Every finding on record at Ashland Nursing and Rehabilitation

Based on staff interview and facility document review, the facility staff failed to notify the physician per the physician orders for one of four residents in the survey sample, Resident #202.The findings include:For Resident #202 (R202) the facility failed to notify the physician of blood sugars outside the physician ordered parameters.R202 was admitted to the facility on [DATE] with recent readmission on [DATE], with diagnoses that included but were not limited to: insulin dependent diabetes, stroke, underweight, depression, anorexia, dementia and high blood pressure.The most recent MDS (Minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/16/2026, coded the resident as scoring a 99, indicating the resident was unable to complete the interview. In Section C0700, the resident was coded as having but short- and long-term memory difficulties. In Section N - Medication, the resident was coded as receiving three insulin injections over the past seven days. The physician order dated, 7/20/2026, documented, Insulin Lispro Injection Solution 100 UNIT/ML (milliliter); Inject 4 units subcutaneously three times a day for *HOLD IF BLOOD SUGAR IS LESS THAN 120 PER (NAME OF NURSE PRADCTTIONER) RELATED TO Tyle 2 DIABETES Mellitus with hyperglycemia (high blood sugar). Call MD (medical doctor) if BG (blood glucose) is < (less than) 60 or > 250.The May 2026 MAR (medication administration record) documented the above order. On the following dates and times, the blood sugars were documented:5/2/2026 at 1:00 p.m. = 3185/3/2026 at 9:00 a.m. = 347; 1:00 p.m. = 3195/4/2026 at 9:00 a.m. = 308; 1:00 p.m. = 256; 5:00 p.m. = 3085/5/2026 at 9:00 a.m. = 278; 1:00 p.m. = 312Review of the clinical record failed to evidence documentation that the physician or nurse practitioner was notified of the above blood sugars per the physician orders. The physician order dated 4/26/2026 documented, Insulin Lispro Injection Solution; Inject as per sliding scale: if 140-199= 0 units; 200-259 = 2 units; 300-349=4 units; 350-400=Call MD, subcutaneously before meals for DM (diabetes mellitus).An interview was conducted with LPN (licensed practical nurse) #1 on 7/1/2026 at 2:35 p.m. The above orders and MAR were shown to LPN #1 who worked on several of the days there was no documented notification to the doctor or NP. When asked if she notified the nurse practitioner or doctor of the blood sugars according to the order, LPN #1 stated, I didn't call anyone. When asked should she have called, LPN #1 stated, Yes.An interview was conducted on 7/1/2026 at 3:21 p.m. with the Medical Director. The Medical Director stated that if there is an order for he or the nurse practitioner to be call, then he would expect them to call. The above orders were reviewed with the Medical Director. He stated he felt the order for to call for a blood sugar greater than 150 is a bit low for notification, but if an order is there, then it should be followed.The Administrator and the DON were made aware of the above findings on 7/2/2026 at 10:00 a.m.No further information was provided prior to exit.

For Resident #202 (R202), the facility staff failed to clarify two orders for insulin.R202 was admitted to the facility on [DATE] with recent readmission on [DATE], with diagnoses that included but were not limited to: insulin dependent diabetes, stroke, underweight, depression, anorexia, dementia and high blood pressure.The most recent MDS (Minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/16/2026, coded the resident as scoring a 99, indicating the resident was unable to complete the interview. In Section C0700, the resident was coded as having but short- and long-term memory difficulties. In Section N - Medication, the resident was coded as receiving three insulin injections over the past seven days. The physician order dated, 7/20/2026, documented, Insulin Lispro Injection Solution 100 UNIT/ML (milliliter); Inject 4 units subcutaneously three times a day for *HOLD IF BLOOD SUGAR IS LESS THAN 120 PER (NAME OF NURSE PRADCTTIONER) RELATED TO Tyle 2 DIABETES Mellitus with hyperglycemia (high blood sugar). Call MD (medical doctor) if BG (blood glucose) is < (less than) 60 or > 250.The May 2026 MAR (medication administration record) documented the above order. On the following dates and times, the blood sugars were documented:5/2/2026 at 1:00 p.m. = 3185/3/2026 at 9:00 a.m. = 347; 1:00 p.m. = 3195/4/2026 at 9:00 a.m. = 308; 1:00 p.m. = 256; 5:00 p.m. = 3085/5/2026 at 9:00 a.m. = 278; 1:00 p.m. = 312Review of the clinical record failed to evidence documentation that the physician or nurse practitioner was notified of the above blood sugars per the physician orders. The physician order dated 4/26/2026 documented, Insulin Lispro Injection Solution; Inject as per sliding scale: if 140-199= 0 units; 200-259 = 2 units; 300-349=4 units; 350-400=Call MD, subcutaneously before meals for DM (diabetes mellitus).May 2026 MAR documented the above order. On 5/1/2026 at 11:30 a.m. the resident's blood sugar was documented as 500. The nurse practitioner (NP) was notified.An interview was conducted with LPN (licensed practical nurse) #1 on 7/1/2026 at 2:35 p.m. The above orders and MAR were shown to LPN #1 who worked on several of the days there was no documented notification to the doctor or NP. When asked if she notified the nurse practitioner or doctor of the blood sugars according to the order, LPN #1 stated, I didn't call anyone. When asked should she have called, LPN #1 stated, Yes.An interview was conducted with the Director of Nursing (DON), on 7/1/2026 at 4:56 p.m. The above orders were reviewed with the DON. She stated the orders should have been clarified.The Administrator and the DON were made aware of the above findings on 7/2/2026 at 10:00 a.m.No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to prevent an alleged allegation sexual abuse for one of four residents in the survey sample, Resident #202.The findings include: For Resident #202 (R202), the facility staff failed to protect the resident from an allegation of alleged sexual abuse from Resident #203 (R203)R202 was originally admitted to the facility on [DATE] with diagnoses that included but were no limited to: vascular dementia, peripheral vascular disease, anxiety disorder, and unsteadiness on her feet.The most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date (ARD) of 6/3/2026, the resident was coded as having both short- and long-term memory difficulties.Resident #203 was initially admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, alcohol dependence with alcohol-induced persisting dementia, altered mental status obsessive-compulsive behavior and anxiety disorder.The most recent MDS, an annual assessment with an ARD of 5/11/2026, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions.The facility synopsis of the event documented in part, On 6/9/2026 at approximately 11:15 a.m., (name of another resident) alerted the Business Office Manager [BOM], who was coming down the hall toward the Unit 2 Nurse Station, that another resident, (R203) was touching a female resident (R204). The Business Office Manager went over and observed (R203), leaning over on (R204)'s chair, he had his arm around her and his other hand between her legs rubbing, mid-thigh. She asked him to stop and move away, which he did. The Unit Manager and Nurse returned to the Nurse Station after hearing (name of resident) alert the BOM. The Nurse did a complete body assessment on (R204) and there were no areas of concern, (R203) was immediately place on continuous 1:1 and was subsequently relocated to a different unit.An interview was conducted with the BOM on 7/2/2026 at approximately 9:12 a.m. The BOM verified the above information of the occurrence between R203 and R204.The facility presented information of the actions taken after the incident;1. R204 was assessed for injuries, and none were noted. R203 was immediately placed on 1:1 continuous monitoring. The MD/NP (medical doctor and nurse practitioner) were notified, and no new orders were given. An evaluation was conducted for both residents by the psych (psychiatric) NP with no changes in current medication regimen. Responsible Parties for both Residents were notified. No concerns were expressed. (Name of Local Police Department) was notified. APS (Adult Protective Services) was notified.2. All female resident on the unit with BIMS under 9 was given a skin assessment. Female resident with BIMS score above 9 were interviewed regarding recent inappropriate interactions with male residents. No concerns were raised.3. The facility completed an in-service on Abuse - Resident to Resident for all staff. The education was completed on 6/11/2026.4. Allegation of compliance was 6/11/2026.This citation is being cited as past non-compliance.

