Every finding on record at The Nursing and Rehab Center at Stadium Place

Based on record review and staff interview, it was determined that the facility failed to ensure there was a Registered Nurse working at least 8 hours a day. This was evident in 3 out of 14 days reviewed during the Staffing task in the recertification survey. The findings include:On 7/10/2026 at 9:16 AM, a review of the staff assignment sheets for 6/25/2026 to 7/9/2026 were reviewed. The facility did not have a Registered Nurse (RN) working for any shift on 6/30/2026, 7/4/2026, and 7/5/2026. On 7/10/2026 at 9:44 AM, an interview with the Director of Nursing was conducted. When asked if they were aware that the facility did not have Registered Nurses on 6/30/2026, 7/4/2026, and 7/5/2026, they stated that they were aware. When asked what is being done to ensure they are meeting staffing requirements, the DON stated that they are working on hiring more staff.

Based on resident interview, observations, and staff interview, it was determined that the facility failed to maintain a functional and comfortable environment. This was evident on 4 out of 4 units reviewed for environment.The findings include:1.On 7/7/2026 at 12:22 PM, The 1st floor shared bathroom's walls were bubbled with unpainted repairs on the opposing walls. When asked what was being done to repair the walls, Staff #1 stated that repairs have been completed for the 2nd and 3rd floor. Staff #1 stated that he will be repairing the 1st floor shared bathroom next. Staff #1 stated that he made administration aware that paper towels were causing the pipes to clog resulting in leaks and damaging the walls of the lower bathrooms. The maintenance director stated that paper towel dispensers were replaced with an air drying system in the bathrooms.2. On 7/6/2026 at 9:12 AM, Interview with Resident #1 was conducted. When asked if the temperature in the facility was comfortable, Resident #1 stated that it was fine at the moment but the weekend was rough. When asked what was rough about it, Resident #1 stated that it was too hot. On 7/7/2026 at 12:46 PM, an interview with Staff #1 was conducted. When asked about why there were portable air units in the main hallways, the maintenance director stated that the A/C unit has been under repair since his arrival to the facility. Stated he arrived about a year ago. When asked what is being done to permanently fix the main A/C unit, Staff #1 stated that the Air Conditioning system is running at its highest capacity and only maintenance is required at this time. When asked what needs to be done for the facility temperature to be maintained without portable units, Staff #1 stated that the A/C unit would have to be replaced or upgraded. On 7/10/2026 at 11:05 AM, an interview with the Administrator was conducted. When asked how long the main A/C had needed portable A/C units to maintain facility temperature, the Administrator stated that the portable A/C units have been supporting the main units since their arrival in the beginning of June 2026.

Based on interviews, record reviews, and observations, it was determined that the facility failed to promote and maintain resident dignity by failing to answer residents' call lights promptly to address residents basic care needs. This was evident for 4 (Resident #17, #2, #60 and #22) out of 8 residents reviewed for dignity during the recertification survey.The findings include:On 07/06/2026 at 9:34 AM, an interview with Resident #17 was conducted. They reported that it took too long for call bells to be answered, so they avoided going to the bathroom a lot therefore avoiding the need to call a staff member to change their brief. When asked for a specific date or time, they responded that it happened frequently and on various shifts. On 07/06/2026 at 10:06 AM, an interview with Resident #2 was conducted. They reported that when their colostomy bag got full and called the facility staff for help, it took them too long to respond to the call bell. They added that at times when they pressed the call bell, no staff came to check on them. On 07/07/2026 at 1:14 PM, an interview with Resident #22 was conducted. They reported that it was easier to call 911 and get help than to press the call bell for assistance. The resident called for help at 1:14 PM, and the surveyor observed the call bell light was on. No staff responded to the call until 1:54 PM.On 07/13/2026 at 8:06 AM, a review of Complaint #2966643 submitted to the Office of Health Care Quality (OHCQ) was conducted. Resident #60 alleged that residents waited for an hour for call bells to be answered. On 07/09/2026 at 10:01 AM, an interview with the Director of Nursing (DON) was conducted. She reported that when a resident calls for help, nursing staff have a pager which alerted the staff to which resident needed help. The pager would sound or buzz within 5-10 seconds of a resident calling for staff assistance and the call could only be turned off once the staff checked on the resident. When asked what the expectation was to respond to residents' call bell, DON stated as soon as possible and not more than 15- 20 minutes. On 07/09/2026 at 1:03 PM, the surveyor reviewed the call audit report for Resident #17 with the DON. On 7/5/2026, the report indicated that the resident called for assistance twice and waited for 48 minutes and 59 minutes. DON reported that she was not aware of any staffing shortage that day and is unsure why the resident had to wait for that long.Further review of the call bell system audit for 3rd and 4th floor revealed that 58 out of 221 calls were answered with a wait time of 15 minutes or longer.

Based on observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment. This was evident in 4 out of 4 units observed for environment. The findings include:1.On 7/06/2026 at 9:12 AM, an observation of Resident #1's room was conducted. The carpet in the room was sticking to the surveyors shoes. 2.On 7/07/2026 at 12:16 PM, observations of 1st, 2nd, and 3rd floor and interview with the Maintenance Director (Staff #1) were conducted. Multiple windows in resident rooms bottom rails are separating from the glass. This was observed in rooms [ROOM NUMBER]. When asked if the facility was aware of the windows, Staff #1 stated that they were aware and the only solution they have at the moment is duct taping the gaps in the windows. When asked what can be done to fix the windows, Staff #1 stated that because of the age of the windows the only solution is to replace the windows. 3. On 7/07/2026 at 12:20 PM, The 1st floor carpet in the hallway between room [ROOM NUMBER] and the kitchen door had a strong smell of urine. When asked if he was aware of the smell, Staff #1 stated that he was not aware. Staff #1 stated that the smell is a combination of the built-up urine in the carpet and the high humidity and temperatures over the weekend. When asked what can be done to eliminate the odor, Staff #1 stated that the only way is to replace the carpet.

Based on interviews and record reviews, it was determined that the facility failed to administer medications in accordance with professional standards. This was evident for 5 (Resident #46, #2, #60, #59 and #64) out of 5 residents reviewed for medication administration. The findings include: 1. On 07/06/2026 at 9:06 AM, an interview with Resident #46 was conducted. They reported that the medications are administered late. On 07/09/2026 at 9:58 AM, a review of Resident #46's Medication Administration Review (MAR) audit was conducted. A review of July 1st to July 8th medication administration times revealed that the resident received medications late on 8 out of 8 days on various shifts. 2. On 07/06/2026 at 11:24 AM, an interview with Resident #2 was conducted. They reported that the medications were constantly given late. On 07/08/2026 at 12:34 PM, a review of Resident #2's Medication Administration Review (MAR) audit was conducted. A review of July 1st to July 8th medication administration times revealed that the resident received medications late every day and on various shifts. 3. On 07/13/2026 at 8:06 AM, a review of Complaint #2966643 submitted to the Office of Health Care Quality (OHCQ) was conducted. Resident #60 alleged that medications were not administered as prescribed. On 07/08/2026 at 2:11 PM, an interview with the Director of Nursing (DON) was conducted. She stated that residents should be given medications as prescribed and to be administered within 1 hour before or after the ordered time. Additionally, facility staff were expected to sign off medications at the time of administration. At this time, the surveyor reviewed Resident #46, #2, and #60 medication administration audits with the DON who confirmed that medications were administered late and others were not administered. 4. On 7/13/2026 at 9:39 AM, a review of Complaint 2974726 was conducted. The complainant (Resident #59) stated that they were receiving their medication late. On 7/13/2026 at 1:47 PM, a review of the Medication Administration Audit report for Resident #59 for the month of April was conducted. Resident #59 received the following medications late:-Jardiance (a medication used to treat diabetes) late 4 times-Carvedilol (a medication used to regulate blood pressure) late 10 times-Dolutegravir (an antiretroviral drug) late 3 times-Bupropion (a medication used to help with anxiety) late 3 times-Losartan (an antihypertensive medication) late 3 times-Clonidine (an antihypertensive medication) late 1 time 5. On 7/09/2026 at 2:32 PM, a review of Complaint 3073715 was conducted. The complainant stated that Resident #64 did not administer the medications as ordered. On 7/09/2026 at 2:56 PM, a review of the Medication Administration Audit report for Resident #59 for the month of July was conducted. Resident #64 received the following medications late:-Carvedilol Oral Tablet 3.125 MG (Carvedilol) 5 times-Senna-Plus Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) 4 times-Bumetanide Oral Tablet 2 MG (Bumetanide) 2 times On 7/13/2026 at 2:48 PM, an interview with the DON was conducted. When asked about the expectation for the medication documentation and administration, the DON stated that the medications should be documented at the time the medication is administered. When asked what time frame the medication should be given from the ordered time, the DON stated that the medication should be given between 1 hour before and 1 hour after the ordered administration time. This surveyor made the DON aware of Resident #59 and #64 receiving medications late, and the DON confirmed the surveyor's findings.

