Every finding on record at The Hilltop on Main

Based on interview and record review, the facility failed to have licensed nurses on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans, in thatThe facility failed to have a 24 hour licensed nursing service on 7/19/25, 7/20/25, 08/02/25 and 09/27/25This failure placed all residents at risk for unmet needs and/or injury.Findings included: Record review of the PBJ staffing data report for the fourth quarter of the financial year 2025 reflected that there was no licensed nursing coverage for 24 hours/day on 07/09/25, 07/20/25, 08/02/25 and 09/27/25.During an interview on 03/03/26 at 10:42 a.m., LVN B reported that she had worked at the facility approximately 2.5 years prior to the interview date. She stated that her work hours were from 6:00 AM to 2:00 PM, Monday through Friday. LVN B indicated that she did not recall any days during her tenure when the facility lacked licensed nurses. She emphasized the importance of 24/7 licensed nurse coverage in ensuring resident safety, noting that such staffing supports staff in effectively implementing interventions. Additionally, LVN B highlighted the critical role of licensed nurses in coordinating residents' care, asserting that their presence is essential because many nursing tasks can only be performed by licensed professionals.During an interview on 03/03/26 at 1:40 p.m., LVN C stated that she had previously worked at the facility, with her second term beginning in October 2025 after a hiatus. She reported working on a rotating schedule from Monday through Sunday, from 2:00 PM to 10:00 PM, with additional hours when necessary and take-off days only when required. LVN C indicated that she had never experienced a day without 24-hour licensed nurse coverage during her shifts. She emphasized that the presence of a licensed nurse was mandatory, given the limited scope of practice for CNAs and the numerous tasks that could only be performed by a licensed nurse.During a telephone interview on 03/03/26 at 1:10 p.m., the MD, who has been affiliated with the facility for approximately two years, noted that while many DONs had come and gone, he was unaware of any lapses in 24/7 licensed nurse staffing. The MD expressed concern that such gaps could pose significant risks, particularly because licensed nurses are responsible for performing tasks that only they are qualified to carry out. He emphasized that the absence of licensed staff during these times could compromise resident safety.During an interview on 03/03/26 at 3:17 p.m., the DON stated that she officially assumed her responsibilities on 02/28/2026. She reported that she was not aware of any days at the facility without licensed nurses, whether fully or partially, but committed to preventing such situations in the future while serving as the DON. She emphasized that even a few hours without a licensed nurse could put residents' lives at risk, given their age and health conditions.During an interview on 03/03/26 at 3:27 p.m., the ADM stated that she had been employed at the facility since August 2025. She acknowledged occasional shortages of LVN coverage until October 2025 but confirmed that, since that time, there have been no days without licensed nurse coverage, whether LVN or RN. The ADM emphasized that the facility maintained sufficient skilled LVNs on payroll, many of whom were dedicated and willing to work beyond their scheduled hours when needed.Record review of the facility's policy staffing, Sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competence necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.Licensed nurses and certified assistants are available 24 hours a day, seven days a week to provide competent care services . 2. A licensed nurse is designated as a charge nurse on each shift .

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week and designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON (DON) and 1 of 1 RN (RN) reviewed for DON and RN coverage.The facility failed to have an RN on a regular basis in the facility since August 2025.The facility failed to have a full-time DON on regular basis from 10/01/25 to 02/28/26.This failure could place residents at risk of harm due to being left without supervisory coverage for coordination of events such as emergency care, disasters and providing quality care.Findings included:Record review of the facility timecard report revealed the facility did not have a DON from 10/01/25 to 11/30/25 and 12/26/25 to 02/28/26.Record review of the facility time card report revealed the facility did not have RN coverage in year 2025 on 09/01, 09/02, 09/05 to 09/07 , 09/10 to 09/13, 09/15 to 10/05, 10/07 to 10/10, 10/13 to 10/23, 10/25 to 11/14, 11/17 to 11/21 , 11/24 to 12/3 , 12/5, 12/9 , 12/10, 12/12 to 12/15, 12/17 to 12/19, 12/21, 12/24 to 12/26, 12/29 to 12/31 and there were no RN coverages as on 03/03/26 since 01/01/26.During an interview on 03/03/26, at 10:42 AM, LVN B reported that she had previously worked at the facility and, after a period of absence, resumed employment approximately 2.5 years prior to the interview. She stated she had felt the lack of RN and DON as a concern during her new tenure as LVN and on certain occasions posed significant challenges. She said, although the facility occasionally employed RNs and DONs, there were periods when neither was present. In such instances, LVN B indicated that she would seek supervisory guidance by consulting physicians, RNs, or DONs from sister facilities. LVN B mentioned that, when appropriate, she would seek advice from the pharmacy or dietitian as well.During an interview on 03/03/26 at 1:40 p.m., LVN C, who had a longstanding history with the facility and returned to work in October 2025 after a hiatus, stated that there had been no consistent RN or DON coverage since her reemployment. She noted that the DONs employed at the facility had short tenures and frequently resigned. LVN C reported that managing without a regular RN or DON was consistently difficult; nevertheless, she managed these gaps by reaching out to RNs and DONs at sister facilities to obtain their expertise when needed.During a telephone interview on 03/03/26 at 1:10 PM, the MD, who had been with the facility for approximately two years, observed that many DONs had come and gone, resulting in periods during which the facility lacked a DON. The MD said , he was unaware of the absence of RNs but expressed concern regarding the lack of DON services. He stated that the absence of a DON compromised the continuity of care and negatively impacted overall quality. The MD further noted that, in the past, the facility had conducted numerous QAPI meetings without the presence of a DON on the QAPI committee, which he considered problematic with respect to maintaining high standards of nursing care.During an interview on 03/03/26 at 3:17p.m., the DON stated that she was appointed on 01/29/2026 but was unable to commence her duties immediately due to her RN license being overdue for renewal. She said she officially assumed her responsibilities on 02/28/2026, following the renewal of her license. She stated the DON had a critical role in a nursing facility, noting that the DON was responsible for overseeing nursing staff, providing guidance as needed, and ensuring compliance with regulations, policies, and procedures to maintain quality of care. She also mentioned the importance of RNs in such settings, as they provided guidance, support, and performed nursing tasks beyond the scope of CNAs and LVNs. The DON further stated, the role of a DON on the QAPI committee was vital, as the DON was best positioned to articulate nursing-related issues and facilitate discussions aimed at improving the quality of care and residents' quality of life.During an interview on 03/03/26 at 3:27 p.m., the ADM stated that she had been employed at the facility since August 2025. She stated the recurring shortage of RNs and DONs had been an ongoing issue, prompting her to bring this matter to the attention of the director of operations and business partners. She said she had requested the assignment of an RN from sister facilities to serve as an interim DON, given that sister facilities had available RNs and DONs without any outcome. She stated that a registered nurse was currently on the facility's payroll but required clinical supervision for a period of time as per the Board of Nursing due to compromised competency issue in the past. The ADM stated this RN had been working as an RN whenever a DON was present and was expected to resume his duties now that a DON was appointed. The ADM also stated that the corporate office had advertised RNs; however, recruitment was challenging because the facility's remote location limited access to main towns and cities. She further indicated that there were no reported quality concerns attributable to the lack of RNs or DONs, citing the experience of the LVNs and CNAs employed at the facility, as well as the low resident census and the absence of residents with complex health conditions during this period.Record review of the facility's policy staffing, Sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competence necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.A register nurse provides services at least eight consecutive hours every 24 hours, seven days a week. RNs may be scheduled more than eight hours depending on the acuity needs of the resident.Inquiries or concerns related to our facility's staffing should be directed to the director of nursing services (DNS) or his/her designee .

Based on observations, interviews and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and review the risk and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 5 (Resident #2, #7, #12, #18, #26) of 14 residents reviewed for bedrails. The facility failed to properly assess the risk of entrapment, or obtain documentation of informed consents for Resident #2, #7, #12, #18, and #26 prior to the installation and use of bed rails. This failure could place residents at risk of entrapment, restraint, and injury. Findings included: Record review on 3/3/2026 of Resident #2's admission record and 5-day scheduled MDS assessment, dated 1/23/2026, reflected an [AGE] year-old female admitted [DATE] and readmitted on [DATE]. Resident #2 was shown to be her own decision maker with no other RP listed. The resident's diagnoses included cerebral infarction (stroke), contracture of right hand (condition in which one or more fingers bend toward the palm), muscle weakness, and other lack of coordination (inability to perform smooth and precise movements due to a breakdown in communication between the brain, muscles, and nerves). The resident's BIMS score was 12, which indicated moderate cognitive impairment. Section J of the MDS assessment regarding Fall History, reflected the resident had no falls or fractures in the six months prior to admission/entry or reentry. Section P of the MDS assessment regarding restraints and alarms reflected physical restraints were not used, including bed rails. Record review on 3/3/2026 of Resident #2's physical restraint assessment, signed and locked on 12/26/2025, reflected that the resident did not use any form of physical restraint. Record review on 3/3/2026 of Resident #2's care plan reflected an intervention/task initiated and revised on 1/2/2026 that stated, The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working reachable call light, the bed in low position at night; [Slide fails] as ordered, handrails on walls. Personal items within reach. Record review on 3/3/2026 of Resident #2's physical restraint assessment, signed and locked on 1/17/2026, reflected that the resident did not use any form of physical restraint. Record review on 3/3/2026 of Resident #2's Visual/Bedside EHR Report with an admission date on 1/17/2026 reflected, BED MOBILITY: The resident uses positioning bar to maximize independence with turning and repositioning. Record review on 3/3/2026 of Resident #2's MDS EHR Report with an admission date of 1/17/2026 and a review date of 2/8/2026 reflected no physical restraints used in bed including bed rail. Record review on 3/3/2026 of Resident #2's order summary report reflected an active verbal order dated 3/2/2026 that stated, Positioning bar for bed mobility per resident request with no start or end date. Record review on 3/3/2026 of Resident #2's undated Clinical Miscellaneous documents did not reveal any consent form related to bed rail/grab bar usage or the risks and advantages of the use of bed rail/grab bar. Record review on 3/3/2026 of Resident #7's admission record and comprehensive MDS assessment, dated 1/2/2026, reflected a [AGE] year-old female admitted t 6/22/2017 and readmitted [DATE]. Resident #7 was shown to be her own decision maker with the responsible party listed as self. The resident's diagnoses included: chronic respiratory failure (long term condition where the lungs cannot maintain adequate oxygen levels or remove carbon dioxide effectively), chronic obstructive pulmonary disease (progressive lung disease making it hard to breathe), morbid (severe) obesity due to excess calories (BMI of 40 or higher due to the intake of calories in excess of what is used for energy), acquired absence of left leg above knee (loss of the left leg above the knee due to trauma or medical condition), and acquired absence of right leg above knee (loss of the right leg above the knee due to trauma or medical condition). The resident's BIMS score was 12, indicating moderate cognitive impairment. Section P of the MDS assessment regarding restraints and alarms reflected bed rail not in use. Record review on 3/3/2026 of Resident #7's CAA worksheet, dated 1/2/2026, reflected the use of physical restraints was not checked or indicated. Record review on 3/3/2026 of Resident #7's care plan, initiated on 4/10/2018 and revised on 12/14/2023, reflected, SIDE RAILS: Half rails up as per [Dr.s] order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition at least every 2 hours and as necessary to avoid injury. Record review on 3/3/2026 of Resident #7's undated order summary report reflected no order for bed rails or side rails. Record review on 3/3/2026 of Resident #7's undated Clinical Miscellaneous documents did not reveal any form related to bed rail/grab bar/side rail usage or the risks and advantages of the use of bed rail/grab bar/side rail. Record review on 3/3/2026 of Resident #7's Assessments in the EHR did not show an assessment for the safe use of bed rails/grab bars/side rails. Record review on 3/2/2026 of Resident #12's admission record and quarterly MDS assessment, dated 12/19/2025, reflected a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident #12 was shown to have a guardian as her RP. Resident #12's diagnoses included cerebral palsy (group of conditions that affect movement and posture caused by brain damage before birth), severe intellectual disability (disorder that causes difficulties with reasoning, problem-solving, abstract thinking, and learning), muscle weakness, and pain the right hip and left knee. A BIMS was not conducted due to the resident being rarely/never understood. Section P of the MDS assessment regarding restraints and alarms reflected bed rail not in use. Record review on 3/2/2026 of Resident #12's care plan, initiated on 11/3/2016, reflected no focus, goal, or intervention/tasks listed involving the usage of bed rail/grab bar/side rail. The care plan reflected an entry for ADL Self Care Performance Deficit r/t Aggressive Behavior, Confusion, Impaired Balance with intervention/tasks for bed mobility as I require assistance from staff with bed mobility care at times, Level of assistance may vary depending on my condition. Record review on 3/2/2026 of Resident #12's undated order summary report reflected no order for bed rails or side rails. Record review on 3/2/2026 of Resident #12's undated Clinical Miscellaneous documents did not reveal any form related to bed rail/grab bar/side rail usage or the risks and advantages of the use of bed rail/grab bar/side rail. Record review on 3/2/2026 of Resident #12's Assessments in the EHR did not show an assessment for the safe use of bed rails/grab bars/side rails. Record review on 3/3/2026 of Resident #18's admission record and comprehensive MDS assessment, dated 10/31/2025, reflected a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident #18 was shown to have a RP listed. Resident #18's diagnoses included type 2 diabetes with diabetic peripheral angiopathy (disorder that occurs when the body becomes resistant to insulin or the pancreas fails to produce insulin leading to high blood sugar that damages blood vessels and reduces blood flow to the limbs), chronic obstructive pulmonary disease (progressive lung disease making it hard to breathe), traumatic hemorrhage of cerebrum (brain bleed caused by trauma), and muscle weakness. The resident's BIMS score was 15, indicating normal cognitive functioning with minimal or no impairment. Section P of the MDS assessment regarding restraints and alarms reflected bed rail not in use. Record review on 3/3/2026 of Resident #18's care plan, initiated on 12/9/2022, reflected no focus, goal, or intervention/tasks listed involving the usage of bed rail/grab bar/side rail. The care plan reflected resident had an ADL self-care performance deficit with interventions/tasks initiated on 2/20/2025 and revised on 5/5/2025 related to bed mobility listed as, I require setup assistance from staff with bed mobility care at times, Level of assistance may vary depending on my condition. Record review on 3/3/2026 of Resident #18's order summary report reflected no order for bed rails or side rails. Record review on 3/3/2026 of Resident #18's undated Clinical Miscellaneous documents did not reveal any form related to bed rail/grab bar/side rail usage or the risks and advantages of the use of bed rail/grab bar/side rail. Record review on 3/3/2026 of Resident #18's Assessments in the EHR did not show an assessment for the safe use of bed rails/grab bars/side rails. Record review on 3/3/2026 of Resident #26's admission record and quarterly MDS assessment, dated 12/26/2025, reflected an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident #26 was listed as her own RP. The resident's diagnoses included chronic obstructive pulmonary disease (progressive lung disease making it hard to breathe), type 2 diabetes mellitus with diabetic neuropathy (disorder that occurs when the body becomes resistant to insulin or the pancreas fails to produce insulin leading to nerve damage), morbid (severe) obesity due to excess calories (BMI of 40 or higher due to the intake of calories in excess of what is used for energy), and muscle weakness. The resident's BIMS score was 13, indicating normal cognitive functioning with minimal or no impairment. Section P of the MDS assessment regarding restraints and alarms reflected bed rail not in use. Record review on 3/3/2026 of Resident #26's care plan, initiated on 1/9/2020 and revised 12/30/2025, reflected no focus, goal, or intervention/tasks listed involving the usage of bed rail/grab bar/side rail. Record review on 3/3/2026 of Resident #26's undated order summary report reflected no order for bed rails or side rails. Record review on 3/3/2026 of Resident #26's Clinical Miscellaneous documents did not reveal any form related to bed rail/grab bar/side rail usage or the risks and advantages of the use of bed rail/grab bar/side rail. Record review on 3/3/2026 of Resident #26's Assessments in the EHR did not show an assessment for the safe use of bed rails/grab bars/side rails. During an observation of Resident #12's bed area on 3/1/2026 at 1:19 p.m. revealed bed rails attached to the resident's bed. During an observation of Resident #7's bed area on 3/1/2026 at 1:48 PM revealed bed rails attached to the resident's bed. Observation of Resident #2's bed area on 3/3/2026 at 11:00 a.m. revealed bed rails attached to the resident's bed. During an observation of Resident #18's bed area on 3/3/2026 at 2:30 p.m. revealed bed rails attached to the resident's bed. During an observation of Resident #26's bed area on 3/3/2026 at 2:33 p.m. revealed bed rails attached to the resident's bed. During an interview on 3/2/2026 at 4:15 p.m., MD A stated that he was the MD for the facility for approximately the last 1.5 years. MD A stated that he does not recall being consulted for the use of bed rails of any resident at the facility. MD A stated that he would strongly prefer the facility consult with him prior to use or installation, MD A said he did not recall writing an order for bed rails for any resident at the facility. MD A stated the use of bed rails posed a risk for entrapment and restraint. MD A stated he did not prefer the use of bed rails for that reason. MD A stated that he would ensure that he followed up with the facility and ensure the use of bed rails is discontinued. In an interview on 3/3/2026 at 10:41 AM, LVN B stated that she was employed with the facility for 2.5 years as a LVN LVN B confirmed the use of bed rails within the facility. LVN B stated that bed rails were used for positioning and bed mobility purposes. She did not know when bed rails were implemented for those in use. She stated that use of bed rails would require the MDS assessment to reflect their use, an order for use, their use be documented in the care plan, and consent forms to have been obtained from residents or their representatives. LVN B stated that consultation with therapy services, the doctor, the ADM, and the DON should be done for alternative options before bed rails are utilized to determine if they're appropriate. LVN B stated that she was sure a safety assessment should be completed for each resident before bed rail use was implemented. She said there were no problems or accidents related to bed rails or grab bars that she knew of. LVN B stated that the possible negative outcomes related to the use of bed rails or side rails could be injury or accidents such as skin tears if the resident's arm gets caught in the rail. LVN B stated failure to follow the proper process for bed rail use could pose a threat to the residents' safety. Interview on 3/3/2026 at 1:08 p.m. revealed RP #1 stated she was the assigned court appointed guardian case manager for Resident #12 for two yrs, but the agency in which she worked was the assigned guardian for some time. RP #1 stated that she had no concerns or issues related to the care or supervision provided to Resident #12 at the facility. RP #1 stated Resident #12 had no accidents or injuries at the facilit. RP #1 said Resident #12 was very happy at the facility and RP #1 was very satisfied with the facility, too. RP #1 stated she was not aware of the use of bed rails for Resident #12 and she did not sign a consent for their use. RP #1 stated that consent could have been provided by the prior case manager. RP #1 said she had not noticed bed rails were being used. She said she was not opposed to their use if their use was recommended and ordered due to an identified need. RP #1 said she was included in care plan meetings and care plan developments and never had concerns for abuse, neglect, or exploitation of the resident in the facility. During an interview on 3/3/2026 at 2:30 p.m., Resident #18 stated that it was her preference to have bed rails installed on her bed for mobility purposes. During an interview on 3/3/2026 at 2:33 p.m., Resident #26 stated that it was her preference to have bed rails installed on her bed for mobility purposes. During an interview on 3/3/2026 at 3:27 p.m., the ADM revealed she was employed at the facility since August 2025. She stated that in-service and training were regularly provided to staff regarding resident care and needs topics. The ADM stated that her expectation regarding the use of bed rails was to follow their policy. She said the use of bed rails should be documented and ensure residents were restraint free. She said she expected each resident using bed rails to have a care plan in which the use was documented and orders were obtained prior to their use. The ADM stated she believed consents were required as well. The ADM stated there were benefits and risks when bed rails were used such as keeping resident safe, but she stated, a lot could go wrong mentally and physically and they could cause harm. The ADM stated the MDS should reflect residents' status and needs accurately. The ADM stated this could negatively impact the safety of the residents. Record review of the facility's policy titled, Restraint-Free Care: Upholding Dignity and Safety at The Hilltop on Main, reflected the following: The Hilltop on Main is committed to maintaining a restraint-free environment in all areas of care. Restraints are any physical or mechanical device, material, or equipment attached to or adjacent to a resident's body that the individual cannot easily remove and that restricts freedom of movement or normal access to one's body. A restraint free environment protects the physical, emotional, and psychological health of residents. Restraints can cause harm, agitation, confusion, or loss of function. Federal and state standards uphold the right of every resident to live free from unnecessary restraints.restraints are only used as a last resort in cases where immediate harm is imminent and no other safe alternatives exist Staff are trained to utilize alternative interventions such as.scheduled toileting, hydration, and mobility routines. Each staff member plays a vital role in maintaining a restraint free culture. Record review of the facility's policy and procedures regarding Bed Safety and Bed Rails reflected the following: The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The resident sleeping environment is evaluated by the interdisciplinary team.Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 10. Additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment (e.g., altered mental status, restlessness, etc.) Use of Bed Rails .bed rails include:Side railsSafety rails; and Grab/assist bars2. a. The definition of restraints is based on the functional status of the resident and not on the device.3. The use of bed rails or side rails.is prohibited unless the criteria for use of bed rails have been met, including attempts to use other alternatives, interdisciplinary evaluation, resident assessment, and informed consent.5. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. The interdisciplinary evaluation includes: a. an evaluation of alternatives to bed rails that were attempted. b. the resident's risk associated with the use of bed rails. c. input from the resident and/or representative. d. consultation with the attending physician.6. The resident assessment to determine risk of entrapment includes, but is not limited to: a. medical diagnosis b. size and weight c. sleep habits d. medication(s) e. acute medical and surgical interventions f. underlying medical conditions g. existence of delirium h. ability to toilet self safely i. cognition j. communication k. mobility (in and out of bed; and l. risk of falling.8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.

Based on observation, interview, and record review, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 3 days (03/01/26, 03/02/26 and 03/03/26) of 3 days reviewed for posted nurse staffing information.The facility did not post the required current nurse staffing information from 03/01/26 through 03/03/26.This failure could place residents at risk of not having access to information regarding staffing data and the facility census.Findings included:During an observation on 03/01/26 at 10:00 a.m., it was revealed that there was no staffing posting present at the facility with facility name and date containing the total number of staff and actual hours worked by RNs, LPNs and LVNs or CNAs who are directly responsible for resident care.During an observation and interview on 03/03/26 at 1:25 p.m., LVN C searched the nursing station and surrounding area for the daily staffing postings. She stated that there was no staffing posting present. She also searched various folders for previous days' postings but was unable to locate any. LVN C indicated that there were no staffing postings for 03/01/16 and 03/02/26. She stated that it was the responsibility of the DON to ensure the daily staffing information was posted.During an interview on 03/03/26 at 1:40 p.m., the DON stated that she was new to the facility, having started on 02/28/26, and was not aware that it was her duty to post the daily staffing information. The DON stated that staffing postings were important for residents, their families, and visitors, as they provided information regarding the number of staff members in various roles available for nursing-related tasks. She stated she would post the staffing information as soon as possible.Record review of the facility's policy, Staffing, sufficient and competent nursing, revised in August 2022, reflected: .Direct care daily staffing numbers (the number of nursing professional responsible for providing direct care to residents) are posted in the facility for every shift.

Based on observation, interviews and record review, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs safely and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being for 2 of 2 (Resident #22 and #24) reviewed for competent nursing staff. The facility failed to ensure CNA A utilized appropriate communication, intervention, and redirection methods with Resident #24 which led to an escalation of conflict between Resident #22 and Resident #24 resulting in Resident #22 making threatening gestures and a threat of harm to Resident #24. This failure could place the residents at risk of serious injury or harm. Findings included: Record review on 3/1/2026 of Resident #22's admission record and modified quarterly MDS assessment, dated 2/13/2026, reflected an [AGE] year-old male admitted on /2022 and readmitted [DATE]. Resident #22 was his own RP. Resident #22's diagnoses included chronic obstructive pulmonary disease (trouble breathing), Alzheimer's disease with late onset dementia, (condition causing confused thinking) and major depressive disorder (sadness, lack of interest or pleasure in doing things that does not resolve on it's own) The resident's BIMS score was 11, indicating moderate cognitive impairment. Record review on 3/1/2026 of Resident #22's care plan reflected an intervention/task initiated on 3/16/2022 stated, Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Record review reflected this intervention/task was the responsibility of the CNA. Record review on 3/1/2026 of Resident #24s admission record and modified quarterly MDS assessment, dated 2/13/2026, reflected a [AGE] year-old male admitted [DATE] and 1/30/2021. Resident #26 had a responsible party/POA listed. Resident #26's diagnoses included type 2 diabetes mellitus with hyperglycemia ((a condition characterized by insulin resistance and high blood sugar), chronic obstructive pulmonary disease (progressive lung disease making it hard to breathe), vascular dementia, moderate, with other behavioral disturbance (cognitive decline due to reduced blood flow to the brain, leading to various behavioral changes), personality change due to known physiological condition (alterations in behavior, mood, and interpersonal interactions), psychotic disorder with delusions, and major depressive disorder, without psychotic features (depression that significantly impairs daily functioning with symptoms including sadness, loss of interest in activities and a decrease in daily functioning). Resident #26's BIM score was 01, indicating severe cognitive impairment. Resident #26's MDS assessment reflected the resident had unclear speech, his ability to express his ideas and wants was limited to making concrete requests, and he sometimes made himself understood with simple, direct communication only. The MDS assessment reflected Resident #26 had no behavioral symptoms, including physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behaviors. Record review on 3/1/2026 of Resident #26's care plan focus task initiated on 7/31/2015 and revised on 4/28/2022 stated, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs[)]Disease process. Care Conference Resident only [involves] in activities with food, occasionally church, [watch] tv and resident shopping[)]. The intervention for this focus task stated, Modify daily schedule, treatment plan PRN to accommodate activity participation as requested by the resident. This focus task, goal and intervention was the responsibility and duty of the CNA. Resident #26's care plan included a focus task initiated 7/29/2015 and revised on 5/20/2025 which stated, The resident has a communication problem r/t stroke, expressive aphasia sometimes understands and sometimes understood and speech unclear SHAKES HEAD YES/NO OR USES HAND GESTURES. and an interventions initiated 7/29/2015 which stated, Anticipate and meet needs, and Speak on an adult level, speaking clearly and slower than normal initiated on 11/6/2022, which were the responsibility of and duty of the CNA. During an observation on 3/1/2026 at 12:10 p.m. during dining service, Resident #22 was sitting at a table with three other residents waiting for lunch to be served. Resident #26 was observed sitting alone at a table approximately three ft from Resident #22. CNA A and LVN A were observed in the dining room as well. Resident #26 was observed motioning toward the TV in the activity area of the dining room and using simple words to indicate he wanted the TV turned on. He did this repeatedly. CNA A responded to Resident #26 as if he was a child in a belittling tone telling him, No! We are not watching TV and That is not your TV. We aren't turning the TV on! You are not watching TV. It's too loud. We want it quiet. CNA A was observed taking the TV remote out of Resident #26's hand. CNA A was observed saying this repeatedly. esident #26 continued to ask for the TV to be turned on. Resident #26 began wheeling himself toward the TV to turn it on manually. As Resident #26 was wheeling toward the TV, Resident #22 stood up and said, Boy, you better not turn on that TV while pointing at Resident #26. Resident #22 said this several times while standing and attempting to follow Resident #26. Resident #26 managed to manually turn on the TV and when he returned to his table, Resident #22 pointed his finger in Resident #26's face and said, I'm going to kick your ass. Resident #26 did not seem bothered by Resident #22's behavior or words. Resident #26 did not respond to Resident #22. LVN A then returned to the dining room and was made aware of the situationby the state surveyor During an interview on 3/1/2026 at approximately 12:20 p.m., LVN A said that the behavior described was typical of the residents. LVN A said that the residents should not be sitting so close to each other and moved Resident #26 to another table. LVN A stated that she was unaware of whether the behaviors observed were care planned or what interventions were appropriate for each resident. CNA A did not return to the dining room for the remainder of the observation period. Record review of Resident #22's progress notes for the prior 30 days on 3/3/2026 at 1:33 PM revealed the following regarding group activities: 2/26/2026 17:55 Resident attended card bingo and travelogue. Resident needs to be redirected with instructions during functions. 2/24/2026 17:04 .Resident needed to be redirected with instructions during functions.2/18/2026 10:00 .Resident needed to be redirected with instructions during functions. 2/17/2026 16:34 . Resident needed to be redirected with instructions during functions. 2/16/2026 08:39 . Resident needed to be redirected with instructions during functions. During an interview on 3/3/2026 at 12:37 p.m., the AD stated that she was employed at the facility for four years. The AD stated that she received good support and training in order to do her job well. Regarding Resident #22 and #26, the AD stated that she heard they had an incident on 3/1/2026. The AD stated that these residents did not typically have issues with each other and during activities they don't really interact. AD stated that Resident #22 could be mean or inconsiderate. AD stated that she attributed this to his age. AD stated that when Resident #22 acted this way, she would remove the resident from the activity or redirect him. AD stated that Resident #22 makes comments to other residents by bossing them around or calling them names. AD stated that she utilized pleasant verbal redirection with the resident and if his behavior continued, she would take the resident out of the activity. AD stated that she would have handled the situation between Resident #22 and #26 differently. AD stated that she would have turned the TV on for Resident #26. AD stated that Resident #22 would not have acted in this way had CNA A not escalated the situation. AD stated CNA is aware of the residents' needs and triggers but continued to interact with the residents in a way that escalated their behaviors. AD stated that she had reported CNA A to the nurses over the last year that CNA A isn't mindful of the residents' rights. The nursing staff said they were going to talk to CNA A and provide inservice. AD stated that CNA A should never have argued with the resident or refused the TV. AD stated that she reminded CNA A often that this is the residents' home, not theirs. AD said the TV was the residents' TV. AD stated that they usually have the TV on during lunch and it's never been a problem and the residents liked it on. Observation of Resident #22 attempted on 3/3/2026 at 12:58 p.m. but the resident was sent out to the hospital on 3/2/2026 for an unrelated situation and was not available for observation or interview. During an observation and interview of Resident #26 on 3/3/2026 at 12:58 PM in the dining room revealed the resident pleasantly eating lunch at a table sitting alone. He responded with yes responses or head nods. He indicated that he was doing well and had no problems. He indicated that he was enjoying his lunch. No signs of distress or negative psycho social outcomes observed. In an interview on 3/3/2026 at 12:58 p.m. with RP #2, Resident #26's RP, stated there were no concerns with the resident's care or supervision voiced. RP #2 stated she had no concerns for the resident's safety or well being. She stated she was notified of the incident between Resident #26 and #22. She stated that the resident had no prior incidents with other residents. RP #2 said she Resident #26 has had no negative occurrences with staff to her knowledge. RP #2 said she visits Resident #26 a couple of times a month and has not had any concerns. During an interview on 3/3/2026 at 1:51 p.m., LVN A stated that there aren't usually problems between Resident #22 and #26. She said Resident #26 has a history of screaming out but Resident #22 doesn't. LVN A stated that CNA A was the problem because she does not appropriately interact or intervene with residents. LVN A stated that CNA A is demanding and controlling of the residents and didn't utilize appropriate deescalation techniques. LVN A said CNA communicated with residents in a disrespectful manner. LVN A stated that CNA A often disappeared and didn't help with resident care. LVN A stated that she had reported her concerns and observations to management in the past and the issue continued. She stated that the staff turnover and the lack of consistent management staff had made reporting all concerns difficult. During an interview on 3/3/2026 at 2:16 p.m., CNA A stated she was employed at the facility for 18 months. She stated she was educated, trained and regularly in serviced on resident care, meeting resident needs, and resident interventions. CNA A stated the facility is understaffed and she felt unsupported in that manner. She said she had made staffing concerns known to the charge nurse. She said the facility had only had a DON for 2 weeks so she had not made a report to the DON. CNA A stated that she is often tired because of the amount of hours and work she had to complete. In regards to the incident between the residents observed, CNA A stated Resident #22 wanted the TV off and Resident #26 wanted the TV on so she told Resident #26 they couldn't turn the TV on. CNA A said the AD hid the remote. CNA A stated she overheard #22 tell other residents he did not want the TV on so she honored that. CNA A stated that she left the dining room to go help elsewhere. CNA A stated she thought it was appropriate to tell the residents to keep the TV off. CNA A stated that she usually told the residents what to do to keep peace and maintain order and talked in a tone to make them understand. Record review on 3/3/2026 at approximately 2:30 p.m of CNA A's personnel file revealed an orientation list for CNA regarding relevant resident care, dementia care and relevant resident related topics but no indication that CNA reviewed this list and no indication of a skills check-off. The file reflected two prior disciplinary actions in approximately February and August 2025 related to refusal to provide resident care and inappropriate resident interaction and response. In an interview on 3/3/2026 at 3 PM, the DON stated that she was made aware of the incident between Resident #22 and #26 on 3/1/2026 by LVN B. The DON stated that she gave LVN B instructions on what to do and who to notify. She said she read the nurses notes to make sure all necessary tasks were done. The DON said she interviewed staff to ensure resident safety. DON said she hadn't observed CNA A's interactions with the residents much but had no concerns from her limited observations. DON said she wasn't fully aware of how the incident was handled until this day but once she learned, CNA A was terminated. DON said CNA A's interventions and actions were inappropriate and no consistent with her duties and responsibilities. DON stated that she didn't know CNA had been previously disciplined but if she did she would've taken her off of the floor immediately and made sure she was held to the proper standards and ensured her competency. DON said any refusal of care would've been a problem because that was the basis of CNA A's job. DON stated that potential negative outcomes of the situation could have been hurt feelings of the residents and residents feeling disrespected in their own home. DON said it could have also led to residents' needs not being met. DON stated that it was possible that this situation might not have occurred if CNA A didn't engage in an argument with residents about the TV in the first place. In an interview on 3/3/2026 at 3:27 p.m., the ADM stated she was employed at the facility since August 2025 and regular in-service education and training on relevant resident care topics had been provided to staff during her time at the facility. The ADM stated she made regular rounds to observe staff to resident interactions and had no concerns. She stated no concerns were reported to her by anyone else. The ADM stated if she learned of staff failures, she would provide specific in-service education and provide counseling or coaching. The ADM stated that she expected staff to treat residents with respect and dignity and provide care they are trained to provide.

