At approximately 4:05 PM, the DON provided a copy of an Incident Report dated 11-16-15 which stated: Resident (2) stated to this nurse that the back of her right leg burns/painful. States that she thinks it maybe from the water in the shower .today . gave Tylenol for pain . notified Supervisor . did not see any redness to leg. Review of the followup to the incident revealed that the water temperature was not taken until 11-17-15, at which time it was 108 degrees. During an interview on 3-22-16 at 9:46 AM, Resident #24 stated s/he had gotten burned in the shower because the water was too hot. S/he stated s/he told the Certified Nursing Assistant who stated Its supposed to be hot and continued the shower. When asked if s/he had reported the incident, the resident stated,Yes. They checked me and said I wasn't burned. During an interview on 3-25-16 at 10:25 AM, the beautician stated residents had complained about hot water intermittently over the past six months. The stated the last complaint s/he had received was this past Monday.S/he was unable to specify the name of the resident involved. The resident in the beautician's chair spoke up and verified that the water had been too hot. During an interview on 3-23-16 at approximately 3:35 PM, the Administrator verified ongoing fluctuations in hot water temperatures. The Director of Nurses provided water temperature logs for review which noted hot water temperatures that varied as much as 10 degrees between rooms immediately adjacent to each other. Schematics of the hot water lines were requested. During an interview on 3-24-15 at approximately 10:30 AM, with the Maintenance Supervisor and Assistant Administrator present, the master plumber stated the hot water temperatures needed to be measured daily in all resident care areas and kept in a log to ensure resident safety. S/he noted problems on Unit 4 with shower valves, piping causing corrosion, mixing valve, thermostat, and circulating pump. A list of identified areas for correction was requested. On 3-25-16 at 10:45AM, the Administrator stated s/he had been unable to locate the schematics for the plumbing/water lines in the facility as had been requested on 3-22-16. -------------------------------- The facility admitted Resident #166 with [DIAGNOSES REDACTED]. During an interview on 3/21/2016 at 12:41 PM, Licensed Practical Nurse (LPN) #6 stated that Resident #166 had fallen twice in the prior 30 day period (3-1-16 and 3-4-16), sustaining a minor injury with one of the falls. Review of Norse's Notes and Incident/ Accident reports provided by the Director of Nurses (DON) on 3-24-16 revealed that Resident #166 sustained six falls since the previous recertification survey: (1) On 12-18-14 at 7:15 PM, the resident was found on the floor. The Incident Report stated s/he was attempting to get out of the wheelchair unassisted. Review of the Care Plan revealed that the resident had cognitive loss, short- and long-term memory loss, and a Brief Interview for Mental Status (BlMS) score indicating severe cognitive impairment. Interventions included: Body alarm in w/ch (wheelchair) and bed to alert staff of resident rising unassisted. Nurse's Notes nor the fall investigation mentioned alarm placement at the time of the fall. Further review of the Care Plan revealed that it had not been updated with changes in interventions to prevent recurrence. (2) On 2-2-15 at 4:45 PM, the resident slid off the bed onto the floor. There was no evidence that the alarm was in place as ordered. (3) On 11-19-15 at 4:45 PM While being prepared to get a shower resident wheelchair was rolled to the wooden bar so resident could stand . and be transferred to shower chair.Resident stated when she (he) stood up . felt light headed and lost her (his) balance and fell to the floor . sustained a skin tear to the left hand and 2 skin tears to the left elbow. Review of the Care Plan revealed no changes until 12-23-15 when an intervention was added: Requires assist X I with gaitbelt and standby assist for all transfers . (4) On 1-29-16 at 8 AM, the resident was lowered to the floor during a transfer. S/he sustained 2 skin tears on arms. There was no Nurse's Note regarding the incident. Review of the Care Plan revealed that it had not been updated with the fall or changes in interventions put in place to prevent recurrence. (5) On 3-1-16, Resident #166 was lowered to the floor in the shower when s/he let go of the rail, sustaining a