Every finding on record at Live Oak

Based on record reviews and interviews the facility failed to report alleged allegations of abuse and neglect in the required timeframe to the State Survey and Certification Agency for 2 (#19 and #70) of 3 residents reviewed for facility reported incidents. Findings:Resident #19Review of Resident #19's medical record revealed an admission date of 02/21/2020 and diagnoses including atherosclerosis native arteries of left leg with ulceration other foot, insomnia, glaucoma, muscle wasting and atrophy multiple sites, and difficulty in walking.Review of the facility's incident log for dates 03/27/2026 through 07/27/2026 revealed Resident #19 had a fall with injury 07/12/2026 at 5:15 a.m.Review of Resident #19's incident on 07/12/2026 at 5:15 a.m. of alleged neglect [fall with injury] revealed the incident was reported to the State Survey and Certification Agency on 07/13/2026 at 1:44 p.m.Review of resident #19's progress notes revealed in part:07/12/2026 at 6:18 a.m. Resident #19 had a fall and denied pain.07/12/2026 at 7:05 p.m. for Resident #19 had complaints of pain, x-ray was completed at 2 p.m., and Tylenol was given at 9:15 a.m. and 5:15 p.m.During a telephone interview on 07/28/2026 at 2:49 p.m., S5LPN confirmed she assessed Resident #19 after the fall on 07/12/2026 at 5:15 a.m. S5LPN reported Resident #19 was found on the side of the bed by the window on the floor. S5LPN further confirmed resident #19 denied pain and had no injuries at time of fall. During an interview on 07/28/2026 at 12:17 p.m., S4Nurse Practitioner reported she ordered an x-ray after Resident #19's fall on 07/12/2026 after Resident #19 complained of pain at 9:00 a.m. S4Nurse Practitioner confirmed Resident #19's x-ray result from 07/12/2026 revealed Resident #19 had a left femur fracture.During an interview on 07/29/2026 at 12:30 p.m., S1DON confirmed Resident #19 had a fall with injury on 07/12/2026 at 5:15 a.m. and the alleged neglect was not reported to state agencies until 07/13/2026 at 1:44 p.m. S1DON acknowledged reporting was out of compliance with the 24 hour window of reporting for neglect. Resident #70Review of Resident #70's medical record revealed an admission date of 11/19/2021 and diagnoses including dysphagia, amyotrophic lateral sclerosis, neuralgia and neuritis, and chronic kidney disease.Review of the facility's grievance form dated 07/08/2026 revealed in part, Resident #70 reported an agency CNA was assisting him this morning and said he was a crazy f__d up person.Review of Resident #70's incident on 07/08/2026 at 6:30 a.m. of alleged verbal abuse revealed the incident was reported to the State Survey and Certification Agency 07/08/2026 at 3:21 p.m.During an interview on 07/29/2026 at 8:40 a.m., S3CNA Coordinator reported Resident #70 informed her an agency CNA called him a crazy f__d up person on the morning of 07/08/2026. S3 CNA Coordinator reported she informed Resident #70 the agency CNA would no longer be working with him and reported this incident to S1DON. During an interview on 07/29/2026 at 3:15 p.m., S1DON acknowledged Resident #70's incident was discovered on 07/08/2026 at 6:30 a.m. and was reported on 07/08/2026 at 3:21 p.m. S1DON further acknowledged she did not report the allegation of abuse within 2 hours to the appropriate state agency and should have. Review of the facility's Abuse Prevention Program and Abuse Reporting for Health Center Residents policy with a revision date of 04/23/2028 revealed:Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents or at residents within hearing distance, regardless of their age, ability to comprehend, or disability.Review of the facility's Recognizing Signs and Symptoms of Abuse/Neglect policy with a revision date of 04/23/2018 revealed in part:Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness.Review of the facility's Abuse Prevention Program and Abuse Reporting for Health Center Residents policy with a revision date of 04/23/2018 revealed in part:PURPOSE: It is the policy of The Oaks of Louisiana to ensure that Live Oak Health Center residents have the right to be free from abuse as per S483.13 of the Long Term Care Survey. It is the responsibility of Live Oak Health Center employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown origin, and theft or misappropriation of resident property to facility management.PROCEDURE: When an alleged case of mistreatment, neglect, injuries of unknown origin, or abuse is reported, the Health Center Administrator, or his/her designee shall adhere to the Department of Health's protocol for reporting such incidents.

Based on record review and interviews, the facility failed to implement the plan of care to meet the needs of 1 (#90) of 29 sampled residents. The facility failed to administer Resident #90's final dose of a diuretic regimen and order imaging for Resident #90 in a timely manner. Findings:Review of Resident #90's medical record revealed an admission date of 05/06/2024 with diagnoses including in part, Alzheimer's disease, hypertension and anxiety disorder. Review of Resident #90's physician orders revealed in part: 06/04/2026 Chest x-ray (Due: 06/04/2026) due to edema 06/04/2026 Lasix 20 mg give 1 po now then give 40 mg po x 3 days Review of Resident #90's June 2026 MAR failed to reveal Resident #90 received the final Lasix 40 mg dose of the ordered 3 day diuretic regimen on 06/08/2026. Review of Resident #90's medical record failed to reveal a 06/04/2026 chest x-ray result. Further review of Resident #90's medical record revealed a chest x-ray dated 06/09/2026 with an impression of a large left-sided pleural effusion with overlying atelectasis versus consolidation. Review of Resident #90's progress notes revealed a nurse's note dated 06/10/2026 at 9:49 a.m. which read in part, Resident #90 was sent out to a local ER for evaluation of large left pleural effusion and SOB. During an interview on 07/28/2026 at 3:00 p.m., S2Unit Manager, reported imaging had not been notified of Resident #90's chest x-ray order on 06/04/2026 until 06/09/2026. S2Unit Manager, acknowledged Resident #90 had not received the final dose of the 3 day diuretic regimen as ordered and had not received a chest x-ray in a timely manner. During an interview on 07/28/2026 at 3:05 p.m., S1DON acknowledged Resident #90 had not received the chest x-ray in a timely manner and had not received the 3rd dose of Lasix 40 mg as ordered.

Based on record review and interview, the facility failed to ensure 1 (#56) out of 5 residents reviewed for unnecessary medications completed a consent for a psychotropic medication.Findings:Review of Resident #56's medical record revealed an admit date of 08/11/2025 with the following diagnoses, including in part: vascular dementia unspecified severity without behaviors/psych/mood/anxiety, pseudobulbar affect, and depression unspecified.Review of Resident #56's physician orders revealed an order dated 08/25/2025 for Zoloft tablet 25 mg give 1 by mouth daily for depression.Review of Resident #56's medical record failed to reveal a psychotropic consent for Zoloft.During an interview on 07/28/2026 at 2:35 p.m. S2 Unit Manager acknowledged Resident #56 did not have a consent for Zoloft.

