Every finding on record at The Shores Post-Acute

Based on observation, interview, and record review, the facility failed to ensure two of two residents (Resident 1 and Resident 2) had preventative measures in place to prevent elopement when:An elevator that led to the facility basement was easily accessible to residents.Certified nursing assistant (CNA) 5 did not know what a Code [NAME] (emergency plan when a resident goes missing) was.The Exit Monitoring Logs were not consistently completed once a shift by maintenance staff.The Safety and Security Reminder In-service dated 6/30/26 had inaccurate information.Q (every)15-30-minute elopement monitoring logs for Resident 1 had missing documentation.Hall monitor times were not followed in the secured unit (a closed unit that housed residents with cognitive impairment who were at high risk for elopement)Assigned hall monitors on the secured unit attended to other resident needs during their hall monitoring time.IDT did not do a thorough investigation into elopement.As a result of these deficient practices, Resident 1 and Resident 2 eloped from the facility placing the residents at risk for serious harm. In addition, this deficient practice potentially placed the 80 residents on the secured unit at risk for elopement. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include Schizoaffective Disorder (mental health condition), Difficulty in Walking, Morbid (Severe) Obesity Due to Excess Calories, Major Depressive Disorder (mental health condition), Psychotic Disorder (mental health condition) with Delusions Due to Known Physiological Condition, Bipolar Disorder (mental health condition), and Anxiety Disorder. A review of Resident 1's Nurses Notes dated 7/10/26 indicated Resident 1 was sent to the hospital and did not return to the facility. A review of Resident 1's Care Plan Report dated 4/14/25 indicated Resident 1 had episode/history of elopement. Resident with history of wandering out of the facility. A review of Resident 1's Wandering/Elopement Risk Scale dated 4/15/26 indicated a score of 11. The score 11 indicated High Risk for Wandering. A review of Resident 1's Alert Charting record dated 6/29/26 at 10:12 P.M., .Resident is observed having episodes of calling 911 saying he wants to leave. A review of IDT (interdisciplinary team) Comprehensive Resident Support Notes dated 6/30/26 indicated, On June 30th [Resident 1] was found outside of the facility unattended and without having a out on pass order. Resident said that around 2000 [8 P.M.] he called the cops because he felt unsafe in the facility. Resident said origin: he was in the courtyard of station 2 when he heard voices telling him to leave. Resident said he attempted to climb the fence in station 2 but was unsuccessful at the attempt. Resident said after that he went to the back dining room and went down the elevator. Once the resident exit [sic] the building he went towards the [freeway]. On 7/15/26 at 8:40 A.M., an interview was conducted with the assistant director of nursing (ADON) 1. ADON 1 stated that on 6/30/26, Resident 1 became upset after speaking with his mother on the phone. ADON 1 stated that Resident 1 attempted to jump over the fence behind the dining room but was unsuccessful. ADON 1 stated that Resident 1 then reentered the facility, walked toward station three, took the elevator to the basement, exited through the basement door, and left the facility through the open parking lot gate. ADON 1 stated Resident 1 had schizophrenia and lacked the mental capacity to make safe decisions. ADON 1 stated Resident 1 wanted, revenge against the facility and would call 911 often. On 7/15/26 at 9 A.M., a joint observation and interview with ADON 1 was conducted. ADON 1 identified the elevator located behind station three and stated that this elevator was the only elevator in the facility. To the left of the elevator, a button panel with three horizontal buttons was observed. Each button contained a keyhole in the center. ADON 1 stated that the facility did not have a key for the elevator. ADON 1 used his fingers to press and turn the third button which activated the elevator. An observation of the basement was then conducted with ADON 1. ADON 1 stated that the basement was, not for residents. An exit door adjacent to the elevator was observed. ADON 1 stated that Resident 1 exited through that door and then left the facility through the parking lot gate during the elopement. On 7/15/26 at 9:17 A.M., an interview was conducted with CNA 5. CNA 5 stated that he was familiar with Resident 1. CNA 5 stated Resident 1 frequently sat in the hallways yelling, intentionally would vomit in the hallways, and preferred wearing soiled clothing. CNA 5 stated that Resident 1 required frequent staff monitoring. CNA 5 stated he was unsure if Resident 1 had a history of elopement. CNA 5 stated that he did not know what Code [NAME] was. On 7/15/26 at 10:21 A.M., a joint observation, interview, and record review was conducted with the Maintenance Supervisor (Main 1). The elevator behind station three was observed. Main 1 stated the elevator had previously required a key for access but no longer required one. Main 1 stated, anybody can get in the elevator and the elevator was not secured. The basement was then observed with Main 1. The kitchen, mechanical storage area, laundry area, and central supply area were identified to be part of the basement. Main 1 stated the mechanical storage area, parts of the laundry area, and the central supply area remained unlocked at all times. The mechanical storage area contained electrical panels, exposed wiring, and a, Beware High Voltage signage was hanging from the ceiling piping. The central supply area contained numerous boxes, coiled and tangled cords, broken equipment, maintenance parts, and miscellaneous tools on the floor. Main 1 stated the basement was, hazardous, posed a safety concern for residents, and residents should not have access to these areas. The basement exit door adjacent to the elevator was observed. A red exit alarm was mounted next to the exit door. Main 1 stated the alarm had been in place approximately two to three years. A binder labeled, Door Log was observed hanging on a shelf next to the alarm. Main 1 stated the exit door had not previously locked, the alarm had not previously been activated, and the Door Log had only recently been implemented. A review of the July Door Log indicated missing documentation for 7/2/26, 7/4/26, and 7/10/26. Main 1 stated the Door Log should have been completed every night. Main 1 stated that maintenance staff was expected to clock out, activate the alarm, verify the alarm was functioning, document completion in the Door Log, and then lock the basement exit door. Main 1 stated that if the basement exit door had been locked, Resident 1 would not have been able to exit through that door. The parking lot gate was then observed with Main 1. Main 1 stated that the parking lot gate had previously been left unlocked. Main 1 stated Resident 1 was able to elope from the facility because the exit door and the parking lot gate were unlocked. At 11:03 A.M., the basement exit door alarm was tested. This writer remained in the basement with Main 1 while a second surveyor was positioned on station three to determine if the alarm was audible upstairs. Main 1 activated the basement exit door alarm. During the test, the second surveyor notified this writer by telephone that the alarm was not audible on station three. ADON 1, who was also present on station three during the alarm test, confirmed by telephone that he also could not hear the alarm. Main 1 stated that he had never tested whether the alarm was audible from station three. Main 1 stated there was no point having the alarm because nobody could hear it unless you were in the basement. Main 1 stated he was not asked to be part of the IDT investigation following Resident 1's elopement on 6/30/26. Main 1 stated he should have been involved in the IDT investigation because he was knowledgeable about the facility's layout, the facility's alarms, and facility exits that may have posed a risk for elopement. On 7/15/26 at 11:25 A.M., a joint interview and record review of the facility's Emergency Exit/ Alarm Checks Per Shift logs was conducted with Main 1. Main 1 stated the emergency exit and alarms were to be checked and the logs to be completed and documented each shift. A review of the logs indicated incomplete documentation. For 6/30/26, only the AM shift check was completed. In addition, for June 2026, only the AM shift check was documented on 6/1/26, 6/2/26, 6/8/26, 6/17/26, 6/18/26, 6/19/26, 6/23/26 and 6/26/26. For July 2026, only the AM shift check was documented on 7/1/26 and 7/8/26. Main 1 stated it was his expectation that the emergency exit and alarm checks should have been completed and documented every shift because another resident could elope if the alarms were not verified to be functioning. A review of Resident 1's Nurses Notes dated 6/30/26 at 10:25 A.M., indicated, Resident has been heard a couple of times tellings staff and other residents that he has no issue leaving again. Resident is currently on q15 monitoring for whereabouts and activities. Resident will be continued to be monitored. A review of Resident 1's Social Services Notes dated 6/30/26 stated, Resident came to Social Services office to say, 'did you hear what I did [referring to the elopement]. no one can stop me.' Resident also stated multiple times that he does not want to be in the facility and he would prefer to be homeless. A review of Resident 1's Primary Physician Progress Note dated 7/1/26 stated, .Patient is seen due to.passive suicidal statement in context of feeling unsafe and wanting to leave the facility.He reports feeling unsafe in the facility and verbalizes desire to leave. He made a passive statement, 'I would kill myself first if I had to be here another day'. Continue close monitoring. On 7/15/26 at 2:14 P.M., a joint interview and record review was conducted with ADON 1. ADON 1 stated Resident 1 was at high risk for wandering and elopement. ADON 1 stated Resident 1 did not like being at the facility. ADON 1 further stated Resident 1 was alert, knew how to leave the facility, and would know how to remove a wander guard (safety and security device) if one were applied. ADON 1 stated after Resident 1 returned to the facility following the 6/30/26 elopement, Resident 1 was on Q 15-30-minute (documentation of whereabouts and activities every 15-30 minutes) until Resident 1's discharge on [DATE]. Resident 1's Q 15-30-minute Minutes Monitoring Logs were reviewed. ADON 1 stated Q 15-30-minute monitoring required staff to visually check on Resident 1 and document Resident 1's whereabouts, 24/7. A review of the monitoring logs revealed multiple undocumented rounds: On 6/30/26 11:30 P.M.-11:45 P.M. On 7/2/26 11:15 P.M. -11:45 P.M. On 7/3/26 11:30 P.M. On 7/4/26 12 MN (midnight) – 11:45 P.M. On 7/5/26 12 MN-6:30 A.M. and 11:30 P.M. On 7/6/26 1:30 A.M.- 2:30 P.M and 11:30 P.M. On 7/7/26 7 A.M.-2:30 P.M. On 7/8/26 9:30 A.M-2:30 P.M. On 7/9/26 7:15 A.M.- 12:30 P.M. and 11:30 P.M.- 11:45 P.M. ADON 1 acknowledged the Q 15-30-minute monitoring logs had missing documentation. ADON 1 stated it was his expectation that Q 15-30-minutes be completed and documented every 15- 30-minutes because Resident 1 remained at risk for another elopement. ADON 1 stated residents should not have access to the elevator due to the hazards in the basement and the basement exit door. ADON 1 further stated the elevator remained still easily accessible to residents. ADON 1 then stated he attended a facility in-service on 6/30/26 where staff were instructed that maintenance staff locked the back dining room doors leading to the elevator each night. On 7/15/26 at 2:43 P.M., a joint observation, interview, and record review was conducted with Main 1. Main 1 reviewed undated lesson plan for the All Staff In-Service conducted on 6/30/26 titled, Safety and Security Reminder. Main 1 read the section titled Back Dining Room Doors which stated, Housekeeping (Janitorial Staff) will lock the back dining room doors each night at 9:30 PM. The back dining room doors were then observed with Main 1. Main 1 stated the back dining room doors could not be locked because they did not have locks. Main 1 stated maintenance staff did not lock the doors each night but only closed them. Main 1 stated staff who believed the doors were locked might not closely monitor residents who wandered towards the doors, increasing the risk for resident elopement. On 7/15/26 at 2:54 P.M., a joint interview and record review was conducted with the infection preventionist registered nurse (IPRN). The director of staff development (DSD) was unavailable. The IPRN stated she was part of the IDT investigation following Resident 1's elopement on 6/30/26. The IPRN stated Main 1 should have been included in the investigation because he was very familiar with the facility and knew the areas where the building was vulnerable to elopement. The IPRN stated the IDT investigation would have been more thorough if Main 1 had been included. The IPRN stated she attended the All Staff In-Service Training titled, Safety and Security Reminder. The IPRN read the section of the lesson plan titled Back Dining Room Doors which stated, Housekeeping (Janitorial Staff) will lock the back dining room doors each night at 9:30 PM. The IPRN stated she believed the back dining room doors were locked each night because that was the information provided during the in-service. The IPRN stated staff could develop a false sense of security and may not closely monitor residents who wander towards the doors which could lead to another elopement. The IPRN stated it was a concern if the doors were unlocked because the elevator led to the basement. The IPRN stated residents should not have access to the elevator because the basement was, not safe for residents. The IPRN stated the basement alarm was not a working solution. The undated lesson plan titled The Elopement Prevention In- Service which was conducted on 7/7/26 and 7/8/26 was reviewed with the IPRN. Under section: Residents at higher risk, .Residents who may be at an increased risk include those with.History of wandering or previous elopement attempts, exit seeking behaviors. psychiatric illness.Code [NAME]. When a resident is suspected of leaving the facility. Immediately announce Code [NAME] according to the facility policy. Notify the charge nurse. Secure all exits. Begin organized search of the facility grounds. Assign Search Areas. The Elopement Prevention In-Service sign in sheet was reviewed with the IPRN. On 7/7/26, CNA 5's name, signature, and title was documented indicating CNA 5 attended the training. The IPRN stated it was her expectation that all staff who attended the in-service understood the training content. The IPRN stated a post-test, or competency assessment was not administered following the training. The IPRN stated it was important to conduct a post-test or competency assessment after an in-service to evaluate staff knowledge and verify understanding of the material presented. Resident 1's Q 15-30-Minutes Monitoring Logs were reviewed with the IPRN. The IPRN acknowledged there was missing documentation on the monitoring logs. The IPRN stated the documentation should not have been left blank and if the monitoring logs were not documented, there was no evidence that the required checks were completed. The IPRN stated the Q 15-30 Minute Monitoring Logs were important for Resident 1's safety and for preventing elopement. The IPRN stated Resident 1 could have eloped again and staff would not have known the residents' whereabouts or when the resident was last observed. On 7/15/26 at 2:54 P.M., a joint interview and record review was conducted with the administrator (ADM). The administrator in training (AIT) was also present. The ADM stated residents were not permitted to use the elevator because it provided access to the basement which posed potential safety hazards. The ADM stated the alarm located by the basement exit door was ineffective and could not be heard on any of the nursing stations. The undated lesson plan titled The Elopement Prevention In- Service was reviewed with the ADM. The ADM stated the information in the in-service was inaccurate because the back dining room doors which accessed the elevator were not locked at night. The ADM acknowledged the in-service was unclear and stated she understood how staff may have misunderstood the expectations. The ADM stated competency checks were necessary following in-services to verify that staff understood and retained the training information. The ADM stated she was part of the IDT investigation following Resident 1's elopement on 6/30/26 however, Main 1 was not included in the investigation. The ADM stated Main 1 should have been included in the investigation. The ADM stated the IDT investigation into recent elopement incidents should have been more thorough. Resident 1's Q 15-30-Minutes Monitoring Logs were reviewed with the ADM. The ADM acknowledged the missing documentation on the monitoring logs. The ADM stated she expected staff to have completed the monitoring every 15-30 minutes and accurately documented each observation. The facility's Emergency Exit/ Alarm Checks Per Shift logs for June and July 2026 were reviewed with the ADM. The ADM acknowledged the missing documentation on the alarm logs. The ADM stated the required logs should have been completed and documented every shift because malfunctioning alarms could have placed residents at risk for elopement. 2. A review of the facility's daily census dated 7/14/26, indicated the secured unit had a total census of 80. The census further indicated Resident 2 resided in the secured unit. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of Dementia (decline in memory, thinking and reasoning skills), Psychotic Disorder (mental illnesses), anxiety disorder, and altered mental status. He was discharged to the hospital on 7/14/26 for agitation and did not return. A review of Resident 2's care plan initiated 6/27/26 indicated, .resident exhibited wandering behavior, has verbalized wanting to get out and go home. At risk for elopement due to history of wandering out of home prior to placement. A review of the facility's Report of Suspected Dependent Adult/Elder Abuse dated 7/6/26 indicated, .On 7/5/26 Resident [Resident 2] was noticed missing around 11:45 am. Code [NAME] activated. Resident found on [name of road omitted]. All appropriate parties were contacted. unknown how Resident was able to leave. investigation pending. On 7/15/26 at 9:04 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated a certified nursing assistant (CNA) reported Resident 2 could not be found on 7/5/26 at 11:40 A.M. The DSD stated she did not know how Resident 2 left the facility. The DSD stated she believed Resident 2 followed the kitchen staff when they exited the secured unit after delivering the meal cart. The DSD stated the facility had assigned hall monitors in the secured unit that monitored the hallways and both exit doors. The DSD stated the unit did not have a hall monitor assigned at the time of Resident 2's elopement. The DSD stated sometimes the hall monitors walked around the unit. The DSD stated Resident 2 should not have been able to leave the facility unsupervised. The DSD stated all staff entering and exiting the secured unit should have ensured the exit doors were shut and locked behind them. The DSD stated staff found Resident 2 walking on the street near the facility. On 7/15/26 at 9:27 A.M., an interview was conducted with CNA 1 in the secured unit hallway. CNA 1 stated the CNAs had 30-minute shifts as the hall monitor with the responsibility to monitor the two exit doors and hallways to ensure residents did not leave the secured unit. CNA 1 stated there was a hall monitor to watch the exit door going out to station 2 and there was a second hall monitor that monitors the dining room and exit door that led out to station 3. CNA 1 stated there should be eyes on the exit doors 24 hours a day for the safety of the residents. CNA 1 stated if a resident got out of the secured unit, she would follow the resident and call for help. On 7/15/26 at 11:19 A.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated hall monitors sometimes left their post to assist with resident needs. LN 1 stated the assigned hall monitors should not leave their post. On 7/15/26 at 11:22 A.M., a joint observation and interview was conducted with CNA 2 in the secured unit hallway near station 2 exit door during her hall monitor scheduled time. CNA 2 stated she would leave her post if she needed to redirect a resident. CNA 2 stated all CNAs passed meal trays during meals so there was no hall monitor coverage during that time. CNA 2 was then observed leaving her hall monitor post to get a glass of water in a utility room for a resident. The station 2 exit door was not visible from the utility room. On 7/15/26 at 11:33 A.M., an observation and interview was conducted with the dietary aide (DA) 1 and DA 2 in the secured unit after delivering a meal cart. Both DA 1 and DA 2 stated it was very important to ensure the secured unit doors were completely closed after they entered and exited the unit to ensure residents did not follow them out. On 7/15/26 at 11:35 A.M., an observation was conducted in the secured unit. The secured unit CNAs and LNs passed out meal trays to the residents' rooms or the dining room. There was no hall monitor observed near the station 2 exit door at this time. On 7/15/26 at 12:31 P.M., an interview was conducted with the DSD. The DSD stated there should always be staff assigned as a hall monitor and they should never leave their post. On 7/15/26 at 12:44 P.M., an interview was conducted with CNA 3. CNA 3 stated the residents in the secured unit did not use wander guards (electronic device that alerts staff when a resident is exiting the unit). CNA 3 stated the secured doors and hallway monitors took the place of the wander guard to ensure the residents did not leave the unit. On 7/15/26 at 12:45 P.M., an interview was conducted with LN 2 in the secured unit. LN 2 stated wander guards were not used in the secured unit, instead they used hall monitors. On 7/15/26 at 1 P.M., an interview was conducted with CNA 1 in the secured unit. CNA 1 stated there was no coverage for hallway monitors during meal times because all the CNAs were passing meal trays to the residents. A record review of the undated monitoring schedule titled [Facility name] AM MONITORING SCHEDULE WITH 9 CNA STATION 1 in the secured unit was conducted. The monitoring schedule indicated 30 minutes shift for CNAs to monitor the hallways and dining room. In addition, the schedule also indicated: .CNA WHO COMES IN AT 6:30AM TO MONITOR IN THE DINING ROOM NOC SHIFT STAFF: 7:00AM-7:30 AM (MONDAY-SUNDAY)-HALLWAY SOCIAL SERVICES: 7:30AM-8:00AM (MONDAY-FRIDAY)- HALLWAY MEDICAL RECORDS: 11:30AM-12:00PM (MONDAY-FRIDAY)-HALLWAY LN CART A: 11:30AM-12:00PM (SATURDAY-SUNDAY)-HALLWAY LN CART B: 7:30AM-8:00AM (SATURDAY-SUNDAY) -HALLWAY LN CART B: 12:00PM-12:30PM (SATURDAY-SUNDAY)-HALLWAY ACTIVITIES: 12:00PM-12:30PM (MONDAY-SUNDAY)-HALLWAYS. On 7/15/26 at 3:46 P.M., a joint interview and record review was conducted with LN 1 and LN 3 in the secured unit. Both LN 1 and LN 3 stated they were not aware of the hallway monitoring schedule to include LN coverage. On 7/15/26 at 3:52 P.M., an interview was conducted with the administrator (ADM). The ADM stated they did not have a job description for the hall monitor. On 7/15/26 at 3:59 P.M., an interview and record review was conducted with the social services director (SSD). The SSD reviewed the undated Monitoring Schedule with 9 CNA. The SSD stated she was unaware that a staff from the social services department was supposed to be assigned as the hall monitor routinely from 7:30-8:00 AM Monday through Friday. The SSD stated there should have been no gaps in the hall monitoring schedule for the secured unit. On 7/15/26 at 4:05 P.M., a joint interview and record review was conducted with medical records director (MRD) and medical record assistant (MRA). The MRD and the MRA reviewed the undated AM Monitoring Schedule with 9 CNA. The MRD stated CNAs covered the hall monitor role in the secured unit. MRD stated, We don't do that [hall monitor]. Maybe only when they ask us to do it. The MRA was in agreement with the MRD. The MRD and the MRA both stated neither one of them monitored the hall in the secured unit today between 11:30 A.M.- 12:00 P.M. as scheduled. Both the MRD and the MRA stated they never knew about the hall monitoring until today. On 7/15/26 at 4:38 P.M., a joint interview and record review was conducted with the ADM in the conference room. The administrator in training (AIT) was also present. The AM Monitoring Schedule with 9 CNA was reviewed with the ADM. The ADM stated it was very important to monitor the secured unit exit doors. The ADM stated the hall monitors were used in place of the wander guard. The ADM stated hall monitors should have been devoted to monitoring the halls and exit doors only. The ADM stated the hall monitors should not have had any other duties during their scheduled times. The ADM stated there should not have been any gaps in the hall monitoring schedule. The ADM stated, I can see the loophole [in the monitoring schedule]. The ADM further stated the facility's investigation into Resident 2's elopement should have been more thorough. A review of the facility's policy titled Wandering and Elopement revised March 2019 did not provide guidance related to supervision on the secured unit, monitoring exit alarms, securing the elevator, and Q 15-30 monitoring.