skin tear. There was no evidence in the Nurses Notes or fall investigation to indicate that a gait belt was in use at the time of the fall. Review of the Care Plan revealed that it had not been updated with changes in interventions to prevent recurrence. (6) On 3-4-16 at 7:20 PM, the resident was Found sitting on floor next to bed and wheelchair. States slid out of chair. There were no Nurse's Notes in the record to describe the incident. The investigation noted that the alarm was in place as care planned but resident removed clip .no alarm sounded. Further review revealed that the Care Plan had not been updated with the fall or changes in interventions to prevent recurrence. Review of the Care Plan on 3-25-16 at 2:52 AM revealed that the resident had current Problems/Needs related to fall risk and [DIAGNOSES REDACTED]. During an interview on 3-25-16 at 1:23 PM, Licensed Practical Nurses (LPNs) #4 and #5 and Registered Nurse #2 verified that the care plan had not been updated with falls to include changes in interventions to prevent recurrence since 12-15. The Administrator was notified at approximately 7 PM on 3-21-16 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (AOC) was submitted by the facility on 3-25-16 at 11:30 AM. The actions listed in the AOC included the following: -During the survey on 3-21-16, it was noted by the surveyors that the water temperature was above 120 degrees in Rooms Unit 1: 103, 113, 115, 123, 124 and the shower room on Unit 1; Unit 4: 419 . -The Maintenance Supervisor was called to make a round with the surveyor at or around 5 PM . all temperatures fell within the normal range at that time except for Room 19 which recorded at 144 degrees and Room 13 on Unit 1 which was recorded at 126 degrees. -Following the 3-21-16 temperature recheck on Unit 4, the Maintenance Supervisor turned off the hot water flow to the faucets in rooms 18 and 19. -The Maintenance Department installed a (new) hot water heater and rerouted the hot water supply lines to the 2 affected rooms (4-18 and 4-19) . -On 3-21-16 at approximately 8 PM, (staff) checked water temperatures on Units 2, 3, and 4. At 9 PM temperatures were checked on Unit 4. (17 Rooms on Unit 4 had water temps greater than 120 degrees (121-125.7).) At 9:30 PM, the mixing valve was adjusted by the Administrator . on Unit 4. (By 10:45 PM, recorded temps were within acceptable range.) -The temperatures on Unit 4 were checked again at 7:30 AM on 3-22-16 . (4 of 7 rooms ranged from 122.7 to 127.5 degrees. On 3-22-16 at 8:11 AM, the Supervisor dialed back the water heater on Unit 4 . and bled approximately half of the water from the water heater .(By) 9:45AM, (temperatures were and remained within acceptable range.) -The Administrator developed a formal, written Water temperatures Control Plan. All staff .were inserviced on 3-22-16 beginning at 3:30 PM .All facility personnel will be inserviced on the new plan before allowed to clock in . -Starting on 3-23-16 ., water temperature audits will be conducted on Units 1, 2, 3, & 4 to ensure on going compliance . in 10 randomly selected rooms in addition to rooms noted as non-compliant during the survey .3 times per day. Any room on resident care area that is found to have a water temperature greater than 120 degrees will have the hot water supply turned off immediately, the Maintenance Director and Administrator will be notified immediately and corrective acting will be taken . -On 3-23-16 contact was made with a local Master Plumber to .evaluate our plumbing system with recommendations for solutions to fluctuating water temperatures. Master Plumber is scheduled to begin repairs no later than 3-25-16. Master Plumber will provide education related to the maintenance of the repair items . -All maintenance staff . will be educated on (Procedure for Calibration of the Digital Thermometer as specified by the manufacturer) by the Administrator no later than 3-24-16. -All nursing staff. have been inserviced on how to safely check water temperature prior to use on a resident . by the In-service Coordinator, DON (Director of Nurses) & the 2nd Shift RN (Registered Nurse) Supervisor . Observations, review of policies, review of inservice sign-in sheets, and staff interviews on 3-25-16 revealed the Allegation of Compliance submitted by the facility on that date had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 3-25-16 at 7:30 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.

