Every finding on record at Gregory Wing of St Andrews Village

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions for 1 of 2 units([NAME] Wing), an activity office and the Laundry/kitchen areas on 3 of 3 environmental tours.1. On 8/11/25 from 10:00 a.m. to 10:20 a.m., a surveyor and the Facilities Manager toured the laundry room and the [NAME] Wing hallway and observed the following findings:Laundry: - There was a ceiling tile, over the stackable dryers, that was broken and had fallen out of place. - The entire floor was dirty and heavily soiled with dirt. - There were approximately 10 cracked/broken floor tiles throughout the laundry room. - There were three stained ceiling tiles in the soiled area of the laundry room. [NAME] Wing hallway- A laundry cart had a ripped cover and also had tape on it holding some of the cover together.On 8/11/25 at 10:20 a.m., in an interview with a surveyor, the Facilities Manager confirmed the findings. 2. On 8/13/25 from 8:45 a. m. to 8:55 a. m., a surveyor and a Maintenance Worker conducted a tour of the facility and observed the following findings:[NAME] Wing- Resident room [ROOM NUMBER] - The privacy curtain was missing hooks, hanging down and in disrepair.- Resident room [ROOM NUMBER] - The floor was dirty around the base of the toilet. There were two floor tiles, under the bathroom door by the door jamb, that were broken and missing.-The activity office had dead bugs in all three ceiling lights. On 8/13/25 at 8:55 a. m., in an interview with a surveyor, a Maintenance Worker confirmed the findings. 3. On 8/13/25 from 9:40 a.m. to 10:10 a.m., a surveyor and the Environmental Services Laundry/Housekeeping Supervisor conducted a tour of the laundry/kitchen areas and observed the following findings: -The kitchen hallway had two large wall air vents that were heavily soiled with dust. - The kitchen mat drying rack, stored in the kitchen hallway, had large amounts of rust on the base area. - The laundry hallway had wooden chair rails on the walls that had chipped/missing paint that created uncleanable surfaces.- The laundry room had 2 ceiling tiles, in the corner behind the folding table, that had brown stains on them.- The ceiling air vent, over the 3 large dryers, was dusty. - The ceiling air vent, over the stackable dryers, was dusty. On 8/13/25 at 10:10 a.m., in an interview with a surveyor, the Environmental Services Laundry/Housekeeping Supervisor confirmed the findings.

Based on record review, interview, and facility policy, the facility failed to ensure an Interdisciplinary Meeting was held within 7 days of completed Minimum Data Set (MDS)/ Assessment Reference Date (ARD) for 3 of 14 Residents reviewed (Resident's (7, 19 and 35). 1. Review of facility policy Care Plans-Comprehensive-Preliminary dated 3/1998 states . The resident's/patient's comprehensive care plan is developed within seven (7) days of the completion of the resident's/patient's comprehensive assessment (MDS) . Review of Resident [R]7's Quarterly MDS/ARD dated 7/18/25. Review of R7's clinical record revealed the IDT was held 7/16/25 (2 days prior to MDS/ARD) completion. During an interview on 8/12/25 at 11:21 a.m., the Licensed Social Worker (LSW) stated that she is supposed to schedule IDTs within 7 days of the MDS /ARD date. At this time LSW confirmed R7's IDT was held 2 days prior to MDS/ARD completion date. 2. Review of Resident (R) 35's clinical record revealed a Minimum Data Set (MDS) admission Assessment was completed on 7/30/25. Further review of the clinical record lacked evidence that an interdisciplinary team (IDT) meeting was held within 7 days following the assessment. 3. Review of R19's clinical record revealed an MDS Quarterly Assessment was completed on 5/17/25 and that an IDT meeting was held 5/29/25 (12 days after the assessment). On 8/12/25 at 11:24 a.m., the above findings were discussed with the Licensed Social Worker (LSW). At this time, the LSW stated she tries to hold the IDT meeting within 7 days of the MDS assessments but thought she had up to 14 days to hold the meeting and stated she has not yet scheduled an IDT meeting for Resident #35.