Based on observations, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to protect one of eight residents in the survey sample, Resident #1, from sexual abuse when the resident was unable to consent to sexual acts and failed to prevent neglect due to lack of adequate supervision for Resident #1 with a history of elopement. This resulted in Immediate Jeopardy and substandard quality of care. After the Immediate Jeopardy was removed the scope and severity level was lowered to a level two (2) pattern.The findings include:a. For Resident #1, the facility staff failed to protect him from consenting to sexual activities with Resident #2, that Resident #1 did not have the cognitive capacity to consent to.Resident #1 was most recently admitted to the facility on [DATE]. Diagnoses included Wernicki's Encephalopathy, hypertension, alcohol use disorder, and thrombocytopenia.Resident #1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2-18-26 coded the Resident with a BIMS (Brief Interview of Mental Status) score of 99 which indicated severe cognitive impairment. The Resident was fully ambulatory requiring no devices to walk independently.Resident #2 was most recently admitted to the facility on [DATE]. Diagnoses included Anemia, adult failure to thrive, and anxiety.Resident #2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1-20-26 coded the Resident with a BIMS (Brief Interview of Mental Status) score of 13 of a possible 15 points which indicated mild cognitive impairment. Resident #2 was dependent on a wheelchair for ambulation, which he self-propelled independently.Observations of the facility and the Resident population began on 3-17-26 during delivery of the facility lunch meal while making the initial tour. Resident #1 was observed walking alone down the main hallway of the facility from his housing unit toward the main dining room which he entered. He was interviewed and not found to be oriented, nor a reliable historian, however, was very pleasant.Resident #2 was self-propelling in his wheelchair down the same hallway coming from the opposite direction. He was interviewed and found to be alert, oriented to person, place, and situation. The Resident denied having any contact with Resident #1. The Resident stated, I am not a homosexual.The progress note dated, 2-23-26, documented, Resident was in another resident's (male) room on his knees performing oral sex. Residents were immediately separated. Resident does not have any recollection of event occurring.The progress note dated, 3-5-26, documented, Resident found sitting on the side of another (female) resident's bed with his pants off. The other resident was fully clothed lying under the covers. (This third Resident was not identified and so not added to the sample. Staff were not able to tell surveyors who this third individual was.)The comprehensive care plan dated 2/24/26, documented in part, Resident has psychosocial well-being problem related to sexual/physical contact with another resident - intervene as to protect the resident's rights and safety. Immediately separate and remove from situation. Notify NP and RP (responsible party)/guardian. The care plan dated, 3/9/26, documented, Resident has obsessive compulsive behavior - 1:1 (1 Resident to 1 dedicated staff member at all times) monitoring for behaviors, administer medications as ordered, redirect and cue as needed.On 3-17-26, and 3-18-26 interviews were conducted with multiple nursing staff and CNAs (certified nursing assistants) who denied knowing that the Resident's care plan stated he was to be 1 Resident to 1 dedicated staff member at all times. Supervision was not provided to the Resident, and the care plan stated to intervene, immediately separate, and remove from situation if the Resident was found engaging in sexual/physical contact with another resident. This reflects no preventative measures to protect the Resident from himself nor to protect others from him, and to act only after the contact was found.A psychiatric evaluation for Resident #1 was conducted on 2-2-26 revealing a Resident history of alcohol use disorder, Dementia, Wernicke's Encephalopathy, and altered mental status. The physician ordered Donepezil (1) 5mg (milligrams) every night as the only new treatment addition as a result of this lone evaluation during the Resident's four month stay in the facility.The Director of Nursing (DON), and Administrator were asked for copies of all incidents, allegations of abuse, investigations and reports which included Resident #1. Those were provided and the Administrator stated, this is everything we have, the former Administrator resigned and no other documents could be found. Those five categories of documents all dated only for the 2-23-26 sexual incident follow below.Face sheets (facility document) for Resident #1, and Resident#2 giving general admission information, such as payment, and general care provider information.A nursing note dated 2-23-26 from the unit LPN (Licensed Practical Nurse) recounting a report given to her by another staff member who witnessed the sexual incident between Resident #1 and Resident #2, however, the note does not describe the incident as the note in the clinical record did. This note stated that Resident #2 was lying on his bed receiving oral sex from Resident #1, and that Resident #2 (name) was placed on every 15-minute checks.One skin check (observation form) dated 2-24-26 showing skin intact for Resident #2 (name).One interview note for each Resident #1, and #2, dated 2-23-26, and allegedly documented by the Social Services (SSD) Director. The notes were typed and not signed by the SSD. That SSD was no longer employed by the facility at the time of survey and could not be contacted by phone for interview or authentication.The final document was a fax cover sheet and 2 additional pages which alleged they were a Final facility synopsis of event (also known as a five day follow up) to the initial report. The final report documented that it was the follow up to an initial (facility synopsis of event) dated 2-24-26, however, that 2-24-26 original (facility synopsis of event) document was not provided with this alleged follow up. The Interim Administrator was asked for the initial report (facility synopsis of event) faxed allegedly on 2-24-26. He stated that that Administrator no longer works here and he could not find the initial report, he also stated but when I realized the five day follow up had not been sent, I sent it on 3-4-26. The fax cover sheet documented the follow up report as being faxed on 4-4-26 as the date, and no fax confirmation time stamp for successful sending to the state agency for either document could be found by the facility.Federal law and state law mandate that allegations of abuse/neglect must be reported to the state agency within 2 hours after the allegation is made if serious injury occurs and within 24 hours if no injury occurs. The mandate continues to include a 5-business day follow-up report of the facility's full investigation into the incident with all statements and findings. The 5-day follow-up report would have been late if it had been sent. No record exists in the state agency of the follow-up report being sent. No investigation notes were found, no staff statements were obtained from witnesses, and the facility policy was not implemented.The facility abuse policy documented the following: After an allegation of abuse/neglect is known, the employee is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse/neglect or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law.b. The facility staff failed to prevent neglect due to lack of adequate supervision for Resident #1 with a history of elopement.For Resident #1, the facility staff failed to supervise the resident with a known wandering and exit seeking behavior and failed to secure exit doors resulting in the Resident eloping.Observations of the facility and the Resident population began on 3-17-26 during delivery of the facility lunch meal while making the initial tour. Resident #1 was observed walking alone down the main hallway of the facility from his housing unit toward the main dining room which he entered. He was interviewed and not found to be oriented, nor a reliable historian, however, was very pleasant.The dining room was equipped with an exit door to the courtyard which was the location for facility allowed smoking. The courtyard was enclosed and encircled by a 6-foot-tall metal fence with a gate which opened. The gate was inspected by surveyors and found to be equipped with an audible alarm when opened. The alarm had a keyed lock which appeared to be in the off position. Two surveyors were present and one pushed the gate open with no alarm sounding. There were no staff present in the courtyard and there were four Residents in the courtyard. Surveyors waited for approximately five minutes at the open gate with no staff present. At this time one of the surveyors left to retrieve the Maintenance Director to observe the gate. The Maintenance Director returned and stated that the alarm had been shut off by someone, and there were multiple keys floating around everywhere. He stated that he had tried to recover and account for the keys to the gate, however, some still existed that he had no knowledge of. The maintenance director stated that the gate did not have the Wander-Guard alarm.Nursing and physician progress notes were reviewed and revealed the following nine examples of Resident #1's behaviors endangering himself and others.11-26-25 staff documented wandering into other resident rooms, Wander-Guard applied.12-1-25 staff documented Resident #1 continues to exhibit wandering behavior with repeated entry into other residents' rooms causing disruption to other residents. Resident going into other residents' rooms while CNA staff was providing them personal care. Redirection required multiple times throughout shift. Resident also putting soiled garments in his nightstand drawers.12-15-25 Staff documented resident went to outside patio (courtyard) .pushed gate to exit patio. Two CNA's from another unit were in the parking lot behind the building and witnessed resident exiting gate. Resident redirected inside of the building without incident, NP (nurse practitioner) and legal guardian both aware.12-17-25 Resident witnessed going to numerous exit doors and pushing on them. Resident wanders around entire building seeking exit doors. Resident stated, Hey I found the front door. Resident found on units 1 and 3 numerous times throughout shift remains easily redirected.12-18-25 resident exit seeking set off door alarm.2-16-26 Elopement Evaluation History of elopement while at home: No., Wandering behavior a pattern or goal directed: Yes. Wandering behavior likely to affect the safety or wellbeing of self/others: No. Wandering behavior likely to affect the privacy of others: No. By this time the Elopement Evaluation was produced Resident #1 had eloped on 12-15- 25, and the behaviors he exhibited had affected other residents and himself, to include on 12-1-25 privacy for other residents during hygiene care from staff such as bathing and dressing. The Elopement Evaluation had been documented incorrectly.7. 2-19-26 Resident took isolation supply cart from the hallway into his room and is using it for his personal use. The cart had alcohol-based hand sanitizer on it.8. 3-5-26 Resident found sitting on the side of another (female) resident's bed with his pants off. The other resident was fully clothed lying under the covers. (This third Resident was not identified and so not added to the sample. Staff were not able to tell surveyors who this third individual was.9. 3-8-26 Resident removed Wander-Guard and it is nowhere to be found, passed it on that resident needs a new one.On 3-17-26, during the survey no Wander-Gard device was found on the Resident, and the device was not added to the care plan until 3-17-26 when surveyors cited Immediate Jeopardy. Nursing staff would not have had direction for the use of the device until denoted in the care plan.None of the care plan interventions for behaviors or elopement were ever documented as having been implemented and no behaviors were ever documented on the medication administration records (MAR) for the Resident's stay.Physician's orders were reviewed and indicated that a Wander-Guard device was ordered for Resident #1 on 11-13-25, however, none was found on the Resident on 3-17-26, and the Resident was known to have had removed it previously on 3-8-26.Care plans for Resident #1 were reviewed and revealed that beginning on 11-13-25 (4) behavior focuses and interventions were added to that care plan. Those follow below.11-24-25 - The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. - All staff to converse with resident while providing care, ensure the activities the resident is attending are compatible with physical and mental capabilities.11-25-25 - Resident is an elopement risk/wanderer related to history of wandering, impaired safety awareness, Resident wanders aimlessly. - Assess for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.2-24-26 Resident has psychosocial well-being problem related to sexual/physical contact with another resident - intervene as to protect the resident's rights and safety. Immediately separate and remove from situation. Notify NP and RP (responsible party)/guardian.3-9-26 Resident has obsessive compulsive behavior - 1:1 (1 Resident to 1 dedicated staff member at all times) monitoring for behaviors, administer medications as ordered, redirect and cue as needed.On 3-17-26, and 3-18-26 interviews were conducted with multiple nursing staff and CNA's who denied knowing that the Resident's care plan stated he was to be 1 Resident to 1 dedicated staff member at all times. Supervision was not provided to the Resident, and the care plan stated to intervene, immediately separate, and remove from situation if the Resident was found engaging in sexual/physical contact with another resident. This reflects no preventative measures to protect the Resident from himself nor to protect others from him, and to act only after the contact was found.Neglect is defined as the withholding of goods and services required by a Resident. This would include staff supervision required for an individual who is known to be in danger of injury to himself or others due to cognitive decline and poor safety awareness. Therefore, withholding supervision (knowingly or unknowingly) is a direct hazard for accidents to the individual or others impacted by the individual. The facility staff knew the Resident was a threat to himself and others as demonstrated by the addition of 1:1 supervision added to his care plan on 3-9-26, however, staff were not aware of it, and so it was not implemented.The elopement of the Resident on 12-15-25 was never reported to the state agency. The intrusion by Resident #1 unclothed into a female Resident's room on 3-5-26 was never reported to the state agency.On 3-17-26 at 4:30 PM the facility was notified that Immediate Jeopardy (IJ) existed in the facility for the areas of Accidents and Hazards, as well as Ause and Neglect. The Administrator and his team were requested to provide an Immediacy Removal plan to protect all facility Residents. On 3-17-26 at 4:30 PM the facility was notified that Immediate Jeopardy (IJ) existed in the facility for the areas of Accidents and Hazards, as well as Ause and Neglect. The Administrator and his team were requested to provide an Immediacy Removal plan to protect all facility Residents. The Administrator and his team were provided with the IJ notification document which follows below.Resident #1, with a BIMS (Brief Interview for Mental Status) score of 99. This score reflected severe cognitive impairment with Wernicke's encephalopathy. Resident #1 was not supervised after he was found to be actively engaged in an oral sex act with another Resident on 2-23-26. Resident #1 did not have the decision-making capacity to willfully engage in sexual acts. The Resident's wandering continued and he was found again in another third Resident's room sitting without pants, on the resident's bed who was fully clothed.Failure to supervise Resident #1 during continued hazardous behaviors including elopement, and sexual contact that he was unable to consent for, placed Resident #1 and other Residents in jeopardy with the likelihood of serious adverse outcomes. Immediate corrective action must be implemented to ensure supervision for the safety of Resident #1 and other cognitively impaired Residents to protect them from serious injury, harm, or death. On 3-17-26 at 10:00 P.M. after several iterations with corrections, an immediacy removal plan was received and accepted by the survey team and the State Agency from the facility. That plan follows below. Immediacy Removal Plan for F689This immediacy removal plan serves as (facility name) Center's response to the Immediate Jeopardy that was identified on March 17, 2026. Immediate ActionResident #1 was placed on 1:1 continuous supervision 24 hours/day starting 3/17/2026 at 5:20pm. The resident provider and resident representative were notified.Residents who have a BIMs score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility. No concerns voiced.Residents who have a BIMs score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse. Any new identified areas will be reported to the residents' provider and the residents' representative. No new areas were identified.Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.System ChangesA staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.The courtyard gate alarm was activated on 3/17/2026 at 7:30pm and is being monitored every 30 minutes to ensure that it remains engaged.All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent. If the staff person is unable to participate in the training, they will be educated prior to their next scheduled shift.All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement and documenting functionality and placement of the Wander Guard. If the staff person is unable to participate in the initial training, they will be educated prior to their next scheduled shift.The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms. If the staff person is unable to participate in the initially held training, they will be educated prior to their next scheduled shift.Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms. All aspects of the plan will be completed by 3/18/2026 at 9:00am.On 3-18-26 at 9:00 A.M. testing was conducted by the survey team to ensure all aspects of the facility plan had been implemented as espoused by the facility. Those observations continue below.On 3-18-26, beginning at 9:00 AM, the survey team conducted environmental rounds to verify exit doors were locked and the courtyard gate alarm was turned on. Staff response to that alarm was also tested. The survey team identified that the courtyard gate alarm sounded for 10 seconds when opened, then went silent. No facility staff responded. The surveyors notified the Acting Administrator immediately. The Administrator then placed a chain on the courtyard gate adjacent to the outside parking lot to ensure residents would not be able to exit the gate without supervision.The survey team verified interviews had been completed on residents with a BIMs score of 9 or greater to determine if they have experienced any unwanted sexual interaction with another resident. Interviews did not produce any concerns regarding other residents wandering into their rooms and no concerns were voiced that they felt unsafe in the facility.The survey team verified skin assessments had been completed for residents with a BIMs score of less than 9 to identify any new areas of concern; no evidence of new areas was identified.The survey team verified completion of elopement assessments and a random sample of residents with Wander-Gard's were observed to ensure the devices were in place and functioning. No issues were identified.Rounds were conducted to verify a staff member was in place continuously monitoring the facility exit door to the courtyard until another alarm system could be installed.Resident #1 was observed to be continuously monitored by a staff member 1:1.After accepting the plan for removal of Immediate Jeopardy from the Administrator on 3-17-26 at 10:00 P.M. and determining that the Immediate Jeopardy was removed on 3-18-26 at 11:45 A.M., the deficiency was assigned a Scope and Severity level of two (2) pattern.The facility Administrator and Director of Nursing were made aware of the findings on 3-17-26, and 3-18-26 as the survey progressed. On 3-18-26 at approximately 11:50 A.M. all final information was shared, and the Administrator stated they had no further information to provide. References:1. Donepezil is used to treat dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) in people who have Alzheimer's disease (AD; a brain disease that slowly destroys the memory and the ability to think, learn, communicate and handle daily activities). Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function (such as memory, attention, the ability to interact with others, speak, think clearly, and perform regular daily activities) by increasing the amount f a certain naturally occurring substance in the brain. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a697032.html.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide an accident and hazard free environment which lacked supervision involving two of eight residents in the survey sample, Residents #1, and #2. This resulted in Immediate Jeopardy and substandard of care. After the Immediate Jeopardy was removed the scope and severity was lowered to a level two (2) pattern. The findings include: a. For Resident #1, the facility staff failed to supervise the resident with a known wandering and exit seeking behavior and failed to secure exit doors, resulting in the Resident eloping.Resident #1 was most recently admitted to the facility on [DATE]. Diagnoses included Wernicki's Encephalopathy, hypertension, alcohol use disorder, and thrombocytopenia.Resident #1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2-18-26 coded the Resident with a BIMS (Brief Interview of Mental Status) score of 99 which indicated severe cognitive impairment. The Resident was fully ambulatory requiring no devices to walk independently.Observations of the facility and the Resident population began on 3-17-26 during delivery of the facility lunch meal while making the initial tour. Resident #1 was observed walking alone down the main hallway of the facility from his housing unit toward the main dining room which he entered. He was interviewed and not found to be oriented, nor a reliable historian, however, was very pleasant.The dining room was equipped with an exit door to the courtyard which was the location for facility allowed smoking. The courtyard was enclosed and encircled by a 6-foot-tall metal fence with a gate which opened. The gate was inspected by surveyors and found to be equipped with an audible alarm when opened. The alarm had a keyed lock which appeared to be in the off position. Two surveyors were present and one pushed the gate open with no alarm sounding. There were no staff present in the courtyard and there were four Residents in the courtyard. Surveyors waited for approximately five minutes at the open gate with no staff present. At this time one of the surveyors left to retrieve the Maintenance Director to observe the gate. The Maintenance Director returned and stated that the alarm had been shut off by someone, and there were multiple keys floating around everywhere. He stated that he had tried to recover and account for the keys to the gate, however, some still existed that he had no knowledge of. The maintenance director stated that the gate did not have the Wander-Guard alarm.Nursing and physician progress notes were reviewed and revealed the following nine examples of Resident #1's behavior endangering himself and others.11-26-25 staff documented wandering into other resident rooms, Wander-Guard applied.12-1-25 staff documented Resident #1 continues to exhibit wandering behavior with repeated entry into other residents' rooms causing disruption to other residents. Resident going into other residents' rooms while CNA staff was providing them personal care. Redirection required multiple times throughout shift. Resident also putting soiled garments in his nightstand drawers.12-15-25 Staff documented resident went to outside patio (courtyard) .pushed gate to exit patio. Two CNA's from another unit were in the parking lot behind the building and witnessed resident exiting gate. Resident redirected inside of the building without incident, NP (nurse practitioner) and legal guardian both aware.12-17-25 Resident witnessed going to numerous exit doors and pushing on them. Resident wanders around entire building seeking exit doors. Resident stated, Hey I found the front door. Resident found on units 1 and 3 numerous times throughout shift remains easily redirected.12-18-25 resident exit seeking set off door alarm.2-16-26 Elopement Evaluation History of elopement while at home: No., Wandering behavior a pattern or goal directed: Yes. Wandering behavior likely to affect the safety or wellbeing of self/others: No. Wandering behavior likely to affect the privacy of others: No. By this time the Elopement Evaluation was produced Resident #1 had eloped on 12-15- 25, and the behaviors he exhibited had affected other residents and himself, to include on 12-1-25 privacy for other residents during hygiene care from staff such as bathing and dressing. The Elopement Evaluation had been documented incorrectly.7. 2-19-26 Resident took isolation supply cart from the hallway into his room and is using it for his personal use. The cart had alcohol-based hand sanitizer on it.8. 3-5-26 Resident found sitting on the side of another (female) resident's bed with his pants off. The other resident was fully clothed lying under the covers. (This third Resident was not identified and so not added to the sample. Staff were not able to tell surveyors who this third individual was.9. 3-8-26 Resident removed Wander-Guard and it is nowhere to be found, passed it on that resident needs a new one.On 3-17-26, during the survey no Wander-Gard device was found on the Resident, and the device was not added to the care plan until 3-17-26 when surveyors cited Immediate Jeopardy. Nursing staff would not have had direction for the use of the device until denoted in the care plan.None of the care plan interventions for behaviors or elopement were ever documented as having been implemented and no behaviors were ever documented on the medication administration records (MAR) for the Resident's stay.Physician's orders were reviewed and indicated that a Wander-Guard device was ordered for Resident #1 on 11-13-25, however, none was found on the Resident on 3-17-26, and the Resident was known to have had removed it previously on 3-8-26.Care plans for Resident #1 were reviewed and revealed that beginning on 11-13-25 (4) behavior focuses and interventions were added to that care plan. Those follow below.11-24-25 - The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. - All staff to converse with resident while providing care, ensure the activities the resident is attending are compatible with physical and mental capabilities.11-25-25 - Resident is an elopement risk/wanderer related to history of wandering, impaired safety awareness, Resident wanders aimlessly. - Assess for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.2-24-26 Resident has psychosocial well-being problem related to sexual/physical contact with another resident - intervene as to protect the resident's rights and safety. Immediately separate and remove from situation. Notify NP and RP (responsible party)/guardian.3-9-26 Resident has obsessive compulsive behavior - 1:1 (1 Resident to 1 dedicated staff member at all times) monitoring for behaviors, administer medications as ordered, redirect and cue as needed.On 3-17-26, and 3-18-26 interviews were conducted with multiple nursing staff and CNA's who denied knowing that the Resident's care plan stated he was to be 1 Resident to 1 dedicated staff member at all times. Supervision was not provided to the Resident, and the care plan stated to intervene, immediately separate, and remove from situation if the Resident was found engaging in sexual/physical contact with another resident. This reflects no preventative measures to protect the Resident from himself nor to protect others from him, and to act only after the contact was found.Neglect is defined as the withholding of goods and services required by a Resident. This would include staff supervision required for an individual who is known to be in danger of injury to himself or others due to cognitive decline and poor safety awareness. Therefore, withholding supervision (knowingly or unknowingly) is a direct hazard for accidents to the individual or others impacted by the individual. The facility staff knew the Resident was a threat to himself and others as demonstrated by the addition of 1:1 supervision added to his care plan on 3-9-26, however, staff were not aware of it, and so it was not implemented.The elopement of the Resident on 12-15-25 was never reported to the state agency. The intrusion by Resident #1 unclothed into a female Resident's room on 3-5-26 was never reported to the state agency.b. For Resident #1, the facility staff failed to protect him from consenting to sexual activities with Resident #2, that Resident #1 did not have the cognitive capacity to consent to.Resident #2 was most recently admitted to the facility on [DATE]. Diagnoses included Anemia, adult failure to thrive, and anxiety.Resident #2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1-20-26 coded the Resident with a BIMS (Brief Interview of Mental Status) score of 13 of a possible 15 points which indicated mild cognitive impairment. Resident #2 was dependent on a wheelchair for ambulation, which he self-propelled independently.Observations of the facility and the Resident population began on 3-17-26 during delivery of the facility lunch meal while making the initial tour. Resident #1 was observed walking alone down the main hallway of the facility from his housing unit toward the main dining room which he entered. He was interviewed and not found to be oriented, nor a reliable historian, however, was very pleasant.Resident #2 was self-propelling in his wheelchair down the same hallway coming from the opposite direction. He was interviewed and found to be alert, oriented to person, place, and situation. The Resident denied having any contact with Resident #1. The Resident stated, I am not a homosexual.The progress note for Resident #1, dated, 2-23-26, documented, Resident was in another resident's (male) room on his knees performing oral sex. Residents were immediately separated. Resident does not have any recollection of event occurring.The progress note for Resident #1, dated, 3-5-26, documented, Resident found sitting on the side of another (female) resident's bed with his pants off. The other resident was fully clothed lying under the covers. (This third Resident was not identified and so not added to the sample. Staff were not able to tell surveyors who this third individual was.)The comprehensive care plan dated 2/24/26, documented in part, Resident has psychosocial well-being problem related to sexual/physical contact with another resident - intervene as to protect the resident's rights and safety. Immediately separate and remove from situation. Notify NP and RP (responsible party)/guardian. The care plan dated, 3/9/26, documented, Resident has obsessive compulsive behavior - 1:1 (1 Resident to 1 dedicated staff member at all times) monitoring for behaviors, administer medications as ordered, redirect and cue as needed.On 3-17-26, and 3-18-26 interviews were conducted with multiple nursing staff and CNAs (certified nursing assistants) who denied knowing that the Resident's care plan stated he was to be 1 Resident to 1 dedicated staff member at all times. Supervision was not provided to the Resident, and the care plan stated to intervene, immediately separate, and remove from situation if the Resident was found engaging in sexual/physical contact with another resident. This reflects no preventative measures to protect the Resident from himself nor to protect others from him, and to act only after the contact was found.A psychiatric evaluation for Resident #1 was conducted on 2-2-26 revealing a Resident history of alcohol use disorder, Dementia, Wernicke's Encephalopathy, and altered mental status. The physician ordered Donepezil (1) 5mg (milligrams) every night as the only new treatment addition as a result of this lone evaluation during the Resident's four month stay in the facility.The Director of Nursing (DON), and Administrator were asked for copies of all incidents, allegations of abuse, investigations and reports which included Resident #1. Those were provided and the Administrator stated, this is everything we have, the former Administrator resigned and no other documents could be found. Those five categories of documents all dated only for the 2-23-26 sexual incident follow below.Face sheets (facility document) for Resident #1, and Resident#2 giving general admission information, such as payment, and general care provider information.A nursing note dated 2-23-26 from the unit LPN (Licensed Practical Nurse) recounting a report given to her by another staff member who witnessed the sexual incident between Resident #1 and Resident #2, however, the note does not describe the incident as the note in the clinical record did. This note stated that Resident #2 was lying on his bed receiving oral sex from Resident #1, and that Resident #2 (name) was placed on every 15-minute checks.One skin check (observation form) dated 2-24-26 showing skin intact for Resident #2 (name).One interview note for each Resident #1, and #2, dated 2-23-26, and allegedly documented by the Social Services (SSD) Director. The notes were typed and not signed by the SSD. That SSD was no longer employed by the facility at the time of survey and could not be contacted by phone for interview or authentication.The final document was a fax cover sheet and 2 additional pages which alleged they were a Final facility synopsis of event (also known as a five day follow up) to the initial report. The final report documented that it was the follow up to an initial (facility synopsis of event) dated 2-24-26, however, that 2-24-26 original (facility synopsis of event) document was not provided with this alleged follow up. The Interim Administrator was asked for the initial report (facility synopsis of event) faxed allegedly on 2-24-26. He stated that that Administrator no longer works here and he could not find the initial report, he also stated but when I realized the five day follow up had not been sent, I sent it on 3-4-26. The fax cover sheet documented the follow up report as being faxed on 4-4-26 as the date, and no fax confirmation time stamp for successful sending to the state agency for either document could be found by the facility.On 3-17-26 at 4:30 PM the facility was notified that Immediate Jeopardy (IJ) existed in the facility for the areas of Accidents and Hazards, as well as Ause and Neglect. The Administrator and his team were requested to provide an Immediacy Removal plan to protect all facility Residents. On 3-17-26 at 4:30 PM the facility was notified that Immediate Jeopardy (IJ) existed in the facility for the areas of Accidents and Hazards, as well as Ause and Neglect. The Administrator and his team were requested to provide an Immediacy Removal plan to protect all facility Residents. The Administrator and his team were provided with the IJ notification document which follows below.Resident #1, with a BIMS (Brief Interview for Mental Status) score of 99. This score reflected severe cognitive impairment with Wernicke's encephalopathy. Resident #1 was not supervised after he was found to be actively engaged in an oral sex act with another Resident on 2-23-26. Resident #1 did not have the decision-making capacity to willfully engage in sexual acts. The Resident's wandering continued and he was found again in another third Resident's room sitting without pants, on the resident's bed who was fully clothed.Failure to supervise Resident #1 during continued hazardous behaviors including elopement, and sexual contact that he was unable to consent for, placed Resident #1 and other Residents in jeopardy with the likelihood of serious adverse outcomes. Immediate corrective action must be implemented to ensure supervision for the safety of Resident #1 and other cognitively impaired Residents to protect them from serious injury, harm, or death. On 3-17-26 at 10:00 P.M. after several iterations with corrections, an immediacy removal plan was received and accepted by the survey team and the State Agency from the facility. That plan follows below. Immediacy Removal Plan for F689This immediacy removal plan serves as (facility name) Center's response to the Immediate Jeopardy that was identified on March 17, 2026. Immediate ActionResident #1 was placed on 1:1 continuous supervision 24 hours/day starting 3/17/2026 at 5:20pm. The resident provider and resident representative were notified.Residents who have a BIMs score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility. No concerns voiced.Residents who have a BIMs score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse. Any new identified areas will be reported to the residents' provider and the residents' representative. No new areas were identified.Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.System ChangesA staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.The courtyard gate alarm was activated on 3/17/2026 at 7:30pm and is being monitored every 30 minutes to ensure that it remains engaged.All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent. If the staff person is unable to participate in the training, they will be educated prior to their next scheduled shift.All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement and documenting functionality and placement of the Wander Guard. If the staff person is unable to participate in the initial training, they will be educated prior to their next scheduled shift.The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms. If the staff person is unable to participate in the initially held training, they will be educated prior to their next scheduled shift.Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms. All aspects of the plan will be completed by 3/18/2026 at 9:00am.On 3-18-26 at 9:00 A.M. testing was conducted by the survey team to ensure all aspects of the facility plan had been implemented as espoused by the facility. Those observations continue below.On 3-18-26, beginning at 9:00 AM, the survey team conducted environmental rounds to verify exit doors were locked and the courtyard gate alarm was turned on. Staff response to that alarm was also tested. The survey team identified that the courtyard gate alarm sounded for 10 seconds when opened, then went silent. No facility staff responded. The surveyors notified the Acting Administrator immediately. The Administrator then placed a chain on the courtyard gate adjacent to the outside parking lot to ensure residents would not be able to exit the gate without supervision.The survey team verified interviews had been completed on residents with a BIMs score of 9 or greater to determine if they have experienced any unwanted sexual interaction with another resident. Interviews did not produce any concerns regarding other residents wandering into their rooms and no concerns were voiced that they felt unsafe in the facility.The survey team verified skin assessments had been completed for residents with a BIMs score of less than 9 to identify any new areas of concern; no evidence of new areas was identified.The survey team verified completion of elopement assessments and a random sample of residents with Wander-Gard's were observed to ensure the devices were in place and functioning. No issues were identified.Rounds were conducted to verify a staff member was in place continuously monitoring the facility exit door to the courtyard until another alarm system could be installed.Resident #1 was observed to be continuously monitored by a staff member 1:1.After accepting the plan for removal of Immediate Jeopardy from the Administrator on 3-17-26 at 10:00 P.M. and determining that the Immediate Jeopardy was removed on 3-18-26 at 11:45 A.M., the deficiency was assigned a Scope and Severity level of two (2) pattern.The facility Administrator and Director of Nursing were made aware of the findings on 3-17-26, and 3-18-26 as the survey progressed. On 3-18-26 at approximately 11:50 A.M. all final information was shared, and the Administrator stated they had no further information to provide. References:1. Donepezil is used to treat dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) in people who have Alzheimer's disease (AD; a brain disease that slowly destroys the memory and the ability to think, learn, communicate and handle daily activities). Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function (such as memory, attention, the ability to interact with others, speak, think clearly, and perform regular daily activities) by increasing the amount f a certain naturally occurring substance in the brain. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a697032.html.

