Every finding on record at Southwind at Spearville

The facility had a census of 22 residents and identified 22 residents with signed arbitration agreement and no residents in active arbitration. Based on record review and interview, the facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator agreed on by both parties and for selection of a venue convenient to both parties. Findings included:- The admission Packet contained Exhibit E Arbitration Provision. Review of the provision revealed it lacked notification to the residents or representatives of their right for the selection of a neutral arbitrator agreed on by both parties and for the selection of a venue convenient to both parties. On 01/28/26 at 04:13 PM, Administrative Staff B stated that the Abirritation Provision provided with the admission Packet was all that was provided about the agreement. She stated she did explain the agreement to new admits when they signed it. On 01/29/26 at 11:23 AM, Administrative Nurse D stated the previous company that ran the facility wrote the Arbitration Provision, and the current board of directors and the administrator might have changed it a bit. Administrative Nurse D was not aware of the language required to be in the Arbitration Provision. On 01/29/26 at 11:24 AM, Administrative Staff A stated the facility followed whatever the admission Agreement says about the Arbitration Provision. Administrative Staff A was not aware of the items that were required to be in the Arbitration Provision and said she will get it corrected immediately.

The facility had a census of 22 residents and identified 22 residents with signed arbitration agreement and no residents in active arbitration. Based on record review and interview, the facility failed to ensure the arbitration agreement contained the required language to notify the residents or representatives of their right to rescind the agreement within 30 days of signing and failed to ensure the Arbitration agreement notified the residents or representatives that signing the agreement is not a requirement of admission. Findings included:- The admission Packet contained Exhibit E Arbitration Provision. Review of the provision revealed it lacked notification to the residents or representatives of their right to rescind the Abirritation Provision within 30 days of signing. The provision also lacked notification to the residents or representatives that signing the agreement is not a requirement of admission. On 01/28/26 at 04:13 PM, Administrative Staff B stated the Abirritation Provision provided with the admission Packet was all which was provided about the agreement. She stated she did explain the agreement to new admits when they signed it. On 01/29/26 at 11:23 AM, Administrative Nurse D stated the previous company which ran the facility wrote the Arbitration Provision. The current board of directors and the administrator might have changed it a bit. Administrative Nurse D was not aware of the language required to be in the Arbitration Provision. On 01/29/26 at 11:24 AM, Administrative Staff A stated the facility followed whatever the admission Agreement says about the Abirritation Provision. Administrative Staff A was not aware of the items which were required to be in the Arbitration Provision and said she would get it corrected immediately.

The facility reported a census of 22 residents and one main kitchen. Based on observation, record reviews, and interviews, the facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria. Findings included:- On 1/28/26 at 11:50 AM observation during the noon meal revealed Dietary Staff CC wore gloves. She picked up the plates, removed the lid to the roasting pan, and used utensils for the meat, potatoes, and spinach. Wearing the same gloves, she picked up the roll with her gloved hand. She touched her face and glasses then, without removing her gloves and washing her hands, she continued the plating process. In an interview on 01/28/26 at 12:15 PM, Dietary Staff CC stated she had been trained to serve that way. She stated she typically would change her gloves about three times during the process. On 01/29/26 at 08:16 AM Dietary Manager BB said she would re-educate her staff regarding the serving process and not touching their face and glasses without washing their hands and changing gloves. The facility's policy on Food Preparation and Handling: Hand Hygiene Policy for all food handlers, hands must always be washed in designated hand washing sinks. Gloves would be worn when serving residents who are on transmission-based precautions but do not need to wear gloves when distributing foods to residents at dining tables or when assisting residents to dine unless they are touching ready to eat food. Staff will perform hand washing prior to disturbing meals.

The facility reported a census of 22 residents. Based on observation, interview, and record review, the facility failed to monitor bowel movements for Resident (R) 4, a resident with a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). Findings included:- R4's Electronic Medical Records (EMR), documented diagnoses which included colostomy and obstruction of the intestinal tract. R4's 11/13/2025 admission Minimum Data Set (MDS) documented R4 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R4 had a colostomy bag. R4's Care Plan, dated 05/19/25, documented R4 had dehydration or a potential fluid deficit related to use of a diuretic and the care plan directed staff to monitor and document bowel sounds and frequency of bowel movements. R4's Progress Notes lacked documentation of monitoring of bowel movements. R4's Tasks documented that continence was not rated due to a colostomy. The documentation lacked documentation of amount, frequency, or consistency. On 01/28/26 at 01:00 PM, Certified Nurse Aide (CNA) M emptied the colostomy bag into a plastic trash bag, tied the bag, and threw it away. On 01/28/26 at 01:00 PM, Certified Nurse Aide (CNA) M stated the staff do not monitor, frequency of bowel movements, amount, or consistency. They do not tell the nurse about the bowel movements. CNA M stated that R4 had loose stool. On 01/28/26 at 1:08 PM, Licensed Nurse (LN) G stated the night shift nurse runs a bowel movement report for the residents to check for constipation. The staff did not document or monitor R4's bowel movements. On 01/28/26 at 02:49 PM, Administrative Nurse D stated she expected staff to document and monitor R4's bowel movements. The facility's undated Ostomy (Ileostomy, Colostomy) Care policy documented the stool output, consistency, and color were to be documented in the resident's chart every shift.

