Every finding on record at Providence Living Center

Based on observation, record review, and interviews, the facility failed to provide adequate supervision for Resident (R) 1, who took medications to prevent alcohol relapses and was at risk for self-harm, to prevent an elopement and the staff did not identify the resident was missing for over nine hours. On 06/14/2026 at approximately 04:18 AM staff observed R1 wandering in the facility and this was the last time staff knew R1's whereabouts. On 06/14/2026 at approximately 02:00 PM, staff identified R1 was not in her room, and it appeared she had not been there all day. During the time R1 was out of the facility, without staff knowledge or supervision, there were severe thunderstorm warnings, flash flood warnings, and the temperatures ranged from a low of 55 degrees Fahrenheit (F) to highs of 81 degrees F. The facility's failure to monitor R1 to prevent elopement and self-harming behaviors placed R1 in immediate jeopardy. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of anxiety disorder, posttraumatic stress disorder (PTSD), borderline personality disorder (disorder characterized by disturbed and unstable interpersonal relationships and self-image along with impulsive, reckless, and often self-destructive behavior), insomnia, major depressive disorder, schizoaffective disorder bipolar type (a chronic mental health condition that combines symptoms of schizophrenia with episodes of mania and sometimes depression), and nicotine dependence. R1's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1's MDS documented inattention, disorganized thinking, and an altered level of consciousness with behaviors that were present but fluctuated. The MDS documented R1 had hallucinations and delusions, which occurred one to three days during the look-back period. The MDS documented R1 had little interest or pleasure in doing things, felt depressed or hopeless, had trouble falling asleep or slept too much, felt tired or had little energy, felt bad about herself and thought she would be better off dead or of hurting herself in some way, for 12 to 14 days during the look-back period. The MDS documented R1 had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. R1 was independent with her activities of daily living (ADL). R1 took antianxiety, antidepressant, and anticonvulsant (medication used to prevent seizures) medications. The MDS documented R1's change in behavior or other symptoms of current behavior status, care rejection, or wandering compared to prior assessment were worse. R1's Cognitive Loss Care Area Assessment (CAA) dated 09/23/2025 documented R1 had behaviors of drinking all types of alcohol related to PTSD, anxiety disorder, borderline personality disorder, and major depressive disorder. R1 would be free from drinking all types of alcohol, including hand sanitizer, and the staff would monitor R1 for alcohol drinking behaviors. R1's Psychosocial Well-Being CAA dated 09/23/2025 documented R1 had the potential to demonstrate physical behaviors with a history of hitting and kicking staff, non-compliance, worrying, pacing related to depression, a history of harm to others, and refusing showers. The CAA documented if R1 became agitated, staff were to intervene before agitation escalated, guide R1 away from the source of distress, and engage R1 calmly in conversation. If R1 responded aggressively, staff were directed to walk calmly away and approach R1 later. R1's Falls CAA dated 09/23/2025 documented R1 was at risk for falls and she took psychoactive drugs that put her at risk for falls. The CAA documented R1 was encouraged to wear appropriate non-slip footwear and keep the floor free from spills, and/or clutter. R1's Quarterly MDS dated 03/26/2026 documented she had a BIMS score of 15. The MDS documented R1 had hallucinations, delusions, physical behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others four to six days during the look-back period. R1's Behaviors for Drinking All Types of Alcohol Care Plan revised 11/11/2025 documented R1 was at risk for self-harm. The plan of care further documented R1 had ingested chemicals such as laundry soap related to her diagnosis of borderline personality disorder and schizophrenia. R1's plan of care documented R1 would alert staff when she left the faciity on pass. R1's plan of care directed staff to report any signs or symptoms of intoxication, such as tiredness, confusion, altered mental status, agitation, refusal of care, etc., to the charge nurse. Review of R1's Guardianship and Conservatorship document revealed R1 had a court-appointed guardian as of 07/21/2023. R1 was documented as an adult with an impairment in need of a guardian and conservator. R1's Nursing: Wandering and Elopement Evaluation 2016 dated 05/13/2026 documented a score of 1.0, which indicated no wandering/elopement risk. R1's physician orders recorded an order for Naltrexone (prescription medication used to treat alcohol use disorder and opioid use disorder) medication 50 milligrams (mg) tablet by mouth at bedtime for alcohol relapse prevention ordered on 07/18/2025. Review of R1's Monitoring: Wandering on the Tasks tab dated 06/14/2026 at 04:18 AM documented R1 was wandering. R1's Nursing Note dated 06/14/2026 at 05:52 PM documented the charge nurse was informed at approximately 02:00 PM that R1 was not in her room, and it appeared she had not been in her room all day. R1's room reportedly looked the same as it had around noon when the Certified Medication Aide (CMA) went in to give R1 her medications (R1 was not in the room at that time). Staff confirmed the resident had not shown up for smoke breaks. R1's room, including the bathroom and closet, were searched as well as the smoking area including the stairwells, but R1 was not found. The facility was searched further, staff spoke with R1's peers, and the outside perimeter was searched. R1's roommate stated the last time she saw R1 was at 03:00 AM. The facility contacted and informed R1's guardian at 03:20 PM and notified law enforcement (LE) at 03:24 PM. Staff called both emergency rooms (ER) to see if R1 was there, but both ERs denied that R1 was there. R1's Third Eye Health Note dated 06/14/2026 at 06:18 PM documented R1 was an elopement risk with a history on eloping from a previous facility and was last seen by facility staff at 04:00 AM. The orders documented staff were to notify the clinician if R1 returned to the facility. R1's Nursing Note dated 06/14/2026 at 07:11 PM documented staff called LE for a status update. The facility called R1's guardian and updated him of R1's elopement status and that R1 was still not present in the facility. R1's guardian gave permission to the facility to reach out to R1's ex-spouse so staff called left a message. R1's Nursing Note dated 06/14/2026 at 09:47 PM documented facility staff updated R1's guardian that R1's room appeared to be more decluttered, and her belongings were no longer in the dresser drawers. R1's guardian stated that R1 had a history of leaving facilities in the past. The facility told R1's guardian that R1's absence appeared intentional. R1's guardian stated he would go look for R1 but did not know where to look for her. The facility stated they would keep him updated. R1's Nursing Note dated 06/14/2026 at 10:12 PM the facility contacted emergency services via 911 to provide an update that R1 had not been located and she was not returning phone calls. R1's Nursing Note dated 06/14/2026 at 10:18 PM documented the facility asked R1's guardian if he might know where R1 would have gone. R1's guardian stated that the last time R1 had done this, she was out drinking alcohol and staying behind convenience stores and other places. R1's Nursing Note dated 06/15/2026 at 03:11 PM documented the facility spoke with R1's ex-spouse, who reported R1 was not with him. He would not share family contact information with the facility when asked. R1's ex-spouse revealed R1 had two close family members who lived in town. Review of R1's June 2026 Medication Administration Record (MAR) revealed an order to monitor closely for misuse of alcohol containing perfumes and hand sanitizers every shift for a history of alcohol abuse. The MAR was blank (indicating not done). R1's June 2026 MAR recorded a 1 for most of the morning medications indicating the resident refused the medications. The noon medications were charted as 11 to indicate out [of facility] without medications. Review of R1's June Behavior Monitoring Record lacked any documentation for R1 for 06/14/26. Review of Wunderground.com for 06/14/26 to 06/16/26 revealed several thunderstorm warnings and flash flood warnings, and the temperatures ranged from a low of 55 degrees Fahrenheit (F) to highs of 81 degrees F. Licensed Nurse (LN) H's unnotarized Witness Statement dated 6/13/26 [sic] documented R1 communicated with LN H around 09:30 PM to 10:00 PM on 06/13/2026 to discuss her medications. LN H documented that around 04:00 AM (on 06/14/2026) she had visual contact with R1. LN H documented R1 was ambulating up the hallway around the nurse's desk. CMA S's unnotarized Witness Statement dated 06/14/2026 documented CMA S went to R1's room for the noon medication pass. CMA S documented R1 was not in her room and CMA S continued her medication pass. CMA S documented that she went back to look for R1, could not locate her, and then told the charge nurse right away. LN I's unnotarized Witness Statement documented on 06/14/2026 LN J informed LN I that R1 had not been seen for some time, and LN J asked if LN I had seen R1. LN I documented she had not seen R1 and then followed LN J to attempt to locate R1. On 06/16/2026 at 10:25 AM, Certified Nurse Aide (CNA) M stated she checked on her residents every two hours. CNA M stated that if a resident normally smoked and that resident was not available at the designated smoking time, she would go look for the resident to see where they were. CNA M stated R1 usually woke up late in the day and if R1 had not come out for the smoke breaks she would have gone to look for R1. On 06/16/2026 at 10:30 AM, CMA R stated staff were supposed to check on residents every two hours. On 06/16/2026 at 10:33 AM, LN G stated that on his shift, the staff were always good at looking for the residents if the residents have not been seen for over 20 minutes. LN G stated that if a resident was not seen either by himself or another staff member, he would go check on that resident. On 06/16/2026 at 10:52 AM, Administrative Nurse D stated that R1 was located at the hospital, detoxing. On 06/16/2026 at 10:59 AM, Administrative Nurse D stated she expected her staff to locate R1 if she had not been seen for a while. On 06/16/2026 at 10:57 AM, Administrative Staff A stated R1 took her belongings out as she left the building on pass. He stated R1 had been doing this for the past three weeks after the facility started to investigate the concern. Administrative Staff A stated he did not feel this was an elopement due to R1's planning. Administrative Staff A revealed that R1 did not have approval from her guardian for an overnight pass or to be out on pass. Administrative Staff A stated he felt the facility had protective oversight for R1 with a guardian but still did not feel that R1 had eloped from the facility. On 06/16/2026 at 01:10 PM, R1's guardian stated he was notified R1 was at the ER. R1's guardian stated he went to the ER to help R1 and see about her treatment, but she left before he arrived. R1's guardian stated he was unsure where she went. R1's guardian confirmed that as of the time of the interview, R1's location was still unknown. The facility's F689 Accidents - Elopements policy, last approved June of 2025, documented the staff would evaluate, investigate, and report all cases of missing residents. The policy documented that an elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge or supervision if necessary, and the situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration, and/or other medical complications, drowning, or being struck by a motor vehicle. The policy further documented for residents with Substance Use Disorder (SUD) staff would address the risk of leaving the community to satisfy an addiction to alcohol, prescription drugs, or illegal substances. On 06/16/26 at 02:50 PM, Administrative Staff A and Administrative Nurse D received the Immediate Jeopardy [IJ] Template and were informed that the facility's failure to provide adequate supervision to prevent an elopement and failure to monitor R1 to prevent self-harming behaviors placed R1 in immediate jeopardy. The facility submitted an acceptable IJ removal plan on 06/17/2026 which included the following corrective actions:Immediate Action Taken - Law Enforcement notification and guardian informed. Re-education sessions on elopement prevention policy were conducted with current staff. Re-education of elopement policy were completed on 06/16/2026.1:1 education with staff members was completed on 06/16/2026, with no staff member working until they were educated.The CMA that was involved in the occurrence was verbally coached on 06/14/2026 on the proper pathway of medication administration.Current licensed nursing staff were re-educated on medication administration and refusal protocols on 06/14/2026.IDT were educated on the process of Authorized Leave or Pass with differentiation of a day-pass versus an overnight pass.The involved door was immediately sealed and subsequently repaired the following day. Door checks were conducted on 06/14/2026 to ensure proper functionality. Access codes to the building were changed on 06/14/2026 Elopement assessments and care plans were reviewed on 06/14/2026 and updated as needed on 06/16/2026. The facility is collaborating with Guardian and Astra to coordinate placement for the resident at the a Detox Center.Re-education was provided to the Administrator and Director of Nursing per the regional team.The facility Completed an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 06/17/2026 regarding the event that occurred on 06/14/2026 and the elopement procedures. Implementation of the corrective actions and the removal of the immediate jeopardy was verified onsite on 06/17/2026. The deficient practice remained at a scope and severity of G (actual harm, isolated).

Based on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Findings included:- On 06/16/2026 at 02:30 PM, observation revealed the sidewalk that leads away from the patio right outside of the back doors from the dining room area had a four-foot-long by three inches wide gap in the sidewalk that dropped in depth, causing an uneven walking surface area on the sidewalk. Then approximately 16 feet down the sidewalk, going towards the back of the courtyard, there was a patched area to the sidewalk, approximately one foot wide by three feet long, with uneven cracks surrounding the outside of the patch that ranged from one inch in width to approximately six inches in width. Proceeding towards the back of the courtyard, approximately five feet further, there was another misshapen patch with cracks around the outside noted to be uneven with approximately a half an inch in depth, ranging from one inch to six inches in length. Proceeding from there, another 14 feet, another cement patch was applied with no change in depth or trip hazard seen. Proceeding four feet from that area, the sidewalk has an inch and a half wide gap the length of the sidewalk, approximately one fourth of an inch deep. About 15 feet from that gap in the sidewalk, there was a two-and-a-half-foot crack ranging in six inches to two inches in width, approximately one inch deep. At the intersection of the sidewalk that runs North and South at the back of the courtyard, the sidewalk going to the North side of the building has an area of cracked sidewalk, triangular in shape. The area was noted to have uneven ground around the crack. Proceeding to the North side, approximately six feet from the intersection, the sidewalk dropped approximately one inch across the width of the sidewalk. At the intersection of the sidewalk proceeding to the South side there are two significant cracks along the sidewalk that are angles cracks with a significant drop in height of one and a half inches on one angle, then the second angle had a height drop of an inch to a half an inch in height. On 06/16/2026 at 02:32 PM, Resident (R) 2 stated that the sidewalk was a risk for people to walk on. R2 further stated that people could fall because of those cracks. On 06/16/2026 at 02:33 PM, R3 stated that she felt the sidewalk was unsafe and was worried about people falling. On 06/16/2026 at 03:42 PM, Certified Nurses Aide (CNA) N stated that someone could trip on the holes in the sidewalk. CNA N stated she wished that the administration would repair the entire sidewalk like that one area. CNA N stated that there were big 'gashes' that someone could definitely fall or trip if they had a walker and that got stuck. On 06/16/2026 at 04:21 PM, Administrative Nurse D confirmed that the areas of the sidewalk had gaps and changes in height were present and a risk. Administrative Nurse D stated that the residents who walk out there had a risk of falling, especially if the resident has a cane or walker. The facility did not provide a policy related to environmental safety and care when asked on 06/16/2026 at 4:21 PM.