Based on staff interview and facility document review, the facility staff failed to review and revise the Facility Assessment with changes in the administrative team members.The findings include:Review of the Facility assessment on 5/13/2026 documented the name of the administrator prior to November 2025. The next administrator employed was not listed, and the current interim administrator, who started in February 2026, was not listed. The Current Director of Nursing was not listed, and she came in November 2025. The Medical Director listed had ended his contract with the facility on April 1, 2026. The date the assessment was updated or revised was August 27, 2025.[NAME] interview was conducted with the Executive Director on 5/13/2026 at 4:50 p.m. When asked why the Facility Assessment hasn't been reviewed and updated, he stated, I haven't had time to update it.The Executive Director, Director of Nursing and Regional Director of Operations, were made aware of the above concern on 5/13/2026 at 6:00 p.m.No further information was obtained prior to exit.

Based on observation, resident and staff interviews, the facility staff failed to maintain a clean, comfortable, and homelike environment and appropriate grooming for residents on 2 of 3 nursing units within the facility. (Units W1 and W2).Findings included:On 3/17/26 at approximately 10:45 AM, upon entering the facility, a strong pervasive odor (that of old dried urine) was noted in the front lobby.On 3/17/26 during the initial tour of Unit W1 at approximately 11:10 AM, privacy curtains were observed with dark smeared substance, baseboard buckling away from wall, halos of yellow brown stains noted on bed linens, foul odors of feces and urine at various times of the day, food particles on resident clothes and in their wheelchairs, and residents observed with wet pants, stained clothes and oily hair.On 3/17/26 during the initial tour of Unit W2 at approximately 11:10 AM, room [ROOM NUMBER]-B baseboard near HVAC (heating and air conditioning) unit not attached to the wall and board appeared be to crumbling, window blinds bent, paint on wardrobe scuffed, both residents noted with hair under chin, very foul odor in room; room [ROOM NUMBER]-B bedside table noted with missing drawer, area under the sink noted with yellow orange (rusty colored) stains on floor various trash on floor including a wound dressing, glove and straw; room [ROOM NUMBER]-A bedside table and overbed table noted with liquid spills and dried substances, very foul odor in room; room [ROOM NUMBER]-B resident observed in bariatric bed, per the resident, bariatric sheets are not always available when she needs her linens changed, states they run out of towels, not enough towels to start the shifts but has been better lately. She confirmed she had linens changed today and pointed to 3 extra towels and 2 washcloths on her overbed table. An observation of linen carts on Unit 2 on 3/18/26 at approximately 9:30 AM revealed carts stocked with towels, washcloths, regular and bariatric sheets and pillowcases.On 3/18/2026 at 10:45 AM, an interview was conducted with two housekeeping aides as they were cleaning resident rooms on Unit 2. When asked what their workload was like on regular day they responded, We usually have about 18-20 rooms to do. It may change depending on how many residents are in the building or when residents go to hospital or if they go home. When asked what the tasks were for cleaning the resident rooms, they responded, We clean the floors and bathrooms and if the resident wants us to, we will wipe off their tables, but they usually have lots of stuff on them.On 3/18/26 at 11:30 AM, an interview was conducted with C.N.A. (certified nursing assistant) #5 regarding if they had adequate amount of linens to care for the residents, C.N.A#5 stated, Sometimes we don't have enough towels at the beginning of our shift, we just go to another unit and see if they have any. When asked if she had bariatric sheets to change residents bed linens when needed (room [ROOM NUMBER]-B) she responded, Yes, most of the time, once in a while we haven't had one. On 3/18/2026 at 1:30 PM, during the end of day meeting, the [NAME] President of Operations (Interim Administrator), Director of Nursing, Regional Director Clinical Services and Regional MDS (minimum data set) Coordinator were informed of the findings of unclean rooms, poorly groomed residents and the presence of odors observed during the survey. They had no further information to provide.

Based on staff interview, facility document review and clinical record review, the facility staff failed to clarify two separate orders for insulin administration for one of four residents in the survey sample, Resident #202.The findings include:For Resident #202 (R202), the facility staff failed to clarify two orders for insulin.R202 was admitted to the facility on [DATE] with recent readmission on [DATE], with diagnoses that included but were not limited to: insulin dependent diabetes, stroke, underweight, depression, anorexia, dementia and high blood pressure.The most recent MDS (Minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/16/2026, coded the resident as scoring a 99, indicating the resident was unable to complete the interview. In Section C0700, the resident was coded as having but short- and long-term memory difficulties. In Section N - Medication, the resident was coded as receiving three insulin injections over the past seven days. The physician order dated, 7/20/2026, documented, Insulin Lispro Injection Solution 100 UNIT/ML (milliliter); Inject 4 units subcutaneously three times a day for *HOLD IF BLOOD SUGAR IS LESS THAN 120 PER (NAME OF NURSE PRADCTTIONER) RELATED TO Tyle 2 DIABETES Mellitus with hyperglycemia (high blood sugar). Call MD (medical doctor) if BG (blood glucose) is < (less than) 60 or > 250.The May 2026 MAR (medication administration record) documented the above order. On the following dates and times, the blood sugars were documented:5/2/2026 at 1:00 p.m. = 3185/3/2026 at 9:00 a.m. = 347; 1:00 p.m. = 3195/4/2026 at 9:00 a.m. = 308; 1:00 p.m. = 256; 5:00 p.m. = 3085/5/2026 at 9:00 a.m. = 278; 1:00 p.m. = 312Review of the clinical record failed to evidence documentation that the physician or nurse practitioner was notified of the above blood sugars per the physician orders. The physician order dated 4/26/2026 documented, Insulin Lispro Injection Solution; Inject as per sliding scale: if 140-199= 0 units; 200-259 = 2 units; 300-349=4 units; 350-400=Call MD, subcutaneously before meals for DM (diabetes mellitus).May 2026 MAR documented the above order. On 5/1/2026 at 11:30 a.m. the resident's blood sugar was documented as 500. The nurse practitioner (NP) was notified.An interview was conducted with LPN (licensed practical nurse) #1 on 7/1/2026 at 2:35 p.m. The above orders and MAR were shown to LPN #1 who worked on several of the days there was no documented notification to the doctor or NP. When asked if she notified the nurse practitioner or doctor of the blood sugars according to the order, LPN #1 stated, I didn't call anyone. When asked should she have called, LPN #1 stated, Yes.An interview was conducted with the Director of Nursing (DON), on 7/1/2026 at 4:56 p.m. The above orders were reviewed with the DON. She stated the orders should have been clarified.The Administrator and the DON were made aware of the above findings on 7/2/2026 at 10:00 a.m.No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their abuse policies involving a sexual encounter between two of eight residents in the survey sample, Residents #1 and #2. The findings include: For Resident #1, the facility staff failed to supervise a Resident with a known wandering and exit seeking behavior and failed to secure exit doors resulting in the Resident eloping and being involved in sexual acts that the Resident did not have the cognitive capacity to consent to.Resident #1 was most recently admitted to the facility on [DATE]. Diagnoses included Wernicki's Encephalopathy, hypertension, alcohol use disorder, and thrombocytopenia.Resident #1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2-18-26 coded the Resident with a BIMS (Brief Interview of Mental Status) score of 99 which indicated severe cognitive impairment. The Resident was fully ambulatory requiring no devices to walk independently.Resident #2 was most recently admitted to the facility on [DATE]. Diagnoses included Anemia, adult failure to thrive, and anxiety.Resident #2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1-20-26 coded the Resident with a BIMS (Brief Interview of Mental Status) score of 13 of a possible 15 points which indicated mild cognitive impairment. Resident #2 was dependent on a wheelchair for ambulation which he self-propelled independently.Observations of the facility and the Resident population began on 3-17-26 during delivery of the facility lunch meal while making the initial tour. Resident #1 was observed walking alone down the main hallway of the facility from his housing unit toward the main dining room which he entered. He was interviewed and not found to be oriented, nor a reliable historian, however, was very pleasant.Resident #2 was self-propelling in his wheelchair down the same hallway coming from the opposite direction. He was interviewed and found to be alert, oriented to person, place, and situation.The dining room was equipped with an exit door to the courtyard which was the location for facility allowed smoking. The courtyard was enclosed and encircled by a 6-foot-tall metal fence with a gate which opened. The gate was inspected by surveyors and found to be equipped with an audible alarm when opened. The alarm had a keyed lock which appeared to be in the off position. Two surveyors were present and one pushed the gate open with no alarm sounding. There were no staff present in the courtyard and there were 4 Residents in the courtyard. Surveyors waited for approximately 5 minutes at the open gate with no staff present. At this time one of the surveyors left to retrieve the Maintenance Director to observe the gate. The Maintenance Director returned and stated that the alarm had been shut off by someone, and there were multiple keys floating around everywhere. He stated that he had tried to recover and account for the keys to the gate, however, some still existed that he had no knowledge of. The maintenance director stated that the gate did not have the Wander-Gard alarm.Nursing and physician progress notes were reviewed and revealed the following 10 examples of Resident #1's behaviors endangering himself and others.11-26-25 staff documented wandering into other resident rooms, Wander-Gard applied.12-1-25 staff documented Resident #1 continues to exhibit wandering behavior with repeated entry into other residents' rooms causing disruption to other residents. Resident going into other residents' rooms while CNA staff was providing them personal care. Redirection required multiple times throughout shift. Resident also putting soiled garments in his nightstand drawers.12-15-25 Staff documented resident went to outside patio (courtyard) .pushed gate to exit patio. Two CNA's from another unit were in the parking lot behind the building and witnessed resident exiting gate. Resident redirected inside of the building without incident, NP (nurse practitioner) and legal guardian both aware.12-17-25 Resident witnessed going to numerous exit doors and pushing on them. Resident wanders around entire building seeking exit doors. Resident stated, Hey I found the front door. Resident found on units 1 and 3 numerous times throughout shift remains easily redirected.12-18-25 resident exit seeking set off door alarm.2-16-26 Elopement Evaluation History of elopement while at home: No., Wandering behavior a pattern or goal directed: Yes. Wandering behavior likely to affect the safety or wellbeing of self/others: No. Wandering behavior likely to affect the privacy of others: No. By this time the document was produced Resident #1 had eloped on 12-15-25, and the behaviors he exhibited had affected other residents and himself, to include on 12-1-25 privacy for other residents during hygiene care from staff such as bathing and dressing. The Elopement Evaluation had been documented incorrectly.7. 2-19-26 Resident took isolation supply cart from the hallway into his room and is using it for his personal use. The cart had alcohol-based hand sanitizer on it.8. 2-23-26 Resident was in another resident's (male) room on his knees performing oral sex. Residents were immediately separated. Resident does not have any recollection of event occurring.9. 3-5-26 Resident found sitting on the side of another (female) resident's bed with his pants off. The other resident was fully clothed lying under the covers. (This third Resident was not identified and so not added to the sample. Staff were not able to tell surveyors who this third individual was.10. 3-8-26 Resident removed Wander-Gard and it is nowhere to be found, passed it on that resident needs a new one.On 3-17-26, during the survey no Wander-Gard device was found on the Resident, and the device was not added to the care plan until 3-17-26 when surveyors cited Immediate Jeopardy. Nursing staff would not have had direction for the use of the device until denoted in the care plan.None of the care plan interventions for behaviors or elopement were ever documented as having been implemented and no behaviors were ever documented on the medication administration records (MAR) for the Resident's stay.Physician's orders were reviewed and indicated that a Wander-Gard device was ordered for Resident #1 on 11-13-25, however, none was found on the Resident on 3-17-26, and the Resident was known to have had removed it previously on 3-8-26.Care plans for Resident #1 were reviewed and revealed that beginning on 11-13-25 (4) behavior focuses and interventions were added to that care plan. Those follow below.11-24-25 - The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. - All staff to converse with resident while providing care, ensure the activities the resident is attending are compatible with physical and mental capabilities.11-25-25 - Resident is an elopement risk/wanderer related to history of wandering, impaired safety awareness, Resident wanders aimlessly. - Assess for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.2-24-26 Resident has psychosocial well-being problem related to sexual/physical contact with another resident - intervene as to protect the resident's rights and safety. Immediately separate and remove from situation. Notify NP and RP (responsible party)/guardian.3-9-26 Resident has obsessive compulsive behavior - 1:1 (1 Resident to 1 dedicated staff member at all times) monitoring for behaviors, administer medications as ordered, redirect and cue as needed.On 3-17-26, and 3-18-26 interviews were conducted with multiple nursing staff and CNA's who denied knowing that the Resident's care plan stated he was to be 1 Resident to 1 dedicated staff member at all times. Supervision was not provided to the Resident, and the care plan stated to intervene, immediately separate, and remove from situation if the Resident was found engaging in sexual/physical contact with another resident. This reflects no preventative measures to protect the Resident from himself nor to protect others from him, and to act only after the contact was found.A psychiatric evaluation for Resident #1 was conducted on 2-2-26 revealing a Resident history of alcohol use disorder, Dementia, Wernicke's Encephalopathy, and altered mental status. The physician ordered Donepezil 5mg (milligrams) every night as the only new treatment addition as a result of this lone evaluation during the Resident's 4 month stay in the facility.The Director of Nursing (DON), and Administrator were asked for copies of all incidents, allegations of abuse, investigations and reports which included Resident #1. Those were provided and the Administrator stated, this is everything we have, the former Administrator resigned and no other documents could be found. Those 5 categories of documents all dated only for the 2-23-26 sexual incident follow below.Face sheets (facility document) for Resident #1, and Resident#2 giving general admission information, such as payment, and general care provider information.A nursing note dated 2-23-26 from the unit LPN (Licensed Practical Nurse) recounting a report given to her by another staff member who witnessed the sexual incident between Resident #1 and Resident #2, however, the note does not describe the incident as the note in the clinical record did. This note stated that Resident #2 was lying on his bed receiving oral sex from Resident #1, and that Resident #2 (name) was placed on every 15 minute checks.One skin check (observation form) dated 2-24-26 showing skin intact for Resident #2 (name).One interview note for each Resident #1, and #2, dated 2-23-26, and allegedly documented by the Social Services (SSD) Director. The notes were typed and not signed by the SSD. That SSD was no longer employed by the facility at the time of survey and could not be contacted by phone for interview or authentication.The final document was a fax cover sheet and 2 additional pages which alleged they were a Final FRI (facility reported incident) (also known as a 5 day follow up) to the initial report. The final report documented that it was the follow up to an initial FRI dated 2-24-26, however, that 2-24-26 original (FRI) document was not provided with this alleged follow up. The Interim Administrator was asked for the initial report (FRI) faxed allegedly on 2-24-26. He stated that that Administrator no longer works here and he could not find the initial report, he also stated but when I realized the 5 day follow up had not been sent, I sent it on 3-4-26. The fax cover sheet documented the follow up report as being faxed on 4-4-26 as the date, and no fax confirmation time stamp for successful sending to the state agency for either document could be found by the facility.Federal law and state law mandate that allegations of abuse/neglect must be reported to the state agency within 2 hours after the allegation is made if serious injury occurs and within 24 hours if no injury occurs. The mandate continues to include a 5-business day follow-up report of the facility full investigation into the incident with all statements and findings. The 5-day follow-up report would have been late if it had been sent. No record exists in the state agency of the follow-up report being sent. No investigation notes were found, no staff statements were obtained from witnesses, and the facility policy was not implemented.The facility policy for Abuse/Neglect was reviewed and mirrored the legal requirements above exactly.Neglect is defined as the withholding of goods and services required by a Resident. This would include staff supervision required for an individual who is known to be in danger of injury to himself or others due to cognitive decline and poor safety awareness. Therefore, withholding supervision (knowingly or unknowingly) is a direct hazard for accidents to the individual or others impacted by the individual. The facility staff knew the Resident was a threat to himself and others as demonstrated by the addition of 1:1 supervision added to his care plan on 3-9-26, however, staff were not aware of it, and so it was not implemented.The elopement of the Resident on 12-15-25 was never reported to the state agency. The intrusion by Resident #1 unclothed into a female Resident's room on 3-5-26 was never reported to the state agency. Resident #1 was not supervised during episodic wandering and an elopement from an open courtyard on 12-15-25. That courtyard was found today (3-17-26) to be unlocked, with no alarm system activated, and no alarm activated on the facility exit door to the courtyard. Secondarily, for a Resident with a BIMS (Brief Interview for Mental Status) score of 99. This score reflected severe cognitive impairment with Wernicke's encephalopathy. Resident #1 was not supervised after he was found to be actively engaged in an oral sex act with another Resident on 2-23-26. Resident #1 did not have the decision-making capacity to willfully engage in sexual acts. The Resident's wandering continued and he was found again in another third Resident's room sitting without pants, on the resident's bed who was fully clothed.The facility Administrator and Director Of Nursing were made aware of the findings on 3-17-26, and 3-18-26 as the survey progressed. On 3-18-26 at approximately 11:50 A.M. all final information was shared, and the Administrator stated they had no further information to provide.