Based on observations, interviews, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 13 residents (Resident #8) reviewed for accuracy of assessments. The facility failed to accurately indicate Resident #8's receipt of injections and insulin injections on the resident's quarterly MDS assessment completed on 12/10/2025. This failure could place residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review on 3/2/2026 of Resident #8's quarterly MDS assessment, dated 12/19/2025, reflected a [AGE] year-old male admitted [DATE]. His diagnoses included neurocognitive disorder with Lewy bodies (protein deposits that develop in nerve cells of the brain that affect thinking, memory and movement), Type 2 Diabetes with moderate non-proliferative retinopathy without macular edema, right eye (a condition characterized by insulin resistance and high blood sugar that has caused right eye damage), neuroleptic induced parkinsonism (movement disorder caused by the use of antipsychotic medications), and acquired absence of right foot (loss of the right foot due to a condition not present at birth). Resident #8's BIMS score was 10, indicating moderate cognitive impairment. Section N of the assessment regarding medications showed Resident #8 received 0 injections of any type during the prior seven days or since admission/entry or reentry if less than seven days. Section N of the assessment regarding insulin had no entries for the number of days that insulin injections were received during the prior seven days or since admission/entry. Record review on 3/2/2026 of Resident #8's care plan reflected dated 8/5/2024, The resident has Diabetes Mellitus On NCS diet (dietary approach that eliminates extra sugar in the diet;diet, No Concentrated Sweets. Trulicity, Jardiance, Metformin and regular insulin administered on a sliding scale every am and hs. Record review on 3/2/2026 of Resident #8's Order Summary Report revealed an active order for Insulin Regular Human Injection Solution Injection.Inject as per sliding scale.and call MD for another further orders if above 400, subcutaneously (method of delivering medication into the fatty tissue just beneath the skin, allowing slow and steady absorption into the bloodstream. in the morning related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA ordered on 8/31/2024, started on 9/1/2024, with no end date listed, and an active order for Trulicity Subcutaneous Solution Auto-injector 1.5MG/.5ML (Dulaglutide) Inject 1 dose subcutaneously (under the skin) in the morning every Mon related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA ordered on 1/24/2025, started on 1/27/2025, with no end date listed. Record review on 3/2/2025 of Resident #8's Medication Administration Record, dated December 2025, revealed Insulin and Trulicity injections were administered to Resident #8 as ordered and in the 7 days prior to the completion of the MDS quarterly assessment completed on 12/19/2025. During an observation and interview on 3/1/2026 at 1:39 p.m., Resident #8 stated was diabetic and received insulin to manage his blood sugar. During an interview on 3/2/2026 at 2:54 p.m., MDS A stated that she had 30 years of experience conducting MDS assessments. She stated that she was a Clinical Reimbursement Specialist for the company that operated the facility. MDS A stated she conducted MDS assessments for this facility and was employed with the company for five yrs. She stated that she had the proper training and skills to conduct MDS assessments and received ongoing education, inservice, and support to do her job well. During record review of MDS A Resident #8's quarterly MDS assessment, dated 12/19/2025, physician orders, and Medication Administration Record for December 2025 during the interview and confirmed Resident #8 did receive insulin and injections during the seven days prior to the completion of the quarterly MDS assessment completed by MDS A on 12/19/2025. MDS A stated this was a mistake and oversight on her part. MDS A stated that there would be no negative outcome to the resident due to her mistake, but it would have a negative effect on the reimbursement amount the facility received for services. During an interview on 3/3/2026 at 10:41 a.m., LVN B stated that she was employed with the facility for 2.5 years as a Licensed Vocational Nurse. LVN B stated that MDS assessments should accurately reflect the needs and characteristics of the residents, LVN B stated that the MDS assessment should accurately reflect the needs and characteristics of the residents, including the use of insulin and receipt of injections. LVN B stated an inaccurate MDS assessment could have a negative impact on residents' health and safety because it is the basis of the creation of the plan of care and the use of insulin and injections needed to be monitored. LVN B stated it would also not provide a clear clinical picture. During an interview on 3/3/2026 at 3:27 p.m., the ADM stated that she was employed at the facility since 8/13/2025 as the administrator. She stated that she oversaw staff and resident care at the facility. She reported no observed concerns with the care provided to the residents. The ADM stated that her expectation was that the MDS assessments completed on residents would accurately reflect the status and needs of the residents. She stated that inaccurate MDS assessments could negatively impact the safety of the residents. The ADM stated, specifically regarding insulin, an inaccurate assessment could lead to their blood sugar being off and negatively impact the resident's health. Record review on 3/2/2026 of the facility's Electronic Transmission of the MDS policy revised September 2010 reflectedAll staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS RAI Instruction Manual, before being permitted to use the MDS Information System. A copy of the MDS RAI Instruction Manual is maintained by the Resident Assessment Coordinator. Record Review on 3/2/2026, of the Long-Term Care Facility RAI 3.0 User's Manual revised October 2025 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for the facility's only kitchen reviewed for food service safety. 1. The facility failed to ensure food was labeled with a product name and use by date in the facility's only walk-in freezer, walk-in cooler, and side-by-side refrigerator. 2. The facility failed to clean, and sanitize, the kitchen's only industrial can opener. 3. The facility failed to ensure the sanitizer in the facility's only dishwasher was at 50 PPM. These failures placed residents at the facility at risk for ingesting food borne pathogens. Findings included: Observation and interview on [DATE] at 10:08 AM revealed the kitchen's only industrial can opener (a metal can opener attached to a table/counter to open large metal cans.) The industrial can opener had a 6-inch-long handle which rotated a metal gear (like the size and shape of a hockey puck,) which in turn rotated a metal can. On the underside of the 6-inch-long handle mechanism, was a 1-inch piece of sharp metal, which ended at a point, which pierced the top of the can. Inside the metal gear, and on the 1-inch piece of sharp metal, was a black sticky substance. The black sticky substance was easily removed with gloved fingers. The black sticky substance was easy to roll between two fingers and produce 1 pea-sized amount of contamination. Observations on [DATE] at 10:11 AM of the facility's only walk-in freezer revealed 3 bags of frozen chicken in 3 individual bags. Two bags contained frozen chicken; neither plastic bag had a label for the product name, or a label with a date to use by. The third bag of chicken was not sealed, open to air, and did not have a label for the product name or a label with a date to use by. All three bags had frost and ice built up inside the bag. Observations on [DATE] at 10:12 AM of the facility's only walk-in cooler revealed a large cardboard box on the middle shelf. The large cardboard box contained 12 small bags of green beans. The outside of the cardboard box did not have a label for the product name or a label with a date to use by. The small individual bags of green beans did not have a label for the product name or a label with a date to use by. Observations on [DATE] at 10:13 AM of the facility's only side-by-side refrigerator revealed a large sealable bag of cooked bread. The bag of cooked bread did not have a label for the product name or a label with a date to use by. Interview and observation on [DATE] at 10:20 AM with the KM revealed the industrial can opener was supposed to have been swapped out yesterday, [DATE], but a lot was going on. She messaged the MD to come to the kitchen. He presented promptly; he was observed having removed the old industrial can opener and installing a new one. Interview and observation on [DATE] at 10:28 AM of the facility's only dishwasher revealed the KM operating the dishwasher to check the amount of liquid sanitizer in the rinse cycle. The dishwashing machine had an information plate that reflected the appropriate chemical concentration was 50 PPM. To check the amount of the liquid sanitizer in the rinse cycle, the KM utilized a small piece of test paper provided by the company that serviced the machine. The KM was observed taking a small piece of test paper (about the size of a fortune from a fortune cookie) and rested it across an item that just exited from the dishwashing machine. After placing the test paper on the item, the test paper was supposed to react to the sanitizing chemical and darken to correspond with a color chart on the test strip container, representing an acceptable amount of sanitizer. The observation revealed the test strip, which was originally off-white, did not change color. The amount of sanitizer in the rinse cycle was not sufficient to cause a chemical change on the test paper, nor sufficient to sanitize the dishes run through the machine. The KM stated she would not run any more dishes through the machine until it was fixed. She stated she was going to call the dishwashing company to come out and look at the machine. Record review of a photo of the information plate on the facility's only dishwasher reflected the chemical sanitizing concentration was supposed to be 50 PPM. Interview on [DATE] at 11:18 AM with the KA revealed staff had to put a used by date and labeled all the food. She stated staff had to put a used by date so they would know when food went bad. She stated when the food expired, they would throw it out. She stated if residents were served expired food, they could have gotten food poisoning, diarrhea, and dehydrated. She stated before the staff used the can opener, they should have made sure it was clean so it would not grow bacteria. She demonstrated how she checked the dishwasher temperatures. Interview on [DATE] at 11:33 AM with the KM revealed food storage could not have food out of date. She stated they used the first-in, first-out method which involved using the older food first. She stated when food had reached the used by date, they would throw it out. She stated they should have checked the dates before they send the food out and food was thrown out after 72 hours. She stated if a resident would have eaten food that had sat for a long period of time, the residents could have gotten a sickness such as food poisoning. She stated the equipment had to be kept clean so bacteria would not transfer. She stated they should have sanitized the equipment before and after use. She stated the dishwasher was used to kill all the germs and bacteria. She stated if a resident ingested bacteria they could get sick. She stated most of the residents were more susceptible to getting sick. She stated they had to make sure the dishwasher had the right temperature and sanitizer. She stated for training, she took notes, spot checked, and redirected. Interview on [DATE] at 11:47 AM with the DON revealed, regarding the food borne pathogens, if temperatures were not checked or food was stored too long, the residents could get illnesses. She stated the residents could get stomach viruses such as nausea, vomiting, or dehydration. She stated there had not been any residents in the three-week period that she had worked at the facility with outbreaks of food borne pathogens that she was aware of. She stated they should have a safeguard in place and should have had a policy in place that they dated and checked the food. She stated the kitchen supervisor should have checked and made sure staff had cleaned the equipment. Interview on [DATE] at 11:55 AM with the ADM revealed they should have labeled and dated all foods that were opened. She stated food should be discarded after 72 hours. She stated they should not keep expired food and it could cause stomach issues such as diarrhea. She stated schedules should have been made by the KM, so everyone knew what needed to be cleaned. She stated they should have checked the dishwasher temperatures during a wash. She stated she checked the temperature once a week. She stated the staff had been trained and she went in the kitchen weekly and followed up with manager. She stated she also checked everything in the kitchen to make sure staff were complying. Record review of the facility's Food Receiving and Storage Policy, dated [DATE], reflected that all food in the freezer of refrigerator will be covered, labeled, and dated with a use by date. Record review of the facility's Dishwasher Machine Use Policy, dated [DATE], reflected the dishwasher chemical sanitizer concentration was ,d+[DATE] PPM. Corrective action would be taken immediately if sanitizer concentration was too low. If chemical concentration did not meet requirements, use of the machine would cease immediately until PPM were adjusted. Record review of the facility's Sanitization Policy, dated [DATE], reflected all equipment was supposed to be kept clean, maintained in good repair. All equipment was supposed to have been washed to remove or completely loosen soils by manual or mechanical means necessary and sanitized with hot water or chemical sanitization. Record review of the Food and Drugs Administration 2022 Food Code, [DATE] Edition, reflected guidance for Ware-washing Machine, Data Plate Operating Specifications. Section ,d+[DATE].113 reflected the data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The ware-washing machine has been tested , and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored. Record review of the Food and Drugs Administration 2022 Food Code, [DATE] Edition, reflected guidance for Sanitizing Solutions, Testing Devices. Section ,d+[DATE].14 Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic. Record review of the Food and Drugs Administration 2022 Food Code, [DATE] Edition, reflected guidance for Reduced Oxygen Packaging. Annex 6, Food Processing Criteria indicated the shelf life of foods was based on storage temperature for a certain time and other intrinsic factors of the food. Each package of food was supposed to have born a [use-by date.] Record review of the Food and Drugs Administration 2022 Food Code, [DATE] Edition, reflected guidance for Can Openers. Section ,d+[DATE].19 indicated the cutting, or piercing, surfaces of a can opener could have directly contacted food as the contain was opened. These surfaces must have been protected from contamination.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #1) of 6 residents reviewed for infection control. The DON failed to use enhanced barrier precautions during a gastrostomy feeding for Resident #1 on 01/22/2025 by not donning a gown prior to administering the feeding. This failure could place residents at risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #1 face sheet dated 1/22/2025 reflected she was a [AGE] year-old female with diagnoses of unspecified dementia (a loss of thinking, remembering, and reasoning skills), type 2 diabetes mellitus (elevated blood sugars), dysphagia (difficulty swallowing), and encounter for attention to gastrostomy (care of gastrostomy tube). Record review of Resident #1s annual MDS assessment dated [DATE] reflected she had a BIMS score of 6 indicating Resident #1 had severe cognitive impairment. The MDS reflected Resident #1 was Dependent for eating (indicating the helper does all the effort and the resident does none of the effort to complete the activity). The MDS reflected Resident #1 received 51% of her total calories through parenteral or tube feeding. Record review of Resident #1's care plan dated 07/09/2023 and updated 08/22/2024 reflected Resident #1 had a diagnosis of severe oropharyngeal dysphagia. She had a history of aspiration pneumonia, and a feeding tube was recommended and placed. The goal was that Resident #1 would be free of aspiration pneumonia through the review date. Interventions included that Resident #1 was dependent with tube feeding and water flushes. Interventions also included to Monitor/document/report PRN any signs and symptoms of: Aspiration- fever, SOB, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Record review of Resident #1's Physicians Order summary report dated 01/22/2025 reflected give Glucerna 1.5 237 ml five times a day for Nutrition. Flush tube with 60mL water before and after every feeding and/or meds dated 01/15/2025. In an observation of a gastric tube bolus feeding on 1/22/25 at 11:00 am, the DON failed to don her gown Prior to entering the room and the administration of the gastrostomy feeding for Resident #1. In an interview on 1/23/25 at 10:49, the [NAME] stated she had been employed at the facility for 3 weeks as the Director of Nursing Services. She stated she was curious why enhanced barrier precautions were not in place, but she had been working the floor as charge nurse and had not had time to address the issue. She stated her administrator was the certified infection preventionist. The DON stated the administrator or infection preventionist was responsible for educating the staff and ensuring proper enhanced barrier precautions were in place for residents that required them. The DON stated some of the negative effects related to not having enhanced barrier precautions in place for residents with g-tubes could be the spreading of infection. In an interview on 1/23/25 at 11:15am with the ADM, she stated all staff should have monitored for the needs for enhanced barrier precaution for the residents. She stated the DON was new; she just started on the January 6th, 2025. The ADM stated she was responsible for infection preventionist monitoring. She stated she was responsible for educating the staff on enhanced barrier precautions. She stated the previous DON made rounds daily and monitored for the need of enhanced barrier precautions. She stated gown and gloves should be used during those high contact resident care activities to prevent the spread of infection. Record review of facility policy titled Enhanced Barrier Precautions dated August 2022 reflected Enhanced barrier precautions are utilized to prevent spread of multi-drug-resistant organisms to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to the resident. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.)