Based on observations, record reviews, interviews and facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 2 residents reviewed for respiratory care (Resident [R] 6). Additionally, the facility failed to ensure physician orders were followed for 1 of 2 residents receiving oxygen therapy (R1) and failed to ensure complete and accurate documentation of the assessment and monitoring of the resident's respiratory condition for 2 of 2 residents receiving oxygen therapy (R1, R6). 1. On 8/11/25 at 9:09 a.m. and 11:22 a.m., R1 was observed wearing oxygen (O2) via a nasal cannula (NC) with the concentrator flow rate set at 1.5 liters per minute (L/min). On 8/12/25 at 9:34 a.m. during a follow-up observation, Resident #1 was wearing oxygen via nasal cannula with the concentrator flow rate set at 1L/min. Review of R1's clinical record revealed the following orders: -order with a start date of 6/5/25 for Oxygen 2L/min via NC PRN [as needed] for dyspnea [shortness of breath], comfort, and/or 02 sat [saturation] below 90% as needed . -order with a start date of 8/11/25 for Oxygen 2L/min via NC every shift for dyspnea, comfort. On 8/12/2025 at 11:05 a.m., during an interview, Registered Nurse (RN) #1 stated R1 had been receiving oxygen PRN but recently had aspiration pneumonia and now requires continuous oxygen at 2L/min. RN #1 then stated when she took R 1's vital signs this morning, his/her oxygen saturation was 83%, and she noticed the flow rate on the concentrator was set to 1L, so she adjusted the setting to 2L. RN #1 then stated that R1 should be receiving 2L of continuous oxygen and that there is no physician order to titrate the oxygen flow rate. On 8/12/25 at 11:27 a.m., during an interview in the presence of 4 surveyors, the above finding was discussed with the Nurse Manager. At this time, the Nurse Manager stated there are no standing orders to titrate oxygen and that R1 should be on continuous oxygen at 2L/min per the physician order. 2. Review of R1's clinical record revealed a physician order with a start date of 6/5/25 for Oxygen 2L/min via NC PRN [as needed] for dyspnea [shortness of breath], comfort, and/or 02[oxygen] sat [saturation] below 90% as needed . Review of R1's O2 Sat Summary indicated R1 was wearing oxygen via nasal cannula for all documented O2 sat measurements from 6/5/25 through 8/13/25. Review of R1's June 2025 and July 2025 Treatment Administration Record (TAR) indicated R1 received PRN oxygen on 6/8/25 and lacked evidence that R1 received oxygen on any other dates in June or July 2025. On 8/13/25 at 12:22 p.m., during an interview with 2 surveyors, the above finding was discussed with the Nurse Manager, and she stated R1 had been using PRN oxygen in June and July 2025, and it should have been documented on the TAR. The facility's Oxygen Therapy policy, last revised 9/2024, stated in Section II. Key Procedural Points, 3. Oxygen in Use, o. Oxygen tubing, masks, should be changed weekly. Section VI. Assessment. 1. The resident's preliminary and comprehensive assessment should address: a) That oxygen therapy is needed. b) How often oxygen is to be administered. e) Other as appropriate and necessary. Section VII. Charting and Documentation. 1. When oxygen therapy has been ordered, the staff/charge nurse should record the following data in the resident's medical record: a) the date and time the procedure was ordered. b) the rate of flow, route, and rationale. c) the name of the person administering the oxygen. d) the frequency and duration of the treatment. e) the resident's tolerance to the treatment. f) the reason for prn (as needed) administration. j) All pertinent observations, k) the signature and title of the person recording the data. 3. On 8/11/25 at 10:37 a.m., a surveyor observed an oxygen concentrator in R6's room and noted the label indicating when the tubing was last changed was dated 7/31/25. R6 stated he/she only uses it when need and the last time was a couple of weeks ago. A review of R6's clinical record noted diagnoses that included Chronic obstructive pulmonary disease (COPD), and Congestive heart failure (CHF). The Minimum Data Set (MDS) 3.0, admission Assessment, completed 6/15/25, Section O – Special Treatments, Procedures and Programs, indicated R6 did not receive oxygen therapy. A review of R6's care plan, initiated 6/9/25 and revised 7/29/25, included the focus area: Oxygen therapy related to respiratory illness (COPD), and with interventions that included: Report symptoms of respiratory distress and report to (physician as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Provider orders, dated 6/11/25, included Oxygen (O2) as needed for dyspnea/comfort 1-2 liters per minute via nasal cannula. And, Change oxygen tubing weekly. Rinse filter, pat dry and replace. Initial and date orange tubing sticker every day shift every 7 days. A review of R6's Treatment Administration Record (TAR) for June, July, and August, 2025, noted no use of oxygen in July or August. In June, R6 received oxygen at 2 liters on 6/10/25. Documentation on the TAR noted R6's oxygen tubing was last changed on 8/7/25. A review of the vital signs recorded by staff in R6's electronic medical record noted daily oxygen saturations (SpO2) ranging from 86-97%. Staff had documented oxygen use as follows: 6/11/25 at 7:50 a.m., SpO2 at 90% Oxygen via Nasal Cannula 6/12/25 at 7:41 a.m., SpO2 at 93% Oxygen via Nasal Cannula 6/19/25 at 7:26 a.m., SpO2 at 91% Oxygen via Nasal Cannula 6/23/25 at 7:58 a.m., SpO2 at 92% Oxygen via Nasal Cannula 6/23/25 at 7:38 p.m., SpO2 at 96% Oxygen via Nasal Cannula 6/24/25 at 7:50 p.m., SpO2 at 93% Oxygen via Mask 6/25/25 at 9:17 a.m., SpO2 at 89% on Room Air 6/28/25 at 8:04 a.m., SpO2 at 91% Oxygen via Nasal Cannula 6/29/25 at 7:37 a.m., SpO2 at 90% Oxygen via Nasal Cannula 7/5/25 at 8:55 a.m., SpO2 at 92% Oxygen via Nasal Cannula 7/20/25 at 8:14 a.m., SpO2 at 92% Oxygen via Nasal Cannula On 8/13/25 at 11:25 a.m., a surveyor confirmed with Registered Nurse #2 that R6's oxygen tubing was still dated 7/31/25, indicating the date it was last changed. On 8/13/25 at 11:30 a.m., in an interview with a surveyor, RN #3 stated if the oxygen saturation dips to the 80's, the RN will add oxygen and check back within 5-10 minutes to assess the effect. If the oxygen saturation has improved, RN #3 will leave the oxygen on and recheck again later. Asked how this would be documented, RN #3 stated I would put that in a nursing note. On 8/13/25 at 12:20 p.m., in an interview with the Nurse Manager, 2 surveyors discussed the lack of documentation for prn oxygen use, including when oxygen was applied and at what liter flow, and follow up assessment for effectiveness and oxygen saturation. In addition, the oxygen tubing for R6 was observed on two occasions with the date of 7/31/25, and documentation in the TAR indicating the tubing was last changed on 8/7/25. The Nurse Manager confirmed the findings.

