Every finding on record at Rinaldi Convalescent Hospital

Based on observation, interview, and record review, the facility failed to provide a functioning call light for one of four sampled residents (Resident 2). This deficient practice had the potential to delay the provision of care and services and had the potential for Resident 2's needs not being met.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted the resident on 6/24/2025 and readmitted the resident on 9/29/2025 with diagnoses including acute and chronic respiratory failure (a condition when not enough oxygen passes from the lungs to the blood) with hypoxia (low levels of oxygen in the body tissues), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty breathing) unspecified, and unspecified asthma (a long-term lung disease that makes it hard to breathe). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 6/18/2026, the MDS indicated that Resident 2 had severe cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impairment and required maximal assistance from staff for toileting hygiene, lower body dressing and personal hygiene. During a concurrent observation and interview on 7/30/2026 at 3:15 p.m., with the Maintenance Assistant (MA), observed Resident 2's call light indicator on the wall by the doorway did not light up when the call light was pressed. The MA stated the call light button should have been working for Resident 2 to be able to call for assistance. The MA also stated that without the call light button working for Resident 2, it could result in a delay in care and services. During an interview on 8/12/2026 at 4:10 p.m., with the Director of Nursing (DON), the DON stated the call light button should have been working for Resident 2 to be able to call for assistance. The DON also stated that without the call light button working for Resident 2, it could result in a delay of care and services that Resident 2 needs. During a review of the facility's policy and procedure titled, Call Light, dated 1/29/2026, the policy indicated ensure timely responses to the resident's requests and needs. The resident call system remains functional at all times. The resident call system is routinely maintained and tested by the maintenance department. Answer the resident call system in a timely manner.

Based on observation, interview, and record review, the facility failed to implement and maintain an infection control program for one of four sampled residents (Resident 4) when Resident 4's reuseable bilevel positive airway pressure (BiPAP- keeps the airway open) mask and humidifier (a device that adds moisture to the air) were not clean and observed with residue. This deficient practice placed Resident 4 at risk for infection.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility initially admitted the resident on 7/6/2025 and readmitted the resident on 6/10/2025 with diagnoses including acute and chronic respiratory failure (a condition when not enough oxygen passes from the lungs to the blood) with hypoxia (low levels of oxygen in the body tissues), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty breathing) unspecified, and acute pulmonary edema (a condition caused by too much fluid in the lungs). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 6/29/2026, the MDS indicated that Resident 4 had minimal cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance from staff for toileting hygiene, shower/bathe self, and lower body dressing. During a concurrent observation and interview on 8/11/2026 at 9:15 a.m., with the Assistant Director of Nursing (ADON), observed Resident's 4 BiPAP mask and humidifier with white residue. The ADON stated the BiPAP mask and humidifier should have been cleaned to prevent Resident 4 from getting an infection. During an interview on 8/12/2026 at 4:10 p.m., with the Director of Nursing (DON), the DON stated the BiPAP mask and humidifier should have been cleaned because of the risk of infection. During a review of the facility's recent policy and procedure titled, Infection Control, last reviewed on 1/29/2026, indicated it is the policy of this facility to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and practices are to prevent, detect, investigate, and control infections in the facility; provide guidelines for the safe cleaning and reprocessing of reuseable resident-care equipment.

Based on interview and record review, the facility failed to implement a follow-up process to ensure the formulation of the resident's Advance Directive (AD - a written document that states a resident's wishes regarding medical care if the resident is no longer able to make medical decisions due to a serious illness or injury) for one of six sampled residents (Resident 3). This deficient practice had the potential to result in uncertainty regarding the resident's healthcare preferences, which could lead to decisions that are inconsistent with the resident's expressed wishes. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident (Resident 3) on 10/25/2021 and readmitted on [DATE] with diagnoses that included pressure ulcers (PU -localized damage to the skin and underlying tissue, usually occurring over a bony prominence as a result of pressure, friction or shear) of right buttock stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), PU of right hip unstageable (a severe wound with full-thickness tissue loss where the true depth and damage cannot be assessed), diabetes mellitus (DM - disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcers (an open sore or lesion [any area of abnormal or damaged tissue in the body, caused by injury, infection or diseases] on the skin of the foot that fails to heal or keeps returning), dementia (a progressive state of decline in mental abilities that is severe enough to interfere with daily life), depression (a serious mood disorder characterized by a persistent feeling of sadness, emptiness, and a prolonged loss of interest in daily activities), and bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration). During a review of Resident 3's AD Acknowledgement dated 11/4/2021, signed by Resident 3, the AD Acknowledgement indicated the following: The box stating, I have not executed an AD was marked with an 'X'. The box for Yes under tube feeding (a medical way to deliver liquid food and medications directly into the stomach or small intestine) was marked with an 'X'. Resident 3's initials were documented in the section indicating the resident was capable of making decisions regarding the preferred intensity of medical treatment. During a review of Resident 3's History and Physical (H&P - document created when a resident is admitted , consists of a resident's medical history and a physical examination) note dated 1/19/2026, the H&P note indicated Resident 3 did not have capacity to understand and make decisions. During a review of Resident 3's Psychiatric (anything related to diagnosing, treating, and preventing mental, emotional, and behavioral disorders) Note dated 5/25/2026, the Psychiatric Note indicated that Resident 3's mental status could not be fully assessed due to dementia, the resident's condition, and lack of cooperative with the examination. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 3 had severely impaired cognition (mental process of acquiring, processing, and storing information). The MDS indicated Resident 3 was dependent on staff for Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 3's Multidisciplinary Care Conference note dated 6/10/2026, the Multidisciplinary Care Conference note indicated that the Interdisciplinary Team (IDT - the group of different healthcare professionals who work together to create and manage the residents' overall care, therapy, and recovery plan) conducted the quarterly care plan review with Resident 3's friend (Friend 1). The IDT discussion included the resident's current plan of care, diagnoses, medication regimen, discharge planning, and the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life). During a concurrent interview and record review on 6/23/2026 at 3:06 p.m., with Social Services Assistant 1 (SSA 1), SSA 1 reviewed Resident 3's AD Acknowledgment dated 11/4/2021 and the Multidisciplinary Care Conference note dated 6/10/2026. When SSA 1 was asked whether the IDT discussed or offered to formulate and AD with Friend 1 after Resident 3 lost decision-making capacity, SSA 1 stated the IDT reviewed the POLST with Friend 1 and confirmed there were no changes but did not address or formulate an AD. When SSA 1 was asked who made Resident 3's healthcare decisions, SSA 1 stated Resident 3 was not alert or oriented and was unable to make healthcare decisions, then referred the issue to the Social Services Director (SSD). During a concurrent interview and record review on 6/23/2026 at 3:43 p.m., with the Administrator (ADM) and the Acting Director of Nursing (Acting DON), reviewed Resident 3's AD Acknowledgment dated 11/4/2021 and the facility's policy and procedure (P&P) for AD. The ADM stated that when a resident does not have an AD, the facility should approach the resident or the resident's responsible party during quarterly reviews or at least annually, to offer the opportunity to formulate an AD and document if the offer is declined. The Acting DON stated Friend 1 did not always wish to make healthcare decisions for Resident 3 depending on the situation and confirmed the facility had only one AD acknowledgement dated 11/4/2021, in Resident 3's medical record. During an interview on 6/23/2026 at 4:40 p.m., with the ADM and the Acting DON, the ADM stated that Resident 3 no longer had decision-making capacity and stated that the facility's Ethics Committee (an advisory group that helps resolve medical, legal, and ethical dilemmas) should have assisted in facilitating the formulation of an AD including clarifying Resident 3's wishes regarding tube feeding based on Resident 3's current clinical condition, including weight loss. During a review of the facility's P&P titled, Advance Directives last reviewed on 1/29/2026, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated. Legal Representative (i.e., substitute decision-maker, proxy, agent) - a person designated and authorized by an advance directive or state law to make treatment decisions for another person in the event the other person becomes unable to make necessary health care decisions. POLST paradigm form - a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration. A POLST paradigm form is not an advance directive.

Based on interview and record review, the facility failed to implement its policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the results of its investigation of an allegation of neglect (failure to provide necessary goods or services required to maintain a resident's physical or mental health) to the State Survey Agency (SSA) within five (5) working days of the incident for one of six sampled residents (Resident 1). This deficient practice had the potential to delay the SSA's oversight of measures necessary to ensure the protection of residents. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident (Resident 1) on 8/26/2022 and readmitted on [DATE] with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), bullous pemphigoid (a disease that causes large, fluid-filled blisters [small, fluid-filled sac that develops under the outer layers of the skin] on the skin), diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/4/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene, lower body dressing and showering, and required moderate assistance from staff with upper body dressing, personal hygiene and bed mobility (movement) including rolling left and right. The MDS further indicated that Resident 1 was at risk for developing pressure ulcers/pressure injuries (PUs/PIs -localized damage to the skin and underlying tissue, usually occurring over a bony prominence as a result of pressure, friction or shear). During a review of the facility's initial report verification for Resident 1's allegation of neglect, the email verification indicated that the facility submitted the initial report to the SSA on 6/8/2026 at 5:58 p.m.During a review of the facility's follow-up investigation report verification for Resident 1's neglect allegation, the email verification indicated that the facility submitted the follow-up investigation report to the SSA on 6/18/2026 at 10:39 p.m. During a review of the undated facility's Resident Abuse Investigation Report Form regarding Resident 1's neglect allegation, the investigation report form indicated the following: Date Incident Occurred: 6/8/2026 Date Incident Reported: 6/8/2026 at 4:50 p.m. Summary of Interview with Person(s) Reporting the Incident: During a conversation with Resident 1's family member 1 (FM 1) on 6/08/2026 at around 4:50 p.m., FM 1 stated that they believed Resident 1 had been subjected to neglect and abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish) at the facility. Results of Findings and Corrective Action taken reported to: State Licensing Agency on 6/18/2026 at 10 p.m. by the Administrator (ADM). During a concurrent interview and record review on 6/23/2026 at 3:31 p.m., with the ADM, the ADM reviewed the facility's reporting verification for both the initial and follow-up reports related to Resident 1's neglect allegation. The ADM stated that no staff were found to have committed abuse or neglect. The ADM stated that FM 1 became upset after Resident 1 missed a scheduled dermatology (the medical study and treatment of the skin, hair, and nails) appointment on 6/8/2026 and alleged that the missed appointment constituted abuse and neglect related to Resident 1's skin condition. The ADM stated that the facility submitted the initial report to the SSA on 6/8/2026 at 5:58 p.m., approximately two hours after the allegation was reported and immediately initiated an investigation however, the ADM was unable to identify the exact date the investigation was completed. The ADM stated that although the final investigation report was submitted on 6/18/2026, it should have been submitted/reported by 6/15/2026. The ADM stated the facility failed to submit the follow-up investigation report within the required timeframe. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation (illegal or improper act of using a resident's funds, property, or assets for another person's profit or advantage, often involving coercion, manipulation, or fraud) and Misappropriation (deliberate misplacement, exploitation, or wrongful temporary/permanent use of a resident's belongings or money without their consent) Prevention Program last reviewed on 1/29/2026, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview, and record review, the facility failed to ensure the proper use of low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries [PU/PI- injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) by placing multiple layers of linens over the LALM for two of two sampled residents (Resident 1 and Resident 3), which had the potential to interfere with the pressure-redistribution function of the LALMs. These failures had the potential to reduce the therapeutic effectiveness of the LALMs, increasing the residents' risk for skin breakdown and/or delaying the healing of existing PU/PI.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident (Resident 1) on 8/26/2022 and readmitted on [DATE] with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), bullous pemphigoid (a disease that causes large, fluid-filled blisters [small, fluid-filled sac that develops under the outer layers of the skin] on the skin), diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/4/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene, lower body dressing and showering, and required moderate assistance from staff with upper body dressing, personal hygiene and bed mobility (movement) including rolling left and right. The MDS further indicated that Resident 1 was at risk for developing pressure ulcers/pressure injuries (PUs/PIs -localized damage to the skin and underlying tissue, usually occurring over a bony prominence as a result of pressure, friction or shear). During a review of Resident 1's Order Summary Report dated 4/30/2026, the Order Summary Report indicated Resident 1's physician ordered a LALM for Resident 1 for skin maintenance and PU prevention. During a review of Resident 1's Surgical Consult Notes, dated 6/9/2026, the Surgical Consult Notes indicated that Resident 1 had skin lesions (any distinct area of skin that differs from its surrounding tissue in color, texture, shape or size) on the right lower leg, left lower leg. The Surgical Consult Notes further indicated that Resident 1 was at risk for developing a PI due to the following risk factors: a history of healed stage III (full-thickness skin loss where the underlying subcutaneous fat [soft, jiggly layer of fat stored directly beneath the skin and above the muscle] is visible), or stage IV (involves full-thickness skin and tissue loss where bone, muscle, tendon, or joint structures are directly exposed), DM, and limited mobility. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident (Resident 3) on 10/25/2021 and readmitted on [DATE] with diagnoses that included pressure ulcers (PU -localized damage to the skin and underlying tissue, usually occurring over a bony prominence as a result of pressure, friction or shear) of right buttock stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), PU of right hip unstageable (a severe wound with full-thickness tissue loss where the true depth and damage cannot be assessed), diabetes mellitus (DM - disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcers (an open sore or lesion [any area of abnormal or damaged tissue in the body, caused by injury, infection or diseases] on the skin of the foot that fails to heal or keeps returning), dementia (a progressive state of decline in mental abilities that is severe enough to interfere with daily life), depression (a serious mood disorder characterized by a persistent feeling of sadness, emptiness, and a prolonged loss of interest in daily activities), and bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 3 had severely impaired cognition (mental process of acquiring, processing, and storing information). The MDS indicated Resident 3 was dependent on staff for Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated that Resident 3 was at risk for developing PUs/PIs. During a review of Resident 3's Order Summary Report dated 1/18/2026, the Order Summary Report indicated Resident 3's physician ordered a LALM for Resident 3 for wound management and PI prevention. During a review of Resident 3's Surgical Consult Notes dated 6/9/2026, the Surgical Consult Notes indicated that Resident 3 had the following wounds: Right buttock: Stage IV PU/PI Right trochanter (the bony prominence on the upper part of the thigh bone): Unstageable PU/PI Left lateral malleolus (the bony prominence on the outside of the ankle): Diabetic wound 1. During a concurrent observation and interview on 6/23/2026 at 10:51 a.m., in Resident 1's room, with Treatment Nurse 1 (TN 1), observed Resident 1 lying in bed on a LALM. Resident 1 had a spread sheet with two cloth incontinence (loss of bowel or bladder control) pads made of two different layers of cloth, and the two cloth incontinence pads overlapped by approximately 10 centimeters (cm - a unit of measurement). TN 1 stated that the overlapping pads extended from Resident 1's mid-back to the feet and overlapped in the upper thigh area, resulting in a total of three layers of linen in the non-overlapping areas and five layers of linen in the overlapping areas beneath Resident 1. TN 1 further stated that the purpose of using the LALM was for skin management to prevent PU, and that staff should use only one layer of linen because multiple layers would prevent the LALM from functioning effectively to prevent PUs. 2. During a concurrent observation and interview on 6/23/2026 at 11:16 a.m., in Resident 3's room, with TN 1, and Certified Nursing Assistant 1 (CNA 1), observed Resident 3 lying on a LALM while wearing an incontinence brief over a total of five layers of linen (one spread sheet and four layers of linen by folding a spread sheet twice) resulting in six total layers of linen between the resident and the mattress surface. CNA 1 stated that Resident 3 had multiple wounds on his body and that only one layer of linen should be used with the LALM. CNA 1 further stated that using multiple layers would prevent the LALM from functioning effectively to promote wound healing and stated the extra linens would be removed. During a concurrent interview and record review on 6/23/2026 at 4:44 p.m., with the Acting Director of Nursing (Acting DON) and the Administrator (ADM), the Acting DON reviewed the LALM manual and stated that the minimal padding meant using one spread sheet and one incontinent barrier pad if needed. The Acting ADON further stated that using multiple layers of linen would defeat the purpose of the LALM and impair its ability to promote wound healing. The ADM stated that using multiple layers of linen with a LALM could trap moisture and heat, negatively affecting the mattress's performance and increasing the resident's risk of developing a new PU. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries last reviewed on 1/29/2026, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Support Surfaces and Pressure Redistribution. 1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. During a review of the LALM's manual provided by the facility, titled, User-Service Manual copyrighted 2024, the LALM manual indicated, Recommended Linen. Based upon the patient's specific needs, the following may be utilized: Draw or slide sheet to aid in positioning and to further minimize friction and shearing. Incontinence barrier pad for urine and/or stool and patients with heavily draining wounds. Minimal padding between the patient and the surface to provide optimum performance.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was identified as being at high risk for falls, had a landing mat (a cushioning pad placed beside the resident's bed to help absorb the impact of a fall) in place as ordered by the physician. This deficient practice had the potential to increase the resident's risk of injury in the event of a fall.During a review of Resident 2's admission Record (the front page of the medical record containing a summary of the resident's basic information), the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to left knee effusion (the accumulation of fluid around the knee joint), left and right knee pain, type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness. During a review of Resident 2's Care Plan (CP), revised on 3/18/2026, the CP indicated that the resident was at risk for falls due to a history of falls, impaired mobility, use of psychotropic medications (any medication that affect the mind, emotions, or behavior), and multiple comorbidities (two or more medical and psychiatric conditions). The CP included interventions to maintain a safe, hazard-free environment. During an interview on 6/11/2026 at 2:53 p.m. with Director of Staff Development (DSD), the DSD stated that the last Fall/Fall Prevention In-Service (refers to on-the-job educational training for staff) provided to staff was conducted one week ago. During an interview on 6/12/2026 at 9:48 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that the floor landing mats are placed for residents who are at risk for falls when there is a physician order. The ADON further stated that a care plan is implemented for fall prevention interventions, the bed is placed in the lowest position, and the Falling Star Program (Falling Star Program - a program implement in hospitals and long-term facility to identify residents at high risk for falls and reduce fall-related injuries) is utilized. During a concurrent observation and interview on 6/12/2026 at 12:34 p.m., with Licensed Vocational Nurse 2 (LVN 2), in Resident 2's room, Resident 2 was observed lying in bed and there was no landing mat on the floor beside the bed. During a concurrent interview and record review on 6/12/2026 at 12:36 p.m., with LVN 2, Resident 2's Physician Order dated 5/22/2026 was reviewed. The Physician Order indicated the use of a landing mat. LVN 2 stated that a landing mat should have been placed on the floor as indicated in the Physician Order. During a review of the facility's policy and procedure (P&P) titled, Fall and Fall Risk, Managing, revised March 2018, the P&P indicated the staff will implement resident-centered fall-prevention measures, with the input of the attending physician, for each resident at risk for fall or with a history of falls; and minimize complications of falling.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), was wearing heel protectors (soft protective devices placed around a person's heels to reduce pressure and friction to the heels) to bilateral heels while positioned in bed. This deficient practice had the potential to increase Resident 1's risk for impaired skin integrity, skin breakdown, and the development of pressure ulcers/injuries (PU/PI- damaged to the skin and underlying tissue resulting from prolonged pressure). During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 8/26/2022, with the most recent admission on [DATE] with diagnoses that included but not limited to paraplegia (loss of movement and/or sensation, to some degree, of the legs), neuromuscular dysfunction of bladder (the nerves and muscles that control the bladder are not working properly), and benign prostatic hyperplasia (a condition in which the prostate gland [a small, firm, partly muscular gland that helps make up the male reproductive system] grows larger than normal, blocking the flow of urine) with lower urinary tract symptoms. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1 had mild cognitive (ability to remember things, solve problems, or make decisions) impairment skills for daily decision making. The MDS further indicated Resident 1 was dependent on toileting hygiene, showering/bathing, lower body dressing and putting on/taking off footwear and was independent in eating. During a review of Resident 1's Braden Scale (a tool used to assess a resident's risk for PU/PI development) assessment dated [DATE], the assessment indicated Resident 1 had a score of 12, which indicated Resident 1 as being at high risk for PU/PI development. During a review of Resident 1's Order Summary Report dated 4/29/2026, the Order Summary Report indicated a physician's order to apply heel protectors to bilateral heels for pressure injury prevention and management. During a review of Resident 1's Care Plan (CP) dated 8/8/2024 and revised 12/11/2025, the CP indicated Resident 1 was at risk for unavoidable PU/PI. The CP further indicated the goal for Resident 1 to maintain intact skin free from redness, blisters (a small pocket of fluid that forms within the upper layers of the skin) or discoloration (refers to any change in your natural skin tone) through interventions that included application of heel protectors to bilateral heels. During an observation on 5/12/2026 at 9:20 a.m. in Resident 1's room, Resident 1 was observed lying flat in bed without heel protectors applied to either heel. During an interview on 5/12/2026 at 10:01 a.m., with the Treatment Nurse (Tx Nurse), the Tx Nurse stated Resident 1 should have been wearing heel protectors while in bed. The Tx Nurse further stated heel protectors are important to reduce pressure to the heels and prevent the development of PU/PI. During an interview on 5/12/2026 at 12:10 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 1 was not wearing heel protectors because night shift staff may have removed them and failed to reapply them. CNA 2 further stated heel protectors are important to prevent pressure to the heels that could result in PU development. During an interview on 5/12/2026 at 3:56 p.m., with the Director of Nursing (DON), the DON stated heel protectors are required to be applied in accordance with physician orders. The DON further stated heel protectors are important to prevent the development of PU/PI. During a review of the facility's policy and procedure (P&P) titled, Prevention of pressure injuries, last revised on 1/2026, the P&P indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Provide support devices.

