Every finding on record at Chateau Living Center

Based on observations and interviews, the facility failed to serve residents with proper utensils and dishware during meal service. Findings: Observation of Dining Room A on 06/27/2026 at 11:30AM revealed residents were given plastic utensils for use during the lunch meal service. Further observation revealed staff removed the plastic utensils from the tables and then provided silverware. In an interview on 06/27/2026 at 11:35AM, Resident #133 stated, we must be special today, we get silverware. Resident #133 indicated residents were typically given plastic utensils during meal service. Observations of Dining Room A and Dining Room B on 06/27/2026 at 12:10PM revealed all residents were served gumbo and dessert in Styrofoam containers. Observation on 06/27/2026 at 12:20PM revealed beverages for the hall trays were served in Styrofoam cups and some desserts were served in Styrofoam containers. In an interview on 06/27/2026 at 12:20PM, S4Certified Nursing Assistant (CNA) indicated there were many times residents were given plastic utensils and served using Styrofoam containers. S4CNA further indicated drinks for the hall trays were always served in Styrofoam cups. In an interview on 06/28/2026 at 11:50AM, Resident #35 indicated she received small plastic utensils often, but Resident #35 preferred silverware. Resident #35 further indicated the plastic utensils were cheap and bent when used. Observation of Dining Room B on 06/28/2026 at 12:00PM revealed unidentified residents were using their hands, forks, or spoons in attempt to cut the meat served for lunch. Further observation revealed 9 out of the 10 residents who were served regular meat were not provided a knife to cut their meat. In interviews on 06/28/2026 at 12:00PM, the unidentified residents indicated they were not provided a knife to cut their meat. In an interview on 06/28/2026 at 12:04PM, Resident #124 indicated he was served meals with plastic utensils and Styrofoam all the time. In an interview on 06/29/2026 8:00AM, S3Dietary Supervisor indicated residents were given Styrofoam cups daily on the halls because the regular cups were not returned to the kitchen. S3Dietary Supervisor further indicated residents had the right to be provided proper utensils and dishware during meal service, and the residents should not have been served in Styrofoam containers or given plastic utensils regularly for meal service.

Based on observations, interviews, and record review, the facility failed to: 1. Ensure opened food, available for resident consumption, was dated and labeled; and 2. Ensure food, available for resident consumption, was maintained in a sanitary manner. Findings: Review of the facility's policy revised on 10/2018 and titled, Food Receiving and Storage revealed, in part, all temperature controlled foods and ready to eat foods that were prepared in the facility shall be labeled with the food name, date and time of storage and use by date. Further review revealed the food was routinely monitored in storage to identify and discard foods that had passed the expiration date or use by date. Observation on 06/27/2026 at 8:57AM revealed the facility's kitchen refrigerator had the following opened, undated and unlabeled food items:1- Package of crinkled fries;1- Package of fish; and,1- Package of hotdog buns. Observation on 06/27/2026 at 8:59AM revealed the facility's kitchen refrigerator had the following unsanitary and/or expired food items:1- Box that contained cracked eggs; and, 1- Package of light brown discolored lettuce. In an interview on 06/27/2026 at 9:00AM, S3Dietary Supervisor confirmed the opened, crinkled fries, fish and hotdog buns should have been labeled and dated. S3Dietary Supervisor further indicated the box of cracked eggs and the package of light brown discolored lettuce should not have been stored in the facility's refrigerator and available for resident consumption. In an interview on 06/28/2026 at 2:30PM, S2Assistant Director of Nursing indicated the above mentioned food items should have been stored in a sanitary manner and not available for resident consumption. In an interview on 06/28/2026 at 2:31PM, S1Director of Nursing indicated the above mentioned food items should have been stored in a sanitary manner and not available for resident consumption.

Based on interviews and record reviews, the facility failed to revise a care plan to reflect a resident's nutritional status for 1 (Resident #4) of 1 sampled residents investigated for tube feeding.Findings:Review of the facility's Care Plan policy and procedure, dated 05/22/2017, revealed the comprehensive plan of care was an interdisciplinary tool used to communicate and address care issues that were relevant to the resident's individual needs. Further review revealed the care plan would be revised on an ongoing basis to reflect changes in the resident status and care received.Review of Resident #4's Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/10/2026 revealed, in part, Resident #4 had a feeding tube.Review of Resident #4's June 2026 Physician Orders revealed, in part, Resident #4 was NPO (nothing by mouth) with a start date of 06/08/2026. Further review revealed an order for trials of food by mouth with speech therapy only with a start date of 06/08/2026.Review of Resident #4's Care Plan revealed Resident #4 required assistance with meal tray set up and eating from the Certified Nursing Assistant and Licensed Practical Nurse. Further review revealed Resident #4 was not care planned to be NPO or have food trials completed with speech therapy.In an interview on 06/29/2026 at 10:47AM, S1Director of Nursing (DON) indicated he was not aware Resident #4's nutritional status had changed to NPO on 06/08/2026. S1DON reviewed Resident #4's June 2026 Physician Orders and Care Plan and indicated Resident #4's Care Plan had not been revised to reflect Resident #4's current nutritional status and it should have been.In an interview on 01/23/2025 at 2:00PM, S6Administrator indicated the facility failed to revise Resident #4's care plan to reflect Resident #4's nutritional status.

Based on observations, interviews, and record reviews, the facility failed to ensure dietary staff performed proper hand hygiene technique for 1(S5Dietary Aide) of 3 dietary staff observed for hand hygiene. Findings: Review of the facility's policy dated 11/28/2016 and titled, Standard Precautions revealed, in part, the purpose of standard precautions was to prevent the spread of infection. Further review revealed standard precautions included but was not limited to hand hygiene. Observation on 06/27/2026 at 9:09AM revealed S5Dietary Aide demonstrated improper handwashing technique when she applied soap to her hands, then proceeded to rub only the palms of her hands together for approximately 5 seconds. Observation further revealed S5Dietary Aide then turned on the water at the handwashing sink and rinsed the soap off of her hands for approximately 5 seconds. Further observation then revealed S5Dietary Aide proceeded to turn the knob of the faucet, at the hand washing sink with her washed hands and then S5Dietary Aide dried her hands off with paper towels. In an interview on 06/27/2026 at 9:10AM, S3Dietary Supervisor confirmed S5Dietary Aide did not use the proper hand washing technique during her hand washing demonstration and she should have. In an interview on 06/28/2026 at 2:32PM, S2Assistant Director of Nursing indicated the S5Dietary Aide did not use the proper hand hygiene technique and she should have. In an interview on 06/28/2026 at 2:33PM, S1Director of Nursing indicated the S5Dietary Aide did not use the proper hand hygiene technique and she should have.

Based on interviews and record reviews, the facility failed to clarify the orthopedic physician's recommendation, obtain the necessary physician order, and implement the use of a right arm sling for 1 (Resident #1) of 3 sampled residents reviewed for quality of care and treatment. Findings:Review of Resident #1's Significant Change assessment with an Assessment Reference Date of 02/18/2026 revealed, in part, Resident #1 had a diagnosis right humerus (upper arm) fracture. Review of Resident #1's progress notes revealed, in part, on 02/07/2026 Resident #1 was found on the floor complaining of right shoulder pain and was transferred to the hospital for evaluation. Further review revealed on 02/08/2026 S4Licensed Practical Nurse documented Resident #1 returned to the facility with a right humerus fracture and had a sling in use to the right arm. Review of Resident #1's orthopedic consultation report dated 02/10/2026 revealed, in part, the orthopedic physician recommended the facility maintain Resident #1's right arm sling and to remove the sling during exercise. Review of Resident #1's Physician Orders Summary report revealed, in part, no documentation the facility obtained a physician order indicating the use a sling for Resident #1, including the location and frequency of use. Review of Resident #1's clinical record revealed no documentation the facility implemented the orthopedic physician's recommendation to maintain Resident #1's right arm sling pending physician clarification. In an interview on 06/24/2026 at S3Assistant Director of Nursing (ADON) indicated any recommendations from Resident #1's orthopedist should have been sent to Resident #1's primary physician for review and to obtain a physician order for the use, location, and frequency of Resident #1's right arm sling. In an interview on 06/24/2026 at 12:30PM, S4Licensed Practical Nurse (LPN) indicated she was the nurse responsible when Resident #1 returned from the hospital on [DATE] with a right humerus fracture. S4LPN further indicated Resident #1 returned from the hospital wearing a sling to mobilize her right arm. S4LPN further indicated she did not clarify or obtain an order for the use, location, and frequency of Resident #1's right arm sling. In an interview on 06/24/2026 at 1:55PM, S2Director of Nursing (DON) indicated when Resident #1 returned from the hospital with a right arm sling in place, S4LPN should have called Resident #1's primary physician to clarify and obtain a physician's order for use of the sling. S2DON confirmed the facility had no documented evidence Resident #1's primary physician was notified of Resident #1's orthopedist 02/10/2026 recommendation to maintain use of the right arm sling, and no evidence physician order was obtained for continued use of the sling, as required.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not greater than 5% for 2 (Resident #R5 and Resident #R6) of 4 residents observed during medication administration.Findings:Review of the facility's Medication Administration and Storage Policy, Med Pass Guidelines dated 12/04/2017 revealed, in part, staff was to check directions (for medication administration) against a resident's medication administration record. Further review revealed, in part, staff must check the medication cart for out-of-date medications. Further review revealed staff were to make sure that drugs matched the medication administration record. Resident #R5 Review of Resident #R5's electronic medical record revealed, in part, Resident #R5 was admitted on [DATE] and had diagnoses, which included, Alzheimer's disease, vascular dementia, generalized anxiety disorder, and hemiplegia. Review of Resident #R5's physician's orders revealed, in part, an order dated 03/06/2026 to administer Resident #R5 one oral tablet of Risperidone (an antipsychotic medication) 0.25 milligrams (MG) one time a day. Review of Resident #R5's March 2026's electronic medication administration record revealed, in part, Resident #R5 was administered one Risperidone 0.5MG tablet once per day from 03/01/2026 through 03/05/2026. Further review revealed Resident #R5's Risperidone 0.5MG dosage was discontinued on 03/05/2026. Further review revealed an order to administer one Risperidone 0.25MG tablet with a start date of 03/06/2026. Observation on 03/31/2026 at 9:03AM revealed S5Licensed Practical Nurse administered one Risperidone 0.5MG tablet by mouth to Resident #R5. In an interview on 03/31/2026 at 10:40AM, S5Licensed Practical Nurse confirmed she had administered 0.5MG tablet by mouth of Risperidone and she should have administered 0.25MG of Risperidone by mouth as per Resident #R5's physician's orders. Resident #R6 Review of Resident #R6's electronic medical record revealed, in part, Resident #R6 was admitted on [DATE] and had diagnoses, which included, unspecified sequelae of cerebral infarction and adjustment disorder with depressed mood. Review of Resident #R6's quarterly Minimum Data Set with an Assessment Reference Date of 03/11/2026 revealed, in part, Resident #R6 was cognitively intact with a Brief Interview for Mental Status score of 15. Review of Resident #R6's physician's orders revealed, in part, an order dated 03/03/2026 to administer Resident #R6 2.5 oral tablets of Fluoxetine HCl (an antidepressant medication) 20 milligrams (MG) by mouth one time a day. Observation on 03/31/2026 at 9:08AM revealed S4Licensed Practical Nurse administered one Fluoxetine HCl 40MG tablet by mouth to Resident #R6. In an interview on 03/31/2026 at 10:42AM, S4Licensed Practical Nurse confirmed she had administered 40MG tablet by mouth of Fluoxetine HCL and she should have administered 50MG by mouth as per Resident #R6's physician's order. In an interview on 03/31/2026 at 11:10AM, S6Corporate Nurse confirmed S4Licensed Practical Nurse had administered Resident #R6 40MG by mouth of Fluoxetine HCL, and S4Licensed Practical Nurse should have administered Fluoxetine HCl 50MG by mouth as per Resident #R6's physician's order. S6Corporate Nurse further confirmed S5Licensed Practical Nurse had administered Resident #R5 0.5MG by mouth of Risperidone and S5Licensed Practical Nurse should have administered 0.25MG by mouth as per Resident #R5's physician's order. In an interview on 03/31/2026 at 12:50PM, S3Director of Nursing confirmed S4Licensed Practical Nurse had administered Resident #R6 40MG by mouth of Fluoxetine HCL, and S4Licensed Practical Nurse should have administered 50MG by mouth as per Resident #R6's physician's order. S3Director of Nursing further confirmed S5Licensed Practical Nurse had administered Resident #R5 0.5MG by mouth of Risperidone and S5Licensed Practical Nurse should have administered 0.25MG by mouth as per Resident #R5's physician's order. In an interview on 03/31/2026 at 12:58PM, S2Assistant Administrator confirmed S4Licensed Practical Nurse had administered Resident #R6 40MG by mouth of Fluoxetine HCL, and S4Licensed Practical Nurse should have administered Fluoxetine HCl 50MG by mouth as per Resident #R6's physician's order. S2Assistant Administrator further confirmed S5Licensed Practical Nurse had administered Resident #R5 0.5MG by mouth of Risperidone and S5Licensed Practical Nurse should have administered 0.25MG by mouth as per Resident #R5's physician's order. In an interview on 04/01/2026 at 9:33AM, S1Administrator confirmed the above-mentioned medications were administered incorrectly, and should have been administered according to the physician's orders for Resident #R5 and Resident #R6.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's privacy was maintained during perineal care for 1 (Resident #1) of 2 sampled residents observed for privacy/dignity rights during perineal care. Findings: Review of the facility's policy titled Perineal Care Policy and Procedure, dated 11/17/2015 revealed, in part, the residents' door and privacy curtain should have been closed during perineal care. Observation on 02/09/2026 at 12:28PM revealed S2Certified Nursing Assistant (CNA) and S3CNA failed to ensure Resident #1's privacy was maintained during perineal care by closing the privacy curtain. Further observation revealed Resident #1's buttocks was exposed to Resident #1's roommate due to S2CNA and S3CNA failing to close Resident #1's privacy curtain. Further observation revealed a random resident walked into Resident #1's room during Resident #1's above-mentioned perineal care. Further observation revealed Resident #1's buttocks was exposed to this random resident due to S2CNA and S3CNA failing to close Resident #1's door and/or Resident #1's privacy curtain. In an interview on 02/09/2026 at 2:10PM, S2CNA confirmed she did not close Resident #1's room door and/or privacy curtain while performing perineal care and she should have. In an interview on 02/09/2026 at 2:12PM, S1Director of Nursing indicated S2CNA and S3CNA should have closed Resident #1's door and/or privacy curtain while performing Resident #1's perineal care.

Based on interviews and record reviews, the facility failed to ensure a resident's medication was not available for administration for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for medication administration.Findings:Review of Resident #1's August 2025 physician's orders revealed, in part, an order to administer Resident #1 one Hydrocodone-Acetaminophen (a medication used to treat pain) 10-325 milligrams (mg) tablet every eight hours as needed for pain.Review of the Individual Narcotic Record for Resident #1's Hydrocodone-Acetaminophen 10-325 mg tablets revealed, in part, Resident #1's had zero Hydrocodone-Acetaminophen 10-325 mg tablets available after she was administered the last Hydrocodone-Acetaminophen 10-325 mg tablet on 08/29/2025 at 8:43PM.In a telephone interview on 09/19/2025 at 1:14PM, Resident #1 indicated she was in pain related to a previous fall and her chronic pain on the night of 08/29/2025 to the morning of 08/30/2025. Resident #1 further indicated she had requested her pain medication, but the facility's nurse told her the pain medication was not available because the medicated had not been reordered.In a telephone interview on 09/22/2025 at 12:40PM, S5Licensed Practical Nurse (LPN) indicated when she arrived at the facility on the morning of 08/30/2025, Resident #1 had complained of pain. S5LPN further indicated Resident #1's Hydrocodone-Acetaminophen 10-325 mg tablets were not available. S5LPN further indicated she was not able to administer Resident #1's Hydrocodone-Acetaminophen 10-325 mg tablet as needed because none were available.In an interview on 09/22/2025 at 1:08PM, S4Staff Development/Charge Nurse/Infection Preventionist indicated when a resident had an active order for a medication, the mediation should have been available for administration.In an interview on 09/22/2025 at 2:08PM, S1DON indicated a resident's medication should have been ordered from the pharmacy before a resident was out of a medication.