Based on observations, interviews, the facility's Storage - Food and Non Food Items policy, the facility's Sanitation-Warewashing-Mechanical/Manual Cleaning/Sanitizing policy, and the facility's Dish machine Temperature and Cleaning Records, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap cover, floor drain covers and the walk-in freezer; failed to ensure kitchen staff wore appropriate hair coverings; failed to ensure foods were properly dated, labeled and/or discarded past the manufacturer's best used by date for 1 of 1 kitchen tour.(8/11/25)The facility's Sanitation-Ware washing-Mechanical/Manual Cleaning/Sanitizing policy effective date: 04/20/12 noted: Procedure: d) Check temperatures. Record daily the wear washing machines temperatures of both the wash and the rinse cycles on the dishwasher temperature record form. Temperatures shall be maintained in accordance with the manufacturer's instructions.The facility's Storage - Food and Non Food Items policy effective date: 04/20/12 noted: Procedure: 1) General Storage Information- b) Expiration dates must be checked on a regular basis. 2) Refrigerator Storage- d) Food items will be properly labeled and dated as appropriate when placed under refrigeration. 3) Freezer Storage- d) All items to be frozen must be properly wrapped, labeled and dated.On 8/11/25, a surveyor did an Initial Kitchen Tour with [NAME], RD. from 9:30 a.m. to 10:10 a.m. in which the following findings were observed: > The grease trap cover was dirty and rusty. > A male kitchen worker, with a facial hair, did not have a facial hair covering on. > There were 3 floor drain covers that were dirty and had chipped/missing paint creating uncleanable surfaces. > Reach-in refrigerator #5 had one 8-ounce container of fat free milk with a best used by date of July 7, 2025. > The walk-in freezer had 3 packages of a white substance and two large bags of french fries that were not labeled and dated. Additionally, there was a bag of french fries and a bag of [NAME], under the freezer compressor, that had chunks of ice buildup on them. On 8/11/25 at 10:10 a.m., in an interview with a surveyor, the Registered Dietician confirmed the findings.On 8/12/25 at 2:30 p.m., the Administrator provided kitchen documentation to the surveyor that had been requested. The Dish Machine and Cleaning Records Temperature check sheet show that the dinner time dish machine temperatures were not monitored and documented for the following dates: May 2025= 1,2,3-6, 8-31. June 2025= 2-9, 11-17, 19-30. July 2025= 4-6, 9, 12-14, 16, 17, 18-21, 23, 27,28, 31. At this time in an interview with a surveyor, the Administrator confirmed the findings.