Based on staff interview and facility document review, the facility staff failed to notify the physician per the physician orders for one of four residents in the survey sample, Resident #202.The findings include:For Resident #202 (R202) the facility failed to notify the physician of blood sugars outside the physician ordered parameters.R202 was admitted to the facility on [DATE] with recent readmission on [DATE], with diagnoses that included but were not limited to: insulin dependent diabetes, stroke, underweight, depression, anorexia, dementia and high blood pressure.The most recent MDS (Minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/16/2026, coded the resident as scoring a 99, indicating the resident was unable to complete the interview. In Section C0700, the resident was coded as having but short- and long-term memory difficulties. In Section N - Medication, the resident was coded as receiving three insulin injections over the past seven days. The physician order dated, 7/20/2026, documented, Insulin Lispro Injection Solution 100 UNIT/ML (milliliter); Inject 4 units subcutaneously three times a day for *HOLD IF BLOOD SUGAR IS LESS THAN 120 PER (NAME OF NURSE PRADCTTIONER) RELATED TO Tyle 2 DIABETES Mellitus with hyperglycemia (high blood sugar). Call MD (medical doctor) if BG (blood glucose) is < (less than) 60 or > 250.The May 2026 MAR (medication administration record) documented the above order. On the following dates and times, the blood sugars were documented:5/2/2026 at 1:00 p.m. = 3185/3/2026 at 9:00 a.m. = 347; 1:00 p.m. = 3195/4/2026 at 9:00 a.m. = 308; 1:00 p.m. = 256; 5:00 p.m. = 3085/5/2026 at 9:00 a.m. = 278; 1:00 p.m. = 312Review of the clinical record failed to evidence documentation that the physician or nurse practitioner was notified of the above blood sugars per the physician orders. The physician order dated 4/26/2026 documented, Insulin Lispro Injection Solution; Inject as per sliding scale: if 140-199= 0 units; 200-259 = 2 units; 300-349=4 units; 350-400=Call MD, subcutaneously before meals for DM (diabetes mellitus).An interview was conducted with LPN (licensed practical nurse) #1 on 7/1/2026 at 2:35 p.m. The above orders and MAR were shown to LPN #1 who worked on several of the days there was no documented notification to the doctor or NP. When asked if she notified the nurse practitioner or doctor of the blood sugars according to the order, LPN #1 stated, I didn't call anyone. When asked should she have called, LPN #1 stated, Yes.An interview was conducted on 7/1/2026 at 3:21 p.m. with the Medical Director. The Medical Director stated that if there is an order for he or the nurse practitioner to be call, then he would expect them to call. The above orders were reviewed with the Medical Director. He stated he felt the order for to call for a blood sugar greater than 150 is a bit low for notification, but if an order is there, then it should be followed.The Administrator and the DON were made aware of the above findings on 7/2/2026 at 10:00 a.m.No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure it was clinically appropriate for the self-administration of medications for one resident (Resident #7) in survey sample of eight residents. Findings included:For Resident # 7(R7), the facility staff failed to ensure there was a self-administration of medication assessment related to medication found at the bedside. R7, was admitted to the facility on [DATE]. The diagnoses included but were not limited to alcoholic cirrhosis of liver with ascites, and gastro-esophageal reflux disease without esophagitis. The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 03/13/2026. Resident # 7's BIMS (Brief Interview for Mental Status) Score was 13 out of 15, indicating mild cognitive impairment. On 03/17/2026, during the initial tour of the facility a medicine cup with seven [NAME]-colored tablets and two oblong white tablets were observed on the overbed table of R7. R7 was not in the room. On 03/17/26, during an evening tour R7 was not observed in his room. The medication cup with the seven [NAME]-colored tablets were still observed on the overbed table. The two oblong white tablets were not present. Review of the clinical record was conducted on 03/17/2026 through 03/18/2026. On 03/17/26 at 1:34 p.m., an interview was conducted with the Licensed Practical Nurse (LPN) #2. LPN#2 stated that R7 requested Tylenol after breakfast. R7 was given two 500mg Tylenol at approximately 10:00 a.m. LPN#2 said, He must have put them down instead of taking them as he said he would. She also stated medications should never be left at the bedside without a self-administration assessment and orders from the Physician. LPN#2 stated none of the residents on the unit had an assessment with orders for self-administration of medications. Review of the Physicians Orders revealed no active order for the medication found at the bedside or an order for self-administration for Resident #7. Review of the Self-Administration of Medication and Treatments Policy was reviewed and revealed Residents have the right to self-administer medications/treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. During the end of day debriefings on 03/17/26, the Administrator and Director of Nursing (DON) were informed of the findings. They stated medications should not be left at the bedside unless a resident has been assessed for self-administration of medications. No further information was provided.

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in Behavioral Health for four of ten employee records reviewed, CNA (certified nursing assistant) #2, CNA #3, other staff member (OSM) #2, dietary, and OSM #3, housekeeping.The findings include:On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #3. The review of the employee training records revealed CNA #2, CNA #3, OSM #2 and OSM #3 no documented education regarding behavioral health.On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that CNA #2, CNA #3, OSM #2 and OSM #3 did not have the required training in behavioral health.A request for the policy for the required training elements was requested but not provided prior to exit.The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m.No further information was provided prior to exit.

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in QAPI (quality assurance performance improvement) for one of ten employee records reviewed, CNA (certified nursing assistant) #3.On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #3. The review of the employee training records revealed that CNA #3 did not have the required training in QAPI. On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that the CNA #3 did not have the required training in QAPI.A request for the policy for the required training elements was requested but not provided prior to exit.The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m.No further information was provided prior to exit.

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in resident rights for one of ten employee records reviewed, CNA (certified nursing assistant) #3.The findings include:On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #3. The review of the employee training records revealed that CAN #3 did not have the required training in resident rights. On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that the CNA #3 did not have the required training in resident rights.A request for the policy for the required training elements was requested but not provided prior to exit.The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m.No further information was provided prior to exit.

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in communication for three of ten employee records reviewed, CNA (certified nursing assistant) #1, CNA #2, and CNA #3The findings include:On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #1, CNA #2, CNA #3. The review of the employee training records revealed that the three CNAs did not have the required training in communication. On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that the three CNAs did not have the required training in communication.A request for the policy for the required training elements was requested but not provided prior to exit.The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m.No further information was provided prior to exit.

Based on observation and staff interview, the facility staff failed to post the staff posting at the beginning of the shift on one of three days observed.The findings include: Observation was made of the staff posting at the receptionist desk on 5/14/2026 at 9:03 a.m. The posting was documented for 5/13/2026.An interview was conducted with the Staffing Coordinator on 5/14/2026 at 9:23 a.m. The Staffing Coordinator stated that she posts the daily posting when she gets in the facility in the morning, around 8:00 a.m. She stated she updates it before every shift, and she has just started asking the night nurse to post it in the mornings to reflect any call offs received over night. When asked what happened in the morning of 5/14/2026, the Staffing Coordinator stated she got involved with passing breakfast trays and forgot to get it up.An interview was conducted with the Assistant Director of Nursing (ADON) on 5/14/2026 at 1:11 a.m. She stated the scheduler (staffing coordinator) should post the staff posting early in the morning. The night nurse has the schedule and should put it up front at the receptionist desk.The Executive Director (ED), Director of Nursing and Regional Director of Operations, were made aware of the above concern on 5/14/2026 at 4:10 p.m. The ED stated they had no policy for the staff posting.No further information was obtained prior to exit.

Based on staff interview and facility document review, the facility staff failed to provide evidence of updated contracts with outside providers for three of three contracts reviewed, potentially affecting all residents.The findings include:The facility staff failed to provide updated contracts for mobile imaging services, mobile imaging equipment, and an agreement for contract dialysis services.On 8/20/25 at 5:13 p.m., copies of current facility contracts were requested as part of the extended survey process. ASM (administrative staff member) #1, the executive director, stated he may not be able to provide the survey team with contracts that meet the regulation. He stated that due to the facility sale in June of 2024, the former company ceased to exist, and a new company took over as owner. He added: We had to go back in and negotiate contracts with all of our venders.On 8/21/25 at 8:36 a.m., ASM #1 provided a book of contracts for outside service providers to the facility. A review of three of these contracts revealed there was no contractual agreement between the providers of mobile imaging, the mobile imaging equipment company, and the facility's dialysis providers. All of these contracts were between the outside provider and the name of the previous owner of the facility, a company no longer in existence.On 8/21/25 at 11:06 a.m., ASM #1 was interviewed. He stated the former owner of the facility filed for bankruptcy protection and was sold on 6/1/25. He explained that on that day, the bankrupt company ceased to exist. He stated he and the corporate staff had attempted to contact the facility's attorneys. He said that they had not yet been able to secure the legal documents needed to satisfy the regulation. ASM #1 did not provide the survey team with a policy related to updated contracts with outside providers.No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined that the facility staff failed to review and revise the facility assessment after a change of ownership effective 6/1/2025.The findings include:Review of the provided facility assessment documented a date of 7/18/2024. The facility assessment documented the former executive director and director of clinical services at the facility. It further documented information under the staff training/education and competencies that reflected the previous owner.On 8/20/2025 at 5:08 p.m., an interview was conducted with ASM (administrative staff member) #1, the executive director, who stated that the facility assessment provided was from 2024 prior to the change of ownership. He stated that they had planned to update the assessment in a QAPI (Quality Assurance Performance Improvement) meeting that they had scheduled for 8/20/2025. ASM #1 stated that the change of ownership sale was completed effective 6/1/2025 when the former owner ceased to exist and the new owner took over. He stated that they had to renew all their contracts and change the names on everything. When asked if the facility assessment should have been updated, ASM #1 stated that he did not think that the patient aspect much would change but there would be some things that would need to be reviewed and revised, same as the contracts. On 8/21/2025 at 9:03 a.m., ASM #1, the executive director was made aware of the concern.No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure the activities program was directed by a qualified professional between 1/29/2025 and 6/27/2025 potentially affecting all residents in the facility.The findings include:The facility staff failed to ensure a director of activities was in place between 1/29/2025 and 6/27/2025.On 8/19/2025 at 2:09 p.m., an interview was conducted with Resident #17 (R17) who stated that they could remember a time this year when there were no activities. R17 stated that he liked to go to various activities, but there were none being done that he knew of. He stated he thought there should have been someone to do them for him and other residents. R17 was assessed as being cognitively intact for making daily decisions on the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/26/2025.On 8/20/2025 at 2:00 p.m., an interview was conducted with Resident #18 (R18) who stated that there were no activities in the building from February through June. R18 stated that a person came back but left shortly thereafter and that activities are a must for residents in a nursing home. R18 was assessed as being cognitively intact for making daily decisions on the most recent MDS, a quarterly assessment with an ARD of 6/29/2025.On 8/18/2025 at 4:03 p.m., a request was made to ASM (administrative staff member) #2, the director of clinical services, for evidence of an activities director in place from 1/1/2025 to the present with evidence of their qualifications.A review of employment documentation provided by ASM #2, the director of clinical services, documented the previous activities director terminated on 1/29/2025 and the current activities director (OSM (other staff member) #9) hired on 6/27/2025.On 8/19/2025 at 2:00 pm, ASM #2 stated that there was an employee from a contacted managed care company who came to the facility once a week to do activities in the absence of the activities director. She stated that the person did not single out certain residents and did activities for the whole building but were not employed by the facility as the activities director. ASM #2 stated that they also had an activities assistant who was a CNA, but they did not have the credentials to be the activities director. She stated that they had a regional activities director come to the facility for a couple of weeks to do activities during the time also and provided timesheets to evidence the time spent at the facility. Review of the timesheets provided documented the regional staff member working 24 hours between 6/5-6/18/25 and 8 hours between 6/19-7/2/25.On 8/19/2025 at 2:14 p.m., an interview was conducted with OSM #2, activities assistant, who stated that they had been handling activities on the memory care unit since 6/28/25. She stated that she worked as a CNA (certified nursing assistant) on the unit prior to that date and there was someone who would come over off and on to do some activities, but it was not every day. She stated that she did some activities with residents on the memory care unit in addition to her CNA duties when there was no activities director in place to keep residents occupied.On 8/19/2025 at 4:32 p.m., an interview was conducted with OSM #4, the director of social services. OSM #4 stated that for months there were no activities going on in the memory care unit and staffing had been a challenge. She stated that things were much better now, and activities were going on every day.On 8/20/2025 at 9:01 a.m., ASM #1, the executive director, stated that the current activities director had started working at the facility at the end of June and prior to that they were challenged with days when no one was at the facility. On 8/20/2025 at 9:03 a.m., an interview was conducted with OSM #9, activities director, who stated that they determined activity preferences by developing interpersonal connections with the residents during rounding and morning breaks. She stated that she liked getting an idea of what the residents liked to do, and she offered activities of preference and one-on-one activities as well. OSM #9 stated that since she began working at the facility in June she had created a daily activity sheet that documented the activities for the day, and the attendance logs of residents. She stated that her current activities staff consisted of herself and two activities assistants with one dedicated to the memory care unit. OSM #9 stated that they offered activities such as one-on-one, spa treatments, devotionals, religious activities, arts and crafts and games. She stated that activities should be offered to residents daily to ensure that they are engaged and to give them something to do and a sense of purpose in their day-to-day living.On 8/20/2025 at 10:57 a.m., an interview was conducted with LPN (licensed practical nurse) #4, who stated that there was a time in early 2025 when there was no activities director. She stated that one of her CNA staff would play some games and take residents outside on the memory care unit to give them something to do. LPN #4 stated that the facility tried to have someone come in from the outside, but the CNA had done most everything for memory care until the new activities director and activities aide started in June 2025.The facility policy Group Activities dated 11/01/2021, documented in part, Group activities are scheduled to enhance the resident's well-being and self-esteem. The activities are planned and organized to meet a specific purpose.The facility policy Community Life Director dated 11/01/2021, documented in part, The Community Life department provides and coordinates services and support to meet the interests and social needs of each resident. Programming focuses on enhancing the physical, mental, and psychosocial well-being of each resident incorporating the domains of wellness. A Community Life Director, in addition to the above requirements, has completed additional training and/or credentialing by an accredited body in therapeutic recreation services or a training course approved by the state and is licensed or registered by the state in which practicing if applicable.The facility job description for Manager of Resident Activities documented in part, .The primary purpose of your job position is to assist in planning, organizing, developing the operation of the Activity Department in accordance with current federal, state and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Executive Director, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.On 8/19/25 at 2:43 p.m., ASM #1, the executive director and ASM #2, the director of clinical services were made aware of the concern.No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to facilitate resident council meetings for three of nine months, potentially affecting all residents, and failed to resolve grievances identified in the resident council meetings for two months reviewed.1. The facility staff failed to facilitate resident council meetings from 5/1/2025 through the present potentially affecting all residents in the facility. A review of the facility resident council meeting minutes from 10/1/2024 to the present failed to evidence any meeting minutes after 4/17/2025. On 8/20/2025 at 2:00 p.m., an interview was conducted with Resident #18 (R18) who stated that there were no activities in the building from February through June. R18 stated that he called resident council meetings himself when there was no activities director and he had independently met with some other residents and former administrative staff to discuss the need for an activities director and person to file grievances through. R18 stated that he had offered to write up the other residents grievances in the absence of the activities director because that was one of the primary concerns he had about not having resident council meetings. He stated that the social worker started taking down their grievances at that point and the former administrative staff promised him that they would fill the position. R18 stated that in the resident council meetings they discussed any concerns the residents had with staff, activities they wanted to do, grievances, and changes in leadership. He stated that there were still ongoing problems that needed to be addressed, and he was working one-on-one with the new executive director and director of clinical services who have been very receptive and helpful. R18 was assessed as cognitively intact for making daily decisions on the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 6/29/2025. On 8/20/25 at 9:01 a.m., ASM (administrative staff member) #1, the executive director stated that the current activities director had started working at the facility at the end of June and prior to that they were challenged with days when no one was at the facility. On 8/20/2025 at 12:53 p.m., ASM #2, the director of clinical services stated that the resident council meeting minutes provided were what they had and there were none for 5/1/2025 to the present. The facility policy Resident Council Meeting dated 11/1/21 documented in part, Residents will be provided the opportunity to meet together at least monthly in an organized group setting to discuss current issues/topics of their choice. These topics may include events, activities, resident rights, care, and service and concerns. In addition, a review of old business, problem resolution, and development of action plans may be discussed. The Recreational and Community Life Department staff will serve as facilitators for the meetings and will document minutes as approved by Resident Council . On 8/20/25 at 4:30 p.m., ASM #1, the executive director and ASM #2, the director of clinical services were made aware of the concern. No further information was provided prior to exit. 2. For November and December 2024, the facility staff failed to provide evidence of resolution of resident grievances expressed during Resident Council meetings. A review of the 11/6/24 Resident Council meeting minutes revealed the following “new business” items of concern: CNAs (certified nursing aides) not making beds or changing bed linens, pain medications not being given in a timely fashion, and a shortage of paper towels and toilet paper in rooms. A review of the 11/12/24 Resident Council meeting minutes revealed no evidence that the new concerns raised in the 11/6/24 meeting had been resolved. Additionally, these minutes revealed the following “new” concerns: beds not being made or linens changed, smoking times needing to be reviewed, resident/staff respect, residents not being introduced to caregivers each shift, and missing clothing items. A review of the 11/18/24 Resident Council meeting minutes revealed no evidence that the new concerns raised in the 11/12/24 meeting had been resolved. Additionally, these minutes revealed the following “new” concerns: CNAs and nurses treating residents with respect, lack of housekeeping services on the weekends, snacks on each unit, residents going to the kitchen to request coffee, and more trips needed to area stores. A review of the 11/25/24 Resident Council meeting minutes revealed no evidence that the new concerns raised in the 11/18/24 meeting had been resolved. Additionally, these minutes revealed the following “new” concerns: beds not being made, staff treating residents disrespectfully, adding a smoke break after dinner, CNAs and nurses on their cell phones, call bells not working, medications being given late, and missing personal items. A review of the 12/2/24 Resident Council minutes revealed no evidence that the new concerns raised in the 11/25/24 meeting had been resolved. Additionally, these minutes revealed the following “new” concern: beds not being made. A review of the 12/26/24 Resident Council minutes revealed no evidence that the new concerns raised in the 11/25/24 meeting had been resolved. On 8/20/25 at 4:45 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of clinical services, were informed of these concerns. On 8/20/25 at 5:13 p.m., ASM #1 was interviewed. He stated that he started working at the facility within the last month. He could not provide evidence of resolutions for grievances expressed in November and December 2024 Resident Council meetings. It is his process to review all concerns identified as grievances during a Resident Council meeting, and to make sure these are appropriately documented so they can be tracked. He reviews each and every new concern from the past 24 hours during each day’s morning meeting with staff. He assigns responsible staff to each concern and emphasized that the resident/responsible party must be involved in the resolution process. He added that resolutions need to occur in a timely manner, must be documented, and the loop must be closed. A review of the facility policy, “Complaint/Grievance,” revealed, in part: “The Center will support each resident’s right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of the progress toward resolution.” No additional information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a safe environment for one of ten residents in the survey sample, Resident #8. This citation was originally found at a level four isolated and upon acceptance of the plan of correction, it was lowered to a level two isolated. An oxygen cylinder tank was observed in Resident #8's room. The tank was unsecured. There was an approximate 1,000 PSI (pounds-force per square inch) reading on the gauge of the tank. It was standing approximately two inches from the wall, without a stand or holder and no support. The observation constituted the notification of immediate jeopardy. The findings include: Resident #8 was admitted to the facility on [DATE]. Resident #8's [DIAGNOSES REDACTED]. Resident #8's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/6/18, coded the resident's cognition as severely impaired. Section G coded the resident as requiring extensive assistance of two or more staff with bed mobility and only transferring once or twice during the seven-day look back period. Section O coded Resident #8 as not receiving oxygen therapy during the last 14 days. Review of the physician's orders [REDACTED].#8, signed by the physician on 1/7/19 failed to reveal a physician's orders [REDACTED].#8's care plan initiated on 11/30/18 failed to reveal documentation regarding oxygen. On 1/9/19 at 4:58 p.m., an unsecured oxygen cylinder tank was observed in Resident #8's room. The tank was freestanding approximately two inches from the wall, without a stand or holder, and was located on Resident #8's, roommate's side of the room. Resident #8 was observed lying in bed. The resident's roommate was not in the room. On 1/9/19 at 5:05 p.m., the survey team conducted a sweep of the entire facility and there were no other unsecured oxygen tanks found in the building. On 1/9/19 at 5:16 p.m., CNA (certified nursing assistant) #3 and CNA #4 were observed entering Resident #8's room and then exiting the room without removing the oxygen tank. On 1/9/19 at 5:25 p.m., the supervisors at the VDH (Virginia Department of Health), OLC (Office of Licensure and Certification) were contacted regarding the Immediate Jeopardy for Resident #8. After a discussion, OLC Supervisors agreed with the Immediate Jeopardy assessment concerning Resident #8. On 1/9/19 at 5:30 p.m., ASM (administrative staff member) #1 (the executive director) and RN (registered nurse) #2 (the assistant director of clinical services) were made aware of Immediate Jeopardy. On 1/9/19 at 5:35 p.m., observation of the unsecured oxygen tank in Resident #8's room was conducted with ASM #1, RN #2 and LPN (licensed practical nurse) #2. Per this surveyor's request, RN #2 placed a gauge on the oxygen tank. LPN #2 confirmed there was a 1,000-PSI (pounds-force per square inch) reading on the gauge of the tank. RN #2 and LPN #2 immediately secured the tank following the reading of the gauge. On 1/9/19 at 5:48 p.m., an interview was conducted with CNA #3. CNA #3 was asked if he observes for safety concerns when he is in residents' rooms. CNA #3 stated, Yeah to see if anything is out of place. When asked what types of things he observes for, CNA #3 stated he observes for oxygen tanks, oxygen tubing, marks or bruises on residents and wet/soiled linen. When asked how oxygen tanks should be stored, CNA #3 stated oxygen tanks should be stored outside. When asked what should be done if he observes an unsecured oxygen tank in a resident room, CNA #3 stated the oxygen tank should be taken outside on a cart with wheels. At this time, CNA #3 confirmed he was recently in Resident #8's room. CNA #3 stated he did not notice the unsecured oxygen tank in Resident #8's room. On 1/9/19 at 5:50 p.m., an interview was conducted with LPN #2 (the nurse caring for Resident #8). LPN #2 was asked if she observes for safety concerns when she is in residents' rooms. LPN #2 stated, For the most part, yeah. When asked if she observes for unsecured oxygen tanks, LPN #2 stated, Yeah, if I saw it. When asked what should be done if she observes an unsecured oxygen tank in a resident room, LPN #2 stated she would place the tank in a rolling caddy (a secure rolling dolly) and remove it from the room. When asked how oxygen tanks should be stored in residents' rooms, LPN #2 stated she thought the tank would have to be in a rolling caddy. At this time, LPN #2 confirmed Resident #8's roommate was out of the facility. When asked what time the resident's roommate left, LPN #2 stated she arrived to the facility at 3:00 p.m. and Resident #8's roommate was gone. LPN #2 was asked to explain when she was last in Resident #8's room. LPN #2 stated she administered pain medication to Resident #8 at approximately 5:30 p.m. but she did not see the unsecured oxygen tank. When LPN #2 was asked if she could explain who left the unsecured oxygen tank in the room and why, LPN #2 stated she could not. On 1/9/19 at 5:59 p.m., an interview was conducted with CNA #4. CNA #4 was asked if he observes for safety concerns when he is in residents' rooms. CNA #4 stated, Yeah. When asked what he observes for, CNA #4 stated he usually ensures call bells are safely placed. When asked if he observes for any other safety concerns, CNA #4 stated he looks at electrical cords. When asked if he observes to ensure oxygen tanks are safely secured, CNA #4 stated, Yeah. When asked how oxygen tanks should be stored, CNA #4 stated, We usually have a portable holder on wheels (a secure rolling dolly). CNA #4 was asked to explain the last time he was in Resident #8's room. CNA #4 stated he had been in the room twice between 3:20 p.m. and the present time. When asked if he noticed the unsecured oxygen tank in the room, CNA #4 stated he did not. CNA #4 was asked if he should have noticed the unsecured oxygen tank in the room. CNA #4 stated, Yeah. Usually she (Resident #8's roommate) goes to [MEDICAL TREATMENT] (an outside specialized treatment for [REDACTED]. When asked if an unsecured oxygen tank should be observed freestanding in a resident room, CNA #4 stated, No because if it falls down it may cause flame or fire. On 1/9/19 at 6:33 p.m., ASM #1 presented an acceptable plan of correction. The plan of correction documented: 1. Accident and incident prevention. Facility staff will store oxygen properly. 1. Oxygen tank was noted in a resident care area free standing. 1. Facility staff lack knowledge on proper storage of oxygen tank. 1. The oxygen tank in room has been removed. The resident was not affected. 2. Residents that reside in the facility have the potential to be affected. All resident areas will be inspected to ensure no free standing oxygen tanks are found. 3. NHA (Nursing home administrator) will educate current facility staff on the proper storage of oxygen tanks to include that oxygen tanks must never be free standing they must always be transported in an oxygen dolly and if left in the room they must remain in the dolly by 6:15 p.m. On 1/9/2019. All remaining staff will be educated prior to returning to work. The facility will monitor resident care areas on each shift to ensure no tanks are left free standing. 4. Findings will be reviewed monthly during QAPI (quality assurance and performance improvement). A[NAME] 1/9/2019 at 10:59 pm. Interviews were conducted with multiple staff of varying departments related to the storage of oxygen from 1/9/19 at 6:35 p.m. to 1/10/19 at 8:28 a.m. All staff members received education regarding the storage of oxygen tanks and could verbalize the facility policy on the storage of oxygen tanks. On 1/10/19 at 8:45 a.m., review of facility documentation revealed all facility staff received education regarding the storage of oxygen tanks and verification of the facility plan of correction was completed. At this time, VDH OLC supervisory staff were notified and the Immediate Jeopardy was abated. On 1/10/19 at 8:48 a.m., ASM #1 and ASM #2 (the director of clinical services) were made aware of the abatement of Immediate Jeopardy. The facility policy titled, Safety Precautions- Fire Prevention documented, Oxygen Equipment Storage: 1. Oxygen cylinders shall only be stored in approved locked storage areas, in racks with chains, sturdy portable carts, or stands . The oxygen cylinder manufacturer's instructions documented, DO keep cylinders upright and secure them against being knocked over. The American Society for Healthcare Engineering documented, 2. General Storage Requirements for All Medical Gas Cylinders. 2.1. All medical gas cylinders (including E (emergency) cylinders) must be physically supported, either in a stand or rack or chained or strapped to the wall. This requirement is intended to prevent mechanical hazards caused by a sudden release of gas if a tank falls over. This information was obtained from http://www.ashe.org/compliance/ec_02_06_01/01/pdfs/mg2012mclaughlin.pdf Guidance for safe handling of oxygen cylinders was provided by the Joint Commission at www.jointcommission.org <http://www.jointcommission.org> as follows: It may be impractical for some organizations to have piped nonflammable medical gases, so they may provide these gases in freestanding cylinders of various sizes. All freestanding cylinders must be stored in a rack, a cart, or another enclosure to protect them. Unsecured cylinders could fall, breaking the valve and possibly resulting in a rapid release of the gas, propelling the cylinder and turning it into a dangerous projectile.

