Every finding on record at Pine Haven Rehabilitation and Wellness Center

Based on interviews, resident record review, review of a facility policy titled ABUSE PREVENTION, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative file, the facility failed to protect residents from abuse. On 02/08/2023 Resident Identifier (RI) #5's was verbally abused by RI #6. On 02/09/2023 RI #3 was physically abused by RI #2. On 05/21/2024 RI #8 and RI #9 were each verbally abused by the other. The facility further failed to substantiate the occurrences as abuse. These deficient practices affected RI #'s 3, 5, 8 and 9, four of 14 sampled residents. This deficiency was cited as a result of the investigation of complaint/report numbers AL00043323, AL00043305 and AL00047916. Findings include: Review of a facility policy titled ABUSE PREVENTION with a history date of 07/2018, revealed the following: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: . other residents . DEFINITIONS: . b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents . d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking. 1) RI #5 was admitted to the facility on [DATE]. RI #5's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 11/11/2022 indicated RI #5 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment with daily decision making skills during this assessment period. RI #6 was admitted to the facility on [DATE]. RI #6's admission MDS assessment, with an ARD of 11/11/2022, indicated RI #6 had severe cognitive impairment with daily decision making skills. On 02/08/2023, the State Agency received an Online Incident Report from the facility alleging RI #6 verbally abused RI #5 and accused RI #5 of stealing RI #6's clothes. The facility's investigative file was reviewed and a summary of the facility's investigation documented the following: February 8, 2023 . The allegation of verbal abuse is found to be unsubstantiated. On 2/08/2023 At approximately 7:30am both residents were in their room when the charge nurse overheard the residents arguing . (RI #6) was accusing (his/her) room mate of stealing (his/her) things, (he/she) would not stop cursing even when staff stepped in and asked them to calm down. (RI #6) continued to curse and at one point blocked the door when the charge nurse and the other resident attempted to leave the room. On 05/31/2024 at 2:42 PM, an interview was conducted with the Administrator (ADM), who is also the facility's abuse coordinator. The ADM said her responsibility as the abuse coordinator was to investigate and determine abuse to any resident. The surveyor shared with the ADM on 02/08/2023, the facility submitted an initial report alleging verbal abuse occurred between RI #5 and RI #6; but the facility's investigation concluded that the verbal abuse was not substantiated. When asked why was the verbal abuse not substantiated, the ADM said the residents were not interviewable due to their cognitive status. When asked what type of abuse would using profanity and cursing be considered, the ADM said, verbal. 21055 2) RI #2 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #2's quarterly MDS assessment, with an ARD of 11/18/2022, documented RI #2 had long and short term memory problems and moderately impaired cognition during this assessment period. RI #3 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #3's annual MDS assessment, with an ARD of 11/02/2022, documented a BIMS score of 12 which indicated RI #3 had moderately impaired cognition. On 02/09/2023, the State Agency received an Online Incident Report alleging RI #2 physically abused RI #3 when RI #2 hit RI #3's arm several times and grabbed RI #3's shirt. The facility's investigative file was reviewed and a summary of the facility's investigation documented the following: . The allegation of physical abuse is found to be unsubstantiated. On 02/09/2023 At approximately 11:20am both residents were sitting in front of the nurses desk on B wing of the facility. (RI #3) bumped into (RI #2's) wheel chair . (RI #2) became upset and started using profanities toward (RI #3), (RI #2) hit (RI #3) on (RI #3's) upper left arm grabbed (RI #3's) shirt sleeve. On 02/09/2023 (RI #3) was interviewed . during the interview (RI #3) stated (he/she) was rolling by (RI #2) in (his/her) wheel chair and (he/she) bumped (RI #2's) chair by accident and (RI #2) hit (RI #3's) arm (RI #3) stated it didn't hurt . Conclusion: The facility concluded their investigation and could not substantiate the allegation of Physical Abuse . On 05/31/2024 at 2:42 PM, when asked what type abuse hitting someone would be considered, the ADM said physical. The surveyor shared with the ADM that on 02/09/2023, the facility submitted an initial report alleging physical abuse occurred between RI #2 and RI #3; and the facility's investigation concluded the physical abuse was not substantiated. When asked why the physical abuse was not substantiated, the ADM said she thought it was a reflex. The surveyor asked the ADM to her knowledge had RI #2 had any other incidents where she had that type reflex. The ADM said not to her knowledge. When asked what type of abuse hitting someone would be, ADM said, physical abuse. 3) RI #8 was admitted to the facility on [DATE]. RI #8's quarterly MDS assessment, with an ARD of 01/15/2024, revealed RI #3 scored a 15 on the BIMS assessment indicating RI #8 had intact cognitive decision making skills during this assessment period. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE]. On review of RI #9's quarterly MDS assessment, with an ARD of 03/15/2024, revealed RI #9 scored a 10 on the BIMS assessment indicating RI #9 had moderately impaired decision making skills during this assessment period. On 05/21/2024, the State Agency received an Online Incident Report alleging RI #8 and RI #9 were verbally abusing each other, curing each other in the dining room. The facility's investigative file was reviewed and a summary of the facility's investigation dated 05/27/2024 documented the allegation was unsubstantiated even though RI #8 and RI #9 were witnessed arguing over candy during a bingo game and RI #9 was heard yelling at RI #8 and saying . shut up bitch, I can get some if I want it . and RI #8 was heard to reply to RI #9 saying . get the hell out of here . On 05/30/2024 at 10:45 AM, an interview was conducted with the Activity Assistant (AA)/CNA. The AA said she heard a lot of profanity being used between RI #8 and RI #9 on 05/21/2024. On 05/31/2024 at 2:42 PM, the surveyor shared with the ADM that on 05/21/2024, the facility submitted an initial report alleging verbal abuse occurred between RI #8 and RI #9; but the facility's investigation concluded that the verbal abuse was not substantiated. When asked why the verbal abuse was not substantiated, the ADM said when interviewing RI #9, the resident did not remember the incident. The ADM further stated she thought RI #9 cursed RI #8 because RI #8 was cursing at RI #9. When asked if the facility should have substantiated that abuse occurred with the above incidents, the ADM said she thought the incidents occurred but did not think they were abuse. When asked what type of abuse would using profanity and cursing be considered, the ADM, said, verbal abuse.

Based on observations, interviews and a copy of the facility's RESIDENT BILL OF RIGHTS, the facility failed to ensure 26 of 89 residents' rooms were found in a homelike condition. This affected 26 of 89 rooms observed during the survey. Findings Include: A review of the RESIDENT BILL OF RIGHTS with a most recent review date of 11/17, revealed, Each resident has a right to a dignified existence, . and in an environment that promotes maintenance or enhancement of (his or her) quality of life, . A. Facility residents have the right to: . 33. A safe clean, comfortable home like environment. On 10/11/2022 04:33 PM during the initial tour, the following observations were made by the surveyor: 10/11/2022 04:57 PM Area Locator (AL) 21 patchy touched up paint, 10/11/2022 04:58 PM AL 22 wall paint was scraped, 10/11/2022 05:02 PM AL 23 wall by beds were patched and painted different color, 10/11/2022 05:25 PM AL 26 wall paint was scraped, 10/11/2022 05:27 PM AL 25 walls behind bed patched up paint behind door beds, 10/11/2022 05:30 PM AL 24 walls by bed were patched up paint with different color, 10/11/2022 05:46 PM AL 27 wall paint patched, and 10/11/2022 05:52 PM AL 28 the wall on other side of room where bed would go was patched. On 10/15/2022 02:06 PM, the following observations were made during another tour of the facility: AL 1 Paint touched up around wall outlet in the middle of the room with a different color paint, AL 2 paint scraped on wall behind headboards of both beds, AL 3 paint touch ups in several locations with scrapes on wall noted by call light outlet in the middle of the wall, AL 4 paint touch up on wall behind D (Door) Bed, AL 6 paint touched up on concrete wall behind W (Window) Bed, AL 7 paint touch ups on wall beside bed with different color (Private room), AL 9 paint touch ups on concrete wall by D Bed. AL 8 paint scraped on concrete wall behind the headboard of D Bed, AL 10 paint touch up on wall above D Bed, and AL 11 paint touched up on the wall to the left of the headboard of D Bed. Another observation was made of resident rooms on 10/17/2022 at 4:08 PM and revealed the following: AL 12 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, AL 13 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, AL 14 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, AL 15 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, AL 16 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, AL 17 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, AL 18 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, and AL 19 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions. These observations were not reflective of a homelike environment. On 10/18/2022 at 3:38 PM an interview with EI #14, the Maintenance Director. EI #14 reported he/she was responsible for the maintenance of resident rooms and residential areas. Regarding how often resident rooms and residential areas were checked for condition, EI #14 reported it was done during weekly staff room-rounds, during their heart to heart/one on one meeting with residents. He/she added that during those weekly meetings, the staff assess the rooms and then maintenance request forms are filled out from the findings. EI #14 was asked to describe the findings of the tour he/she had done on AL #s 1 through 28. EI #14 described each Area Locator as the head area behind the head of the bed or accent wall was found with mismatched paint. EI #14 observed this in a total of 28 rooms. EI #14 stated the concern of resident rooms having painted walls with mismatched colors, the area not being painted in a uniform shape, but in an irregular up, down, and with different length of strokes in all different directions, was not a neatly finished room made for a good home environment. EI #14 added that in regards to the expectations of the facility to provide a homelike atmosphere, the facility's resident rooms needed an update.

Based on an observation, interviews and review of facility policies titled, . SMALL VOLUME NEBULIZER THERAPY and . SELF ADMINISTRATION PROTOCOL ., the facility failed to ensure the licensed nurse remained with (Resident Identifier) RI #55, a resident not assessed to self-administer his/her nebulizer breathing treatment, when RI #55 received a nebulizer treatment on 10/11/2022. This deficient practice affected RI #55; one of one sampled resident observed receiving a nebulizer breathing treatment. Findings Include: Review of facility policy titled, . SMALL VOLUME NEBULIZER THERAPY, with a revision date of 8/16, revealed the following: .RESPONSIBILITY: All Licensed Nursing Personnel/Respiratory Therapist . PROCEDURE: . 10. Assist/instruct resident to close lips around the mouthpiece. 11. Instruct to inhale deeply and hold for several seconds before exhaling. 12. Encourage and instruct resident to cough at completion of treatment. A second policy titled, . SELF ADMINISTRATION PROTOCOL . with a revision date of 8/16, revealed, . RESPONSIBILITY: All Licensed Nursing Personnel/Interdisciplinary Team PROCEDURE: 1. If the resident wishes to participate, the Interdisciplinary Team will complete the Medication Self-Administration Assessment. 2. A written order for the bedside storage of medication is placed in the resident's medical record. RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #55's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . BUDESONIDE 0.25MG (Milligrams)/2ML (Milliliters) SUSP (Suspension) ONE (1) [MEDICATION(S)] PER NEBULIZER TWICE DAILY . [MEDICATION(S)] 20 MCG (Micrograms)/2 ML NEB (Nebulizer) TWICE DAILY DX (diagnosis): SOB (Shortness of Breath) . On 10/11/2022 at 5:02 PM, RI #55 was lying in bed receiving a nebulizer treatment. At 5:08 PM, RI #55 sat up in bed, turned off the nebulizer machine and placed the mask on the bed rail. On 10/11/2022 at 5:08 PM an interview was conducted with RI #55. He/she stated They come in here and put stuff in there. I put on the mask. I don't make them come in and cut off. On 10/11/2022 at 5:31 PM, an interview was conducted with Employee Identifier (EI) #10, a Licensed Practical Nurse (LPN). EI #10 stated when administering a nebulizer treatment, nurses should check the resident's pulse and respirations, make sure the cup is clean, put the medication in cup, start the machine, standby to make sure the resident is okay, and re-assess the resident afterwards. EI #10 admitted she left the room while administering the nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #10 stated she did not follow the medication administration policy. EI #10 stated the concern of leaving a resident alone while administering a nebulizer treatment was anything could go wrong. She added the resident might not get all of the medication. On 10/17/2022 at 11:15 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 stated residents are allowed to self-administer medication if the doctor writes an order. She stated the resident must be assessed and the care plan implemented. EI #2 was asked about the concerns of the nurse allowing RI #55 to self-administer the nebulizer treatment and she stated that was not self-administering, that was a nebulizer treatment.

Based on interviews, record review, and review of a facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS with a revision date of 11/17, the facility failed to provide evidence Resident Identifier (RI) #110's physician and sponsor were notified when RI #110 had ant bites to his/her left arm, left lower abdomen, and under his/her neck. This deficient practice affected RI #110, one of one resident sampled for notification. Findings Include: Facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, documented: . POLICY: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, . PROCEDURE: . d. Any accident or incident . The Incident Log documented RI #110 on 10/10/2022 at 7:00 AM . Incident type: Insect Bite . Raised Red Area . Resident room . In-house treatment . On 10/10/2022, RI #110's Resident Incident Report documented: . staff was providing care and noted several ants on the pillow where the resident's left arm was laying . small red areas to left upper anterior arm, also noted red areas to right eye, face and neck . Immediate Actions Taken: removed the pillow and checked the resident and bed for ants . An interview on 10/18/2022 at 1:41 PM an interview was conducted with the Medical Director. He stated the facility did not inform him of the incident dated 10/10/2022 that indicated Insect Bite or Raised Red Area, and no one told him that staff had seen ants in RI #110's room. On 10/19/2022 at 9:36AM an interview was conducted with RI #110's Representative. The Representative stated the facility never informed him that RI #110 had been bitten by ants. He said that they told him RI #110 was moved into a different room because they were detailing his/her room. He further stated that when he asked them what that meant he said that they said painting, floor being waxed and putting everything in plastic boxes to keep ants out of the room, but they never told him there had been an ant issue.

Based on an interview, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) 55's Minimum Quarterly Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/22 was accurately coded to reflect RI #55 was receiving oxygen. This deficient practice affected RI #55, one of three sampled resident's whose MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed: Section O: Special Treatments, Procedures, and Programs Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. O0100: Special Treatments, Procedures, and Programs Facilities may code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff . Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days. Coding Instructions for Column 1 Check all treatments, procedures, and programs received or performed by the resident prior to admission/entry or reentry to the facility and within the 14-day look-back period. Leave Column 1 blank if the resident was admitted /entered or reentered the facility more than 14 days ago. If no items apply in the last 14 days, check Z, none of the above. Coding Instructions for Column 2 Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period. RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, revealed, . Order date 7/13/22 start date 7/13/22 . O2 (Oxygen) AT 2L(Liters)/NC (via Nasal Cannula) TO KEEP 02 SAT (Saturation) > (greater than) 90% CHECK O2 SATS Q (every) SHIFT. Review of a quarterly MDS with an Assessment Reference Date (ARD) of 08/11/2022, Section O . 0100C2 Treatment: oxygen therapy while resident was not identified at the time of the assessment. An interview was conducted with Employee Identifier (EI) #5, a Registered Nurse (RN), MDS Coordinator on 10/16/2022 at 4:06 PM. EI #4 stated RI #55 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #5 admitted O2 was not identified on RI #55's Quarterly MDS assessment dated [DATE]. She stated it should have been identified on the assessment. EI #5 admitted the assessment was not accurate. EI #5 stated the concern of an inaccurate assessment was the staff may not know how to provide accurate care.

