Every finding on record at Creekside Health and Rehabilitation Center

Based on observation, record review and interview, the facility failed to protect the right to be free from involuntary seclusion for 1 (Resident #2) or 4 residents reviewed.The findings included:Review of the facility policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin (ANEMMI), revision date 3/2025 indicated the resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish.On 2/4/26 at 11:39 a.m., Resident #2 was observed in the secured memory care unit. Resident #2 said, They moved me back here against my will. He said they taped the door up saying do not enter and he was locked in his room for 3 days.Clinical Record review for Resident #2 revealed Power of Attorney paperwork allowing his children to make decisions about his healthcare if he could not decide for himself anymore. The clinical record lacked documentation of a physician's incapacity statement that Resident #2 was not able to make his own health care decisions. Record review also indicated Resident #2 had a BIMS score (Brief Interview for Mental Status) of 15 indicating he was cognitively intact.On 2/4/26 at 12:04 p.m., in an interview the Director of Regional Operations said for the safety of female residents Resident #2 was moved to the secured memory care unit as he had made inappropriate statements and behaviors. She said Resident #2 had confusion, but he made that decision himself. She said it was documented throughout the progress notes that the resident made the decision to move to the secured unit. The Director of Regional Operations said there was nothing signed by the resident that he agreed to move to the secured unit. She verified that Resident #2 did not have a lacks capacity statement from a physician. She said Resident #2 was concerned about people coming in his room. They had placed a stop sign across the door as an intervention so no one would enter his room.Review of a psychology progress note dated 1/22/26 revealed that Resident #2 reported making statements related to self-harm following distress about being moved to a different room within the facility. He did not articulate a specific plan or intent and stated that his comments were directly related to feeling upset about the room change. Resident #2 reported that if he were moved back to his previous room, he would not engage in self-harm statements. Social Service Administration was advised of Resident #2's behavior.On 2/5/26 at 1:04 p.m., in an interview the Social Services Director (SSD) said Resident #2 had reached out to the VA (Veterans Administration) suicide hotline and they in turn notified her. She said she notified the psychiatry provider. She said Resident #2 did not make any attempts and when interviewed he denied wanting to harm himself. On 2/5/26 at 1:10 p.m., in an interview the Regional Nuse said they had just completed an audit on 2/2/26 on what residents have as far as advanced directives, including incapacity statements. The audit didn't indicate if they need it, just if they currently have one. He said the next step would be to review whether they need one.

Based on record review and interview, the facility failed to protect the resident's right to be free from misappropriation of property for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of the facility policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin (ANEMMI), revision date 3/2025 revealed Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.On 2/3/26 at 10:30 a.m., the Regional Director of Operations provided incident investigations for November 2025 which included an investigation into an allegation of misappropriation of resident's property. Review of the facility provided investigations revealed that on 11/13/25, the facility initiated an investigation into an allegation of unauthorized transfer of money from Resident #1's bank account to Certified Nursing Assistant (CNA) Staff A's money transfer application. The facility's investigation included documentation from local law enforcement indicating that the bank statement from 10/6/25 to 10/31/25 showed transactions totaling $13,250.00 went from Resident #1's bank account to CNA Staff A's (brand name) money transfer application. On 2/6/26 at 10:42 a.m., in an interview the Business Office Manager (BOM) said she wrote a statement that on 11/13/25 she was doing her rounds and entered Resident #1's room. She said after asking Resident #1 a few questions, he asked why he was being charged $14,000 per month for his stay at the facility. The BOM said she explained to the resident that the Veterans Administration paid for his stay and the facility did not receive any funds from him. Resident #1 asked her to look at his bank account statements and explain the charges to him. The BOM said she noted transfers made to CNA Staff A through (brand name), a mobile application that allows users to send and receive money instantly. She said Resident #1 asked her to help him and call the police. BOM said she told Resident #1 that she would notify the Administrator and an investigation ensued.On 2/5/26 at 12:12 p.m., in an interview the Director of Nursing (DON) confirmed he wrote a statement which indicated that on 11/13/25 he interviewed Resident #1. The DON said Resident #1 gave him permission to look at his cell phone and bedside computer with his assistance. The DON said Resident #1 and himself validated that he did not have the (brand name) application used to transfer the money from his bank account linked to his phone or computer. When asked, Resident #1 said he kept his debit card in his room in his bedside dresser. Resident #1 said he did not give anyone permission to use his debit card. He said he could have given his debit card to CNA Staff A once to purchase items for him, but he could not remember for sure. Resident #1 stated that he had called his bank and cancelled the debit card. Review of Resident #1's bank statements provided by the facility from October 2025 showed multiple transfers made to CNA Staff A through (brand name) application.

Based on observation, record review, review of facility policy, resident and staff interviews, the facility failed to provide the necessary care and services for personal hygiene and incontinent care for 2 (Resident #100 and #2) of 3 residents reviewed for activities of daily living.The findings included:Review of the facility's policy, Standards and Guidelines: ADL Care and Services, initiated 4/2020 (revised 1/24) revealed, Residents who are unable to carry out activities of daily living (ADL's) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with including but not limited to:Hygiene (bathing/showers, dressing, grooming and oral care).Elimination (toileting).The resident has the right to refuse any and all ADL care. The refusal of care will be documented in the resident's medical record with appropriate notification including the physician and resident representative. 1. Review of the clinical record revealed Resident #100 was readmitted on [DATE]. Diagnoses included chronic kidney disease, major depressive disorder, type 2 diabetes mellitus, severe morbid obesity, and anxiety disorder.Review of the Quarterly Minimum Data Set (MDS), standardized assessment tool used in nursing homes to evaluate a resident's health and functional abilities with a target date of 6/29/25 revealed Resident #100 was always incontinent of bowel and bladder and was dependent for bathing. The MDS indicated the resident's cognitive skills for daily decision making were intact.On 8/18/25 at 9:25 a.m., Resident #100 was observed in her room in bed. She had very foul breath and a strong, offensive body odor noted from three feet away.In an interview, Resident #100 said the staff do not brush her teeth because she has too many broken teeth. The resident said the dentist wanted to extract her teeth, but she did not want that. Resident #100 said she rinses her mouth every morning with mouth wash. Resident #100 said the staff do not give her showers because she can't walk. They say it is too much work. The resident said, I get bed baths. No, I don't like bed baths but what can I do? They say I like to complain a lot but if I don't, no one pays attention to me. I am wet all the time because they are not changing me.A review of the certified nursing assistant (CNA) documentation for June 2025, July 2025 and August 2025 revealed no documentation incontinent care was provided:On the 7:00 a.m., to 3:00 p.m. shift on 6/7/25, 6/10/25, 6/11/25, and 6/25/25. 7/3/25, 7/9/25, 7/11/25, 7/20/25, 7/23/25, 7/26/25, 7/30/35, 7/31/25, 8/3/25, 8/6/25, 8/7/25 and 8/16/25.On the 3:00 p.m., to 11:00 p.m. shift on 6/1/25, 6/15/25, 7/3/25, 7/18/25, 7/20/25, 8/10/25 and 8/16/25.On the 11:00 p.m., to 7:00 a.m. shift on 6/1/25, 6/6/25, 6/8/25, 6/17/25, 6/18/25, 6/23/25, 6/29/25, 6/30/25. 7/3/25, 7/7/25, 7/8/25, 7/11/25, 7/12/25, 7/13/25, 7/21/25, 7/29/25, 7/31/25, 8/1/25, 8/4/25, 8/5/25, 8/8/25, 8/9/25, 8/10/25, 8/14/25, and 8/16/25.A review of the shower schedule revealed Resident #100's scheduled showers were on Mondays, Wednesdays and Fridays during the 7:00 a.m., to 3:00 p.m. shift.Review of the CNA documentation for bathing for June 2025, July 2025 and August 2025 revealed Resident #100 received a bed bath on the scheduled shower days on Mondays ( 6/2/25, 6/9/25, 7/7/25, 7/14/25, 7/21/25, 8/4/25, 8/11/25), Wednesdays (6/4/25, 6/16/25, 6/30/25, 7/2/25, 7/16/25, 7/30/25, 8/13/25), Fridays (6/6/25, 6/18/25, 7/4/25, 7/18/25, 7/25/25, 8/1/25, 8/8/25, 8/15/25).There was no documentation of care provided on 6/11/25,6/25/25, 7/9/25, 7/11/25, 7/23/25, 7/30/25, and 8/6/25.On 8/18/25 at 2:00 p.m., in an interview CNA Staff D said, I work 7-3 and I have Resident #100 every day, 5 days a week, she is mine. Residents get changed twice a shift. Resident #100 can wash her face and feed herself, that is about it. She is dependent for everything else. She is not able to walk. I give her a full bed bath every day. Now I can't say anything about the other shifts because I don't know, I don't work them unless I do a double. I don't know why she does not get showers, sometimes we don't have 2 people to do it. You can't shower her by yourself.On 8/18/25 at 2:10 p.m., in an interview the Director of Nursing (DON) said, We don't have set times or schedules the residents are to be changed. Usually, it's every 3-4 hours. With Resident #100, because she is such a large woman she takes two people, and it is not always easy to find help right away. We usually change her when she gets up and when she gets back to bed.2. Review of the clinical record revealed Resident #2 had a date of admission of 8/13/24. Diagnoses included senile degeneration of the brain, type 2 diabetes mellitus, Alzheimer's disease, and dementia.Review of the Quarterly MDS dated [DATE] revealed the resident was always incontinent of bowel and bladder and dependent for all care. The MDS noted Resident #2 was rarely, never understood. Review of the CNA documentation for June 2025, July 2025, and August 2025 revealed no documentation of incontinent care provided for Resident #2:On the 7:00 a.m. to 3:00 p.m. shift on 6/7/25, 6/8/25, 6/10/25, 6/11/25, 6/25/25, 7/3/25, 7/9/25, 7/11/25, 7/20/25, 7/23/25, 7/26/25, 7/30/25, 7/31/25, 8/3/25, 8/6/25, 8/7/25, 8/16/25 and 8/17/25 .On the 3:00 p.m., to 11:00 p.m. shift on 6/1/25, 6/10/25, 6/15/25, 7/3/25, 7/20/25, 8/10/25, and 8/16/25.On the 11:00 p.m., to 7:00 a.m. shift on 6/1/25, 6/2/25, 6/6/25, 6/8/25, 6/15/25, 6/17/25, 6/18/25, 6/23/25, 6/29/25, 6/30/25, 7/3/25, 7/8/25, 7/11/25, 7/12/25, 7/13/25, 7/21/25, 7/25/25, 7/31/25, 8/1/25, 8/4/25, 8/5/25, 8/8/25, 8/9/25, 8/10/25, 8/11/25, 8/12/25, 8/14/25 and 8/16/25.Review of shower schedule revealed Resident #2's scheduled showers were on Mondays, Wednesdays and Fridays during the 3:00 p.m., to 11:00 p.m. shift.Review of the CNA documentation for June 2025, July 2025 and August 2025 revealed Resident #2 received a sponge bath on 6/2/25, 6/4/25, 6/6/25, 6/9/25, 6/11/25, 6/13/25, 6/16/25, 6/20/25, 6/23/25, 6/25/25, 7/2/25, 7/4/25, 7/7/25, 7/9/25, 7/11/25, 7/14/25, 7/16/25, 7/18/25, 7/21/25, 7/28/25, 7/30/25, 8/4/25, 8/6/25, 8/8/25, 8/13/25, 8/15/25 and 8/18/25.On 6/16/25, 6/30/25, 7/23/25, 8/11/25 N/A (not applicable) was documented.On 8/18/25 at 1:42 p.m., in an interview CNA Staff C said, I only work on 7-3 shift and we change everyone every 2-3 hours and we turn them at the same time because you have to roll them to change them.