Based on record review, observations, and staff interview, it was determined that the facility failed to supervise a resident (#49) to prevent them from hazards. This was evident for 1 out 3 residents reviewed for accidents and supervision.The findings include:On 7/10/2026 at 8:45 AM, a review of facility reported incident #3067330 was conducted. The incident was reported the state agency after Resident #49's representative reported that the resident had cuts and bruises from an unknown origin. A Nursing Investigation form created on 7/1/2026 stated that the resident had been admitted with bruises on both arms and a skin tear on the right elbow at the time of admission. The Nursing Investigation form stated that Resident #49 had additional bruises and a skin tear from striking a nurse on an attempt to elope through the rehab window on 6/28/2026.On 7/10/2026 at 11:23 AM, a review of Resident #49's progress notes. A Behavior note written by Staff #10 on 6/28/2026 stated: Type of Behavior: upon resuming my shift at 11.15pm the resident was in bed during my rounds. At 12am I went to the 2nd floor to give medication and came back to the 1st floor, my Gna made me aware to the resident was not in his room, after searching all the rooms and the toilets in the building 911 was called The writer opens the PT room and finds the resident at the back of the [Physical Therapy] room using a [NAME] to cut the fence in order to elope the writer was trying to stop [them], [s/he] was combative, and [s/he] used the [NAME] to hit the nurse several times. The on-call order for [them] to be transferred to the hospital but the [Representative] declined and said [they] will stay with [them] over the night. The policemen said is part of [their] diagnosis and [s/he] should not be sent out also blaming the facility for allowing [them] to have access to the [NAME].On 7/10/2026 at 11:40 AM, an observation of the Screened-in porch and therapy room was conducted with the Director of Nursing (DON). The therapy room was observed to have a lock at the bottom of the door. When asked if the lock on the door is new, the DON stated that the lock has been there even prior to the incident. A keypad locked door knob was observed on the door leading out to the screened-in porch. The DON stated that this was added to the door after the incident. The screen on the porch was observed to have 2 - 1 foot long tears and 1 screen detached from the bottom of the section. On 7/10/2026 at 12:08 PM, an interview with DON was conducted. When asked how the resident able to access pliers on the incident of 6/28/2026, the DON stated that they did not know. When asked when the facility staff was able to locate the resident, the DON stated 1:13 AM. When asked if the resident was reassessed for elopement risk after the incident, the DON confirmed that the resident is not a low elopement risk now but there was no reassessment completed for elopement risk after the incident.

Based on medical record review and interview, the facility failed to update the resident's care plan after the resident had a change in condition. This was evident in 1 of 3 residents (Resident #3) reviewed during a complaint survey. The findings include:Surveyor review of complaint (2723293) alleging facility nursing staff failed to provide adequate colostomy care to Resident #3.Review of Resident #3's medical records on 2/24/26 at 12:45pm revealed the resident had orders for the care and maintenance of the resident's colostomy bag and the stoma. A progress note dated 2/18/26 revealed that the resident frequently manipulated his/her colostomy bag and removed the colostomy bag requiring facility nursing staff to change the bag frequently. The frequent manipulation of the colostomy bag and stoma also caused irritation at the colostomy site. Review of Resident #3's care plan revealed no evidence that the resident's behavior of manipulating the colostomy site were listed nor where there any interventions listed to prevent the behavior. Interview with the Director of Nursing (DON) on 2/24/26 at 2:15pm regarding Resident #3's colostomy care. The DON confirmed that the resident removes his/her colostomy bag frequently without understanding how to reattach the colostomy bag by him/herself. The surveyor pointed out that there was no evidence that the resident's care plan had an interventions for the resident's behavior of frequently removing his/her colostomy bag. The DON agreed and added the behavior and interventions to the care plan.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure adequate nursing staff coverage as required and failed to ensure that call bells were answered in a timely manner. This deficient practice was evident for all four nursing units during the complaint survey.The findings include:On 10/16/25 at 8:07AM, during the initial observation of the second-floor unit (unit two of four total floors and units), the surveyor asked Geriatric Nursing Assistant (GNA) #1 a question. The GNA responded to the question and then continued assisting residents on unit 2. The surveyor then proceeded to the third-floor unit. At 8:33AM, during the observation of the third floor, the surveyor observed GNA #1 assisting residents. When asked which unit she is assigned to, the GNA stated that the facility was short-staffed, and she was covering multiple floors.A review of the facility's staffing sheet for 10/16/25, for day shift for all four units indicated that the facility had one Registered Nurse (RN), one Licensed Practical Nurse (LPN), and three GNA's on duty. The staffing sheet was reviewed with the Director of Nursing who confirmed the facility's staffing. When asked how the facility staffs its units, the DON stated that one nurse covers two floors and four GNAs are assigned to each floor. When asked about the required RN coverage, the DON stated that the facility requires a minimum of 8 hours of RN coverage per day.On 10/16/25 at 8:38 AM, during an interview with Resident #307, the surveyor asked whether they had to wait a long time for staff to respond to their call bell. The resident stated that they have waited more than 30 minutes for staff to respond.A review of complaint intake #2563259 on 10/16/25 at 9:00 AM, revealed that the complainant stated Resident #300 reported pressing the call bell, but staff did not respond. The complainant mentioned the dates of 07/01/25, 07/05/25, and 07/06/25 as examples of when this occurred. The complainant also indicated that the facility is consistently understaffed. Review of the facility's staffing sheets for the month of July 2025 revealed that, out of 31 days, the facility staffed only three GNA's for 21 days instead of four as stated by the DON. The review also showed that on the following dates, the facility did not have 24-hour RN coverage as required. 07/05/25 day, evening and night shift- no RN07/13/25 day, evening and night shift-no RN07/19/25 day, evening and night shift-no RN 07/20/25 day, evening and night shift-no RNReview of the facility staff call bell response time in July 2025 revealed the following wait times: 07/05/25- 29 minutes(m) 47 seconds(s), 27m 56s, 25m 58s, 19m 56s07/06/25- 25m 45s, 17m 29s,07/13/25- 27m 59s, 26m 4s, 21m 14s, 17m 16s,07/19/25- 18m, 55s, 16m 15s, 15m 58s07/20/25- 27m, 47s, 25m 49s, 24m 52s, 20m 59s, 20m 30s, 19m 55s, 19m 8s, 19m 2s, 15m 46sOn 10/16/25 at 1:41 PM, an observation was conducted on the second-floor unit to assess staff response to call bells. At the time of arrival, the surveyors noted that no nurses or GNA's were present on the unit. The surveyors remained on the unit until 2:01 PM; during this time, no nursing staff arrived. The surveyor asked a dietary staff about the nurse and GNA assigned to the unit. The staff member stated that the GNA #1 was in therapy with a resident and that the nurse assigned to this unit was covering the first-floor unit.On 10/17/25 at 9:33 AM, during an interview with the DON, the surveyor asked what the expected staff response time is for call bells. The DON stated that she expects staff to respond to call bells within 15 minutes. She further stated that there are times when residents may wait longer than expected; however, her expectation is that call bells be answered within 15 minutes or less. The surveyor discussed call bell response times and staffing concerns for July 2025, and the DON acknowledged the issue. The findings were revealed to the Administrator on 10/17/25 at 11:30 AM.

Based on record reviews and interviews, it was determined that the facility failed to ensure that the facility's assessment accurately reflected the facility's staffing requirements. This deficient practice was evident during the complaint survey.The findings include: During an interview with the Director of Nursing (DON) on 10/16/25 at 11:54 AM, the surveyor reviewed the facility assessment with her. The DON stated that she participates in the facility assessment process. When asked if the assessment was up to date, she stated that she believed it was. The surveyor informed her that the date on the facility assessment was August 2024.The surveyor and the DON discussed the staffing requirements outlined in the facility assessment which indicated the following: one nurse and Geriatric Nursing Assistant (GNA) to each unit (4 units) on the day shift; one nurse covering two units and one GNA assigned on the evening shift; and one nurse with three GNA's splitting coverage across the units on the night shift. The DON stated the information on the facility assessment was incorrect. She reported that one nurse covers two floors during the day, evening, and night shift; one Certified Medication Aide (CMA) covers the entire building during the day and evening shifts, with no CMA coverage at night; and four GNAs are scheduled for day, evening and night shift. The surveyor informed the DON that based on the staffing numbers she provided, and staffing sheets reviewed for July 2025, the facility is operating below the staffing levels indicated in the facility assessment. The DON acknowledged this concern. During an interview with the Administrator on 10/16/25 at 12:38 PM, the surveyor reviewed the facility assessment he had provided earlier in the day. When asked if the facility assessment was up to date, the Administrator stated that it was. The surveyor informed him of the staffing ratios listed in the facility assessment, and the Administrator stated that the information was incorrect. The Administrator then provided the surveyor with a second copy of the facility assessment, which was also dated August 2024. However, the section regarding staffing requirements was blank on the second copy. The Administrator stated that the staffing ratios reported by DON are the facility's current expected staffing requirement. The surveyor asked the Administrator if there was an updated facility assessment for 2025. The Administrator stated that the most recent assessment available was dated August 2024.