Based on interviews, review of Resident Identifier (RI) #98's medical record including the PASRR (Pre-Admission Screening and Resident Review) Screening & Results, and documents provided by the facility (the Regulatory Requirements) used as their guidance for the pre-admission screening process, the facility failed to ensure a valid Level 1 PASRR was completed for RI# 98. This affected RI #98, one of five residents whose Pre-Admission Screening and Resident Reviews were reviewed for completion. Findings Include: A facility document dated October 15, 2022, documented: (Name of Facility) does not have a Policy or Procedure regarding PASRR however we follow the federal guidelines. A review of RI #98's . PASRR Level 1 Screening & Results for Mental Illness . Intellectual Disability . Related Condition . with a screening date of 5/20/21, revealed, . ** MAY REQUIRE A LEVEL II ** . For compliance with Federal and State PASRR regulations, Admitting NFs (Nursing Facilities) must: Report this admission to the OBRA (Omnibus Budget Reconciliation Act) PASRR Office at the time of admission to start the Level II Evaluation process to determine eligibility. A review of the medical record for Resident Identifier #98 revealed he/she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 10/16/2022 at 9:13 AM with Employee Identifier (EI) #7, the Social Worker, who reported she was responsible for making the referral to the appropriate state designated authority when the need for a valid Level 1 screening was indicated. An interview was conducted on 10/17/2022 at 3:43 PM with EI #8, the LMSW (Licensed Master of Social Work)/Supervisor and Corporate Social Worker. EI #8 reported the Level 1 PASRR screening for RI #98 on admission to the facility on [DATE] indicated that they may have required a Level II screening. EI #8 added whoever had done the one on admission failed to send in the information to go with it. So, no Level 1 determination was received by the facility. EI #8 said the concern with a valid Level I determination not being obtained for a resident was not knowing if the resident met the criteria to be admitted to the facility.

Based on observation, interviews, record review and review of a facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure a care plan was developed/implemented for the following residents: 1) Resident Identifier (RI) #71's newly identified Pressure Ulcer, 2) RI #81's diabetes and insulin use, and 3) RI #55's use of oxygen. These deficient practices affected RI #'s 71, 81, and 55, three of thirty-one residents whose care plans were reviewed. Findings Include: The facility's COMPREHENSIVE PERSON CENTERED CARE PLANS policy dated 3/18, revealed the following: POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . PROCEDURE: . 5. For each problem, need, or strength a resident-centered goal is developed. 1) RI #71 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Weekly Skin assessment dated [DATE] for RI #71's wound revealed: Wound Location Left Heel . Status Ulcer . that was not present on admission. The INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY dated 10/6/2022, revealed: . CHIEF COMPLAINT Patient presents with a wound on (his/her) left heel. PLAN OF CARE REVIEWED AND ADDRESSED Recommendations Float heels in bed; Sponge boot . A review of RI #71's medical record identified no care plan for the newly acquired pressure ulcer. Employee Identifier (EI) #6, the Wound Care Nurse provided a Care Plan page identical to the previous Pressure Ulcer care plan with the date the Stage 2 Pressure Ulcer was identified on 10/5/2022. She reported it was a generic care plan. See interview below. An interview was conducted on 10/15/2022 at 5:33 PM with EI #6, the Wound Care Nurse. EI #6 reported RI #71's left heel Pressure Ulcer was identified on 10/5/2022. EI #6 reported a standard care plan for wounds was put in place, nothing specific to the Left Heel wound that had been newly identified. EI #6 stated the purpose of a care plan being individualized was to show the interventions put in place were for that particular resident. EI #6 reported she was responsible for developing care plan for newly identified Pressure Ulcers/Injuries. EI #6 was asked about the Wound Care Physician's Care Plan recommendations and agreed they should have been included in RI #71's Plan of Care. EI #6 stated she was given the standardized or generic care plan to put in place for every new wound by the previous wound care nurse and the DON (EI #3) was aware. EI #6 reported the plan of care that was initiated did not include the Wound Care Physicians' recommendations. She added she did not know she had to add the recommendations to the care plan. EI #6 said staff would not know to implement those interventions because they were not added to the plan of care. EI #6 stated the concern of not having a Care Plan that was specific to a resident with a newly identified Pressure Ulcer was the interventions would not have been implemented. An interview was conducted on 10/15/2022 at 6:02 PM with EI #3, the Director of Nursing. EI #3 said when the resident has something specific going on with them, staff should care plan for that specific issue. She added for newly identified wounds staff should add interventions to address the specific resident's wounds. She further added for CNAs (Certified Nursing Assistants) to know to implement those interventions for RI #71, those interventions should be on the plan of care, so that they would be on the pocket guide. EI #3 verbalized specific interventions would not have been implemented for the newly identified Pressure Ulcer for RI #71 if the care plan was not specific to the concern of injury/wound. An interview was conducted on 10/17/2022 at 2:58 PM with EI #5, the Care Plan Coordinator. EI #5 acknowledged the care plan initiated on 10/05/2022 did not address RI #71's left heel wound. EI #5 stated the purpose of a person-centered plan of care was so that a person would receive individualized care to meet their needs. EI #5 added that it was important to improve or assist in the healing process. EI #5 said the Physician's recommendations should be included in the plan of care so the nurses and aides could follow the ordered recommendations. 2) RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #55's October 2022 Physicians' Orders documented: . O2 (Oxygen) AT 2L (Liters)/NC (via Nasal Cannula) TO KEEP O2 SAT (Oxygen saturation) >90% CHECK O2 SATS Q (every) SHIFT . On 10/12/2022 at 11:13 AM observed resident with oxygen cannula in nose, set at 2 (LPM, Liters Per Minute). A review of RI #55's medical record on 10/12/22, revealed there was no care plan for use of oxygen. On 10/16/2022 at 4:06 PM, an interview was conducted with Employee Identifier (EI) #5, Registered Nurse (RN), MDS/Care Plan. EI #5 stated RI #55 was ordered for oxygen on 7/13/22. EI #10 stated a care plan for oxygen use was initiated on 10/13/22 and admitted it should have been initiated on 7/13/22. EI #5 stated the concern of not having a care plan is the staff not knowing how to provide accurate care. 3) RI #81 admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #81's October 2022 Physicians' Order documented: .INSUILIN [MEDICATION(S)]-YFGN U100 VL INJECT 6 UNITS SUBQ (subcutaneous) EVERYDAY AT BEDTIME . Order date: 5/20/22 . On 10/19/2022 at 8:58 AM, an interview was conducted with Employee Identifier (EI) #5, Registered Nurse (RN), MDS/Care Plan. EI #5 stated RI #81 was admitted to facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #5 stated the concern of not having a care plan for diabetes is the staff may not know exactly how to provide care.

Based on observations, interviews and review of the facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to review and revise the care plan for Resident Identifier (RI) #14 regarding a hand splint that was not in use during the survey. This affected RI #14, one of 31 residents whose care plans were reviewed. Findings Include: Review of the facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, with a last review date of 3/18, revealed, . POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. 9. Upon a change in condition, the Comprehensive Person Centered Care Plan or Baseline Care Plan will be updated . RI #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set Assessment) dated 10/02/2022 revealed, . Splint or brace assistance: number of days 0 . Observations were made of RI #14 on 10/12/2022 at 2:35 PM, 10/13/2022 at 4:37 PM and 10/14/2022 at 11:14 AM and it was noted that he/she had no hand splints in place. Review of the care plan revealed RI #14 as care planned for splints daily with an onset date of 12/4/2015. An interview was conducted on 10/16/2022 at 10:13 AM with Employee Identifier (EI) #4, the Administrator in Training. She indicated the MDS (Minimum Data Set) assessment/Care Plan Nurse should be made aware of changes in the Medicare meetings and was responsible for reviewing and revising care plans. She admitted RI #14's care plan had not been updated as it should have. EI #4 said that it should have been updated to ensure the plan of care was accurate for the resident. A follow-up interview was conducted on 10/17/2022 at 10:32 AM with EI #4, the Administrator in Training. EI #4 reported the significance of the care plan being accurate was to reflect the resident's needs and ensure staff met the resident's needs. An interview was conducted on 10/17/2022 at 2:51 PM with EI #5, the Care Plan Coordinator. She said RI #14's MDS indicated the number of days splints or braces were used was zero. She reviewed RI #14's care plan and reported it indicated RI #14 would tolerate splints daily per instructions. She admitted the care plan and resident assessment did not match. She gave the reason as the care plan was not updated to match the assessment. EI #5 said the concern of the care plan not being reviewed and revised to match the assessment was the patient may not receive the care they needed.

Based on observations, interviews, record review, and review of the facility's policy titled, . SMALL VOLUME NEBULIZER THERAPY, the facility failed to ensure Resident Identifier (RI) #55's nebulizer mask was stored in a covering on three of three days of the survey. This deficient practice affected one of one resident sampled for nebulizer administration. Findings Include: Review of the facility policy titled, . SMALL VOLUME NEBULIZER THERAPY, with a revision date of 8/16, revealed the following: . RESPONSBILITY: All Licensed Nursing Personnel/Respiratory Therapist . PROCEDURE: . 15. Store in a labeled plastic bag. RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #55's Physician Orders for October 2022 revealed RI #55 had orders for . BUDESONIDE 0.25MG (Milligrams)/2ML (Milliliters) SUSP (Suspension) ONE (1) [MEDICATION(S)] PER NEBULIZER TWICE DAILY . [MEDICATION(S)] 20 MCG (Micrograms)/2 ML NEB (Nebulizer) TWICE DAILY DX (diagnosis): SOB (Shortness of Breath) . On 10/11/2022 at 5:02 PM, RI #55 was lying in bed receiving a nebulizer treatment. At 5:08 PM, RI #55 sat up in bed, turned off the nebulizer machine and placed the mask on the bed rail in no bag. On 10/12/2022 at 11:13 AM the nebulizer was observed sitting on nightstand, tube dated 10/12/22 mask was hanging on side of the bed rail in no bag. According to the MAR (Medication Administration Record), the last time RI #55 received a nebulizer treatment was 10/12/22 at 9AM. On 10/13/2022 at 1:35 PM mask for nebulizer was observed hanging on side of the bed rail in no bag. According to the MAR, the last time RI #55 received a nebulizer treatment was 10/13/22 at 9 AM. On 10/13/2022 at 5:14 PM resident sleeping in bed and the nebulizer mask was observed uncovered and hanging on right of the bed rail. According to the MAR, the last time RI #55 received a nebulizer treatment was 10/13/22 at 9:00 AM. On 10/13/2022 at 5:15 PM, an interview was conducted with Employee Identifier (EI) #10, a Licensed Practical Nurse (LPN). EI #10 was asked to observe RI #55's nebulizer in the room. EI #10 stated the mask was not in a bag and was hanging on the bed rail. EI #10 admitted the mask should have been stored in a bag with the date on it. EI #10 stated the concern of not storing the mask properly was an infection control issue. On 10/13/2022 at 5:18 PM, an interview was conducted with EI #9, a Registered Nurse (RN), Unit Manager. EI #9 was asked to observe RI #55's nebulizer in the room. EI #9 stated RI #55's mask was not in a bag and hanging on the bed rail. EI #9 stated the mask should be stored in a plastic bag and on the holder of nebulizer machine with the room number and name on it. EI #9 stated the concern of not storing nebulizer mask properly was germs and possible infection.

Based on interviews, record reviews, a review of Potter and Perry, Fundamentals of Nursing, NINTH EDITION, and the Facility's form titled, Medication Administration-General Guidelines, the facility failed to provide evidence the licensed nurse was consistently documenting on the resident's eMAR (electronic Medication Administration Record) the administration of the resident's insulin. This affected RI #81, one of three residents sampled for Medication Administration. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, NINTH EDITION, page 370, revealed the following: . Chapter 26 Documentation and Informatics . Informatics and Information Management in Health Care . A nurse's electronic or handwritten signature on an entry in a record designates accountability for the contents of that entry. Review of facility's form titled, Medication Administration-General Guidelines dated 1/15, documented, POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices . PROCEDURE: . 11. The resident's MAR/TAR (Treatment Administration Record) was initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose following medication administration . RI #81 admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #81's MAR for September 2022 documented, . INSULIN [MEDICATION(S)]- . U (Units)100 VL(Vial) INJECT 6 UNITS SUBQ (Subcutaneous) EVERYDAY AT BEDTIME . Order date: 5/20/22 . Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #81's MAR for October 2022 documented . INSUILIN [MEDICATION(S)]- . U100 VL INJECT 6 UNITS SUBQ EVERYDAY AT BEDTIME . Order date: 5/20/22 . Review of the October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/15/2022 at 6:44 PM, an interview was conducted with Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN). EI #11 stated she could not remember what days she cared for RI #81 in September and October. EI #11 stated that some days when she came to work the computer system was down and once it came back up, she was unable to reboot it. EI #11 stated there was supposed to be a dumb book which contained MARs. EI #11 stated she has always given residents there medications even if the system was down. She stated on those days, she had to ask another nurse to look at MARs for residents in order to see what medications were to be given. EI #11 admitted medications given on those days were not documented on eMAR due to her not having access to the computer. In a follow-up interview conducted with EI #11 on 10/17/2022 at 12:16 PM. EI #11 stated if the eMAR was not available, medication that has was not given should be documented on MAR books located on the hall. EI #11 admitted she did not document medications given on those days. EI #11 stated the concern of not documenting medication given was staff would not know if the resident received the medication. On 10/17/2022 at 9:11 AM an interview was conducted with EI #3, the Director of Nursing (DON). EI #3 stated sometimes the computer system is unavailable and nurses were not able to document on the eMAR. She stated if that happened, nurses were instructed to document medication given on the paper MAR. EI #3 said, there was a book at the nurse's station with MARs. EI #3 stated the concern of not documenting medication given, was the next person coming on wouldn't know if medication had been given.

Based on observations, interviews, and review of the facility's policy titled EXPIRATION DATING & DOCUMENT REQUIREMENTS, the facility failed to ensure expired mediation and medical supplies were discarded after the expiration date. This deficient practice was observed in four of four medication storage areas in the facility. Findings include: The facility's policy titled EXPIRATION DATING & DOCUMENT REQUIREMENTS dated January 2015, documented POLICY: Time frames for expiration of medications / solutions are to be followed per manufacturer's recommendation . RESPONSIBILITY All Licensed Nursing Personnel . PROCEDURE: 1. Medications will be discarded by the product expiration date OR the date on which the suggested length of time after opening the product has passed, whichever occurs first . On 6/7/2021 at 11:23 AM, an observation of the A-wing medication storage area was conducted with Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN). [MEDICATION(S)], an antihistamine used to treat pain and itching, had an expiration date of September 2020 and Geri [MEDICATION(S)], cough medicine, had an expiration date of May 2021. EI #5 acknowledged the medications were expired. On 6/7/2021 at 11:45 AM, an observation of the B-wing medication storage area was conducted with EI #6, a LPN. Mantoux, an injectable fluid used to screen for [CONDITION(S)], had an opened date of 2/28/2021. EI #6 stated Mantoux expired 28 days after opened. The Mantoux manufacturer's information indicated . A vial of [MEDICATION(S)] (Mantoux) which has been entered (opened) and in use for 30 days should be discarded . On 6/7/2021 at 11:56 AM, an observation of the D-wing medication storage area was conducted with EI #7, a Registered Nurse. There were 13 VanishPoint IV (intravenous) Catheters with an expiration date of May 2018. EI #7 acknowledged the expiration date. EI #7 stated the Charge Nurse checked (for expired medications and supplies) and it was responsibility of the Unit Manager to go behind the Charge Nurse and check once a week. On 6/7/2021 at 12:15 PM, an observation of the C-wing medication storage area was conducted with EI #8, a LPN. The Medikmark IV Start Kit had an expiration date of June 2017 and the Care Fusion NeutraClear needle-free connector had an expiration date of January 2021. EI #8 acknowledged the supplies were expired. She stated the Charge Nurse is responsible to check but ultimately the Unit Manager was responsible and supposed to check once a week. During an interview on 6/8/2021 at 3:21 PM, EI #3, the Director of Nursing stated the Charge Nurse check the medication storage area first and then the Unit Manager checked them once a week.