Based on observation, interview, and record review, the facility failed to ensure that refusal of physician-ordered wound treatment was properly documented for one of three sampled residents (Resident 1), in accordance with facility policy and procedure (P&P) and professional standards of practice. This deficient practice had the potential to result in the absence of appropriate follow-up care, delayed physician notification and evaluation of the resident's condition, and may contribute to delayed wound healing, increased risk of infection, and potential decline in the resident's overall condition. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 8/26/2022, with the most recent admission on [DATE] with diagnoses that included but not limited to paraplegia (loss of movement and/or sensation, to some degree, of the legs), neuromuscular dysfunction of bladder (the nerves and muscles that control the bladder are not working properly), and benign prostatic hyperplasia (a condition in which the prostate gland [a small, firm, partly muscular gland that helps make up the male reproductive system] grows larger than normal, blocking the flow of urine) with lower urinary tract symptoms. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1 had mild cognitive (ability to remember things, solve problems, or make decisions) impairment skills for daily decision making. The MDS further indicated Resident 1 was dependent on toileting hygiene, showering/bathing, lower body dressing and putting on/taking off footwear and was independent in eating. During a review of Resident 1's Admission/readmission Skin Review dated 4/29/2026, the Admission/readmission Skin Review indicated Resident 1 had skin scabbing (the process where your body creates a protective crust of dried blood over a wound or skin break to stop bleeding and keep out bacteria), plaque with red borders (typically refers to a skin lesion or rash with an elevated, flat-topped surface greater than one centimeter [cm- unit of measure] in diameter, surrounded by an inflamed, reddish ring or margin), white abnormalities over it and lesions (abnormal area of the skin) to the front right lower leg and front right thigh. During a review of Resident 1's Order Summary Report dated 5/1/2026, the Order Summary Report indicated, a physician order for the right lower leg wound to be cleansed with normal saline (NS- a mixture of water and salt), patted dry, to apply Vaseline (a skin protectant used to temporarily protect and relieve minor cuts, scrapes and burns), and cover with a non-adherent dressing (a type of dressing and wrapped with Kerlix (a soft rolled gauze bandage used to secure dressings and absorb wound drainage) daily for 14 days. During a review of Resident 1's Care Plan (CP) dated 4/30/2026, the CP indicated Resident 1 had actual skin issues affecting bilateral lower extremities related to bullous pemphigoid (a rare skin condition that causes large fluid-filled blisters). The goal was for Resident 1 to remain free from signs and symptoms of infection and for wounds to show signs of improvement through administration of treatments as ordered and monitoring for effectiveness. During an observation on 5/12/2026 at 10:55 a.m., in Resident 1's room, the Treatment Nurse (Tx Nurse) cleansed Resident 1's right lower leg wound with NS, patted dry and applied Vaseline, dressing and covered the wound with a two by two dressing with adhesive sides to help keep the dressing in place. During a concurrent interview and record review on 5/12/2026 at 11:03 a.m., with Tx Nurse, Resident 1's Physician Order, dated 5/1/2026 was reviewed. The Tx Nurse stated the order indicated cleansing the right lower leg with NS, patting dry, applying Vaseline, and covering with a non-adherent dressing and wrapping with kerlix daily for 14 days. The Tx Nurse stated kerlix was not applied to Resident 1's right lower leg because Resident 1 refused. The Tx Nurse stated that Resident 1's refusal should have been documented in the Nurse's Progress Notes and that documentation is necessary to ensure proper wound monitoring, physician notification, and follow-up with Resident 1's wound care. During an interview on 5/12/2026 at 3:56 p.m., with the Director of Nursing (DON), the DON stated Resident 1's refusal of kerlix application should have been documented in the Nurse's Progress Notes. The DON further stated that residents have the right to refuse treatment; however, refusals must be documented to ensure the physician is notified and able to reassess and modify the treatment plan as needed. During a review of the facility's policy and procedure (P&P) titled, Wound care, last revised on 1/2026, the P&P indicated, The following information should be recorded in the resident's medical record: . If the resident refused the treatment and the reason(s) why.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified for one of three sampled residents (Resident 1), when Resident 1's indwelling catheter (a thin flexible tube that is placed into the bladder [a hollow, muscular organ in the lower abdomen that stores urine] and left in place to continuously drain urine into a collection bag) was observed to have sediments and cloudiness, in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in a delay in treatment for Resident 1 and increase the risk of urinary complications, including catheter obstruction and urinary tract infection (UTI- an infection in the bladder or urinary tract [body's drainage system for filtering blood and removing liquid waste as urine]), that can lead to worsening infection and may result in hospitalization.During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 8/26/2022, with the most recent admission on [DATE] with diagnoses that included but not limited to paraplegia (loss of movement and/or sensation, to some degree, of the legs), neuromuscular dysfunction of bladder (the nerves and muscles that control the bladder are not working properly), and benign prostatic hyperplasia (a condition in which the prostate gland [a small, firm, partly muscular gland that helps make up the male reproductive system] grows larger than normal, blocking the flow of urine) with lower urinary tract symptoms. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1 had mild cognitive (ability to remember things, solve problems, or make decisions) impairment skills for daily decision making. The MDS further indicated Resident 1 was dependent on toileting hygiene, showering/bathing, lower body dressing and putting on/taking off footwear and was independent in eating. During a review of Resident 1's Order Summary Report dated 5/4/2026, the Order Summary Report indicated an order was noted for an indwelling catheter for neurogenic bladder. During a review of Resident 1's Care Plan (CP), dated 1/22/2026 and revised 3/28/2026, the CP indicated Resident 1 was at risk for urinary retention related to neuromuscular dysfunction of bladder. The CP goal indicated Resident 1 would not exhibit signs and symptoms of urinary retention (inability to completely empty the bladder) and or infection by reporting to physician signs and symptoms of UTI, such as pain, fever (a temporary rise in body temperature, usually signaling that your body's immune system is actively fighting an infection or illness), foul smelling urine, no output, cloudiness, blood-tinged urine and altered mental status (any sudden or gradual change in a person's baseline level of awareness, cognition or consciousness). The CP further indicated that cloudy urine with sediment was identified on 4/3/2026, with the goal that Resident 1 would have no complications related to indwelling catheter drainage. The CP interventions included close monitoring for increased sediments and or cloudiness, notification of the physician if symptoms persisted, and reporting of any further abnormalities. During an observation on 5/12/2026 at 9:20 a.m. in Resident 1's room, Resident 1 was observed with an indwelling catheter draining cloudy yellow urine with whitish and pink-tinged sediment throughout the tubing and drainage bag. During an interview on 5/12/2026 at 11:03 a.m., with Treatment (Tx) Nurse, the Tx Nurse stated the indwelling catheter had sediments and appeared cloudy. The Tx Nurse further stated the physician should have been notified of the cloudy urine and sediment to prevent potential catheter obstruction, UTI, and possible decline in Resident 1's condition. During an interview on 5/12/2026 at 3:56 p.m., with the Director of Nursing (DON), the DON stated it is important to notify the physician of cloudy urine and sediment in accordance with the resident's CP to prevent the development of UTI. During a review of the facility's policy and procedure (P&P) titled, Change in a resident's condition or status, last revised on 1/2026, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition; specific instruction to notify the physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or implementing standard disease related clinical interventions (is not self-limiting).

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide) for two of 19 sampled residents (Resident 40, Resident 5) by: a. Failing to implement interventions for Resident 40 to help prevent and treat constipation. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 40 b. Failing to develop a care plan that specifically address Resident 5's diet. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 5. a. During a review of Resident 40's admission Record, the admission Record indicated the facility admitted Resident 40 on 1/10/2026 with diagnoses including intercerebral hemorrhage (CVA - stroke, loss of blood flow to a part of the brain by a broken blood vessel causing bleeding into the brain), dysphagia (difficulty swallowing) and muscle weakness. During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40 could make himself understood and understand others and required partial assistance (helper dose less than half the effort) for oral hygiene and personal hygiene and was dependent (helper does all the work) on staff for toileting, showering, lower body dressing and putting off/on footwear. During a concurrent observation and interview on 3/28/2026 at 8:37 A.M. in Resident 40's room with Resident 40 and family member 1 (FM 1), Resident 40 was sitting up in bed with FM 1 next to him. FM 1 stated Resident 40 had not had a bowel movement (BM) for several days and it happens often. Resident 40 stated he was constipated, felt uncomfortable and has told staff in the past but could not remember who he told. During a review of Resident 40's Potential for Constipation Care Plan (CP) with a goal to pass soft formed stool at the preferred frequency of every three days. The CP indicated interventions to administer medications and treatments as ordered by the physician and monitor for effectiveness, and for the certified nursing assistant (CNA) to record BM pattern each day. During a review of Resident 40's BM Task filled out by CNAs, the task indicated: 3/11/2026 – None 3/12/2026 – None 3/13/2026 – None 3/14/2026 – None 3/15/2026 – None 3/16/2026 – None 3/18/2026 – None 3/192026 – None 3/20/2026 – None 3/21/2026 – None 3/22/2026 – None During a review of Resident 40's Order Summary Report with active orders as of 3/29/2026 included: -1/10/2026 – Docusate Sodium (stool softener) 100 MG (milligrams – unit of measurement) Give one capsule by mouth two times a day for constipation. - 2/3/2026 – Senna (medicine used to stimulate the colon causing contractions to relieve constipation) 8.6 MG. Give 1 tablet by mouth as needed for constipation every bedtime as needed (PRN). Give if docusate sodium is ineffective. - 2/9/2026 - Docusate Sodium Oral Capsule 100 MG (Docusate Sodium) Give 2 capsules by mouth PRN for constipation twice daily During a review of Resident 40's electronic medication administration record (eMAR) for 3/2026, the eMAR did not have documented evidence that PRN Docusate Sodium and Senna were administered for the month of 3/2026. During a concurrent interview and record review on 3/29/2026 at 10:22 A.M. with CNA 2, CNA 2 reviewed Resident 40's BM task online. CNA 2 explained every shift (7:00 A.M. – 3:00 P.M., 3:00 P.M. – 11:00 P.M, 11:00P.M. -7:00 A.M.), Resident 40's CNA must indicate if and how much his BM is. CNA 2 explained: None – no BM Small – small BM Medium – medium BM Large – Large BM Resident Refused - the resident refused to be checked Not Applicable – if the resident is out of the building for that shift. CNA 2 stated, according to the documentation, Resident 40 did not have a bowel movement from 3/11/2026 – 3/16/2026 (6 days) and from 3/18/2026 – 3/22/2026 (5 days) and a couple other instances of no BMs for 3 days plus. CNA 2 stated she was not aware that she had to notify the charge nurse if the resident did not have a BM for several days and that Resident 40 never notified her specifically that he was constipated. CNA 2 stated more that 3 days is way too long for a resident to go without a BM and the charge nurse should have been notified to give more medication or call the doctor. During a concurrent interview and record review on 3/29/2026 at 11:18 A.M. with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 40's Constipation CP, BM Task and 3/2026 MAR. The ADON stated it was unacceptable for Resident 40 to be constipated for more than six days without the certified nursing assistants notifying the charge nurse so they can call the doctor or at the very least give a PRN medication for constipation. The ADON stated the Constipation CP clearly states the goal is to not go for more than 3 days without a BM was not met by the licensed staff. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, last reviewed and revised on 1/29/2026, the P&P indicated CPs include measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. b. During a review of Resident 5's admission Record, the admission Record indicated the resident was readmitted to the facility on 3/9/2026 with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure) and dependence on renal dialysis (a life-sustaining medical treatment that filters waste products, toxins, and excess fluids from the blood when the kidneys are failing). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought experience and the sense) was moderately impaired. The MDS indicated Resident 5 required supervision or touching assistance (helper provides cues and/or touching/steadying assistance) with eating and oral hygiene, required partial/moderate assistance (helper does less than half the effort) with personal hygiene and required substantial/maximal assistance (helper does more than half the effort) with toileting. During a review of Resident 5's Order Summary Report, the Order Summary Report indicated an order dated 3/9/2026 for Liberal Renal (a specialized eating plan for people with kidney disease that limits specific minerals and fluids to reduce strain on the kidneys and prevent waste buildup)- No Added Salt (NAS) diet for ESRD. During an interview and concurrent record review on 3/29/2026, at 9:50 a.m. with the Desk Nurse (DN), the DN reviewed Resident 5's care plans and stated that there was no care plan created addressing Resident 5's renal diet. The DN stated that Resident 5 should have a specific care plan for Resident 5's renal diet because a care plan will provide interventions for Resident 5 specific to a renal diet. The DN stated that all staff are responsible for initiating diet care plans. The DN further stated that care plans are important because care plans are a form of communication for the interdisciplinary team to help provide quality of care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, last reviewed and revised on 1/29/2026, the P&P indicated CPs include measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review the facility failed to promote the resident's right to be informed of and participate in their treatment for three of six (Resident 71, 102, and 75) residents observed for medication administration by failing to provide the name of medications and their indication (reason for the use of the medication) prior to administration of the medications. This deficient practice violated Resident 71, 102, and 75`s rights to make decisions regarding their medication regimen and to refuse any or all the medications. Findings: a. During a review of Resident 71's admission Record, the admission Record indicated the facility admitted the resident on 8/25/2020 with diagnosis including, hypertension (high-blood pressure) and chronic kidney disease (a serious, long-term condition where kidneys are damaged and cannot properly filter blood, often leading to waste buildup). During a review of Resident 71's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 2/23/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 71 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting hygiene, shower, upper body dressing, personal hygiene and totally dependent on staff for lower body dressing and putting on/taking off footwear. During an observation on 3/28/2026 at 4:22 p.m., in Resident 71's room observed Licensed Vocational Nurse 1 (LVN 1) administering docusate sodium (stool softener used to treat occasional constipation [infrequent bowel movement]) 10 milligrams (mg-unit of measurement) tablet and amlodipine besylate (a medication to treat high blood pressure) 4 mg tablet orally to Resident 71. LVN 1 was not observed informing Resident 70 of the name of each medication and its indication during administration of the medications. During a review of Resident 71`s Order Summary Report (OSR) as of 3/28/2026, the OSR indicated the following prescribed medications administered by LVN 1 to Resident 70. 1.Docusate Sodium 100 milligram (mg) tablet, 1 tablet by mouth for bowel management. 2. Amlodipine Besylate Tablet 5 mg, give 1 tablet by mouth two times a day for hypertension. b. During a review of Resident 102's admission Record the admission Record indicated the facility admitted the resident on 3/22/2026 with diagnosis including muscle weakness and chronic kidney disease (a serious, long-term condition where kidneys are damaged and cannot properly filter blood, often leading to waste buildup). During a review of Resident 102's History and Physical (H&P- a foundational medical document and examination performed by a clinician to assess a patient's condition, documenting their story [history] and physical findings to guide diagnosis and treatment) dated 3/23/2026, the H&P indicated that the resident has decision making capacity at the time of admission. During an observation and interview on 3/28/2026 at 4:36 p.m., in Resident 102's room, observed Licensed Vocational Nurse 1 (LVN 1) administering gabapentin (a medication used to treat nerve pain) 100 mg capsule and furosemide (a medication used to treat fluid retention) tablet 40 mg orally to Resident 102. LVN 1 was not observed informing Resident 102 of the name of each medication and its indication during administration of the medications. During an interview with LVN 1, on 3/28/2026 at 4:41 p.m., LVN 1 stated the residents have the right to be informed of and participate in decisions regarding their care and treatment. LVN 1 stated she forgot to inform Resident 71 and Resident 102 the name of the medications and their indications and asked for their consent to administer the medications prior to medication administration. During a review of Resident 102`s Order Summary Report (OSR) as of 3/28/2026, the OSR indicated the following prescribed medications orders that were administered by LVN 1 to Resident 102: 1.Gabapentin 100 mg oral capsule, 1 capsule by mouth two times a day for Neuropathy (nerve damage causing numbness, tingling, burning pain, or weakness, usually starting in the hands or feet). 2. Furosemide Oral Tablet 40 mg, 1 tablet by mouth two times a day for edema. c. During a review of Resident 75's admission Record the, admission Record indicated the facility admitted the resident on 1/23/2026 with diagnosis including, hypertension (high-blood pressure) and muscle weakness. During a review of Resident 75's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 75 required partial/moderate assistance (helper does more than half the effort) from staff for toileting hygiene, shower, lower body dressing, and putting off footwear. During a concurrent observation and interview on 3/29/2026 at 4:11 p.m., in Resident 75's room, observed Licensed Vocational Nurse 6 (LVN 6) administering metoclopramide (medication used to treat gastroesophageal reflux disease [GERD-a chronic condition where stomach acid frequently flows back into the esophagus, causing irritation, heartburn, and potential damage])tablet 5 mg, omeprazole (used to treat conditions where there is too much acid in the stomach) 20 mg capsule, Creon (digestive enzyme medication) capsule 24000 units orally to Resident 75. LVN 1 was not observed informing Resident 102 of the name of each medication and its indication during administration of the medications. LVN 6 stated she did not inform Resident 75 the name of the medications and their indications and asked for Resident 75's consent to administer the medications prior to medication administration. LVN 6 stated that it a violation of the resident's right to participate in their care and make decisions regarding their care if the resident was not informed of their treatment and medication regimen. During a review of Resident 75`s Order Summary Report (OSR) as of 3/29/26, the OSR indicated the following prescribed medications that were administered by LVN 6 to Resident 75: 1.Metoclopramide Oral Tablet 5 mg, give 1 tablet by mouth before meals for nausea and vomiting. 2. Omeprazole 20 mg cap, give 1 capsule by mouth two times a day for gastroesophageal reflux disease (GERD). 3. Creon Oral Capsule 24000-76000 Unit, give 24000 unit by mouth with meals for pancreatic enzyme replacement therapy give with meals. 4. Famotidine Oral Tablet 20 mg, give 1 tablet by mouth two times a day for GERD. During a review of the facility`s Policy and Procedure (P&P) titled Resident Rights, last reviewed on 1/29/2026, the P&P indicated that Employees shall treat all residents with kindness, respect, and dignity.be informed of, and participate in, his or her care planning and treatment.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect to three of three residents (Resident 8, Resident 11 and Resident 2) by failing to: a. Ensure a Certified Nursing Assistant 1 (CNA 1) was not sitting in a Resident 8's room with her personal belongings while waiting for the end of her shift during a random observation. b. Ensure staff were not standing over Resident 11 while assisting with feeding. c. Ensure a staff member knocked prior to entering a resident`s room observed during resident screening. These deficient practices violated the resident's right to privacy, to be treated with dignity and had the potential to affect the residents' sense of self-worth and self-esteem. Findings: a. During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 4/16/2020 with diagnoses including dysphagia (difficulty swallowing) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 8's Minimum Date Set (MDS- a standardized assessment and care screening tool), dated 11/5/2025, the MDS indicated Resident 13 could sometimes make himself understood and sometimes understand others and required substantial assistance (helper dose more than half the effort) for oral hygiene, upper body dressing and personal hygiene and was dependent (helper does all the work) on staff for toileting, showering, lower body dressing and putting off/on footwear. During an initial pool interview on 3/28/2026 at 9:42 A.M. in Resident 8's room with Resident 8, Resident 8 was lying in bed and unable to respond to questions. Resident 8 responded with one or two words and nonsensical (having no meaning; making no sense) phrases. During an observation on 3/28/2026 at 2:22 P.M., in Resident 8's room, Resident 8 was lying in bed asleep in the bed nearest to the door and Certified Nursing Assistant 1 (CNA 1) was sitting between the wall with the entrance door and the left side of Resident 8's bed. In front of CNA 1 was Resident 8's bedside table and on top of the bedside table was CNA 1's personal purse and her personal cell phone. During an interview on 3/28/2026 at 2:24 P.M. with CNA 1, CNA 1 stated the purse on Resident 8's bedside table belonged to her, that her shift was almost over and she was in Resident 8's room to wait for the time to wind down till she is off the clock. CNA 1 stated she did not ask before she sat down in Resident 8's room, that Resident 8 was confused, and most likely not be able to consent or deny her sitting in his room. CNA 1 stated she should have used the break room, and her actions did not respect Resident 8's dignity and privacy. During an interview on 3/29/2026 at 11:41 A.M. with the Assistant Director of Nursing (ADON), the ADON stated staff may not bring personal items into resident rooms, nor can they use resident rooms for breaks. The ADON stated CNA 1's actions were not acceptable, and she did not provide dignity to Resident 8 that the facility strive to give to each resident. During a review of the facility's policy and procedure (P&P) titled, Dignity, last reviewed and revised on 1/29/2026, the P&P indicated the facility must care for each resident in a manner that promotes and enhances his or her sense of well-being.and feelings of self-worth and self-esteem. The P&P indicates the resident's private space and property are respected at all times; staff do not handle or move resident's belongings without the resident's permission. During a review of the facility's P&P titled, Resident Rights, last reviewed and revised on 1/29/2026, the P&P indicated employees must treat all residents with kindness, respect and dignity. b. During a review of Resident 11's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a temporary, reversible brain dysfunction caused by chemical imbalances in the body), muscle weakness, dysphagia (difficulty swallowing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 11's MDS dated 1/1/2026, the MDS indicated Resident 11's cognition (a mental process of acquiring knowledge and understanding through thought experience and the sense) was moderately impaired. The MDS indicated Resident 11 required substantial/maximal assistance (staff does more than half the effort) with eating and personal hygiene and was dependent (staff does all of the effort) on staff with oral care and toileting hygiene. During an observation on 3/28/2026 at 1:30 p.m., in Resident 11's room, observed Certified Nursing Assistant 3 assisting Resident 11 with feeding, standing over and hovering over Resident 11. Observed a folding chair next to CNA 3. During a concurrent observation and interview on 3/28/2026 at 1:31 pm with the Desk Nurse (DN), in Resident 11's room, the DN stated that CNA 3 is standing over Resident 11 while assisting with feeding. The DN stated that CNA 3 should be sitting down and should be at eye level while feeding Resident 11 so CNA 3 staff can properly observe the resident while eating to ensure safety while maintaining the resident's dignity and respect. The DN stated that CNA 3 should have sat down on the chair since the chair is next to CNA 3. During an interview on 3/28/2026 at 2:47 p.m. with CNA 3, CNA 3 stated that she would feed Resident 11 and wipe her mouth, after which t CNA 3 would sit down. CNA 3 stated that she is unable to sit in the chair because the rolling bedside table does not roll under Resident 11's bed, preventing CNA 3 from positioning herself comfortably. During an interview on 3/29/2026 at 4:34 p.m., with the Director of Staff Development (DSD), the DSD stated that all staff should respect residents while assisting with feeding by sitting down on a chair. The DSD continued to state that staff should be at eye level with the resident to make meals pleasant and to be able to interact with residents within eye level. The DSD stated nursing staff should be sitting at eye level with the resident during meals to facilitate proper observation of chewing and swallowing. During a review of the facility's policy and procedure (P&P) titled Dignity, with review date 1/29/2026, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-steam. b. During a review of Resident 11's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a temporary, reversible brain dysfunction caused by chemical imbalances in the body), muscle weakness, dysphagia (difficulty swallowing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 11's MDS dated 1/1/2026, the MDS indicated Resident 11's cognition (a mental process of acquiring knowledge and understanding through thought experience and the sense) was moderately impaired. The MDS indicated Resident 11 required substantial/maximal assistance (staff does more than half the effort) with eating and personal hygiene and was dependent (staff does all of the effort) on staff with oral care and toileting hygiene. During an observation on 3/28/2026 at 1:30 p.m., in Resident 11's room, observed Certified Nursing Assistant 3 assisting Resident 11 with feeding, standing over and hovering over Resident 11. Observed a folding chair next to CNA 3. During a concurrent observation and interview on 3/28/2026 at 1:31 pm with the Desk Nurse (DN), in Resident 11's room, the DN stated that CNA 3 is standing over Resident 11 while assisting with feeding. The DN stated that CNA 3 should be sitting down and should be at eye level while feeding Resident 11 so CNA 3 can properly observe the resident while eating to ensure safety while maintaining the resident's dignity and respect. The DN stated that CNA 3 should have sat down on the chair since the chair is next to CNA 3. During an interview on 3/28/2026 at 2:47 p.m. with CNA 3, CNA 3 stated that she would feed Resident 11 and wipe her mouth, after which t CNA 3 would sit down. CNA 3 stated that she is unable to sit in the chair because the rolling bedside table does not roll under Resident 11's bed, preventing CNA 3 from positioning herself comfortably. During an interview on 3/29/2026 at 4:34 p.m., with the Director of Staff Development (DSD), the DSD stated that all staff should respect residents while assisting with feeding by sitting down on a chair. The DSD continued to state that staff should be at eye level with the resident to make meals pleasant and to be able to interact with residents within eye level. The DSD stated nursing staff should be sitting at eye level with the resident during meals to facilitate proper observation of chewing and swallowing. During a review of the facility's policy and procedure (P&P) titled Dignity, with review date 1/29/2026, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-steam.