Based on review of complaint #2611976, record reviews, and staff interviews, it was determined that the facility failed to ensure a resident's clinical record was accurately documented regarding the date and acquisition of pressure injuries. This was evident for 1 out of 2 complaints reviewed during the complaint survey.The findings include:Section M of the Minimum Data Set (MDS) is a part of the Resident Assessment Instrument used in long-term care facilities to document the risk, presence, appearance, and changes of skin conditions, primarily pressure ulcers. It also tracks other skin ulcers, wounds, lesions, and related treatments to ensure a comprehensive approach to skin care, prevention, and treatment. On 10/16/2025 at 9:50 AM, review of complaint #2611976 showed that on 09/09/2025, the resident's family filed a complaint with the State Agency stating concerns regarding Resident #301's wounds and care while the resident was at the facility.On 10/16/2025 at 10:12 AM, review of Section M of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #301 had no pressure sores upon admission but was at risk for developing pressure ulcers and used a pressure-reducing device for the bed and review of Section M of the MDS assessment dated [DATE] showed that the resident had unhealed pressure injuries that were unstageable and identified as Deep Tissue Injuries (DTI) to both heels.On 10/07/2025 at 10:21 AM, review of Resident #301's electronic medical record showed weekly skin assessments were completed from 07/28/2025 through 09/01/2025. The assessment dated [DATE] documented the resident's skin as intact. The next assessment, dated 09/08/2025, indicated the presence of unstageable pressure injuries to the right heel and deep tissue injury to the left heel.On 10/07/2025 at 10:41 AM, review of the wound assessment note dated 09/08/2025, completed by the Wound Nurse Practitioner (Staff #9), revealed documentation stating the wound was not acquired in house and listed the acquisition date as 07/19/2025.On 10/16/2025 at 1:13 PM, during an interview with the Director of Nursing (DON), she was asked whether Resident #301's wounds were avoidable. The DON stated that the wounds were unavoidable because Resident #301 was totally dependent upon admission and continued to decline. When asked to clarify how and when the wounds were acquired, the DON stated that the wounds were acquired in the facility and were first noted on 09/08/2025, the same day the resident was transferred to the hospital upon the Responsible Party's request. When informed of the discrepancy between her statement and the wound documentation, the DON stated she would inform Staff #9.On 10/16/2025 at 1:20 PM, the surveyor requested to speak with Staff #9 and the DON provided the surveyor with a phone number. On 10/16/2025 at 1:25 PM, the surveyor attempted multiple calls to Staff #9 but received no answer and left a voicemail messageOn 10/16/2025 at 2:10 PM, the DON informed the surveyor that she had spoken with Staff #9 regarding the error in the wound documentation. The DON stated that Staff #9 acknowledged incorrectly documenting that the heel wounds were not facility-acquired and had entered an incorrect acquisition date of 07/19/2025. The DON further stated that Staff #9 agreed to write an addendum correcting the documentation to reflect that the wounds were facility-acquired with accurate dates.On 10/17/2025 at 8:08 AM, Staff #9 called the surveyor and stated that Resident #301 had incontinence-associated dermatitis (IAD) on the buttocks and pressure injuries to both heels. When informed that the acquisition and date of the wounds were incorrectly documented, Staff #9 confirmed that the documentation error was hers and that she had written an addendum correcting the information following her discussion with the DON.On 10/17/2025 at 8:29 AM, the DON was informed that inaccurate wound documentation was a concern. The DON acknowledged the issue and stated that she would conduct a facility-wide audit of all residents with wounds to verify the accuracy of wound acquisition documentation and prevent future errors.

Based on record reviews, observations, and interviews it was determined that the facility failed to perform bed rail assessments and obtain resident consent for bedrails. This was evident for 4 (Resident #17, # 21, #68, and #64) out of 5 residents reviewed for bedrails during the survey. The findings include: Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bedrails. 1. On 07/14/2025 at 08:35 AM the surveyor observed Resident # 64 was in bed with bilateral bed rails and the bed was in the high Fowler position. On 07/15/2025 at 10:45 AM the surveyor reviewed the electronic medical record and found the resident did not have a bed rail assessment form present in the chart and the resident was admitted on [DATE]. On 07/16/2025 at 09:30 AM the surveyor interviewed Resident # 64 who stated the staff had not discussed the bedrails with him/her. The resident stated the bedrails did assist him/her with mobility while in the bed and with exiting the bed. On 07/16/2025 at 12:30 PM the surveyor reviewed the electronic medical record and there was no documentation of a completed bed rail assessment. On 07/16/2025 at approximately 1:30 PM the surveyor interviewed the DON and asked whether the facility had a bed rail assessment policy and if the resident and /or resident representative would normally consent to the bedrail placement. The DON stated yes. The surveyor informed the DON that a bed rail assessment was not present in the electronic medical record for Resident #64. On 07/17/ 2025 at 2:30 PM the DON provided the surveyor with a hard copy of Resident # 64’s bed rail assessment and consent with a completion date of 07/17/2025 at 13:40 PM. This deficient practice was also reviewed with the DON and administrator during the exit conference on 07/23/2025. 2. On 7/15/2025 at 9:15AM, the Surveyor observed Resident #17 laying in bed sleeping. The head of the bed was raised to about 30 degrees and the resident was facing the left side towards the window. There were half bedrails on each side of the bed and the bedrail on the left side was raised. On 7/16/2025 at 9:30AM, the Surveyor observed Resident #17 lying in bed with the head of the bed at about 30 degrees facing the left side. The left bedrail was raised. The resident was awake watching TV. During an interview, Surveyor was informed that the resident did not request the bedrails and was not asked if they needed the bedrails, however the bedrails are helpful with bed mobility. A review of Resident #17’s electronic medical record on 7/17/2025 at 8:15AM failed to reveal documentation of a Bed Side Rail Tool assessment, the resident’s consent for use of bedrails, and a device assessment for the half bedrails. On 7/17/2025 at 9:20AM the Surveyors and the Director of Nursing (DON) confirmed that Resident #17 had half bedrails in place after going to the resident’s room. The DON stated that any resident with bedrails should have a Bed Side Rail Tool assessment, the resident’s or resident representative’s consent for use of bedrails, and a device assessment for the half bedrails documented in their electronic medical record. The Surveyor expressed the concern that the resident did not have these documents. The Surveyor requested the documents. On 7/17/2025 at 2:00PM, the DON stated that Resident #17 did not have a Bed Side Rail Tool assessment, the resident’s consent for use of bedrails, and a device assessment for the half bedrails. The nursing staff were working on completing all assessments. The DON provided the Surveyor with a copy of the Resident #17’s device assessment. On 7/18/2025 at approximately 1:00PM, the DON provided the Surveyor with a copy of the Bed Side Rail Tool assessment with the resident’s consent. 3. On 7/15/2025 at 9:25AM, during an interview with Resident #21, the Surveyor observed half size bedrails on each side of the resident’s bed. The head of the bed was raised to about 90 degrees and the right bedrail was raised. The Surveyor was informed that the resident did not need the bedrails, but they were already on the bed when he/she was admitted to that room. A review of Resident #21’s electronic health on 7/17/2025 at 8:10AM failed to reveal documentation of a Bed Side Rail Tool assessment, the resident’s consent for use of bedrails, and a device assessment for the half bedrails. On 7/17/2025 at 9:20AM, the Surveyor and the Director of Nursing (DON) confirmed that any resident with bedrails should have a Bed Side Rail Tool assessment, the resident’s or resident representative’s consent for use of bedrails, and a device assessment for the half bedrails documented in their electronic medical record. The Surveyor expressed the concern that the resident did not have these documents. The Surveyor requested the documents. On 7/17/2025 at 2:00PM, the DON stated that Resident #21 did not have a Bed Side Rail Tool assessment, the resident’s consent for use of bedrails, and a device assessment for the half bedrails. The nursing staff were working on completing all assessments. The DON provided the Surveyor with a copy of the Resident #21’s device assessment. On 7/18/2025 at approximately 1:00PM, the DON provided the Surveyor with a copy of the Bed Side Rail Tool assessment with the resident’s consent. 4. On 7/22/2025 at 2:30PM, during an interview with a family member, the Surveyor observed Resident #68 in bed with the head of the bed raised about 30 degrees and half bedrails raised on each side of the bed. The resident appeared anxious and restless. The resident grabbed the right bedrail with his/her right arm and swung his/her feet to the right side of the bed attempting to get out of the bed. The family member was able to redirect the resident back to a laying position on the bed. On 7/23/2025 at 7:30AM, a review of Resident #68’s electronic medical record failed to reveal documentation of a Bed Side Rail Tool assessment.

Based on observation and interview with staff, it was determined that the facility failed to maintain proper infection control procedures and failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice was evident for 2 of 4 kitchens that prepare food for residents within the facility. The findings include:During a tour of the facility's 2nd floor kitchen conducted on 7/15/2025 at 8:00AM, the Surveyor observed [NAME] #28, Dietary Aide #29, and Dietary Aide #30 standing in the kitchen without hairnets while breakfast was being prepared. [NAME] #28 stated that they ran out of hairnets and the Dietary Manager #25 ordered some and they should be in today. The Surveyor observed a personal black handbag on the counter between the portable steam tray and sink, and a fabric covered book and two 16.9oz bottles of Pepsi sitting on the silver island in the food prep area. The black handbag was moved into a tall brown cabinet with a sticky-like substance on the handles. Inside the cabinet, the Surveyor observed one open 25lb white bag of sugar and one open 25lb white bag of flour, neither in plastic containers or labeled.During a continued tour of the 2nd floor kitchen, the Surveyor observed the brown cabinets and drawers. The handles of the cabinets and drawers had sticky-like substance on them and the doors had dried cream colors stains. Inside the cabinets were random items like white towels with tan colored stains on them, clear plastic trash bags, and serving utensils. The fans were blowing with a thick gray dust like material stuck to tall black fan and thick brown and gray dust like material stuck to the white floor fan. Under the base of the black fan, there was an orange color stain with a circular pattern. The floor had tan and brown stains, especially in the corners.During a tour of the facility's 3rd floor kitchen conducted on 7/15/2025 at 8:24AM, the Surveyor observed the refrigerator. There was a container of watermelon pieces that was not fully covered with plastic wrap and sitting on the bottom shelf. There was a carton of Sysco Thickened cranberry cocktail with opened and labeled with a date of 6/30-7/19; the directions state to refrigerate after opening and discard after 7 days.On a continued tour of the 3rd floor kitchen, the Surveyor observed the brown cabinets and drawers. The handles of the cabinets and drawers had sticky-like substance on them and the doors had dried cream colors stains. Inside the cabinets were random items like white towels with tan colored stains on them, clear plastic trash bags, serving utensils, a clear plastic container with a silver and black coffee container, and dried food-like substance by the door. There was a paper cup of dried brown meat sitting in the cabinet next to the plastic container. The kitchen floor had tan and brown stains, especially in the corners. In the dry goods area, there was a clear cup with a white granule-like substance inside. On 7/15/2025 during an interview with Dietary Manager #25, the Surveyor reviewed the concerns of the 2nd and 3rd floor kitchens. The Surveyor reviewed the staff not wearing hairnets, the personal items in the food prep area, the cleanliness of the fans, floors, and cabinets, the opened and unlabeled bags of sugar and flour, the poorly covered container of watermelon on the bottom shelf of the refrigerator, and the expired carton of thickened cranberry cocktail. Dietary Manager #25 stated that there were hairnets available to the kitchen staff on the 3rd floor kitchen. Once the stock gets low, she places an order for more. The personal items were removed from the food prep area and tall cabinet, the sugar and the flour needed to be replaced, the watermelon and the expired thickened cranberry cocktail was discarded. The cup of dried brown meat and clear cup of white granule-like substance were discarded.On 7/18/2025 at 12:30PM, the Regional Dietary Manager #26 informed the Surveyor that the fans, floor, and cabinets were cleaned out on the 2nd and the 3rd floor kitchens.