Based on observation and interview the facility failed to ensure a controlled medication record was maintained and reconciled for 1 of 3 narcotic records reviewed on Medication Cart B. The facility failed to maintain an accurate Phenobarbital count for Resident #58. Findings:Observation of the facility's Medication Cart B on 07/29/2026 at 3:40 p.m. with S3LPN revealed the medication card for Resident #58's Phenobarbital 64.8mg revealed 9 tablets remaining. Further review of the facility's Medication Cart B narcotics binder revealed Resident #58's Phenobarbital 64.8mg narcotic log sheet with a count balance of 10 tablets.During an interview on 07/29/2026 at 3:45 p.m. S3LPN acknowledged Resident #58's Phenobarbital count was incorrect. S3LPN reported she did not sign out Resident #58's Phenobarbital 64.8mg tablet when she administered it and should have. S3LPN stated narcotics should be signed out at the time it was administered. Review of the facility's narcotic administration policy dated 05/19/2011 revealed the following in part:PURPOSE: It is the policy of the facility's nursing staff to be accountable for the ordering, storage and administration of resident medications. This includes an accurate account of each medication received, given and administered. Narcotics must be inventoried at every change of shift.

Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#61) of 5 (#29, #33, #43, #61 and #63) residents reviewed for unnecessary medications. The facility failed to ensure Resident #61's PRN order for psychotropic medication was limited to 14 days. Findings: Review of Resident #61's medical record revealed an admit date of 03/29/2022 with diagnoses of but not limited to chronic kidney disease and dementia. Review of Resident #61's June 2025 physician's orders revealed an order for Atarax/Hydroxyzine 25mg (milligrams) give one tablet three times a day PRN for anxiety for one year. Review of Resident #61's June 2025 MAR (Medication Administration Record) revealed documentation that Resident #61 was administered Atarax/Hydroxyzine 25mg twice for anxiety. During an interview on 06/24/2025 at 1:30 p.m. S2 LPN (Licensed Practical Nurse) confirmed Resident #61 was prescribed Atarax/Hydroxyzine 25mg PRN for anxiety ordered for 1 year. During a phone interview on 06/25/2025 at 10:45 a.m. S5 NP (Nurse Practitioner) confirmed there was not a rationale for ordering Resident #61's PRN Atarax/Hydroxyzine 25mg for 1 year and confirmed it should have been ordered with a 14 day limit.

Based on record review and interviews, the facility failed to ensure narcotic records were maintained and reconciled for 1 (Cart A) of 3 (Cart A, Cart B, Cart C) medication carts reviewed. This had the potential to affect any of the 11 residents receiving narcotics from Cart A. Findings: Review of the facility's Medication Narcotic Count policy dated 04/11/2011 revealed in part: Procedure: III. Each nurse who is going off duty, along with the nurse that is coming on duty, counts the narcotics together. Each nurse signs the form Narcotic Control Record validating that these two (2) nurses counted all narcotics inside the narcotic drawer of the medication cart and that these drugs were reconciled with the individual Resident Narcotic Records stating the amount of drugs that are inside the narcotic drawer. Cart A: Review of medication Cart A's Narcotic Control Record on 06/23/2025 at 10:45 a.m. revealed 2 nurses had not signed validating all narcotics inside the narcotic drawer had been counted and reconciled with the individual resident narcotic records each shift as required. Further review of the Narcotic Control Record logs for Cart A from 01/01/2025 to 06/23/2025 revealed: 4 missing signatures for January 2025 narcotic count, 7 missing signatures for February 2025, 9 missing signatures for March 2025, 13 missing signatures for April 2025, 14 missing signatures for May 2025, and 9 missing signatures for June 2025. During an interview on 06/23/2025 at 10:45 a.m., S3 LPN (Licensed Practical Nurse) confirmed the Narcotic Control Records for Cart A's narcotic reconciliation were not fully completed and should have been. During an interview on 06/24/2025 at 10:30 p.m., S1 Director of Nursing verified the Narcotic Control Records for Cart A's narcotic reconciliation were not completed as required and should have been.

Based on record review, observations, and interviews, the facility failed to ensure residents who required respiratory care received the care and services consistent with professional standards by failing to properly store CPAP (Continuous Positive Airway Pressure) face device for 1 (#29) of 1 (#29) residents reviewed for respiratory care. Findings: Review of resident #29's medical diagnoses revealed in part: Obstructive sleep apnea, chronic respiratory failure with hypercapnia, dependence on other enabling machines and devices. Review of resident #29's current Physicians orders revealed the following: Check CPAP every shift to make sure filled with distilled water at all times. Assist resident with CPAP machine: on at HS (bedtime) and off AM (morning) Diagnosis: sleep apnea. Review of resident #29's Care Plans revealed the following: I'm at risk for altered oxygen exchange related to diagnosis of sleep apnea with appropriate approaches like elevate head of bed and assist resident with CPAP machine setting on 7, put on at 8 pm and off at 8 am as well as outcomes. Review of Minimum Data Set, dated [DATE] revealed the following: BIMS (Brief Interview for Mental Status) score: 11 (moderately impaired) Section I Active Diagnosis: medically complex Obstructive sleep apnea Section O Special Treatments, Procedures, and Programs G1 Non-invasive Mechanical Ventilator -yes- G3 - CPAP During observations on 06/23/2025 at 9:00 a.m., 12:30 p.m., 2:25 p.m., and 06/24/2025 at 7:35 a.m. resident #29's CPAP head gear was sitting on top of a small refrigerator next to her bed. The head gear was not in any type of bag or container. During an interview on 06/24/2025 at 7:40 a.m., S4 LPN (Licensed Practical Nurse) acknowledged that resident #29's CPAP headgear should have been stored in a bag and not just left on top of the refrigerator. During an interview on 06/24/2025 at 9:50 a.m., S1 DON (Director of Nursing) acknowledged that resident #29's CPAP head gear should have been stored in a bag when not in use.

Based on record reviews and interview the facility failed to ensure the resident's representative was notified of a resident's change in health condition for 2 residents (#2, #4) out of 4 residents records reviewed. The facility failed to notify Resident #2 and Resident #4's representatives of acquired pressure injuries. Findings: Review of the facility policy titled Change in a Resident's Condition or Status dated 06/13/2016 included: -Purpose: It is the policy of ______ that ______ shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). -Procedure: 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; . 3. Unless otherwise instructed by the resident, the Staff Nurse will notify the resident's family or representative (sponsor) when: b. There is a significant change in the resident's physical, mental, or psychosocial status; . 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition of status 5. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident/responsible party or representative of any changes in his/her medical care or nursing treatments 6. The Staff Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of Resident #2's record revealed Resident #2 acquired an unstageable pressure injury to his left ischium and a stage 3 pressure injury to his right gluteal fold on 05/18/2024, a deep tissue injury to his scrotum and an arterial ulcer to his left outer ankle on 05/29/2024, and an unstageable pressure injury to his right heel on 06/03/2024. Further review of Resident #2's record failed to reveal Resident #2's representative was notified of Resident #2's acquired pressure injuries. Review of Resident #4's record revealed Resident #4 acquired a stage 2 pressure injury to her left inner ankle on 05/03/2024 and a stage 2 pressure injury to her left inner foot on 06/03/2024. Further review of Resident #2's record failed to reveal Resident #4's representative was notified of Resident #4's acquired pressure injuries. During an interview on 07/16/2024 at 10:14 a.m. S1 Director of Nursing reviewed Resident #2 and Resident #4's records and acknowledged there was no documentation that the resident's representatives were notified of the resident's acquired pressure injuries.