Based on observation, interview, and record review the facility failed to provide services that promote the prevention of pressure ulcer injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure that one of four sampled residents (Resident 36) had heel protectors (a specialized medical device or wearable cushion designed to prevent or treat pressure ulcers on the heel) in place as ordered by the physician.This deficient practice placed Resident 36 at risk for developing a new pressure injury.Findings:During a review of Resident 36's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 6/26/2025, and readmitted on [DATE], with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), pressure ulcer of right buttock stage three (full-thickness loss of skin in which dead and black tissue may be visible), and dysphagia (difficulty swallowing) following cerebral infarction (stroke, loss of blood flow to a part of the brain).During a review of Resident 36's Minimum Data Set (MDS- a resident assessment tool) dated 12/23/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making were severely impaired (never or rarely made decisions). The MDS indicated that Resident 36 was dependent (helper does all of the effort) on staff for showering/bathing, toileting hygiene, and lower body dressing. The MDS indicated that Resident 36 required substantial/maximum assistance (helper does more than half the effort) for oral hygiene, personal hygiene, and upper body dressing. The MDS further indicated that Resident 36 was at risk for developing pressure ulcers and had pressure-reducing devices for both bed and chair.During a review of Resident 36`s Physician Order Summary Report (physician orders) dated 3/27/2026, the Order Summary Report indicated to apply bilateral (both) heel protectors for pressure injury prevention and management during every shift.During a review of Resident 36's Care Plan (CP- a document that outlines how a resident`s health care needs will be met) titled The resident is at risk for pressure sore or potential for pressure ulcer development, initiated on 8/27/2025, the CP indicated that the goal was for the resident to maintain intact skin, free from redness, blister (a painful skin condition where fluid fills a space between layers of skin) or discoloration (any abnormal change in skin color). The CP interventions included monitoring, documenting and reporting any changes in skin condition to the physician, as well as conducting weekly skin checks/assessments.During a concurrent observation, and interview on 3/28/2026 at 10:04 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 36`s room, Resident 36 was observed lying in bed without heel protectors in place. CNA1 stated that Resident 36 was not wearing heel protectors. CNA1 stated that she (CNA 1) was not aware of a physician's order requiring the application of heel protectors for Resident 36. During a concurrent observation, and interview on 3/28/2026 at 10:10 a.m., with Licensed Vocational Nurse 3 (LVN 3), inside Resident 36`s room, LVN3 stated that Resident 36`s was not wearing heel protectors. LVN 3 searched for heel protectors at Resident 36`s bedside and inside the resident`s closet. However, LVN 3 was unable to locate any.During a concurrent interview and record review on 3/28/2026 at 10:14 a.m., with LVN 3, Resident 36`s Physician Order Summary Report dated 3/27/2026 and Treatment Administration Record (TAR- a daily documentation record used by a licensed nurse to document treatments given to a resident) for March 2026 were reviewed. LVN 3 stated that on 3/27/2026, Resident 36`s physician ordered the application of bilateral heel protectors for the prevention of pressure injuries. However, Resident 36 was not wearing heel protectors. LVN 3 further stated that Resident 36`s TAR indicated licensed staff had documented the resident as wearing heel protectors on 3/27/2026 and 3/28/2026; however, LVN 3 stated she (LVN 3) was unable to locate any heel protectors in Resident 36`s room. LVN 3 stated licensed staff are responsible for implementing physician orders. LVN 3 stated Resident 36 was not wearing heel protectors as ordered by his (Resident 36) physician, placing the resident at risk for developing new pressure injury.During an interview on 3/30/2026 at 4:50 p.m., with the Director of Nursing (DON), the DON stated that licensed staff are required to implement physician orders to prevent pressure injuries in residents. The DON stated Resident 36 was not wearing bilateral heel protectors as ordered by the physician. The DON stated the potential outcome is skin breakdown and an increased risk for the development of pressure ulcers.During review of the facility`s Policy and Procedure (P&P) titled Prevention of Pressure Injuries, last reviewed on 1/29/2026, the P&P indicated that review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the devise, monitor regularly for comfort and signs of pressure related injury. For prevention measures associated with specific devices, consult clinical practice guidelines.

Based on observation, interview, and record review, the facility failed to provide services and treatments to maintain joint range of motion (ROM- full movement potential of a joint) for one of three sampled residents (Resident 10) by failing to follow physician's orders for a Restorative Nursing program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) treatment to apply an inflatable therapy orthosis carrot (a soft, cone-shaped, inflatable hand splint used to treat severe finger contractures [clenched fists]). This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 10. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident to the facility on 6/29/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), lack of coordination, and contracture (a permanent tightening or shortening of muscles, tendons, skin, or tissues that causes joints to become stiff and restricts normal movement) of muscle, multiple sites. During a review of Resident 10's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 12/24/2025, the MDS indicated Resident 10's cognition (a mental process of acquiring knowledge and understanding through thought experience and senses) was severely impaired. The MDS indicated Resident 10 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 10's Order Summary Report, the Order Summary Report dated 9/11/2025, indicated an order for RNA: - to apply inflatable therapy Carrot orthosis to Right hand to prevent more fingers flexion contracture every day seven times a week. Seven hours daily as tolerated. Every day shift. Every Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday. During a review of Resident 10's care plan (CP) addressing risk for decline in range of motion and risk of decreased muscle strength, initiated 7/31/2024, the CP indicated an intervention for RNA to apply an inflatable therapy carrot orthosis to the right hand to prevent more fingers flexion contracture every day seven times a week, seven hours daily as tolerated. During an observation on 3/29/2026 at 8:40 a.m., in Resident 10's room, observed Resident 10 in bed, without Resident 10's inflatable therapy carrot orthosis on his right hand. Observed Resident 10's inflatable therapy Carrot orthosis on top of Resident 10's bedside table. During an observation on 3/29/2026 at 10:10 a.m., in Resident 10's room, observed Resident 10 in bed, without Resident 10's inflatable therapy carrot orthosis on his right hand. Observed Resident 10's inflatable therapy Carrot orthosis on top of Resident 10's bedside table. During an observation on 3/29/2026 at 12:30 p.m., in Resident 10's room, observed Resident 10 in bed, without Resident 10's inflatable therapy carrot orthosis on his right hand. Observed Resident 10's inflatable therapy Carrot orthosis on top of Resident 10's bedside table. During a concurrent interview and observation on 3/29/2026 at 2:36 p.m. with the Desk Nurse (DN), in Resident 10's room, observed Resident 10 in bed. The DN stated that Resident 10's inflatable therapy carrot orthosis had not been applied. The DN stated that RNAs are responsible for applying Resident 10's inflatable therapy carrot orthosis. During an interview on 3/29/2026 at 2:37 p.m. with RNA 1, RNA 1 stated that he is assigned to Resident 10 today (3/29/2026), however, RNA 1 stated he did not apply Resident 10's inflatable therapy carrot orthosis. When asked why RNA 1 did not apply Resident 10's inflatable therapy carrot orthosis as ordered by the physician, RNA 1 did not respond. During a follow up interview on 3/29/2026 at 2:50 p.m. with the DN, the DN stated that Resident 10 should have had Resident 10's inflatable therapy Carrot orthosis applied because it is a physician's order. The DN stated that it is important to apply Resident 10's inflatable therapy Carrot orthosis to prevent further decline and worsening of contractures in the resident's right hand. During a review of the facility's policy and procedure titled, Restorative Nursing Services, reviewed on 1/29/2026, the P&P indicated resident will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. During a review of the facility's policy and procedure titled, Assistive Devices and Equipment, reviewed on 1/29/2026, the P&P indicated that the facility maintains and supervises the use of assistive devices and equipment for residents. The P&P indicated certain devices and equipment that assist resident mobility, safety, and independence are provided for residents.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accidents and hazards for two of four sampled residents investigated under accidents (Resident 12 and Resident 20) by failing to: 1.Apply landing pads (a floor pad designed to help prevent injury should a person fall) at Resident 12`s bedside as ordered by the physician. This deficient practice had the potential to place Resident 12 at risk for injuries in the event of a fall. 2. Check for placement and functionality of Resident 20`s wander management system (WMS - a wearable bracelet security technology designed to keep residents with memory issues from wandering away from safe areas) every shift from 3/5/2026 - 3/29/2026. This deficient practice placed Resident 20 at an increased risk for injuries and elopement (when a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected)). 2. During a review of Resident 20's admission Record, the admission Record indicated the facility admitted Resident 20 on 3/27/2021 with diagnoses including diabetes type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and peripheral vascular disease (a narrowing of blood vessels that slows down the movement of blood in the body). During of review of Resident 20's History and Physical (H&P), the H&P indicated Resident 20 can make his needs known but cannot make medical decisions. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 could sometimes make himself understood and sometimes understand others and required substantial assistance (helper dose more than half the effort) for oral hygiene, upper body dressing and personal hygiene, showering, lower body dressing and putting off/on footwear. During a review of Resident 20's At risk for Elopement Care Plan (CP) initiated on 2/16/2024, the CP indicated an intervention for Resident 20 to wear a WMS and monitor for placement and function every shift. During a review of Resident 20's March 2026 Medication Administration Record (MAR), the MAR indicated to monitor for WMS placement and function each shift (7:00 A.M. – 3:00 P.M., 3:00 P.M. – 11:00 P.M, 11:00P.M. -7:00 A.M.) until 3/5/2026. Monitoring for placement and function was not completed from 3/5/3036 to 3/29/2026. During an initial pool interview on 3/28/2026 at 8:33 A.M. in Resident 20's room with Resident 20, Resident 20 was lying in bed and was unable to answer some questions properly and said some nonsensical (having no meaning, making no sense) phrases. Observed the WMS bracelet applied to Resident 20's right wrist. During a concurrent interview and record review on 3/29/2026 at 11:56 A.M., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 20's March 2026 MAR and elopement CP. The ADON stated monitoring of placement and function of the WMS should be ongoing and not have ended on 3/5/2026. The ADON stated Resident 20 can get confused and has had an elopement attempt in the past and the WMS is important to help prevent any future elopement attempts. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, last reviewed and revised on 1/29/2026, the P&P indicated the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Findings: a.During a review of Resident 12's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 12/3/2025, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), nondisplaced fracture of base of neck of femur (a hip fracture where the thigh bone is broken at its lowest point near the hip joint, but the bone pieces remain in their normal position), and dysphagia (difficulty swallowing). During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool) dated 2/5/2026, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 12 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 12's Post Fall Review form dated 1/29/2026, the Post Fall Review form indicated that on 1/29/2026 at 4:00 a.m., the resident was observed on the floor lying on the left side of the bed. The form indicated that Resident 12`s fall was unwitnessed and the resident denied hitting his head during the fall. The Interdisciplinary (IDT-a group of professionals from different disciplines such as physicians, nurses, social workers, and therapists who work together to develop and implement a comprehensive care plan for a patient) Review Summary of Root Cause section indicated that IDT recommended to apply bilateral (both) landing pads at the resident`s bedside. During a review of Resident 12's Change in Condition Evaluation form (COC-an improvement or worsening of a patient`s condition which was not anticipated) dated 1/29/2026 at 4:00 a.m., the COC evaluation form indicated that on 1/29/2026 at 4:00 a.m. Resident 12 had an unwitnessed fall. During a review of Resident 12's physician Order Summary Report (physician order) dated 1/29/2026, the order summary report indicated to apply landing pad on both sides of the resident`s bed. During a review of Resident 12`s Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated that Resident 12 had one-two falls within the last six months. The fall risk assessment indicated that Resident 12 was at high risk for falls. During an observation on 3/28/2026 at 7:40 a.m., inside Resident 12`s room, the resident was observed in bed, and no landing pads were present at the bedside. During a concurrent interview and record review on 3/28/2026 at 8:06 a.m. with Registered Nurse 1 (RN 1), Resident 12's Physician Order Summary Report was reviewed. RN 1 stated that on 1/29/2026, Resident 12`s physician ordered to apply landing pads on both sides of the resident`s bed. During a concurrent observation and interview on 3/28/2026 at 8:10 a.m. with RN 1, inside Resident 12`s room, RN 1 stated there are no landing pads placed at the resident`s bedside. RN 1 stated there should be landing pads placed at Resident 12`s bedside as ordered by his physician to protect the resident from injuries if fall occurs. During a concurrent interview and record review on 3/28/2026 at 6:52 p.m. with the facility`s Assistant Director of Nursing (ADON), Resident 12's physician order summary report, COC and post fall review forms dated 1/29/2026 were reviewed. The ADON stated That Resident 12 had a fall on 1/29/2026, and one of the IDT recommendations was to apply landing pads at the resident`s bedside. The ADON stated Resident 12`s physician ordered to apply landing pads on both sides of the resident`s bedside on 1/29/2026, however, staff failed to place landing pads at Resident 12`s bedside. The ADON stated the potential outcome is increased risk of injury if fall occurs. During an interview on 3/29/2026 at 5:04 p.m. with the Director of Nursing (DON), the DON stated that staff are required to implement physician orders for fall precautions. The DON stated Resident 12 had a physician order for landing pads on both sides of the bed, which was not implemented by staff. The DON stated the potential outcome is increased risk of injuries in the event of a fall. During a review of the facility's policy and procedure(P&P) titled, Falls and Fall Risk, Managing, last reviewed on 1/19/2026,the P&P indicated that the IDT team with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) for falls for each resident at risk or with a history of falls. In conjunction with the attending physician, licensed staff will identify and implement relevant interventions (e.g., low bed position, floor pad) to try to minimize serious consequences of falling.

Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance) within reach for one of three residents reviewed under the environment task (Resident 11). This deficient practice had the potential to result in Resident 11 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being. Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a temporary, reversible brain dysfunction caused by chemical imbalances in the body), muscle weakness, dysphagia (difficulty swallowing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 11's Minimum Date Set (MDS- a standardized assessment and care screening tool) dated 1/1/2026, the MDS indicated Resident 11's cognition (a mental process involved in knowing, learning, and understanding things) was moderately impaired. The MDS indicated Resident 11 required substantial/maximal assistance (staff does more than half the effort) with eating and personal hygiene and was dependent (staff does all of the effort) on staff with oral care and toileting hygiene. During an observation on 3/28/2026 at 8:30 a.m., in Resident 11's room, observed Resident 11 in bed, with the call light not within the resident's reach. Observed Resident 11's call light tucked in between Resident 11's mattress and pillow. During a concurrent observation and interview on 3/28/2026 at 8:48 a.m., with the RN Case Manager (RNCM), in Resident 11's room, observed Resident 11 in bed with the call light not within the resident's reach. Observed Resident 11's call light tucked in between Resident 11's mattress and pillow. Observed RNCM place the call light within Resident 11' s reach, next to Resident 11's right hand and stated Resident 11' s call light was not within reach. The RNCM continued to state that the call light should always be next to the resident so that the resident can call for assistance and for Resident 11's safety. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 1/29/2026, the P&P indicated the purpose of this procedure is to ensure timely responses to the resident's request and needs. The P&P further indicated staff must ensure the call light is accessible to the resident when in bed.

Based on interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 12) was provided written information regarding their rights to refuse or accept medical or surgical treatment and to formulate an Advanced Directive (AD- a written instruction, recognized under State law, relating to the provision of health care when an individual is unable to make decisions for themselves).This deficient practice had the potential to result in the facility not honoring the residents' medical decisions regarding end-of-life care. Findings:During a review of Resident 12's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 12/3/2025, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), nondisplaced fracture of base of neck of femur (a hip fracture where the thigh bone is broken at its lowest point near the hip joint, but the bone pieces remain in their normal position), and dysphagia (difficulty swallowing).During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool) dated 2/5/2026, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making were severely impaired, as the resident rarely or never made decisions. The MDS further indicated that Resident 12 was dependent (helper does all of the effort) on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 12's Advance Healthcare Directive Acknowledgement form (ADA- a document provided by the facility that indicates whether a resident has an AD, would like information regarding creation of an AD, or refusal to create an AD) dated 12/3/2025, the ADA form indicated that Resident 12`s representative signed the form on 12/3/2025. The ADA form further indicated that Resident 12 did not have an AD.During a review of Resident 12's Social Service Review form dated 3/6/2026, the Social Service Review form indicated that Resident 12 has not issued an AD about his care and treatment. The social service review form further indicated that the resident and/or Resident 12's representative were not provided with written information regarding AD, and that the facility representative did not offer assistance in formulating an AD.During a concurrent interview and record review on 3/28/2026 at 3:02 p.m., with Social Service Assistant (SSA), Resident 12's ADA form dated 12/3/2025 and Social Service Review form were reviewed. SSA stated that Resident 12`s ADA form completed on 12/3/2025 indicated the resident did not have an AD. However, the resident`s ADA form did not indicate whether the resident or their representative wished to receive additional information regarding AD. SSA stated Resident 12`s ADA form was not completed thoroughly. SSA further stated that Resident 12`s Social Service Review form dated 3/6/2026 indicated that the resident or their representative was not provided with written information about ADs, and the facility staff did not offer assistance in formulating one. SSA stated facility policy requires that residents or their representatives be provided with written information regarding AD and be offered assistance in completing the AD. SSA stated that failure to provide this information and support may result in the resident's wishes not being known or honored. During a concurrent interview and record review on 3/11/2025 at 5:10 p.m., with the Director of Nursing (DON), Resident 12`s ADA form dated 12/3/2025 and Social Service Review form dated 3/6/2026 were reviewed. The DON stated it is the policy of the facility to provide written information regarding formulating AD to residents or their representatives and offer assistance to formulate AD. The DON stated Resident 12`s ADA form dated 12/3/2025, did not indicate whether the resident or their representative wished to receive information regarding AD. The DON stated Resident 12`s Social Service Review form dated 3/6/2026 indicated that the resident or their representative was not provided with written information about ADs and facility representative did not offer assistance to formulate an AD. The DON stated the potential outcome of not offering information and assistance to formulate AD to residents or their representative is that the residents` wishes may not be honored.During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, last reviewed on 1/29/2026, the P&P indicated that the resident has the right to formulate an AD, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an AD if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an AD, the information may be provided to the resident`s legal representative. Nursing staff will document in the medical record the offer to assist and the resident`s decision to accept or decline assistance.