Based on observations, record reviews and interviews, the Administrator failed to provide proper training for the facility Maintenance Director and failed to ensure on-going preventive maintenance policies were developed and followed to ensure safety of residents related to hot water temperatures which contributed to immediate jeopardy and/or substandard quality of care. Water temperatures exceeded 140 degrees Fahrenheit on the locked Alzheimer's Unit. The facility's Maintenance Director and Administrator were aware the water temperatures exceeded a safe range. The Maintenance Director did not have a system of recording water temperatures and was unaware of how to calibrate a thermometer. These findings resulted in Immediate Jeopardy existing in the facility at the time of discovery on 3/21/16. The facility Administrator was informed of the Immediate Jeopardy on 3/21/16 at 7:00 PM. The findings included: Cross refer CFR 483.25 F-323 Free of Accident Hazards During an interview on 3/21/2016 at 5:05 PM, the Maintenance Director stated that s/he checked hot water temperatures on Mondays and Fridays but had kept no records of which rooms were checked and no temperatures had been recorded. S/he stated s/he used to record the water temperatures but no longer did so. The Maintenance Director had been aware that the last two rooms on Unit 4 (418, 419) ran off the same water heater as the laundry below them since the 1980's when laundry service began. Unit 4 was a locked unit specifically used for cognitively impaired self-mobile residents who were at much greater risk for injury. On 3/21/2016 at 6:18 PM, the Maintenance Director was unable to demonstrate proper use/calibration of the thermometer with which to measure hot water temperatures. Interview with the Administrator on 3/22/2016 at 4:13 PM revealed that the Maintenance Director had stated several months previously that the rooms over the laundry needed their own water heater. Although the Administrator had been made aware, no action had been taken regarding protection of the residents. The Administrator was unaware that the Maintenance Director was unable to demonstrate proper use/calibration of the thermometer with which to measure hot water temperatures. Interview with the Administrator on 3/23/2016 at 4:48 PM revealed (s)he could not confirm whether or not the Maintenance Director was recording the water temperatures. Interview with the Maintenance Director on 3/21/2016 at 5:05 PM revealed (s)he checked water temperatures on Mondays and Fridays. (S)he stated the water heaters/mixers were checked six days each week and were maintained at a setting of 120 degrees Fahrenheit. (S)he stated the water in Unit 3 had to run awhile before it would get warm. (S)he stated Units 1 and 2 had a circulating pump. The Maintenance Director then stated (s)he bet the Unit 4 room with the high water temperature was at the back of the hall because the last two rooms ran off the same water heater as the laundry below them. (S)he stated the two rooms at the end of the hall, including room [ROOM NUMBER], needed to have a separate water heater. The Maintenance Director confirmed a water temperature of 126 degrees Fahrenheit on Unit 1 in room [ROOM NUMBER] at this time and stated this room was near the water heater. The Maintenance Director stated (s)he used to record the water temperatures, but (s)he did not record them anymore. (S)he proceeded to Unit 4 where a water temperature of 144 degrees Fahrenheit was confirmed in room [ROOM NUMBER]. The Maintenance Director stated (s)he would turn the hot water valves off tightly on Unit 4 in rooms [ROOM NUMBERS]. When asked about how to calibrate a thermometer, the Maintenance Director stated on 3/21/2016 at 6:18 PM that (s)he had an old thermometer with a round top and (s)he did not check it for accuracy other than looking at it with a magnifying glass for accurate readings. On 3/22/2016 at 9:40 AM the Administrator was asked for work orders related to any plumbing issues or repairs and none were available or provided. Interview with the Maintenance Director on 3/22/2016 at 9:49 AM revealed (s)he last checked the water temperature on Unit 4 in rooms [ROOM NUMBERS] on Friday 3/18/2016 during the morning. (S)he stated those rooms are usually fine during the day when the laundry was running. The Maintenance Director further stated that those rooms have used the same water heater as the laundry room since the 1980's when laundry service began. Interview with the Administrator on 3/22/2016 at 4:13 PM revealed the Maintenance Director stated several months ago that the rooms over the laundry needed their own water heater. Interview with the Maintenance Director on 3/22/2016 at 4:19 PM revealed (s)he had not reported any problems to the Administrator recently regarding the hot water