Based on staff interview and facility document review, it was determined the facility staff failed to verify the certifications of seventeen out of 79 currently employed CNA's (certified nursing assistant) that been providing direct care to residents, CNA #3, CNA #5, CNA #7 and CNA #19 through 32. The facility staff failed to obtain certification verification of seventeen currently employed CNAs (certified nursing assistants) CNA #3, CNA #5, CNA #7 and CNA #19 through 32, that been providing direct care to residents. Review of the as-worked schedule from the past two weeks prior to entrance, revealed the 17 CNAs identified had been directly working with residents and providing care, and the facility staff failed to verify CNA #3's certification prior to hire on [DATE], who was found to have a pending violation on her certification. This resulted in the identification of immediate jeopardy at a pattern. After a plan of correction was presented, verified and accepted, the immediate jeopardy was abated and the deficiency was assigned a level II pattern. The findings include: On [DATE] at 1:15 p.m. surveyors entered the facility to investigate a two-day complaint. During the course of investigation an immediate jeopardy was called and a substandard review and expanded survey was initiated. Part of the substandard review is to ensure all currently employed CNAs (certified nursing assistants) have registry verification of their certifications. A list of currently employed CNAs was requested on [DATE] at approximately 5:30 p.m. with their employee file. On [DATE] at approximately 9:00 a.m., review of the CNA employee files was conducted. Less than 50 percent of the 79 currently employed CNAs had an up-to-date certification in their employee file. On [DATE] at 10:44 a.m., an interview was conducted with OSM (other staff member) #2, the human resources director. When asked who was responsible for verifying certifications, OSM #2 stated she verified certifications. When asked about the process followed for verifying certifications, OSM #2 stated when a future employee fills out an application, she will decide from the application if they are a good fit for the company. She will then have the applicant come into the facility to introduce them to the DON (Director of Nursing). OSM #2 stated she will then run a background check and if the background check comes out clean, she will run their certification. When asked if there were any other times she would verify certifications, OSM #2 stated she has a computer system (payroll program) that alerts her when an employee's certification needs to be verified. When asked why certifications need to be verified, OSM #2 stated certifications need to be verified to ensure that certifications are not expired and to ensure there are no violations against the certification. When asked where certifications should be filed, OSM #2 stated certifications should be filed in the employee's file. OSM #2 stated she would try to find additional certifications. On [DATE] at approximately 3:00 p.m., OSM #2 handed this writer a stack of certifications that were verified on [DATE]. OSM #2 stated that she had realized that some CNAs had expired certifications in their employee file and she had printed out current certifications from the department of health professions website. OSM #2 stated that if a current certification was not in the employee file or in the stack of paper just given to this writer, then she did not have them. On [DATE] at approximately 3:00 p.m., review of the stack of CNA certifications was conducted. Seventeen out of the 79 currently employed CNAs did not have their certification verified. Seventeen out of the 79 current CNAs had expired certifications in their employee file. The CNAs included CNA #3, CNA #5, CNA #7 and CNA #19 through 32. Review of the as-worked schedule from the past two weeks prior to entrance, revealed that the 17 CNAs identified had been directly working with residents and providing care. On [DATE] at 3:13 p.m., The Office of Licensure and Certification long term care division director was notified of the above findings and concerns. The supervisor confirmed that the facility was in a second immediate jeopardy. On [DATE] at 3:27 p.m., the facility staff (Administrator and DON (Director of Nursing) were notified that the facility was in a second immediate jeopardy starting on [DATE] at 3:13 p.m. The facility staff presented a P(NAME) (plan of correction) on [DATE] at 4:00 p.m. The plan documented the following: 1. Identified C.N.A's certification obtained and placed in the employee file [DATE]. Identified C.N.A's without a current certification removed from the schedule. 2. A quality review of current CNA employee files completed by the Human Resources Coordinator (HRC) to ensure certifications are current and located in the file. CNA's without a current certification to be removed from schedule until a certification is obtained, validated, and placed in their employee file prior to accepting an assignment. 3. HRC re-educated by the Executive director (ED), to ensure C.N.A.'s certifications are current and located in the employee file prior to accepting an assignment. HRC re-educated by the ED to ensure CNAs without a current certification are removed from the schedule until a certification is obtained, validated and placed in their employee file prior to accepting an assignment. 4. HRC/Designee to conduct random quality monitoring of C.N.A employee files 5 times a week for 4 weeks, weekly x 4 weeks then monthly and PRN. Findings to be reported to QAPI committee monthly and updated as indicated. Quality monitoring schedule modified based on findings. Results to be discussed during QAPI. 5. Completion date: [DATE]. On [DATE] at 4:00 p.m., facility staff presented current certification verifications of the identified 17 CNAs. The certifications were printed from the DHP (Department of Health Professions) website on [DATE]. All identified CNA's had a current certification. CNA #3, who was hired on [DATE], had a pending violation against her certification that had not been resolved by the Board of Nursing. The following was documented on CNA #3's certification: Additional public information: YES .YES means that there is information the Department of Health must make available to the public pursuant to 54XXX,[DATE]. G The Code of Virginia; please note that this may also include proceedings in which a finding of no violation was made. On [DATE] at 4:20 p.m., further interview was conducted with OSM #1. When asked the process if she were to verify a CNA's certification and found a YES on their certification indicating that there may be a pending violation against their certification, OSM #1 stated that she would not know what to do at that time. OSM #1 stated that she would go to the DON about the certification. OSM #1 stated that the pending violation may also need to be investigated by the administrator. OSM #1 could not recall a time when a CNA had a pending violation against their certification. On [DATE] at 4:23 p.m. an interview was conducted with ASM (administrative staff member) #2, the DON. When asked the DON about her involvement in the hiring and certification verification process, ASM #2 stated after the application was reviewed by human resources, she would have the applicant come in for an interview and introduce the applicant to the administrator. ASM #2 stated if they liked the applicant, they would run a background check. If the background check was clean, then human resources would verify the certification. ASM #2 stated the administrator would make the final decision to hire an applicant. ASM #2 was not aware of a time where they hired an applicant with a pending violation against their certification. ASM #2 could not recall verifying CNA #3's certification. ASM #2 stated if a CNA had a pending violation, it would be the administrator decision whether the applicant was hired. On [DATE] at 4:44 p.m., an interview was conducted with ASM #1, the administrator. ASM #1 stated that the human resources director was responsible for verifying certifications. When asked why certifications should be verified, ASM #1 stated certifications should be verified to ensure that a certification is current and in good-standing. ASM #1 stated certifications should be checked before her interview with the applicant. ASM #1 stated she cannot interview the applicant without the employee file and a copy of their current certification. ASM #1 stated all CNAs should have a current certification in their employee file. When asked the process if a CNA had a pending violation against their certification, ASM #1 stated her decision to hire an applicant would depend on the violation. ASM #1 stated that if the violation was still pending, she would not hire that person until she found additional information from the Board of Nursing. When asked if she had recently hired a CNA that had a pending violation against their certification, ASM #1 stated, No, not recently. Not at this job at all. When asked what she could recall about hiring CNA #3, ASM #1 stated that she was not aware that CNA #4 had a pending violation against her certification. ASM #1 stated she would suspend CNA #3 until she receives additional information regarding her pending violation from the Board of Nursing. On [DATE] at 5:25 p.m., the Administrator and DON (Director of Nursing) were able to evidence CNA #4 had been suspended until further investigation. The Administrator and DON were able to evidence they removed this CNA from the working schedule dated [DATE] through [DATE]. The P(NAME) (Plan of Correction was accepted) on [DATE] at 5:25 p.m. On [DATE] at approximately 9:30 a.m., ASM (administrative staff member) #2, the DON, stated the human resources director, OSM #2 had walked out of the facility on [DATE] during the middle of survey. ASM #2 presented a revised P(NAME). The following was documented: Removal of Immediacy Plan of Correction- C.N.A licenses- [DATE] 1. Identified C.N.A's certification obtained and placed in the employee file [DATE]. Identified C.N.A's without a current license removed from the schedule. 2. A quality review of current CNA employee files completed by the Assistant Business Office Manager to ensure licenses are current and located in the file. CNA's without a current license to be removed from schedule until a license is obtained, validated, and placed in their employee file prior to accepting an assignment. 3. ABOM (assistant business office manager)/designee re-educated by the Executive director (ED), to ensure C.N.A.'s licenses are current and located in the employee file prior to accepting an assignment. HRC re-educated by the ED (executive director) to ensure CNAs without a current license are removed from the schedule until a license is obtained, validated and placed in their employee file prior to accepting an assignment. 4. ABOM/Designee to conduct random quality monitoring of C.N.A employee files 5 times a week for 4 weeks, weekly x4 weeks then monthly and PRN. Findings to be reported to QAPI committee monthly and updated as indicated. Quality monitoring schedule modified based on findings. Results to be discussed during QAPI. 5. Completion date: [DATE]. On [DATE] at 9:30 a.m., CNA #3's employee file was requested along with her time card from ASM #2. When asked what CNA #3's violation was on her certification, ASM #2 stated her pending violation was from 2013 and that no violation was found. ASM #2 stated the board of nursing had not yet taken the pending violation off the website. ASM #2 stated she could not obtain additional information regarding the violation. ASM #2 stated she had also found two additional CNAs who had pending violations on their certification but they were clear to work. ASM #2 was asked to provide evidence these CNAs had no violations on their certification. ASM #2 stated she would try to get in touch with the department of health professions. Review of CNA#3's employee file revealed she had signed a sworn statement on [DATE], indicating that she had not been convicted of or currently pending charges of murder, abduction for immoral purposes, assaults, robbery, sexual assault, arson, pandering, crimes against nature involving children, taking indecent liberties with children, abuse or neglect with children, failure to secure medical attention for an injured child, obscenity offenses, or abuse or neglect of an incapacitated adult. Further review of her employee file revealed that CNA #3's background check was not run until [DATE] (Over three months after she was hired). CNA #3's background check was clean. Review of CNA #3's time card revealed that she had worked approximately 70 shifts as a CNA providing direct patient care from [DATE] until [DATE] (when CNA #3 was suspended). Further review of the time card revealed that CNA #3 was removed from the schedule on [DATE] and remained off the schedule on [DATE]. Review of an Employee Corrective Action Form for CNA #3, documented the following: Employee was suspended via telephone secondary to violation of level 2 -#30. Employee was told that she cannot clock in or return to work until the investigation is complete. Employee verbalized understanding and stated she had a letter to bring in from the board. Further review of the P(NAME) revealed that the facility had identified two additional CNAs, CNA #10 and CNA #11 who had pending violations on their certifications. 1. CNA #10 was hired on [DATE] and her certification was not verified until [DATE]. CNA #10's background check was not completed until [DATE]. CNA #10's background check was clean. Review of her time card revealed she had worked approximately 73 shifts as a CNA providing direct patient care from [DATE] until [DATE] (when CNA #10 was suspended). Further review of the time card revealed that CNA #10 was removed from the schedule on [DATE] and remained off the schedule on [DATE]. Review of an Employee Corrective Action Form for CNA #10, documented the following: Employee was suspended secondary to level 2 -#30. Employee was informed that she is suspended pending investigation. Employee stated she has a letter at home clearing her. Employee was informed to bring in. Employee comments: I went to the board of nursing for verbal abuse and they cleared it and said I wasn't guilty and cleared me from the verbal abuse and nothing was on my certification. 2. CNA #11 was hired on [DATE] and her certification was not verified until [DATE]. CNA #11's background check was clean and completed in a timely manner. Review of her timecard revealed that she had worked approximately 83 shifts as a CNA providing direct patient care from [DATE] until [DATE] (when she was removed from the schedule). Further review of the time card revealed that CNA #10 was removed from the schedule on [DATE] and remained off the schedule on [DATE]. Review of an Employee Corrective Action Form for CNA #11, documented the following: Employee was suspended secondary to level 2 -#30. Employee was informed that she is suspended pending investigation. Employee stated she has a letter at home clearing her. Employee was informed to bring it in. Employee comments: I went to the state boards for having to put a woman down on the floor from a sit to stand because I went to put the other strap on and the chair moved. And I never had used a sit to stand before and I was told I could hook them up by myself and then go get someone to transfer. On [DATE] at 11:10 a.m., an interview was conducted with OSM (other staff member) #6, the Discipline Specialist for the Virginia Board of Nursing. OSM #6 stated that CNA #3, CNA #10, and CNA #11 had no violation pending on their certification. OSM #6 stated that when a certificationd professional has a pending violation on their certification, an informal conference with the certificationd professional and board of nursing will occur. OSM #6 stated that is when the board of nursing will review the case and decided whether the certificationd professional is guilty of a violation or cleared. OSM #6 stated that all CNAs should have received a letter from the board stating that no violation was found. OSM #6 stated it takes a while for this information to come off the website. When asked the reason for each CNA to be presented to the board, OSM #6 stated, That is not public information. OSM #6 could not give any information of when each CNA was cleared from their pending violation. On [DATE] at 11:31 a.m., an interview was conducted with OSM #7, the assistant business office manager. OSM #7 confirmed education regarding certification verification and the process if a pending violation is found on the certification. On [DATE] at 1:20 p.m., [DATE] at 1:20 p.m., the immediate jeopardy was abated and ASM (administrative staff member) #1, the administrator and ASM #2, the DON were made aware of the abatement. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that staff failed to ensure adequate supervision and an environment free from accident hazards for three of six residents in the survey sample, (Resident #1, Resident #3 and Resident #5). Resident #1 sustained third and second [MEDICAL CONDITION] 1/8/18 to the right side of the face, back of the right hand, chest and left shoulder after becoming unconscious and slumping over onto the PTAC (packaged terminal air conditioner (a wall mounted heating and cooling unit)) model number AZ22EO9D5BM2 in his room. The facility had 37 model number AZ22EO9D5BM2 PTAC units in the facility, accessible to residents with ambient air temperatures sufficient to cause tissue injury, resulting in the identification of immediate jeopardy. 1. On 1/8/18, Resident #1 received third [MEDICAL CONDITION] the right side of his face, the top of his right hand and second [MEDICAL CONDITION] the chest and left shoulder after becoming unconscious and slumping over onto the PTAC (model number AZ22EO9D5BM2) in his room. Resident #1 required transfer to a local hospital for treatment, and admission to the intensive care unit with ten percent total body surface burns. On 1/10/18 the ambient air temperature of the PTCA unit in Resident #1's room was obtained, by OSM (other staff member) #4, the maintenance technician, using a facility laser thermometer, following the unit's temperature being set to high heat. OSM #4 easily set the PTCA unit to high heat and the high heat setting on the PTCA unit was easily accessible to residents to adjust. The temperature was 133 degrees Fahrenheit (F). When the surveyor's held the back of their hands to the unit, within 30 seconds it was too hot to keep the hand on the unit. The facility currently had 37 model number AZ22EO9D5BM2 PTAC units in resident rooms, accessible to residents. Random observation and ambient air temperature checks of PTAC units in resident rooms, revealed PTCA units with ambient air temperatures ranging from 118 to 165 degrees Fahrenheit (F), temperatures sufficient to cause tissue injury, resulting in the identification of immediate jeopardy at a pattern. After receipt and verification of the facility plan of correction, the immediate jeopardy was abated and the deficiency was assigned a level III isolated. 2. The facility staff failed to ensure a safe environment for Resident #3 including even floors as per the comprehensive care plan to prevent falls. Multiple observations of Resident #3's room revealed an entire 12-inch by 12-inch floor tile missing in the middle of the room. 3. The facility staff failed to ensure a safe environment in the resident's bathroom for one of six residents in the survey sample, Resident #5. Observation of Resident #5's bathroom revealed broken and missing tiles. The broken tiles had sharp pointed edges and some tiles pushed into the wall. The findings include: 1. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) a quarterly assessment with an ARD (assessment reference date) of 10/3/17 coded the resident as having three out of 15 on the BIMS (brief interview for mental status) indicating the resident was severely impaired cognitively. The resident was coded as completing activities of daily living independently. Review of the care plan initiated on 8/21/17 and revised on 9/12/17 documented, Focus. (Name of Resident #1) has the potential for injury r/t (related to) Confusion, [MEDICAL CONDITIONS], Psychoactive drug use, poor safety awareness and Wandering AED (as evidence by) a hx (history) of falls. Interventions. The resident needs a safe environment with: (even floors free from spills and/or clutter; adequate glare-free light: a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Review of the physician's notes dated 11/7/17 did not evidence any significant change in Resident #1's condition. Review of the physician's orders [REDACTED]. Review of the nurses' notes from 1/1/18 to 1/7/18 did not evidence any changes in the resident's condition. Review of the SBAR (situation, background, assessment and recommendation) dated 1/8/18. With a time of 8:45 a.m. documented, BACKGROUND Resident Description Primary [DIAGNOSES REDACTED]. Resident Evaluation: 1. Mental Status Evaluation (compared to baseline; check all that you observe) Decreased level of consciousness (sleepy, lethargic) (was checked). Functional Status Evaluation (compared to baseline; check all that you observe) Decrease mobility. Needs more assistance with ADLs (activities of daily living). Weakness (general) (were all checked). 8. Skin Evaluation. Abrasion. Burn. Discoloration Wound (were all checked). Describe symptoms or signs. (R) (right) side of face + (R) hand noted with [MEDICAL CONDITION] (swelling), burn d/t (due to) resident layed (sic) on heater. 10. Neurological Evaluation. Decreased level of consciousness. Weakness or [MEDICAL CONDITION] (were all checked). APPEARANCE Summarize your observations and evaluations. Resident appeared to [MEDICAL CONDITION] (R) side of face + (R) hand also appeared to have had a stroke very weak + lethargic (with) yellow drainage to face. Review of the skin evaluation form dated 1/8/18 documented, Blister - (R) eye/ (R) forehead/ (R) cheek - (L) 3 (sic) or 4th finger - (R) top of hand - Reddened areas - under (R) chest wall. Open area - sacrum - unable to assess (L) side of body due to arrival of EMS (emergency medical service) + difficulty (with) positioning. Review of Resident #1's emergency department visit dated 1/8/18 at 9:12 a.m. documented in part, History of Present Illness. The patient presents with major trauma. The onset was just prior to arrival. The course of symptoms is constant. Type of injury: burn. The location where the incident occurred was at home. The character of symptoms is redness and swelling. Associated symptoms: altered level of consciousness. 57 y.o. (year old) DNR (do not resuscitate) male with PMHx (prior medical history) [MEDICAL CONDITION], TBI who presented to the ED (emergency department) via EMS as DELTA TTA (trauma team activation) after being found asleep laying on top of a heater for unknown length of time. Noted to have 3rd [MEDICAL CONDITION](1)[MEDICAL CONDITION] R (right) side of face and back of R hand, 2nd (2) [MEDICAL CONDITION] chest and L (left) shoulder. R eye is swollen shut. Estimate 10% TBSA (total burn surface area) affected. Review of the hospital's admission history and physical dated 1/8/18 documented, HISTORY OF PRESENT ILLNESS: The patient is a [AGE] year-old patient at a nursing home who was found over a space heater. He was responsive to questions by blinking. PHYSICAL EXAMINATION: His vital signs on arrival here are blood pressure 106/81(3), heart rate of 140 (4), respiratory rate of 27 (5), O2 (oxygen) sat (saturation) 94% (6) on a non-rebreather (7) .The right pupil is obscured due to significant [MEDICAL CONDITION] around the right orbit with inability to open the eye. The left pupil is 4 mm (millimeters) and reactive The right side of the face has blistering around the orbit and maxilla (8) .There is a small blister of 2x3 cm (centimeter) along the right lower chest. He has blistering over the right dorsal (9) hand wrapping around to the hypothenar eminence (10) with some surrounding [DIAGNOSES REDACTED] (redness). Review of the nurse's notes dated 1/8/18 at 4:20 p.m. documented, Aide informed nurse to come to room to check on resident because she observed resident lying on heater (R) (right) side of face + (and) hand was on heater noted yellow drainage coming from hand, this nurse came in to room to assess resident called residents (sic) name (no) answer observed (R) side of face + (R) hand swollen + discolored yellow substance appeared to be coming from face. (R) side weak noted leaning to that side resident transferred to bed, cleaned up vs (vital signs) obtained 90/86 (blood pressure) - 116 (pulse) - 18 (respirations) - 104 (temperature). O (sic) (oxygen) - 93% on 2 L (liters) O2 (oxygen) 911 called EMT (emergency medical transport) arrived resident to (name of hospital) MD (medical doctor) aware at this time RP (responsible party) notified, prior to incident this AM @ approx (at approximately) 815 AM (8:15 a.m.), this writer observed resident sitting in chair by heater + appeared sleep (sic) @ approx 445 AM (4:45 a.m.) did not appear to be in any distress @ the time, talked (with) RP in regards to residents (sic) condition RP states she is aware that resident has had a decline, states hospital is trying to rule out bleeding of brain and or stroke will keep us updated + will be in town tonight but will go to hospital to see resident in AM. Review of the PTAC vendor's letter to the facility dated 1/9/18 documented in part, (Name of vendor company) was asked to check out GE (General Electric) PTAC Model #AZ22EO9D5BM2 in room [ROOM NUMBER] (Resident #1's room number). The unit was thoroughly checked out and found to be in good working order to the GE (General Electric) Manufacturer Specifications. (Name of vendor company) is an authorized servicer for Amana PTAC Units, but we also service all other brands of PTAC units. A facility tour was conducted on 1/10/18 at 1:15 p.m. by five surveyors. Each resident room was entered. During the tour, there were two different types of PTACs observed. An old model unit (model #AZ22EO9D5BM2) with a plastic grill on the front with 1 to 1 and 1/2 inch openings with a wire mesh behind the grill. There were two dials on the unit. The right dial had markings for High heat, low heat, stop, low fan, high fan, low cool, high cool. The left dial had markings for, High heat when the dial was turned all the way to the left and High cool when turned all the way to the right. The dials on the PTAC unit were easily turned and accessible to residents to adjust temperature settings. The other newer model had a digital display and the plastic grill openings were one inch wide. No portable space heaters were found in any resident rooms. An observation of Resident #1's room was made on 1/10/18 at 2:45 p.m. with OSM (other staff member) #4, the maintenance technician. There were no other residents in the room. Resident #1's bed was against the left wall. There was a red nylon camping chair sitting in front of the PTAC unit. OSM #4 was asked to turn the PTAC unit onto high heat and to check the PTAC unit's surface temperature. OSM #4 adjusted the unit dial easily to high heat and obtained the temperature with a facility laser [MEDICAL CONDITION] thermometer. The door to the resident's room was closed and the temperature was checked. The surface temperature of the unit registered 133 degrees. The resident's room door was opened as was the resident's practice and the surface temperature of the unit was rechecked. The temperature was 133 degrees F. When the surveyor's held the back of their hands to the unit, within 30 seconds it was too hot to keep the hands on the unit. When OSM #4 was asked to check the heat coming from the unit with his hand, OSM #4 did not have a response. When asked what the thermostat was set at on the unit, OSM #4 stated, I would have to look it up. OSM #4 stated the (PTAC) vendor had been in and said that the unit was operating correctly. When asked how many different types of PTAC units the facility had, OSM #4 stated that there were two types and that as the older units (as in Resident #1's room) broke down the newer digital units were put in place. When asked how many of the older units were still in use in resident rooms in the facility, OSM #4 stated he thought there were 24 of the old units remaining. An interview was conducted on 1/10/18 at 2:55 p.m. with OSM #3, the director of maintenance and ASM (administrative staff member) #1, the administrator. When asked how often preventative maintenance was done on the PTAC units, OSM #3 stated, They're cleaned once a month. We don't physically service them. When they break we replace them. When asked to check the heat on the surface of the unit with their hands and to check the temperature of the wire mesh behind the grill, ASM #1 stated, Yeah, you can get your hand in the slot there. ASM #1 agreed that the wire mesh was hot to the touch. When asked what the maximum temperature from the unit should be, OSM #3 stated, We talked to the vendor. He said it should be 120 degrees F. A surface temperature check was then made with the laser [MEDICAL CONDITION] thermometer on a digital PTAC unit. The unit was turned to the maximum 90 degrees and allowed to run with the resident room door closed for approximately five minutes. The surface temperature check was 90 degrees. The grill to the unit was warm to the touch. When asked how many of the older units were in the facility, OSM #3 stated there were 37. A telephone interview was conducted on 1/10/18 at 3:09 p.m. with OSM # 5, the PTAC vendor. OSM #5 stated he had checked the unit in Resident #1's room on 1/9/18. OSM #5 stated the unit was operating correctly and that the temperature coming out of the unit was 123 degrees F when he checked it. When told informed of the units 133-degree F surface temperature obtained by OSM #3 earlier this day, OSM #5 stated, The laser is picking up heat on the surface. The thermostat will shut off at 136 degrees. When asked if a steak would cook on the surface of the PTAC unit with this temperature, OSM #5 stated it would but it would take hours. When asked if skin would burn if it came in contact with the PTAC unit's grill, OSM #5 stated, I just told you steak would cook. On 1/10/18 at 3:15 p.m., the facility's investigation for the incident with Resident #1 was requested from ASM #8, Regional Director of Clinical Services. The investigation was received at 3:25 p.m. and included a four-point plan of correction. Review of the 1/8/18 investigation documented in part: 1/7/2018-10 p.m.-Resident accepted and tolerated medication. 1/8/2018- 2 a.m. - Resident was observed sitting up in chair with eyes closed. 1/8/2018- 3:30 a.m.- Resident was observed sitting up in chair with eyes closed. 1/8/2018- 5:30 a.m. - Resident observed sitting up in chair with eyes close. Resident alert and responsive and accepted medications as indicated. 11(sic)/8/2018- 4:45 a.m.-Resident observed sitting in chair beside heater with eyes closed. 11(sic)/8/2018- 8-8;( sic) 15 am alerted by CNA (certified nursing assistant) #6 to come to room to see about patient. 1/8/2018 8:26 a.m. - RN (registered nurse) asked to assess resident and it is a 911 . Review of the four-point plan of correction revealed the plan was incomplete and did not mitigate the concern for immediate jeopardy. The four-point plan of correction provided documented, A complete review has been done on all the PTAC in current resident rooms to ensure they are in proper working order. Education has been provided to current residents in the facility on the importance of not being in close proximity of the PTAC when in heat mode. The plan did not address how the PTAC unit's temperatures would be controlled to prevent [MEDICAL CONDITION] other residents. In addition, only twenty-three residents had signed that they had received education. On 1/10/18 at 4:37 p.m. the supervisors at the Virginia Department of Health, Office of Licensure and Certification (OLC) were contacted regarding Resident #1's second and third [MEDICAL CONDITION] from the older model PTAC unit and the concern for Immediate Jeopardy as a result of older model PTAC units being accessible to residents with temperatures sufficient to cause tissue injury, third and second degree burns. After a discussion, OLC Supervisors agreed with the Immediate Jeopardy assessment. On 1/10/18 at 4:40 p.m. ASM #1, the administrator, ASM #2 the director of nursing and ASM #8 were made aware of the above concern of Resident #1 having sustained second and third degree burn injuries on an older model PTAC unit, and the concern of older model PTAC units, being accessible to residents with ambient temperatures sufficient to cause tissue injury, resulting in Immediate Jeopardy. ASM #1, ASM #2 and ASM #8 were made aware that the Immediate Jeopardy started on 1/8/18 at 8:25 a.m. when Resident #1 was found unconscious [MEDICAL CONDITION] the face, chest and hands. All agreed that although the unit (in Resident #1's room) had been checked by the PTAC vendor and found to be working correctly the issue was the temperature of the surface of the unit leading to the risk [MEDICAL CONDITION] other residents, creating an unsafe environment. Random PTAC unit checks were conducted on 1/10/18 starting at 4:51 p.m. with OSM #3 and another surveyor. At 4:51 p.m., in room [ROOM NUMBER], upon entering room, The PTAC unit heat was on almost all the way on high heat. OSM #3 obtained the ambient air temperature coming from the unit with a facility infrared/laser temperature reader. When asked if the thermometer had been calibrated, OSM stated it had been. The temperature reading was 133 degrees F. The temperature on the unit was turned up all the way. At 4:55 p.m., the temperature reading after 4 minutes on high was fluctuating between 135 and 140 degrees F. 4:57 p.m., in room [ROOM NUMBER], the PTAC unit heat was on high upon entering the room. The ambient air temperature coming from the unit was tested by OSM #3 using the facility infrared/laser temperature reader. The temperature reading on the thermometer was fluctuating between 144 and 150 degrees F. 5:07 p.m., in room [ROOM NUMBER], upon entering the room, the PTAC heat was turned off. OSM #3, the maintenance director turned the heat up to high at 5:08 pm. At 5:10 p.m., the ambient air temperature coming from the unit was tested by OSM #3 using the infrared/laser temperature reader. The temperature reading was 146 degrees F. 5:11 p.m., in room [ROOM NUMBER], upon entering the room, the PTAC heat was running on high. The ambient air temperature coming from the unit was tested by OSM #3 with the facility infrared/laser temperature reader. The temperature was 165 degrees F. 5:15 p.m., in room [ROOM NUMBER], upon entering the room, the PTAC heating unit was off, OSM #3 the maintenance director, was not able to get the unit to turn on. The PTAC unit was not functioning. 5:19 p.m., in room [ROOM NUMBER], upon entering the room, the PTAC unit was off., OSM #3 the maintenance director, turned the PTAC heat to high. At 5:22 p.m., OSM #3 tested the ambient air temperature coming from the unit with the facility infrared/laser temperature reader. The temperature was 150 degrees F. 5:26 p.m., in room [ROOM NUMBER], upon entering the room, the PTAC unit was off., OSM #3 the maintenance director, turned the PTAC heat to high at 5:27 p.m. At 5:31 p.m., OSM #3 tested the ambient air temperature coming from the unit with the facility infrared/laser temperature reader. The temperature was 132 degrees F. 5:32 p.m., in room [ROOM NUMBER], on entering the room the PTAC unit was running on low fan, no heat. Ambient air temperature coming from the unit was tested by OSM #3 with the facility infrared/laser temperature reader. The temperature was 73 degrees F. OSM #3 turned the heat to high at 5:32 p.m. At 5:35 p.m., the temperature reading was 118 degrees F. At 5:36 p.m., the temperature reading was 130 degrees F. An additional observation was made of Resident #1's unit with another surveyor on 1/10/18 at approximately 5:15 p.m. The red nylon camper chair was measured to be 14 and 1/2 inches off the floor. The seat of the chair came up to the bottom of the grill on the unit. When Resident #1 was sitting in the chair next to the heater and when he slumped over, his cheek would be directly over the grill. The grill on the PTAC unit was observed to contain four fixed sections ranging from one to one and one half inches wide. There was a dried yellow substance on the left lower grill of the unit. The surveyors were able to touch the wire mesh with their fingertips through the grill. The unit was placed on high heat and high fan settings. The surveyors could not hold the back of their hands to the unit for longer than 30 seconds before the unit was too hot to touch. An interview was conducted on 1/10/18 at 5:30 p.m. with CNA (certified nursing assistant) #9, an aide who worked with Resident #1. CNA #9 was asked to enter Resident #1's room and to touch the unit's grill and the wire mesh. CNA #9 stated, Yeah, it's hot. When asked what room temperature the resident liked, CNA #9 stated, The (Resident #1 and the roommate) loved to keep it warm. It's actually a little cooler than normal. On 1/10/18 at 8:45 p.m., a request was made from ASM #1 to have the surveyors come to Resident #1's room. ASM #1, the administrator, ASM #2, the director of nursing, ASM #8, the regional director of clinical services, ASM #7, the corporate director of nursing services, ASM #6, the regional director of maintenance, OSM #3, the director of maintenance and OSM #5, the PTAC vendor were all present. ASM #6, the corporate director of maintenance stated, We've adjusted the temperature so the residents can't put it on high. OSM #5, the PTAC vendor stated, That laser thermometer must have measured the element temperature. OSM #5 was asked to measure the unit's surface temperature with his equipment. The temperature registered at 136 degrees F. When asked what the room temperature was, OSM #5 stated, About 90 degrees. When asked when the heater would turn off OSM #5 stated, It'll turn off when the room gets to temperature but with the door open it's going to keep running. OSM #5 asked OSM #3 if the laser thermometer had been calibrated, OSM #3 stated yes. When asked if the surface temperature of the unit would remain as hot, OSM #5 stated, The internal coil will shut down at 136 degrees. All present were asked to check the unit's grill. ASM #1 and ASM #8 and two surveyors all agreed that the unit felt hot to the touch. OSM #5 then lowered the unit's temperature again by placing a metal peg under the temperature dial preventing the dial from being turned to the high heat setting. OSM #5 stated, It's set for 72 to 74 degrees. A recheck of the unit's surface temperature by OSM #5, three minutes later showed the temperature to range between 77.4 degrees to 104 degrees F. On 1/10/18 at 9:51 p.m., ASM #1 provided a four-point plan of correction that documented the following: 1. Resident found slumped over PTAC unit at approximately 8:25 am. The Resident was provided treatment and sent to the ER (emergency room ) for further evaluation and treatment. The PTAC unit was locked out and tagged out and place out of use pending an outside vendor's inspection. The resident's roommate was voluntarily moved to another room pending PTAC's inspection. 2. A quality review of identified PTAC Units in resident rooms completed by a certified outside vendor on 1/10/18. Identified PTAC units mechanical thermostat stop adjusted to the lowest position in order to prevent the thermostat from allowing the air to rise to a higher unsafe temperature ensuring resident's safety. 3. Education provided to the Maintenance Director, IDT (interdisciplinary team) and facility staff on the importance of ensuring resident safety while in PTAC is in use in heat mode and maintaining the mechanical thermostat in the lowest position in order to prevent the air from rising to a higher unsafe temperature. Education provided to the residents in the facility on the risks of injury when using the PTAC system while in heat mode. During the months of January, February, and March residents to be re-educated at Resident Council of risks of injury when using PTAC units in heat mode. 4. The Maintenance Director/designee to complete quality monitoring 5 times a week for 4 week, weekly x4 weeks then monthly and PRN (as needed) to ensure PTAC units mechanical thermostat stop adjusted to the lowest position in order to prevent the air from rising to a higher unsafe temperature ensuring residents safety. Quality monitoring schedule to be modified based on findings. -Results to be discussed during QAPI (quality assessment plan and improvement). -Completion date: 1/10/2018. On 1/11/18 at 8:15 a.m., a repeat request for the PTAC unit manufacturer's manual to was made to ASM #1, the administrator. On 1/11/18 at 8:30 a.m., the manufacturer's manual was received. Review of the manual did not document information regarding the surface temperature of the unit. An interview was conducted on 1/11/18 at 8:48 a.m. with CNA (certified nursing assistant) #6, Resident #1's aide on 1/8/18. When asked what routine staff follow when they come on duty, CNA #6 stated, I get report and I go walk down the hall. I visualize the residents and start my day. When asked what occurred on 1/8/18, CNA #6 stated, I visualized (name of Resident #1) sitting by the heater (PTAC) but that's normal for him. That was about seven-ish. When asked Resident #1's position in the chair, CNA #6 stated, He was slumped over with his right arm across the chair arm touching the floor by the heater. When asked if that was an unusual position for Resident #1, CNA #6 stated, No. It wasn't unusual to see him in all sorts of unusual positions. Sometimes he slept with his head off the side of the bed or he'd sleep on the floor. When asked if Resident #1 was resting his head on the heater, CNA #6 stated, I couldn't tell that his face was on the heater. I thought he was asleep because when I brought his breakfast in I said, '(Name of Resident #1) you have to eat your cheerios and drink your coffee' and when I straightened him up that's when I saw his hand and face. When asked what time the breakfast was brought in, CNA #6 stated, Around 8:15 (a.m.). When asked what she saw, CNA #6 stated, I see this gigantic blister on his hand. When asked about Resident #1's face, CNA #6 stated, At that point I didn't (see his face) because I'm standing behind him in the chair. When asked what she did next, CNA #6 stated, I flew out, went, and got the nurse. I told the nurse 'you got to see (name of Resident #1) he's got a blister on his hand. It's the size of a grapefruit.' When asked what happened after next, CNA #6 stated, The nurse came in. We straightened him up and then we saw the right side of his face was swollen and there was dried yellow substance along the side of his face and mouth and nose. When asked if Resident #1 was responsive, CNA #6 stated, He was sorta kinda unresponsive. When asked about the temperature in the room, CNA #6 stated, He loved that room boiling hot. When asked if she had ever touched the heater in the room, CNA #6 stated, No. I didn't think they'd get that hot to burn. When asked if she had received any education since the incident, CNA #6 stated, We had an in-service on rounding. Make sure you do your rounds and it may have been prevented if someone had done their rounds. Keep the residents and their belongings off the heaters. On 1/11/18 at 9:08 a.m., a tour of the facility was conducted with the OSM #3, the director of maintenance. Each of the 37 rooms that was utilizing the old PTAC heating unit was checked. For each room, upon entering, if the unit was off, the OSM #3 turned it on. Then a period of 1 to 2 minutes was allowed to pass and then the temperature was checked by OSM #3. If the unit was already on and running upon entering the room per resident preference, the temperature was checked immediately. The ambient temperatures of the air coming from the PTAC unit was obtained with the same infrared laser temperature reader previously used. The temperature range of PTAC units was 63 degrees to 157 degrees F, depending on if the unit had already been running and was up to temperature, or had to be turned on from cold. In every case, the PTAC units turned off automatically after the unit ran for approximately 1 to 3 minutes. The surface temperature of the PTAC units did not get too hot to touch at any time. An interview was conducted with two residents on 1/11/18 between 9:40 a.m. and 9:45 a.m. When asked if they had received education regarding the heaters under the windows in their rooms in the past few days, both residents stated they had not had any education, though their names were listed on the education sign off sheet. The one resident stated, no, I am blind. When asked if they had spoken to him about his heating unit, the resident emphatically stated, No. Both resident had a BIMS (brief interview for mental status) score of 15 indicating they were cognitively intact to make daily decisions. On 1/11/18 at 10:15 p.m., a telephone conversation was held with OLC supervisor. The supervisor was updated regarding the facility staff education and that there was no definition of which residents were to be educated. A decision was made to have the facility update the plan of corrections at that time. On 1/11/18 at 10:25 a.m., ASM #1 and ASM #7 were made aware of the need to clearly state when facility staff would be educated and which residents were appropriate to be educated. ASM #1 and ASM #7 were made aware that two residents who had signed the education form that they had been educated about the PTAC units, stated they were not educated. An interview was conducted on 1/11/18 at approximately 9:45 a.m. with RN (registered nurse) #1, Resident #1's nurse on 1/8/18. When asked what had occurred on 1/8/18, RN #1 stated she was the night shift supervisor that night. RN #1 stated, I went in there and I seen him (Resident #1) sitting in his chair with his head down towards his chest and his arms were on the arms of the chair. When asked what time that was, RN #1 stated, That was about 4:45-ish (a.m.). When asked if there was anything unusual about Resident #1 at that time, RN #1 stated, No ma'am, not at all. He always liked to be in the heat and he liked to sit next to the heater. When asked what happened then, RN #1 stated, The aide called me into the room. She said she gave him (Resident #1) his tray and that when he was sat up he was not responding. When asked what she did next, RN #1 stated she had gone into the room and that she noted a yellow substance on the resident's face and hand and that substance was on the heater. When asked what she thought the yellow substance was from, RN #1 stated, I think it was fluid from his skin. It didn't seem like it was coming from his mouth. When asked how she thought Resident #1 sustained the blister to his hand, RN #1 stated she did not know. When asked how Resident #1 looked, RN #1 stated, It looked like he might have had a stroke because he was weak on that (the right) side. When asked if she was his nurse at the time the aide came to get her, RN #1 stated she was. When asked if she had seen Resident #1 since 4:45 a.m. RN #1 stated she had not. When asked what information she received in report about the resident that day, RN #1 stated, I hadn't seen him for about a year. They told me he was himself and he was sleeping in the chair. An interview was conducted on 1/11/18 at 10:30 a.m. with LPN (licensed practical nurse) #4, the resident's night nurse. When asked what routine staff follow when they arrive on duty, LPN #4 stated, I started my shift about 5:30 (p.m.) to six o'clock. I counted out my cart (checked the medications) and I made rounds on all my residents. When asked when she had seen Resident #1 on her shift, LPN #4 stated, I saw (name of Resident #1) a couple times. When asked what the resident was doing, LPN #4 stated, At nine p.m. he was sitting straight up (in the chair) with his arms folded. His baseline at night is that he's up and down. He never sleeps. When asked when was the last time she saw Resident #1 prior to going home, LPN #4 stated, It was around 5:30 (a.m.) I was just passing the room. I said 'Hey (name of Resident #1) you want to go to bed? He said, no leave me alone'. When asked where Resident #1 was at that time, LPN #4 stated he was sitting in his chair next to the heater. LPN #4 was asked what staff should do if they notice a res (TRUNCATED)