Based on observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (8/11/25, 8/12/25 and 8/13/25).1. On 8/11/25 at 8:30 a.m., two surveyors observed one of two dumpsters with the front right lid open exposing trash. There was also trash on the ground around the two dumpsters. Additionally, two surveyors observed a trash storage area, outside the maintenance shop area, that had trash piled in and on 3 large, uncovered trash receptacles. On 8/11/2025 at 9:12 a.m., in an interview with a surveyor, the Administrator confirmed the finding. 2. On 8/11/25 at 8:30 a.m., a surveyor and the Facilities Manager observation of trash storage area outside the maintenance shop area. 1 of 3 large, uncovered trash receptacles had trash in it. At this time, in an interview with a surveyor, the Facilities Manager confirmed that the staff puts trash in the bins daily to take to the dumpsters at the end of the day and the bins are not covered. 3. On 8/12/25 at 8:15 a.m., a surveyor and the observed trash on the ground around the two dumpsters. The surveyor also observed trash in 2 of the 3 large, wheeled uncovered trash receptacles outside the maintenance shop area. On 8/12/25 at 8:30 a.m., in an observation and interview with a surveyor, the Facilities Manager confirmed the findings.4. On 8/13/25 at 8:15 a.m., two surveyors observed one trash dumpster with the right side slide door open exposing trash. Also, there was a trash bag on the ground in front of the other dumpster. On 8/13/25 at 8:30 a.m., in an interview with a surveyor, the Facilities Manager confirmed the findings.

Based on Certified Nurse's Aide (CNA) employee education reviews and interview, the facility failed to monitor and ensure that a CNA attended the required 12 hours of annual in-service education, for 1 of 5 randomly selected CNA's employed greater than 1 year. (CNA1).Certified Nursing Assistant (CNA1) was hired on 4/11/16.CNA1 's yearly Inservice education records from 4/11/24 through 4/11/25 state she received 7.09 hours of Inservice hour education and not the required 12 hours. During a review of CNA1's in-service hours on 8/13/25 at 11:03 a.m., Nurse Manager confirming CNA1 did not receive the required 12 hours of in-service education.

Based on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 11 residents reviewed for baseline care plans (Resident #19 (R19).R19 was admitted in February 2025. Review of R19's clinical record lacked evidence that a baseline care plan, including goals and interventions, was developed and implemented within 48 hours of admission. On 8/12/25 at 4:00 p.m. during an interview, the Nurse Manager reviewed R19's baseline care plan and confirmed it was not developed and implemented until 4 days after admission.

Based on observation, interview, and record review, the facility failed to ensure a resident's care plan was developed in the area of oxygen use for 1of 2 residents reviewed for respiratory care (Resident [R] 1).On 8/11/2025 at 9:09 a.m. and 8/12/25 at 9:00 a.m., R1 was observed wearing oxygen via a nasal cannula.Review of R1's clinical record indicated he/she has diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) and aspiration pneumonia. Review of R1's Quarterly Minimum Data Set assessment, dated 6/9/25, indicated oxygen therapy while a resident. Review of R1's physician orders revealed the following:-order with a start date of 6/5/25 for Oxygen 2L/min [2 liters per minute] via NC [nasal cannula] PRN [as needed] for dyspnea [shortness of breath], comfort, and/or 02 [oxygen] sat [saturation] below 90% .-order with a start date of 8/11/25 for Oxygen 2L/min via NC every shift for dyspnea, comfort.Review of R1's care plan lacked evidence that goals/interventions for oxygen were implemented until after the start of the survey (8/11/25).On 8/12/2025 at 4:00 p.m. during an interview, the Nurse Manager reviewed R1's care plan and confirmed that a comprehensive care plan had not been developed or implemented for R1's oxygen use.