Based on observations, record review, and interviews with residents and staff, it was determined that the facility failed to ensure a system was in place to timely respond to the needs of a resident (Resident #21) reviewed for accommodation of needs during the survey.The findings include: On 07/15/2025 at 9:25AM, the Surveyor conducted an interview with Resident #21. The resident stated that he/she had to wait for 2 hours to get cleaned up over the weekend. The resident stated that he/she would not use the call bell because the staff does not respond and they do not carry the pagers they are supposed to carry to alert them to the resident's call. Instead, the resident has to yell out into the hallway for assistance. The resident pressed the call bell at that time.On 7/15/2025 at 9:45AM, the Surveyor walked into the hallway and observed staff passing out breakfast trays and preparing PPE carts. The Surveyor did not hear any beeping sounds. The Surveyor stopped Geriatric Nursing Assistant (GNA) #24 in the hallway. The Surveyor asked the GNA how she would know when a resident needs assistance. The GNA informed the Surveyor that the facility uses pagers. When the resident presses the call bell, a message is sent to the pagers. The Surveyor requested to see the pager to see how the alert message would appear. GNA #24 did not have a pager. Resident #21's call bell was still on in his/her room.On 7/15/2025 at 10:15AM, during an interview with the Nursing Home Administrator (NHA), the Surveyor was informed that the facility uses a pager system for call bells. The nursing staff and the NHA carry pagers which alert them when a resident needs assistance. The Surveyor expressed the concern that Resident #21 stated that they have to yell out in order to get assistance because the nursing staff do not carry or use their pagers. The NHA stated that all nursing staff should be carrying pagers.On 7/16/2025 at 1:00PM, the Surveyor requested to see Registered Nurse (RN) #9's pager. RN#9 stated the pager was not currently on her, it was in the nurse's office. The Surveyor requested to see GNA #15's pager. The GNA stated she did not have one.On 7/17/2025 at 9:12PM An interview with the DON was conducted. The Surveyor expressed the concern that nursing staff do not have pagers to alert them when a resident needs assistance. The DON stated that GNA's and nurses should have pagers. There are 2 nurses, one on first and second floors and one on third and fourth floors, the DON, the Assistant Director of Nursing (ADON), and NHA have all floor pagers. The GNA's have floor specific pagers. The resident would press the call bell in their room or bathroom, the message would go to the pagers with the room number and the location of the resident (room or bathroom). Reasonably, staff should answer within 15-20 mins. If they check on the resident and they are in the middle of care with another, they should let them know what they are doing and give a time they will come back. When the staff answers the call bell and presses the lit button in the room, the pager will show cancelled. Some staff do not have pagers. People have taken them home and haven't brought them back or they are just lost. If nursing staff do not have a pager, they should be making frequent rounding on their residents, every 1-2 hours every shift especially for those residents who usually need more assistance. The DON advised the facility had to order more pagers and there will be 8 new pagers used for all floors and 8 floor specific pagers for total of 16 new pagers. The new pagers should be in 7/18/2025 at 10:30AM.On 7/19/2025 at 8:00AM during a tour of the facility, the Surveyor observed nursing staff with pagers and the Surveyor could hear the beeping alert when a resident used the call bell.

Based on reviews of medical records, interviews with residents, and interviews with facility staff, it was determined that facility staff failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 1 of 2 residents (Resident #66) reviewed for pain management and 1 of out of 4 residents (Resident #68) reviewed for accidents during the survey. The findings include: 1. Resident #66 was diagnosed with displaced closed fracture of the left tibia and admitted to the facility on [DATE]. On [DATE] at 11:24 AM Resident #66 stated that right leg pain occurs regularly and there has been a delay in the staff responding to the call bell which means the resident is in pain for longer periods of time. The resident's spouse stated that he/she spoke to nursing staff regarding the delay in the delivery of pain medication and some improvements occurred, but the delays in the staff’s response to the call bells still occur routinely. On [DATE] at 9:10 AM Resident #66 's care plan and medication administration record (MAR) was reviewed by the surveyor via the electronic medical record. The review of the Resident # 66's MAR revealed that the PRN Tylenol Extra Strength Oral table 500mg ( 2 tablets) by mouth every 8 hours as needed (ordered on [DATE]) was not documented as given on 07/19 and [DATE] the evening shifts (3PM-11:00PM). Both the Resident #66's and the Resident # 66's spouse stated the Tylenol for pain was received 30 to 60 minutes after requested on these two dates. On [DATE] at 1:39 PM Resident #66's hard copy MAR was reviewed by the surveyor. Specific instructions regarding the order of and use of a Pain Assessment using a 0-10 scale or non-verbal scoring tool every shift had an order date of [DATE] on the resident’s medication administration record. On [DATE] at 12:48 PM the surveyor interviewed the resident # 66's spouse and the resident. Resident #66 stated that she/he wanted to leave the facility. Stated that over the weekend there were terrible problems to the evening staff answering the call bells in a timely manner. The resident's spouse stated that he/she had to return to the facility on Saturday, [DATE]th, because Resident #66 was upset because his/her pain medication and bedtime medications were not delivered in a timely manner. On [DATE] at 3:02 PM the surveyor received a copy of the Resident #66's MAR that reflected the LPN #13 assigned to administer medications did not sign off that the PRN pain medication was given on evening of [DATE]th or the evening of [DATE]. On [DATE] at 3:10 PM the DON stated that she had spoken with Resident #66 and the Resident's spouse. The DON stated that she informed the couple that the medication administration time for the 1st floor was 8:00 PM and that the physician would need to be contacted to change the administration of Resident #66's evening shift pain medication and bedtime (HS) medication in order for them to be given at the same time as requested by the resident. The potential deficit practice was discussed with the administrator and DON prior to and during the exit conference on [DATE]. 2. On [DATE] at 7:40AM, during a review of Resident #68’s electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis after a stroke affecting the left dominant side, seizures, high blood pressure, diabetes, difficulty walking, and adult failure to thrive. Additional review revealed Resident #68 was taking medications for high blood pressure, diabetes, seizures, and insomnia. On [DATE] at 8:00AM, the Surveyor discovered that Resident #68 had an un-witnessed fall on [DATE] at 7:30AM. At the time, the resident was alert to self and confused. A Fall Risk Scoring Tool assessment was completed on [DATE] at 9:05AM. The resident scored a 10, equaling moderate risk. Scores less than 9 are low risk, 10-11 moderate risk, and 12 and above high risk. A review of the Fall Risk Scoring Tool assessment failed to reveal Resident #68’s predisposing diagnoses of a cerebrovascular accident (CVA or stroke) and seizures or the use of antiseizure medication for seizures. The Fall Risk Scoring Tool assessment did not include the current fall history. On [DATE] at 9:00AM, the Surveyor expressed the concern that the resident had an inaccurate Fall Risk Scoring Tool assessment completed after the fall on [DATE]. The DON stated she would review the assessment. On [DATE] at 9:51AM, the DON provided the Surveyor with an updated Fall Risk Scoring Tool. Resident #68 scored 16 and was considered a high fall risk. 3. Do Not Resuscitate (DNR) is an order placed in a person’s medical record by a doctor informs the medical staff that CPR should not be attempted. Do Not Intubate (DNI) is an order placed in a person’s medical record by a doctor informs the medical staff that chest compressions and cardiac drugs may be used, but no breathing tube will be placed. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. On [DATE] at 7:40AM, during a review of Resident #68’s electronic medical record, the Surveyor discovered a physician’s Medical Visit note created on [DATE] which identified the resident’s code status as DNR/DNI with all other interventions under the Advance care planning section. Further review revealed a MOLST form, signed and dated [DATE] by the physician, which stated that Resident #68’s code status of “No CPR”, DNR/DNI. A full code provides full support, including CPR, and allows all interventions needed to restore breathing and/or heart functioning. On [DATE] at 7:51AM, during a review of Resident #68’s active physician’s orders, the Surveyor noted an order for Full Code created on [DATE]. On [DATE] at 8:44AM, during an interview conducted with the Director of Nursing (DON), the Surveyor expressed the concern that Resident #68 had a active physician’s order stating that the resident was a Full Code and a MOLST stating that the resident’s current code status was DNR/DNI as of [DATE]. The DON confirmed the Surveyors’ findings and stated that the resident’s orders would be reviewed and revised to reflect the resident’s current code status of DNR/DNI.