because there was not anything wrong until this week. Interview with the Administrator on 3/23/2016 at 4:48 PM revealed (s)he could not confirm whether or not the Maintenance Director was recording the water temperatures. The Administrator was notified at approximately 7 PM on 3-21-16 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (AOC) was submitted by the facility on 3-25-16 at 11:30 AM. The actions listed in the AOC included the following: -During the survey on 3-21-16, it was noted by the surveyors that the water temperature was above 120 degrees in Rooms Unit 1: 103, 113, 115, 123, 124 and the shower room on Unit 1; Unit 4: 419 . -The Maintenance Supervisor was called to make a round with the surveyor at or around 5 PM . all temperatures fell within the normal range at that time except for room [ROOM NUMBER] which recorded at 144 degrees and room [ROOM NUMBER] on Unit 1 which was recorded at 126 degrees. -Following the 3-21-16 temperature recheck on Unit 4, the Maintenance Supervisor turned off the hot water flow to the faucets in rooms [ROOM NUMBERS]. -The Maintenance Department installed a (new) hot water heater and rerouted the hot water supply lines to the 2 affected rooms (4-18 and 4-19) . -On 3-21-16 at approximately 8 PM, (staff) checked water temperatures on Units 2, 3, and 4. At 9 PM temperatures were checked on Unit 4. (17 Rooms on Unit 4 had water temps greater than 120 degrees (121-125.7).) At 9:30 PM, the mixing valve was adjusted by the Administrator . on Unit 4. (By 10:45 PM, recorded temps were within acceptable range.) -The temperatures on Unit 4 were checked again at 7:30 AM on 3-22-16 . (4 of 7 rooms ranged from 122.7 to 127.5 degrees. On 3-22-16 at 8:11 AM, the Supervisor dialed back the water heater on Unit 4 . and bled approximately half of the water from the water heater .(By) 9:45AM, (temperatures were and remained within acceptable range.) -The Administrator developed a formal, written Water temperatures Control Plan. All staff .were inserviced on 3-22-16 beginning at 3:30 PM .All facility personnel will be inserviced on the new plan before allowed to clock in . -Starting on 3-23-16 ., water temperature audits will be conducted on Units 1, 2, 3, & 4 to ensure on going compliance . in 10 randomly selected rooms in addition to rooms noted as non-compliant during the survey .3 times per day. Any room on resident care area that is found to have a water temperature greater than 120 degrees will have the hot water supply turned off immediately, the Maintenance Director and Administrator will be notified immediately and corrective acting will be taken . -On 3-23-16 contact was made with a local Master Plumber to .evaluate our plumbing system with recommendations for solutions to fluctuating water temperatures. Master Plumber is scheduled to begin repairs no later than 3-25-16. Master Plumber will provide education related to the maintenance of the repair items . -All maintenance staff . will be educated on (Procedure for Calibration of the Digital Thermometer as specified by the manufacturer) by the Administrator no later than 3-24-16. -All nursing staff. have been inserviced on how to safely check water temperature prior to use on a resident . by the In-service Coordinator, DON (Director of Nurses) & the 2nd Shift RN (Registered Nurse) Supervisor . Observations, review of policies, review of inservice sign-in sheets, and staff interviews on 3-25-16 revealed the Allegation of Compliance submitted by the facility on that date had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 3-25-16 at 7:30 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.

Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 6/2/15 at approximately 5:02 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR 483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to ensure that the Quality Assurance (QA) process was utilized to identify, monitor and implement a plan of action to ensure routine monitoring of water temperatures to prevent potential injuries to residents. Water temperatures exceeded 140 degrees Fahrenheit on the locked Alzheimer's Unit. The facility's Maintenance Director and Administrator were aware the water temperatures exceeded a safe range. The Maintenance Director did not have a system of recording water temperatures and was unaware of how to calibrate a thermometer. These findings resulted in Immediate Jeopardy existing in the facility at the time of discovery on 3/21/16. The facility Administrator was informed of the Immediate Jeopardy on 3/21/16 at 7:00 PM. The findings included: Cross refer CFR 483.25 F-323 Free of Accident Hazards CFR 483.25 F-323 was identified at a scope and severity level of (L). The Immediate Jeopardy existed on 3/21/15 when water temperatures were checked in resident rooms on Units 1 and 4 and observed