The facility reported a census of 22 residents. Based on observation, interview, and record review, the facility failed to ensure a copy of Resident (R) 17's advanced directive for a Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest) was included in the clinical record. Findings included:- R17's Electronic Medical Record (EMR) revealed a diagnosis of atrial fibrillation (rapid, irregular heartbeat). R17's admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. R17's Care Plan, dated [DATE], indicated she chose to be a DNR and the DNR order would be part of the medical record and would be reviewed with the care plan review. R17's EMR documented a physician's order for a DNR dated [DATE]. R17's EMR lacked evidence of the signed DNR document. Observation on [DATE] at 08:10 AM revealed R17 was in the dining room at the table visiting with another resident. On [DATE] at 04:01 PM, Administrative Nurse D said during R17's transfer from the assisted living to the long-term care, her signed DNR did not transfer over into her current chart, Administrative Nurse D stated the facility did not have a process or system in place to monitor or verify changes for advanced directives. The facilities policy Advance Directives, undated, documented it is the policy of this facility to recognize the right of residents and or representative to make informed decision about medical care, including the right to accept or refuse medical treatment. A signed physician's DNR order indicates the physician has discussed the use of cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) with the resident/representative to recognize the residents' decisions to refuse CPR. The physician DNR order will be accompanied by supporting documentation in the resident clinical record.

The facility reported a census of 22 residents and three residents who were cognitively impaired but independently mobile. Based on observation, record review, and interviews, the facility failed to provide a safe environment when the beauty shop, which contained heating devices and chemicals, was left unlocked. Findings included:- On 01/27/26 at 10:06 AM observation revealed the door to the beauty shop was unlocked and open with the following items on the counter: two cans of Clippercide spray (liquid disinfectant chemical), shampoo, hair spray, two curling irons, and an electric razor. Further observation revealed an unlocked cabinet with access to a can of Lysol (spray disinfectant). There were no staff in the beauty shop at the time of the observations. On 01/28/26 at 02:09 PM, Administrative Staff D stated she expected the beauty shop to be closed and locked if there was no one in there. The facility policy Control of Hazardous Chemicals undated the facility is committed to eliminating and controlling hazards that could cause injury or illness to our elder. The facility will meet the requirements of safety standards where there are specific rules about hazards or potential hazards in our facility.

The facility had a census of 22 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 16 who did not receive medications as ordered Additionally, the facility further failed to notify the physician of the error. Findings included:- R16's Electronic Medical Records (EMR), documented diagnoses which included hypertension (HTN-elevated blood pressure) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R16'sQuarterly Minimum Data Set (MDS), dated [DATE], documented R16 had a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. R16 had hypertension and heart failure. R16 took a diuretic (a medication to promote the formation and excretion of urine). R16's Care Plan, dated 08/07/24, documented R16 had hypertension related to lifestyle choices and directed staff to give medications as ordered, monitor R16's blood pressure, and hold medications per parameters set by the physician. R16's Physicians Orders, ordered on 08/12/25, revealed an order for valsartan (an antihypertensive medication) 320 milligrams (mg) one time a day for hypertension. Staff are to notify the physician if the systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) is less than 90 millimeters (mm) of mercury (Hg) or over 180 mm/Hg, diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) less than 4 mm/Hg0 or over 100 mm/Hg, or a pulse less than 50 or greater than 110 on two consecutive checks two hours apart. R16's Physicians Orders, ordered on 08/12/25, revealed an order for metoprolol tartrate 50 mg two times a day related to hypertension. Staff are to notify the physician if SBP is less than 90 mm/Hg or greater than 180 mm/Hg; DBP less than 40 mm/Hg or greater than 100 mm/Hg, pulse less than 50 or greater than 110 on two consecutive checks two hours apart.R16's Physicians Orders, ordered 06/25/25, revealed an order for furosemide (diuretic medication) 40 mg one time a day related to hypertension. Notify the physician if SBP is less than 90 mm/Hg or greater than 180 mm/Hg; DBP less than 40 mm/Hg or greater than 100 mm/Hg, pulse less than 50 or greater than110 on two consecutive checks two hours apart. R16's Physicians Orders, ordered 08/13/25, revealed an order for hydrochlorothiazide (diuretic medication) 12.5 mg one time a day related to hypertension. Hold and notify the physician if SBP is less than 90 mm/Hg or greater than 180 mm/Hg; DBP less than 40 mm/Hg or greater than 100 mm/Hg, pulse less than 50 or greater than110 on two consecutive checks two hours apart. R16's Medication Administration Record, reviewed from 11/01/25 to 01/27/26, documented on 01/27/26 that valsartan, metoprolol tartrate, furosemide, and hydrochlorothiazide were not given to R16. R16's blood pressure was 105/45 mm/Hg at that time. R16's Orders - Administration Note on 01/27/26 at 08:47 AM, revealed Certified Medication Aide (CMA) R documented hydrochlorothiazide 12.5 mg was held per nursing judgement. R16's Orders - Administration Note on 01/27/26 at 08:48 AM, revealed CMA R documented furosemide 40 mg was held per nursing judgement. R16's Orders - Administration Note on 01/27/26 at 08:49 AM, revealed CMA R documented metoprolol tartrate 50 mg was held per nursing judgement. R16's Orders - Administration Note on 01/27/26 at 08:49 AM, revealed CMA R documented valsartan 320 mg was held per nursing judgement. On 01/28/26 at 08:42 AM, R16 sat in her wheelchair in her room. Certified Medication Aide (CMA) S entered R16's room and obtained her blood pressure. It was 125/58 mm/Hg. CMA S then gave R16 her blood pressure medications. On 01/27/26 at 04:45 PM, CMA R stated that she took R16's blood pressure and it was about 111/49 mm/Hg. CMA R stated she rechecked it and the bottom number was still in the 40's, so she told the nurse and the nurse said to hold the medications. On 01/27/26 at 04:47 PM, Licensed Nurse (LN) H stated she did tell the CMA to hold the medications because R16's blood pressure was low. LN H confirmed she did not notify the physician. On 01/28/26 at 02:49 PM, Administrative Nurse D stated that the CMA notified the nurse of the low blood pressure, and the nurse used her nursing judgement to tell the CMA to hold the medication. Administrative Nurse D said LN H did not notify the physician because the blood pressure was not in the parameters to notify the provider. The facility's undated Medication Administration Policy documented medications shall be administered in a safe method as ordered by the physician.