Based on record reviews and interviews, the facility failed to ensure dietary services were provided in a safe, sanitary environment to prevent contamination and food borne illness for 98 residents served a meal tray from the kitchen as reported by S5 Assistant Dietary Manager. The facility failed to label frozen uncooked chicken out of its original package in the walk in freezer and failed to clean the meat slicer after each use. Findings: Observations during the initial tour of kitchen with S5 Assistant Dietary Manager on 05/20/2024 at 8:00 A.M. revealed a large unlabeled and undated rectangular silver pan containing frozen uncooked chicken in the walk in freezer and dried debris to bottom of covered meat slicer. During an interview on 05/20/2024 at 8:00 A.M. S5 Assistant Dietary Manager confirmed the frozen uncooked chicken should have been labeled and dated. S5 Assistant Dietary Manager reported the meat slicer should have been cleaned after each use. During an interview on 05/20/2024 at 11:50 A.M. S5 Assistant Dietary Manager confirmed 98 trays were served for breakfast.

Based on record reviews and an interview, the facility failed to ensure 4 out of 4 glucometers reviewed were maintained in safe operating condition for 11 (#41, #12, #29, #69, #5, #87, #7, #46, #64, #302, #75) residents residing in the facility with orders for glucose monitoring. S3 LPN (Licensed Practical Nurse) Unit Manager provided a list of 11 (#41, #12, #29, #69, #5, #87, #7, #46, #64, #302, #75) residents who resided on Hall A, Hall B, Hall C, and Hall D that received glucometer checks. Findings: Review of facility's Obtaining A Fingerstick Glucose Level policy dated 11/6/2017 revealed in part: Purpose: It is the policy of _________ to obtain a blood sample to determine the resident's blood glucose level. Procedure: Ensure that equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility. Review of facility's glucometer control logs for January 1, 2024 through May 21, 2024 with S3 LPN (Licensed Practical Nurse) Unit Manager revealed glucometer checks were not done on the following dates: Hall A's: January 2024: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 25, 28, 30, 31 February 2024: 2, 3, 4, 5, 7, 8, 10. 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 26, 29 March 2024: 3, 6, 7, 11, 12, 13, 16, 17, 18, 19, 26, 27, 28 April 2024: 1, 2, 4, 9, 10, 12, 13, 14, 15, 17, 18, 19, 20, 23, 24, 28, 29 May 2024: 1, 2, 4, 5, 6, 7, 8, 11, 12, 13, 16, 17 Hall B's: January 2024: unable to provide documentation that glucometer checks were done for the entire month of January 2024. February 2024: unable to provide documentation that glucometer checks were don for the entire month of February 2024. March 2024: 2, 7, 13, 25 April 2024: 3, 8, 9, 10, 16, 17 May 2024: 1, 2, 8, 9, 10, 11, 16 Hall C's: January 2024: 1, 2, 6, 18, 19, 20, 21, 22, 25, 26, 30 February 2024: 2, 4, 6, 7, 8, 10, 12, 15, 16, 18, 19, 21, 25, 26, 27 March 2024: 3, 5, 6, 10, 11, 12, 14, 15, 16, 17, 18, 19 April 2024: 1, 3, 5, 9, 14, 16, 26, 29, 30 May 2024: 1, 15, 17, 18 Hall D's: January 2024: 2, 3 February 2024: 3, 4, 5, 12, 15, 16, 21, 25 March 2024: 1, 5, 18, 19 During an interview on 05/22/2024 at 1:10 p.m. S3 LPN (Licensed Practical Nurse) Unit Manager reported glucometer checks should be done daily by the floor nurse on the overnight shift, and further acknowledged glucometer checks were not done.

Based on record reviews and interview, the faciltiy failed to ensure reportable incidents were reported to the State Survey and Certification Agency for 1 (#86) of 2 (#86, #91) residents reviewed for accidents. The facility failed to report an elopement for Resident #86. Findings: Review of Resident #86's medical records revealed an admitted [DATE] with the following diagnoses, in part: difficulty in walking/not elsewhere classified, age-related physical debility, Alzheimer's disease/unspecified, muscle weakness (generalized) and cognitive communication deficit. Review of Resident #86's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) 03 indicating severely impaired cognition. Review of Resident #86's Incident Tracking revealed an incident dated 04/16/2024 at 3:47 p.m. - elopement - front of building - nurse was notified by ward clerk on west wing that resident was outside of the front of the facility, walking around the parking lot - assessed resident and notified family and MD (Medical Director) - no injury. Quality indicators: baseline cognition - name YES, other - confused/disoriented. Review of Facility's SIMS (Statewide Incident Managment System) Reports failed to reveal a report for Resident #86's elopement on 04/16/2024. During an interview on 05/22/2024 at 9:40 a.m., S1 Director of Nursing acknowledged Resident #86's elopement on 04/16/2024 was not reported to the State Survey and Certification Agency.

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#86) of 2 (#86, #91) sampled residents reviewed for accidents. The facility failed to ensure a plan of care for elopement had beed developed and implemented for Resident #86 who had a history of elopement. Findings: Review of Facility's Wandering, Unsafe Resident Policy and Procedure (10/17/2017) revealed: - Purpose: will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. - Procedure: .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Review of Resident #86's medical records revealed an admitted [DATE] with the following diagnoses, in part: difficulty in walking/not elsewhere, age-related physical debility, Alzheimer's disease/unspecified, muscle weakness (generalized), unspecified non-displaced fracture of second cervical vertebra and cognitive communication deficit. Review of Resident #86's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) 03 indicating severely impaired cognition. Review of Resident's Comprehensive Care Plan revealed the following and approaches: - At risk for altered thought processes - staff will assist resident to make simple decision, reality orientation prn (as needed). - At high risk for falls/injury r/t (related to) impaired mobility/unsteady gait/history of falls -04/16/2024 elopement - notified by front desk that was outside the front of the facility walking; No injuries noted. Instructed to notify nurse before going outside alone - voiced understanding. Front desk notified she cannot leave facility without assistance of family or staff. Further review failed to reveal approaches for wandering/elopement. Further review of care plan failed to reveal interventions to prevent elopement. Review of Resident #86's Incident Tracking revealed an incident dated 04/16/2024 at 3:47 p.m. - elopement - front of building - nurse was notified by ward clerk on west wing that resident was outside of the front of the facility, walking around the parking lot. During an interview on 05/22/2024 at 8:40 a.m. S2 MDS Nurse acknowledged the only interventions on Resident #86's care plan for elopement was telling the resident to notify the nurse when she goes outside and notifying the front desk she is not to go outside without staff or family. During an interview on 05/22/2024 at 9:40 a.m. S1 Director of Nursing acknowledged the only interventions on Resident #86's care plan for elopement was telling the resident to notify the nurse when she goes outside and notifying the front desk she is not to go outside without staff or family.

Based on personnel record reviews and interview, the facility failed to ensure an annual performance review was completed for 1 [S7 Certified Nurse Assistant (CNA)] out of 5 CNA personnel records reviewed. Findings: Review of S7 CNA's personnel record revealed S7 CNA worked for the facility through an agency and had done so since 12/15/2020. Further review of S7 CNA's personnel record failed to reveal documentation of annual performance reviews. During an interview on 05/22/2024 S1 Director of Nursing reviewed S7 CNA's personnel record and acknowledged there was no documentation of annual performance reviews.

Based on personnel record reviews and interview, the facility failed to provide at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired for 1 [S7 Certified Nurse Assistant (CNA)] out of 5 CNA personnel records reviewed. Findings: Review of S7 CNA's personnel record revealed S7 CNA worked for the facility through an agency and had done so since 12/15/2020. Further review of S7 CNA's personnel record failed to reveal documentation of at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired. During an interview on 05/22/2024 S1 Director of Nursing reviewed S7 CNA's personnel record and acknowledged there was no documentation of at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired.