Based on review of performance evaluations and interviews, the facility failed to complete annual performance evaluations timely, at least once every 12 months, for 2 of 5 Certified Nursing Assistants (CNA's 1 & 2).1.Review of CNA1's 2024 Annual Performance Appraisal initiated by Nurse Manager on 10/10/24 states Impersonation Mode You are currently impersonating another user. To stop impersonating, click on the user menu and select Stop Impersonating. I understand that my electronic signature carries the same legal weight and authority as my written signature. Name [CNA1] date 8/12/25. sign: is blank. This evaluation lacks evidence that it was reviewed/or signed by CNA1.During an interview on 8/13/25 at 10:55 a.m., CNA1 reviewed 2024 Annual Performance Appraisal dated 8/12/24 and stated she did not receive or sign an evaluation yesterday (8/12/25), and she was working all day and never went onto a computer all day long.2. Review of CNA2's 2024 Annual Performance Appraisal initiated by Nurse Manager on 10/28/24 states . I understand that my electronic signature carries the same legal weight and authority as my written signature. Name [CNA2] date 8/12/25. sign: is blank. This evaluation lacks evidence that it was reviewed/or signed by CNA2.During an interview on 8/13/25 at 11:03 a.m., Nurse Manger confirmed that would have been something signed by Human Recourses (HR). CNA1 CNA2 did not sign the evaluations. During an interview on 8/13/25 at 11:31 a.m., in presence of 4 surveyors the Administrator stated she had spoken with HR and was told that an employee does not have to sign an evaluation. A surveyor asked if an employee doesn't sign the evaluation, how is there proof that they received the evaluation and were made aware of any concerns that were noted on the evaluation. Administrator replied, That is a good question.

Based on interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for 37 of 37 beds. Findings: On 5/14/24 at 11:42 a.m., a surveyor met with the Director of Facilities and asked for the bed gap measurements and side rail gap measurement documentation. The Director of Facilities stated that he had never heard of those before and he would check with the other maintenance men. He came back and stated that they had never heard of them either. At this time, the Director of Facilities confirmed that the facility had never completed bed gap measurements and/or side rail gap measurements at the facility for any of the resident's beds. On 5/14/24 at 11:50 a.m., in an interview with the Administrator and the Director of Facilities, the Administrator stated that she had never heard of bed gap measurements or side rail gap measurements. At this time, the Administrator confirmed that the facility had never completed bed gap measurements and/or side rail gap measurements at the facility for any of the resident's beds. The surveyor asked for the facility's Bed Safety and Bed Rails policy and procedure. On 5/14/24 at 1:30 a.m., in an interview with the Administrator, she stated that she can't locate any Bed Safety and Bed Rails policy and procedure documentation and can't provide any to the surveyor.

Based on observations, interview and the facility's Storage - Food and Non Food Items policy effective date: 04/20/12, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap base, floor drains, ceiling vents, lights and ceiling tiles; failed to ensure facial hair protection was worn; and failed to ensure foods in the walk-in freezer were dated and/or labeled. Findings: On 5/13/24 from 9:10 a.m. to 9:35 a.m., an initial kitchen tour was conducted with the Food Service Director in which the following findings were observed: > The cement base under the grease trap had chipped/missing paint creating an uncleanable surface. > There were 3 floor drain grates that had chipped/missing paint creating uncleanable surfaces. > There were 3 ceiling vents, above food preparation areas, and surrounding ceiling tiles that were moderately soiled with dust. > The dry storage room had a ceiling vent and a light that were moderately soiled with dust. > There was a male kitchen worker with facial hair that was not wearing facial hair protection while preparing food in the kitchen. > The walk-in freezer had an unlabeled and undated bag of bread and also had a package of unlabeled bacon bits. > The dry storage room had a ceiling vent and a ceiling light that were moderately soiled with dust. On 5/13/24 at 9:35 a.m., in an interview, the Food Service Director confirmed the findings.

Based on observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (5/13/24, 5/14/24 and 5/15/24). Findings: 1. On 5/13/24 at 9:00 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. 2. On 5/14/24 at 8:15 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. 3. On 5/15/24 at 8:15 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. On 5/15/24 at 10:50 a.m., in an interview, the surveyor discussed the findings with the Administrator and the Director of Nursing at the survey Exit meeting.

Based on facility policy, record reviews and interviews, the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 6 residents reviewed for advanced directives (Resident's #24 and #26). Findings: Review of facility policy titled Advance Directives effective date 10/1991 states Purpose: To comply with Federal and Critical access hospitals conditions of participation, the Federal Patient Self-Determination Act, the Main Uniform Health Care Decisions Act and to provide the community with a method for healthcare decision making, [NAME] health has adopted this Advance Directive Policy to provide: 1. B. Written information to patients and or their support person concerning their right to make decisions about medical care. C. Documentation of patients declaration of an advanced healthcare directive form. 2.B.1. [NAME] health will provide written information to all adult patients, emancipated minors, persons authorized to make medical decisions on behalf of patients and or the patient support person during every inpatient admission, at time of registration, to outpatients or their representative, to those who are in in emergency department, those undergoing same day surgery, are those who are in observation status. C.4. Any employee or medical staff were receives a copy of Advanced Healthcare Directive form will submit it as part of the patient's medical record . 1. Resident #24 was admitted to the facility on [DATE]. A review of Resident #24's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #26 was admitted to the facility on [DATE]. A review of Resident #26's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 5/13 24 at 11:50 a.m., during an interview, the Registered Nurse (RN #2) confirmed the above findings.