Based on reviews of medical records, interviews with residents, and interviews with facility staff, it was determined that facility staff failed to document administration of as needed (PRN) pain medications in a resident's medication administration record. This was evident for 1 (Resident #66) of two residents reviewed for pain management during the survey.The findings include:Resident #66 was diagnosed with displaced closed fracture of the left tibia and admitted to the facility on [DATE].On 07/16/2025 at 11:24 AM Resident #66 stated that right leg pain occurs regularly and there had been a delay in the staff responding to the call bell which meant the resident was in pain for longer periods of time. The resident's spouse stated that he/she spoke to nursing staff regarding the delay in the delivery of pain medication and some improvements occurred, but the delays in the staff's response to the call bells still occur routinely. Resident # 66's spouse explained that the staff response to the call bell would sometimes be between thirty minutes to an hour.On 07/18/2025 at 9:10 AM Resident #66 's care plan and medication administration record (MAR) was reviewed by the surveyor via the electronic medical record. On 07/18/2025 at 1:39 PM Resident #66's hard copy MAR was reviewed by the surveyor. Specific instructions regarding the order of and use of a Pain Assessment using a 0-10 scale or non-verbal scoring tool every shift had an order date of 07/02/2025 on the resident's medication administration record. On 07/21/2025 at 12:48 PM the surveyor interviewed the Resident # 66's spouse and the resident. Resident #66 stated that she/he wanted to leave the facility. Stated that over the weekend there were terrible problems to the evening staff answering the call bells in a timely manner. The resident's spouse stated that he/she had to return to the facility on July 19th, because Resident #66 was upset because his/her pain medication and bedtime medications were not delivered in a timely manner. On 07/21/2025 at 1:48 PM the surveyor interviewed the DON regarding Resident # 66's concerns with untimely delivery of pain and bedtime medications to the resident in a timely fashion on evening shift as well as the delayed response of staff to the call lights on evening shift this past Saturday and Sunday, July 19th and 20th. The surveyor also requested a copy of the medication reconciliation review document located in the Point Click Care electronic medical record (EMR). The surveyor, upon review of the medication administration review form electronically, found that there was no documentation of the Resident #66 receiving Tylenol 650 mg po for pain during the evening shift on 07/19/2025 and 07/20/2025.On 07/21/2025 at 2:48 PM the surveyor informed the DON of the results of the surveyor's review of the EMR related to Resident #66's medication administration record for July 19, 2025, and July 20, 2025 evening shift. On 07/21/2025 at 2:58 PM the surveyor requested a copy of the Medication Administration Record (MAR) for the dates of July 19th and 20th, 2025 related to Resident #66's evening pain and bedtime medications.On 07/21/2025 at 3:02 PM the surveyor received a copy of the Resident #66's MAR that reflected the LPN assigned to administer medications did not sign off that the PRN pain medication was given on evening of July 19th or the evening of July 20, 2025. On 07/21/2025 at 3:10 PM the DON stated that she had spoken with Resident #66 and the resident's spouse. The DON stated that she informed the couple that the medication administration time for the 1st floor was 8:00 PM and that the physician would need to be contacted to change the administration of Resident #66's evening shift pain medication and bedtime (HS) medication in order for them to be given at the same time as requested by the resident.On 07/22/2025 at 08:52 AM the surveyor requested that the administrator provide a copy of the staffing assignment sheet for the evening shifts on July 19th and 20th for Resident #66. On 07/22/2025 at 09:38 AM the surveyor reviewed the staffing assignment sheets for evening shift LPNs for 07/19 and 07/20, 2025. Resident #66's assigned LPN for both days 7/19 and 7/20 was LPN # 13. The surveyor's review of the MAR revealed, LPN #13 did not document in the electronic MAR that Resident # 66 received his/her pain medication on the evening shift on both days. The review of the Resident # 66's MAR revealed that the PRN Tylenol Extra Strength Oral table 500mg (2 tablets) by mouth every 8 hours as needed (ordered on 07/02/25) was not documented as given on 07/19 and 07/20/2025 the evening shifts (3PM-11:00PM). Both the Resident #66's and the Resident # 66's spouse stated the Tylenol for pain was received 30 to 60 minutes after requested on these two dates.The potential deficit practice was discussed with the administrator and DON prior to and during the exit conference on July 23, 2025.

Based on administrative record review and interviews with the residents, family and facility staff, it was determined the facility staff failed to provide an environment that promotes dignity and respect for residents who require assistance with their daily care. This was found to be evident for 1(Resident #49) of 5 residents reviewed for abuse allegations during the survey.The findings include:Intake #331013 was reviewed on 7/21/25 at 11:00AM for allegations of resident abuse to Resident # 49. The abuse allegations were unsubstantiated.Resident #49 was admitted to the facility with the following but not limited diagnosis: Osteoarthritis (Degenerative Joint Disease) Right Hip and Muscle Weakness.An interview was conducted with Resident #49 on 7/22/25 at 10:59AM and the resident was asked about the care that s/he received while at the facility. The resident went on to say that a few months ago while in the facility a nurse (Staff #21) did not provide assistance when requested. The resident stated that the nurse questioned why s/he did not ask the aide for assistance. The resident stated s/he called their daughter, and their daughter wrote down the date and the staff name.During an interview with the resident daughter on 7/23/25 at 11:10AM she stated that she received a call from Resident #49 and the resident explained to her what happened. She stated that she wrote down the nurse name (Staff #21) and the date, which was 4/25/25 and she immediately spoke with the facility administration and reported this to the state office.Review of Staff #21's employee file had a corrective action form dated 4/25/25 which indicated the employee conduct during an interaction with a resident was inappropriate and did not reflect the respectful, compassionate and patient-centered care that the facility was committed to providing, and the disciplinary action includes termination.During an interview on with the DON with the Administrator present on 7/23/25 at 1:04 PM they explained to the survey team that the corrective action form was a result of the interaction regarding Resident #49 and the nurse (#21). The DON went on to explain that it was reported to her that while the nurse was in the resident room, the resident asked the nurse to give him/her the TV remote, and the nurse told the resident that s/he could have asked the aide to get it. The DON went on to explain that this behavior is unacceptable and that the nurse was to assist the resident. The DON explained that everyone is responsible for assisting the resident and the resident was not treated with respect and the nurse was terminated.All concerns were discussed with the administration team at the exit conference on 7/23/25 at 4:00PM.

Based on medical record review and interviews with facility staff, it was determined the facility failed to ensure that a resident and /or the resident representative (RP) received notice in a timely manner regarding notification and explanation of their rights pending discharge from Medicare. This was found to be evident for 1 (Resident # 67) of 4 residents reviewed regarding liability notices during the survey.The findings include:Notice of Medicare Non-Coverage (NOMNC) is notification to residents and/or their representative (RP) regarding the end of their Medicare coverage. Notification is required to be minimally 48 hours prior to the scheduled effective date that coverage will end, therefore, affording the resident an opportunity to appeal the decision or to prepare for discharge.During a medical record review on [DATE] at approximately 11:30AM for Resident # 67 for discharge, the facility provided the survey team with the non-medical coverage documentation. The form indicated that the resident services were going to expire on [DATE]. The notice was signed by the resident on [DATE].An interview was conducted with the Business Office Manager (BOM) on [DATE] at 12:02 PM and she was asked to explain why the resident was provided with the non-medical coverage form after the services expired and she stated the following:Resident # 67 did not discharge from the facility until [DATE] and that the resident should have been provided with the notice two days before the date the services were due to expire. She went on to say that she recognized that this was an error and submitted that the resident cost be wiped out as the resident was billed.During a subsequent meeting with the survey team, the BOM provided an activity report of the resident account that showed a note dated [DATE] as follows: an amount submitted for potential write off. Prior days used removed from census. Exhausted Medicare A days. Facility responsibility. She confirmed that the resident should have been provided with the notice 48 hours prior to the date that the services were due to end and that the resident should not have been charged. All concerns were discussed with the Administration team on [DATE] at 4:00PM at the exit conference.

Based on interview and record review, it was determined that the facility failed to maintain documentation related to an allegation of abuse. This was evident for 2 of 6 facility reports reviewed during the annual recertification survey.The findings include: 1.) On 07/18/2025 at 11:45 AM, the surveyor requested information related to an abuse allegation reported by the facility to the State Agency on 2/23/23. The Director of Nursing stated that the facility had no records related to the report. On 07/21/2025, the surveyor requested additional information from the State Agency. The initial report and 5-day report were reviewed and indicated that the investigation had been completed in a satisfactory manner, and reporting appeared to have occurred within the required 2-hour timeframe. However, exact incident times were not documented, and the facility failed to retain required records of the incident investigation or reporting process. 2.) On 07/17/25 at 1:10 PM the surveyor reviewed the change in condition report dated 01/03/2023 which was located in the electronic medical record (EMR). There was a late entry created by the current DON which documented the statements made by the resident and the actions of the DON. Per the documentation in the EMR on 01/02/2023, on the night shift, Resident # 63 stated that a geriatric nursing assistant (GNA) tried to fight him/her and refused to help him/her put on a pull up. The resident stated that he/she feels safe here and this was the first time this had happened. Police were called and an investigation was initiated. Resident was followed by psych services. The resident reported to nursing staff that she/he was concerned about her/his daughter not visiting. Resident #63 stated that she/he did not like the way the GNA spoke to him/her. Resident admitted to being the person who asked the GNA if she/he wanted to fight. Resident #63 continued to be followed by psych services after the incident on 01.02.2023. The change in condition report revealed that the alleged perpetrator/employee/GNA was immediately suspended and did not return to work until after the investigation was completed. According to the intake information, the facility determined there was insufficient evidence to support the allegations of abuse. On 07/17/25 at 1:15 PM the surveyor requested a copy of the FRI for this Resident #63. As of 2:37 PM the surveyor had not received the FRI for review. On 07/17/2025 2:41 PM Resident #63's hard copy facility incident report had not be received from the DON. On 07/18/25 at 09:44 AM the administrator stated that the DON was unable to locate the hard copy of the facility report for the incident that allegedly occurred on 01/02/2023. On 07/18/2025 at 09:47 AM the administrator stated in the presence of two other surveyors that the DON stated that she could not locate any electronic and/or hard copy documentation of the FRI related to the alleged incident that occurred on 01.02.2023.