Based on record review and interviews, the facility failed to ensure residents' medical records reflected the resident's advance directive wishes for 1 (#82) of 32 residents reviewed for advance directives in the initial pool. The facility failed to ensure Resident #82's medical record was consistent with the resident's wishes for DNR (Do Not Resuscitate). Findings: Review of the facility's Advance Directive policy dated [DATE] revealed in part: Purpose: It is the policy of __________ that advance directives will be respected in accordance with state law and facility policy. Procedure: 1. Upon admission of a resident to our facility, the social services director or designee will provide written information to the resident concerning his/ her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Review of face sheet revealed Resident #82 was initially admitted to the facility on [DATE] with a current admitted [DATE]. Further review of Resident #82's face sheet revealed full code. Resuscitate: yes. Review of Resident #82's Medical Record (paper chart) revealed: STOP DO Not Resuscitate signed on [DATE]. No code order Certification Statement Form: Do not use a feeding tube, respirator or resuscitation, signed by responsible party on [DATE] and physician signed on [DATE] and [DATE]. Review of Resident #82's care plan revealed I am a full code and I do wish for CPR (cardiopulmonary resuscitation) to be performed with approaches for CPR to be provided to resident as per consent. During an interview on [DATE] at 12:00 p.m. S3 LPN (Licensed Practical Nurse) Unit Manager reported she would check the residents' medical chart in the advance directive tab to determine code status. S3 LPN Unit Manager reviewed Resident #82's medical record (paper chart) and reported the face sheet, facility's code status sheet and No Code order Certification Statement form should all match and confirmed Resident #82's code status did not match throughout the medical record. During an interview on [DATE] at 12:15 p.m. S1 DON (Director of Nursing) reported S4 Social Services Director (SSD) should ensure resident code status/advance directive wishes matched. During an interview on [DATE] at 2:30 p.m. S4 SSD reported Resident #82 was a full code upon admit until the resident and family completed the admission agreement. S4 SSD reported after completing the admission agreement the family chose for Resident #82 to be a DNR. S4 SSD confirmed Resident #82's code status was not updated when family made decision to make Resident #82 a DNR. S4 SSD reported when Resident #82's code status changed, the system should have been updated to reflect Resident #82's DNR status and a new face sheet should have been printed and placed on the chart.

Based on record review and interviews the facility failed to ensure an injury of unknown origin was reported to the State Survey Agency for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of facility's policy named Abuse Prevention Program and Abuse reporting for Health Center Residents, revised on 04/23/2018 revealed, in part: It is the policy of (the owner) to ensure that (facility) residents have the right to be free from abuse as per S483,13 of the Long Term Care Survey. It is the responsibility of (facility) employees, facility, consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries unknown origin, and theft or misappropriation of resident property to facility management. PROCEDURE . VI. When an alleged case of mistreatment, neglect, injuries of unknown origin, or abuse is reported, the Health Center Administrator, or his/her designee shall adhere to the Department of Health's protocol for reporting such incidents. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included, in part, displaced intertrochanteric fracture right femur, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, unspecified pain, difficulty in walking and dysphagia. Further review of Resident #2's medical record revealed a discharge date of [DATE]. Review of Resident #2's 11/12/2022 at 3:58 p.m. Nurse Note revealed: 1500-CNA (certified nursing assistant) notified writer that resident has a bruise to the back of her left knee. Resident had been c/o (complaining of) pain all day. 1530-Mobile x-ray contacted to perform x-ray to left femur, knee and tib/fib (tibia/fibula). RP (responsible party) notified. Review of NP (Nurse Practitioner) progress note with 11/14/2022 date of service revealed: History of Present Illness: Knee pain: Resident with new onset complaint of pain to bilateral knees X 2 days. Pain alleviated with rest, aggravated with activity . Reports increased left knee pain noted 11/12/2022 after transferring from wheelchair to bed. No falls reported. 11/12/2022 left femur, knee, tib-fib x-ray obtained revealing curvilinear lucency superimposed over the left hip, left total knee is anatomic, no fracture or dislocation left lower leg. Review of Resident #2's medical record revealed the following nursing note: 11/17/2022 at 11:58 - Resident had MD (Medical Doctor) appointment with Dr. _____ Orthopedic. Results were MCL (medial collateral ligament) tear with Grade 2 of left knee. MD prescribed immobilizer to left knee at all times only off for bathing . Needs follow-up appointment in 10 days to 2 weeks . Review of Resident #2's medical record revealed a signed physician order noted on 11/17/2022 that indicated patient complaint of left knee pain after transfer chair to bed.Clinically has a femoral attachment MCL tear with Grade 2. Would place in knee immobilizer and should stay in place except for bathing.Plan: Return to clinic 10 days - 2 weeks for repeat x-rays. Review of SIMs (Statewide Incident Management System) Logs for the last year failed to reveal Resident #2's Left MCL tear with Grade 2 injury of unknown origin had been reported. During an interview on 09/11/2023 at 10:45 a.m. S2 DON (Director of Nursing) reviewed SIMs report binder and reported she did not see where a SIMs report had been filed in regard to Resident #2's left MCL tear injury. During an interview on 09/12/2023 at 12:20 p.m. S1 Administrator confirmed Resident #2's newly diagnosed MCL tear was an injury of unknown origin and reported he was not aware if a SIMs report had been filed in regard to the injury. S1 Administrator further confirmed if S2 DON had reported there was not a SIMs report for the injury, then one had not been done and should have been.