Based on record review and interview, the facility failed to identify an elopement that went undiscovered by staff for over eight hours as an allegation of neglect and report it to the State Agency (SA) as required. (Refer to F689) Findings included:- Resident (R)1's Electronic Medical Record (EMR) documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and borderline personality disorder (disorder characterized by disturbed and unstable interpersonal relationships and self-image along with impulsive, reckless, and often self-destructive behavior). R1's Annual Minimum Data Set (MDS) dated 09/23/2025 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1's MDS documented inattentive, disorganized thinking, and altered level of consciousness behaviors were present but fluctuated (comes and goes, changes in severity). The MDS documented R1 had hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue, persistent belief or perception held by a person, although evidence shows it was untrue) behaviors that occurred one to three days during the look-back period. The MDS documented R1 had little interest or pleasure in doing things, The MDS documented R1 had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. R1 was independent with her activities of daily living (ADL). R1 took antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), and anticonvulsant medications. The MDS documented R1's change in behavior or other symptoms of current behavior status, care rejection, or wandering compared to prior assessment noted to be worse. R1's Cognitive Loss Care Area Assessment (CAA) dated 09/23/2025 documented R1 had behaviors of drinking all types of alcohol related to PTSD, anxiety disorder, borderline personality disorder, and major depressive disorder. R1 would be free from drinking all types of alcohol, including hand sanitizer, and the staff would monitor R1 for alcohol drinking behaviors. R1's Psychosocial Well-Being CAA dated 09/23/2025 documented R1 had the potential to demonstrate physical behaviors with a history of hitting and kicking staff, non-compliance, worrying, pacing related to depression, a history of harm to others, and refusing showers. The CAA documented if R1 became agitated, staff were to intervene before agitation escalated, guide R1 away from the source of distress, and engage R1 calmly in conversation. If R1 responded aggressively, staff were directed to walk calmly away and approach R1 later. R1's Quarterly MDS dated 03/26/2026 documented R1 had a BIMS score of 15, which indicated cognition was intact. The MDS documented R1 had hallucinations, delusions, physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others one to three days during the look-back period. The MDS documented R1 displayed wandering behaviors that occurred four to six days during the look-back period. R1's Behaviors for Drinking All Types of Alcohol Care Plan revised 11/11/2025 documented R1 was at risk for self-harm. The plan of care further documented R1 had ingested chemicals such as laundry soap related to her diagnosis of borderline personality disorder and schizophrenia. R1's plan of care documented R1 would alert staff when she left the faciity on pass. R1's plan of care directed staff to report any signs or symptoms of intoxication, such as tiredness, confusion, altered mental status, agitation, refusal of care, etc., to the charge nurse. Review of R1's physician orders under the Orders tab revealed Naltrexone (prescription medication used to treat alcohol use disorder and opioid use disorder) medication 50 milligrams (mg) tablet, give one tablet by mouth at bedtime for alcohol relapse prevention ordered on 07/18/2025. Review of R1's Monitoring: Wandering on the Tasks tab dated 4/14/2026 documented R1 was wandering at 04:18 AM. Review of R1's Guardianship and Conservatorship document noted that R1 had a court-appointed guardian as of 07/21/2023. R1 was documented as an adult with an impairment in need of a guardian and conservator. R1's Nursing Note dated 06/14/2026 at 05:52 PM documented the charge nurse was informed at approximately 02:00 PM that R1 was not in her room, and it appeared that R1 had not been in her room all day. R1's room reportedly looked the same as it had when the Certified Medication Aide (CMA) went in around noon to give R1 her medications. Staff confirmed the resident had not shown up for smoke breaks. R1's room, including the bathroom and closet were searched, the smoking area, including the stairwells were searched, and R1 was not found. The facility was searched further, R1's peers were spoken to and the outside perimeter was searched. R1's roommate stated that the last time she had seen R1 was at 03:00 AM. R1's guardian was contacted and informed at 03:20 PM, and law enforcement (LE) was notified at 03:24 PM. Staff called both emergency rooms (ER) to see if R1 was there, at which both ERs denied having R1. R1's Third Eye Health Note dated 06/14/2026 at 06:18 PM documented R1 was an elopement risk with a history on eloping from a previous facility and was last seen by facility staff at 04:00 AM. The orders documented to notify clinician if R1 returned to the facility. On 06/16/2026 at 10:57 AM, Administrative Staff A stated that R1 had taken her belongings out like she left the building on a pass. Administrative Staff A stated he did not feel this was an elopement due to R1's planning. Administrative Staff A revealed that R1 did not have approval from her guardian for an overnight pass or to be out on pass. Administrative Staff A stated he felt the facility had protective oversight for R1, along with R1'but still did not feel that R1 had eloped from the facility therefore the facility had not reported it to the SA The facility's F 609, Reporting of Abuse Allegations policy, last approved in October of 2025, documented that an alleged violation was a situation or occurrence that was observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, abuse, including injuries of unknown source, and misappropriation of resident property. The facility's policy documented that should the investigation reveal findings of abuse, such findings would be reported to the State Abuse Registry or other agencies deemed appropriate by the state. If the abuse rises to the level of a suspicious crime, then the following reporting schedule is to be adhered to. The policy further documented that reporting was based upon real clock time, not business hours: Seriously bodily injuries are reported with in two-hour limit, and all others are reported within 24 hours.

The facility identified a census of 69 residents. The sample included three residents. Based on record review, observation, and interview, the facility failed to ensure medications were secured and inaccessible to residents. On 02/11/26 at 07:55 PM, the pharmacy delivered three bags of medications to the facility, which included one white bag, one blue bag, and one red bag. The red bag contained 90 tablets (tabs) of alprazolam (a medication used to treat anxiety, panic disorders, and depression) and 90 tabs of lorazepam (a medication used to treat anxiety, insomnia, and seizure disorders). Licensed Nurse (LN) G took possession of the medications and left them in the nurse's station without securing them. At 09:55 PM, Resident (R) 1 and R2 identified the nurse's station was unmanned. R2 went into the unsupervised, unsecured area, obtained some drinking cups, and at the request of R1 took the red bag of medications. R2 then gave the bag of medications to R1. R1 took the pills back to his room and at an unknown time, ingested 14 alprazolam and 18 lorazepam. Early the next morning, on 02/12/26 at 12:40 AM, R1 was lethargic, could not speak, and had repeated episodes of vomiting. R1 went to the hospital, where he was intubated (a critical medical procedure involving the insertion of a tube into the windpipe to maintain an open airway, deliver oxygen, and connect patients to a mechanical ventilator (a machine used when a patient cannot breath on their own.) and treated for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) due to inhalation of vomit.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), suicidal ideation (thoughts of death or harm to self), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R1's Quarterly Minimum Data Set (MDS), dated 01/12/26, documented R1 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R1 had a total mood severity score of 24, which indicated severe depression. R1 had hallucinations, delusions, and rejection of care during the look-back period. R1 was independent for all activities of daily living (ADLs). The MDS documented R1 received anti-psychotic (class of medications used to treat major mental conditions which cause a break from reality) medications, anti-anxiety (class of medications that calm and relax people) medications, and anti-depressant (class of medications used to treat mood disorders) medications during the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/26/25, documented R1 had multiple comorbidities (the presence of one or more additional conditions co-occurring with a primary disease). The CAA documented R1 had wandering behaviors and a diagnosis of schizophrenia. The Care Plan, dated 12/24/25, documented R1 experienced trauma-related distress, hallucinations, and substance use which exacerbated suicidal thoughts. The care plan directed staff to monitor grief cues, hallucinations, intoxication/withdrawals as triggers and to initiate immediate safety supports and redirection (12/24/25). The care plan documented R1 experienced intermittent passive suicidal ideation and required continued emotional support and monitoring to maintain R1's safety and emotional stability. The care plan directed staff to assess for suicidal ideation, intent, and plan each shift (especially at night). The Pharmacy Receipts, dated 02/11/26, documented the pharmacy delivered 90, 1 milligram (mg) tablets of alprazolam to the facility on [DATE] at 07:55 PM. LN G signed for the medications. The Pharmacy Receipts, dated 02/11/16, documented the pharmacy delivered 90, 0.5 mg tablets of lorazepam for R4 to the facility on [DATE] at 07:55 PM. LN G signed for the medications. The Nurses Note, dated 02/12/26 at 01:19 AM, documented R1 ambulated to the nurse's station, staggering and swaying around 12:40 AM. R1 was lethargic, unable to open his eyes, and had slurred speech. R1 was given a glass of water and then threw it as he walked back down the hallway to his room. The LN went to R1's room to perform an assessment. Upon entering R1's room the LN saw R1 vomit from his nose and mouth. The vomit was very dark. R1 had short, labored breaths, incoherent speech, and exhibited lethargic behavior. The Certified Nurse's Aide (CNA) and LN assisted R1 to the nurse's station. The primary care provider was notified, and orders were received to send R1 to the hospital. R1 continued to vomit. R1's vital signs measured as follows: blood pressure 209/190 millimeters of Mercury (mm/Hg) (high), pulse 78 beats per minute, and respirations 12 breaths per minute (low). Emergency Medical Service (EMS) responded and transported R1 to the hospital. The Social Services Note, dated 02/12/26 at 07:45 AM, documented the Social Services Designee communicated with R1's responsible party and informed her R1 was currently in the intensive care unit and was intubated. The Social Services Note, dated 02/12/26 at 08:48 AM, documented R1's responsible party notified the Social Services Designee R1 had developed pneumonia and fever secondary to suspected fluid aspiration into his lungs. R1's responsible party reported medical staff was performing a bronchoscopy-type (a procedure where a thin, lighted tube is inserted through the nose or mouth to view the airways and lungs) procedure to visualize R1's airways and remove accumulated pulmonary secretions. The unnotarized e-mailed statement from LN G, dated 02/12/26, documented LN G signed for the medication and set it aside, putting them on the overflow med cart to be put away later. Later in the shift, Certified Medication Aid (CMA) R put the medications that arrived earlier in the shift away. CMA R's unnotarized Witness Statement, dated 02/12/26, documented CMA R stated she never received a hand transaction of medications from LN G or anyone on 02/11/26 and further stated she never received any narcotics or a red bag of medications. CMA R stated she saw the blue bag and white bag of medications and put them in the overflow medication cart. LN I's unnotarized Witness Statement, dated 02/12/26, documented on 02/12/26 at approximately 08:00 PM, revealed Housekeeping Staff came and told her he found a stack of pill cards in the paper towel dispenser. LN I stated there were three cards of alprazolam 1 mg tablets, two of the cards were full of 30 tablets each, and one of the cards had 12 tablets out of 30 tablets left. The medications were prescribed to R3. The other set of three cards were noted to be lorazepam 0.5 mg; two of the cards were full of 30 tablets each, and one of the cards had 16 tablets out of 30 tablets left. The medications were prescribed to R4. The Nurses Note, dated 02/16/26, documented R1's responsible party reported R1 was sedated and on a ventilator. The Facility Incident Report, dated 02/19/26, documented at approximately 11:49 AM, LN H reported that narcotic medications were missing from the medication supply for R3 and R4. The medications missing were alprazolam and lorazepam. LN H reported the medications were delivered to the facility on [DATE]. Upon notification, all medication carts on the unit were checked and the missing narcotics were not located. The pharmacy delivery forms could not be located, and the controlled substance count sheets were also not located. The pharmacy was contacted regarding the missing medications, and they reported the controlled substances were delivered on 02/11/26 at 07:55 PM. LN G stated upon receipt of the medications he gave the medications to CMA R to put away. CMA R reported putting medications away but did not recall any of them being controlled substances. Local police were notified, and camera footage was reviewed by Administrative Nurse D. Administrative Nurse D viewed LN G accepting the medication from the pharmacy delivery on 02/11/26 at 07:55 PM. LN G set the pharmacy delivery on a chair in the nurse's station, which included one white bag, one blue bag, and one red bag. Shortly after, LN G left the nurse's station (at approximately 09:55 PM), R1 and R2 were standing outside of the unattended nurse's station. R2, the female resident, walked into the nurse's station and began taking items, which included drinking cups and began putting them in her pockets. R2 pointed to the pharmacy bags located in the chair and directed R2 over to the bags. R2 took the red bag then walked out of the nurse's station and out of the line of sight of the camera. On 02/12/26 at 08:00 PM, housekeeping staff opened a paper towel dispenser in a resident's room and found the medications. The medications were counted and secured. The medication counts were alprazolam 72 tablets and lorazepam 76 tablets. The Social Services Note, dated 02/20/26 at 01:01 PM, documented R1 returned from the hospital. Social Services Designee and Administrative Nurse D met with R1 to discuss his health status and R1 admitted he had taken a handful of pills from a red package but believed they would not have a significant effect due to their size. When asked directly if this was a suicide attempt, R1 denied suicidal intent and stated he would not repeat the behavior. R1 verbalized remorse for his actions, however R1's affect was somewhat incongruent with the seriousness of the event. R1's affect ranged from euthymic (a state of normal, stable, and tranquil mood) to mildly elevated with intermittent laughter and playful demeanor while discussing the incident. On 03/10/26 at 10:00 AM, observation revealed the nurse's station was unattended. The swinging gate into the nurse's station was locked with a barrel bolt lock on the inside. This surveyor reached over the gate, unbolted the lock, and walked into the nurse's station. A resident stood at the counter of the nurse's station. On 03/10/26 at 01:00 PM, observation revealed R1 lying in his bed completely covered from head to toe with a blanket. This surveyor said R1's name, and R1 yelled, Get the [expletive] out of my room. An interview with LN G could not be obtained. On 03/10/26 at 10:45 AM, CMA R stated LN G never handed off any medications to her to be placed in the med cart. She found the white and blue bag of medication in the nurse's station and put the medications away. CMA R stated she never knew any narcotics were delivered. On 03/10/26 at 11:30 AM, Administrative Nurse D stated the medications were noted to be missing on 02/12/26 around noon. R3 and R4's medications, lorazepam and alprazolam, were found to be missing. The pharmacy was notified, and the pharmacy told the facility they were delivered the previous night at 07:55 PM to LN G and further revealed he had signed for them. Camera footage was reviewed, which showed LN G accepted the pharmacy delivery, put it down in a chair in the nurse's station, and then shortly after left the nurses' station. R1 and R2 were seen outside of the unattended nurses' station. R2, the female resident, went into the nurse's station, started picking up drinking cups and other random items, and started putting them in her coat. R1 was seen pointing to the bags of medication in the chair and directed her to the red bag. Administrative Nurse D stated R1 must have known narcotics were in the red bag. R1 and R2 walked out of the camera's view. R2 admitted to the facility staff she had given R1 the red bag of pills. Administrative Nurse D stated LN G lied when he said he had handed the medications off to CMA R. LN G was fired from the facility. Administrative Nurse D stated the facility did not know what exactly happened to R1 until after they found the pills in his room, R2 admitted to giving R1 the pills, and R1 admitted to taking a handful of the pills. Administrative Nurse D stated the medications should have been secured immediately to ensure all the residents were safe. On 03/10/26 at 01:30 PM, CMA S stated all staff educated regarding narcotic diversion, securing medications promptly after delivery, keeping residents out of staff work areas, and providing necessary supervision of residents. The facility's Storage of Medications Policy, revised October 2024, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility's Accepting Delivery of Medications Policy, revised November 2023, documented community staff shall follow a consistent procedure in accepting medications The facility's Safety and Supervision of Residents Policy, revised December 2007, documented the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. On 03/10/26 at 01:45 PM, Administrative Nurse D was provided the Immediate Jeopardy [IJ] Template and was notified the facility's failure to ensure medications were secured and inaccessible to residents placed the R1 in immediate jeopardy. The facility identified and implemented immediate corrective actions, which were completed on 02/13/26 and included: re-education on narcotic safekeeping to prevent diversions, as well as provision of adequate resident supervisions to ensure safety, LN G was terminated from employment. Since all corrective actions were completed on 02/13/26, prior to the onsite survey, the deficient practice was deemed past noncompliance and remained at a sope and severity of J ( isolated, immediate jeopardy).