Based on facility policy, record review and interviews, the facility failed to report in a timely manner, an injury of unknown origin with serious injury to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) for 1 of 1 residents sampled for injuries/accidents. (#27) Finding: Review of the facility's Abuse. Neglect, and/or Exploitation Reporting Policy # 02-7080-246, effective date: 05/1999, noted in 1. Policy Statement: 2. All personnel who suspect any incident of resident abuse, neglect or exploitation, including injuries of an unknown source or misappropriation of resident property, must promptly report the incident to (the Department of Health and Human Services)DHHS through the Division of Licensing and Regulatory Services(DLRS) within 24 hours of the incident and to Adult Protective Services. Attachment one: 1. All incidents: All incidents must be reported to DHS through the division of licensing and regulatory services DSLRs . Within 24 hours of the incident or the next working day, when the incident occurs or on a holiday or weekend.) . On 3/18/24 at 3:09 p.m., the Division of Licensing and Certification received from the facility a fax which indicated an injury of unknown origin to Resident #27 which was discovered during morning care. A review of Resident #27's clinical record noted a nursing note written by Nursing n 3/15/24 a 10:59 indicating Resident with some right shoulder swelling noted this am during am care/dressing. When sitting on edge of bed, right shoulder is not symmetric, right shoulder appears lower/? dropped compared to left. Resident winces when assisted with dressing. No eventer fall has happened with resident recently. Small rash area noted on right chest and irregular bruise noted on right inner upper arm, non tender. Will try ice and Tylenol and monitor. On 3/15/24 a 2:05p.m., the resident was transported to an acute care hospital emergency room for evaluation. Resident #27 was found to have right humeral head fracture and fracture Compression Thoracic 5, 6,and 7. On 5/13/24 at 10:50 a.m., in an interview, the Director of Nursing stated this injury was discovered on Friday 3/15/24. She went on to state that the facility knew about the serious injury the same evening in a report from the hospital. She further stated that the facility report to the state was not sent in until 3/18/24. On 5/13/24 at 12:10 p.m., in an additional interview, the Director of Nursing confirmed that the facility did not send a report timely to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) regarding this injury of unknown origin.

Based on observations, record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate documentation for 1 of 3 sampled residents reviewed for Oxygen (#189). Finding: On 5/13/24 at 10:25 a.m. and on 5/14/24 at 9:56 a.m., observations of Resident #189 on Oxygen set at 2 Liters Per Minute (LPM) via nasal cannula. Review of the hospital discharge history and physical states the resident has diagnosis of chronic respiratory failure with hypoxia and obstructive sleep apnea and required oxygen at home at 2LPM continuously. The Assessment and Plan states, Patient on continuous home oxygen, 2 LPM via nasal cannula. Review of the Physician order dated 5/7/24 states O2 every day and night shift for ILD (Interstitial Lung Disease), the order lacked the amount of oxygen / LPM to be administered. On 5/14/24 at 10:19 a.m., during an interview, both the surveyor and the Registered Nurse (RN) Admission Coordinator reviewed the admission orders which indicated the 2LPM. The RN stated she will update the orders immediately to reflect the LPM of oxygen.

Based on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a commode for 1 of 3 days of survey. (5/13/24) Finding: On 5/13/24 at 10:05 a.m., two surveyors observed a commode over a toilet in Resident room [ROOM NUMBER]'s bathroom. The left armrest had been worn down and the right armrest was broken open with sharp/jagged plastic edges exposed. On 5/13/24 at 10:13 a.m., in an interview with two surveyors, the Director of Nursing confirmed that the sharp/jagged plastic edges on the armrest was an accident hazard.