Based on interview and record review, the facility failed to develop a resident-specific care plan for one of four residents (Resident 3) when the interdisciplinary team (IDT) did not identify Resident 3's areas of incompatibility with potential roommates.As a result of this deficient practice, Resident 3 and Resident 4 (who were roommates) were verbally aggressive with each other which then led to a physical altercation. Findings:A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit and major depressive disorder.A review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include schizoaffective (mental health condition) disorder, bipolar type and anxiety disorders.A review of Resident 4's Minimum Data Set Assessment (MDS - A comprehensive assessment tool) dated 6/23/26 indicated the resident had a Brief Interview of Mental Status score of 14 (a score of 13 to 15 meant the resident was cognitively intact).A review of the facility's undated Resident Abuse Investigation report indicated on 6/23/26, .[Resident 3] was yelling.CNA responded and entered room.[Resident 4] also came in and requested [Resident 3] to be silent. [Resident 3] continued yelling. [Resident 4] came to her side of the bed and placed her hand on [Resident 3]'s arm, saying 'be quiet now'.staff members report.[Resident 4] was frustrated with [Resident 3] yelling to begin with and the situation escalated.A review of Resident 4's progress notes dated 6/17/26 indicated the resident was moved into Resident 3's room as a roommate. The progress note did not indicate if both residents had been assessed for roommate compatibility.According to the facility's undated Resident Abuse Investigation Report, Resident 4 was moved out of the room she shared with Resident 3 after the incident on 6/23/26.On 7/15/26 at 9 A.M., an interview was conducted with Resident 3. Resident 3 stated she did not remember what happened when asked about the altercation with her previous roommate (Resident 4). On 7/15/26 at 9:15 A.M., an interview was conducted with certified nursing assistant (CNA) 21. CNA 21 stated Resident 3 was picky and would want to do things on her own. CNA 21 stated Resident 3 would make noise by yanking the curtain when she did not like her roommates. CNA 21 stated this was a known behavior of Resident 3. CNA 21 stated Resident 3 would be quiet when she did not see her roommate (Resident 4). CNA 21 stated Resident 3 would tell Resident 4 to leave the room and get out when Resident 4 wanted to use the bathroom in their shared room. CNA 21 stated staff would escort Resident 4 to the bathroom because of Resident 3's behavior. CNA 21 stated Resident 3 was bedbound and never left the room. CNA 21 stated Resident 3 did not want roommates. CNA 21 stated staff would bring Resident 4 to the smoking area or to the staff area after she used the bathroom to keep Resident 4 away from Resident 3. CNA 21 stated Resident 4 would wait to go back inside their shared room when it was late and when Resident 3 was asleep to avoid an altercation. CNA 21 stated Resident 4 was loud when she talked. CNA 21 stated Resident 4 would say bad words which caused Resident 3 to become agitated.On 7/15/26 at 11:02 A.M., a telephone interview was conducted with CNA 22. CNA 22 stated she was a witness to the altercation between Resident 3 and Resident 4 on 6/23/26. CNA 22 stated Resident 3 was yelling inside the room before the altercation. CNA 22 stated Resident 4 went inside the room while Resident 3 was yelling. CNA 22 stated Resident 4 was agitated and opened her side of the curtain. CNA 22 stated Resident 4 went over to Resident 3, touched her right wrist and told Resident 3 to be quiet. CNA 22 stated Resident 4 got back to her wheelchair and left the room. On 7/15/26 at 11:25 A.M., an interview was conducted with licensed nurse (LN) 21. LN 21 stated Resident 3 yelled all the time and did not want any roommates. LN 21 stated Resident 3 always said bad words and would yank the curtain to make noise. LN 21 stated this was a known behavior for Resident 3. LN 21 stated Resident 3 was confused. LN 21 stated Resident 4 had verbal aggression. LN 21 stated Resident 4 and Resident 3 often yelled at each other. On 7/15/26 at 2:20 P.M., an interview and record review was conducted with LN 21. LN 21 stated there was no care plan regarding roommate compatibility with Resident 3. A review of Resident 3's IDT - Comprehensive Resident Support dated 6/24/26 indicated, .After discussions with both residents, it became clear that they were not suitable as roommates. The IDT did not identify what resident traits were incompatible with Resident 3.On 7/15/26 at 3:40 P.M., a concurrent interview was conducted with LN 21 and assistant director of nursing (ADON) 2. ADON 2 stated Resident 4 was not a good fit for Resident 3 as a roommate. ADON 2 stated residents who were alert and cognitively intact, had mental disorders, were ambulatory, and had aggression were not compatible as a roommate for Resident 3. ADON 2 stated the IDT meeting conducted to investigate Resident 3 and Resident 4's altercation on 6/23/26 should have identified the type of residents who were incompatible as a roommate for Resident 3. ADON 2 stated these identified incompatibility traits should have been care planned. ADON 2 stated care planning this roommate incompatibility would prevent further altercations with Resident 3. LN 21 stated she agreed with what ADON 2 had said.On 7/15/26 at 5:10 P.M., an interview was conducted with the administrator (ADM). The ADM stated a care plan should have been developed to prevent future altercations and to promote safety between Resident 3 and her roommates. The ADM stated the IDT should have identified Resident 3's compatibility and incompatibility with residents as roommates.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2016, indicated, .10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.13. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to honor the rights for one of three sampled residents (Resident 1) when the facility would not accept Resident 1 back after a visit to the Emergency Department.This failure violated Resident 1's rights per facility policy, and had the potential for Resident 1 to not receive continuity of care. Findings:According to the undated admission Record, Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, schizoaffective disorder, and anxiety disorder.A record review of the Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/5/26 indicated Resident 1 had a Brief Interview For Mental Status (BIMS) of 15, which indicated Resident 1 had intact cognition.During a record review of the document titled SBAR & Initial COC (Change of Condition) dated 5/7/26, the document indicated, [Resident 1] Self-called [Ambulance name] c/o [complaining of] bladder pain. Resident has a behavior of calling 911 and wanting to go to hospital [sic] every other day or sometime every day. On 5/05/26 resident was sent to [Acute Care Hospital] for c/o back and neck pain.At around 0830 [8:30 A.M.] AFTER RESIDENT EATING BREAKFAST [SIC] IN the dining room, resident approached LN [Licensed Nurse] that he is going to hospital today.[Resident 1] stated that I'm having bladder pain. LN [Licensed Nurse] tried to convince resident that we will call his DR [Doctor] to get orders for stat labs and UA [urianlysis] but resident strongly refused and stated, no I want to go to the hospital, and I don't trust [Facility Name].During an interview with the Director of Nursing (DON) on 5/22/26 at 9:07 A.M., the DON stated Resident 1 was a long term resident of the facility for over a year. The DON stated Resident 1 a behavior of calling 911 for non-emergent reasons. The DON further stated on 5/5/26, Resident 1 was transferred to the Emergency Department after he called 911 himself. The DON stated Resident 1 was not admitted to the hospital, and the facility refused to take him back when he was ready to return. The DON stated, We took his phone, but he ended up using a friend's phone.We wanted to teach him a lesson, that we won't take him back [to the facility]. The DON acknowledged Resident 1 had the right to return to the facility, despite any behaviors of calling 911.During a review of the facility's policy titled Resident Rights, revised February 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be treated with respect, kindness, and dignity.exercise his or her rights as a resident of the facility.be supported by the facility in exercising his or her rights.participate in decision-making regarding his or her care.