The facility identified a census of 67 residents. The sample included 17 residents. Based on interview and record review, the facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents. Findings included: - A review of the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) for Fiscal Year (FY) 2025 Quarter 1, FY 2025 Quarter 2, FY 2025 Quarter 3, and FY 2025 Quarter 4 revealed the facility triggered for excessively low weekend staffing. Review of the Facility Assessment dated 01/01/25 documented the specific needs of each resident would be identified and adjusted as necessary. This included staffing needs for each shift, such as day, evening, night, and weekend. Day shift staffing would include two nurse shifts, four Certified Nurse Aide (CNA) shifts, and two Certified Medication Aide (CMA) shifts (eight total staff). Night shift would include two nurse shifts, two CNA shifts, and two CMA shifts (six total staff). The assessment documented there would be no change in staffing patterns during weekend and/or holiday shifts. The facility's schedule data documented the day shift was defined as 06:00 AM to 06:00 PM and the night shift was defined as 06:00 PM to 06:00 AM. Review of the facility's historical payroll data revealed the following: On 10/12/24 (Saturday), the day shift had four CNA staff on shift, but CNA Y clocked out at 06:10 AM and CNA AA clocked out at 01:20 PM, which left two CNA staff on the clinical floor. Three CMA staff on shift and two nurses, but Licensed Nurse (LN) LN G clocked out at 03:34 PM (six staff members for the full shift). Night shift had four CNA staff; however, CNA T and CNA DD clocked out at 09:35 PM, and CNA JJ clocked out at 12:00 AM, which left one CNA on the clinical floor. Two CMA staff, but CMA II, clocked out at 09:33 PM, and CMA EE clocked out at 09:42 PM, which left zero CMA staff on the clinical floor. Two nurse staff, but LN K, clocked out at 12:00 AM, which left one nurse on the clinical floor (two staff members for the full shift). On 02/08/25 (Saturday) day shift had three CNA staff on shift, two CMA staff on shift but the agency (contracted worker) CNA clocked out at 06:18 AM which left one CMA staff on the clinical floor, two nurse staff on shift from 06:00 AM to 07:00 AM, three nurse staff on shift from 07:00 AM to 02:00 PM, two nurse staff on shift from 02:00 PM to 02:30 PM, three nurse staff on shift from 02:30 PM to 04:00 PM, and two nurse staff on shift from 04:00 PM to 06:00 PM (five staff members for the full shift). Night shift had one CNA staff on shift from 06:04 PM, but CNA KK clocked out at 12:00 AM, which left zero CNA staff on the clinical floor. One CMA staff was on shift, but the agency CMA clocked out at 10:33 PM, which left zero CMA staff on the clinical floor. Two nurse staff on shift (two staff members for the full shift). Review of the facility's historical payroll data revealed on 04/26/25 (Saturday), the day shift had four CNA staff on shift, one CMA staff on shift, and two nurse staff on shift (seven staff members total). Night shift had zero CNA staff on shift, two CMA staff on shift, but CMA R clocked out at 09:13 PM, which left one CMA staff on the clinical floor and two nurse staff on shift (three staff members total for the full shift). On 07/06/25 (Sunday), the day shift had three CNA staff, but CNA S clocked out at 01:47 PM, and CNA O clocked in at 04:03 PM, which left one CNA staff on the clinical floor from 01:47 PM to 04:03 PM. One CMA staff shift and two nurse staff (four staff members total for the full shift). Night shift had two CNA staff, three CMA staff, and zero nurse staff on shift (five total staff members for the full shift). On 10/12/25 (Sunday), the day shift had four CNA staff on shift, but CNA Y clocked out at 06:10 AM and CNA AA clocked out at 01:20 PM, which left two CNA staff on the clinical floor. Three CMA staff on shift and two nurses, but Licensed Nurse (LN) LN G clocked out at 03:34 PM (six staff members for the full shift). Night shift had four CNA staff; however, CNA T and CNA DD clocked out at 09:35 PM, and CNA JJ clocked out at 12:00 AM, which left one CNA on the clinical floor. Two CMA staff, but CMA II, clocked out at 09:33 PM, and CMA EE clocked out at 09:42 PM, which left zero CMA staff on the clinical floor. Two nurse staff, but LN K, clocked out at 12:00 AM, which left one nurse on the clinical floor (two staff members for the full shift). During an interview on 12/18/25 at 11:40 AM, CMA T said that if the facility is short-staffed, the care team works together to get tasks done. Occasionally, if tasks go unperformed, it is the resident's showers that do not get done. CMA T revealed there are other staff in the building who are also CNAs who seldom help with tasks when the staffing is low. During an interview on 12/18/25 at 11:55 AM, CNA Q said that weekend staffing tends to run short of the required number of staff. CNA Q reported that when staff call off for a shift, it normally happens on nights and weekends, which makes caring for the residents hard. During an interview on 12/18/25 at 12:10 PM, CMA L said the facility does not utilize agency staff for CNAs anymore, just nurses. CMA L stated that low staffing is a problem at the facility, but would not address the subject further. The facility's Nursing Services F725, F726 policy, dated 04/2025, documented the facility provided adequate staffing to provide services to assure resident safety and attain or maintain the well-being of each resident. The facility would maintain adequate staffing on each shift to ensure that the residents' needs and services were met.

The facility had a census of 67 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for the residents who resided in the facility and received their meals from the kitchen. Findings included:- On 12/15/25 at 12:35 PM, observation revealed Dietary Staff BB cleaning up the kitchen after meal service. On 12/16/25 at 11:30 AM, Dietary Staff BB stated she had recently completed a certified dietary management course and would be scheduling her test soon. Dietary Staff BB was unable to provide proof of completion of the course upon request. On 12/18/25 at 01:35 PM, Administrative Staff A verified the facility should have a certified dietary manager. Administrative Staff A verified she was unable to provide proof of Dietary Staff BB's completion of the Dietary Management course, certification, or evidence Dietary Staff BB had the required experience for the position. The facility's Food Service Staffing policy, dated 10/2023, stated a Food Services Manager would oversee the production, storage, and delivery of food. If the dietician is not full-time, the facility would employ a nutritional professional to serve as the dietary manager. The person must meet one of the following qualifications: Certified dietary manager, certified food service manager, similar certification in food service management and safety from a national certifying body, an associate's degree or higher in food services management from an accredited institution of higher learning, two or more years of experience in the position of dietary manager and has completed a course of study in food safety and management by 10/01/23, or meets the state established standards.

The facility reported a census of 67 residents, and one kitchen. Based on interviews, observations, and record review, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food-borne bacteria. Findings included:- Observation of the kitchen and food storage areas on 12/15/25 at 09:46 AM with Dietary BB, revealed the following areas of concern:The bottom shelf of the heat table was visibly dirty with caked-on grease.There were empty boxes (not broken down) stacked in the large trash can, near the handwashing sink. The boxes and a wire rack were on the step-to-open trash can, next to the handwashing sink, making it inaccessible. Several different buckets of two types of dishwasher sanitizer were under the dishwasher area, grey and brown dirt built up against the baseboards of the wall, and visible rust on pipes under the dishwasher. There was a large plastic dishwashing pan on the floor in the back sink area under an unused triple-basin sink to catch leaking water, as well as warm water on the floor in the area. The triple-basin sink had dried, caked on substances, as well as a white residue. There was one non-slip floor mat folded up under the unused triple-basin sink. There were no other floor mats in use in the kitchen.The back of the cook station was covered entirely with a thick, black, greasy substance.The exhaust hood above the dishwasher had visible dirt and grease. Three blackened muffin tins lay with their food surfaces right side up on top of a warmer. The warmer had debris noted inside and out. There was a box of rotted sweet potatoes on the floor near the double-door oven.The microwave in the food preparation area was greasy, inside and out. There was a large stack of coffee filters on the lower shelf of the spice rack. There was debris on the filters that appeared to be coffee grounds, as well as a liquid stain which appeared to have come from the tipped bottle of vanilla extract stored above the filters on the rack. Four out of seven large containers of spices were undated. There were five bags of moldy buns, and one unopened loaf of bread had visible gnat-like insects within the wrapper. There was one package of tortillas, which was opened and ripped across the top of the package, making it unable to be sealed.One oven mitt was frayed with its inner stuffing exposed. There was an open box of cookies on the bread rack, unsealed, open to air, and undated. The top of the dishwasher has dust what appeared to be wood shavings. There were soiled towels in a pile under the dishwasher. There was an open partial sleeve of Styrofoam cups on the floor, between two rolling plastic carts.The steam table had old, discolored water at the bottom of it. There was a large container of dry oats open and undated. The glass plate storage rack in the corner to the right of the steam table held plates stored with the eating surface upwards and uncovered. On a wire rack near the food prep table, a large metal colander was observed with several dents, a large rectangular pan had bent corners, and a black substance coated the bottom and outside surfaces. Observation of the cooler storage area revealed the following concerns:A bag of lettuce was open to the air and undated. Several packages of sliced turkey, opened and undated. A jug of Italian salad dressing was half full and undated. Observation of and around the dry storage area revealed the following concerns:The floor was unclean and had large food particles, dust, and dirt present.There were open snacks belonging to staff on the shelf in the dry storage area.A bulk bag of unlabeled cereal (closed) and an unopened bag of popcorn were on the floor, under the steel shelving. An individually wrapped snack was also on the floor. In an interview with Dietary BB on 12/16/25 at 10:12 AM, she stated the triple-basin sink was not currently in use due to a major leakage issue. This leak has caused loosened, dirty floor tiles, which were attempted to be tarred or glued back into place. Dietary BB stated that items should be dated when opened, and items in the freezer that were undated were labeled with a yellow sticker, which identified when they were received by the facility. Dietary BB confirmed the above-identified concerns and discarded the items in the trash. Dietary BB identified the items that belonged to staff, stated they should not be stored with resident food items, and discarded the items that belonged to staff. The facility's Food Safety Requirements F812 policy, dated 10/2025, documented foods would be received and stored in a manner that complied with safe food handling practices. Staff would always maintain clean food storage areas. Non-refrigerated foods would be stored and kept clean and free of insects. All foods would be labeled and dated. The facility's Sanitation F812 policy, dated 10/2025, documented the food service area would be maintained in a clean and sanitary manner. Utensils, counters, shelves, and equipment would be kept clean, maintained in good order, and would be free from defects that may affect correct use or cleaning. Damaged or broken equipment that cannot be repaired would be discarded. Kitchen and dining surfaces not in contact with food would be cleaned regularly to prevent the accumulation of grime. Management would be responsible for scheduling staff for regular cleaning of the kitchen and dining areas, which included maintaining cleanliness through the work areas during all tasks, after each task, and before proceeding to the next task.

The facility reported a census of 67 residents; the sample included 17 residents. Based on record review and interview, the facility failed to ensure the Medical Director ( or designee) attended Quality Assurance Performance Improvement (QAPI) meetings at least quarterly.Findings included:-Review of the facility's QAPI attendance binder noted the following: Upon request, the facility was unable to provide evidence of the quarterly attendance of the Medical Director (or designee) completed within the last year. During an interview on 12/18/25 at 01:53 PM, Administrative Staff A reported the quarterly attendance signature sheets lacked detailed signatures, which indicated the Medical Director attended the QAPI meetings only twice in the 12-month look-back period. Administrative Staff A reported he expected the Medical Director to be in attendance quarterly. The facility's policy Providence QAPI Plan 2025, dated 01/01/24, documented the QAPI Committee reports to the Governing Body and meets monthly, or at additional times when deemed necessary. The Administrator may delegate the necessary authority to a QAPI Coordinator.

The facility had a census of 67 residents. Based on record review and interview, the facility failed to ensure the staff member designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control and possessed the required certification. Findings included:- The Department Heads form completed by the facility on 12/15/25 listed Administrative Nurse E as the designated IP. Upon request, the facility could not provide documentation of a certification for the designated IP. On 12/18/25 at 07:57 AM, Administrative Nurse E confirmed she was the designated IP but was not currently certified. She stated she shared some of the duties with Administrative Nurse D, but she was not sure if Administrative Nurse D was certified. The facility's Infection Prevention and Control Program F 880 policy, revised 01/2024, stated the IP would report monthly to the Quality Assurance and Performance Improvement committee.

The facility census totaled 67 residents. Based on observation, interviews and record review, the facility failed to maintain the building in good condition and provide a safe and hazard free environment for the residents, visitors and staff. Findings included:- On 12/15/2025 at 11:00 AM, observation revealed the sidewalk was cracked in several areas and uneven in the courtyard that connected the north and south sides of the facility. The sidewalk that connected the east and west sides of the facility courtyard was missing a large piece of concrete and was uneven. On 12/15/25 at 11:13 AM in the north hallway, observation revealed a large hole in the ceiling; the tiles surrounding the large hole were discolored brown. There was pink insulation that was discolored black in some areas; the discolored insulation hung from the large hole. During an observation on 12/16/2025 at 11:20 AM, the clean laundry room area had a barrel in the doorway. Further observation of the ceiling above the barrel revealed an unintended black substance, and there were brown, dried, discolored areas indicating water damage. One tile was damaged. During a walkthrough on 12/18/25 at 11:30 AM of the facility with Maintenance U, the following areas were identified as needing repair:In the north hallway, a large crack in the ceiling between rooms [ROOM NUMBERS] and between rooms [ROOM NUMBERS] was present.In the south hallway, a large crack in the ceiling was present between rooms [ROOM NUMBERS] and between rooms [ROOM NUMBERS].During an interview on 12/15/2025 at 11:16 AM, Certified Nurse Aide (CNA) S reported the large hole in the north hallway ceiling had been like that since 12/14/25. During an interview on 12/16/2025 at 11:20 AM, Laundry Staff V revealed the ceiling dripped water when the shower room in the north hallway was used, and that was why the barrel was placed in the doorway. During an interview on 12/18/25 at 07:20 AM, Administrative Staff A reported the environment of the facility as a whole needed repair, and the facility was aware and planned for improvements. During an interview on 12/18/25 at 11:30 AM, the hole in the ceiling was identified by Maintenance U, which had developed on 12/12/25 from a frozen fire sprinkler line. Maintenance U revealed the attic access holes in the ceiling were open throughout the building to allow heat from the building to escape into the attic to prevent the fire sprinkler lines from freezing. He reported that the facility had obtained a bid for repairs but did not provide the survey team with proof that an attempt at repairs had been initiated. The facility policy Other Environmental Conditions dated 10/2025 documented the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.