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide adequate supervision and implement interventions to prevent a fall with major injury for one of 15 residents in the survey sample, Resident #10. Resident #10 sustained a fall on [DATE] at approximately 11:30 a.m. No new interventions were implemented to prevent further falls and on [DATE] at approximately 1:30 a.m., Resident #10 fell again and sustained extensive bleeding into her brain. The findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a significant change assessment, with ARD (assessment reference date) [DATE], she was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). She was coded as being independent with setup help only from staff for bed mobility, transfers, walking on and off the unit, dressing, eating, toileting and personal hygiene. She was coded as always continent of both bowel and bladder. She was coded as having experienced no falls during the look back period. She was coded as being steady at all times when walking and moving from a seated to a standing position. She was coded as receiving hospice services. A review of the facility fall risk assessment on admission ([DATE]) for Resident #6 revealed a score of 11. According to the assessment form: Total score of 10 or above deems resident at risk. A review of the facility fall risk assessment form dated [DATE] revealed a score of seven. A review of the clinical record for Resident #10 revealed the following order, written [DATE]: Morphine (1) 20 mg/ml (milligrams per milliliter) 0.25 ml SL (sublingual (under the tongue)) q 12H (every 12 hours) scheduled for pain, anxiety. Lorazepam (Ativan) (2) 2 mg/ml 0.25 ml SL q12H scheduled. A review of the MARs (medication administration records) for the resident revealed that these medications were administered as ordered. A review of Resident #10's clinical record revealed an SBAR (Situation Background Assessment Recommendation) dated [DATE] at 11:30 a.m. and completed by LPN (licensed practical nurse) #2 which documented, in part, the following: Situation: The change in condition, symptoms, or signs observed and evaluated is/are: Fall, found on floor .Functional Status Evaluation: Falls. Describe symptoms or signs: Found on floor in sitting position, no apparent injury .Nursing Notes: Resident found on floor by staff in sitting position, Resident stated she was going to restroom, no apparent injury .Interventions: Toilet q2h (every two hour) program. A review of the facility document entitled Fall Root Cause Investigation Report revealed, in part, the following: Locomotion Status: Ambulatory Unusual circumstances past 24 hours contributing to fall risks: Morphine and Ativan given. Toileting: Last time toileted: Continent .What activity, event, environment, etc. was resident engaged in prior to the fall or at the time of fall: Ambulating .New Medications: Morphine/Ativan. Date started: [DATE]. Last dose taken [DATE] 8 am (8:00 a.m.). Narcotic. Hypnotic. Other Factors: Gait disturbance Other contributing factors: Resident lost balance during ambulating. Resident received Morphine and Ativan at 8 am .Summary: Resident was found in sitting position on floor by staff. Resident stated she was going to restroom. Resolution/Intervention for minimizing future occurrences: Toilet program q2hours, assist resident with ambulating. A review of the comprehensive care plan for Resident #10 dated [DATE] revealed no updates or interventions related to this fall. A review of the nurses' notes revealed no evidence of q2h toileting or of staff assisting the resident with walking. A review of a nurse's note dated [DATE] at 2:00 a.m. revealed, in part, the following: Pt (patient) was observed lying on hallway floor. Lying on right side with right (arm) underneath her. Right hematoma (bruise) observed with bleeding. Applied pressure to head. Initiated neuro (neurological) checks. EMS (emergency medical services) called out. A review of the progress notes for Resident #10 from a local hospital dated [DATE] revealed, in part, the following: Caucasian female who presents with fall this evening. Patient has dementia .Per EMS report patient was wondering (sic) around and had a ground level fall. Patient was laying (sic) on the ground by the time EMS arrived on scene. Patient was brought to the ED (emergency department). Her work up in ED showed she has bilateral (both sides) frontal subarachnoid hemorrhage (3) with small left-sided subdural hematoma (4) and right occipital (lower back lobe of the brain) parenchymal hemorrhage (5) on CT (computed tomography) brain .Pt with dx (diagnosis) of malnutrition for hospice .T/C (telephone call) to daughter .who states that the plan .was for pt (patient) to remain in the hospital for 24 hours for observation without any treatment except for comfort and not to be admitted to ICU (intensive care unit). Daughter wants her mother to be 'comfortable and safe.' Hospice will resume care once pt returns to (name of facility). Further review of Resident #10's clinical record revealed that she returned to the facility on [DATE] at approximately 3:00 p.m. and expired at the facility on [DATE]. On [DATE] at 9:20 a.m., LPN #13 was interviewed regarding the care of Resident #10 on [DATE] and [DATE]. She stated: I wasn't assigned to her - I was working the other end of the hall. I was working the day shift (on [DATE]). She stated that the resident had started to decline in the last few weeks due to her [DIAGNOSES REDACTED] and dementia. She stated that the resident was put on hospice services, and was given Morphine and Ativan for her comfort. She stated: The daughter pushed for her to be put on scheduled (Morphine and Ativan). But she (Resident #10) was still ambulatory. It made her gait more unsteady. Then add those meds (medications) and she was at a higher fall risk. She stated that she was working when the resident fell on [DATE], and that the resident fell again the next day, and was sent to the hospital. On [DATE] at 9:50 a.m., LPN #14 was interviewed regarding the care of Resident #10 on [DATE] and [DATE]. She stated: I know I was on the schedule that day, but I remember very little, if anything. She stated: I don't remember her fall in detail, or what happened, or what we did. I just remember who she was as a person. On [DATE] at 10:00 a.m., LPN #8 was interviewed regarding the care of Resident #10 on [DATE] and [DATE]. While she was on the schedule as having taken care of Resident #10 on these days, she stated she had no memory of the resident. On [DATE] at 1:40 p.m., LPN #2 was interviewed regarding the care of Resident #10 on [DATE] and [DATE]. She stated: I can only go by what I wrote on my SBAR. She stated she did not have anything to add to her documentation, as described above. When asked if she placed the interventions on the resident's care plan, she stated: I'm not sure. When asked if she informed any other staff members about the need to offer Resident #10 assistance with toileting every two hours, and assistance with ambulating, she stated: I'm not sure. When asked who is responsible for implementing immediate interventions to prevent further falls, she stated: I'm not sure. Maybe the unit managers. On [DATE] at 2:25 p.m., LPN #13 was interviewed regarding the updating of care plans and implementing interventions to prevent further falls. She stated: The unit manager or administration decide what needs to be done. I have not ever updated a care plan as a floor nurse. On [DATE] at 2:35 p.m., LPN #12, a unit manager, was interviewed regarding the process to be followed when a resident falls. She stated that the nurse should fill out an SBAR and a fall packet. She stated the fall packet includes a root cause investigation form. She stated that the nurse should perform a head to toe assessment, range of motion assessment and institute neuro checks if the fall was unwitnessed, or if the resident was observed to hit his/her head. She stated that the floor nurse or the unit manager should come up with an immediate intervention to try to prevent further falls. She stated that this intervention(s) should be placed on the care plan and that staff members should be informed. On [DATE] at 6:00 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services (DCS), ASM #3, the assistant director of clinical services (ADCS) and ASM #4, the regional DCS, were informed of these concerns. The administrative team was asked to provide evidence of implemented interventions to attempt to prevent further falls for Resident #10 after her fall on [DATE]. On [DATE] at 8:35 a.m., ASM #3 provided this surveyor a document from Resident #10's clinical record entitled Resident Safety Check. It was dated [DATE] and contained staff initials every 15 minutes from 7:00 a.m. until 2:45 p.m. The document contained no staff initials from 3:00 p.m. until 10:45 p.m. ASM #3 also gave the surveyor a Resident Safety Check form for Resident #10 dated [DATE]. It contained no staff initials from 11:00 p.m. (on [DATE]) through 6:45 a.m. (on [DATE]). When asked if these forms provided credible evidence that Resident #10 was supervised, offered every two hour toileting and offered assistance with walking between the times of her falls on [DATE] and [DATE], she stated: No. They do not. I do not have anything else to give you. On [DATE] at 9:22 a.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services (DCS), ASM #3, the assistant director of clinical services (ADCS) and ASM #4, the regional DCS, were informed of these concerns. They were informed of the concern for harm; as no new interventions were put in place/implemented to prevent further falls after Resident #10 had sustained a fall on [DATE]. ASM #2 stated: We were supposed to put the toileting program in place and do a review of her meds (medications). That's what we talked about in the fall committee meeting we had after she fell . When asked what the facility staff did immediately after the fall on [DATE] to prevent further falls, ASM #2 stated: Nothing that we can show. On [DATE] at 10:10 a.m., CNA (certified nursing assistant) #10 was interviewed regarding what she was told by the nurse regarding caring for Resident #10 on [DATE]. She stated: I was not here when she fell the second time. She stated: I had heard (on [DATE]) that she'd had a fall, but that was it. I wasn't told to do anything different. On [DATE] at 10:15 a.m., CNA #11 was interviewed regarding what she was told by the nurse regarding caring for Resident #10 on [DATE]. She stated: I don't remember anything specific. I know she'd had some falls maybe. And that she was on hospice. That's all I really needed to know. A review of the facility policy entitled Fall Checklist revealed, in part, the following: Initiate appropriate interventions to reduce risk. Care plan updated. Document identified risk and intervention(s) in the resident's plan of care. No further information was provided prior to exit. In Fundamentals of Nursing, 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates. (1) Morphine is used to relieve moderate to severe pain. Morphine extended-release tablets and capsules are only used to relieve severe (around-the-clock) pain that cannot be controlled by the use of other pain medications. Morphine extended-release tablets and capsules should not be used to treat pain that can be controlled by medication that is taken as needed. Morphine is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. This information is taken from the National Institutes of Health website https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 3.html. (2) Lorazepam is used to relieve anxiety. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information is taken from the National Institutes of Health website https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 3.html. (3) Subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space. This information is taken from the National Institutes of Health website https://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm. (4) A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. A subdural hematoma is usually the result of a serious head injury. When it occurs this way, it is called an acute subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death. This information is taken from the National Institutes of Health website https://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm. (5) The bleeding into the tissue of the brain and especially of the cerebrum from a ruptured blood vessel. This information is taken from the National Institutes of Health website <https://ghr.nlm.nih.gov/glossary=cerebralhemispherehemorrhage>