Based on interview, and record review, the facility failed to implement a comprehensive care plan that describes the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents(Resident #1) reviewed for care plans. The facility failed to revise the nutritional careplan and develop and implement a care plan for severe weight loss of 16.1% and refusal to eat identified in a two month period from admission on 12/05/2023 and last record of weight on 02/05/2024. The facility failed to develop and implement a care plan related to Resident # 1 self isolating, blocking his room door,signs, symptoms of depression, and refusal to see Psych NP on 01/15/2024 which resulted in Resident # 1 to attempt suicide on 03/01/2024. An Immediate Jeopardy (IJ) situation was identified on 03/22/2024 at 3:00 p.m. While the IJ was removed on 03/23/2024 at 07:50 a.m., the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for accidents, diminished quality of life, and suicide. Findings included: Review of Resident #1's undated face sheet revealed an [AGE] year-old male with an admitted [DATE]. Diagnoses included hypertension(high blood pressure), cardiomyopathy(disease of heart muscle), and hyperlipidemia(high cholesterol). Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated moderate cognitive impairment. MDS indicated no behaviors and malnutrition(protein or calorie) or at risk for malnutrition for Resident #1. Review of Resident #1's care plan undated revealed no record of observed behavior that was listed in Resident #1's progress notes dated 02/22/2024. Review of Resident # 1's care plan undated revealed no record of weight taken once a month every day shift starting on the 1st and ending on the 5th of every month and Health Shakes offered two times a day with lunch and supper meal. Review of Resident #1's physician orders revealed the following: * dated 12/30/2023 to start 01/01/2024 Weigh once a month every day shift starting on the 1st and ending on the 5th every month for weight management. *dated 02/23/2024 to start 02/23/2024 Health Shakes two times a day offer health shake with lunch and supper meal. There was no order to address Resident # 1's behaviors. Review of Resident #1's hospital records dated 03/01/2024 at 11:45 a.m. reflected Resident #1 was presented to the emergency roiagnom on [DATE] for Psychiatric Evaluation (Patient cut wrists) Patient was evaluated in the ER today. He reported not doing well. He stated he is still angry about the situation with his RP. He noted that he asked his RP for money and she refused to give him any. He then asked her if he can only have $15 and she declined. Patient reported that the incident got him upset. When asked about previous episodes of anger, patient noted that in the past when he got angry, he would just say ok and move on but couldn't this time. Review of Resident#1 hospital records dated 03/01/2024 at 1:40 p.m. reflected SW went into room to speak with patient about inpatient hospitalization in a psychiatric facility. Patient stated that will be good because when I leave here I know how to use a gun.'. Review of Resident #1's progress note dated 02/22/2024 at 7:11 p.m. written by LPN G reflected: Resident had turned his bedside table upside down and put it in front of his door to try and block it closed. When asked why he did that he stated that the guy told him he could do that to keep people out of his room. Nurse explained that he could not do that because it was a safety issue and if staff needed to get in there in case of an emergency they couldn't if he blocked the door. Table was taken out of the room. He then pointed to his TV and stated that the guy came and fixed his TV so that the channel couldn't be changed and that the channel it is on now is designed to brainwash him. Nurse tried to explain that the TV was not brainwashing him, but he was insistent that the TV was brainwashing him. Review of Resident # 1's progress note dated 03/01/2024 at 8:30 a.m. written by LVN B reflected CNA called this nurse to resident's room. Noted resident laying on his back on his bed with his back leaning against the wall. Bilateral arms stretched out by his sides. Noted lacerations and blood on bilateral wrist. Broken glass from the picture frame scattered on floor. Moderate amount of blood on the floor. CNA removed any items that could be used to self harm from immediate area. Noted numerous lacerations to bilateral wrist. No active bleeding noted. No other injury noted. BP-139/69 P-95 R-18 Temp-97.8 States I was trying to kill myself I cut my wrist with the glass from the picture frame. Then this Nurse asked the resident why he did this to himself resident made comments I've done some bad things in my life. My RP and I was in a inappropriate relationship for a long time. Before my RP married her husband, she found me and wanted to start the relationship back and we did that's why her husband wants me to die I heard him say he wished I was dead Am I going to jail now? One on One initiated at 7:35-Administrator notified. Administrator to notify resident's. Treatment initiated. Hospice nurse notified. 8:10 call placed to 911 for transfer to ER for evaluation and treatment due to suicide attempt. Resident sitting with this Nurse waiting on EMS. This Nurse asked the resident how long he has thought about hurting himself resident states for about 3-4 hours Nurse asked resident did he call for a Nurse or staff member to talk to prior to cutting himself resident states no. Resident transferred to ER by ambulance. Resident laughing and joking with staff. NP notified of above. During an interview on 03/02/2024 at 11:53 a.m. LVN B stated around 7:30 a.m. on 03/01/2024 CNA C reported to her that she noticed blood on the floor in Resident # 1's room. LVN B stated when she went to the resident's room she observed Resident # 1 was laying on his back in the bed with both his arms stretched out along his side. LVN B observed numerous lacerations to both wrists with blood on the floor. LVN B stated she assessed the resident and did not observe active bleeding or any other injuries. LVN B stated a broken picture frame glass was observed to be scattered on the floor. LVN B stated the resident told her he cut his wrist with the glass from the picture frame and he tried to kill himself. LVN B stated she asked the resident why he cut himself and he stated to her that he had done bad things in his life. LVN B stated Resident # 1 stated to her that he and his RP had an inappropriate relationship for a very long time. He expressed to LVN B before his RP married her husband she wanted to start the relationship back and that's why the RP husband wanted him to die. LVN B stated that Resident # 1 stated he had heard his RP husband say he wished he was dead. LVN B stated she had asked Resident #1 how long he had thought of hurting himself and he stated about three to four hours. In an attempted interview on 03/22/2024 at 2:05 p.m. with the DON was unsuccessful by phone call. In an interview on 03/22/2024 at 2:19 p.m. with the ADM stated she expected care plans to be updated when a resident had a change in condition, medication change, or significant event. ADM stated the current MDS nurse worked off-site and did not come to the facility. The ADM stated the MDS nurse did not know the residents and she had requested corporate to get the facility an MDS nurse onsite so when they had incidents and changes in condition the updates could be made at that time. The ADM stated the DON had educated Resident # 1 but did not document the education, or care plan to reflect the interventions. In an interview on 03/22/2024 (time not documented) the MDS nurse stated that Resident #1 was on hospice and weight loss was expected. The MDS nurse stated nutrition was care planned for health snacks, and super cereal twice a day if Resident # 1 did not eat over 50% of the meal. The MDS nurse stated the facility still tried to put interventions in place even though the weight loss was expected. The MDS nurse was not able to give elaboration on revisions and dates made to Resident #1's care plan. A record review of the care plans, comprehensive person-centered policy statement revised December 2016 reflected that A comprehensive, person-centered care plan that includes measurable objects and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident. A record review of care plans, goals, and objectives revised in 2009( month not dated ) reflected that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. This was determined to be an Immediate Jeopardy (IJ) on 03/22/2024 at 3:00 p.m. The ADM was notified. The ADM was provided with the IJ template on 03/22/2024 at 3:00 p.m. The following Plan of Removal submitted by the facility was accepted on 03/23/2024 at 07:50 a.m. and included: Plan of Removal F656 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on March 22nd, 2024, for facility failing to initiate, develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs. 1. Action: To ensure the development and implementation of a comprehensive person-centered care plan, the MDS and DON conducted audits and developed care plans on all center residents. If a significant change in the resident condition and treatment is noted during the widespread audit, a change of care plan will be initiated by the MDS nurse and DON to meet individual residents' needs. Completion Timeline: Beginning March 22nd, 2024, and ending March 23rd, 2024. Responsible: DON/MDS Nurse 2. Action: DON and MDS nurse were in-service by the [NAME] President of Clinical Services on March 22nd, 2024, regarding: 1) the development and implementation of comprehensive person-centered care plan upon identification of a resident change in condition to include behaviors, weight loss noted during monthly weight monitoring; and 2) Baseline care plan must be initiated upon admission. Completion Timeline: Beginning March 22nd, 2024, and thereafter. Responsible: [NAME] President of Clinical Services 3. Action: Beginning on March 22nd,2024 and for the next 30 days the Director of Nursing will utilize the Daily Clinical Meeting Process and 24 hours report to identify a change in resident conditions including behaviors, weight loss, and new medication orders. DON and MDS nurses will update the resident care plan during the daily clinical meetings. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion Timeline: Beginning March 22nd, 2024, and thereafter. Responsible: DON Monitoring of the plan of removal was completed on 03/24/2024 and revealed the following: In an interview on 03/23/2024 at 3:50 p.m. the ADM stated updating the care plans was the responsibility of the MDS nurse and the DON. The ADM stated that the care plan should be updated the same or within 24 hours after a care conference with the interdisciplinary team. The ADM stated after any identified incidents in-service with staff would be conducted to ensure care plans are being followed. The ADM stated that she and the DON will do rounds to check that residents have care plan interventions in place. A record review of Resident #1's care plan revised dated 03/24/2024 revealed The resident will maintain adequate nutritional status as evidenced by maintaining weight within 3% range through review date with Interventions Identified as: - Diet consult as needed - Observe likes and dislikes when serving diet - Serve supplements if less than 50% of meal intake - Record and report to MD s/s of skin breakdown - Assess oral status, and proper fit of dentures if applicable - ST referral as indicated - Record and report s/s of dehydration to MD - Document % of meal intake in the clinical record. Risk for harm problem: Self-Directed or Other-Directed Behavior Potentially Causing Harm (Episodic) 3/1/24 - resident cut wrist and stated it was a suicide attempt. With a goal of resident will not harm self or others last revised on 03/22/24. A record review of Resident #1's undated care plan revealed intervention of 1to 1 with resident until able to discharge from the hosptial for risk for harm problem. A record review of the care plan audit of the Resident's care plan revisions was completed on 03/24/2024. A total of 18 residents' care plans were audited A record review of Inservice completed on the care plans was completed by the DON and MDS on 03/22/2024. The DON and MDS were trained to ensure that care plans are developed and updated upon a significant change in the resident's condition. DON and MDS were also trained on base line care plans must be initiated upon admission. The ADM was informed the Immediate Jeopardy was removed on 03/26/2024 at 4:360 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 4 residents (Resident #1) reviewed for nutrition status maintenance. The facility failed to ensure Resident # 1 did not sustain a severe weight loss of 16.1% in a two month period from admission on 12/05/2023 and last record of weight on 02/05/2024 The facility failed to follow MD order to take monthly weights beginning on 01/01/2024 for a weight to be taken the 1st through the 5th of each month. The facility failed to include 01/16/2024 weight of 134.6 in Resident # 1's weight log. The facility failed to identify there was a decrease from health shakes being administered three times per day decreasing down to two times a day. An Immediate Jeopardy (IJ) was identified on 03/04/2024 The IJ template was provided to the facility on [DATE] at 10:14 p.m. While the IJ was removed on 03/06/2024 at 4:00 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm. This failure could place residents at risk of weight loss, weight gain, nutritional deficit, and adverse health consequences. Findings included: Review of Resident #1's undated face sheet revealed an [AGE] year-old male with an admitted [DATE]. Diagnoses included hypertension (high blood pressure), cardiomyopathy (disease of heart muscle), hyperlipidemia (high cholesterol), and protein-calorie malnutrition (inadequate amount of protein). Review of Resident #1's physician order dated 12/30/2023 to start 01/01/2024 reflected: Weigh once a month every day shift starting on the 1st and ending on the 5th every month for weight management. Order dated 02/23/2024 to start 02/23/2024 Health Shakes two times a day offer health shake with lunch and supper meal. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated moderate cognitive impairment. Review of Resident #1's care plan undated revealed resident has a nutritional problem and appetite stimulant ordered. On NAS diet. [DATE] wt 153.1 lbs. Resident # 1 care plan did not include his updated weights or refusal to eat. Resident # 1's care plan did not include signs, symptoms of depression, and refusal to see Psych NP. Review of Resident #1's progress notes dated 12/05/2023 to 03/01/2024 revealed medication refused. 12/23/2023 01/12/2024 01/13/2024 01/14/2024 01/15/2024 01/17/2024 01/18/2024 01/19/2024 01/20/2024 01/21/2024 01/22/2024 01/23/2024 01/24/2024 01/25/2024 01/26/2024 01/27/2024 01/28/2024 01/29/2024 01/30/2024 02/03/2024 02/05/2024 02/06/2024 02/07/2024 02/08/2024 02/09/2024 02/10/2024 02/11/2024 02/12/2024 02/14/2024 02/15/2024 02/16/2024 02/17/2024 02/19/2024 01/31/2024 Review of Resident #1's progress notes dated 12/05/2023 to 03/01/2024 revealed meals refused. 01/13/2024 01/15/2024 01/16/2024 01/20/2024 01/21/2024 01/24/2024 Review of Resident #1's progress note dated 01/13/2024 at 7:11 p.m. written by LVN B reflected that Resident refusing to eat, drink, and take his medication. Told this nurse that he was tired of taking medicine and said he didn't feel like eating. Offered different meal options to entice him to eat. Will call his RP to discuss, also letting NP know of his change in condition. Review of Resident #1's progress note dated 01/15/2024 at 1:30 p.m. written by CMA D reflected that Resident continues to only take a few bites of meals and is refusing medications. RP aware. Review of Resident #1's progress note dated 01/16/2024 at 10:29 a.m. written by LVN B reflected that Resident refused regular breakfast this AM. Ate 1/2 of a blueberry muffin. Resident weight 134.6. 18.5 lbs weight loss noted from 12/5/2023. Call placed to NP, informed of weight loss and change of condition. New orders received to start Remeron 7.5mg for appetite stimulant. MAR updated. Pharmacy faxed notified. Resident aware and agrees to new orders. Consent signed. Fluids encouraged. Able to make needs known. Call light in reach. Review of Resident #1's progress note dated 01/20/2024 at 2:11 p.m. written by LVN B reflected that Resident taken to dining room for both meals today. Only a couple of bites taken from each meal. Resident continues to refuse medications. This nurse spoke with DON, resident, and resident's regarding resident refusing meals and medication and weight loss. Review of Resident #1's progress note dated 01/21/2024 at 2:23 p.m. written by LVN B reflected that Resident resting in bed. Refused meals and medications after numerous attempts made by this Nurse'. Review of Resident # 1's vitals for weights summary only showed weights for admission 12/05/2023 (wheelchair) 153.1 lbs. 01/17/2024 (standing) 153.1 lbs 02/05/2024 (standing) 128.4 lbs. -10% change comparison weight 12/05/2023 153.1 lbs, -16.1%,-24.7(lbs) -5.0% change comparison weight 01/17/2024,153.1 lbs,-16.1%-24.7(lbs)-7.5% change comparison weight 12/05/2023, 153.1 lbs, -16.1%-24.7 lbs.'. Resident # 1 had significant weight loss from admission on 12/05/2024 and the last record of weight on 02/05/2024. Review of Resident # 1's MAR reflected health shakes on MAR twice. Once as three times per day until 02/23/2024 after the 8:00 a.m. administration , then decreased to twice per day with lunch and supper on 02/23/2024. During an interview on 03/04/2024 at 1:30 p.m. CNA C stated Resident # 1 on some days would lay in bed and refuse to eat. Resident #1 would eat a little bit of his breakfast but not lunch or dinner. CNA C stated she reported to LVN B when the resident would refuse to eat. CNA C stated the resident did not drink and refused the health shakes. CNA C stated the resident did not like the texture of the health shakes. CNA C stated she was not aware if any substitution was given. During an attempt on 03/04/2024 at 1:55 p.m. unsuccessful attempt in reaching the Medical Doctor. During an interview on 03/04/2024 at 5:30 p.m. CNA D stated that she reported to LVN B when the resident would refuse to eat. CNA D stated the resident had lost a lot of weight due to not eating. Resident # 1 would decline the health shakes because he did not like them. During an interview on 03/04/2024 at 6:15 p.m. the Dietician stated a nutritional assessment was conducted on 02/12/2024 that showed Resident # 1 had experienced weight loss. The dietician stated weekly weights were to be conducted and nursing staff was responsible for weights. Resident # 1 was added a nutritional protein milkshake to aid in helping gain weight. During an interview on 03/04/2024 at 6:57 p.m. the DON stated she started as the DON on 03/01/2024. The DON stated weights for normal residents are done once a month by the nurse but if there is a resident who is not eating, losing, or gaining weight they are placed on weekly weights. The DON stated if weight loss is not monitored it would not identify the weight loss. The DON stated not receiving proper nutrients may cause further illness and complications. The DON stated that she, the Dietician, and the Dietary Manager meet to discuss weight and during that time the Dietician writes up the nutrition assessment and recommendations for that particular resident. During an interview on 03/04/2024 at 8:10 p.m. the Dietary Manager stated the DON, the Dietician, and the Dietary Manager discuss weight/loss. The Dietician would write the nutrition assessments. The Dietary Manager stated she talks with residents about their food types/ recommendations followed by The Dietician's orders. The Dietary Manager stated Resident # 1 some days would only eat a few bites of his food. The Dietary Manager stated that she did not document when the resident did not eat. The Dietary Manager stated the DON was responsible for documenting progress notes when residents was not eating. The Dietary Manager stated the Nursing staff was responsible for taking weekly weights when it was determined significant/severe weight loss. The Dietary Manager stated if weights are not conducted weekly it may cause further weight loss that would be too hard on the resident to be weak without protein or nutrients which may cause further illness. During an interview on 03/04/2024 at 8:30 p.m. the ADM stated the nursing staff are responsible for weights and she was unable to give an answer to why Resident#1 weights was not taken. The ADM stated that she would have to take a look into why Resident # 1's weight was not checked weekly with having weight loss. The ADM stated that when residents are not receiving weekly weight checks would cause a slower process in healing and further complications The ADM stated the DON the Dietitian, and the Dietary Manager are responsible for discussing weights for nutritional needs. Review of the facility's policy titled Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol revised 09/2017 reflected: The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. This was determined to be an Immediate Jeopardy (IJ) on 03/04/2024 at 10:14 p.m. The ADM and DON were notified. The ADM was provided with the IJ template on 03/04/2024 at 10:14 p.m. The following Plan of Removal submitted by the facility was accepted on 03/06/2024 at 10:05 a.m. Plan of Removal F692 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on March 4th, 2024, for facility failing to initiate timely intervention to prevent significant weight loss. 1. Action: To ensure identification of weight loss, the facility licensed nursing staff conducted/weigh and documented all weight of all center residents. If a change in weight is noted during the widespread audit, the attending physician and Registered Dietitian will be notified to obtain treatment orders as indicated and a change of care plan will be initiated. Weight loss and potential risk factors will be documented in the progress noted and care planned to meet individual residents' needs. Completion Timeline: Beginning March 4th, 2024, and ending March 5th, 2024. Responsible: Licensed Nurses/ Activity Director/DON/MDS 2. Action: DON was in-service by the [NAME] President of Clinical Services on March 4th, 2024, regarding: 1) Notification to attending physician, Registered Dietitian, and responsible representative upon identification of resident change in condition to include weight loss noted during monthly, weekly weight monitoring; and 2) Inspection and documentation of resident weight upon admission, monthly, and weekly thereafter. Beginning March 4th, 2024, Nursing Administration to conduct education with licensed nursing staff on the above education. PRN and New hires who have not received the above stated education will be educated by DON prior to providing resident direct care. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Director of Nursing 3. Action: Director of Nursing was in-service by the [NAME] President of Clinical Services on March 4th, 2024, regarding certified nursing assistants notifying charge nurse upon identification of change in resident appetite and refusal of a meal. Beginning March 4th, 2024, Nursing Administration to conduct the above education with certified nursing assistants. New hires and PRN who have not received the above stated education will be educated by the DON prior to providing resident direct care. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Director of Nursing. 4. Actions: The Director of Nursing, Registered Dietitian, and Dietary Manager will meet weekly to discuss resident weight. Each month, the nursing staff will weigh all residents. DON, RD, and DM will compare current weight to previous weight. Based on the report, the IDT will identify weight loss and decide on resident that will receive weekly and daily weight. Registered Dietitian recommendation will be entered and documented into the electronic medical record system by DON. The provider and family representative will be notified of resident weight change and dietary recommendation. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Administrator and [NAME] President of Clinical Services 5. Action: The Nursing Administration began auditing the electronic medical record of each resident to ensure monthly, weekly, and daily weight are scheduled to be performed by the nursing staff. The DON will ensure that the nursing staff document the resident weight on the EMR. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Director of Nursing 6. Action: Beginning on March 4th, 2024. and for the next 30 days the Director of Nursing will utilize the Daily Clinical Meeting Process and the weight report to validate charge nurse compliance with inspection, notification, and documentation of resident weight checks which are to be conducted upon admission, monthly, weekly, and daily thereafter. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Administrator, Director of Nursing Monitoring of the plan of removal was completed on 03/06/2024 and revealed the following: During an interview on 03/06/2024 at 12:00 p.m. RN A stated that he has been in-serviced on reporting weight loss. RN A stated that the Nurses are responsible for weights and to ensure they were recorded accurately. RN A stated the Nurses must report any weight loss observed. RN A stated that the provider, physician, and the Registered Dietitian will be notified of the resident weight loss. During an observation on 03/06/2024 at 12:20 p.m. residents was in the dining room eating lunch. None of the residents refused lunch or appeared to have a lack of an appetite. During an interview on 03/06/2024 at 1:00 p.m. LVN B stated that he had been in-serviced on reporting weight loss. LVN B stated that the Nurse is responsible for recording weight loss. LVN B stated the nurse must report any weight loss and if there is a 4-5-pound weight loss it should be reported immediately. LVN B stated that the RP, physician, and the Registered Dietitian would be notified of the resident weight loss. During an interview on 03/06/2024 at 1:30 p.m. CNA C stated if the CNA's noticed a resident not eating or having a change in appetite they are to report the change in behavior to the Charge Nurse so they can document it. CNA's can document a lack of appetite on the resident's ADL charting. During an interview on 03/06/2024 at 2:00 p.m. the Activity Director stated if the CNA's noticed a change in appetite or a resident refusing to eat they are supposed to notify the Charge Nurse immediately. The Activity Director stated if the CNAs noticed a resident was losing weight, they was supposed to notify the Charge Nurse immediately. During an interview on 03/06/2024 at 3:00 p.m. the DON stated she has been in-serviced by the [NAME] President of Clinical Services on the following: CNAs must notify the Charge Nurse about changes in resident appetite and refusing to eat. The DON stated CNA's would notify a Charge Nurse if a resident doesn't eat or even if they only eat half of their meal. The DON stated a nurse would be responsible for documenting the change in condition. The DON and interdisciplinary team will address change in condition, DON, RD, and DM must meet weekly to discuss residents' weights, weekly weights, and look at weight trends. The DON stated she would be responsible for auditing the electronic medical records to ensure residents were weighed. DON stated she trained the RNs, LVNs, and CNAs on resident's weights. Review of the Inservice completed on 3/04/2024 for Charge Nurses provided by the DON. Charge Nurses Inservice- responsible to ensure weights are completed and report weight loss to the provider. Review of the Inservice completed on 3/04/2024 for CNA's and CMA's provided by the DON. CNA's CMA's Inservice-reporting change in appetite and refusals of meals to the Charge Nurse. The DON was informed the Immediate Jeopardy was removed on 03/06/2024 at 4:00 p.m. The facility remained out of compliance at a scope of iolated severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interviews and record reviews the facility failed to ensure a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 4 residents (Resident # 1) reviewed for treatment and services for mental and psychosocial concerns. The facility failed to develop and implement a plan of care to address Resident #1's signs and symptoms first documented on 01/15/2024 when Resident #1 refused to see the Psych NP for signs and symptoms of depression. CMA D failed to to report Resident #1 expressing to her many times that he was tired, his body was giving out, and he was ready to go. The facility failed to act upon ,care plan develop, and implement Resident # 1's changes noted by CNA C, CMA D reported to LVN B and CNA E reported to the former DON. An Immediate Jeopardy (IJ) was was identified on 03/04/2024 The IJ template was provided to the facility on [DATE] at 10:14 p.m. While the immediacy was removed on 03/06/2024 at 4:00 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm. This deficient practice placed residents at risk for prolonged pain, suffering, injury, hospitalization , and death. Findings included: Review of Resident #1's undated face sheet revealed an [AGE] year-old male with an admitted [DATE]. Diagnoses included hypertension (high blood pressure), cardiomyopathy (disease of heart muscle), and hyperlipidemia (high cholesterol). Review of Resident #1's physician order dated 12/05/2023 reflected: Psychiatric evaluation and treatment as indicated. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated moderate cognitive impairment. Review of Resident #1's care plan undated revealed no record of observed behavior that was listed in Resident #1's progress notes dated 02/22/2024. No record of plan to address changes in condition for Resident #1. Resident #1's care plan did not address the changes noted by CNA C, CMA D, and CNA E reported to LVN B and the previous DON. Review of Resident #1's progress notes dated 12/05/2023 to 03/01/2024 there was no documentation of education,encouragement, additional attempt/encouragement to obtain/ provide treatment documented regarding psych services. Review of Resident #1's progress notes dated 12/05/2023 to 03/01/2024 revealed medication refused. 12/23/2023 01/12/2024 01/13/2024 01/14/2024 01/15/2024 01/17/2024 01/18/2024 01/19/2024 01/20/2024 01/21/2024 01/22/2024 01/23/2024 01/24/2024 01/25/2024 01/26/2024 01/27/2024 01/28/2024 01/29/2024 01/30/2024 02/03/2024 02/05/2024 02/06/2024 02/07/2024 02/08/2024 02/09/2024 02/10/2024 02/11/2024 02/12/2024 02/14/2024 02/15/2024 02/16/2024 02/17/2024 02/19/2024 01/31/2024 Review of Resident #1's progress notes dated 12/05/2023 to 03/01/2024 revealed meals refused. 01/13/2024 01/15/2024 01/16/2024 01/20/2024 01/21/2024 01/24/2024 Review of Resident # 1's progress note dated 01/13/2024 at 3:11 p.m. written by PREV DON reflected: Resident refusing to eat, drink and take his medications. Told this nurse that he was tired of taking medicine and said he didn't feel like eating. Offered different meal option to entice him to eat. Will call his daughter to discuss, also letting NP know of this change in condition. Review of Resident # 1's progress note dated 01/15/2024 at 1:30 p.m. written by LVN B reflected: Resident continues to only take a few bites of meals and is refusing medications. RP aware. This Nurse spoke with the resident in length. Resident states I've never lived in trash like this. Resident has been in a different room d/T Covid. Resident states I want to go back to my room. Resident and belongings moved back to room [ROOM NUMBER]-A. Administrator aware. Residents daughter notified and thanked this Nurse. Resident did eat 1/2 bowl of soup for lunch. Vitals stable. Lone Star Psych NP here at the time. This Nurse spoke with the resident about seeing Psych Services for s/s of depression. Resident states not right now I think I'm going to be feeling better now. Resident refused Psych services at this time. This Nurse encouraged resident to eat meals and take his medication as ordered. Informed resident that he can ask for alt food if he does not like/want what is on the menu. Resident verbalized understanding. Able to make needs known. Call light in reach. Review of Resident # 1's progress note dated 01/16/2024 at 4:25 p.m. written by PREV DON reflected: Spoke with resident about his medications. He thinks he is taking too many. I explained most of them he came from the hospital with. I sent a message to the NP to see if we can d/c anything. Awaiting response at this time. Review of Resident #1's progress note dated 02/22/2024 at 7:11 p.m. written by LPN G reflected: Resident had turned his bedside table upside down and put it in front of his door to try and block it closed. When asked why he did that he stated that the guy told him he could do that to keep people out of his room. Nurse explained that he could not do that because it was a safety issue and if staff needed to get in there in case of an emergency they couldn't if he blocked the door. Table was taken out of the room. He then pointed to his TV and stated that the guy came and fixed his TV so that the channel couldn't be changed and that the channel it is on now is designed to brainwash him. Nurse tried to explain that the TV was not brainwashing him but he was insistent that the TV was brainwashing him. Review of Resident # 1's progress note dated 03/01/2024 at 8:30 a.m. written by LVN B reflected CNA called this nurse to resident's room. Noted resident laying on his back on his bed with his back leaning against the wall. Bilateral arms stretched out by his sides. Noted lacerations and blood on bilateral wrist. Broken glass from the picture frame scattered on floor. Moderate amount of blood on the floor. CNA removed any items that could be used to self harm from immediate area. Noted numerous lacerations to bilateral wrist. No active bleeding noted. No other injury noted. BP-139/69 P-95 R-18 Temp-97.8 States I was trying to kill myself I cut my wrist with the glass from the picture frame. Then this Nurse asked the resident why he did this to himself resident made comments I've done some bad things in my life. My RP and I was in a inappropriate relationship for a long time. Before my RP married her husband, she found me and wanted to start the relationship back and we did that's why her husband wants me to die I heard him say he wished I was dead Am I going to jail now? One on One initiated at 7:35-Administrator notified. Administrator to notify resident's. Treatment initiated. Hospice nurse notified. 8:10 call placed to 911 for transfer to ER for evaluation and treatment due to suicide attempt. Resident sitting with this Nurse waiting on EMS. This Nurse asked the resident how long he has thought about hurting himself resident states for about 3-4 hours Nurse asked resident did he call for a Nurse or staff member to talk to prior to cutting himself resident states no. Resident transferred to ER by ambulance. Resident laughing and joking with staff. NP notified of above. Review of Resident #1's hospital records dated 03/01/2024 at 11:45 a.m. reflected Resident #1 was presented to the emergency roiagnom on [DATE] for Psychiatric Evaluation (Patient cut wrists) Patient was evaluated in the ER today. He reported not doing well. He stated he is still angry about the situation with his RP. He noted that he asked his RP for money and she refused to give him any. He then asked her if he can only have $15 and she declined. Patient reported that the incident got him upset. When asked about previous episodes of anger, patient noted that in the past when he got angry, he would just say ok and move on but couldn't this time. Review of Resident#1 hospital records dated 03/01/2024 at 1:40 p.m. reflected SW went into room to speak with patient about inpatient hospitalization in a psychiatric facility. Patient stated that will be good because when I leave here I know how to use a gun.'. During an interview on 03/02/2024 at 11:53 a.m. LVN B stated around 7:30 a.m. on 03/01/2024 CNA C reported to her that she noticed blood on the floor in Resident # 1's room. LVN B stated when she went to the resident's room she observed Resident # 1 was laying on his back in the bed with both his arms stretched out along his side. LVN B observed numerous lacerations to both wrists with blood on the floor. LVN B stated she assessed the resident and did not observe active bleeding or any other injuries. LVN B stated a broken picture frame glass was observed to be scattered on the floor. LVN B stated the resident told her he cut his wrist with the glass from the picture frame and he tried to kill himself. LVN B stated she asked the resident why he cut himself and he stated to her that he had done bad things in his life. LVN B stated Resident # 1 stated to her that he and his RP had an inappropriate relationship for a very long time. He expressed to LVN B before his RP married her husband she wanted to start the relationship back and that's why the RP husband wanted him to die. LVN B stated that Resident # 1 stated he had heard his RP husband say he wished he was dead. LVN B stated she had asked Resident #1 how long he had thought of hurting himself and he stated about three to four hours. During an interview on 03/02/2024 at 1:17 p.m. CMA D stated Resident # 1 expressed to her often that he was tired, his body was giving out, and he was ready to go. (as in death). CMA D stated she did not make a report to anyone as she did not think Resident # 1 would harm himself. CMA D stated it was many times Resident # 1 would not eat and refuse his medication. During an interview on 03/02/2024 at 1:47 p.m. CNA C stated on 03/01/2024 around 7:30 a.m. she was passing Resident # 1's breakfast tray and upon entering the resident's room she observed Resident # 1 with both arms covered in blood. CNA C stated there was blood on the floor in front of the bed, along with a family picture frame broken. CNA C stated that she observed broken glass that was scattered on the floor. CNA C stated that she asked Resident #t what had happened and he only stated he just messed up. During an interview on 03/02/2024 at 3:00 p.m. the ADM stated LVN B notified her by phone around 8:00 a.m. on 03/01/2024 that Resident # 1 had harmed himself. The ADM stated she asked Resident #1 as he was leaving with EMS what had happened and his response was he had tried to kill himself. The ADM stated the incident with the bedside table at the front door Resident # 1 was only trying to prevent staff from coming into his room and interrupting his sleep. The ADM stated this is what Resident # 1 stated to her. During an attempted interview on 03/04/2024 at 1:55 p.m. was unsuccessful reaching the Medical Doctor. During an interview on 03/04/2024 at 5:00 p.m. CNA C stated Resident # 1 did have days that he would just lay in bed and not want to eat his food. CNA C stated she reported to LVN B that the resident would just lie in bed and refuse to eat. CNA C stated she could not recall the number of times or the dates Resident # 1 would lie in bed and refuse meals. During an interview on 03/04/2024 at 5:30 p.m. CMA D stated that she would report to LVN B when she observed Resident # 1 was not eating meals or refusing his medications. During an interview on 03/04/2024 at 5:45 p.m. CNA E stated she sat with Resident # 1 until the ambulance arrived to transport him to the hospital. CNA E stated she asked Resident # 1 what had happened and he said he just thought about leaving (as in death). Resident # 1 did not elaborate or discuss any further. CNA E stated she would report changes in conditions to the previous DON (no longer with the facility) when Resident # 1 would just lie around and refuse his meals During an interview on 03/04/2024 at 8:30 p.m. the ADM stated changes in conditions when identified will need to be reported to the Charge Nurse and they are responsible for the documentation. Review of the facility's policy titled BEHAVIOR HEALTH SERVICES revised 02/2019 reflected: Policy Statement The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. This was determined to be an Immediate Jeopardy (IJ) on 03/04/2024 at 10:14 p.m. The ADM and DON were notified. The ADM was provided with the IJ template on 03/04/2024 at 10:14 p.m. The following Plan of Removal submitted by the facility was accepted on 03/06/2024 at 10:05 a.m.: Plan of Removal F742 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on March 4th, 2024, for facility failing to initiate timely intervention to treat psychosocial concerns. 1. Action: To ensure identification of psychosocial concerns, the facility licensed nurses/social service staff conducted and documented psychosocial concerns such as depression and suicide thoughts on all center residents. If a change in the resident behavior and mood is noted during the widespread audit, the attending physician will be notified to obtain treatment orders as indicated and a change of care plan will be initiated. The Director of Nursing and charge nurse will refer the resident for psychological services and potential risk factors will be documented in the progress note and care planned to meet individual residents' needs. Completion Timeline: Beginning March 4th, 2024, and end March 5, 2024. Responsible: Licensed Nurses/ Activity Director/DON/MDS 2. Action: Director of Nursing was in-service by the [NAME] President of Clinical Services on March 4th, 2024, regarding: 1) Notification to attending physician and family representative upon identification of resident change in condition to include mental and psychosocial behavior noted during auditing/monitoring and 2) Inspection and documentation of resident behavior upon admission, monthly, and weekly thereafter. Beginning March 4th, 2024, Nursing Administration to conduct the above education to licensed nurses. PRN and new hires who have not received the above stated education will be educated by the DON prior to providing resident direct care. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Director of Nursing 3. Action: Director of Nursing was in-service by the [NAME] President of Clinical Services on March 4th, 2024, regarding certified nursing assistant notifying the charge nurse upon identification of change in resident condition such as behavior and mood. Beginning March 4th, 2024, Nursing Administration to conduct the above education with certified nursing assistants. New hires and PRN who have not received the above stated education will be educated by the DON prior to providing resident direct care. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Director of Nursing 4. Actions: The Director of Nursing and the interdisciplinary team will meet 5 days a week to discuss resident change in condition including mental and psychosocial concerns. The DON will ensure that the provider is made aware of the patient's change in condition, referral order for psychological services and treatment plan is entered and documented into the electronic medical record system. The family representative will be notified of the resident change in condition and treatment plan. Completion Timeline: Beginning March 5, 2024, and thereafter. Responsible: Administrator and [NAME] President of Clinical Service. 5. Action: The Nursing Administration began auditing the electronic medical record of each resident to ensure treatment plans are scheduled to be performed by the nursing staff. The DON will ensure that the nursing staff are monitoring and documenting the resident's change of condition such as behavior on the progress note. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Director of Nursing 6. Action: Beginning on March 4th, 2024. and for the next 30 days. The Director of Nursing will utilize the 24 hours report to validate charge nurse compliance with inspection, notification, and documentation of resident change in behavior and mood are conducted upon admission and daily thereafter. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion Timeline: Beginning March 4th, 2024, and thereafter. Responsible: Administrator, Director of Nursing Monitoring of the plan of removal was completed on 03/06/2024 and revealed the following: During an interview on 03/06/2024 at 12:00 p.m. RN A stated that he was on monitor for residents that may have psychosocial concerns. RN A stated if a resident is not acting their normal self such as crying, sad, or depressed those were signs of change in behavior. RN A stated a change in behavior, change in appetite, or lack of eating also should be reported to nursing staff if witnessed. RN A stated the DON, Physician, and Charge nurse should be notified of the resident's changes. RN A stated it is important to report and document the changes in behavior so the resident can get the appropriate help they may need. RN A stated the change of condition should be followed up on for 72 hrs. During an interview on 03/06/2024 at 1:00 p.m. LVN B stated that she was on monitor for residents that may have psychosocial concerns. LVN B stated changes of behavior signs are depressed, crying, or sad. LVN B stated the change in behavior signs should be documented and reported. LVN B stated the DON, Physician, and Charge nurse should be notified of the resident's changes. LVN stated it was important to report and document the changes in behavior so the residents could get their medical needs met. During an interview on 03/06/2024 at 1:30 p.m. CNA C stated if she noticed a resident with a change in condition she would report the change in behavior to the Charge Nurse. CNA C stated that the Charge Nurse would document the change in behavior if a resident was sleeping more than normal, being agitated, or having aggressive outbursts. During an interview on 03/06/2024 at 2:00 p.m. the Activity Director stated that if a resident stated they don't want to live or acting differently the CNAs should notify the Charge Nurse so that the resident can get the appropriate medical help. The Activity Director stated signs of change of behavior are becoming aggressive, withdrawn, sad, depressed, and not eating. During an interview on 03/06/2024 at 3:00 p.m. the DON stated she had been in-serviced by the [NAME] President of Clinical Services on notifying the Charge Nurse of changes in the conditions of residents. The DON stated the Charge Nurse would be responsible for documenting changes in conditions. Nurses must notify the attending provider of the resident change in condition including mental psychosocial behavior, along with documenting and monitoring. The DON stated CNA's and CMA's must report changes in mood or behavior to the Charge Nurse. The DON stated that she trained the RNs, LVNs, and CNAs on changes in conditions. Review of the Inservice completed on 3/04/2024 for Charge Nurses provided by the DON. Charge Nurses Inservice- monitor resident's behavior's, documenting ,notify attending provider, and psychosocial behavior. Review of the Inservice completed on 3/04/2024 for CNA's and CMA's provided by the DON. CNA's CMA's Inservice-reporting change in conditions and behaviors to the Charge Nurse. The DON was informed the Immediate Jeopardy was removed on 03/06/2024 at 4:00 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #1) of 4 residents reviewed for psychotropic drug use. The facility failed to: 1. ensure Resident #1 was prescribed Seroquel for a specific diagnosis and instead prescribed it for behavioral disturbance at bedtime This failure could affect residents by placing them at risk of receiving psychotropic medications which could cause a decrease in quality of life and increase the risk of injury. Findings included: Review of Resident #1's undated face sheet revealed an [AGE] year-old male with an admitted [DATE]. Diagnoses included hypertension (high blood pressure), cardiomyopathy (disease of heart muscle), hyperlipidemia (high cholesterol), and protein-calorie malnutrition (inadequate amount of protein). Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated moderate cognitive impairment. It further revealed he usually understood others. It revealed that he had no hallucinations nor did he have delusions that would be potential indicators of psychotic behaviors. Review of Resident #1's progress note revealed a note by LPN G on 02/22/2024 at 7:11 p.m. reflected: Resident had turned his overbed table upside down and put it in front of his door to try and block it closed. When asked why he did that he stated that the guy told him he could do that to keep people out of his room. Nurse explained that he could not do that because it was a safety issue and if staff needed to get in there in case of an emergency they couldn't if he blocked the door. Table was taken out of the room. He then pointed to his tv and stated that the guy came and fixed his tv so that the channel couldn't be changed and that the channel it is on now is designed to brainwash him. Nurse tried to explain that the tv was not brainwashing him but he was insistent that the tv was brainwashing him. Record review of Resident #1's progress notes revealed a note by RN G on 02/24/2024 at 12:41 a.m. reflected Resident started Seroquel 50mg last night to help with sleep and decrease agitation. Resident appears to be sleeping normally. Record review of Resident #1's progress notes revealed a note by LVN E on 02/24/2024 at 6:56 p.m. reflected Continue Seroquel for sleep and agitation with no adverse reactions noted. No complaints voiced at the time. Record review of Resident #1's progress notes revealed a note by LVN E on 02/25/2024 at 10:17 p.m. reflected Continue Seroquel for sleep and agitation with no adverse reactions noted. No complaints voiced at the time. In an interview on 03/02/2024 at 2:30 p.m. the DON stated Resident # 1 was placed on Seroquel because of the incident on 02/22/24 of Resident # 1 turning the bedside table upside down in front of his room door. The DON stated Resident # 1 was not placed on 1 to 1 and it was figured the Seroquel would help. In an interview on 03/02/2024 at 3:00 p.m. with the ADM stated Resident #1 had an incident with placing his bedside table in the front of his door was only to prevent staff from coming in and interrupting his sleep. The ADM could not answer why Seroquel's medication was given without any diagnosis. In an interview on 03/04/2024 at 1:59 p.m. with the Hospice Medical Director stated he was getting telephone calls from the facility that Resident # 1 was having aggressive behaviors toward staff was that was the reason for Resident #1 being placed on Seroquel. In an interview on 03/04/24 at 6:57 p.m. the DON stated the previous DON (no longer employed) should have notified the Hospice Medical Director to advise on the consent for Seroquel it showed a diagnosis of sundowning and that is not a diagnosis. The DON stated Resident #1's RP signed off on the consent for Seroquel and she wanted Resident #1to be on the medication. The DON stated the Hospice Medical Director should have been more specific because Medical Doctors have to make a medical diagnosis of a resident. The DON stated the facility was not able to care plan without a medical diagnosis of Seroquel. The DON stated medication was given as ordered by the Doctor and not by a diagnosis. The DON stated any medication can cause an adverse effect or harm if taken if it hasn't been prescribed for a diagnosis. In an interview on 03/04/2024 at 8:30 p.m. with the ADM stated the previous DON (no longer employed) last day in the building on 02/23/2024 overlooked there was not a diagnosis for the Seroquel. The ADM stated the previous DON (no longer employed) should had confirmed if there was a diagnosis for the Seroquel. The ADM stated diagnoses are made by physicians. The ADM stated the orders made by the physician were followed by the facility. The ADM stated if medical diagnosis had not been confirmed and psychotropic medications were given to the resident it could cause suicidal thoughts. Record review of Resident #1's Order dated 02/23/2024 revealed an order for Seroquel oral tablet 50 mg start date of 02/23/2024. Give 1 tablet by mouth at bedtime for agitation and hallucinations. Record review of Resident #1's MAR, February of 2024, revealed he was administered Seroquel on the following dates: 02/23/2024 02/24/2024 02/25/2024 02/26/2024 02/27/2024 02/28/2024 02/29/2024 Record review of Resident #1's diagnoses list viewed 03/02/2024 revealed no diagnosis of psychosis, schizophrenia, or bipolar disorder. Resident # 1 did not have any mental health diagnoses, no anxiety, no depression, or no insomnia. Review of the facility's policy titled Antipsychotic Medication revised 07/2022 reflected: Residents will not receive medications that are not clinically indicated to treat a specific condition.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 9 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 11/5/23,11/11/23,11/12/23,11/18/23,11/19/23,11/25/23, 11/26/23,12/3/23 and 12/04/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatments. Findings Include Review of RN staffing for November 2023 revealed zero hours worked by an RN on 11/5/23,11/11/23,11/12/23,11/18/23,11/19/23,11/25/23,11/26/23. Review of RN staffing for December 2023 revealed zero hours worked by an RN on 12/3/23 and 12/04/23. Interview on 12/7/23 at 1145 AM with DON, she stated that she is aware of the lack of RN coverage every other weekend, they are advertising for an RN, but because of the small community and the commute time from the larger city in the area, they have very little response. She stated that she is aware of both the regulation and their policy that requires RN coverage 8 hours a day 7 days a week. They have reached out to corporate for assistance and are currently not utilizing outside agencies that provide contract nursing staff. She stated that she is available by phone and lives 20 minutes away, so she does not see any potential for harm as she is available if needed. She also stated there are clear protocols for any resident injuries or illnesses that may happen when an RN is not in the building, that include always contacting the resident's physician. Interview on 12/7/2023 at 2:00 pm with ADM, stated that she is aware of the holes in the RN coverage and is aware of the regulation that requires 8 hours of RN coverage each day, 7 days a week. She stated that their policy also states they are to have an RN 8 hours a day , 7 days a week. They have open positions and are actively recruiting but face barriers of having to compete with other small-town facilities and the commute from a bigger city. She stated that the DON is available by phone, and she feels that there is no potential for harm to the residents because of the lack of coverage in the building. Record Review of Policy titled Department Supervision, Nursing dated August 2022, revealed 2. A registered nurse provide services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 5 residents reviewed for medication administration (Resident's #31, #10, #14, and #8) and for 5 of 6 resident (Resident's #31, #10, #30, #14, and #8) reviewed for blood pressure readings. MA failed to properly sanitize blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressure for Residents #31, #10, #14, and #8 . MA failed to wash or sanitize her hands while going from one resident to another resident when administering medication for Resident's #31, #10, #30, #14, and #8. This deficient practice placed residents at risk for cross contamination and the spread of infection. Findings included: Record Review of Resident #31's face sheet dated 12/06/23 reflected Resident #31 was a [AGE] year-old male with an admitted [DATE]. Resident #31's diagnoses included peripheral vascular disease (a sign of fatty deposits and calcium building up in the walls of the arteries), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #31 had a BIMS score of 12 indicating Resident #31 was moderately cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, dressing, eating, and toileting, and limited assist of one person for personal hygiene. An interview and observation on 12/05/23 at 8:57 AM revealed Resident #31 was lying in bed on top of covers fully dressed. Resident appeared clean and stated he was doing well, and staff took good care of him. He stated he had no concerns. Record Review of Resident #10's face sheet dated 12/06/23 reflected Resident #10 was an [AGE] year-old male with an admitted [DATE]. Resident #10's diagnoses included dementia (decline in cognitive abilities that impact a person's ability to perform everyday activities), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #10 had a BIMS score of 11 indicating Resident #10 was moderately cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, eating, and toileting, and limited assist of one person for dressing and personal hygiene. An interview and observation on 12/05/23 at 9:20 AM revealed Resident #10 was lying in bed with blankets pulled up to chest area. Resident #10 appeared clean and stated he was doing fine, and staff took good care of him. He stated he had no concerns with his medications or anything else at that time. Record Review of Resident #30's face sheet dated 12/06/23 reflected Resident #30 was a [AGE] year-old male with an admitted [DATE]. Resident #30's diagnoses included peripheral vascular disease (a sign of fatty deposits and calcium building up in the walls of the arteries), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), COPD (progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and anemia (condition in which the blood doesn't have enough healthy red blood cells). Record Review of the most recent annual MDS assessment dated [DATE] reflected Resident #30 had a BIMS score of 12 indicating Resident #30 was moderately cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, dressing, eating, and toileting, and limited assist of one person for personal hygiene. In an observation and interview on 12/05/23 at 9:27 AM Resident #30 was observed sitting up on the side of his bed with blankets draped over his lap. Resident #30 appeared clean and groomed and was in no sign of distress. Resident #30 stated everything was fine and he was happy in the facility. He stated he was ready to go to smoke break at that time and he had no concerns. Record Review of Resident #14's face sheet dated 12/06/23 reflected Resident #14 was an [AGE] year-old male with an admitted [DATE]. Resident #14's diagnoses included dementia (decline in cognitive abilities that impact a person's ability to perform everyday activities), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), cerebral infarction (stroke), and hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #14 had a BIMS score of 06 indicating Resident #14 was severely cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, supervision only for eating, limited assist of one person for dressing, and extensive assist of one person for toileting and personal hygiene. In an observation and interview on 12/05/23 at 9:39 AM Resident #14 was observed lying in bed with covers over his head. He stated he did not want to talk to anyone, and he wanted his door shut immediately. Record Review of Resident #8's face sheet dated 12/06/23 reflected Resident #8 was an [AGE] year-old male with an admitted [DATE]. Resident #8's diagnoses included anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), COPD (progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #8 had a BIMS score of 08 indicating Resident #8 was moderately cognitively impaired. MDS reflected resident required supervision with set-up help for eating, limited assist of one staff for with bed mobility, transfer, dressing, and personal hygiene, and limited assist of two persons for toilet use. In an observation and interview on 12/05/23 at 9:45 AM Resident #8 was observed sitting up in his wheelchair. Resident #8 was clean and dressed appropriately. Resident #8 stated he was doing great, and he was well taken care of by the staff. He stated he had no concerns with his medications and everything else was great as well. In an observation on 12/05/23 at 8:47 AM the MA took a blood pressure reading with an automated cuff on Resident #31 without washing her hands after she had given medication to another resident. In an observation on 12/05/23 at 8:55 AM the MA administered medication to Resident #31 without washing her hands after she had given medication to another resident. In an observation on 12/05/23 at 9:07 AM the MA took a blood pressure reading with an automated cuff on Resident #10 without sanitizing the blood pressure cuff which had just previously been used on Resident #31 and without washing hands after she had given medication to Resident #31. In an observation on 12/05/23 at 9:14 AM the MA administered medication to Resident #10 without washing her hands after she had given medication to Resident #31. In an observation on 12/05/23 at 9:24 AM of Resident #31 and Resident #10's room, a sink and soap was available for handwashing right inside the door and was visible to those who may have entered or exited the room. In an observation on 12/05/23 at 9:25 AM of hallway of medication administration pass outside of Resident #31, #10, #30, #14, and #8 's room, there were 5 hand sanitizer dispensers hanging on the wall full of hand sanitizer. In an observation on 12/05/23 at 9:26 AM the MA took a blood pressure reading with an automated cuff on Resident #30 without sanitizing the blood pressure cuff which had just previously been used on Resident #10 and washing her hands after she had given medication to Resident #10. In an observation on 12/05/23 at 9:29 AM of hallway of medication cart which the MA had used to pass medications to Resident's #31, #10, #30, #14, and #8, a bottle of hand sanitizer was available on side of medication cart and a hand sanitizer dispenser was attached to the side of the medication cart. Both the bottle and dispenser had hand sanitizer inside. In an observation on 12/05/23 at 9:32 AM the MA took a blood pressure reading with an automated cuff on Resident #14 without sanitizing the blood pressure cuff which had just previously used on Resident #30 without washing her hands. In an observation on 12/05/23 at 9:36 AM the MA administered medication to Resident #14 without washing her hands after she had taken a blood pressure reading for Resident #30. In an observation on 12/05/23 at 9:43 AM the MA took a blood pressure reading with an automated cuff on Resident #8 without sanitizing the blood pressure cuff which had just previously been used on Resident #14 without washing her hands after she had given medication to Resident #14. In an observation on 12/05/23 at 9:43 AM the MA administered medication to Resident #8 without washing her hands after she had given medication to Resident #14. In an observation on 12/05/23 at 9:46 AM of Resident #30, Resident #14, and Resident #8's room, a sink and soap was available for handwashing right inside the door and was visible to those entering or exiting residents rooms. In an interview on 12/05/23 at 9:55 AM the MA stated she had not sanitized or washed her hands during the medication pass and she had not sanitized the blood pressure cuff in between obtaining blood pressures on Residents #31, #10, #30, #14, and #8. She stated she should have washed her hands in between every resident's medication pass and she should have sanitized the blood pressure cuff in between use for each resident as well. She stated she had been trained on handwashing and sanitizing equipment, medication administration, and infection control. She stated it was the facility policy to wash or sanitize her hands in between each resident and also to sanitize the blood pressure cuff or any equipment between residents. She stated if hands were not washed or sanitized in between residents' medication administration or blood pressure cuffs were not sanitized after use in between residents, that could cause the spread of infection and put residents at risk for infection. In an interview on 12/06/23 at 2:13 PM the ADM stated staff should have sanitized equipment, including blood pressure cuff's, with use in between residents and staff should have washed their hands at all times when going from one resident to the next during medication pass or any other time. She stated it was facility policy to do both. She stated staff had been trained on handwashing and sanitizing their hands and also on sanitizing equipment, including blood pressure cuff's, infection control, and medication administration. She stated if staff did not wash or sanitize their hands or did not sanitize a blood pressure cuff when using for multiple residents in between residents, it could cause the transfer or spread of infection from resident to resident. In an interview on 12/07/23 at 10:33 AM the DON stated staff should have washed or sanitized their hands in between residents while administering medications and they should have sanitized any equipment, including blood pressure cuffs, when going from one resident to another. She stated it was the facility policy for staff to wash or sanitize hands and to sanitize any equipment used when they went from one resident to the next. She stated staff had been trained on infection control, handwashing, sanitizing equipment, and medication administration. She stated they all knew what could happen if staff had not washed or sanitized their hands or sanitized equipment, such as blood pressure cuffs, when they went from one resident to another, and residents could have gotten sick due to the spread of infection. Record review of the Handwashing/Hand Hygiene policy dated 2001 and revised August 2015, reflected the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; i. After contact with a resident's intact skin; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . Record review of the Cleaning and Disinfection of Resident-Care Items and Equipment) policy dated 2001 and revised September 2022 reflected the following: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 1. The [NAME] Classification System is used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: c. non-critical items are those that came in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (3) Non-critical items require cleaning followed by either low- or intermediate- level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use and disposal). 5. Reusable items are cleaned and disinfected or sterilized between residents. 7. Only equipment that is designated reusable is used by more than one resident. Record review of the Infection Control Guidelines for All Nursing Procedures policy dated 2001 and revised August 2012 reflected the following: Purpose: To provide guidelines for general infection control while caring for residents. General Guidelines: 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 3. Employees must wash their hands for (10) to (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. before and after direct contact with residents. Record review of the Standard Precautions) policy dated 2001 and revised September 2022 reflected the following: Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation: 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions include the following practices: 1. Hand hygiene: a. Hand hygiene refers to handwashing with soap (antimicrobial or non-antimicrobial) or the use of ABHR, which does not require access to water. b. Hand hygiene is performed with ABHR or soap and water: (1) before and after contact with resident.

Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 (Common Shower) of 1 shower room observed for Environment. The floor tiles had been missing from the floor as far back as 6 years. The facility failed to have an effective maintenance communication system for when items needed to be repaired or replaced, which resulted in an unsafe environment in the Residents' Common Shower room. This failure could place residents at risk of tripping and falling, the shower chair wheels getting stuck, or cross contamination, which could cause injury, pain, distress and gastro-intestinal illnesses and result in a decrease in their health and psycho-social well-being. Findings included: Observation on 11/09/23 at 3:30 pm revealed the floor in the Common Shower room with multiple sections of missing floor tiles. There were missing sections of floor tile along the wall, beside the drain, and between the wall and the drain. The floor tiles were not a consistent color. Interview on 11/09/23 at 4:55 pm, the MTD stated he was aware the Common Shower had missing floor tiles along the wall and next to the drain. The MTD stated the Common Shower floor tiles were in this condition when he started his employment last year in September 2022. He stated he informed the VP back in December 2022 of the condition of the floor tiles in the Common Shower. The MTD stated he was unsure of how he informed the VP, but he believes it was via a Conference Call with himself and the previous Administrator. The MTD stated he told the former ADM that the tiles were different colors, and some were missing. The MTD stated the facility had so many things that took priority over replacing the floor tiles, and fixing the floor kept getting pushed back. The MTD stated for better or worse, the State Surveyor being at the facility has pushed Administration to give him the authority to replace the tiles. The MTD stated the current ADM gave him approval to replace the missing tiles or the entire floor this morning (Friday, 11/10). The MTD stated if the residents were to walk in the area with the missing tiles, it would be an uneven foot path that could cause them to trip or fall resulting in a serious injury, or even death. Interview on 11/09/23 at 5:40 pm, CNA A stated the Common Shower had missing floor tiles close to the wall and the water drain. She stated a resident or staff member could trip and fall. CNA A stated the wheel of the shower chair could get stuck, and the resident could be injured if staff had to pull or push the chair hard to free the chair from the open space. Interview on 11/09/23 at 6:20 pm, the DON stated she started her employment in August 2023 and the floor tiles in the Common Shower room were already missing. The DON stated replacing the missing floor tiles had been discussed during the Morning Meeting. She stated the ADM discussed replacing the floor tiles on Sunday (11/12) and it would take 24 hours to cure. Interview on 11/09/23 at 7:10 pm, the ADM stated the floor tiles had been repaired in the past. She stated sometimes the floor tiles become loose due to the constant running of water. The ADM stated once they find the correct size tiles to cover the missing parts, it would be fixed immediately. Observation on 11/10/23 at 10:35 am revealed the Common Shower to still have missing floor tiles. Interview on 11/10/23 at 10:45 am, the MTD stated he will purchase the floor tiles today, but the tiles will not be the same color. He stated he had setup a website for staff to create Service Tickets, but only a few utilized it, so he disabled the website. He stated the facility reverted back to the paper method last month (October 2023). The MTD stated there was a binder at the nurse's station, and he checks the binder at the start of his shift. He stated if it were an emergency, staff would call or text him directly. Interview on 11/10/23 at 11:25 am, CNA B stated the floor tiles had been missing since she started working at the facility 4 years ago. CNA B stated it was a minor issue and she cannot understand why it was taking so long for the facility to fix it. CNA B stated for the resident, this was their home, and the shower room should reflect a home environment. CNA B stated she would not want to stand in a shower with missing and broken tiles. She stated it could cause harm to the resident, as they could cut their foot, trip and fall, or the shower chair could get stuck, and they would have to pull the resident. Interview on 11/10/23 at 11:40 am, CNA C stated the floor tiles had been in the current condition since she returned to the facility in June 2023. She stated the condition could cause the shower chair to get stuck and if they tried to pull the chair with the resident in it, the resident could fall out. CNA C stated if a resident walked on the floor, they could stump their toe, or their foot could get caught causing them to fall and hit their head on the wall. She stated she likes her home to look nice and presentable and the condition of the Common Shower's floor tiles would concern her if it was her home. Interview on 11/10/23 at 12:00 pm, CNA D stated the floors have been in this condition since she started working at the facility 6 years ago. CNA D stated being in this condition, a resident could fall or trip over the missing tile. She stated to her, the appearance of the shower room floor, was like walking into a public bathroom. Interview on 11/10/23 at 12:20 pm, CNA E stated the missing and broken tiles gradually increased over the years. CNA E stated she noticed when she was giving a resident a shower, the missing parts were much larger. CNA E stated the floor tiles being in this condition could cause the shower chair to get stuck and tip over with the resident in it. She stated it was a fall risk, and the resident could be injured. Interview on 11/10/23 at 12:40 pm, the AD stated the floor tiles in the Common Shower had been in disarray for about five years. She stated the residents in wheelchairs can slide their feet and cut or stub their toe. The AD stated the mobile residents can trip and fall and hurt themselves. She stated the residents that use a walker or wheelchair, when they were transferred to the shower chair, they can trip or fall. The AD stated even though the residents were always supervised, the staff can trip and fall on the resident. Interview on 11/10/23 at 2:30 pm, LVN B stated the missing tiles could cause the chair to tip over causing the resident to fall and cut or injure themselves. LVN B stated it could then become an infection control issue. LVN B stated a resident on a blood thinner could bleed out and a resident with diabetes can actually contract Sepsis. She stated there was a maintenance log at the nurse's station, or they can call or text the MTD if it was an emergency. Interview on 11/10/23 at 3:20 pm, the MTD informed surveyor he just returned from the store to purchase the floor tiles, but the store did not have the size required. The MTD stated he had to now order the tiles, and they will be changing out the entire floor. Interview on 11/10/23 at 3:30 pm, the ADM stated she first noticed the floor tiles missing around 6 weeks ago. She stated she did not report the missing tiles to Corporate because they had so many other things that they had already reported. She stated she told the MTD to start looking for tiles, but he could not find the right size. The ADM stated they were going to replace the entire floor. She stated they will use the Common Shower on the Secure Unit if it takes more than one day. Record review of the Facility's undated Physical Environment - Maintenance Service Policy revealed, Maintenance service shall be provided to all areas of the building, grounds, and equipment. Under the Policy Interpretation and Implementation section, it reads: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free from hazards. i. Providing routinely scheduled maintenance service to all areas. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Record review of the Facility's undated Physical Environment - Work Orders, Maintenance Policy revealed, Maintenance work orders shall be completed in order to establish a priority of maintenance service. 2. It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director.

Based on observation, interview, and record review, the facility failed to review and revise quarterly a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of ten residents reviewed for care plans, in that: The facility failed to revise quarterly care plans in the necessary time frame for Resident #1. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental and/or psychosocial well-being. Findings included: Review of Resident # 1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Type 2 Diabetes Mellitus, and shortness of breath. The resident was discharged from the facility on 12/13/2022 to the hospital due to injury sustained from fall. Review of Resident #1's quarterly MDS assessment, dated 11/7/2022, reflected he required extensive assistance in the following areas: 1. Transfer 2. Locomotion movement between locations in the building 3. Dressing 4. Toileting 5. Personal hygiene The MDS further reflected Resident # 1 was unsteady when walking and only able to stabilize with staff assistance. Review of Resident # 1's care plan, dated 9/14/2020, reflected he was a high risk for falls related to impaired balance with interventions of ensuring his chair alarm was in working order and supervising to monitor his movements and redirect when weak or tired. During an interview on 12/21/2022 at 3:00pm with CNA A and CNA B, they stated they would watch the residents to see what care they required. CNA A and CNA B stated they were using the alarms on Resident #1's bed and chair months ago, but stated they were told they could no longer use the alarms when the new administrator started in June 2022, so all bed alarms and chair alarms were removed. During a telephone interview on 12/21/2022 at 3:13pm with RDO, she stated the care plans should have been updated to reflect any new interventions for the residents. She stated absolutely, the care plans should have reflected the current interventions and reflected which interventions were discontinued. During a phone interview on 12/21/2022 at 3:32pm with the MDS Nurse, she stated she was responsible for updating the care plans. However stated she does not know how to work the electronic records system that the facility used. MDS nurse further stated that she wanted someone to show her how to update the care plans in the system. MDS nurse stated the care plan should have been updated to reflect any changes made. During a telephone interview on 12/21/2022 at 4:40 pm with D.O.N, she stated she did not know how to update the care plans in Point Click Care system. D.O.N stated she had added information to the care plan but did not know that the care plan needed to be reviewed quarterly or how to update the care plan in the system when changes were made. During an interview on 12/21/2022 at 5:30pm with ADM, he stated it was his expectation that staff were updating the care plans when there was a change in condition, quarterly, and annually. ADM stated the MDS nurse was working remotely. ADM stated he expected the MDS nurse to know how to update the care plans in the Point Click Care system. ADM stated the care plans should have been updated to reflect current interventions and care for the residents. Review of facility's Comprehensive Person-Centered Care Plan Policy, dated May 2011, reflected the following: . 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in resident's condition b. When the desired outcome is not met c. At least quarterly, in conjunction with the required MDS assessment

30633 Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, and personal hygiene for nine (9) of seventeen (17) residents reviewed for ADL care. (Residents #1, #16, #27, #11, #25, #15, #33, #18, #29) The facility did not provide nail care for Residents #1, #16, #27, #11, #25, #15, #33, #18, and #29 which left them with long, dirty, jagged fingernails. This failure could place residents who were dependent on staff for personal care services at risk for embarrassment, infections and discomfort. Findings included: Record review of a face sheet dated 10/11/2022 reflected Resident #1 was a [AGE] year-old male admitted to the facility 11/15/2016 and readmitted on [DATE] with diagnoses of Malignant Neoplasm of Cecum, (malignant cancer of a pouch connected to the junction of the small and large intestines), Encounter for Palliative Care, (comfort care), Essential (primary) Hypertension (high blood pressure), Unspecified Psychosis not due to a substance or known physiological condition, Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Alcohol Dependence with alcohol-induced Amnestic Disorder (inability to remember events for a periods of time), Psychoactive substance abuse with psychoactive substance induced persisting Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of an annual MDS dated [DATE] reflected Resident #1 had a BIMS score of 7 indicating severe cognitive impairment. His functional assessment indicated he required one-person physical assist for personal hygiene. Record review of a care plan for Resident #1 dated 11/15/2016 and revised on 06/29/2022 reflected he had an ADL self-care performance deficit r/t aggressive behavior, confusion, dementia. Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Observation on 10/10/2022 at 8:32 AM in Resident # 1's room revealed his fingernails on both hands were 3/4 to 1 inch past his fingertips . Record review of a face sheet dated 10/11/2022 reflected Resident #16 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Fracture of right acetabulum (break in the socket portion of the ball and socket hip joint), Type 2 Diabetes (non-insulin dependent), limitation of activities due to trauma and history of falling. Record review of an annual MDS dated [DATE] reflected Resident #16's functional assessment indicated he was totally dependent on one-person physical assist for personal hygiene. Record review of a care plan for Resident #16 revised on 08/03/2022 reflected she had an ADL self-care deficit r/t Dementia. Check nail length and clean and trim on bath days and as necessary. Observation on 10/10/2022 at 10:42 AM in the facility lobby revealed Resident #16 was being assisted up onto a walker by PT. His fingernails on both hands were noted to be long, 3/4 to 1 inch past his fingertips and jagged with brown debris underneath. Resident #16 was very HOH and unable to be interviewed. Record review of a face sheet dated 10/11/2022 reflected Resident #27 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Asthma, (condition in which airways become inflamed, narrow and swell and produce extract mucus which makes it difficult to breath), Covid-19, Psoriasis, (condition in which skin cells build up and form scales, and itchy dry patches), limitation of activities due to weakness and Cerebral Infarction (brain stroke) Record review of a quarterly MDS quarterly dated 08/22/2022 reflected Resident #27 functional assessment indicated she required extensive assistance and one-person physical assist for personal hygiene. Record review of a care plan for Resident #27 dated 06/09/2022 reflected she had a rash of the upper and lower extremities r/t Psoriasis. Avoid scratching. The resident has an ADL self-care deficit r/t aggressive behavior, Hemiplegia (paralysis of one side of the body), impaired balance. The resident requires skin inspection. Observe for redness, open areas and scratches. Observation and interview on 10/10/2022 at 10:00 AM revealed Resident # 27 had what appeared to be Psoriasis plaques on her arms. Her fingernails were curved and 3/4-inch-long with brown debris underneath. She stated her psoriasis was bad and something on her back itched. She stated her nails needed care and they were curling over. She stated it bothered her to have long dirty nails. Record review of a face sheet dated 10/11/2022 reflected Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of nutritional Anemia (lack of red blood cells in the body leading to reduced oxygen flow to the body's organs), Covid-19, Essential (Primary) Hypertension, Dementia, Psoriasis and muscle weakness. Record review of a quarterly MDS quarterly dated 07/25/2022 reflected Resident #11 functional assessment indicated he required extensive assistance and one-person physical assist for personal hygiene. Record review of a care plan for Resident #11 dated 11/17/2016 and revised on 11/05/2019 reflected he had an ADL self-care deficit r/t aggressive behavior, confusion, Dementia. The resident is dependent on staff for personal hygiene. The resident has a history of rash of body r/t Psoriasis. Avoid scratching. Monitor skin rashes for increased spread or signs of infection. Observation on 10/10/2022 at 8:55 am revealed Resident #11 in a chair trying to scoot it down the hall. He had long, jagged fingernails approximately 3/4 to 1 inch long past the fingertips with brown debris underneath. Record review of a face sheet dated 10/11/2022 reflected Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Dementia, Cerebral Infarction, Neurosyphilis (infection of the central nervous system in a patient with syphilis, causing abnormal gait, numbness in toes, feet or legs, problems with thinking, mental problems. Loss of bladder control), Schizoaffective Disorder Bipolar type (chronic mental health condition characterized by hallucinations or delusions with some episodes of mania and some depression), cocaine dependence, in remission, Hypertension and alcohol dependence in remission. Record review of an annual MDS dated [DATE] reflected Resident #25's functional assessment reflected he required supervision of personal hygiene and one-person physical assist. Record review of a care plan for Resident #25 dated 08/14/2018 and revised on 02/10/2022 reflected he had an ADL self-care performance deficit r/t Dementia. Check nail length and trim and clean on bath day and as necessary. Observation on 10/10/2022 at 10:38 am revealed Resident #25 had fingernails on both hands 3/4 - 1 inch long past the fingertips with brown debris underneath . Record review of a face sheet dated 10/11/2022 reflected Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis (paralysis on one side of body and weakness on one side of body) following Cerebral Infarction. Type 2 Diabetes, Chronic Obstructive Pulmonary Disease (group of disease that cause airflow blockage and breathing related problems), Aphasia (inability to speak) following Cerebral Infarction. Psychotic Disorder with delusions (presence of one or more delusions. Delusion is unshakeable belief in something that isn't true). Record review of a quarterly MDS dated [DATE] reflected Resident #15's functional assessment indicated he required extensive assistance and one-person physical assist for personal hygiene. Record review of a care plan for Resident #15 dated 07/20/2018 and revised on 11/06/2018 reflected he had an ADL self-care performance deficit r/t activity intolerance, Hemiplegia, limited ROM and stroke. Check nail length and trim and clean on bath day and as necessary. Observation and interview on 10/10/2022 10:50 am with Resident #15 revealed he had fingernails on both hands 3/4 - 1 inch long past the fingertips with brown debris underneath and a contractured contracted right hand. He stated the fingernails are hurting my hand. Record review of a face sheet dated 10/11/2022 reflected Resident #33 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time affecting functional abilities and usually result in movement, thinking, and psychiatric disorders), Multiple Sclerosis, (disease in which the immune system eats away at the protective coating of nerves and disrupts communication between the brain and the body), Essential (Primary) Hypertension, Dysphagia (difficulty swallowing) and Schizoaffective Disorder Bi-polar type (chronic mental health condition characterized by hallucinations or delusions with some episodes of mania and some depression). Record review of an annual MDS dated [DATE] reflected Resident #33's functional assessment indicated he required extensive assistance and one-person physical assist for personal hygiene. Record review of a care plan for Resident #33 dated 11/17/2018 and revised on 10/28/2019 reflected he had an ADL self-care performance deficit r/t aggressive behavior, confusion and impaired balance. Check nail length and trim and clean on bath day and as necessary. Observation on 10/10/2022 at 12:05 pm revealed Resident #33 attempting to get out of his wheelchair in the dining room and was noted to have 3/4 to 1-inch long fingernails with brown debris underneath . Review of the face sheet for Resident #18 reflected he was admitted on [DATE] with diagnoses of: COPD, High blood pressure, Unspecified Joint Pain, Major Depressive Disorder recurrent, Type 2 diabetes and an Anxiety disorder. Review of the quarterly MDS assessment for Resident #18 dated 08/24/2022 reflected a BIMS score of 11 indicating moderate cognitive impairment. His functional assessment reflected he required extensive assistance for bathing and dressing, but only supervision for all other ADLs. He was assessed as occasionally incontinent. Review of care plan for Resident #18 dated 08/22/2022 reflected interventions were in pace for: full code status, ADL self-care performance deficit, will not allow staff to help him up slight uphill grades. Impaired cognitive function r/t COPD and shortness of breath, missing teeth r/t nutrition, joint pain, oxygen therapy. Review of Physician's orders for Resident #18 dated 05/04/2022 and renewed to 10/30/2022 reflected as part of Anti-Depressant Behavior Monitoring, he was to be encouraged not to scratch, fight or finger paint in feces. Monitoring for fingernail length would reduce the chances of injury and infection associated with these behaviors. Observation on 10/10/2022 at 8:32 AM of Resident #18 revealed he was seated in his wheelchair in the television viewing area, holding hands with a female Resident. It was observed his fingernails were long, yellow and pointed. Some fingernails extended 1 and 1/4 inches past his fingertips. All were observed to be well past the ends of his fingertips. Review of the face sheet for Resident #29 reflected he was admitted on [DATE] with diagnoses of: Asthma, Legal Blindness, Hypothyroidism, High Blood Pressure, Major Depressive Disorder, Visual Hallucinations and Mood Disorder with Major Depressive symptoms. Review of the annual MDS assessment for Resident #29 dated 09/02/2022 reflected a BIMS score of 15 indicating normal cognitive function. Review of his functional assessment reflected he required extensive assistance for transfers and utilizing his wheelchair, he required only supervision for his other ADLs. He was assessed as always continent of bowel and bladder. Review of the care plan for Resident #29 dated 08/07/2022 reflected interventions were in place for: his Full Code status, Resident had stated dislike of group activities, utilized divided plate to eat independently, ADL self-performance deficit r/t blindness, Fall Risk, antidepressant Mediations. Interventions for Resident #29 reflected he was to keep his fingernails short to avoid scratching related to a dry skin condition. The interventions reflected scratches left the resident at greater risk of infection. Observation and interview on 10/10/2022 at 9:12 AM of Resident #29 revealed he was seated in his wheelchair in his room with the lights turned out. Light coming in through the window blinds made observation easily performed. Resident #29 had long fingernails 1/2 inch past the end of all fingers. Resident #29 stated he had no discomfort from his fingernails and was not aware that they had reached such length. Review of Physician's orders for Resident #29 reflected an order was entered on 09/01/2017 for nail care. It reflected he was to have fingernail care on evening shift on the 22nd of every month. Interview on 10/11/2022 at 8:40 AM LVN M stated all residents were supposed to get their fingernails trimmed on Sunday. She stated the Sunday nail trimming had been a facility practice for as long as she could recall . LVN M stated resident's fingernails could be cut on shower days, and shower sheets were used to record skin conditions but not fingernails. She stated she would cut the fingernails for Resident #29 and #18 right away (after surveyor informed her of long fingernails). Observation and interview on 10/11/2022 at 3:06 PM with LVN M who observed Resident #1's fingernails and agreed they needed trimming. LVN M stated Resident #1 is on hospice and the hospice aides are supposed to do his nails, but we do it if they don't. LVN M observed Resident # 11, # 16, #15, and #25's fingernails and stated Yes they're all too long. She stated the weekend nurse is supposed to cut all nails on Sundays. It's everyone's responsibility to cut nails. Interview on 10/11/2022 at 3:20 PM CNA A stated the CNAs and the weekend nurse cut fingernails. She stated she had not seen a place to document it. Interview on 10/11/2022 at 3:25 PM the Lead CNA stated she told her charge nurse when she cut fingernails and they document it. She stated she did not think the facility had any nail files. She stated she would have to go to a local store and buy some nail files. Observation on 10/11/2022 at 3:30 PM revealed LVN M found two toenail clippers in a drawer at the nurse's station and two fingernail clippers in a locked treatment cart that was not accessible to CNAs. No nail files were located. Interview on 10/11/2022 at 3:27 PM with the DON who stated she had been at the facility since 10/05/2022. Her expectations were that fingernails would be cleaned and trimmed. She stated she was not sure about the system for documenting nail care. She stated bacteria under fingernails could absolutely cause infections. Interview on 10/12/2022 at 1:40 PM with the Administrator who stated nail care would typically be part of ADLs every day or as needed and as the resident would allow. He agreed the potential issue with dirty fingernails could be bacteria and scratches. Review of a Nail Care policy and procedure dated 04/01/2009 reflected, Responsibility: Licensed Nurse or Podiatrist performs the procedure on high risk residents. Nursing assistants may perform the procedure ifs the resident is not at risk for complications or infection. Purpose: to provide cleanliness. To prevent spread of infection. Equipment: Nail clippers, Nail file. Basin with warm water and soap. Nail brush. Towel.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals were labeled according to accepted professional principals and included cautionary instructions for 2 of 2 medication carts and 1 of 2 medication storage rooms reviewed for labeling and storage of drugs and biologicals. The facility failed to ensure expired medications were removed from the carts; failed to ensure potential contaminants including loose pills and debris were not on the carts and failed to ensure the medication storage room was free of potential contaminants. This failure could place residents at increased risk of receiving expired and/or contaminated medications resulting in adverse health consequences. Findings include: Observation and interview on 10/11/2022 at 1:30 PM of the large medication storage room revealed two pills on the floor, one white and one pink. There was loose debris, empty boxes, dirt, and a large dead roach on the floor. LVN A observed the debris and loose pills on the floor and stated, Only nurses can get into the medication storage rooms. She had no explanation for why the room was in disarray. Observation and interview on 10/11/2022 at 1:40 PM of medication storage cart 1 (one) revealed seven loose pills in the drawers, hair, spilled liquids and debris. There was a bottle of MVI which expired 09/2022, Omeprazole 20 mg expiration date 09/2022 and Famotidine which expired 09/2022. LVN A confirmed the medications were expired and should not be on the cart. She agreed the cart should not have loose pills and debris in it. Observation and interview on 10/11/2022 at 2:00 PM of medication cart 2 (two) revealed a bottle of MVI expiration date 09/2022. There was spilled medication and loose debris in the drawers. LVN A agreed the expired medications should not be on the cart and stated the potential risk was the resident not receiving the desired potency of the medication. She stated any nurse or medications aide could remove the expired medications, clean the medication storage room and the carts. She stated the 10-6 shift used to do it and it was also a weekend nurse responsibility. Observation on 10/12/2022 at 1:30 PM revealed the large medication storage room still had loose debris, empty boxes, dirt, and a dead roach on the floor. LVN M observed the debris on the floor and stated, I'll get housekeeping to come clean it. Interview on 10/11/2022 at 3:27 PM with the DON who when informed there were expired meds on the medication carts stated she would find out who was responsible for ensuring expired medications were removed. She stated the potency of expired medications could be affected. When informed the medication carts were dirty and the large medication storage room was observed to be dirty for two days, she stated there absolutely could be a problem with infection control. Interview on 10/12/2022 at 1:40 PM the Owner stated any medication that was close to expiring should be removed. He stated medication carts needed to be checked weekly and the med rooms could be cleaned by housekeeping and the nurse would stand at the door. He stated the medication carts should be deep cleaned one-time a month. He stated if there were spills, our expectations would be for them to be cleaned right away. Review of a policy titled Medication Storage in the Facility dated 2006 reflected All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Medication storage areas are kept clean, well-lit and free of clutter.

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 for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1. Onions and bananas in the kitchen were overly ripped and/or rotting. 2. The beverage gun handle used to portion resident beverages from the beverage dispenser machine had accumulated solidified buildup on the area were the beverages are released. 3. Cook D did not submerge the thermometer in the sanitizing solution for the required time for sanitization when using it to take the temperature of the food on the steamtable. These deficient practices could place residents who receive meals from the main kitchen refrigerator at-risk for food borne illness. The findings were: 1. During an observation and interview on 8/03/2021 at 10:38 AM revealed an open case of bananas and a bag containing roughly over 10 yellow onions. The case of bananas had bananas that were the banana peel had opened and the banana meet was exposed. There were also bananas that had turned a dark brown and black color. The in the bag with the yellow onions there were some of the onions that had shriveled up and were brown, green and white in color. The Dietary Manager confirmed some of the onions and bananas looked old and need to be disposed of. 2. During an observation and interview on 8/03/2021 at 10:52 a.m., revealed a beverage dispensing machine with a nozzle gun in the kitchen. The Dietary Manager removed the nozzle from the beverage gun handle to expose the area were the beverages are dispensed from the gun. In the exposed area there was a solidified buildup of the beverage juices. The Dietary Manger confirmed there was the buildup shouldn't be on the beverage handle were the beverages are released. She reported she would clean it. 3. During an observation and interview on 8/05/2021 at 4:58 p.m., revealed Cook D taking the temperature of the food items on the steamtable before service. The observation revealed Cook D initially taking the temperature of the breaded chicken then dipped it into a cup of clear solution then immediately removed and shook it to dry. Then Cook D proceeded to take the temperature of the rice pilaf and then dipped the thermometer into the clear solution. Cook D continued with the pattern with taking the temperature of the pureed bread, pureed green beans and mashed potatoes. Cook D reported the clear solution was the chemical sanitizer they used to sanitize the dishes in their 3-compartment sink. The Dietary Manager reported they were told by another surveyor to use the chemical sanitizer to clean the thermometer in between food items instead of alcohol pads. The surveyor asked the Dietary Manager if there was a time requirement for how long the item had to be in the sanitizer solution to be sanitized and she reported that she was not sure. Observation on 8/05/21 at 5:05 p.m., revealed the Auto-Chlor Solution QA botte revealed the direction for use were to leave the items fully submerged for 60 seconds (1 minute). The Dietary Manager reported that if the bottle indicated it needed to be submerged for a minute than that what should have been done. Record review for the EPA's Label Amendment - To update label Product Name: Auto-Chlor Solution QA, dated 4/03/2018, revealed in the section on Sanitizing Food Contact Surfaces that For sanitizing and cleaning of equipment and utensils, prepare a 200 ppm active quaternary solution by adding 0.5 ounce of this product to 1 gallon of water (or equivalent dilution). Prior to application, remove gross food particles and soil by a pre-flush, or pre-scrape and, when necessary, pre-soak treatment. Follow with thorough washing in a good detergent or compatible cleaner, followed by a potable water rinse before applying sanitizer. Apply use solution to dinnerware and food utensils by immersion. For items which are too large for immersion, solution may be applied with a cloth, mop, sponge or coarse sprayer. Treated surfaces must remain wet for 60 seconds (1 minute). Drain thoroughly and allow to air dry before reuse. No potable water rinse is required after application of sanitizer. (https://www3.epa.gov/pesticides/chem_search/ppls/ 3- - 403.pdf) Record review of the facility's policy of Safe Food Handling, undated, revealed it is the policy of this facility that food acquisition, storage, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing food borne illness. The policy also revealed the food preparation area and utensils used to prepare foods are cleansed and sanitized prior to each use, using approved washing and sanitizing techniques.