Based on observations and interview, the facility failed to have an effective pest control program so that flying insects were not observed in the kitchen. This deficient practice had the potential to affect all residents who received food from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) completed by Employee Identifier (EI) #3, the Director of Nursing and dated 6/7/2021 indicated the facility had a total of 126 residents; 12 of which received nutrition by way of a tube feeding. Findings include: During a tour of the kitchen on 6/6/2021 at 9:47 AM, with EI #9, the Certified Dietary Manager (CDM), there were a small number of flying insets observed near the back door. During the lunch tray line observation on 6/7/2021 at 11:15 AM, multiple flying insects were observed in the kitchen area. The insects landed on cups, food, and pieces of cake on the residents' food trays. Two dietary staff members were observed fanning their hands to prevent flies from landing on the food. A staff member who observed the insects replaced the cake. Two of the dietary staff members were observed fanning his/her hands over the food to prevent flies from landing on food. EI #10, another CDM, fanned flying insects as she took the temperatures of the food on the tray line. During an observation of the area outside the kitchen near the backdoor on 6/7/2021 at 4:50 PM with EI #11, the Administrator, there were several flying insects. The area was also noted with several cardboard boxed and a dustpan full of trash items. EI #11 confirmed the presence of the insects and items and how they could contribute to the pest control issues.

Based on observation, interviews, and review of Resident Identifier (RI) #70's medical record, the facility failed to consistently provide wound care to RI #70's non-pressure chronic left foot ulcer as ordered by the physician. This deficient practice affected RI #70; one of three sampled residents reviewed for non-pressure related wounds. Findings include: RI #70 was admitted to the facility on [DATE] with a medical history to include diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #70's Admission Minimum Data Set with an assessment reference date of 4/7/2021 indicated the resident was cognitively intact with a Brief Interview for Mental Status of 15. RI #70 was assessed as having a diabetic foot ulcer during this assessment period. According to a review of RI #70's medical record, on 5/10/2021, the resident was transferred and admitted to a local hospital. RI #70 returned to North Mobile Nursing and Rehabilitation Center on 5/14/2021 with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the May 2021 eTAR (electronic Treatment Administration Record) for RI #70 indicated the treatment was documented as being administered on 5/15/2021, 5/16/2021, 5/22/2021, 5/23/2021 and 5/24/2021. During wound care observation on 6/7/2021 at 9:07 AM, Employee Identifier (EI) #12, a Registered Nurse (RN) removed an undated soiled dressing from RI #70's left heel. When RI #70 was asked if his/her dressing was changed on yesterday (6/6/2021), the resident replied No, it hasn't been changed since Saturday (6/5/2021). In an interview on 6/7/2021 at 9:26 AM, EI #12, a RN stated it was the facility's protocol to initial and date when the dressing was changed so that one would know who and when the dressing was changed. During an interview on 6/8/2021 at 2:04 PM, EI #7, the RN Unit Manager stated the eTAR reflected whether the dressing change was done. EI #7 acknowledged the blank spaces on the May and June eTAR and stated, we can't prove if it (the dressing change) was done or not. In an interview on 6/8/2021 at 3:09 PM, EI #3, the Director of Nursing stated when the eTAR is signed (initialed), it acknowledges the treatment was done. EI #3 acknowledged the blank spaces on the May and June eTAR. EI #3 stated the purpose of signing the eTAR and doing the dressing changes were to carry out the orders of the physician to ensure the wound was healing properly. EI #3 stated she expected the nurses to document when the dressing change was done. EI #3 further stated if it is not documented, that meant it wasn't done.

Based on interview and review of Resident Identifier (RI) #60's medical record, the facility failed to adequately monitor the effects of [CONDITION(S)] medication for RI #60 when they failed to ensure physician ordered laboratory tests were done. This deficient practice affected RI #60; one of five sampled residents reviewed for unnecessary medications. Findings include: RI #60 was readmitted to the facility on [DATE] with a medical history to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to RI #60's medical record, on 12/17/2019 the resident was ordered to have a TSH ([CONDITION(S)]-Stimulating Hormone) IN 6 WEEKS AND EVERY 3 MONTHS DX (diagnosis): [CONDITION(S)] According to RI #60's medical record, on 12/18/2019 the resident was ordered [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) 88 MCG (microgram) TABLET ONE (1) TABLET BY MOUTH 30 MINS (minutes) BEFORE BREAKFAST DX: LOW [CONDITION(S)] LEVELS to begin on 1/22/2020. A review of RI #60's medical record revealed on 5/11/2021, a TSH laboratory test was done, which indicated the resident's [CONDITION(S)] level was low at 0.31. The normal reference range was 0.45 to 5.33. During an interview on 6/8/2021 at 11:00 AM, Employee Identifier (EI) #8, the Licensed Practical Nurse stated the facility could not find laboratory results other than the 5/11/2021 laboratory results. In an interview with EI #13, the facility's Certified Registered Nurse Practitioner on 6/8/2021 at 1:00 PM, she stated she had never seen (been made aware of) RI #60's 5/11/2021 laboratory results. EI #13 stated had she been aware of those results, she would have changed the dosage of the resident's medication ([MEDICATION(S)]) before today. EI #13 further stated she was called by the facility this morning and given the results of RI #60's 5/11/2021 laboratory test. EI #13 stated she gave the facility orders for a new dosage of the medication and follow-up laboratory test. RI #60's PHYSICIAN'S TELEPHONE ORDERS dated 6/8/2021, documented [MEDICATION(S)] .75 mcg TSH 6 weeks. Then every 3 months. The prescribing information for [MEDICATION(S)] revised February 2017, documented . 2.4 Monitoring TSH and/or Thyrooxine (T4) Levels Assess the adequacy of therapy by periodic assessment of laboratory tests and clinical evaluation . In adult patients with primary [CONDITION(S)], monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dose. In patients on a stable and appropriate replacement dose, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status .

Based on observations, interviews, review of Resident Identifier (RI) #75's medical record and the facility's policy titled FINGERNAILS/TOENAILS CARE, the facility failed to provide nail care to RI #75, a resident assessed as requiring extensive assistance with personal hygiene and bathing, to ensure the resident's fingernails were cleaned. This deficient practice affected RI #75; one of one resident reviewed for Activities of Daily Living. Findings include: The facility's policy titled FINGERNAILS/TOENAILS CARE dated October 2009, documented POLICY: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection. RESPONSIBILITY: Nursing Assistant of Licensed Nurse Key Procedural Points: 1. Nails can be partially cleaned during bath care. 2. Nursing Assistants do not trim the nails of diabetic residents. 3. Nail care includes daily cleaning and regular trimming . RI #75 was admitted to the facility on [DATE]. RI #75's Quarterly Minimum Data Set with an assessment reference date of 3/25/2021 indicated the resident required extensive assistance with personal hygiene and bathing. On 6/6/2021 at 10:59 AM, RI #75's fingernails were observed to be dirty. On 6/7/2021 at 11:52 AM and 6/8/2021 at 9:12 AM, RI #75's fingernails were full of layers of brownish colored debris. During an interview on 6/8/2021 at 9:33 AM, Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) stated RI #75 required total care. EI #2 stated the CNAs cleaned the residents' nails daily with bathing and as needed. The surveyor and EI #2 observed RI #75's fingernails at 9:36 AM. When EI #2 looked at RI #75's fingernails she stated, Yes it's dirty under (his/her) nails, it needs cleaning bad. In an interview on 6/8/2021 at 1:11 PM, EI #3, the Director of Nursing stated the CNAs should provide a complete head to toe bed bath, and to clean and cut the resident's nails as the resident allowed. The CNAs should check the resident's nails every day and clean them as needed. During interview on 6/8/2021 at 1:33 PM, EI #4, a Registered Nurse stated the CNAs should have noticed RI #75's dirty nails and cleaned them when the resident was gotten up every day. EI #4 stated RI #75's nails are just nasty.

Based on interview, review of Resident Identifier (RI) #45's medical record and the facility's policy titled MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure RI #45's Quarterly MDS dated [DATE] indicated the resident was receiving hospice services. This deficient practice affected RI #45; one of 41 sampled residents. Findings include: The facility's policy titled MDS assessment dated [DATE], documented POLICY: The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations. These assessments provide information on the resident's condition to facilitate development of an individualized plan of care is a means by which the facility can track changes in a resident's status . PROCEDURE: . 2. Non-Medicare Covered Residents Upon admission, discharge, quarterly and annual reviews, an MDS assessment will be completed as per Federal/State requirements . RI #45 was admitted to the facility on [DATE]. According to the RI #45's June 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #45's Quarterly MDS with an assessment reference date of 12/16/2020 did not indicate the resident was receiving hospice services. In an interview on 6/8/2021 at 11:15 AM, Employee Identifier (EI) #1, a Licensed Practical Nurse confirmed hospice services should have been coded but it was missed and there was a need to do a correction.

Based on interview, review of Resident Identifier (RI) #60's medical record and the facility's policy titled LABORATORY TESTS, the facility failed to promptly notify the physician of RI #60's abnormal laboratory test result. This deficient practice affected RI #60; one of 41 sampled residents. Findings include: The facility's policy titled LABORATORY TESTS dated November 2017, documented POLICY: . Lab tests are completed as ordered by the physician or physician extended (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist) . RESPONSIBILITY: All Licensed Nursing Personnel monitored by Director of Nursing or Designee . PROCEDURE: 1. Licensed Nurse, or designee, shall obtain the labs ordered by the physician or physician extender . 9. The physician or physician extender will be promptly notified of abnormal results according to facility policy. 10. The Licensed Nurse, or designee, will review all labs scheduled routinely to ensure all scheduled labs have been drawn and results have been received . RI #60 was readmitted to the facility on [DATE] with a medical history to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #60's medical record revealed on 5/11/2021, a [CONDITION(S)]-Stimulating Hormone (TSH) laboratory test was done, which indicated the resident's [CONDITION(S)] level was low at 0.31. The normal reference range was 0.45 to 5.33. During an interview on 6/8/2021 at 11:00 AM, Employee Identifier (EI) #8, the Licensed Practical Nurse stated she called the Certified Registered Nurse Practitioner (CRNP) earlier today to notify her of RI #60's abnormal laboratory results dated [DATE]. EI #8 stated she should have notified the CRNP after the laboratory result was received. In an interview with EI #13, the CRNP, stated she had never seen (been made aware of) RI #60's 5/11/2021 laboratory results. EI #13 stated had she been aware of those results, she would have changed the dosage of the resident's medication ([MEDICATION(S)]) before today. EI #13 further stated she was called by the facility this morning and given the results of RI #60's 5/11/2021 laboratory test. EI #13 stated she gave the facility orders for a new dosage of the medication and follow-up laboratory test. RI #60's PHYSICIAN'S TELEPHONE ORDERS dated 6/8/2021, documented [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) .75 mcg (microgram) TSH 6 weeks. Then every 3 months.

