ARLINGTON RESIDENCE AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to treat residents with respect and dignity for one of six residents (Resident #1) reviewed for resident rights. The facility failed to ensure RN A did not stand over Resident #1 while opening his brief and looking at his genitals with the door open and no curtain used, for anyone to see from the hallway on 08/29/25. This failure could affect residents who require assistance with ADLs of not wanting to get staff assistance if it were not done in private which could cause a decrease in the resident's self-esteem and psycho-social well-being resulting in embarrassment. Findings included: Observation on 08/29/25 at 2:40 PM, the door to Resident #1's room was open revealing RN A and CNA B in Resident #1's room. RN A had on gloves and was standing over Resident #1 with the resident's brief unfastened. RN A was looking at the resident's genital area, and the resident's legs was uncovered with his bedsheets at his ankles. When RN A saw the investigator, she quickly closed the brief back and pulled his bed covers up to his chest. CNA B walked out of the room with a bag of dirty wipes and brief. RN A then completed hand hygiene and walked out of the room. Record review of Resident #1's Annual MDS assessment dated [DATE] by RN Consultant reflected the resident was a [AGE] year-old male who admitted [DATE]. He had a Staff Assessment score of 00 and severely impaired cognition. And had no upper impairment and bilateral lower extremity impairment and used a walker. He was dependent and help did all ADL assistance. He required substantial/maximal assist with transfers and turning from side to side and always incontinent of bowel and bladder. He had progressive neurological conditions with diagnosis, anemia (low iron), HTN (high blood pressure), GERD (digestive disease/stomach acid), DM (diabetes mellites), hyperlipidemia (high fat particles), thyroid disorder (hormone gland disorder), osteoporosis (bone weakness), cerebral palsy (abnormal developed brain), seizure disorder (disruption in normal brain activity), malnutrition (lack of nutrients/digestive condition). Record review of Resident #1's Care Plan printed 08/29/25 reflected: Revision date 08/06/25 has potential impairment to skin integrity related to diabetes, incontinence of bowel and bladder and limited mobility. And had a communication problem and at increased risk for shears, and impaired skin integrity 2/2 (two muscle limbs tightening) contractures and impaired ADL's. Observation on 08/29/25 at 2:45 PM revealed Resident #1 was lying flat on his back with a blanket up to his chest. The resident was not able to communicate. There were no odors noted. Interview on 08/29/25 at 2:42 PM, CNA B stated Resident #1 was covered up after the nurse checked him. She stated she was not sure why Resident #1 did not have a privacy curtain and why his room door was not closed. She stated RN A checked to see if Resident #1 needed to be changed and was waiting for ADON C to come to the room for something (after several attempts she did not say what they were waiting for). Interview on 08/29/25 at 2:46 PM, RN A stated she had asked CNA B if she had changed Resident #1, and CNA B said she had. RN A stated she then went to check for herself because Resident #1 could not speak for himself. She stated the staff needed to give the residents privacy, and the only thing she forgot to do when checking Resident #1 was close the door. She stated she normally closed the door when checking the resident's briefs, and she forgot this time. She stated she was sorry for that she knew she should have closed the door and was checking Resident #1's brief quickly. She stated CNA B forgot to close the door and was also waiting for ADON C to bring some gloves to Resident #1's room. She stated they did not have any gloves on Resident #1's side of the room and had told Maintenance to put some in Resident #1's room but he had not done so yet, so they did not have to look for them. She stated for future reference the CNA and herself needed to have everything in the room so they would not have to wait for other staff to bring them. She stated she was not sure why Resident #1 did not have a privacy curtain and said she would ensure she notified laundry to get one put up. She stated she needed to ensure she closed the door and pulled the curtains forward for the resident's privacy. Interview on 08/29/25 at 3:10 PM, ADON C stated she had just put some gloves in the Resident #1's room because RN A and CNA B said there were none on his side of the room. She stated they asked for some gloves and just put one full box of large and one full box of medium gloves in Resident #1's. Interview on 08/29/25 at 7:47 PM, the Administrator stated the privacy curtains should cover residents, even if their briefs were being checked and hoped that was being done. She stated there were no reports why Resident #1 did not have a privacy curtain. She stated she was aware of what happened earlier in Resident #1's room of RN A leaving Resident #1's door open while checking his brief. She stated it could affect the residents who got their briefs checked may not like being seen by anyone passing their rooms and some residents may care and some may not. She stated the person providing care was responsible and DON ultimately for ensuring the residents had privacy for personal