Based on observation, interview and record review, the facility failed to maintain a homelike environment for two of two residents (Resident 15 and 82) by failing to ensure the window screen was in good repair and did not have a tear which created an opening measuring approximately 24 inches from top to bottom. This deficient practice had the potential to allow insects, dirt, and outside debris to enter the room, placing the residents at increased risk for infection and compromising their safety.Findings: a. During a review of Resident 15's admission Record, the admission Record indicated the facility originally admitted the resident on 7/01/2025 and readmitted the resident on 12/17/2025 with diagnosis including, muscle weakness and hypertension (high-blood pressure). During a review of Resident 15's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/02/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 15 required partial/moderate assistance (helper does more than half the effort) from staff for oral hygiene, upper body dressing and substantial/maximal assistance (helper does more than half the effort) with toileting, shower and personal hygiene. b. During a review of Resident 82's admission Record, the admission Record, indicated the facility originally admitted the resident on 8/23/2023 with diagnosis including history of falling and hypertension (high-blood pressure). During a review of Resident 82's MDS dated [DATE], the MDS indicated the resident had the ability to sometimes make self-understood and the ability to sometimes understand others. The MDS indicated that Resident 82 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, upper body dressing, lower body dressing and personal hygiene. During an observation on 3/28/2026 at 9:01 a.m., in Resident 15 and Resident 82's room, observed both residents sleeping in their bed. Observed the room's sliding door screen with a tear measuring approximately 24 inches.During a concurrent observation and interview on 03/28/2026 at 9:35 a.m. with the Director of Nursing (DON) in Resident 15 and 82`s room, the DON confirmed the observation of the torn screen door. The DON stated that the resident`s room must be sealed from the outside by a screen to prevent small insects from entering the room. The DON stated the torn screen posed a health and safety risk to residents, as it had the potential to allow entry of insects that may transmit infection. During a review of the facility`s policy and procedures (P&P) titled, Homelike Environment,, the P&P indicated that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment.

Based on interview, and record review, the facility failed to review, and update a care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a resident`s Change of Condition (COC- an improvement or worsening of a resident`s condition which was not anticipated) for one of 19 sampled residents (Resident 12 ) by failing to review and revise the resident`s CP after his fall on 1/29/2026.This deficient practice had the potential to result in Resident 12 receiving inadequate care and supervision at the facility and an increased risk of recurrent falls. Findings: During a review of Resident 12's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 12/3/2025, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), nondisplaced fracture of base of neck of femur (a hip fracture where the thigh bone is broken at its lowest point near the hip joint, but the bone pieces remain in their normal position), and dysphagia (difficulty swallowing).During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool) dated 2/5/2026, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making were severely impaired, as the resident rarely or never made decisions. The MDS further indicated that Resident 12 was dependent (helper does all of the effort) on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 12's Post Fall Review form dated 1/29/2026, the Post Fall Review form indicated that on 1/29/2026 at 4:00 a.m., the resident was observed lying on the floor on the left side of the bed. The form indicated that Resident 12`s fall was unwitnessed and the resident denied hitting his head during the fall. The Interdisciplinary Team (IDT- a group of professionals from different disciplines such as physicians, nurses, social workers, and therapists who work together to develop and implement a comprehensive care plan for a resident) Review Summary of Root Cause section of the form indicated that IDT recommended to apply bilateral (both) landing pads (a floor pad designed to help prevent injury should a person fall) at the resident`s bedside to mitigate the risk of injury related to falls.During a review of Resident 12's COC Evaluation form dated 1/29/2026, timed at 4:00 a.m., the COC Evaluation form indicated that on 1/29/2026 at 4:00 a.m. Resident 12 had an unwitnessed fall.During a review of Resident 12's Physician Order Summary Report (physician order) dated 1/29/2026, the Order Summary Report indicated to apply landing pads on both sides of the resident`s bed.During a review of Resident 12`s Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated that Resident 12 had one to two falls within the last six months. The Fall Risk Assessment indicated that Resident 12 was assessed as being at high risk for falls.During a review of Resident 12's Safety and Fall Prevention care plan initiated on 12/19/2025, and last revised on 2/12/2026, the care plan indicated a goal for the resident to remain free from any injuries. The care plan interventions included providing supervision as needed, removing tripping hazards (any obstruction, uneven surface, or irregularity in a walking path that causes a person's foot to strike it, leading to a loss of balance and a potential fall), and encouraging the use of the call light for assistance.During a review of Resident 12's Risk for Fall and Injuries Related to Limited Mobility care plan initiated on 12/03/2025, the care plan indicated a goal for the resident to have less fall with injuries through next review period. The care plan interventions included maintaining the resident`s bed in a low position, ensuring adequate lighting, placing personal items within the resident`s reach, and providing a safe environment.During an observation on 3/28/2026 at 7:40 a.m., inside Resident 12`s room, the resident was observed in bed, with no landing pads present at the bedside.During a concurrent interview and record review on 3/28/2026 at 6:52 p.m., with the facility`s Assistant Director of Nursing (ADON), Resident 12's Physician Order Summary dated 1/29/2026, COC Evaluation form dated 1/29/2026, Safety and Fall Prevention care plan initiated on 12/19/2025, Risk for Fall and Injuries Related to Limited Mobility care plan initiated on 12/03/2025 and Post Fall Review form dated 1/29/2026 were reviewed. The ADON stated that Resident 12 had a COC due to a fall on 1/29/2026, and one of the IDT recommendations was to apply landing pads at the resident`s bedside. The ADON stated Resident 12`s physician ordered placement of landing pads on both sides of the resident`s bed on 1/29/2026. The ADON stated Resident 12`s Safety and Fall Prevention care plan was initiated on 12/19/2025, and last revised on 2/12/2026. However, the care plan did not include the use of bilateral landing pads as an intervention. The ADON stated Resident 12`s Risk for Fall and Injuries Related to Limited Mobility care plan, initiated on 12/03/2025 was not reviewed or revised following the resident`s fall on 1/29/2026. The ADON stated that licensed staff are required to review and update all fall care plans following a resident fall to ensure that any necessary new interventions are included and implemented. The ADON stated licensed staff did not review and update Resident 12`s care plans following the resident`s fall on 1/29/2026. Consequently, one of the IDT recommendation to place landing pads at the resident`s bedside was not incorporated as an intervention in the care plan. The ADON stated that this failure had the potential to result in inadequate care and an increased risk of injury to the resident.During an interview on 3/29/2026 at 5:06 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to review and revise residents` care plans following a COC, on a quarterly (every three months) basis, and as needed. The DON stated the purpose of reviewing and re-evaluating care plans is to assess the effectiveness of the care plan interventions and to ensure that all pertinent information and interventions related to the resident's care are accurately included in the care plan. The DON stated that failure to review and revise a resident's care plan after a fall could result in inadequate care and an increased risk of recurrent falls. During a review of the facility`s Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed on 1/29/2026, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident`s conditions changed. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident`s condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, at least quarterly, in conjunction with the quarterly MDS assessments.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for one of one two residents (Resident 65) reviewed under the Activities of Daily Living care area by failing to ensure Resident 65's nails were trimmed.This deficient practice placed the resident at risk for skin injury and breakdown and infection. Findings: During a review of Resident 65's admission Record, the admission Record indicated the facility admitted the resident to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition (a life-threatening condition caused by an extreme lack of protein and total calories, leading to severe weight loss, muscle wasting, and fat depletion), lack of coordination, and muscle weakness. During a review of Resident 65's Minimum Date Set (MDS- a standardized assessment and care screening tool) dated 2/11/2026, the MDS indicated Resident 65's cognition (a mental process of acquiring knowledge and understanding through thought experience and senses) was severely impaired. The MDS indicated Resident 65 was independent with eating, required partial/moderate assistance (helper does less than half the effort) with oral hygiene, and required substantial/maximal assistance (helper does more than half the effort) with toileting and personal hygiene. During an observation on 3/28/2026 at 10:05 a.m., in Resident 65's room, observed Resident 65's fingernails to be long, untrimmed, and unkempt. During a concurrent observation and interview on 3/29/2026 at 10:01 a.m. with the Desk Nurse (DN), in Resident 65's room, the DN observed Resident 65's fingernails. The DN stated that Resident 65's fingernails are long and unclean. The DN stated that Resident 65's fingernails should be kept trimmed and clean. During an interview on 3/29/2026 at 10:14 a.m. with the Director of Staff Development Assistant (DSDA), the DSDA stated that Certified Nursing Assistants (CNAs) are responsible for keeping residents' nails clean and trimmed. The DSDA stated that when CNAs see that residents' nails are long it is the CNAs responsibility to trim the residents' fingernails. The DSDA stated that there is no specific schedule for trimming the residents' nails. During a follow up interview on 3/29/2026 at 10:15 a.m. with the DN, the DN stated that residents' nails should be kept short and clean to promote personal hygiene, infection control and dignity. During a review of the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, reviewed on 1/29/2026, the P&P indicated the purpose of the procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The P&P indicated under general guidelines, the P&P indicates nail care includes daily cleaning and regular trimming.

Based on observation, interview, and record review, the facility failed to provide a safe environment for 95 of 95 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, and 95), staff, and visitors, by: 1. Failing to ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. Failing to ensure that the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof. 3. Failing to maintain the ceiling structure free from moisture, water damage, active leaking, and degradation due to rainwater penetrating through cracks, holes, or other damaged areas of the roof. These deficient practices resulted in an outburst of 13 water leaks throughout the facility on 2/5/2024 during a rainstorm resulting in Resident 20, 23, and 90 being displaced (being forced to leave their home) and endangering the lives of the remaining 92 of 95 residents remaining in the facility by placing them at risk for electrical shocks, electrical fires, and subjecting the residents to possible serious structural damage. On 2/5/2024 at 9:06 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation for the facility's failure to ensure that the facility's roof was well maintained and in working order in order to provide a safe and comfortable environment for the residents in the presences of the Administrator, the Director of Nursing (DON), the Infection Preventionist (IP), and the Maintenance Supervisor (MS). On 2/7/2024 at 7:00 p.m., the SSA notified the Administrator and the Senior Director of Clinical Operations that the IJ situation was not removed, while onsite, after the facility submitted an IJ Removal Plan that was not accepted. On 2/9/2024 at 5:23 p.m., the Department accepted the IJ Removal Plan (IJ Removal Plan #5). On 2/10/2024 at 2:00 p.m., after confirming the facility's implementation of the accepted IJ Removal Plan, the Department removed the IJ while onsite, in the presence of Administrator and DON. The acceptable IJ Removal Plan for F921 included the following: On 2/5/2024 at approximately 2:00PM facility personnel (IP and Restorative Nursing Assistant [RNA]) initiated 15 to 30 min rounding to log (using facility floorplan) and monitor any water damage within the facility caused by severe rain. Through the course of several hours, nine areas of the facility were identified with leakage from the ceiling (resident rooms [ROOM NUMBERS], four hallways, family room, dining room and facility kitchen) Upon discovery, the residents in rooms [ROOM NUMBERS] were relocated for safety purposes. Ambulatory residents remaining in the facility will be monitored every (Q) shift by assigned licensed nurse for feeling safe, dry, and comfortable. On 2/5/2024 at approximately 6:30PM the facility's contracted roofing company arrived at the facility to assist in the temporary repair of the affected locations on the roof identified by the facility during rounds. On 2/7/2024 the facility's contracted drywall company made rounds to the facility to review ceiling patches due to water leaks. The facility Administrator obtained a contractual agreement on 2/7/2024 with the contracted roofing company pertaining to the detailed immediate repairs. On 2/5/2024 at approximately 9:30PM the facility's contracted electric company arrived at the facility and conducted rounds to ensure electrical areas and equipment were functioning properly and did not pose a safety hazard. All facility residents were checked for safety and comfort and received updates to their plans of care on 2/5/2024 to 2/6/2024 by the DON, Assistant Director of Nursing (ADON) and IP. The updates included at risk for emotional and psychological distress due to potential or actual displacement in or out of the facility caused by water leakage. The facility Administrator/Designee secured a contract the facility's contracted roofing company on 2/7/2024 agreeing to conduct a quarterly, full roofing assessment (and as needed) to identify any new or existing areas in need of repair and complete the repairs in full as recommended. The facility Maintenance Director/Designee will conduct monthly visual inspections of the roof and internal ceilings to identify and monitor any issues of concern. All visual inspection reports will be documented using facility roof inspection log/form and maintained in a binder in the maintenance office. The Dietary Supervisor provided an in-service education to the kitchen staff on 2/7/2024 regarding the three (3) identified locations of water leaks inside the kitchen; and infection control management to prevent cross contamination of food items and food preparation areas. The facility will complete a full roof replacement project by 1/1/2025. Any issues identified during the monthly roof inspection will be brought to the attention of the facility's contracted roofing company for repair or consultation. All findings will be brought to Quality Assessment and Assurance committee (QAA- committee that identifies quality deficiencies) for three months for further recommendations and interventions or until the committee determines resolution. Findings: During the review of the facility record titled Inspection Report 6602 dated 9/29/2022 the report's findings indicated the following for the facility's roof assessment: 1. Lifting roof along all edge metal [NAME] and South edges 2. Cracked mastic (high-grade construction adhesive) at all flashings (water resistant layers, metals, plastics, or other durable materials installed inside walls during construction) and platform corners 3. Exposed nails at platform 4. Lifting torch repair (when an area of the roof is heated so that the materials adhere to the surface) 5. Exposed nails at top of parapet walls (heavy railing around the edge of a roof) 6. Large low areas at torch repair where water pools 7. Cracks in sheet at low areas 8. Needs new platform where sheet metal was used 9. Loose slash (accumulation of debris) 10. One missing heat stack cap (allow air and fumes to exit the duct freely) eight (8) inches 11. Exposed coping metal over cap sheet at East and [NAME] wall 12. Hole and parapet wall 13. Cracked and peeling repair 14. Lifting cap sheet (covers and protects the layers below it, helping to extend the life of the roof) along entire South wall 15. Torn cap sheet at base of Air Conditioning platform During a review of the facility's record titled Maintenance Request dated 12/16/2022 to 1/2/2023 the log indicated there was a maintenance request submitted for a hole in the ceiling 6A - dripping on 12/31/2022 at 9:00 PM. During a concurrent observation and interview on 2/5/2024 at 2:05 PM with the Maintenance Assistant 1 (MA 1), observed MA 1 checking a water leak from the ceiling lamp inside the lobby. MA 1 stated that a roofing company was called to assess the status of the facility's roof. When MA1 was asked when the last check of the roof was before starting a current storm, MA 1 stated that that MS was responsible for checking the status of the facility's roof. During a concurrent observation and interview on 2/5/2024 at 2:10 PM with the MS, observed water leaking from the uncovered ceiling lamp in the lobby and observed a bucket on the floor in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] with water leaking into the bucket from the ceiling. Observed MS tell MA 1 to turn off the light for the affected ceiling lamp in the lobby. MS stated that the ceiling in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] was wet and swelling from the water dripping onto the ceiling. When the MS was asked when was the last time he or his staff checked the condition of the roof, MS stated he was unable to recall the last time the facility roof was assessed. When MS was asked to provide the log of the date and times the facility staff assessed the condition of the roof, MS stated that he does not have any documented logs. MS stated that he checks the facility roof monthly or on an as needed basis, but MS stated that he does not document his assessment. When MS was asked if he checked the facility roof prior to the current ongoing rainstorm, MS stated he did check the roof but was unable to recall the date and stated that there is no documented evidence that he conducted a roof assessment. During a concurrent observation and interview on 2/5/2024 at 3:13 PM with the MS and the IP, the IP stated that the water was dripping from the ceiling in the hallway between room [ROOM NUMBER] and 112. The IP stated that the ceiling seemed to have been previously patched. During an interview on 2/5/2024 at 3:13 PM with the DON, the DON stated that the ceiling inside room [ROOM NUMBER] had started to leak water. The DON stated that they will begin to move the residents (Resident 36, Resident 37, and Resident 38) out of room [ROOM NUMBER]. During a concurrent observation and interview on 2/5/2024 at 3:15 PM with the MS and the IP, the IP stated that the water was dripping from the curtain rail inside room [ROOM NUMBER] between Bed-B (middle bed) and Bed-C (by the window). Observed a bucket placed on the floor collecting the water leaking from the ceiling. During a concurrent observation and interview on 2/5/2024 at 3:18 PM with the IP, observed the hallway between the Central Supply (CS) Room and room [ROOM NUMBER]. IP stated that there was water leaking from the ceiling lamp. IP stated that the water leaking from the ceiling lamp is being collected by the bucket that was placed on the floor. During a concurrent observation and interview on 2/5/2024 at 3:30 PM with the IP, observed water leaks from the ceiling dripping into a bucket placed on the floor in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. IP stated that there was an active water leak from the ceiling in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. During a concurrent observation and interview on 2/5/2024 at 3:30 PM with the IP and Dietary Aide 1 (DA 1), observed the facility kitchen with three ongoing water leaks. DA 1 stated that the three areas of the water leaks in the kitchen are as follows: a. There is a water leak in the kitchen's small storage room. DA 1 stated that water was dripping from the ceiling ventilation and dripping into a bucket placed on the floor. b. There is a water leak from the ventilation opening near the walk-in refrigerator. DA 1 stated that water is leaking directly onto the floor. DA 1 stated that the leaking water had just started and that he was going to place a bucket on the floor. c. There is a water leak from the ventilation opening near the kitchen's plate warming station. The water leaking from the ceiling was being collected in a bucket that was placed on the floor next to the plate warming station. DA 1 stated that the leak by the plate warming station had started the previous night on 2/4/2024. During a concurrent observation and interview on 2/5/2024 at 3:47 PM with the IP and Activity Assistant 1 (AA 1), observed three areas of water leaking from the ceiling in the Dining/Activity Room. The IP stated that there were three spots of the water leaks from the ceiling: one spot from the corner of left side of the ceiling and two spots of water leaks at the end of the room to the opposite side of the door next to the fireplace. AA 1 stated that the water leaks had started the morning of 2/5/2024. During a concurrent observation and interview on 2/5/2024 at 3:50 PM with the IP, observed the water leak in the facility's Family Room. The IP stated that there was water dripping from the hole of the ceiling into a bucket placed on the floor in the Family Room. During an interview on 2/5/2024 at 6:20 PM with the Maintenance Supervisor (MS), the MS stated that the facility had active leaks inside at 2:15 PM when he arrived at the facility for the day. The MS stated that he verified that the water leaks were coming from the rain because the leaking from the ceiling started happening when the rains started happening. During an interview on 2/5/2024 at 6:51 PM with the Roofing Company Employee (RCE), the RCE stated that he was there to look at the roof. The RCE stated that the roof was an old gravel (small stones applied on top of the final coating of asphalt to protect the roof) roof and that they were looking for holes that they would temporarily fix it that night. During an interview on 2/5/2024 at 6:57 PM with the DON, the DON stated Resident 20, Resident 23 and Resident 90 had to be transferred to other facilities to protect the residents due to the on-going water leaks in the building. A review of Resident 90's physician order dated 2/5/2024, timed at 6:33 PM, indicated, temporary transfer of resident to skilled nursing facility 1 (SNF 1) due to environmental hazard (substance, state or event which has the potential to threaten the surrounding environment or adversely affect the resident's health including pollution and disasters such as storms and earthquakes). A review of Resident 20's physician order dated 2/5/2024, timed at 6:41 PM, indicated, temporary transfer of resident to skilled nursing facility 1 (SNF 1) due to environmental hazard. A review of Resident 23's physician order dated 2/5/2024, timed at 7:08 PM, indicated, temporary transfer of resident to skilled nursing facility 2 (SNF 2) due to environmental hazard. During an interview on 2/5/2024 at 6:58 PM with Resident 90, Resident 90 stated that she became aware of the leaks out in the hallway when she overheard the facility staff discussing the leaking from the ceiling outside of her room. During a concurrent observation and interview on 2/5/2024 at 7:17 PM with the Administrator in the Family Room, a hole in the ceiling to the left of the television mounted on the wall was observed with an active leak dripping from the open hole. The Administrator stated he was not sure if the ceiling material had fallen by itself or if somebody had taken it down. The Administrator stated that he did not think that it was likely that somebody would have opened a hole in the ceiling purposefully. During a concurrent observation and interview on 2/5/2024 at 8:05 PM with the Administrator in the hallway outside of room [ROOM NUMBER], evidence of a previous patch work (a repair job that involves the repair or replacement of the drywall, usually for the purposes of repairing damage) job on the ceiling was observed with an active water leak dripping from the center of the patched area of the ceiling. The Administrator stated that there was an active leak and stated that the ceiling appeared to have had previous patchwork done in the area where the leak was occurring. During a concurrent observation and interview on 2/5/2024 at 8:10 PM with the Administrator in the hallway outside of the Central Supply Closet, evidence of a previous patchwork along with discoloration was observed on the ceiling. A water leak dripping from the center of the old patchworked area was observed to be actively dripping. Pieces from the ceiling were observed to have fallen on to the floor below where the active leak was dripping into a trash can. The Administrator stated that the patchwork on the ceiling appeared to have been from repair work that had been done previously and stated that the ceiling material that was on the floor had likely fallen directly from the area where the leak was occurring. During a concurrent interview and record review on 2/5/2024 at 8:30 PM with the IP, the IP reviewed the facility's list of ambulatory (ability to move) residents. The IP stated that the facility homed a total of 22 ambulatory residents, eight walking residents (Resident 9, 11, 20, 26, 27, 73, 80, and 84) out of the total 22, and 14 wheelchair bound residents (Resident 8, 10, 12, 15, 16, 18, 24, 35, 58, 62, 65, 72, 83, and 87) out of the total 22. The IP stated that these residents have a potential risk of compromised safety while walking or moving around in the hallways which could lead to residents falling on the floor, or residents being hit by falling debris from the ceiling caused by the ongoing water leaking. During an interview on 2/6/2024 at 1:34 PM with the facility's Director of Environmental Services (DES), the DES stated that the roof had been temporarily repaired last night (2/5/2024). During a concurrent observation and interview on 2/6/2024 at 3:03 PM with the DS, observed in the kitchen that there was water around the ventilation opening still actively leaking into a bucket placed on the floor. The DS stated that the leak above the ventilation opening by the plate warming station was still ongoing. During a concurrent observation and interview on 2/6/2024 at 3:22 PM with the Administrator in Training (AIT) in the Family Room, the previously observed hole in the ceiling, to the left of the television mounted on the wall, appeared to have increased in area. The hole measured at 11 inches at its widest point, by six (6) inches at its narrowest point. An active water leak was dripping from the open hole. Pieces of drywall were observed to have fallen from the open hole to the floor, beneath the active leak. The AIT stated after measuring the size of the hole with a measuring tape that the hole measured 11 inches by six inches. The AIT stated that the material on the floor appeared to be from the ceiling above, and further stated that there was still an active water leak ongoing. During a concurrent observation and interview on 2/6/2024 at 3:23 PM with the IP, observed two newly identified areas affected by water leaks, one leak observed in the ceiling near room [ROOM NUMBER], and a second leak observed near the Therapy room [ROOM NUMBER]. IP stated that there were two newly identified ceiling water leaks; one by room [ROOM NUMBER], and a second by Therapy room [ROOM NUMBER]. During a concurrent observation and interview on 2/6/2024 at 3:31 PM with the AIT in the Dining/Activity Room, a crack in a previous patch job was observed by the doors closest to the kitchen. The AIT measured the crack to be one inch long. The AIT stated that water had been leaking from this area the day before. During a concurrent observation and interview on 2/6/2024 at 3:33 PM with the AIT in the Dining/Activity Room, brown discoloration around a crack on the ceiling in the middle of a previous patch job by the fireplace was observed with an active water leak pouring from the area. The AIT measured the crack to be 22 inches long and measured the brown discoloration (change in color) to be seven inches in diameter. The AIT stated that the ceiling area appeared to have an old patch job and that there was an active leak coming from the crack. During a concurrent observation and interview on 2/6/2024 at 3:44 PM with the AIT in the Kitchen, an active water leak was observed dripping from the ventilation in the kitchen ceiling, to the left of the ventilation hood. The AIT stated that there was an active water leak coming from the ventilation. During a concurrent observation and interview on 2/6/2024 at 3:58 PM in the hallway by room [ROOM NUMBER], a crack and discoloration was observed in the ceiling with an active water leak dripping from the area. A piece of ceiling material, measured to be 17 by 20 inches by the AIT was observed to be missing from the ceiling around the leaking area. The AIT stated that there was a piece of the ceiling that had fallen and stated that there was an active leak. During a concurrent observation and interview on 2/6/2024 at 4:03 PM with the AIT in the hallway by Central Supply Room, a discolored and damp area measuring nine (9) inches by nine (9) inches was observed on the ceiling with an active leak dripping from a light fixture. The AIT stated that the discolored area on the ceiling was damp by touching it with his hand and stated that there was an active leak dripping from the light fixture. During a concurrent observation and interview on 2/6/2024 at 4:04 PM with the AIT in the hallway outside of room [ROOM NUMBER], a damp discolored area was observed on the ceiling. The AIT stated the area was damp after checking it with his hand and measured the discolored area to be 1.5 inches by two (2) inches. During a concurrent observation and interview on 2/6/2024 at 4:11 PM with the AIT inside of room [ROOM NUMBER], an active leak was observed dripping from a crack over the television mounted on the wall. The AIT measured the crack to be 10 inches long and stated that the crack was in an area where there was a previous patch job. Discoloration on the ceiling was observed and the AIT stated that the area of the discoloration was at the previous patch job. During a concurrent observation and interview on 2/6/2024 at 4:16 PM with the AIT inside of room [ROOM NUMBER], an active water leak from a hole was observed to be dripping into a trash can on Bed B. The AIT measured the hole to be 1/4 inch in diameter and stated that it was actively leaking. A second water leak dripping from the ceiling was observed to be dripping onto the mattress of Bed B. The AIT stated the dripping from the ceiling was an active water leak. A third water leak was observed to be dripping from the bed curtain rails next to Bed B. The AIT stated that the water was dripping from the bed rail from an active water leak. During a concurrent observation and interview on 2/6/2024 at 4:20 PM with the AIT in the hallway by room [ROOM NUMBER], a damp, discolored area was observed along a cracked ceiling in the hallway. The AIT stated that the discolored area was damp by checking it with his hand and measured the missing ceiling piece to be 20 by 9.5 inches. During a concurrent observation and interview on 2/7/2024 at 8:38 AM with the Construction Manager, inside room [ROOM NUMBER], observed water draining from the ceiling in the middle of the room over Bed B. When the Construction Manager made a hole to the ceiling from where the water was draining, observed water drain out from the ceiling hole totaling 3400 milliliters (mL-unit of measure) once measured. During a concurrent observation and interview on 2/7/2024 at 12:30 PM with the facility's Inspector on Record (IOR) in the Dining/Activity Room, moisture was observed on the wooden joists (structure to provide support to the building) inside of the ceiling space visible through an open hole in the ceiling. The IOR stated that the moisture had likely penetrated through the roof and leaked into the space between the roof and ceiling from the rain. During an interview on 2/7/2024 at 4:21 PM with the Administrator, a second request for written evidence of communication to the Department on the re-roofing progress, the permit for the re-roofing project, and re-roofing approval, and weekly roof inspection log was requested. The Administrator stated that he did not have any written evidence of progress updates sent to the Department of Public Health and did not have an application for a permit to re-roof the facility. During an interview on 2/7/2024 at 6:55 PM with the Administrator, the Administrator stated that the facility did not have any weekly inspection logs for visual inspections of the roof. During a review of the facility's policy and procedure titled Reopening the Facility after Wind or Water Damage last revised on 5/2011, last reviewed on 8/18/2023, the policy indicated Prior to opening a healthcare facility that has undergone extensive water and wind damage, inspections will be conducted to determine if the building is salvageable. During a review of the facility's policy and procedure titled Safety Precautions, Electrical last revised on 1/2011, last reviewed on 8/18/2023, the policy indicated Do not use any electrical device that has been dropped or abused or liquid has spilled into it wait until it has been checked and declared safe for use. During a review of the facility's policy and procedure titled Homelike Environment last revised on 2/2021, last reviewed on 8/18/2023, the policy indicated The facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a personalized, home like setting. These characteristics include clean, sanitary, and orderly environment. During a review of the facility's policy and procedure titled Maintenance Service last revised on 12/2009, last reviewed on 8/18/2023, the policy indicated The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times, Functions of maintenance personnel include but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines and maintaining the building in good repair and free from hazards, and Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 1) when on 1/21/2024, Certified Nurse Assistant 1 (CNA 1) witnessed Resident 2 punch Resident 1's right side of the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's moderately impaired cognition (ability of think and make decisions), an individual subjected to physical abuse can have lifetime physical pain and or psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 11/16/2023 and readmitted the resident on 1/12/2024 with diagnoses that included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and psychotic disorder (mental disorders that cause abnormal thinking and perceptions). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/8/2023 indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1 had moderately impaired cognition and required moderate assistance from staff with mobility (the ability to move freely). A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a tool used by medical professionals to communicate with one another regarding a resident's medical condition), Communication Form dated 1/21/2024, timed at 8 a.m., indicated that at around 7 a.m., Resident 1 was yelling and screaming about his cigarettes at the Nursing Station (NS) near Resident 2's room. The form further indicated that Resident 2 then came out of his room and punched Resident 1's right side of the face. A review of Resident 1's care plan for at risk for emotional distress dated 1/21/2024, indicated that Resident 1 was at risk for emotional distress due to Resident 1 being attacked by another resident (Resident 2). The goal for Resident 1 is to not have any episodes of emotional distress. A review of Resident 1's Progress Note dated 1/22/2024, timed at 3:29 p.m., indicated that on 1/21/2024, Resident 2 abruptly came out of his room and physically hit Resident 1's right temple (side of the head). The progress notes further indicated that Resident 1 was noted minor abrasions (a wound to the epidermis [thin outer layer of the skin]) to the right temple. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 9/21/2018 and readmitted the resident on 1/6/2024 with diagnoses that included congestive heart failure (CHF-a condition that develops when a heart doesn't pump enough blood for the body needs that cause fluid buildup in the feet, arms, lungs, and other organs), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). A review of Resident 2's MDS dated [DATE] indicated Resident 2 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 2 had intact cognition and required supervision and assistance from staff with mobility. A review of Resident 2's SBAR Communication Form dated 1/21/2024, timed at 8:00 a.m., indicated that there was concern that Resident 2 had right hand discomfort with mild pain. A review of Resident 2's physician order dated 1/21/2024, timed at 3:04 p.m., indicated that the physician ordered for X-radiation (X-ray - creation of pictures of the inside of the body) of Resident 2's right hand and wrist. A review of Resident 2's Progress Note dated 1/22/2024, timed at 2:35 p.m., indicated that on 1/21/2024, Resident 2 had physically hit another resident (Resident 1). The Progress Note further indicated that Resident 2 right hand was x-rayed due to pain after Resident 2 hit Resident 1. During an interview with Resident 2 on 2/5/2024 at 11 a.m., Resident 2 stated that on 1/21/2024, Resident 2 hit Resident 1 because Resident 1 disturbed Resident 2's sleep. Resident 2 stated that he did not understand why facility staff allows Resident 1 to yell in the middle of night or in the early morning. Resident 2 further stated that he was so upset that on 1/21/2024, after Resident 1 was yelling and screaming in the hallway, Resident 2 went out into the hallway and hit Resident 1. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/5/2024 at 12:49 p.m., LVN 1 stated that on 1/21/2024, Resident 2 should not have hit Resident 1. LVN 1 stated that unfortunately the incident that occurred on 1/21/2024 where Resident 2 hit Resident 1 was resident to resident physical abuse. During an interview with the Director of Nursing (DON) on 2/6/2024 at 12:05 p.m., the DON stated that on 1/21/2024 Resident 2 came out of his room and hit Resident 1's right temple area. The DON further stated that Resident 2 then complained of pain to his right wrist and hand (the hand used to hit Resident 1). The DON stated that unfortunately the facility staff were not able to stop the resident-to-resident physical abuse that happened when Resident 2 hit Resident 1 on 1/21/2024. The DON stated that physical abuse should not happen in the facility. A review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 and last reviewed on 8/18/2023, indicated, Protect residents from abuse .by anyone including, but not necessarily limited to facility staff, other residents Any other individual.