Based on observation, interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care in a timely manner for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for ADL care. Findings: Review of Resident #2's Electronic Medical Record (EMR) revealed, in part, Resident #2 was admitted to the facility on [DATE]. Further review revealed Resident #2 had diagnoses, in part, of overactive bladder and unspecified urinary incontinence. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/2025 revealed, in part, Resident #2 required supervision/touching assistance with toileting hygiene and had occasional bladder incontinence. Review of Resident #2's Care Plan with a goal date of 10/17/2025 revealed, in part, an intervention for staff to assist Resident #2 with perineal cleansing as needed. Further review revealed Resident #2 required assistance with toilet transfers, dressing, and hygiene. Observation on 09/22/2025 at 12:49PM revealed Resident #2 was seated in her wheelchair crying in the hallway outside of her room. Further observation revealed S6Licensed Practical Nurse (LPN) passed by and questioned Resident #2 as to why she was crying. Further observation revealed Resident #2 stated she had an accident on herself and S6LPN stated she would find a certified nursing assistant (CNA) to change her. Observation on 09/22/2025 at 1:18PM revealed Resident #2 wheeled herself down the hallway in her wheelchair crying, looking in rooms, and appeared in distress. Resident #2 approached S7Certified Nursing Assistant Supervisor (CNA Supervisor) in the hall to tell her she couldn't find any clothes and she was soaking wet while gesturing towards her groin area. S7CNA Supervisor stated she would check and see after she finished her current task. Observation on 09/22/2025 at 1:27PM revealed S7CNA Supervisor came back to Resident #2's room and showed Resident #2 she had clothes in her closet and walked out without giving assistance to Resident #2. Observation on 09/22/2025 at 1:30PM revealed Resident #2 wheeled herself back into the hallway in her wheelchair, crying and indicated she did not have any panties. Observation on 09/22/2025 at 1:31PM revealed Resident #2 did not receive incontinence care from the facility's staff until 09/22/2025 at 1:31PM, when S8CNA observed Resident #2 crying in the hallway and brought Resident #2's into her room to provide incontinence care.In an interview on 09/22/2025 at 1:40PM, S8CNA indicated Resident #2 had an episode of urinary incontinence and Resident #2's underwear and pants were wet with urine. In an interview on 09/22/2025 at 2:09PM, S7CNA Supervisor indicated once a resident had an episode of incontinence, they should be changed within 15 to 20 minutes. In an interview on 09/22/2025 at 2:12PM, S2Assistant Director of Nursing (ADON) indicated it was the facility's process for staff to change a resident after a known episode of incontinence within 15 to 20 minutes. In an interview on 09/22/2025 at 03:09PM, S3ADON indicated it was the facility's process for staff to change a resident after a known episode of incontinence within 15 minutes. In an interview on 09/22/2025 at 3:40PM, S7CNA Supervisor indicated she did hear Resident #2 state she was soaking wet but was unaware Resident #2 was incontinent of bladder and required assistance from staff for incontinence care.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure staff used soap and water to perform hand hygiene for a resident on physician ordered contact precautions for Clostridium Difficile (a highly contagious encapsulated bacteria that causes severe abdominal pain and diarrhea and is resistant to alcohol based hand sanitizer [ABHS])(C. Difficile) (Resident #75);2. Ensure staff wore proper personnel protective equipment (PPE) while caring for a resident on C. Difficile contact isolation precautions (Resident #75); and,3. Ensure housekeeping used the proper cleaning agent to clean and disinfect a room on contact isolation precautions for C. Difficile (Resident #75). This deficient practice was identified for 1 (Resident #75) of 1 (Resident #75) sampled residents investigated for infection control surveillance. Findings:1.Review of the facility's Hand Hygiene policy and procedure, dated 07/01/2020, revealed, in part, after contact with a resident with infectious diarrhea, including C. difficile, hands shall be washed with soap and water. Review of the facility's Isolation policy and procedure, dated 11/30/2020, revealed, in part, alcohol rub is not effective in eradicating C. Difficile spores, therefore handwashing with soap and water was required prior to exiting room. Further review revealed if gloves were to become exposed to the pathogen while in the resident's room, staff should discard gloves, wash hands, and reapply gloves. Further review revealed after cleaning room, wash hands thoroughly with soap and water prior to exiting room. Review of Resident #75's July 2025 physician's orders revealed, in part, an order for contact precautions with strict isolation related to an active infection of C. Difficile. Observation on 07/21/2025 at 10:30AM revealed no signage on the outside or inside of Resident #75's room door indicating staff members should use soap and water to clean their hands. Further observation revealed, a contact isolation sign with a picture of ABHS being used to clean hands. Observation on 07/22/2025 at 1:25PM revealed S11Certified Nursing Assistant (CNA) entered Resident #75's room to perform catheter care and incontinence care. S11CNA cleaned Resident #75's catheter tubing, then changed gloves using ABHS without washing her hands with soap and water. S11CNA then removed Resident #75's urine and feces soiled brief, cleaned Resident #75's buttock area of feces, and placed a clean brief on Resident #75 without washing her hands with soap and water in between glove changes. In an interview on 07/22/2025 at 2:15PM, S11CNA indicated she did not use soap and water to wash her hands in between glove changes and should have. In an interview on 07/23/2025 at 9:12AM, S12Housekeeper confirmed she was assigned to clean Resident #75's room. S12Housekeeper further indicated she had just completed cleaning Resident #75's room and used ABHS to clean her hands upon completion. S12Housekeeper further indicated she did not use soap and water to wash her hands prior to exiting Resident #75's room. In an interview on 07/22/2025 at 3:10PM, S3Director of Nursing confirmed the contact precautions sign on Resident #75's door was the only visual sign posted for notifying staff of Resident #75's precautions. S3DON could not provide any further explanation as to why there was no signage requiring staff to wash their hands with soap and water. In an interview on 07/23/2025 at 11:16AM, S7Infection Control Nurse (ICN) confirmed there was no signage on the outside or inside of Resident #75's room which indicated staff members should use soap and water to wash their hands before leaving the room and should have been. S7ICN further confirmed the facility's policy indicated ABHS was not effective against C. Difficile and S11CNA and S12Housekeeper should have washed their hands with soap and water. 2.Review of the facility's Isolation policy and procedure, dated 11/30/2020, revealed, in part, contact isolation infections such as C. Diff, are transmitted via contact or indirect contact with the resident or the resident's environment; therefore, gown and gloves are to be utilized for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Further review revealed gloves are to be utilized at all times. If gloves become exposed to the pathogen while in the resident's room, discard gloves, wash hands, and reapply gloves. Observation on 07/22/2025 at 1:25PM revealed S11CNA entered Resident #75's room to perform catheter care and incontinence care. Upon completing care, S11CNA removed her soiled gloves and used ABHS to perform hand hygiene. S11CNA then used her ungloved hands to cover Resident #75 with his used linen. Further observation revealed, S9Wound Care Nurse entered Resident #75's room to perform a sacral wound dressing change. Upon completion of the dressing change, S11CNA recovered Resident #75 with his used linens using her ungloved hands. In an interview on 07/22/2025 at 2:15PM, S11CNA indicated she could not provide any explanation as to why she did not put on new gloves before handling Resident #75's used linen. In an interview on 07/23/2025 at 11:16AM, S7ICN indicated all of the surfaces in Resident #75's room are potentially contaminated with C Difficile spores; therefore, staff members should wear gloves at all times while inside Resident #75's room. 3.Review of the facility's Isolation policy and procedure, dated 11/30/2020, revealed, in part, cleaning of an isolation room should be with bleach wipes with a 1:10 bleach solution or bleach wipes that kill C. Difficile spores. Observation on 07/23/2025 at 9:00AM revealed S12Housekeeper exiting Resident #75's room carrying a bottle of Micro-kill Q3 general disinfectant. In an interview on 07/23/2025 at 9:12AM, S12Housekeeper indicated she used MicroKill Q3 general disinfectant and Multisurface peroxide to clean Resident #75's room. S12Housekeeper indicated she did not know if the general cleaner was effective against C. Difficile. Review of the Environmental Protection Agency's (EPA) Registered Antimicrobial Products Effective against Clostridium Difficile Spores list, updated 02/2025, revealed, in part, the above mentioned general disinfectants were not on the list of effective agents against C. Difficile. In an interview on 07/23/2025 at 10:55AM, S6Housekeeping Supervisor (HS) indicated S12Housekeeper should have used Micro-kill bleach wipes to clean Resident #75's room. S6HS further indicated the above mentioned general cleaning solution used to clean Resident #75's room was not effective against C. Difficile and should not have been used in Resident #75's room. In an interview on 07/23/2025 at 11:16AM, S7ICN confirmed the Micro-kill Q3 general cleaner was not effective against C-Difficile spores. S7ICN further confirmed S12Housekeeper should have used the Micro-kill bleach wipes and/or a bleach solution to clean Resident #75's room. In an interview on 07/23/2025 at 1:30PM, S1Administrator was presented with the above mentioned findings and offered no further explanation for the deficient practice.

Based on interviews and record reviews, the facility failed to ensure an incident of resident to resident physical abuse was thoroughly investigated for 1 (Resident #110) of 1 (Resident #110) sampled residents identified to have physically abused residents during a mood and behavior investigation.Findings:Review of the facility's policy and procedure titled, Abuse-Prevention and Prohibition dated 03/25/2023 revealed, in part, the administrator should complete a thorough investigation of allegations of abuse to include interviews with employees and the administrator should obtain signed statements from the employees. Further review revealed the investigator should interview cognitive residents involved or the roommate if the resident was cognitively impaired. Review of Resident #110's incident report dated 07/02/2025 revealed, in part, Resident #110 hit Resident #62 and punched Resident #180 in the chest.In an interview on 07/23/2025 at 8:50AM, Resident #62 indicated Resident #110 entered her room and hit her legs several times with a closed fist. Resident #62 further indicated Resident #110 punched her roommate, Resident #180. There was no documented evidence, and the provider could not present any documented evidence, a thorough investigation, that included witness statements from nurses and cognitive residents, was completed for the above mentioned resident to resident physical abuse incident. In an interview on 07/23/2025 at 10:25AM, S15Corporate Administrator indicated the facility did not have witness statements for the incident of resident to resident physical abuse which occurred on 07/02/2025. In an interview on 07/23/2025 at 10:25AM, S2Corporate Nurse indicated the facility did not have witness statements for the incident of resident to resident physical abuse which occurred on 07/02/2025. In an interview on 07/23/2025 at 11:15AM, S2Corporate Nurse confirmed the above mentioned resident to resident physical abuse incident was not thoroughly investigated.

Based on interviews and record reviews, the facility failed to ensure an incident of resident to resident physical abuse was reported to the state agency for 1 (Resident #110) of 1 (Resident #110) sampled residents identified to have physically abused residents during a mood and behavior investigation.Findings:Review of the facility's policy and procedure titled, Abuse-Prevention and Prohibition dated 03/25/2023 revealed, in part, the administrator shall immediately initiate a report to the state agency after forming the suspicion the allegation involves abuse of any type. Review of Resident #110's incident report dated 07/02/2025 revealed, in part, Resident #110 hit Resident #62 and punched Resident #180 in the chest. Review of the facility's list of incidents reported to the state agency for the last six months revealed no documented evidence, and the facility presented no documented evidence, the facility had reported incidents involving physical abuse as noted in the above mentioned incident report dated 07/02/2025. In an interview on 07/22/2025 at 3:30PM, S1Administrator indicated he was informed on 07/02/2025 that Resident #110 hit Resident #62 and punched Resident #180. S1Adminstrator further indicated he did not report the incidents of resident to resident physical abuse to the state agency as required.

Based on observations, interviews, and record reviews the facility failed to ensure resident equipment and rooms were maintained in a sanitary manner for 2 (Resident #57, Resident #148) of 2 (Resident #57, Resident #148) sampled residents investigated for tube feeding.Findings: Resident #57Review of Resident #57's electronic medical record revealed, in part, Resident #57 was admitted to the facility on [DATE] with diagnoses of encounter for attention to gastrostomy (surgical creation of an opening in the stomach to administer feedings), dysphagia (difficulty swallowing), and cognitive communication deficit. Review of Resident #57's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/2025 revealed, in part, Resident #57 was non-interviewable, dependent for all activities of daily living, had a feeding tube, and received enteral feeding.Observation on 07/21/2025 at 11:35AM revealed multiple areas of a reddish/brown substance located on Resident #57's tube feeding pump, on the base of Resident #57's tube feeding pole, and on Resident #57's floor near the tube feeding pole.Observation on 07/22/2025 at 12:49PM revealed multiple areas of a reddish/brown substance located on Resident #57's tube feeding pump, on the base of Resident #57's tube feeding pole, and on Resident #57's floor near the tube feeding pole. Resident #148Review of Resident #148's electronic medical record revealed, in part, Resident #148 was admitted to the facility on [DATE] with a diagnoses of an encounter for attention to gastrostomy and dysphagia following cerebral infarction (death of brain tissue due to insufficient blood flow).Review of Resident #148's Quarterly MDS with an ARD date of 05/07/2025 revealed, in part, Resident #148 was non-interviewable and received enteral feedings through tube feedings. Observation on 07/21/2025 at 10:30AM revealed multiple areas of a reddish/brown substance located on Resident #148's tube feeding pump, on the base of Resident #148's tube feeding pole, and on Resident #148's floor near the tube feeding pole.Observation on 07/22/2025 at 12:20PM revealed multiple areas of a reddish/brown substance located on Resident #148's tube feeding pump, on the base of Resident #148's tube feeding pole, and on Resident #148's floor near the tube feeding pole.In an interview on 07/22/2025 at 1:55PM, S1Administrator indicated the above mentioned findings in Resident #57's and Resident #148's rooms were not maintained in a sanitary manner.In an interview on 07/22/2025 at 3:30PM, S3Director of Nursing indicated the above mentioned findings in Resident #57's and Resident #148's rooms were not maintained in a sanitary manner.

Based on observations and interviews the facility failed to maintain an effective pest control management program for 7 (Resident #16, Resident #24, Resident #67, Resident #72, Resident #95, Resident #139, Resident #148) of 7 (Resident #16, Resident #24, Resident #67, Resident #72, Resident #95, Resident #139, Resident #148) sampled resident rooms observed for pests, 1 (Hall C ) of 3 (Hall C, Hall D, Hall E) sampled halls reviewed for environment, and for 2 (Dining Room A, Dining Room B) of 2 (Dining Room A, Dining Room B) sampled dining rooms observed during dining observations. Findings:Observation on 07/21/2025 at 10:30AM revealed a brown flying insect in Resident #148's room.In an interview on 07/21/2025 at 10:47AM, Resident #24 indicated it bothered her that there were flying insects in her room. Observation on 07/21/2025 at 10:48AM revealed brown flying insects in Resident #24's room. Observation on 07/21/2025 at 11:14AM revealed a brown flying insect in Resident #95's room. Observation on 07/21/2025 at 11:26AM revealed two brown flying insects on Resident #67's blanket while she was in bed. Observation on 07/21/2025 at 11:27AM revealed two brown flying insects on Resident #72's blanket while she was in bed. Observation on 07/21/2025 at 11:35AM revealed a brown flying insect on Resident #16's food on her breakfast tray in her room. Observation on 07/21/2025 11:43AM revealed a brown flying insect landed on the surveyor's arm in Dining Room A. Observation on 07/21/2025 at 12:30PM revealed two brown flying insects were present in Dining Room B. Observation on 07/21/2025 at 3:43PM revealed a brown flying insect were present on Hall C.Observation on 07/22/2025 at 11:30AM revealed brown flying insects were present in Dining Room A. Observation on 07/22/2025 at 3:40PM revealed a brown unknown flying insect was present in Dining Room A. In an interview on 07/22/2025 at 12:38PM, Resident #139 indicated a brown flying insect landed on her bread this morning at breakfast. In an interview on 07/22/2025 at 1:34PM the facility's contracted pest management company's administrator indicated they had not received any reports from the facility regarding brown flying insects. In an interview on 07/22/2025 at 1:55PM, S1Administrator indicated he was not aware of the presence of brown flying insects in the above mentioned areas of the facility.

Based on observations and interviews, the facility failed to ensure food was stored in a sanitary manner. Findings:Observation on 07/21/2025 at 8:45AM revealed an employee's frozen drink was present in the facility's freezer. In an interview on 07/21/2025 at 8:46AM, S8Dietary Manager indicated the employee's frozen drink should not have been stored in the facility's freezer. In an interview on 07/21/2025 at 1:20PM, S1Administrator confirmed the employee should not have stored her frozen drink in the facility's freezer. Observation on 07/22/2025 at 12:21PM revealed a bottle of clear liquid labeled with S21Dietary Aide's name and date stored in the facility's freezer. In an interview on 07/22/2025 at 12:22PM, S21Dietary Aide confirmed she had placed her water bottle in the facility's freezer. S21Dietary Aide further indicated she should not have put her bottle of water in the facility's freezer. In an interview on 07/22/2025 at 12:23PM, S8Dietary Manager confirmed S21Dietary Aide should not have put her water in the facility's freezer.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's fingernails were maintained for 1 (Resident #174) of 2 (Resident #119, Resident #174) sampled residents investigated for activities of daily living (ADL). Findings:Review of Resident #174's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/21/2025, revealed Resident #174 required substantial/maximal assistance with personal hygiene.Review of Resident #174's Care Plan revealed Resident #174 required staff assistance with ADL care with an initiation date of 10/11/2024. Observation on 07/21/2025 at 10:29AM revealed the fingernails on Resident #174's right and left hands extended past the end of the tip of Resident #174's fingers. Further observation revealed the fingernails on Resident #174's right 3rd finger (middle finger) and 5th finger (the smallest finger or the finger furthest from the thumb) were approximately one-fourth of an inch past Resident #174's fingertips. Observation on 07/22/2025 at 8:24AM revealed the fingernails on Resident #174 right and left hands extended past the end of the tip of Resident #174's fingers. Further observation revealed the fingernails on Resident #174's right 3rd finger and 5th finger were approximately one-fourth of an inch past Resident #174's fingertips. In an interview on 07/22/2025 at 4:17PM, S5Assistant Director of Nursing (ADON) indicated a resident's fingernails were to be trimmed as needed by the Certified Nursing Assistants (CNA) during showers and by activities personnel during scheduled rounding. Observation on 07/22/2025 at 4:51PM conducted with S4ADON revealed, in part, S4ADON was at Resident #174's bedside. Further observation revealed the fingernails on Resident #174's right and left hands extended past the end of the tip of Resident #174's fingers. Further observation revealed the fingernails on Resident #174's right 3rd finger and 5th finger were approximately one-fourth inch past Resident #174's fingertips and Resident #174's right 5th fingernail was jagged.In an interview on 07/22/2025 at 4:51PM, S4ADON confirmed the fingernail growth to Resident #174's right and left hands were long and extended past his fingernails and should not have. S4ADON further acknowledged the fingernail's on Resident #174's right hand were long and the length on the right 3rd finger and right 5th finger were excessive. S4ADON indicated Resident #174's nails appeared to not have been trimmed in a couple of weeks. S4ADON confirmed Resident #174's fingernails should have been trimmed prior to this observation.In an interview on 07/23/2025 at 10:46AM, S18ACT stated nails should not be long. S18ACT indicated fingernails should be trimmed if they extend past the tip of the finger. In an interview on 07/23/2025 at 2:10PM, S4ADON indicated, in part, she would expect a resident's fingernails to be trimmed if they extended past the tip of the finger.