Based on interviews, review of the facility's policy titled DISCHARGE AND TRANSFER POLICIES - INVOLUNTARY, a complaint received by the Alabama State Survey Agency and Resident Identifier (RI) #1's medical and hospital records, the facility failed to allow Resident Identifier (RI) #1 to return to the facility. On 9/2/2020, the facility sent RI #1 to a local hospital for evaluation of his/her [MEDICAL CONDITION]. When the resident was cleared to return to the facility, the facility would not let the resident return, stating they could not meet the resident's needs. There was no documentation within RI #1's medical record by his/her physician as to why the facility was unable to meet the needs of the resident or an attempt to implement the recommendations from the hospital. This deficient practice affected RI #1, one of four sampled residents reviewed for admission/transfer/discharge. Findings include: The facility's policy titled DISCHARGE AND TRANSFER POLICIES - INVOLUNTARY revised May 2019, documented . PROCEDURE: . 12. The resident may be transferred or discharged on ly when the Interdisciplinary Care Team, in consultation with the resident's designated representative, determines that one or more of the following criteria are met: . c. The facility may involuntary transfer or discharge the resident (#1-4 require physician documentation in the medical record) : 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; 2. The resident's health has improved sufficiently that the resident is no longer in need of the level of service provided by the facility. 3. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident 4. The health of individuals in the facility would otherwise be endangered 5. The resident has failed after reasonable and appropriate notice to pay for a stay at the facility; 6. If the facility closes or ceases to exist; 7. The resident's urgent medical needs require an immediate transfer or discharge . On 9/8/2020, the Alabama State Survey Agency received a complaint which alleged the facility failed to allow RI #1 to return to the facility after being sent to a local hospital for suicidal thoughts/ideations. RI #1 was admitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Departmental Notes dated 9/1/2020 7:44 AM, documented . When questioned about suicidal thoughts resident denied having these thoughts. RI #1's Departmental Notes dated 9/1/2020 10:15 AM, documented . Resident denies any thoughts on (of) harming (him/herself) this am (morning). RI #1's Departmental Notes dated 9/1/2020 1:31 PM, documented . Spoke to resident today in reference to current mindset. Resident reported that (he/she) is feeling a little better today. (He/She) stated that (he/she) is still suicidal but does not have a plan . Resident remains on 1:1 observation . RI #1's Departmental Notes dated 9/2/2020 6:55 AM, documented . (He/She) denied any suicidal thoughts. RI #1's Departmental Notes dated 9/2/2020 11:15 AM written by Employee Identifier (EI) #3, the Director of Nursing Service (DNS), documented Writer and ss (social service) director spoke with (RI #1) today in reference to current state of mind. Resident stated (he/she) was feeling Great, but (he/she) is still suicidal without a plan . 1:1 observation remains in place. Spoke with Mr. (name) (father) . Father also stated that he had a conversation with (RI #1) and (he/she) stated to him that (he/she) is receiving excellent care . Father was notified that per crnp (Certified Registered Nurse Practitioner ) orders that (RI #1) was being sent to hospital for continuous thoughts of suicidal . Approximately 5 minutes later a call was received from (name) (Mother). She asked what was going on and writer proceeded to give an update on (RI #1) current condition . RI #1's PHYSICIAN'S TELEPHONE ORDERS dated 9/2/2020 documented Send resident to (local hospital) ER (emergency room ) for evaluation of suicidal ideation. RI #1's Departmental Notes dated 9/2/2020 2:22 PM written by EI #1, the facility's Executive Director (ED), documented In DNS office with IDT (Interdisciplinary team) on call with (RI #1's mother), explained that there was an order received from the MD (Medical Director) to send (RI #1) to the hospital for evaluation due to continued [MEDICAL CONDITION] and working on a plan. (RI #1's mother) stated I do not want (him/her) to go . (RI #1's mother) wanted to know that the facility would guarantee her that the facility would take (RI #1) back after the stay. I explained that we may not be able to meet (his/her) needs but would re eval if needed . In a telephone interview on 12/2/2020 at 7:15 PM, RI #1's responsible party stated she was informed the Administrator would not allow RI #1 to return to the facility after being sent to the hospital on [DATE]. RI #1's responsible party stated the staff at the hospital was ready to send RI #1 back to the nursing facility but the staff at the nursing facility said RI #1 could not come back. On 12/3/2020 at 4:04 PM, a telephone interview was conducted with the hospital's Social Worker (SW). The SW was asked what he could tell the surveyor about RI #1, who was sent to the hospital for psychiatric evaluation on 9/2/2020, when the initial attempt to send the resident back to the facility was denied. The SW stated he had gotten report from the ER that they were wanting to send RI #1 back to the nursing home. The SW reported he called the facility to speak with the Admissions clerk. At 11:01 AM on 9/3/2020, he received a call from the Admissions Clerk and unknowingly on speaker was the facility's Administrator. When the SW explained the psychiatric order had been given for RI #1 to return to the nursing home with close observation, the Administrator reported the facility had given RI #1 a 30-day notice of discharge on 9/2/2020. According to the SW, when he was explaining the nursing home would have to allow the resident to return, the Administrator stated the nursing home was not taking RI #1 back and the Medical Director would not accept RI #1 back into the facility. When asked if there was a reason given as to why RI #1 could not return to the facility, the SW stated he was told in report from the ER that the facility could not do close observation. On 12/3/2020 at 4:13 PM, a telephone interview was conducted with a Registered Nurse (RN) from the local hospital. The RN stated she recalled the nursing home would not let RI #1 return to the facility after the resident had been cleared by psychiatry. On 12/3/2020 at 10:30 AM, Employee Identifier (EI) #3, the Director of Nursing Service (DNS) acknowledged the facility had provided the State Surveyor will all physician documentation from RI #1's medical record. There was no documentation provided from RI #1's primary physician or any physician as to why the facility could not meet the needs of the resident. When asked what is required in the medical record if the resident's needs could not be met in the facility, EI #3 replied, physician documentation in the medical record. When asked why this was not done, EI #3 stated she could not say. In a telephone interview on 12/3/2020 at 11:42 AM, the facility's Psychiatrist was asked if at any time he had informed the facility that he felt RI #1's needs could not be met in the facility. The Psychiatrist stated he did not do that. According to the Psychiatrist, the last time he visited RI #1 was on 8/28/2020. On 9/2/2020, the facility issued a 30-day notice of discharge to RI #1's responsible party which documented . After careful review of (RI #1's) condition, our team has determined that (he/she) is no longer appropriate for North Mobile. (RI #1) is a danger to himself due to active [MEDICAL CONDITION] upon which (he/she) had taken affirmative action. More specifically, on August 18, 2020, (RI #1 broke a common bowl and cut (him/herself) on (his/her) wrist. Since that time, North Mobile has had to provide (RI #1) with 1:1 monitoring because (he/she) had continuously indicated that (he/she) is thinking about suicide. (RI #1) is seeking treatment related to (his/her) suicidal) thoughts but stated I don't have a plan yet. The facility can no longer meet the needs of (RI #1) which, as noted above, has required 1:1 monitoring. We are more than willing to assist you in finding alternate placement. As noted above, the thirty days period begins today, September 2, 2020, and (RI #1) will be discharged to your care on October 2, 2020 . The Psychiatry Consultation from the local hospital for RI #1 dated 9/2/2020, documented . Subjective: (RI #1) is a . who presents to (hospital) due to [MEDICAL CONDITION] . (RI #1) stated that (he/she) currently has suicidal thoughts but denies any plan . He (nurse at North Mobile) also stated that the patient has been placed on one-to-one observation but it has been difficult for them lately due to inadequate staff . Assessment/Plan The patient has a history of major [MEDICAL CONDITION]. (He/She) stated (his/her) depression has been worse lately and (he/she) has had suicidal thoughts. Due to (him/her) being bedbound (he/she) is likely not a danger to (him/herself) or others as long as (his/her) environment is controlled and modified to ensure that (he/she) does not have a way of hurting (him/herself) . 1. Safety: Patient does not appear to be a danger to (him/herself) or others as long as suicidal precautions are taken at the rehab center that (he/she) came from: - Ensure the patient's environment is safe - The patient should be on close observation - Optimize visibility of the patient - Do not allow patient access to any sharp objects - Perform frequent checks on patient 2. Psychiatric medication suggestions: We recommend increasing the patient's [MEDICATION NAME] to 75 mg (milligram) daily and adding [MEDICATION NAME] 7.5 mg nightly. 3. Please have patient return to North Mobile nursing and rehab and follow-up with an outpatient psychiatrist . On 12/3/2020 at 11:55 AM, a telephone interview was conducted with EI #2, the facility's Medical Director, who is also RI #1's primary physician. EI #2 was asked if he performed a Transfer / Discharge evaluation indicating why the facility could not meet the needs of RI #1. EI #2 answered no. When asked if RI #1 should have been allowed back in the facility after being cleared by the local hospital, EI #2 answered yes, that was the protocol. This deficiency was cited as a result of the investigation of complaint/report number AL 649.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the local hosptial medical records for RI #1, the facility's investigation file and a complaint received by the Alabama State Survey Agency, the facility failed to follow-up on RI #1's discharge plan for on-going mental health care, and monitor RI #1 after RI #1 informed the Certified Registered Nurse Practitioner (CRNP) that he/she had a plan to harm him/herself. On 8/11/2020, the facility sent RI #1 to the local hospital for psychiatric evaluation for his/her suicidal thoughts. The Columbia Suicide Severity Rating Scale (CSSRS) done at the hospital indicated RI #1 was at severe risk for suicide. The hospital record also indicated RI #1 required in-patient psychiatric care because of his/her suicidal potential. However, the local hospital was not an adult psychiatric in-patient treatment facility and discharged RI #1 back to the facility with instructions for the facility to provide on-going mental health care for RI #1. When RI #1 returned to the facility on [DATE], the CRNP wrote orders for RI #1 to be monitored for his/her [MEDICAL CONDITION], and to see the facility's Psychiatrist related to his/her suicidal thoughts. The facility failed to fully assess RI #1's environment to ensure any item RI #1 could use to harm him/herself was removed. The facility continued to provide RI #1 with regular dishware and on 8/18/2020, during the dinner meal, RI #1 deliberately broke a bowl and used the sharp piece of glass to cut his/her wrist in an attempt to commit suicide. RI #1 was transported to the local hospital for suicide attempt. According to the Social Service Director (SSD), Employee Identifier (EI) #3, RI #1 was not evaluated by the facility's Psychiatrist until 8/28/2020, 17 days later after an order was written for the Psychiatrist to see the resident. These deficient practices affected RI #1, one of three residents sampled for behaviors, and placed RI #1 in immediate jeopardy as this failure was likely to cause serious injury, harm, impairment or death. On 8/28/2020 at 8:05 PM, the Administrator, Assistant Administrator, Director of Nursing (DON), Regional Dietitian and Clinical Operations Nurse were notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Behavioral Health, F742. Findings include: RI #1 was admitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. On 8/24/2020, the Alabama State Survey Agency received a complaint which alleged the facility failed to follow their protocol when they continued to serve RI #1 meals on regular dinnerware instead of paper products and/or Styrofoam. On 8/11/2020, RI #1 informed the CRNP that he/she had a plan to kill him/herself by popping the lenses out of his/her glasses and cutting his/her wrist. During the dinner meal on 8/18/2020, RI #1 deliberately broke a glass bowl served on his/her tray and used it to cut his/her wrist. On 08/26/2020 at 1:15 PM, an interview was conducted with Employee Identifier (EI) #6, the CRNP. When asked how she became aware that RI #1 wanted to commit suicide, EI #6 stated she and another Nurse Practitioner were checking on RI #1. EI #6 asked RI #1 how he/she was doing and, RI #1 replied by typing on his/her laptop that he/she was not good. EI #6 said when they further questioned RI #1, RI #1 admitted he/she was depressed and had been thinking about harming him/herself. According to EI #6, RI #1's plan was to break his/her glasses and cut him/herself with the glass. EI #6 said she informed RI #1 they were going to send him/her out for an evaluation and get some help for him/her. EI #6 stated the resident's glasses were taken and RI #1's mother was called to explain the situation. RI #1's Departmental Notes dated 8/11/2020 2:12 PM, documented . CRNP IN TODAY TO SEE RESIDENT. NEW ORDERS TO TRANSFER RESIDENT TO (local hospital) R/T (related to) EVALUATION OF SUICIDAL THOUGHTS WITH PLAN . RI #1's physician's orders [REDACTED]. The local hospital medical record for RI #1 with an admitted [DATE] documented . CHIEF COMPLAINT Psychiatric evaluation. HISTORY OF PRESENT ILLNESS . (RI #1) presents to the ER via (by way of) EMS (Emergency Medical Service) from North Mobile nursing home with complaint of suicidal thoughts. Patient is nonverbal and nonambulatory. (He/She) types on a special computer to communicate. Patient typed out that (he/she) wanted to take (his/her) glasses and break them and use them to cut (his/her) wrist. When asked if there was anything we could do for (him/her) while in the ER (his/her) response was I need a gun . Mental Health Problem The primary symptoms include dysphoric (feeling of uneasy, unhappy, unwell) mood. This is a chronic problem. Additional symptoms of the illness include adhedonia (inability to feel pleasure). (He/She) admits to suicidal ideas. (He/She) does have a plan to commit suicide. (He/She) contemplates harming (himself/herself) . Per Intake Nursing: PSYCH CONSULT: Pt. (patient) To ER today via EMS from North Mobile rehab for having suicidal thoughts. Pt. Has history [MEDICAL CONDITION](Cardiovascular Accident) and [MEDICAL CONDITIONS] . Appears sad and tearful during the interview . Depression is worse due to [MEDICAL CONDITION] and not being able to see family as (he/she) use to. History of cutting forearm with a piece of glass from breaking glasses. That is (his/her) same plan today. (He/She) is also asking staff for a gun. I just want this to end . MSE (Mental Status Exam): . endorses suicidal thoughts with plans for cutting or shooting (himself/herself) . CSSRS (Columbia Suicide Severity Rating Scale) - SCREENING Patient screened as: Severe risk . CSSRA Assessment: . Major depressive episode, Hopelessness and Perceived burden on family or others ASSESSMENT . Both hands are contractured. Unsure how able (he/she) is to hold things. Probable someone has to help feed (him/her). Legitimate complaint of depression but threat of suicide is highly unlikely. Pt states (he/she) does not get to see a therapist or speak with a psychiatrist. Likely (his/her) situation would be improved greatly with access to a therapist . DIAGNOSIS 1.) [MEDICAL CONDITION] 2.) Situational Depression . DISPOSITION: (RI #1) does require inpatient psychiatric care because of (his/her) suicidal potential, the inability to care for self due to mental illness, the potential for complications due to medication management that precludes outpatient approach, to consider/manage medications, and to involve in the inpatient therapeutic milieu. Chart to be faxed to surrounding adult psychiatric units since there is no adult psychiatric inpatient treatment at this facility. PLAN: . 2.) F/U (follow-up) w/ (with) selected provider at the facility for ongoing mental health care. 3.) Would suggest to increase the pt's (patient's) current dose of [MEDICATION NAME] to manage symptomatic depression . RI #1's PHYSICIAN'S TELEPHONE ORDERS dated 8/12/2020 received by EI #7, a Licensed Practical Nurse (LPN) from EI #6, the CRNP, documented [MEDICATION NAME] 10 mg (milligram) tablet one by mouth QD (everyday). DC (discontinue) [MEDICATION NAME] 10 mg suspension. DC Aripiprazole ([MEDICATION NAME]) 5 mg tab (tablet). Monitor for Suicidal thoughts . RI #1's INTERDISCIPLINARY PROGRESS NOTES dated 8/12/2020 10:00 AM, written by EI #7, an LPN documented . Spoke with CRNP about previous day medication ordered by hospital physician (with) new orders received and implemented form of medication . During an interview on 8/27/2020 at 9:23 AM, EI #7, an LPN stated she became aware on 8/12/2020 that RI #1 had voiced a desire to harm him/herself. According to EI #7, the CRNP, EI #6, gave her an order for [REDACTED].#1 was to be monitored, EI #7 stated she would spend a little extra time talking with RI #1, asking the resident how he/she was feeling. EI #7 said RI #1 was not placed on one-on-one monitoring or paper products until he/she came back from the hospital the second time, on 8/19/2020. When asked how it was determined RI #1 was able to break a bowl and harm his/herself on 8/18/2020, EI #7 said she had no idea. In a telephone interview on 8/27/2020 at 12:33 PM, EI #9, a Certified Nursing Assistant (CNA) was asked how RI #1 was to be monitored when the resident returned to the facility on [DATE]. EI #9 replied, there was nothing different. In a follow-up interview with EI #9, a CNA on 8/29/2020 at 12:37 PM, she was asked what specifically the staff was to do in monitoring RI #1. EI #9 replied nothing that she knew of. EI #9 explained that she wasn't told to do anything different. When asked if she was told to monitor the resident, EI #9 answered, not the first time (8/11/2020) but when the resident went out the second time (on 8/18/2020), RI #1 was placed on one to one when he/she returned to the facility. In an interview on 8/28/2020 at 10:30 AM, EI #10, the Social Services Assistant (SSA) was asked what type of mental health care follow-up RI #1 received after he/she returned to the facility on [DATE]. EI #10 stated she was not sure; she knew RI #1 was placed on the waiting list for inpatient, but she was unaware as to the date the resident was placed on the list. RI #1's Departmental Notes dated 8/18/2020 10:14 PM, written by EI #5, an LPN, documented Called to room by CNA. Upon entering resident was smiling and laughing. Resident apparently tried to cut (his/her) wrist with a piece of ceramic broke bowl. Laceration approx (approximately) 1/2 inch noted on L (left) wrist/ approx 1/4 inch deep. Prick holes and scratches noted to L AC. Superficial laceration to fingers on R (right) hand. CRNP and Dr. (EI #11) called. Parents of resident both called no answers left message on machine. Cleaned wounds with NS (Normal Saline) bandaged. (EMS) called to take to ER for eval (evaluation). Resident did tell CNA (he/she) has suicidal thoughts while laughing and smiling. On 8/26/2020 at 3:39 PM, an interview was conducted with EI #5, the LPN assigned to care for RI #1 on 8/18/2020. EI #5 said the CNA, EI #4, called him to RI #1's room close to shift change. EI #5 said when he entered RI #1's room there was blood on the sheets. EI #5 said there was a broken piece of ceramic bowl about three inches long in RI #1's bed. EI #5 said he had no idea where RI #1 got the broken piece of bowl from. EI #5 said he cleaned RI #1 up and called everyone he was supposed to call. When asked how the staff was to monitor RI #1 when the resident returned to the facility on [DATE], EI #5 said they were just observing the resident for behaviors. Contained within the facility's investigation file was a Witness Statement from EI #4, a CNA dated 8/19/2020, which read . I walked in on break and saw (RI #1's) light on I answered it and open the door (He/She) had a gash on (his/her) wrist and abrasions on (his/her) upper arm and I asked (him/her) why did (he/she) do it and (he/she) told me that nobody cared about (him/her) and (he/she) wanted to kill (his/herself) after that I grabbed the broken plate that (he/she) used and ranned (ran) to (EI #5) the nurse at the time. In an interview on 8/26/2020 at 5:44 PM, EI #4, the CNA said when he walked in RI #1's room to answer the call light he could see blood running down RI #1's left arm. EI #4 said he called for EI #5, the nurse assigned to care for RI #1, and showed EI #5 the sharp piece of bowl/plate he (EI #4) thought RI #1 used to cut him/herself with. EI #4 said when he asked RI #1 where he/she got the sharp piece of broken bowl/plate from, RI #1 said from supper. According to EI #4, he fed RI #1 the supper meal and there was not a bowl on the tray when he picked the resident's meal tray up. The facility's planned menu for Tuesday, 8/18/2020 indicated the supper meal was: Hoppin' John, Mixed Greens (A), Gooey Butter Cookies, Chilled Peaches, Cornbread/Marg, Milk/Beverage *****ALTERNATE***** Chicken Salad Sandwich Marinated Cucumber & Onions Blushing Pears. In an interview on 8/27/2020 at 1:40 PM, EI #12, the Dietary Manager was asked what food items were served for dinner on 8/18/2020. EI #12 replied, Hoppin John, which is a mixture of black-eyed peas, rice and ham; greens; buttered cookies; peaches; and cornbread. When asked which food items would have been served on a plate, EI #12 answered the greens and the cornbread. EI #12 stated the Hoppin' John would have been in a bowl and the peaches would have been in a dessert bowl. EI #12 was asked if the plate and bowl were ceramic. EI #12 replied, yes. The local hospital medical record for RI #1 with an admitted [DATE] documented . CHIEF COMPLAINT Psychiatric evaluation. HISTORY OF PRESENT ILLNESS . (RI #1) presents via EMS from North Mobile rehab with complaint of suicide attempt. Patient is nonverbal but types on a tablet and communicates this way. Patient reports on a tablet I do not want to live. EMS reports patient got a plate in (his/her) room and cut (him/herself) on the left wrist . Review of Systems . Psychiatric/Behavioral: Positive for self-injury and suicidal ideas . Per Intake Nursing: Psych Consult: pt's assessment is limited due to pt being non verbal. Ipad used to communicate with pt. Superficial abrasions noted to left forearm. 2 sutures noted to left wrist, scars noted to left forearm . Pt reports that (he/she) is lonely because (he/she) cannot have visitors due to Covid. Pt reports very little social interaction. Pt noted smiling at this writer throughout assessment . Pt could benefit from having a sitter or some type of companionship at the nursing home . CSSRS - SCREENING Patient screened as: Severe risk . ASSESSMENT . Asked if (he/she) was attempting to harm (him/herself) or also seek attention. Pt smiled and typed, Cant it be both. Again says (he/she) is not monitored very well. (He/She) is seen when food is served . DIAGNOSIS 1.) Intentional self-harm by sharp object 2.) Borderline Personality 3.) [MEDICAL CONDITION] recurrent 4.) TBI ([MEDICAL CONDITION] .5.) H/O (history of) intentional self-harm . PLAN: . 2. Please limit pt's room to psych safe only. Does not need glass in (his/her) room at all. (He/She) needs to use paper plates. If (he/she) needs a fork then someone will need to help (him/her) or move to finger foods. Needs to be moved as close to the nurses station as possible for more routine observation . On 8/19/2020, RI #1 was discharged back to the nursing facility. During an interview on 8/29/2020 at 12:54 PM, EI #3, the Licensed Baccalaureate Social Worker (LBSW)/Social Service Director (SSD) acknowledged that she didn't review the local hospital's discharge summary for RI #1 from the first incident (8/11/2020) until RI #1 had returned to the facility from the second incident (8/18/2020). When asked what the 8/11/2020 discharge summary indicated RI #1 required, EI #3 replied, RI #1 needed psychiatric care for his/her suicidal potential. EI #3 explained the local hospital's discharge summary revealed RI #1 should follow-up with a selected provider at the nursing facility for his/her ongoing mental health care needs. When asked if she was involved in any of the follow-up mental health care, EI #3 replied, not with this because she didn't receive any orders. When asked if she spoke with EI #7, the LPN on 8/12/2020 regarding the need for RI #1 to be seen by the facility's Psychiatrist and the resident would be placed on the list to be seen, EI #3 said she didn't remember. EI #3 was asked if she was ever told RI #1 needed to be seen by the facility's Psychiatrist. EI #3 replied yes, it was discussed in the heart to heart meeting that is held every day. According to EI #3, it must have been that Tuesday or Wednesday after RI #1 first mentioned that he/she wanted to harm himself/herself. EI #3 stated she called EI #8, the facility's Psychiatrist but he was busy with a client. EI #3 stated it wasn't until the resident's second incident, on 8/18/2020 that she was informed by the LPN, EI #7, that there was an order for [REDACTED]. RI #1's INTERDISCIPLINARY PROGRESS NOTES dated 8/12/2020 10:00 AM, written by EI #7, an LPN documented . Spoke with social worker advised resident needed to see house psychiatrist. Was advised she was putting (him/her) on the list to be seen. In a follow-up interview on 8/29/2020 at 1:27 PM, EI #3, the LBSW/SSD was asked if she informed EI #7, the LPN, that the resident was placed on the list to be seen by the facility's Psychiatrist after EI #7 informed her that RI #1 needed to be seen by the facility's Psychiatrist. EI #3 replied, no. During an interview on 8/29/2020 at 6:20 PM, EI #3, the LBSW/SSD was asked if she followed up with an alternate Psychiatrist to see RI #1 for his/her suicidal thoughts when EI #8, the facility's Psychiatrist was unavailable. EI #3 answered, No ma'am. In a follow-up telephone interview on 8/29/2020 at 2:30 PM, EI #6, the CRNP acknowledged that she gave a verbal order on 8/11/2020 to EI #5, an LPN, for RI #1 to have ongoing mental health care. When asked what the order meant, EI #6 stated RI #1 needed to follow-up with the facility's mental health provider, EI #8. According to EI #6, when she came in the next morning, 8/12/2020, the LPN, EI #7, asked her to clarify the order that had previously been given to EI #5. EI #6 stated she clarified the order even though she had previously given the order to EI #5 by way of the telephone. When EI #6 asked EI #7 if EI #5 had written the order from the night before, EI #7 said yes that she (EI #7) had the order in her hand and she was about to take it to the Social Worker. EI #6 was asked why she wrote an order to monitor RI #1 for suicidal thoughts. EI #6 replied, she felt it was only appropriate since that is what the resident was sent out for. When asked if she knew if EI #8, the Psychiatrist had been notified, EI #6 said she did not know. RI #1's Physician's Telephone Order dated 8/11/2020 8:32 PM, entered and received by EI #5, an LPN documented SE (See) Dr. (EI #8) R/T (related to) SUICIDAL THOUGHTS FOR TOMORROW (tomorrow). There was no documentation in RI #1's medical record that the resident was seen by the facility's Psychiatrist on 8/12/2020 or attempts made to contact the Psychiatrist. In a telephone interview on 8/28/2020 at 5:42 PM, EI #8, the Psychiatrist stated after telecommunicating with RI #1 on today, he felt the resident has true suicidal thoughts and should be involuntary hospitalized in an inpatient facility. On 8/29/2020 at 4:12 PM, EI #8 telephone the State Surveyor and stated he couldn't really say whether the facility contacted him about RI #1, but he did recall speaking with the facility's Medical Director, EI #11. When the State Surveyor informed EI #8 that EI #11 had acknowledged speaking with EI #8 after 8/19/2020, EI #8 stated the facility may have tried to call him but he couldn't recall. EI #8 explained that he probably would not have been able to see the resident because it was close to the weekend and he doesn't work on the weekend{The date the order was written was Tuesday, 8/11/2020 for the resident to be seen the next day, Wednesday, 8/12/2020}. When asked what should be done when there was an order for [REDACTED].#8, he did eventually speak with RI #1 and the resident is truly suicidal and should be involuntary committed. EI #8 explained that mental health is not taken seriously. RI #1 is truly depressed. EI #8 further stated he didn't think RI #1 would really do anything to die but in the process he/she may die if he/she tried to harm himself/herself. On 8/28/2020 at 11:54 AM, an interview was conducted with EI #11, the facility's Medical Director. EI #11 was asked if RI #1 had been seen by the Psychiatrist. EI #11 replied he was not sure. According to EI #11 he spoke with the Psychiatrist after RI #1's suicide attempt on 8/18/2020 and the Psychiatrist advised him that RI #1 needed to be committed. When asked how a visit with the Psychiatrist could have been arranged for RI #1, EI #11 stated it could have been done by way of telecommunications. In a follow-up interview on 8/28/2020 at 2:16 PM, with EI #11, the facility's Medical Director was asked how RI #1 got a piece of glass to cut himself/herself, if the resident was being monitored by the staff. EI #11 offered no explanation. During an interview on 8/26/2020 at 4:31 PM, EI #2, the Director of Nursing (DON) stated when the resident returned to the facility on [DATE], the resident had an order for [REDACTED].#2 said the facility did this to err on the side of caution since the hospital felt RI #1 could not carry out suicide because of his/her paralysis. When asked where RI #1 got the broken bowl to cut him/herself, EI #2 replied the resident may have gotten it off the breakfast or lunch meal tray. In an interview on 8/27/2020 at 10:35 AM, EI #2, the DON was asked how the staff was to monitor RI #1 when he/she returned to the facility on [DATE]. EI #2 replied, the nurses would go in and talk with RI #1 every shift and ask the resident if he/she was having suicidal; thoughts. If the resident had a plan, the physician and the responsible party would be notified, and the resident would be sent to the local ER for evaluation. In a follow-up interview on 8/27/2020 at 4:49 PM, EI #2, the DON stated when RI #1 returned to the facility from the hospital on [DATE], the resident was not provided any sharp objects on his/her meal tray; however, he/she was still given a regular plate and/or bowl. When asked why the resident was allowed to continue to receive regular dishware, EI #2 stated because the staff was present at meals to assist the resident as needed. When asked if the facility considered the resident may be able to harm him/herself with regular dishware, EI #2 replied, it was not considered that those items would cause risk for harm. On 8/28/2020 at 2:17 PM, EI #2, the DON provided the State Surveyor with evidence that the Psychiatrist was not consulted until 8/19/2020. When asked why the Psychiatrist was not consulted until 8/19/2020, EI #2 replied because that was when the order was written. However, RI #1's Physician's Telephone Order dated 8/11/2020 8:32 PM, entered and received by EI #5, an LPN documented SE (See) Dr. (name of Psychiatrist) R/T (related to) SUICIDAL THOUGHTS FOR TOMORROW (tomorrow). In an interview on 8/27/2020 at 1:48 PM, EI #1, the facility's Administrator was asked how it was determined RI #1 obtained a piece of broken ceramic to cut his/herself. EI #1 replied, the resident told her that he/she broke a bowl and hid it underneath his/her pillow. RI #1 then used this piece of broken bowl to cut his/her wrist. In a follow-up interview on 8/28/2020 at 1:22 PM, EI #1, the facility's Administrator was asked what type of mental health care follow-up was done after RI #1 returned to the facility on [DATE]. EI #1 stated there were medication changes for the resident and the facility reached out to several entities; however, no one would help. When asked to provide evidence of when and who the facility contacted for mental health care follow-up, the survey team was provided with evidence that it wasn't until 8/22/2020, that the facility contacted an inpatient psychiatric facility for RI #1. ************************* On 8/29/2020 at 10:00 PM, the facility submitted a Removal Plan for F742 which documented: North Mobile Nursing and Rehabilitation Center, LLC Removal Plan for F742 On 8/11/2020 RI #1 voiced to CRNP that he/she had a plan to harm him/herself and that he/she would do so by popping the lens of his/her glasses and cutting him/herself. o 1:1 observation was initiated until ems arrived for transportation to hospital o Eyeglasses where immediately removed o RI #1 was sent to (local hospital) for an evaluation and treatment o RI #1 was sent back to NMNR on 8/11/2020 o 8/12/2020 [MEDICATION NAME] increased to 10mg po daily o 8/12/2020 Facility psychiatrist called but was unable to reach o Q shift monitoring initiated On 8/18/2020 RI #1 cut (himself/herself) with a piece of glass from a bowl or plate in an attempt of suicide. o 1:1 observation initiated until ems arrived for transportation to hospital o MD/CRNP notified and new orders received and implemented to send to hospital o RI #1 was sent to (local hospital) for an evaluation and treatment o RI #1 was sent back to NMNR o 8/19/2020 1:1 observation initiated o 8/19/2020 Facility Psychiatrist consulted o 8/19/2020 Paper products initiated for all meals o 8/19/2020 Food preferences updated (Per residents request) o 8/22/2020 Referrals sent to (name of Psychiatric) hospital on [DATE], 8/24/2020, 8/25/2020 8/28/2020, 8/29/2020 for possible inpatient treatment. o 8/21/2020 Careplan meeting to include mother o 8/22/20 Call returned from (name) at (name of Psychiatric hospital) Crisis to care line (No beds available) o 8/24/2020 Call returned from (name) at (name of Psychiatric hospital) Crisis to care line from (No beds available) o 8/28/20 Telemed visit with facility psychiatrist new orders received o 8/28/20 [MEDICATION NAME] 20mg po daily initiated o 8/28/20 Trazadone 50mg po qhs initiated o 8/28/2020 Clinical Operations nurse began in-servicing all licensed nurses, MD, CRNP, DNS, ADNS and AED on how to ensure that all orders are reviewed and transcribed properly. o 8/29/2020 All residents were interviewed for [MEDICAL CONDITION]/thoughts none were noted at that time. o 8/29/2020 Quality Assurance Nurse/ Staff Development/DNS/ADNS and AED began educating residents on the role of social services and how to contact Social Services for any mental health needs and/or concerns. o 8/28/2020 Quality Assurance Nurse/ Staff Development/DNS/ADNS and AED began in-services for all direct staff which can be designated to conduct one to one supervision for residents with [MEDICAL CONDITION] or attempts to include visual and verbal queues to help assess the resident's current state of mind. o 8/28/2020 Quality Assurance Nurse/ Staff Development/DNS/ADNS and AED began inservices to Direct staff on how to identify verbal and nonverbal communication to determine a residents state of mind. o 8/28/2020 Quality Assurance Nurse/ Staff Development/DNS/ADNS and AED began inservices to Direct staff to assess surroundings for potentially hazardous items that could be used to cause self harm. o 8/28/2020 Quality Assurance Nurse/ Staff Development/DNS/ADNS and AED began inservices to Direct staff on how to engage in conversation and activities to create a more positive environment. o 8/28/2020 Quality Assurance Nurse/ Staff Development/DNS/ADNS and AED began inservices to direct staff to be educated on whom to IMMEDIATELY report any abnormal findings which may include charge nurse, ADNS, DNS, CRNP, MD, AED and Executive Director. o 8/29/2020 All remaining staff will be in-serviced prior to the beginning of their next scheduled shift.(Staff will not be allowed to return to work until in-service is completed.) o 8/28/2020 Executive Director and Clinical Operations Nurse Consultant initiated inservices to social service staff on how to properly care plan and monitor a resident with newly onset or continual [MEDICAL CONDITION]. In-servicing will include effective daily monitoring/documentation of the resident throughout their stay in the facility while exhibiting [MEDICAL CONDITION]/thoughts. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F742 was lowered to a D level on 8/29/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 875.