The facility reported a census of 13 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data report for the Fiscal Year (FY) report for Quarter 2, 2023 revealed (January 1 - March 31), the data indicated that the facility failed to have Licensed Nursing Coverage 24 hours/Day on the following dates: On 01/01/23, Sunday (SU); 01/07/23, Saturday (SA); 01/09/23, Monday (MO); 01/14/23 (SA); 01/15/23 (SU); 01/20/23, Friday (FR) 01/2;123 (SA);02/04/23 (SA); 02/11/23 (SA); 02/23/23, Thursday (TH); 02/2523 (SA); 02/26/23 (SU); 02/27/23 (MO);03/06/23 (MO); 03/07/23, Tuesday (TU); 03/14/23 (TU); 03/17/23 (FR); 03/18/23 (SA); and 03/25/23 (SA). Review of the PBJ Staffing Data Report for FY for Quarter 3- 2023 (April 1 - June 30), revealed the data indicated that the facility failed to have Licensed Nursing Coverage 24 hours/Day on the following dates: On 04/04/23 (TU); 04/1423 (FR); 04/18/23 (TU); 04/23/23 (SU); 04/24/23 (MO); 04/29/23 (SA);05/07/23 (SU); 05/08/23 (MO); 05/11/23 (TH); 05/20/23 (SA); 05/22/23 (MO); 06/17/23 (SA); 06/24/23 (SA) and 06/30/23 (FR). Review of the PBJ Staff Data Report for FY for Quarter 4 2023 (July 1 - September 30), revealed the data indicated that the facility failed to have Licensed Nursing Coverage 24 hours/Day on the following dates: On 07/04/23 (TU); 07/10/23 (MO); 07/13/23 (TH); 07/17/23 (MO); 07/22/23 (SA); 07/28/23 (FR); 07/31/23 (MO); 08/04/23 (FR); 08/05/23 (SA); 08/07/23 (MO); 08/12/23 (SA); 08/13/23 (SU); 08/17/23 (TH); 08/22/23 (TU); 08/25/23 (FR); 08/31/23 (TH); 09/02/23 (SA); 09/03/23 (SU); 09/04/23 (MO) and 09/08/23 (FR). Review of the nursing schedule and clocking sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage. On 03/27/24 at 11:09 AM, Administrative Nurse B reported that an outside agency contracted by the previous ownership company was responsible for submission of payroll data prior to 11/01/23 and was unable to provide an explanation for inaccurate data. The facility's undated Mandatory Submission of Uniform Format Staffing Information (PBJ) policy documented that the facility would electronically submit to CMS (Centers for Medicare/Medicaid Services - a federal regulatory agency) complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. The facility administrator was responsible to ensure the submitted data was accurate and timely. The facility failed to submit complete and accurate staffing information to the federal regulatory agency through PBJ when the facility failed to accurately submit hourly staffing data for all nursing personnel.

The facility census totaled 13 residents with 8 residents included in the sample. Based on observation, interview, and record review, the facility failed to revise the care plans for four residents that included Resident (R)5 and R13, related to falls, and R1 and R3 for use of nebulizer equipment (device which changes liquid mediation into a mist easily inhaled into the lungs). Findings included: - Review of R1 signed Physician Orders dated 03/19/24, revealed the diagnosis included chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Review of the Admission Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R1 received oxygen (a colorless, odorless reactive gas supporting component of the air). Review of the Care Plan dated 06/23/23, failed to include interventions/staff guidance related to R1's nebulizer treatment for respiratory care. Review of the Physician's Orders dated 06/28/23, included the following: Yupeilri (long-term medication used to treat an ongoing lung disease, chronic obstructive pulmonary disease. It must be used regularly to reduce and prevent symptoms such as shortness of breath, cough, and wheezing) inhalation solution 175 microgram (mcg), three milliliters (ml), inhale orally one time a day. Arformoterol Tartrate (a bronchodilator, relaxing the muscles in the airways to improve breathing) inhalation nebulization solution, 15 mcg/two ml, inhale orally via nebulizer two times a day. Observation on 03/25/24 at 01:04 PM, revealed R1's nebulizer tubing and medication chamber/mouthpiece hung off the bed side cabinet, hooked on a drawer handle. Observation on 03/26/24 at 08:20 AM, R1 was in her room eating breakfast, with oxygen at four liters per nasal cannula. The nebulizer continued to remain stored on the drawer handle. Interview on 03/26/24 at 10:15 AM with Licensed Nurse (LN) C, revealed staff should wash nebulizer chambers and mouthpiece between treatments. R1 has numerous treatments during the day and the nebulizer is not rinsed between the treatments. Interview with LN F on 03/27/24 at 10:30 AM, revealed that the updates on the care plan are wrote on a note and given to the director of nursing to update the care plan or make a revision. Interview on 03/27/24 at 08:35 AM with Administrative Nurse B, revealed the resident's nebulizers have not been washed and or rinsed after each treatment. Reported the facility would be Implementing that all nebulizers are to be rinsed, air dried, and placed in a bag. The administrative nurse B revealed that she does not know how to update the care plans with the facility's software program. The facility failed to provide a policy regarding Care Plans as requested on 03/27/24. The facility failed to update or revise R1's care plan to reflect the use of a nebulizer. - Review of R3's signed Physician Orders dated on 01/29/24, revealed the following diagnoses included chronic obstruction pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and pleural effusion (abnormal accumulation of fluid in the lungs). Review of the Significant Change Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of eight, indicating moderate impaired cognition. R3 received oxygen therapy. Review of the Care Plan dated 01/25/24 lacked intervention/staff guidance regarding R3's nebulizer treatments. Review of the Physician's Orders dated 01/25/24 revealed the following orders: Budesonide inhalation suspension, 0.25 milligrams (mg)/2milliliter (ml), one vial, inhale orally, two times a day. Perforomist inhalation nebulization solution, 20 mg/2 ml, one vial, inhale orally via nebulizer, two times a day. Ipratropium-albuterol solution, 0.5 mg/ 3 ml, one vial, inhale orally, every four hours as needed. Observation on 03/26/24 at 10:10 AM, revealed R3 in bed with oxygen on per nasal cannula. Licensed Nurse (LN) C prepared to start R3's nebulizer treatment. Interview on 03/26/24 at 10:15 AM with LN C, revealed staff should wash out the nebulizers in between the treatments R1 has numerous treatments during the day, and the nebulizer is not rinsed between the treatments. Interview with Licensed Nurse LNF on 03/27/24 at 