Based on observation, interviews, and record reviews, the facility failed to ensure chemicals in the beauty shop room were secured and not accessible to wandering residents. Findings:Review of the facility's Wandering Residents List revealed, in part, 11 residents were identified by the facility as at risk for wandering. Observation on 07/21/2025 at 1:05PM revealed the facility's beauty shop room was unlocked, open, and unmonitored. Further observation revealed a container of blue solution labeled Barbicide on the counter not secured. Review of the Barbicide Safety Data Sheet provided by the facility, dated 06/14/2018, revealed, in part, the chemical was irritating to skin and eyes and harmful if swallowed and poison control should be called immediately if ingested. Further review revealed safety glasses and googles should be worn when handling the chemical. In an interview on 07/23/2025 at 12:00PM, S6Housekeeping Supervisor (HS) confirmed the beauty room should be closed and locked when unmonitored or unsupervised. S6HS further confirmed the Barbicide chemical was in the beauty room, unsecured on the counter, and should not have been accessible to residents. In an interview on 07/23/2025 at 1:30PM, S1Administrator was presented with the above mentioned findings and offered no further explanation for the deficient practice.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by a resident for 1 (Resident #110) of 1 (Resident #110) sampled residents identified to have physically abused residents during a mood and behavior investigation. Findings: Review of the facility's policy and procedure titled, Abuse - Prevention and Prohibition, and dated 03/25/2023 revealed in part, physical abuse included hitting, slapping, pinching, biting, shoving, and kicking. Further review revealed each resident has the right to be free from abuse. Review of Resident #110's incident report dated 07/02/2025 revealed, in part, Resident #110 hit Resident #62 and punched Resident #180 in the chest. Review of S1Administrator's documentation dated 07/02/2025 revealed, in part, Resident #110 slapped Resident #62 on the foot and punched Resident #180 in the upper chest. In an interview on 07/23/2025 at 8:50AM, Resident #62 indicated Resident #110 entered her room and hit her legs several times with a closed fist. Resident #62 further indicated Resident #110 punched her roommate, Resident #180. Resident #180 was unable to be interviewed due to her cognitive status. In an interview on 07/23/2025 at 3:23PM, S16Licensed Practical Nurse (LPN) indicated she witnessed Resident #110 hit Resident #62. S16LPN further indicated she then attempted to remove Resident #110 from Resident #180's bed and Resident #110 became upset and punched Resident #180 in the chest with a closed fist. In an interview on 07/22/2025 at 3:30PM, S1Administrator acknowledged Resident #110 hit Resident #62 and Resident #180.

Based on interviews and record reviews, the facility failed to ensure:1. The skilled nurse documented adequate indication for use of an anti-psychotic (medication used to treat psychosis) medication used on an as needed (PRN) basis (Resident #3); and,2. The physician re-evaluated the use of an anti-psychotic used on a PRN basis and documented the rational and duration for an as needed (PRN) anti-psychotic drug (Resident #3). This deficient practice was identified for 1 (Resident #3) of 5 (Resident #3, Resident #16, Resident #98, Resident #110 Resident #119) sampled residents investigated for unnecessary medications. Findings:Review of Resident #3's record revealed diagnoses of, in part, unspecified dementia (condition which caused atrophy of the brain with loss of cognitive function), delusional disorder (condition which caused altered reality), major depressive disorder (condition which caused prolonged episodes of sadness), and psychosis (condition which caused altered reality). Review of Resident #3's July 2025 Physician Order revealed, in part, Haldol 1mg give one tablet by mouth every 24 hours as needed for agitation with an order date of 05/15/2025. 1.Review of Resident #3's July 2025 electronic Medication Administration Record (eMAR) revealed, in part, 1mg of Haldol was administered to Resident #3 on 07/05/2025 at 6:42PM. Further review of Resident #3's July 2025 eMAR revealed on 07/05/2025 on the evening and night shifts Resident #3 was documented as monitored for behaviors of agitation with no behaviors present. Review of Resident #3's Nurses Notes dated 07/05/2025 revealed Haldol was administered and was effective. There was no documented evidence, and the facility did not present any documented evidence, of the behaviors which were the indication for the administration of Haldol 1mg PRN, nor the non-pharmacological interventions attempted prior to having administered the PRN Haldol 1mg. In an interview on 07/23/2025 at 4:40PM, S2Corporate Nurse indicated the facility did not have any documentation of the reason for the administration of the as needed Haldol other than agitation, or the documentation of any non-pharmacological interventions attempted for Resident #3's agitation prior to the administration of the as needed Haldol. 2.Review of Resident #3's Pharmaceutical Consultant Report dated 05/20/2025 revealed, in part, the consultant pharmacist made a recommendation to limit the use of as needed antipsychotics to 14 days, and to provide a diagnosis code for Haldol. There was no documented evidence, and the facility did not present any documented evidence, Resident #3's physician evaluated Resident #3 for the continued use of Haldol or documented: If Resident #3 still required Haldol 1 mg on a PRN basis;The benefits Haldol 1 mg provided to Resident #3; and/or,If Resident #3's expressions or indications of distress improved because of the PRN medication. In an interview on 07/23/2025 at 4:40PM, S2Corporate Nurse indicated the facility did not have documented evidence Resident #3's physician evaluated Resident #3 for the continued use of Haldol 1mg after it was ordered on 05/15/2025, or the duration of the order.

Based on observations, interviews, and record reviews, the facility failed to have evidence a resident's oxygen tubing was changed weekly for 1 (Resident #74) of 2 (Resident #74, Resident #187) residents reviewed for respiratory care. Findings: Review of the facility's Oxygen Administration Policy and Procedure dated 11/16/2014 revealed, in part, at regular intervals, the facility staff were responsible to check and clean oxygen equipment, masks, tubing and cannula. Review of Resident #74's electronic health record revealed diagnoses of chronic obstructive pulmonary disease with an acute exacerbation (lung disease that blocks air flow) and acute chronic respiratory failure with hypoxia (absence of oxygen in body tissue).Review of Resident #74's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15 (score of 08-15) which indicated Resident #74 was cognitively intact. Further review revealed Resident #74 required oxygen. Review of Resident #74's physician orders dated 08/13/2024 revealed, in part, an active order to change Resident #74's oxygen tubing every week and as needed. Observation on 07/22/2025 at 10:14 AM revealed Resident #74's oxygen tubing was not dated. Observation on 07/22/2025 at 8:50AM revealed Resident #74's oxygen tubing was not dated. Observation on 07/23/2025 at 8:34AM revealed Resident #74's oxygen tubing was not dated.In an interview on 07/23/2025 at 8:35AM, Resident #74 indicated the facility staff did not change her oxygen tubing weekly as required.In an interview on 07/23/2025 at 8:43AM, S24Clinical Care Specialist indicated oxygen tubing should be changed as required per physician orders. In an interview on 07/23/2025 at 10:03AM, S3Director of Nursing indicated Resident #74's oxygen tubing should be changed as required per physician orders.

Based on observations, interviews and record reviews, the facility failed to ensure the resident's environment remained free of accident/hazards, identify and eliminate the risk of accident hazards to keep a resident free from elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents investigated for accidents/hazards. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 12/23/2024 at 8:50 a.m., when Resident #1 who was ordered a WanderGuard transmitter (a personal safety device that will alert facility staff when the resident approaches an exit and/or has left the building) exited the facility through Exit b. On 12/23/2024 at 9:25 a.m., Resident #1 was found 0.4 miles away from the facility with a skin tear to the back of his head. Resident #1 was then transferred via Emergency Medical Services (EMS) to the emergency department (ED) where he was diagnosed with a right temporal bone fracture and a right subdural hematoma (brain bleed). The IJ situation continued on 01/02/2025 at 12:30 p.m. when S10 Assistant Administrator used a secondary reset code that should have only been used by S1Administrator to open exits f and i; when using the secondary reset code, door exits f and i failed to alarm when a WanderGuard transmitter was placed near the door. The IJ situation continued on 01/02/2025 at 1:01 p.m. when S7CNA was observed using the secondary reset code that disabled the alarm. The IJ situation continued on 01/02/2025 at 1:30 p.m. when S3CNA was observed using the secondary reset code to unlock exit d. The IJ situation continued on 01/02/2025 when interviews of S3CNA, S4Maintenance, S5CNA and S6CNA verified they all used the secondary reset code to open exits f and d and that using this code disabled the alarm system. S1Administrator/Regional Administrator was notified of the Immediate Jeopardy on 01/02/2025 at 4:48 p.m. This deficient practice had the likelihood to cause more than minimal harm to the 6 residents identified by the facility as being at risk for elopement. Findings: Review of the facility's policy effective 07/31/2019 titled, Elopement, Resident Policy and Procedure revealed, in part, the facility would provide at least one of the following safety precautions for residents who are at risk for elopement: door alarms on facility exits, a personal safety device that will alert facility staff when the resident has left the building without supervision, and staff supervision. Further review revealed at no time shall a personal safety alarm or door alarm be turned off without the continual supervision of the exit. Further review revealed all staff shall be trained on preventing and responding to an elopement. Further review revealed staff training would include risk factors and interventions for prevention of elopement. Review of WanderGuard's (Door GUARDIAN) Installation Manual dated 03/11/2016 revealed, in part, if a nursing staff member was required to escort a resident with a WanderGuard transmitter out of the protected area, an escort code (secondary reset code) can be entered into the door panel/monitor to allow both the transmitter to pass through the perimeter without creating an alarm. Further review revealed the secondary reset code was used to escort a resident with a WanderGuard transmitter through the monitored door. Resident #1 Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #1 had moderate cognitive impairment. Review of Resident #1's Elopement Risk Evaluation dated 12/09/2024 revealed in part, Resident #1 wandered aimlessly. Further review revealed Resident #1 had an elopement score of 1, which indicated Resident #1 was at risk for elopement. Review of Resident #1's nurse's note dated 12/23/2024 revealed, in part, Resident #1 was noted to have been found by staff outside of the facility and lying on the ground. Further review revealed Resident #1 had a small skin tear to his posterior head with minimal bleeding. Resident #1 was sent to the ED. Review of the facility's incident investigation dated 12/23/2024 revealed, in part, on 12/23/2024 at 8:50 a.m., Resident #1 was observed to unsuccessfully exit through door b. Resident #1 was then observed engaged in conversation with another resident, attempted to open door b again, and successfully opened door b and walked away from the facility. Subsequently, on 12/23/2024 at 9:25 a.m., Resident #1 was found 0.4 miles away from the facility and on the ground. Resident #1 was then transported via EMS to the ED where he was diagnosed with a right temporal bone skull fracture and a right subdural hematoma (a collection of blood outside the brain that are usually caused by severe head injuries). Review of Resident #1's hospital record dated 12/23/2024, revealed, in part, Resident #1 reportedly absconded (escaped) from his nursing home and was found after a ground level fall several blocks away. Review further revealed a Computed Tomography Scan (CT) (a type of scan that shows detailed images of the body) of Resident #1's head revealed a Non-displaced right temporal bone skull fracture and a right subdural hematoma. In a telephone interview on 01/03/2025 11:41 a.m., a 3rd party WanderGuard vendor staff member indicated the facility's original WanderGuard transmitters had a sleep mode function that would activate if a resident remained motionless for 20 to 30 seconds. Review of the facility's Elopement Binder located at Nursing Station j revealed a list dated 12/30/2024 of the following residents who required a WanderGuard transmitter and were considered at risk for elopement: Resident #2, #3, #R4, #R5, #R6, and #R7. Review of the facility's schedule dated 01/02/2025 revealed S7CNA provided direct care to #R4 and #R7. In an interview on 01/02/2025 at 1:01 p.m., S7CNA indicated Resident #R7 was the only resident at risk for elopement in her room assignment. S7CNA failed to identify Resident #R4 as a resident at risk for elopement. In a telephone interview on 01/02/2025 at 3:25 p.m., S7CNA indicated she used the secondary reset door code to open exit f. In an interview on 01/02/2025 at 1:15 p.m., S1Administrator/Regional Administrator indicated that he was the only person who used the secondary reset door code because it bypassed the WanderGuard panel/monitor security alert; if an elopement risk resident were to attempt to exit the facility the door would not alarm. S1Administrator/Regional Administrator confirmed the secondary reset door code should not be used by staff to open the facility's exit doors. Observation on 01/02/2025 at 1:30 p.m. revealed S3CNA used the secondary reset door code to unlock exit d. In an interview on 01/02/2025 at 1:32 p.m., S3CNA confirmed she used the secondary reset door code to unlock exits d and f. In an interview on 01/02/2025 at 1:40 p.m., S4Maintenance indicated the secondary reset door code was the code used to unlock both exits d and f. In an interview on 01/02/2025 at 1:41 p.m., S5CNA indicated the secondary reset door code was used to unlock both exits d and f. In an interview on 01/02/2025 at 1:45 p.m., S6CNA indicated the secondary reset door code was used to unlock both exits d and f. In an interview on 01/02/2025 at 2:27 p.m., S2Director of Nursing (DON) indicated Resident #1 obtained the right temporal bone (a bone in the skull) fracture and a right subdural hematoma after he eloped from the facility. S2DON further indicated Resident #1 should not have been able to get out the facility. The Immediate Jeopardy was removed on 01/03/2025 at 11:55 a.m., after it was verified through observations, interviews, and record reviews that the provider implemented an acceptable Plan of Removal prior to the survey exit. A Plan of Removal was accepted on 01/03/2025 at 11:55 a.m. which included the following actions to correct the deficient practice: Immediately after the elopement on 12/23/2024 at approximately 10:00 a.m., S2Director of Nursing and designees performed a census check to ensure all residents with WanderGuard transmitters were accounted for and that the WanderGuard transmitters were functioning properly. All residents were accounted for and all WanderGuard transmitters were checked by 10:20 a.m. On 12/13/2024 S1Administrator/Regional Administrator contacted a 3rd party WanderGuard vendor to inspect the facility's WanderGuard system. The inspection was completed on 12/23/2024 with no issues. S1Administrator/Regional Administrator discovered on 12/23/2024 at 10:00 a.m. that some WanderGuard transmitters have a sleep mode feature. S1Administrator/Regional Administrator immediately verified that the WanderGuard transmitters actively used by the facility's residents did not have the sensor with the sleep mode function. S1Administrator/Regional Administrator also ordered additional WanderGuard transmitters without a sleep mode on 12/23/2024 and received the new WanderGuard transmitters on 12/26/2024 at 9:00 a.m. S1Administrator/Regional Administrator immediately locked all entrances on 12/23/2024 at approximately 10:00 a.m. and they will remain locked indefinitely. Immediately after the elopement on 12/23/2024, S2DON and designees began in-servicing all staff on the WanderGuard system and appropriate monitoring for WanderGuard transmitter residents. S2DON also placed binders at each nurses' station identifying WanderGuard residents so that staff would be aware. Staff were in-serviced on the binders. S1Administrator/Regional Administrator, S2DON, S8Assistant DON and S9Assistant DON randomly completed follow up interviews with staff to ensure they had understanding of the WanderGuard system and appropriate monitoring of residents. On 12/23/2024 S2DON, S8Assistant DON and S9Assistant DON placed every 1 hour monitoring to WanderGuard transmitter residents' electronic Medication Administration Record for increased supervision. S2DON and designees also began hourly visual checks on WanderGuard residents. Starting on 12/23/2024, S10Assistant Administrator and designee began performing daily WanderGuard system checks to ensure proper functioning. On 12/23/2024 S1Administrator/Regional Administrator sent a letter to resident family members educating them on not opening entries for residents allowing them to leave the facility. On 01/02/2025 at approximately 2:00 p.m. S1Administrator/Regional Administrator reset all primary and secondary door codes that will remain confidential. All staff have access to the primary code and department head staff have access to the secondary code. On 01/02/2025 at approximately 5:00 p.m. S1Administrator/Regional Administrator and designees began in-servicing staff on how to identify WanderGuard transmitter residents and ensuring WanderGuard transmitter residents were not allowed to exit the facility. All staff would be in-serviced via phone or in person upon arriving for their shift. The in-servicing of all staff would be completed by 01/03/2025. The likelihood of serious harm to any resident related to elopement no longer existed as of 01/03/2025.