Based on record review and interviews the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (# 2) of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of Policy Health Center Accidents and Incidents-Investigation and reporting dated 08/17/2017 and approved on 01/29/18 revealed, in part: Purpose: It is the policy of the (owner) that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring at the (facility) shall be investigated and reported to the Administrator. PROCEDURE: 1. The Nurse Supervisor/Floor Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a) The date and time the accident or incident took place; b) The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c) The circumstances surrounding the accident or incident; d) Where the accident or incident took place; e) The name(s) of witnesses and their accounts of the accident or incident; f) The injured person's account of the accident or incident if capable; g) The time the injured person's Attending Physician was notified; h) The date/time the injured person's family was notified and by whom; i) The condition of the injured person, including his/her vital signs; j) The disposition of the injured (i.e. transferred to hospital, put to bed, sent home, returned to work, etc.); k) Follow-up information; l) Other pertinent data as necessary or required; and m) The signature and title of the person completing the report. 3. The Nurse Supervisor/Floor Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services. 4. The Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included, in part, displaced intertrochanteric fracture right femur, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, unspecified pain, difficulty in walking and dysphagia. Further review of Resident #2's medical record revealed a discharge date of [DATE]. Review of Resident #2's 11/12/2022 at 3:58 p.m. Nurse Note revealed: 1500-CNA (certified nursing assistant) notified writer that resident has a bruise to the back of her left knee. Resident had been c/o (complaining of) pain all day. 1530-Mobile x-ray contacted to perform x-ray to left femur, knee and tib/fib (tibia/fibula). RP (responsible party) notified. Review of NP (Nurse Practitioner) progress note with 11/14/2022 date of service revealed: History of Present Illness: Knee pain: Resident with new onset complaint of pain to bilateral knees X 2 days. Pain alleviated with rest, aggravated with activity . Reports increased left knee pain noted 11/12/2022 after transferring from wheelchair to bed. No falls reported. 11/12/2022 left femur, knee, tib-fib x-ray obtained revealing curvilinear lucency superimposed over the left hip, left total knee is anatomic, no fracture or dislocation left lower leg. Review of Resident #2's 11/12/2022 incident report revealed: Incident Date/time: 11/12/2022 / 15:00 Location: 300 hall Description of Incident: CNA reported bruising to the back of leg while doing patient care. Resident's Description: Resident #2 stated she was treated roughly by CNAs last night and reports pain to left leg. Staff actions at the time of the Incident was blank. Review Staff Signatures: S1 Administrator on 01/24/2023 at 15:49 and S2 DON (Director of Nursing) on 06/01/2023 at 15:24. Investigation/Follow-Up Incident Investigation Note on 11/25/2022 at 16:58 entered by S3 LPN (Licensed Practical Nurse) revealed bruising and pain reported. Assessment done no bruising noted. X-rays completed-no findings noted. Second x-ray completed still no findings noted. Resident to be seen by orthopedic doctor in a few days due to constant complaint of pain previous and now. Further review of the 11/12/2022 Incident Report failed to reveal statements had been taken from Resident #2 or the CNAs involved in the incident. During an interview on 09/11/2023 at 10:45 a.m. S2 DON reported any interviews conducted for Resident #2's 11/12/2022 incident would have been included with the 11/12/2022 incident report and S3 LPN would have completed the investigation for Resident #2's 11/12/2022 incident. During an interview on 09/11/2023 at 4:05 p.m. S3 LPN confirmed statements were not obtained from Resident #2 or the 2 CNAs involved in the incident dated 11/12/2022 and statements should have been obtained. During an interview on 9/12/2023 at 10:50 a.m. S2 DON confirmed the 11/12/2022 incident should have been reported to administration and a more thorough investigation should have been conducted. During an interview on 09/12/2023 at 12:20 p.m. S1 Administrator indicated he had not been made aware of the 11/12/2022 incident with Resident #2 and did not obtain statements from Resident #2 or staff involved regarding the incident and statements should have been obtained.

Based on record review and interviews the facility failed to ensure an injury of unknown origin was thoroughly investigated for 1 (#336) out of 3 (#38, 336, #13) residents reviewed for accidents. Findings: Review of Resident #336's medical record revealed diagnoses of, but not limited to displaced bimalleol fracture low leg, closed fracture with routine healing, unspecified fracture shaft of left tibia, unspecified fracture shaft of left fibula, weakness, bed confinement status, unspecified dementia without behavioral disturbances. Review of MDS (Minimum data sets) dated 3/9/2023 revealed a BIMS (Brief Interview of Mental Status) of 99 with being severely impaired-never/rarely made decisions. Review of Incident dated 3/26/2023 at 10:45 AM: @ 10:45 Upon CNA (Certified Nurse Assistant) rounding CNA notified writer after pericare at 11:05 to come assess resident lower left limb. Writer assessed noticed left foot had a potential injury and notified ADON (Assistant Director of Nurses) @ 11:07 RN (Registered Nurse) shift supervisor. @11:35 ADON notified NP (Nurse Practitioner) of potential injury to left lower limb @ 11:45 911 called @11:50 EMS (Emergency Medical Service) arrived @12:00 EMS transported patient to local hospital RP (responsible party) [NAME] called; no answer @ 2nd RP. No number available 3rd RP called; He is aware verbalized understanding @ 12:46 1st RP called back she is aware of current situation and verbalized understanding DON (Director of Nursing) aware. Staff actions at time of incident: at the time of potential injury staff assessed resident head to toe and placed resident in a comfortable position until EMS arrived. During an interview on 4/11/2023 at 1:00 p.m. Resident # 336's RP reported about 2 weeks on Sunday, March 26, 2023 she was notified Resident #336 had a left tibia fibula fracture in the facility. Resident #336's RP reported she was unsure how the left tibia/ fibula fracture occurred. Resident #336's RP further reported the orthopedic surgeon indicated with Resident #336's bones not being good he was unable to tell how the fracture occurred. Resident #336's RP reported she has not been able to get any answers of how Resident #336's left leg was fractured. Resident #336's RP further reported she requested details from the staff about how the fracture occurred and the only response she received was the CNA came in to get Resident #336 ready for breakfast and saw her foot was deformed and the nurse called 911. During a telephone interview on 4/11/2023 at 2:00 p.m. Resident #336's RP reported she had a meeting with S20 Administrator and S18 Unit Manager on Wednesday or Thursday after Resident #336's left leg fracture occurred. Resident #336's RP reported S20 Administrator and S18 Unit Manager did not have any information about the incident at the time. Resident #336's RP reported S20 Administrator informed her protocol was followed and an investigation was opened on Monday, March 27, 2023. During an interview on 4/11/2023 at 1:45 p.m. S2 ADON (Assistant Director of Nursing) reported she asked staff to write statements and these were the only two written statements from the 11PM CNA and 7AM CNA S2 DON reported staff were interviewed but did not have any documentation of their statements. During an interview on 4/11/2023 at 1:50 p.m. S20 Administrator, S1 DON, and S2 ADON reported no one witnessed the actual incident and camera footage was not reviewed. During an interview on 4/11/2023 at 2:00 p.m. S1 DON reported the investigative process is a collective effort with the supervisors. S1 DON reported S2 ADON was working on the day of the incident and started the investigation and S1 DON confirmed she completed the investigation.