10:30 AM revealed that the updates on the care plan are wrote on a note and given to the director of nursing to update the care plan or make revisions. Interview on 03/27/24 at 08:35 AM with Administrative Nurse B, revealed the nebulizers have not been washed and or rinsed after each treatment. The administrative nurse B revealed that she does not know how to update the care plans with the facility's software program. The facility failed to provide a policy regarding Care Plans as requested on 03/27/24. The facility failed to update or revise R3's care plan to reflect the use of a nebulizer. - Review of R5's signed Physician's Orders, dated 02/04/24, revealed the following diagnosis included Alzheimer's disease unspecified (progressive mental deterioration characterized by confusion and memory failure). Review of the Admission Minimal Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Review of the falls since admission indicated one fall since admission with no major injury. Review of the Care Area Assessment falls, dated 07/13/23 R5 had episodes of weakness, dizziness, and impaired balance. R5 required staff to assist to transfer to a chair. Review of the care plan dated 07/22/23 and revised on 01/16/24, revealed R5 was at risk for falls related to weakness, medication use, and recent falls. R5 had falls on 07/11/23, 09/19/23, and 12/7/23. Review of the care plan lacked no new interventions for falls on 09/23/23 and 12/07/23. Review of the fall reports for 09/19/23, revealed R5 was found on the floor sitting between a small dresser and the bathroom doorway. R5 was unable to voice how he had fallen. The care plan lacked interventions to prevent a further fall. Review of the fall report dated 12/07/23 at 06:20 PM, revealed R5 was found in front of his toilet with no pants on, bowel movement in the stool, and was able to ambulate with a walker. The care plan lacked interventions to prevent a further fall. On 03/25/24 at 11:40 AM, observed R5 in the dining room for lunch, with a walker beside the table. On 03/27/24 at 10:00 AM, observed R 5 ambulating in the commons area with a walker. Interview with Certified Nurse Aide (CNA) D revealed R5 was independent but did require cueing. He is able to go to the bathroom with staff assist. R5 does not use his call light, so staff must check on him frequently. Interview with Licensed Nurse (LN) F on 03/27/24 at 10:30 AM, regrading changes or revisions to the care plan, one would be to changing his toilet routine to prevent falls during the night shift. The staff try to keep him out in the commons area where staff can visualize R5 and keep an eye on him. On 03/27/24 at 08:35 AM, Interview with Administrative Nurse B reported staff should include revisions/ interventions to the care plan to include the falls on R5. The administrative nurse B revealed that she does not know how to update the care plans with the facility's software program. The facility failed to provide a policy regarding Care Plans as requested on 03/27/24. The facility failed to update or revise R5's care plan to reflect the new intervention on falls. 46960 - Review of the Electronic Health Record (EHR) documented R13 had diagnoses which included aftercare following joint replacement surgery. The 01/13/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R13 required substantial assistance of staff for toileting and dressing but was otherwise independent with cares. R13 had two or more falls in the facility since admission, falls in the month prior to admission, falls in the previous two to six months prior to admission and a fracture (broken bone) in the six months prior to admission. The 01/13/24 Cognitive Loss / Dementia Care Area Assessment (CAA) documented R13 had severe cognitive impairment. The 01/13/24 ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential CAA documented R13 was a new admission following hospitalization due to a fall with a fracture of the right femur (thigh bone) with repair and joint replacement. R13 had intermittent confusion with three or more falls in the previous three months. R13 had balance problems when standing and walking with decreased muscle coordination and required maximum assistance for toileting, dressing, transfer and ambulation (walking). R13 used a wheelchair propelled by staff. The 01/13/24 Falls CAA documented R13 had intermittent confusion with three or more falls in the previous three months and was chair bound due to balance problems while standing and walking from decreased muscle coordination. The Care Plan documented R13 was at risk for falls related to confusion and gait (manner or style of walking) and balance problems due to recent right hip replacement and instructed the staff to perform the following interventions: 1. On 01/08/24, staff would anticipate and meet the resident's needs. 2. On 01/08/24, staff would ensure R13's call light was within reach and that R13 required prompt response for all requests for assistance. 3. On 01/08/24, staff would ensure R13 was wearing appropriate footwear when ambulating or self-propelling in the wheelchair. 4. On 01/15/24, staff would place body pillows on both sides of R13's bed when R13 was in bed to define the edges of the bed for R13. 5. On 01/15/24, staff would place R13's four wheeled walker (FWW - a lightweight three-sided structure that aids individuals with balance problems with ambulation) in the middle of the side of his bed facing the bathroom to cue resident to use his walker if R13 got out of bed independently. 6. On 01/15/24, staff would place R13 where he could be quickly visualized by staff and not left alone until his balance and weakness were improved. 7. On 03/17/24, staff would encourage and assist resident to wear non-skid socks at bedtime. 8. On 03/18/24, staff would place a video camera on the resident at night, staff were to leave the resident's room door open at night, leave a night light on in R13's room at night, schedule times for staff to go in and assist with toileting and would consider moving resident's room closer to nursing station for easy visualization. The Fall Risk Score Assessments documented between 01/08/24 and 03/18/24 revealed 10 fall risk assessments performed that indicated that R13 was at a high risk for falls. The Progress Notes documented the following: 1. On 01/11/24 at 09:00 PM, an unnamed Certified Nurse Aide (CNA) found R13 on the floor in his room. The care plan lacked an intervention to prevent further falls. 2. On 01/15/24 at 01:45 PM, an unidentified CNA found R13 on the floor in the doorway of his bathroom. 