Based on the interview and record review, the facility failed to report to the Department an unusual occurrence when a resident was known to had Legionnaires' disease (LD- a serious lung infection) for one of the three sampled residents (Resident 1). This failure resulted in a delay by the Department in beginning their investigation.Findings: On [DATE] at 9:15 A.M., an unannounced visit was conducted for an abbreviated survey.On [DATE] at 9:30 A.M., an interview was conducted with the Infection Preventionist Nurse (IPN). The IPN stated that on [DATE], Resident 1 was transferred to the hospital for altered mental status and a very low oxygen saturation of 38% (normal is 95%-100%). On [DATE], Resident 1 died in the hospital. The IPN further stated they were not aware Resident 1 had Legionnaires' disease until [DATE], when the County Nurse notified them of a positive test result. The IPN acknowledged that the case was not reported to the Department, as required.On [DATE] at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the incident should have been reported to the Department to ensure compliance with facility policy and regulations.Per the undated facility's policy and procedure, titled Unusual Occurrences, The facility shall report any occurrences such as epidemic outbreaks, poisoning, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety, or health of residents, personnel or visitors, within 24 hours.

Based on observations and interviews, the facility failed to use the correct Personal Protective Equipment (PPE- specialized clothing or gear worn by healthcare workers to protect themselves and patients from infections and hazards) for one (Resident 10) of 12 sampled residents on contact/droplet precautions for Influenza (a contagious respiratory infection).This failure had the potential to spread Influenza virus to staff and residents.Findings:Record review of Resident 10's admission Record indicated Resident 10 was admitted on [DATE] for Hemiplegia (severe or complete paralysis on one side of the body).Record review of SBAR AND INITIAL COC/ALERT CHARTING for Resident 10 dated 2/26/26 at 2:37 P.M. indicated RESIDENT TESTED POSITIVE FOR INFLUENZA A (2ND TEST) DUE TO PERSISTENT COUGH AND FLULIKE SYMPTOMS.TRANSFER FROM RM [ROOM NUMBER]B TO 256A D/T MEDICALLY NECESSARY.On 3/5/26 at 9:45 A.M., an interview with the Infection Preventionist (IP) was conducted. The IP stated that the 1st case of flu (Influenza) was a change of condition on 2/18/26, and Resident 10 was sent out to the ER, and tested positive for Influenza A. The IP stated 2 days later, there was another COC (change of condition) with another resident, and a staff member tested positive for Influenza A, by 2/26/26 they had 12 cases of Influenza A. The IP stated the positive cases were in different units so they chose to isolate those residents in those rooms. Per the IP, Residents families were notified of the Influenza outbreak, and sign was posted on the front door making visitors aware. Positive residents were isolated for 5 -7 days. Mandatory masking of all staff was instituted. PPE for contact/droplet isolation rooms were as follows: surgical mask, gown, and gloves. Per the IP, the facility was down to one resident still on contact/droplet isolation for flu in room [ROOM NUMBER].On 3/5/26 at 1:05 P.M., a concurrent observation of Resident 10's room (256) and interview with CNA 4 was conducted. room [ROOM NUMBER] had signage for droplet/contact precautions with a sign next to it showing the required PPE (personal protective equipment) with a picture of a surgical mask, gown, and gloves. CNA 4 was observed in the room talking with Resident 10 with no gown or gloves, touching resident's lunch tray and interacting with Resident 10. CNA 4 was observed exiting the room without gown or gloves. CNA 4 stated that she didn't realize it was a contact/droplet precaution room. CNA 4 stated that the expectation for contact/droplet precautions was to sanitize hands, don the full PPE, mask, gown, and gloves before entering the room, and doff the PPE when leaving the room, and then perform hand hygiene again. CNA 4 stated that by not wearing required PPE, she could catch the virus and/or spread it (the virus) to residents and other staff.On 3/5/26 at 1:15 P.M., a follow-up interview with the IP was conducted. The IP stated the expectation was for staff entering a droplet/contact precautions room was to wear the required PPE as indicated by the signage in front of resident's room, which was gown, glove, and mask. The IP stated the importance of following signage was to wear the required PPE to prevent the spread of the infection to other staff and residents.On 3/5/26 at 1:25 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation is that staff need to wear the required PPE for the assigned isolation type. The DON stated the importance of wearing the required PPE was to prevent the spread of infection to other staff and residents.Review of facility policy titled Personal Protective Equipment dated October 2018 indicated Personal protective equipment is appropriate to specific task requirements is always available.3. Not all tasks involve the same risk of exposure, or same kind of protection. The type of PPE requires for task if based on a. the type of transmission-based precaution.c. the likelihood of exposure.e. the probably route of exposure.4.PPE required for transmission-based precautions is maintained outside and inside resident's room, as needed.6. Employees who fail to use personal protective equipment when indicated may be disciplined in accordance with personnel policies.

Based on interview and record review, the facility failed to ensure a resident's right to access and manage their personal funds for one of one resident (Resident 1) when money entrusted to the facility for safekeeping was reported missing. This failure resulted in Resident 1 being unable to access their own money and placed all residents at risk for financial loss due to inadequate protections. FINDINGSOn 3/4/26 8:50 A.M., a joint interview was conducted with the Administrator (ADM) and Director of Nursing (DON). The ADM stated that Resident 1 had deposited $1000 cash into the safe on 9/25/25 through the social services office. The ADM stated the money was logged in correctly. The ADM stated that when Resident 1 went to withdraw his money from the safe on 2/17/26, the money was missing and there was no documentation that a withdrawal of the money had been made. The ADM stated that social services staff were unable to account for the missing funds or provide documentation showing authorized withdrawal or release. The DON stated that the facility provided Resident 1 with a cashier's check for $1000 on 2/23/26 and the Resident was happy with the outcome. A record review of the facility's safe log documented receipt of the resident's funds on 9/25/25, however, there was no corresponding documentation of authorized access, withdrawal or release. A review of the facility's policy titled Links Healthcare Resident Trust Policy dated [DATE] indicated .to handle all resident funds received in the facility in a manner that ensures the safety and integrity of the transaction.

Based on interviews and record reviews, the facility failed to ensure adequate supervision during an outpatient appointment for one of one sample resident (Resident 1) when: 1. A Certified Nursing Assistant (CNA) 1 did not set eyes on a resident (Resident 1) while escorting the resident on 11/5/25 to her outpatient appointment. Resident 1 was under conservatorship (when a judge appoints another person to act or make decisions for the person who needs help), who was placed in a lock unit (a locked, secure area designed specifically for residents with a risk of wandering) in the skilled nursing facility (SNF). Resident 1 wandered out of the SNF and was not found for more than 24 hours. 2. When Resident 1 was located on 11/6/25 at the general acute care hospital (GACH) emergency department (ED), Resident 1 was found more than 11 miles from the facility's location, intoxicated with alcohol, reported to have taken antipsychotic and antidepressant medications and found to have pneumonia (lung infection). 3. Resident 1 was assessed as having a high risk for wandering and Licensed Nurses (LNs) did not develop a care plan (detailed plan with information about a resident's treatment, goal, and interventions) for her wandering. As a result, the lack of a resident centered care plan with specific interventions had Resident 1 successfully eloped (when resident departs unsupervised and undetected) and unsafely wandered out of the SNF on 11/5/25. Resident 1 was not found as of onsite visit on 11/6/25. The facility did not specifically know Resident 1's whereabouts during the onsite visit. In addition, when Resident 1 was located, she was found to be intoxicated with alcohol. Cross Reference: F 655Findings: On 11/5/25, the Department received a facility reported incident related to quality of care and resident safety. On 11/6/25, an unannounced onsite to the facility was conducted. On 11/6/25, a review of Resident 1's clinical record was conducted.Resident 1 was readmitted to the facility on [DATE], with diagnoses which included convulsions (uncontrollable muscle contraction), bipolar disorder (periods of extremely up, elated, irritable, or energized behavior [known as manic episodes] and very down, sad, indifferent, or hopeless periods [known as depressive episodes]), psychosis (a condition in which one is unable to distinguish between what is and is not real), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), among other diagnoses per the facility's admission Record. A review of Resident 1's GACH 1 record was conducted. GACH 1 record prior to SNF admission, indicated Resident 1 had psychiatric evaluation and was admitted to GACH 1 on 9/10/25 due to extreme agitation and unable to keep shelter endangering others. A review of Resident 1's History and Physical (H&P), dated 9/23/25, was conducted. The H&P indicated Resident 1 was admitted to the SNF for psychiatric care, and monitoring, did not have the capacity to make her own decisions and was under conservatorship. The H&P also indicated Resident 1 had a history of increased agitation and worsening auditory hallucinations (hearing voices that was not there) which included voices to harm herself. A review of Resident 1's wandering/elopement risk assessment dated [DATE] was conducted. The form wandering/ elopement risk assessment indicated Resident 1 had a history of wandering and was at high risk for wandering. A review of Resident 1's care plan was conducted. There was no care plan developed for Resident 1's high risk of wandering. A review of Resident 1's SNF's interdisciplinary team (IDT, group of healthcare professionals and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) was conducted. The IDT notes dated 11/6/25 indicated the timeline as follows:- On 11/5/25 at 11:30 A.M., Resident 1 and her CNA escort (CNA 1) were picked up by an ambulance.- On 11/5/25 at 11:32 A.M., CNA 1 and Resident 1 checked in at the outpatient clinic and sat down in the waiting area. CNA 1 briefly fell asleep while waiting, and woke up with the resident still beside him.- On 11/5/25 at 12:05 P.M., CNA 1 went to the bathroom. When CNA 1 returned from the bathroom, he noted that Resident 1 was not in sight, however, CNA 1 assumed Resident 1 was called in to her appointment. - About 10 -15 minutes later, CNA 1 heard clinic staff calling for Resident 1's name and this time CNA 1 realized Resident 1 left the clinic unnoticed. CNA 1 started to search around the building and notified the facility immediately.- On 11/5/25 at around 1:05 P.M., LN 1 received a call from CNA 1 stating Resident 1 left the clinic while CNA 1 was in the bathroom. CNA 1 searched around the area but did not find Resident 1.The IDT notes indicated Resident 1 was not found as of their IDT meeting on 11/6/25. When Resident 1 was located at the GACH on 11/6/25, Resident 1 was found more than 11 miles from the facility's location. The GACH record indicated Resident 1 was intoxicated with alcohol. A review of the GACH 2 record for Resident 1 was conducted on 11/13/25. Resident 1's GACH 2 ED physician notes on 11/6/25 at 11:51 A.M. indicated Resident 1 was brought in by ambulance to the ED reportedly coming from the streets and consumed 375 milliliter (ml) vodka in the morning with home medication olanzapine (Antipsychotic medication) and fluoxetine (Antidepressant medication). The ED notes from GACH 2 indicated Resident 1 had altered mental status, was Hard to wake up and reported eloped from the [name of the SNF]. The ED notes indicated two kinds of antibiotics (anti-infection medication) were prescribed for Resident 1 for left lower lobe pneumonia. The ED notes indicated Resident 1 was coded as homeless upon GACH admission and the disposition was to discharge the resident, and the resident declined discharge to shelters and destination details. Last documentation at GACH 2 ED was on 11/6/25 at 5:20 P.M. indicating Resident 1 was with GACH ED security prior to departure at the ED to the waiting room. A review of Resident 1's GACH 3 record was conducted. Resident 1's GACH 3 records indicated Resident 1 was at the GACH 3 ED on 11/6/25 at 7:33 P.M., and presented at the ED with alcohol intoxication, potentially eloped from GACH 2 ED and was missing from her SNF. Resident 1's physician's assessment at the ED indicated Resident 1 was lethargic (having difficulty concentrating and doing simple tasks) but arousable and had slurred speech. Per the ED physician's notes, This patient presents with a high risk highly complex clinical presentation involving agitation and altered mental status .considered multiple differential processes as noted above which may result in increased morbidity (having a disease or a symptom of disease), and/or mortality (the state of being mortal [destined to die]) for this patient during this visit. This presenting acute illness poses a threat to life and/or functionality which may significantly impact the patient's morbidity during this visit.discussed the evaluation, diagnostic findings, and return precautions with the patient and SNF staff, emphasizing the need for close monitoring for recurrent altered mental status, new neurologic symptoms, or behavioral changes. On 11/6/25 at 2:12 P.M., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 was alert, oriented and was ambulatory. CNA 2 stated Resident 1 was in a lock unit and would stroll in the patio when the patio was opened for smoking. CNA 2 stated for residents in the lock unit, the residents were closely monitored. CNA 2 stated the process was when a resident had an outpatient appointment, a staff member was assigned to escort the resident. CNA 2 stated, on 11/5/25, Resident 1 had an outpatient appointment, left at around 11:30 A.M. and was escorted by CNA 1. CNA 2 stated on 11/5/25 at around 1 P.M., CNA 1 called CNA 2 over the phone stating he lost Resident 1 while they were at Resident 1's outpatient appointment. On 11/6/25 at 2:47 P.M., an interview with CNA 3 was conducted. CNA 3 stated Resident 1 would walk around but could be redirected. CNA 3 stated the facility did not anticipate Resident 1 would elope because there was no indication that she would leave. CNA 3 further stated CNA 1 had been escorting residents out prior to the incident. CNA 3 stated, If we escort, that is our responsibility, we should not let our eyes away because we don't know what is in their minds. It is for their safety; it is our responsibility to make sure they are safe. CNA 1 was no longer employed at the facility and was not available for interview. On 11/6/25 at 3:03 P.M., a joint review of Resident 1's wandering assessment, and care plan and an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated she was familiar with Resident 1 and had worked with the resident since her admission to SNF. LN 1 stated Resident 1 was alert and oriented with forgetfulness. LN 1 stated Resident 1's wandering assessment was coded as high but there was no care plan related to Resident 1's high risk of wandering. LN 1 stated she received a call on 11/5/25 at 1 P.M. from CNA 1 and was informed Resident 1 eloped while at Resident 1's outpatient appointment. On 11/6/25 at 3:43 P.M., a joint record review of Resident 1's clinical record and an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was never to leave the residents unattended and if they needed to use the bathroom, the staff was to notify someone else for the resident's safety. The DON stated, That is the purpose of having an escort. The DON further stated the LNs were to develop a care plan to meet the expectation and to evaluate the intervention provided to the residents for their care and needs for resident's safety. On 11/17/25 at 5:22 P.M., an observation and an interview with Resident 1 was conducted in her room. Resident 1 was sitting up in bed, ready to eat her dinner. Resident 1 stated it was okay to talk to her. Resident 1 stated she remembered what happened on 11/5/25. Resident 1 stated she and CNA 1 were picked up for her outpatient appointment, checked in at the clinic and waited at the waiting area. Resident 1 stated, He (CNA 1) fell asleep and so I left. Resident 1 stated she got on the bus and went downtown, got her money and went shopping across the street in the downtown area. Resident 1 stated she took her home (antipsychotic and antidepressant) medications, took the trolley and the bus and went to the beach. At the beach, Resident 1 stated she had a couple of alcohol drinks, also bought a bottle of vodka and drank the vodka. Resident 1 stated, I enjoyed that. Resident 1 stated she felt like having shortness of breath and had some coughing and she walked from the ocean to GACH 2. Resident 1 stated she walked at the beach and ended up in GACH 2. At GACH 2, Resident 1 stated, she was told to leave, and a security guard took her to the trolley station. At the trolley station, Resident 1 stated, I feel effy because I did not have proper sleep and so she asked two strangers to call 911 for her to take her to the emergency room. Resident 1 stated she ended up in GACH 3 and from there she was transferred back to the facility. Resident 1 stated, I guess they called here so here I am. A review of the facility's policy titled, Wandering and Elopements, revised March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy titled, Care Plans, Baseline, revised March 2022, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care.