Based on record reviews, interviews and facility policy, the facility failed to update/implement goals and interventions in the area of antibiotic medication use for 1 of 6 residents reviewed for medications (Resident #15). Findings: Review of facility policy Care Planning/Interdisciplinary Team/Family Participation dated 3/98 states .A comprehensive care plan is developed within seven days of completion of the resident comprehensive assessment (MDS).Reviewing care plans to assure that: They reflect the resident's actual needs . Review of Resident 15's care plan initiated 3/22/23 revealed .Focus: I have a Urinary Tract Infection; Goal: UTI will resolve without complications; Interventions: Administer antibiotic as prescribed by Provider Review of Resident 15's clinical record revealed order with start date of 2/23/24 for Amoxicillin-Pot Clavulanate 875-125 mg tablet. Give 1 tab by mouth twice daily for 7 days for UTI [Urinary Tract Infection]. Further review of Resident #15's clinical record lacked evidence his/her care plan was updated after this medication was completed. On 5/14/23 at 11:26 a.m., during an interview, the Director of Nursing indicated that Resident #15's care plan should have been updated within 7 days of the antibiotic completion and confirmed the above findings.

Based on interview, record review and facility policy, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 7 sampled residents (Resident #17). Findings: Review of facility policy Care Planning/Interdisciplinary Team/Family Participation dated 3/98 states .A comprehensive care plan is developed within seven days of completion of the resident comprehensive assessment (MDS).Reviewing care plans to assure that: They reflect the resident's actual needs . Resident #17 was admitted to the facility on [DATE]. During review of Resident #17's medical record, the surveyor noted quarterly Minimum Data Set (MDS) Assessments dated 2/6/24. The clinical record lacked evidence that a care plan meeting was held by the IDT, resident and/or representative for this assessment. In addition, the last documented IDT meeting was held on 11/14/23. On 5/14/24 at 2:32 p.m., during an interview, the Social Worker reviewed Resident #17's entire clinical record and confirmed there was no evidence that an IDT was held. On 5/14/24 at 2:54 p.m., the above was discussed with Director of Nursing.

Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 3 residents that were reviewed for new admissions. (#189) Finding: On 5/13/24 at 10:25 a.m., During an interview, Resident #189 stated, he/she has a pacemaker which is checked via his/her phone. Resident #189 was admitted to the facility on [DATE]. The hospital history and physical included information that the resident had a pacemaker placed for tachybradycardia syndrome and heart block. Further review indicates resident #189's code status as Do Not Resuscitate. Review of the clinical record lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #189's immediate health and safety needs for the above concerns. On 5/14/24 at 10:19 a.m., during an interview, the Registered Nurse Admission Coordinator confirmed the above and stated she will add the presence of a cardiac pacemaker immediately.

Based on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents reviewed for discharge (Resident #33). Findings: Resident #33 was admitted to facility on 2/9/24 for skilled services. On 2/24/24 resident #33 was discharged to the community. The clinical record lacked evidence a recapitulation of the resident's stay was completed at discharge. On 5/15/24 at 10:09 a.m., during an interview, the Director of Nursing indicated that she reviewed Resident #33's clinical record and was unable to find evidence that a recapitulation of stay was completed for this resident.