Based on interview and record review, the facility failed to ensure the bed alarm (a physical or electronic device that monitors resident movement and alerts the staff when movement is detected while the resident is in bed) was functional and turned on for one of three sampled residents (Resident 1) as ordered by the physician and indicated in the care plan. This deficient practice resulted in a fall incident in which Resident 1 sustained an occipital (rear portion of the head) scalp hematoma (abnormal collection of blood outside of a blood vessel) and laceration (a deep cut or tear in the skin). Findings: A review of Resident 1 ' s Admission Record indicated the resident was admitted into the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses that included, but not limited to, [CONDITION(S)] (a medical condition in which a person's kidneys cease functioning on a permanent basis), failure to thrive, and a history of [CONDITION(S)] (temporary blockage of blood flow to the brain) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area without residual deficits). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/25/2022, indicated Resident 1 has the ability to make self understood and has the ability to understand others. The MDS indicated Resident 1 requires one-person extensive assistance with bed mobility, transferring to or from bed, dressing, toilet use, and personal hygiene. The MDS further indicated the bed alarm was being used daily for the resident. A review of Resident 1 ' s Order Summary Report from April 2022, indicated the following order: - Sensor pad alarm (type of bed alarm) on bed. Monitor for function and placement q (every) shift, ordered on 11/15/2021. A review of Resident 1 ' s Quarterly Risk Data Collection Tool, dated 3/1/2022, indicated the resident is at risk for falls. A review of Resident 1 ' s Care Plan for risk for falls, initiated on 11/12/2021 and revised on 3/15/2022, indicated a goal that the resident will be free of fall-related injuries. The care plan indicated an intervention, revised on 3/8/2022, for sensor pad alarm on bed and to monitor for function and placement every shift. A review of the nursing progress note, dated 4/21/2022 at 11:05 p.m., indicated resident was found lying on her right side on the landing pad (floor mat to protect residents from fall-related injuries). The Certified Nursing Assistant (CNA) called the charge nurse that resident was on the floor. Upon completing a body assessment, Resident 1 was found with a three centimeter laceration to the back of her head with moderate bleeding. The physician was notified with orders to transfer the resident to the hospital. A review of Resident 1 ' s computed tomography (CT - noninvasive diagnostic imaging procedure that produces images of the inside of the body) head without contrast (substance taken by mouth or injected into bloodstream that cause the particular organ or tissue to be seen clearly) indicated a result of small occipital scalp hematoma and laceration. During an interview, on 4/25/2022 at 4:33 p.m., Licensed Vocational Nurse 1 (LVN 1) stated CNA 1 had found Resident 1 on the floor during her initial rounds and notified her of the fall. LVN 1 stated she found Resident 1 laying on her right side on the landing pad on the right side of the bed upon checking on her. LVN 1 stated a body assessment was completed and a laceration to the back of her head was noted with moderate bleeding. LVN 1 stated Resident 1 was identified as a high fall risk since the resident is confused and always tries to get out of bed and explained staff were performing frequent checks, ensured bed was in the lowest position, and landing pads and bed alarm were in place to prevent Resident 1 from falling. LVN 1 confirmed the bed alarm did not sound when she came to check on Resident 1. LVN 1 stated she was not sure if the bed alarm was not working or if the CNA had turned it off after the bed alarm went off. During an interview, on 5/10/2022 at 11:46 a.m., Certified Nursing Assistant 1 (CNA 1) verified she was the first person to find Resident 1 on the floor at around 11 PM on 4/21/2022. CNA 1 stated she was making rounds in the beginning of her shift and passing by when she heard someone yelling for help. When CNA 1 looked inside Resident 1 ' s room, CNA 1 stated she found Resident 1 laying with her body on the landing pad and her head partially on the floor. CNA 1 stated Resident 1 sustained an injury to the back of her head and was bleeding. CNA 1 stated she immediately called for help and everyone ran towards Resident 1 ' s room. CNA 1 stated that Resident 1 had a yellow fall risk wristband, bed alarm, and landing pads in place for fall prevention measures. CNA 1 stated that she did not hear anything besides the resident yelling for help when she found Resident 1 on the floor. CNA 1 stated she saw the bed alarm on the resident ' s bed but confirmed the bed alarm did not go off. CNA 1 stated she would have heard it if the bed alarm was on. CNA 1 further stated she honestly did not see a green or red light on the bed alarm and explained that the light on the bed alarm should be blinking green if the bed alarm was working or turned on. During an interview, on 5/10/2022 at 4:12 p.m., Registered Nurse 1 (RN) 1 stated she was in Station 1 when LVN 1 notified her that Resident 1 had fallen. RN 1 stated she ran over to Resident 1 ' s room and found Resident 1 laying in her right side on the landing pad located on the floor to the right side of the bed. RN 1 verified she did not hear anything when she arrived at Resident 1 ' s room. RN 1 stated that if LVN 1 had not called her and gotten her attention, she would not have known that the resident had gotten out of bed and fallen. RN 1 further stated she was more concerned about Resident 1 ' s condition during that time and did not pay attention to see if Resident 1 had a bed alarm or not. During an interview and record review, on 5/10/2022 at 4:50 p.m., the Director of Nursing (DON) stated Resident 1 was identified as a high fall risk and verified Resident 1 had an order for sensor pad alarm in bed that was ordered on 11/15/2021. The DON stated Resident 1 was sleeping in bed prior to when she attempted to get out of bed and fell . The DON confirmed the bed alarm should have been on since the resident was in bed sleeping. When asked what it means if the interviewed staff (CNA 1, LVN 1, and RN 1) at the scene are saying that they did not hear any sound upon attending to Resident 1 while she was on the floor, the DON stated it means the bed alarm was not working. The DON explained the bed alarm is checked for function and placement every shift by staff and that the bed alarm has to be blinking a green light, indicating the alarm is on and functional. The DON stated staff should notify central supply immediately to replace the bed alarm sensor if it is not working. When asked if the facility did everything to prevent Resident 1 from falling, the DON answered no and confirmed the intervention for bed alarm was missed. The DON further stated it is possible the fall could have been avoidable if the bed alarm was working. The DON stated the purpose of the bed alarm is to remind residents not to get up by themselves and to alert staff. A review of the facility ' s policy and procedure titled, Tab Alarms, Bed Alarm, Wanderguard System, last reviewed and updated on 4/12/2022, indicated tab alarms or bed alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident ' s care plan that the resident is at risk for falls. The policy and procedure further indicated the bed alarm will be utilized on the resident while they are in bed and that after applying the tab alarm or bed alarms in place, a safety check to make sure they are in proper working condition must be done before leaving the resident.