Based on interviews and record reviews, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) for one of one sample resident related to a resident's (Resident 1) high risk of wandering/ elopement (when a resident leaves the facility without staff knowledge or supervision). As a result, the lack of a resident centered care plan with interventions had Resident 1 successfully eloped and unsafely wandered out of the facility on 11/5/25. Cross Reference: F 689Findings: On 11/5/25, the Department received a facility reported incident related to quality of care and resident safety. On 11/6/25, an unannounced onsite to the facility was conducted. On 11/6/25, a review of Resident 1's clinical record was conducted. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included convulsions (uncontrollable muscle contraction), bipolar disorder (periods of extremely up, elated, irritable, or energized behavior [known as manic episodes] and very down, sad, indifferent, or hopeless periods [known as depressive episodes]), psychosis (a condition in which one is unable to distinguish between what is and is not real), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), per the facility's admission Record. Resident 1's History and Physical (H&P), dated 9/23/25, indicated Resident 1 was admitted to the facility for psychiatric care, and monitoring, did not have the capacity to make her own decisions and was under conservatorship (when a judge appoints another person to act or make decisions for the person who needs help). The H&P also indicated Resident 1 had a history of increased agitation and worsening auditory hallucinations which included voices to harm herself. Resident 1's wandering/elopement risk assessment dated [DATE] indicated Resident 1 had a history of wandering and was at high risk for wandering. Resident 1's care plan was reviewed. There was no care plan developed for Resident 1's high risk of wandering. On 11/6/25 at 2:12 P.M., an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA 2 stated Resident 1 was alert, oriented and was ambulatory. CNA 2 stated Resident 1 was in a lock unit and would stroll in the patio when the patio was opened for smoking. CNA 2 stated for residents in the lock unit, the residents were closely monitored. CNA 2 stated the process was when a resident had an outpatient appointment, a staff member was assigned to escort the resident. CNA 2 stated, on 11/5/25, Resident 1 had an outpatient appointment, left at around 11:30 A.M. and was escorted by CNA 1. CNA 2 stated on 11/5/25 at around 1 P.M., CNA 1 called CNA 2 over the phone stating he lost Resident 1 while they were at Resident 1's outpatient appointment. On 11/6/25 at 2:47 P.M., an interview with CNA 3 was conducted. CNA 3 stated Resident 1 would walk around but could be redirected. CNA 3 stated the facility did not anticipate Resident 1 would elope because there was no indication that she would leave. CNA 3 further stated CNA 1 had been escorting residents out prior to the incident. CNA 3 stated, If we escort, that is our responsibility, we should not let our eyes away because we don't know what is in their minds. It is for their safety; it is our responsibility to make sure they are safe. CNA 1 was no longer employed at the facility and was not available for interview. On 11/6/25 at 3:03 P.M., a joint review of Resident 1's wandering assessment and an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated she was familiar with Resident 1 and had worked with the resident since her admission. LN 1 stated Resident 1 was alert and oriented with forgetfulness. LN 1 stated Resident 1's wandering assessment was high but there was no care plan developed related to Resident 1's high risk of wandering. On 11/6/25 at 3:43 P.M., a joint record review of Resident 1's care plan and an interview were conducted with the Director of Nursing (DON). The DON stated the expectation was for the LNs to develop a care plan to meet the expectation and to evaluate the intervention provided to the residents for their care and needs for resident's safety. A review of the facility's policy titled, Care Plans, Baseline, revised March 2022, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care.

Based on interview and record review, the facility failed to ensure documents were entered into residents' medical records in a timely manner when coordination of care was not documented for one of three residents (Resident 1) reviewed for discharge process. These failures had the potential to result in an ineffective transition of care between facilities. Findings: 1. According to the facility's admission Record, Resident 1 was admitted on [DATE] with diagnoses which included Parkinsonism (a condition which results in slowed movements, stiffness, and tremors), and End Stage Renal Disease (a condition in which the kidneys cannot adequately filter waste from the blood) and discharged on 5/15/25. On 6/4/25 at 11:07 A.M., a concurrent interview and record review was conducted with Case Manager (CM) 1. CM 1 stated Resident 1 was discharged to an Assisted Living Facility (ALF-facility that helps residents with Activities of Daily Living such as dressing, grooming) on 5/15/25. CM 1 stated Resident 1 required transportation to dialysis, and this was relayed to the ALF. CM 1 stated she kept records of on her emails and text messages, but did not document any communication with the ALF in Resident 1's chart. CM 1 stated although she had all information of the coordination of care in her emails and text messages, it should have been charted in Resident 1's Electronic Health Record. CM 1 stated it was important to enter information in Resident 1's EHR because it indicated communication was conducted with the receiving facility. During a record review on 6/23/25 at 1:24 P.M., the Case Manager Progress Notes was created on 6/23/25 at 9:57 A.M., and signed on 6/23/25 at 1:06 P.M. During an interview with the Director of Nursing (DON) on 7/1/25 at 9:48 A.M., the DON stated, .[CM 1] is not used to the practice of documenting .moving forward she needs to document no matter what . The DON stated her expectation was for documentation to be entered into residents' medical records. The DON stated although it was a late entry, .if its not documented, its not done. During a record review on 7/1/25, the facility policy titled Transfer or Discharge Documentation revised 12/2016 indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider .

Based on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process for one of three residents (Resident 1) reviewed for discharge. As a result, Resident 1 was re-hospitalized due to ineffective discharge planning and care-giver support related to care. Findings: A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (also known as a stroke; disrupted blood flow to the brain) with left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it difficult to perform everyday activities such as eating or dressing) affecting the left side of the body. Resident 1 discharged home on 1/13/25. A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/2/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 1 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 1/30/25 at 1:05 P.M., an interview was conducted with the Social Service Director (SSD). The SSD stated that Resident 1 wanted to discharge home, and that she (the SSD) physically visited Resident 1's son in November 2024, to speak with him regarding Resident 1 ' s request to discharge home with him. The SSD stated that the son stated he was fine with Resident 1 returning home, but requested for Resident 1 to have a 24-hour caregiver since he was unable to provide the 24-hour care for his mom due to work and the level of care that she needed. The SSD stated Resident 1 did not qualify for 24-hour caregiver services, and that Resident 1 informed the SSD that Resident 1's former roommate at the facility would live with Resident 1 and be involved with Resident 1 ' s care in exchange for rent assistance at Resident 1 ' s son ' s house. On 1/30/25 at 1:18 P.M., an interview was conducted with Resident 1, in Resident 1 ' s room. Resident 1 stated the facility discharged her to her son ' s home without a care-giver present to assist her. Resident 1 stated the facility did not set me up with a care giver like they told me they would, and when I got home there was nobody to help me, and I need 24-hour care. Resident 1 stated [former roommate name] can ' t help me all on her own. She was not supposed to be my care giver. Resident 1 stated that her son was the one taking care of her but that she returned to the hospital because they (son and son ' s wife) couldn ' t take care of me properly, so I went back to the hospital the next day. On 1/30/25 at 1:43 P.M., a concurrent interview and record review was conducted with the SSD. The SSD stated that she was unable to verbally get confirmation from the son if he would be home on 1/13/25 for when Resident 1 discharged back to his home. The SSD reviewed Resident 1 ' s clinical chart and stated there was no documentation regarding her attempt to reach out to Resident 1 ' s son to confirm if he would be home during Resident 1 ' s discharge date d 1/13/25. The SSD stated Resident 1 required 24-hour care because Resident 1 was not fully independent with care needs, requiring maximal (helper does more than half the effort of lifting) to partial assistance (helper less than half the effort of lifting) with toileting due to incontinence (unable to control urine and feces), and required assistance for incontinent pad changes, transfers, bathing/showers, dressing, and set-up assistance with eating. The SSD stated Resident 1 was unable to walk and required a wheelchair. The SSD stated that prior to discharge, they did not set up any teaching or return demonstration with Resident 1 ' s son or former roommate to assure the safety of Resident 1. The SSD stated she relied on [Care Management Name] to provide the care giver assistance required for Resident 1 ' s care upon discharge. The SSD stated [Care Management Name] would not provide 24-hour care giver services for Resident 1. On 1/30/25 at 3 P.M., an interview was conducted with the Administrator (ADM). The ADM stated it was important for the SSD to ensure that a safe discharge plan was in place and documented to support Resident 1 ' s discharge plan home. On 1/30/25 at 5 P.M., a clinical chart review of Resident 1 ' s discharge care plan was conducted. The discharge care plan initiated 6/12/24, revised 6/12/24 indicated Resident has no plans for discharge. Unable to return home of record. Family unable to care for needs . On 1/31/24 10:06 A.M., a concurrent interview and record review was conducted with the Case Manager (CM) and the SSD. The CM stated that text messages were exchanged between [Care Management Name] for Resident 1 ' s discharge, but was unable to provide clinical documentation to support that Resident 1 would be receiving care giver assistance by [Care Management Name] on the 1/13/25 discharge date home. The SSD stated she was responsible for Resident 1 ' s discharge planning and stated she did not update Resident 1 ' s care plan timely. The SSD stated, it ' s important to update the care plan because it shows that the discharge planning was taking place. The SSD stated that Resident 1 ' s discharge plan did not reflect a safe discharge when [Company Management Name] was not available, because they were not providing 24 hour care-giving assistance. The SSD further stated it was important that the discharge care plan be updated and discussed with those involved with Resident 1 ' s discharge plans to ensure safety, care giver burden, and to prevent re-hospitalization s. On 1/31/25 at 12:06 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated she was unable to find documentation that supported Resident 1 ' s discharge plan of care was updated and planned accordingly by the SSD. The DON stated her expectations for the interdisciplinary team (IDT) discharge process included meeting with Resident 1 and family members involved with Resident 1 ' s discharge care to be thorough and followed up within 24-72 hours. The DON further stated it was important to include care-giver training for Resident 1 as part of the discharge process to make sure Resident 1 ' s care givers can safely provide the necessary care needed for Resident 1 to prevent injuries, re-hospitalization s and care giver burden. A review of the facility's policy and procedure titled DISCHARGING the RESIDENT revised December 2016, indicated .5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions . Based on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process for one of three residents (Resident 1) reviewed for discharge. As a result, Resident 1 was re-hospitalized due to ineffective discharge planning and care-giver support related to care. Findings: A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (also known as a stroke; disrupted blood flow to the brain) with left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it difficult to perform everyday activities such as eating or dressing) affecting the left side of the body. Resident 1 discharged home on 1/13/25. A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/2/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 1 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 1/30/25 at 1:05 P.M., an interview was conducted with the Social Service Director (SSD). The SSD stated that Resident 1 wanted to discharge home, and that she (the SSD) physically visited Resident 1's son in November 2024, to speak with him regarding Resident 1's request to discharge home with him. The SSD stated that the son stated he was fine with Resident 1 returning home, but requested for Resident 1 to have a 24-hour caregiver since he was unable to provide the 24-hour care for his mom due to work and the level of care that she needed. The SSD stated Resident 1 did not qualify for 24-hour caregiver services, and that Resident 1 informed the SSD that Resident 1's former roommate at the facility would live with Resident 1 and be involved with Resident 1's care in exchange for rent assistance at Resident 1's son's house. On 1/30/25 at 1:18 P.M., an interview was conducted with Resident 1, in Resident 1's room. Resident 1 stated the facility discharged her to her son's home without a care-giver present to assist her. Resident 1 stated the facility did not set me up with a care giver like they told me they would, and when I got home there was nobody to help me, and I need 24-hour care. Resident 1 stated [former roommate name] can't help me all on her own. She was not supposed to be my care giver. Resident 1 stated that her son was the one taking care of her but that she returned to the hospital because they (son and son's wife) couldn't take care of me properly, so I went back to the hospital the next day. On 1/30/25 at 1:43 P.M., a concurrent interview and record review was conducted with the SSD. The SSD stated that she was unable to verbally get confirmation from the son if he would be home on 1/13/25 for when Resident 1 discharged back to his home. The SSD reviewed Resident 1's clinical chart and stated there was no documentation regarding her attempt to reach out to Resident 1's son to confirm if he would be home during Resident 1's discharge date d 1/13/25. The SSD stated Resident 1 required 24-hour care because Resident 1 was not fully independent with care needs, requiring maximal (helper does more than half the effort of lifting) to partial assistance (helper less than half the effort of lifting) with toileting due to incontinence (unable to control urine and feces), and required assistance for incontinent pad changes, transfers, bathing/showers, dressing, and set-up assistance with eating. The SSD stated Resident 1 was unable to walk and required a wheelchair. The SSD stated that prior to discharge, they did not set up any teaching or return demonstration with Resident 1's son or former roommate to assure the safety of Resident 1. The SSD stated she relied on [Care Management Name] to provide the care giver assistance required for Resident 1's care upon discharge. The SSD stated [Care Management Name] would not provide 24-hour care giver services for Resident 1. On 1/30/25 at 3 P.M., an interview was conducted with the Administrator (ADM). The ADM stated it was important for the SSD to ensure that a safe discharge plan was in place and documented to support Resident 1's discharge plan home. On 1/30/25 at 5 P.M., a clinical chart review of Resident 1's discharge care plan was conducted. The discharge care plan initiated 6/12/24, revised 6/12/24 indicated Resident has no plans for discharge. Unable to return home of record. Family unable to care for needs . On 1/31/24 10:06 A.M., a concurrent interview and record review was conducted with the Case Manager (CM) and the SSD. The CM stated that text messages were exchanged between [Care Management Name] for Resident 1's discharge, but was unable to provide clinical documentation to support that Resident 1 would be receiving care giver assistance by [Care Management Name] on the 1/13/25 discharge date home. The SSD stated she was responsible for Resident 1's discharge planning and stated she did not update Resident 1's care plan timely. The SSD stated, it's important to update the care plan because it shows that the discharge planning was taking place. The SSD stated that Resident 1's discharge plan did not reflect a safe discharge when [Company Management Name] was not available, because they were not providing 24 hour care-giving assistance. The SSD further stated it was important that the discharge care plan be updated and discussed with those involved with Resident 1's discharge plans to ensure safety, care giver burden, and to prevent re-hospitalization s. On 1/31/25 at 12:06 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated she was unable to find documentation that supported Resident 1's discharge plan of care was updated and planned accordingly by the SSD. The DON stated her expectations for the interdisciplinary team (IDT) discharge process included meeting with Resident 1 and family members involved with Resident 1's discharge care to be thorough and followed up within 24-72 hours. The DON further stated it was important to include care-giver training for Resident 1 as part of the discharge process to make sure Resident 1's care givers can safely provide the necessary care needed for Resident 1 to prevent injuries, re-hospitalization s and care giver burden. A review of the facility's policy and procedure titled DISCHARGING the RESIDENT revised December 2016, indicated .5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions .

Based on observation, interview, and record review, the facility failed to develop and implement care plans for four of 38 sampled residents (264, 283, 95, 145) when: 1. A care plan for potential fluid overload (when a resident has too much fluid in their system) was not developed for a resident who was on fluid restrictions; 2. A care plan for safe smoking was not developed; 3. A medication patch was not removed before applying a new patch; 4. A pressure relieving mattress was not set to the correct setting; and 5. A personalized care plan for activities was not developed. These failures had a potential for inconsistent care, while approaches for interventions were not being conducted by staff. Findings: 1. Resident 264 was readmitted to the facility on [DATE], with diagnoses which include emphysema, (a chronic lung disease that damages the air sacs in your lungs, making it difficult to breathe), and arteriosclerotic heart disease (a condition of reduced blood flow and oxygen to the heart muscle), per the facility's Admission Record. Resident 264's clinical record was reviewed on 12/3/24: The Minimum Data Set (a clinical assessment tool), dated 10/28/24, listed a cognitive score of 11, indicating moderate cognitive impairment. According to the physician's order, dated 9/6/24, Fluid restriction 1500 milliliters (ml)/24 hours dietary. The Medication Administration Record (MAR) was reviewed from 11/1/24 through 12/4/24. Three of the 34 days had over the limit of 1500 ml in a 24 hour period. (11/6/24 totaled 1660 ml, 11/28/24 totaled 1600 ml, and 12/2/24 totaled 1560 ml). There was no documented evidence a care plan for fluid overload, or fluid restrictions was developed. An interview and record review was conducted with licensed nurse (LN) 33 on 12/4/24 at 9:03 A.M. regarding Resident 264's fluid restriction. LN 33 stated if a resident went over their fluid limit, the nurse should have contacted the physician and document it in the nurse's notes. LN 33 reviewed Resident 264's nurse's notes for 11/6/24, 11/28/24, and 12/2/24, and stated there were no nurse's notes indicating the physician had been notified. LN 33 stated residents on fluid restrictions were at risk for respiratory problems such as their lungs filling with excess fluid. LN 33 stated the resident could also experience heart problems, and ankle swelling from too much fluid. LN 33 stated this resident did not always comply with the fluid restrictions and there should have been a care plan for non-compliance, along with the risk of fluid overload. An interview and record review of Resident 264's care plans was conducted with LN 32 on 12/04/24 at 9:19 A.M. LN 32 stated Resident 264 was on fluid restrictions and the resident's care plans were reviewed. LN 32 stated she could not locate a care plan related to fluid overload, fluid restrictions, or for non-compliance of fluid restrictions. LN 32 stated care plans were important for goals and consistent interventions. LN 32 stated by not having a care plan, the resident was at risk for respiratory problems, heart problems, and weight gain, which could put him at risk of harm. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:04 A.M. The DON stated care plans needed to be developed and followed for consistent approaches of interventions. According to the facility's policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, .7. The comprehensive, person-centered care plan will: .g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; .k. reflect treatment goals, timetables and objectives in measurable outcomes; .m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; . 2. Resident 283 was admitted to the facility on [DATE], with diagnoses which include chronic kidney disease (when the kidneys are damaged and cannot filter blood toxins properly), per the facility's Admission Record. An observation and interview was conducted with Resident 283 in his room on 12/2/24 at 8:29 A.M. Resident 283 was standing up, dressed, and checking his watch, stating I can go and smoke at 9 A.M. Resident 283's clinical record was reviewed on 12/03/24: According to the Minimum Data Set (a clinical assessment tool) dated 7/29/24, a cognitive score of 14 was listed, indicating cognition was intact. An initial Smoking assessment dated [DATE] was reviewed. The assessment indicated the resident was identified as a smoker and required supervision. Section 9 of the smoking assessment indicated a Plan of Care was being used to assure Resident 283 was safe while smoking. There was no documented evidence a plan of care for safe smoking had been developed. An interview and record review was conducted with licensed nurse (LN) 32 on 12/4/24 at 8:05 A.M., regarding Resident 283's care plan and smoking assessment. LN 32 stated care plans for smoking were important to identify strengths and weakness, so goals and interventions could be implemented. LN 32 reviewed Resident 283's care plans and stated she could not find any documented evidence a care plan for safe smoking had been developed. An interview and record review was conducted with Minimum Data Set Nurse (MDSN) 1 on 12/4/24 at 8:57 A.M., regarding Resident 283's smoking. MDSN 1 stated all resident's that smoke, should have had a smoking care plan. MDSN 1 reviewed Resident 283's care plans and stated he could not locate a care plan related to smoking. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:04 A.M. The DON stated Resident 283 should have had a care plan for smoking, to ensure his safety needs were being met. According to the facility's policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, .7. The comprehensive, person-centered care plan will: .g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; .k. reflect treatment goals, timetables and objectives in measurable outcomes; .m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; . According to the facility's policy, titled Smoking Policy-Residents, dated August 2022, .Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues . 39448 3. Per the facility's Admission Record, Resident 95 was admitted to the facility on [DATE] with diagnoses which included dementia (a mental and physical decline). On 12/2/24 at 9:22 A.M., an observation was conducted. Resident 95 was lying in bed. Two medication patches were adhered on his left shoulder. The patches were both labeled rivastigmine (a medication to treat dementia). One patch was dated 11/30, and the other was dated 12/2. Per the facility's Order Details, there was an order for Resident 95 dated 1/8/24 for, .Rivastigmine transdermal (a medication delivered through the skin) patch 24 hour .Apply 1 patch .one time a day .and remove per schedule . On 12/2/24 at 10:08 A.M., a concurrent observation and interview was conducted with Licensed Nurse (LN) 34. LN 34 stated, he thought he removed the old rivastigmine patch when he applied the new one that morning, but he might have forgotten to remove it. LN 34 further stated, when they applied a new patch of rivastigmine, they should have removed the old one, and he should only have had one patch on at a time. On 12/5/24 at 8:53 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, when a nurse placed a new medication patch, they should have removed the old one. The DON further stated, it would not have been okay for a resident to have two medication patches on at once. Per the facility's policy, titled Administering Topical Medications, revised October 2010, .b. Remove old patch . 4. Per the facility's Admission Record, Resident 95 was admitted to the facility on [DATE] with diagnoses that included dementia (a mental and physical decline) and contracture (a shortened muscle preventing movement of the joint) of the legs. On 12/2/24 at 9:22 A.M., an observation was conducted. Resident 95 was lying on a pressure relieving mattress which was set to 170. Per the facility's Order Details, Resident 95 had an order dated 2/1/24 for, SETTINGS: 150 Apply LAL (low air-loss. Pressure relieving) mattress for wound management/preventive measures. Check placement, settings and functionality QS (every shift). On 12/4/24 at 12:28 P.M., an interview was conducted with Licensed Nurse (LN) 34. LN 34 stated, Resident 95's pressure relieving mattress should have been set to 150. On 12/5/24 at 8:51 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, pressure relieving mattresses should have been set to the manufacturers guidance, and to the resident's weight. The facility's policy, titled Support Surface Guidelines, revised September 2013 did not have directions on what settings to use for a pressure relieving mattress. 48263 5. A review of Resident 145's Admission Record indicated Resident 145 was readmitted to the facility on [DATE] with diagnoses which included a history of adult failure to thrive (a gradual decline in overall health caused by illnesses, depression, or social isolation). On 12/2/24 at 10:27 A.M., an interview was conducted with Resident 145, in Resident 145's room. Resident 145 had a lamp table on the right side of his bed that had a compact disc (CD) case and a CD player placed on top of the table. Resident 145 stated he liked to listen to music and chat on the phone with his daughters and walk around outside, but has not done any activities for a while. Resident 145 stated he was unable to enjoy his own music at times, because he would not be able to hear it due to the roommate's music or television noise. Resident 145 stated that the facility did not give him headphones or asked if he wanted to use headphones to enjoy his music and stated that was the reason why he just wanted to lay in bed most of the time. On 12/3/24 at 3:40 P.M., an interview was conducted with Resident 145, in Resident 145's room. Resident 145 was lying in bed resting and stated he did not participate in any activities for the last two days. Resident 145 stated that his roommate's television (TV) had been on most of the day and it was a bit loud but he did not notify the staff about the noise because, no one listens. On 12/3/24 at 3:54 P.M., an interview was conducted with Certified Nurse Assistant (CNA) 53. CNA 53 stated that she had been assigned to Resident 145 on more than one occasion and that Resident 145 also liked to listen to music just like his roommate. CNA 53 stated that Resident 145 did not have headphones. On 12/4/24 at 8:36 A.M., an interview was conducted with Resident 145, in Resident 145's room. Resident 145 denied doing any activities that he enjoyed and stated he had not chatted with his daughters because the facility phone was out of reach and not on top of his lamp table until that day. Resident 145 stated that he really wanted to go outside to enjoy the outdoors instead of being in his room most of the day. On 12/4/24 at 3:31 P.M., a concurrent interview and record review was conducted with the Activities Assistant (AA) and the Activities Director (AD). The AA stated Resident 145 did not participate in any group activities from November to December of this year. The AA stated Resident 145 liked listening to his music CD's but did not have headphones to enjoy them without disturbing his other roommates. The AA stated if she were in Resident 145's shoes (place/situation) and was unable to enjoy the music she wanted, this would make her feel sad. The AD stated that Resident 145's preferred activities should have been incorporated into his care plan for personalization. The AD stated that care plans were revised quarterly and should have been based on the activities that Resident 145 enjoyed. The AD stated that the care plan was last updated on 10/11/24, but was generic and did not include person-centered activities such as music, outdoor, and physical activities that Resident 145 liked to do. On 12/5/24 at 9:31 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 145's care plan should have reflected the activities that he enjoyed, such as his music, outdoors activities, telephone/visits with his daughters. The DON stated Resident 145's care plan should have been person-centered and not generic. A review of the facility's policy and procedure, titled CAREPLANS, COMPREHENSIVE PERSON-CENTERED, Revised March 2022, indicated .7. The comprehensive, person-centered care plan .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to maintain infection prevention practices for six of 38 sampled residents (218, 75, 65, 8, 147, 448) when: 1. Resident 218's urinary catheter tubing was in contact with the floor; 2. A wrist splint for Resident 75 was not maintained in a sanitary manner; 3. Oxygen tubings were undated for Residents 65 and 8; 4. Disposable gowns were not used for direct care of residents (147, 448) who were on Enhanced Barrier Precautions (EBP, infection control measures to reduce the spread of germs). These failures had the potential to spread germs to residents and staff. Findings: 1. Resident 218 was readmitted to the facility on [DATE], with diagnoses which included urinary tract infection (infection in the bladder), per the facility's Admission Record. An observation was conducted of Resident 218 in bed on 12/2/24 at 9:23 A.M. A urinary catheter bag was clipped to the left side of the bed frame and was visible upon entering the room. Approximately 12 inches of the urinary catheter tubing was in contact with the floor. A review of Resident 218's clinical record was conducted on 12/2/24. According to the physician's order, dated 11/18/24, .Catheter: Indwelling urinary (Foley) catheter . According to the care plan, dated 11/16/24, titled Indwelling Foley Catheter, listed interventions such as, .Cleanse foley catheter . An observation and interview was conducted with Certified Nursing Assistant (CNA) 31 of Resident 218 in bed on 12/2/24 at 9:25 A.M. CNA 31 observed Resident 218 and stated the catheter tubing was on the floor, which could have caused a worsening infection to the resident. An interview was conducted with Licensed Nurse (LN) 32 on 12/2/24 at 9:50 A.M. LN 32 stated the catheter tubing should have always been kept off the floor, because it exposed the resident to a higher risk of infection. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:04 A.M. The DON stated urinary catheter tubing should have never been in contact with the floor, because infections could have occurred. According to the facility's policy, titled Catheter Care, Urinary, dated September 2014, .Infection Control .b. Be sure the catheter tubing and drainage bags are kept off the floor . 2. Resident 75 was readmitted to the facility on [DATE], with diagnoses which included left wrist sprain secondary to fall, per the facility's Admission Record. An observation of Resident 75 was conducted on 12/2/24 at 9:42 A.M., in the activity room. Resident 75 was dressed, sitting in a wheelchair with a plaster-type splint over and beneath her left wrist. The splint was held in place with a [brand of gauze] dressing wrap near the left forearm. The splint had dark brown/black smudges over the top and bottom areas near the palm of her left hand and wrist. An interview was conducted with LN 32 on 12/2/24 at 9:53 A.M. LN 32 stated Resident 75 had a sprain due to osteoarthritis (a breakdown of cartilage causing degeneration of the joint). LN 32 stated the splint had been on for over a month and the physician wanted the splint to stay on. LN 32 stated she has seen the splint, and it was dirty. LN 32 stated a nurse changed the [brand of gauze] wrap last week, but the splint itself remained dirty. Resident 75's clinical record was reviewed on 12/2/24. According to the physician's order, dated 9/29/24, .Splint to left wrist for support. May remove during ADLs (activities of daily living ie [that is/for example], showers, eating, dressing) Check skin integrity for any redness .every shift for sprain. According to the Minimum Data Set (a clinical assessment tool), dated 10/25/24, the resident was dependent and required total assistance with Functional Abilities and ADLs. An observation of Resident 75 and interview with LN 33 was conducted on 12/2/24 at 11:32 A.M. in the lunch room. LN 33 stated that Resident 75's splint was filthy, but she thought someone changed the gauze last week. LN 33 stated she did not know why Resident 75 had the splint, but it should have been changed because it was dirty and could have caused cross contamination to other residents if touched. An observation of Resident 75 was conducted on 12/3/24 at 7:36 A.M. Resident 75 was sitting up in bed with no splint on, and mumbling unintelligently. A subsequent interview was conducted with LN 32 on 12/3/24 at 4:17 P.M. LN 32 stated they contacted the physician the previous day, who ordered a repeat x-ray. LN 32 stated the physician informed them they could remove the splint, after the x-ray results were reviewed. LN 32 stated the physician should have been contacted sooner, due to the dirty splint, to see if it could have been replaced with something else. LN 32 stated that since the splint was dirty, it could have caused an infection to others. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:04 A.M. The DON stated Resident 75's splint was dirty and the physician should have been contacted sooner for an alternative wrist support. The DON stated the splint could have caused cross contamination to staff, residents, and objects. The DON was unable to locate a policy related to maintaining splints and cleanliness. 49330 3. (a) Resident 65 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung failure) and chronic respiratory failure (lung failure) per the Admission Record. On 12/2/24 at 10:01 A.M., an observation was conducted in Resident 65's room. Resident 65 was wearing a nasal cannula (a tube used to deliver oxygen). The nasal cannula was connected to a portable oxygen concentrator (a device used to provide supplemental oxygen) and was undated. On 12/5/24 at 8:53 A.M., an interview was conducted with the Respiratory Therapist (RT) 42. RT 42 stated nasal cannulas were replaced every two weeks and should be dated. RT 42 stated, .the nasal cannula goes into [Resident 65's] nose and it holds moisture, especially because most are on some kind of humidifiers. It should be dated for infection control, so we know when it was replaced . An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 10:25 A.M. The DON stated it was her expectation for nasal cannulas to be labeled with the date changed. The DON stated, .It's important to have a date [on the oxygen tubing] for infection control . 50175 3. (b) Resident 8 was admitted to the facility on [DATE] with diagnoses which included pulmonary fibrosis (a lung disease that causes the lungs to become scarred and stiff over time, making it difficult to breathe) and chronic obstructive pulmonary disease, per the Admission Record. An observation and interview was conducted on 12/2/24 at 9:33 A.M., with Resident 8. Resident 8 was wearing a nasal cannula. The nasal cannula was not dated. Resident 8 stated she needed oxygen continuously. An observation was conducted on 12/3/24 at 8:59 A.M. in Resident 8's room. Resident 8 was wearing a nasal cannula. The nasal cannula was not dated. An interview was conducted with LN 34 on 12/4/24 at 3:10 P.M. LN 34 stated the nasal cannula should have been changed every two weeks. LN 34 stated staff knew when a nasal cannula needed to be changed by looking at the date on the tubing. An observation and interview was conducted with LN 12 on 12/4/24 at 3:13 P.M. LN 12 observed and stated Resident 8's nasal cannula was not dated. LN 12 stated she did not know when the nasal cannula was last changed because there was no date on the nasal cannula. LN 12 stated that bacteria would grow and cause infection if the nasal cannula was not changed when it was due to be changed. A review of Resident 8's active physician's orders was conducted on 12/4/24, which indicated to administer oxygen continuously. An interview was conducted with the Director of Staff Development (DSD) on 12/4/24 at 3:34 P.M. The DSD stated oxygen tubing needed to be dated. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 9:14 A.M. The DON stated nasal cannula was changed every 14 days if in continuous use. The DON stated nasal cannula should have been dated. The DON stated that if the nasal cannula was not dated, staff would not know when it was last changed. The DON stated there would be a potential for infection if the nasal cannula was not changed when it was due to be changed. A review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, indicated .7. Change the oxygen cannula and tubing every fourteen (14) days, or as needed . 46980 4. (a) Per the facility's Admission Record, Resident 147 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region (a skin wound at the base of the spine). Resident 147 had a tube feeding (a medical procedure that delivered nutrition, fluids and medication directly into the stomach or small intestine through a tube) and an indwelling urinary catheter (a thin, flexible tube that is inserted into the bladder to drain urine and is left in place for a period of time). On 12/2/24 at 10 A.M., an observation of Certified Nursing Assistant (CNA) 25 changing Resident 147's brief and some linens was conducted. CNA 25 was not wearing a gown during Resident 147's care. There was a sign on the wall outside of Resident 147's room indicating EBP. There was a red dot next to Resident 147's name on the wall next to the EBP sign. CNA 25 stated, I changed her brief and some linen. I should have worn a gown. I need to wear a gown to prevent infection from spreading. (b) Resident 448 was admitted on [DATE] with diagnoses that included pressure ulcer and urinary tract infection. On 12/2/24 at 8 A.M. a concurrent observation of LN 21, LN 23, and Certified Nursing Assistant (CNA) 24 and interview with LN 21 and CNA 24 were conducted at Resident 448's room. There was a sign on the wall outside of Resident 448's room that indicated, Alcohol based hand rub (a liquid gel or foam that is used to reduce the number of microorganisms on the hands), gloves, gown must be worn for dressing . transferring, changing linens (bedsheets), providing hygiene, changing briefs .A red dot was next to Resident 448's name on the wall next to the sign. A set of plastic drawers containing only two clean briefs (a disposable clothing item that catches urine and stool) was outside the door. The drawers did not have any gowns in them. LN 21, LN 23, and CNA 24 were changing Resident 448's linens while not wearing gowns. An interview was conducted with LN 21 who stated, We did not wear gowns, we are at risk to cross contaminate (the transfer of harmful microorganisms from one person, object or place to another) ourselves and other residents if we don't wear a gown during care. CNA 24 stated, I did not wear a gown and gloves during care. I could catch an infection or transfer it to another resident. On 12/3/24 at 9:50 A.M. an interview and concurrent record review were conducted with the Director of Staff Development (DSD) who stated, The IP (Infection Preventionist) and I do trainings. There was an infection control training on 1/29/24 and 6/21/24. A concurrent review of the infection control training indicated, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs, a microorganism [germs] that is resistant to one of more types of antibiotics) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition .The following direct care activities that require PPE are as follows: dressing .changing linen .incontinent care . On 12/5/24 at 1:39 P.M. an interview was conducted with the IP who stated, It's stated on the signage with close body contact you need to wear the gowns. The expectation is they need to follow the signage. The risk is spreading MDRO's to their clothing and body then transfer it to another resident or they might get the microorganism. A review of the facility policy titled Enhanced Barrier Precautions revised August 2022 indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity .

Based on observation, interview, and record review, the facility failed to ensure safe food handling practices when: 1. Fruit was not labeled and dated when prepared and placed in one of four refrigerators (reach-in refrigerator #1); 2. Food was not labeled and dated when placed in one of five resident refrigerators (Station 5); 3. A temperature log for one of five resident refrigerators (Station 3) was incomplete; and, 4. Dishwasher (DSWH) 1 and DSWH 2 did not perform hand hygiene after disposing trash. These failures had the potential to cause food-borne illness to residents. Findings: 1. An interview and observation of the kitchen's reach-in refrigerator #1 was conducted with the Registered Dietician (RD) during the initial kitchen tour on [DATE] at 7:42 A.M. On the bottom right of the refrigerator were two clean plastic containers with lids. One container contained a ,d+[DATE] cut and peeled cantaloupe. The second larger container contained two large chunks of cut and peeled watermelon. No dates were on either container, indicating when the fruit was received, cut, prepared, and placed in the refrigerator. The RD stated the fruit could have been expired and no one would have known, since it was not dated and labeled. According to the facility's policy, titled Labeling and Dating of Food, dated 2023, .All prepared foods need to be covered, labeled, and dated. Produce is to be dated with received date. Leftovers will be covered, labeled, and dated . 2. An interview and observation of Station 5's refrigerator was conducted with Certified Nursing Assistant (CNA) 32 on [DATE] at 3:12 P.M. Inside the resident refrigerator was a glass container, labeled cheese dip. The jar was ,d+[DATE] consumed and on the outside, written in black felt pen was #5XX, E. BXXX. CNA 32 stated the cheese dip jar was not labeled with the date of when it was opened and room [ROOM NUMBER]XX had a different resident in it. CNA 32 stated she did not know who E. BXXX was, and most likely that resident had been discharged . CNA 32 stated the resident food was not labeled correctly and should have been thrown away. An interview was conducted with the RD on [DATE] at 9:35 A.M. The RD stated all resident food needed to be dated and labeled with the resident's name, when placed in the resident refrigerator. The RD stated since the cheese dip jar was not dated when it was opened, no one knew how long it had been sitting in the refrigerator and it could have been unsafe to eat. According to the facility's undated policy, titled Bringing in Food for a Resident, .Food or Beverages should be labeled and monitored .Unused food will be discarded within 2 days . 3. An interview and observation of the temperature log for Station 3's resident refrigerator was conducted with licensed nurse (LN) 34 on [DATE] at 3:24 P.M. The temperature log had no entries for [DATE], PM shift (3 P.M.-11:30 P.M.) and on the A.M. shift (7 A.M.-3:30 P.M.). LN 34 stated the harm for not documenting the temperature on the temperature log was that the refrigerator temperature could have been on the wrong setting, and the food would have spoiled, possibly causing harm if ingested. An interview was conducted with the RD on [DATE] at 9:35 A.M. The RD stated the resident refrigerator temperatures should have been checked in the morning and evening by staff, and documented to ensure the food was safe for consumption. The RD stated if the temperatures were not maintained at a safe level, residents could have become sick from food-borne illness. 4. An observation of trash removal from the machine dishwasher room was conducted with the RD on [DATE] at 10:02 A.M. DSWH 1 wore disposable gloves and tied off a large black trash bag. The trash bag was lifted out of the trash can and walked outside. The trash bag was tossed into a large dumpster and DSWH 1 returned to the machine dishwashing room. DSWH 1 had on the same gloves and returned to cleaning dirty dishes, without removing the gloves and performing hand hygiene. An interview and record review was conducted with the RD on [DATE] at 10:08 A.M. The RD stated DSHW 1 knew better and should have washed his hands. The RD stated that when staff did not wash their hands after trash disposal, there was a risk of cross contamination. An observation of trash removal from the three (3) -sink dishwashing room was conducted with the RD on [DATE] at 10:10 A.M. DSWH 2 removed his gloves and tied off a large black trash bag within a trash can. The trash can was wheeled outside and the plastic bag was lifted out of the trash can and tossed into a large dumpster. DSWH 2 washed out the inside of the trash can with a spray hose. DSWH 2 wheeled the trash can back into the 3-sink dishwashing room. DSWH 2 proceeded to handle pots with his bare hands and did not perform hand hygiene before returning to the 3-sink area. An interview was conducted with the RD on [DATE] at 10:20 A.M. The RD stated by DSWH 2 not performing hand hygiene when returning to the kitchen, all residents were at risk for cross contamination. According to the facility's policy, titled Handwashing/Hand Hygiene, dated [DATE], .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognize as the best practice for preventing healthcare-associated infections .

Based on interview and record review, the facility failed to report one of one resident's (Resident 75) sampled for a Significant Change of Condition to the Centers for Medicare and Medicaid Services (CMS, a federal health care agency). This failure had the potential for CMS to not be informed of Resident 75's current health status. Findings: Resident 75 was readmitted to the facility on [DATE], with diagnoses which included sprain to left wrist secondary to fall, per the facility's Admission Record. An observation of Resident 75 was conducted on 12/2/24 at 9:42 A.M., in the activity room. Resident 75 was dressed, sitting in a wheelchair, with a plaster-type splint on top and beneath her left wrist. The splint was held in place with a [brand of gauze dressing] wrap near the left forearm. The splint had dark brown/black smudges over the top and bottom areas near the palm of her left hand and wrist. Resident 75's clinical record was reviewed on 12/2/24: According to the SBAR (Situation, Background, Assessment, Recommendation) report, dated 9/26/24, Resident 75 had an unwitnessed fall on 9/26/24 at 7:15 A.M., and complained of left wrist pain. According to the emergency room record, dated 9/26/24, the x-ray indicated soft tissue swelling with severe osteoarthrosis, (degenerative joint disease). According to the physician's order, dated 9/29/24, .Splint to left wrist for support. May remove during ADLs (activities of daily living i.e.[that is/for example], showers, eating, dressing). Check skin integrity for any redness .every shift for sprain . According to the Minimum Data Set (MDS; a clinical assessment tool), dated 10/25/24, titled Significant Change of Condition, the resident was not identified as having any falls. An interview and record review was conducted with the Minimum Data Set Nurse 1 (MDSN 1) on 12/03/24 at 3:59 P.M. MDSN 1 stated Resident 75 had a Significant Change of Condition reported to CMS on 10/25/24, for a G-Tube placement (a small tube that's surgically inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine). MDSN 1 stated Resident 75's fall should have been captured and reported during the Significant Change of Condition report, but it was missed. The MDSN 1 stated since the fall was missed and not reported, CMS did not have an accurate picture of what was currently going on with the resident. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:04 A.M. The DON stated she expected all MDS data to be accurate, so CMS could be informed of the resident's current status. According to the Resident Assessment Instrument, dated October 2019, Section J1800: any fall since admission with a six month look back period, are required to be reported to CMS. Falls with injury (except major) includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprain, any fall-related injury that causes the resident to complain of pain. According to the facility's policy, titled Falls and Fall Risk, Managing, dated March 2018, .definition: According to MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or lower level .A fall without an injury is still a fall .

Based on observation, interview and record review, the facility failed to provide a low air loss (LAL) mattress (a specialized mattress designed to prevent and treat pressure related wounds) for one of two residents (Resident 105) reviewed for pressure injuries (injury to the skin caused by pressure, usually over bony areas). As a result, there was a potential for Resident 105 to develop new wounds and/or for his pressure injuries to become worse. Findings: According to the Admission Record, Resident 105 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (weakness on one side of the body) affecting left non-dominant side, pressure ulcer of the back, left upper back, and left hip. On 12/3/24 at 9:35 A.M., Resident 105 was observed laying on his back in bed, on a regular mattress. A review of Resident 105's physician's orders dated 10/22/24 indicated, Apply LAL mattress for wound management/preventive measures. Check placement, settings and functionality QS (every shift). On 12/3/24 at 3:13 P.M., an interview was conducted with the Treatment Nurse (TN). The TN stated Resident 105 needed a low air loss mattress due to multiple pressure injuries. The TN acknowledged Resident 105 did not have a low air loss mattress, but should have had one when he was admitted because it was a physician's order. The TN stated, .It looks like he was overlooked . On 12/4/24 at 11:32 A.M., an interview was conducted with the Wound Nurse Practitioner (WNP). The WNP stated a low air loss mattress was important for Resident 105, .to help distribute the weight and pressure points (bony areas of the body prone to pressure injuries) throughout the body. It would've benefited [Resident 105] to have a low air loss mattress . On 12/5/24 at 10:25 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for the nurses to follow the physician's order for a low air loss mattress. The DON stated, [Resident 105] came in with multiple wounds .if there are wounds present, we don't want the patient to regress (worsen) . A review of Resident 105's care plan dated 10/22/24 indicated, Resident is at risk for pressure injury development and skin breakdown r/t (related to) bony prominences (pressure points) .hx (history) of pressure injury, immobility (difficulty moving) .Apply Low Air Loss Mattress as ordered to relieve pressure points & (and) check placement QS . A review of the facility's policy titled Support Surface Guidelines, revised 9/2013 indicated, .Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as .air-loss .when lying in bed .