Based on observations, and interviews, the facility failed to ensure that hot water temperatures, accessible to residents and guests, did not exceed 120 degrees Fahrenheit on the(NAME)Wing, in a public restroom, and in shower room for 1 of 3 days of survey, and on the Zimmerli Unit for 2 of 3 days of survey. The failure of the facility to ensure that hot water temperatures accessible to residents and guests did not exceed 120 degrees Fahrenheit created the potential for residents and guests to be burned by the domestic hot water. Findings: 1. On 3/18/19 three surveyors measured and observed the following hot water temperatures on the(NAME)Wing Unit: -At 9:52 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 128.8 degrees Fahrenheit. -At 10:00 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 124.6 degrees Fahrenheit. -At 10:01 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 130.2 degrees Fahrenheit. -At 10:03 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 124.2 degrees Fahrenheit, and the hot water temperature in bedroom sink was 124.7 degrees Fahrenheit. -At 10:04 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 130.2 degrees Fahrenheit. -At 10:05 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 130.0 degrees Fahrenheit. -At 10:07 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 127.1 degrees Fahrenheit. -At 10:15 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 129.0 degrees Fahrenheit. -At 10:21 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 128.4 degrees Fahrenheit. -At 10:25 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 129.0 degrees Fahrenheit. On 3/18/19 at approximately 10:30 a.m., two surveyors met with the Administrator in Training and the Maintenance Assistant to inform them of hot water temperatures above 120 degrees Fahrenheit in resident accessible locations. The facility provided the surveyors with a document titled St.(NAME)Village-Plant Operations-St.(NAME)Village Monthly Water Temperature Check dated 2019. The document identifies the months of the year by using letters only, data reviewed under J, F, and M representing January, February, and (MONTH) 2019 have check marks indicating water temperature checks were conducted in random resident rooms and random locations within the facility, however; the document does not provide a date, time, or temperature of the checks completed. On 3/18/19 at 10:45 a.m., the Immediate Jeopardy (IJ) template was provided to the Senior Executive Director of Senior Living by the surveyor Team Leader. On 3/18/19 at approximately 10:57 a.m., a surveyor and the Maintenance Assistant measured and observed the hot water temperatures. At this time, the surveyor confirmed the finding in an interview with the Maintenance Assistant. Additionally, on 3/18/19 a surveyor measured and observed the following hot water temperatures on the Zimmerli Unit and a public restroom: -At 11:15 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 122.0 degrees Fahrenheit. -At 11:20 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 122.0 degrees Fahrenheit. -At 11:17 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 121.8 degrees Fahrenheit. -At 11:17 a.m., the hot water temperature in the public restroom's bathroom sink was 123.0 degrees Fahrenheit. On 3/18/19 at 11:43 a.m., an immediate plan of correction for the unsafe hot water temperatures was provided and accepted by the survey team. The Action Plan included the following immediate interventions: Facility would immediately adjust the water temperature, Staff were made aware to use caution and to observe residents closely, showers and baths were to be avoided until the temperature was corrected, and the facility would be monitoring temperatures to ensure safe temperatures of 120 degrees Fahrenheit or below. 2. On 3/19/19 at 5:30 a.m., a calibration check of the surveyors digital thermometer in a glass of ice water was conducted by the surveyor. The digital thermometer reading was 32.4 degrees Fahrenheit. On 3/19/19 at approximately 8:15 a.m., hot water temperatures were measured and observed on the(NAME)Wing, with none noted to be above 120 degrees Fahrenheit. On 3/19/19 a surveyor measured and observed the hot water temperatures on the Zimmerli Unit: -At 8:23 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 127.7 degrees Fahrenheit. -At 8:26 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 125.7 degrees Fahrenheit. On 3/19/19 at approximately 8:30 a.m., a surveyor confirmed the findings in an interview with the Administrator in Training. Additionally, the surveyor was provided with The Action Plan's hot water temperature logs, a review reveals that hot water temperatures where monitored throughout the evening and night, with no noted hot water temperatures to exceed 120 degrees Fahrenheit, and the facility continues to monitor hot water temperatures throughout the facility. On 3/19/19 a surveyor continued to measure and observe the hot water temperatures on the Zimmerli Unit: -At 1:45 p.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 120.5 degrees Fahrenheit. -At 1:37 p.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 127.5 degrees Fahrenheit. -At 1:40 p.m., the hot water temperature in the Shower Room sink was 121.5 degrees Fahrenheit. 3/19/19 at 1:30 p.m., a surveyor met with Administration staff and the Maintenance group about hot water temperatures fluctuating and still too hot on Zimmerli Unit. The surveyor was questioned as to whether his digital thermometer was accurate, the surveyor indicated a thermometer check was completed that morning for accuracy by placing the digital thermometer in a glass of ice water, and the reading was 32.4 Fahrenheit. The surveyor was asked to get a different thermometer and agreed to do so. The surveyor asked another surveyor for their digital thermometer and checked them at a sink location. The two State thermometers were with-in 1 degree Fahrenheit of each other. The surveyor went to the Zimmerli Unit and conducted hot water temperature checks with the facility and still had temperatures over 120 degrees Fahrenheit in some locations on both the surveyor's digital thermometer and the facility's dial thermometer. On 3/19/19 at approximately 2:00 p.m., a surveyor confirmed the finding in an interview with the Maintenance Director. The Maintenance Director indicated that the hot water temperatures continued to be monitored throughout the facility, a part was ordered, and would be installed immediately upon arrival to the facility. On 3/19/19 at approximately 2:55 p.m., the Senior Executive Director of Senior Living informed the survey team that the part to fix the domestic hot water system had arrived and would be installed immediately. 3. On 3/20/19 at 5:30 a.m., a calibration check of the surveyors digital thermometer in a glass of ice water was conducted by the surveyor. The digital thermometer reading was 32.3 degrees Fahrenheit. On 3/20/19 at approximately 9:10 a.m., a surveyor met with the Maintenance Director, observed and measured hot water temperatures on the(NAME)Wing and the Zimmerli Unit, all hot water temperatures measured and observed were noted to be under 120 degrees Fahrenheit. Random checks were conducted by the survey team for the remainder of the survey with no hot water temperatures exceeding 120 degrees Fahrenheit. The immediacy of the hot water was corrected; however, quality assurance activities and systemic changes to ensure continued compliance will need to be addressed.