Based on observation, staff interviews, and record reviews, the facility failed to follow proper sanitation and cleaning practices in the kitchen to prevent the outbreak of foodborne illness. The findings included: On 2/17/25 at 9:20 a.m., an initial tour of the kitchen was completed with the Certified Dietary Manager (CDM). The ice machine was observed first. It had a monthly maintenance check sheet attached to the front. The last month signed on the maintenance log for the ice machine was checked by maintenance was August of 2024. Photographic evidence obtained In an interview the CDM said to her knowledge no one had checked it since she had been she had been employed at the facility, approximately three months. Dietary Aide Staff E was observed using the 3-compartment sink. The third sink was empty. A metal bin with a sanitizing solution was observed in the third sink. Dietary Aide Staff E was observed washing and rinsing a pan. Staff E dunked the pan and left it floating on the sanitizing solution in the metal bin. Staff E did not ensure the pan was completely submerged in the solution. Photographic evidence obtained In an interview Dietary Aide Staff E said the dishes were supposed to be in the sanitizing solution for 10 seconds. Review of the instructions affixed to the wall for use of the sanitizer revealed the dishes had to stay submerged for 1-2 minutes in the sanitizing solution. Staff E said he was not aware the dishes had to be submerged for 1-3 minutes in the sanitizing solution. Staff E said the third compartment used for the sanitizer had been leaking for the past 4-5 days which is why he was using the metal bin. The CDM and Dietary Aide Staff E said they had notified the Maintenance Department that the third sink was leaking. In an interview the CDM said Dietary Aide Staff E was hired after she started employment at the facility three months ago. She could not provide documentation Dietary Aide Staff E was trained on the proper use of the 3 compartment sink. During the tour, a staff member was observed entering and walking through the kitchen without a hair restraint. When asked about hair restraint she said there were no hairnet at the entrance so she walked through the other entrance to get one. There were also multiple areas of black bio growth noted throughout the kitchen, on the ceiling and vents with dust/debris. Photographic evidence obtained. In an interview the CDM said that maintenance has not cleaned the air-conditioning vents or the ceiling since she started employment at the facility three months ago. On 2/18/25 at 9:15 a.m., in a follow up tour of the kitchen, the 3 compartment sink was observed. The 3rd sink containing the sanitizing solution was full of dishes. Not all the dishes were completely submerged in the sanitizing solution. The CDM was present during the observation. In an interview, when asked if this was proper use of the sanitizer sink, the CDM replied no. On 2/18/25 at 9:30 a.m., in an interview the Maintenance Director said he has been employed at the facility for only 3 weeks and has been putting out fires. He said he has taken care of a drainage issue for the steam table and affixed an appliance to the wall for the kitchen. On 2/18/25 The CDM Provided the Three Compartment Sink Operation Manual which stated, The ware is then immersed for 60 seconds in the third sink, which contains the sanitizing solution. It must stay immersed for 60 seconds to comply with the Environmental Protection Agency's (EPA) requirements. On 2/20/25 at 11:15 a.m., the Maintenance Director provided a TELS (Web-based building management platform) printout of closed work orders for July 1, 2024, to [DATE]. Included on this list was to clean bio growth off ceiling, paint falling from ceiling, ceiling vents dirty, ceiling needs repair and paint. None of the listed items had a completion date. On 2/20/2025 at 11:30 a.m., in an interview the Administrator said kitchen ceilings should be cleaned monthly. He also agreed that if there was a monthly sign-in sheet on an appliance, that would indicate it required a monthly servicing. He also said that no employee should enter the kitchen (other than the designated area at the main entrance) without wearing a hair net.

Based on observations, record reviews and staff interviews, the facility failed to ensure licensed nurses followed infection prevention practices during blood glucose monitoring for 2 (Residents #447 and #131) of 2 residents observed. The facility failed to ensure urinary catheter drainage bags were stored in a safe and sanitary manner for 2 (Residents #103 and #75) of 2 residents observed with urinary catheter drainage bags stored on the floor. The findings included: 1. Review of the policy for Hand Hygiene and Infection Control last revised on 6/2023 revealed that the facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Situations that require hand hygiene include but are not limited to: Before and after performing any invasive procedure (e.g. fingerstick blood sampling) and after removing gloves or aprons. On 2/19/25 at 11:30 a.m.,, Registered Nurse (RN) Staff D was observed doing a fingerstick to measure Resident #447's blood glucose. RN Staff D donned a pair of gloves that he removed from his pocket. Staff D did not perform hand hygiene before donning the gloves. RN Staff D removed a glucometer (machine to measure blood glucose) from a plastic container in the medication cart and placed it on the resident's bedside. RN Staff D did not clean/disinfect the glucometer before taking it to the resident's room. RN Staff D performed the fingerstick and measured the resident's blood glucose. RN Staff D removed the gloves and did not perform hand hygiene. He took the glucometer back to the medication cart at the nurse's station, accessed the computer and medication in the cart. RN Staff D did not perform hand hygiene, donned a pair of gloves and prepared insulin for the resident. RN Staff D returned to the resident's room and administered insulin to Resident #447. He removed the gloves and did not perform hand hygiene before leaving the resident's room and walking down the hallway. Staff D RN took a telephone call at the nurse's station and returned to the medication cart. RN Staff D did not perform hand hygiene and placed the cleaned glucometer and supplies back in the plastic container. 2. On 2/19/25 at 11:40 a.m., RN Staff D was observed preparing to monitor Resident #131's blood glucose. He did not perform hand hygiene and donned a pair of gloves. RN Staff D removed a glucometer from a plastic container in the medication cart and took it to the resident's room. RN Staff D did not clean or sanitize the glucometer before using it to monitor the resident's blood glucose. RN Staff D obtained a drop of blood via fingerstick and measured Resident #131's blood glucose. RN Staff D removed the gloves and did not perform hand hygiene before leaving the resident's room. RN Staff D removed and prepared insulin to administer to Resident #131. RN Staff D donned gloves and administered insulin subcutaneously to Resident #131. RN Staff D removed the gloves and did not perform hand hygiene before leaving the resident's room. RN Staff D sanitized the glucometer and placed it back in the plastic container. He did not perform hand hygiene and accessed the computer. On 2/19/25 at 2:00 p.m., in an interview RN Staff D said he was not aware that he needed to perform hand hygiene before donning gloves and after doffing gloves. He said he believed that using a sanitizing wipe for the glucometer was a sufficient form of hand sanitizing. He said he believed he may have picked up bad habits. On 2/20/25 at 9:00 a.m., the observation of lack of hand hygiene before donning gloved and after doffing gloves were shared with the Director of Nursing (DON). She said the facility provides handwashing training. 3. Review of the Catheter Care policy last revised on 1/2024 revealed that the facility will maintain infection control guidelines related to catheter use and catheter care to minimize catheter associated infections. 1. Ensure the retainage spigot (flow valve) is not touching the floor, the tubing is free of kinks and the catheter is kept at an appropriate level to promote urine flow. On 2/17/25 at 9:15 a.m., Resident #103 was observed in bed. The bed was in the low position. Resident #103 had an indwelling urinary catheter (catheter inserted in the bladder to drain urine). The urinary catheter drainage bag was touching the floor. On 2/17/25 at approximately 9:30 a.m., Resident #75 was observed in bed. The resident had an indwelling urinary catheter. The catheter drainage bag was not secured to the bed and was laying on the floor.

Based on observation, record review, residents and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment for 9 (Rooms #238, #240, #243, Residents #75's room, #103's room, #109's room, and #81's room)of 22 residents' rooms observed, and 2 (Unit 2A and 2B) of 2 shower rooms observed. The findings included: On 2/17/25 at 9:46 a.m., during the initial tour the following observations were made: 1. room [ROOM NUMBER]: A shampoo bottle, and a spray bottle were stored on the floor next to bed B. 15 unrefrigerated yogurts and a carton of milk were stored on the air-conditioning unit and the windowsill. The shared bathroom had a pile of soiled towels on the floor. Unlabeled dishes and washbasins were stored on a shelf above the toilet. An unlabeled urine measuring container was stored on the toilet tank. Photographic evidence obtained. 2. Resident #108's room: Resident #108 was observed in bed. Her urinary catheter drainage bag was on the floor. 3. room [ROOM NUMBER] A: The mattress on the bed was frayed, torn and soiled covering 50% of the upper portion of the mattress. 4. Resident #75's room: Resident #75 was observed in bed. The urinary catheter drainage bag was on the floor. Garbage was scattered on the floor and the trashcan was not within the residents reach. Photographic evidence obtained. There was damage to one of the walls in the room. A ceiling tile was missing from the shared bathroom, exposing the ceiling pipes. An unlabeled wash basin was stored on top of the sharp container. An unlabeled wash basin was stored on the toilet seat. Photographic evidence obtained. Outside of room [ROOM NUMBER] there was a fire extinguisher holder with red scattered, unknown substance on the side of the holder. Photographic evidence obtained. 5. Resident #103's shared room and bathroom: Soiled gloves were observed on the floor, next to a pile of unbagged soiled linen. Uncovered and unlabeled wash basins were stored on top of the sharps container. Photographic evidence obtained. The room had a pungent smell of urine and feces. 6. room [ROOM NUMBER]'s shared bathroom: An unlabeled and uncovered wash basin was stored on the toilet tank. 7. Resident #109's room: Snacks foods, and bottles of lemon-aid stored were stored on the floor. A nebulizer (a small machine that turns liquid medication into a mist that is inhaled) was stored uncovered on the floor under the bed. In an interview, Resident #109 said she was using the nebulizer to treat her cough and shortness of breath. The resident said the showers on Unit 2 B and Unit 2 A were broken. There was only one shower that did not always work. Photographic evidence obtained. 8. Resident #107's room: Resident #107 was observed sitting in bed with books piled at end of bed. The resident's clothes were hanging from the privacy curtains, and from a broken television unit on the wall. A urinal 75% full of urine was on the bedside table. Two empty urinals were observed hanging inside of the trash can. In an interview during the observation, Resident #107 said the closet was too small and did not hold all of his clothing. In the shared bathroom: Resident #107's dentures and toothbrush were stored on the back of the toilet tank. The resident said he stored his items on the back of the toilet because there was no storage or shelving in the bathroom. He said he did not receive showers since the showers in the shower room on the unit were broken. Photographic evidence obtained. On 2/18/25 at 2:45 p.m., the Director of Nursing (DON) observed Resident #107's room and confirmed his clothing was hanging from the privacy curtain. She said the resident liked his things a certain way. She said the resident had too much stuff. The DON said the staff have been working with him to reduce the amount of items he has. The DON said the resident's clothing hanging from the wall where the television was once attached was not an issue or concern. She said the clothing hanging from the privacy curtain was not a safety issue and was ok to be there because the curtain was able to be opened and closed. The DON confirmed the resident's personal care items stored on the back of the toilet tank including dentures and toothbrush was not acceptable. She said they should be stored in a wash basin and placed in the nightstand. She confirmed there were three urinals in the trash can and they would have to come up with a plan for that. 9. On 2/17/25 at 11:00 a.m., Resident #74 was observed in the television room on unit seated in his wheelchair with a towel covering his laps. The resident's shirt was dirty, he had no pants, briefs or underwear on. His sides and back visible through wheelchair gaps. In an interview, Resident #74 said he was not able to find any of his pants. A female resident sat at a table in the room looking at a magazine. 10. On 2/17/25 at 11:27 a.m., Resident #81 was observed in his room. A urinal filled with approximately 25% with urine was sitting on the nightstand. There were dirty linen scattered on the floor. Photographic evidence obtained. 11. On 2/17/25 at 11:42 a.m., observation of the shower room on Unit 2 A revealed a broken and missing shower head in the first stall. Photographic evidence obtained. On 2/17/25 at 11:45 a.m., in an interview Licensed Practical Nurse (LPN) Staff K confirmed the showers on Unit 2 A were not functioning. Staff K said the showers had been broken for a long time. On 2/18/25 at 10:16 a.m., in an interview Certified Nursing Assistant (CNA) Staff O said the showers on Unit 2 A and 2 B have been broken for months. Observation of the shower room on Unit 2 B the 2 B revealed 2 functioning showers. The CNA said she did not know exactly how long the showers had not been working but said Maintenance knew about the problem. She said the facility had no maintenance person for several months, so things did not get repaired. On 2/18/25 at 2:45 p.m., in an interview the DON said she was aware the showers on Unit 2 A were not working and confirmed there were only two functioning showers on the 2nd floor. On 2/18/25 at 3:30 p.m., in an interview Resident #109, the Resident Council President said Today was my shower day and I was not offered a shower. Just a little longer and I will go outside and use a hose. The situation with the showers has been going on for a long time, for months. The staff get to go home, and they get to take a shower. This is our home, and we can't get a shower. They give a sponge bath and I'm sorry, but a sponge bath is not a shower. I need a shower, and the shower situation has got to be resolved. I can go into the bathroom and wash myself up, so they don't even offer me a sponge bath. No one here ever offered me a shower. I can tell you, We, as in the Resident Council and other residents who can express themselves feel like we are being ignored. This is our last stop in life for most of us and they need to treat us with respect. No one ever offers me a shower. It is not right. Review of the facility Maintenance Logs revealed on 12/4/24, both showers on unit 2 A are flooded and unable to use. On 1/8/25, Staff report the showers are not working on unit 2 A. On 1/8/25 a maintenance request documented, shower not working, or draining on the 2nd floor unit 2 B. The Maintenance Requests were still marked as open requests and not completed.