The facility reported a census of 67 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, sanitary and homelike environment in the facility. Findings included: - During a walkthrough of the facility on 12/18/25 at 05:30 AM, the combined dining and common area floor was dirty and had several areas of spilled popcorn and empty soda cans. Several tables had food containers and various spilled liquids, and on the floor as well, where no residents were seated. No staff members were present in the combined dining and common room. During an observation on 12/18/25 at 06:45 AM in the combined dining and common area, the tables were rearranged but had not been cleaned. The litter had been removed, but food debris remained on the floor. During an observation on 12/18/25 at 07:05 AM in the combined dining and common area, residents were being served breakfast on tables that still had food debris and spilled liquids. During a walkthrough of the facility on 12/18/25 at 11:30 AM with Maintenance U, the following areas were identified as being in need of repair:The windows in Resident (R) 46 and R12's room had plastic covering the windows. Maintenance U identified the plastic as being in place to minimize drafts caused by leaky windows.The walls in R17 and R63's room had gouges in the drywall material.The walls of R26's room had writing and various other marks on the paint.The floor of R19 and R11's room had missing floor tiles on the transition to the bathroom.The walls of R34's room had scrapes and gouges in the drywall material.The walls of R7's room had a hole in the drywall material.The walls of R29's room had multiple holes in the drywall material that were covered with blue duct tape. Additionally, R29 identified a hole in the closet wall that he kept covered with clothing to hide the hole.The wall of R1's room had scratches in the drywall materialThe walls of R64 and R62's room had scratches in the drywall material. Additionally, R62's side of the room had writing and various other marks on the paint.The walls of R25's room had scratches in the drywall material.The floor of R67 and R56's room had drag marks on the linoleum material with exposed sub-floor material.The walls of R35's room had scratches in the drywall material.The walls of R21's room had gouges in the drywall material.The closet door of R66's room had a hole in the door.The closet door of R32's room had a hole in the door.The closet door of R20's room had a hole in the door.The walls of R49 and R33's room had writing and various other marks on the paint.The elevator in the south hallway from the first floor to the basement was out of order.The wall in the north hall tub room had an area of drywall that was repaired but not repainted. During an interview on 12/16/25 at 03:35 PM, Administrative Staff B stated that residents used to use the activity area in the basement, but haven't been able to use it for activities since the elevator broke down. During an interview on 12/18/25 at 05:55 AM, Licensed Nurse (LN) H said staff should clean up the common and dining area during the night shift, but residents leave trash and spill food and drinks throughout the night. LN H said if something were broken, she would send a message to the maintenance department for repairs. During an interview on 12/18/25 at 06:15 AM, Certified Nurse Aide (CNA) O reported staff would normally clean up the common and dining area, but some residents just like to make messes. CNA O reported if something needed repair, the nurse was notified and would put a work order in the computer for the maintenance department. During an interview on 12/18/25 at 06:36 AM, Maintenance FF said each morning, the floors in the common and dining area were always dirty and had food debris from the previous day's evening meal service and snacks. Maintenance FF said that staff have asked residents to properly dispose of their trash. Maintenance FF said that the floors are the worst on Monday mornings. During an interview on 12/18/25 at 07:10 AM, Dietary BB said she had cleaned off the tables prior to the residents being served breakfast. Dietary BB identified debris that remained on the tables and reported she cleaned the tables in a darkened room. During an interview on 12/18/25 at 07:20 AM, Administrative Staff A said he expected the common and dining area to be clean before and after each meal service. Administrative Staff A toured the common/dining area and identified debris on the floor and tables that were from the previous day's evening meal service that was present where residents were currently dining, and said that conditions were unacceptable. During an interview on 12/18/25 at 12:30 PM, Maintenance U stated the identified areas were not consistent with a home-like environment for the residents. Additionally, Maintenance U stated that the elevator had been out of order for over a year. Further, Maintenance U stated the activity room in the basement that residents used to use daily is now inaccessible to residents since the elevator is inoperable. During an interview on 12/18/25 at 12:00 PM, Activity Z revealed the residents used to spend a lot of time in the activity room in the basement doing various activities that included playing billiards pool and watching TV in a more private setting in the activity area in the basement; however, the residents have not been able to participate in these activities since the elevator broke and has been out of order. The facility's Safe, Clean, Comfortable, Homelike Environment F584 policy, dated 11/2017, documented residents have the right to a safe, clean, comfortable, and homelike environment. The facility staff and management would maximize the characteristics of the facility to reflect a personalized, homelike setting, which included cleanliness and order.

The facility had a census of 67 residents. The sample included 17 residents with four residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 1, R33 R52 and R70. Additionally, the facility failed to notify the Ombudsman for transfers.Findings included1.R1's Electronic Medical Record (EMR) recorded R1 was transferred to the hospital on 7/14/25, 8/17/25, and 9/14/25. R1's EMR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R1 and/or his representative. Upon request, the facility was unable to provide the documentation. 2. R33's EMR recorded R33 was transferred to the hospital on 7/03/25. R33's EMR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R33 and/or her representative. Upon request, the facility was unable to provide the documentation. 3. R52's EMR recorded R52 was transferred to the hospital on [DATE] and 11/20/25. R52's EMR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R52 and/or her representative. Upon request, the facility was unable to provide the documentation. 4. R70's EMR recorded R70 was transferred to the hospital on [DATE]. R70's EMR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R70 and/or her representative. Upon request, the facility was unable to provide the documentation. During an interview on 12/16/25 at 03:22 PM, Licensed Nurse (LN) J reported when a resident was transferred to the hospital, a bed hold form should be in the transfer packet, and the nurse on duty should obtain the signature from the resident or phone consent from their representative, then the bed hold was placed in the Administrative Nursed D's door-mailbox. LN J reported Administrative Nurse D would then give the bed holds to Medical Records to scan to the EMR. During an interview on 12/16/25 at 03:26 PM, Certified Nurse Aide (CNA) S, who completed medical records, reported the bed holds and written notifications were routed to Administrative Nurse D, then to Social Service Designee (SSD) X or maybe Administrative Staff B to be filed and or scanned to the residents' EMR. During an interview on 12/16/25 at 03:35 PM, Administrative Staff B reported all bed holds and written notifications were held by SSD X and then filed or scanned to the EMR. During an interview on 12/18/25 at 11:00 AM, SSD X reported when a resident was transferred to the hospital, the nurse would complete the bed hold form during the non-business hours. SSD X reported she would complete a bed hold through email with the representatives, and all the bed holds would go to medical records to be uploaded into the residents' EMR. SSD X revealed she was unaware until 12/17/25 that she was responsible for notifying the Ombudsman of transfers. During an interview on 12/18/25 at 03:00 PM, Administrative Nurse E reported she expected the bed holds to be completed upon transfer to the hospital by the nurse; if unable to complete the bed hold due to an emergency, she expected SSD X to complete the bed hold the next business day. The facility's policy Bed Hold dated 06/25 documented the community staff shall inform residents upon admission and prior to a transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed hold policy. The bed-hold information would include any charges that the resident may incur, as well as the time limit established by the State Medicaid Plan for which the facility will reserve the resident's bedspace.

The facility reported a census of 67 residents; the sample included 17 residents sampled with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to acknowledge the Consultant Pharmacist's monthly medication regimen review (MRR) and failed to ensure the MRR recommendations were filed in the clinical record for Resident (R) 1, R7, R9, R13, and R30. Findings included:1. R1's Electronic Medical Record (EMR) recorded the following Medication Regimen Review (MRR):R1's Pharmacy Consultant Note on 07/21/25 documented MRR completed, irregularities noted, see report. R1's Pharmacy Consultant Note on 10/13/25 documented MRR completed, The Consultant Pharmacist requested a vitamin level, but no results were found until the facility provided lab results dated 12/18/25. R1's Pharmacy Consultant Note on 11/13/25 documented MRR completed, irregularities noted, see report. R1's clinical record lacked the actual recommendations made and lacked evidence the facility and physician acknowledged and responded. 2. R7's EMR recorded the following MRR:R7's Pharmacy Consultant Note on 07/21/25 documented MRR completed, irregularities noted, see report.R7's Pharmacy Consultant Note on 08/19/25 documented MRR completed, irregularities noted, see report.R7's Pharmacy Consultant Note on 11/13/25 documented MRR completed, irregularities noted, see report.R7's clinical record lacked the actual recommendations made and lacked evidence the facility and physician acknowledged and responded. R7's Pharmacy Consultant Note on 10/13/25 documented MRR completed, The Consultant Pharmacist requested a magnesium level, but no results were found until the facility provided lab results dated 12/17/25. 3. R9's EMR recorded the following MRR:R9's Pharmacy Consultant Note on 07/21/25 documented MRR completed, irregularities noted, see report.R9's Pharmacy Consultant Note on 08/18/25 documented MRR completed, irregularities noted, see report.R9's Pharmacy Consultant Note on 09/08/25 documented MRR completed, irregularities noted, see report.R9's clinical record lacked the actual recommendations made and lacked evidence the facility and physician acknowledged and responded. 4.R13's EMR recorded the following MRR:R13's Pharmacy Consultant Note on 07/21/25 documented MRR completed. The Consultant Pharmacist documented R13 had diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and recommended considering monitoring hemoglobin A1c (HbA1c-blood test used to evaluate the level of glucose control over the past 90 days) on the next lab day and every 6 months.R13's Pharmacy Consultant Note on 09/08/25 documented MRR completed, Pharmacist documented R13 had diabetes mellitus and recommended to consider monitoring hemoglobin A1c on the next lab day and every 6 months.R13's EMR lacked any results or evidence the physician reviewed and declined as of 12/17/25.R13's Pharmacy Consultant Note on 11/13/25 documented MRR completed, irregularities noted, see report. The Consultant Pharmacist requested a review of the listed psychoactive medication for gradual dose reductions including Depakote (an anti-convulsant) sprinkles 500 milligrams daily, haloperidol (antipsychotic medications used to treat major mental conditions that cause a break from reality) 2 mg twice daily, quetiapine (antipsychotic) 500 mg at bedtime, lithium (mood stabilizer) extended release 300 mg at bed time and citalopram (an antidepressant a class of medications used to treat mood disorders) 20 mg daily. R13's EMR lacked any responses from the physician corresponding to the 11/13/25 report. 5. R30's EMR recorded the following MRR:R30's Pharmacy Consultant Note on 08/18/25 documented MRR completed, irregularities noted, see report. R30's Pharmacy Consultant Note on 09/08/25 documented MRR completed, irregularities noted, see report.R30's Pharmacy Consultant Note on 11/13/25 documented MRR completed, irregularities noted, see report.R13's clinical record lacked the actual recommendations made and lacked evidence the facility and physician acknowledged and responded. During an interview on 12/16/25 at 01:11 PM, Administrative Nurse D reported that she only received the gradual dose reduction reports, not the entire reports. She reported she would not receive a full report with all the residents' names on it, and she was not aware every resident every month was assessed by the pharmacist for an MRR. During an interview on 12/16/25 at 01:40 PM, Administrative Nurse D reported she was responsible for the process of receiving and follow-up for the MRR. During an interview on 12/18/25 at 12:50 PM, Consultant GG and Consultant HH revealed the facility/physician response to the MRR should be completed and returned to the pharmacy within a reasonable time frame, defined as 30 days or less. The facility's policy Pharmacy Services Overview dated 10/2025 documented the facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility, the Medical Director, and the Attending Physician. Help establish procedures for conducting the monthly medication regimen review for each resident in the facility.

The facility identified a census of 67 residents. The sample included 17 residents with five residents reviewed for vaccinations. Based on record review nad interview, the facility failed to ensure the residents were offered and received the pneumococcal vaccine or informed declinations for the vaccine were obtained for Resident (R) 13, R5, R6 and R34. Findings included:R13's Electronic Medical Record (EMR) documented a signed declination for the influenza vaccine on 10/03/25. The EMR lacked evidence of administration of the pneumovax and lacked evidence of an informed declination signed by the resident or her representative. R5's EMR recorded the resident received the influenza vaccine on 10/08/25, but refused the pneumovax. The EMR lacked evidence of an informed declination signed by the resident or his representative. R6's EMR recorded the resident received the influenza vaccine on 10/08/25 but refused the pneumovax. The EMR lacked evidence of an informed declination signed by the resident or her representative. R34's EMR recorded the resident received the influenza vaccine on 10/08/25 but refused the pneumovax. The EMR lacked evidence of an informed declination signed by the resident or his representative. On 12/18/25 at 10:25 AM, Consultant GG confirmed the facility was not able to provide the informed declinations for the pneumovax vaccines for the above-listed residents. The facility policy F883 F884 F887 Vaccination of Residents, Including Influenza, Pneumococcal., revised 09/2023, noted prior to receiving vaccinations, the resident or legal representative would be provided information and education regarding the benefits and potential side effects of the vaccinations, and provision of such education would be documented in the resident's medical record. The residents would be offered the flu, pneumovax, and COVID-19 vaccinations per the Centers for Disease Control and Prevention and Centers for Medicare and Medicaid guidelines. The policy noted if vaccinations were refused, the refusal would be documented in the resident's medical record.

The facility reported a census of 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to provide a safely secured handrail in the stairwell corridor leading to the basement. Findings include:- During an observation on 12/15/25 at 12:30 PM, the handrail to the stairwell on the north side of the courtyard was wobbly and not secured. Resident (R) 62 sat at the bottom of the stairway near the secured basement door. During an interview on 12/16/25 at 11:00 AM, Administrative Staff A observed the loose, wobbly handrail in the stairwell corridor leading to the basement and reported he had not been aware of the loose handrail. Administrative Staff A moved the railing, observed the base was out of the hole in the concrete, and reported it would need to be fixed. The facility policy Other Environmental Conditions dated 10/2025 documented the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Equip corridors with firmly secured handrails on each side.

The facility reported a census of 67 residents, the sample included 17 residents. Based on interview and record review, the facility failed to inform Resident (R) 1 and R13 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included: - Review of both Electronic Health Record (EHR) and paper records revealed the following:1.R1's EHR under the Orders tab revealed orders for the following:Fluphenazine HCl (an antipsychotic [a class of medications used to treat major mental conditions that cause a break from reality] medication), five milligrams (mg) to be given orally two times daily for schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), dated 11/19/25.Mirtazapine (antidepressant medication used to treat mood disorders), 15 mg to be given orally at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dated 11/15/25.Lorazepam (an antianxiety [a class of medications that calm and relax people] medication), one mg to be given two times daily for anxiety, dated 10/28/25.Escitalopram oxalate (an antidepressant medication) 20 mg to be given orally once daily for depression, dated 10/06/25.Quetiapine fumarate (an antipsychotic medication) 50 mg to be given orally twice daily for psychosis, dated 07/16/25. R1's scanned document revealed Informed Consents for Use of Psychotropic Medication consents, which listed the medications and potential risks but lacked R1's signature indicating he received the information. During an interview on 12/16/25 at 02:40 PM, Administrative Nurse D revealed R1 made his own decisions and did not have a durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) or a guardian on file. Administrative Nurse D and Consultant GG stated that R1 should have signed the forms. 2. R13's EHR Orders tab revealed orders for the following:Clonazepam (an antianxiety medication), 0.5mg to be given every 12 hours as needed for anxiety, dated 05/59/25.Quetiapine fumarate, 300 mg to be given orally each day at bedtime for schizoaffective disorder, dated 07/16/25.Quetiapine fumarate, 200 mg to be given orally each day at bedtime for schizoaffective disorder, dated 01/21/25.Citalopram hydrobromide (an antidepressant medication), 20 mg to be given orally once per day for depression, dated 01/21/25.Lithium (a mood stabilizer), 300 mg to be given orally at bedtime for mood/depression, dated 05/02/25. R13's EHR scanned documents did not contain consent forms for the above-listed medications and lacked evidence of informed consent. Upon request, the facility could not provide evidence of informed consent by the resident and/or representative. On 12/18/25 at 11:45 AM, Consultant GG revealed that signed consents should be completed if a new psychotropic medication is prescribed or if there is a change in the dose. The facility's F605 Use of Psychotropic Drugs (Formerly F 758 policy, dated 04/2025, documented residents would only receive psychotropics or other approved medications that affect brain activity when necessary to treat specific conditions, and residents and/or their representative(s) have the right to refuse such treatment. Resident(s) and/or their representative(s) would be informed of new or change orders that included benefits, risks, and alternatives prior to the mediation(s) being initiated or increased. Staff would obtain the consent for the new or changed order, add it to the record, and document the conversation in the clinical record.