Based on record reviews and interviews the facility failed to ensure 1(#336) out of 3 (#38, #336, #13) residents reviewed for accidents received care and treatment in accordance with professional standards of practice and by following Resident #336's comprehensive care plan. Findings: Review of Resident #336's medical record revealed diagnoses of but not limited to displaced bimalleol fracture low leg, closed fracture with routine healing, unspecified fracture shaft of left tibia, unspecified fracture shaft of left fibula, weakness, bed confinement status, unspecified dementia without behavioral disturbances Review of MDS (Minimum Data Sets) dated of 3/09/2023 revealed a BIMS (Brief Interview of Mental Status) of 99 with being severely impaired-never/rarely made decisions. Review of Functional Status revealed Resident #336 had impairment on both sides with range of motion with upper and lower extremities Review of Resident #336's Comprehensive Care Plan revealed the following problems and approaches dated 3/26/2023: Fall sent to local hospital left lower tibia/fibula ankle fracture, returned the same day with splint/ace bandage with approaches including splint and ace bandage to left lower extremity, follow up appointment next day, Ortho: increase monitoring to more than once every 2 hours. Review of Resident #336 March 2023 Electronic Health Record and Medical Record including Interdisciplinary notes from March 27, 2023 through April 5, 2023 failed to reveal assessment and monitoring of Resident #336 of ace and bandage to left lower extremity. Review of Resident #336 emergency room discharge note dated 3/26/2023 revealed a follow up care appointment the next business day with an orthopedic physician. During an interview on 4/11/2023 at 1:00 p.m. Resident # 336's RP (responsible party) reported about 2 weeks on a Sunday Resident #336 went to the emergency room for left tibia/fibula fracture that was set with a cast/splint in the emergency room and was discharged back to facility on the same evening. Resident #336 was to be referred to an orthopedic physician the next business day. Resident #336's RP reported the orthopedic physician denied Resident #336 referral and Resident #336 was then referred to a second orthopedic physician which also denied her referral. Resident #336's RP reported the following Monday, April 4, 2023 a third orthopedic physician agreed to evaluate her. Resident #336 reported she attended the third orthopedic appointment with Resident #336 and when the third orthopedic physician removed Resident #336's cast, findings included a 35 degree angle break across the ankle in the same place, breakdown in skin behind knee, and a wound on top of foot. Resident #336 RP reported the third orthopedic physican gave them options (1) to set and bandage tibia/fibula fracture, (2) place a pin from knee down and bandage, (3) amputate and will not have to continue care and questionable treatment. Resident #336's RP reported Resident #336 remained in the facility until having a left above the knee amputation on 4/05/2023. During an interview on 4/11/2023 at 3:30 p.m. S16 LPN (Licensed Practical Nurse) reported proving care for Resident #336 while she had a splint/cast to her left lower extremity. S16 LPN reported while Resident #336 was in splint/cast ongoing monitoring of pedal pulses, foot discoloration was done but there was not a special form to complete and she did not document her findings in Resident #336's medical record. During an interview on 4/12/2023 at 7:55 a.m. S17 LPN reported she provided care for Resident #336 on April 3, 2023 while she had a splint/cast in place. S17 LPN reported she did not assess Resident #336's left lower extremity in a splint/cast. S17 LPN reported she only charts on skilled residents and maybe S18 Unit Manager handled that. During an interview on 4/12/2023 at 8:40 a.m. S18 Unit Manager reported Resident #336 was sent out to the emergency roiagnom on Sunday 3/26/2023 and returned that evening around 6:55 p.m. with a splint/cast in place to left leg. S18 Unit Manager confirmed Resident #336 went out for surgery with the third orthopedic physician on 4/05/2023 and returned to facility on 4/10/2023. During this time, S18 Unit Manager reported she did not assess Resident #336's pulses as the splint/cast was wrapped covering her feet and could only observe the toes and above the knee. During an interview on 4/12/2023 at 11:10 a.m. S13 Nurse Practitioner reviewed progress notes dated 3/27/2023 and reported observing Resident #336 one time since she returned to the facility from the emergency room visit on 3/26/2023. S13 Nurse Practitioner reviewed progress notes from 3/27/2023 and reported Resident #336 had a splint in place to stabilize the fracture when she returned from the emergency room and only her toes were visible from underneath the splint. S13 Nurse Practitioner reported Resident #336 went out for surgery on 4/05/2023 for left above the knee amputation and returned to the facility on [DATE]. During a telephone interview on 4/12/2023 at 2:56 p.m. S15 Medical Director did not recall being notified regarding a delay in referral appointment for Resident #336 to Orthopedic. S15 Medical Director reported the facility is not always required to notify him they can notify the nurse practitioner that is in the building. S15 Medical Director reported the nurse practitioner was in the facility on 3/27/2023 and assessed Resident #336. S15 Medical Director reported in a case where a dressing is in place for stabilization he would not remove the dressing but Resident #336 should have been monitored for capillary refill. During an interview on 4/12/2023 at 3:40 p.m. S19 Evening Shift Supervisor reported while Resident #336's left lower extremity was placed in a splint, assessment should have been completed daily for capillary refill, touch the toes, and make sure splint dressing is not too tight or constricting blood flow. S19 Evening Shift Supervisor reported there is no flow sheet to chart this assessment but monitoring for Resident #336 in cast/splint but should have been documented in the interdisciplinary notes. During an interview on 4/12/2023 at 4:00 p.m. S1 DON (Director of Nursing) comfirmed an intervention for increase in monitoring to more than once every two hours for Resident #336 was added to the care plan after placement of splint/ ace bandage to left lower extremity. S1 DON reviewed Resdient #336's medical record and confirmed there was no documentation of increase monitoring. .

Based on interviews and record reviews, the facility failed to have a process in place to ensure residents were free from significant medication errors for 1 sampled resident (Resident #22) of 5 (Resident #13, Resident #22, Resident #30, Resident #57, and Resident #79) sampled residents with physician orders for antibiotics. Findings: Review of Resident #22's nurse's note dated 04/10/2023 revealed, in part, an order was received for Zyvox (an antibiotic used to treat skin infections) 600 milligrams (mg) two times a day for 10 days due to culture of right toe pressure ulcer that was positive for pseudomonas aeruginosa and enterococcus faecalis (two different types of bacteria). Review of Resident #22's April 2023 physician orders revealed, in part, an order dated 04/10/2023 for Zyvox 600 mg two times a day for 10 days. Review of Resident #22's April 2023 electronic medication administration record (eMAR) revealed, in part, Zyvox 600 mg two times a day for 10 days was not given for the 9:00 p.m. doses on 04/10/2022 and 04/11/2022. In an interview on 04/12/2023 at 2:54 p.m., S11 LPN (Licensed Practical Nurse) stated Resident #22 was not on Zyvox 600 mg two times a day for 10 days, and that she could not produce a medication card for Resident #22's Zyvox 600 mg two times a day for 10 days. S11 LPN reviewed Resident #22's physician orders, and agreed Resident #22 had an order for Zyvox 600 mg two times a day for 10 days. S11 LPN further indicated Resident #22's Zyvox was not given due to there being no medication card to give Zyvox 600 mg two times a day for 10 days. S11 LPN further agreed she should not have documented that the 9:00 a.m. dose of Zyvox 600 mg was given on 04/12/2023. Review of facility's Consolidated Delivery Sheets from the pharmacy dated 04/10/2023 revealed, in part, no documentation that Zyvox 600 mg was delivered to facility. In an interview on 04/12/2023 at 3:00 p.m., S12 Unit Manager stated Resident #22's Zyvox 600 mg two times a day for 10 days was not sent to the facility by pharmacy due to needing a prior authorization. S12 Unit Manager further stated Resident #22 did not receive a dose of Zyvox 600 mg for the 9:00 a.m. administration time on 04/10/2023, 04/11/2023, or 04/12/2023, and Resident #22 did not received a dose of Zyvox 600 mg for the 9:00 p.m. administration time on 04/10/2023 and 04/11/2023. S12 Unit Manager stated Resident #22 had not received any doses of Zyvox 600 mg since it was ordered on 04/10/2023 because the facility did not have Resident #22's Zyvox 600 mg. In an interview on 04/12/2023 at 3:30 p.m., S1 DON (Director of Nursing) stated Resident #22 did not receive a dose of Zyvox 600 mg for the 9:00 a.m. administration time on 04/10/2023, 04/11/2023, or 04/12/2023, and Resident #22 did not received a dose of Zyvox 600 mg for the 9:00 p.m. administration time on 04/10/2023 and 04/11/2023 because the facility did not have Resident #22's Zyvox 600 mg.