Based on observation, interview, and record review, the facility failed to provide safe environment for the residents, staff, and visitors, as indicated in the facility's policies and procedures by failing to: 1. Provide safe water temperatures of less than 121 degrees Fahrenheit (°F [F-unit of measure]) in 12 of 12 resident restroom hand sinks (Rooms 220 to 237) in Station 2 and six of ten resident restroom hand sinks (Rooms 105/107, 109/111, 110/112, 114, 117, 118/119) in Station 1. 2. Maintain required range water temperatures (105°F-120°F) in 18 of 22 resident restroom hand sinks and three of four shower rooms (Shower Room 1, Shower Room 2, and Shower Room 4). 3. Check water temperatures in rooms and showers used by residents and maintain record of water temperature logs for 5/10/2021 and 5/11/2021. 4. Maintain boiler (a device providing a hot-water supply) room mixing valve (valve that blends hot water with cold water to ensure constant and safe temperatures) in safe operating conditions in one of two boiler rooms. 5. Ensure two of four shower room valves (fittings designed to control water flow and temperature in the shower) were in good working condition. 6. Ensure hot faucet fixture in one of 22 resident restroom hand sinks (Room 105/107) was in good working condition. 7. Ensure regulating thermostatic (controls temperature of a room by changing the flow of hot water to the radiator) or pressure valves ( safety valve used to control or limit the pressure in a system) were inspected monthly and records retained in the facility. These deficient practices had the potential for residents, staff, and visitors to sustain [CONDITION(S)], scalding (injury from hot liquid or steam), and uncomfortable water temperatures. On 5/15/2021 at 12:53 p.m., an Immediate Jeopardy was called (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) and the facility. The Administrator (ADM), Director of Nursing (DON), and Environmental Services Supervisor (EVSS), were notified of the findings regarding high water temperatures in resident restroom sinks, low water temperatures in resident restroom sinks and shower rooms, malfunctioning valves, and malfunctioning faucet fixture. On 5/19/2021 at 9:11 a.m., the ADM provided an acceptable plan of action (POA) that included the following summarized actions: 1. Immediately identify affected resident restroom sinks and shower rooms to be out of range (outside 105-120°F). 2. Posting of signs in resident restrooms and monitoring of signs twice daily during water temperature checks. 3. Plumber made site assessment, installed local mixing valves at each faucet exceeding 120°F, replace Shower Room 1 mixing valve, and replace main mixing valve in Boiler Room. 4. Replaced faucet in Room 105/107 restroom sink. 5. Skin assessments performed for all residents to ensure no residents were affected by high water temperatures. 6. Resident's primary contacts informed of hot water issues by sharing contents of letter, titled, Memo: Hot Water. 7. Residents were informed of hot water issues in the facility. 8. In-services performed to all staff regarding resident safety during hot water issue. 9. In-services performed to all staff regarding immediate reporting of maintenance issues. Maintenance request binder kept in Nursing Station 1 and 2. 10. Complete Environmental Services (EVS) staff competencies related to facility water temperature maintenance and monitoring. On-going training schedule with EVS staff. 11. Developed an inspection and maintenance plan of essential plumbing equipment (boilers/water heaters and faucet fixtures) and thermostatic or pressure valves on hot water fixtures for EVS staff. New log was established to include annual service, monthly mechanical inspections, and weekly visual inspections. 12. New water temperature log was established to include twice daily readings and verification of temperatures by ADM or designee. Negative findings to be recorded in the comments section. 13. Quality Assurance and Performance Improvement (QAPI) committee performed Root Cause Analysis (RCA) and developed Performance Improvement Plan (PIP). ADM to present any negative findings to QAPI Committee monthly, including quarterly QAPI meetings. On 5/20/2021 at 5:24 p.m., while onsite and after verifying satisfactory implementation of the facility's immediate corrective actions within the POA , the Immediate Jeopardy was lifted in the presence of the ADM, DON, EVSS and facility's Regional Consultant. Findings: 1. During a facility tour with the EVSS on 5/12/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 3:26 p.m., in Room 233, shared restroom with Room 231, a water temperature reading of 125°F was observed after having the water ran for less than one minute. The EVSS confirmed the finding. b. At 3:27 p.m., in Room 226, a water temperature reading of 124.5°F was observed after having the water ran for two minutes. The EVSS confirmed the finding. c. At 3:37 p.m., in Room 221, a water temperature reading of 135°F was observed after having the water ran for one minute. The EVSS confirmed the finding. During a concurrent observation and interview on 5/12/2021, at 3:57 p.m., with the EVSS, a temperature gauge for a water heater storage tank was observed registering at 142°F in the boiler room. The EVSS stated that the water heater storage tank serves water to the resident's rooms and showers. EVSS stated that he does not know which boiler and tanks serves which parts of the facility. When asked where the temperature dial control or thermostat was located for the boilers, the EVSS answered, the equipment was old and that he does not know if the boiler had one. During an interview on 5/12/2021, at 4:39 p.m., with the ADM, the ADM stated that 135°F water temperature in resident restroom hand sink was too hot and that it can burn someone. The ADM added, he must figure out which water heaters were allocated to which rooms and showers, to have the plumber visit the facility, and make adjustments as there was a big discrepancy in the temperature. During an interview on 5/14/2021, at 10:17 a.m., with Certified Nursing Assistant 5 (CNA 5) , CNA 5 stated that for many years the facility had issues with water temperature and that he had seen plumbers in the facility. CNA 5 also stated, in some rooms, when hot water was left running for few minutes, the water would continue to get hot. During an interview on 5/14/2021, at 10:56 a.m., with the EVSS, the EVSS stated that the required minimum water temperature for resident rooms and showers was 105°F and the maximum water temperature was 120°F. The EVSS explained that water checks were conducted to ensure proper temperatures for residents as to prevent accidental burning and uncomfortable bath temperatures. Upon further investigation and during a facility tour with the EVSS on 5/14/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 12:36 p.m., in Room 237, shared restroom with Room 235, a water temperature reading of 127°F was observed after having the water ran for two minutes. The EVSS confirmed finding. b. At 12:38 p.m., in Room 236, shared restroom with Room 234, a water temperature reading of 131.2°F was observed after having the water ran for three minutes. The EVSS confirmed finding. c. At 12:42 p.m., in Room 233, shared restroom with Room 231, a water temperature reading of 134.6°F was observed after having the water ran for less than one minute. The EVSS confirmed finding. d. At 12:44 p.m., in Room 232, shared restroom with Room 230, a water temperature reading of 127.9°F was observed after having the water ran for five minutes. The EVSS confirmed finding. e. At 12:50 p.m., in Room 229, a water temperature reading of 135°F was observed after having the water ran for one minute. The EVSS confirmed finding. f. At 12:52 p.m., in Room 228, shared restroom with Room 227, a water temperature reading of 131.7°F was observed after having the water ran for five minutes. The EVSS confirmed finding. g. At 12:57 p.m., in Room 226, a water temperature reading of 134.2°F was observed after having the water ran for four minutes. The EVSS confirmed finding. h. At 1:01 p.m., in Room 225, shared restroom with Room 224, a water temperature reading of 135°F was observed after having the water ran for two minutes. The EVSS confirmed finding. i. At 1:10 p.m., in Room 222, a water temperature reading of 139.5°F was observed after having the water ran for one minute. The EVSS confirmed finding. j. At 1:11 p.m., in Room 221, a water temperature reading of 136.4°F was observed after having the water ran for two minutes. The EVSS confirmed finding. k. At 1:14 p.m., in Room 220, a water temperature reading of 138.7°F was observed after having the water ran for one minute. The EVSS confirmed finding. During an interview on 5/14/2021, at 3:15 p.m., with the ADM, when asked what can happen to residents or staff when water temperature was more than 120°F, the ADM answered, Depending on the temperature, it could burn and At the minimum it could be discomfort. During the daily monitoring with the EVSS on 5/15/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 10:01 a.m., in Room 229, a water temperature reading of 127.6°F was observed after having the water ran for three minutes. The EVSS confirmed finding. b. At 10:06 a.m., in Room 222, a water temperature reading of 142.9°F was observed after having the water ran for one minute. EVSS confirmed finding. c. At 10:08 a.m., in Room 221, a water temperature reading of 142°F was observed after having the water ran for one minute. The EVSS confirmed finding. d. At 10:13 a.m., in Room 220, a water temperature reading of 142.2°F was observed after having the water ran for less than one minute. During a concurrent interview, the EVSS stated, that the water reached a high temperature level quickly. e. At 1:49 p.m., in Room 223, a water temperature reading of 129.6°F was observed after having the water ran for five minutes. The EVSS confirmed finding. f. At 2:34 p.m., in Room 227, shared restroom with Room 228, a water temperature reading of 128.8°F was observed after having the water ran for four minutes. The EVSS confirmed finding. During a concurrent observation and interview on 5/15/2021, at 10:16 a.m., with the EVSS, temperature gauges for two water heater tanks serving resident rooms and showers were observed registeri ng (measuring) at 140°F and 130°F in the boiler room. The EVSS stated that he does not know another way to lower the water temperature other than adjusting the mixing valve. The EVSS added, he's not a professional plumber. During a concurrent observation and interview on 5/16/2021, at 3:15 p.m., with the EVSS, a temperature control dial for one of the water heater tanks was observed in the boiler room. The EVSS took off the dial cover and revealed registered temperature of 145°F. When asked if it was possible for the dial to be adjusted to a lower temperature setting, the EVSS stated, he was not comfortable doing that as he was worried he might cause something to go wrong with the system. A review of the Maintenance Test Log Daily/Weekly Water Temperature Log indicated hot water temperatures ranging from 125°F to 139°F for ten of 22 resident restroom hand sinks (in Rooms 220 to 228, 231 to 237) on 5/16/2021 morning check. During the daily monitoring with the EVSS on 5/17/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 3:25 p.m., in Room 234, shared restroom with Room 236, a water temperature reading of 124.5°F was observed after having the water ran for four minutes. The EVSS confirmed finding. b. At 3:30 p.m., in Room 231, shared restroom with Room 233, a water temperature reading of 128.5°F was observed after having the water ran for two minutes. The EVSS confirmed finding. c. At 3:35 p.m., in Room 230, shared restroom with Room 232, a water temperature reading of 123.3°F was observed after having the water ran for four minutes. The EVSS confirmed finding. During the daily monitoring with the EVSS on 5/19/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 10:54 a.m., in Room 118, shared restroom with Room 119, a water temperature reading of 127.6°F was observed after having the water ran for two minutes. The EVSS confirmed findings. b. At 10:58 a.m., in Room 117, a water temperature reading of 124.5°F was observed after having the water ran for three minutes. The EVSS confirmed findings. c. At 11:37 a.m., in Room 114, a water temperature reading of 122°F was observed after having the water ran for eight minutes. The EVSS confirmed findings. d. At 1:45 p.m., in Room 105, shared restroom with Room 107, hot water faucet handle was not functioning. A water temperature reading of 65.5°F was observed after running the cold water. In a concurrent interview, the EVSS stated, the faucet fixture was loose, and the hot water cannot be turned on as the handle was stuck. During an interview on 5/20/2021, at 12:12 p.m., with the ADM, the ADM stated, six resident restroom hand sinks were out of range on 5/19/2021 (Rooms 105/107, 109/111, 110/112 , 114, 117 and 118/119) with high water temperatures ranging from 121°F to 124°F. A review of the facility's Maintenance procedures with an effective date of 4/2018, indicated for daily water temperature checks in rooms used by residents (e.g. bathrooms, showers, etc.) including: a. Periodic check of different rooms to ensure hot water used by residents is heating to 105-115°F (or applicable requirement). b. Set thermostats on boilers or hot water heaters to obtain the required temperature. c. Check pilot lights daily or whenever the water temperature drops. d. Re-light the boiler according to posted instructions. A review of the Centers for Disease Control (CDC ) document titled, Nonfatal Scald-Related [CONDITION(S)] Among Adults Aged ?[AGE] years --- United States, 2001-2006 dated 9/18/2009 , the document indicated that an estimated 51,700 initial visits to emergency departments (EDs) by persons aged [AGE] years or older for nonfatal scald [CONDITION(S)] occurred during 2001 to 2006, for an average of 8,620 visits per year. The highest estimated annual numbers of ED visits were for scald [CONDITION(S)] to the arm/hand and leg/foot, and the highest number of ED visits were for scald [CONDITION(S)] caused by hot food, hot water, or steam. A review of the American Burn Association (ABA) document titled, Scald Statistics and Data Resources, dated 8/13/2018, indicated the following: a. While the proportionate rate of scald burn injuries in older adults is comparable to all others greater than [AGE] years old, the risk of complications (a marker of morbidity [dealing with a disease]) and mortality increases. Scald [CONDITION(S)] to adults [AGE] years and older frequently result in loss of independence. b. It only takes 3 seconds of exposure to 140°F water to cause a burn serious enough to require surgery A review of the American Burn Association (ABA) document titled, Scald Injury Prevention Educator's Guide (undated), indicated the following: a. Although scald [CONDITION(S)] can happen to anyone, young children, older adults, and people with disabilities are the most likely to incur such injuries. b. Older adults have thinner skin so hot liquids cause deeper [CONDITION(S)] with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation (circulation of blood in the smallest blood vessels), heat is removed from burned tissue rather slowly compared to younger adults. c. Individuals who may have physical, mental, or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgment, or awareness may hinder the person's ability to recognize a dangerous situation or respond appropriately to remove themselves from danger. d. Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. e. Time and Temperature Relationship to Severe [CONDITION(S)]: i. Water temperature of 155°F takes one second for a third degree burn to occur. ii. Water temperature of 148°F takes two seconds for a third degree burn to occur. iii. Water temperature of 140°F takes five seconds for a third degree burn to occur. iv. Water temperature of 133°F takes 15 seconds for a third degree burn to occur. v. Water temperature of 127°F takes one minute for a third degree burn to occur. vi. Water temperature of 124°F takes three minutes for a third degree burn to occur. vii. Water temperature of 120°F takes five minutes for a third degree burn to occur. A review of the Centers for Disease Control (CDC) document titled , [CONDITION(S)] (undated), indicated the following types of [CONDITION(S)]: a. First-degree [CONDITION(S)] involve the top layer of skin. Sunburn is a first-degree burn. These may present as red and painful to touch, and the skin will show mild swelling. b. Second-degree [CONDITION(S)] involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. c. Third-degree [CONDITION(S)] penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree [CONDITION(S)] surrounding third-degree [CONDITION(S)]), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. 2. During an interview on 5/12/2021, at 3 p.m., with Resident 1, Resident 1 stated, she takes showers in Shower Room 4 and Sometimes the water is cold. When asked if she had told facility staff about the water being too cold, Resident 1 answered, Everybody knows. During an interview on 5/12/2021, at 3:05 p.m., with Resident 2, Resident 2 stated , The water from the faucet has trouble getting hot sometimes and that the Certified Nursing Assistant (CNA) knows about it. During an interview on 5/12/2021, at 3:11 p.m., with Resident 3 and Resident 4 , Resident 4 stated, the water is cold in the morning when the CNAs wash her down using the water from the restroom hand sink. Resident 3 added, the staff knows about the water issue and explained, They tell the person to fix it, but they don't do anything. During an interview on 5/12/2021, at 3:17 p.m., with the EVSS, EVSS stated, water temperature in resident rooms and in the showers should be 110°F to 112°F on average. During a concurrent observation and interview on 5/12/2021, At 3:39 p.m., in Room 118, shared restroom with Room 119, the EVSS measured water temperature by turning on the hot water faucet fixture in the resident restroom hand sink and placing a probe thermometer through the running water. A water temperature reading of 93.4°F was observed after having the water ran for five minutes. The EVSS confirmed the finding. During a facility tour with the EVSS on 5/12/2021, the EVSS measured water temperatures in shower rooms by turning the shower handle to the hottest setting and placing a probe thermometer through the running water. The following were observed: a. At 3:30 p.m., in Shower Room 2, a water temperature reading of 102.5°F was observed after having the water ran for six minutes. In a concurrent interview, the EVSS stated, the water temperature fluctuates and confirmed the finding of low water temperature. b. At 3:50 p.m., in Shower Room 1, a water temperature reading of 88°F to 93°F was observed after having the water ran for four minutes. In a concurrent interview, the EVSS stated, that the water temperature fluctuates and that confirmed the finding of low water temperature. During an interview on 5/12/2021, at 4:05 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, some of the residents were complaining of water being too cold when it comes to bed bath. CNA 1 also stated that, they must wait five to ten minutes after turning on the hot water in the showers before the water gets warm no matter the time of the day. During an interview on 5/12/2021, at 4:19 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, resident restroom hand sink in Rooms 117 and 119 takes time to get warm and that the week prior, Rooms 101 to 105 resident restroom hand sinks were also taking a while to get warm. During an interview on 5/12/2021, at 4:26 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated, residents had complained of water being too cold and that they must wait ten minutes for the water to get warm. During an interview on 5/14/2021, at 9:56 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated, when giving resident showers in Shower Room 2, the water gets cold. CNA 4 added that the issue could be from the remodeling of the showers. CNA 4 added that the facility had fixed Shower Room 4 which was previously not working. During an interview on 5/14/2021, at 10:17 a.m., with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated, the water temperature fluctuates in Shower Room 2, it gets a little warm and then cold, and that he had reported the issue to the charge nurse and the maintenance. During an interview on 5/14/2021, at 10:56 a.m., with the EVSS, the EVSS stated that the required minimum water temperature for resident rooms and showers was 105°F and the maximum water temperature was 120°F. The EVSS explained that water temperature checks were conducted to ensure proper temperatures for residents as to prevent accidental burning and uncomfortable bath temperatures. During a concurrent interview and record review on 5/14/2021, at 10:56 a.m., with the EVSS, Maintenance Test Log Daily/Weekly Water Temperature Log was reviewed. The Maintenance Test Log indicated 98°F to 99°F water temperatures for Shower Room 1 from 4/11/2021 to 5/9/2021. The EVSS stated, water temperatures stayed the same in Shower Room 1, and that it had always been around 99°F. EVSS stated that when temperatures were not in required range, he would adjust the water flow from the mixing valve, but it did not work and had previously informed the ADM. During an interview on 5/14/2021, at 11:35 a.m., with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated, restroom sink in Room 118 does not get warm water. She stated that resident in Room 118 prefers bed bath and that she would get warm water from the neighboring room. Upon further investigation and during a facility tour with the EVSS on 5/14/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 1:16 p.m., in Room 118, shared restroom with Room 119, a water temperature reading of 74.7°F was observed after having the water ran for two minutes. In a concurrent interview, the EVSS stated, that the water temperature was not increasing. b. At 1:45 p.m., in Room 105, shared restroom with Room 107, the knob for the hot water faucet fixture was not functioning. A water temperature reading of 65.5°F was observed after running the cold water. In a concurrent interview, the EVSS stated, the faucet fixture was loose, and the hot water cannot be turned on as the knob was stuck. During the daily monitoring with the EVSS on 5/14/2021, the EVSS measured water temperatures in shower rooms by turning the shower handle to the hottest setting and placing a probe thermometer through the running water. The following were observed: a. At 1:04 p.m., in Shower Room 2, a water temperature reading of 104°F and a quick drop to 101°F was observed after having the water ran for five minutes. The EVSS confirmed finding of low water temperature. b. At 1:23 p.m., in Shower Room 1, a water temperature reading of 95.4°F was observed after having the water ran for three minutes. In a concurrent interview, the EVSS stated, that the water temperature was not increasing. During the daily monitoring with the EVSS on 5/15/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 2:07 p.m., in Room 232, shared restroom with Room 230, a water temperature reading of 97.5°F was observed after having the water ran for four minutes. Observed a posted Temporary Out of Service sign, the EVSS confirmed finding. b. At 2:44 p.m., in Room 112, shared restroom with Room 110, a water temperature reading of 87.4°F was observed after having the water ran for four minutes. In a concurrent interview, the EVSS stated, that the water temperature was not increasing. During the daily monitoring with the EVSS on 5/15/2021, the EVSS measured water temperatures in shower rooms by turning the shower handle to the hottest setting and placing a probe thermometer through the running water. The following were observed: a. At 1:46 p.m., in Shower Room 2, a water temperature reading of 84.4°F was observed after having the water ran for two minutes. In a concurrent interview, the EVSS stated that the water temperature was stable at 84°F. b. At 2:22 p.m., in Shower Room 4, a water temperature reading of 89 to 90°F was observed after having the water ran for three minutes. During a concurrent interview, the EVSS stated that the water temperature was not consistent and the valve in the boiler room was causing the problem. c. At 2:57 p.m., in Shower Room 1, a water temperature reading of 79°F was observed after having the water ran for three minutes. In a concurrent interview, the EVSS stated, that the water temperature was not increasing. During an interview on 5/18/2021, at 11:06 a.m., with Plumber 2, he stated that they were changing the valves in Shower Room 1 and that low water temperatures to the shower room and neighboring restroom hand sinks were due to hot and cold water mixing in the pipes. During a concurrent interview and record review on 5/18/2021, at 12:13 p.m., with the ADM, Maintenance Test Log Daily/Weekly Water Temperature Log was reviewed. The Maintenance Test Log indicated 98°F to 102°F water temperatures for Shower Room 1 from 6/23/2020 to 5/14/2021. The ADM stated, the EVSS oversee the water temperature log which he monitors every month. ADM stated that he was not checking if written temperatures were within range. During an interview on 5/18/2021, at 3:44 p.m., with CNA 7, CNA 7 stated, the hot faucet fixture in resident restroom hand sink in Room 105/107 was not working about one week before the out of order sign was posted. During an interview on 5/19/2021, at 8:52 a.m., with the DON, the DON stated, the EVSS had previously mentioned water being too cold in the showers during stand-up meetings attended by facility's Department heads including the ADM. During an observation on 5/19/2021, at 9:29 a.m., in Shower Room 2, the EVSS turned on the shower handle to the hottest setting and placed a probe thermometer through the running water. A water temperature reading of 97°F was observed after having the water ran for five minutes. During a concurrent interview, the EVSS stated that the water temperature was stable at 97°F. During an interview on 5/19/2021, at 9:52 a.m., with the ADM, the ADM stated, the plumbers were working on changing the valves in Shower Room 2. During an observation on 5/19/2021, at 10:36 a.m., in Room 230, shared restroom with Room 232, the EVSS turned on the hot water faucet fixture in the resident restroom hand sink and placed a probe thermometer through the running water. A water temperature reading of 93.6°F was observed after having the water ran for five minutes. The EVSS confirmed finding. A review of 2019 California Plumbing Code, Domestic Hot-Water Distribution Systems for Health Facilities and Clinic s, indicated that temperature control valves shall be provided to automatically regulate the temperature of hot water delivered to plumbing fixtures used by patients to a range of 105°F (41 degree Celsius [C-unit of measure]) minimum to 120°F (49°C) maximum. High temperature alarm set at 125°F (52°C) shall be provided. A review of the facility's Maintenance Service policy, revised on 12/2009, the policy indicated, The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. The document also indicated, Functions of maintenance personnel include, maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, maintain the building in good repair and free from hazards, maintaining the heat/cooling system, plumbing fixtures, and wiring in good working order, and providing routinely scheduled maintenance service to all areas. 3. During an interview on 5/14/2021, at 10:56 a.m., with the EVSS, the EVSS stated that while he was on vacation, Maintenance 1 (M1) was overseeing water temperature checks in the facility. EVSS stated that M1 called off work on 5/10/2021 and 5/11/2021 and water temperature checks were not conducted during those days. A review of the Maintenance Test Log Daily/Weekly Water Temperature Log revealed no water temperature measurements were noted for resident restroom hand sinks, shower rooms, laundry, and kitchen for 5/10/2021 and 5/11/2021. During a review of the facility's Maintenance Service policy, revised on 12/2009 , the policy indicated, the Maintenance Director is responsible for maintaining records/reports of building inspection, work order requests, and maintenance schedules. The document also indicated that records shall be maintained in the Maintenance Director's office. 4. During an interview on 5/14/2021, at 12:33 p.m., with the EVSS, the EVSS stated that the plumber was in the facility the day before. The plumber attempted to adjust water temperature from the mixing valve in the boiler room but was unsuccessful. He stated that the mixing valve does not work, and that the plumber had ordered replacement parts. During an interview on 5/14/2021, at 3:15 p.m., with the ADM, the ADM stated, the plumber was in the facility on 5/13/2021 and had explained to him that the hot and cold water were not mixing properly and that the valves will be replaced. The ADM stated that when the facility had issues with water temperature, the EVSS fixed the temperature by adjusting the water heater temperature or by calling a plumber. During an interview on 5/17/2021, at 2:55 p.m., with the EVSS, the EVSS stated, the plumbers had installed regulating valves in resident restroom hand sinks affected by hot water temperatures. EVSS stated that however, the plumbers did not have the replacement valve for the boiler and was scheduled to return the following day. A review of the facility's Mai