Based on staff interview, a complaint investigation, clinical record review and facility document review it was determined the facility staff failed to provide social services to maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 7 sampled residents (Resident #5). On [DATE] after discussion with the physician, Resident #5's power of attorney (POA) decided the resident's code status was, do not resuscitate (DNR). On [DATE] after discussion with the social worker, the resident's POA changed Resident #5's code status from DNR to undecided. The social worker did not inform the physician and other facility staff members of the change in the resident's health care choices. The resident's code status remained DNR. Resident #5 was found unresponsive on [DATE] at 4:52 AM. Resident #5 did not receive CPR and expired. The findings include: Resident #5's clinical record was reviewed as a closed record. Resident #5 was an [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Her 30 day Minimum Data Set assessment dated [DATE] stated she usually understood others and was sometimes understood by others. Her summary score for the Brief Interview for Mental Status was 3 out of a possible 15, indicating she had severe cognitive impairment. Clinical record review revealed a document titled Power of Attorney and signed on [DATE] indicating the resident's cousin was her POA. A physician's progress note, dated [DATE] stated the resident's POA was the only relative involved in her care. The note stated the physician discussed end of life issues with the POA. The note documented the POA requested a DNR status, which would be honored. The note documented the POA would be in to sign the papers the next week. On [DATE], the physician signed the Durable Do Not Resuscitate (DDNR) Order form. The form was checked in the boxes, which said "...2. The patient is incapable of making an informed decision about providing, withholding or withdrawing a specific medical treatment or course of a medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision...C. The patient has not executed a written advanced directive (living will or durable power of attorney for health care). (Signature of "Person Authorized to Consent on the Patient's behalf' (sic) is required; see reverse)..." The form was not signed by the POA. A physician's orders [REDACTED]. The Initial Social Service History and Social Progress Note, dated [DATE] did not mention the resident's code status. Her care plan, dated [DATE] documented the resident's code status was DNR. The goal was the "Resident will have Advanced Directives followed as evidenced by: DNR". There were several approaches including "Discuss Advanced Directives with Resident and or Family...Honor Resident's/family's wishes..." The target date was [DATE]. The care plan was not updated, indicating it was not changed. The Care Conference Record stated a meeting, which Social Worker (SW) #1 attended, was held on [DATE]. The Social Progress Note, dated [DATE] and signed by SW #1 stated the resident and her POA were invited to attend the care plan meeting, but neither attended. The note stated the facility staff would continue to monitor and provide support. The note did not refer to the resident's code status. Clinical record review revealed a facility document titled Advanced Directive Discussion Document, dated [DATE] and signed by the POA and SW #1. The document stated "The purpose of this document is to obtain information regarding your wishes on specific life support decisions you may have made, advanced directives and/or substitute decision makers you may have appointed to speak for you. In addition, this facility wished to inform you that you have a right to make decisions regarding your medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. Listed below are three particular type (sic) of life support systems. Please indicate your feelings regarding the following: Cardiopulmonary Resuscitation...Artificial Respiration (including respirator)...Artificial means of providing nutrition or hydration..." There were X's in the column titled Undecided for all 3 life support systems listed above. Under the section, which stated "Please indicate if you possess any of the following documents or have (sic) substitute decision-maker" the word "yes" was written next to living will and durable POA. There was no evidence in the clinical record, such as a social work note, a nurse's note, a physician's progress note or a physician's orders [REDACTED].#5's code status was acted upon. A nurse's note dated [DATE] at 5:30 AM documented "Resident found in bed unresponsive to verbal stimuli extremities cool to touch X 4 (no) carotid pulse obtained (no) heart beat heard Resident DNR found at 0452 (4:52 AM) RP (responsible party), ADON (assistant director of nursing) notified ...funeral home called Dr ...paged and notified." On [DATE] at 11:10 AM, the director of social work, SW #2 said advanced directives or living wills were discussed with the resident if possible or the POA, and recorded on the Advanced Directives Discussion Document. She noted there were 3 choices on the form, withhold, provide and undecided. She said the facility staff discouraged choosing undecided for a code status. She said the resident or POA would be told the resident would receive CPR if they were undecided. SW #2 stated it was important to make a decision and the resident or POA would be re-approached. SW #2 said if the resident or POA was undecided after a discussion with the physician it "might be a time for a family meeting with the family, physician and nursing." On [DATE] at 11:50 AM, SW #1 was interviewed. SW #2 was present during the interview. SW #1 said she remembered she spoke to the POA on the phone and mailed the form to the POA. SW #1 later stated she could not remember if she put the form at the desk or mailed it. When asked, SW #1 said she wrote the X's on the Advanced Directive Discussion Document and the POA wrote "yes" next to living will and durable POA. She noted she would normally write a progress note (as noted above there were no social progress notes after [DATE]). She said she gave education, and talked to the POA on the phone to obtain the advanced directive. SW #1 stated if a resident or POA were undecided the code status would be full code. She said she would review the clinical record prior to a discussion about an advanced directive. She said she did not know the resident was a DNR. SW #1 said the DNR was not in the record at the time (as noted above the DNR order was written on [DATE] and the care plan stated the resident was a DNR). SW #1 stated she would inform the nursing staff if the resident or family were undecided. She noted if the resident or family were undecided she would try a family meeting or speak to the physician. SW #1 said she could not remember if she informed the nursing staff. On [DATE] at 12:45 PM, SW #1 said she wanted to make sure this surveyor didn't need any more information from her. This surveyor asked if she had any more information to provide, and she stated "no". On [DATE] at 1:45 PM, the unit manager at the time of the resident's stay was interviewed by phone. She noted the SW and the nurse worked together to obtain signatures on the DDNR form. She noted the POA was contacted but never signed the form. She stated she did not remember a conversation with the SW about the POA being undecided about the resident's code status. She noted if the POA was undecided then the physician would talk to the POA. She noted the person who was told the POA was undecided should have notified the physician to change the order. She said if she had been told, she would have followed up with a family meeting or spoken to the physician. On [DATE] at 2:20 PM, these concerns were reviewed with the administrator, the director of nursing (DON) and the nurse consultant (NC). The DON and NC stated the DDNR form was not valid without the POA's signature. They noted they would follow the physician's orders [REDACTED]. She stated the physician's orders [REDACTED]. The DON and the NC said the physician should have been called for clarification. The NC stated she would have expected some follow up regarding the POA being undecided. A copy of the facility policy on the Advanced Directive Discussion Document was requested. On [DATE] at approximately 9:25 AM, the facility policy titled Advanced Directives - Admissions/Social Services and revised on ,[DATE] was provided. The policy stated "Policy: The facility Social Service staff will abide by resident advanced directives, if known...3. Social Services and/or Admissions staff must complete the Advanced Directives Discussion Document (Attachment A), which must be a part of the resident's file confirming the parties were appropriately informed and an advanced directive, if one exists, was obtained or was identified as to its location...4. Upon completion of the Advanced Directive Discussion Document, fill out Attachment B, Notification of Physician, to alert physician that discussion has taken place and place in the medical record...6. After admission, Social Services must be aware of expressions by the resident or responsible party regarding changes or revocation of any advanced directives and communicate these desires to Administration and Medical and Nursing staff for discussion and further action..." On [DATE] at 9:25 AM, the administrator was asked to provide Attachment B for Resident #5. On [DATE] at 12:20 PM, an interview with the DON and NC was conducted. The NC stated she could not locate Attachment B for Resident #5. She said she was not able to find documentation the social worker informed the physician or the nurse that the POA was undecided about the resident's code status. The NC stated she did not know why Attachment B was not in the clinical record. She noted the document should have been completed but it was not. She noted if there was ambiguity on the family's part it should have been followed up on and clarified. She said if the POA was undecided, then CPR should be performed. She said she would have followed the physician's orders [REDACTED]. COMPLAINT DEFICIENCY