Based on observations, interviews, and record reviews, the facility failed to ensure that the menus were followed for 1 of 2 meals (dinner meal) reviewed for meal accuracy, in that: The facility failed to serve citrus grill chicken as per the menu for the dinner meal. In addition, the residents receiving a puree diet were served mashed potatoes and pureed green beans instead of pureed rice and zucchini as per the menu. This failure could affect residents who were ordered a regular, mechanical ground meats and/or pureed diet by contributing to dissatisfaction, poor intake, and/or weight loss. The findings included: Record review of the facility's Week 2 Thursday 2021 weekly menu revealed the resident were to be served citrus grilled chicken, rice pilaf, zucchini, dinner roll and fresh fruit. Record review of the facility's Week 2 Thursday 2021 Diet Spreadsheet revealed all residents were to be served citrus grilled chicken, rice pilaf and zucchini. During an observation and interview in the kitchen on 8/05/21 at 4:18 p.m., revealed Cook D preparing the dinner meal items. Cook D reported she was preparing a breaded chicken patty instead of a grill citrus chicken as listed on the menu. Cook D reported she was not aware the menu called for the other chicken. During an observation and interview in the kitchen on 8/05/21 at 4:51 p.m., revealed Cook D has some of the dinner meal food items on the steamtable. Cook D reported for the puree residents she had prepared pureed spaghetti, mashed potatoes and pureed green beans. The Dietary Manager reported to her that she should have pureed the chicken, zucchini and rice for the puree meal residents as the menu stated. The Dietary Manager told Cook D she would help her by pureeing these items for her and she removed the pureed spaghetti from the steamtable. During an observation on 8/05/21 at 4:58 p.m., the Dietary Manager provided Cook D with pureed breaded chicken patty. Cook D then placed it on the steamtable. During an observation on 8/05/21 at 5:10 p.m., Cook D began serving the dinner meal. The steamtable still had the mashed potatoes and pureed green beans for the puree residents. During an interview at the end of the dinner meal service on 8/05/21 at 5:42 p.m., Cook D confirmed she served the residents on a puree diet the mashed potatoes and pureed green beans. The Dietary Manager asked her why because she had made the pureed rice and zucchini and left it in the steamer for her. The Dietary Manager asked her why she didn't get it out of the steamer. Cook D reported she didn't know those items were in the steamer. During an interview on 8/05/21 at 4:51 p.m., the Dietary Manager confirmed the menu the dinner was supposed to be the grill citrus chicken. The Dietary Manger reported Cook D must have pulled out the wrong type of chicken to cook for the dinner. During an observation and interview on 8/05/21 at 4:51 p.m., the Dietary Manager confirmed they had the chicken breasts in the freezer that should have been used for the grilled citrus chicken. The Dietary Manger went to the freezer and showed the surveyor the box of chicken breast to be used. Record review of the policy on Meal Service, undated, did not address serving the meal according to the menu.

Based on observation, interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents.(Resident #6) On 1/7/15 Resident #6 jumped head first out of a window on the secure unit, and ran down the street with no coat and only one shoe on in freezing temperatures. On the morning of 1/7/15, he walked into a private residential home in the neighborhood without knocking. On 5 previous occasions, (12/20/14, 12/21/14, 12/22/14 and twice on 12/25/14), he eloped from the facility and the facility had not developed and revised a plan to prevent further elopements. This failure resulted in an Immediate Jeopardy (IJ) on 1/07/15. While the IJ was removed on 1/08/15, the facility remained out of compliance at a level of potential for more than minimal harm at a scope of a pattern, that is not an IJ, because the facility staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 8 residents identified at risk for elopement, physical harm, and injury. Findings include: Resident #6's Admission Face Sheet dated 12/22/14 reflected he was [AGE] years old and admitted to the facility on [DATE]. Resident #6's Hospital Discharge Progress Notes dated 12/19/14 reflected the following Diagnoses: [REDACTED]. LBP (Low Back Pain) Hypertension Dementia The hospital Discharge Progress Notes dated 12/19/14 reflected that Resident #6 had eloped from a nursing home and was brought to the hospital by the police. The notes reflected that Resident #6 was impulsive, combative, and verbally abusive. Resident #6 was to be discharged and placed in a long term care facility by APS (Adult Protective Service). Review of Resident #6's MDS (Minimum Data Set) dated 12/30/14 reflected that he had entered the facility from a Psychiatric Hospital, his Brief Interview for Mental Status (BIMS) score was 2 (0-7 score is severe impairment according to CMS ' RAI Version 3.0 Manual). The MDS reflected that Resident #6 Signs and Symptoms of Delirium showed that he had difficulty focusing attention, i.e., easily distracted, out of touch or difficulty following what was said. He had Disorganized thinking, i.e., Rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. The MDS reflected the following Diagnoses: [REDACTED]. Review of a facility Admission Wander Data Collection Tool dated 12/21/14 reflected that Resident #6 had a history of [REDACTED]. It reflected the resident was a new admission non-accepting of the new situation and cognitively impaired with poor decision-making skills. Review of facility Nurses Notes reflected the following: -12/20/14 8:10 AM Received call from Police Department stating they found resident (Resident #6) and will be bringing him back to facility. Employee was asked when resident was last seen. At 7:30 AM. -8:30 AM received resident back in facility with 2 Police Officers. Head to toe assessment done. Alert, confused, noting scratches per left arm. When asked resident what happened, he states received scratches when he jumped the fence. Area cleaned with N/S (Normal Saline), pat dry and TAO (Triple Antibiotic Ointment) applied and wrap with kerlix. Tolerated well, denies pain/discomfort. ADON (Assistant Director of Nurses informed. One-on-one care with resident. There was no documentation for time frame for one-on-one care for Resident #6. Review of a facility Incident/Accident Report dated 12/20/14 at 8:10 AM reflected that the facility received a call from the police at 8:10 AM stating they had Resident #6 and will bring him back to facility. Comments and/or steps taken to prevent recurrence: All doors checked, locked, key removed and placed at nursing station. Close observation in secure unit. Reorient resident several times each shift Re-direct one-on-one. Interventions recommended: Resident in secure unit increase observation. Check all doors each shift. Make rounds on resident. Review of Resident #6 ' s Nurses Notes dated 12/21/14 at 11:30 PM reflected the following: Resident at nurses ' station, talking to nurse. Nurse walked with Resident to his room, saw him get in bed. Approximately 20 minutes later, local police officer arrives with resident, stating he was walking down the street. Resident admits he climbed out the window in his room after nurse left his room. Led back to secure unit. Will monitor. No injury or complaints noted. Review of a facility Incident/Accident Report dated 12/21/14 at 11:30 AM Description of Incident: Resident #6 admits that he climbed out of the window in his room shortly after nurse left his room. Was brought back to facility by police approximately 20 minutes later. Comments and /or steps taken to prevent recurrence: check doors, put window back down. Explained to resident the dangers of wandering outside the facility. Review of Resident #6 ' s Nurses Notes dated 12/22/15 reflected the following: -06:30 AM Resident stated he needed to leave because he had animals to tend too. CNA (Certified Nurse Aide) tried to redirect him without success. LVN (Licensed Vocational Nurse) was able to redirect. Resident sat on the couch drinking coffee. -07:30 AM Called back to secured unit. Resident had opened his window in his room and climbed out of the window. CNA left to go look for him. ADON notified. Sheriff's office was notified. -07:55 AM Resident was found by CNA. He was in a field by the high school. Resident was safe no injuries apparent at this time. -08:30 AM Resident was returned to the facility with ADON and CNA. Review of a facility Resident Monitoring Sheet dated 1/22/14 for Resident #6 revealed that the resident was provided with one-to-one care which started at 0900 (9:00 AM) and ended at 1430 (2:45 PM) on 12/22/14. Review of a facility Incident/Accident Report dated 12/22/14 at 1:15 AM, description of Incident: Resident #6 went into his room and opened his window and climbed out of it. Resident was found in a field by the high school and was brought back. Comments and/or steps taken to prevent recurrence: no comments or steps documented. Review of Social Service Progress Notes dated 12/22/14 reflected the Social Worker (SW) met with resident after his elopement on 12/22/14 and the resident stated that he wants to go home and misses his partner. The notes revealed that Resident #6 was placed in the facility by APS and his case worker was looking for other placement. Review of Nurses Notes dated 12/23/14 at 1800 (6:00 PM) Resident made attempt/elopement raising window, continue on-on-one. No resident monitoring sheet for one-to-one care was furnished to surveyor. Review of Nurses Notes dated 12/25/14 at 7:00 AM revealed the following: "After first escape thru the bedroom window. I was on the unit with this resident. The rest of the night. I had key to door on me because he began going from one door to another. He was pacing and started to cry. He said he did not want to be there. I left the unit and had a nurse aide stay with the resident and go everywhere the resident went. I was gone from the unit about 30 minutes when the nurse aide called and told me the resident went out the back door and was on the ground. I went out to check on the resident and called EMS (Emergency Medical Services). They told me that the resident did not have any broken bones. They called the police. The policeman said I would be responsible for the resident if he gets away from the people at the hospital." The nurse's notes did not reflect that Resident #6 was sent out to the hospital. Review of Resident #6's facility Incident/Accident Report dated 12/25/14 with no documented time reflected the following: Resident is on our lock down unit. He has dementia. He keeps trying to break out of the unit and go home. He kicked out the screen in his room and went out the window. We found him and brought him back to the unit and later he broke out again. Cops were called. When he broke out the second time he fell on the ground. EMS checked him out. Additional Comments and/or Steps taken to prevent recurrence: He fell outside the building. He escaped from the nursing unit. He wants to go back home. During an interview on 1/8/15 at 9:12 AM, CNA B stated that she did one-to-one care for Resident #6, but sometimes she still had to see to other residents. Review of Resident #6's Social Service Progress Notes dated 12/31/14 revealed that the APS Case Worker for Resident #6 had found placement at a long term care (LTC) facility in another city. Review of Nurses Notes dated 12/31/14 revealed the following: -1:00 AM Resident climbed through window, staff out looking for resident at this time. On call nurse informed. -1:05 AM Staff unable to find resident. -1:15 AM Staff in car looking for resident. 911 called. -1:45 Returned to facility by police. Head to toe assessment done. Noting abrasions to both arms and right leg. -2:00 AM Geodon (Antipsychotic medication) 20 mg given. -2:45 AM resident continues to have anxiety. Re-directed continue one-on-one. -1600 (4:00 PM) late entry Resident taken to another Long Term Care facility by private transport. Resident not in physical distress however exhibiting emotional distress. -1745 (5:45 PM) Resident returned to facility. The other Long Term Care facility declined to admit him. To provide one-on-one observation. Resident's bed placed in front of nurse's desk. No s/s (signs/symptoms) of distress. -2245 (10:45 PM) Resident anxiety Lorazepam (Antianxiety medication) 1 mg IM (Intramuscular) injection right deltoid (muscle in shoulder). During an interview on 1/7/15 at 1:00 PM, the Director of Nurses (DON) stated that Resident #6 had been transferred to the other LTC facility on 12/31/14, but as soon as the van doors were opened Resident #6 ran into the woods and the police had to find him. She stated the LTC facility refused to admit him and he was returned to their facility. In a continued interview the DON was asked if they could do one-to-one care with Resident #6, she stated that the facility did not have the staff to do one-to-one care for the resident; however, the facility could not seek other placement for the resident or treatment for [REDACTED]. The DON stated that they had been encouraging him to comply with his medication regime and trying distractions and re-direction with the resident. There was no further documentation in Nurses Notes or Resident Monitoring Sheets (for one-to-one care). Review of Nurses Notes dated 1/7/15 at 8:00 AM reflected the following: Resident jumped head first out of a window on secure unit. Nurse was in room with resident when he suddenly opened the window and jumped out. Nurse tried to keep resident from hitting the ground with the help of a CNA. Resident hit and kicked nurse and CNA as he jumped. When he got to the ground, he jumped to his feet and ran down the street. Nurse and CNA ran after him. Attempted to reason with resident, but he kept running. Resident approached a residential home and opened the door, went inside. Told the occupant of the home that nurse was trying to kill him. After nurse, CNA and Social Worker spoke to him about coming back to the facility; he finally agreed to get in the Social Worker's car to go back to the facility. Late entry, after full assessment of resident, called resident's PCP (Primary Care Physician) and left message explaining this morning's incident. Review of a facility Incident/Accident Report dated 1/7/15 at 8:00 AM Description of Incident: Resident #6 jumped out of window and run up the street, nurse and CNA following. Resident opened the door to someone's house and went inside. Comments and/or steps taken to prevent recurrence: No comment documented. There was no documentation on the facility Incident/Accident Report that Resident #6's physician had been notified of the incident on 1/7/15. During an interview on 1/7/15 at 3:02 PM, the Nurse Practioner stated that he was aware of Resident #6's elopement. During an interview on 1/8/15 at 9:08 AM LVN (Licensed Vocational Nurse) A stated that Resident #7 was so fast that they did not have time to stop him before he threw open his window and jumped out head first. She stated they chased him down the street and convinced him to return to the facility. Review of Resident #6's Social Service Progress Note dated 1/7/15 revealed the following: "As this writer was pulling into the parking lot this morning, I observed Resident #6 running from the building followed closely by three staff members. He was headed toward town and moving fast. Staff was within close proximity of resident at all times. Staff was trying to get resident to slow down and/or stop which he did not do. Attempts to redirect him were unsuccessful. This writer also tried to get resident into car but was not successful. Resident continued running toward town and went down a side street to the next street over. He ran into a residential yard and went to the door and began knocking. Again staff was there attempting to redirect him and come with us to the facility. At this time we were joined by another staff member who gave resident her jacket to put on to be warmer. He was wearing only one shoe and said he did not know where the other one was. After much time and effort, the resident agreed to get into car and return to the facility. Upon returning to facility, resident came into this SW office and we discussed why he is here and the court order. In the moment, he appears to process and understand the conversation, but, within minutes, he is repeating the same questions. The Chief of Police also spoke with the SW and spoke to resident. Resident returned to secure unit with nursing staff." Review of The National Weather Service website accessed on 1/8/15 reflected the outside temperature on 1/7/15 was 32 degrees and windy. During an interview on 1/7/15 at 1:00 PM, the DON stated that this morning (1/7/15) Resident #6 jumped head first out his window and ran down the street and into someone's home. She stated that the staff was able to get him back to the facility. She stated that the facility could not seek treatment or placement for him because he had been placed in their facility by APS. When asked if the facility had a court order to keep him in the facility she stated no. That APS had the order. The DON stated they were using distraction, pleasant activities and redirection to try to manage Resident #6's elopement behavior. She stated that the facility has requested an order from Resident #6's physician to send to APS so he could be sent home for a supervised visit today (1/7/15) for 24 hours. The DON stated that they have asked the Ombudsman to talk with the Judge about the resident ' s placement. She stated that they did not ask if the facility could send him to the hospital to be evaluated because he is an APS placement and they cannot send him out of the building. During an interview on 1/7/15 at 3:02 PM, with the Facility Manager, DON, and SW, they were asked what they would do to treat the resident if he needed emergency care and the DON and the Facility Manager stated they would have to notify APS and get permission to transfer him to the hospital because they could not send him out of the facility for treatment because he was an APS placed resident. They stated that as long as APS had placed him in there facility they could not do anything. At this point in the interview they stated that Resident #6's arm was hurting after jumping through his window and that they had gotten a portable x-ray but no results had been called to the facility. The DON stated that they could not send the resident out for treatment or evaluation of his arm or his behaviors. She stated that he had to stay in the facility because of APS' court order. The SW explained to the Facility Manager and the DON that the court order was for APS to be his guardian, not a court order for the facility keeping him and not treating him. The SW stated that the facility could call the resident's physician and get an order to send him to the emergency room for evaluation of his arm and a psychological exam. Observations on 1/7/15 at 4:40 PM revealed Resident #6 sitting quietly in the Social Worker's office. He was clean and neatly dressed. During an interview on 1/8/15 at 2:00 PM, the Regional Director of Operations (RDO) stated that he had agreed to accept Resident #6 in the facility and if he had known about the DON and Facility Manager misunderstanding an APS placement, he would have explained the process to them and the Resident would have been given a psych evaluation. He stated that he would speak with them and tell them they could always call someone in the organization with questions. Review of Resident #6's Care Plan dated 12/19/14 revealed the following: New Admission: Did not have any interventions for elopement risk. Review of Resident #6's Care Plan dated 12/30/14 furnished by the DON revealed the following: Focus The resident is an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended. Date Initiated: 12/30/14 with a revision on 1/7/15 Goal the resident's safety will be maintained through the review date. Date Initiated: 12/30/14, Revisions: 1/7/15. Target Date 4/7/15 Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: no documentation of preferences Date initiated: 01/07/15. Provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. Date Initiated: 01/07/15. State Ombudsmen contacted 1/6/15 regarding incidents of elopement and how to maintain resident rights and safety in facility. Date Initiated 1/07/15. Position of person responsible for all interventions CNA. The facility did not furnish the surveyor with an elopement policy. The Facility Manager, Director of Nurses, Assistant Director of Nurses, and the Social Worker were notified on 1/7/15 at 3:30 PM that an IJ situation had been identified due to the above failures and a Plan of Removal was requested. A Plan of Removal was submitted by the Facility Manager on 1/7/15 at 4:30 PM. The final Plan of Removal was accepted by the surveyor on 1/8/15 at 1:48 PM. Plan of removal: Findings: residents that are an elopement risk. Resident where basic needs cannot be met. Corrective Action: Resident #6 is to be discharged to a local hospital for comprehensive physical/psychiatric evaluation under order of his Primary Physician. We will than contact his Adult Protective Services worker and inform her of his transport to the hospital and explain we cannot meet this resident ' s need. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/7/15 Responsible: Facility Manager, DON/Designee Corrective Action: In-service of Staff: 1. Prevention and Management of Aggressive Behavior 2. Elopement Policy & Procedure 3. Nursing Documentation Implementation date: 1/7/15 Projected Completed Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: All resident room windows on the secure unit will have window alarms installed. Timeline: Implementation Date: 1/5/2015 Projected Completion date: 1/10/15 Responsible: Facility Manager, DON/Designee Corrective Action: Any resident that has behaviors will be monitored and documented. It will be reviewed by IDT (Interdisciplinary team) (Mm-Th) and present to QA (Quality Assurance). Physician and/or psychiatric services will be notified of increase of behaviors as needed. (Contract with Psych-on-Site). Timeline: Implementation Date: 1/7/2015 Projected Completion Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: Psych-on-Site has agreed to provide services. Psychological services will enter the facility by 1/17/15 to evaluate and/or treat the resident requiring services. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/17/15 The surveyor monitored the current plan of removal as follows: Observation on 1/7/15 at 5:00 PM revealed that Resident #6 was transferred to a local hospital for evaluation and treatment for [REDACTED]. Observation on 1/8/15 at 8:45 AM of the facility's secure unit revealed 5 residents watching TV in the common area. During interviews on 1/8/15 at 9:00 AM, three (3) LVNs (Licensed Vocational Nurses) stated that they had been in-serviced on behavior management, elopement policies and procedures, and how to do documentation. During interviews on 1/8/15 at 9:20 AM, two (2) CNAs (Certified Nurse Aides) stated that they had been in-serviced on elopement of residents and how to manage resident behaviors. Review of facility in-service records on 1/8/15 reflected that staff was being in-serviced on Managing Resident Behaviors, Resident Elopement Policies and Procedures, and on Documentation of Behaviors and Elopement. On 1/8/15 at 1:58 PM, the facility Owner, Regional Director of Operations, Facility Manager, DON, ADON, DON Consultant, and MDS Coordinator were informed the IJ was removed. However, the facility remained out of compliance at a severity of a potential for more than minimal harm with a scope of a pattern due to the facility requiring time to monitor their Plan of Removal. Eight (8) residents were reviewed for behaviors and elopement risks.

Based on observation, interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for 1 of 8 residents reviewed for behaviors. (Resident #6) On 1/7/15 Resident #6 jumped head first out of a window on the secure unit, and ran down the street with no coat and only one shoe on in freezing temperatures. On the morning of 1/7/15, he walked into a private residential home in the neighborhood without knocking. On 5 previous occasions, (12/20/14, 12/21/14, 12/22/14, and twice on 12/25/14), he eloped from the facility and the facility had not developed and revised a plan to prevent further elopements. This failure resulted in an Immediate Jeopardy (IJ) on 1/07/15. While the IJ was removed on 1/08/15, the facility remained out of compliance at a level of potential for more than minimal harm at a scope of a pattern, that is not an IJ, because the facility staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 8 residents identified at risk for elopement, physical harm, and injury. Findings include: Review of a current (undated) facility policy titled "Prohibition of Abuse, Neglect, or Exploitation of residents reflected the following: Procedure: This facility endeavors to protect each resident from abuse, neglect and misappropriation of property through the implementation of polices that include the screening of potential employees, training of employees, prevent of abuse and neglect, identifying incidents which need investigation, investigation of incidents or allegation, and the reporting of incidents, investigations, and the facility's response to investigations. Resident #6's Admission Face Sheet dated 12/22/14 reflected he was [AGE] years old and admitted to the facility on [DATE]. Resident #6's Hospital Discharge Progress Notes dated 12/19/14 reflected the following Diagnoses: [REDACTED]. LBP (Low Back Pain) Hypertension Dementia The hospital Discharge Progress Notes dated 12/19/14 reflected that Resident #6 had eloped from a nursing home and was brought to the hospital by the police. The notes reflected that Resident #6 was impulsive, combative, and verbally abusive. Resident #6 was to be discharged and placed in a long term care facility by APS (Adult Protective Service). Review of Resident #6's MDS (Minimum Data Set) dated 12/30/14 reflected that he had entered the facility from a Psychiatric Hospital, his Brief Interview for Mental Status (BIMS) score was 2 (0-7 score is severe impairment according to CMS ' RAI Version 3.0 Manual). The MDS reflected that Resident #6 Signs and Symptoms of [MEDICAL CONDITION] showed that he had difficulty focusing attention, i.e., easily distracted, out of touch or difficulty following what was said. He had Disorganized thinking, i.e., Rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. The MDS reflected the following Diagnoses: [REDACTED]. Review of a facility Admission Wander Data Collection Tool dated 12/21/14 reflected that Resident #6 had a history of [REDACTED]. It reflected the resident was a new admission non-accepting of the new situation and cognitively impaired with poor decision-making skills. Review of facility Nurses Notes reflected the following: -12/20/14 8:10 AM Received call from Police Department stating they found resident (Resident #6) and will be bringing him back to facility. Employee was asked when resident was last seen. At 7:30 AM. -8:30 AM received resident back in facility with 2 Police Officers. Head to toe assessment done. Alert, confused, noting scratches per left arm. When asked resident what happened, he states received scratches when he jumped the fence. Area cleaned with N/S (Normal Saline), pat dry and TAO (Triple Antibiotic Ointment) applied and wrap with kerlix. Tolerated well, denies pain/discomfort. ADON (Assistant Director of Nurses informed. One-on-one care with resident. There was no documentation for time frame for one-on-one care for Resident #6. Review of a facility Incident/Accident Report dated 12/20/14 at 8:10 AM reflected that the facility received a call from the police at 8:10 AM stating they had Resident #6 and will bring him back to facility. Comments and/or steps taken to prevent recurrence: All doors checked, locked, key removed and placed at nursing station. Close observation in secure unit. Reorient resident several times each shift Re-direct one-on-one. Interventions recommended: Resident in secure unit increase observation. Check all doors each shift. Make rounds on resident. Review of Resident #6 ' s Nurses Notes dated 12/21/14 at 11:30 PM reflected the following: Resident at nurses' station, talking to nurse. Nurse walked with Resident to his room, saw him get in bed. Approximately 20 minutes later, local police officer arrives with resident, stating he was walking down the street. Resident admits he climbed out the window in his room after nurse left his room. Led back to secure unit. Will monitor. No injury or complaints noted. Review of a facility Incident/Accident Report dated 12/21/14 at 11:30 AM Description of Incident: Resident #6 admits that he climbed out of the window in his room shortly after nurse left his room. Was brought back to facility by police approximately 20 minutes later. Comments and /or steps taken to prevent recurrence: check doors, put window back down. Explained to resident the dangers of wandering outside the facility. Review of Resident #6 ' s Nurses Notes dated 12/22/15 reflected the following: -06:30 AM Resident stated he needed to leave because he had animals to tend too. CNA (Certified Nurse Aide) tried to redirect him without success. LVN (Licensed Vocational Nurse) was able to redirect. Resident sat on the couch drinking coffee. -07:30 AM Called back to secured unit. Resident had opened his window in his room and climbed out of the window. CNA left to go look for him. ADON notified. Sheriff's office was notified. -07:55 AM Resident was found by CNA. He was in a field by the high school. Resident was safe no injuries apparent at this time. -08:30 AM Resident was returned to the facility with ADON and CNA. Review of a facility Resident Monitoring Sheet dated 1/22/14 for Resident #6 revealed that the resident was provided with one-to-one care which started at 0900 (9:00 AM) and ended at 1430 (2:45 PM) on 12/22/14. Review of a facility Incident/Accident Report dated 12/22/14 at 1:15 AM, description of Incident: Resident #6 went into his room and opened his window and climbed out of it. Resident was found in a field by the high school and was brought back. Comments and/or steps taken to prevent recurrence: no comments or steps documented. Review of Social Service Progress Notes dated 12/22/14 reflected the Social Worker (SW) met with resident after his elopement on 12/22/14 and the resident stated that he wants to go home and misses his partner. The notes revealed that Resident #6 was placed in the facility by APS and his case worker was looking for other placement. Review of Nurses Notes dated 12/23/14 at 1800 (6:00 PM) Resident made attempt/elopement raising window, continue on-on-one. No resident monitoring sheet for one-to-one care was furnished to surveyor. Review of Nurses Notes dated 12/25/14 at 7:00 AM revealed the following: "After first escape thru the bedroom window. I was on the unit with this resident. The rest of the night. I had key to door on me because he began going from one door to another. He was pacing and started to cry. He said he did not want to be there. I left the unit and had a nurse aide stay with the resident and go everywhere the resident went. I was gone from the unit about 30 minutes when the nurse aide called and told me the resident went out the back door and was on the ground. I went out to check on the resident and called EMS (Emergency Medical Services). They told me that the resident did not have any broken bones. They called the police. The policeman said I would be responsible for the resident if he gets away from the people at the hospital." The nurse's notes did not reflect that Resident #6 was sent out to the hospital. Review of Resident #6's facility Incident/Accident Report dated 12/25/14 with no documented time reflected the following: Resident is on our lock down unit. He has dementia. He keeps trying to break out of the unit and go home. He kicked out the screen in his room and went out the window. We found him and brought him back to the unit and later he broke out again. Cops were called. When he broke out the second time he fell on the ground. EMS checked him out. Additional Comments and/or Steps taken to prevent recurrence: He fell outside the building. He escaped from the nursing unit. He wants to go back home. During an interview on 1/8/15 at 9:12 AM, CNA B stated that she did one-to-one care for Resident #6, but sometimes she still had to see to other residents. Review of Resident #6's Social Service Progress Notes dated 12/31/14 revealed that the APS Case Worker for Resident #6 had found placement at a long term care (LTC) facility in another city. Review of Nurses Notes dated 12/31/14 revealed the following: -1:00 AM Resident climbed through window, staff out looking for resident at this time. On call nurse informed. -1:05 AM Staff unable to find resident. -1:15 AM Staff in car looking for resident. 911 called. -1:45 Returned to facility by police. Head to toe assessment done. Noting abrasions to both arms and right leg. -2:00 AM [MEDICATION NAME] (Antipsychotic medication) 20 mg given. -2:45 AM resident continues to have anxiety. Re-directed continue one-on-one. -1600 (4:00 PM) late entry Resident taken to another Long Term Care facility by private transport. Resident not in physical distress however exhibiting emotional distress. -1745 (5:45 PM) Resident returned to facility. The other Long Term Care facility declined to admit him. To provide one-on-one observation. Resident's bed placed in front of nurse's desk. No s/s (signs/symptoms) of distress. -2245 (10:45 PM) Resident anxiety [MEDICATION NAME] (Antianxiety medication) 1 mg IM (Intramuscular) injection right deltoid (muscle in shoulder). During an interview on 1/7/15 at 1:00 PM, the Director of Nurses (DON) stated that Resident #6 had been transferred to the other LTC facility on 12/31/14, but as soon as the van doors were opened Resident #6 ran into the woods and the police had to find him. She stated the LTC facility refused to admit him and he was returned to their facility. In a continued interview the DON was asked if they could do one-to-one care with Resident #6, she stated that the facility did not have the staff to do one-to-one care for the resident; however, the facility could not seek other placement for the resident or treatment for [REDACTED]. The DON stated that they had been encouraging him to comply with his medication regime and trying distractions and re-direction with the resident. There was no further documentation in Nurses Notes or Resident Monitoring Sheets (for one-to-one care). Review of Resident #6's Nurses Notes dated 1/7/15 at 8:00 AM reflected the following: Resident jumped head first out of a window on secure unit. Nurse was in room with resident when he suddenly opened the window and jumped out. Nurse tried to keep resident from hitting the ground with the help of a CNA. Resident hit and kicked nurse and CNA as he jumped. When he got to the ground, he jumped to his feet and ran down the street. Nurse and CNA ran after him. Attempted to reason with resident, but he kept running. Resident approached a residential home and opened the door, went inside. Told the occupant of the home that nurse was trying to kill him. After nurse, CNA and Social Worker spoke to him about coming back to the facility; he finally agreed to get in the Social Worker's car to go back to the facility. Late entry, after full assessment of resident, called resident's PCP (Primary Care Physician) and left message explaining this morning's incident. Review of a facility Incident/Accident Report dated 1/7/15 at 8:00 AM Description of Incident: Resident #6 jumped out of window and run up the street, nurse and CNA following. Resident opened the door to someone's house and went inside. Comments and/or steps taken to prevent recurrence: No comment documented. There was no documentation on the facility Incident/Accident Report that Resident #6's physician had been notified of the incident on 1/7/15. During an interview on 1/7/15 at 3:02 PM, the Nurse Practioner stated that he was aware of Resident #6's elopement. During an interview on 1/8/15 at 9:08 AM LVN (Licensed Vocational Nurse) A stated that Resident #7 was so fast that they did not have time to stop him before he threw open his window and jumped out head first. She stated they chased him down the street and convinced him to return to the facility. Review of Resident #6's Social Service Progress Note dated 1/7/15 revealed the following: "As this writer was pulling into the parking lot this morning, I observed Resident #6 running from the building followed closely by three staff members. He was headed toward town and moving fast. Staff was within close proximity of resident at all times. Staff was trying to get resident to slow down and/or stop which he did not do. Attempts to redirect him were unsuccessful. This writer also tried to get resident into car but was not successful. Resident continued running toward town and went down a side street to the next street over. He ran into a residential yard and went to the door and began knocking. Again staff was there attempting to redirect him and come with us to the facility. At this time we were joined by another staff member who gave resident her jacket to put on to be warmer. He was wearing only one shoe and said he did not know where the other one was. After much time and effort, the resident agreed to get into car and return to the facility. Upon returning to facility, resident came into this SW office and we discussed why he is here and the court order. In the moment, he appears to process and understand the conversation, but, within minutes, he is repeating the same questions. The Chief of Police also spoke with the SW and spoke to resident. Resident returned to secure unit with nursing staff." Review of The National Weather Service website accessed on 1/8/15 reflected the outside temperature on 1/7/15 was 32 degrees and windy. During an interview on 1/7/15 at 1:00 PM, the DON stated that this morning (1/7/15) Resident #6 jumped head first out his window and ran down the street and into someone's home. She stated that the staff was able to get him back to the facility. She stated that the facility could not seek treatment or placement for him because he had been placed in their facility by APS. When asked if the facility had a court order to keep him in the facility she stated no. That APS had the order. The DON stated they were using distraction, pleasant activities and redirection to try to manage Resident #6's elopement behavior. She stated that the facility has requested an order from Resident #6's physician to send to APS so he could be sent home for a supervised visit today (1/7/15) for 24 hours. The DON stated that they have asked the Ombudsman to talk with the Judge about the resident ' s placement. She stated that they did not ask if the facility could send him to the hospital to be evaluated because he is an APS placement and they cannot send him out of the building. During an interview on 1/7/15 at 3:02 PM, with the Facility Manager, DON, and SW, they were asked what they would do to treat the resident if he needed emergency care and the DON and the Facility Manager stated they would have to notify APS and get permission to transfer him to the hospital because they could not send him out of the facility for treatment because he was an APS placed resident. They stated that as long as APS had placed him in there facility they could not do anything. At this point in the interview they stated that Resident #6's arm was hurting after jumping through his window and that they had gotten a portable x-ray but no results had been called to the facility. The DON stated that they could not send the resident out for treatment or evaluation of his arm or his behaviors. She stated that he had to stay in the facility because of APS' court order. The SW explained to the Facility Manager and the DON that the court order was for APS to be his guardian, not a court order for the facility keeping him and not treating him. The SW stated that the facility could call the resident's physician and get an order to send him to the emergency room for evaluation of his arm and a psychological exam. Observations on 1/7/15 at 4:40 PM revealed Resident #6 sitting quietly in the Social Worker's office. He was clean and neatly dressed. During an interview on 1/8/15 at 2:00 PM, the Regional Director of Operations (RDO) stated that he had agreed to accept Resident #6 in the facility and if he had known about the DON and Facility Manager misunderstanding an APS placement, he would have explained the process to them and the Resident would have been given a psych evaluation. He stated that he would speak with them and tell them they could always call someone in the organization with questions. Review of Resident #6's Care Plan dated 12/19/14 revealed the following: New Admission: Did not have any interventions for elopement risk. Review of Resident #6's Care Plan dated 12/30/14 furnished by the DON revealed the following: Focus The resident is an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended. Date Initiated: 12/30/14 with a revision on 1/7/15 Goal the resident's safety will be maintained through the review date. Date Initiated: 12/30/14, Revisions: 1/7/15. Target Date 4/7/15 Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: no documentation of preferences Date initiated: 01/07/15. Provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. Date Initiated: 01/07/15. State Ombudsmen contacted 1/6/15 regarding incidents of elopement and how to maintain resident rights and safety in facility. Date Initiated 1/07/15. Position of person responsible for all interventions CNA. The facility did not furnish the surveyor with an elopement policy. The Facility Manager, Director of Nurses, Assistant Director of Nurses, and the Social Worker were notified on 1/7/15 at 3:30 PM that an IJ situation had been identified due to the above failures and a Plan of Removal was requested. A Plan of Removal was submitted by the Facility Manager on 1/7/15 at 4:30 PM. The final Plan of Removal was accepted by the surveyor on 1/8/15 at 1:48 PM. Plan of removal: Findings: residents that are an elopement risk. Resident where basic needs cannot be met. Corrective Action: Resident #6 is to be discharged to a local hospital for comprehensive physical/psychiatric evaluation under order of his Primary Physician. We will than contact his Adult Protective Services worker and inform her of his transport to the hospital and explain we cannot meet this resident ' s need. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/7/15 Responsible: Facility Manager, DON/Designee Corrective Action: In-service of Staff: 1. Prevention and Management of Aggressive Behavior 2. Elopement Policy & Procedure 3. Nursing Documentation Implementation date: 1/7/15 Projected Completed Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: All resident room windows on the secure unit will have window alarms installed. Timeline: Implementation Date: 1/5/2015 Projected Completion date: 1/10/15 Responsible: Facility Manager, DON/Designee Corrective Action: Any resident that has behaviors will be monitored and documented. It will be reviewed by IDT (Interdisciplinary team) (Mm-Th) and present to QA (Quality Assurance). Physician and/or psychiatric services will be notified of increase of behaviors as needed. (Contract with Psych-on-Site). Timeline: Implementation Date: 1/7/2015 Projected Completion Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: Psych-on-Site has agreed to provide services. Psychological services will enter the facility by 1/17/15 to evaluate and/or treat the resident requiring services. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/17/15 The surveyor monitored the current plan of removal as follows: Observation on 1/7/15 at 5:00 PM revealed that Resident #6 was transferred to a local hospital for evaluation and treatment for [REDACTED]. Observation on 1/8/15 at 8:45 AM of the facility's secure unit revealed 5 residents watching TV in the common area. During interviews on 1/8/15 at 9:00 AM, three (3) LVNs (Licensed Vocational Nurses) stated that they had been in-serviced on behavior management, elopement policies and procedures, and how to do documentation. During interviews on 1/8/15 at 9:20 AM, two (2) CNAs (Certified Nurse Aides) stated that they had been in-serviced on elopement of residents and how to manage resident behaviors. Review of facility in-service records on 1/8/15 reflected that staff was being in-serviced on Managing Resident Behaviors, Resident Elopement Policies and Procedures, and on Documentation of Behaviors and Elopement. On 1/8/15 at 1:58 PM, the facility Owner, Regional Director of Operations, Facility Manager, DON, ADON, DON Consultant, and MDS Coordinator were informed the IJ was removed. However, the facility remained out of compliance at a severity of a potential for more than minimal harm with a scope of a pattern due to the facility requiring time to monitor their Plan of Removal. Eight (8) residents were reviewed for behaviors and elopement risks.