3. On 01/18/24 at 04:15 AM, unidentified staff found R13 on the floor beside his bed. 4. On 02/25/24 at 01:11 AM, (a late entry), that on 02/24/24 at 09:10 PM, unidentified staff found R13 on his bathroom floor in the bathroom shower area. However, the care plan lacked an intervention to prevent further falls. 5. On 03/13/24 at 03:00 AM, R13 fell when he attempted to transfer self to go to the bathroom. However, the care plan lacked an intervention to prevent further falls. 6. On 03/17/24 at 01:41 AM, unidentified staff found R13 on the floor in front of his recliner. R13 reported he lowered himself to the floor when he started to slip. 7. On 03/18/24 at 04:18 AM, unidentified staff found R13 on the floor in his shower. Review of facility's fall investigations revealed the following: 1. On 01/11/24, R13 fell . The facility determined the root cause that the resident was ambulating without assistance and had recently received pain medication and initiated the immediate intervention of placing brightly colored signs to remind the resident to use the call light system for assistance. On 03/27/24 at 10:29 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 2. On 01/15/24, R13 fell . The facility investigation lacked a root cause analysis and staff initiated the immediate intervention of the resident placed for easy visualization for staff. On 03/27/24 at 10:32 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 3. On 01/18/24, R13 fell . The facility investigation determined the root cause to be that resident rolled out of bed since he was unable to determine where the bed edges were, and staff initiated an immediate intervention that resident would be monitored more closely by staff. On 03/27/24 at 10:30 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 4. On 02/24/24, R13 fell . The facility investigation determined the root cause to be that R13 ambulated without assistance to the bathroom and staff initiated the immediate intervention that R13 would always be in sight of staff until R13 was ready for bed. On 03/27/24 at 10:58 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 5. On 03/13/24, R13 fell . The facility investigation determined the root cause to be R13 ambulated without assistance and staff initiated the immediate intervention to reorient the resident to use the call light system for assistance. On 03/27/24 at 11:01 AM. Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. On 03/27/24 at 09:18 AM, CNA D revealed that cares should be driven by the care plan which is available for staff to view in the EHR in the point of care section. CNA D stated that in the event of a fall, CNA staff were to remain with the resident and use the radio that staff carries for assistance. Upon the arrival of the nurse, CNA staff were to perform whatever tasks were delegated by the nurse. On 03/27/24 at 09:32 AM, CNA F revealed that in the event of a fall, the CNA staff should alert other staff of the fall and then wait with the resident until the nurse arrives, then follow the direction of the nurse. CNA F reported that the cares provided to residents are driven by what's on the care plan, and that the individual care plans are available to view in the EHR, as well as changes that are reported by previous shifts during shift change. On 03/27/24 at 09:42 AM, Licensed Nurse (LN) E defined a fall as a change in the resident's plane (for example, bed to floor, chair to floor or standing to floor). LN E revealed that in the event of a fall, CNA staff were to alert the licensed nurse on duty. The licensed nurse will then respond to the area of the fall and assess the resident for injuries and render aid if needed. CNA staff and licensed nurse would assist the resident back to the bed or the wheelchair or the chair. The licensed nurse on duty was responsible for filling out the fall paperwork which included a root cause analysis to determine if the appropriate safety measures were in place and to develop an immediate intervention to prevent additional falls. The immediate intervention would then be communicated verbally to all the staff on duty. Then the licensed nurse on duty was also responsible to create a permanent intervention to be placed in the resident's care plan binder in the nurses' station. Administrative Nurse B would then transcribe/update the care plan intervention from the binder into the care plan that's in the EHR. On 03/27/24 at 10:06 AM, Administrative Nurse B confirmed LN E's statements and stated that it was her expectation that staff perform those steps. Administrative Nurse B then stated that after a fall report is completed the reports are delivered to her and any needed education is completed as needed and care plan updates are completed at that time. Administrative Nurse B revealed that there was no interdisciplinary team (IDT) meeting or fall huddle that occurred in the facility. Administrative Nurse B confirmed that R13's care plan had not been revised after the falls that occurred on 01/11/24, 01/18/24, 02/24/24 and 03/13/24. The facility failed to provide a policy related to care plan revision as requested on 03/27/24. The facility failed to update the care plan for R13 related to falls and accident hazards. This deficient practice led to additional falls and had the potential for R13 suffering physical and psychosocial injuries.

The facility reported a census of 13 residents. Based on interview and record review, the facility failed to conduct criminal background checks for one of three staff members, to ensure no abuse to the residents of the facility. Findings included: - Review of employee files on 03/26/24 at 03:00 PM, revealed a lack of criminal background check for one of three employee records reviewed. Review of Certified Nurse Aide (CNA) G's preemployment screening information with a date of hire of 07/08/22, revealed the file lacked criminal background check information attempted and/or completed by the facility. On 03/26/24 at 03:00 PM, Administrative Nurse B confirmed the lack of criminal background check information for CNA G and stated that she did not know if one had occurred prior or since employment began. Administrative Nurse B stated that criminal background checks should be performed prior to employment offer being extended to prospective employees. The facility's undated Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy documented that the resident abuse, neglect and exploitation prevention program consisted of a facility-wide commitment and resource allocation to conduct employee background checks. The facility failed to conduct a criminal background check. This deficient practice had the potential to negatively affect the care delivered to residents.