Based on observation, interview, and record review, the facility failed to ensure dignity related to the use of a urinary catheter bag (a flexible, plastic tube inserted into the body, in order to drain urine to an external collection bag) was maintained for one of three residents' (Resident 218) reviewed for dignity and resident rights. This failure had the potential for Resident 218, to feel embarrassed or humiliated when the draining urine was visible to others. Findings: Resident 218 was readmitted to the facility on [DATE], with diagnoses which included urinary tract infection (infection in the urine), per the facility's Admission Record. An observation was conducted on 12/2/24 at 9:23 A.M. Resident 218 was in bed. A urinary catheter bag was clipped to the left side of the bed frame and was visible upon entering the room. The urinary catheter bag was 1/4 full of cloudy, pale colored urine. A dignity bag (a dark colored bag which covers the urine collection bag to protect a resident's dignity) was not present. A review of Resident 218's clinical record was conducted on 12/2/24. According to the physician's order, dated 11/18/24, .Catheter: Indwelling urinary (Foley) catheter is in a privacy bag . According to the care plan, dated 11/16/24, titled Indwelling Foley Catheter, listed interventions such as, .cover with dignity bag . An observation and interview was conducted with certified nursing assistant (CNA) 31 on 12/2/24 at 9:25 A.M. CNA 31 observed Resident 218 and stated there was no dignity bag covering the urinary drainage bag, and there should be one. CNA 31 stated Resident 218 returned from the hospital the night before, and someone should have placed a dignity bag when she returned. An interview was conducted with licensed nurse (LN) 32 on 12/2/24 at 9:50 A.M. LN 32 stated that all residents with urinary drainage bags should have the bag covered with a dignity bag to protect the resident's privacy. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:04 A.M. The DON stated that all residents with a urinary catheter should have their bag contained within a dignity bag for the resident's dignity. The DON stated it did not matter if the resident was alert or not, that a resident's dignity should always be protected. According to the facility's policy, titled Quality of Life, dated August 2009, .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered; .

Based on interview and record review, the facility failed to provide a written notice of transfer to a resident's responsible party (RP) and the Long-Term Care Ombudsman for one of three residents (Resident 296) reviewed for closed records. This deficient practice had the potential for the Resident 296's RP to not be aware of the resident's rights pertaining to transfers. Findings: A review of Resident 296's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 296's Alert Charting dated 9/27/24, indicated the resident was found unconscious and was transferred to the hospital for evaluation. On 12/5/24 at 11:40 A.M., an interview was conducted with the director of nursing (DON). The DON stated she reviewed Resident 296's clinical record and that there was no documentation a written notice of transfer was provided to the resident's RP, nor sent to the Long-Term Care Ombudsman. The DON stated Resident 296's written notice of discharge should have been completed by nursing staff and a copy provided to the resident's RP and the Long-Term Care Ombudsman. A review of the facility's policy titled Transfer or Discharge Notice, revised March 2021, indicated, .4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge .d. An immediate transfer or discharge is required by the resident's urgent medical needs .5. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer .b. The effective date of the transfer .c. The location to which the resident is being transferred .d. An explanation of the resident's right to appeal the transfer .6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .

Based on observation, interview, and record review, the facility failed to update a care plan to include a positioning aide to prevent falls for one of 38 sampled residents (273). As a result, the positioning aide may not have been used consistently among staff caring for Resident 273. Findings: Per the facility's Admission record, Resident 273 was admitted to the facility on [DATE] with diagnoses which included dementia (a mental and physical decline), weakness, and repeated falls. On 12/3/24 at 3:50 P.M., an observation of Resident 273 was conducted. Resident 273 was lying in bed. A pillow was under the sheet at the exit of the bed. On 12/4/24 a review of Resident 273's medical record was conducted. There were no orders or care plans that included instructions to place a pillow under the sheet, or for a positioning aide to prevent the resident from falling out of the bed. On 12/4/24 at 10:01 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated, he often placed a pillow under the sheet. CNA 3 stated, if the pillow were not there, Resident 273 would have gotten out of bed and fallen to the ground. On 12/4/24 at 10:06 A.M., an interview was conducted with Licensed Nurse (LN) 4. LN 4 stated, Resident 273 was at high risk for falls, and placing a pillow under the sheet was necessary to keep him from falling out of bed. On 12/4/24 at 3:52 P.M., an interview was conducted with CNA 22. CNA 22 stated, she did not place a pillow under the sheet when she worked with Resident 273. On 12/5/24 at 1:42 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, staff were placing a pillow under Resident 273's sheet as a positioning aide to keep him from falling out of bed. The DON further stated, the care plan should have been updated to include the positioning aide. Per the facility's policy, titled Care Plans, Comprehensive Person-Centered, revised March 2022, .The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident's highest .well-being .

Based on observation, interview, and record review, the facility failed to ensure a physician's order was followed for one of four residents observed during medication administration, when Resident 58's medication was held (not administered) without an order. This failure had the potential for Resident 58's needs to go unmet. Findings: Resident 58 was admitted to the facility on [DATE] with a diagnosis including hypertensive chronic kidney disease (a cycle where kidney damage leads to high blood pressure and high blood pressure leads to kidney damage) per the Admission Record. A medication administration observation was conducted on 12/4/24 at 9:49 A.M. Licensed Nurse (LN) 13 administered medications to Resident 58. However, LN 13 did not administer prazosin (a medication used to treat high blood pressure in patients with kidney disease) to Resident 58. A review of Resident 58's active physician's orders was conducted on 12/4/24, which indicated prazosin was ordered starting on 6/27/24. There were no hold parameters ordered (a physician's order indicating when a licensed nurse would not give the medication). A review of Resident 58's medication administration record indicated the medication was scheduled to be given at 9 A.M. An interview with LN 13 was conducted on 12/4/24 at 11:42 A.M. LN 13 stated that prazosin was held even though there were no hold parameters. LN 13 stated he had not yet notified the physician that prazosin was held. An interview with the Director of Nursing (DON) was conducted on 12/5/24 at 9:20 A.M. The DON stated it was their expectation for the nurse to notify the physician right away if a medication was held and there were no hold parameters, so as not to delay the administration of the medication. A review of the facility's policy, titled Administering Medications, revised 4/2019, indicated .4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time .

Based on observation, interview, and record review, the facility failed to complete a quarterly safe Smoking Assessment, and ensure a resident's meal was set to ensure safety while eating, for two of 38 sampled resident's (283, 259). As a result, residents were placed at an increased risk of injury. Findings: 1. Resident 283 was admitted to the facility on [DATE], with diagnoses which include chronic kidney disease (when the kidneys are damaged and cannot filter blood toxins properly), per the facility's Admission Record. An observation and interview was conducted with Resident 283 in his room on 12/2/24 at 8:29 A.M. Resident 283 was standing up, dressed, and checking his watch, stating I can go and smoke at 9 A.M. Resident 283's clinical record was reviewed on 12/3/24: According to the Minimum Data Set (MDS; a clinical assessment tool) dated 7/29/24, a cognitive score of 14 was listed, indicating cognition was intact. An initial Smoking assessment dated [DATE] was reviewed. The assessment indicated the resident was identified as a smoker and required supervision. There was no documented evidence a quarterly safe Smoking Assessment (due 10/2024) had been conducted after the initial assessment (7/29/24). An interview and record review was conducted with Licensed Nurse (LN) 32, on 12/4/24 at 8:05 A.M., regarding Resident 283's smoking assessment. LN 32 stated she did not see a quarterly smoking assessment, only the initial smoking assessment was completed. LN 32 stated quarterly assessments were important to ensure the resident could smoke safely and to identify any deterioration in their function, such as holding cigarettes. LN 32 stated Minimum Data Set Nurse (MDSN) 1 was responsible for quarterly assessments. An interview and record review was conducted with MDSN 1 on 12/4/24 at 8:57 A.M., regarding smoking assessments. MDSN 1 stated the Activities Director, conducted the quarterly smoking assessments, since they were the ones who monitored the resident who smoked. MDSN 1 stated quarterly smoking assessments needed to be completed because a resident's condition could have deteriorated, which would put them at a higher risk for injury, while smoking. MDSN 1 reviewed Resident 283's assessments and stated a quarterly smoking assessment was due on 10/29/24, and he could not see that one was completed. MDSN 1 stated all residents who smoked should have had quarterly smoking assessments completed. An interview and record review was conducted with the Activities Director (AD) on 12/4/24 at 9:49 A.M. The AD stated she did (completed/conducted) all quarterly smoking assessments for residents who smoked, which was every four months. The AD stated she observed the residents during smoking sessions, noted any changes, and then she discussed the observations with LNs and the social worker. The AD reviewed Resident 283's assessments and stated Resident 283 should have had a quarterly smoking assessment completed in October 2024, and she could not see that one was completed. The AD stated, I missed it. The AD stated Resident 283's health could have declined. The AD stated by not completing the quarterly smoking assessment, Resident 283 could have been harmed. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 11:04 A.M. The DON stated by not completing a quarterly Smoking Assessment, there could have been a safety issue and potential harm occurring to Resident 283. According to the facility's policy, titled Smoking Policy-Residents, dated August 2022, .8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (Physical or cognitively) and as determined by staff . 39448 2. Per the facility's Admission Record, Resident 259 was admitted to the facility on [DATE] with diagnoses which included mild neurocognitive disorder (a decline in mental abilities), malnutrition (a lack of nutrients), and gout (a disorder of joint pain). On 12/2/24 at 8:57 A.M., an observation and interview was conducted with Resident 259. Resident 259 stated that she had problems with her balance. Resident 259 was observed to be standing in her room moving unsteadily from side to side. Certified Nursing Assistant (CNA) 25 came into Resident 259's room and placed a meal tray on the table at the foot of the bed. The table was in the low position and there was no place to sit near the table. CNA 25 left the tray on the table without adjusting the table's position, or asking Resident 259 where she wanted to eat her meal. Resident 259 walked to the table, bent down to reach her plate, and cut and ate her pancakes while standing in a hunched over position. Resident 259 stated that she wished she could sit while eating, but sometimes staff set her meal tray so that she had to stand, bend over her tray, and try to maintain her balance while eating. On 12/2/24 at 9:12 A.M., an interview was conducted with CNA 25. CNA 25 stated, Resident 259 had a problem with her foot which made it difficult for her to walk, and she primarily used a wheelchair when she needed to go somewhere further than across the room. CNA 25 further stated, she thought that Resident 259 would have told her if she wanted to sit while eating. On 12/4/24 at 4:02 P.M., an interview was conducted with CNA 2. CNA 2 stated, Resident 259 ate her meals while sitting in the wheelchair or on the bed, but never standing. CNA 2 further stated, Resident 259 wobbled while standing and had an increased risk for falls. CNA 2 stated, she did not think it was safe for Resident 259 to eat while standing and leaning over the table. On 12/5/24 at 8:48 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, a resident could eat while standing if they requested it, but otherwise the CNA should have set up Resident 259's meal so that she could safely sit while eating. The facility did not have a policy on setting up resident meal trays.