Based on observation, record review and interviews, the facility failed to ensure 2 (Residents #6 and #123) of 3 sampled residents received care in accordance with the established plan of care. The findings included: 1. Review of Resident #6's clinical record revealed an admitted [DATE]. Diagnoses included chronic diastolic congestive heart failure, a condition in which the heart doesn't pump blood as well as it should. Review of the Admission Minimum Data Set (MDS) assessment with a target date of 1/7/25 revealed Resident #6's cognition was intact with a Brief Interview for Mental Status score of 15. Review of the Treatment Administration Record (TAR) for February 2025 revealed a physician's order dated 1/30/25 for TED hose (compression stockings) on during the day and off at night to Bilateral Lower Extremities (BLE), every day and evening for BLE edema (swelling caused by excess fluid buildup in tissues) and orthostatic hypotension (sudden drop in blood pressure upon standing up). On 2/17/25 at 3:55 p.m., Resident #6 was observed sitting in a wheelchair. Observation of the resident's lower legs revealed she was wearing tennis shoes and socks rolled down to the ankle. The resident's lower legs were clearly visible. She was not wearing the compression stockings. On 2/18/25 at 11:00 a.m., Resident #6 was observed in the therapy gym. The resident's lower legs were clearly visible. She was not wearing the compression stockings. On 2/18/25 at 4:39 p.m., Resident #6 was observed sitting in a wheelchair. The resident's lower legs were visible. She was not wearing the compression stockings. In an interview, Resident #6 said she did not own a pair of compression stockings. She said the staff have not given her compression stockings and have never applied compression stockings to her legs. Resident #6 said, I wonder if I am being charged for them. On 2/18/25, review of the TAR for February 2025 revealed on 2/1/25 through 2/18/25, each day the nurses placed their initials on the TAR verifying Resident #6 had the compression stockings on during the day and the stockings were removed in the evening. On 2/6/25, the TAR showed the compression stockings were applied in the morning but lacked documentation the stockings were removed in the evening. On 2/18/25 at 4:45 p.m., in an interview Registered Nurse (RN) Staff P verified she documented the compression stockings were applied on 2/18/25 without verifying Resident #6 had them on. On 2/18/25 at 4:52 p.m., the DON was observed in Resident #6's room. In an interview she said she could not find compression stockings or any wraps in Resident #6's room. Resident #6 said she's never worn compression stockings since her admission to the facility, no one had offered or asked her to apply compression stockings. The DON said she would expect the nurses to verify the compression stockings were applied before documenting on the TAR. On 2/19/25 at 9:57 a.m., in an interview RN Staff D verified he signed on the TAR the compression stockings were applied on 2/1/25, 2/2/25, 2/3/25, 2/5/25, 2/6/25, 2/7/25, 2/10/25, 2/11/25, 2/12/25, 2/13/25, 2/15/25, 2/16/25 and 2/17/25. He said Resident #6 began refusing the compression stockings but he kept documenting on the TAR they were applied to the resident's legs. He said he never verified the resident was wearing the compression stockings when he signed the TAR. 2. Review of the clinical record for Resident #123 revealed an admitted [DATE]. Diagnoses included fracture of the lower end of the right femur (thigh bone). Review of the Admission MDS with a target date of 12/21/24 revealed the resident's cognition was intact with a BIMS score of 14. Review of the MAR for February 2025 revealed an order dated 2/5/25 for a compression sock to the right leg, on in am (morning) and off at HS (hour of sleep/bedtime). On 2/17/25 at 10:30 a.m., Resident #123 was observed in her room sitting in a wheelchair. The resident's lower legs were clearly visible. She was not wearing a compression sock to the right leg. On 2/18/25 at 5:13 p.m., Resident #123 was observed sitting in a wheelchair in her room. Her lower legs were clearly visible. She was not wearing a compression sock to the right lower extremity as ordered. The DON was present during the observation and verified Resident #123 was not wearing the compression sock to the right lower leg. In an interview during the observation, Resident #123 said the compression sock was in her drawer but no one has asked her to wear the compression sock or applied it for her. On 2/18/25 at 5:15 p.m., the DON found a package of compression stocking in the drawer of the resident's bedside table. Review of the MAR for February 2025 revealed each day on 2/6/25 through 2/11/25 and 2/13/25 through 2/18/25 the licensed nurses signed the MAR verifying the compression sock was applied to the resident's right leg and removed in the evening. On 2/18/25 at 5:20 p.m., in an interview, Licensed Practical Nurse (LPN) Staff J verified she signed on the MAR the compression sock was applied to the resident's right leg on 2/6/25, 2/8/25, 2/9/25, 2/10/25, 2/11/25, 2/13/25, 2/14/25, and 2/18/25. LPN Staff J said she never applied the compression sock to Resident #123's right leg and did not verify the compression sock was applied before signing the TAR.

Based on record review and interview, the facility failed to ensure that resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine and that the resident's medical record includes documentation that the resident or resident representative were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, documentation of COVID-19 vaccine administered to the resident; or documentation the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for 5 (Residents #97, #67, #133, #104, #108 ) of 5 residents reviewed for vaccinations. The findings included: Facility policy for Infection Control COVID 19 Revised 6/24/24 indicated under section titled Vaccination 1. COVID 19 Vaccines are offered to residents and staff in accordance with CDC (Centers for Disease Control) guidance Stay Up to Date with COVID-19 Vaccines. CDC guidance Stay Up to Date with COVID-19 Vaccines indicates: It is especially important to get your 2024-2025 COVID-19 vaccine if you are ages 65 and older, are at high risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine. *Getting the 2024-2025 COVID-19 vaccine is especially important if you: *Are ages [AGE] years and older *Are at high risk for severe COVID-19 *Are living in a long-term care facility On 2/20/25 at 10:00 a.m., the Regional Nurse provided documentation regarding COVID vaccination status for Residents #97, #67, #133, #104, and #108. This documentation indicated the following as status of vaccination: Resident #97 historical 4/29/21, historical 5/21/21, complete Left Deltoid 10/26/2 Resident #67 historical 5/24/21, historical 3/8/22 Resident #133 not eligible Resident #104 not eligible Resident #108 complete 10/26/21 On 2/20/25 at 10:40 a.m., the Director of Nursing (DON) said residents were asked if they've had the COVID vaccine before and if they wanted it again. She said the residents just tell them yes or no. The DON was unaware if there was any form or documentation for this. On 2/20/25 at 12:00 p.m., the Assistant Director of Nursing (ADON) acknowledged she was the Infection Preventionist for the facility. The ADON said if they have had the vaccination in the past, she enters it as historic, as opposed to a declination that they had it before. ADON agrees the way it is currently handled she cannot verify resident/representative education or acceptance/refusal was discussed. She said they had not been using consent forms for COVID vaccinations.