Based on observations, interviews, record reviews, and review of the American Burn Association Scald Injury Prevention Educator's Guide, the facility failed to ensure the resident's environment was free of accident hazards for 19 (#30, #59, #27, #60, #58, #81, #53, #57, #3, #39, #45, #35, #91, #9, #117, #84, #14, #10, and #19) residents identified with room water temperatures between 125.5 degrees F (Fahrenheit) and 133 degrees F of 26 (#30, #59, #91, #9, #60, #27, #81, #53, #89, #57, #3, #117, #84, #114, #39, #33, #109, #45, #14, #144, #130, #10, #35, #19, #76, and #58) residents residing on the 200 West Hall out of a total facility census of 113 residents. The facility failed to: 1. Ensure a system was in place to monitor and ensure water temperatures in resident's rooms were maintained at a level to prevent residents from being burned. 2. Ensure resident room water temperatures were monitored after plumbing repairs were made on 11/15/11. The Immediate Jeopardy began on 11/15/11 when repairs were made to the hot water system and hot water temperatures were not monitored. The Immediate Jeopardy continued for the following residents residing on the 200 West Hall: #30, #59, #91, #9, #60, #27, #81, #53, #89, #57, #3, #117, #84, #114, #39, #33, #109, #45, #14, #144, #130, #10, #35, #19, #76, and #58. The facility's Administrator S1 was informed of the Immediate Jeopardy on 2/16/12 at 6:50 p.m. The Immediate Jeopardy was removed on 2/17/12 at 4:00 p.m. when observations and record reviews revealed the following immediate Plan of Removal was implemented: 1. Reduced water temperature immediately. 2. Put monitors in place to ensure temperatures were brought into acceptable range. 3. Contacted plumber, who immediately came to campus, to check equipment and is presently making necessary repairs/replacement to ensure compliance. 4. Building services staff is continuing to monitor during plumbing repairs to ensure water temperatures are within acceptable range and no residents are in harms way. 5. In-serviced building services staff on proper monitoring techniques. After removal of the immediate jeopardy, the following plan will be implemented: 1. Building Services personnel will daily monitor and log temperatures taken at faucet sites in resident rooms on the 200 Hall for 2 weeks including all 20 rooms. If satisfactory results are obtained, 10 rooms will be monitored during the following 2 weeks. Positive outcomes will result in random checks on a weekly basis on the 200 Hall to align with other areas of the facility. 2. During the same 4 week period, random checks at the rate of 2 rooms per day on the 100, 300, and 400 Halls will be monitored and logged. If an improper temperature is detected in any area, the staff member will immediately notify the Building Manager and/or Chief Operating Officer and/or Administrator and the temperature issue will be addressed and corrected. 3. Once it has been determined that water temperatures are being maintained within the acceptable range of 100-120 degrees F, checks will be monitored and logged weekly in random resident care areas. If a problem exists, the same protocol of notification will be initiated and the temperature issue will be resolved. The deficient practice continued at a scope and severity of second level/widespread. Findings: Review of the "American Burn Association Scald Injury Prevention Educator's Guide" revealed the following under Time and Temperature Relationship to Severe Burns: Water Temperature Time for a third degree burn to occur 155 degrees F 1 Seconds 148 degrees F 2 Seconds 140 degrees F 5 Seconds 133 degrees F 15 Seconds 127 degrees F 1 Minute 124 degrees F 3 Minutes 120 degrees F 5 Minutes 100 degrees F Safe temperature for bathing Further review revealed the following under High Risk Groups: 1. Older Adults - Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. 2. People with disabilities or special needs - Individuals who may have physical, mental, or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Sensory impairments can result in decreases sensation, especially to the hands and feet, so the person may not realize if something is "too hot". Changes in a person's intellect, perception, memory, judgment, or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. During environmental tour of the 200 West Hall on 2/16/12 at 3:15 p.m. with S23 Maintenance Assistant revealed resident #30 and #59's room to have sink water temperature of 133 degrees F on the hot water side. Further water temperature checks at that time revealed the following: 1. Resident #27 - 130 degrees F 2. Resident #60 - 130 degrees F 3. Resident #58 - 127.5 degrees F During an interview at that time, S23 Maintenance Assistant agreed with the above findings and stated there must be a problem with the mixer in the attic. S23 Maintenance Assistant further stated a resident on the 100 East Hall was complaining about their water being too cold and a plumber came out and did some work on the system. S23 Maintenance Assistant stated he thought the plumber made some adjustments in the ceiling where the 100 and 200 halls meet. When asked if the facility had any documentation of resident's rooms being checked for water temperatures, S23 Maintenance Assistant stated "no". S23 Maintenance Assistant further stated the only monitoring of water temperatures that are documented is the boiler room in-coming water after circulation through the facility. S23 Maintenance Assistant further stated he was new to some of the monitoring that is being done and recently found out he was recording the wrong temperature on the monitoring sheets. During a follow-up check on 2/16/12 at 4:25 p.m. of resident water temperatures, the following temperatures were observed: 1. Residents #81 and #53 - 129.5 degrees F 2. Residents #57 and #3 - 128 degrees F 3. Resident #39 - 127 degrees F 4. Resident #45 - 126.5 degrees F 5. Resident #35 - 125.5 degrees F 6. Residents #91 and #9 - 132 degrees F 7. Residents #117 and #84 - 128 degrees F 8. Resident #14 - 125.5 degrees F 9. Resident #10 - 125.5 degrees F 10. Resident #19 - 127.5 degrees F Review of the Water Temperatures for the facility boiler room for 12/2011 thru 2/2012 revealed documentation of daily hot water temperatures. Further review of the monitoring sheets revealed water temperatures ranging from 120 degrees F to 140 degrees F in December 2011 and January 2012 and temperatures ranging from 110 degrees F to 119 degrees F beginning 2/9/12. During an interview on 2/16/12 at 5:20 p.m., S4 Chief Operating Officer stated the facility recently experienced a problem with a resident on the 100 West Hall complaining her water was too cold. S4 Chief Operating Officer further stated a plumber was called out and did some work to correct the problem. After contacting the plumber to obtain more information, S4 Chief Operating Officer stated the plumber told him he was there on 11/15/11 for a complaint of water being too cold on the 100 West Wing hall. S4 Chief Operating Officer further stated the plumber reported he replaced the out-going hot water temperature gauge in the boiler room and added an in-coming hot water temperature gauge which was not part of the system before. When asked if the facility has performed any monitoring of the individual room water temperatures since the plumbing changes, S4 Chief Operating Officer stated "I cannot answer that since my building manager is out with a sick family member". S4 Chief Operating Officer further stated the facility has records showing the in-coming water temperatures have been monitored and it would make sense if the temperature is good coming back in to the boiler room, then the room temperatures should also be good. Review of a facility work order dated 11/13/11 revealed a complaint of water not being hot enough on the 100 West Hall. Further review revealed the issue was resolved on 11/18/11. During an interview on 2/17/12 at 4:20 p.m. S5 Building Manager stated since he has been employed at the facility, May of 2011, there has not been any monitoring of water temperatures in resident's rooms. S5 Building Manager further stated some checks were done in the past from what he has heard but the former maintenance man had been at the facility for a number of years and did not keep good records and did not pass along very much information on the facility when he left. When asked if he could show where monitoring of resident room temperatures were performed after the November 2011 repairs were made, S5 Building Manager stated "no". During an interview on 2/17/12 at 10:50 p.m. S1 Administrator stated the facility's administration should have known about the maintenance issues regarding monitoring of water temperatures in resident rooms but did not. Review of the 200 West Hall resident list provided by the facility revealed a total resident census of 26. Further review revealed 10 residents with intact cognition, 2 residents with moderately impaired cognition, and 12 residents with severely impaired cognition.