Based on record review and interview with staff, it was determined that the facility failed to ensure a resident's person-centered care plan was reviewed and revised to reflect the resident's current code status. This was evident for 1 (Resident #68) out of 2 residents reviewed for care planning during the survey.The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.Do Not Resuscitate (DNR) is an order placed in a person's medical record by a doctor informs the medical staff that CPR should not be attempted.Do Not Intubate (DNI) is an order placed in a person's medical record by a doctor informs the medical staff that chest compressions and cardiac drugs may be used, but no breathing tube will be placedMaryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options.On [DATE] at 7:40AM, during a review of Resident #68's electronic medical record, the Surveyor discovered a physician's Medical Visit note created on [DATE] which identified the resident's code status as DNR/DNI with all other interventions under the Advance care planning section.Further review revealed a MOLST form, signed and dated [DATE] by the physician, which stated that Resident #68's code status of No CPR, DNR/DNI.A full code provides full support, including CPR, and allows all interventions needed to restore breathing and/or heart functioning.On [DATE] at 7:51AM, during a review of Resident #68's active physician's orders, the Surveyor noted an order for Full Code created on [DATE].An additional review of the electronic medical record revealed a care plan created on [DATE] with a focus stating, The resident has an advanced directive of Full Code.On [DATE] at 8:44AM, during an interview conducted with the Director of Nursing (DON), the Surveyor expressed the concern that the resident's care plan had not been revised to reflect the resident's current code status of DNR/DNI. The DON confirmed the Surveyors' findings and stated that the resident's care plan will be reviewed and revised to reflect the resident's current code status of DNR/DNI.On [DATE] at 9:51AM, the Surveyor was informed that Resident #68's care plan was revised to reflect the resident's code status of DNR/DNI.

Based on observations, record review, and interviews with residents and staff, it was determined that the facility failed to ensure a physician's order for tube feeding was accurately followed (Resident #12) who was reviewed for tube feeding. The findings include:On 7/15/2025 at 8:53AM, during an interview with Resident #12, the Surveyor observed the resident's tube feeding running at 75ml/hour and the flush bag was not labeled.On 7/15/2025 at 10:30AM, a review of Resident #12's electronic medical record revealed an active physician's order for Jevity 1.5kcal Up : 5 pm Down : 3 am TV : 75 mL/hr x 10 hrs.During an interview with the Director of Nursing on 7/21/2025 at 12:45PM, the Surveyor was informed that Resident #12's order for the tube feed to be started at 5PM and ended at 3AM. The tube feed should be labeled with the resident name, room number, name of the formula, formula rate, the date and time hung, and nurse initials. The flush bag should also be labeled with the resident name, flush rate, date and time hung, and the nurse initials. The Surveyor expressed the concern that Resident #12's tube feed was running on 7/15/2025 at 8:53AM and the flush bag was not labeled.

Based on medical record review, observations, and interview with facility staff, it was determined that the facility failed to address and implement interventions for a resident admitted with a suprapubic catheter. This was identified during the review of 1 of 1 residents with suprapubic catheters. The findings include: On 1/4/23 Surveyor met with Resident #20 during the initial tour. During this initial meeting and interview, Resident #20 reported that s/he was in discomfort and believed that they had a urinary tract infection (UTI) as there was some pressure and discomfort in their abdomen and they could tell that the catheter was probably clogged as s/he could feel it was leaking. Surveyor asked if this was reported to the staff, and s/he stated that staff were aware. Medical record review of Resident #20 starting on 1/09/23 at 9:56 AM revealed admitting diagnoses' including multiple sclerosis (the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body) and neuromuscular dysfunction of bladder (the nerves that carry messages back-and-forth between the bladder and the spinal cord and brain don't work the way they should). Further review revealed an initial history and physical (H and P) completed by the resident's attending physician staff #22, on 12/21/2021. This H and P documented in the resident's plan #4. 'The patient needs a follow up with Urology.' Surveyor review of the 'misc.' (miscellaneous) section of the facility's electronic health record (EHR) noted a Physicians Standard Written Order-Urinary Catheter form, uploaded into the system on 12/16/2022. This form was completed with Resident #20's personal information, insurance information, and specific catheter information noted with a request for '12' refills signed by staff #22. Staff #22 saw Resident #20 on 12/2/21 and 1/27/22 and continued to document that Resident #20 needed a Urology follow-up. On 2/24/22 Resident #20 saw a Urologist. The recommendations and report from the consultation were that the catheter was changed and that it needed to be changed monthly. In addition, 'the resident needs to see a spinal cord/neurogenic bladder expert for urology care, and information was provided to the facility for that expert.' Staff #22 saw Resident #20 on 3/3/22 and on 3/8/22 and in the Plan: #2 for the neurogenic bladder documented that the catheter needed to be changed every four week the attending visit. Staff #22 saw Resident #20 on 3/29 and 4/2 and 5/3 and still noted in the 'Plan' to continue with catheter care and that s/he is to follow up with a neurogenic bladder specialist. Surveyor concurrent review of Resident #20's 2022 March and April medication and treatment administration record (MAR/TAR) failed to identify an order or staff signing off that the suprapubic catheter was changed since 2/24/22 as noted from the consult and the physician progress notes. On 5/11/22 Resident #20 was sent to the emergency room (ER) with a noted change in condition and for possible sepsis (the body's extreme response to an infection). Continued review on 1/9/23 at 12:06 PM of Resident #20's hospital record from 5/11/22 noted that on arrival to the hospital, s/he was 'noted with a blocked suprapubic catheter that was manipulated and flushed in the ER that drained 1400 milliliters (ml/cc) of old infected urine.' Resident #20 was started on antibiotics. According to the National Institutes of Health (NIH) the urinary bladder can store up to 500 ml of urine in women and 700 ml in men. A person can feel the need to urinate when their bladder has between 200 and 350 ml of urine in it. On 8/11/22 Resident #20 was sent to the ER again with concerns related to Diabetic ketoacidosis (DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy). However, while in the ER it was determined that Resident #20 additionally had another UTI and was started on antibiotics again. Surveyor continued to review Resident #20's medical record on 1/9/23 including nursing progress notes. This review revealed on 11/10/22, Resident #20 was noted with no drainage from the catheter with abdominal distention and green drainage noted from the genital area. A Health status note was completed by the Director of Nursing on 11/10/22 at 6:19 PM that the suprapubic catheter was changed and tolerated well. According to the note, Resident#20 stated s/he felt better when the catheter was replaced, and the genitals were cultured. Resident #20 was again started on antibiotics as the culture results were positive. On 12/5/22 Resident #20 saw the neurogenic bladder specialist as recommended from February 2022, more than 9 months after the urologist documented that the resident needed to see the specialist. The recommendations from this neurogenic bladder consultant stated that s/he cannot return to this office as they do not have the accommodations to care for him/her. In addition, the consultant stated that the catheter was changed because it was 'not in the proper location.' A culture was completed at the consult and resulted in another positive UTI. The results were reported back to the facility on [DATE] that the culture results were positive, and Resident #20 was started on antibiotics again. A nursing health status note documented on 12/18/22 that geriatric nursing assistant (GNA) caring for Resident #20 reported that his/her adult brief was wet. Upon assessment of the resident, s/he reported 'pressure and feeling like they had to urinate.' The nurse documented that the lower abdomen felt firm and tender upon palpation. The catheter was irrigated, and 900 cc of urine was drained into a new catheter bag. Review on 1/19/23 at 8:00 AM revealed that nursing notes documented that on 1/7/23 Resident #20 was complaining of frequent urine out of his/her genitals. Another urine culture was completed and resulted in a positive UTI and Resident #20 was started on antibiotics again and an order was placed for a Urology consult. On 1/17/23 his/her catheter was changed by the facility DON. Review of the treatment administration record on 1/19/2023 at 8:30 AM from January 2022 through December 2022 failed to show any documentation of regularly ordered or scheduled catheter changes. The DON was interviewed on 1/19/2023 at 9:08 AM. She was asked about her credentials related to suprapubic catheters. She stated that she and the Assistant Director of Nursing (ADON), who was also present, were both trained in changing and caring for suprapubic catheters. She was asked at that time that if they were both trained in the care, why they did not change the catheter monthly as ordered by the consultant or as previously asked why the resident did not go to the urologist monthly and she stated that she did not have an answer. The ADON also shook her head 'no' that she did not have an answer either. Resident #20 had an appointment with another urologist on 1/23/23. This consultant report stated that the catheter was replaced again using sterile technique, recommended 'performance of routine catheter care, and follow up in 1 month.' The cumulative review of Resident #20's 13 month stay in the facility has resulted in the official diagnosis of 5 UTI's, 2 hospitalization s and only 3 consultations at a Urologist out of the recommended monthly consultations. The failure of the facility to provide suprapubic catheter care according to recommendations by the facility attending and Urologist and the resultant infections and hospitalization s were reviewed with the Administrator and DON throughout the survey and again during exit on 1/23/23.