Based on observation, interview, and record review, the facility failed to ensure 8 (Residents #109, #346, #196, #108, #138, #103, #9, and #65) of 9 residents dependent upon staff for care received the necessary care and assistance for activities of daily living. The findings included: 1. Review of the Clinical Record Review for Resident #109 revealed an Annual Minimum Data Set (MDS) assessment with a target date of 3/14/24. The assessment noted the resident felt it was very important to choose a shower, bed bath, tub bath or sponge bath. The Quarterly MDS with a target date of 1/2/25 revealed Resident #109's cognitive skills for daily decision making was intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident #109 required set-up or clean-up assistance with showers or bathing and supervision or touching assistance to get in and out of a tub/shower. On 2/17/25 at 10:00 a.m., in an interview Resident #109 stated, Staff do not offer to shower me and no, I did not receive my shower yesterday. The resident said the showers on this side were broken. The shower that is working does not have a grab bar, so she can't use it. Resident #109 said, I'll just have to keep taking a sink bath until they get the showers fixed. On 2/18/25 at 3:15 p.m., in an interview Resident #109 said no one offered to shower her today. The resident said she was afraid to go in the shower because there was no ramp and no grab bar. The resident said she will continue to wash up in the sink, or they can help me find a hose outside until the 2A unit showers are repaired. Resident stated the showers on Unit 2A have been an issue for several months. The issue had been discussed in Resident Council meetings. She has gone months without a shower. Record review of the Certified Nursing Assistant (CNA) bathing documentation failed to reveal documentation Resident #109 received a shower in January 2025 and February 2025. The documentation showed Resident #109 received a sponge bath on 1/2/2025 1/4/2025, 1/6/2025, 1/9/2025, 1/16/2025, 1/20/2025,1/22/2025,1/23/2025, 1/24/2025, 1/29/2025, 1/30/2025, 2/1/2025, 2/6/2025, 2/8/2025, 2/12/2025, 2/13/2025, 2/14/2025, 2/15/2025, 2/17/2025. 2. Review of the clinical record for Resident #346 revealed an admitted [DATE]. Diagnoses included Traumatic Brain Injury, Seizures, Spastic Hemiplegia affecting the left side and muscle weakness. The Annual Minimum Data Set (MDS) assessment with a target date of 1/30/25 revealed Resident #346 had no impairment in functional range of motion in bilateral upper and lower extremities and required supervision with meals and oral hygiene. The MDS noted the residents' cognitive skills for daily decision making were moderately impaired with a Brief Interview for Mental Status (BIMS) score of 06. Review of the Kardex (Provides instructions for safe care) for Resident #346 revealed to encourage, offer assist fluids at meals. Encourage and assist with all ADL tasks as indicated and as tolerated by resident, including meals. On 2/17/25 at 12:00 p.m., Dietary Aide Staff G was observed serving the noon meal to the residents in the dining room. In an interview, Dietary Aide Staff G said no one from the nursing department comes to assist the residents with dining. Staff G said someone from the kitchen or a dietary aid are in the dining room. In an emergency, he would run down the hallway to the nursing desk for assistance. He confirmed no other staff were in the dining room during the meal. On 2/17/25 at 12:30 p.m., Resident #346 was observed in the dining room. A family member was assisting the resident with his lunch. No staff were observed in the dining room to assist resident #346 with his meal. On 2/17/25 at 1:30 p.m., in an interview Resident #346's family member stated that the nursing staff were not providing ADL care or supervision during mealtime. She said, There is not enough staff. Things have changed with the new ownership. The family member said there was an increased use of agency nursing and the CNAs (Certified Nursing Assistants), They don't care the same way that the regular staff does and I feel the care has really declined here. They don't help him at mealtime and I am afraid that he could choke. I feel that he is declining. The family member said Resident #346 had not received a shower in five weeks. Any type of bathing the resident gets is if she provides it. On 2/18/25 at 9:35 a.m., CNA Staff H said Resident #346 was independent with meals and she did not feed him. On 2/18/25 continuous observation from 12:00 p.m., to 12:15 p.m., revealed Resident #346 in the dining area during the lunch meal. Resident #346's eyes were closed. He appeared to be sleeping. Resident #346 had no napkin or silverware. Resident #346 did not start eating until CNA Staff M held the resident's soup container and placed a glass of juice in the resident's hand and guided it towards his mouth. Resident #346 required Staff M's cueing and encouragement throughout the meal. On 2/18/25 at 3:10 p.m., in an interview the Director of Nursing (DON) said that the dining room on the first floor was intended for residents who are independent diners or need staff cueing. On 2/20/25 at 11:30 a.m., Resident #346 was observed sitting at a table in the dining area. Resident #346 was holding a fork but was not eating his meal. No staff was observed in the dining area assisting or cueing Resident #346. On 2/20/25 at 11:40 a.m., the Assistant Director of Nursing (ADON) arrived in the dining area. The ADON verified that there was no nursing staff in the dining room. She said the kitchen staff could go find a nurse down the hall if there was a need. She said if the facility policy states that a member of the nursing team is to be in the dining area during mealtime, then it was not ok not to have someone there. During the observation and interview, kitchen staff were observed walking through the dining room and back to the kitchen with little interaction with the residents. Review of the CNA documentation for January 2025 and February 2025 failed to reveal Resident #346 received assistance with meals during the 3:00 p.m., to 11:00 p.m. shift on 1/1/2025, 1/2/2025, 1/3/2025, 1/4/2025, 1/5/2025, 1/6/2025, 1/7/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/14/2025, 1/15/2025, 1/16/2025, 1/17/2025, 1/18/2025, 1/19/2025, 1/20/20225, 1/21/2025, 1/22/2025, 1/23/2025, 1/24/2025, 1/25/2025, 1/26/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, 1/31/2025, 2/1/2025, 2/2/2025, or 2/3/2025. There was no documentation Resident #346 received a shower on 1/2/2025, 1/3/2025, 1/4/2025, 1/5/2025, 1/6/2026, 1/7/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/14/2025, 1/16/2025, 1/17/2025, 1/18/2025, 1/18/2025, 1/19/2025, 1/20/2025, 1/21/2025, 1/23/2025, 1/24/2025, 1/25/2025, 1/26/2025, 1/27/2025, 1/28/2025, 1/30/2025, 1/31/2025, 2/1/2025, 2/2/2025, 2/3/2025, or 2/4/2025. 3. Review of the clinical record for Resident #108 revealed a re-entry date of 12/29/24. Review of the Quarterly MDS with a target date of 12/11/24 revealed Resident #108's cognitive skills for daily decision making were intact with a BIMS score of 15. The resident was dependent on staff to get in and out of a tub/shower and to showers and bathe self. On 2/17/25 at 9:15 a.m., in an interview Resident #108 stated the showers have been broken for at least one month and she has not been able to get a shower. On 2/19/25 at 9:00 a.m., in an interview Resident #108 said her shower days were Tuesdays and Thursdays on the evening shift. She said no one offered her to shower the previous evening (Tuesday 2/18/25). Resident #108 said they do not offer her showers. She has to remember her shower days and track down an aide to ask for a shower. Review of Resident #108's Kardex revealed the resident was independent to supervision, able to transfer in and out of shower and complete the bathing task. Review of the CNA Activities of Daily Living documentation report failed to show Resident #108 received a shower on 1/2/2025, 1/4/2025, 1/7/2025, 1/9/2025, 1/11/2025, 1/14/2025, 1/16/2025, 1/18/2025, 1/21/2025, 1/23/2025, 1/28/2025, 2/1/2025, 2/4/2025, 2/6/2025, 2/11/2025, 2/13/2025, 2/15/2025 and 2/18/2025. The resident received a sponge bath on 2/8/25. 4. Review of the clinical record for Resident #103 revealed a Quarterly MDS with a target date of 2/2/25. The MDS noted the resident's cognitive skills for daily decision making were intact with a BIMS score of 15. Resident #103 had an indwelling urinary catheter and was always incontinent of stool. Resident #103 was dependent on staff for toileting and required substantial/maximal assistance to shower/bathe self. Review of Resident #103's Kardex revealed staff was to encourage and assist with all ADL as indicated and as tolerated by resident, including bathing, and toileting. On 2/17/25 at 9:15 a.m., Resident #103 was observed in bed. The room had a strong urine odor. The resident's hair was uncombed and greasy. In an interview during the observation, Resident #103 said no one changed her incontinent briefs since the previous night. Resident #103 stated, I can tell that I smell. I did not get changed last night. The CNA ADL documentation for January 2025 and February 2025 lacked documentation of bathing on 1/2/2025, 1/4/2025, 1/7/2025, 1/9/2025, 1/14/2025, 1/16/2025, 1/18/2025, 1/28/2025, 1/30/2025, 2/4/2025, 2/6/2025, 2/8/2025, and 2/11/2025. There was no documentation Resident #108 received personal hygiene care on 1/4/2025, 1/6/2025, 1/7/2025, 1/9/2025, 1/10/2025, 1/16/2025, 1/17/2025, 1/21/2025, 2/4/2025, and 2/8/2025. 30599 5. Review of the clinical record for Resident #9 revealed an admitted [DATE]. Diagnoses included Osteomyelitis, Major Depressive Disorder, Arthritis and Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 12/9/24 revealed the resident's cognitive skills for daily decision making were intact with a BIMS score of 14. Resident #9 was dependent on staff for showering and did not reject care. Review of the care plan for activities of daily living initiated on 3/10/24 and revised on 9/13/24 revealed Resident #9 was dependent on staff for bathing needs, including transfer in and out of the shower. On 2/20/25 at 10:45 a.m., in an interview Resident #9 said she does not get a shower when she wants one. She said she would like to shower twice a week but it has been a while since she's had a shower. Review of Resident #9's Kardex showed no scheduled days for showers. On 2/20/25 at 12:30 p.m., in an interview the Director of Nursing (DON) said the Kardex is used to communicate the residents' needs to the CNAs and the shower schedule should be listed on the Kardex. A Shower Schedule list observed hanging behind the B Nursing Station showed Resident #9's showers were scheduled on Tuesdays and Fridays. On 2/20/25 at 1:15 p.m., in an interview Resident #9 said she did not know when she was scheduled to have a shower. Review of the electronic Shower/bathing Task schedule for January 2025 and February 2025 showed documentation of bathing or showers five times in the past 30 days. The most recent documentation of bathing was on 2/15/25. 6. Review of the clinical record for Resident #65 revealed an admitted [DATE]. Diagnoses included Diabetes, Epilepsy, Psychotic Disorder, Traumatic Brain Injury, and Depressive Disorder. Review of the Quarterly MDS with a target date of 12/30/24 revealed Resident #65's cognition for daily decision making was severely impaired with a BIMS score of 7. Resident #65 was dependent on staff for bathing and did not reject care. Review of the resident's care plan revised on 7/17/24 revealed Resident #65 had self-care deficit for activities of daily living and was dependent on staff to transfer him in and out of the shower. The care plan did not include a shower schedule. On 2/19/25 at 3:49 p.m., Resident #65 was observed in the dining room on the [NAME] unit watching television. The resident's hair was uncombed and greasy. Review of the shower schedule list hanging behind the nursing station on the [NAME] Unit showed Resident #65 was scheduled for showers on Tuesdays and Fridays. Review of the electronic Shower/Bathing checklist for January 2025 and February 2025 showed Resident #65 received a shower/bath three times in the last 30 days, on 2/7/25, 2/14/25 and 2/18/25. On 2/20/25 at 12:15 p.m., in an interview the Assistant Director of Nursing verified there was no documentation Resident #65 received his scheduled showers twice weekly. 7. Review of the clinical record for Resident #138 revealed an admitted [DATE]. Diagnoses included Hemiplegia (paralysis of one side of the body), Malnutrition, Cerebral Infarction, and Seizures. Review of the Quarterly MDS with a target date of 2/1/25 showed Resident #138's cognitive ability for daily decision making were moderately impaired with a BIMS score of 08. Resident #138 was dependent on staff for showering and did not refuse care. Review of the care plan for Activities of Daily Living initiated on 11/30/24 revealed the resident was dependent on staff for bathing needs, including to transfer in and out of the shower. Review of the electronic Kardex revealed no documentation of a shower schedule for Resident #138. Review of the unit's shower book revealed shower days were listed for each room. Resident #138's room was not included on the list. Review of the electronic Shower/Bathing checklist from 1/20/25 through 2/18/25 revealed Resident #138 received a bath/shower twice in the last 30 days, on 1/21/25 and 2/17/25. On 2/18/25 at 9:43 a.m., Resident #138 was observed in his room, in bed. The resident had a full beard. In an interview, Resident #138 was asked if he liked having a beard. The resident shook his head and said, No. On 2/19/25 at 12:30 p.m., in an interview Registered Nurse (RN) Staff D verified Resident #138 was not included in the book with the shower schedule. Staff D said he did not know why the resident was not included in the shower schedule. On 2/19/25 at 12:46 p.m., in an interview CNA Staff C said she did not know Resident #138's shower schedule. On 2/19/25 12:45 p.m., in an interview the ADON said Resident #138 had not been listed on the shower schedule since 3/8/24. She said she could only find documentation the resident received a shower twice in the last 30 days, on 1/21/25 and 2/17/25. 8. Review of the clinical record revealed Resident #196 had an admitted [DATE] and resided in the memory care unit. Diagnoses included Hemiplegia (Weakness on one side of the body), Traumatic Brain Injury and Obesity. Review of the Admission MDS with a target date of 2/8/25 revealed the resident's cognition was severely impaired with a BIMS score of 04. Resident #196 did not reject care. Resident #196 required substantial/maximum assistance to shower/ bathe self, and supervision for eating. On 2/18/25 at 11:14 a.m., Resident #196 was observed in bed, sleeping. The resident's hair was uncombed and greasy. The lunch tray in front of the resident was untouched. On 2/19/24 at 1:43 p.m., Resident #196 was observed bed sleeping. The resident's hair remained greasy. On 2/19/25 at 1:45 p.m., in an interview Licensed Practical Nurse (LPN) Staff N said Resident #196's showers were scheduled for the night shift (11:00 p.m., to 7:00 a.m.). Review of the electronic Shower/Bathing checklist revealed since admission of 2/5/25, Resident #196 received one shower on 2/18/25. On 2/20/25 at 12:15 p.m., in an interview the Assistant Director of Nursing verified there was no documentation Resident #196 received his scheduled showers twice a week as scheduled.

Based on resident and staff interviews, the facility failed to support the resident's right to voice a grievance without fear of discrimination or reprisal for 1(Resident #103) of 2 residents reviewed for grievances. The findings included: The facility policy Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin issued 8/2022, defined Mental abuse: the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame. Review of the clinical record revealed Resident #103 had a readmitted [DATE] with diagnoses including multiple sclerosis, anxiety and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) with a target date of 2/2/25. The MDS noted the resident's cognitive skills for daily decision making were intact with a BIMS score of 15. Resident #103 had an indwelling urinary catheter and was always incontinent of stool. Resident #103 was dependent on staff for toileting and required substantial/maximal assistance to shower/bathe self. On 2/17/25 at 10:00 a.m., Resident #103 was observed in her room in bed. She said she was bedbound and not able to stand. The room had a strong, pungent odor of urine and feces. Resident #103 said she had not received incontinent care since last night. The resident said, I know I smell right now; I can smell myself. On 2/19/25 at 9:13 a.m., in an interview Resident #103 said she valued her privacy. Two staff members from the management team came to speak with her immediately after her interview with a member of the survey team on 2/17/25 at 10:00 a.m. They wanted to know what was discussed during the interview and made her feel guilty. Resident #103 said she felt insecure about it now. On 2/20/24 at 11:15 a.m., in an interview the Assistant Director of Nursing (ADON) verified she did ask Resident #103 about her interview with a member of the survey team but did not file a grievance for the resident.

Based on interview and record review, the facility failed to develop a care plan to meet the needs of 1 (Resident #51) of 4 residents reviewed for comprehensive care plan. The findings included: Review of the clinical record for Resident #51 revealed an admitted [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease. Review of the smoking evaluation dated 1/20/25 at 8:27 a.m., revealed Resident #51 was a smoker, used cigarettes and agreed to the smoking policy. Resident #51 also agreed to remove oxygen source before smoking. Review of the care plan failed to reveal a care plan for smoking with goals and interventions to meet the resident's needs. On 2/18/25 at 3:36 p.m., in an interview Resident #51 said she's been smoking for a long time. She said when her sister visits, she goes outside with her to smoke. On 2/18/25 at 4:06 p.m., in an interview Minimum Data Set (MDS) Licensed Practical Nurse (LPN) Staff R said there should be a smoking care plan if the resident was smoking while residing at the facility. On 2/20/25 at 12:11 p.m., in an interview Registered Nurse (RN) MDS Staff S said he was not sure why a care plan was not developed to address Resident #51's smoking.