The facility reported a census of 13 residents with eight residents sampled, which included two residents sampled for accident hazards. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe environment as free of accident hazards as possible for one resident, Resident (R) 13. Findings included: - Review of the Electronic Health Record (EHR) documented R13 had diagnoses which included aftercare following joint replacement surgery. The 01/13/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R13 required substantial assistance of staff for toileting and dressing but was otherwise independent with cares. R13 had two or more falls in the facility since admission, falls in the month prior to admission, falls in the previous two to six months prior to admission and a fracture (broken bone) in the six months prior to admission. The 01/13/24 Cognitive Loss / Dementia Care Area Assessment (CAA) documented that R13 had severe cognitive impairment. The 01/13/24 ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential CAA documented R13 was a new admission following hospitalization due to a fall with a fracture of the right femur (thigh bone) with repair and joint replacement. R13 had intermittent confusion with three or more falls in the previous three months. R13 had balance problems when standing and walking with decreased muscle coordination and required maximum assistance for toileting, dressing, transfer and ambulation (walking) and used a wheelchair propelled by staff. The 01/13/24 Falls CAA documented R13 had intermittent confusion with three or more falls in the previous three months and was chair bound due to balance problems while standing and walking from decreased muscle coordination. The Care Plan documented R13 was at risk for falls related to confusion and gait (manner or style of walking) and balance problems due to recent right hip replacement and instructed the staff to perform the following interventions: 1. On 01/08/24, staff would anticipate and meet the resident's needs. 2. On 01/08/24, staff would ensure R13's call light was within reach and that R13 required prompt response for all requests for assistance. 3. On 01/08/24, staff would ensure R13 was wearing appropriate footwear when ambulating or self-propelling in the wheelchair. 4. On 01/15/24, staff would place body pillows on both sides of R13's bed when R13 was in bed to define the edges of the bed for R13. 5. On 01/15/24, staff would place R13's four wheeled walker (FWW - a lightweight three-sided structure that aids individuals with balance problems with ambulation) in the middle of the side of his bed facing the bathroom to cue resident to use his walker if R13 got out of bed independently. 6. On 01/15/24, staff would place R13 where he could be quickly visualized by staff and not left alone until his balance and weakness were improved. 7. On 03/17/24, staff would encourage and assist resident to wear non-skid socks at bedtime. 8. On 03/18/24, staff would place a video camera on the resident at night, staff were to leave the resident's room door open at night, leave a night light on in R13's room at night, schedule times for staff to go in and assist with toileting and would consider moving resident's room closer to nursing station for easy visualization. The Fall Risk Score Assessments documented between 01/08/24 and 03/18/24 revealed 10 fall risk assessments performed that indicated that R13 was at a high risk for falls. The Progress Notes documented the following: 1. On 01/11/24 at 09:00 PM, an unnamed Certified Nurse Aide (CNA) found R13 on the floor in his room. 2. On 01/15/24 at 01:45 PM, an unidentified CNA found R13 on the floor in the doorway of his bathroom. 3. On 01/18/24 at 04:15 AM, unidentified staff found R13 on the floor beside his bed. 4. On 02/25/24 at 01:11 AM, (a late entry), that on 02/24/24 at 09:10 PM, unidentified staff found R13 on his bathroom floor in the bathroom shower area. 5. On 03/13/24 at 03:00 AM, R13 fell when he attempted to transfer self to go to the bathroom. 6. On 03/17/24 at 01:41 AM, unidentified staff found R13 on the floor in front of his recliner. R13 reported he lowered himself to the floor when he started to slip. 7. On 03/18/24 at 04:18 AM, unidentified staff found R13 on the floor in his shower. Review of facility's fall investigations revealed the following: 1. On 01/11/24, R13 fell . The facility determined the root cause that the resident was ambulating without assistance and had recently received pain medication and initiated the immediate intervention of placing brightly colored signs to remind the resident to use the call light system for assistance. On 03/27/24 at 10:29 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 2. On 01/15/24, R13 fell . The facility investigation lacked a root cause analysis and staff initiated the immediate intervention of the resident placed for easy visualization for staff. On 03/27/24 at 10:32 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 3. On 01/18/24, R13 fell . The facility investigation determined the root cause to be that resident rolled out of bed since he was unable to determine where the bed edges were, and staff initiated an immediate intervention that resident would be monitored more closely by staff. On 03/27/24 at 10:30 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 4. On 02/24/24, R13 fell . The facility investigation determined the root cause to be that R13 ambulated without assistance to the bathroom and staff initiated the immediate intervention that R13 would always be in sight of staff until R13 was ready for bed. On 03/27/24 at 10:58 AM, Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. 5. On 03/13/24, R13 fell . The facility investigation determined the root cause to be R13 ambulated without assistance and staff initiated the immediate intervention to reorient the resident to use the call light system for assistance. On 03/27/24 at 11:01 AM. Administrative Nurse B confirmed the care plan lacked an intervention related to this fall to prevent further falls. On 03/27/24 at 09:18 AM, CNA D revealed that cares should be driven by the care plan which is available for staff to view in the EHR in the point of care section. CNA D stated that in the event of a fall, CNA staff were to remain with the resident and use the radio that staff carries for assistance. Upon the arrival of the nurse, CNA staff were to perform whatever tasks were delegated by the nurse. On 03/27/24 at 09:32 AM, CNA F revealed that in the event of a fall, the CNA staff should alert other staff of the fall and then wait with the resident until the nurse arrives, then follow the direction of the nurse. CNA F reported that the cares provided to residents are driven by what's on the care plan, and that the individual care plans are available to view in the EHR, as well as changes that are reported by previous shifts during shift change. On 03/27/24 at 09:42 AM, Licensed Nurse (LN) E defined a fall as a change in the resident's plane (for example, bed to floor, chair to floor or standing to floor). LN E revealed that in the event of a fall, CNA staff were to alert the licensed nurse on duty. The licensed nurse will then respond to the area of the fall and assess the resident for injuries and render aid if needed. CNA staff and licensed nurse would assist the resident back to the bed or the wheelchair or the chair. The licensed nurse on duty was responsible for filling out the fall paperwork which included a root cause analysis to determine if the appropriate safety measures were in place and to develop an immediate intervention to prevent additional falls. The immediate intervention would then be communicated verbally to all the staff on duty. Then the licensed nurse on duty was also responsible to create a permanent intervention to be placed in the resident's care plan binder in the nurses' station. Administrative Nurse B would then transcribe/update the care plan intervention from the binder into the care plan that's in the EHR. On 03/27/24 at 10:06 AM, Administrative Nurse B confirmed LN E's statements and stated that it was her expectation that staff perform those steps. Administrative Nurse B stated after a resident fell , a fall report would be completed, and the reports delivered to her, and any needed education would be completed, and care plan updates were to be completed at that time. Administrative Nurse B reported the facility did not have an interdisciplinary team (IDT) meeting or fall huddle that occurred. Administrative Nurse B confirmed that the staff did not follow the care plan interventions to prevent additional falls. The facility's undated Accident Prevention policy documented all staff would ensure that each resident's environment remained as free from accident hazards as possible and that each resident would receive adequate supervision and to prevent accidents. The facility failed to ensure staff provided a safe environment as free of accident hazards as possible for R13. This deficient practice led to additional falls and had the potential for R13 suffering physical and psychosocial injuries.