to be greater than 120 degrees. On 3/21/15 beginning at 3:42 PM surveyors thermometers were used to check rooms throughout the facility. During an interview on 3/21/2016 at 5:05 PM, the Maintenance Director revealed that s/he checked hot water temperatures on Mondays and Fridays but had kept no records of which rooms were checked and no temperatures had been recorded. S/he stated s/he used to record the water temperatures but did not do so any longer. The Maintenance Director had been aware that the last two rooms on Unit 4 (118, 119) ran off the same water heater as the laundry below them since the 1980's when laundry service began. Unit 4 was a locked unit specifically used for cognitively impaired self-mobile residents who were at much greater risk for injury. Interview with the Administrator on 3/22/2016 at 4:13 PM revealed that the Maintenance Director had stated several months previously that the rooms over the laundry needed their own water heater. Although the Administrator had been made aware, no action had been taken regarding protection of the residents. During an interview at 3:23 PM on 3-25-16, the QA Coordinator stated that all department heads submit monthly reports to the QA Committee but that no one had identified concerns related to hot water temperatures. The QA Coordinator stated the facility had no plan of action in place relative to hot water concern prior to the survey. The Administrator was notified at approximately 7 PM on 3-21-16 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (AOC) was submitted by the facility on 3-25-16 at 11:30 AM. The actions listed in the AOC included the following: -During the survey on 3-21-16, it was noted by the surveyors that the water temperature was above 120 degrees in Rooms Unit 1: 103, 113, 115, 123, 124 and the shower room on Unit 1; Unit 4: 419 . -The Maintenance Supervisor was called to make a round with the surveyor at or around 5 PM . all temperatures fell within the normal range at that time except for room [ROOM NUMBER] which recorded at 144 degrees and room [ROOM NUMBER] on Unit 1 which was recorded at 126 degrees. -Following the 3-21-16 temperature recheck on Unit 4, the Maintenance Supervisor turned off the hot water flow to the faucets in rooms [ROOM NUMBERS]. -The Maintenance Department installed a (new) hot water heater and rerouted the hot water supply lines to the 2 affected rooms (4-18 and 4-19) . -On 3-21-16 at approximately 8 PM, (staff) checked water temperatures on Units 2, 3, and 4. At 9 PM temperatures were checked on Unit 4. (17 Rooms on Unit 4 had water temps greater than 120 degrees (121-125.7).) At 9:30 PM, the mixing valve was adjusted by the Administrator . on Unit 4. (By 10:45 PM, recorded temps were within acceptable range.) -The temperatures on Unit 4 were checked again at 7:30 AM on 3-22-16 . (4 of 7 rooms ranged from 122.7 to 127.5 degrees. On 3-22-16 at 8:11 AM, the Supervisor dialed back the water heater on Unit 4 . and bled approximately half of the water from the water heater .(By) 9:45AM, (temperatures were and remained within acceptable range.) -The Administrator developed a formal, written Water temperatures Control Plan. All staff .were inserviced on 3-22-16 beginning at 3:30 PM .All facility personnel will be inserviced on the new plan before allowed to clock in . -Starting on 3-23-16 ., water temperature audits will be conducted on Units 1, 2, 3, & 4 to ensure on going compliance . in 10 randomly selected rooms in addition to rooms noted as non-compliant during the survey .3 times per day. Any room on resident care area that is found to have a water temperature greater than 120 degrees will have the hot water supply turned off immediately, the Maintenance Director and Administrator will be notified immediately and corrective acting will be taken . -On 3-23-16 contact was made with a local Master Plumber to .evaluate our plumbing system with recommendations for solutions to fluctuating water temperatures. Master Plumber is scheduled to begin repairs no later than 3-25-16. Master Plumber will provide education related to the maintenance of the repair items . -All maintenance staff . will be educated on (Procedure for Calibration of the Digital Thermometer as specified by the manufacturer) by the Administrator no later than 3-24-16. -All nursing staff. have been inserviced on how to safely check water temperature prior to use on a resident . by the In-service Coordinator, DON (Director of Nurses) & the 2nd Shift RN (Registered Nurse) Supervisor . Observations, review of policies, review of inservice sign-in sheets, and staff interviews on 3-25-16 revealed the Allegation of Compliance submitted by the facility on that date had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 3-25-16 at 7:30 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.