Based on observations, interviews and review of Resident Identifier (RI) #9's medical record, the facility failed to ensure RI #9 was served his/her meals on regular dishware during five of five days of the survey. This deficient practice affected RI #9, one of three residents observed for meals. Findings include: RI #9 was admitted to the facility on [DATE]. RI #9's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/12/2020, identified RI #9 was moderately impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status score of 11. RI #9 was assessed as having no behaviors and required supervision with eating. A review of RI #9's care plans did not include a problem and/or approach as to why the resident was not served meals on regular dishware. On 8/25/2020 at 11:45 AM, RI #9 was served his/her lunch meal on a Styrofoam hinged plate and the resident's liquids were in Styrofoam cups. On 8/25/2020 at 5:36 PM, RI #9 was served his/her dinner meal on paper products and not regular dishware. On 8/26/2020 at 7:50 AM, RI #9 was served his/her breakfast meal on paper products and not regular dishware. On 8/27/2020 at 7:42 AM, RI #9 was served his/her breakfast meal on paper products and not regular dishware. On 8/28/2020 at 12:00 PM, RI #9 was served his/her lunch meal on paper products. When the resident was asked why was his/her meals being served on paper products, RI #9 replied I don't know. When asked if anyone informed him/her that his/her meals would be served on paper products. RI #9 said no. During a telephone interview on 8/28/2020 at 6:13 PM, RI #9's responsible party stated he didn't know why RI #9's meals were being served on paper products. When asked if he had been informed the resident would be served meals on paper products, RI #9's responsible party said no. On 8/29/2020 at 12:18 PM, RI #9 was served his/her lunch meal on paper products and not regular dishware. This deficiency was cited as the result of the investigation of complaint/report number AL 875.