Based on observation, interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for 1 of 8 residents reviewed for behaviors. (Resident #6) On 1/7/15 Resident #6 jumped head first out of a window on the secure unit, and ran down the street with no coat and only one shoe on in freezing temperatures. On the morning of 1/7/15, he walked into a private residential home in the neighborhood without knocking. On 5 previous occasions, (12/20/14, 12/21/14, 12/22/14 and twice on 12/25/14), he eloped from the facility and the facility had not developed and revised a plan to prevent further elopements. This failure resulted in an Immediate Jeopardy (IJ) on 1/07/15. While the IJ was removed on 1/08/15, the facility remained out of compliance at a level of potential for more than minimal harm at a scope of a pattern, that is not an IJ, because the facility staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 8 residents identified at risk for elopement, physical harm, and injury. Findings include: Resident #6's Admission Face Sheet dated 12/22/14 reflected he was [AGE] years old and admitted to the facility on [DATE]. Resident #6's Hospital Discharge Progress Notes dated 12/19/14 reflected the following Diagnoses: [REDACTED]. LBP (Low Back Pain) Hypertension Dementia The hospital Discharge Progress Notes dated 12/19/14 reflected that Resident #6 had eloped from a nursing home and was brought to the hospital by the police. The notes reflected that Resident #6 was impulsive, combative, and verbally abusive. Resident #6 was to be discharged and placed in a long term care facility by APS (Adult Protective Service). Review of Resident #6's MDS (Minimum Data Set) dated 12/30/14 reflected that he had entered the facility from a Psychiatric Hospital, his Brief Interview for Mental Status (BIMS) score was 2 (0-7 score is severe impairment according to CMS ' RAI Version 3.0 Manual). The MDS reflected that Resident #6 Signs and Symptoms of [MEDICAL CONDITION] showed that he had difficulty focusing attention, i.e., easily distracted, out of touch or difficulty following what was said. He had Disorganized thinking, i.e., Rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. The MDS reflected the following Diagnoses: [REDACTED]. Review of a facility Admission Wander Data Collection Tool dated 12/21/14 reflected that Resident #6 had a history of [REDACTED]. It reflected the resident was a new admission non-accepting of the new situation and cognitively impaired with poor decision-making skills. Review of facility Nurses Notes reflected the following: -12/20/14 8:10 AM Received call from Police Department stating they found resident (Resident #6) and will be bringing him back to facility. Employee was asked when resident was last seen. At 7:30 AM. -8:30 AM received resident back in facility with 2 Police Officers. Head to toe assessment done. Alert, confused, noting scratches per left arm. When asked resident what happened, he states received scratches when he jumped the fence. Area cleaned with N/S (Normal Saline), pat dry and TAO (Triple Antibiotic Ointment) applied and wrap with kerlix. Tolerated well, denies pain/discomfort. ADON (Assistant Director of Nurses informed. One-on-one care with resident. There was no documentation for time frame for one-on-one care for Resident #6. Review of a facility Incident/Accident Report dated 12/20/14 at 8:10 AM reflected that the facility received a call from the police at 8:10 AM stating they had Resident #6 and will bring him back to facility. Comments and/or steps taken to prevent recurrence: All doors checked, locked, key removed and placed at nursing station. Close observation in secure unit. Reorient resident several times each shift Re-direct one-on-one. Interventions recommended: Resident in secure unit increase observation. Check all doors each shift. Make rounds on resident. Review of Resident #6's Nurses Notes dated 12/21/14 at 11:30 PM reflected the following: Resident at nurses ' station, talking to nurse. Nurse walked with Resident to his room, saw him get in bed. Approximately 20 minutes later, local police officer arrives with resident, stating he was walking down the street. Resident admits he climbed out the window in his room after nurse left his room. Led back to secure unit. Will monitor. No injury or complaints noted. Review of a facility Incident/Accident Report dated 12/21/14 at 11:30 AM Description of Incident: Resident #6 admits that he climbed out of the window in his room shortly after nurse left his room. Was brought back to facility by police approximately 20 minutes later. Comments and /or steps taken to prevent recurrence: check doors, put window back down. Explained to resident the dangers of wandering outside the facility. Review of Resident #6 ' s Nurses Notes dated 12/22/15 reflected the following: -06:30 AM Resident stated he needed to leave because he had animals to tend too. CNA (Certified Nurse Aide) tried to redirect him without success. LVN (Licensed Vocational Nurse) was able to redirect. Resident sat on the couch drinking coffee. -07:30 AM Called back to secured unit. Resident had opened his window in his room and climbed out of the window. CNA left to go look for him. ADON notified. Sheriff's office was notified. -07:55 AM Resident was found by CNA. He was in a field by the high school. Resident was safe no injuries apparent at this time. -08:30 AM Resident was returned to the facility with ADON and CNA. Review of a facility Resident Monitoring Sheet dated 1/22/14 for Resident #6 revealed that the resident was provided with one-to-one care which started at 0900 (9:00 AM) and ended at 1430 (2:45 PM) on 12/22/14. Review of a facility Incident/Accident Report dated 12/22/14 at 1:15 AM, description of Incident: Resident #6 went into his room and opened his window and climbed out of it. Resident was found in a field by the high school and was brought back. Comments and/or steps taken to prevent recurrence: no comments or steps documented. Review of Social Service Progress Notes dated 12/22/14 reflected the Social Worker (SW) met with resident after his elopement on 12/22/14 and the resident stated that he wants to go home and misses his partner. The notes revealed that Resident #6 was placed in the facility by APS and his case worker was looking for other placement. Review of Nurses Notes dated 12/23/14 at 1800 (6:00 PM) Resident made attempt/elopement raising window, continue on-on-one. No resident monitoring sheet for one-to-one care was furnished to surveyor. Review of Nurses Notes dated 12/25/14 at 7:00 AM revealed the following: "After first escape thru the bedroom window. I was on the unit with this resident. The rest of the night. I had key to door on me because he began going from one door to another. He was pacing and started to cry. He said he did not want to be there. I left the unit and had a nurse aide stay with the resident and go everywhere the resident went. I was gone from the unit about 30 minutes when the nurse aide called and told me the resident went out the back door and was on the ground. I went out to check on the resident and called EMS (Emergency Medical Services). They told me that the resident did not have any broken bones. They called the police. The policeman said I would be responsible for the resident if he gets away from the people at the hospital." The nurse's notes did not reflect that Resident #6 was sent out to the hospital. Review of Resident #6's facility Incident/Accident Report dated 12/25/14 with no documented time reflected the following: Resident is on our lock down unit. He has dementia. He keeps trying to break out of the unit and go home. He kicked out the screen in his room and went out the window. We found him and brought him back to the unit and later he broke out again. Cops were called. When he broke out the second time he fell on the ground. EMS checked him out. Additional Comments and/or Steps taken to prevent recurrence: He fell outside the building. He escaped from the nursing unit. He wants to go back home. During an interview on 1/8/15 at 9:12 AM, CNA B stated that she did one-to-one care for Resident #6, but sometimes she still had to see to other residents. Review of Resident #6's Social Service Progress Notes dated 12/31/14 revealed that the APS Case Worker for Resident #6 had found placement at a long term care (LTC) facility in another city. Review of Nurses Notes dated 12/31/14 revealed the following: -1:00 AM Resident climbed through window, staff out looking for resident at this time. On call nurse informed. -1:05 AM Staff unable to find resident. -1:15 AM Staff in car looking for resident. 911 called. -1:45 Returned to facility by police. Head to toe assessment done. Noting abrasions to both arms and right leg. -2:00 AM [MEDICATION NAME] (Antipsychotic medication) 20 mg given. -2:45 AM resident continues to have anxiety. Re-directed continue one-on-one. -1600 (4:00 PM) late entry Resident taken to another Long Term Care facility by private transport. Resident not in physical distress however exhibiting emotional distress. -1745 (5:45 PM) Resident returned to facility. The other Long Term Care facility declined to admit him. To provide one-on-one observation. Resident's bed placed in front of nurse's desk. No s/s (signs/symptoms) of distress. -2245 (10:45 PM) Resident anxiety [MEDICATION NAME] (Antianxiety medication) 1 mg IM (Intramuscular) injection right deltoid (muscle in shoulder). During an interview on 1/7/15 at 1:00 PM, the Director of Nurses (DON) stated that Resident #6 had been transferred to the other LTC facility on 12/31/14, but as soon as the van doors were opened Resident #6 ran into the woods and the police had to find him.She stated the LTC facility refused to admit him and he was returned to their facility. In a continued interview the DON was asked if they could do one-to-one care with Resident #6, she stated that the facility did not have the staff to do one-to-one care for the resident; however, the facility could not seek other placement for the resident or treatment for [REDACTED]. The DON stated that they had been encouraging him to comply with his medication regime and trying distractions and re-direction with the resident. There was no further documentation in Nurses Notes or Resident Monitoring Sheets (for one-to-one care). Review of Resident #6's Nurses Notes dated 1/7/15 at 8:00 AM reflected the following: Resident jumped head first out of a window on secure unit. Nurse was in room with resident when he suddenly opened the window and jumped out. Nurse tried to keep resident from hitting the ground with the help of a CNA. Resident hit and kicked nurse and CNA as he jumped. When he got to the ground, he jumped to his feet and ran down the street. Nurse and CNA ran after him. Attempted to reason with resident, but he kept running. Resident approached a residential home and opened the door, went inside. Told the occupant of the home that nurse was trying to kill him. After nurse, CNA and Social Worker spoke to him about coming back to the facility; he finally agreed to get in the Social Worker's car to go back to the facility. Late entry, after full assessment of resident, called resident's PCP (Primary Care Physician) and left message explaining this morning's incident. Review of a facility Incident/Accident Report dated 1/7/15 at 8:00 AM Description of Incident: Resident #6 jumped out of window and run up the street, nurse and CNA following. Resident opened the door to someone's house and went inside. Comments and/or steps taken to prevent recurrence: No comment documented. There was no documentation on the facility Incident/Accident Report that Resident #6's physician had been notified of the incident on 1/7/15. During an interview on 1/7/15 at 3:02 PM, the Nurse Practioner stated that he was aware of Resident #6's elopement. During an interview on 1/8/15 at 9:08 AM LVN (Licensed Vocational Nurse) A stated that Resident #7 was so fast that they did not have time to stop him before he threw open his window and jumped out head first. She stated they chased him down the street and convinced him to return to the facility. Review of Resident #6's Social Service Progress Note dated 1/7/15 revealed the following: "As this writer was pulling into the parking lot this morning, I observed Resident #6 running from the building followed closely by three staff members. He was headed toward town and moving fast. Staff was within close proximity of resident at all times. Staff was trying to get resident to slow down and/or stop which he did not do. Attempts to redirect him were unsuccessful. This writer also tried to get resident into car but was not successful. Resident continued running toward town and went down a side street to the next street over. He ran into a residential yard and went to the door and began knocking. Again staff was there attempting to redirect him and come with us to the facility. At this time we were joined by another staff member who gave resident her jacket to put on to be warmer. He was wearing only one shoe and said he did not know where the other one was. After much time and effort, the resident agreed to get into car and return to the facility. Upon returning to facility, resident came into this SW office and we discussed why he is here and the court order. In the moment, he appears to process and understand the conversation, but, within minutes, he is repeating the same questions. The Chief of Police also spoke with the SW and spoke to resident. Resident returned to secure unit with nursing staff." Review of The National Weather Service website on 1/8/15 reflected the outside temperature on 1/7/15 was 32 degrees and windy. During an interview on 1/7/15 at 1:00 PM, the DON stated that this morning (1/7/15) Resident #6 jumped head first out his window and ran down the street and into someone's home. She stated that the staff was able to get him back to the facility. She stated that the facility could not seek treatment or placement for him because he had been placed in their facility by APS. When asked if the facility had a court order to keep him in the facility she stated no. That APS had the order. The DON stated they were using distraction, pleasant activities and redirection to try to manage Resident #6's elopement behavior. She stated that the facility has requested an order from Resident #6's physician to send to APS so he could be sent home for a supervised visit today (1/7/15) for 24 hours. The DON stated that they have asked the Ombudsman to talk with the Judge about the resident ' s placement. She stated that they did not ask if the facility could send him to the hospital to be evaluated because he is an APS placement and they cannot send him out of the building. During an interview on 1/7/15 at 3:02 PM, with the Facility Manager, DON, and SW, they were asked what they would do to treat the resident if he needed emergency care and the DON and the Facility Manager stated they would have to notify APS and get permission to transfer him to the hospital because they could not send him out of the facility for treatment because he was an APS placed resident. They stated that as long as APS had placed him in there facility they could not do anything. At this point in the interview they stated that Resident #6's arm was hurting after jumping through his window and that they had gotten a portable x-ray but no results had been called to the facility. The DON stated that they could not send the resident out for treatment or evaluation of his arm or his behaviors. She stated that he had to stay in the facility because of APS' court order. The SW explained to the Facility Manager and the DON that the court order was for APS to be his guardian, not a court order for the facility keeping him and not treating him. The SW stated that the facility could call the resident's physician and get an order to send him to the emergency room for evaluation of his arm and a psychological exam. Observations on 1/7/15 at 4:40 PM revealed Resident #6 sitting quietly in the Social Worker's office. He was clean and neatly dressed. During an interview on 1/8/15 at 2:00 PM, the Regional Director of Operations (RDO) stated that he had agreed to accept Resident #6 in the facility and if he had known about the DON and Facility Manager misunderstanding an APS placement, he would have explained the process to them and the Resident would have been given a psych evaluation. He stated that he would speak with them and tell them they could always call someone in the organization with questions. Review of Resident #6's Care Plan dated 12/19/14 revealed the following: New Admission: Did not have any interventions for elopement risk. Review of Resident #6's Care Plan dated 12/30/14 furnished by the DON revealed the following: Focus The resident is an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended. Date Initiated: 12/30/14 with a revision on 1/7/15 Goal the resident's safety will be maintained through the review date. Date Initiated: 12/30/14, Revisions: 1/7/15. Target Date 4/7/15 Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: no documentation of preferences Date initiated: 01/07/15. Provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. Date Initiated: 01/07/15. State Ombudsmen contacted 1/6/15 regarding incidents of elopement and how to maintain resident rights and safety in facility. Date Initiated 1/07/15. Position of person responsible for all interventions CNA. The facility did not furnish the surveyor with an elopement policy. Review of a current (undated) facility policy titled "Prohibition of Abuse, Neglect, or Exploitation of residents reflected the following: Procedure: This facility endeavors to protect each resident from abuse, neglect and misappropriation of property through the implementation of polices that include the screening of potential employees, training of employees, prevent of abuse and neglect, identifying incidents which need investigation, investigation of incidents or allegation, and the reporting of incidents, investigations, and the facility's response to investigations. The Facility Manager, Director of Nurses, Assistant Director of Nurses, and the Social Worker were notified on 1/7/15 at 3:30 PM that an IJ situation had been identified due to the above failures and a Plan of Removal was requested. A Plan of Removal was submitted by the Facility Manager on 1/7/15 at 4:30 PM. The final Plan of Removal was accepted by the surveyor on 1/8/15 at 1:48 PM. Plan of removal: Findings: residents that are an elopement risk. Resident where basic needs cannot be met. Corrective Action: Resident #6 is to be discharged to a local hospital for comprehensive physical/psychiatric evaluation under order of his Primary Physician. We will than contact his Adult Protective Services worker and inform her of his transport to the hospital and explain we cannot meet this resident ' s need. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/7/15 Responsible: Facility Manager, DON/Designee Corrective Action: In-service of Staff: 1. Prevention and Management of Aggressive Behavior 2. Elopement Policy & Procedure 3. Nursing Documentation Implementation date: 1/7/15 Projected Completed Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: All resident room windows on the secure unit will have window alarms installed. Timeline: Implementation Date: 1/5/2015 Projected Completion date: 1/10/15 Responsible: Facility Manager, DON/Designee Corrective Action: Any resident that has behaviors will be monitored and documented. It will be reviewed by IDT (Interdisciplinary team) (Mm-Th) and present to QA (Quality Assurance). Physician and/or psychiatric services will be notified of increase of behaviors as needed. (Contract with Psych-on-Site). Timeline: Implementation Date: 1/7/2015 Projected Completion Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: Psych-on-Site has agreed to provide services. Psychological services will enter the facility by 1/17/15 to evaluate and/or treat the resident requiring services. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/17/15 The surveyor monitored the current plan of removal as follows: Observation on 1/7/15 at 5:00 PM revealed that Resident #6 was transferred to a local hospital for evaluation and treatment for [REDACTED]. Observation on 1/8/15 at 8:45 AM of the facility's secure unit revealed 5 residents watching TV in the common area. During interviews on 1/8/15 at 9:00 AM, three (3) LVNs (Licensed Vocational Nurses) stated that they had been in-serviced on behavior management, elopement policies and procedures, and how to do documentation. During interviews on 1/8/15 at 9:20 AM, two (2) CNAs (Certified Nurse Aides) stated that they had been in-serviced on elopement of residents and how to manage resident behaviors. Review of facility in-service records on 1/8/15 reflected that staff was being in-serviced on Managing Resident Behaviors, Resident Elopement Policies and Procedures, and on Documentation of Behaviors and Elopement. On 1/8/15 at 1:58 PM, the facility Owner, Regional Director of Operations, Facility Manager, DON, ADON, DON Consultant, and MDS Coordinator were informed the IJ was removed. However, the facility remained out of compliance at a severity of a potential for more than minimal harm with a scope of a pattern due to the facility requiring time to monitor their Plan of Removal. Eight (8) residents were reviewed for behaviors and elopement risks.

Based on record review and interview the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 1/7/15 Resident #6 jumped head first out of a window on the secure unit, and ran down the street with no coat and only one shoe on in freezing temperatures. On the morning of 1/7/15, he walked into a private residential home in the neighborhood without knocking. On 5 previous occasions, (12/20/14, 12/21/14, 12/22/14, and twice on 12/25/14), he eloped from the facility. The Administrator, Facility Manager and the DON (Director of Nurses) failed to make changes to Resident #6's care and to monitor the care provided to manage Resident #6's elopement behaviors. This failure resulted in an Immediate Jeopardy (IJ) on 1/07/15. While the IJ was removed on 1/08/15, the facility remained out of compliance at a level of potential for more than minimal harm at a scope of a pattern, that is not an IJ, because the facility staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 8 residents identified at risk for elopement, physical harm, and injury. Findings include: Resident #6's Admission Face Sheet dated 12/22/14 reflected he was [AGE] years old and admitted to the facility on [DATE]. Resident #6's Hospital Discharge Progress Notes dated 12/19/14 reflected the following Diagnoses: [REDACTED]. LBP (Low Back Pain) Hypertension Dementia The hospital Discharge Progress Notes dated 12/19/14 reflected that Resident #6 had eloped from a nursing home and was brought to the hospital by the police. The notes reflected that Resident #6 was impulsive, combative, and verbally abusive. Resident #6 was to be discharged and placed in a long term care facility by APS (Adult Protective Service). Review of Resident #6's MDS (Minimum Data Set) dated 12/30/14 reflected that he had entered the facility from a Psychiatric Hospital, his Brief Interview for Mental Status (BIMS) score was 2 (0-7 score is severe impairment according to CMS ' RAI Version 3.0 Manual). The MDS reflected that Resident #6 Signs and Symptoms of [MEDICAL CONDITION] showed that he had difficulty focusing attention, i.e., easily distracted, out of touch or difficulty following what was said. He had Disorganized thinking, i.e., Rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. The MDS reflected the following Diagnoses: [REDACTED]. Review of a facility Admission Wander Data Collection Tool dated 12/21/14 reflected that Resident #6 had a history of [REDACTED]. It reflected the resident was a new admission non-accepting of the new situation and cognitively impaired with poor decision-making skills. Review of Resident #6's Incident/Accident Reports dated 12/20/14, 12/21/14, 12/22/14, 12/25/14, 12/31/14, and 1/7/15 reflected that he had eloped from the facility and was returned by the local police or facility staff. The elopement on 1/7/15 reflected that the resident jumped head first through a window, ran down the street and entered a private residential home without knocking. He did not have on a coat and had on one shoe. Review of The National Weather Service website accessed on 1/8/15 revealed the temperature on the morning of 1/17/15 was 32 degrees. During an interview on 1/7/15 at 1:00 PM, the Director of Nurses (DON) stated that Resident #6 had been transferred to an other LTC facility on 12/31/14, but as soon as the van doors were opened Resident #6 ran into the woods and the police had to find him. She stated the LTC facility refused to admit him and he was returned to their facility. She stated that when he was returned to their facility they did not have the staff to do one-to-one care for the resident; however, the facility could not seek other placement for the resident or treatment for [REDACTED]. The DON stated that they had been encouraging him to comply with his medication regime and trying distractions and re-direction with the resident. During an interview on 1/7/15 at 1:00 PM, the DON stated that this morning (1/7/15) Resident #6 jumped head first out his window and ran down the street and into someone's home. She stated that the staff was able to get him back to the facility. She stated that the facility could not seek treatment or placement for him because he had been placed in their facility by APS. When asked if the facility had a court order to keep him in the facility she stated no. That APS had the order. The DON stated they were using distraction, pleasant activities and redirection to try to manage Resident #6's elopement behavior. She stated that the facility has requested an order from Resident #6's physician to send to APS so he could be sent home for a supervised visit today (1/7/15) for 24 hours. The DON stated that they have asked the Ombudsman to talk with the Judge about the resident's placement. She stated that they did not ask if the facility could send him to the hospital to be evaluated because he is and APS placement and they cannot send him out of the building. In a continued interview the DON was asked if they could do one-to-one care with Resident #6, she stated that the facility did not have the staff to do one-to-one care for the resident; however, the facility could not seek other placement for the resident or treatment for [REDACTED]. The DON stated that they had been encouraging him to comply with his medication regime and trying distractions and re-direction with the resident. During an interview on 1/7/15 at 3:02 PM, with the Facility Manager, DON, and SW, they were asked what they would do to treat the resident if he needed emergency care and the DON and the Facility Manager stated they would have to notify APS and get permission to transfer him to the hospital because they could not send him out of the facility for treatment because he was an APS placed resident. They stated that as long as APS had placed him in there facility they could not do anything. At this point in the interview they stated that Resident #6's arm was hurting after jumping through his window and that they had gotten a portable x-ray but no results had been called to the facility. The DON stated that they could not send the resident out for treatment or evaluation of his arm or his behaviors. She stated that he had to stay in the facility because of APS' court order. The SW explained to the Facility Manager and the DON that the court order was for APS to be his guardian, not a court order for the facility keeping him and not treating him. The SW stated that the facility could call the resident's physician and get an order to send him to the emergency room for evaluation of his arm and a psychological exam. Observations on 1/7/15 at 4::40 PM revealed Resident #6 sitting quietly in the Social Worker's office. He was clean and neatly dressed. During an interview on 1/8/15 at 2:00 PM, the Regional Director of Operations (RDO) stated that he had agreed to accept Resident #6 in the facility and if he had known about the DON and Facility Manager misunderstanding an APS placement, he would have explained the process to them and the Resident would have been given a psych evaluation. He stated that he would speak with them and tell them they could always call someone in the organization with questions. Review of Resident #6's Care Plan dated 12/19/14 revealed the following: New Admission: Did not have any interventions for elopement risk. Review of Resident #6's Care Plan dated 12/30/14 furnished by the DON revealed the following: Focus The resident is an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended. Date Initiated: 12/30/14 with a revision on 1/7/15 Goal the resident's safety will be maintained through the review date. Date Initiated: 12/30/14, Revisions: 1/7/15. Target Date 4/7/15 Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: no documentation of preferences Date initiated: 01/07/15. Provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. Date Initiated: 01/07/15. State Ombudsmen contacted 1/6/15 regarding incidents of elopement and how to maintain resident rights and safety in facility. Date Initiated 1/07/15. Position of person responsible for all interventions CNA. The Facility Manager, Director of Nurses, Assistant Director of Nurses, and the Social Worker were notified on 1/7/15 at 3:30 PM that an IJ situation had been identified due to the above failures and a Plan of Removal was requested. A Plan of Removal was submitted by the Facility Manager on 1/7/15 at 4:30 PM. The final Plan of Removal was accepted by the surveyor on 1/8/15 at 1:48 PM. Plan of removal: Findings: residents that are an elopement risk. Resident where basic needs cannot be met. Corrective Action: Resident #6 is to be discharged to a local hospital for comprehensive physical/psychiatric evaluation under order of his Primary Physician. We will than contact his Adult Protective Services worker and inform her of his transport to the hospital and explain we cannot meet this resident ' s need. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/7/15 Responsible: Facility Manager, DON/Designee Corrective Action: In-service of Staff: 1. Prevention and Management of Aggressive Behavior 2. Elopement Policy & Procedure 3. Nursing Documentation Implementation date: 1/7/15 Projected Completed Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: All resident room windows on the secure unit will have window alarms installed. Timeline: Implementation Date: 1/5/2015 Projected Completion date: 1/10/15 Responsible: Facility Manager, DON/Designee Corrective Action: Any resident that has behaviors will be monitored and documented. It will be reviewed by IDT (Interdisciplinary team) (Mm-Th) and present to QA (Quality Assurance). Physician and/or psychiatric services will be notified of increase of behaviors as needed. (Contract with Psych-on-Site). Timeline: Implementation Date: 1/7/2015 Projected Completion Date: 1/8/15 Responsible: Facility Manager, DON/Designee Corrective Action: Psych-on-Site has agreed to provide services. Psychological services will enter the facility by 1/17/15 to evaluate and/or treat the resident requiring services. Timeline: Implementation Date: 1/7/15 Projected Completion Date: 1/17/15 The surveyor monitored the current plan of removal as follows: Observation on 1/7/15 at 5:00 PM revealed that Resident #6 was transferred to a local hospital for evaluation and treatment for [REDACTED]. Observation on 1/8/15 at 8:45 AM of the facility's secure unit revealed 5 residents watching TV in the common area. During interviews on 1/8/15 at 9:00 AM, three (3) LVNs (Licensed Vocational Nurses) stated that they had been in-serviced on behavior management, elopement policies and procedures, and how to do documentation. During interviews on 1/8/15 at 9:20 AM, two (2) CNAs (Certified Nurse Aides) stated that they had been in-serviced on elopement of residents and how to manage resident behaviors. Review of facility in-service records on 1/8/15 reflected that staff was being in-serviced on Managing Resident Behaviors, Resident Elopement Policies and Procedures, and on Documentation of Behaviors and Elopement. On 1/8/15 at 1:58 PM, the facility Owner, Regional Director of Operations, Facility Manager, DON, ADON, DON Consultant, and MDS Coordinator were informed the IJ was removed. However, the facility remained out of compliance at a severity of a potential for more than minimal harm with a scope of a pattern due to the facility requiring time to monitor their Plan of Removal. Eight (8) residents were reviewed for behaviors and elopement risks.