Based on record reviews, interviews, and observations, the facility failed to ensure residents who had a history of unsafe use of smoking materials were supervised and did not have smoking materials in their possession for 4 (Resident #33, Resident #83, Resident #86, and Resident #568) of 4 (Resident #33, Resident #83, Resident #86, and Resident #568) sampled residents reviewed for smoking. The deficient practice resulted in an Immediate Jeopardy situation on 07/19/2023 for Resident #568, a severely cognitively impaired resident, when Resident #568 had a cigarette lighter removed from his possession by S9Licensed Practical Nurse after Resident #568 attempted to enter the facility with a lit cigarette in his mouth and the facility failed to reassess the resident as an unsafe smoker and implement new interventions to prevent future smoking incidents. On 09/16/2023, Resident #568 sustained 2nd degree facial burns and required hospital emergency medical attention due to unsafely igniting a lighter in his room while using oxygen. Resident #33, Resident #83, and Resident #86 had a history of unsafe smoking in the facility and were assessed to need their smoking materials kept by staff. Observation on 09/20/2023 at 7:01 p.m. on the smokers' patio revealed Resident #33 requested Resident #86's blue lighter to light her cigarette. Observation revealed Resident #86 (a resident with a history of lighting a cigarette inside the facility) gave Resident #33 (a cognitively impaired resident who required supervision to ensure smoking in designated areas) his lighter and Resident #33 began to light her cigarette without staff supervision. Observation on 09/21/2023 at 9:55 a.m. revealed Resident #83 (a resident with a history of smoking in undesignated areas) was lying in his bed and was in possession of smoking materials. S1Administrator was notified of the Immediate Jeopardy on 09/21/2023 at 2:32 p.m. The Immediate Jeopardy was removed on 09/21/2023 at 5:56 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. The facility's Plan of Removal included the following: 1. Corrective actions were taken for the resident (Resident #33, Resident #83, Resident #86, and Resident #568) by the alleged deficient practice by: -S1Administrator began in-servicing staff on 09/21/2023 at 3:00 p.m. on the following: (will in-service staff prior to working shift on day, evening and night shift) the facilities smoking policy, -All smoking incidents (resident is caught lighting a cigarette in the facility, sharing cigarettes and lighters with unsafe smokers, etc.) must be reported to S1Administrator, S2Director of Nursing or the immediate supervisor immediately, It was absolutely forbidden to purchase or share cigarettes/lighters with all residents, and if a staff member was caught it would result in reprimand up to termination. -S32Assistant Administrator and Staff Development Nurse completed rounds on 09/21/2023 to ensure Resident #33, Resident #83, Resident #86, and Resident #568 were not in possession of smoking materials. -The Minimum Data Set Department completed smoking assessments on all residents that smoke on 09/21/2023 to determine safe and unsafe smokers. Resident #76 was also identified as unsafe. S5Corporate Nurse placed a nursing intervention on Resident #33, Resident #83, Resident #86, Resident #568, and Resident #76 electronic medication administration record to be signed off every shift informing nursing staff that these residents need their smoking materials held by staff. -S1Administrator performed resident council meeting on 09/21/2023 with residents that smoke informing them of the facilities smoking policies. -S1Administrator sent a group-cast communication on 09/21/2023 to the resident's responsible parties on ensuring smoking materials are given to the facility staff rather than to residents when delivering smoking materials. -A designated employee will be responsible for supervising unsafe smokers while smoking every shift starting on 09/21/2023. 2. All residents with a history of unsafe use of smoking materials have the potential to be affected by the alleged deficient practice. 3. Measures put in place to ensure the alleged deficient practice will not recur are: - Starting on 09/21/2023, S2Director of Nursing or designee will perform quality assurance rounds twice a day to ensure Resident #33, Resident #83, Resident #86, and Resident #568, and any other resident identified as an unsafe smoker, are not in possession of smoking materials and are appropriately supervised until 10/12/2023. -The Minimum Data Set Department was to ensure smoking assessments are completed on residents at admission, readmission and as needed. The Minimum Data Set Team is to communicate to the Interdisciplinary Team any smokers identified as unsafe or needing materials to be held by staff. - Starting 09/21/2023, S2Director of Nursing or designee to spot check smoking assessments at random twice a week to ensure compliance until 10/12/2023. - S5Corporate Nurse placed a nursing intervention on Resident #33, Resident #83, Resident #86, Resident #568, and Resident #76's electronic medical record to be signed off every shift informing nursing staff that these residents need their materials held by staff. - S2Director of Nursing or designee to place nursing intervention on any unsafe smoker identified after 09/21/2023. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: - Starting on 09/21/2023, S2Director of Nursing or designee will perform quality assurance rounds twice a day to ensure Resident #33, Resident #83, Resident #86, Resident #568, and Resident #76 and any other resident identified as an unsafe smoker are not in possession of smoking materials and are appropriately supervised. 5. The likelihood of serious harm to Resident #33, Resident #83, Resident #86, Resident #568 and Resident #76 no longer existed after 4:30 p.m. on 09/21/2023. The deficient practice has the potential to cause more than minimum harm to any remaining unsafe smokers in the facility. Findings: Review of the facility's Smoking Policy and Procedure revealed, in part, safe smoking assessment and/or Interdisciplinary (ID) Team will determine if resident is safe to smoke. Residents deemed unsafe will be discussed with ID Team to determine protocol to be implemented on individual basis (ex. smoking apron needed, cigarettes stored at nurses station, lighter removed from resident from resident possession, direct supervision needed, etc.). Safe smoking assessments will be completed on residents who smoke upon admission, re-smoking assessments will be completed on residents who smoke upon admission, readmission, quarterly, annually, significant changes, and as needed. Further review revealed no documented evidence for the protocol of when direct supervision was required for unsafe smokers. Resident #568 Review of Resident #568's medical record revealed Resident #568 was admitted to the facility on [DATE] with diagnoses of depression, latent syphilis, CHF, COPD, alcohol dependence, hypertension, tobacco use, dependence on supplemental oxygen and nicotine dependence cigarettes. Review of Resident #568's Quarterly MDS with ARD of 06/28/2023 revealed, in part, Resident #568 had BIMS score of 7 which indicated severe impaired cognition. Review of Resident #568's Assessment for Safe smoking with a completion date of 06/28/2023 revealed, in part, memory ok and modified independence with decision making. Further review revealed, in part, Resident #568 is an occasional smoker and is considered a safe smoker. Review of Resident #568's Comprehensive Care plan, with a start date of 06/28/2023, revealed, in part Resident #568 was a safe smoker. Further review revealed, Resident #568's care plan was updated 09/16/2023 and indicated Resident #568 now an unsafe smoker because Resident #568 received burns from lighting a lighter in his room with oxygen in place. Further review revealed the following interventions, in part, Resident #568 will be reminded to smoke in designated smoking areas, Resident #568 will have cigarettes and lighter be administered to him and Resident #568 will need to be taken to the designated smoking areas at times. Review of Resident #568's nursing progress notes completed on 07/19/2023 at 1:31 p.m. by S9LPN revealed Resident #568 came from the back patio with a lit cigarette from his mouth, and S9LPN immediately removed the cigarette from Resident #568's mouth and put it out. S9LPN further indicated Resident #568's lighter was taken from him. ADON notified. Review of Resident #568's medical record revealed no documentation of a safe-smoking assessment or re-assessment following the resident's attempt to enter the facility with a lit cigarette on 07/19/2023. In an interview on 09/20/2023 at 2:55 p.m., S9LPN stated on 07/19/2023 Resident #568 had activated the automatic door to enter the facility through vestibule from designated smoking area and had a lit cigarette in his mouth. S9LPN stated she stopped Resident #568 prior to him entering the doorway and extinguished his cigarette and took his lighter away. S9LPN stated she took Resident #568's lighter because she felt he was unsafe to be in possession of his smoking material due to his cognitive status and other behaviors that displayed Resident #568's safety awareness was impaired. S9LPN stated Resident #568 was sent out to an inpatient psychiatric facility on 07/20/2023 for inappropriate sexual behaviors. S9LPN further stated she notified S4Assistant Director of Nursing of the unsafe smoking incident on 07/19/2023. In an interview on 09/20/2023 at 3:00 p.m., S4Assistant Director of Nursing stated she did not recall being told about the incident with Resident #568 on 07/19/2023. Review of Resident #568's nursing progress note completed on 07/20/2023 at 9:34 pm revealed Resident #568 was sent to inpatient psychiatric facility. Review of Resident #568's nursing progress note completed on 07/28/2023 at 12:37 p.m. revealed Resident #568 returned to the facility from the hospital. Further review of Resident #568's medical record revealed no documentation that a safe smoking re-assessment was completed upon the Resident's 07/28/2023 readmission. In an interview on 09/20/2023 at 3:20 p.m., S2DON stated the Assessment for Safe Smoking is completed upon admission, readmission, and quarterly and as needed. S2DON confirmed Resident #568 returned from hospital on 07/28/2023 and an Assessment for Safe Smoking was not completed. S2DON stated they did not deem Resident #568 an unsafe smoker after the incident on 07/19/2023 because he did not enter the facility with a lit cigarette. In an interview on 09/20/2023 at 4:00 p.m., S21Minimum Data Set (MDS) nurse stated the Assessment for Safe Smoking are not done on readmission unless there is a need for a MDS to be done. S21MDS Nurse confirmed Resident #568 did not have a smoking assessment done on 07/28/2023 when he returned from the hospital. S21MDS Nurse stated she was not aware the facility Smoking policy stated Assessment for Safe Smoking are supposed to be completed on readmission. Review of Resident #568's nursing progress notes completed on 09/16/2023 at 1:33 p.m. revealed strong smoke smell noted on hallway. Resident #568 up in wheelchair on hallway outside of doorway with black soot noted to his face. Nurse asked Resident #568 what happened and Resident #568 stated he was playing with a lighter with his oxygen on with a nasal cannula in his nose. Resident #568 says he was just flicking the lighter. Nurse asked Resident #568 why he would do that and he stated he knows he is not supposed to smoke with oxygen. Resident #568 stated because I'm an idiot and started laughing. Nurse took lighter from Resident #568 and nurse checked Resident #568's belongings for more cigarettes and cigarettes were removed out of the room. Resident #568 was noted with black soot inside nostrils on bilateral cheeks and eyebrows. Nurse cleaned Resident #568's face with wet towel and applied ice and cold wet compresses to face. Redness noted to Resident #568's face. Nurse notified MD and an order obtained to send to the hospital for evaluation and call placed to Resident #568's daughter. Review of Resident #568's After Visit Summary from hospital emergency visit completed on 09/16/2023 revealed Resident #568's reason for visit was facial burn and diagnosis of facial burn, second degree. Review of Resident #568's Wound Assessment Report completed on 09/16/2023 revealed, in part, Resident #568 with a burn to upper lip, left cheek and right cheek measuring 7.00 cm x 11.00 cm. Burn type was thermal. Burn depth was superficial partial thickness. In an interview on 09/18/2023 at 12:56 p.m., Resident #568 stated he lit his face on fire with a lighter on 09/16/2023 when he was attempting to smoke. Resident #568 further stated when he went to light his cigarette it caught his mustache on fire. Observation on 09/20/2023 at 8:30 a.m. revealed Resident #568 up in his wheelchair rolling around in designated smoking area asking other residents for cigarettes and was unable to obtain one. Resident #568 then rolled back into the facility. In an interview on 09/20/2023 at 11:45 a.m., S26Certified Nursing Assistant (CNA) stated she was here on 09/16/2023 when Resident #568 caught his face on fire. S26CNA stated in regards to Resident #568's incident on 09/16/2023, she and the nurse were doing rounds, smelled something burning and Resident #568 came into the hallway with soot on his face. S26CNA further stated Resident #568 stated he was playing with a lighter with oxygen on. In an interview on 09/20/2023 at 11:48 a.m., S9LPN stated they are informed about unsafe smokers in a binder that is kept at the nursing station. S9LPN stated for residents who are unsafe smokers, the nurses hold their smoking materials and staff have to supervise them when they smoke. S9LPN stated there is a designated smoking area but there are no designated smoking times. S9LPN stated Resident #568 is an unsafe smoker and is not allowed to have cigarettes and lighters in his personal belongings. In an interview on 09/20/2023 at 12:50 p.m., S2Director of Nursing stated unsafe smokers are not allowed to have their cigarettes or lighters, these items are held by the nurse and they are supervised by staff members when they go out to smoke. Resident #33 Review of Resident #33's face sheet revealed, in part, Resident #33 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease. Review of Resident #33's Minimal Data Set (MDS) with an Assessment Reference Date of 08/13/2023 revealed, in part, Resident #33's Brief Interview for Mental status score was 5 which indicated Resident #33 had severe cognitive impairment. Review of Resident #33's assessment for safe smoking with a completion date of 08/14/2023 revealed, in part, Resident #33 was an unsafe smoker. Review of this assessment revealed, Resident #33 was deemed an unsafe smoker related to having a diagnosis of Dementia. Review revealed Resident #33 had been known to light cigarettes in her room and in her restroom. Review revealed Resident #33's cigarettes were to be kept on the nursing cart and were to be distributed to Resident #33 by the floor nurse. Further review revealed Resident #33 was to be monitored by staff in the designated smoking area. Review of Resident #33's Comprehensive Care Plan, with a start date of 03/16/2023, revealed, in part, Resident #33 had a history of smoking in unauthorized areas. Review revealed Resident #33 needed her cigarettes and lighter administered to her. Further review revealed Resident #33 needed to be redirected to the authorized smoking areas. In an interview on 09/21/2023 at 12:55 p.m. S5Corporate Nurse stated the interventions on Resident #33's care plan are the interventions that should be followed for Resident #33 when she was smoking. Observation on 09/20/2023 at 3:55 p.m. revealed Resident #33 sitting outside in the designated smoking area holding two cigarettes. Observation revealed Resident #33 placed one cigarette in the right side of her bra, requested a light from a random resident, and began smoking a brown cigarette without staff supervision. In an interview on 09/20/2023 at 4:06 p.m., Resident #33 stated she enjoys smoking. Resident #33 further stated, she likes to smoke in the evening because staff do not bother her in the evening. In an interview on 09/20/2023 at 4:58 p.m. Resident #33's family member stated Resident #33 had a history of smoking in the her room and her bathroom. Resident #33's family member stated Resident #33 is not allowed to have smoking materials on her person per the facility's administration team. In an interview on 09/20/2023 at 6:56 p.m., Resident #33 stated she was going outside to smoke. Observation on 09/20/2023 at 6:57 p.m. revealed Resident #33 removed 2 cigarettes from her bra and proceeded to the nurse's station. Observation revealed Resident #33 informed S25Ward Clerk and S24Licensed Practical Nurse she was going outside to smoke. Further observation revealed Resident #33 proceeded outside to the designated smoking area without staff present. Observation on 09/20/2023 at 7:01 p.m. revealed, Resident #33 requested Resident #86's blue lighter to light her cigarette. Observation revealed Resident #86 gave Resident #33 his lighter and Resident #33 began to attempt to light her cigarette without staff supervision. In an interview on 09/20/2023 at 7:03 p.m., S25Ward Clerk stated Resident #33 required supervision when smoking. S25Ward Clerk stated the facility does not have an assigned person in place to supervise residents who smoke. S25Ward Clerk further stated the certified nursing assistants on shift and the facility's ward clerks try to alternate supervising the residents who smoke, but they are not able to do it all the time. In an interview on 09/20/2023 at 7:10 p.m., Resident #110, a resident with a BIMS score of 13 indicating Resident #110 was a cognitively intact resident, stated Resident #33 smoked multiple times a day, mainly in the evening time. Resident #110 stated she does not smoke, but enjoyed sitting outside in the designated smoking area with Resident #33. Resident #110 stated Resident #33 received her cigarettes from the nurse's cart or other residents. Resident #110 stated once Resident #33 received a lighter from other residents that have their lighter in the designated smoking area. Resident #110 stated staff do not supervise Resident #33 when she is smoking. Resident #110 further stated she supervised Resident #33 smoke and made sure she was safe. In an interview on 09/21/2023 at 1:00 p.m., S1Adminstrator stated residents who require assistance are not unsafe smokers. S1Administrator stated residents who smoke all have specific interventions specified on their careplan and smoking assessments that outlines the reason they require assistance. S1Administrator further stated residents who have smoked in the facility should be considered an unsafe smoker. S1Administrator stated to his knowledge, Resident #33 was not an unsafe smoker. S1Administrator further stated he was not informed of the prior incidents mentioned above. In an interview on 09/21/2023 at 2:42 p.m., S34Minimum Data Set Nurse stated smoking assessments are completed on admission and quarterly. S34Minimum Data Set Nurse further stated Resident #33 should have had a smoking assessment completed in June 2023 when her quarterly MDS was completed and she did not. Resident #83 Review of Resident #83's medical record revealed admitted to the facility on [DATE] with diagnoses of neuropathy, major depressive disorder, attention deficit hyperactivity disorder, peripheral vascular disease, insomnia, pain in leg, chronic pain, tobacco use, polyneuropathy, anxiety disorder, and opioid dependence. Review of Resident #83's Quarterly Minimum Data Set (MDS) with Assessment Reference Date of 07/31/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Review of Resident #83's Assessment for Safe Smoking for 07/31/2023 revealed, in part, Resident #83 is a frequent smoker and was considered an unsafe smoker because of reports of Resident #83 lighting cigarettes in the facility. Further review revealed Resident #83's smoking material is held at nurses' station and is given to him by the nurse. Review of Resident #83's Comprehensive Care Plan with start date of 03/07/2023, updated on 05/31/2023 and 07/31/2023 revealed, in part, Resident #83 was a safe smoker but had a history of smoking in undesignated areas and required staff to keep Resident #83's cigarettes and give them to him when it was time to smoke. Further review revealed Resident #83 would be reminded to smoke in designated smoking areas and may need supervision when smoking. Review of the facility's smoker's list with a date of 09/19/2023 revealed Resident #83 was a safe smoker who required smoking materials be held for him. Observation on 09/21/2023 at 8:34 a.m. revealed Resident #83 wheeling his wheelchair in the hallway with brown cigar lying on his lap. In an interview on 09/21/2023 at 8:34 a.m., Resident #83 stated he was going outside to smoke. Observation on 09/21/2023 at 9:43 a.m. revealed Resident #83 outside in designated smoking area smoking a brown cigarette without staff present. Observation on 09/21/2023 at 9:55 a.m. revealed Resident #83 lying in bed and resident showed this surveyor a gray scripto lighter he had in his pants waist band. In an interview on 09/21/2023 at 9:55 a.m., Resident #83 stated he is a smoker and his uncle brings him a carton of Santa Fe filtered cigars every one and a half weeks. Resident #83 further indicated he stores his cigars in his dresser drawer. Resident #83 stated he only has the one gray scripto lighter which is in his waist band of pants but he usually buys his lighters from a staff member. Resident #83 stated he has always been able to hold his cigarettes and lighters and has never had to be supervised by staff while he smoked. In an interview on 09/21/2023 at 9:57 a.m., S9Licensed Practical Nurse (LPN) stated Resident #83 has always had his cigarettes and lighter on him and nursing staff have never had to hold his cigarettes and lighter for him. S9LPN stated she was not aware Resident #83 was listed on Smoker list dated 09/19/2023 as a Smoker whose material must be held. Resident #86 Review of Resident #86's face sheet revealed, in part, Resident #86 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, and Tobacco Use. Review of Resident #86's Minimal Data Set with an Assessment Reference Date of 08/23/2023 revealed, in part, Resident #86's Brief Interview for Mental status score was 12 which indicated Resident #86 was moderately cognitively impaired. Review of Resident #86's assessment for safe smoking with a completion date of 08/23/2023 revealed, in part, Resident #86 was a safe smoker. Further review revealed, Resident #86 had to have his cigarettes administered to him due to lighting a cigarette in the facility. Review of Resident #86's Comprehensive Care Plan, with a start date of 02/01/2023, and a revision date of 08/18/2023 revealed, in part, staff were currently holding Resident #86's cigarettes. Further review revealed, staff were to report any unsafe smoking and/or smoking in unauthorized area to nursing staff. Review of the facility's smoker's list with a date of 09/19/2023 revealed Resident #86 was a safe smoker, but needed his smoking materials held by facility staff. Review of Resident #86's assessment for safe smoking with a completion date of 08/23/2023 revealed, in part, Resident #86 was a safe smoker. Further review revealed, Resident #86 had to have his cigarettes administered to him due to lighting a cigarette in the facility. Observation on 09/20/2023 at 3:56 p.m. revealed Resident #86 was outside with a pack of cigarettes and a cigarette lighter in his possession, smoking in the designated smoking area, without staff supervision. Observation on 09/20/2023 at 7:00 p.m. revealed, Resident #86's in the designated smoking area in possession of a blue lighter and cigarettes. Observation revealed Resident #86 gave Resident #33 his blue lighter when Resident #33 requested it to light her cigarette. In an interview on 09/21/2023 8:45 a.m., Resident #86 stated he had one incident in the past where he smoked in the facility. Resident #86 stated the facility never informed him he was considered an unsafe smoker or he was not allowed to keep his smoking materials. Resident #86 stated prior to last night, he was able to keep his own cigarettes and lighter. Resident #86 stated he shares his lighter with other residents and he was unaware that was unsafe smoking practices. In an interview on 09/21/2023 at 10:05 a.m., S9Licensed Practical Nurse stated worked at the facility on day shift. Resident #86 became an unsafe smoker as of 09/21/2023. S9Licensed Practical Nurse stated prior to 09/21/2023, she did not keep Resident #86's smoking material on her cart, because she was unaware he was an unsafe smoker. In an interview on 09/21/2023 at 11:15 a.m., S23Minimum Data Set Nurse stated she completed Resident #86's Assessment For Safe Smoking dated 08/23/2023 because she was informed by another staff member that Resident #86 lit a cigarette in his room and attempted to smoke.S23MDS Nurse further stated the safe smoking assessment was the facility's tool for identifying whether a resident was a safe smoker or an unsafe smoker. In an interview on 09/21/2023 at 11:20 a.m. S1Adminstrator stated to his knowledge, Resident #86 had no previous incidents with smoking material prior to 09/20/2023. S1Adminstrator further stated any resident that was caught smoking in the facility should be deemed an unsafe smoker and should not smoke unsupervised nor have smoking materials in their possession without staff supervision. S1Administrator further stated he was not informed of the previous unsafe smoking incidents listed above. 48148