Based on observation, clinical record review, review of facility Standards and Guidelines, resident and staff interviews, the facility failed to ensure proper storage of medication for 2 (Residents #107 and #81) of 2 residents observed with unsecured over the counter medications at bedside and 1 (Unit 1A) of 3 units observed with medication left unsecured and unattended. The findings included: The facility Standards and Guidelines: Medication Storage and Labeling documented, The facility stores all drugs and biologicals in a safe, secure and orderly manner . Drugs used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications . On 2/17/25 at 10:43 a.m., an unsecured bottle of acetaminophen 500 milligrams (mg) tablets was observed at Resident #107's bedside. In an interview, Resident #107 said he took the acetaminophen as needed for headaches. Photographic evidence obtained. Review of Resident #107's clinical record failed to show documentation that the Interdisciplinary Team (IDT) determined the resident was able to safely self-administer the medication and ensure the medication was stored safely and securely. On 2/17/25 at 1:57 p.m., in an interview Licensed Practical Nurse (LPN) Staff K confirmed the bottle of acetaminophen at the resident's bedside was not stored safely and securely. LPN Staff K reviewed Resident #107's clinical record and said there was no evaluation indicating the resident was able to keep the medication at the bedside and was able to ensure the acetaminophen was stored safely. 2. On 2/17/25 at 11:27 a.m., Resident #81 was observed in his room at his computer desk. A large, half full bottle of antacid tablets was observed on the desk and one full bottle of antacid tablets was observed on the floor next to his wheelchair. Resident #81 said the medications were his. Photographic evidence obtained. On 2/17/25 at 2:00 p.m., LPN Staff L confirmed Resident #81 had two unsecured bottles of antacids in his room. LPN Staff L reviewed Resident #81's clinical record and confirmed he had no physician order or assessment to self-administer the medication. 3. On 2/18/25 at 2:20 p.m., during an observation at the 1A unit nursing desk there was a box of Ipratropium Bromide (relaxes the airway) belonging to Resident #116, sitting on top of the desk. There were no staff present for several minutes. Residents and visitors were in the hallways. Photographic evidence obtained. On 2/18/25 at 2:40 p.m., in an interview the Director of Nursing (DON) said she was informed of the unsecured medication at the bedside of Residents #107 and #81. She said she was not aware of the unsecured medication left at the 1 A nursing station today.

Based on record review, resident, resident representative and staff interviews, the facility failed to allow 1 (Resident #18) of 2 residents reviewed the right to participate in their care by failing to inform the resident and representative in advance of the discontinuation of a medication. The findings included: Review of Resident #18's clinical record revealed an admitted [DATE] from an acute care hospital. Review of the Admission Minimum Data Set (MDS) assessment revealed the resident's cognition was intact with a Brief Interview for Mental Status score of 15. Diagnoses included seizure disorder or epilepsy. The clinical record revealed an amended letter of plenary guardianship dated 11/3/17, noting Resident #18 had a court appointed limited guardian of his person and property. Review of the hospital discharge summary dated 12/25/24 revealed discharge diagnoses included Epilepsy without status epilepticus (seizure lasting more than 5 minutes or seizures very close together). The discharge medications included Epidiolex liquid (approved to treat seizures), 400 mg orally two times a day. On 2/17/25 at 11:00 a.m., in an interview Resident #18 said he was under the care of a neurologist and took Epidiolex to prevent seizures. The resident said the facility stopped giving him the Epidiolex on 12/29/24. He said the facility did not tell him why or when they stopped the medication. Resident #18 said on 12/31/24 he had two seizures. On 2/18/25 at 8:55 a.m., in an interview Resident #18's guardian said upon the resident's admission on 12/26/24 she provided the Epidiolex to the facility. She said on 12/30/24 she checked the medication list and found out the facility had stopped the medication. The guardian said no one at the facility notified her the medication was stopped. She went to the Administrator to find out when and why the medication was stopped. The Administrator told her the corporate office told them they could not give the Epidiolex. Resident #18's guardian said the facility accepted the resident knowing he needed the medication. Review of the physician's orders revealed on 12/29/24 the Assistant Director of Nursing (ADON) wrote a verbal order to discontinue the Epidiolex. The physician signed the order on 1/6/25. Review of the Medication Administration Record (MAR) for December 2024 revealed the Epidiolex was scheduled to be given twice a day, every day at 10:00 a.m., and 6:00 p.m. The last dose of Epidiolex was given on 12/29/24 at 10:00 a.m. The clinical record lacked documentation Resident #18 and the guardian were notified in advance of the discontinuation of the medication, and the reason for stopping the medication. On 2/19/25 at 11:56 a.m., in an interview the ADON said she was working from home on 12/29/24 when she wrote the verbal order to discontinue the Epidiolex. She verified she did not inform the resident or the guardian before discontinuing the medication. She said the guardian was made aware on 12/30/24, one day after the medication was discontinued. . .

Based on observation, and staff interview the facility failed to provide maintenance services to maintain a clean and comfortable environment in 1 (Memory Care) of 3 units observed. The findings included: On 9/17/24 at 9:10 a.m., and on 9/18/24 at 1:00 p.m., the following observations were made: Wallpaper peeling away from the wall above the floor, along wallpaper seams and along the ceiling in the Memory Care Hallway. rooms [ROOM NUMBER] were missing cove moldings. Sheetrocks were cracked with holes noted in the walls. Resident rooms 123, 125 and 129 were missing pull cords on the overbed lights. Observation of the Memory Care shower room window revealed a broken blind, and broken lights in the bathroom stall and shower stall. The shower room floor tile and stall tiles were covered with orange and brown film. On 9/18/24 at 1:00 p.m., the Administrator verified the wallpaper was peeling away from the wall above the floor, along the wallpaper seams and along the ceiling in the Memory Care Hallway. He also verified the missing cove moldings in rooms 123, 125 and 129. He observed and verified the broken blinds in the shower room, the broken lights in the bathroom and shower stall and the floor tile covered with orange and brown film.

Based on observation, and staff interview, the facility failed to provide a clean, and sanitary environment in the kitchen by not having clean walls, air conditioning vents, food appliances, food preparation, and storage areas. The facility also failed to properly store food, clean, and make necessary repairs in 2 (nourishment rooms 1B and 2B) of 2 nourishment rooms observed. This failure had the potential to cause food borne illness in residents receiving an oral diet. The findings included: On 8/8/2022 at 9:20 a.m., during the initial kitchen tour with the Food Service Director and the Regional Dietary Consultant, the following was observed: The oven, stove top, flat top cooker, and steam and hold table had caked on grease and grime. Photographic evidence obtained The reach-in refrigerators were dirty with spills, black bio-growth. Unlabeled food including a rotten tomato in a bin with lettuce was observed in the reach-in refrigerator. Photographic evidence obtained A snack cart with residents' snacks had dried spills down the side. Photographic evidence obtained Two air conditioner vents near the steam table and clean dish storage area had large accumulation of black substance, peeling paint around the vents. The vents were dripping. Photographic evidence obtained The ice machine was heavily stained with a dark brown substance. Photographic evidence obtained A kitchen wall had large amount of dried-up brown stains. Photographic evidence obtained The Food Service Director present during the tour said he did not have a cleaning schedule for the kitchen. He said he was the one who usually cleaned the kitchen and it had been at least two months since he had cleaned. On 8/9/2022 at 11:30 a.m., the food service lunch tray line was observed. The two air conditioner vents observed during initial tour remained with large accumulation of black substance and dripping clear fluid next to tray line and clean dish storage. Photographic evidence obtained. A light fixture over the tray line had large amount of black substance and was not working. Photographic evidence obtained On 8/10/2022 at 11:27 a.m., a tour of the nourishment rooms was conducted. In the nourishment room 2B, there was an unlabeled, undated grilled cheese sandwich wrapped in cellophane stored at room temperature in the cabinet. Photographic evidence obtained Observation of the refrigerator in nourishment room 1B revealed: A container of cream cheese labeled Use by [DATE] [July 9, 2022]. Photographic evidence obtained An unidentified object wrapped in foil was dripping a greenish liquid. Photographic evidence obtained The counter behind the sink and microwave was damaged and in need of repair. photographic evidence obtained. On 8/10/2022 at 1:00 p.m., the Assistant Director of Nursing said the refrigerator in the Nourishment room 1B was now a staff refrigerator. She said the drawers and cabinets in the room still stored snacks for the residents. There was no sign on the refrigerator to identify it as a staff refrigerator. On 8/10/2022 at 3:00 p.m., in a joint interview, the Food Service Director and the Regional Dietary Consultant said they thought the refrigerators in the nourishment rooms were for residents. The Food Service Director and the Regional Dietary Consultant said they had not noticed the air conditioning vents in the kitchen were dripping. They said maintenance would know more about it. On 8/11/2022 at 11:10 a.m., the Administrator verified the refrigerator in the nourishment room in station 1B did not have a sign identifying it as staff only refrigerator. On 8/11/2022 at 11:15 a.m., the Maintenance Director said the air conditioning vents were cleaned last week and the reason they drip was from the thermostat set so low by the staff. He also verified the light in the kitchen needed to be cleaned and changed. The Maintenance Director also verified the damaged countertop in nourishment room 1B.

Based on observation, record review and staff interview, the facility failed to ensure implementation of a person centered, meaningful activity program for 1 (Resident #72) of 7 residents reviewed for activities. The findings included: Review of the clinical record for Resident #72 revealed an admitted [DATE]. The Annual Minimum Data Set (MDS) assessment with a target date of 3/8/22 revealed Resident #72 scored a 9 on the Brief Interview for Mental Status, indicative of moderate cognitive impairment. The MDS noted it was somewhat important for Resident #72 to keep up with news, do things with groups of people, do his favorite activities, and participate in religious services or practices. Resident #72 was totally dependent on physical assistance of staff for transfer and locomotion on and off unit. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The activity care plan initiated on 5/25/2017 with a target date of 9/23/22 noted the resident reported little interest or pleasure in doing things. He preferred independent activities such as a variety of music, card games, television, current events, movies, the outdoors and more. The goal was for Resident #72 to actively participate in independent activities of choice daily to promote overall positive well-being. The interventions included to assist in planning and/or encourage to plan own leisure time activities; Encourage participation in group activities of interest; Provide 1:1 (one to one) activity visits for support and socialization; Provide supplies/materials for leisure activities as needed/requested. On 8/9/22 at 11:14 a.m., and 2:51 p.m., Resident #72 was observed in bed. The resident was not participating in any activity. The television wasn't turned on or any radio observed in the resident's room. On 8/10/22 at 3:00 p.m., Resident #72 was observed in bed, on his back. The resident was not observed in any activity. The television wasn't on or any radio on. Resident #72 was leaning to the right in bed and requested a drink. On 8/11/22 at 8:59 a.m., and 9:57 a.m., Resident #72 was observed in bed, on his back. No activity, television or music observed. On 8/10/22 at 3:35 p.m., Activity Assistant Staff H said the activity calendar includes friendly visits. She said friendly visits with the residents included passing out the daily chronicles, smiling and saying hello. The one-to-one visits last 10 to 15 minutes. She said as of August 1st, 2022, the activities are documented in the computer. Activity Assistant Staff H said she could not remember her password to the computer, therefore could not access any activity documentation. On 8/10/22 at 4:14 p.m., the Activity Director said one-to-one visits are documented on paper and include time spent with the resident and the activity conducted. She said the goal is once a week for the one-to-one visits. The Activity Director said she could not locate any activity documentation, including one-to-one visits for Resident #72 for August 2022. On 8/11/22 at 2:52 p.m., the Activity Director said the activity calendar for August 2022 did not include one to one visits. She said they were currently not doing any one-to-one visits with residents due to staffing shortage. She said those visits can only be done when there is down time.

Based on observation, review of facility policy and staff interviews, the facility failed to remove and discard expired medications from 2 (Memory Care and 2B) of 4 medication carts, and 1 (medication storage room [ROOM NUMBER]A) of 2 medication storage rooms observed. This has the potential for expired medications to be administered to residents. The findings included: The policy titled Storage and Expiration Dating of Medications, Biologicals with a revision date of 7/21/22 noted, . Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications . Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable law. The Insulin Storage Recommendations document dated April 2019 noted to store opened vials of [MEDICATION(S)] (insulin) at room temperature for 42 days. 1. On 8/8/22 at 10:26 a.m., observation of the Memory Care Unit medication cart with Licensed Practical Nurse (LPN) Staff A revealed a vial of [MEDICATION(S)] insulin belonging to Resident #28 with an opened date of 6/20/22. The label affixed to the vial specified to Discard 42 days after opening. LPN Staff A verified the [MEDICATION(S)] insulin was opened on 6/20/22 and should have been discarded on 8/1/22 (42 days after opening). Photographic evidence obtained 2. On 8/8/22 at 11:12 a.m., observation of the refrigerator in Medication room [ROOM NUMBER]A with LPN Staff B showed one syringe of [MEDICATION(S)] ([MEDICATION(S)] diluted) 0.1 milliliter with an expiration date of 8/3/22. LPN Staff B confirmed the [MEDICATION(S)] injection was expired and should have been discarded. Photographic evidence obtained 3. On 8/8/22 at 3:30 p.m., observation of Medication Cart #2B with LPN Staff C revealed one opened bottle of aspirin with an expiration date of 6/22/22. LPN staff C verified the bottle of aspirin in medication cart #2B was expired. Photographic evidence obtained. On 8/9/22 at 12:08 p.m., the Director of Nursing said she was aware of the expired [MEDICATION(S)] insulin, bottle of aspirin and [MEDICATION(S)] syringe found in the medication carts and the medication room.