The facility identified a census of 67 residents. The sample included 17 residents with one resident reviewed for advanced directives. Based on observation, record review, and interviews, the facility failed to accurately identify Resident (R) 30's advanced directives for a Do Not Resuscitate (DNR- expressed desire to not receive cardiopulmonary resuscitative measures in the event of cardiac or respiratory arrest). Findings included:- R30's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R30's Significant Change Minimum Data Set [MDS] dated 11/10/25 documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R30 received hospice (palliative) care. R30's Care Plan dated 09/19/18 documented she wished to have a DNR. R30's EMR under the MISC tab revealed an outside-of-hospital DNR signed by the resident and other required parties. R30's profile information in her EMR documented she was a Full Code (desires full cardiopulmonary resuscitative measures). On 12/16/25 at 11:00 AM, R30 was in her room attempting to put her pants on. R30 requested assistance, and staff arrived to assist the resident. On 12/16/25 at 02:00 PM, Administrative Nurse D confirmed R30's profile in the EMR showed R30 was a Full Code. Administrative Nurse D confirmed R30 had a signed DNR advance directive in the scanned documents. Administrative Nurse D said if the resident had a change in code status, regarding an advance directive related to DNR, the change should be reflected in the EMR, and the information would also be relayed to other staff during both verbal and written reports. The facility policy, revised on 11/2023, F578 Advance Directives, recorded each resident had the right to formulate advance directives. The policy noted the information about whether the resident had executed an advance directive would be displayed prominently in the medical record.

The facility reported a census of 67 residents. The sample included 17 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with nail care for Resident (R) 9, who participated in her hygiene activities but needed staff assistance. Findings included:- R9's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and a need for assistance with personal care. R9's 07/22/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS documented R9 required moderate assistance with bathing, dressing, and personal hygiene. R9's 08/05/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R9 was at risk for falls. The plan of care would be reviewed and revised to ensure proper interventions were in place to prevent falls. The CAA lacked information related to functional abilities and self-care. R9's Care Plan, revised on 03/26/24, directed staff to provide set-up assistance with prompts to complete personal hygiene. During an observation on 12/15/25 at 01:18 PM, R9's fingernails were very long; nail polish was chipped on some of her nails. Observation revealed brown residue underneath several of R9's fingernails. During an observation on 12/16/25 at 11:16 AM, R9's fingernails were very long. The nail polish was unchanged from the 12/15/25 observation. R9 continued to have brown residue underneath several of her fingernails. R9 reported she liked her fingernails long. During an interview on 12/18/25 at 01:07 PM, Certified Nurse Aide (CNA) Q reported the nurses would cut R9's nails, but the CNAs should make sure her nails were clean. CNA Q reported that R9 liked her nails long. During an interview on 12/18/25 at 01:10 PM, Licensed Nurse (LN) I reported the CNAs should clean residents' fingernails. LN I reported that R9 would refuse to have her nails cut as she liked them long, but stated R9's fingernails should be clean and polished. During an interview on 12/18/25 at 03:00 PM, Administrative Nurse E reported she expected the staff to provide fingernail care to the residents who could not complete that task independently. The facility did not provide a policy for ADLs.

The facility reported a census of 67 residents; the sample included 17 with one resident reviewed for prevent decrease in range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) and mobility. Based on observation, interview, and record review, the facility failed to provide a palm guard to prevent contractures (abnormal fixation of a joint or muscle) to Resident (R) 44. Findings included:- R44's Electronic Medical Record (EMR) revealed diagnoses including acute cerebrovascular insufficiency (CVI- a sudden, temporary lack of blood flow to part or all of the brain, often due to blocked arteries or low blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) R44's 11/25/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 99, which indicated severely impaired cognition. R44's MDS recorded impairment to both sides of her upper and lower extremities. The MDS recorded R44 required total dependence on staff for all activities of daily living (ADLs). R44's 12/16/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R44 had severe immobility. She depended on the staff for ADL function. R44's Care Plan dated 09/17/24 documented she had pain in her left hand related to contractures. The plan instructed staff to apply a gel support to her left hand for 20 minutes four times a day for three days, then for 30 minutes four times a day for three days, then to the left hand at tolerated intervals for contractures. R44's Physician Orders documented to remove the palm guard protectors each shift to check for skin integrity, date ordered, 01/30/25. R44's Progress Note on 01/28/25 at 08:12 AM documented staff spoke with Hospice regarding the gel support for R44's left hand contracture and discontinued at that time. Hospice would reevaluate later that day during the visit. During an observation on 12/15/25 at 11:24 AM, R44 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline). Her left hand was contracted, and she did not have a palm guard device in her left hand. R44 was unable to stretch out her left hand when asked. During an observation on 12/16 /25 at 08:49 AM, Certified Nurse Aide (CNA) N and Certified Medication Aide (CMA) R assisted R44 out of bed with the mechanical lift and into her Broda chair. Further observation revealed the staff did not place a palm guard in R44's left hand and propelled R44 out of the room towards the dining room without the palm guard. During an observation and interview on 12/18/25 at 05:35 AM, CNA O reported she had just provided ADL care to R44. CMA O walked down to R44's room, where R44 was in bed, and knocked on the door. R44 opened her eyes and smiled. She did not have a palm guard in her left hand. During an observation on 12/18/25 at 08:38 AM, R44 sat in her Broda chair without a palm guard in her left hand, which remained tight. R44 had clear mucus hanging down from her nose to her chin. During an interview on 12/18/25 at 08:40 AM, CNA T reported there was no restorative aide, and the CNA staff were responsible to complete restorative tasks. She reported that the other CNA completed ADL care for R44 and said she just assisted with R44's transfer. CNA T reported she did not realize R44 did not have her palm guard applied. During an interview and observation on 12/18/25 at 08:43 AM, Licensed Nurse (LN) I reported that she checked the skin of R44's palm every day to make sure it was intact. LN I walked down to R44's room and opened the top drawer of her nightstand. R44's palm guards were buried under personal items and pictures in that drawer. LN I reported that R44 should have the palm guard placed in her hands every shift and said she was uncertain why R44 did not have a palm guard in her hand the past few days. During an interview on 12/18/25 at 03:00 PM, Administrative Nurse E reported she expected staff to apply devices to help prevent contractures as per the physicians' orders. The facility did not provide a policy for Restorative Therapy/Splint Devices.

The facility had a census of 67 residents. The sample included 17 residents, with one resident reviewed for smoking. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 33 when staff failed to assess R33 for safe smoking ability and determine if safety equipment was required. Findings included:- R33's Electronic Medical Record (EMR) revealed diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) R33's 12/20/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R33's MDS documented she had no behaviors and no depression. The MDS documented R33 did not use tobacco. R33's 01/03/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R33 received psychotropic (alters mood or thought) medications related to schizoaffective disorder. She was compliant with her current medication regimen and was followed by psychiatry and pharmacy for medication review. R33's 10/11/25 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. R33's MDS documented Patient Health Questionnaire-9 (PHQ-9, a depressive symptom scale) score of 24, which indicated severe depression. The MDS lacked information related to R33's tobacco use. R33's Care Plan, revised 03/26/24, instructed staff R33's preferred activities were bingo, music, iPad, and she was an outdoors (smoker). The plan lacked interventions regarding safe smoking practices or smoking equipment needs. R33's EMR under the Assessments tab revealed a Smoking Evaluation dated 01/22/24, which noted the resident had no cigarettes. R33 was safe to smoke. The Smoking Evaluation dated 04/05/24 documented R33 required no adaptive safety equipment for smoking. R33's EMR lacked any further Smoking Evaluation assessments. R33's Progress Note on 04/20/25 at 01:09 PM documented R33 was smoking on the patio. She attempted to smoke her cigarette but could not hold her head up. She dropped a cigarette and burned a hole in her shirt. Staff assisted the resident back inside, told her that smoking was unsafe, and reported it to the nurse. R33's Progress Note on 06/7/2025 at 08:18 PM documented during the 07:30 PM smoking period, R33 was seated and kept drooping head forward. R33 had to be told constantly to hold her head up and sit up. R33 said she could not, so staff assisted R33 up and walked with her. R33 had taken off her sock and gave it to a Certified Nursing Aide (CNA). The CNA placed the sock in the resident's pocket and, in doing so, found a vape (electronic smoking device). Staff confiscated the vape, and R33 cried and begged the CNA to give her vape back. Staff notified Administrative Nurse D and R33 lost smoking privileges for 24 hours. Staff placed R33's on her vape and placed it in the cigarette container. Review of the undated Providence Living Center Smoking List which hung at the nurses' station for the scheduled smoke breaks, revealed R33 was checked off to wear a smoke apron. During an observation on 12/16/25 at 10:05 AM, R33 was outside in a supervised smoking area. She did not have any safety equipment. During an interview on 12/16/25 at 10:10 AM, CNA N reported the smoking aprons were probably stored in the smoking storage closet, and if a resident was supposed to wear an apron, she would not know, as she had not been told. CNA N reported she had the sign-out form for cigarettes for the residents, but no list as to who was supposed to wear an apron. During an interview on 12/16/25 at 03:13 PM, Licensed Nurse (LN) J reported the smoking evaluations were completed quarterly to coincide with the MDS, and the floor nurse completed the smoking evaluations. LN J confirmed that R33 has been a smoker at the facility for over a year and verified that the last smoking safety evaluation for R33 was completed on 04/05/24. LN J reported that if a resident had burned their clothing while smoking in the past, they should wear a smoking apron. LN J was unsure who printed off the smoking list that was hung on the wall at each nurse station. During an interview on 12/16/25 at 03:18 PM, LN G revealed that Activity Director Z hung the Providence Living Center Smoking List at the nurses' stations. During an interview on 12/16/25 at 03:20 PM, Activity Director Z reported they typed the smoking list that was posted at each nursing station and had just hung a newly updated form the other day. Activity Director Z reported the previous MDS nurse had given her a list of the smokers and told her what to type on the form. Activity Director Z reported she would not even know where to find out if a resident required an apron or other safety equipment for smoking. During an interview and observation on 12/18/25 at 10:00 AM, R33 sat outside on a supervised smoke break with no smoking apron on. CNA Q reported that R33 was now crossed off the list and provided the updated list, which had a pink line drawn through R33's name. CNA Q reported that Activity Director Z removed R33's name. During an interview on 12/18/25 at 03:00 PM, Administrative Nurse E confirmed the most current smoking evaluation in R33's EMR was completed on 04/05/24 and reported that the evaluation had not been entered to automatically open quarterly. Administrative Nurse E reported the residents required a safe smoking evaluation quarterly and as needed. Administrative Nurse E reported if a resident had a history of burning their clothes, the resident should wear a smoking apron when smoking. The facility's policy Accident Prevention - Smoking Policy dated 08/25 documented residents who wish to smoke will be evaluated for safe smoking per community protocol. The staff would review the status of a resident's smoking privileges periodically, per community protocol.

The facility had a census of 76 residents. The sample included 18 residents with four reviewed for nutrition. Based on observation, record review, and interview, the facility failed to implement Registered Dietician (RD) interventions for Resident (R) 27's significant weight loss, resulting in a 12.61 % loss over three months. This also placed the resident at risk for continued weight loss. Findings Included: - R27's Electronic Medical Record (EMR) documented R27 had diagnoses of chronic pain syndrome, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual deficits, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), schizoaffective disorder (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), bipolar type (major mental illness that caused people to have episodes of severe high and low moods), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), gastro-esophageal reflux disease (GERD-backflow of stomach contents to the esophagus), malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of left kidney and hepatitis C (inflammatory condition of the liver). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R27 had intact cognition, hallucinations (sensing things while awake that appear to be real, but the mind created), and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R27 required setup or clean-up assistance with eating and was independently mobile. The MDS further documented R27 had no swallowing disorder, was 64 inches tall, and weighed 157 pounds (lbs.). The Nutrition Care Area Assessment (CAA), dated 03/26/23, documented R27 continued a regular diet with a good intake of meals recorded. R27's current weight showed no significant weight changes and remained above the normal body mass index (BMI) range. There were no nutrition recommendations at that time, and the facility continued with the current plan of care. R27's Care Plan dated 01/05/24, documented R27 had a potential nutritional problem related to diagnoses of schizoaffective disorder, COPD, CVA, Parkinson's disease, hepatitis C, kidney cancer, GERD, depression, and hypertension (elevated blood pressure). The care plan further documented R27 had a history of significant weight changes and refused Med-Pass (condensed calorie and protein supplement). The care plan directed staff to monitor, record, and report to the physician and RD signs and symptoms of malnutrition which included emaciation (abnormally thin or weak), muscle wasting, or a significant weight loss of three lbs. in one week, greater than five percent (%) in one month, greater than 7.5 % in three months and greater than 10% in six months. The care plan further directed staff to provide and serve supplements as ordered, monitor intake, and record every meal. The RD would evaluate and make diet change recommendations as needed. The Physician Order, dated 08/29/23, directed staff to give four ounces (oz) house supplement daily for hypoproteinemia (low protein levels). A review of R27's EMR revealed R27 was weighed monthly. R27's EMR, dated 12/07/23, recorded she weighed 157.0 lbs. ON 01/08/24, R27 weighed 149 lbs. The Physician Progress Note, dated 01/08/24, documented R27 had not been eating well or coming out of her room much. R27 stated she wanted to be quiet for a while and did not feel like talking or participating in things. The progress note further documented R27 exhibited symptoms of depressed mood. R27 had a mechanical soft diet due to dysphagia (swallowing difficulty) and ate small amounts. The note documented that psychiatry would visit with R27 on their next visit. R27's clinical record lacked evidence psychiatry visited with R27 per the physician's documentation. The RD Progress Note, dated 01/18/24, documented R27 weighed 149 lbs. which showed an eight lb. loss over the past month related to decreased intake. Staff reported R27 went through periods of not eating periodically; she remained on a regular diet with an intake of 50-75%. The note included interventions to provide food in the resident's room upon R27's request, increase her supplement to twice a day, and refer to her physician for an appetite stimulant. R27's clinical record lacked evidence the facility increased R27 's supplement to twice daily and lacked evidence the recommendation for an appetite stimulant was forwarded to the physician. R27's EMR, dated 02/01/24 recorded R27 weighed 137.2 lbs. which indicated a loss of 12.61% in three months. On 02/12/24 at 11:58 AM observation revealed R27 stood in her room next to the bed. R27 reported she was not doing well, but she was unable to verbalize what was wrong. R27 refused lunch. On 02/12/24 at 12:00 PM, Licensed Nurse (LN) H reported R27 went through cycles of not eating well and staying in her room. R27 received a nutritional supplement and R27's preferred flavor was strawberry. On 02/13/24 at 10:05 AM, Administrative Nurse D reported residents were weighed monthly unless there was a weight concern issue, then weekly weights would be obtained. The nursing and dietary department reviewed the weights, and the RD would review and make recommendations. Administrative nurse D said the RD recommendations were sent to the physician for comment and orders. Administrative Nurse D reported the RD recommendations for R27 were missed and verified she was unable to locate if the physician was notified of the significant weight loss. The facility's Weight Assessment and Intervention policy, dated 10/2023, documented the interdisciplinary team will strive to prevent, monitor, and intervene, for undesirable weight loss or gain for our residents. Each resident is weighed upon admission and monthly thereafter. The RD will review the community's Weight Record of the month to follow weight trends over time. The threshold for significant unplanned and undesired weight changes will be based on the following criteria: one month with a 5% weight change, three months with a 7.5%, and six months with 10% significant/severe. The facility failed to respond to R27's weight loss and act upon the RD's recommendation. This placed the resident at risk for complications related to a significant weight loss of 12.61% in three months.