The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to provide the necessary administrative oversight to ensure systems were in-place and implemented for residents who had a history of unsafe use of smoking materials were supervised and did not have smoking materials in their possession for 4 (Resident #33, Resident #83, Resident #86, and Resident #568) of 4 (Resident #33, Resident #83, Resident #86, and Resident #568) sampled residents reviewed for smoking. The deficient practice resulted in an Immediate Jeopardy situation on 07/19/2023 for Resident #568, a severely cognitively impaired resident, when Resident #568 had a cigarette lighter removed from his possession by S9Licensed Practical Nurse after Resident #568 attempted to enter the facility with a lit cigarette in his mouth and the facility failed to reassess the resident as an unsafe smoker and implement new interventions to prevent future smoking incidents. On 09/16/2023, Resident #568 sustained 2nd degree facial burns and required hospital emergency medical attention due to unsafely igniting a lighter in his room while using oxygen. Resident #33, Resident #83, and Resident #86 had a history of unsafe smoking in the facility and were assessed to need their smoking materials kept by staff. Observation on 09/20/2023 at 7:01 p.m. on the smokers' patio revealed Resident #33 requested Resident #86's blue lighter to light her cigarette. Observation revealed Resident #86 (a resident with a history of lighting a cigarette inside the facility) gave Resident #33 (a cognitively impaired resident who required supervision to ensure smoking in designated areas) his lighter and Resident #33 began to light her cigarette without staff supervision. Observation on 09/21/2023 at 9:55 a.m. revealed Resident #83 (a resident with a history of smoking in undesignated areas) was lying in his bed and was in possession of smoking materials. S1Administrator was notified of the Immediate Jeopardy on 09/21/2023 at 2:32 p.m. The Immediate Jeopardy was removed on 09/21/2023 at 5:56 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. The facility's Plan of Removal included the following: 1. Corrective actions were taken for the residents (Resident # 33, Resident # 83, Resident # 86 and Resident # 568) by the alleged deficient practice by: -S5Coorporate Nurse in-serviced administrative staff (S2Director of Nursing, S1Administrator, S32Assistant Administrator, S4Assistant Director of Nursing, Minimum Data Set Department) on 09/21/2023 on ensuring the safety of unsafe smokers. -Facility audit performed on 09/21/2023 revealed that Resident # 33, Resident # 83, Resident # 86, and Resident # 568, and Resident # 76 were not in possession of smoking materials. 2. All residents with the history of unsafe smoking habits have the potential to be affected by the alleged deficient practice. 3. Measures put in place to ensure the alleged deficient practice will not reoccur are: -S5Coorporate Nurse in-serviced administrative staff on 09/21/2023 on ensuring the safety of unsafe smokers. -Facility audit performed on 09/21/2023 revealed that Resident # 33, Resident # 83, Resident # 86 and resident # 568 and Resident # 76 were not in possession of smoking materials. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: - Beginning on 09/21/2023 S6Regional Director or designee will perform Quality Assurance Administration audits once a week until 10/12/23 to ensure the facility is being administered in a manner that uses resources to effectively and efficiently meet the needs and safety of unsafe smokers. S6Regional Director will monitor the facility administrator weekly to ensure the S1Administrator is providing appropriate monitoring and supervision for unsafe smokers. - Beginning on 09/21/2023 S5Coorporate Nurse or designee will perform Quality Assurance Administration nursing audits two times per week until 10/12/2023 to ensure the facility is being administered in a manner that uses resources to effectively and efficiently meet the needs and safety of unsafe smokers. -S5Cooporate Nurse or designee to review S2Director of Nursing audits once per week to ensure compliance until 10/12/2023. 5. The likelihood of serious harm to Resident # 33, Resident # 83, Resident # 86, Resident # 568 and Resident # 76 no longer existed after 4:30 p.m. on 09/21/2023. The deficient practice has the potential to cause more than minimum harm to any remaining unsafe smokers in the facility. Findings: Cross Reference F-689. In an interview on 09/21/2023 at 11:20 a.m., S1Adminstrator stated to his knowledge, Resident #86 had no previous incidents with smoking material prior to 09/20/2023. S1Adminstrator further stated any resident, including Resident #33, Resident #83, and Resident #86, and Resident #568, caught smoking in the facility should be deemed an unsafe smoker and should not smoke unsupervised nor have smoking materials in their possession without staff supervision. Further, when this surveyor asked S1 Administrator, what was the facility's process to ensure unsafe smokers are supervised while smoking and do not have smoking materials in their possessions, S1Administrator declined to answer. In an interview on 9/21/2023 at 11:20 a.m., when this surveyor asked S5Corporate Nurse, what was the facility's process to ensure unsafe smokers are supervised while smoking and do not have smoking materials in their possessions, S5Corporate Nurse declined to answer. 48148

Based on observations, interviews, and records review, the facility to: 1. Ensure a newly admitted resident (Resident #1), with a known history of smoking, who displayed confusion, was supervised while smoking; and 2. Have a system in place to ensure residents who were identified as unsafe smokers, did not have access to smoking materials and were supervised while smoking for 5 of 5 (Resident #2, #3, #7, #8, and #9) unsafe smokers reviewed for safe smoking. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on [DATE] at 4:25am, when the fire alarm sounded and Resident #1 was found in a smoke filled room after the sprinkler system activated, extinguishing fire from Resident #1's bed. Resident #1 was screaming in pain and could not breathe. The resident's skin was singed and sloughing off. A cigarette lighter was found in Resident #1's room on the floor. On [DATE] at 4:36 a.m., Resident #1 was transferred to a local hospital where he was treated for third degree [CONDITION(S)]. Resident #1 later expired on [DATE] from his injuries. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 1:15pm. The Immediate Jeopardy was removed on [DATE] at 4:36 a.m. for Resident #1 when Resident #1 was transferred to a local hospital. The likelihood of harm and/or death continued for five other residents (#2, #3, #7, #8, and #9) who were identified by the facility staff as unsafe smokers. The Immediate Jeopardy was removed on [DATE] at 8:00am, after it was determined through observation, interview, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. [DATE] at 8am S4DON (Director of Nursing), evening supervisor, and weekend supervisor or designee initiated all staff in-services which was to continue until all staff were in-serviced on the following: a. All residents admitted to the facility will have their belongings searched for smoking materials and if found, they will be stored in a locked medication cart until a smoking assessment had been completed and deemed a safe smoker; b. If smoking materials are found in resident's belongings, they will be taken and locked in the medication cart until a smoking assessment is completed by MDS (Minimum Data Set) nurses; c. All new admits will be considered an unsafe smokers until a smoking assessment is completed by MDS nurses; d. A Smoking status will be included in the admission note to ensure staff was aware if a resident was a smoker; e. An inventory of a new admit's belongings will be completed upon admission per the designated Certified Nursing Assistant (CNA); f. An updated resident smoker list will be placed at each nurse's station in the schedule/skilled binder. The list will be updated with any new admissions or discharges; and g. Nurses will keep smoking materials locked in the medication cart for any resident who was assessed as an unsafe smoker and nursing staff will distribute smoking materials. 2. [DATE] at 8:00am: Director of Nursing (DON) or designee to observe new admits weekly to ensure new procedures are being followed. 3. [DATE] at 8:00am: New admission packet questionnaire was developed and was initiated for smoking, with the admissions department in-serviced. All direct care staff that has worked up to this point was in-serviced on this new procedure per DON/designee. All other staff will be in-serviced per the DON, evening supervisor and weekend supervisor prior to working by [DATE]. 4. [DATE] at 12:36pm: NFA (nursing facility administrator) and staff removed smoking materials from unsafe smoker's room. 5. [DATE] at 8:00am: staff were assigned to monitor unsafe smokers. Three CNAs were assigned to supervise during the weekdays on the day and evening shift, the night nurse was assigned to supervise/monitor the unsafe smokers on the night shift, and the Weekend Supervisor was assigned to supervise/monitor the unsafe smokers during the day and evening shift on the weekends. Smoking times will be done at 9am, 11am, 2pm, 6pm and 10pm at the designated smoking patio. This process was initiated and will be fully compliant by [DATE]. 6. [DATE] staff were in-serviced again on where to find documentation on identifying safe and unsafe smokers. 7. Resident Council meeting will be held on [DATE] at which time new smoking policies and search of belongings. The admissions department will make new admits aware of policies upon admit beginning [DATE]. Residents will be in-serviced again on not sharing smoking materials with other residents and if found to do so, they will be deemed unsafe smokers and have their smoking materials secured on a locked medication cart. 8. DON or designee will complete random audits weekly to ensure compliance with new procedures. 9. Facility created a consent form to ensure residents consent and allow the facility to search their belongings and remove unsafe smoking materials by [DATE]. Findings: Review of the facility's Smoking Policy and Procedure revealed, in part: the Smoking Assessment and/or IDT (Interdisciplinary Team) will determine if a resident is safe to smoke. Residents who were deemed unsafe will be discussed with the IDT to determine protocol to be implemented on individual basis (ex: direct supervision needed). Further review revealed no documented evidence for the protocol of when direct supervision was required for unsafe smokers. Resident #1 Review of Resident #1's Discharge Hospital Medical Records dated [DATE] revealed Resident #1 was diagnosed with transient disorientation, selective memory deficits, and had a history of cannabis abuse. Further review revealed Resident #1 had a [AGE] year history of smoking and currently smoked one pack a day. Review of Resident #1's Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Disorientation, Cannabis Abuse, Tobacco use, and Cortical Age-Related Cataract. Review of Resident #1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed Resident #1 had short and long term memory problems. Further review revealed Resident #1 decision-making skills were moderately impaired. Review of Resident #1's Interim Care Plan dated [DATE] revealed no documented evidence of his cognition or smoking risk having been assessed, or care planned. Review of Resident #1's Nursing Notes dated [DATE] revealed the resident was alert to self with confusion noted. Review of the facility's Fire Investigation for Resident #1 for the [DATE] incident revealed, in part: [DATE] at 7:40pm Resident #1 arrived to the facility and was assessed by S7License Practical Nurse (LPN). [DATE] at 8:06pm Resident #1 was taken to the smoker's patio by S9CNA. Resident #1 was seen on video being given a cigarette and lighter from Resident #R1, smoked one cigarette, and returned the lighter to Resident #R1. [DATE] at 10:04pm S8LPN brought Resident #1 a bag of personal belongings delivered to the facility by his wife. [DATE] at 4:25am Fire alarm activates. [DATE] at 4:26am Staff calls 911. [DATE] at 4:27am Staff identifies room where smoke was coming from and pulls Resident #1 out of the room. [DATE] at 4:36am Resident #1 was taken out of the facility, and sent to the emergency room for evaluation and treatment. Further review revealed an orange cigarette lighter was noted to the left of the bed on the floor during investigation. Observations on [DATE] at 10:55am revealed Resident #1's top left side of his mattress was approximately 75% black with the padding of the bed melted, and approximately 25% of the bottom left side of the mattress was black and melted. Observation revealed the bedding was approximately 40% black and burnt. Observation revealed a pair of athletic shorts were on the bed approximately ,d+[DATE]% black and melted. The pillow on the bed was approximately 90% melted and black. The corner of the walls closest to Resident #1's bed, ceiling, and floors were covered in black soot like substance. Further observation revealed Resident #1's blinds on the windows were approximately 20% misshaped. The floors in the room, closet, and bathroom were covered with thin layer of water with a black floating substance. Review of Resident #1's Emergency Department to Hospital Admission Note dated [DATE] revealed Resident #1 was treated for third degree [CONDITION(S)] to ,d+[DATE]% of body, and [CONDITION(S)] of any degree to 85% of total body surface area. Resident #1 expired on [DATE] at 2:43pm. In an interview on [DATE] at 12:31pm, S4DON (Director of Nursing) stated the smoking assessment on Resident #1 had not been completed on Resident #1 prior to the fire incident. In an interview on [DATE] at 8:49pm, S6LPN stated in report for her shift on [DATE] S7LPN stated Resident #1 was very confused and tried to get out of bed all night. S6LPN stated on [DATE] at 4:35am, the fire alarm went off and she got up to check on it. When she got to the hallway she saw smoke coming out of Resident #1's open doorway and smoke was filling the hallway. S6LPN stated Resident #1 was screaming he could not breath and screaming in pain. S6LPN stated Resident #1 was naked and his skin especially his arms already had skin sloughing off and his skin was singed almost completely. S6LPN stated she was unaware the resident had a lighter. S6LPN stated the firefighter told her they found a lighter but no cigarettes in Resident #1's room during their investigation. In an interview on [DATE] at 11:12am, S7LPN stated when Resident #1 was admitted he was alert but could not keep a steady conversation and would change topics. S7LPN stated he appeared alert only to self and that he liked to smoke and had he asked where the smoking section was located. S7LPN stated he was trying to get out of bed often and she had redirected him on not getting out of bed. S7LPN stated she did not complete a smoking assessment because it was usually completed the next day, and did not know what personal items were in the bag his spouse had brought in. In an interview on [DATE] at 11:35am, S8LPN stated she received the phone call from Resident #1's wife around 9:45pm that she had dropped off the bag of items outside and asked if somebody could bring it to him. S8LPN stated she brought a purple zipped bag to Resident #1 but did not know what the contents of the bag were. S8LPN stated Resident #1 did seem a little confused. In an interview on [DATE] at 2:00pm, Resident #R1 stated she had given Resident #1 a cigarette on [DATE]. Resident #R1 stated on [DATE], Resident #1 was on the smoker's patio and seemed confused. Resident #R1 stated a CNA introduced him to us and then left him there with us for a while. Resident #R1 stated Resident #1 did not have cigarettes at first and he called his wife for cigarettes. Resident #R1 stated Resident #1 had given her back her lighter after smoking. In an interview on [DATE] at 3:07pm, S9CNA stated Resident #1 asked to go to the smoker's patio, and did not have any cigarettes with him. S9CNA stated the nurse knew I was bringing Resident #1 outside to the smoker's patio, but she did not notify me if he was a safe smoker. S9CNA stated she was not sure how the CNA staff would be notified if a resident was a safe smoker or not. S9CNA also stated she brought him to the smoker's patio, but did not stay out on the patio with him to ensure safety. A Review of the facility's security footage, on [DATE] at 2:30pm, with S1Administrator revealed Resident #1 was taken to the smoker's patio by S9CNA on [DATE] at 8:06pm and was left unsupervised with other residents while smoking. Further review revealed Resident #R1 gave Resident #1 a cigarette and lighter to smoke and Resident #1 gave Resident #R1 back the lighter. Review of the facility's list of unsafe smokers revealed Resident #2, #3, #7, #8, and #9 were identified as unsafe smokers. Resident #2 Review of Resident #2's Record revealed he was admitted on [DATE] with diagnoses of, in part: Intracranial Injury, [CONDITION(S)], and Dementia. Review of Resident #2's MDS (Minimum Data Set) ARD (Assessment Reference Date) [DATE] revealed, in part: BIMS (Brief Interview for Mental Status) score of 11 (score of ,d+[DATE] indicated moderate cognitive impairment); Resident with no s/s (signs and symptoms) of [CONDITION(S)] or [CONDITION(S)]; resident required only setup and supervision for ADLs (Activities of Daily Living). Review of Resident #2's Care Plan revealed problems of, in part: Resident #2 had impaired skin integrity with [CONDITION(S)] to fingers from cigarettes with goal date of [DATE], with approaches of, in part: supervise smoking, lighter, and cigarettes to be placed on cart. Review of Resident #2's Physician Telephone Orders dated [DATE] revealed supervise while smoking, and keep lighter and cigarettes on the medication cart at all times. Review of Resident #2's Assessment for Safe Smoking dated [DATE] revealed in part: Resident #2 has recently burned her fingers while smoking on [DATE], and has a history of this occurring. Review further revealed the facility would continue to have Resident #2 as an unsafe smoker. Review of Resident #2's Nurse's Notes revealed the following, in part: [DATE] - Resident #2 was noted with [CONDITION(S)] to the right hand second and third digit. Resident #2 stated she burned fingers while smoking cigarettes. [DATE] - Resident #2's third finger to the right hand had a burn from smoking. [DATE] - orange/brown discoloration noted to middle finger on her right hand. [DATE] - Resident #2 was noted with a closed blister to the right lateral pointer finger measuring 1.5cm x 1cm and right middle finger closed blister measuring 2cm by 1.2cm. Resident #2 stated she was smoking her cigarettes and burned herself. In an interview on [DATE] at 12:15pm, Resident #2 stated she spends most of her day out on the patio smoking. Resident #2 was asked if she had cigarettes and she stated no the nurse keeps them. Resident #2 was then asked if she had a lighter and she stated yes, and opened the top drawer of her bedside table, and the surveyor observed an orange disposable lighter. In an interview on [DATE] at 12:20pm, S10LPN stated she kept Resident #2's cigarettes and lighter in her cart. S10LPN stated she will give Resident #2 her lighter and cigarette when she requests to smoke, and applies a cigarette extender to the cigarette. S10LPN was asked who supervises the resident while she smokes and S10LPN stated the facility used to have staff that would go out with the smokers, but the facility no longer had someone to go out with the smokers. In an interview on [DATE] at 12:30pm, S11CNA stated Resident #2 goes outside to smoke by herself. Observation on [DATE] at 12:32pm, revealed Resident #2 was sitting on the patio with cigarette extender and orange lighter smoking a cigarette. Further observation revealed no staff present with the residents on the smoker's patio. In an interview on [DATE] at 12:33pm, Resident #2 stated she had received the cigarette from another male resident. Resident #3 Review of Resident #3's Record revealed Resident #3 was admitted to the facility on [DATE]. Review of Resident #3's MDS with an ARD of [DATE] revealed in part a BIMS score of 01 (score of ,d+[DATE] indicating the resident was severely cognitively impaired). Review of Resident #3's Assessment for Safe Smoking dated [DATE] revealed, in part, Resident #3 was identified as a heavy smoker. Review of Resident #3's Care Plan revealed on [DATE] the resident's Care Plan was updated to include the resident had a potential for injury related to at times Resident #3 was an unsafe smoker. Further review revealed interventions of, in part, Resident #3 may need supervision when he smokes. In interview on [DATE] at 1:10pm, S17LPN indicated Resident #3 was a smoker and was classified as an unsafe smoker because of his confusion. S17LPN stated Resident #3's lighter was removed from his possession on [DATE]. Resident #7 Review of Resident #7's Record revealed Resident #7 was admitted to the facility on [DATE] with diagnosis, in part, Dementia. Review of Resident #7's MDS with an ARD of [DATE] revealed Resident #7 was moderately cognitively impaired. Review of Resident #7's Assessment for Safe Smoking dated [DATE] revealed a note of, in part, Resident #7 was smoking in an un-authorized smoke area, in bathroom. Further review revealed Resident #7 was classified as an unsafe smoker, and smoking material would be kept on the nurse's medication cart. Review of Resident #7's Care Plan revealed on [DATE] the resident's care plan was updated to include Resident #7 had a potential for injury related to being an unsafe smoker and needed supervision when he smoked. In an interview on [DATE] at 1:48pm, S10LPN stated she would distribute only four cigarettes at a time to Resident #7. Resident #7 would smoke a partial cigarette and then keep it for another time and accumulate cigarettes and therefore had to be monitored. Resident #8 Review of Resident #8's Record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses, in part, Dementia, Major Depressive Disorder. Review of Resident #8's MDS with an ARD of [DATE] revealed a Resident #8 had a BIMS score of 03 (score ,d+[DATE] indicating severely cognitively impaired). Review of Resident #8's Assessment for Safe Smoking dated [DATE] revealed, in part, Resident #8 was an unsafe smoker. Review of Resident #8's Care Plan with latest revision date of [DATE] revealed a problem of Resident #8 was an unsafe smoker. Further review revealed Resident #8 needed his cigarettes and lighter administered to him when he needed to smoke, and Resident #8 may need supervision when he smoked. In an interview on [DATE] at 1:55pm, S12CNA stated Resident #8 was considered a safe smoker and required no supervision. Resident #9 Review of Resident #9's Record revealed the resident was admitted on [DATE] with diagnoses of, in part: Dementia, Alcohol Abuse, [CONDITION(S)], Major Depressive Disorder, and Head Injury. Review of Resident #9's Safe smoking assessment dated [DATE] revealed Resident #9 was identified as an unsafe smoker at the time related to his memory problems, and severe impairment of cognition. Further review revealed Resident #9 was observed sharing his smoking materials. Review revealed Resident #9 was observed by staff borrowing cigarettes from another resident. Review of Resident #9's Care Plan with latest revision date of [DATE] revealed a problem of Resident #9 was identified as an unsafe smoker. Further review revealed Resident #9 needed his cigarettes and lighter administered to him when he needed to smoke, and Resident #9 may need supervision when he smoked. In an interview on [DATE] at 3:41pm, S4DON stated prior to the fire incident on [DATE], the facility did not have a central area for safe and unsafe smoker information. S4DON stated if a resident was an unsafe smoker, then on the assessment it would indicate if they need extra supervision. S4DON stated if the resident was an unsafe smoker then the resident should always have staff supervision while smoking, and the resident should not be left unattended while smoking. An interview was conducted on [DATE] at 3:48pm, with S1Administrator and S4DON, with S2Regional Director of Operations and S3Corporate Quality Improvement (QI) Nurse present during the interview. S4DON stated prior to the fire incident the nurse would know if the resident was a safe smoker from information on the history and physical from the hospital or after the MDS staff completes the assessments. S4DON stated prior to the assessment being completed the nurse would have to use their clinical judgement to decide if the resident was a safe smoker or not. S1Administrator stated the facility currently did not have designated smoking times, or a designated staff for unsafe smokers. S1Administrator stated the facility did not have a system in place for monitoring of residents from the time the resident received the cigarette until the resident finished.