Based on observation, interview, and record review, the facility failed to ensure the boiler (a device providing a hot-water supply) room, shower room, and resident room plumbing equipment were in good working condition that provides safe environment for the residents, staff, and visitors, as indicated in the facility's policies and procedures by failing to: 1. Maintain boiler room mixing valve (valve that blends hot water with cold water to ensure constant and safe temperatures) in safe operating conditions in one of two boiler rooms. 2. Ensure regulating thermostatic (controls temperature of a room by changing the flow of hot water to the radiator) or pressure valves ( safety valve used to control or limit the pressure in a system) were inspected monthly and records retained in the facility. 3. Provide safe water temperatures of less than 121 degrees Fahrenheit (°F [F-unit of measure]) in 12 of 12 resident restroom hand sinks (Rooms 220 to 237) in Station 2 and six of ten resident restroom hand sinks (Rooms 105/107, 109/111, 110/112, 114, 117, 118/119) in Station 1. 4. Ensure two of four shower room valves were in good working condition. 5. Maintain required range of water temperatures (105°F-120°F) in 18 of 22 resident restroom hand sinks and three of four shower rooms (Shower Room 1, Shower Room 2, and Shower Room 4). 6. Ensure hot faucet fixture in one of 22 resident restroom hand sinks (Room 105/107) was in good working condition. 7. Check water temperatures in rooms and showers used by residents and maintain record of water temperature logs for 5/10/2021 and 5/11/2021. These deficient practices had the potential for residents, staff, and visitors to sustain [CONDITION(S)], scalding (injury from very hot liquid or steam), and uncomfortable water temperatures. On 5/15/2021 at 12:53 p.m., an Immediate Jeopardy was called (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) and the facility. The Administrator (ADM), Director of Nursing (DON), and Environmental Services Supervisor (EVSS), were notified of the findings regarding high water temperatures in resident restroom sinks, low water temperatures in resident restroom sinks and shower rooms, malfunctioning valves, and malfunctioning faucet fixture. On 5/19/2021 at 9:11 a.m., the ADM provided an acceptable plan of action (POA) that included the following summarized actions: 1. Immediately identify affected resident restroom sinks and shower rooms to be out of range (outside 105-120°F). 2. Posting of signs in resident restrooms and monitoring of signs twice daily during water temperature checks. 3. Plumber made site assessment, installed local mixing valves at each faucet exceeding 120°F, replace Shower Room 1 mixing valve, and replace main mixing valve in Boiler Room. 4. Replaced faucet in Room 105/107 restroom sink. 5. Skin assessments performed for all residents to ensure no residents were affected by high water temperatures. 6. Resident's primary contacts informed of hot water issues by sharing contents of letter, titled, Memo: Hot Water. 7. Residents were informed of hot water issues in the facility. 8. In-services performed to all staff regarding resident safety during hot water issue. 9. In-services performed to all staff regarding immediate reporting of maintenance issues. Maintenance request binder kept in Nursing Station 1 and 2. 10. Complete Environmental Services (EVS) staff competencies related to facility water temperature maintenance and monitoring. On-going training schedule with EVS staff. 11. Developed an inspection and maintenance plan of essential plumbing equipment (boilers/water heaters and faucet fixtures) and thermostatic or pressure valves on hot water fixtures for EVS staff. New log was established to include annual service, monthly mechanical inspections, and weekly visual inspections. 12. New water temperature log was established to include twice daily readings and verification of temperatures by ADM or designee. Negative findings to be recorded in the comments section. 13. Quality Assurance and Performance Improvement (QAPI) committee performed Root Cause Analysis (RCA) and developed Performance Improvement Plan (PIP). ADM to present any negative findings to QAPI Committee monthly, including quarterly QAPI meetings. On 5/20/2021 at 5:24 p.m., while onsite and after verifying satisfactory implementation of the facility's immediate corrective actions within the POA, the Immediate Jeopardy was lifted in the presence of the ADM, DON, EVSS and facility's Regional Consultant. Findings: 1. During a facility tour with the Environmental Services Supervisor (EVSS) on 5/12/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 3:26 p.m., in Room 233, shared restroom with Room 231, a water temperature reading of 125°F was observed after having the water ran for less than one minute. EVSS confirmed the finding. b. At 3:27 p.m., in Room 226, a water temperature reading of 124.5°F was observed after having the water ran for two minutes. EVSS confirmed the finding. c. At 3:37 p.m., in Room 221, a water temperature reading of 135°F was observed after having the water ran for one minute. EVSS confirmed the finding. d. At 3:39 p.m., in Room 118, shared restroom with Room 119, a water temperature reading of 93.4°F was observed after having it ran for five minutes. In a concurrent interview, the EVSS stated, the hot water temperature was very slowly going up. During a facility tour with the Environmental Services Supervisor (EVSS) on 5/12/2021, the EVSS measured water temperatures in the shower rooms by turning the shower handle to the hottest setting and placing a probe thermometer through the running water. The following were observed: a. At 3:30 p.m., in Shower Room 2, a water temperature reading of 102.5°F was observed after having it ran for six minutes. In a concurrent interview, the EVSS stated, the water temperature fluctuates and confirmed the low water temperature. The EVSS explained that there are two boilers designated to provide hot water for the resident rooms and the shower rooms. b. At 3:50 p.m., in Shower Room 1, a water temperature reading of 88°F to 93°F was observed after having it ran for four minutes. In a concurrent interview, the EVSS stated, that the water temperature fluctuates and confirmed the low water temperature. During an interview on 5/12/2021, at 4:39 p.m., with the ADM, the ADM stated, the water temperature should be in between 105°F to 115°F in resident rooms and in the showers. The ADM also stated that a 135°F water temperature in a resident restroom hand sink was too hot and that it can burn someone. The ADM added, he must figure out which water heaters were allocated to which rooms and showers, have the plumber visit the facility the following day, and have the plumber make adjustments as there was a big discrepancy in the water temperatures. During an interview on 5/14/2021, at 12:33 p.m., with the EVSS, the EVSS stated that the plumber was in the facility the day before. The plumber attempted to adjust water temperature from the mixing valve in the boiler room but was unsuccessful. He stated that the mixing valve does not work, and that the plumber had ordered replacement parts. During an interview on 5/14/2021, at 3:15 p.m., with the ADM, the ADM stated, the plumber was in the facility on 5/13/2021 and had explained to him that the hot and cold water were not mixing properly and that the valves needed to be replaced. During an interview on 5/17/2021, at 2:55 p.m., with the EVSS, the EVSS stated, the plumbers had installed regulating valves in resident restroom hand sinks affected by hot water temperatures. EVSS stated that however, the plumbers did not have the replacement valve for the boiler and was scheduled to return the following day. A review of the facility's Maintenance Service policy, revised on 12/2009, the policy indicated, The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. The document also indicated, Functions of maintenance personnel include, maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, maintain the building in good repair and free from hazards, maintaining the heat/cooling system, plumbing fixtures, and wiring in good working order, and providing routinely scheduled maintenance service to all areas. The Maintenance procedures also indicated monthly check of regulating thermostatic or pressure valves on hot water fixtures in rooms used by residents including: a. Repair if valve is defective. b. Take extreme caution to ensure that hot water pressure and temperature remain constant. A review of facility's Maintenance Invoice dated 5/13/2021, indicated that the company had ordered mixing valve with a scheduled return for Monday, 5/17/2021, for repair. A review of 2019 California Plumbing Code, Domestic Hot-Water Distribution Systems for Health Facilities and Clinics, indicated that temperature control valves shall be provided to automatically regulate the temperature of hot water delivered to plumbing fixtures used by patients to a range of 105°F minimum to 120°F maximum. High temperature alarm set at 125°F shall be provided and audible/visual device for the high temperature alarm shall annunciate at a continuously occupied location. 2. During an interview on 5/18/2021, at 12:13 p.m., with the ADM, the ADM stated that there were no records of maintenance schedule or inspection records for boiler room equipment, and that there were also no records of monthly checks of thermostatic or pressure valves per facility's policies and procedures. The ADM further stated that these inspections were not being conducted, and that he will create a plan after consulting with the plumber During a review of the facility's Maintenance Service policy, revised on 12/2009, the policy indicated, the Maintenance Director is responsible for maintaining records/reports of building inspection, work order requests, and maintenance schedules. The document also indicated that records shall be maintained in the Maintenance Director's office. A review of the facility's Maintenance procedures with an effective date of 4/2018, indicated monthly check of regulating thermostatic or pressure valves on hot water fixtures in rooms used by residents including: a. Repair if valve is defective. b. Take extreme caution to ensure that hot water pressure and temperature remain constant. 3. During a facility tour with the EVSS on 5/12/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 3:26 p.m., in Room 233, shared restroom with Room 231, a water temperature reading of 125°F was observed after having the water ran for less than one minute. The EVSS confirmed the finding. b. At 3:27 p.m., in Room 226, a water temperature reading of 124.5°F was observed after having the water ran for two minutes. The EVSS confirmed the finding. c. At 3:37 p.m., in Room 221, a water temperature reading of 135°F was observed after having the water ran for one minute. The EVSS confirmed the finding. During a concurrent observation and interview on 5/12/2021, at 3:57 p.m., with the EVSS, a temperature gauge for a water heater storage tank was observed registering at 142°F in the boiler room. The EVSS stated that the water heater storage tank serves water to the resident's rooms and showers. EVSS stated that he does not know which boiler and tanks serves which parts of the facility. When asked where the temperature dial control or thermostat was located for the boilers, the EVSS answered, the equipment was old and that he does not know if the boiler had one. During an interview on 5/12/2021, at 4:39 p.m., with the ADM, the ADM stated that 135°F water temperature in resident restroom hand sink (Room 221) was too hot and that it can burn someone. The ADM added, he must figure out which water heaters were allocated to which rooms and showers, to have the plumber visit the facility, and make adjustments as there was a big discrepancy in the temperature. During an interview on 5/14/2021, at 10:17 a.m., with Certified Nursing Assistant 5 (CNA 5) , CNA 5 stated that for many years the facility had issues with water temperature and that he had seen plumbers in the facility. CNA 5 also stated, in some rooms, when hot water was left running for few minutes, the water would continue to get hot. During an interview on 5/14/2021, at 10:56 a.m., with the EVSS, the EVSS stated that the required minimum water temperature for resident rooms and showers was 105°F and the maximum water temperature was 120°F. The EVSS explained that water checks were conducted to ensure proper temperatures for residents as to prevent accidental burning and uncomfortable bath temperatures. Upon further investigation and during a facility tour with the EVSS on 5/14/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 12:36 p.m., in Room 237, shared restroom with Room 235, a water temperature reading of 127°F was observed after having the water ran for two minutes. The EVSS confirmed finding. b. At 12:38 p.m., in Room 236, shared restroom with Room 234, a water temperature reading of 131.2°F was observed after having the water ran for three minutes. The EVSS confirmed finding. c. At 12:42 p.m., in Room 233, shared restroom with Room 231, a water temperature reading of 134.6°F was observed after having the water ran for less than one minute. The EVSS confirmed finding. d. At 12:44 p.m., in Room 232, shared restroom with Room 230, a water temperature reading of 127.9°F was observed after having the water ran for five minutes. The EVSS confirmed finding. e. At 12:50 p.m., in Room 229, a water temperature reading of 135°F was observed after having the water ran for one minute. The EVSS confirmed finding. f. At 12:52 p.m., in Room 228, shared restroom with Room 227, a water temperature reading of 131.7°F was observed after having the water ran for five minutes. The EVSS confirmed finding. g. At 12:57 p.m., in Room 226, a water temperature reading of 134.2°F was observed after having the water ran for four minutes. The EVSS confirmed finding. h. At 1:01 p.m., in Room 225, shared restroom with Room 224, a water temperature reading of 135°F was observed after having the water ran for two minutes. The EVSS confirmed finding. i. At 1:10 p.m., in Room 222, a water temperature reading of 139.5°F was observed after having the water ran for one minute. The EVSS confirmed finding. j. At 1:11 p.m., in Room 221, a water temperature reading of 136.4°F was observed after having the water ran for two minutes. The EVSS confirmed finding. k. At 1:14 p.m., in Room 220, a water temperature reading of 138.7°F was observed after having the water ran for one minute. The EVSS confirmed finding. During an interview on 5/14/2021, at 3:15 p.m., with the ADM, when asked what can happen to residents or staff when water temperature was more than 120°F, the ADM answered, Depending on the temperature, it could burn and At the minimum it could be discomfort. During the daily monitoring with the EVSS on 5/15/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 10:01 a.m., in Room 229, a water temperature reading of 127.6°F was observed after having the water ran for three minutes. The EVSS confirmed finding. b. At 10:06 a.m., in Room 222, a water temperature reading of 142.9°F was observed after having the water ran for one minute. EVSS confirmed finding. c. At 10:08 a.m., in Room 221, a water temperature reading of 142°F was observed after having the water ran for one minute. The EVSS confirmed finding. d. At 10:13 a.m., in Room 220, a water temperature reading of 142.2°F was observed after having the water ran for less than one minute. During a concurrent interview, the EVSS stated, that the water reached a high temperature level quickly. e. At 1:49 p.m., in Room 223, a water temperature reading of 129.6°F was observed after having the water ran for five minutes. The EVSS confirmed finding. f. At 2:34 p.m., in Room 227, shared restroom with Room 228, a water temperature reading of 128.8°F was observed after having the water ran for four minutes. The EVSS confirmed finding. During a concurrent observation and interview on 5/15/2021, at 10:16 a.m., with the EVSS, temperature gauges for two water heater tanks serving resident rooms and showers were observed registering at 140°F and 130°F in the boiler room. The EVSS stated that he does not know another way to lower the water temperature other than adjusting the mixing valve. The EVSS added, he's not a professional plumber. During a concurrent observation and interview on 5/16/2021, at 3:15 p.m., with the EVSS, a temperature control dial for one of the water heater tanks was observed in the boiler room. The EVSS took off the dial cover and revealed registered temperature of 145°F. When asked if it was possible for the dial to be adjusted to a lower temperature setting, the EVSS stated, he was not comfortable doing that as he was worried he might cause something to go wrong with the system. A review of the Maintenance Test Log Daily/Weekly Water Temperature Log indicated hot water temperatures ranging from 125°F to 139°F for ten of 22 resident restroom hand sinks (in Rooms 220 to 228, 231 to 237) on 5/16/2021 morning check. During the daily monitoring with the EVSS on 5/17/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 3:25 p.m., in Room 234, shared restroom with Room 236, a water temperature reading of 124.5°F was observed after having the water ran for four minutes. The EVSS confirmed finding. b. At 3:30 p.m., in Room 231, shared restroom with Room 233, a water temperature reading of 128.5°F was observed after having the water ran for two minutes. The EVSS confirmed finding. c. At 3:35 p.m., in Room 230, shared restroom with Room 232, a water temperature reading of 123.3°F was observed after having the water ran for four minutes. The EVSS confirmed finding. During the daily monitoring with the EVSS on 5/19/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 10:54 a.m., in Room 118, shared restroom with Room 119, a water temperature reading of 127.6°F was observed after having the water ran for two minutes. The EVSS confirmed findings. In a concurrent interview, the EVSS stated, that there was no regulating valve installed under the sinks in Station 1. b. At 10:58 a.m., in Room 117, a water temperature reading of 124.5°F was observed after having the water ran for three minutes. The EVSS confirmed findings. c. At 11:37 a.m., in Room 114, a water temperature reading of 122°F was observed after having the water ran for eight minutes. The EVSS confirmed findings. d. At 1:45 p.m., in Room 105, shared restroom with Room 107, hot water faucet handle was not functioning. A water temperature reading of 65.5°F was observed after running the cold water. In a concurrent interview, the EVSS stated, the faucet fixture was loose, and the hot water cannot be turned on as the handle was stuck. During an interview on 5/20/2021, at 12:12 p.m., with the ADM, the ADM stated, six resident restroom hand sinks were out of range on 5/19/2021 (Rooms 105/107, 109/111, 110/112, 114, 117 and 118/119) with high water temperatures ranging from 121°F to 124°F. A review of the facility's Maintenance procedures with an effective date of 4/2018, indicated for daily water temperature checks in rooms used by residents (e.g. bathrooms, showers, etc.) including: a. Periodic check of different rooms to ensure hot water used by residents is heating to 105-115°F (or applicable requirement). b. Set thermostats on boilers or hot water heaters to obtain the required temperature. c. Check pilot lights daily or whenever the water temperature drops. d. Re-light the boiler according to posted instructions. A review of the Centers for Disease Control (CDC) document titled, Nonfatal Scald-Related [CONDITION(S)] Among Adults Aged ?[AGE] years --- United States, 2001-2006 dated 9/18/2009, the document indicated that an estimated 51,700 initial visits to emergency departments (EDs) by persons aged [AGE] years or older for nonfatal scald [CONDITION(S)] occurred during 2001 to 2006, for an average of 8,620 visits per year. The highest estimated annual numbers of ED visits were for scald [CONDITION(S)] to the arm/hand and leg/foot, and the highest number of ED visits were for scald [CONDITION(S)] caused by hot food, hot water, or steam. A review of the American Burn Association (ABA) document titled, Scald Statistics and Data Resources, dated 8/13/2018, indicated the following: a. While the proportionate rate of scald burn injuries in older adults is comparable to all others greater than [AGE] years old, the risk of complications (a marker of morbidity) and mortality increases. Scald [CONDITION(S)] to adults [AGE] years and older frequently result in loss of independence. b. It only takes 3 seconds of exposure to 140°F water to cause a burn serious enough to require surgery A review of the American Burn Association (ABA) document titled, Scald Injury Prevention Educator's Guide (undated), indicated the following: a. Although scald [CONDITION(S)] can happen to anyone, young children, older adults, and people with disabilities are the most likely to incur such injuries. b. Older adults have thinner skin so hot liquids cause deeper [CONDITION(S)] with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. c. Individuals who may have physical, mental, or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgment, or awareness may hinder the person's ability to recognize a dangerous situation or respond appropriately to remove themselves from danger. d. Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. e. Time and Temperature Relationship to Severe [CONDITION(S)]: i. Water temperature of 155°F takes one second for a third degree burn to occur. ii. Water temperature of 148°F takes two seconds for a third degree burn to occur. iii. Water temperature of 140°F takes five seconds for a third degree burn to occur. iv. Water temperature of 133°F takes 15 seconds for a third degree burn to occur. v. Water temperature of 127°F takes one minute for a third degree burn to occur. vi. Water temperature of 124°F takes three minutes for a third degree burn to occur. vii. Water temperature of 120°F takes five minutes for a third degree burn to occur. A review of the Centers for Disease Control (CDC) document titled, [CONDITION(S)] (undated), indicated the following types of [CONDITION(S)]: a. First-degree [CONDITION(S)] involve the top layer of skin. Sunburn is a first-degree burn. These may present as red and painful to touch, and the skin will show mild swelling. b. Second-degree [CONDITION(S)] involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. c. Third-degree [CONDITION(S)] penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree [CONDITION(S)] surrounding third-degree [CONDITION(S)]), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. 4. During observations in Shower Room 1 with the EVSS, the following was observed: a. On 5/12/2021, at 3:50 p.m., a water temperature reading of 88°F to 93°F was observed after having the water ran for four minutes. In a concurrent interview, the EVSS stated that the water temperature fluctuates and confirmed the low water temperature. b. On 5/14/2021, at 1:23 p.m., a water temperature reading of 95.4°F was observed after having the water ran for three minutes. In a concurrent interview, the EVSS stated that the water temperature was not increasing. c. On 5/15/2021, at 2:57 p.m., a water temperature reading of 79°F was observed after having the water ran for three minutes. In a concurrent interview, the EVSS stated that the water temperature was not increasing. During observations in Shower Room 2 with the EVSS, the following was observed: a. On 5/12/2021, at 3:30 p.m., a water temperature reading of 102.5°F was observed after having the water ran for six minutes. In a concurrent interview, the EVSS stated, the water temperature fluctuates and that It's taking long, they're never like that. b. On 5/14/2021, at 1:04 p.m., a water temperature reading of 104°F and a quick drop to 101°F was observed after having the water ran for five minutes. The EVSS confirmed finding. c. On 5/15/2021, at 1:46 p.m., a water temperature reading of 84.4°F was observed after having the water ran for two minutes. In a concurrent interview, the EVSS stated that the water temperature was stable at 84°F. During a concurrent interview and record review on 5/14/2021, at 10:56 a.m., with the EVSS, Maintenance Test Log Daily/Weekly Water Temperature Log was reviewed. The Maintenance Test Log indicated 98°F to 99°F water temperatures for Shower Room 1 from 4/11/2021 to 5/9/2021. The EVSS stated, water temperatures stayed the same in Shower Room 1, it had always been around 99°F. EVSS stated that when temperatures were not in required range, he would adjust the water flow from the mixing valve, but the valve was not working, and had informed the ADM. A review of the facility's Maintenance Service policy, revised on 12/2009, the policy indicated, The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. The document also indicated, Functions of maintenance personnel include, maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, maintain the building in good repair and free from hazards, maintaining the heat/cooling system, plumbing fixtures, and wiring in good working order, and providing routinely scheduled maintenance service to all areas. A review of the 2019 International Plumbing code indicated that individual shower and tub-shower combination valves shall be balanced-pressure, thermostatic or combination balanced-pressure/thermostatic valves and shall be installed at the point of use. Shower and tub-shower combination valves shall be equipped with a means to limit the maximum setting of the valve to 120°F (49°C), which shall be field adjusted in accordance with the manufacturer's instructions. 5. During an interview on 5/12/2021, at 3:17 p.m., with the EVSS, EVSS stated, water temperature in resident rooms and in the showers should be 110°F to 112°F on average. During a concurrent observation and interview on 5/12/2021, At 3:39 p.m., in Room 118, shared restroom with Room 119, the EVSS measured water temperature by turning on the hot water faucet fixture in the resident restroom hand sink and placing a probe thermometer through the running water. A water temperature reading of 93.4°F was observed after having the water ran for five minutes. The EVSS confirmed the finding. During a facility tour with the EVSS on 5/12/2021, the EVSS measured water temperatures in shower rooms by turning the shower handle to the hottest setting and placing a probe thermometer through the running water. The following were observed: a. At 3:30 p.m., in Shower Room 2, a water temperature reading of 102.5°F was observed after having the water ran for six minutes. In a concurrent interview, the EVSS stated, the water temperature fluctuates and confirmed the finding of low water temperature. b. At 3:50 p.m., in Shower Room 1, a water temperature reading of 88°F to 93°F was observed after having the water ran for four minutes. In a concurrent interview, the EVSS stated, that the water temperature fluctuates and that confirmed the finding of low water temperature. During an interview on 5/14/2021, at 10:56 a.m., with the EVSS, the EVSS stated that the required minimum water temperature for resident rooms and showers was 105°F and the maximum water temperature was 120°F. The EVSS explained that water temperature checks were conducted to ensure proper temperatures for residents as to prevent accidental burning and uncomfortable bath temperatures. During a concurrent interview and record review on 5/14/2021, at 10:56 a.m., with the EVSS, Maintenance Test Log Daily/Weekly Water Temperature Log was reviewed. The Maintenance Test Log indicated 98°F to 99°F water temperatures for Shower Room 1 from 4/11/2021 to 5/9/2021. The EVSS stated, water temperatures stayed the same in Shower Room 1, and that it had always been around 99°F. EVSS stated that when temperatures were not in required range, he would adjust the water flow from the mixing valve, but it did not work and had informed the ADM. Upon further investigation and during a facility tour with the EVSS on 5/14/2021, the EVSS measured water temperatures by turning on the hot water faucet fixture in resident restroom hand sinks and placing a probe thermometer through the running water. The following were observed: a. At 1:16 p.m., in Room 118, shared restroom with Room 119, a water temperature reading of 74.7°F was observed after having the water ran for two minutes. In a concurrent interview, the EVSS stated, that the water temperature was not increasing. b. At 1:45 p.m., in Room 105, shared restroom with Room 107, the knob for the hot water faucet fixture was not functioning. A water temperature reading of 65.5°F was observed after running the cold water. In a concurrent interview, the EVSS stated, the faucet fixture was loose, and the hot water cannot be turned on as the knob was stuck. During the daily monitoring with the EVSS on 5/14/2021, the EVSS measured water temperatures in shower rooms by turning the shower handle to the hottest setting and placing a probe thermometer through the running water. The following were observed: a. At 1:04 p.m., in Shower Room 2, a water temperature reading of 104°F and a quick drop to 101°F was observed after having the water ran for five minutes. The EVSS confirmed finding of low water temperature. b. At 1:23 p.m., in Shower Room 1, a water temperature reading of 95.4°F was observed after having the water ran for three minutes. In a concurrent interview, the EVSS stated, that the water temperature was not increasing. During the daily monitoring with the