Based on interview and record review the facility failed to have a designated qualified Infection Preventionist with the education, training, experience or certification. The findings included: The Facility's Infection Infection Preventionist Orientation Plan and Skills Competency Checklist dated 10/2020 noted, Either produce validation of completion of CMS/CDC (Center for Medicare and Medicaid/ Center for Disease Control) online course on CDC Train or register for course within first week of appointment to position of infection Preventionist. The course is a 23 module/19-hour Free course. On 8/11/22 9:12 a.m., the Assistant Director of Nursing (ADON) said she has been the designated Infection Preventionist for the facility for six months. She said she started the CDC training 6 months ago but has not yet completed the training and was not certified. On 8/22/22 9:45 a.m., the Director of Nursing (DON) said she was not a certified Infection Preventionist and was under the impression her ADON was.

Based on record review, residents and staff interview, the facility failed to maintain documentation of interventions and efforts to resolve multiple dietary concerns for 1 (Resident #2) of 5 sampled residents. The findings included: Review of the facility's process for concerns with a creation date of 1/10/19 revealed documentation Concerns/grievances were documented using a Concern Form and were tracked and trended using the concern log. Concerns/grievances were resolved through use of the investigation process. On 8/4/20 at 9:20 a.m., during an interview, Resident #2 said she had voiced several grievances over the past few months about dietary services. She said it was an on-going problem. She did not get what she ordered from the menu. Resident #1 said she frequently resorted to eating frozen dinners. She explained she was not able to eat pork, eggs, or fish and she frequently got those items on her tray. On 8/4/20 at 12:45 p.m., Resident #2 said about two weeks ago she collected 21 meal tickets, and only once she received what she requested. The resident said she gave the meal tickets to the Social Worker. She said she requested her meat without gravy, and she got gravy. Resident #1 said she had seen little improvement since she reported it to the Social Worker. Review of the concern forms revealed the following: 1. On 2/21/10 Resident #2 complained the food was often served cold and she did not always receive items that she requested on her tray. On 2/26/20 during a one-to-one discussion with the resident the facility explained they reviewed the select menu trays before the carts left the kitchen. They also would start to cross out and write in substitutions and continued to review the temperature of the food during tray line. 2. On 3/10/20 Resident #2 complained the food was cold. She filled out choice menus, but staff did not send what she asked for. She complained that something was missing from her tray for each meal. During a one-to-one discussion on 3/11/20 the Dietary Manager documented they would continue taking temperature of the food prior to mealtimes. They would write on her ticket if substitutions needed to be made. They also provided contact information so Resident #1 could call directly when issues arised. 3. On 5/14/20 Resident #2 reported the kitchen didn't follow the diet or the tray was always missing something. The resident said she didn't ring or ask for help because the aides were busy. Resident #2 also complained food items were not hot enough. The Food Service Director documented she educated staff to microwave lunch and dinner meals. If substitutions must be made the Food Service Director or the Assistant would call her ahead of time to discuss options. During a one-to-one discussion with the resident dated 5/14/20 the Food Service Director documented additional follow up was needed. Resident #2's response was Let's wait and see if it gets better. 4. On 6/23/20 the Registered Dietician documented Resident #2's concern as follows Same old problems. She does not receive what she selects. There are errors every meal. The resident said she ordered a Mediterranean plate and got a sandwich. She said it happened all the time. The Food Service Director documented, review the resident's preferences and see what items were missing consistently. Upped the Periodic Automatic [MEDICATION NAME] (par#) for yogurt so we would not run out. Will continue to notify resident when substitutions must be made to the menu, so resident knows what the options were. On 6/26/20 the resident was notified during a one-to-one discussion. 5. On 7/2/20 the Social Worker documented on a concern form, Resident stated with a few exceptions, received wrong meal orders from the kitchen. Resident gave Social Worker meal tickets for the last week with notation on the back of what was missing/wrong. The follow up included, if substitutions have to be made the dietary aids will write the substitutions on the ticket so patient was aware of changes. The Assistant Food Service Director checked a box on the form indicating additional follow up was needed. He documented check back to see if write-ins have been happening. 6. On 8/4/20 at 1:30 p.m., during an interview the Registered Dietician said Resident #2 had complained about her meals. She said when she was in the building, she sporadically checked Resident #1's tray and they were accurate. She said she did not have documentation of the audits she completed. The Registered Dietician said she could not locate a copy of the meal tickets Resident #1 gave to the Social Worker and didn't know what the Resident's complaints were. 7. On 8/4/20 at 4:00 p.m., during an interview, the Assistant Food Service Director said he did not have documentation the kitchen had addressed the Resident's complaints. He said the facility did not have any tray audits to ensure Resident #2 consistently received the food items she requested. He said sometimes Resident #2 did not receive what she asked for because they did not have the food item on hand, or the item was not available to them. He did not keep documentation the facility notified Resident #2 when food items were not available. He said she did not have documentation the facility offered substitutions for the missing food items. He said the resident saved all her meal tickets and came forth with everything. He said he could not locate that documentation. 8. On 8/4/20 at 4:15 p.m., during an interview Certified Nursing Assistant (CNA) Staff I said Resident #2 always complained about the food. She said sometimes the food was cold. She also had some health conditions and could not eat certain food items. She said very often the resident got food items on her tray she did not want or did not order. Sometimes items she requested were missing. CNA Staff I said she frequently went to the kitchen and retrieved something else for the resident to eat because the kitchen did not send what the resident selected. She said Resident #2 kept soup and pasta in her room and she warmed it up for her when she did not get what she ordered from the kitchen or when she gets food she cannot eat. CNA Staff I said, someone should be in there to make sure everything she requested is on the tray before sending it up. 9. On 8/4/20 at 4:30 p.m., the Registered Dietician said she didn't have documentation of tray audits. She said she could not locate the meal tickets where the resident wrote her complaints or any documentation showing the resolution of the complaints.

Based on observation and staff interview the facility failed to maintain an infection prevention and control program related to COVID-19 recommendations including the use of facemasks and physical distancing during activities. The findings included: 1. On 8/4/20 at 9:30 a.m., during an observation of the laundry room, Laundry aide Staff C had a surgical mask on, under her chin, exposing her mouth and nose. On 8/4/20 at 9:40 a.m., during an observation of the kitchen, Dietary Staff E, Dietary Staff F, and Dietary Staff G were wearing face masks positioned only over their mouth and chin, exposing their nose. On 8/4/20 at 9:40 a.m., Dietary Staff D was observed washing dishes and had no mask on. CDC guidance (6/25/20) Preparing for COVID-19 in Nursing Homes: Implement Source Control Measures. HCP should wear a facemask at all times while they are in the facility. Refer to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html CDC guidance (7/14/20) Using Personal Protective Equipment (PPE): Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Refer to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html 2. On 8/4/20 at 9:15 a.m., during an observation in the Thalia Memory Care Unit dining room, the residents were seated 4 to a table and were seated 2- 3 feet from one another. Three staff members were observed in the dining room and they did not assist the residents to maintain social distancing. On 8/4/20 at 9:20 a.m., in an interview the Licensed Practical Nurse (LPN) / Infection Preventionist said the facility had attempted to provide social distancing by adding a 2nd seating to the dining schedules to decrease the number of residents in the area at one time. The LPN said it did help maintain social distancing of the residents in the Thalia dining room. On 8/4/20 at 9:15 a.m., during a tour of the second floor of the facility with the Assistant Director of Nursing the following observations were made: Resident #3 was in the hallway with a surgical mask covering his mouth. The mask did not cover the resident's nose. Resident #4 was observed wheeling himself in the hallway with a surgical mask in his hand. He did not apply the mask to his face. Resident #6 was sitting in a wheelchair in a hallway with a face mask below his nose. Resident #7 was sitting in a wheelchair in the hallway with a face mask below his nose. Several staff members were observed coming in and out of residents' rooms and in the hallway. The staff did not encourage the residents to wear their face masks. On 8/4/20 at 9:30 a.m., during an interview Certified Nursing Assistant Staff H said she was aware the residents are supposed to wear a mask when they leave their rooms. She verified she placed Resident #7 in the hallway and did not encourage the resident to wear a mask. She said she should ensure the residents wear a face covering when leaving their rooms. On 8/4/20 at 11:00 a.m., observation of the Thalia memory care unit revealed several residents sitting next to each other in a circle participating in an activity. The residents were placed within 4 feet of each other. The activity assistant did not attempt to keep a minimum of 6 feet space between residents. On 8/4/20 at 7:30 p.m., during a review of the facility's infection prevention and control program the Infection Preventionist verified the facility was not enforcing a minimum of 6 feet social distancing in the memory care unit. She said they had tried alternate dining times. She said it's very difficult to keep the residents separated. The Infection Preventionist said they can probably do a better job of social distancing during activities. She said they should have tried smaller groups for activities and should try to maintain social distancing. The Infection Preventionist said they've tried to social distance residents during activities and dining in the memory care unit. On 8/4/20 at 8:25 p.m., during an interview the Activity Director said they try to do smaller groups and keep everything as sanitary as possible in the memory care unit. She told her staff to try to keep the residents distanced as much as possible, but with only one activity assistant it's difficult to have separate groups. She said she instructed the activity assistant to limit the number of residents who participate in activities at a time to maintain social distancing in the memory care unit. The Activity Director provided a copy of each resident's participation in activity for 8/4/20. She said the physical activity documented on the daily recreation/activity participation form represented the ball tossing activity. She verified 20 residents participated in the ball tossing activity in the memory care unit. She said she will revise the plan and come up with something to do smaller group activities. CDC guidance (5/12/20) Considerations for Memory Care Units in Long-term Care Facilities, nursing homes and assisted living facilities providing memory care should consider the following: Routines are very important for residents with dementia. Try to keep their environment and routines as consistent as possible while still reminding and assisting with frequent hand hygiene, social distancing, and use of cloth face coverings (if tolerated). Continue to provide structured activities, which may need to occur in the resident's room or be scheduled at staggered times throughout the day to maintain social distancing. Provide safe ways for residents to continue to be active, such as personnel walking with individual residents around the unit or outside. Limit the number of residents or space residents at least 6 feet apart as much as feasible when in a common area, and gently redirect residents who are ambulatory and are in close proximity to other residents or personnel. Refer to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/memory-care.html?deliveryName=USCDC_425-DM