The facility reported a census of 13 residents, with eight residents in the sample and two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to provide necessary respiratory care consistent with professional standards of practice regarding the use of a nebulizer (a device that delivers medication as a mist to the lungs) for Residents (R) 1 and R3. Findings included: - Review of R1 signed Physician Orders dated 03/19/24 revealed the following diagnosis chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Review of the Admission Minimal Data Set (MDS)dated 06/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R1 received oxygen (a colorless, odorless reactive gas supporting component of the air). Review of the Care Plan dated 06/23/23 failed to include interventions related to use of the nebulizer and/or interventions regarding the care of the nebulizer for R1. Review of the Physician's Orders dated revealed 06/28/23, included the following: Yupeilri (long-term medication used to treat an ongoing lung disease, chronic obstructive pulmonary disease. It must be used regularly to reduce and prevent symptoms such as shortness of breath, cough, and wheezing) inhalation solution 175 microgram (mcg), three milliliter(ml), inhale orally one time a day. Arformoterol Tartrate (a bronchodilator, relaxing the muscles in the airways to improve breathing) inhalation nebulization solution, 15 mcg/two ml, inhale orally via nebulizer two times a day. Observation on 03/25/24 at 01:04 PM, revealed R1's nebulizer tubing and medication chamber/mouthpiece hung off the bed side cabinet, hooked on a drawer handle. Observation on 03/26/24 at 08:20 AM, R1 was in her room eating breakfast, with oxygen at four liters per nasal cannula. The nebulizer continued to remain stored on the drawer handle. Interview on 03/26/24 at 10:15 AM with Licensed Nurse (LN) C, revealed staff should wash nebulizer chambers and mouthpiece between treatments. R1 has numerous treatments during the day and the nebulizer is not rinsed between the treatments. Interview on 03/27/24 at 08:35 AM with Administrative Nurse B revealed the nebulizers have not been washed and or rinsed after each treatment. Implementing that all nebulizers are to be rinsed, air dry and placed in a bag. The facility failed to provide a policy regarding Respiratory Care as requested on 03/27/24. The facility failed to provide respiratory care consistent with professional standards of care for R1 regarding the use and cleaning of the nebulizer. - Review of R3 signed Physician Orders dated on 01/29/24 revealed the following diagnoses of chronic obstruction pulmonary disease ((progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and pleural effusion (abnormal accumulation of fluid in the lungs). Review of the Significant Change Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of eight indicating moderate impaired cognition. R3 receives oxygen therapy. Review of the Care Plan dated 01/25/24 lacked the intervention regarding nebulizer treatments. Review of the Physician's Orders dated 01/25/24 revealed the following orders: Budesonide inhalation suspension, 0.25 milligrams (mg)/2milliliter (ml), one vial, inhale orally, two times a day. Perforomist inhalation nebulization solution, 20 mg/2 ml, one vial, inhale orally via nebulizer, two times a day. Ipratropium-albuterol solution, 0.5 mg/ 3 ml, one vial, inhale orally, every four hours as needed. Observation on 03/26/24 at 10:10 AM revealed R3 in bed with oxygen per nasal cannula, LN C in room preparing to start R3 nebulizer treatment. Interview with Licensed Nurse (LN) C on 03/27/24, revealed staff should wash out the nebulizers in between the treatments R1 has numerous treatments during the day, and the nebulizer is not rinsed between the treatments. Interview on 03/27/24 at 08:35 AM with Administrative Nurse B revealed the nebulizers have not been washed and or rinsed after each treatment. The facility failed to provide a policy regarding Respiratory Care as requested on 03/27/24. The facility failed to provide respiratory care consistent with professional standards of care for R5 regarding the use and cleaning of the nebulizer.

The facility reported a census of 13 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for three Certified Nurse Aides (CNA) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. The facility identified three CNA's employed over 12 month period. Findings included: - Review of employee files on 03/27/24 at 11:40 AM revealed a lack of performance evaluations for three of three records reviewed for CNA D, CNA G and CNA H. On 03/27/24 at 11:40 AM, Administrative Nurse B confirmed the lack of annual performance evaluations. On 03/27/24 at 11:40 AM, Administrative Staff A stated that it was her expectation that either Administrative Staff A or Administrative Staff B perform annual performance evaluations with all staff and confirmed the evaluations were not completed. The facility provided an undated and untitled document that documented that performance evaluations were to be performed at an unknown/undocumented frequency to measure employee's overall effectiveness and to set goals for future performance and professional growth. The facility failed to complete an annual performance review at least once every 12 months for three Certified Nurse Aides (CNA) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility.