Based on observation, interview and record review the facility failed to provide adequate supervision and assistive devices for two (2) of three (3) residents reviewed for incidents and accidents. (Resident #'s 6 and 13) A. Resident #6 experienced falls on 2/15/13 and received a skin tear to her elbow; on 3/4/13 and received a hematoma to her forehead. The facility failed to put new interventions in place following each of the falls to help prevent Resident #6 from repeated falls and injury. On 3/9/13, Resident #6 fell and was diagnosed with [REDACTED]. B. Resident #13 sustained cigarette burns on her fingers 1st and 2nd on 2/2/13 and on her 2nd and 3rd fingers 3/15/13 while smoking unsupervised. The facility failed to assess Resident #13 for safe unassisted/unsupervised smoking or that the resident was allowed control of a cigarette lighter. The resident continued to smoke cigarettes unsupervised. These deficient practices resulted in an Immediate Jeopardy (IJ) on 5/22/13 for Resident #6 and the identification of a 2nd Immediate Jeopardy on 05/23/13 for Resident #13. While both IJ's were lowered on 5/23/13 prior to exit, the facility remained out of compliance at a level of actual harm at a scope of a pattern, that is not an IJ, because the facility administrator and staff needed time to monitor their plans of removal for effectiveness. These deficient practices affected one (1) resident at risk for further falls and injuries and affected 13 residents who smoke cigarettes. Findings include: A.1 Review of Resident #6 s Physician Orders dated 5/1/13 reflected the following Diagnoses: [REDACTED]. Observation on 5/20/13 at 9:20 AM revealed Resident #6 in bed. She was non-interviewable. Observation of Resident #6 on 5/21/13 at 10:30 AM revealed her to be up in a geri chair. Review of Resident #6's annual MDS (Minimum Data Set) dated 12/5/12 reflected she had one fall without injury during the reporting time for the annual MDS. Review of Resident #6's quarterly MDS dated [DATE] reflected that she had 1 fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains, or any fall-related injury that causes the resident to complain of pain) and 1 fall with a major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma). Further review of Resident #6's MDS dated [DATE] and 4/23/13 reflected changes in her ADL (activities of daily living) performance. The MDS dated [DATE] reflected Resident #6 needed supervision and setup help to transfer, walk in room, walk in corridor, locomotion on unit, dressing, and eating. The MDS dated [DATE] revealed that Resident needed limited assistance (staff provide guided maneuvering of limbs or other non-weight bearing assistance) with one person physical assist in transferring, locomotion on unit, dressing, and eating. Walk in room and corridor did not occur. Review of a Report of an Incident/Accident dated 2/15/13 reflected Resident #6 fell and received a skin tear to her left elbow. The report reflected the following "Additional Comments and o/or steps taken to prevent recurrence: Residents responsible party notified via voicemail, Doctor notified via fax. Skin tear approximately 1 centimeter (cm) x 1 cm to left elbow steri-strips after cleansing with NS (normal saline). No new interventions to prevent future falls with injury were put in place. Review of Resident #6's nurses notes reflected the following: Date 3/4/13 at 2145 (9:45 PM) "Resident fell walking from DR (dining room) to shower, has hematoma to left side of FH (forehead) 1.5 cm laceration. Neuro's (neurological checks) WNL (with in normal limits) Daughter called. Date 3/4/13 at 09:30 AM) Resident continues on f/u (follow-up) for fall with neuro's WNL. Resident, MAE (moves all extremities) without s/s (signs/symptoms) or c/o (complaints of) pain. Hematoma to left side of forehead. remains slightly raised, blue in color and spreading down causing left eye to look bruised. Will continue to monitor." Review of a Report of an Incident/Accident dated 3/9/13 reflected Resident #6 was being walked to the dining room when the Certified Nursing Aide (CNA) C left the resident and went to get the resident's walker. Resident #6 fell while attempting to follow the CNA. Resident #6 was sent to the emergency room and diagnosed with [REDACTED]. Further review of the report revealed the following: Past interviews/actions attempted: encourage resident to use walker but resident frequently forgets it and ambulates unassisted. New intervention/action recommended: Resident currently in wheelchair for transport/transfers. During an interview on 5/22/13 at 2:25 PM, CNA C stated that Resident #6 attempted to follow her when she was getting the resident's walker and she tried to catch Resident #6 to keep her from falling. Review of Resident #6's nurse's notes dated 4/9/13 reflected she had a fall with an abrasion to her right knee. Review of Resident #6 's Care Plan dated 7/6/10 with review date of 4/13/13 reflected the following: Date 7/6/10, Problem: Resident has had a Fall and is at Risk for Increased Falls and Fractures. Goal: dignity will be maintained incidence of falls will be reduced and no occurrence of injury will occur over the next 90 days. Approach: 1) Encourage resident to ask for assistance of staff prn (as needed) 2) Ensure call light is in reach, answer promptly 3) Therapy to evaluate and treat per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance - as tolerated 7) Monitor frequently with visual checks 8) Give meds as ordered and monitor for side effects Date 2/15/13 Problem: Fall Goal: Continue above Approaches Date 3/9/13 Problem: Fall-pelvis fx (Fracture) Goal: heal without complications return to previous functioning Approaches: (as above) Date 4/13/13 Problem: Fall Goal: Ditto marks to indicate same as above goal Approaches: Ditto marks to indicate as above During an interview on 5/22/13 at 2:45 PM, the Administrator, the Operating Manager, and the consulting Registered Nurse (RN) stated that interventions should have been in place to help prevent incidents/accidents, and incidents should be thoroughly investigated, care plans updated with new interventions, and the interventions put to use. On 5/22/13 at 12:25 PM, the Administrator, the Operations Manager, and the Registered Nurse Consultant were notified that an Immediate Jeopardy (IJ) had been identified for Resident #6 due to the above failures. A plan of removal was requested. The facility's plan of removal for the IJ dated 5/22/13 and accepted on 5/23/13 at 10:50 AM reflected the following: 1. All Accidents/Incidents and falls will be reported to the Director of Nurses (DON). 2. All Accidents/Incidents and falls will have an intervention performed. i.e. Low bed, Mat, Helmet, referral to therapy, etc. 4. All Accidents/Incidents and fall risks will be care planned immediately. 5. All Accidents/Incident and falls will be updated as needed on the care plan. 6. All care plans will include new interventions as appropriate relating to accidents/ Incidents and Falls when all interventions as appropriate relating to Accidents/incidents and Falls when all interventions are exhausted a doctor will be consulted. 7. All staff will be In-Serviced by RN on Accident/Incident fall prevention. 8. QA will monitor quarterly for accident/incidents and falls. 9. Administrator will monitor during morning stand up meetings on-going B. Resident #13's Physician Orders dated 5/1/13 reflected the following Diagnoses: [REDACTED]. Observation on 5/21/13 at 10:45 AM revealed Resident #13 smoking unsupervised outside the building. Resident #13 was confused and unable to interview. Review of a facility report of incident/accident dated 2/2/13 reflected the following:" Resident stated she burned her 1st and 2nd fingers on her left hand when she slid them over the cigarette she was smoking. The burns were treated with A & D ointment and bandage. Additional comments and/or steps taken to prevent recurrence: Ask resident to be more careful when smoking. " Review of a facility report of incident/accident dated 3/15/13 reflected the following "Resident outside smoking, cigarette stuck to her fingers has a blister on 2nd and 3rd fingers of right hand. Additional comments and/or steps taken to prevent recurrence: Advised resident to be careful and we might need to reevaluate smoking. Review of a facility report of incident/accident dated 3/23/13 reflected the following: Description of incident: "Resident self reported fall occurring on Patio. Reports falling asleep in chair and hitting face on ashtray while nodding off. Additional Comments and or steps taken to prevent recurrence: Recommend to resident going to bed when tired to avoid reoccurrence. "Further review of the incident/accident report reflected the following: "Medications/medical conditions/equipment/environmental factors etc., that may have contributed: Resident takes numerous meds. Makes poor decisions because of mental instability. Summary of investigation: From the information available on the Incident Report resident fell asleep in her chair, fell forward into ash tray. Abrasion under right eye. Review of a fax to Resident #13's physician dated 3/23/13 reflected the following: "Resident reports nodding off while on smoking patio and hitting head on ashtray. Resident 2 cm abrasion under right eye. Neuros/vs initiated, cleaned abrasion with NS (normal saline) and TAO. Past interventions/actions attempted: Reminded repeatedly about safety measures. New interventions/actions recommended: Reminded resident she needs to go to bed when tired to avoid reoccurrence. " Review of Resident #13's Safe Smoking Evaluation dated 2/12/13 reflected the following: Cognitive Patterns Decision making skills are reasonable and consistent , "No" is checked. Alert and oriented and can consistently perform safe smoking techniques. Has the words "Poor impulse control hand written". "Yes" was checked. Balanced while sitting or standing, "Yes" was checked. Has total or limited range of motion of forearms and hands, "Yes" was checked. Has fine motor skills needed to securely hold cigarette., "Yes" was checked. Does not burn furniture, clothing, skin, self or others? (Surveyor was unable to read what was written in the answer area for this question.) Review of Resident #13's Safe Smoking Evaluation dated 5/19/13 reflected the following: Cognitive Patterns : Decision making skills are reasonable and consistent. "No" was checked. Communicates effectively with others, "No" was checked. Has total or limited range of motion of forearms and hands, "No" was checked. Has fine motor skills needed to securely hold cigarette, "Yes" was checked. Does not forget that he/she is smoking or falls asleep holding cigarette, "No" was checked. Keeps lighter under continuous personal possession, " Yes" was checked. Review of Resident #13's Care Plan dated 11/19/12 and updated on 2/26/13, and 5/14/13 reflected the following: Problem: Resident is a smoker and is at Risk for Injury Goal: Will smoke in designated areas without occurrence of injury over next 90 days. Approach: 1: Perform smoking assessment according to facility policy 2) Explain/show where designated smoking areas are---repeat PRN 3) Monitor prn when smoking to assure residents safety 4) Remind of smoking policy prn, such as do not light cigarettes for other residents, smoke only in designated areas, etc. Resident #13 burned her fingers while smoking on 2/2/13 and 3/15/13. The care plan did not address the burns and that the resident was allowed control of her cigarette lighter. The care plan did not include interventions to prevent further injury. Observation on 5/21/13 at 10:45 AM revealed Resident #13 smoking unsupervised outside the building. During an interview on 5/22/13 at 10:45 AM, Resident #4 stated, "Yes" when he was asked if he was allowed to keep his cigarette lighter on him. During an interview on 5/22/13 at 12:19 PM, the Assistant Director of Nurses (ADON) stated that every resident that smoked had their cigarettes and lighters. When asked would she be concerned that Resident #13 went to sleep while smoking and hit her head on the ashtray and has burned her fingers. The ADON stated, "Yes, I would be concerned." When asked if she believed that Resident #13 needed supervision while she smoked, she answered, "Yes, she needs to be supervised. She is not a safe smoker." When asked if another smoking assessment was done after the incidents, she stated, "No." During an interview on 5/22/13 at 1:45 PM, the Social Worker stated that she did not perform the smoking assessments because she was not a smoker. She stated that the Activity Director (AD) and the Assistant Director of Nurses (ADON) did them. She stated the residents have always kept their cigarettes and lighters with them. During an interview on 5/22/13 at 1:50 PM, the AD stated she helped with the smoking assessments and every resident was safe. She stated the residents are allowed to go out and smoke whenever they wish. During an interview on 5/22/13 at 1:55 PM, the ADON stated that the residents are assessed for safe smoking every 90 days and if there is a change in condition or if they see cigarette burns in clothing. She stated that she helps with smoking assessments. She stated that they have no residents that need to be supervised while smoking. When asked if the residents were monitored continuously for keeping there cigarette lighters under their continuous personal possession she stated she could not answer that question. She stated she was unaware of Resident #13' s cigarette burns or her fall into the ashtray. The ADON stated that the residents that smoke are allowed to keep their cigarette lighters in their possession. Review of the facility policy dated April 1, 2007 titled, Admission Agreement Amendment "Facility Operations Policy" revealed the following elements: SMOKING Many residents are permitted to keep cigarette lighters because they have assessed as being safe to smoke without direct supervision. Some residents must be supervised during smoking for safety reasons. Review of a current (undated) facility policy titled "Resident Smoking Policy and Assessment" reflected the following elements: A safety assessment for residents who smoke will be done upon admission and quarterly/significant change thereafter. Based upon the assessment, residents may smoke independently without supervision, or will be required to smoke on a schedule so that they will be supervised. The smoking schedule will be determined based upon resident needs/desires. *Staff will review smoking policy with resident upon admission. *Resident will be required to sign a copy of the smoking policy after demonstration a verbal understanding of the policy. *Resident are not permitted to leave smoking materials unattended so they are available to other residents. *Residents are not permitted to light smoking products for other residents. *Supervised smokers are not permitted to keep a source of fire such as lighters or matches. *Oxygen bottles or concentrators are never permitted in smoking areas. *Residents are permitted to smoke only in authorized areas. On 5/22/13 at 12:25 PM, the Administrator, the Operations Manager, and the Registered Nurse Consultant were notified that an Immediate Jeopardy (IJ) had been identified for Resident #13 due to the above failures. A plan of removal was requested. The facility's plan of removal for the IJ identified on 5/23/13 was accepted on 5/23/13 at 10:50 AM and reflected the following: 1. All residents deemed unsafe will be supervised at all times. 2. A smoking schedule was created for smoking times for unsafe smokers. 3. New smoking assessments were performed on all smokers. 4. Smoking residents will be re-assessed ever thirty (30) days or change of condition. 5. All paraphernalia for smokers will be kept in the med room during non smoking hours. 6. All smokers needing smoking vest will be equipped with garment. 7. DON or ADON will monitor for unsafe smokers monthly for smoking residents and QA will monitor quarterly. 8. In-Service will be given to all staff on new smoking policy by RN (Registered Nurse). 9. Resident Council meeting will be given to all resident in attendance for revised smoking policy. 10. Administrator will monitor during morning stand up meetings on-going. On 5/23/13 at 9:45 AM, random smokers were interviewed and none had possession of their cigarettes or lighters. Resident #13 was observed to have supervision while smoking. Smoking assessments and care plans were updated. Inservices conducted with staff on 5/22/13 at 5:00 PM addressed update of care plans to include new interventions, and the current facility smoking policy. Awareness of residents who require supervision while smoking and to whom to report changes. While both IJ ' s were lowered on 5/23/13 prior to exit at 3:07 PM, the facility remained out of compliance at a Severity level of Actual Harm at a Scope of a Pattern, that is not an IJ, because the facility administrator and staff needed time to monitor their plans of removal for effectiveness. On 5/23/13, the Administrator and the Operating Manager were notified the IJ was lowered due to facility in-services on reporting, and updated care plans to include new interventions to prevent further accidents/incidents/falls. However, the facility remained out of compliance at a severity level of actual harm at a scope of a pattern because the facility Administrator and staff needed time to monitor their plan of removal for effectiveness. On 5/23/13, the Administrator and the Operating Manager were notified the 2nd IJ was lowered due to facility in-services on the new smoking policy, smoking assessments were completed and care plans were updated to reflect level of supervision while smoking. However, the facility remained out of compliance at a severity level of potential for more than minimal harm at a scope of a pattern because the facility Administrator and staff needed time to monitor their plan of removal for effectiveness. The facility completed CMS form 672 identified nine (9) residents at risk for falls. The ADON identified 13 residents who smoke.

Based on observation, interview and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for 32 of 32 residents living in the facility who were exposed to airborne asbestos, a human carcinogen, when unexpected asbestos-containing materials were revealed during a renovation project. The facility Maintenance Supervisor started a renovation project on or about 01/04/12 in which he removed flooring on 3 of 3 hallways (Bottom Hall, Middle Hall and Top Hall). He removed old carpet, which pulled up the tiles under the carpet. The mastic (black glue) that adhered the tiles to the base flooring was exposed. A Department of State Health Services (DSHS) Asbestos Inspector visited the facility in response to a complaint on 01/11/12. His testing of the old flooring materials confirmed positive findings, on 01/13/12, of asbestos in the remnants of the mastic. This deficient practice resulted in the identification of an Immediate Jeopardy (IJ) on 01/24/12 at 5:40 p.m. While the IJ was lowered on 02/08/12 at 2:30 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because resident-use areas of the facility, though contained at that time, were still known to contain previously airborne asbestos fibers which could be disturbed by normal facility operations until completely abated. This deficient practice had the potential to increase the risk for all 32 residents, staff and visitors of developing [MEDICAL CONDITION], mesothelioma and nonmalignant disorders of the lungs and the pleura (the thin covering that protects and cushions the lungs), including [MEDICAL CONDITION], pleural plaques (fibrous buildups on the outer pleura), pleural thickening, and pleural effusion (excess build-up of fluid inside the chest cavity). Asbestos fibers may be released into the air by the disturbance of asbestos-containing material during building repair and remodeling. Findings include: Observation on 01/21/12 between 9:40 a.m. and 11:40 a.m., revealed the following: The facility had two halls occupied by residents (Middle Hall and Top Hall). The Middle Hallway had a faux wood vinyl plank floor covering. The flooring covered the entire hall, but the rubber wall base had been removed and not replaced, leaving open areas at the base of the wall along both sides of the hallway. The Top Hallway had a strip of the vinyl flooring approximately 18 to 20 inches wide. On either side of the partially installed vinyl was bare concrete with streaks of a black substance (mastic, a floor tile adhesive) that had been partially removed from the concrete subfloor. Residents were observed on both hallways and in the common areas (TV and sun rooms). During an interview on 01/21/12 at 10:15 a.m., the Director of Nurses (DON) stated, "Before the renovation was started, the residents were informed about the process. We explained they would be moved to a different hallway while the renovation took place. We developed a care plan to address the potential for adjustment due to changing rooms, and possible respiratory complications with the potential that they might be exposed to dust, etc. Staff were in-serviced to be observant for any respiratory symptoms. Middle Hall residents were moved from their rooms to the Top Hall. We sealed the middle hall with plastic at the end, and then the flooring was stripped off and replaced with new. Then housekeeping stripped and cleaned all surfaces in every room, before the residents were moved back in. We started the process again, moving Top Hall residents to the Middle Hallway, stripped off the old flooring, and started laying the new floor. They had a strip of vinyl flooring laid down the center of the Top Hall, and then the State (DSHS) came in and stopped the work. We did not know anything about asbestos until the State came in on 01/11/12. " During a telephone interview on 01/21/12 at 10:30 a.m., the facility Administrator stated, "We tore up the rug (carpet) by hand, and used a scraper to scrape up the glue from the foundation. Then they put down a material that leveled the floor base, to put in the new floor. When the people from the Asbestos company came out, they said the air quality tests were all negative (for airborne asbestos), and we don't have to move the patients. They said, 'It's not a problem if it's not disturbed, and that the air is clean (of asbestos)'. The only thing we have to do is get the (asbestos) consultant out to seal the floor. The Abatement Company said they would put the sealer on the floor, wait 1 hour, and then we can complete the flooring project. When we tore out the carpet, we put up plastic at the end of the hall to seal it, and sat up an exhaust out the back door for any dust or debris. The Asbestos Investigator (the DSHS Asbestos Inspector (a person employed by DSHS to investigate complaints regarding suspected asbestos-containing materials in public buildings)) said a law had been in place since 1985 regarding asbestos removal, but we did not know about it. " Review of an email from the Asbestos Individual Consultant to the facility Owner, sent on 01/26/12 at 10:14 a.m., reflected that the Asbestos Individual Consultant collected three air samples on 01/12/12 in the Top Hall and that the samples measured less than the 0.010 fibers per cubic centimeter clean air guideline established by the U.S. Environmental Protection Agency (EPA). The samples were collected approximately seven days after the old flooring had been removed and the black mastic removed by buffing, giving previously-airborne asbestos time to settle. Samples were not collected in resident rooms or other resident use areas. In a telephone interview on 01/23/12 at 10:30 a.m., the DSHS Asbestos Inspector stated the following: He visited the facility on 01/11/12 in response to an anonymous complaint alleging that the facility had not conducted an asbestos survey prior to renovation activities which posed a potential risk of asbestos exposure to the occupants of the facility, facility staff, and the general public visiting facility, as required by Texas Asbestos Health Protection Rules (TAHPR) - 25 Texas Administrative Code (TAC) ?295.31, and National Emission Standards for Hazardous Air Pollutants (NESHAP) - 40 Code of Federal Regulations (CFR), Part 61, Subpart M, 157. He observed during his investigation that renovation activities had been conducted on two occupied wings of the facility; that carpet and floor tile had been removed exposing black mastic on one of the wings when he arrived at the site; and that a flooring contractor was installing new flooring in the area. He observed that installation of the flooring had been completed on the Bottom Hall and Middle Hall of the facility but that there were still ordinary waste dumpsters located on-site that contained carpet and floor tile with black mastic that had been removed during the renovation. The proper removal of asbestos requires that asbestos containing materials be double-bagged and labeled as hazardous material, then transported by a licensed asbestos transporter (not in ordinary trash dumpsters) to a landfill licensed to receive and properly dispose of the material. He suggested to the Administrator that the waste disposal company be informed that the dumpsters, containing waste from renovation activities, should not be removed until an asbestos survey and abatement could be conducted. The Administrator and Maintenance Supervisor told him that they were unaware that an asbestos survey was required prior to conducting renovation activities. He stated that he did not have the authority to stop the facility from completing the renovation. He informed the facility Administrator that if the facility proceeded without performing the required asbestos survey that the facility would remain in violation of the state (TAHPR) and federal (NESHAP) regulations. He suggested that the facility engage a licensed asbestos consultant to perform an asbestos survey and proceed with the renovation work following DSHS regulations. He directed the facility to the public directory (at http:://www.dshs.state.tx.us/asbestos/locate.shtm) of licensed entities that could perform an asbestos survey and design an asbestos abatement project, if required. He further stated that he had collected samples of the exposed black mastic, from the floor in the living room, and of floor tile and adhered black mastic from the waste dumpster outside. He had received sample test results from his lab on Friday, 01/13/12, which reflected that both the mastic and the floor tile samples contained two to five times the regulated amount of asbestos. He believed it was possible that the asbestos contamination had become widespread because the disturbed renovation areas were high traffic areas with residents living in rooms along the halls and residents, facility staff, and visitors passing through the areas, treading on the exposed, asbestos-containing mastic and that the disturbed areas and adjacent rooms must be considered to be contaminated with asbestos until further testing and abatement could be initiated. Review of a PLM (Bulk) - Asbestos Analysis Report, dated 01/13/12, prepared from samples the Asbestos Individual Consultant collected at the facility on 01/12/12, reflects that tan floor tile with adhered black mastic collected from the two dumpsters located outside the South Wing of the Top Hall, and from the adjacent ground, contained three to five times the regulated amount of asbestos. During a confidential interview with an alert resident, he stated that he had been a construction superintendent for [AGE] years. He stated, "They tell us they are just deep cleaning, but I know what is going on. They are removing asbestos." When asked if the residents were told that asbestos was being abated, he said, "No." Review of a communication sent by facsimile to the residents' designated Primary Care Physicians (PCP) on 01/23/12 reflected the following: " Recently we were attempting to replace the flooring in our facility. We were stopped before we were completed and told that the possibility for asbestos was there in the glue that held the old tiles down. After testing, it was found that the glue did in fact have asbestos, but our air quality was clean. We had carefully moved each resident prior to old floor removal, shut off heat/air units, put up plastic to close off the area, and carefully vented the dust away. This information is an FYI (for your information) and a request to see if you want to do a chest x-ray to determine possible exposure. This resident has no s/s (signs/symptoms) of any respiratory effects noted to date. " Observations on 01/24/12 between 1:30 p.m. and 4:30 p.m., revealed the following: The facility did not have a finished floor in place in portions of the Middle Hall and Top Hall (1,657 square feet of floor area). The unfinished structural concrete floor slab was exposed. There was smooth black mastic visible in the unfinished areas. Self-leveling compound, used to level uneven concrete floors, was visible in some areas. There were uniform, fine-grained, circular swirl marks, which were consistent with the use of an electric floor buffer, visible in the surface of the self-leveling compound. An additional 2,674 square feet of flooring had already been removed and replaced with new [MEDICATION NAME] chloride (PVC) flooring. Residents and staff ambulated and/or rolled wheelchairs over the partially exposed floor going from one hall to the other, and to common areas such as the Dining Room, Living Room and Beauty Shop. In an interview on 01/24/12 at 2:30 p.m., the Maintenance Supervisor stated the following: The renovation plan had been to remove existing carpet and install new PVC flooring with a faux wood appearance. He began removing the old carpet on 01/04/12. When the carpet was removed, it was found to be directly adhered to old vinyl tile. He believed the carpet had been installed in 1991. During the removal of the old carpet, it was ultimately found that there were three layers of old vinyl tile below the carpet being removed. The carpet and all three layers of tile had been directly adhered to one another and removal of the carpet had lifted the old tiles from the concrete floor slab. Realizing that the tile and mastic would also have to be removed to prepare the area for new flooring, the Maintenance Supervisor stated that he purchased large scrapers at a home center to remove the tile and mastic. The facility Administrator and Owner were notified on 01/24/12 at 5:40 p.m. that an IJ had been identified due to the above failures. In an interview on 01/24/12 at 5:50 p.m., after the Adminstrator and Owner had been notified of the IJ, the Administrator asked how the immediacy might be removed, and stated that, if the facility had to remove the residents from the building, the facility " might as well close the doors now because the residents would not return. " In an interview on 01/25/12 at 4:55 p.m. the facility Owner stated that there had been no buffing of the floor to remove the black mastic and that, as a result, there was no widespread contamination of the facility but that " even if there had been contamination, it doesn't matter, because it will take ten or fifteen years for (health) problems to show up. " Reference: Review of ASBESTOS CAS# 1332-21-4 issued by the Agency for Toxic Substances and Disease Registry of the U.S. Department of Health and Human Services (DHHS), Public Health Service (http://www.atsdr.cdc.gov/tfacts61.pdf), and dated September 2001, reflects: DHHS, the World Health Organization (WHO), and the EPA have determined that asbestos is a human carcinogen. It is known that breathing asbestos can increase the risk [MEDICAL CONDITION] in people. It is likely that health effects seen in children exposed to asbestos will be similar to the effects seen in adults. Asbestos mainly affects the lungs and the membrane that surrounds the lungs. Breathing high levels of asbestos fibers for a long time may result in scar-like tissue in the lungs and in the pleural membrane (lining) that surrounds the lung. This disease is called [MEDICAL CONDITION] and is usually found in workers exposed to asbestos, but not in the general public. Breathing lower levels of asbestos may result in changes called plaques in the pleural membranes. Pleural plaques can occur in workers and sometimes in people living in areas with high environmental levels of asbestos. Effects on breathing from pleural plaques alone are not usually serious, but higher exposure can lead to a thickening of the pleural membrane that may restrict breathing. On 01/25/12 at 3:10 p.m., the facility Administrator presented the surveyors with a written Plan of Removal which included the following: The facility had contracted with an Asbestos Individual Consultant (a person licensed by DSHS to design asbestos abatement projects, per 25 TAC ?295.47) and an Asbestos Abatement Contractor (a company licensed to engage in asbestos abatement (reduction) or removal in a public building, per 25 TAC ?295.45). The plan reflected that the Asbestos Individual Consultant had designed an asbestos abatement project limited to the areas in the Middle and Top Halls where asbestos-containing black mastic was exposed. The abatement was scheduled to commence on the evening of 01/26/12 and was expected to be completed in three hours. The Flooring Company was scheduled to return on 01/27/12 and complete the installation of the PVC flooring. The Asbestos Individual Consultant would also prepare a detailed management plan which detailed what non-friable (not readily crumbled) asbestos-containing materials, which present no risk of asbestos fiber release, had been identified in the building and how those materials would be handled at such time as they were disturbed by renovation or maintenance operations. The plan did not address limiting resident exposure to airborne asbestos or settled asbestos fibers that could be disturbed by normal facility operations. The plan also did not address any area of the facility except the areas where asbestos-containing mastic was exposed. This Plan of Removal was not accepted. Observations on 01/25/12 between 3:00 p.m. and 5:45 p.m., revealed: The portions of the Middle and Top Halls that were observed on 01/24/12 continued to be incomplete. Residents, staff, and visitors, were walking and using wheelchairs on the floor areas with exposed black mastic. Residents were residing in sleeping rooms that opened directly on to the hallways. There was no route from the sleeping rooms on the halls that did not require treading on the exposed mastic area. Residents in other halls could not access the Dining Room or Living Room without crossing the areas with exposed mastic. Review of an email from the DSHS Asbestos Inspector, sent on 01/26/12 at 2:11 p.m., reflected: He performed a follow-up investigation at Meridian Manor on 01/23/12. In his email he stated that he conducted an interview with the Administrator on 01/23/12 where the procedure for installation of the new flooring was discussed. The Administrator told him that the representatives with the Flooring Company said that the new flooring would not remain in place if installed over the existing black mastic. The Flooring Company told the Administrator that the mastic would have to be removed or prepared in such a manner that glue and the new flooring would remain in place. His email further reflected that the Administrator stated that the black mastic was removed using a buffer (which would have caused any asbestos in the mastic to become airborne) , a sealant was applied, then glue and the new flooring. The Asbestos Compliance Inspector also stated that he observed that the black mastic had not been removed, that it was visible on the floor in the hallway where the new flooring had not been installed. When he told the Administrator about his observation, the Administrator told him that the mastic was buffed to remove it, but that some remained and that the buffing removed the rough surface of the mastic to a point that rendered it acceptable to lay the new flooring on top of it. When the Asbestos Compliance Inspector asked the Administrator if the buffing was conducted by Facility maintenance staff or the Flooring Company, the Administrator stated that he did not observe the work because he was in his office and did not know who removed or buffed the mastic. The Asbestos Compliance Inspector further stated that he observed on both 01/11/12 and 01/11/23 that the remaining mastic on the floor was thin and the surface was smooth, indicating that it had been buffed, and that if the mastic was removed using a buffing machine the risk of widespread asbestos contamination of surrounding areas was increased. Observations on 01/26/12 between 2:00 p.m. and 3:45 p.m., revealed the following: The portions of the Middle and Top Halls that were observed on 01/24/12 continued to be incomplete. Residents, staff, and visitors, were walking and using wheelchairs on the floor areas with exposed black mastic. Residents were residing in sleeping rooms that opened directly on to the hallways. There was no route from the sleeping rooms on the halls that did not require treading on the exposed mastic area. Residents in other halls could not access the Dining Room or Living Room without crossing the areas with exposed mastic. In an interview with the Administrator on 01/26/12 at 3:15 p.m., he stated that the Facility would submit a revised plan of removal which incorporated procedures to demonstrate that the facility had not been contaminated with asbestos over a widespread area as a result of the flooring replacement activities. Observation on 01/27/12 at 2:15 p.m., revealed two men laying flooring on the Top Hall and in the Sun Room. No residents were observed in the work area. All residents were in their rooms on the Middle Hall. No residents were observed in the hallways. On 01/27/12 at 10:43 p.m., the facility Administrator presented the surveyors with a revised written Plan of Removal which included the following: An Addendum, marked " RE: Environmental " had been added to the first (unacceptable) Immediate Jeopardy Removal Plan. The Addendum stated that further testing would be performed in seven resident rooms and three common areas to demonstrate that the facility had not been contaminated with asbestos over a widespread area as a result of the flooring replacement activities. Wipe Analysis and Dust Analysis (of samples collected from carpet by microvac) would be performed in rooms 16, 25, 30, 33, 38, 39, and 48. Carpet would also be tested in the Living Room area at Station 2 (the Top Hall) and carpet in the North and South wings of Station 1 (the Bottom Hall). The plan did not address limiting resident exposure to airborne asbestos or settled asbestos fibers that could be disturbed by normal facility operations. The Plan of Removal was not accepted. Observation on 01/28/12 at 4:30 p.m., revealed installation of the PVC flooring had been completed but neither wall base or transition strips to other flooring materials had been installed. Areas of asbestos-containing black mastic were exposed at the transition areas to other flooring materials (carpet in common areas and resident rooms) at doorways and openings. In an interview on 01/28/12 at 4:25 p.m., the Assistant Administrator stated that the abatement as described in the first plan of removal had been performed on the evening of 01/26/12 as planned. The Asbestos Individual Consultant had monitored the abatement, as required by DSHS regulations, but no documents certifying the abatement were available. She did not know whether the exposed, asbestos-containing black mastic at the unfinished transitions had been abated as part of the abatement project. Observation on 01/29/12 at 8:00 a.m. revealed that no additional work had been performed at the facility. No revised Plan of Removal was available. Observation on 01/30/12 at 1:15 p.m. revealed the Asbestos Individual Consultant was in the building conducting testing. All of the tile had been installed. The transitions/thresholds at the doorways had not been installed. Residents were in their rooms. No residents were observed in the hallways. In a telephone interview on 01/30/12 at 11:45 a.m., the Asbestos Individual Consultant stated that he had recommended to the facility that Wipe Analysis samples be collected at the time he performed air samples on 01/12/12, but that the facility had declined to have the tests performed. He further stated he believed that the Wipe Analysis samples he was collecting on 01/30/12 would return positive results and that the entire facility would require abatement and the removal of residents from the facility during the abatement. Observation on 01/31/12 at 3:00 p.m., revealed that wood transition strips were being installed by gluing them to the floor slab. Some newly installed transition strips appeared to be loose and movable. Residents were in their rooms. In an interview on 01/31/12 at 2:20 p.m., the Administrator stated that the additional test samples outlined in the revised plan of removal submitted by the facility 01/27/12, at 10:42 a.m., had been collected but the results were not yet available. New baseboard materials had been ordered but had not been delivered. He thought the baseboards might arrive on 02/02/12. Observation on 02/01/12 at 6:30 p.m., revealed that installation of wood threshold/transition strips had been completed. Residents were in their rooms, in the halls and living room. Review of a Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12, of samples collected on 01/30/12 by the Asbestos Individual Consultant reflected that samples collected on 2 of 2 wings (North and South wings of Bottom Hall), the Living Room (on the Top Hall), and 5 of 7 resident rooms (rooms 25, 30, 33, 38, 39) tested positive for loose asbestos fibers. In a telephone interview on 02/01/12 at 3:00 p.m., the Asbestos Individual Consultant stated that the Wipe Analysis samples that he collected on 01/30/12 would only have tested positive for asbestos, in the areas from which he collected samples, if the asbestos had been airborne prior to the time the samples were collected. On 02/03/12 at 12:41 p.m., the facility Administrator presented the surveyors with a second revised written Plan of Removal which included the following: The previous addendum, marked " RE: Environmental " had been removed and an appendix marked " Meridian Manor - Appendix A " had added to the first (unacceptable) Immediate Jeopardy Removal Plan. The Appendix outlined a project to clean-up disturbed asbestos materials in Facility. The project had been designed by the Asbestos Individual Consultant according to DSHS regulations. The plan included the laundering of all outer bedding; sampling of heating, ventilation and air conditioning (HVAC) returns and discharges for contamination; collection of background air samples; erection of polyethylene sheeting to isolate the Top Hall from the Middle and Bottom hall; construction of a 3-stage decontamination area for abatement personnel; isolation of HVAC components and exhaust and ventilation fans; and, decontamination by wet wipe and HEPA (a high-efficiency air filter) vacuuming, on all areas of ceilings, walls, floors and furniture within the rooms. The Appendix also indicated that once the project had been completed for Middle and Bottom Halls, and required test results indicated the abatement was a success, the residents would all be relocated into the abated area and the remaining areas of the facility would be isolated from the cleaned area and abated. The plan did not address limiting resident exposure to airborne asbestos or settled asbestos fibers in the unabated portion of the facility (where residents were living) that could be disturbed by normal facility operations while the Middle and Bottom Halls were being abated. The Plan of Removal was not accepted. In an interview on 02/02/12 at 10:55 a.m., the Asbestos Individual Consultant stated that he would collecting five air samples, using the more agressive standard required for school buildings, to confirm the pending abatement was complete. He also stated he would be collecting high volume vacuum samples from carpeted areas because the previous microvac sampling method was not agressive enough to draw loose fibers from the carpet. Observation on 02/02/12 at 11:00 a.m. revealed that residents were living on the Top and Middle Halls. Residents were in the Sun Room and in the Living Room watching television. Breakfast had been served in the Dining Room. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12. Observation on 02/03/12 at 11:30 a.m. revealed the Asbestos Abatement Contractor had begun erecting polyethylene sheeting to isolate the Top Hall from the Middle and Bottom halls. Residents were in their rooms on the Top Hall and in the Sun Room, Living Room, and at the Nurse Station, all of which opened on to the Top Hall. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12. Observation on 02/04/12 at 11:00 a.m. revealed baseboards had not been installed; the Middle and Bottom Halls were sealed off from the Top Hall with plastic sheeting and negative pressure was being maintained relative to the Top Hall. Asbestos abatement workers in protective suits and using respirators were working in the isolated portion of the Middle Hall. Residents were in the entrance lobby (Living Room) and on the Top Hall watching television and moving about. There were no residents on the Middle Hall. Lunch was served to residents in the Dining Hall. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12, and were not part of the abatement activities that were underway. Observation on 02/05/12 at 3:00 p.m. revealed residents sitting in the entrance lobby (Living Room) and on the Top Hall. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12, and were not part of the abatement activities that were underway. There were no residents on the Middle Hall, which was sealed off with clear plastic sheeting. No asbestos abatement workers were observed working on the Middle and Bottom halls. Negative pressure was being maintained relative to the Top Hall. Observation on 02/7/12 at 5:50 p.m. revealed residents were living on the Bottom Hall, where the abatement had been completed. Containment separating the Bottom Hall from the unabated portion of the facility was not in place. No residents were living on the Top Hall. In an interview on 02/07/12 at 5:40 p.m. the Administrator stated that the abatement in the Bottom and Central halls was completed and air samples were collected on 02/04/12. The test results were received on 02/07/12 and the residents were moved that morning. He further stated that the containment for the Top Hall would be installed on 02/08/12 and the Abatement Company would proceed with the abatement of the rest of the facility. In an interview on 02/07/12 at 8:30 a.m., the Asbestos Individual Consultant stated that he had collected wipe samples from the face of return air registers and that samples from three areas were found to be positive for asbestos fibers. (The only way that asbestos could be found on the face of an air register was if it had been airborne). He also stated that he did not collect any samples from carpeted areas using high volume collection methods that would have revealed whether loose asbestos fibers were in the carpet. The five air samples he collected using aggressive methods under the standard for school buildings were found to be negative for asbestos fibers and the abatement of the Bottom and Middle Halls was considered complete. Observation on 02/08/12 between 8:30 a.m. and 2:30 p.m. revealed residents were now living and receiving services in a portion of the facility that had been fully abated and isolated from the still-contaminated building areas. The Abatement Company had completed the erection of the containment for the Top Hall and negative air pressure relative to the Middle and Bottom Halls had been established. Abatement workers had begun the abatement of the Top Hall. A Medication Room had been created on the Bottom Hall (in the clean, isolated area). All exits from the area where residents were living were readily available and did not require travel through contaminated areas. Meals were being served in the Kitchenette or in Resident Rooms, both in the clean, isolated area. Food was being transported from the Kitchen to the Bottom Hall by van and delivered to the South entrance (parking lot side) of the Bottom Hall in foam containers without passing through the still-contaminated building areas. On 02/08/12 at 2:30 p.m., the facility Administrator was informed that the IJ was lowered. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because resident-use areas of the facility, though contained at that time, were still known to contain previously airborne asbestos fibers which could be disturbed by normal facility operations until completely abated. The census of 32, as of 01/24/12, was provided by the Administrator. New findings: Based on observation and interview the facility failed to ensure a safe, functional, sanitary, and comfortable environment for 28 of 28 residents living in the facility who were exposed to airborne asbestos, a human carcinogen, when unexpected asbestos-containing materials were revealed during a renovation project by providing final documentation for the asbestos monitoring of asbestos abatement and flooring installation activities. This deficient practice placed all 28 Residen