Based on observations, record reviews, and interviews the facility failed to be administered in a manner that used resources effectively and efficiently for 19 (#30, #59, #27, #60, #58, #81, #53, #57, #3, #39, #45, #35, #91, #9, #117, #84, #14, #10, and #19) residents identified with room water temperatures between 125.5 degrees F (Fahrenheit) and 133 degrees F of 26 (#30, #59, #91, #9, #60, #27, #81, #53, #89, #57, #3, #117, #84, #114, #39, #33, #109, #45, #14, #144, #130, #10, #35, #19, #76, and #58) residents residing on the 200 West Hall out of a total facility census of 113 residents. The Administration failed to: 1. Ensure a system was in place to monitor and ensure water temperatures in resident's rooms were maintained at a level to prevent residents from being burned. 2. Ensure resident room water temperatures were monitored after plumbing repairs were made on 11/15/11. The Immediate Jeopardy began on 11/15/11 when repairs were made to the hot water system and hot water temperatures were not monitored. The Immediate Jeopardy continued for the following residents residing on the 200 West Hall: #30, #59, #91, #9, #60, #27, #81, #53, #89, #57, #3, #117, #84, #114, #39, #33, #109, #45, #14, #144, #130, #10, #35, #19, #76, and #58. The facility's Administrator S1 was informed of the Immediate Jeopardy on 2/16/12 at 6:50 p.m. The Immediate Jeopardy was removed on 2/17/12 at 4:00 p.m. when observations and record reviews revealed the following immediate Plan of Removal was implemented: 1. Reduced water temperature immediately. 2. Put monitors in place to ensure temperatures were brought into acceptable range. 3. Contacted plumber, who immediately came to campus, to check equipment and is presently making necessary repairs/replacement to ensure compliance. 4. Building services staff is continuing to monitor during plumbing repairs to ensure water temperatures are within acceptable range and no residents are in harms way. 5. In-serviced building services staff on proper monitoring techniques. After removal of the immediate jeopardy, the following plan will be implemented: 1. Building Services personnel will daily monitor and log temperatures taken at faucet sites in resident rooms on the 200 Hall for 2 weeks including all 20 rooms. If satisfactory results are obtained, 10 rooms will be monitored during the following 2 weeks. Positive outcomes will result in random checks on a weekly basis on the 200 Hall to align with other areas of the facility. 2. During the same 4 week period, random checks at the rate of 2 rooms per day on the 100, 300, and 400 Halls will be monitored and logged. If an improper temperature is detected in any area, the staff member will immediately notify the Building Manager and/or Chief Operating Officer and/or Administrator and the temperature issue will be addressed and corrected. 3. Once it has been determined that water temperatures are being maintained within the acceptable range of 100-120 degrees F, checks will be monitored and logged weekly in random resident care areas. If a problem exists, the same protocol of notification will be initiated and the temperature issue will be resolved. The deficient practice continued at a scope and severity of second level/widespread. Findings: Review of the "American Burn Association Scald Injury Prevention Educator's Guide" revealed the following under Time and Temperature Relationship to Severe Burns: Water Temperature Time for a third degree burn to occur 155 degrees F 1 Seconds 148 degrees F 2 Seconds 140 degrees F 5 Seconds 133 degrees F 15 Seconds 127 degrees F 1 Minute 124 degrees F 3 Minutes 120 degrees F 5 Minutes 100 degrees F Safe temperature for bathing Further review revealed the following under High Risk Groups: 1. Older Adults - Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. 2. People with disabilities or special needs - Individuals who may have physical, mental, or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Sensory impairments can result in decreases sensation, especially to the hands and feet, so the person may not realize if something is "too hot". Changes in a person's intellect, perception, memory, judgment, or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. During environmental tour of the 200 West Hall on 2/16/12 at 3:15 p.m. with S23 Maintenance Assistant revealed resident #30 and #59's room to have sink water temperature of 133 degrees F on the hot water side. Further water temperature checks at that time revealed the following: 1. Resident #27 - 130 degrees F 2. Resident #60 - 130 degrees F 3. Resident #58 - 127.5 degrees F During an interview at that time, S23 Maintenance Assistant agreed with the above findings and stated there must be a problem with the mixer in the attic. S23 Maintenance Assistant further stated a resident on the 100 East Hall was complaining about their water being too cold and a plumber came out and did some work on the system. S23 Maintenance Assistant stated he thought the plumber made some adjustments in the ceiling where the 100 and 200 halls meet. When asked if the facility had any documentation of resident's rooms being checked for water temperatures, S23 Maintenance Assistant stated "no". S23 Maintenance Assistant further stated the only monitoring of water temperatures that are documented is the boiler room in-coming water after circulation through the facility. S23 Maintenance Assistant further stated he was new to some of the monitoring that is being done and recently found out he was recording the wrong temperature on the monitoring sheets. During a follow-up check on 2/16/12 at 4:25 p.m. of resident water temperatures, the following temperatures were observed: 1. Residents #81 and #53 - 129.5 degrees F 2. Residents #57 and #3 - 128 degrees F 3. Resident #39 - 127 degrees F 4. Resident #45 - 126.5 degrees F 5. Resident #35 - 125.5 degrees F 6. Residents #91 and #9 - 132 degrees F 7. Residents #117 and #84 - 128 degrees F 8. Resident #14 - 125.5 degrees F 9. Resident #10 - 125.5 degrees F 10. Resident #19 - 127.5 degrees F Review of the Water Temperatures for the facility boiler room for 12/2011 thru 2/2012 revealed documentation of daily hot water temperatures. Further review of the monitoring sheets revealed water temperatures ranging from 120 degrees F to 140 degrees F in December 2011 and January 2012 and temperatures ranging from 110 degrees F to 119 degrees F beginning 2/9/12. During an interview on 2/16/12 at 5:20 p.m., S4 Chief Operating Officer stated the facility recently experienced a problem with a resident on the 100 West Hall complaining her water was too cold. S4 Chief Operating Officer further stated a plumber was called out and did some work to correct the problem. After contacting the plumber to obtain more information, S4 Chief Operating Officer stated the plumber told him he was there on 11/15/11 for a complaint of water being too cold on the 100 West Wing hall. S4 Chief Operating Officer further stated the plumber reported he replaced the out-going hot water temperature gauge in the boiler room and added an in-coming hot water temperature gauge which was not part of the system before. When asked if the facility has performed any monitoring of the individual room water temperatures since the plumbing changes, S4 Chief Operating Officer stated "I cannot answer that since my building manager is out with a sick family member". S4 Chief Operating Officer further stated the facility has records showing the in-coming water temperatures have been monitored and it would make sense if the temperature is good coming back in to the boiler room, then the room temperatures should also be good. Review of a facility work order dated 11/13/11 revealed a complaint of water not being hot enough on the 100 West Hall. Further review revealed the issue was resolved on 11/18/11. During an interview on 2/17/12 at 4:20 p.m. S5 Building Manager stated since he has been employed at the facility, May of 2011, there has not been any monitoring of water temperatures in resident's rooms. S5 Building Manager further stated some checks were done in the past from what he has heard but the former maintenance man had been at the facility for a number of years and did not keep good records and did not pass along very much information on the facility when he left. When asked if he could show where monitoring of resident room temperatures were performed after the November 2011 repairs were made, S5 Building Manager stated "no". During an interview on 2/17/12 at 10:50 p.m. S1 Administrator stated the facility's administration should have known about the maintenance issues regarding monitoring of water temperatures in resident rooms but did not. Review of the 200 West Hall resident list provided by the facility revealed a total resident census of 26. Further review revealed 10 residents with intact cognition, 2 residents with moderately impaired cognition, and 12 residents with severely impaired cognition.