Based on observations, interviews, review of Resident Identifier (RI) #1's medical record, and review of the facility's incident report dated 10/19/2017 and witness statements, the facility failed to ensure: 1) Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), did not heat two cups of water in the microwave for use during a bed bath for RI #1. When the CNA was unable to obtain hot water from the sink faucet in RI #1's room and the pantry on the unit, the CNA heated two Styrofoam cups of water in the microwave. The CNA took these two cups of heated water, with visible steam, and placed them on RI #1's rolling bedside table, within arms reach of the resident. Subsequently, these cups of water were spilled onto RI #1's left forearm, resulting in a second degree burn. This deficient practice placed RI #1, one of six sampled residents in immediate jeopardy of serious injury, harm or death, with the potential to affect the remaining 41 additional residents who reside on the B-wing of the facility. On 11/02/2017 at 4:30 p.m. EI #2, the Administrator, and EI #3, the Director of Nursing, were notified of the findings of Immediate Jeopardy at F323, Quality of Care. The facility further failed to ensure: 2) RI #1, a resident with a [DIAGNOSES REDACTED]. The facility's van driver left RI #1 unattended and unsupervised in the lobby, on the first floor of the building. The doctor's office was located on the 4th floor in the building. 3) RI #1's bathroom wall was free of rough and/or sharp edges, which created a hazard. On 10/24/2017, an injury to RI #1's right great toe was identified, which was reportedly caused by bumping the toe on RI #1's bathroom wall. Further, after identifying this injury, the facility performed maintenance repairs in RI #1's bathroom that left a 5/8 (five eighth) inch protrusion, just to the front, right side of RI #1's commode, creating the potential for further injury; and 4) RI #4's bathroom doors were free of rough, splintered edges, creating the potential for injuries, including skin tears. 5) RI #6's bathroom doors were free of rough, splintered edges, creating the potential for injuries, including skin tears. These failures affected RI #s 1, 4, and 6, three of six residents reviewed for potential hazards. However, the lack of available hot water for resident care had the potential to affect all 42 residents residing on the B wing, one of four units in the facility. Findings include: On 10/26/2017, the Alabama State Survey Agency received a complaint that North Mobile Nursing and Rehabilitation Center had been having problems with hot water for three to four months. The complainant alleged that as a result, on 10/19/2017, a CNA heated water in a coffee pot for RI #1's bed bath. The water then spilled onto RI #1, resulting in a second degree burn from RI #1's left wrist to the elbow. RI #1 was admitted to the facility on [DATE] with a medical history to include: Schizophrenia. RI #1's Annual Minimum Data Set with an assessment reference date of 8/22/2017, indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status Score (BIMS) of 13. RI #1 was assessed as requiring extensive assistance for bathing. RI #1's Departmental Notes written by EI #4, the night shift Registered Nurse (RN) Supervisor, dated 10/20/2017 7:53 AM, documented . 10/19/17 11p-7a shift This nurse was notified by staff, while preparing for bed bath. Hot water had fallen on resident left forarm (forearm). CNA bumped bedside table with hot water on top. Upon entering resident's room ., resident noted laying on bed, alert. Nurse (LPN) at bedside providing treatment. Resident assessed . Burned (Burn) noted to left forearm. No blood noted. Skin peeled. Physician notified. Responsible party (name) notified (responsible party) requested for (RI #1) to be transferred to (local hospital) . RI #1's Resident Incident Report reviewed by EI #8, the Quality Assurance (QA) Nurse, revealed on 10/19/2017 RI #1 received a second-degree burn. The report indicated the associate involved was EI #1, a CNA and first aid was provided by EI #9, a LPN. The report further documented . Informed by CNA while preparing to give a bed bath (water basin and cup of hot water was placed on bedside table near resident left side of bed). CNA tripped and bumped into the bed side table. The cup of hot water fell over onto resident's left lower arm. Blister noted to left forearm. No blood noted. Top layer of skin peeled . In an interview on 11/1/2017 at 11:00 AM, EI #8, the QA Nurse stated she reviewed the RI #1's Resident Incident Report to make sure notifications were made, documentation was complete, and interventions were put in place. When asked what happened, EI #8 said from what she understood, a CNA on night shift (EI #1) was assisting RI #1 with a bed bath and the resident complained the water was not hot enough. The CNA then heated water in the microwave in an attempt to accommodate the resident. The CNA then bumped the table and the hot water fell on RI #1's arm. When asked if the heated water should have been placed on a table by RI #1's bed, EI #8 said she would not have put it there for fear the resident could be burned. EI #8 said she thought this incident could have been avoided if the CNA had sought water from an alternate area or notified the Supervisor of the resident's concern about the water temperature. Contained within the facility's investigation file was a Witness Statement from EI #1, the CNA involved in the incident, dated 10/20/2017, which documented . Resident was complaining of water being cold so I went into the Pantry to get water from the sink but still wasn't warm. So I heated a little in the microwave. I took it to the resident room and sat it down on the table. I turned to get some cold water from the sink in the room, but when I turned around I stumbled and the water spilled . On 10/31/2017 at 12:20 PM, EI #1, the CNA assigned to care for RI #1 on 10/19/2017 was interviewed. When asked to explain what happened, EI #1 said at about 5:45 AM or a little later, she gathered items for RI #1's bed bath. EI #1 said she turned on the hot water in RI #1's room and let it run a few minutes into the basin. When she handed the basin to RI #1 so the resident could wash his/her face, RI #1 complained the water was too cold. EI #1 then ran water again into the basin, but RI #1 was still not satisfied with the temperature and asked EI #1 to please get some warm water. EI #1 said she then went to the pantry (on the B wing) to get water because it was normally warmer than the water in residents' rooms. EI #1 said she got two cups of water and heated them in the microwave for about one minute. When the cups were removed from the microwave, EI #1 said she could see steam. EI #1 then placed the cups of heated water on RI #1's rolling bedside table within arms reach of the resident. As EI #1 retrieved the basin to mix the water, she turned, tripped, and bumped the table, causing the water to spill on RI #1's arm. EI #1 said at times, RI #1 will accept the water from the room, but on the night of the incident, the water would not get hot. When asked how long this had been a problem, EI #1 said she was not sure, but it was an intermittent problem for about the last six months. EI #1 said this was reported to EI #7, the Maintenance Director. When asked what was done to address the problem after it was reported, EI #1 said she did not know, because the problem continued. EI #1 explained RI #1's burn could have been avoided if there had been hot water available for the bath, because she would not have heated water in the microwave. The CATEGORY TWO VIOLATION EMPLOYEE CORRECTIVE COUNSELING MEMORANDUM signed by EI #1 on 10/20/2017 indicated EI #1 received a Category Two Violation for failure to follow safety rules. The memorandum further documented . Describe specifically how employee violated Department/Company Policy or Procedure: AEB (as evidenced by): On 10/19/17 heated hot water up in cups in the microwave to go into cold water for a bed bath with resident in room (RI #1's room). Tripped and hot water spilled onto resident . Describe the specific standards that must be met directly from Company Policy, . Do not heat water in microwave to (for) any reason. This serves as a final warning. Any other violation of company policy will result in termination . On 10/31/2017 at 12:20 AM, EI #9, the LPN who provided first aid to RI #1 on 10/19/2017 was interviewed. EI #9 said EI #1, the CNA, reported to her that RI #1 was burned. According to EI #9, EI #1 told her she tripped, which caused hot water to fall on the resident. EI #9 said she went to the resident's room to assess the injury and observed RI #1's skin had peeled back. In an interview on 11/1/2017 at 9:20 AM, EI #4, the night shift RN Supervisor stated while she was on C-wing, EI #1 came and told her there had been an incident with RI #1. EI #4 stated she went to RI #1's room and noticed the skin on RI #1's left lower arm had peeled back. It was then the CNA, EI #1, reported that hot water had spilled on the resident. When asked where the water came from, EI #4 stated it was determined EI #1 had heated the water in the microwave. When asked if RI #1's burn could have been avoided, EI #4 said it could have been avoided by not heating water. EI #4 explained that water should never be heated in the microwave because it could cause burns. During an interview with RI #1's sponsor on 10/31/2017 at 10:20 AM, she stated the CNA was unable to get hot water from the sink in RI #1's room, so the CNA was going to mix cups of hot water for RI #1's bed bath. RI #1's sponsor said she felt the hot water should have been mixed down the hall or at the sink and not beside RI #1's bed. RI #1's emergency room record from 10/19/2017 documented . Chief Complaint . Pt (patient) presents to ED (Emergency Department) from North Mobile Rehab via (by ways of ) EMS (Emergency Medical Services) c/o (complaint of) burn to L (left) forearm. Pt states they were getting ready to give (him/her) a bath when the water splashed on (his/her) arm and burned it. Pt has second degree burns to L forearm. Open blisters . History of Present Illness (RI #1's name) . presents from North Mobile Rehab with a 2% TBSA (Total Body Surface Area) second degree burn of left forearm s/p (status [REDACTED]. (He/She) states (his/her) pain is minimal 4/10, sudden, decreasing, nonradiating, and worse with palpation . The Patient Education Materials provided to RI #1 upon discharge from the emergency room , revealed the following: . Second-Degree Burn A second degree burn affects the 2 outer layers of skin. The outer layer (epidermis) and the layer underneath it (dermis) are both burned . ************************* On 11/02/2017 at 10:40 p.m., the facility submitted an acceptable Allegation of Compliance (AoC), which documented: 1. The microwaves have been removed from pantry on B wing effective 11/2/17. 2. The Facility hired a local plumber on 11/1/17 and he came to the facility twice that day but no issues with water temperatures or availability of hot water on B wing were identified. Also the plumber returned to the facility on [DATE] and again found no issues with the water on B-wing. The facility has since hired a third plumbing service that will arrive at 1 1a.m. 11/3/17 to further assess irregularities in water temperatures. He will be accompanied by a Property Development manager. An ongoing investigation related to the water on B-wing will continue in the meanwhile to maintain safety of the residents the shower room on B-wing will remain closed until a solution of the water issue can be resolved. All residents on B wing requiring or desiring a bed bath will be allowed to test the water for comfort by touching the water with their fingers. Prior to allowing the resident to check the water the Certified Nursing Assistant will ensure that the bath/shower water is between 100-110 degrees by checking the temperature with a thermometer. If the resident expresses that water is too cool, water will be obtained from an alternate faucet in efforts to ensure resident comfort is achieved. If the resident expresses the water is too warm it will be cooled down by adding cool water. The shower room on B wing was rendered out of order on 10/31/17 until the root cause of fluctuating temperatures could be identified and resolved. Showers will be offered on alternate wings. The policy for baths/showers was updated on 11/2/17 updated to reflect the monitoring of the water temps. 3. On 10/19/17 at 5:50am, RI # 1 sustained a second degree burn to the left forearm. Resident was evaluated immediately by the LPN and RN supervisor and first aide administered. The attending physician was notified at 6:32am and resident representative notified at 6:47am. Immediately after RI #1 Representative arrived, the resident was transported to the emergency room for evaluation and treatment. RI#1was treated and returned to the facility the same day. RI #1 received follow up care with the wound center on 10/23/17 at 11:00 a.m. and on 10/27/17 when he/she was discharged from their care. 4. All other residents receiving care from responsible Certified Nursing Assistant have been evaluated on 10/19/17-11/2/17 and have no skin injury related to exposure to hot water. A complete skin audit was performed on 11/2/17 for all residents that reside on B-wing and again no issues were noted. The CNA who heated the water will be monitored each time she works when giving a bed bath/shower to ensure that no water is heated by her for one month then monthly for six months. Incidents over the past 6 months were reviewed and no other burn injuries were noted related to hot water. 5. All residents residing on B wing have had a skin assessment completed from 10/19/17 through 11/2/17 and no water related injury noted. 6. The certified nursing assistant was suspended immediately on 10/19/17 pending investigation. The certified nursing assistant then received 1:1 in-service education on 10/20/17 regarding never heating water from alternative sources for bed bathing by the Staff Development coordinator. 7. All RN's, LPN's CNA's received In-servicing on 11/2/17 regarding never heating water from an alternative source for bathing and how to check water temps with a thermometer any staff that has not been in-serviced will not be allowed to work until in-services have been completed. The Director of Nursing in-serviced the RN's and LPN's on 11/2/17 then the RN's, LPN's in-serviced the CNA's. The RN's, LPN's and CNA's will be in-serviced on the 11-7 and 7-3 shift by the RN supervisor as the employees clock in for their shift. The employees will be stopped and in-serviced before they are allowed to work. CNA's will be monitored while giving bed baths three times a week until the water issue can be resolved. ************************** After reviewing the facility's documentation of items outlined in their AoC, inservice records completed as of 11/03/2017 and interviews with facility staff including Maintenance, the Administrator, CNAs, LPNs and RNs on multiple shifts, and observing to verify the microwave was removed as specified, it was determined the facility had implemented their AoC. The immediate jeopardy was relieved and the scope and severity was lowered to a E level on 11/03/2017 at 12:45 a.m This deficiency was cited as a result of the investigation of complaint/report number AL 394. 2) On 10/26/2017 the State Agency received a complaint that RI #1 was transported to an outside appointment and left there, despite the resident's [DIAGNOSES REDACTED]. RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with a medical history to include: Altered Mental Status, Schizophrenia, and Bipolar Disorder. RI #1's Yearly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/22/2017, indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status Score (BIMS) of 13 and required extensive assistance for all Activities of Daily Living, except eating. Review of RI #1's Departmental Notes revealed a note dated 09/13/2017 documenting RI #1 had left the facility for an appointment with his/her physician. This note also indicated the resident's family also attended the appointment. RI #1's sponsor was interviewed on 10/31/2017 at 10:20 a.m RI #1's sponsor indicated on the day of RI #1's appointment, before she arrived, staff left RI #1 on the bottom floor of the building in the lobby unsupervised, but the appointment was on the fourth floor. RI #1's sponsor said when she arrived, RI #1 was sitting in in the lobby in his/her wheelchair, holding paperwork. The sponsor indicated RI #1 could not propel the wheelchair his/herself. On 10/31/2017 beginning at 2:45 p.m. observations were made of the clinic in which RI #1 had his/her appointment on 09/13/2017. The surveyor entered through the entrance door into the reception area, which was a circular area. A pharmacy was noted on the left side and a laboratory on the right. A semi-circle of 10-12 chairs was noted in the area. After 5-7 minutes of observation, a pharmacy employee directed the surveyor to a receptionist who was sitting in an area, not visible from the lobby area. This receptionist also indicated they do not observe clients/residents who need supervision while waiting on family members to arrive. The surveyor then went to the fourth floor, where RI #1's doctor's office was located. The doctor's office reception staff indicated they do not normally interact with residents who come by transport from nursing homes. The receptionist stated they do not supervise residents until family or staff members arrive. EI #18, the facility's van driver, was interviewed on 11/01/2017 at 8:50 a.m. EI #18 recalled transporting RI #1 to the doctor's office on 09/13/2017. EI #18 said they called the family to let them know they are on their way to the appointment, and if they do not see the family when they arrive, they call to find out where they are. EI #18 said if the family is not there, she tells an employee at the doctor's office the family is on the way. EI #18 said on the day of RI #1's appointment, she had another resident to drop off and one to pick up so she told an employee in the lobby RI #1's family was coming and left. EI #18 was unsure of the title of the individual she informed RI #1 was waiting on family to arrive. When asked if there was any reason a resident should not be left until the family arrives, EI #18 said if the resident is unable to do for themselves, they would need someone to assist them. EI #3, the Director of Nursing, was interviewed on 10/31/2017 at 6:25 p.m EI #3 said the procedure for transporting residents to outside appointments consisted of the following: making the appointment, notifying family and asking them to attend, and if the family is unable to attend have a CNA or another staff member stay with them during the appointment. When asked what she be done if a resident is transported to an appointment and the family is not there yet, EI #3 said a CNA or the van driver should stay with the resident until the family arrives. EI #3 said if a resident is alert and oriented, they do not stay with them, depending on their physical abilities. EI #3 was asked if RI #1 should have someone with her until family arrives, and EI #3 said RI #1 needs someone with him/her due to [DIAGNOSES REDACTED]. EI #3 explained RI #1 hears voices and may need someone to redirect him/her. EI #3 also said RI #1 was dependent for Activities of Daily Living. 3) On 10/26/2017 the State Agency received a complaint regarding RI #1 injuring his/her right great toe on an area of the bathroom door, that had been in need of repair for months. RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with a medical history to include: Altered Mental Status, Glaucoma, Schizophrenia, Bipolar Disorder, Diabetes Mellitus Type Two, and Acute Kidney Failure. RI #1's yearly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/22/2017, indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status Score (BIMS) of 13. Review of the facility's Resident Incident Report, dated 10/24/2017, indicated RI #1 sustained an abrasion to the right great toe when he/she bumped it on the wall while being transferring to the toilet. A typed statement from EI #2, the Administrator, dated 10/24/2017, indicated he had asked Maintenance to perform work in RI #1's bathroom to ensure a smooth wall near the toilet. On 10/30/2017 at 9:26 p.m., the surveyor entered RI #1's room to talk with the resident. When asked how he/she injured his/her toe, RI #1 told the surveyor to open the bathroom door and look. RI #1 said there was a board in the bathroom and when toileting, he/she hit his/her toe on it. The surveyor observed a board/panel affixed to the far wall in the bathroom, that would be located on the resident's right side while sitting on the commode. A baseboard that did not run the entire length of the wall was also noted, that stopped just in front of the commode, leaving a sharp protrusion. On 10/31/2017 at 10:20 a.m. the surveyor asked RI #1's family to describe the condition of the the bathroom prior to the facility working on it. The family indicated the board affixed to the wall was frayed along the bottom, and said the baseboard had been added since the injury occurred. Another family member present observed the bathroom and said the way the baseboard was still protruding from the wall could still be a hazard. During an interview with EI #7, the Maintenance Director, on 10/31/2017 at 2:30 p.m., EI #7 said he was not present at the time the repairs had been made in RI #1's bathroom. EI #7 indicated EI #19, Maintenance Supervisor, had completed the work. EI #7 said EI #18 made the baseboard uniform with the paneling affixed to the wall, but he wished he had brought it the whole length of the wall. EI #7 said the baseboard protruded 5/8 inches from the wall. EI #19, the Maintenance Supervisor, was interviewed on 11/01/2017 at 10:02 a.m EI #18 affirmed he completed the repairs to RI #1's bathroom wall. EI #19 indicated the work was done to repair cracks at the bottom to prevent water from getting under it. EI #19 was asked to describe the wall prior to the work he completed. EI #19 indicated the paneling was one inch thick and there had been a 1/4 (one quarter) inch gap between the bottom of the panel and the floor. EI #19 said he was unaware of RI #1 injuring his/her toe on the wall and stated no one asked him to ensure the wall had smooth surfaces. 4) RI #4 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #4's care plan for Activities of Daily Living, dated 07/24/2009, indicated RI #4 was assisted with toileting as needed. Another care plan, also dated 07/24/2009, indicated RI #4 was at risk for falls. The following care plan approach was listed: . Maintain resident environment free of . safety hazards . During the initial tour of the facility on 10/30/2017, beginning at 6:02 p.m. RI #4's bathroom door was observed with splintered, rough edges where the door hinges connect to the door frame. RI #6 indicated he/she could toileted his/her self. On 10/31/2017 at 3:15 p.m., EI #7, the Maintenance Director, and the surveyor made rounds to observe the bathroom doors with concerns. EI #7 observed RI #4's bathroom door and agreed it was broken on the left side. EI #7 indicated bathroom door repairs were listed on the budget, but no time frame had been set for the work to be completed. 5) RI #6 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #6's admission MDS assessment, with an ARD of 07/07/2017, indicated RI #6 was cognitively intact, with a BIMS score of 15. RI #6's care plan, dated 07/11/2017, indicated RI #6 was at risk for falls. The following care plan approach was listed: . Maintain resident environment free of . safety hazards . During the initial tour of the facility on 10/30/2017 beginning at 6:02 p.m. RI #6 indicated he/she did not require assistance for toileting. RI #6's bathroom door had rough, splintered edges on the door knob side of the door. RI #6 indicated he/she had never seen Maintenance come to check for things like that. On 10/31/2017 at 3:15 p.m., EI #7, the Maintenance Director, and the surveyor made rounds to observe the bathroom doors with concerns. EI #7 observed RI #6's bathroom door. When asked about the splintering, EI #7 said it would be best to reskin the doors to avoid skin tears. EI #7 indicated bathroom door repairs were listed on the budget, but no time frame had been set for the work to be completed.