Based on observation, interview and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for 32 of 32 residents living in the facility who were exposed to airborne asbestos, a human carcinogen, when unexpected asbestos-containing materials were revealed during a renovation project. The facility Maintenance Supervisor started a renovation project on or about 01/04/12 in which he removed flooring on 3 of 3 hallways (Bottom Hall, Middle Hall and Top Hall). He removed old carpet, which pulled up the tiles under the carpet. The mastic (black glue) that adhered the tiles to the base flooring was exposed. A Department of State Health Services (DSHS) Asbestos Inspector visited the facility in response to a complaint on 01/11/12. His testing of the old flooring materials confirmed positive findings, on 01/13/12, of asbestos in the remnants of the mastic. This deficient practice resulted in the identification of an Immediate Jeopardy (IJ) on 01/24/12 at 5:40 p.m. While the IJ was lowered on 02/08/12 at 2:30 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because resident-use areas of the facility, though contained at that time, were still known to contain previously airborne asbestos fibers which could be disturbed by normal facility operations until completely abated. This deficient practice had the potential to increase the risk for all 32 residents, staff and visitors of developing [MEDICAL CONDITION], mesothelioma and nonmalignant disorders of the lungs and the pleura (the thin covering that protects and cushions the lungs), including [MEDICAL CONDITION], pleural plaques (fibrous buildups on the outer pleura), pleural thickening, and pleural effusion (excess build-up of fluid inside the chest cavity). Asbestos fibers may be released into the air by the disturbance of asbestos-containing material during building repair and remodeling. Findings include: Observation on 01/21/12 between 9:40 a.m. and 11:40 a.m., revealed the following: The facility had two halls occupied by residents (Middle Hall and Top Hall). The Middle Hallway had a faux wood vinyl plank floor covering. The flooring covered the entire hall, but the rubber wall base had been removed and not replaced, leaving open areas at the base of the wall along both sides of the hallway. The Top Hallway had a strip of the vinyl flooring approximately 18 to 20 inches wide. On either side of the partially installed vinyl was bare concrete with streaks of a black substance (mastic, a floor tile adhesive) that had been partially removed from the concrete subfloor. Residents were observed on both hallways and in the common areas (TV and sun rooms). During an interview on 01/21/12 at 10:15 a.m., the Director of Nurses (DON) stated, "Before the renovation was started, the residents were informed about the process. We explained they would be moved to a different hallway while the renovation took place. We developed a care plan to address the potential for adjustment due to changing rooms, and possible respiratory complications with the potential that they might be exposed to dust, etc. Staff were in-serviced to be observant for any respiratory symptoms. Middle Hall residents were moved from their rooms to the Top Hall. We sealed the middle hall with plastic at the end, and then the flooring was stripped off and replaced with new. Then housekeeping stripped and cleaned all surfaces in every room, before the residents were moved back in. We started the process again, moving Top Hall residents to the Middle Hallway, stripped off the old flooring, and started laying the new floor. They had a strip of vinyl flooring laid down the center of the Top Hall, and then the State (DSHS) came in and stopped the work. We did not know anything about asbestos until the State came in on 01/11/12. " During a telephone interview on 01/21/12 at 10:30 a.m., the facility Administrator stated, "We tore up the rug (carpet) by hand, and used a scraper to scrape up the glue from the foundation. Then they put down a material that leveled the floor base, to put in the new floor. When the people from the Asbestos company came out, they said the air quality tests were all negative (for airborne asbestos), and we don't have to move the patients. They said, 'It's not a problem if it's not disturbed, and that the air is clean (of asbestos)'. The only thing we have to do is get the (asbestos) consultant out to seal the floor. The Abatement Company said they would put the sealer on the floor, wait 1 hour, and then we can complete the flooring project. When we tore out the carpet, we put up plastic at the end of the hall to seal it, and sat up an exhaust out the back door for any dust or debris. The Asbestos Investigator (the DSHS Asbestos Inspector (a person employed by DSHS to investigate complaints regarding suspected asbestos-containing materials in public buildings)) said a law had been in place since 1985 regarding asbestos removal, but we did not know about it. " Review of an email from the Asbestos Individual Consultant to the facility Owner, sent on 01/26/12 at 10:14 a.m., reflected that the Asbestos Individual Consultant collected three air samples on 01/12/12 in the Top Hall and that the samples measured less than the 0.010 fibers per cubic centimeter clean air guideline established by the U.S. Environmental Protection Agency (EPA). The samples were collected approximately seven days after the old flooring had been removed and the black mastic removed by buffing, giving previously-airborne asbestos time to settle. Samples were not collected in resident rooms or other resident use areas. In a telephone interview on 01/23/12 at 10:30 a.m., the DSHS Asbestos Inspector stated the following: He visited the facility on 01/11/12 in response to an anonymous complaint alleging that the facility had not conducted an asbestos survey prior to renovation activities which posed a potential risk of asbestos exposure to the occupants of the facility, facility staff, and the general public visiting facility, as required by Texas Asbestos Health Protection Rules (TAHPR) - 25 Texas Administrative Code (TAC) ?295.31, and National Emission Standards for Hazardous Air Pollutants (NESHAP) - 40 Code of Federal Regulations (CFR), Part 61, Subpart M, 157. He observed during his investigation that renovation activities had been conducted on two occupied wings of the facility; that carpet and floor tile had been removed exposing black mastic on one of the wings when he arrived at the site; and that a flooring contractor was installing new flooring in the area. He observed that installation of the flooring had been completed on the Bottom Hall and Middle Hall of the facility but that there were still ordinary waste dumpsters located on-site that contained carpet and floor tile with black mastic that had been removed during the renovation. The proper removal of asbestos requires that asbestos containing materials be double-bagged and labeled as hazardous material, then transported by a licensed asbestos transporter (not in ordinary trash dumpsters) to a landfill licensed to receive and properly dispose of the material. He suggested to the Administrator that the waste disposal company be informed that the dumpsters, containing waste from renovation activities, should not be removed until an asbestos survey and abatement could be conducted. The Administrator and Maintenance Supervisor told him that they were unaware that an asbestos survey was required prior to conducting renovation activities. He stated that he did not have the authority to stop the facility from completing the renovation. He informed the facility Administrator that if the facility proceeded without performing the required asbestos survey that the facility would remain in violation of the state (TAHPR) and federal (NESHAP) regulations. He suggested that the facility engage a licensed asbestos consultant to perform an asbestos survey and proceed with the renovation work following DSHS regulations. He directed the facility to the public directory (at http:://www.dshs.state.tx.us/asbestos/locate.shtm) of licensed entities that could perform an asbestos survey and design an asbestos abatement project, if required. He further stated that he had collected samples of the exposed black mastic, from the floor in the living room, and of floor tile and adhered black mastic from the waste dumpster outside. He had received sample test results from his lab on Friday, 01/13/12, which reflected that both the mastic and the floor tile samples contained two to five times the regulated amount of asbestos. He believed it was possible that the asbestos contamination had become widespread because the disturbed renovation areas were high traffic areas with residents living in rooms along the halls and residents, facility staff, and visitors passing through the areas, treading on the exposed, asbestos-containing mastic and that the disturbed areas and adjacent rooms must be considered to be contaminated with asbestos until further testing and abatement could be initiated. Review of a PLM (Bulk) - Asbestos Analysis Report, dated 01/13/12, prepared from samples the Asbestos Individual Consultant collected at the facility on 01/12/12, reflects that tan floor tile with adhered black mastic collected from the two dumpsters located outside the South Wing of the Top Hall, and from the adjacent ground, contained three to five times the regulated amount of asbestos. During a confidential interview with an alert resident, he stated that he had been a construction superintendent for [AGE] years. He stated, "They tell us they are just deep cleaning, but I know what is going on. They are removing asbestos." When asked if the residents were told that asbestos was being abated, he said, "No." Review of a communication sent by facsimile to the residents' designated Primary Care Physicians (PCP) on 01/23/12 reflected the following: " Recently we were attempting to replace the flooring in our facility. We were stopped before we were completed and told that the possibility for asbestos was there in the glue that held the old tiles down. After testing, it was found that the glue did in fact have asbestos, but our air quality was clean. We had carefully moved each resident prior to old floor removal, shut off heat/air units, put up plastic to close off the area, and carefully vented the dust away. This information is an FYI (for your information) and a request to see if you want to do a chest x-ray to determine possible exposure. This resident has no s/s (signs/symptoms) of any respiratory effects noted to date. " Observations on 01/24/12 between 1:30 p.m. and 4:30 p.m., revealed the following: The facility did not have a finished floor in place in portions of the Middle Hall and Top Hall (1,657 square feet of floor area). The unfinished structural concrete floor slab was exposed. There was smooth black mastic visible in the unfinished areas. Self-leveling compound, used to level uneven concrete floors, was visible in some areas. There were uniform, fine-grained, circular swirl marks, which were consistent with the use of an electric floor buffer, visible in the surface of the self-leveling compound. An additional 2,674 square feet of flooring had already been removed and replaced with new [MEDICATION NAME] chloride (PVC) flooring. Residents and staff ambulated and/or rolled wheelchairs over the partially exposed floor going from one hall to the other, and to common areas such as the Dining Room, Living Room and Beauty Shop. In an interview on 01/24/12 at 2:30 p.m., the Maintenance Supervisor stated the following: The renovation plan had been to remove existing carpet and install new PVC flooring with a faux wood appearance. He began removing the old carpet on 01/04/12. When the carpet was removed, it was found to be directly adhered to old vinyl tile. He believed the carpet had been installed in 1991. During the removal of the old carpet, it was ultimately found that there were three layers of old vinyl tile below the carpet being removed. The carpet and all three layers of tile had been directly adhered to one another and removal of the carpet had lifted the old tiles from the concrete floor slab. Realizing that the tile and mastic would also have to be removed to prepare the area for new flooring, the Maintenance Supervisor stated that he purchased large scrapers at a home center to remove the tile and mastic. The facility Administrator and Owner were notified on 01/24/12 at 5:40 p.m. that an IJ had been identified due to the above failures. In an interview on 01/24/12 at 5:50 p.m., after the Adminstrator and Owner had been notified of the IJ, the Administrator asked how the immediacy might be removed, and stated that, if the facility had to remove the residents from the building, the facility " might as well close the doors now because the residents would not return. " In an interview on 01/25/12 at 4:55 p.m. the facility Owner stated that there had been no buffing of the floor to remove the black mastic and that, as a result, there was no widespread contamination of the facility but that " even if there had been contamination, it doesn't matter, because it will take ten or fifteen years for (health) problems to show up. " Reference: Review of ASBESTOS CAS# 1332-21-4 issued by the Agency for Toxic Substances and Disease Registry of the U.S. Department of Health and Human Services (DHHS), Public Health Service (http://www.atsdr.cdc.gov/tfacts61.pdf), and dated September 2001, reflects: DHHS, the World Health Organization (WHO), and the EPA have determined that asbestos is a human carcinogen. It is known that breathing asbestos can increase the risk [MEDICAL CONDITION] in people. It is likely that health effects seen in children exposed to asbestos will be similar to the effects seen in adults. Asbestos mainly affects the lungs and the membrane that surrounds the lungs. Breathing high levels of asbestos fibers for a long time may result in scar-like tissue in the lungs and in the pleural membrane (lining) that surrounds the lung. This disease is called [MEDICAL CONDITION] and is usually found in workers exposed to asbestos, but not in the general public. Breathing lower levels of asbestos may result in changes called plaques in the pleural membranes. Pleural plaques can occur in workers and sometimes in people living in areas with high environmental levels of asbestos. Effects on breathing from pleural plaques alone are not usually serious, but higher exposure can lead to a thickening of the pleural membrane that may restrict breathing. On 01/25/12 at 3:10 p.m., the facility Administrator presented the surveyors with a written Plan of Removal which included the following: The facility had contracted with an Asbestos Individual Consultant (a person licensed by DSHS to design asbestos abatement projects, per 25 TAC ?295.47) and an Asbestos Abatement Contractor (a company licensed to engage in asbestos abatement (reduction) or removal in a public building, per 25 TAC ?295.45). The plan reflected that the Asbestos Individual Consultant had designed an asbestos abatement project limited to the areas in the Middle and Top Halls where asbestos-containing black mastic was exposed. The abatement was scheduled to commence on the evening of 01/26/12 and was expected to be completed in three hours. The Flooring Company was scheduled to return on 01/27/12 and complete the installation of the PVC flooring. The Asbestos Individual Consultant would also prepare a detailed management plan which detailed what non-friable (not readily crumbled) asbestos-containing materials, which present no risk of asbestos fiber release, had been identified in the building and how those materials would be handled at such time as they were disturbed by renovation or maintenance operations. The plan did not address limiting resident exposure to airborne asbestos or settled asbestos fibers that could be disturbed by normal facility operations. The plan also did not address any area of the facility except the areas where asbestos-containing mastic was exposed. This Plan of Removal was not accepted. Observations on 01/25/12 between 3:00 p.m. and 5:45 p.m., revealed: The portions of the Middle and Top Halls that were observed on 01/24/12 continued to be incomplete. Residents, staff, and visitors, were walking and using wheelchairs on the floor areas with exposed black mastic. Residents were residing in sleeping rooms that opened directly on to the hallways. There was no route from the sleeping rooms on the halls that did not require treading on the exposed mastic area. Residents in other halls could not access the Dining Room or Living Room without crossing the areas with exposed mastic. Review of an email from the DSHS Asbestos Inspector, sent on 01/26/12 at 2:11 p.m., reflected: He performed a follow-up investigation at Meridian Manor on 01/23/12. In his email he stated that he conducted an interview with the Administrator on 01/23/12 where the procedure for installation of the new flooring was discussed. The Administrator told him that the representatives with the Flooring Company said that the new flooring would not remain in place if installed over the existing black mastic. The Flooring Company told the Administrator that the mastic would have to be removed or prepared in such a manner that glue and the new flooring would remain in place. His email further reflected that the Administrator stated that the black mastic was removed using a buffer (which would have caused any asbestos in the mastic to become airborne) , a sealant was applied, then glue and the new flooring. The Asbestos Compliance Inspector also stated that he observed that the black mastic had not been removed, that it was visible on the floor in the hallway where the new flooring had not been installed. When he told the Administrator about his observation, the Administrator told him that the mastic was buffed to remove it, but that some remained and that the buffing removed the rough surface of the mastic to a point that rendered it acceptable to lay the new flooring on top of it. When the Asbestos Compliance Inspector asked the Administrator if the buffing was conducted by Facility maintenance staff or the Flooring Company, the Administrator stated that he did not observe the work because he was in his office and did not know who removed or buffed the mastic. The Asbestos Compliance Inspector further stated that he observed on both 01/11/12 and 01/11/23 that the remaining mastic on the floor was thin and the surface was smooth, indicating that it had been buffed, and that if the mastic was removed using a buffing machine the risk of widespread asbestos contamination of surrounding areas was increased. Observations on 01/26/12 between 2:00 p.m. and 3:45 p.m., revealed the following: The portions of the Middle and Top Halls that were observed on 01/24/12 continued to be incomplete. Residents, staff, and visitors, were walking and using wheelchairs on the floor areas with exposed black mastic. Residents were residing in sleeping rooms that opened directly on to the hallways. There was no route from the sleeping rooms on the halls that did not require treading on the exposed mastic area. Residents in other halls could not access the Dining Room or Living Room without crossing the areas with exposed mastic. In an interview with the Administrator on 01/26/12 at 3:15 p.m., he stated that the Facility would submit a revised plan of removal which incorporated procedures to demonstrate that the facility had not been contaminated with asbestos over a widespread area as a result of the flooring replacement activities. Observation on 01/27/12 at 2:15 p.m., revealed two men laying flooring on the Top Hall and in the Sun Room. No residents were observed in the work area. All residents were in their rooms on the Middle Hall. No residents were observed in the hallways. On 01/27/12 at 10:43 p.m., the facility Administrator presented the surveyors with a revised written Plan of Removal which included the following: An Addendum, marked " RE: Environmental " had been added to the first (unacceptable) Immediate Jeopardy Removal Plan. The Addendum stated that further testing would be performed in seven resident rooms and three common areas to demonstrate that the facility had not been contaminated with asbestos over a widespread area as a result of the flooring replacement activities. Wipe Analysis and Dust Analysis (of samples collected from carpet by microvac) would be performed in rooms 16, 25, 30, 33, 38, 39, and 48. Carpet would also be tested in the Living Room area at Station 2 (the Top Hall) and carpet in the North and South wings of Station 1 (the Bottom Hall). The plan did not address limiting resident exposure to airborne asbestos or settled asbestos fibers that could be disturbed by normal facility operations. The Plan of Removal was not accepted. Observation on 01/28/12 at 4:30 p.m., revealed installation of the PVC flooring had been completed but neither wall base or transition strips to other flooring materials had been installed. Areas of asbestos-containing black mastic were exposed at the transition areas to other flooring materials (carpet in common areas and resident rooms) at doorways and openings. In an interview on 01/28/12 at 4:25 p.m., the Assistant Administrator stated that the abatement as described in the first plan of removal had been performed on the evening of 01/26/12 as planned. The Asbestos Individual Consultant had monitored the abatement, as required by DSHS regulations, but no documents certifying the abatement were available. She did not know whether the exposed, asbestos-containing black mastic at the unfinished transitions had been abated as part of the abatement project. Observation on 01/29/12 at 8:00 a.m. revealed that no additional work had been performed at the facility. No revised Plan of Removal was available. Observation on 01/30/12 at 1:15 p.m. revealed the Asbestos Individual Consultant was in the building conducting testing. All of the tile had been installed. The transitions/thresholds at the doorways had not been installed. Residents were in their rooms. No residents were observed in the hallways. In a telephone interview on 01/30/12 at 11:45 a.m., the Asbestos Individual Consultant stated that he had recommended to the facility that Wipe Analysis samples be collected at the time he performed air samples on 01/12/12, but that the facility had declined to have the tests performed. He further stated he believed that the Wipe Analysis samples he was collecting on 01/30/12 would return positive results and that the entire facility would require abatement and the removal of residents from the facility during the abatement. Observation on 01/31/12 at 3:00 p.m., revealed that wood transition strips were being installed by gluing them to the floor slab. Some newly installed transition strips appeared to be loose and movable. Residents were in their rooms. In an interview on 01/31/12 at 2:20 p.m., the Administrator stated that the additional test samples outlined in the revised plan of removal submitted by the facility 01/27/12, at 10:42 a.m., had been collected but the results were not yet available. New baseboard materials had been ordered but had not been delivered. He thought the baseboards might arrive on 02/02/12. Observation on 02/01/12 at 6:30 p.m., revealed that installation of wood threshold/transition strips had been completed. Residents were in their rooms, in the halls and living room. Review of a Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12, of samples collected on 01/30/12 by the Asbestos Individual Consultant reflected that samples collected on 2 of 2 wings (North and South wings of Bottom Hall), the Living Room (on the Top Hall), and 5 of 7 resident rooms (rooms 25, 30, 33, 38, 39) tested positive for loose asbestos fibers. In a telephone interview on 02/01/12 at 3:00 p.m., the Asbestos Individual Consultant stated that the Wipe Analysis samples that he collected on 01/30/12 would only have tested positive for asbestos, in the areas from which he collected samples, if the asbestos had been airborne prior to the time the samples were collected. On 02/03/12 at 12:41 p.m., the facility Administrator presented the surveyors with a second revised written Plan of Removal which included the following: The previous addendum, marked " RE: Environmental " had been removed and an appendix marked " Meridian Manor - Appendix A " had added to the first (unacceptable) Immediate Jeopardy Removal Plan. The Appendix outlined a project to clean-up disturbed asbestos materials in Facility. The project had been designed by the Asbestos Individual Consultant according to DSHS regulations. The plan included the laundering of all outer bedding; sampling of heating, ventilation and air conditioning (HVAC) returns and discharges for contamination; collection of background air samples; erection of polyethylene sheeting to isolate the Top Hall from the Middle and Bottom hall; construction of a 3-stage decontamination area for abatement personnel; isolation of HVAC components and exhaust and ventilation fans; and, decontamination by wet wipe and HEPA (a high-efficiency air filter) vacuuming, on all areas of ceilings, walls, floors and furniture within the rooms. The Appendix also indicated that once the project had been completed for Middle and Bottom Halls, and required test results indicated the abatement was a success, the residents would all be relocated into the abated area and the remaining areas of the facility would be isolated from the cleaned area and abated. The plan did not address limiting resident exposure to airborne asbestos or settled asbestos fibers in the unabated portion of the facility (where residents were living) that could be disturbed by normal facility operations while the Middle and Bottom Halls were being abated. The Plan of Removal was not accepted. In an interview on 02/02/12 at 10:55 a.m., the Asbestos Individual Consultant stated that he would collecting five air samples, using the more agressive standard required for school buildings, to confirm the pending abatement was complete. He also stated he would be collecting high volume vacuum samples from carpeted areas because the previous microvac sampling method was not agressive enough to draw loose fibers from the carpet. Observation on 02/02/12 at 11:00 a.m. revealed that residents were living on the Top and Middle Halls. Residents were in the Sun Room and in the Living Room watching television. Breakfast had been served in the Dining Room. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12. Observation on 02/03/12 at 11:30 a.m. revealed the Asbestos Abatement Contractor had begun erecting polyethylene sheeting to isolate the Top Hall from the Middle and Bottom halls. Residents were in their rooms on the Top Hall and in the Sun Room, Living Room, and at the Nurse Station, all of which opened on to the Top Hall. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12. Observation on 02/04/12 at 11:00 a.m. revealed baseboards had not been installed; the Middle and Bottom Halls were sealed off from the Top Hall with plastic sheeting and negative pressure was being maintained relative to the Top Hall. Asbestos abatement workers in protective suits and using respirators were working in the isolated portion of the Middle Hall. Residents were in the entrance lobby (Living Room) and on the Top Hall watching television and moving about. There were no residents on the Middle Hall. Lunch was served to residents in the Dining Hall. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12, and were not part of the abatement activities that were underway. Observation on 02/05/12 at 3:00 p.m. revealed residents sitting in the entrance lobby (Living Room) and on the Top Hall. These areas had been confirmed to be contaminated with loose asbestos fibers in the Transmission Electron Microscopy (TEM) Report of Wipe Analysis, dated 02/01/12, and were not part of the abatement activities that were underway. There were no residents on the Middle Hall, which was sealed off with clear plastic sheeting. No asbestos abatement workers were observed working on the Middle and Bottom halls. Negative pressure was being maintained relative to the Top Hall. Observation on 02/7/12 at 5:50 p.m. revealed residents were living on the Bottom Hall, where the abatement had been completed. Containment separating the Bottom Hall from the unabated portion of the facility was not in place. No residents were living on the Top Hall. In an interview on 02/07/12 at 5:40 p.m. the Administrator stated that the abatement in the Bottom and Central halls was completed and air samples were collected on 02/04/12. The test results were received on 02/07/12 and the residents were moved that morning. He further stated that the containment for the Top Hall would be installed on 02/08/12 and the Abatement Company would proceed with the abatement of the rest of the facility. In an interview on 02/07/12 at 8:30 a.m., the Asbestos Individual Consultant stated that he had collected wipe samples from the face of return air registers and that samples from three areas were found to be positive for asbestos fibers. (The only way that asbestos could be found on the face of an air register was if it had been airborne). He also stated that he did not collect any samples from carpeted areas using high volume collection methods that would have revealed whether loose asbestos fibers were in the carpet. The five air samples he collected using aggressive methods under the standard for school buildings were found to be negative for asbestos fibers and the abatement of the Bottom and Middle Halls was considered complete. Observation on 02/08/12 between 8:30 a.m. and 2:30 p.m. revealed residents were now living and receiving services in a portion of the facility that had been fully abated and isolated from the still-contaminated building areas. The Abatement Company had completed the erection of the containment for the Top Hall and negative air pressure relative to the Middle and Bottom Halls had been established. Abatement workers had begun the abatement of the Top Hall. A Medication Room had been created on the Bottom Hall (in the clean, isolated area). All exits from the area where residents were living were readily available and did not require travel through contaminated areas. Meals were being served in the Kitchenette or in Resident Rooms, both in the clean, isolated area. Food was being transported from the Kitchen to the Bottom Hall by van and delivered to the South entrance (parking lot side) of the Bottom Hall in foam containers without passing through the still-contaminated building areas. On 02/08/12 at 2:30 p.m., the facility Administrator was informed that the IJ was lowered. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because resident-use areas of the facility, though contained at that time, were still known to contain previously airborne asbestos fibers which could be disturbed by normal facility operations until completely abated. The census of 32, as of 01/24/12, was provided by the Administrator.