The facility reported a census of six residents and identified two residents as cognitively impaired and at risk of elopement. The sample included two residents for wandering/elopement risks. Based on observation, interview, and record review the facility failed to ensure a safe/secure environment for the two residents including Resident (R )1 with cognitive impairment being independently mobile, when staff left the door into the kitchen, the resident entered, walked through the kitchen, and exited the kitchen door into the assisted living dining room without staff knowledge. R1 continued and then exited the front unlocked or alarmed exit door without staff knowledge, on 04/07/23 at 10:04 AM. The staff lacked knowledge of the resident's elopement until family came to visit and could not find R1. The resident was missing for eight minutes before being found in an outside field area across from the facility, which was within 1 and 1/2 miles from a busy highway with speeds limit of 65. These deficient practices placed Rand the other resident identified by the facility at risk for wandering in immediate jeopardy for elopement. Findings included: - R1's 01/05/23 signed Physician Orders revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). The dated 01/05/23 Quarterly Date Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate impaired cognition. The dated 03/16/23 Significant Change Minimum Data Set indicated a BIMS score of three, which indicated severely impaired cognition. The Cognitive Care Area Assessment (CAA) revealed R1 had a diagnosis of dementia with behaviors, and physical behaviors of entering other residents' space, throwing food, agitation, restlessness, and wandering. The resident could walk with a walker. The Elopement Assessment indicated if the score was 14 or above the resident was considered a high risk for potential elopement and would warrant the need for extra supervision and interventions. The Elopement Assessment completed on 03/15/23 revealed a score 16 at high risk. The Care Plan on 10/04/22, the facility identified R1 as an elopement risk. Addition on 02/24/23, instructed staff to identify a pattern of wandering and intervene as appropriate. (The resident eloped from the facility without staff knowledge on 04/07/23). An addition, dated 04/07/23, included the staff were instructed to document visualization and location of the resident every 15 minutes to ensure his safety. Another addition on 04/09/23 instructed the staff to allow R1 to wander as he felt driven, but to maintain his location. The 04/07/23 at 11:30 AM Nurse Notes documented R1's son and wife in to visit with R1. The resident was not in his room and both the staff member and son then looked for R1 in the facility nursing care area and in the assist living care area. They observed R1 to be outside, west of the building, and just off the parking lot area. The staff assisted R1 back inside the facility and the LN assessment revealed no injuries noted. (The facility staff did not know the resident was missing until the family members questioned his whereabouts upon their visit). Review of the facility Investigation regarding the elopement of R1 on 04/07/23 at 10:04 AM, revealed that the resident's family visited and could not locate R1. A Certified Nurse Aide (CNA) M observed R1 outside at 10:08 AM. Per CNA M statement included documentation, .Resident was seen outside of the facility in the field across the way from the facility. He was walking when I approached him. I asked what he was doing his response was [I'm walking home] The CNA redirected R1 back into the building at 10:11 AM. Staff monitored R1 every shift for behaviors of elopement and wandering. The unlock code had been disabled to prevent vendors from unlocking the main door to deliver products. The kitchen door which led to the assisted living would always remain closed. Review of the historical weather information for 04/07/23 at 10:00 AM, recorded by Wunderground.com revealed the temperature at the time of the elopement was 70 degrees Fahrenheit(F) and no extreme weather at the time. Observation on 04/17/23 at 11:30 AM, found R1 seated in the common's area with no behaviors noted and a walker next to the resident. At 02:30 PM, R1 was in the dining room with his spouse playing bingo together without any behaviors noted. On 04/17/23 at 01:55 PM, Maintenance Staff U reported the day of the resident's elopement, the kitchen door was left open during service and at that same time the exit door from the assisted living unit was turned off with a toggle code. The facility removed the toggle code following the incident and currently no one could change the code and the staff had to put in the current numbers to open the door. On 04/17/23 at 03:35 PM, interview with Administration Staff A revealed as soon as the R1 exited the building/eloped out the front doors and returned the staff received education on elopement. The doors between the kitchen and assisted living unit had been changed and remains locked. The front door code changed to prevent vendors or staff from going/ or coming in the door without using the code. Interview with CNA M on 04/17/23 at 04:43 PM, revealed the staff would watch R1 especially if he was wandering, and at that point staff would walk with him and try to find out his needs. Staff now are to document every 15 minutes a visual check. Interview with Licensed Nurse (LN) G, on 04/17/23 at 04:55 PM, revealed R1 did go outside and staff found R1 in the grass next to the parking lot. The facility 2001 policy for, Wandering and Elopements revealed the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. On 04/17/23 at 05:14 PM Administrative Staff A was provided with the immediate jeopardy template and notified that the facility failed to provide adequate supervision to a cognitively impaired, independently mobile Resident (R) 1, identified as high risk for elopement, who left the facility unsupervised/without staff knowledge on 04/07/23. The facility had identified and implemented the following corrective actions: 1. On 04/04/23 at 11:00 AM, maintenance staff disabled the toggle code to unlock the exit doors. Therefore, the entering and exiting of the building doors will always require a code. 2. On 04/07/23 at 11:00 AM, a sign was placed on the west kitchen door into the assisted living, to remind staff to keep the door closed. And the facility dietary staff began checking and logging, all 6 kitchen doors to ensure closure, every 24 hours. 3. On 04/07/23 at 05:00 PM, the staff initiated a 15-minute watch sheet initialed by staff and location for visual checks of the resident. 4. On 04/07/23 from 11:00 AM through 09:00 PM, all staff were educated on the elopement policy and procedures and the changes to the exit door codes. Due to the facility's implementation of the corrective actions prior to the surveyor entering the facility on 04/17/23 at 11:21 AM, the deficient practice was cited as past non-compliance and existed at a J (isolated, immediate jeopardy) scope and severity.