The facility identified a census of 74 residents. The sample included 4 residents. Based on observation, record review, and interview, the facility failed to protect residents from further abuse when an allegation arose of inappropriate touching from direct care staff M to resident #1 on 10/19/18. Direct care staff M worked his/her night shift from 10/19/18 through 10/20/18 and had access to all residents. This deficient practice placed the residents of the facility in immediate jeopardy. Findings included: - The clinical record for resident #1 documented [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was independent with toileting and required supervision with personal hygiene. The care plan revised 9/14/18 documented the resident had impaired thought processes due to mental illness. He/she required limited assistance of staff with toileting at times. The care plan directed staff to cue the resident to change his/her soiled clothing as needed. The witness statement dated 10/19/18 from social services staff X documented the resident reported (opposite gender) staff touched him/her inappropriately between midnight and 4:30 AM that morning. The witness statement documented the resident gave a specific description of the staff and that staff X reported the allegation to administrative nursing staff D, social services staff Y, and administrative staff A. Review of the staffing schedule for (MONTH) (YEAR) documented one opposite gender staff worked the night shift from 10/18/18 to 10/19/18 and from 10/19/18 to 10/20/18. On 10/25/18 at 3:29 PM, the resident sat in a recliner in the day area of the facility. He/she was alert, calm and watched TV. On 10/25/18 at 3:29 PM, the resident reported staff touched him/her inappropriately. On 10/25/18 at 3:30 PM, administrative nursing staff E stated administrative nursing staff D did not suspend direct care staff when the allegation of abuse arose. On 10/29/18 at 1:13 PM, administrative staff A stated he/she expected staff to protect the residents when allegations of abuse arose and during the investigation by not allowing the accused staff access to the residents. The facility's policy Abuse, Neglect, and Exploitation, created 11/17, documented after alleged abuse, the facility would make efforts to protect residents. The facility failed to protect residents from further potential abuse after an allegation of inappropriate touching on 10/19/18. This deficient practice placed the residents in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 10/22/18 when the facility implemented the following: The Interdisciplinary Team was re-educated on abuse/neglect reporting on 10/22/18; suspension of direct care staff M; interim administrator was re-educated on abuse/neglect reporting on 10/22/18 to include necessity to suspend; all staff were re-educated on the abuse policy with a post-test on 10/22/18 and any staff not educated at that time would be educated before returning to work; director of nursing or designee and administration will review progress notes, 24-hour report sheet and communicate with nursing staff 5 days a week to ensure incidents are investigated and managed; director of nursing or designee will review risk management 5 days a week to ensure incidents are documented every shift and care planned; administrator/designee will interview 5 employees about abuse weekly for 30 days, then 2 employees for 60 days; administrator/designee will interview 3 residents weekly for 3 months, and administrator/director of nursing will report compliance monthly to the Quality Assurance and Performance Improvement team.

The facility had a census of 75 residents with 24 sampled for review. Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents sampled for hospitalization received appropriate assessments and monitoring in accordance with professional standards. Resident #24 started on [MEDICATION NAME], an antipsychotic medication, without monitoring of serum [MEDICATION NAME] levels. The resident developed symptoms and required hospitalization for [MEDICATION NAME] toxicity. The facility also failed to document nursing assessments for resident #70 after readmission to the facility from a hospital and subsequent transfer/readmission to the hospital. The facility failed to assess and document non-pressure related skin issues 1 of 1 resident sampled for skin issues. (#122) Findings included: - Resident #24's 11/11/17 annual MDS (minimum data set) assessment revealed the resident had intact cognition, no delusions or hallucinations, and was independent with ADLs (activities of daily living) except he/she needed supervision with eating and personal hygiene. The resident received antipsychotic medications for 7 days on a routine daily basis. The 11/11/17 [MEDICAL CONDITION] drug use CAA (care area assessment) stated the resident took [MEDICAL CONDITION] medications related to his/her mental illness. The resident was compliant with his/her medication regimen. AIMS (abnormal involuntary movement scale) assessment revealed no abnormal involuntary movements. The 5/11/18 quarterly MDS indicated the resident had intact cognition and had verbal behaviors directed towards others during 1-3 days of the assessment period. The revised 5/25/16 nursing care plan directed staff to observe the resident for any unusual behaviors and report to the charge nurse immediately, and to the social worker and physician, who may need to review his/her medications. Staff to provide medications as prescribed by the physician and report immediately any non-compliance with medications. A revision on 5/19/17 directed staff to observe and document medication effectiveness and to keep the physician informed in a timely manner. The 7/26/17 revision included a potential for adverse reactions related to taking [MEDICATION NAME]. The care plan listed [MEDICATION NAME] toxicity as a warning and stated toxicity can occur at doses close to therapeutic levels. Treatment should only be started if prompt accurate serum [MEDICATION NAME] determinations were available. Review of MAR (medication administration records) from (MONTH) to (MONTH) of (YEAR), revealed the resident received [MEDICATION NAME] 150 mg (milligrams) at hour of sleep from 1/30/18 - 4/27/18. The resident started [MEDICATION NAME] (an antipsychotic medication) 40 mg daily on 4/28/18. A behavioral progress note dated 6/5/18 at 5:11 p.m. documented the resident had [MEDICAL CONDITION] (thoughts of suicide), increased hopelessness, anger, and agitation. The social worker documented the resident felt like his/her medications were not effective. The resident was receptive to meeting with his/her physician. The resident felt like his/her symptoms increased in the past 2 weeks. The resident felt a lot of anger and aggression that he/she never experienced in the past. The social worker indicated the resident was able to verbally contract to safety and also had a written safety plan in place. A behavioral progress note dated 6/5/18 at 5:12 p.m. stated staff notified the resident's physician of increased depression, anxiety, and [MEDICAL CONDITION]. The physician directed staff to give the scheduled [MEDICATION NAME] and to call if it was not effective. A progress note dated 6/9/18 at 6:21 a.m. revealed the resident saw his/her psychiatrist on 6/8/18 as an outpatient. The physician ordered to discontinue the [MEDICATION NAME] and to resume [MEDICATION NAME] 600 mg twice daily. A physician order [REDACTED]. Review of the physician orders [REDACTED]. A psychosocial progress note dated 6/28/18 at 2:22 p.m. stated the resident had slightly slurred speech, difficulty finding words, and slight cough. The social worker informed the charge nurse. Later in the day, the resident's psychotherapist JJ voiced concern of the resident's physical health and had concerns of a possible UTI (urinary tract infection). A psychosocial progress note dated 6/29/18 at 11:50 a.m. documented the resident stood at the nurses' station with slurred speech, lethargy, and confusion. According to the note, the nursing team was aware of the changes. A progress note dated 6/29/18 at 1:59 p.m. revealed staff spoke with physician HH regarding the resident's slurred speech, confusion, and lethargy since the afternoon of the prior day. Physician HH ordered to hold the [MEDICATION NAME] (antipsychotic medication) and Ziprasidone (an antipsychotic medication) until seen in follow up on 7/7/18. A 6/29/18 2:03 p.m. progress note documented that physician extender NN contacted the facility and gave new orders to obtain a CBC (complete blood count), CMP (comprehensive metabolic panel), [MEDICATION NAME] level, and EKG (electrocardiogram). (The [MEDICATION NAME] level was ordered 20 days after initiation of [MEDICATION NAME] 600 mg twice daily.) A progress note dated 6/30/18 at 2:26 p.m. noted staff received a call from the lab with a critical [MEDICATION NAME] level of >3.0. Physician HH ordered to hold the [MEDICATION NAME] until further notice. A progress note dated 7/1/18 at 6:58 a.m. stated the resident continued with slurred speech with shuffled gait and increased confusion. The resident had difficulty making his/her needs known and required more assistance with ambulating. Vitals signs were documented and staff continued to observe for any significant changes. On 7/1/18 at 1:02 p.m., a progress note documented staff spoke with physician OO. He/she reviewed the resident's record. Staff explained concerns from the resident's family about the lab and EKG results. Physician OO ordered for the resident to be sent to the ER (emergency room ) for [MEDICATION NAME] toxicity and [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness). A 7/4/18 Summary of Care from the local hospital included [DIAGNOSES REDACTED]. Drugs@FDA.com included the following boxed warning for [MEDICATION NAME]: [MEDICATION NAME] toxicity is closely related to serum [MEDICATION NAME] concentrations, and can occur at doses close to therapeutic concentrations. Facilities for prompt and accurate serum [MEDICATION NAME] determinations should be available before initiating therapy. According to FDA.com, serum [MEDICATION NAME] concentration assay (lab levels) should be obtained after 4 days, drawn 12 hours after the last oral dose and regularly until stabilized [MEDICATION NAME] concentrations greater than 3 mEq/L (milli-equivelants per liter), may progress to [MEDICAL CONDITION], coma, and irreversible brain damage. Observation on 7/25/18 at 5:15 p.m. revealed the resident sat in the dining room waiting for supper. He/she was alert, oriented, in a pleasant mood, without any slurred speech or symptoms of [MEDICAL CONDITION]. The resident had no residual effects from the [MEDICATION NAME] toxicity. An interview on 7/26/18 at 1:27 p.m. with direct care staff M revealed he/she remembered a time when the resident wasn't acting normal. The resident was dizzy, drowsy, and had a stumbling gait. Staff M stated he/she reported this to the nurse. During an interview on 7/26/18 at 1:59 p.m., licensed nurse G verified the resident went to the hospital with [MEDICATION NAME] toxicity. He/she further stated the physicians usually ordered [MEDICATION NAME] levels when residents started on [MEDICATION NAME]. An interview on 7/26/18 at 5:15 p.m. with administrative nurse D confirmed the resident went to the hospital with [MEDICATION NAME] toxicity. Nurse D indicated he/she would look to see if the consultant pharmacist reviewed the resident's medications for (MONTH) of (YEAR). During an interview on 7/30/18 at 1:50 p.m., consultant pharmacist II indicated he/she looked at labs and made recommendations on labs for medications requiring lab values. Staff II further stated he/she typically asked for a baseline [MEDICATION NAME] level and then routine follow-up once the medication started. Consultant II stated he/she missed the lack of monitoring of the [MEDICATION NAME] for resident #24. The facility failed to adequately monitor [MEDICATION NAME] levels for resident #24 after the physician ordered the medication, in accordance with professionally acceptable standards. Resident #24 required hospitalization for [MEDICATION NAME] toxicity. - Resident #70's 12/29/17 annual MDS (minimum data set) assessment revealed the resident was rarely or never understood and was independent with set-up assistance for most ADLs (activities of daily living) and needed supervision and set-up for eating and toilet use. The resident had no limitations in range of motion and used a wheelchair. The resident received antidepressants and anticoagulants daily. The 1/16/18 nutrition CAA revealed the resident had weight loss and used a wheelchair for ambulation. The resident had other issues that could affect his/her appetite such as cardiovascular disease. The 8/10/16 nursing care plan directed staff to monitor/document/report any changes in lung sounds, [MEDICAL CONDITION] (swelling), and changes in weight. Monitor/document/report any signs or symptoms of CAD ([MEDICAL CONDITION]) such as chest pain or pressure, heartburn, nausea and vomiting, shortness of breath, excessive sweating, and color/warmth of extremities. Progress note dated 8/16/17 at 12:58 a.m. documented the resident needed help of 2 staff to transfer toed and was unable to sit up straight. Vital signs included blood pressure of 180/75, pulse 105 beats per minute (normal 60-100), respirations 18 per minute, oxygen saturation 95% (normal), and no fever. The resident had a decreased level of consciousness and some slurred speech. Staff documented they would continue to monitor. At 5:52 a.m., staff noted the resident still had trouble with transfers and rested in bed. At 7:58 a.m., staff noted the resident had signs and symptoms of stroke-like behavior with slurred speech and left sided-weakness. He/she was unable to follow simple commands or sit upright without assistance. The resident was transferred to the local hospital emergency room . Staff notified the physician and the resident's family. A progress note dated 8/24/1 7at 4:16 p.m. stated the resident returned from the hospital and staff reviewed the discharge instructions. The resident had an order for [REDACTED]. A discharge summary note dated 8/29/18 stated the resident transferred to the local hospital on [DATE] via ambulance as the resident was non-responsive. Staff received an order from the physician to transfer to the hospital. Review of the electronic record revealed no documentation of any nursing assessments or vital signs obtained after the resident readmitted to the facility on [DATE]. The record also lacked documentation of an assessment when the resident was found unresponsive and subsequently readmitted to the hospital with [REDACTED]. Observation on 7/25/18 at 11:15 a.m. revealed the resident sat in his/her wheelchair for lunch. The resident was alert, soft spoken, without any shortness of breath. During an interview on 7/26/18 at 1:59 p.m., licensed nurse G reported that when a resident returned from the hospital staff should monitor more closely. Staff G verified the lack of nursing assessments or documentation that the resident had a change in condition, unresponsive status, and transferred to the emergency room . An interview on 7/26/18 at 4:34 p.m. with administrative nurse D revealed he/she expected licensed staff to monitor residents for any changes after hospitalization , including a nursing assessment for level of consciousness, vital signs, and any change in condition. When staff find a resdient unresponsive, he/she would expect staff to document the incident including an assessment of the resident. The facility's revised 5/2012 Change of Condition policy stated condition changes would be assessed and investigated by nursing staff Charting will continue until the point of resolution. The facility failed to document appropriate nursing assessments for resident #70 when he/she was readmitted to the facility from the hospital, then required a readmission to the hospital when he/she had a [MEDICAL CONDITIONS]. - Resident #122 admitted to the facility on [DATE]. An admission MDS (minimum data set) assessment was in progress. The initial care plan dated 7/17/18 directed staff to inspect his/her skin weekly. Staff should observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. The resident's 7/13/18 admission nursing assessment documented the resident had no skin issues. A skin assessment dated [DATE] also documented no skin issues. An observation on 7/23/18 at 9:28 a.m. revealed the resident wore a short sleeve shirt and had multiple scabbed sores on his/her left forearm. The resident stated a resident at another facility stabbed him/her with a fork. (The clinical record lacked any documentation of the presence of the sores at the time of admission or with the weekly skin assessment.) On 7/24/18 at 11:30 a.m., the resident sat at a dining room table and pulled a washcloth from his/her armpit. The washcloth had a small amount (approximately 2 centimeters in diameter) of pink drainage. The resident said he/she had something under arm that was bleeding and stated he/she showed the nurse, but nothing was done. The resident wore a tank top and raised his/her arm to show an irritated area in the underarm that had bloody drainage. (The clinical record lacked any documentation of the presence of a draining wound in the resident's left underarm.) During an interview on 7/26/18 at 1:27 p.m., direct care staff M stated he/she was unaware of any skin issues. Staff M stated the residents usually reported skin problems to the nurse. An interview on 7/26/18 at 1:59 p.m. with licensed nurse G revealed he/she was unaware of any skin issues. The facility failed to thoroughly assess and document non-pressure skin issues for resident #122. her if she showed the nurse, she said yes, but she didn't do anything about it. 11:30 AM pulled Observe