On (MONTH) 18, 2019, a complaint investigation was investigated. Based on interview and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 1), who was assessed at risk for falls and identified to have pressure/sensor pad alarm (a device that alerts someone that a resident weight is lifted from a bed or wheelchair), received appropriate care to prevent accidents, including: 1. Failure to implement fall prevention interventions specifically for mattress edge bolster (a long, thick pillow that is placed for support) 2. Failure to reassess the resident for risk for falls after the second fall (June 30, (YEAR)) per facility policy 3. Failure to ensure pressure/sensor (a battery powered device intended to be used to alert you with an alarm when a resident attempts to leave their bed, chair, or wheelchair) alarm was working properly. This resulted in Resident 1 having 3 fall incidents including a fall with fracture on (MONTH) 04, (YEAR), Resident 1 was transferred to a General Acute Care Hospital (GACH) on (MONTH) 13, (YEAR), and was diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record (Face Sheet), indicated the resident was initially admitted to the facility on (MONTH) 23, 2012 and readmitted on (MONTH) 8, 2012. Resident 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care screening tool), dated (MONTH) 26, (YEAR), indicated the resident's cognitive (mental action or process acquiring knowledge and understanding) skills for daily decision-making were severely impaired. The MDS indicated that Resident 1 required extensive assistance from staff for moving in bed, dressing, eating, toilet use, personal hygiene, and total dependence for transferring. The MDS also indicated Resident had no history of fall since admission. A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's Risk for Fall Care Plan, initiated on (MONTH) 1, (YEAR) and revised on (MONTH) 3, (YEAR), indicated anticipate and meet the Resident's needs, assist with 2 persons assist during transfer, call light within reach and answer promptly, and keep environment free of hazards. A review of Resident 1's Fall Risk Assessment, dated (MONTH) 1, (YEAR) at 11:02 p.m , indicated the following: 1. History of falls within last 6 months: No history 2. Confined to a chair- if Resident cannot walk; even when assisted by staff they are: Confined to a chair and disoriented. 3. Based on answers to questions 2-11, is resident at risk for falls? Yes A review of Resident 1's Change in Condition Evaluation dated (MONTH) 12, (YEAR), at 1:00 a.m., indicated CNA 1 asked CNA 2 where the Resident 1 was, resident was not in bed. Both CNAs found Resident 1 on the floor. CNA 2 called for assistance. No injuries noted Family and physician made aware of fall incident. A review of Physical Therapy (PT) Evaluation & Plan of care date (MONTH) 14, (YEAR), indicated the following: Resident 1 was referred for skilled PT evaluation by nursing secondary post (after) fall. PT recommended mattress edge bolster (a long, thick pillow that is placed for support) to reduce risk for fall from bed. A review of Resident 1's status [REDACTED]. During an interview and Resident 1's record review with the Director of Nursing, on (MONTH) 26, 2019, at 11:14 a.m., no documentation that low bed with bolster were implemented. She further stated that because the facility was going through a transition from paper charting to computer charting the care plan's intervention for bolsters were missed. This intervention should have been placed on the Medication Administration Record [REDACTED]. A review of Resident 1's Fall Risk Assessment S/P (post) fall, dated (MONTH) 12, (YEAR) at 8:57 a.m., indicated the following: 1. History of falls within the last six months: No History 2. Confined to a chair- if Resident cannot walk; even when assisted by staff they are: Not Applicable 3. Risk Determination- Bases in the answers to questions 2-1, is the resident at risk for falls? - No During an interview with Registered Nurse 1 (RN 1), on (MONTH) 18, 2019, at 9:00 a.m., when asked about the discrepancy of the Fall Risk assessment documented on (MONTH) 1, (YEAR) and the Fall Risk assessment done on (MONTH) 12, (YEAR) RN 1 stated that it was not correctly, night shift nurses do not really know the Residents well. b. A review of Resident 1's Change in Condition dated (MONTH) 30, (YEAR), at 1:00 a.m., Resident 1 was found by CNA 3, sitting on the floor beside her bed on the right side. No injuries were noted. Family and physician made aware. A review Resident 1's physician's orders [REDACTED]. A review of Resident 1's Order Summery Report, order date (MONTH) 30, (YEAR), indicated sensor pad alarm while in bed to alert staff of un-assisted transferred. Monitor for function and placement. A review of Resident 1's care plan dated (MONTH) 30, 2019, s/p Fall from low bed (found resident sitting on the floor right side if her bed), indicated LALM (Low Air Loss Mattress) with side bolster to minimize injury from rolling out of bed. A review of Resident 1's MAR for the month of (MONTH) indicated missing initials for Low Air Loss Mattress for skin maintenance with side bolster once available to minimize injury from rolling out of bed on the following dates (MONTH) 1, (YEAR) 11-7/7-3 shift), (MONTH) 2, (YEAR) (3-11 shift), (MONTH) 5, (YEAR) (3-11 shift), (MONTH) 6, (YEAR) (3-11 shift), (MONTH) 7, (YEAR) (7-3/3-11 shift), (MONTH) 12, (YEAR) (3-11 shift), (MONTH) 15, (YEAR) (11-7 shift), (MONTH) 16, (YEAR) (3-11 shift). During an interview with the RN 1, on (MONTH) 18, 2019, at 10:15 a.m , he stated that since there is no initials on these dates and shift that means the nurses did not check to see if there were bolsters on the Resident's bed. He continued to state that this Resident has a history of falling so the nurses should have made sure that these bolsters were in place to prevent her from falling again. During an interview with RN 1, on (MONTH) 18, 2019, 2:30 p.m , he reviewed the clinical record and was unable to find documentation for a fall re-assessment after the second fall. RN 1 continued to state that a re-assessment should have been done as part of the facility policy. The facility policy and procedure titled Assessing Falls and Their Causes, revised (MONTH) 2010, indicated when a resident falls, the following should be recorded in the resident's medical record: completion of a falls risk assessment. c. A review of Resident 1's Change in Condition Evaluation dated (MONTH) 4, (YEAR), at 1:45 p.m , indicated Resident 1 was found sitting on the top of landing pad with her back against the bed facing toward the door. Resident did not have any pain. No injuries noted. Family and physician made aware. On (MONTH) 18, 2019, at 3:15 p.m., during an interview, Director of Staff Development (DSD) stated while making rounds on (MONTH) 4, (YEAR) at around lunch time, Resident 1 was found sitting on the floor by her bed with her right arm on the bed. When asked if DSD heard an alarm went off, DSD stated that he did not hear any alarm, however he saw the pad alarm on the bed. He continued to state that he did not hear an alarm go off while the resident was sitting on the floor. DSD further stated, the alarm should have gone off. A review of Resident 1's Change in Condition Evaluation dated (MONTH) 11, (YEAR), at 6:00 a.m , indicated upon care Resident complained of pain on the left leg. Family and physician made aware with new orders. A review of Resident 1's physician's orders [REDACTED].m , indicated X-ray on left knee for pain. A review of Resident 1's Radiology Results Report dated (MONTH) 11, (YEAR), at 2:00 p.m , indicated that there was no evidence of acute fracture (broken bone). A review of Resident 1's Facility Progress Notes dated (MONTH) 13, (YEAR), a 3:21 p.m , indicated at 7:30 a.m. Resident 1 complained of pain on left leg when moved. No swelling or discoloration was observed. Pain medication was given. At 3:00 p.m , physician was notified that x-rays have not been done and that Resident 1's pain continued and is has not subsided. LVN 2 received orders to transfer Resident 1 to GACH for further evaluation. A review of Resident 1's GACH records dated (MONTH) 13, (YEAR), at 4:20 p.m., indicated emergency department provider notes: one view left hip x-ray: Fracture (broken) to the proximal femur (thigh bone). The note continued to state that Resident 1 has a fracture of proximal left femur on x-ray. Resident 1 will be admitted and will have an orthopedic (bone) consultation. A review of Resident 1's GACH records dated (MONTH) 13, (YEAR) at 6:04 p.m., indicated left lower extremity was bent at the knee and rotated outwards. The left lower extremity is shorter than the right. The note continued to state the left hip is painful to palpation. A review of Resident 1's GACH records titled Operative Report, indicated date of surgery to be on (MONTH) 15, (YEAR). A review of Resident 1's GACH records titled Death Summary, dated (MONTH) 20, (YEAR) at 4:13 p.m., indicated date of death (MONTH) 17, (YEAR) A review of Resident 1's Death certificate dated (MONTH) 24, (YEAR) indicated immediate cause of death: Femoral Fracture. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), indicated describe the served that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. A review of the facility's policy and procedure titled Assessing Falls and Their Causes, dated (MONTH) 2010, indicated when a resident falls, the following information should be recorded in the resident's medical record: completion of a fall risk assessment. A review of the facility's policy and procedure titled Tab alarm, Bed alarm, Wander Systems, dated (MONTH) 2012, indicated bed alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident' care plan that the resident is at risk for falls.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to: 1. Store food in a safe manner when using a malfunctioning freezer and not monitoring the freezer temperature. 2. Ensure the two-sink compartment for manual dishwashing was used according to the facility's policy and procedures to ensure disinfection of washed dishes. 3. Ensure the dry food was stored at temperatures that maintained food quality, nutrient content, and control of bacterial growth. 4. Ensure safe thawing procedures were followed as indicated in the facility's policy. As a result, the total census of 90 residents was placed at risk of foodborne illness (Food poisoning is a general term for health problems caused by eating contaminated food), 87 residents received oral diets and three residents received tube feeding (A means of providing nutrition via a feeding tube inserted into the gastrointestinal tract) but were administered water from water pitchers washed in the kitchen. Nursing home residents risk serious complications from food borne illness as a result of their compromised health status. Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. The beef and dairy products (ice cream) are considered time/temperature control for safety foods (formerly called potentially hazardous foods) and were stored in the food danger zone. The food danger zone refers to temperatures above 41 Fahrenheit (°F) and below 135°F that allow the rapid growth of disease causing microorganisms that can cause foodborne illness. Foods held in the danger zone for more than six hours (if cooked and cooled) may cause a foodborne illness if consumed (Center for Medicare and Medicaid, State Operations Manual). An immediate jeopardy (A situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called on August 21, 2017, at 7:20 p.m. The facility's Administrator and Director of Nurses were notified of the immediate jeopardy situation. An acceptable plan of correction (P(NAME)) was received on August 22, 2017 at 8:00 a.m., and was validated through observation, interview and record review to verify compliance. The acceptable P(NAME) included: - Dietary staff discarded all of the food items in the freezer. - Freezer and refrigerator consistently hold proper temperature by maintaining temperature log and communicating abnormalities via chain of command. Dietary staff able to describe, and demonstrate proper reading and logging of refrigerator, freezer, storage and water temperature - and exhibit understanding of hazards related to improper temperature, infection/cross contamination and related resident risk factors. - Replace/repaired exhaust fan and water heater to ensure 70 degrees Fahrenheit in kitchen is maintained. - Dietary staff able to describe and demonstrate proper thawing procedure and exhibit understanding of hazards to improper thawing and related resident risk factors. - Dietary staff able to describe and demonstrate proper manual dishwashing procedure for 2-compartment sink - 3 step method - and exhibit understanding related to improper dishwashing and related resident risk factors. The immediate jeopardy was removed on August 24, 2017 at 1:57 p.m., when the facility repaired/replaced equipment, was able to demonstrate knowledge of proper temperatures, thawing procedure, manual dishwashing procedures and appropriate chain of communication. Findings: 1. On August 21, 2017, from 12:25 p.m. to 2:27 p.m., during the initial kitchen observation with the Dietary Service Supervisor (DSS) and Dietary Aide 1 (DA 1), the freezer external liquid crystal display (LCD) panel temperature had a reading indicating Def for defrost. The freezer reading of a thermometer located inside the freezer read over 70°F. At 2:15 p.m., the external LCD panel thermometer had a reading of 35°F. The inside freezer mechanical temperature was greater than 70°F. The freezer contents were as follows: - There were several boxes of three ounces (oz.) ice cream cups of multiple flavors with temperatures ranging from 22°F to 47.8°F. The boxes label indicated to keep frozen from -10°F to -20°F. - Two three-gallon containers of ice cream with a temperature of 41.9°F and 45.7°F. - A10-pound bag of boneless and skinless chicken leg meat with a temperature of 23.2°F. - A five-pound bag of whole chicken legs with a temperature of 23.9°F. - A 10-pound bag of boneless chicken with a temperature of 23.5°F. - Four boxes of chicken with temperatures ranging from 21.2°F to 28.4°F. - A 10-pound pork in a box with a temperature of 20.8°F. - Two packs of hash browns with 10 patties each inside with temperature ranging from 52.7°F to 54.1°F. - Two five-pound mechanically separated turkey with temperature of 28.9°F and 37.4°F. - A two-pound bag and a four-pack bag of two-pound sliced oven roasted turkey breast with temperature ranging from 46.9°F of 48.2°F. - A box of 10-pound of steak opened on June 6, 2017 with a temperature of 50.2°F. - A 16-inch cheese pizza with nine counts/pieces with 42 oz. each in a box had a temperature of 43.7°F. The pizza box indicated keep frozen. - A 12-pound bag of sliced turkey bologna with a temperature of 44.4°F. - A five-pound bag of cookie dough with a temperature of 50.2°F. The bottom of the freezer was soaked with unknown red liquid mixed with white and yellow liquid. A review of the freezer temperature log for the month of August 2017, indicated on August 20, 2017 and August 21, 2017, the log was blank. The last time the temperature was checked was on August 19, 2017, at 6 p.m. with a temperature of -2°F. On August 21, 2017, at 12:45 p.m., during an interview, the Environmental Services Director (ESD) stated yesterday (August 20, 2017) at approximately 1:30 p.m., the vents in the freezer got frozen, he cleaned them, and the freezer was working. The ESD stated he did not take the temperature of the freezer. Today (August 21, 2017), at 8 a.m., the freezer was in defrosted mode and he called the technician. On August 21, 2017, at 1:10 p.m., during observation and concurrent interview, Cook 1 took two hamburger patties from the freezer and explained a resident wanted to have a hamburger. Cook 1 took the patties temperatures, one was 48.2°F and the other was 63.1°F and proceeded to cook the hamburger on the stove top. On August 21, 2017, at 2:15 p.m., during an interview, DA 1 stated Cook 1 was responsible to check the refrigerator and freezer temperatures. On August 21, 2017, at 2:20 p.m., during an interview, Cook 1 stated the day prior (Sunday, August 20, 2017), the freezer was not working, she did not log the daily temperature because the freezer was broken, and she informed the DSS of the broken freezer. Cook 1 also stated the broken freezer was the only freezer in the facility. When asked how she checked the temperature of the freezer, Cook 1 stated she looks at the outside and the inside thermometers. When asked what the external reading of the freezer was, she stated it was 35.5°F (when it read Def). On August 21, 2017, at 2:25 p.m., during an interview, the DSS stated she did not inform the Administrator regarding the malfunctioning freezer. On August 21, 2017, at 4 p.m., during an interview with the Administrator, he stated he was not aware of the problem with the freezer. According to the Food Code U.S. Public Health Service (U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration 2013), indicated under food temperature control, frozen food is solid to the touch. The freezer equipment should be designed and maintained to keep foods in the frozen state. Corrective action should be taken if the storage or display unit loses power or otherwise fails. Raw or ready-to-eat foods or commercially processed bulk-pack food that is packaged on-site presents a greater risk of cross-contamination. Additional product handling, drippage during the freezing process, partial thawing or incomplete seals on the package increase the risk of cross-contamination from these products packaged in-house. Under parasite destruction on freezing, except as specified in the paragraph of this section, before service or sale in ready-to-eat form, raw-marinated, partially cooked, or marinated-partially cooked fish shall be frozen and stored at a temperature of -20°C (-4°F) or below for a minimum of 168 hours (seven days) in a freezer. The facility's undated policy and procedure titled Procedure for Freezer Storage, indicated frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0°F to -10°F. Freezer temperatures should be recorded twice daily. Temperatures are to be recorded upon opening and closing of kitchen by a designated employee and logged in the Sanitation Section, page 8.3. All frozen food should be labeled and dated. Frozen food should be left in the refrigerator to thaw. 2. On August 22, 2017, at 11 a.m., during an observation accompanied by the DSS, DA 4 and DA 1 were manually washing the plate covers in a two-compartment sink. DA 4 got hot water, using a bucket, from the faucet of the other compartment sink which was used for raw food. DA 4 explained there was no hot water coming out from the faucet at one side of the sink because the plumber turned the water off while working on the heater. The plate covers were placed first in the sink then the hot water was placed gradually. The temperature of the hot water from the faucet was 135°F. DA 1 put soap on the plate covers, then put them in the other sink which had sanitizer with water but the level was low and did not cover the plate covers; the plate covers were floating and not submerged in the water with sanitizer. Then, without rinsing, the plate covers were placed in the dish rack. When DA 4 performed the chlorine testing, he dipped the testing strip in the solution of water and not on the dish surface. The result was 200 parts per million (ppm). The plate covers were not rinsed with hot water. A review of the Dish Machine Temperature and Sanitizing Agent Log dated August 2017 indicated the type of dishwashing machine was a low/energy saver machine with a minimum sanitizing agent of 50 ppm. The required temperature for the low temperature machine was 120-140°F and the rinse was no less than 120°F. On August 22, 2017, at 11:15 a.m., during an interview with DA 1, he stated the strip test for chlorine should have been dipped on the dish and not on the solution. On August 22, 2017, at 12:15 p.m., during an interview, the DSS stated the dishwashing machine was not working and she called the plumber the night prior, at 10 p.m. A review of the facility's policy and procedure titled Three Compartment Sink: Manual Washing, Rinsing, and Sanitizing, indicated to rinse, scrape, or soak all items before washing. Wash items in the first sink in a detergent solution. Water should be at least 110°F (43°C). Replace water when suds are gone or water is dirty. Immerse or spray-rinse items in the second sink. Water temperature should be 110°F (43°C). Remove all food and detergent traces. If using immersion method, replace water when it becomes cloudy or soiled. Immerse items in third sink in hot water of 180°F (82°C) or immerse in a chemical sanitizing solution. Manual sanitizing shall be accomplished in the third sink by one of the following methods. Use thermometers and chlorine/quaternary strips for monitoring. Immerse in a solution of 50 ppm available chlorine solution for seven seconds with water greater than 75°F, not to exceed 115°F. Immerse in hot water at least 180°F for 30 seconds. After sanitizing, place items on a drain board to air dry. When a three-compartment sink is not available, a one or two-compartment sink maybe used following guides for temperature and sanitizing, and by using the Drain and Fill method. For example: after washing utensils in the first sink, rinse utensils in the second sink. Now drain the second sink, refilling it with a sanitizing solution. If needed, utilize another approved container, such as a bus tub, for one of the cleaning or sanitizing steps. On August 22, 2017, at 12:25 p.m., during an interview with the Registered Dietitian (RD), she stated the water in the sink should have been drained to rinse the plate covers and the testing of the solution was not done as per policy. 3. On August 21, 2018, at 12:30 p.m., during an observation of the dry food storage area in the presence of the DSS, the thermometer in the room had a temperature reading of 78°F. At 2:25 p.m., the temperature was 82°F. A thermostat, near the dry food section, had a setting of 69°F but the temperature reading was 83°F. On August 21, 2018, at 12:35 p.m., during an interview, the DSS stated they did not keep a log of the temperature in the dry food storage area. According to the Proper Storage Temperatures for USDA Commodities (California Department of Education) http://www.cde.ca.gov: the correct temperature control is essential to maintain food quality, nutrient content, and control of bacterial growth. Daily monitoring of temperatures is necessary to ensure adequate storage conditions. Many items such as canned goods, baking supplies, grains, and cereals may be held safely in dry storage areas. The guidelines should be followed included to keep dry storage areas clean with good ventilation to control humidity and prevent the growth of mold and bacteria; store dry foods at 50 degrees Fahrenheit (°F) for maximum shelf life. However, 70°F is adequate for dry storage of most products. Place a thermometer on the wall in the dry storage area. Check the temperature of the store room daily. The facility's undated policy and procedure titled Storage of Food and Supplies, indicated food and supplies will be stored properly and in a safe manner. The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. Thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50 to 70°F (Maximum temperature of 80°F or re-evaluate cooling system). 4. On August 21, 2017, at 1:40 p.m., during the initial kitchen observation in the presence of the DSS, Cook 1 took roast beef from a malfunctioning freezer. The meat juices were dripping to the floor when transferring from the freezer to the tub over the sink. The temperature measured by the DSS was 32°F and when repeated, the temperature was 31.3°F. According to the DSS, the weight of the meat was between 18 to 20 pounds. The DSS stated she did not know how and for how long the meat was thawed. The facility's policy and procedure titled Thawing of Meats dated March 2013, indicated thawing meat properly can be done in four different ways that included in a refrigerator at 41°F or colder. Allow two to three days to defrost, depending on quantity and total weight of meat. Use a drip pan under food being thawed so drippings do not contaminate other food. The other way was in a microwave, if foods are to be cooked immediately following the thawing process. Next is to submerge under running, potable water at a temperature of 70°F or lower, with a pressure sufficient to flush away loose particles. Fourth, foods can be thawed as part of the cooking process. Under the section of refrigerated storage and storage of frozen food, indicated store raw meat, poultry, and fish separately from cooked and ready-to-eat food to prevent cross-contamination. Estimated time for thawing meats is one day (24 hours) for every five pounds frozen meat in the refrigerator at approximately 40°F.