Based on record review and interview the Facility failed to ensure the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to investigate an injury of unknown source, which lead to the resident sustaining a second injury four days (10/26/2013) later for 1 of 6 sampled residents (Resident #3). The facility failed to investigate the nature of the incidents involving Resident #3 after the resident sustained [REDACTED]. Four day later the resident sustained [REDACTED]. This failed practice resulted in an Immediate Jeopardy situation for Resident #3 on 10/22/2013 at 2:53pm when the resident sustained [REDACTED]. On 10/26/2013, Resident #3 sustained a deep laceration to the right lower leg, chest contusions, and a hematoma on the right forearm, all of unknown source. The Immediate Jeopardy situation was lifted on 10/26/2013 at 7:38am when the resident was transferred to the local hospital. On 11/04/2013 at 2:53pm with S1ADM and S3 DON was informed of the IJ situation that existed for Resident #3, which began on 10/22/2013 from the first laceration until 10/26/2013 when the resident was transferred to the hospital. The deficient practice remains at a scope/severity of at the level of actual harm. This failed practice had the potential to affect all residents in the facility, with a census of 204 residents according to the Resident Census Report. Findings: 1. Cross reference to tag F224. 2. Cross reference to tag F226. Review of the Facility's policy and procedures, with a revised date of 09/10/2013, entitled Prevention and Prohibitions of Abuse read in part: the facility employees or agent who becomes aware of abuse or neglect, including injuries of known source, shall immediately report the matter to the facility administrator. The facility administrator reports to the mandated State agency per reporting criteria within 24 hours of notification of an alleged allegation. Review of the medical record for Resident #3 revealed that the resident was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the resident needed one person to assist with ADLs and transfers. An interview on 11/04/2013 at 9:25am with S1 Administrator was conducted. S1 Administrator stated that no information had been entered into OTIS pertaining to Resident #3. An interview on 11/04/2013 at 12:45pm with S10 LPN was conducted. S10LPN stated that she did not do a total body audit, because she had been in and out the resident ' s room all night. S10LPN stated that she did not have to tell the charge nurse about the severity of the resident ' s injuries because she was in the room during the resident ' s [MEDICAL CONDITION] episode. The resident was sent to the hospital because she was not responding, after the aide got her up in the chair for breakfast. S10LPN stated that the aide's behavior was somewhat suspicious, and she belives the CNA went home after the incident. An interview on 11/04/2013 at 1:10pm with S1ADM, S4ADON, and S3 DON was conducted. S1ADM stated that the incident on 10/22/2013 or 10/26/2013 was not reported via the Online Tracking Incident System. S1 ADM stated that he became aware of the incident on 10/26/2013, later that evening and told the staff to obtain witness statements from the staff. S1 ADM further indicated that he was not informed of the severity of the injuries from the staff.

Based on record review and interview the Facility failed to have a system in place to ensure residents are free from neglect for 1 of 6 sampled residents (Resident #3) by failing to provide services necessary to avoid physical harm. The Facility failed to assess and /or investigate an incident involving Resident #3 after the resident sustained [REDACTED]. Four days (10/26/ later the resident sustained [REDACTED]. An Immediate Jeopardy situation began for Resident #3 on 10/22/2013 at 2:53pm when the resident sustained [REDACTED]. On 10/26/2013, Resident #3 sustained a deep laceration to the right lower leg, chest contusions, and a hematoma on the right forearm, all of unknown source. The Immediate Jeopardy situation was lifted on 10/26/2013 at 7:38am when the resident was transferred to the local hospital. On 11/04/2013 at 2:53pm with S1ADM and S3 DON was informed of the IJ situation that existed for Resident #3, which began on 10/22/2013 from the first laceration until 10/26/2013 when the resident was transferred to the hospital. The deficient practice remains at a scope/severity of at the level of actual harm. This failed practice had the potential to affect all residents in the facility, with a census of 204 residents according to the Resident Census Report. Findings: Review of the Facility's policy and procedures, with a revised date of 09/10/2013, entitled Prevention and Prohibitions of Abuse read in part: the facility employees or agent who becomes aware of abuse or neglect, including injuries of known source, shall immediately report the matter to the facility administrator. The facility administrator reports to the mandated State agency per reporting criteria within 24 hours of notification of an alleged allegation. Review of the medical record for Resident #3 revealed that the resident was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the resident needed one person to assist with ADLs and transfers. Review of Resident # 3 ' s medical record (e-chart) titled Departmental Notes read as followed: 10/22/2013 at 2:53pm resident transferred to local hospital at 2:53pm, deep laceration to left lateral leg, which was noted by wound care nurse. CNA (S6CNA) was asked what happened; CNA stated it could have been done during transfer. The note was written by S5LPN. 10/22/2013 at 6:28pm written by S6 LPN/Wound Care Nurse read in part: wound care nurse called to resident ' s room to assess injury to left lateral leg, laceration with moderate amount of bleeding was noted to site. CNA (S6) stated she was uncertain of cause of injury. 10/24/2013 at 3:45pm written by S6 LPN/Wound Care Nurse read in part: sutures to left lateral leg appear to be tearing skin at application sites. 10/24/2013 at 10:09pm written by S27LPN read in part: resident sent to hospital for increased bleeding to laceration on left lateral leg per doctor ' s order. Pressure was applied to site and resident departed at 9:05pm. 10/26/2013 at 9:07am, written by S10LPN read in part: Around 6:30am the CNA Supervisor (S9) called down the hall to come quick to resident ' s room. Blood noted on the resident ' s sheets and bed. The resident had returned from showering, was dressed and placed back in bed. The CNA Supervisor pointed out that the resident had a skin tear the length of the resident ' s lower leg. A skin tear was noted on the resident ' s right lower leg, with blood oozing from the skin tear. The skin tear was dressed and wrapped with ace bandage to apply pressure. The resident ' s vital signs were taken and the resident rested while in bed. The CNA (S8) got resident out of bed and noted the resident was barely responding and called nurse. Nurse noted resident face was pale, turning blue, and cool to touch. The resident ' s right arm appeared to have a hematoma near the wrist area and was slightly swollen. A skin tear the size of a nickel was noted on the resident ' s wrist. The resident was transported to the emergency room ...A call was received from the resident ' s family inquiring what took place and the incident was explained by the nurse. 11/1/2013 at 10:14am written by S4RN/ADON read in part: Late entry for 10/22/2013. S4RN/ ADON was called to the resident ' s room by the treatment nurse to evaluate a laceration to left lower extremity. S4RN/ADON noted a large deep laceration to left lower extremity with bright red blood ... S4RN/ADON investigated the incident with nurse and CNA (S6). The CNA stated that she had just transferred the resident to bed and may have caused the laceration during transfer. The CNA (S6) was instructed on careful/proper transfers. Resident #3 ' s medical records were obtained from the local hospital and revealed the following: Emergency Department Record dated 10/22/2013 revealed Resident #3 was seen in the emergency room with a chief complaint of left leg laceration. The description noted was an isolated left leg injury. Triangle -shaped 3cm that tapers down to a point by approximately 5cm skin avulsion down to muscle belly with superficial skin tears surrounding this 3cm by 5cm skin avulsion. Three vertical mattress sutures were used to close wound. Emergency Department Note dated 10/24/2013 revealed Resident #3 presented in the emergency room for evaluation of the left lower leg wound which was sutured 3 days ago for bleeding. The left lower extremity was found to have two primary wounds noted. A skin avulsion laceration that is somewhat V-shaped with three sutures in place. There was another wound somewhat proximal to that is more of a puncture type wound that is draining a minimal amount of serosanguineous fluid. The resident was sent back to the nursing home. Emergency Department Note dated 10/26/2013 revealed Resident #3 present with [MEDICAL CONDITION] and altered mental status. History from the nursing home revealed that the resident was given a shower and the aides noticed the resident was bleeding from her right leg. The resident ' s chest wall showed moderated ecchymosis and hematoma formations mostly along the mid sternum. There was a wound to the left lower leg, which had been repaired with sutures. The right leg had a large laceration on the lower leg. The right leg laceration was repaired with staples and measured 8cm in length. Hospital Nursing Admission Note dated 10/26/2013 revealed that on admission the resident had a laceration to the right lower leg multiple lacerations, which were oozing most prominently on the right leg, also had contusions on the chest wall, and her arm. An interview on 11/1/2013 at 12:25pm with S5LPN was conducted. S5 LPN stated that she was called to Resident #3 ' s room by the wound care nurse to observe a laceration to the left lower leg on 10/22/2013. The wound looked like her leg was ripped open. The CNA (S6) said that it may have happened during transfer of the resident from chair to bed. The resident ' s physician was called and the resident was sent to the hospital. An interview on 11/1/2013 at 11:34am with S4RN/ADON was conducted. S4RN/ADON stated that she was called to Resident #3 ' s room on 10/22/2013 to assess the resident ' s left leg, which had sustained a laceration. The injury was not witnessed, but the CNA (S6) said it may have happened during transfer. The incident was not reported because it was an accident. The resident was asked what happened and she stated that she did not know. The resident was sent to the hospital and required sutures. A late entry pertaining to the incident was placed on the closed chart on today (11/1/2013). An interview on 11/04/2013 at 9:25am with S1 Administrator was conducted. S1 Administrator stated that no information had been entered into OTIS pertaining to Resident #3. An interview on 11/04/2013 at 9:30am with S6 CNA was conducted. S6CNA stated that during transfer of Resident # 3 from chair to bed she noticed a large amount of blood on her pant leg and noted the resident had a large laceration to her left lower leg. The CNA (S6) stated that the resident had a bandage on the leg and it was saturated with blood. S6 CNA called the wound care nurse to see the leg. S6 CNA stated that she was in serviced on residents ' transfers on 10/30/2013. A phone interview on 11/04/2013 at 9:49am with S7/ LPN Wound Care Nurse (WCN) was conducted. S7 LPN/WCN stated that she was called to Resident #3 ' s room by the CNA(S6) to evaluate a laceration on the resident ' s left lower leg. A large amount of bleeding was noted from the laceration. The floor nurse was called to the room to assess the resident. The physician was called and informed that the resident needed to be sent to the hospital for treatment. S7 LPN/WCN stated that on 10/24/2013 she noticed that the resident ' s dressing to the left lower leg was saturated with blood. The resident had an ABD pad on the wound, which was removed and a moderate amount of blood was oozing from the wound. The floor nurse was called to evaluate the wound and they decided to call the physician to send the resident to the ER for precautions. An interview on 11/04/2013 at 10:04am with S8 CNA was conducted. S8 CNA stated that she presently works as the bath aide. On 10/26/2013, Resident #3 received a shower. S8 CNA stated that during the resident ' s shower she noticed the resident ' s chest wall was bruised and her right forearm arm had a lump. S8 CNA stated that after the shower, on the way back to the resident ' s room, she told the nurse about the bruises. The resident was placed back to bed. S8 CNA stated that when she returned to the resident ' s room to get the roommate for her shower she noticed that Resident #3 top sheet was saturated with blood. When she pulled the sheet back the resident right leg had a large cut with yellow fat coming out of the cut and there was a large amount of blood coming from the cut. The aide called her supervisor to check the resident ' s leg. The aide stated that she became overwhelmed and started crying because she did not know what had happened to the resident ' s leg. The aide stated the resident ' s leg was not bleeding while they were in the shower. A phone interview on 11/04/2013 at 12:02pm with S9 CNA/Weekend CNA Supervisor was conducted. S9 CNA/Weekend CNA Supervisor stated that she was on duty on 10/26/2013 and could recall the incident with Resident #3. She was called to the resident ' s room by the bath aide (S8CNA). S8CNA was crying and said that the resident ' s leg was bleeding. The CNA (S8) said she did not know what happened to the resident ' s leg. S9 noticed the resident leg (believes it was the right leg) was bleeding and had a large cut. The floor nurse was called to the room and placed gauge on the laceration. The bath aide (S8CNA) was very upset and wanted to go home. She was reassigned to the floor for the day. An interview on 11/04/2013 at 12:45pm with S10 LPN was conducted. S10LPN stated that she was the floor nurse the morning of 10/26/2013. Around 6:30am, the CNA Supervisor called her to Resident #3 ' s room. The resident was found with a skin tear to the right lower leg. The laceration was bleeding a moderate amount of blood and a pressure dressing was applied to the site. The shower aide was hysterical and crying and she could not get anything out of her. S10 LPN noticed yellow marks on the resident ' s right arm and a hematoma/gash on her right wrist. The laceration on the right lower leg was not measured, but she recalled it being the length of the resident lower leg. The bath aide did not tell her anything about bruises on the resident ' s chest. The nurse stated that she did not do a total body audit, because she had been in and out the resident ' s room all night. S10LPN stated that she did not have to tell the charge nurse about the severity of the resident ' s injuries because she was in the room during the resident ' s [MEDICAL CONDITION] episode. The resident was sent to the hospital because she was not responding, after the aide got her up in the chair for breakfast. S10LPN stated that the aide ' s behavior was somewhat suspicious, and she thinks the CNA went home after the incident. An interview on 11/04/2013 at 1:10pm with S1ADM, S4ADON, and S3 DON was conducted. S1ADM stated that the incident on 10/22/2013 or 10/26/2013 was not reported via the Online Tracking Incident System. S1 ADM stated that he became aware of the incident on 10/26/2013, later that evening and told the staff to obtain witness statements from the staff. S1 ADM further indicated that he was not informed of the severity of the injuries from the staff. An interview on 11/4/2013 at 1:30pm with S11 RN/Weekend Supervisor was conducted. S11 RN/Weekend Supervisor stated that 10/26/2013 was her first day working alone as weekend supervisor. The incident with Resident # 3 happened around the change of shift that morning. The resident had a [MEDICAL CONDITION] episode and was in her wheelchair. The resident was sent out to the hospital for an evaluation. She did note that the resident had a bandage to her right lower leg. The staff did not inform her that the resident had sustained a large laceration to her leg, chest contusions, or injury to her right arm. The first she heard of it was when the hospital called and informed the facility of the contusions on the resident chest, right arm hematoma, and the severity of the right lower leg laceration.