Based on observation, staff interview and record review, the facility failed to prevent neglect through lack of adequate supervision and secure environment for a confused resident to prevent elopement from the facility for 1 (Resident #35) of 9 exit seeking residents. The lack of supervision contributed to the elopement of Resident #35, placing her at risk for serious injury, impairment, or death. While the resident was out of the facility unsupervised, there was a likelihood the resident could have been hit by a car, drown in the retention pond and got lost. The facility's failure to prevent neglect resulted in substandard quality of care at the Immediate Jeopardy level starting on 6/22/19. The Administrator was notified of the Immediate Jeopardy on 6/28/19. The Immediate Jeopardy was removed on 6/28/19 after the facility submitted an acceptable removal plan. Cross reference to F689, F725, and F835. The findings included: On 6/27/19 at 12:48 p.m., the Administrator said the definition of neglect was the facility, vendors or providers not supplying goods or services to maintain the resident's highest well-being. The Administrator said she did not believe the incident with Resident #35 was neglect. The resident had no harm, was appropriately dressed and had shoes on. She said this was an unexpected failure. It was not something they could have anticipated; they did not neglect Resident #35. The Thalia unit census on 6/23/19 was 26 residents with two Certified Nursing Assistants (CNA's) to provide care. On 6/24/19, a review of Resident #35's clinical record showed she is a [AGE] year-old female admitted to the facility on [DATE] to the Thalia (a secured memory care unit). Her primary [DIAGNOSES REDACTED]. Record review revealed Resident #35's had a care plan dated 7/19/16 for Wandering/Pacing related to cognitive impairment. The facility implemented a care plan for falls dated 7/12/16 and a care plan for exit seeking and elopement risk related to cognitive impairment dated 7/13/18. The interventions included an alert bracelet and check alert bracelet placement every shift and functioning daily. The care plan did not include any intervention for increased staff supervision of Resident #35, to ensure her safety. Review of the facility's policy Patient Protection: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention (effective (YEAR)) defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility's Behavior Practice Guide (effective date 7/2015) defined elopement as occurs when a resident leaves the premises or a safe area without authorization and, or any necessary supervision to do so. Wandering and exit seeking as a behavioral symptom of special concern in the elderly, and or dementia population. Unsafe wandering occurs when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards. The section, Personal Security Bracelet documented when unsafe wandering or elopement risk has been identified, a behavior assessment will be completed. Patients may be identified as at risk when one or more of the following risk factors are present: verbalizes the desire to exit, demonstrates behavioral symptoms indicating desire to exit, physically attempts to exit center, wanders into potentially unsafe areas and has a history of similar behavior patterns. The personal security bracelet serves as an alert to the patient of safe boundary limits and a alert to staff a patient is close to an alarmed door.Bracelet placement is checked every shift. Bracelet sensor function is checked every day. On 6/26/19 at 9:33 a.m., the Administrator said the Infection Preventionist (IP) was the facility manager on 6/22/19. The IP notified the Administrator on 6/23/19 at 9:00 a.m., the facility's security doors to the exterior of the building were not locking and interior fire doors had closed and could not be held open. All exterior doors in the facility were affected including the doors on Thalia unit. This comprised the security of the back-emergency exit door, the courtyard door and gate door from the Thalia dining room, the storage room door, and the entrance door to the Thalia Unit. The Administrator said staff began watching the doors on 6/23/19 at 9:00 a.m. There was a storage room door, located inside the Thalia unit. In this storage room, there was another door that lead to the outside. The Administrator said she never knew of this other door. She instructed the IP to post staff at the entrance door near nursing station to see all the doors in the Thalia hallway. Instead, staff monitored the double door entrance on the outside of the Thalia unit. This blocked the view of the first interior hall, including the doors to the courtyard door off the Thalia dining room and the storage room door. The Administrator said she did not call additional staff in to the unit to watch the residents, she reallocated the scheduled housekeeping staff to monitor the doors. The Administrator said she was not sure how Resident #35 eloped. She said Resident #35 was brought back to the facility on [DATE] around 9:00 p.m., by the police. The Administrator said Resident #35 was last seen on 6/23/19 at 7:30 p.m. Resident #35 could have exited the facility through any of the 3 unsupervised exits from the Thalia unit. The location of Resident #35 was unknown to the facility until the neighboring Assisted Living Facility (ALF) contacted them and the police brought her back to the facility around 9:00 p.m. On 6/26/19 at 1:10 p.m., Registered Nurse (RN) Staff I said she worked as a facility supervisor on 6/22/19. At about 7:30 p.m., she became aware of the unsecured doors and security system failure (Wander Guard) and stated, I was not focused on Thalia Unit. I did not think of the doors unsecured on the Thalia unit. I did not talk to anyone on the Thalia unit. I don't know if they were aware of the unsecured doors. RN Staff I said on 6/23/19 at about 4:00 p.m., Housekeeper Staff R was sitting outside the entrance doors to the Thalia unit. At 8:15 p.m., a neighboring ALF called to say Resident #35 was there, and the police would be bringing her back. RN Staff I said at 8:15 p.m. no one at the facility was aware Resident #35 was missing. RN Staff I said Resident #35 returned at 9:00 p.m. and seemed confused. RN Staff I said when she left the faciity on [DATE] at 1:30 a.m., Resident #35 did not have a 1:1 sitter to supervise the resident more closely. Observation of video recording from the ALF (located approximately 1200 feet from facility) from 6/23/19 at 8:09 p.m., revealed Resident #35 walking on the area directly in front of the facility heading north towards the generators and trash disposal. She was not on the street sidewalk anytime in the video. There is an entrance to the ALF property from a grassy trail to the south of the facility property. The trail is uneven with inclines, declines, bushes, and water hazards. The video recording then displayed Resident #35 walking with an ALF staff into the ALF. She did not appear distressed and there was sufficient lighting near the building. On 06/26/19 9:21 a.m., during an interview, the ALF Administrator said she can not give a lot of detail. A staff member saw a resident while taking the garbage out to the dumpster in the parking lot area, in the front of the building. The resident was found in the parking lot by the generator. The area has PVC fencing with double doors which were open, it is not a locked area. The ALF staff member brought Resident #35 to the facility nurse. The ALF nurse said resident did not appear in distress. The resident knew her name but did not know where she lived. She was confused and had no identification on her. The ALF Director of Nursing called Manorcare who said they did have a resident with that name. The police arrived at 8:30 p.m., asked the Resident #35 some questions and escorted her back to the facility. The facility administrator said on 6/23/19 at about 4:00 p.m., Housekeeper Staff R was sitting outside the entrance doors to the Thalia unit. At 8:15 p.m., a neighboring facility called to say Resident #35 was there, and the police would be bringing her back. RN Staff I said no one at the facility was aware Resident #35 was missing. RN Staff I said Resident #35 returned at 9:00 p.m. and seemed confused. RN Staff I said when she left the faciity on [DATE] at 1:30 a.m., Resident #35 did not have a 1:1 sitter to supervise the resident more closely. On 6/26/19 at 5:44 p.m., CNA Staff H said on 6/23/19 she and CNA Staff J were working the Thalia unit with LPN Staff U. She said they were told by LPN Staff U to watch the doors, don't let anyone get out. CNA Staff H said she went on break around 7:45 p.m., and CNA Staff J was assisting a resident. She stated, I'm sure the elopement happened during my break time because I did not see resident leave. On 6/27/19 at 11:05 a.m., the IP said she arrived at the facility on 6/23/19 around 10:30 a.m. She said she checked the emergency exit door at the end of the hallway on the Thalia unit which had no staff posted at it. She said the storage room door was unsecured, but she never knew there was another door in there that lead to the outside. She stated, I wasn't worried about it. She said she spoke with the Administrator at 10:02 a.m. The Administrator told her to get housekeeping staff off their carts and post them at the doors. On 6/27/19 at 12:48 p.m., the Administrator said on 6/23/19, CNA's Staff H and J were taking care of the residents on the Thalia unit and were to watch the doors and hallway. She said if CNA Staff H and J were assisting a resident, that would have left the emergency exit door unmonitored. The Administrator was notified of the Immediate Jeopardy on 6/28/19. The immediate jeopardy started on 6/22/19 at approximately 7:30 p.m. and was removed on 6/28/19 lowering the scope and severity to D.

Based on staff interview and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement from the facility for 1 (Resident #35) of 9 residents identified on the memory care unit with exit seeking behaviors. These failures contributed to the elopement of Resident #35, placing her at risk for serious injury/impairment/death. Staff failed to monitor the resident's location resulting in the resident leaving the facility unattended. While the resident was out of the facility unsupervised, there was a likelihood the resident could have been hit by a car, drown in the retention pond and got lost. The facility's failure to provide adequate supervision and a secure environment resulted in substandard quality of care at the Immediate Jeopardy level starting on 6/22/19. The Administrator was notified of the immediate Jeopardy on 6/28/19. The Immediate Jeopardy was removed on 6/28/19. Cross reference to F600, F725, and F835. The findings included: On 6/24/19, review of Resident #35's clinical record showed this [AGE] year-old was admitted to the facility on [DATE] to the Thalia unit (a secured memory care unit). Her primary [DIAGNOSES REDACTED]. Resident #35's care plan identified on 7/12/16, she was at risk for falls. The facility initiated care plan on 7/19/16 for Wandering/Pacing related to cognitive impairment, change in environment. The Care plan dated 7/13/18, included a concern about exit seeking, and elopement risk related to cognitive impairment. The interventions included an alert bracelet and check alert bracelet placement every shift and functioning daily. The care plan did not include any intervention for increased staff supervision of Resident #35 to ensure her safety. The facility's Behavior Practice Guide (effective date 7/2015) defined elopement as occurs when a resident leaves the premises or a safe area without authorization and, or any necessary supervision to do so. Wandering and exit seeking as a behavioral symptom of special concern in the elderly, and or dementia population. Unsafe wandering occurs when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards. When an unsafe wandering or elopement risk has been identified, a behavior assessment is completed. Patients may be identified as at risk when one or more of the following risk factors are present: verbalizes the desire to exit, demonstrates behavioral symptoms indicating desire to exit, physically attempts to exit center, wanders into potentially unsafe areas and has a history of similar behavior patterns. The personal security bracelet serves as an alert to the patient of safe boundary limit as an alert to staff the patient is close to an alarmed door. Bracelet placement is validated every shift. Bracelet functioning of the sensor is validated every day. On 9/26/19 at 9:33 a.m., the Administrator said the weekend of 6/22/19 and 6/23/19 the Infection Preventionist (IP) was the facility manager on duty. The IP notified the Administrator on 6/24/19 at 8:15 a.m., the facility's security doors to the exterior of the building were not locking and interior fire doors had closed and could not be held open. All exterior doors were affected in the facility including the doors on the Thalia unit comprising of the back-emergency exit door, the courtyard door and gate door from the Thalia dining room, the storage room door, and the entrance door to the Thalia unit. The Administrator said staff started watching the doors on 6/23/19 at 9:00 a.m. There was a storage room door, located inside the Thalia unit. In this storage room, there was another door that leads to the outside. The Administrator said she never knew of this other door. She instructed the IP to post staff at the entrance door near nursing station to see all the doors in the Thalia hallway. Instead, staff monitored the double enterance doors on the outside of the Thalia unit preventing her view of the first interior hall, including the doors to the courtyard door off the Thalia dining room and the storage room door. The administrator said she did not call additional staff in to watch the residents, she reallocated the scheduled staff to monitor the doors. Housekeeping staff were used to monitor doors. The Administrator said she did not staff the Thalia unit differently during the time the doors were unsecured, there was no higher ratio. The Thalia census on 6/23/19 was 26 with two CNA's to provide care. The Administrator said she was not sure how Resident #35 eloped to the neighboring ALF. She said Resident #35 was brought back to the facility by the police on 6/23/19 around 9:00 p.m. The Administrator said Resident #35 was last seen in the facility on 6/23/19 at 7:30 p.m. Resident #35 exited the Thalia unit on 6/23/19, while the facility's security system was not functioning. Resident #35 could have exited the facility through any of the 3 unsupervised exits from the Thalia unit. The facility did not know the location of Resident #35 from about 7:30 p.m. until the neighboring Assisted Living Facility (ALF) contacted them. The area between the facility and the neighboring ALF to which the resident went, has heavily overgrown areas and have multiple water hazards. The ground is of mixed elevations. Resident #35 entered the neighboring ALF's property approximately 1200 feet away from the facility. Observation of video recording from the ALF (located approximately 1200 feet from facility) from 6/23/19 at 8:09 p.m., revealed Resident #35 walking on the area directly in front of the facility heading north towards the generators and trash disposal. She was not on the street sidewalk anytime in the video. There is an entrance to the ALF property from a grassy trail to the south of the facility property. The trail is uneven with inclines, declines, bushes, and water hazards. The video recording then displayed Resident #35 walking with an ALF staff into the ALF. She did not appear distressed and there was sufficient lighting near the building. On 6/26/19 at 1:10 p.m., RN Staff I said she worked as a facility supervisor on 6/22/19. At about 7:30 p.m., she became aware of the unsecured doors and security system failure (Wander Guard) and stated, I was not focused on Thalia Unit. I did not think of the doors unsecured on Thalia. I did not talk to anyone from Thalia, I don't know if they were aware of the unsecured doors. She said except for two residents, everybody else was ambulatory and wandered on Thalia. RN Staff I said on 6/23/19 at about 4:00 p.m., Housekeeper Staff R was sitting outside the entrance doors to Thalia. At 8:15 p.m., the neighboring facility called to say Resident #35 was there, and the police would be bringing her back. RN Staff I said no one at the facility was aware Resident #35 was missing. RN Staff I said Resident #35 returned at 9:00 p.m. and seemed confused. RN Staff I said when she left the faciity on [DATE] at 1:30 a.m., Resident #35 did not have a 1:1 sitter to supervise the resident more closely. On 6/26/19 at 10:05 p.m., Licensed Practical Nurse (LPN) Staff U said on 6/23/19, three CNA's were assigned to the Thalia unit, at 7:00 p.m., one CNA was taken away to work upstairs. LPN Staff U said at about 7:45 p.m., CNA Staff H went on break. He stated, (Staff J) watched the door entrance, she was sitting outside the television den. There was no one watching the emergency exit door at the end of the hallway. Housekeeper Staff R was sitting outside the Thalia entrance door. He said it was around 9:00 p.m. when LPN Staff U Staff I told him Resident #35 was missing. On 6/26/19 at 5:44 p.m. CNA Staff H said on 6/23/19 she and CNA Staff J were working the Thalia unit with (LPN) Staff U. She said they were told by LPN Staff U to watch the doors, don't let anyone get out. She said she went on break around 7:45 p.m. and CNA Staff J was assisting a resident. She stated, I'm sure the elopement happened during my break time because I did not see resident leave. On 6/27/19 at 12:48 p.m., the Administrator said on 6/23/19, CNA Staff H and J were taking care of the residents and were to watch the doors and hallway. She said if Staff H and J were assisting a resident, that would have left the emergency exit door unmonitored. On 6/27/19 at 11:05 a.m., the IP said she arrived at the facility on 6/23/19 around 10:30 a.m. She said she checked the emergency exit door at the end of the hallway on Thalia and there was no staff posted at it. She said the storage room door was unsecured, but she never knew there was another door in there that lead to the outside. She stated, I wasn't worried about it. She said she spoke with the Administrator on 6/23/19 at 10:02 a.m. The Administrator told her to get Housekeeping get off their carts and post them at the doors. The Administrator was notified of the Immediate Jeopardy on 6/28/19. The immediate jeopardy started on 6/22/19 at approximately 7:30 p.m. and was removed on 6/28/19 lowering the scope and severity to D.