Based on observation, interview and medical record review it was determined that the facility failed to 1a) have an effective system in place to address dangerously high water temperatures as evidenced by water temperatures in resident rooms above 150 degrees F for at least a 4 hour period of time, 1b) to have a system in place to regularly monitor the temperature of water going into each resident's room, 1c) to have a system to monitor the water temperature of water being used for the bathtubs, and 2. to ensure that the residents' environments remained free from chemical hazards as evidenced by the presence of cleaning chemicals and loose medications in a resident's bathroom (Resident #2). The failure identified in example 1a-1c had the potential to affect all residents of the facility; example #2 had the potential to affect 1 of 40 residents reviewed during stage 1. Due to this failure, on 10/6/16 at 12:01 PM an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to address dangerously high water temperatures in residents room, monitoring of water temperatures in each resident room and monitoring the water temperatures used for resident's bath tubs. An initial plan to remove the immediacy was given to the survey team and the Office of Health Care Quality for review on 10/6/16 at 5:05 PM and was not accepted. The 2nd plan was given to the survey team and the Office of Health Care Quality for review on 10/6/16 at 7:25 PM and was not accepted. On 10/6/16 at 8:05 PM the 3rd plan was given to the survey team and the Office of Health Care Quality for review. This plan of removal was accepted by the survey team and the Office of Health Care Quality and the immediate jeopardy was removed at 8:19 PM. After removal of the immediacy, the deficiency remained at a scope and severity of F. The findings include: Review of Resident #75's medical record revealed that the resident was [AGE] years old with a [DIAGNOSES REDACTED]. During an interview on 10/6/16 at 9:19 AM Resident #75 reported that s/he did not like showers and that s/he sits at the sink and washes him/herself up. At the conclusion of the interview the surveyor checked the water in the resident's sink with a thermometer and found that the water was above 150 degrees F. The surveyor activated the call light which was answered by the shahbaz (Staff #16) at 9:25 AM. The shahbaz stated the water was hot' and confirmed a thermometer reading of 162 degrees. The surveyor left the room while the shahbaz (Staff #16) remained in the room with the resident. The surveyor then informed the shahbaz in the dining area of the high water temperature. The second shahbaz reported that she would inform the Administrator. On 10/6/16 at 9:30 AM the surveyor informed the Administrator of the observation of the 160 degree water in the resident's room and that the shahbaz had been informed. The Administrator informed the surveyor that they were trying to regulate the water temperature because they had experienced a power surge. The Administrator said stated that they had taken water temperatures that morning and that temperatures had been low. She offered to provide the documentation of the morning temperatures for surveyor review. Surveyor informed the Administrator that she would look at the documentation after the Administrator dealt with the immediate issue. Between 9:45 AM and 9:55 AM two Surveyors observed the following water temperatures: Room 103: 152 degrees F Room 111: 138 degrees F Room 305: 140 degrees F Room 409: 146 degrees F At 10:00 AM the Administrator reported that all of the aides were using basins and modulating the temperature of the water and that they were watching the residents as they go in their rooms. The Administrator went on to report that there had been a power surge earlier in the week that had affected the fuse boxes on the water heaters and that there was no regulator working for the second hot water heater. The electrician had been to the facility earlier in the week to address the issue, as well as having been at the facility last night to get partial power to the second hot water heater. Review of the water temperature log, completed by Maintenance Staff (Staff #10) for 10/6/16 at 7:00 AM revealed the following: Basement: Restroom: 108 degrees F; 1st floor: Room 103: 91.2 degrees F; 2nd floor: Room 202: 99 degrees F; 3rd floor: Room 303: 93.3 degrees F; 4th floor: Room 406: 106 degrees F. Tank #1: 130 degrees F Tank #2: 130 degrees F When asked about the 7 AM temperatures being low and what occurred that caused the increase the Administrator responded, I guess obviously the temperatures went up. When asked what she was going to do if she was unable to control the temperatures the Administrator's response was, I guess I'll check it every hour. She went on to report that the electrician would be coming in at 2:30 PM to explain what was going on with the water heater. The survey team then requested to speak with the Maintenance Director. At 10:23 AM the survey team started an interview with the maintenance staff (Staff #10). At 10:25 AM the Administrator came into the room to inform the surveyors that they were going to turn off the second water tank. Staff #10 reported that he was not the Maintenance Director and that the Maintenance Director worked at (name of another facility, owned by same company). Staff #10 reported that he takes water temperatures every morning in different rooms, the kitchen, restrooms and resident rooms. He went on to report that the water heaters were set to 130 degrees F. When asked if he were to get a temperature reading of higher than 125 degrees F in a room what would he do, Staff #10 reported that each room had an adjuster. Staff #10 proceeded to demonstrate, on the sink in the room being utilized by the survey team, how under the sink there was an adjuster that could be set to regulate the amount of hot water going into the sink. At 10:38 AM two surveyors and Staff #10 observed the facility's two water heaters. It was noted that the power was off on Tank #1. Both Tanks currently had thermometer readings of 170 degrees F which was confirmed by Staff #10. Staff #10 went on to report that he had not checked the tank temps that morning, just the temps in the rooms. Staff #10 declined to open the electrical boxes on the water tanks during this observation. Of note, during a subsequent observation of the water heaters on 10/12/16 at 1:38 PM with the Maintenance Director (Staff #13) and Maintenance Staff #10, it was revealed that the temperature that the water heaters were set to were found inside the electrical boxes. Maintenance Director stated to Staff #10 that he should have immediately opened that (electrical box) and checked on what temperature it was set on. On 10/6/16 at 10:46 AM, the surveyor reviewed with Staff #10 his documentation from that morning at 7:00 AM that indicated both water tanks were at 130 degrees F. Staff #10 confirmed that he did not look at the tanks that morning prior to recording the temps of the hot water tanks and reported that he documented 130 degrees because that is where the temperature normally is. On 10/6/16 at 11:05 AM the surveyor informed the Administrator that Staff #10 had reported that he had not actually checked the water heaters this morning, that he wrote 130 on the temperature log because that is what it normally is. The Administrator reported that she had not been aware of this. The surveyor also informed the Administrator that both of the water heaters' thermometers were currently reading 170 degrees F. On 10/6/16 at 11:10 AM the surveyor and the nurse (Staff #11) observed that Resident #75's door was closed. After knocking on the door and entering the room the resident was found sitting in his/her wheelchair between the bathroom and bed. Resident #75 was alone in the room. The Surveyor checked the temperature of the water in the bathroom sink which was 159 degrees F, this reading was confirmed by the nurse (Staff #11) At 11:12 AM the nurse (Staff #8), who was assigned to care for the resident that day, reported that Resident #75 is able to wheel him/herself around very slow. She went on to report that she was aware of the earlier high temperature and that they were working on getting the temperature down. When informed of the most recent temperature reading of 159 degrees F the nurse (Staff #8) reported that she would get the resident out of the room. The nurse asked the surveyor if the high temperatures were just on her floor or throughout the building. The Surveyor informed Staff #8 the high temperatures were being found on all the floors. At approximately 11:30 AM the Administrator informed the surveyor that she had spoken to the alert residents on the floors, except for Resident #1 who was asleep, regarding the hot water. Surveyor had observed Resident #1 earlier in the day laying on her/his bed with eyes closed. At approximately 11:30 AM the thermometers were calibrated in an ice water slurry and found to be accurate. Between 9:30 AM and 12:00 PM, surveyors observed water temperatures above 130 degrees F in resident rooms on all four floors of the facility. Observed temperatures include: Room 103: 152 degrees F Room 111: 138 degrees F Room 201: 140 degrees F Room 203: 160 degrees F Room 204: 140 degrees F Room 205: 132 degrees F Room 305: 140 degrees F Room 309: 146 degrees F Room 311: 144 degrees F Room 409: 146 degrees F At 12:01 PM the surveyors spoke with the Administrator and informed her of the concern regarding the continued hot water in the residents' rooms despite having informed her at 9:30 AM of the observation of the water temperature above 150 in one resident's room. In addition she was also informed of the observation of the water heaters' thermometer reading of 170 and the failure of the maintenance staff to actually observe the thermometers on the water heater prior to documenting their temperature reading this morning. At 12:32 PM the surveyor observed the water in Room 410 was 152 degrees F; and at 12:49 PM the water in Room 403 was noted to be above 120 degrees F. Review of the facility's documentation of recorded water temperatures for 10/6/16 failed to reveal any recorded water temperatures between the 7:00 AM temperatures and those recorded at 11 AM, an hour and a half after the Administrator was informed of the temperature above 150 degrees F. At 11:00 AM Staff #10 recorded the following temperatures: Basement: Restroom: 112 degrees F; 1st floor: Restroom: 106 degrees F; 2nd floor: Restroom: 106 degrees F; 3rd floor: Room 302: 112 degrees F; 4th floor: Room 404: 108 degrees F; No documentation was found that the water temperature was checked in Resident #75's room. At 12:00 PM, Staff #10 recorded the following temperatures: Room 104: 109 degrees F; Room 205: 113 degrees F; 3rd floor restroom: 116.4 degrees F; 4th floor dining room: 116 degrees F; Based on the dangerously high water temperatures observed in 11 separate rooms located on 4 out of the 4 floors of the facility an immediate jeopardy was called on 10/6/16 at 12:01 PM. At approximately 1:00 PM on 10/6/16 a formal statement was provided to the facility with documentation of elevated water temperatures in at least two resident rooms on each of the four floors of the facility. Further review of the 10/6/16 facility water temperature log revealed the following temperatures recorded at 1:30 PM: Room 106: 146 degrees F; Room 104: 109 degrees F; Room 204: 143 degrees F; Room 205: 121 degrees F; Room 211: 136 degrees F; Room 208: 135 degrees F; Room 229: 151 degrees F; Dining Room (no floor): 112 degrees F; Room 311: 159 degrees F; Room 306: 156 degrees F; Room 301: 145 degrees F; Kitchen (no floor): 108 degrees F; Room 403: 146 degrees F; Dining Room (no floor): 114 degrees F; Room 408: 148 degrees F; Room 412: 147 degrees F; These temperatures were recorded by facility staff 4 hours after the Administrator was first informed of the observation of a water temperature above 150 degrees F in a resident's room. Prior to 1:30 PM the facility staff had only checked the temperature in a total of one resident's room on each floor, failing to identify any of the other elevated temperatures and failing to re-check the temperature in Resident #75's room at all. On 10/5/16 during stage one interviews the nursing staff identified 9 out of 30 residents (Residents #55, #75, #1, #84, #53, #109, #86, #6 and #33) as being physically able to get out of bed on his or her own. The following resident's had observed/recorded water temperatures above 130 