Based on record review and interview the Facility failed to implement written policies and procedures that prohibit mistreatment and neglect of residents for 1 of 6 sampled residents (Resident #3). The Facility failed to investigate the nature of the incidents involving Resident #3 after the resident sustained [REDACTED]. Four day later (10/26/2013) the resident sustained [REDACTED]. This failed practice resulted in an Immediate Jeopardy situation for Resident #3 on 10/22/2013 at 2:53pm when the resident sustained [REDACTED]. On 10/26/2013, Resident #3 sustained a deep laceration to the right lower leg, chest contusions, and a hematoma on the right forearm, all of unknown source. The Immediate Jeopardy situation was lifted on 10/26/2013 at 7:38am when the resident was transferred to the local hospital. On 11/04/2013 at 2:53pm with S1ADM and S3 DON was informed of the IJ situation that existed for Resident #3, which began on 10/22/2013 from the first laceration until 10/26/2013 when the resident was transferred to the hospital. The deficient practice remains at a scope/severity of at the level of actual harm. This failed practice had the potential to affect all residents in the facility, with a census of 204 residents according to the Resident Census Report. Findings: Review of Resident # 3 ' s medical record (e-chart) titled Departmental Notes read as followed: 10/22/2013 at 2:53pm resident transferred to local hospital at 2:53pm, deep laceration to left lateral leg, which was noted by wound care nurse. CNA (S6CNA) was asked what happened; CNA stated it could have been done during transfer. The note was written by S5LPN. 10/22/2013 at 6:28pm written by S6 LPN/Wound Care Nurse read in part: wound care nurse called to resident ' s room to assess injury to left lateral leg, laceration with moderate amount of bleeding was noted to site. CNA (S6) stated she was uncertain of cause of injury. 10/24/2013 at 3:45pm written by S6 LPN/Wound Care Nurse read in part: sutures to left lateral leg appear to be tearing skin at application sites. 10/24/2013 at 10:09pm written by S27LPN read in part: resident sent to hospital for increased bleeding to laceration on left lateral leg per doctor ' s order. Pressure was applied to site and resident departed at 9:05pm. 10/26/2013 at 9:07am, written by S10LPN read in part: Around 6:30am the CNA Supervisor (S9) called down the hall to come quick to resident ' s room. Blood noted on the resident ' s sheets and bed. The resident had returned from showering, was dressed and placed back in bed. The CNA Supervisor pointed out that the resident had a skin tear the length of the resident ' s lower leg. A skin tear was noted on the resident ' s right lower leg, with blood oozing from the skin tear. The skin tear was dressed and wrapped with ace bandage to apply pressure. The resident ' s vital signs were taken and the resident rested while in bed. The CNA (S8) got resident out of bed and noted the resident was barely responding and called nurse. Nurse noted resident face was pale, turning blue, and cool to touch. The resident ' s right arm appeared to have a hematoma near the wrist area and was slightly swollen. A skin tear the size of a nickel was noted on the resident ' s wrist. The resident was transported to the emergency room ...A call was received from the resident ' s family inquiring what took place and the incident was explained by the nurse. 11/1/2013 at 10:14am written by S4RN/ADON read in part: Late entry for 10/22/2013. S4RN/ ADON was called to the resident ' s room by the treatment nurse to evaluate a laceration to left lower extremity. S4RN/ADON noted a large deep laceration to left lower extremity with bright red blood ... S4RN/ADON investigated the incident with nurse and CNA (S6). The CNA stated that she had just transferred the resident to bed and may have caused the laceration during transfer. The CNA (S6) was instructed on careful/proper transfers. Resident #3 ' s medical records were obtained from the local hospital and revealed the following: Emergency Department Record dated 10/22/2013 revealed Resident #3 was seen in the emergency room with a chief complaint of left leg laceration. The description noted was an isolated left leg injury. Triangle -shaped 3cm that tapers down to a point by approximately 5cm skin avulsion down to muscle belly with superficial skin tears surrounding this 3cm by 5cm skin avulsion. Three vertical mattress sutures were used to close wound. Emergency Department Note dated 10/24/2013 revealed Resident #3 presented in the emergency room for evaluation of the left lower leg wound which was sutured 3 days ago for bleeding. The left lower extremity was found to have two primary wounds noted. A skin avulsion laceration that is somewhat V-shaped with three sutures in place. There was another wound somewhat proximal to that is more of a puncture type wound that is draining a minimal amount of serosanguineous fluid. The resident was sent back to the nursing home. Emergency Department Note dated 10/26/2013 revealed Resident #3 present with [MEDICAL CONDITION] and altered mental status. History from the nursing home revealed that the resident was given a shower and the aides noticed the resident was bleeding from her right leg. The resident ' s chest wall showed moderated ecchymosis and hematoma formations mostly along the mid sternum. There was a wound to the left lower leg, which had been repaired with sutures. The right leg had a large laceration on the lower leg. The right leg laceration was repaired with staples and measured 8cm in length. Hospital Nursing Admission Note dated 10/26/2013 revealed that on admission the resident had a laceration to the right lower leg multiple lacerations, which were oozing most prominently on the right leg, also had contusions on the chest wall, and her arm. An interview on 11/1/2013 at 12:25pm with S5LPN was conducted. S5 LPN stated that she was called to Resident #3 ' s room by the wound care nurse to observe a laceration to the left lower leg on 10/22/2013. The wound looked like her leg was ripped open. The CNA (S6) said that it may have happened during transfer of the resident from chair to bed. The resident ' s physician was called and the resident was sent to the hospital. An interview on 11/1/2013 at 11:34am with S4RN/ADON was conducted. S4RN/ADON stated that she was called to Resident #3' s room on 10/22/2013 to assess the resident's left leg, which had sustained a laceration. The injury was not witnessed, but the CNA (S6) said it may have happened during transfer. The incident was not reported because it was an accident. The resident was asked what happened and she stated that she did not know. The resident was sent to the hospital and required sutures. A late entry pertaining to the incident was placed on the closed chart on today (11/1/2013). An interview on 11/04/2013 at 9:25am with S1 Administrator was conducted. S1 Administrator stated that no information had been entered into OTIS pertaining to Resident #3. An interview on 11/04/2013 at 9:30am with S6 CNA was conducted. S6CNA stated that during transfer of Resident # 3 from chair to bed she noticed a large amount of blood on her pant leg and noted the resident had a large laceration to her left lower leg. The CNA (S6) stated that the resident had a bandage on the leg and it was saturated with blood. S6 CNA called the wound care nurse to see the leg. A phone interview on 11/04/2013 at 9:49am with S7/ LPN Wound Care Nurse (WCN) was conducted. S7 LPN/WCN stated that she was called to Resident #3 ' s room by the CNA(S6) to evaluate a laceration on the resident ' s left lower leg. A large amount of bleeding was noted from the laceration. The floor nurse was called to the room to assess the resident. The physician was called and informed that the resident needed to be sent to the hospital for treatment. S7 LPN/WCN stated that on 10/24/2013 she noticed that the resident ' s dressing to the left lower leg was saturated with blood. The resident had an ABD pad on the wound, which was removed and a moderate amount of blood was oozing from the wound. The floor nurse was called to evaluate the wound and they decided to call the physician to send the resident to the ER as a precaution. An interview on 11/04/2013 at 10:04am with S8 CNA was conducted. S8 CNA stated that she presently works as the bath aide. On 10/26/2013, Resident #3 received a shower. S8 CNA stated that during the resident ' s shower she noticed the resident ' s chest wall was bruised and her right forearm arm had a lump. S8 CNA stated that after the shower, on the way back to the resident ' s room, she told the nurse about the bruises. The resident was placed back to bed. S8 CNA stated that when she returned to the resident ' s room to get the roommate for her shower she noticed that Resident #3 top sheet was saturated with blood. When she pulled the sheet back the resident right leg had a large cut with yellow fat coming out of the cut and there was a large amount of blood coming from the cut. The aide called her supervisor to check the resident ' s leg. The aide stated that she became overwhelmed and started crying because she did not know what had happened to the resident ' s leg. The aide stated the resident ' s leg was not bleeding while they were in the shower. A phone interview on 11/04/2013 at 12:02pm with S9 CNA/Weekend CNA Supervisor was conducted. S9 CNA/Weekend CNA Supervisor stated that she was on duty on 10/26/2013 and could recall the incident with Resident #3. She was called to the resident ' s room by the bath aide (S8CNA). S8CNA was crying and said that the resident ' s leg was bleeding. The CNA (S8) said she did not know what happened to the resident ' s leg. S9 noticed the resident leg (believes it was the right leg) was bleeding and had a large cut. The floor nurse was called to the room and placed gauge on the laceration. The bath aide (S8CNA) was very upset and wanted to go home. She was reassigned to the floor for the day. An interview on 11/04/2013 at 12:45pm with S10 LPN was conducted. S10LPN stated that she was the floor nurse the morning of 10/26/2013. Around 6:30am, the CNA Supervisor called her to Resident #3 ' s room. The resident was found with a skin tear to the right lower leg. The laceration was bleeding a moderate amount of blood and a pressure dressing was applied to the site. The shower aide was hysterical and crying and she could not get anything out of her. S10 LPN noticed yellow marks on the resident ' s right arm and a hematoma/gash on her right wrist. The laceration on the right lower leg was not measured, but she recalled it being the length of the resident lower leg. The bath aide did not tell her anything about bruises on the resident ' s chest. The nurse stated that she did not do a total body audit, because she had been in and out the resident ' s room all night. S10LPN stated that she did not have to tell the charge nurse about the severity of the resident ' s injuries because she was in the room during the resident ' s [MEDICAL CONDITION] episode. The resident was sent to the hospital because she was not responding, after the aide got her up in the chair for breakfast. S10LPN stated that the aide ' s behavior was somewhat suspicious, and she thinks the CNA went home after the incident. An interview on 11/04/2013 at 1:10pm with S1ADM, S3DON, and S4ADON was conducted. S1ADM stated that the incident on 10/22/2013 or 10/26/2013 was not reported via the Online Tracking Incident System. S1 ADM stated that he became aware of the incident on 10/26/2013, later that evening and told the staff to obtain witness statements from the staff. S1 ADM further indicated that he was not informed of the severity of the injuries from the staff. An interview on 11/4/2013 at 1:30pm with S11 RN/Weekend Supervisor was conducted. S11 RN/Weekend Supervisor stated that 10/26/2013 was her first day working alone as weekend supervisor. The incident with Resident # 3 happened around the change of shift that morning. The resident had a [MEDICAL CONDITION] episode and was in her wheelchair. The resident was sent out to the hospital for an evaluation. She did note that the resident had a bandage to her right lower leg. The staff did not inform her that the resident had sustained a large laceration to her leg, chest contusions, or injury to her right arm. The first she heard of it was when the hospital called and informed the facility of the contusions on the resident chest, right arm hematoma, and the severity of the right lower leg laceration. Review of the Facility ' s policy and procedures, with a revised date of 09/10/2013, entitled Prevention and Prohibitions of Abuse read in part: the facility employees or agent who becomes of abuse or neglect, including injuries of known source, shall immediately report the matter to the facility administrator. The facility administrator reports to the mandated State agency per reporting criteria within 24 hours of notification of an alleged allegation.