Based on observation, staff interview, review of the clinical record, facility document review and during the course of a complaint investigation, it was determined that the facility staff failed to transfer one of 48 residents (Resident # 5) in a safe manner to prevent injury and failed to ensure adequate supervision for 2 of 48 residents (Residents # 8 and # 33). 1. Resident # 5 was transferred by one staff member causing an injury that required sutures. 2. Resident #33 was coded as requiring extensive assistance with one staff physical assistance, for the performance of hygiene and bathing. Resident #33 was left unattended in the shower on 2/20/2010 for an hour. 3. Resident #8 was coded as requiring extensive assistance from staff with one person physical assistance for bathing. Resident #8 was left unattended in the shower on 2/20/2010 for an hour. The findings included: 1. Resident # 5, a [AGE] year old, was admitted to the facility 12/21/07 with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with an assessment reference date of 11/16/09 was reviewed. Resident # 5 was coded for long and short-term memory loss and moderately impaired for decision making skills for daily living. She was coded dependent on staff for transfer, dressing; hygiene and bathing. She was coded incontinent of bowel and bladder. Resident # 5 was coded for edema and an accident in the past 30 days. A related care plan was reviewed for "skin prevention" and revealed problems addressed on the following dates: 1/12/10 "skin tear right lower leg. 1/28/10, laceration left lower leg and on 7/11/10, skin tear to right shin. A goal documented: "Resident will have no breakdown in next 90 days. On 9/14/10 at 4:40 p.m., Resident # 5 was observed up in a reclining wheelchair, in her room. Resident # 5 had on comfortable loose pants on. A bandage was observed on her left leg. Resident # 5 was again observed in her room on 9/15/10 at 7:53 a.m. A CNA (certified nursing assistant) employee #3 was in the room assisting the resident at this time she was interviewed about Resident # 5's skin. She stated that Resident # 5 had very fragile skin which she scratches a lot. She stated that she required the assistance of two staff to be transferred using a mechanical lifting device. She stated that she was waiting for another CNA to assist her, employee #4. At 8:12 a.m., Resident # 5 was observed transferred from bed to the wheelchair using the mechanical lift device. Employees #3 and #4 ensured that the Resident # 5's lower extremities were protected from any further injuries. During clinical record review and in the course of a complaint investigation the following was documented in the nursing notes: "1/12/10 at 9:30 a.m., resident observed/noted to have a small skin tear to right lower leg. No bleeding noted. Area cleansed with normal saline. Bacitracin applied with dry dressing. MD (medical doctor) notified. RP (responsible party) also notified of skin tear." 1/25/10, resident noted not to be transferring as well. Request placed for rehab to see resident for transfers. 1/26/10, order obtained from Dr name. RECOMMEND MECHANICAL LIFT FOR TRANSFERS. RP made aware." Complaint related documentation in the nurses notes: "1/28/10 at 8:30 a.m., CNA (certified nursing assistant) came and reported that resident obtained skin tear to (L) left lower leg 2 inches old bruises at that area. The CNA stated "I was liften (sic) lifting her to sit her in the W/C (wheelchair)." 9 a.m., called to room #___ for skin tear noted. Large laceration bleeding with fluid. Also leaking (sic). NP (nurse practitioner) notified. N.O. (new order) send to ER (emergency room ) for sutures. RP notified." 6 p.m., resident return from (name of emergency room ). Left lower leg laceration. Keflex 500 Milligrams TID (three times a day) times 10 days. Remove sutures in 10 days on 2/7/10. Laceration left leg dry dressing everyday PRN (when necessary). Follow-up with treatment nurse. RP made aware." On 9/16/10 during an interview with the Director of Residential Services employee #2 and Corporate RN (registered nurse) employee #5, they presented in-service training documents for the staff member in question along with training of all staff in the use of the mechanical lifts. Written corrective action notice was provided specifically to the CNA in question for the following: "Resident transfer requirement was not followed causing injuries. Resident was transferred from bed to W/C not using lift and obtained a skin tear. Sent out ER for possible sutures." 2. Resident #33 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most current minimum data set (MDS) was a quarterly assessment dated [DATE] which coded Resident #33 as having short term memory loss, no long term loss and as having some modified independence in making daily life decisions. Resident #33 required extensive assistance with one staff physical assistance, for the performance of activities of daily living including hygiene and bathing (MDS Section G1j and G2). On 9/15/2010 at 3:30 p.m., Certified Nursing Assistant # 15 stated, "...We (the CNA staff) were called to the desk by the supervisor to be searched because another CNA had lost some money...we were kept at the desk for over an hour. This was on February the 20th. We were told to leave our residents...we did. I had a resident (Resident # 33) in the shower she had vomited earlier and fallen in it, I had taken her in the shower to clean her up ....I was told to throw a towel over her and leave her and come to the desk right now...so I did. I feel awful about it. It was terrible...it was scary..." She stated the LPN (licensed practical nurse) supervisor stated this was the facility policy (the search). She stated she thought administration was aware. An interview was conducted on 9/15/10 at 3:40 p.m. with Licensed Practical Nurse (LPN # 13) who worked on the night of 2/20/2010. She stated that night, she was "in the middle" of inserting a Foley catheter and had to stop in order to "go to the desk to be searched." She stated she was able to complete her task prior to the incident, but that it had indeed occurred and all the staff was "made" to stop what they were doing and "go to the desk immediately". Review of the clinical record for Resident #33 revealed a "Nurse's Note" entry dated 02/20/10 at 11:20 p.m., which documented, "At 8:15 p.m., resident was found on the floor beside her bed. Resident had also vomited in the floor by her bed..." Resident #20 stated on 9/16/2010 at 8:50 a.m., "I heard the commotion and I wheeled myself up to the desk. The staff was standing behind the desk and the Nurse supervisor was making them empty their pockets. Child, I have never seen anything like it and never want to see anything like that again... I consider this my home and one sure does not want anything like that going on in their home...all the girls were at the desk being searched...there was no one out helping the other people who live here...the bells were ringing all over...it scared me..." Resident #20 was coded on the most current MDS, a quarterly, dated 9/8/2010 as having no memory impairment. On 9/17/2010 at 12:10 p.m., the facility Administrative/Corporate staff #'s 1, 2, 5 and 7 were notified of the findings above. The Facility A/C staff #1 stated, "We were notified that this happened on Monday and began our investigation and began disciplinary action." Facility A/C staff #1 stated the staff had changed their stories about what transpired on February 20th and that there was some "corporate issues" going on with that situation. A request was made at this time for additional information regarding the above concerns including the facility investigation. No information was provided by the facility prior to the conclusion of the survey. 3. Resident #8 was left unattended in the shower for an hour on 2/20/2010. Resident #8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most current minimum data set (MDS) was a quarterly assessment dated [DATE], which coded Resident #8 as having short term memory loss, no long term loss, and as having modified independence in making daily life decisions (difficulty in new situations). Resident #8 required extensive assistance from staff with one person physical assistance for bathing (MDS Section G2). On 9/15/2010 at approximately 3:50 p.m., Certified Nursing Assistant # 16 who worked and cared for residents' on 2/20/10 was interviewed. CNA # 16 stated, "I had my resident (Resident #8) in the shower and she (Nurse Supervisor) came and told me we had to come to the desk immediately. Her voice was very loud and demanding. I told her that I could loose my license if I left my resident. She said I would loose my license if I didn't. She said to throw a towel over her and come on...so I was afraid, and I did. I left her in the shower. It happened. I wish it had not. I didn't know what else to do. She was the supervisor and we are told we have to do what the supervisor says. We were at the desk for an hour being searched, every one of us. No one was on the floor with the residents...Thank God nothing bad happened..." An interview was conducted on 9/15/10 at 3:40 p.m. with Licensed Practical Nurse (LPN # 13) who worked on the night of 2/20/2010. She stated that night, she was "in the middle" of inserting a Foley catheter and had to stop in order to "go to the desk to be searched." She stated she was able to complete her task prior to the incident, but that it had indeed occurred and all the staff was "made" to stop what they were doing and "go to the desk immediately". Resident #20 stated on 9/16/2010 at 8:50 a.m., "I heard the commotion and I wheeled myself up to the desk. The staff was standing behind the desk and the Nurse supervisor was making them empty their pockets. Child, I have never seen anything like it and never want to see anything like that again... I consider this my home and one sure does not want anything like that going on in their home...all the girls were at the desk being searched...there was no one out helping the other people who live here...the bells were ringing all over...it scared me..." Resident #20 was coded on the most current MDS, a quarterly, dated 9/8/2010 as having no memory impairment. Review of the staff assignment for 3-11 shift on 2/10/2010 revealed Resident #8 was on the list for a shower that evening. On 9/17/2010 at 12:10 p.m., the facility Administrative/Corporate staff #'s 1, 2, 5 and 7 were notified of the findings above. The Facility A/C staff #1 stated, "We were notified that this happened on Monday and began our investigation and began disciplinary action." Facility A/C staff #1 stated the staff had changed their stories about what transpired on February 20th and that there was some "corporate issues" going on with that situation. A request was made at this time for additional information regarding the above concerns including the facility investigation. No information was provided by the facility prior to the conclusion of the survey. Complaint deficiency