Based on observation, staff interviews, and record review, the facility failed to ensure a safe, functional, and sanitary environment for residents who receive food from the kitchen, and all staff who access the kitchen when a sewage backflow flood was observed in the kitchen. The facility prepared and served resident breakfast meals from the kitchen during the sewage flood backflow in the basement, which affected the kitchen. The facility's failure to ensure safe and sanitary conditions in the kitchen due to plumbing backflow sewage flood, had the likelihood for contaminated microorganisms (tiny bacterial organisms) to come into contact with the residents' food and could have led to widespread foodborne illnesses for 247 residents who received food prepared in the kitchen. Cross reference E0015, F812 Findings: 1. During the initial tour of the facility kitchen on 2/14/22 at approximately 9:45 A.M., there was a large three-inch deep pool of light brown, yellow colored odorous fluid with tannish colored particles which streamed out of a floor sink drain in the pots and pans dish room. The Certified Dietary Manager (CDM) stated the area was used to wash food carts. The CDM stated she noticed the yellow-colored fluid backflow from the sink drain a few days ago and notified the facility's maintenance director (MDR) over the weekend. On 2/14/22 at 3:33 P.M., an observation and concurrent interview was conducted in the pots and pans room with the CDM and MDR. A large pool of water had drained down to a smaller puddle in a continuous slow drain. The CDM stated the floor drain had a consistent backflow problem. The CDM stated the Maintenance Director (MDR) snaked (use of long, slender pipe to unclog) the drain pipe earlier that day and stated he may need to do it again for the jets to unclog and clear it. On 2/15/22 at approximately 4:30 P.M., the Monthly Review Dietary Quality and Infection Control Review Audit Inspection reports completed by the Registered Dietitian were reviewed. The reports indicated in August 2021, Maintenance report-Dishroom .5. Drain keeps clogging up, water backs up from drain when using .Emergency water does not seem complete; November 2021, Drains need cleaning in pots and pans room; December 2021, Drains need cleaning in pots and pans room; and February 2022, Drains need cleaning in pots and pans room. On 2/17/22 at 9:18 A.M., a concurrent observation and interview was conducted of the facility's kitchen which was located in the basement. After exiting the first-floor elevator door into the basement, there was presence of an inch deep of a waterlike fluid observed to have flooded the entire basement, including the kitchen. The MDR stood outside the kitchen entrance and stated a kitchen pipe back flowed (unwanted flow of water in the reverse direction) and caused the basement to flood. On 2/17/22 at 9:37 A.M., an observation of the kitchen and interview with the A.M. (morning) Cook (CK 1) was conducted. There were multiple puddles of large waterlike fluid substances throughout the kitchen with a foul odor. CK 1 stated, when he arrived at the facility kitchen early that morning, it was water everywhere and the kitchen was flooded. CK 1 stated he and the kitchen staff still prepared breakfast in the kitchen. On 2/17/22 at 10:15 A.M., an interview was conducted with the Administrator (ADM). The ADM was asked about the plan to handle the kitchen flooding issue and contacting the local county environmental health department to report the incident. The ADM stated the plumbing company said the main sewer pipe under the facility started to flood in the kitchen and traveled throughout the basement. The ADM stated the facility should have enough food to feed the residents for the day. The ADM also stated the facility was prepared to make purchases for food to feed residents the therapeutic diets. The ADM stated staff who were exposed to the sewer water on their foot, got disinfected. The ADM stated the kitchen would be closed for the sanitation company to clean and disinfect it, then reopened when the pipe issue was fixed. According to the Federal FDA Food Code 2017, section 5-202.12, A plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose bib if a hose is attached or on a hose bib if a hose is not attached and backflow prevention is required by LAW . On 2/17/22 at 12:00 P.M., a joint observation of the emergency water located in the maintenance department of the basement next to the kitchen was conducted with the MDR. There were about 400 five-gallon jugs of water inside a closet, with several directly on the ground in the sewage flood water. The jugs were very dusty and were dated BB 8/31/20 (Best By). During an interview with the MDR about the emergency water, the MDR stated the water jugs should have been stored 6 inches off the ground and the expiration dates checked. According to the January 26, 2021, Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Foodborne, Waterborne, and Environmental Diseases (DFWED) document titled Water, Sanitation, & Hygiene (WASH)- related Emergencies & Outbreaks, Creating and Storing an Emergency Water Supply indicated .How much Emergency Water to store .Replace non-store bought water every 6 months . On 2/17/22 at 3:54 P.M., an interview was conducted with the County Registered Environmental Health Specialist (REHS) regarding the kitchen plumbing backflow. The REHS stated the kitchen was self-closed by the facility and should not have served breakfast in a potentially contaminated area. would be re-inspected for re-opening after 24 hours or when the plumbing was fixed. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, section 3-305.11 Food Storage. 3-305.12 Food Storage, titled Prohibited Areas, Preventing Contamination from the Premises. Pathogens can contaminate and/or grow in food that is exposed to contamination and not properly stored. Shoes carry contamination onto the floors of food preparation and storage areas. Even trace amounts of refuse or wastes in rooms used as toilets or for dressing, storing garbage or implements, or housing machinery can become sources of food contamination. Moist conditions in storage areas promote microbial (tiny bacteria that can cause disease) growth and can be sources of microbial contamination for stored food . Review of facility policy dated 2018, titled General Appearance of Food & Nutrition Department, Floors, floor mats, and walls must be .maintained in good condition 11 .The wet floor should not be walked on until it is thoroughly dry . Review of facility policy dated 2018, titled Section 8 Sanitation, indicated .4. Employees are to alert the FNS Director immediately to any equipment needing repair .26.backflow prevention (unwanted flow of water in the reverse direction) . An Immediate Jeopardy (IJ) was called under F921 S483.90(i) Other Environmental Conditions on February 17, 2022, at 4:12 P.M. The Administrator, Registered Dietitian and the Director of Nursing were informed that the IJ was called under F921. The facility developed a plan of action (POA) in response to the Immediate Jeopardy on 2/17/22. However, the IJ was not removed until 2/19/22 at 3:35 P.M. when the POA was completed and verified. The Correction Plan included the following: 1. The facility purchased pudding, saltine crackers, margarine, vanilla wafers, donuts/danishes enough to last for the next 3 days. 2. The facility closed the kitchen and emergency food supply was used and prepared in the dining room by kitchen staff. OSHPD was notified of the kitchen pipe backflow. Sanitary practices were implemented to prepare and cook food for residents. 3. The facility would provide chicken and tuna sandwiches as alternates at dinner and the written menu would be updated on 2/18/22 to reflect snacks, diabetics, renal, vegetarians, and alternates. 4. The facility purchased water cases on 2/17/22 in the amount of 2475 gallons enough to support 550 residents, staff, and visitors for the next 3 days. 5. Operations in the kitchen were stopped as soon as the clogged drain was identified. Kitchen staff were instructed not to go into the kitchen while it was non-operational. 6. Residents on fortified diet provided additional pudding with meals to provide additional calories. The facility purchased more pudding to ensure enough on 2/17/22, for the next 3 days. 7. The facility purchased more food enough for the next 3 days. Kitchen will be closed if not operational and staff will be notified not to enter by putting signs at the doors. 8. All contaminated food will be discarded. All affected areas cleaned and disinfected with bleach solution 100 ppm chlorine. 9. Food served for dinner were from the emergency supply room which were not contaminated. 10. RD will randomly interview 5 residents from each station to ensure they are satisfied with the meal offered. 11. Emergency water will be checked monthly by the Maintenance Director to ensure it does not expire. 12. Kitchen staff will be in-serviced on reporting clogged drains immediately on 2/17/22. 13. RD and/or CDM will ensure the emergency food supply is adequate to meet the needs of the residents on fortified diets by auditing the emergency food supply monthly. The following action plan was completed on or by February 19, 2022. 1. The kitchen was closed on 2/17/22 after breakfast was served to the residents, and cleaned, disinfected, and sanitized by an outside vendor. The kitchen was partially reopened on 2/18/22 with a temporary partition wall the sectioned off the Pots and pans room for the continuation of the plumbing work in floor sink drain. 2. Invoices were provided for additional food items to support the emergency menu 3-day food plan including therapeutic diets of diabetic and renal diets, vegetarians, and alternate menus. 3. Invoices were provided for bottled water and 5-gallon water jugs to restock the emergency water supply to accommodate 550 residents, staff and visitors. 4. The county environmental health extended the temporary partial kitchen closure for 7 days of the Pots and Pans room for the plumbing work to be completed. 5. Kitchen staff were in-serviced by the Registered Dietitian on the following topics: recognizing a clogged drain and reporting to management; cleaning pots and pans through the dish machine, kitchen sanitation and cleanliness, infection control practices for dietary services, ensuring adequate food supply & rotating emergency food before expiration date, fortification of food, and checking refrigerator temperatures. 6. Wall shelves stacked with clean pots and pans outside of the kitchen were covered to protect from cross-contamination from dirty paths of travel. 7. The emergency food and water supply and emergency plan were added to the monthly Quality Assessment and Assurance (QAA) and members will review to ensure adequate monitoring is effective. During a concurrent observation and interview with the ADM on 2/18/22 at 11:40 A.M. of the partially re-opened kitchen, the ADM stated the kitchen was professionally cleaned, sanitized, and disinfected by a company. The ADM stated plumbing in the Pots and Pans room was still being fixed but the kitchen cooking and operational side was reopened. During a concurrent observation and interview with the RD on 2/18/22 at 12:04 P.M. of the lunch trayline service in the partially re-opened kitchen, the RD stated she in-serviced the staff on recognizing a clogged drain and reporting to management; cleaning pots and pans through the dish machine, kitchen sanitation and cleanliness, infection control practices for dietary services, ensuring adequate food supply & rotating emergency food before expiration date, and the fortification of food. The RD also stated she updated the emergency menu to include the alternate menu items including chicken and tuna salad sandwiches, and vegetable soup. During a concurrent observation and interview of the emergency water and food with the RD on 2/18/22 at 2:40 P.M., the RD manually counted and validated there were 500 cases of bottled water with 5.28 gallons which totaled 2640 gallons of emergency water. The expiration date was August 2023. There was a water receipt purchase date of 2/17/22 for 480 cases of bottled water. RD stated an additional food order was expected to arrive on 2/19/22 to complete the emergency food supply missing menu items. During an observation of the kitchen and lunch trayline on 2/19/22 at 11:47 A.M., the kitchen staff served a hot cooked lunch meal of Salisbury steak with mushroom gravy, mashed potatoes, seasoned peas and carrot and raisin salad. The menu alternates were provided, and accurate fortified portions were verified. The floors and dishmachine room were clean and the Pots and Pans room was still partitioned and sectioned off, inaccessible and out of service. During an observation and interview on 2/19/22 at 12:55 PM of the dishwashing in the dishmachine room, The Dishwasher (DSW) 2 correctly demonstrated the process to test the sanitizer of the dish machine using a test strip. DSW 2 also described the additional wash and sanitize process through the dish machine for the large pots and pans due to the Pots and Pans room being out of service. The IJ was lifted on February 19, 2022 at 3:35 P.M., in the presence of the facility's Administrator, Registered Dietitian, Director of Nursing, Nursing Home Administrator Consultant, and RN Consultant after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews, and document review. Review of the County Environmental Health Inspectors report dated 2/18/22, indicated a seven-day partial kitchen closure due to the continuation of the plumbing repair to fix the sink drain pipe that caused the sewage backflow in the Pots and Pans room.

Based on observation, Interview, and record review, the facility failed to provide a safe environment for residents when delayed roof repairs resulted in multiple areas of the facility leaking water in both resident care areas and staff areas. The facility also failed to ensure the safety of residents when it allowed staff to shower residents in 1 of 4 resident shower rooms, when water was leaking from the ceiling into a light fixture and then on to the wet floor of the shower room. Also, the facility failed to maintain the safe storage of medical records when water was leaking in the office where the records were stored. The result had the potential to put residents and staff at risk of electrocution, or other injuries and water damage had the potential to destroy resident medical records. Immediate Jeopardy was called on January 20, 2017 at 3:53 PM. The facility provided an acceptable plan of correction at 6:45 PM and the Immediate Jeopardy was removed at 6:52 PM. Findings: 1. On 1/20/17 at 11:19 AM, during tour of the facility with Director of Nursing (DON), the following was observed: a) In Room 350, the head wall of Bed B appeared to be damp and was spongy to the touch. Water was observed running down the wall, pooling at the wainscoting and then dripping down the remainder of the wall. A total of 11 drips were counted running down the wall. The paint on the wall behind the head board of the bed appeared to be bubbling. In addition, there was a puddle formed on the floor at the base of the dripping area measuring 3.5 inches by 2 inches. The floor at the base of the head wall was also spongy. On 1/20/17 at 11:32 AM, during an observation and interview the DON stated the 6 foot stains on the ceiling, and paint bubbling on the walls were due to previous ceiling leaks. However she could not verify the repairs were completed. On 1/20/17 at 12:36 PM, during an interview with Certified Nursing Assistant 1 (CNA 1), she stated she was usually assigned to care for residents in room 350. CNA 1 said when it rained, the room would drip water from the ceiling. She said, since November 2016 (2 months ago) every time it rained, she verbally reported the dripping ceiling to the 3 licensed nurses assigned to station 3, and to maintenance. According to CNA 1, she would be instructed by the licensed nurses to angle the bed slightly out of the drip path, and place trash bin under the drip to catch the water. The resident would not be moved to another room, and she would be instructed to do the same on the next rainy day. CNA 1 stated it is common knowledge of the ceiling dripping when it rained. On a previous interview on 1/13/17 at 4:25 PM, CNA 3 stated, he had known about the ceiling leaks for the past 2 years. It always leaks, and the same instruction to angle the bed and place a trash bin under the drip would be given. 2. On 1/20/17 at 12:22 PM, The shower room of Station 3 was observed with CNA 2. CNA 2 stated she had provided showers to resident in this shower room, and on 3 occasions had verbally informed maintenance of the condition of the room. On the far wall of the shower room there was water dripping from the ceiling. There was a hole in the drywall measuring 12 inches by .5 inches, in which the plywood behind the drywall was exposed, the wall paint was peeling, and the drywall was saturated with water. In addition, on the ceiling to the left of the hole was a large black area measuring 2 inch by 2 inch. On the far wall of the back shower stall, water was actively leaking down the wall. The tile on the wall was stained with dark and yellow matter. In the ceiling light fixture in the center of the shower room, water could be seen pooling in the light cover and then dripping out the end of the light fixture onto the shower room floor. CNA 2 stated, the licensed nurses and maintenance staff has had knowledge of the ceiling leakage. She had reported the shower room ceiling to the licensed nurses on multiple occasions, and shown the ceiling to the maintenance staff for 2 months. On 1/20/17 at 12:50 PM, during an interview Licensed Nurse 1 (LN 1), LN 1 stated he knew about the ceiling dripping when it rained. He had seen the ceiling drip on 2 separate occasions. On 1/20/17 at 1:46 PM, during an interview Housekeeper 1 (EVS 1), EVS 1 stated she had shown the shower room ceiling condition to maintenance multiple times. According to EVS 1, maintenance informed her the roof of the building was the problem, and would further tell her they fixed it. However, the shower room ceiling was not repaired. 3. On 1/20/17 at 2:30 PM, the Director of Staff Development's (DSD) office on the second floor was observed. In the far right corner of the ceiling was an open hole measuring approximately 4 ft x 5 ft. The drywall was missing and the plywood above the ceiling could been seen. The plywood was saturated with water. Insulation could also be seen. The insulation was wet with water and appeared to be covered in a dark, black substance. There were also a number of wires exposed in this area. Below the open area in the ceiling was a large plastic tarp which was angled to catch and divert water out of a window. Water was observed running down the wall under the window. The carpeting on the floor below the ceiling hole was saturated with water. On 1/20/17 at 3:19 PM during an interview, Director of Staff Development (DSD) stated she started working for the facility on January 3rd, and the ceiling in her office had collapsed before her start date (2 weeks). DSD stated the Administrator and Maintenance knew about the caved in ceiling because on her start date, they provided a temporary office in a different location. 4. On 1/20/17 at 2:43 PM, the resident dining room located on the first floor directly below the DSD's office was observed. In the middle of the back wall of the dining room was a large fireplace. Directly in front of the fireplace sat 2 large industrial sized trash receptacles. Both of these receptacle were filled with a foot of water. Directly above the trash receptacles the ceiling was actively dripping water, and the ceiling dry wall was open and bubbled. Plywood was observed in the open areas of the ceiling. In addition, in the corner of the ceiling to the right of the fireplace water could be seen dripping down the wall and the water was being collected in a small waste basket. On the floor of the dining room in front of the fireplace there were areas of standing water. 5. On 1/20/17 at 2:50 PM, in the main lobby directly adjacent to the dining room, to the left of the main staircase, was a large pool of water. On 1/20/17 at 2:55 PM during an interview, the Administrator acknowledged the pooling of water in both locations and stated the dining room pooling area was partially blocked off, however the residents were still permitted to use the other half of the dining room. 6. On 1/20/17 at 4:06 PM, the Medical Record storage room was observed with Medical Records Aide (MRA). In the Medical Record Room, the facility ' s medical records were stacked on top of filing cabinets about 20 inches high and covered with a clear plastic sheet. On the far corner to the left of the window, charts were not covered with the clear plastic sheet and water was observed dripping down off the ceiling. According to MRA, when it rained hard the ceiling began to drip water, and this had been occurring since September 2016 (4 months). On 1/20/17 at 3:53 PM, the Administrator and Director of Nurses were notified of the Immediate Jeopardy (IJ), and asked to provide an immediate plan of correction to remove the IJ. At 6:45 PM, the Administrator provided a Plan of Correction which included: a. Closure of the shower room in Station 3. Shower room to be locked and signage posted of closure. b. Closure of the Entrance Dining Room. Doors secured and signage posted of closure. c. Remedies to divert rain water in DSD office would remain in place until temporary repairs could be affected. Professional roofing and structural assessments for permanent repairs would be made on Monday 1/23/17. d. Maintenance staff will monitor and remove water in lobby area hourly. e. Any resident with active water leaks would be immediately moved to another room until repairs could be made. f. Monitoring log would be placed on door of all resident rooms, and CNAs would be responsible to monitor resident rooms hourly and record status of room regarding any water leaks. g. Nursing Supervisor to monitor twice a shift to ensure CNAs performing hourly monitoring of resident rooms. Any unusual occurrences to be reported to Administrator or DON immediately, and reported to the Department. h. No further admissions until after facility inspection performed on Monday 1/23/17. i. Maintenance Staff to monitor exterior of building for pooling of water to prevent further water from leaking under exterior doors into resident care areas. The Plan of Correction was reviewed and accepted. The Immediate Jeopardy was removed at 6:52 PM.