degrees in their bathroom on 10/6/16: -Resident #55 whose medical record revealed a [DIAGNOSES REDACTED]. The BIMS is the Brief Interview for Mental Status assessment tool where 0-7 reflects severe cognitive impairment, 8-12 reflects moderate cognitive impairment, and 13-15 reflects a resident considered to be cognitively intact. This resident was identified by staff on 10/5/16 as being able to physically get out of bed on his/her own. -Resident #21 whose medical record revealed a [DIAGNOSES REDACTED]. -Resident #2 whose medical record revealed [DIAGNOSES REDACTED]. On 10/11/16 shahbaz (staff #5) reported that the resident was able to self-propel in his/her wheelchair. -Resident #15 whose medical record revealed [DIAGNOSES REDACTED]. Resident #15 required only limited assistance for locomotion on unit as per the 7/31/16 MDS assessment. -Resident #28 whose medical record revealed [DIAGNOSES REDACTED]. The resident required only limited assistance for locomotion on unit as per the 9/4/16 MDS assessment. -Resident #1 whose medical record revealed a [DIAGNOSES REDACTED]. Interview with Shahbaz (Staff #4) on 10/6/16 at 2:15 PM revealed that Resident #1 walked with a cane and that s/he came down (to dining area) for breakfast. Staff #4 went on to report that she noticed the water was a little too hot around 10:00 AM, some extremely too hot. She went on to report that the nurse had informed her that the water was hot and not to let the resident go in the bathroom by him/herself. This interview occurred in the dining area and Resident #1 was not observed in the area at the time of the interview. On 10/6/16 at 2:07 PM surveyor observed in the 3rd floor living room area 3 residents in wheelchairs. No staff were observed in the kitchen, dining, living room or hallway at this time. At 2:11 PM a Shahbaz (Staff #5) arrived on the unit. Staff #5 reported that she had been informed that the water temperatures were up a little high and to make sure they (residents) were not in the bathrooms alone. She went on to state: On this floor it's easy because a lot cannot go in the bathroom, maybe the three out here and the other two are taking a nap. On 10/6/16 at 2:41 PM the electrician (Staff #12) reported that he had originally come out on Monday (10/3/16) and had been at the facility again last night. He reported that he had identified a potential problem last night when he observed that the insulation was starting to deteriorate (on water heater #1 electrical unit) and that the surge had probably affected both of the water heater units. On 10/6/16 at 3:23 PM the Administrator reported that they had just drained the hot water heaters of the high temperature water, and that the plan was to leave only one of the water heaters on. On 10/6/16 at 3:32 PM the surveyor observed with the electrician and the administrator that tank #2's thermometer now read 120 degrees F. Tank #1 was noted to still be reading 170 degrees F, the electrician reported that Tank #1's temperature gauges were malfunctioning. Tank #1 was noted to be turned off at this time. On 10/6/16 water temperatures observed by the survey team at 5:00 PM failed to reveal any temperatures above 120 degrees F. On 10/6/16 at 8:05 PM the facility provided the survey team with an acceptable plan to remove the immediacy. The plan to remove the immediacy included but was not limited to turning off both boilers and bleeding the tanks, tank #1 will remain off until it is repaired, hourly hot water temperature checks, temperature checks of random resident rooms, education of staff on procedures to follow in the event that hot water temperatures exceed 120 degrees F. On 10/7/16 at 12:30 PM the surveyor asked the Administrator who the Maintenance Director was at this facility. She reported that (name of another facility, owned by same company) had a Maintenance Director (Staff #13), and that Staff #10 is here full time and they contact Staff #13 when they need him. She went on to report that she didn't need him (Maintenance Director Staff #13) yesterday (10/6/16) because she had called the electrician and the power company. The Administrator later reported that she had called Staff #13 on Monday (10/3/16). Monday was the day the initial problem with the water heater was identified. On 10/7/16 at 2:12 PM Staff #10 reported that yesterday morning the Administrator had told him that one of the water tanks had to be repaired. He had taken the temperatures in the morning and that they were kind of low and that he had informed the Administrator, and that she (the Administrator) was waiting for the electrician to come in. Staff #10 denied having been informed of the surveyors' observations of the 160 degrees F water temperature by the Administrator. When asked what he would have done had he been informed, Staff #10 responded, probably went in there and moved the adjuster and got it down to a proper temperature. He reported that the proper temperature would be between 100-120 degrees F. When asked what he would have done if he could not have gotten the temperature down, Staff #10 responded that he probably would have called the Maintenance Director (Staff #13). Staff #10 confirmed that it is possible to turn off the hot water to an individual sink. Review of the facility floor-plan and observations revealed that the facility has 48 resident rooms. Each room has a bathroom with a sink and a shower. Review of the water temperature logs for 8/01/16 thru 10/6/16 failed to reveal any water temperature monitoring at all for 28 out of the 48 resident rooms in the facility. Temperatures were checked only 36 days out of the 67 days reviewed. Of the 36 days that temperatures were recorded, resident rooms were only checked on 19 days. No temperatures were recorded on the weekends or when Staff #10 was on vacation; this included a more than one week period of 8/5/16 through 8/14/16. Despite the facility being aware of an issue with the water heaters on 10/3/16, no temperature monitoring was recorded for 10/4/16 or 10/5/16. Review of the temperature log for revealed two blank entry spaces between 10/3/16 and 10/6/16 with the following notation, VAC. There were no recorded temperatures for the Spa rooms which contain a bathtub. Interview with Staff #10 on 10/7/16 confirmed that he does not check the water temperature in the Spa rooms. On 10/12/16 an interview with Shahbaz (Staff #14) revealed that prior to a tub bath staff test the water with their hands to make sure it is not too hot or too cold. On 10/12/16 at 11:35 AM the Administrator reported that Staff #10's title was Maintenance/Van driver and that he is currently unavailable due to being out on a trip. The Surveyor had asked for the Maintenance Director to tour the facility regarding the temperatures and to discuss the status of the water heater. Review of the employee list provided at the start of the survey revealed Staff #10's title as Driver/Environmental Services. Staff #13 was listed as Central Office: Environmental Specialist. On 10/12/16 at 12:10 PM the surveyor observed a water temperature of 119* in room #103. On 10/12/16 at 1:10 PM the survey team met with the Maintenance Director (Staff #13) and the Administrator. During this conversation it was revealed that Staff #13 had been made aware of the initial issue with the water heaters prior to the start of the survey however had not been made aware of the issue regarding the high water temperatures noted on 10/6/16 until 10/12/16. He reported that the Administrator had spoken to him that day (10/12/16) about a problem with some high temps and low temps. Staff #13 stated he asked if Staff #10 had adjusted the mixing valves (adjusters under the sink). The survey team then reviewed the events of 10/6/16 with the Maintenance Director who said he did not know about any of this. The surveyor asked Staff #13, as a Maintenance Director, what is an acceptable water temperature? Staff #13 responded, 110 for me, if it is during morning care 106 - 110, after it can be 110. He went on to report that he had never gotten over 115 degrees F in any facility. The Surveyor then informed Staff #13 that a temperature of 119 degrees F had been observed in room #103 today. When the surveyor asked if there were scald guards on the showers, Staff #13 reported, Probably not. The Surveyor reviewed the concern regarding no monitoring of the water temperature in the Spa rooms and the failure to have a system in place to ensure water was checked in each room on a regular schedule with Staff #13 and the Administrator.An initial plan of correction was given to the survey team for review on 10/6/16 at 5:05 PM and was not accepted. The 2nd plan of correction was given to the survey team and the Office of Health Care Quality for review on 10/6/16 at 7:25 PM and was not accepted. On 10/6/16 at 8:05 PM the 3rd plan of correction was given to the survey team and the Office of Health Care Quality for review. This plan included but was not limited to: turning off both boilers and bleeding the tanks, tank #1 will remain off until it is repaired, hourly hot water temperature checks, temperature checks of random resident rooms, education of staff on procedures to follow in the event that hot water temperatures exceed 120 degrees F. This plan was accepted by the survey team and the Office of Health Care Quality and the immediate jeopardy was removed at 8:19 PM. Reference: According to the Interpretive Guidelines in the State Operations Manual: Water may reach hazardous temperatures in hand sinks, showers, and tubs. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Table 1. Time and Temperature Relationship to Serious Burns Water Temp Time Required for a 3rd Degree Burn to Occur 155°F 1 sec 148°F 2 sec 140°F 5 sec 133°F 15 sec 127°F 1 min 124°F 3 min 120°F 5 min 100°F Safe Temperatures For Bathing: NOTE--Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Cross Reference to State regulation CO[DATE].07.02.26EE: The water heating equipment shall supply adequate amounts of water according to the following temperature guidelines (1) Washing, bathing and other personal use to not be more than 120*F, or less than 100*F. 2. An observation of Resident #2's living quarters on 10/05/16 at 12:45 PM revealed the presence of an 8 oz. container of Bon Ami, an all-purpose cleaning powder, on the lower shelf of a sink-side shelving set in the resident's bathroom. The powder had open shake holes on its lid and and a warning label which read, avoid contact with eyes. If it does occur, rinse eyes immediately with water. A weekly pill organizer box was also found on this shelf that contained 5 tablets of various prescription medications in one of its compartments. During an interview that took place on 10/05/16 at 1:19 PM, the shahbaz (Staff #3) assigned to Resident stated that Resident #2's family brings items from their home, despite repeated requests for them to not bring in things like that. Staff #3 also stated that the medications in the pill box were the medications of a family member and not the resident's own medications, which were secured behind a locked cabinet. A review of Resident #2's medical record on 10/05/16 at 2:21 PM revealed the resident's most recent BIMS score was 9 out of 15 from an assessment performed in 2014. The Brief Interview of Mental Status (BIMS) assessment is used to evaluate and represent an individual's mental abilities, including someone's ability to make safety-conscious decisions. A BIMS score of 8 to 12 indicates that someone is moderately impaired. The quarterly MDS performed on 9/25/16 evaluated all of Resident #2's activities of daily living (ADL) as requiring one person assistance and stated that he/she required a walker for locomotion. On 10/5/16 at 3:05 PM, the Bon Ami cleaning powder and the pill box were found to have been removed from Resident #2's room. During an interview with the Rehabilitation Director (Staff #15) on 10/11/16 at 1:20 PM, it was discussed that Resident #2 was able to spontaneously stand and would attempt transfer from his/her wheelchair to other seating. On 10/11/16 at 1:35 PM, an interview with a shahbaz (Staff #5) on Resident #2's floor who was familiar with the resident, indicated that Resident #2 had, stood up by himself/herself, and, reached for things that aren't his/hers before. On 10/12/16 at 5:45 PM after discussing the items found in Resident #2's room, the Administrator reported that the facility would have to meet with Resident #2's family because (the family) comes in every week with stuff they shouldn't.