Based on record review and staff interview, the facility failed to provide sufficient staff to assure resident safety for 1 (Resident #35) of 26 residents on the facility Thalia Memory Care Unit. Failure to provide sufficient nursing staff led to Resident # 35's elopement placing her at risk for srious injury/impairment/death. While Resident #35 was unsupervised out of the facility, there was a high likelihood of the resident could have been hit by a car, drown in the retention pond and got lost The facility's failure to provide sufficient staffing resulted in immediate jeopardy starting on 6/22/19. The Administrator was notified of the Immediate Jeopardy on 6/28/19. The immediate jeopardy was removed on 6/28/19. Cross reference to F600, F689, and F835. The findings included: On 6/24/19, review of Resident #35's clinical record showed this [AGE] year-old was admitted to the facility on [DATE] to the Thalia (a secured memory care unit). Her primary [DIAGNOSES REDACTED]. Her care plan dated 7/13/18, identified her as exit seeking/elopement risk related to cognitive impairment. The goal was not to leave center unattended. The resident was also identified as at risk for falls due to impaired cognition with erratic behaviors and had difficulty communicating. The care plan did not include any intervention for increased staff supervision of resident #35, to ensure her whereabouts . On 6/27/19 at 8:34 a.m., in an interview, the facility nursing staff scheduler said she came to the facility on Sunday (6/23/19) morning to check the schedule. She said she normally did not work on Sundays, but she tended to pass by to see if everything was ok. When she arrived on Sunday she found out the security system was not functioning. She monitored the front door until the receptionist came around 8:00 a.m. She said she texted Registered Nurse Staff T, the weekend supervisor to alert her about the security system not functioning. The scheduler said she had three Certified Nursing Assistants (CNA's) scheduled to work the evening shift on 6/23/19 on the Thalia Memory Care Unit, but CNA Staff L called in sick for the 3-11 p.m. shift. She tried calling staff but was unable to find anyone to cover the shift. CNA Staff K volunteered to cover part of the shift until 7 p.m. The only CNA's on the Thalia unit after 7:00 p.m. were Staff H and J. The scheduler said after CNA Staff K left, two CNA's, Staff H and J were to monitor the front and rear exit doors while providing care to a total of 26 residents residing on the Thalia memory unit. She also said they had one housekeeping staff monitoring the entrance doors on the Thalia unit. The scheduler said if there was an emergency, she did the best she could to find coverage. She said she stayed in the facility all of Sunday morning to find additional coverage but was unsuccessful. On 6/23/19 at approximately 8:00 p.m., Resident #35 exited the facility, unsupervised. Resident #35 was identified as cognitively impaired and needed supervision with mobility. Resident #35 was found at a nearby Assisted Living Facility (ALF). A caregiver working at the ALF found Resident #35 in the waste disposal area of the ALF. Resident #35 was able to identify herself but was unable to provide additional information. The ALF facility staff contacted 911. The location of Resident #35 was unknown to the facility until the ALF contacted the facility to ask if Resident #35 was a resident. The police brought Resident #35 back to the facility at approximately 9:00 p.m. on 6/23/19. On 6/27/19 at 1:26 p.m., the Administrator confirmed she was unable to provide evidence of any additional staff being assigned to the Thalia unit to monitor the unsecured doors on the evening of 6/23/19. There were 2 CNA's, the third CNA had been reassigned to another unit. She confirmed there was no staff assigned to watch the back exit door of the unit where Resident #35's room was located. There was a housekeeper stationed at the internal exit door of unit contrary to her instructions for staff to monitor the unsecured exterior doors. The Administrator confirmed there was no additional staff assigned to take care of the 26 residents including the 9 identified wandered during the time the exterior doors were unsecured. She acknowledged this would have been difficult for 2 CNAs to monitor the whereabouts for 26 residents and provide their routine care On 6/28/19 at 1:26 p.m., the Administrator and Assistant Director of Nursing (ADON) acknowledged the purpose of the locked Thalia unit was to keep residents with dementia who wandered safe. The Administrator said the she had increased the staffing a few months ago on the Thalia Unit to 3 CNA's on all shifts. On the evening of 6/23/19, she was not made aware of the third CNA being removed from the unit. The ADON confirmed she was not aware of the unit only having 2 CNA's. She acknowledged it would be difficult for staff to monitor the unsecured doors as well as provide routine care of the 26 residents on the unit. The Thalia unit census on 6/23/19 was 26 residents with two CNA's to provide care. The Administrator said she did not staff the Thalia unit differently during the time the doors were unsecured to ensure the residents, particularly those who wandered to ensure adequate staff supervision of these residents to keep them safe. The Administrator was notified of the Immediate Jeopardy on 6/28/19. The immediate jeopardy started on 6/22/19 at approximately 7:30 p.m. and was removed on 6/28/19 lowering the scope and severity to D.

Based on interviews with the facility's nursing and administrative staff, record review, job description review, and facility policy/procedures review, it was determined facility administration failed to utilize resources effectively based on acuity and facility assessment to protect 1 (Resident #35) of 3 sampled residents from neglect. Facility administration failed to ensure that staff followed the procedure as outlined by Maintenance for staff monitoring the unsecured doors when the facility's Wanderguard (a wander management system for memory care) system failed. This failure resulted in a cognitively impaired Resident #35 exiting the facility and walking to a nearby Assisted Living Facility (ALF) where a concerned staff member observed the resident in front area near the parking lot. The resident eloped into an unsafe area with multiple hazards. Resident #35's whereabouts were unknown to the facility until contacted by the ALF and the resident was brought back to the facility by law enforcement. While the resident was out of the facility unsupervised, there was a high likelihood of serious harm, such as the resident could have been hit by a car, drown in the retention pond and got lost, or possible death. The facility's failure to maintain a secure environment for the 26 residents on the locked memory unit, 9 of which were identified as at risk for elopement, resulted in Immediate Jeopardy, starting on 6/22/19. The Administrator was notified of the Immediate Jeopardy on 6/28/19. The Immediate Jeopardy was removed on 6/28/19. Cross reference to F 600, F 689, and F 725. The findings included: The facility's policy Maintenance, under the issue of Door alarm does not sound directed staff to take immediate action, complete a head count, and post a door monitor at the door until alarm can be re-instated. The Job Description for Mobile Administrator included: follows established safety policies and procedures; ensures potential safety/health hazards are eliminated; and ensures all supervisors are trained in and implement policies and procedures. The Job Description for the Assistant Director of Nursing with Administrative Duties included: assists with managing the department of nursing; coordinates resource utilization; and appropriate care interventions. On 6/26/19 at 9:33 a.m., the Administrator said the Infection Preventionist (IP) was the facility manager on 6/22/19. The IP did not notify the Administrator until 6/23/19 at 9:00 a.m., the facility's security doors to the exterior of the building were not locking and interior fire doors had closed and could not be held open. All exterior doors in the facility were affected including the doors on Thalia unit. This comprised the security of the back-emergency exit door, the courtyard door and gate door from the Thalia dining room, the storage room door, and the entrance door to the Thalia Unit. On 6/24/19 at 12:26 p.m., during a tour of the Thalia unit (the facility's locked memory care unit), Resident #35 was observed lying down in bed with a Certified Nursing Assistant (CNA) at bedside. The Assistant Director of Nursing (ADON) said there was a problem last night where the resident disappeared for a little while. Clinical record review indicated Resident #35 had a [DIAGNOSES REDACTED]. The goal was not to leave center unattended. The resident was also identified as at risk for falls due to impaired cognition with erratic behaviors and had difficulty communicating. The care plan did not include any intervention for increased staff supervision of Resident #35, to ensure her whereabouts . On 6/23/19 at 9:00 p.m., Registered Nurse (RN) Staff I noted she was informed Resident #35 was found in the parking lot of the nearby ALF. Staff went to Resident #35's room, her bed blanket was turned down and she was not in her room. RN Staff I noted staff at the ALF had called 911 and the police were bringing the resident back. Resident #35 was returned to the facility at 9:05 p.m. RN Staff I noted the resident was alert, confused, appeared mildly distressed, and was able to walk with assist back to her room. The resident's physician and daughter were notified of the elopement. On 6/26/19 at 9:33 a.m., the Administrator said she was notified on 6/23/19 at 8:15 a.m., of the doors not locking. The interior fire doors and all the exterior doors were affected, to include all 3 exterior doors and the courtyard gate of the Thalia unit (the facility's locked memory care unit). The Administrator said the Maintenance Director had already been made aware on the evening of 6/22/19 when the system failed. She instructed RN Staff T, to set up a schedule to monitor all the affected exterior doors, not the interior fire doors. Education was initiated by RN Staff T for all staff regarding doors being unlocked and how they were going to monitor them. The Administrator said the system continued to be down and the Maintenance Director said the problem was the facility's Wanderguard system and someone would be out on 6/24/19 to repair it. The Administrator said during this time, staff were being educated and a schedule remained in effect to monitor the exterior doors. On the evening of 6/23/19, she was notified by RN Staff T that Resident #35 had eloped from the facility and police were bringing her back. She started an investigation and believed the resident was last seen by staff around 7:30 p.m. The Administrator said staff were not monitoring the door to the storage room which had an exit to the outside and the resident may have gone out that door after entering the storage room. She said staff were not placed in the areas as per her instructions and there was no one posted in the inside of the Thalia unit to monitor the dining room exit or storage room exit. On 6/27/19 at 1:26 p.m., the Administrator confirmed she was unable to provide evidence of any additional staff being assigned on the Thalia unit to monitor doors on the evening of 6/23/19. There were 2 CNA's and the third CNA had been reassigned to another unit. She confirmed there was no staff assigned to watch the back exit door on the second part of the unit where Resident #35's room was located. There was a housekeeper stationed at the door outside of unit contrary to her instructions of staff to monitor the exterior doors. The Administrator confirmed there was no additional staff other than the 2 CNA's and 1 nurse who were already assigned to take care of the 26 residents including the 9 identified wanderers. She acknowledged this would have been difficult to monitor these residents with this staff assignment and was not in accordance with her instructions. On 6/28/19 at 1:26 p.m., the Administrator and ADON acknowledged the purpose of the locked unit was for the safety of residents with dementia who wandered. The Administrator said the she had increased the staffing a few months ago on the Thalia Unit to 3 CNA's on all shifts. On the evening of 6/23/19, she was not made aware of the third CNA being removed from the unit or the housekeeping staff who were assigned to monitor the doors in the Thalia unit were not in place. The ADON confirmed she was also not aware of this and acknowledged would be difficult for staff to monitor the doors as well as take care of the 26 residents on the unit. The Administrator was notified of the Immediate Jeopardy on 6/28/19. The immediate jeopardy started on 6/22/19 at approximately 7:30 p.m. and was removed on 6/28/19 lowering the scope and severity to D.