The facility identified a census of 77 residents. Based on observation, record review and interview, the facility failed to maintain safe water temperatures when hot water temperatures exceeded 146.8 degrees Fahrenheit (F) in bathroom sinks on the north hall and when water temperatures exceeded 150 degrees F. in a common bathing area (the only functioning shower room) in the bathtub and sink on the north hall. Furthermore, the facility failed to maintain safe water temperatures when water temperatures exceeded 141 degrees F in bathroom sinks on the south hall. This deficient practiced placed all residents of the facility in immediate jeopardy. Findings included: - On 11/14/16 at 11:15 A.M., resident #25's bathroom sink water temperature registered a temperature reading of 130.0 degrees F. On 11/14/16 between 11:15 A.M. and 12:10 P.M., bathroom sink temperatures for residents on the north hall reached 141 degrees F. and reached 152 degrees F. in the north hall community bath(the only functioning shower room). On 11/14/16 between 11:15 A.M. and 12:10 P.M. bathroom sink temperatures for residents on the south hall reached 137.7 degrees F. On 11/14/16 at 12:10 P.M., the water temperature in a north hall resident's bathroom sink reached a reading of 143 degrees F. At this time, maintenance staff Z checked the same resident's bathroom sink with his/her thermometer, and obtained water temperatures that reached 120.0 degrees F A second surveyor staff S revealed a reading of 137.7 degrees F. On 11/14/16 at 3:17 P.M., resident #49 walked down the hall and stated to the surveyor J There was something wrong in his/her room. Observation at this time revealed a pair of jeans in his/her filled bathroom sink and steam rose from the basin. The thermometer recorded a water temperature of 146.8 degrees F from the spout. On 11/14/16 at 1:40 P.M., direct care staff U stated staff checked the water temperature with his/her hand before baths and showers, and asked the residents if the water temperature was comfortable. Staff U further stated maintenance staff checked the water temperatures, but was unsure how often. On 11/14/16 at 1:49 P.M. maintenance staff Z stated he/she was unaware of the hot water temperatures and was unsure of the safe temperature range, but acknowledged the water temperatures were too hot. Maintenance staff Z stated the hot water tank sat directly below a resident's room on the north hall, and a local plumbing contractor serviced the hot water tank recently. Maintenance staff Z further stated water temperatures were checked in all resident rooms and registered 120 degrees F or less on 11/13/16. He/she provided an invoice from a local plumbing contractor dated 10/31/16 for the repair of a leaking pump and parts order. On 11/14/16 at 2:29 P.M. administrative licensed staff D stated the north common bathing room remained locked, except when residents bathed. Staff D reported safe water temperatures ranged 109 to110 degrees F. Staff D further stated maintenance staff checked the water temperatures, and only reported if there were any concerns. Staff D denied any reported concerns, and was unaware of the hot water temperature readings. On 11/14/16 at 4:00 P.M., administrative staff A was unaware of the elevated water temperatures, but acknowledged a local plumbing contractor checked the system recently. On 11/14/16 administrative staff A stated the facility did not have a policy related to water temperatures and later presented a policy dated 11/2016. According to published health information acceptable hot water temperatures range from 98 degrees F to 120 degrees F in both hand washing and bathing areas. According to published information from Kansas University Medical Center: The depth of the injury is directly related to the temperatures of the burning agent and the duration of exposure with body tissue. Only limited duration was necessary for tissue destruction. In full thickness injuries, all layers of the skin and sometimes underlying tissue were destroyed. Examples: 122 degrees F /5 minutes length of exposure; 131 degrees F/30 seconds, 133 degrees F/15 seconds; 140 degrees F/6 seconds and greater than 150 degrees F/1 second. The facility failed to maintain safe water temperatures when hot water temperatures exceeded 120 degrees, 146.8 degrees Fahrenheit (F) in bathroom sinks on the north hall and when water temperatures exceeded 150 degrees F in a common bathing area in the bathtub and sink on the north hall. Furthermore, the facility failed to maintain safe water temperatures when water temperatures exceeded 141 degrees F in bathroom sinks on the south hall. This deficient practiced placed all residents of the facility in immediate jeopardy. The facility abated the immediate jeopardy, on 11/16/16 at 10:00 AM, by implementing the following: Maintenance director drained the hot water tank to reach the required range; Water temperatures were monitored by Maintenance staff Z or his/her designee on an hourly basis for 48 hours and checked all resident areas hourly for 48 hours, and daily until water temperatures did not exceed 120 degrees F; residents were not allowed to shower until water temperatures were stabilized by maintenance; new thermometer purchase for maintenance staff z to ensure accuracy; development of water temperature procedure and education for all staff on November 15, 2016. The facility Water Temperature Procedure dated 11/2016 recorded: The residents' bathrooms and bathing areas on the North and South halls will be placed on a rotating schedule on a daily basis, for a total of 10 resident bathrooms. No resident bathroom will go more than 7 days without being monitored The scope and severity remained at a F.

The facility reported a census of 74 residents. Based on observation, interview and record review, the facility failed to conduct a complete investigation and report allegations of abuse, neglect, or exploitation (ANE) for 3 (#68,#42 and #27) of 3 residents sampled for abuse. Resident #68's allegation that licensed nursing staff H threw the resident to the floor, the incident was not reported or thoroughly investigated and he/she continued to work on 2 of 2 resident halls in the facility after the allegation was made which placed the residents in immediate jeopardy (IJ). Resident #42's incident was not reported to the state and #27 had possible exploitation. Findings included: - The signed Physician order [REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The resident received antipsychotic and antidepressant medications. The Cognitive Care Area Assessment (CAA) indicated the resident exhibited disorganized thinking, inattention, [MEDICAL CONDITION] and hallucinations related to his/her mental illness. Review of the care plan dated 1/2/14 revealed the resident had a history of [REDACTED]. He/she was involved in numerous altercations with staff and peers. The Nursing Note dated 12/30/13 at 12:45 A.M., and an incident/accident report dated 12/30/13 at 12:45 P.M. completed by licensed nursing staff H revealed the resident punched licensed nursing staff H in the nose first and then in the mouth, which broke the staff's dentures. During the altercation, the resident tripped and licensed nursing staff H caught the resident before he/she hit the floor. The resident began to yell, "you threw me to the floor." Review of a witness statement provided by the facility, dated 12/30/13 at 1:45 A.M. completed by direct care staff P, revealed the resident hit licensed nursing staff H in the lip. Licensed nursing staff H blocked several punches at which time the resident fell to the floor on his/her own and became emotional. The witness statement provided by the facility dated 12/30/13 at 1:45 A.M., a notarized complaint investigation witness statement dated 1/29/14 at 12:21 P.M., and interview on 1/29/14 at 12:21 P.M. completed by direct care staff O, revealed this staff member witnessed the resident punch licensed nursing staff H in the face then proceeded to fall to the ground by his/her own will. The resident threatened to hit licensed nursing staff H before he/she actually hit licensed nursing staff H. The resident claimed licensed nursing staff H hit him/her but it was clear that did not happen. The electronic social work note by licensed staff J dated 12/30/13 at 8:29 (does not say A.M. or P.M.) revealed that at 1:33 A.M. licensed nursing staff H reported to licensed staff J the resident walked down the hall, turned around, and started to run towards licensed nursing staff H and hit him/her in the nose and mouth, breaking staff's dentures. The resident tripped and licensed nursing staff H caught him/her before hitting the floor. The resident began to yell, "you threw me to the floor." It was reported the resident stated the voices were telling him/her to hurt others. The electronic social work note by licensed staff J dated 12/30/13 at 8:40 (does not say A.M. or P.M.) revealed that an unsampled resident requested a confidential interview with staff regarding the incident last night in which he/she witnessed. The resident reported he/she saw staff throw a resident to the floor. The resident completed an undated witness statement form, which revealed the resident was "tron" to the ground. The Notarized Complaint Investigation witness statement completed by anonymous staff A dated 1/30/14 revealed the resident was talking to the staff working on his/her hall regarding the incident with licensed nursing staff H the previous week. The resident stated they had got into an argument that escalated to the resident striking licensed nursing staff H, which broke the staff member's dentures. He/she reported staff asked him/her to leave the area and proceeded to shut the doors which blocked the hall in which they were on. The resident stated to this anonymous staff that licensed nursing staff H shoved him/her down the hall and on to the floor. An undated typed statement from anonymous staff A revealed the resident reported this incident to social service staff KK. This anonymous staff member placed a call and left a message with Adult Protective Services immediately following the resident's report of this incident. Licensed nursing staff H continued to work 5 more shifts after this incident occurred. A hand written statement by the resident dated 12/29/13 and interview with the resident on 1/29/14 at 8:05 A.M., revealed licensed nursing staff H shoved him/her into another resident's door, the staff had his/her knee in the resident's hip and shoved the resident to the floor which resulted in a small bruise on his/her right knee and a knot on the head. Licensed nursing staff H shut the door so direct care staff O and R could not see what happened. The Notarized Complaint Investigation witness statement by Administrative nursing staff D dated 1/30/14 revealed this staff member worked with licensed nursing staff H and did not witness any abuse, neglect, or exploitation when working with him/her. Administrative nursing staff D did not have any reports that abuse occurred. Administrative staff D reported the resident stated licensed nursing staff H did not abuse him/her and he/she was just upset and sorry upon return from jail. On 1/29/14 at 7:30 A.M., observation revealed the resident visited with table mates. On 1/29/14 at 8:45 A.M. administrative staff A reported this altercation between resident and licensed nursing staff H was not reported to the state as he/she and administrative nursing staff D did not think it needed reporting, because staff saw the altercation, read the witness statements and licensed nursing staff H did the right thing. An interview on 1/29/14 at 8:30 A.M. direct care staff JJ reported the resident recalled situations appropriately yet at times added additional information. On 1/29/14 at 1:07 P.M. administrative staff A stated when there was any altercation between residents and staff, or other residents, staff started an investigation immediately. He/she said staff reported altercations between residents and staff to the state agency. On 1/29/14 at 3:00 PM direct care staff O stated he/she worked evening and night shift and stated staff were to report all incidents with resident to staff altercations to the Director of Nursing (DON). On 1/29/14 at 3:30 P.M. administrative staff A stated he/she did not receive information from the resident's perspective of the incident. On 1/29/14 at 3:40 P.M. with licensed staff J stated when there was an altercation, he/she spoke with the resident and obtained incident reports, yet agreed that in this case there was no documentation anyone spoke with this resident. He/she reported the staff spoke to the resident and he/she acknowledged hitting licensed nursing staff H and reported he/she was shoved to the ground. On 1/29/14 at 4:19 P.M. administrative nursing staff D stated if there was alleged abuse that during the investigation, the facility would suspend the staff person, and his/her role in the investigation was talking with staff, residents, and reviewing witness statements. He/she was unaware of any alleged abuse in this altercation and did review the incident with administrative staff A, including the nurse's note on 12/30/13 at 12:45 A.M. completed by licensed nursing staff H, and witness reports from direct care staff O and P. He/she was unaware of the witness statements from the unsampled resident and he/she said licensed nursing staff H was not suspended. Interview on 1/29/14 at 5:10 P.M. anonymous staff A reported the resident told this staff member that he/she got into an argument with licensed nursing staff H and the resident hit licensed nursing staff H. This anonymous staff member was worried because licensed nursing staff H still worked at the facility. This staff member reported during the interview with the resident he/she had to pull information out of the resident which was rare for this resident. The resident said licensed nursing staff H closed the doors to the hall and threw the resident to the ground. This anonymous staff member had the resident write a written statement but never turned it in, because the resident had a reputation of making allegations and this staff was off for a week and was not sure what licensed staff H reported. This anonymous staff was worried because usually they suspend nurses who had allegations of abuse and licensed nursing staff H was still working. On 1/30/14 at 11:27 A.M. administrative staff A was informed of IJ for lack of thoroughly investigating alleged abuse and failure to report this alleged abuse to the State agency, while the staff member named in the allegation continued working at the facility. On 1/30/14 at 11:27 A.M. administrative staff A stated he/she reported practically everything to the state. He/she reported serious incidents including, resident to resident abuse, resident to staff altercations, and investigations start immediately. The policy and procedure for ANE last revised on 1/30/14 stated: Investigate each such alleged violation thoroughly, report the results of said investigations to the State agency as required by State and Federal Law and respond to any necessary corrective actions depending on the investigation outcome. The facility failed to complete a thorough investigation of abuse and exploitation and failed to report an alleged incident of abuse to the State Agency. This immediate jeopardy was abated on January 31, 2014 at 4:00 P.M. when the facility revised the facility's ANE policy and procedure, the policy was then translated into terms in which the staff understood, in-serviced staff and residents how to report ANE allegations, training and retraining will occur upon hire, new admission, bi-annually for staff and monthly for residents. The alleged perpetrator was removed from the facility and was not expected to return. This deficient practice of failure to thoroughly investigate and report an allegation of abuse, exploitation remained at a scope and severity of an F. - Resident #27's admission Minimum Data Set ((MDS) dated [DATE] included the resident scored 11 (moderately impaired cognition) on the Brief Interview for Mental Status. Review of the resident's clinical record revealed the resident was admitted to the facility during the month of 2/2013 and discharged to the community during the month of 3/2013. The resident was admitted to the facility on [DATE], discharged to a local hospital on [DATE] for a [DIAGNOSES REDACTED]. On 1/27/2014 at 8:01 A.M. the resident stated upon admission he/she had (3) portable Play Station (PSP), was missing (2) of PSP and $5.00. The resident stated he/she noticed (2) PSP and the $5.00 was missing upon his/his return from the hospital and reported the missing items to social service staff. Housekeeping staff Y entered the resident's room a few minutes later stated after the resident returned from the hospital a couple of weeks ago, the resident reported to him/her that he/she was missing $4.00. Housekeeping staff Y stated he/she looked in the resident's pant pocket as well as in laundry and did not find the money. Housekeeping staff stated to the resident "before you accuse someone of stealing and telling this lady/man this, you need to make sure the items are not in your room." Housekeeping staff Y exited the resident's room and a few minutes later housekeeping staff Y and direct care staff S entered the resident's room. Direct care staff S stated to the resident he/she did not bring in (3) PSP's at admission, he/she worked at the facility for a year, conducted the resident's personal inventories and the resident did not have (3) PSP's upon admission. A few minutes later licensed nurse K entered the resident's room and told the resident he/she was not missing PSP's. Observation revealed (1) PSP in the resident's room. Review of the resident's clinical record lacked evidence the facility performed an inventory of the resident's personal items. On 1/28/14 at approximately 3:56 P.M. direct care staff CC stated he/she was not aware the resident was missing personal items. Direct staff CC stated direct care staff reported to the charge nurse if residents reported they were missing personal items. Direct care staff CC stated when residents were admitted to the facility, staff did an inventory of the resident's personal items and the inventories were updated every month or so. On 1/28/14 at approximately 8:30 A.M. direct care staff S stated she and a charge nurse reviewed the resident's chart on 1/27/14 and did not see a personal inventory. Direct care staff S stated direct care staff performed the personal inventory upon admission and then gave the inventory sheet to administrative staff E. On 1/28/14 at approximately 2:25 P.M. administrative nursing staff E confirmed the facility did not perform an inventory of the resident's personal items upon admission. On 1/28/14 at approximately 2:30 P.M. social service staff KK stated direct care staff did an inventory of the resident's personal items upon admission. Social service staff KK stated the facility determined what actions they took regarding missing items depending upon the resident's cognition and organizational skills. Social service staff KK stated the resident stated he/she was missing items including the PSP (did not give date the resident had reported this). Social service staff KK stated except for the PSP the facility found the other missing items the resident reported. Social service staff KK stated he/she was not aware the resident was missing money until 1/27/14. Social service staff KK stated when residents missed personal items either the resident or staff completed a complaint form and then passed the form on to the licensed social work or the administrator. On 1/30/14 at approximately 1:25 P.M. social service staff KK stated the facility would report the missing items to the state certification and licensing agency. On 1/30/14 at approximately 1:40 P.M. direct care staff S stated direct care staff reported resident's missing items to the charge nurse. On 2/3/14 at approximately 8:00 A.M. housekeeping staff Y stated staff reported missing reported to the Social Service Designee. Housekeeping staff Y stated he/she did not report the resident's missing $4.00 to the SSD. The facility's Abuse, Neglect, Exploitation/Misappropriation of Property Policy and Procedure revised 1/30/14 included the purpose of the policy was to ensure all alleged violations of Federal or State Laws, including exploitation, and misappropriation of residents property were reported immediately to the facility's Executive Director, and to the state agency in accordance with the existing State law...The Executive Director reported all alleged violations within 24 hours to the state agency. The facility failed to immediately report the alleged misappropriation/exploitation of this resident's personal property to the state agency. x - The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/13 indicated a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The resident had verbal behaviors directed towards others, required limited 1 person assistance with bed mobility, transfers, ambulation, toileting, and personal hygiene, extensive 1 person assistance with dressing, supervision and set up with eating, physical help of 1 person with bathing, was not steady but able to stabilize without staff assistance when moving from seated to standing position, with surface to surface transfers, walking, turning around and facing the opposite direction, was steady at all times when moving on and off the toilet, had no upper extremity impairment with range of motion, had impairment on one side of lower extremities, and used a walker and a wheelchair. The Care Area Assessment (CAA) for cognitive loss dated 4/4/13 revealed the resident was alert and oriented, communicated his/her needs effectively, had a mental illness [DIAGNOSES REDACTED]. The CAA for psychosocial well being dated 4/4/13 revealed the resident got along with his/her roommate and that was only peer he/she had a relationship with, his/her roommate often apologized to others for the resident's angry outbursts. The resident's angry outbursts, aggression, and derogatory behavior towards others led to isolation. The care plan dated 7/26/13 with no revision date revealed the resident had a [DIAGNOSES REDACTED]. Staff would encourage positive peer relationships, document all expressions of suicidal thoughts and intervene appropriately, offer medications per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The care plan dated 7/26/13 with no revision date revealed the resident was alert and oriented, made appropriate decisions and set a daily routine, communicated without barriers, and had impaired decision making and communication during anger outbursts. When he/she became upset and yelled he/she was rarely easily redirected, he/she followed staff, blocked staff and yelled repeatedly. Staff attempted to resolve his/her issues although they were usually based on the fact the resident did not want to be in the facility. A nursing note on 11/30/13 at 1:00 P.M. revealed another resident put his/her hands around this resident's neck. This resident hollered for help. A direct care staff person assisted the resident out of the room. This resident yelled and called the police. A nursing note on 11/30/13 with no time revealed the police were at the facility and spoke to this resident. A nursing note on 11/30/13 at 1:30 P.M. revealed social service staff KK was at the facility doing one on one with the resident and administrative nursing staff D was notified of the incident. A nursing note on 11/30/13 at 1:35 P.M. revealed administrative staff C was notified of the incident. A nursing note on 12/1/13 with no time documented revealed the resident was very aggressive, yelled at staff, wanted the other resident involved in the previous incident thrown in jail. The record lacked further documentation regarding the incident. The facility provided documentation the resident in question strangled a second resident in the facility on 12/3/14. The facility provided documentation this incident was reported to the state agency on 12/4/13. Observation on 1/28/14 at 8:40 A.M. revealed the resident laid on his/her bed with oxygen on, first responders and nursing staff attended to him/her. Interview on 1/23/14 at 1:08 P.M. with resident #42 said there was a resident who strangled people and he/she lived at the facility until about 3 weeks ago when the police removed him/her from the facility after he/she attempted to strangle someone again. This resident stated he/she called the police, told the staff at the facility, and called Disability Rights of Kansas the second time it happened. This resident reported the facility did nothing to try and keep the offending resident away from him/her, they only told him/her to stay out of the resident's room. Interview on 1/29/14 at 1:24 P.M. with direct care staff MM revealed the resident who strangled the other residents was started on 15 minute checks and when a second incident happened he/she was started on one on one checks. The facility tried to find placement for the resident. He/she was aware of 2 incidents and the resident was transferred somewhere else. An interview on 1/29/14 at 2:26 P.M. with direct care staff U revealed after the other resident choked resident # 42 he/she was put on 15 minute checks, the resident threatened people all the time, and frequently tried to harm others like when he/she tried to strangle another resident. He/she was unable to recall and new facility interventions for the resident after he/she strangled the second resident to prevent any further incidents. The resident then tried to strangle administrative nursing staff E, the police were called, and the resident was removed from the facility. An interview on 1/28/14 at 8:40 A.M. with licensed nursing staff K indicated the resident was transported to the hospital. He/she was started on an antibiotic for a urinary tract infection last night and became increasingly confused and his/her condition declined. An interview on 1/29/14 at 3:26 P.M. with administrative nursing staff D revealed social services worked with the resident to find out why he/she choked people and it went back to the resident wanted to go to jail. The staff performed 15 minute checks, had him/her on 1 on 1, kept him/her out of other resident's rooms, kept him/her in the day room, and redirected him/her. The resident had a delusion he/she needed to be in jail. The resident was sent to a local mental health clinic for screening and deemed safe the resident safe to return to the facility. The facility called the police every time the resident did something and the last episode was when he/she choked a staff member, went to jail and then to an acute mental hospital. The incident/accident reporting policy dated 10/2011 provided by the facility revealed incidents and accidents including, but not limited to abuse, neglect, and exploitation allegations and resident to resident incidents must be immediately reported to the state agency by the director of nursing or the administrator within 24 hours. The facility failed to report this reportable incident within a timely manner.