On the days of the survey, based on observation, record review and interviews, the facility failed to ensure that 1 of 2 sampled residents were provided assistance devices to prevent accidents. Resident #181 with known behavior of leaning forward while in wheelchair had no interventions in place when a fall occurred on 5/16/13 that cause injuries. The findings included: The facility admitted Resident #181 with [DIAGNOSES REDACTED]. On 5/21/13 at approximately 8:15 AM a random observation on Unit One revealed resident noted with large edematous area in center of the forehead and dark bruising around the eyes and face. Record review on 5/22/13 at approximately 11:25 AM revealed physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Use anti-tip device to front of wheelchair and discontinue half tray. A Nurse Note dated 4/16/13 indicated Resident #181 was "noted to be leaning forward excessively. See order for shoulder support. " A Nurse Note dated 5/06/13 stated " Resident Torso support discontinued related to resident continuously removing it. Torso support not helping with intended use at this time. Physical Therapy made aware. Instructed staff to increase safety checks". On 5/16/13 "resident fell out of chair in to floor in day area. resident banged his/ her head on floor. assessment completed, large knot on forehead turning black, nose bleeding, small cut to inside of mouth, bilateral knees red and left knee turning blue in color, resident is confused and disoriented but this is normal behavior, pupils were equal at time of assessment, Rp (responsible party) notified and resident sent to ER (emergency room ) for eval (evaluation) and treatment." On 5/17/13 a Nurse's Note documented "resident up in wheelchair severe bruising to face and forehead, both eyes black, pupils are at plus 2 and sluggish. Resident seems to in no distress at this time. See new order to add Torso Support while up in wheelchair for safety related to leaning. Anti tip device to front of wheelchair and discontinue half tray" . Further record review revealed there was no alternate safety device in place to prevent resident from leaning while up in wheelchair from 5/06/13 to 5/16/16. There was no documentation to indicate Physical Therapy was notified when the resident was removing the Torso Support or that the Torso Support was no helping with its intended use. There was no documentation as to how often or when the resident was observed removing the Torso Support. An interview on 5/22/13 at approximately 12:55 PM with the DON (Director of Nursing) and RN (Registered Nurse) #1 confirmed there was no documentation related to resident removing the Torso Support. RN #1 verified there was no documentation to indicate when Physical Therapy was notified that the Torso Support was not effective at keeping the resident from leaning forward. On 5/22/13 at approximately 2:07 PM RN #1 stated Physical Therapy was verbally informed about the Torso Support not working but had no documentation. There was no documentation provided that the 30 minute checks were completed per the resident care plan. An interview on 5/22/13 at approximately 3:37 PM with OT (Occupational Therapist) #1 revealed there was on documentation that OT or PT (physical therapy) was informed that the Torso Support needed to be reassessed.

On the days of the survey, based on observation, record review and interviews, the facility failed to ensure that 1 of 2 sampled residents care plans were updated related to falls. Resident #181 had a torso support in place due to leaning forward while in wheelchair on 4/16/13. The torso support was discontinued on 5/06/13 with no other interventions put in place. The findings included: The facility admitted Resident #181 with [DIAGNOSES REDACTED]. On 5/21/13 at approximately 8:15 AM a random observation on Unit One revealed resident noted with large [MEDICAL CONDITION] area in the center of his/her forehead and dark bruising around the eyes and face. Record review on 5/22/13 at approximately 11:25 AM revealed a nurse's note dated 5/16/13 that indicated "resident fell out of chair in to floor in day area. Resident banged his/her head on floor. assessment completed, large knot on forehead turning black, nose bleeding, small cut to inside of mouth, bilateral knees red and left knee turning blue in color, Resident is confused and disoriented but this is normal behavior, pupils were equal at time of assessment, RP (responsible party) notified and resident sent to ER (emergency room ) for eval (evaluation) and treatment." Review of a care plan updated in January 2013, a problem area noted: Requires assist of times 2 with belt for all transfers and physical/cognitive decline with [MEDICAL CONDITION], at risk for falls. In the intervention area for falls dated 4/16/13, was a torso support while in wheel chair related to leaning as a safety precaution. Review of a care plan updated in April 2013 under the problem area Cognitive Loss, the torso support while in wheelchair related to leaning was discontinued 5/07/13. There was no other safety measures to put to prevent leaning. Further reveal of the care plan revealed safety checks every 30 minutes and as needed was added as an intervention on 4/16/13. An interview on 5/22/13 at approximately 12:55 PM with the DON (Director of Nursing) and RN (Registered Nurse) #1 confirmed findings related to care plan. RN#1 further stated a verbal referral was made to Physical Therapy when the torso support to prevent Resident #181 from leaning in the wheelchair was discontinued. Per, RN #1 therapy informed staff to monitor resident. Review of Physical Therapy notes reviewed the use of the torso support was re ordered on [DATE]. An interview on 5/23/13 at approximately 1:30 PM with the DON revealed the care plan was not updated because of the every 30 minutes checks being in place.