Based on observation, record review, and interview the facility failed to maintain water hot water temperatures in a safe range to prevent damage to resident's fragile tissue by allowing the hot water temperature to be as high as 143 degrees Fahrenheit in several places accessible to residents throughout the facility. This resulted in an Immediate Jeopardy (IJ) situation which began on 6/25/12 at 3:00pm when elevated water temperatures range from 122 to 143.2 degrees Fahrenheit were noted throughout the facility including resident bathrooms. The administrator was notified of the IJ situation on 6/25/12 at 4:05pm. The IJ was lifted on 6/25/12 at 5:20pm when the facility submitted an acceptable plan of removal which included shutting off the hot boiler for the hot water system, the thermostat was set to 112?F, the water was drained from the rooms to drop the temperature, monitoring of water temperatures were done on different shifts to ensure water temperatures were below 112? F and subsequent observations by surveyors revealed the water temperatures were less than 120 degrees Fahrenheit throughout the building . The facility also failed to have cigarette extinguishers (Receptacle for collection of cigarettes to prevent fires) that were not flammable (The 2 noted were made of plastic) outside of the building. There were 206 Resident at the facility as documented on Resident Census and Conditions of Residents. The deficient practice remains at Scope/ Severity of level 2 (F), potential for more than minimum harm, widespread. Findings: According to the American Burn Association (2002) time and temperature relationship to severe burns revealed the following: Water temperature Times for a third degree burn to occur at 155? F = 1 second 148? F = 2 seconds for a third degree burn to occur, 140? F = 5 seconds for a third degree burn to occur, 133? F = 15 seconds for a third degree burn to occur, 127? F = 1 minute for a third degree burn to occur, 124? F = 3 minutes for a third degree burn to occur, 120? F = 5 minutes for a third degree burn to occur, 100? F = safe temperature for bathing. Observations on 6/25/12 starting at 3:00pm, revealed hot water coming out of the Resident # 144's (Rm bb) hot water facet in the bathroom at 136.6?F. This bathroom was also shared with resident's in the other side of the room. The water was so hot the surveyor could not keep his finger under the running water and steam was noted. The following rooms, some of which shared the same bathroom (Rm) as other resident's in the next room revealed the following degrees (?) in Fahrenheit (F): Rm a = 135.8?F Rm b = 135.8?F Rm c = 143.2? F Rm d = 142.3?F Rm e = 142?F woman's bathroom on " f " hall =138?F, Rm g-h shared bathroom =139?F Rm i = 136.2 ?F Rm j = 139.8?F Rm k =137.2?F Rm l = 141?F Rm m = 130 ?F Rm n = 128?F Rm o = 128?F Rm p = 130?F Rm q = 126?F Rm r = 132?F Rm s= 122?F Rm-t = 132?F Rm u =122?F Rm-v = 124?F Rm w = 122?F Rm x =135.3?F Rm y = 135.1?F Rm z = 131.3 ?F Rm aa = 132.4?F RM bb=136.6?F Review of the above identified codes for the above room numbers and review of the facility's floor plan revealed the facility had widespread hot water temperatures greater than 120?F. In an interview on 6/25/12 at 3:43pm, Resident #216 stated that the water is always hot,very hot. In an interview on 6/25/12 at 3:45pm, Resident #144 stated, "the water was F---ing hot! it's steaming; I have to be careful when I use it , it burns." Review of the facility's water temperature monitoring log revealed monitoring of only 2 different rooms which were located the farthest away from the facility boiler room where the hot water was contained. Further review revealed in June 2012 on 6/13/12 the recording was documented as 129?F and on 6/14/12 it was documented as 123?F. In an interview on 6/25/12 at 4:30pm, S16/Maintenance stated that he never checks water temperatures in the afternoon. He said the boiler was set at 145 degrees Fahrenheit since the last 3.5 years since he has been there. He said he kept the water temperatures up so other parts of the facility's residents would not complain of cold water. In an interview on 6/29/12 at 10:30am, S16/Maintenance stated that no one taught him on what was the highest allowable hot water temperatures that should be coming out the residents' water facets. In an interview on 6/29/12 at 10:35am, S1/Administrator stated that S16/Maintenance was responsible for water temperatures. He further stated that in regards to documentation of the water temperature being greater than 120?F he should have been notified. In an interview on 6/29/12 at 12:07pm, S1/Administrator stated that the facility had no policy or procedures on water temperatures, but follow the guidelines. Observation on 6/27/12 at 10:19am revealed 2 plastic smoke extinguishers (Receptacle for collection of cigarettes to prevent fires) that were approximately three feet tall which were located in a covered area next to the facility. In an interview on 6/29/12 at 8:05am, S1/Administrator stated that he was not aware the plastic cigarette extinguishers were a fire hazard.

Based on observation, record review, and interview, the facility failed to develop and implement a process to monitor hot water temperatures for a safe environment for resident's by allowing the water temperatures to be as high as 143 degrees Fahrenheit in several places accessible to residents throughout the facility with no adequate monitoring system in place. This resulted in an Immediate Jeopardy (IJ) situation which began on 6/25/12 at 3:00pm when elevated water temperatures range from 122 to 143.2 degrees Fahrenheit were noted throughout the facility including resident bathrooms. The administrator was notified of the IJ situation on 6/25/12 at 4:05pm. The IJ was lifted on 6/25/12 at 5:20pm when the facility submitted an acceptable plan of removal which included shutting off the hot boiler for the hot water system, the thermostat was set to 112?F, the water was drained from the rooms to drop the temperature, monitoring of water temperatures were done on different shifts to ensure water temperatures were below 112? F and subsequent observations by surveyors revealed the water temperatures were less than 120 degrees Fahrenheit throughout the building . There were 206 Resident at the facility as documented on Resident Census and Conditions of Residents. The deficient practice remains at Scope/ Severity of level 2 (F), potential for more than minimum harm, widespread. Findings: According to the American Burn Association (2002) time and temperature relationship to [MEDICAL CONDITION] the following: Water temperature Times for a third degree burn to occur at 155? F = 1 second 148? F = 2 seconds for a third degree burn to occur, 140? F = 5 seconds for a third degree burn to occur, 133? F = 15 seconds for a third degree burn to occur, 127? F = 1 minute for a third degree burn to occur, 124? F = 3 minutes for a third degree burn to occur, 120? F = 5 minutes for a third degree burn to occur, 100? F = safe temperature for bathing. Observations on 6/25/12 starting at 3:00pm, revealed hot water coming out of the Resident # 144's (Rm bb) hot water facet in the bathroom at 136.6?F. This bathroom was also shared with resident's in the other side of the room. The water was so hot the surveyor could not keep his finger under the running water and steam was noted. The following rooms, some of which shared the same bathroom (Rm) as other resident's in the next room revealed the following degrees (?) in Fahrenheit (F): Rm a = 135.8?F Rm b = 135.8?F Rm c = 143.2? F Rm d = 142.3?F Rm e = 142?F woman's bathroom on " f " hall =138?F, Rm g-h shared bathroom =139?F Rm i = 136.2 ?F Rm j = 139.8?F Rm k =137.2?F Rm l = 141?F Rm m = 130 ?F Rm n = 128?F Rm o = 128?F Rm p = 130?F Rm q = 126?F Rm r = 132?F Rm s= 122?F Rm-t = 132?F Rm u =122?F Rm-v = 124?F Rm w = 122?F Rm x =135.3?F Rm y = 135.1?F Rm z = 131.3 ?F Rm aa = 132.4?F RM bb=136.6?F Review of the above identified codes for the above room numbers and review of the facility's floor plan revealed the facility had widespread hot water temperatures greater than 120?F. In an interview on 6/25/12 at 3:43pm, Resident #216 stated that the water is always hot,very hot. In an interview on 6/25/12 at 3:45pm, Resident #144 stated, "the water was F---ing hot! it's steaming; I have to be careful when I use it , it burns." Review of the facility's water temperature monitoring log revealed monitoring of only 2 different rooms which were located the farthest away from the facility boiler room where the hot water was contained. Further review revealed in June 2012 on 6/13/12 the recording was documented as 129?F and on 6/14/12 it was documented as 123?F. In an interview on 6/25/12 at 4:30pm, S16/Maintenance stated that he never checks water temperatures in the afternoon. He said the boiler was set at 145 degrees Fahrenheit since the last 3.5 years since he has been there. He said he kept the water temperatures up so other parts of the facility's residents would not complain of cold water. In an interview on 6/29/12 at 10:30am, S16/Maintenance stated that no one taught him on what was the highest allowable hot water temperatures that should be coming out the residents' water facets. In an interview on 6/29/12 at 10:35am, S1/Administrator stated that S16/Maintenance was responsible for water temperatures. He further stated that in regards to documentation of the water temperature being greater than 120?F he should have been notified. In an interview on 6/29/12 at 12:07pm, S1/Administrator stated that the facility had no policy or procedures on water temperatures, but follow the guidelines. Observation on 6/27/12 at 10:19am revealed 2 plastic smoke extinguishers (Receptacle for collection of cigarettes to prevent fires) that were approximately three feet tall which were located in a covered area next to the facility. In an interview on 6/29/12 at 8:05am, S1/Administrator stated that he was not aware the plastic cigarette extinguishers were a fire hazard.

Based on observation, record review, and interview the facility failed to provide a safe environment for residents, staff and the public by allowing the water temperature to be as high as 143 degrees Fahrenheit in several places throughout the facility. This resulted in an Immediate Jeopardy (IJ) situation which began on 6/25/12 at 3:00pm when elevated water temperatures range from 122 to 143.2 degrees Fahrenheit were noted throughout the facility including resident bathrooms. The administrator was notified of the IJ situation on 6/25/12 at 4:05pm. The IJ was lifted on 6/25/12 at 5:20pm when the facility submitted an acceptable plan of removal which included shutting off the hot boiler for the hot water system, the thermostat was set to 112?F, the water was drained from the rooms to drop the temperature, monitoring of water temperatures were done on different shifts to ensure water temperatures were below 112? F and subsequent observations by surveyors revealed the water temperatures were less than 120 degrees Fahrenheit throughout the building. The facility also failed to have cigarette extinguishers (Receptacle for collection of cigarettes to prevent fires) that were not flammable (The 2 noted were made of plastic) outside of the building. There were 206 Resident at the facility as documented on Resident Census and Conditions of Residents. The deficient practice remains at Scope/ Severity of level 2 (F), potential for more than minimum harm, widespread. Findings: According to the American Burn Association (2002) time and temperature relationship to [MEDICAL CONDITION] the following: Water temperature Times for a third degree burn to occur at 155? F = 1 second 148? F = 2 seconds for a third degree burn to occur, 140? F = 5 seconds for a third degree burn to occur, 133? F = 15 seconds for a third degree burn to occur, 127? F = 1 minute for a third degree burn to occur, 124? F = 3 minutes for a third degree burn to occur, 120? F = 5 minutes for a third degree burn to occur, 100? F = safe temperature for bathing. Observations on 6/25/12 starting at 3:00pm, revealed hot water coming out of the Resident # 144's (Rm bb) hot water facet in the bathroom at 136.6?F. This bathroom was also shared with resident's in the other side of the room. The water was so hot the surveyor could not keep his finger under the running water and steam was noted. The following rooms, some of which shared the same bathroom (Rm) as other resident's in the next room revealed the following degrees (?) in Fahrenheit (F): Rm a = 135.8?F Rm b = 135.8?F Rm c = 143.2? F Rm d = 142.3?F Rm e = 142?F woman's bathroom on " f " hall =138?F, Rm g-h shared bathroom =139?F Rm i = 136.2 ?F Rm j = 139.8?F Rm k =137.2?F Rm l = 141?F Rm m = 130 ?F Rm n = 128?F Rm o = 128?F Rm p = 130?F Rm q = 126?F Rm r = 132?F Rm s= 122?F Rm-t = 132?F Rm u =122?F Rm-v = 124?F Rm w = 122?F Rm x =135.3?F Rm y = 135.1?F Rm z = 131.3 ?F Rm aa = 132.4?F RM bb=136.6?F Review of the above identified codes for the above room numbers and review of the facility's floor plan revealed the facility had widespread hot water temperatures greater than 120?F. In an interview on 6/25/12 at 3:43pm, Resident #216 stated that the water is always hot,very hot. In an interview on 6/25/12 at 3:45pm, Resident #144 stated, "the water was F---ing hot! it's steaming; I have to be careful when I use it , it burns." Review of the facility's water temperature monitoring log revealed monitoring of only 2 different rooms which were located the farthest away from the facility boiler room where the hot water was contained. Further review revealed in June 2012 on 6/13/12 the recording was documented as 129?F and on 6/14/12 it was documented as 123?F. In an interview on 6/25/12 at 4:30pm, S16/Maintenance stated that he never checks water temperatures in the afternoon. He said the boiler was set at 145 degrees Fahrenheit since the last 3.5 years since he has been there. He said he kept the water temperatures up so other parts of the facility's residents would not complain of cold water. In an interview on 6/29/12 at 10:30am, S16/Maintenance stated that no one taught him on what was the highest allowable hot water temperatures that should be coming out the residents' water facets. In an interview on 6/29/12 at 10:35am, S1/Administrator stated that S16/Maintenance was responsible for water temperatures. He further stated that in regards to documentation of the water temperature being greater than 120?F he should have been notified. In an interview on 6/29/12 at 12:07pm, S1/Administrator stated that the facility had no policy or procedures on water temperatures, but follow the guidelines. Observation on 6/27/12 at 10:19am revealed 2 plastic smoke extinguishers (Receptacle for collection of cigarettes to prevent fires) that were approximately three feet tall which were located in a covered area next to the facility. In an interview on 6/29/12 at 8:05am, S1/Administrator stated that he was not aware the plastic cigarette extinguishers were a fire hazard.

Based on observation, record review, and interview the facility failed to be administered in a manner that would ensure a safe environment for residents, staff, and the public by allowing the water temperature to be as high as 143 degrees Fahrenheit in several places accessible to the residents throughout the facility. The facility failed to: 1) Have a policy and procedure to monitor hot water temperatures to ensure the hot water in resident bathrooms and public rooms was maintained at a safe level to prevent burn injuries to residents, staff, and visitors. 2) Ensure maintenance staff had knowledge of acceptable hot water temperature ranges to prevent risk of burn injuries to residents, staff and visitors from water being too hot. 3) Have a system of monitoring hot water temperatures in resident bathrooms and public areas to ensure safe hot water temperature levels were maintained to prevent burn injuries to residents, staff and visitors from water being too hot. 4) Have a system in place to notify administration when hot water temperatures exceeded 120 degrees in resident bathroom faucets and public areas. 5) Have a system in place to ensure hot water temperatures in resident bathrooms were lowered to safe level when hot water temperature was recorded as 129 degrees on 6/13/12 and 123 degrees on 6/14/12 in rooms in the facility. The administrator was notified of the Immediate Jeopardy (IJ) situation on 6/25/12 at 4:05pm. The IJ was lifted on 6/25/12 at 5:20pm when the facility submitted an acceptable plan of removal which included shutting off the hot boiler for the hot water system, the thermostat was set to 112?F, the water was drained from the rooms to drop the temperature, monitoring of water temperatures were done on different shifts to ensure water temperatures were below 112? F and subsequent observations by surveyors revealed the water temperatures were less than 120 degrees Fahrenheit throughout the building. The facility also failed to have cigarette extinguishers (Receptacle for collection of cigarettes to prevent fires) that were not flammable (The 2 noted were made of plastic) outside of the building. There were 206 Resident at the facility as documented on Resident Census and Conditions of Residents. The deficient practice remains at Scope/ Severity of level 2 (F), potential for more than minimum harm, widespread. Findings: According to the American Burn Association (2002) time and temperature relationship to [MEDICAL CONDITION] the following: Water temperature Times for a third degree burn to occur at 155? F = 1 second 148? F = 2 seconds for a third degree burn to occur, 140? F = 5 seconds for a third degree burn to occur, 133? F = 15 seconds for a third degree burn to occur, 127? F = 1 minute for a third degree burn to occur, 124? F = 3 minutes for a third degree burn to occur, 120? F = 5 minutes for a third degree burn to occur, 100? F = safe temperature for bathing. Observations on 6/25/12 starting at 3:00pm, revealed hot water coming out of the Resident # 144's (Rm bb) hot water facet in the bathroom at 136.6?F. This bathroom was also shared with resident's in the other side of the room. The water was so hot the surveyor could not keep his finger under the running water and steam was noted. The following rooms, some of which shared the same bathroom (Rm) as other resident's in the next room revealed the following degrees (?) in Fahrenheit (F): Rm a = 135.8?F Rm b = 135.8?F Rm c = 143.2? F Rm d = 142.3?F Rm e = 142?F woman's bathroom on " f " hall =138?F, Rm g-h shared bathroom =139?F Rm i = 136.2 ?F Rm j = 139.8?F Rm k =137.2?F Rm l = 141?F Rm m = 130 ?F Rm n = 128?F Rm o = 128?F Rm p = 130?F Rm q = 126?F Rm r = 132?F Rm s= 122?F Rm-t = 132?F Rm u =122?F Rm-v = 124?F Rm w = 122?F Rm x =135.3?F Rm y = 135.1?F Rm z = 131.3 ?F Rm aa = 132.4?F RM bb=136.6?F Review of the above identified codes for the above room numbers and review of the facility's floor plan revealed the facility had widespread hot water temperatures greater than 120?F. In an interview on 6/25/12 at 3:43pm, Resident #216 stated that the water is always hot,very hot. In an interview on 6/25/12 at 3:45pm, Resident #144 stated, "the water was F---ing hot! it's steaming; I have to be careful when I use it , it burns." Review of the facility's water temperature monitoring log revealed monitoring of only 2 different rooms which were located the farthest away from the facility boiler room where the hot water was contained. Further review revealed in June 2012 on 6/13/12 the recording was documented as 129?F and on 6/14/12 it was documented as 123?F. In an interview on 6/25/12 at 4:30pm, S16/Maintenance stated that he never checks water temperatures in the afternoon. He said the boiler was set at 145 degrees Fahrenheit since the last 3.5 years since he has been there. He said he kept the water temperatures up so other parts of the facility's residents would not complain of cold water. In an interview on 6/29/12 at 10:30am, S16/Maintenance stated that no one taught him on what was the highest allowable hot water temperatures that should be coming out the residents' water facets. In an interview on 6/29/12 at 10:35am, S1/Administrator stated that S16/Maintenance was responsible for water temperatures. He further stated that in regards to documentation of the water temperature being greater than 120?F he should have been notified. In an interview on 6/29/12 at 12:07pm, S1/Administrator stated that the facility had no policy or procedures on water temperatures, but follow the guidelines. Observation on 6/27/12 at 10:19am revealed 2 plastic smoke extinguishers (Receptacle for collection of cigarettes to prevent fires) that were approximately three feet tall which were located in a covered area next to the facility. In an interview on 6/29/12 at 8:05am, S1/Administrator stated that he was not aware the plastic cigarette extinguishers were a fire hazard.