The facility reported a census of 72 residents and the sample included 8 residents. Based on record review and staff interview, the facility failed to provide supervision as per the care plan to prevent accidental choking for resident #1. This failure place the resident in immediate jeopardy. Findings included: - Resident #1 had [DIAGNOSES REDACTED]. The POS recorded the resident received a diet of mechanical soft, ground meat with gravy, small spoon, shallow bowl, no raw vegetables/fruit, cut up sandwiches into bite size pieces, bread cut into quarters, sandwich at bedtime, and great shakes with meals. The care plan dated [DATE] and last reviewed [DATE] recorded the diet had changed to mechanical soft diet with no raw vegetables/fruits, ground meat with gravy, cut any other foods into bite size pieces, like breads, cakes, boiled eggs, pies, or any other possible choking foods. The care plan dated [DATE] and last reviewed [DATE] recorded the resident choked on a piece of tomato on [DATE], that the resident was at risk for further choking/aspiration, and had a [DIAGNOSES REDACTED]. and check lung sounds as needed. The care plan instructed the staff to cleanse the mouth after meals, and offer diet consistency as ordered. Speech evaluation [DATE] changed the diet to mechanical soft with ground meat and gravy, nickel sized fruits and vegetables. Review of the speech therapy evaluation dated [DATE] recorded under Staff/Family Education the following: 1. Use small bites, cut up all foods to nickel size 2. Put utensil down between bites 3. Alternate bites/sips 2:1 4. Encourage lots of chewing 5. Eat slowly The nurses notes (NN) dated [DATE] at 8:20 P.M. recorded that the staff passed out sandwiches and gave the resident his/her bedtime snack. The NN recorded the staff reported the resident's head was tilted back and the resident was unresponsive. The staff alerted the nurse who assessed the resident and found no breathing or pulse. The staff started cardio pulmonary resuscitation (CPR) and called 911. Mouth sweep revealed the mouth was full of chewed cheese sandwich. The staff attempted stomach thrust which was ineffective, then all staff stood the resident up and attempted the Heimlich maneuver which also was ineffective. The staff continued with CPR until first responders arrived and took over, then the local ambulance service arrived and worked on the resident until about 9:30 P.M. when they transported the resident out of the building. The staff contacted the Durable Power of Attorney, the Director of Nursing, the Social Worker, the Doctor and the Administrator. At 10:10 P.M. the hospital informed the staff the resident had a pulse. NN [DATE] revealed the staff called the hospital, the resident was in the intensive care unit on a ventilator. The facility discharge summary dated [DATE] recorded the facility discharged the resident on [DATE] to the hospital, where the resident expired on [DATE]. The note recorded the resident's diet was regular, and the texture was "food cut up in bite size pieces, no food bigger than a nickel." Review of the facility incident/accident report dated [DATE] recorded that at 8:20 P.M. the staff gave the resident a bedtime (HS) snack, a sandwich. The staff reported to the nurse that the resident was unresponsive. The nurse quickly assessed the resident who was not breathing and had no pulse and then lowered the resident to the floor and started CPR, and called 911. The mouth sweep revealed chewed cheese sandwich which was removed, and the staff attempted rescue breathing but the resident's chest did not rise. The staff attempted stomach thrust and the Heimlich with no success. The staff continued CPR until first responders arrived. Interview on [DATE] at 1:00 P.M. with administrative staff B said the facility had the incident report but no other investigation. Interview on [DATE] at 1:05 P.M. with licensed nursing staff B who said they were the nurse on duty on [DATE] and that he/she was at the nurses station on the South unit. The staff said anyone who wanted could have a snack in the evening, but that sandwiches belonged to specific people who had orders for them. The staff said the resident was in the dining room for a snack. The staff said dietary prepared the snacks, placed them on a tray, and then direct care staff hand out the snacks. He/She said the staff were in the dining room, still passing the snacks, looked up, saw the resident was unresponsive and then hollered for this nurse. The nurse said they immediately went into the dining room and assessed the resident, who had no breathing, and no pulse. The staff placed the resident on the floor to start CPR, checked his/her mouth and found chewed up cheese sandwich in the mouth, which they removed. The staff resumed CPR, but could not get the chest to rise with rescue breathing. The staff thought the food was still there, did a stomach thrust, but did not get food out, so they attempted rescue breathing again and chest compressions, but still did not get the chest to rise. The staff said that all the staff got together, lifted the resident up and did the Heimlich, but no food came up then either, and continued then with CPR until the first responders arrived. The staff said the resident had ? of a sandwich left on the plate. The staff said the first responders immediately started CPR, and had difficulty getting air into the lungs. The staff said the local ambulance service came right behind the first responders, and they put a tube into the throat that hooked up to the oxygen. The staff said they worked on the resident for a long while before they took him/her to the hospital. Interview on [DATE] at 2:12 P.M. with direct care staff A said they were in the dining room passing out HS snacks at a few minutes after 8:00 P.M. on the night of [DATE]. The staff said the snacks came from the kitchen in sandwich bag labeled with residents' names. The staff said the resident had a cheese and Mayo sandwich on white bread. The staff said the resident ate independently. The staff said he/she gave the resident his/her sandwich first as he/she sat waiting and then continued passing out rest of the snacks. The staff said he/she did not see the resident in distress. The staff said the resident had left the table, and then he/she saw the resident sit in the wheel chair with his/her head back, unresponsive around 8:20 P.M. and at that point he/she called for the nurse, and then called 911. The staff said they had not cut up the sandwich into small pieces. The staff said he/she had witnessed another episode, when the resident choked on a piece of tomato. The staff said the resident was a pretty good eater, and that the staff did not have to assist him/her with eating. Interview on [DATE] at 2:48 P.M. with dietary staff A said the resident's food was cut into bite size pieces, and any fruits/vegetables were not bigger than a nickel. The staff said they cut up all foods into pieces, even his/her bread and butter. The staff said the resident shoveled his/her food in and that was their problem. The staff said that a while back the resident choked on a piece of stewed tomato and that was when they changed the resident's diet into nickel sized vegetables/fruit. The staff said HS snacks came from the kitchen, they made the sandwiches in the kitchen either peanut butter or cheese, a whole sandwich or a half, put jelly or Mayo in the packet together with a knife and then the staff on the unit passed them out. If a sandwich had to be cut up, the staff on the unit did it. The staff said the resident got a cheese sandwich at HS, and believed he/she got a whole one. On [DATE] at 2:58 P.M. interview with licensed nursing staff A said the resident fed him/herself, the nursing staff had to provide set up, and the food needed to be in bite size pieces. The staff said the resident did not see very well, and the staff had to tell him/her where things were. The staff said the resident sat at a restorative table, where staff provided set up and extra supervision but that they did not sit at the table, unless someone needed help feeding/was sick, which was rare. The staff was not aware that the resident refused to have his/her food cut up. The staff said he/she communicated the care plan to the direct care staff by leading by example, went out on the floor to teach. The staff also said that they had a cardex book and an activities of daily living (ADL) book. The staff said that the information in these were basic, and would not have gone into detail. On [DATE] at 3:10 P.M. with administrative staff B said he/she communicated the care plan to the direct care staff by the daily roster and the ADL book. The staff explained that the roster had information as to who was on checks, who needed vitals taken, follow-up after falls, who needed a shower for that shift, etc and that the staff carried those on a clip board. On the ADL book the staff filled out who had a bowel movement, who took a shower and other ADLs. The nurse gave to them the clipboard at the beginning of the shift. The residents who sit at the table with a Reserve sign, needed a little extra assist, took longer to eat, and said there were staff in the dining room at all times but not always at that table. Review of the ADL sheet for the resident did not record special dietary needs. The facilities failure to provide adequate supervision and the correct food texture/diet placed this resident in immediate jeopardy. The resident choked and later expired. Review of the facility corrective action plan dated [DATE] recorded the following plan of correction: "1. All residents currently with special needs will have their dietary recommendations immediately recognized on the diet cards. Dietary staff A and Licensed Nursing Staff A will ensure compliance with follow up by the Administrative staff B or her designee. 2. Check care plans on all special diet need residents to ensure proper care plan is in place. Dietary staff A and Licensed Nursing Staff A immediately. 3. All residents utilizing the upstairs/main dining room will have their diet cards, including but not limited to, information such as special recommendations/diets will be kept on resident meal cards, which will be kept on ALL meal trays through distribution. When residents are amenable, they will be seated at reserve tables to be more conducive to close observation. Dietary staff A will be responsible for compliance. 4. Facility care staff will be required to check each diet card before leaving a resident's place setting, and will be required to offer resident assistant as needed to make sure that the plate matches the resident's needs. IMMEDIATE-each staff member passing trays will be responsible for their own passing assignment, with the Admisnistrative staff A or her designee monitoring for continued compliance. 5. Snacks generated by the facility will meet any special needs for our clients, and will be clearly marked-IMMEDIATE. Dietary Staff A or her designee will monitor. 6. Specific nursing assistants will be assigned to offer supervision to any residents with special dietary needs- Adminstrative staff B or her designee will monitor. 7. All therapy orders and recommendations will be reported to the interdisciplinary team who will in turn communicate to facility care staff via the ADL book. Licensed Nursing staff A will be responsible for compliance. 8. Any residents refusing to comply with therapy and/or interdisciplinary team recommendations and/or orders will be required to an informed consent document stating that they understand the potential risks of non-compliance and still choose to follow their wishes-IMMEDIATE -Dietary Staff A will be responsible for compliance. 9. All care staff will be inserviced prior to meal pass to ensure that residents with special needs receive appropriate services. Inservices are starting IMMEDIATELY and will be completed by Wednesday [DATE]. Administrative staff B or her designee will be responsible." The facility abated the immediate jeopardy on [DATE] with implementation of the new procedures. The deficient practice remains at a scope and severity of G.