Based on observations, interviews, review of Resident Council minutes, Maintenance Request Logs, and temperature logs, and review of an article titledBath Water Temperature Safety for the Elderly, the facility failed to ensure the B-wing, one of four units in the facility, produced hot water at a temperature comfortable for resident's bath and shower needs. Interviews with facility staff and residents revealed there had been an ongoing problem dating back to December 2016 with not having hot water. During the survey, Resident Identifier (RI) #3 received a cold shower because there was no hot water in the B-wing shower room. When the water temperature was checked in the shower room, the temperature obtained was 71 degrees Fahrenheit (F). Also, due to the lack of hot water for resident care, a Certified Nursing Assistant (CNA), Employee Identifier (EI) #1 heated water in the microwave on 10/19/2017 to perform a bed bath for RI #1, resulting in RI #1 sustaining a second degree burn. This deficient practice placed all 42 residents residing on the B-wing, one of four units in the facility, in immediate jeopardy, as the deficient practice was likely to result in serious harm, impairment, injury, or death to these residents. On 11/02/2017 at 4:30 p.m. EI #2, the Administrator, and EI #3, the Director of Nursing, were notified of the findings of Immediate Jeopardy at F465, Physical Environment. Findings include: Refer to F 323 The facility's Resident Council Minutes for December 2016, documented . water on B wing not hot enough . During the January 2017 Resident Council meeting held on 1/4/2017, one of the old business topics discussed was water on B wing not hot. The minutes indicated this concern was not resolved to the residents' satisfaction. The RESIDENT COUNCIL DEPARTMENT RESPONSE FORM dated 1/4/2017, documented . Concern/Issue/Request from Resident Council: . water on B wing not hot enough . Department Response: . will talk to (Administrator) about 2nd water heater . The department head that signed this form was EI #7, the Maintenance Director. Within the Maintenance Request Logs was a handwritten note dated 9/16/2017, from the B-wing CNA's (CNAs) 11-7 (11PM - 7 AM) which documented . the water is not getting Hot. The facility's water temperature logs revealed on 10/13/2017, six days prior to RI #1 complaints of cold water that was validated by EI #1, the CNA, the water temperature in RI #1's room measured 81 degrees Fahrenheit (F). There was no documentation of any corrective actions taken. During the initial tour of the facility on 10/30/2017 beginning at 5:55 PM, the water temperature in RI #1's room measured 81 degrees F. The water temperature in Room Locator (RL) #1, also located on the B-wing, measured only 78 degrees F, after allowing the water to run for six minutes. On 10/31/2017 beginning at 3:15 PM, the surveyor accompanied EI #7, the Maintenance Director, to the B-wing of the facility. EI #7 checked water temperatures in residents' rooms using the facility's digital thermometer. Upon entering RI #1's room, RI #1 asked EI #7 why the water did not get hot. EI #7 replied that the resident's room was a little ways away from the water heater and it may take a minute. However, after allowing the water in RI #1's sink to run for three to four minutes, EI #7 obtained a water temperature of only 96 degrees F. When asked if that was warm enough for a resident to bathe, EI #7 said it would depend on the resident's preference. EI #7 later stated the water was lukewarm. EI #7 then entered RL #2, a room on the B-wing, and obtained a water temperature of 96 degrees F. When the surveyor and EI #7 entered RI #3's room, RI #3 said he/she had to take a cold shower this morning because the water didn't get hot at all. RI #3 stated not at all hot. EI #7 then went to the shower room on the B-wing to check the water temperature. The water temperature in the B-wing shower room measured only 71.4 degrees F. When asked what he determined to be the problem after RI #1 was burned on 10/19/2017, EI #7 stated he checked the water temperature and it was good, so he knew it was a supply and demand problem. According to an article titled Bath Water Temperature Safety for the Elderly from www.seniorhealth365.com last updated 11/30/2012 . The temperature of bath water is not often considered as a major safety hazard to adults, but to the elderly with impaired senses and slower movement, it is a significant risk . Ideal Bath Water Temperature Personal preference for the temperature of bath water is one major factor in deciding the levels that are ideal for the individual. Bath water temperature should be just a degree or two high than normal body temperature (98.6 degrees F) . During an interview on 10/31/2017 at 12:30 AM, EI #11, a CNA said bath water should be between 110 to 120 degrees F. When asked was there ever a time when the water was not hot, EI #11 replied yes. EI #11 stated she reported the problem to the maintenance man. When asked if the problem improved after she reported it to maintenance, EI #11 said not right then. During an interview on 10/31/2017 at 12:45 AM, EI #10, a CNA said bath water should be between 106 to 115 degrees F. When asked was there ever a time when the water was not hot, EI #10 said it's not hot like it should be; it's lukewarm. When asked how long it had been like this, EI #10 stated it's been like that since she was hired in July. In an interview on 10/31/2017 at 12:20 PM, EI #1, a CNA indicated there have been times the water on the B-wing would not get hot. EI #1 stated one of those times was on 10/19/2017 (see F 323). EI #1 indicated the problem had been happening intermittently over about the last six months. EI #1 said the problem was reported to EI #7, the Maintenance Director, one to two months prior. EI #1 was unsure what was done to correct the concern, because the problem continued. EI #1 also indicated she was the one who wrote the note about water not getting hot on the B-wing on 9/16/2017. EI #7, the Maintenance Director, was interviewed on 10/31/2017 at 2:30 PM. EI #7 said the temperature of the water should be between 112 to 115 degrees F. EI #7 said sometimes it got lower than that, as he had seen the water temperature get as low as 98 degrees F. According to EI #7, it depended on the time the water temperature was checked. EI #7 said he normally got to the facility around 6:00 AM. EI #7 explained that if the water temperature was checked around the time of showers, the temperature would be lower. EI #7 further explained that when this happened, he would just go back again in a few hours and check the water temperature again, but that would probably not be documented anywhere. EI #7 was asked if he had received any complaints about the water temperature. He said he had been at the facility a little over a year and he had heard residents say the water was cold. EI #7 could not recall the last time a resident or staff member voiced a complaint to him about the water temperatures. EI #7 was then shown a copy of the note dated 9/16/2017 (a Saturday) from the 11 PM - 7 AM B-wing CNAs that documented the water is not getting hot. EI #7 said he did recall that but said he felt it was a lie. EI #7 said he checked the water temperatures the following Monday and the water temperatures were over 100 degrees F. EI #7 was then asked about the temperature documented on 10/13/2017 of 81 degrees F. EI #7 said that temperature could have been due to other people using hot water at the time. EI #7 explained the staff has to allow the hot water to build back up. According to EI #7, on 10/13/2017, he would have rechecked the water temperature in an hour or two, but acknowledged it was not documented anywhere. When asked why it was important to ensure the availability of water at a temperature acceptable for resident care, EI #7 said it was important for cleaning bacteria from hands, the CNAs and nurses use it, and it was important for resident comfort. EI #7 indicated the B-wing had a 100 gallon gas water heater to provide hot water to 23 resident rooms, 23 residents' sinks, the pantry, the nurses' bathroom, and the shower room. When asked if 100 gallons was sufficient to meet the demands of the unit, EI #7 said the water heater on the B-wing was the same one installed when the building was built, so he felt it was sufficient. When asked how it was sufficient if there were times the demand for hot water exceeded the amount available, EI #7 said it was due to usage. EI #7 said a larger water heater would increase the supply of hot water to help meet the demand. EI #7 said he distinctly remembered a conversation with the CNAs in which he told them they may need to wait 15 to 20 minutes for the hot water to build back up. On 11/1/2017 from 1:05 PM to 1:20 PM, EI #14, EI #15, EI #16 and EI #17, all CNAs indicated they had never been instructed on what should be done if they were unable to obtain hot water for resident care. During a follow-up interview on 11/1/2017 at 1:28 PM, EI #1, a CNA indicated she had never been instructed by the facility on what should be done if she could not obtain hot water for resident care. During a follow-up interview on 11/2/2017 beginning at 6:35 AM, EI #7, the Maintenance Director stated the facility had four 100 gallon gas water heaters, one for each wing of the facility. According to EI #7, all water heaters, with the exception of the one located on the B-wing had been replaced. ************************* On 11/02/2017 at 11:28 p.m., the facility submitted an acceptable Allegation of Compliance (AoC), which documented: 1. On 10/19/17 at 5:50am, RI # 1 sustained a second degree burn to the left forearm. Resident received immediately was evaluated by LPN and RN supervisor and first aide administered. The attending physician was notified at 6:32am and resident representative notified at 6:47am. Immediately after RI #1 Representative arrived, the resident was transported to the emergency room for evaluation and treatment. RI#1 was treated and returned to the facility the same day. RI #1 received follow up care with the wound center on 10/23/17 at 11:00am and on 10/27/17 where she was discharged from their care. 2. All other residents receiving care from responsible Certified Nursing Assistant have been evaluated and have no skin injury related to exposure to hot water. 3. All residents residing on B wing have had a skin assessment completed from 10/19/17 through 11/2/17 and no water related injury noted. A complete skin audit was performed on 11/2/17 for all residents that reside on B-wing and again no issues were noted. 4. The facility completed a review of all accident and incidents over the past 6 months were reviewed and no other burn injuries were noted related to hot water. 5. The certified nursing assistant was suspended immediately on 10/19/17 pending investigation. The certified nursing assistant then received 1:1 in-service education on 10/20/17 regarding never heating water from alternative sources for bed/showering. The CNA who heated the water will be monitored each time she works when giving a bed/shower bath to ensure that no water is heated by her. 6. All RN's, LPN's CNA's received In-servicing on 11/2/17 regarding never heating water from an alternative source for bathing and how to check water temps with a thermometer any staff that has not been in-serviced will not be allowed to work until in-services have been completed. The Director of Nursing in-serviced the RN's and LPN's on 11/2/17 then the RN's, LPN's in-serviced the CNA's. The RN's, LPN's and CNA's will be in-serviced on the 11-7 and 7-3 shift by the RN supervisor as the employees clock in for their shift. The employees will be stopped and in-serviced before they are allowed to work. CNA's will be monitored while giving bed/shower baths three times a week until the water issue can be resolved. 7. The Facility hired a local plumber on 11/1/17 and he came to the facility twice that day but no issues with water temperatures or availability of hot water on B wing were identified. Also the plumber returned to the facility on [DATE] and again found no issues with the water on B-wing. The facility has since hired a third plumbing service that will arrive at 11Am 11/3/17 to further assess irregularities in water temperatures. He will be accompanied by a Property Development manager. An ongoing investigation related to the water on B-wing will continue in the meanwhile to maintain safety of the residents the shower room on B-wing will remain closed until a solution of the water issue can be resolved. All residents on B wing requiring or desiring a bed bath will be allowed to test the water for comfort by touching the water with their fingers. Prior to allowing the resident to check the water the Certified Nursing Assistant will ensure that the bath water is between 100-110 degrees by checking the temperature with a thermometer. 8. The Maintenance Director, Maintenance Assistant, and Executive Director have completed in-service education on 11/2/17 by the governing body on recording water temperatures on a daily basis to be recorded on the shifts of 7:00am-3:00pm, 3:00pm-11pm, and 11:00pm-7:00am, while immediately reporting any concerns to the Executive Director for resolution. Included in this education is the requirement that if temperatures are not between 100-110 they will require a corrective action and resolution by the Executive Director to ensure correction is validated. Any corrections that may be needed will be logged and reviewed by the Executive Director. The logs will be documented and kept in the maintenance office to be monitored and signed off by the Executive Director to ensure proper oversight of Maintenance. The Director of Nursing will sign each log additionally to ensure the Executive Director is properly monitoring the logs. ************************* After reviewing the facility's documentation of items outlined in their AoC, inservice records completed as of 11/03/2017 and interviews with facility staff including Maintenance, the Administrator, CNAs, LPNs and RNs on multiple shifts, and observing to verify the microwave was removed as specified, it was determined the facility had implemented their AoC. The immediate jeopardy was relieved and the scope and severity was lowered to a E level on 11/03/2017 at 12:45 a.m This deficiency was cited as a result of the investigation of complaint/report number AL 394.

Based on observations, record review, interviews, and review of the facility's job descriptions for the Executive Director (Administrator) and the Director of Maintenance, the Director of Maintenance failed to communicate to the Executive Director (Administrator) that residents and staff members had voiced concerns, repeatly about the water temperatures not getting hot enough to a comfortable level on the B wing of the facility. Furthermore, the Administrator became aware of a Resident Identifier (RI) #1 receiving a second degree burn as a result of Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) heating water in the microwave, but failed to ensure the facility put a plan in place that would address the problem. The Administrator failed to provide oversight to ensure problems with the water temperatures were addressed. This deficient practice placed all 42 residents residing on the B-wing, one of four units in the facility, in immediate jeopardy, as the deficient practice was likely to result in serious harm, impairment, injury, or death to these residents. On 11/02/2017 at 4:30 p.m. EI #2, the Administrator, and EI #3, the Director of Nursing, were notified of the findings of Immediate Jeopardy at F490, Administration. Findings include: Refer F 323 and F 465 The Maintenance Director's, EI #7's, Job Description effective 8/1/2012, revealed the following . General Description Under the direction of the Executive Director, the Director of Maintenance is responsible to plan and direct the activities of the maintenance staff and is accountable for the upkeep of the grounds, Facility and equipment in a safe and efficient manner . Essential Duties . 2. Acts appropriately under the direction of the Executive Director as an active member of the interdisciplinary team . 5. Verifies that the Facility and its equipment are properly maintained for resident comfort and convenience . Standard Requirements . 3. report and/or correct unsafe working conditions, equipment repair and maintenance needs . 5. Supports and participates in common teamwork: . c. Follows up as appropriate with supervisor, co-workers or residents regarding reported complaints, problems and concerns . EI #7, the Maintenance Director, was interviewed on 10/31/2017 at 2:30 PM. EI #7 said the temperature of the water should be between 112 to 115 degrees F. EI #7 said sometimes it got lower than that, as he had seen the water temperature get as low as 98 degrees F. According to EI #7, it depended on the time the water temperature was checked. EI #7 said he normally got to the facility around 6:00 AM. EI #7 explained that if the water temperature was checked around the time of showers, the temperature would be lower. EI #7 further explained that when this happened, he would just go back again in a few hours and check the water temperature again, but that would probably not be documented anywhere. EI #7 was asked if he had received any complaints about the water temperature. He said he had been at the facility a little over a year and he had heard residents say the water was cold. EI #7 could not recall the last time a resident or staff member voiced a complaint to him about the water temperatures. EI #7 was then shown a copy of the note dated 9/16/2017 (a Saturday) from the 11 PM - 7 AM B-wing CNAs that documented the water is not getting hot. EI #7 said he did recall that but said he felt it was a lie. EI #7 said he checked the water temperatures the following Monday and the water temperatures were over 100 degrees F. EI #7 was then asked about the temperature documented on 10/13/2017 of 81 degrees F. EI #7 said that temperature could have been due to other people using hot water at the time. EI #7 explained the staff has to allow the hot water to build back up. According to EI #7, on 10/13/2017, he would have rechecked the water temperature in an hour or two, but acknowledged it was not documented anywhere. When asked why it was important to ensure the availability of water at a temperature acceptable for resident care, EI #7 said it was important for cleaning bacteria from hands, the CNAs and nurses use it, and it was important for resident comfort. EI #7 indicated the B-wing had a 100 gallon gas water heater to provide hot water to 23 resident rooms, 23 residents' sinks, the pantry, the nurses' bathroom, and the shower room. When asked if 100 gallons was sufficient to meet the demands of the unit, EI #7 said the water heater on the B-wing was the same one installed when the building was built, so he felt it was sufficient. When asked how it was sufficient if there were times the demand for hot water exceeded the amount available, EI #7 said it was due to usage. EI #7 said a larger water heater would increase the supply of hot water to help meet the demand. EI #7 said he distinctly remembered a conversation with the CNAs in which he told them they may need to wait 15 to 20 minutes for the hot water to build back up. When asked if her ever reported this concern to the Administrator, EI #7 said no. When asked if he should have made the Administrator aware of his concern, EI #7 said yes, the Administrator should have been made aware that at times there could be problems with the supply and demand of hot water. The Administrator's, EI #2's Job Description, effective 8/1/2012, revealed the following: . General Description: The Executive Director leads and directs the overall operation of the Facility in accordance with resident needs, government regulations and Facility policies so as to maintain quality care for the residents . Essential Duties 1. Monitors each department's activities, . evaluates performance, provides feedback and assists . During an interview on 10/31/2017 at 5:45 p.m., EI #2, the Administrator, stated he was not aware the CNAs had voiced concerns about not having hot water as recently as 09/2017. When asked if he should have been informed of the concern, EI #2 said he would not need to be notified if Maintenance solved the issue. EI #2 said staff should be able to get water from other areas of the building. EI #2 stated if residents want water than the sink, they should be accommodated, within regulation. EI #2 was then asked about the need for hot water on each unit for the purposes of handwashing. EI #2 then said obviously, staff need to be able to wash hands in the room where care is being provided. EI #2 said the facility could have been doing more frequent water temperature monitoring to determine why the temperatures were different depending on the time of day. During a follow-up interview with EI #2, the Administrator, on 11/02/2017, EI #2 was asked who monitored Maintenance to ensure concerns were corrected. EI #2 said he was the Maintenance Director's supervisor. When asked how he monitored the Maintenance Director, EI #2 said they have monthly and as needed department head meetings. EI #2 explained they would not go into detail on each work order, but if Maintenance felt there was a problem that did not get corrected, they would let him know. When asked if it would be acceptable for the Maintenance Director to tell the CNAs (on B wing) to wait 15 minutes for hot water when they are providing care to residents, EI #2 said he did not know. When asked what he meant by that, EI #2 asked the surveyor to repeat the question and stated, I don't know how to answer that. When asked what was done to address the concern from 09/16/2017 (from Maintenance Request Logs) regarding the water not getting hot, EI #2 said he did not know and had not seen that note previously. EI #2 was asked if the facility made an attempt to monitor the water temperatures during the time for which the CNAs were reporting the problem with water temperatures. EI #2 again stated he did not know. When asked how the action of the CNA was monitored, EI #2 said he did not know, and indicated the surveyor should speak with the Director of Nursing. EI #2 also stated he did not know if the CNAs needed to be monitored. EI #2 was then asked who was ultimately responsible for the facility. EI #2 said he was. He was also asked if there was a system in place to ensure that what Maintenance reported as corrected was actually corrected. Again, EI #2 said he did not know. EI #2 said he hired the Maintenance Director to monitor the problems, and if he said they are resolved, they were. ************************* On 11/02/2017 at 11:28 p.m., the facility submitted an acceptable Allegation of Compliance (AoC), which documented: 1. The Maintenance Director, Maintenance Assistant, and Executive Director have completed in-service education on 11/2/17 by the governing body on recording water temperatures on a daily basis to be recorded on the shifts of 7:00am-3:00pm, 3:00pm-11pm, and 11:00pm-7:00am, while immediately reporting any concerns to the Executive Director for resolution. Included in this education is the requirement that if temperatures are not between 100-110 they will require a corrective action and resolution by the Executive Director to ensure correction is validated. Any corrections that may be needed will be logged and reviewed by the Executive Director. The logs will be documented and kept in the maintenance office to be monitored and signed off by the Executive Director to ensure proper oversight of Maintenance. The Director of Nursing will sign each log additionally to ensure the Executive Director is properly monitoring the logs. 2. The Facility hired a local plumber on 11/1/17 and he came to the facility twice that day but no issues with water temperatures or availability of hot water on B wing were identified. Also the plumber returned to the facility on [DATE] and again found no issues with the water on B-wing. The facility has since hired a third plumbing service that will arrive at 11Am 11/3/17 to further assess irregularities in water temperatures. He will be accompanied by a Property Development manager. An ongoing investigation related to the water on B-wing will continue in the meanwhile to maintain safety of the residents the shower room on B-wing will remain closed until a solution of the water issue can be resolved. All residents on B wing requiring or desiring a bed bath will be allowed to test the water for comfort by touching the water with their fingers. Prior to allowing the resident to check the water the Certified Nursing Assistant will ensure that the bath/shower water is between 100-110 degrees by checking the temperature with a thermometer. If the resident expresses that water is too cool, water will be obtained from an alternate faucet in efforts to ensure resident comfort is achieved. If the resident expresses the water is too warm it will be cooled down by adding cool water. The shower room on B wing was rendered out of order on 10/31/17 until the root cause of fluctuating temperatures could be identified and resolved. Showers will be offered on alternate wings. ************************* After reviewing the facility's documentation of items outlined in their AoC, inservice records completed as of 11/03/2017 and interviews with facility staff including Maintenance, the Administrator, CNAs, LPNs and RNs on multiple shifts, and observing to verify the microwave was removed as specified, it was determined the facility had implemented their AoC. The immediate jeopardy was relieved and the scope and severity was lowered to a E level on 11/03/2017 at 12:45 a.m This deficiency was cited as a result of the investigation of complaint/report number AL 394.

Based on observations, record review, interviews, and review of the facility's policy titled Quality Improvement Committee, the facility's Quality Assessment and Assurance Committee failed to develop an action plan that addressed all causal factors after RI #1 sustained a second degree burn during the provision of a bed bath on 10/19/2017. This deficient practice placed all 42 residents residing on the B-wing, one of four units in the facility, in immediate jeopardy, as the deficient practice was likely to result in serious harm, impairment, injury, or death to these residents. On 11/02/2017 at 4:30 p.m. EI #2, the Administrator, and EI #3, the Director of Nursing, were notified of the findings of Immediate Jeopardy at F520, Administration. Findings include: Refer to F 323, F 465 and F 490 Review of the facility's policy titled Quality Improvement Committee, dated 12/2013, revealed the following: POLICY: The Quality Improvement Committee will assess and monitor the quality of services provided to the residents of the facility in order to identify potential systemic problems. The committee will implement and systematically evaluate processes to identified problems in order to proactively improve health care delivery. OBJECTIVES: . 7. Perform root cause analysis, set targets; implement corrections to improve the process . Review of the facility's action plan related to Resident Identifier (RI) #1's burn on 10/19/2017 revealed a meeting was held on the day the incident occurred. However, review of the facility's action steps indicated no monitoring of the CNAs was implemented to prevent a recurrence. EI #8, the Quality Assurance Nurse, who signed the incident report related to RI #1's burn, was interviewed on 11/01/2017 at 11:00 a.m EI #8 indicated she reviewed the incident report for RI #1's 10/19/2017 burn to make sure notifications were made, documentation was complete, and interventions were put in place. When asked what happened, EI #8 said from what she understood, a CNA on night shift (EI #1) was assisting with a bed bath, but RI #1 complained the water was not hot enough. The CNA then heated the water in the microwave in an attempt to accommodate the resident. The CNA bumped the table and the hot water fell on RI #1's arm. When asked if the facility developed a plan to address the facility's lack of hot water on the B wing, EI #8 said from what she could recall, Maintenance indicated the temperatures were in range, so nothing was done. EI #8 said as far as the burn, they started inservices and educated the CNA involved about not heating water in the microwave. EI #8 said, That's pretty much it. During a follow-up interview with EI #8 on 11/01/2017 at 4:00 p.m., EI #8 was asked if the faciilty developed a plan to address monitoring for ensuring this type of incident did not recur. EI #8 said she did not think the facility had done any monitoring of the CNAs. When asked why monitoring should have occurred, EI #8 said that might be a better question for the Director of Nursing. During an interview with EI #3, the Director of Nursing, on 11/01/2017 at 4:10 p.m., EI #3 said she did not feel there was a need to monitor the actions of the CNA that led to RI #1's burn. ************************* On 11/02/2017 at 11:28 p.m., the facility submitted an acceptable Allegation of Compliance (AoC), which documented: 1. A meeting of the Quality Assurance Committee was completed 11/1/17 with the follow staff members in attendance: Executive Director, Director of Nursing, Medical Director, Maintenance Director, QA nurse and an RN. 2. A comprehensive action plan was developed and approved by the committee to correct the water temperature concern on B wing and to prevent any staff member from heating water in microwave for bathing/showering. ************************* After reviewing the facility's documentation of items outlined in their AoC, inservice records completed as of 11/03/2017 and interviews with facility staff including Maintenance, the Administrator, CNAs, LPNs and RNs on multiple shifts, and observing to verify the microwave was removed as specified, it was determined the facility had implemented their AoC. The immediate jeopardy was relieved and the scope and severity was lowered to a E level on 11/03/2017 at 12:45 a.m This deficiency was cited as a result of the investigation of complaint/report number AL 394.