care including checking the resident's briefs. She stated the nursing staff probably ran out of supplies and needed to get more and left the door open. She stated she was not aware of Resident #1's privacy curtain being missing and would have to get with the laundry department about putting another one up. She stated before touching a resident the nursing staff needed to talk to the resident to let them know what they were about to do and to provide them privacy. She stated when the nursing staff provided care to the residents they needed to look to see if they had gloves in the room before they started. She stated the CNAs, nurses and Central Supply were supposed to look to see what supplies they were out of and replenish it, to prevent having to open the door during resident care. Record review of the Facility's Resident Rights policy dated 2025 reflected: Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. The resident has the right to a dignified existence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure when discharge is anticipated, a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary.<BR/>The facility failed to complete a discharge summary for Resident #1.<BR/>This failure could place residents at risk of not having complete records after permanent discharge from the facility. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 05/29/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. <BR/>Record review of Resident #1's Discharge MDS Assessment, dated 02/11/25, reflected Resident #1 was discharged to Long-Term Care Hospital without a return anticipated. Resident #1 had diagnoses which included unspecified dementia (decline in mental ability, affecting thinking, and memory), anxiety disorder (a type of mental health condition), bipolar disorder (extreme mood swings, ranging from periods of elevated mood), schizophrenia (a chronic brain disorder that affects thinking, feeling, and behavior), and insomnia (sleep disorder), unspecified . Resident #1 cognitive skills for daily decision making was modified independence. Resident #1 required maximal/moderate assistance with toileting, showering and personal hygiene.<BR/>Record review of Resident #1's physician order, dated 02/11/25, reflected May transfer out to [Hospital]. <BR/>Record review of Resident #1's nursing progress note by LVN A, dated 02/11/25 at 14:30 [2:30 PM], reflected Res. has discharged to [Hospice Name] in [city]. Res. alert and oriented x3, able to make needs known. Res. stable, no c/o pain or discomfort. Wheeled to front door for his transportation to [city]. 127/65, 71, 18, 97.9, 96% RA. <BR/>Record review of Resident #1's Summary Episode Note, dated/timed 02/11/24 8:40 PM, reflected resident information, emergency contact, allergies, assessment, diagnosis, goals, medications names, immunizations, and problems. Summary Episode Note did not address reason for discharge, date of discharge, reconciled medications sent to new facility, personal belongings disposition or physician signature. <BR/>Record review of Resident #1's care plan, revised date 02/13/25, did not address discharge goals.<BR/>Record review of Resident #1's clinical records reflected no discharged summary. <BR/>Interview with on 05/29/25 at 2:15 PM with LVN A revealed she was notified Resident #1 was discharging from the facility and to get him ready. She stated when Resident #1 discharged , she provided a copy of the Resident #1's face sheet, medication orders and belongings. She stated she documented in the Resident #1's progress notes of where he was going. <BR/>Interview on 05/29/25 at 4:46 PM with the DON revealed Resident #1 transferred to another facility. She stated prior to the change of management, the nurse, who discharged a resident, was responsible for documenting in the progress notes when a resident transferred or discharged from the facility regarding where the resident was going. The nurse would also be responsible for obtaining a physician order, and then their electronic health records systems, PCC, would generate a summary episode note. She stated the summary episode note provided the resident information. The DON stated she considered the Summary Episode Note, physician order, and progress note the discharge summary. She stated she was not sure of another discharge summary. <BR/>Interview on 05/29/25 at 5:29 PM with the Administrator revealed she had been employed at the facility since mid-March 2025. She stated based on the new company's policy expectations the staff were expected to document any discharge planning with the family, discharge physician order, medications, belongings, and to document in the progress notes. She stated she was still not familiar with PCC clinical standpoint; however, the Social Worker would initiate the discharge summary. If the Social Worker was not in the facility, the discharge nurse would complete it. She revealed she was only familiar with the new company's policy regarding discharge summaries. She stated Resident #1 discharged prior to the change of management which occurred at the beginning of March 2025. <BR/>Record review of the facility's Transfer and Discharge (including AMA), dated 09/1/23 and revised 04/25/25, reflected the following: . A member of the interdisciplinary team will complete relevant sections of the Discharge summary. The nursing caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy and pertinent lab, radiology, and consultation results. A final summary of the resident's status. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). A post discharge plan of care that is developed with the participations of the resident and the resident representative(s) which will assist the resident to adjust to his or her new living environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, for 1 of 4 residents (Resident #9) reviewed for restraints.<BR/>The facility failed to care plan for Reisdent #9's half bedrails.<BR/>This failure could place the resident at risk of entrapment or restraint. <BR/>Findings included:<BR/>Record review of Resident #9's undated admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included muscle weakness, personal care assistance, and diabetes. <BR/>Record review of Resident #9's annual MDS reflected a BIMS score of 5 indicating she had severe cognitive impairment. Her Functional Status indicated she required assistance with all her ADLs. <BR/>Record review of Resident #9's care plan dated 12/05/25 reflected she was at risk for falls and required assitance with transfers, she was at risk for skin breakdown related to decreased mobility and she had short term memory issues. The resident was not care planned for bedrail use. <BR/>Observation and interview on 02/04/25 at 1:42 PM Resident #9 was in bed, bed was not in low position, and the bed had half bedrails in place on both sides of the bed. Resident #9 was unable to follow requests to use the bedrails to reposition herself. <BR/>Record review of Resident #9's EHR reflected she had a physician order for bedrails for mobility. Resident was not assessed for bedrail safety, and there was no consent for bedrail use signed by her Responsible Party. <BR/>Interview on 02/06/25 at 1:55 PM CNA I stated Resident #9 did not use the bedrails for mobility. Residnt #9 would grab onto the rail when she was being turned for incontient care. She stated the resident did not get out of bed on her own because she would fall. <BR/>Interview on 02/06/25 at 2:00 PM the DON stated bedrails could only be used for mobility, not for keeping the resident in bed. She stated she was unaware Resident #9's bedrails were half rails instead of mobility bars. The DON stated the resident needed a physician order for moblity bars, then needed to have consent to use them, and be assessed for safety related to the bars. <BR/>Record review of the facility's undated Proper Use of Side Rails policy reflected:<BR/>The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms.<BR/>General Guidelines<BR/>1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.)<BR/>2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents.<BR/>3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's:<BR/>a. Bed mobility;<BR/>b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet;<BR/>c. Risk of entrapment from the use of side rails; and<BR/>d. That the bed ' s dimensions are appropriate for the resident's size and weight.<BR/>4. The use of side rails as an assistive device will be addressed in the resident care plan.<BR/>5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #39) of 18 reviewed for ADLs. <BR/>The facility failed to ensure Resident #39's contractured hands were kept clean and free of odor.<BR/>This failure had the potential to affectcould place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. <BR/>Findings included:<BR/>Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA, non-Alzheimer's dementia, malnutrition, bullous pemphigoid, and muscle wasting. The MDS further reflected the resident was not able to completed a BIMS due to her cognition being severely impaired.<BR/>Review of Resident #39's care plan, revised on 11/19/23, revealed the resident had an ADL self-care performance deficit. Interventions included the resident was totally dependent on one staff for personal hygiene. <BR/>Observation on 01/08/23 at 9:33 AM revealed Resident #39 was in bed with her eyes closed and she was not easily aroused when she was spoken to. Both her hands appeared to be contracted up to her face.<BR/>Observation and interview on 01/09/23 at 1:55 PM with CNA MM revealed she slowly opened Resident #39's right hand and her fingernails were observed to be about three-quarters of an inch long, they appeared to be digging into the palm of her hand, and there was an odor noted. The skin to the resident's palm was intact and there was no skin breakdown noted. CNA MM attempted to open the resident's left hand but the resident would not allow her to. CNA MM further stated it was the aides responsibility to cut the resident's fingernails and said she had cut Resident #39's fingernails the previous week and said hers just grow really fast. <BR/>Observation and interview on 01/09/24 at 2:47 PM with the PT revealed he pulled Resident #39's covers back and he attempted to slowly open the resident's right and left hand and once opened he stated there was an odor to the palms of the resident's palms from being closed and not cleaned. The PT further stated the fingernails needed to be cut because they were digging into her palms and could cause skin breakdown and the PT also did not think Resident's fingernails could grow that much in a week. <BR/>Interview on 01/10/23 at 12:30 PM with ADON X revealed aides should be cleaning the inside of Resident #39's hands and making sure her fingernails are were trimmed. ADON X stated she did not think the resident's nails would have grown three-quarters of an inch in a week. ADON X further stated it was important to keep the resident's palms clean/dry and fingernails trimmed to keep them from causing skin issues and odors. <BR/>Review of the facility's Fingernails/Toenails, Care of policy, dated 2018, reflected the following:<BR/>Purpose<BR/>The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections <BR/>Review of the facility's Activities of Daily Living (ADL's), Supporting policy, dated 2018, reflected the following:<BR/>Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). <BR/>Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure it received registry verification for 2 (CNA D and CNA E) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide.<BR/>The facility failed to ensure CNA D and CNA E had a current nurse aide certification while employed at the facility, while actively providing care for residents.<BR/>This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. <BR/>Findings included:<BR/>Record review of CNA D's personnel file reflected a date of hire of [DATE]. The facility did not complete an EMR/NAR check upon hire or annually. <BR/>Record review of CNA E's personnel file reflected a date of hire of [DATE]. The last Employability Stats Check Search that was completed on [DATE] reflected CNA E's NAR status would expire on [DATE]. <BR/>Record review of the daily nursing staff schedule, for [DATE] reflected CNA D worked on [DATE] on shift 6:00 PM - 6:00 AM under the CNA Assignments section. <BR/>Interview on [DATE] at 12:12 PM with the HR Manager revealed that she had been the HR Manager since March of 2024. The HR Manager stated that EMR/NAR should be completed annually. The HR Manager stated that she was told by regional on [DATE] that if a staff had both a CNA and a MA, then both certifications must be updated annually. The HR Manager said that until she was told this by regional, she was unaware of the regulation. The HR Manager stated that she had spoken to CNA D last May when she reviewed her personnel file. The HR Manager said CNA D was instructed to renew her CNA certification by her. The HR Manager said she thought CNA D had renewed her license. The HR Manager said that she discovered CNA D's certification had not been renewed when she was asked by the surveyor for evidence of the renewed certification. The HR Manager revealed that she notified the aide that she was suspended immediately. The HR Manager stated that she was notified on [DATE] CNA E's certification was expired. The HR Manager said that she spoke with CNA E on [DATE]. The HR Manager stated that CNA E told her she was unaware her CNA certification had to be renewed. CNA E said she thought if her MA certification was renewed, her CNA certification was automatically renewed. The HR Manager stated she was now aware that CNA E's certification was expired and had notified CNA E that she was suspended immediately. The HR Manager revealed it was her responsibility to ensure that EMR/ENR checks were conducted annually to ensure that all staff working have updated certifications. The HR Manager stated that it was the staff's responsibility to keep their own certifications current. The HR Manager said that if staff did not keep their certifications updated, it could lead to increased falls, accidents, abuse allegations, and infection control issues. <BR/>Interview on [DATE] at 12:30 PM with the DON revealed that it was the HR Manager's responsibility to ensure that the EMR/NAR check were conducted annually for all cna's and medication aides. The DON stated that there was no one that monitored this system to ensure that all certified nurse's aides and medication aides' certifications were active. The DON said that if certified nurse's aides and medication aides' certifications were not active, it could lead to falls, fractures, incorrect transfers and other incorrect procedures. <BR/>Interview on [DATE] at 1:12 PM with the Administrator revealed that EMR/NAR is supposed to be checked by the HR Manager annually and upon hire. The administrator said that it was his responsibility to monitor the process. The Administrator also stated that there was potential for harm to a resident when no EMR/NAR checks are completed on hire or annually. <BR/>Record review of the facility's current, undated Competency of Nursing Staff reflected the following:<BR/>Policy statement <BR/>1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law .

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 washing machines (Washer A) reviewed for essential equipment. <BR/>The facility failed to maintain a laundry washing machine (Washer A) in operating condition. <BR/>This failure could place residents at risk of not having clean linen for their beds or personal clothing. <BR/>Findings included:<BR/>Observation and interview on 02/04/2025 at 11:00 AM with Resident #37 revealed Resident #37 had sheets on his bed with large brown stains on them. Resident #37 stated his sheets had been like that for about six days. Resident #37 also said he had asked two times in the past week to shower but was told by staff that there were no clean towels. <BR/>Observation on 02/04/2025 at 2:45 PM of the facility laundry area revealed the facility had one commercial washing machine and one residential washing machine. The commercial washing machine appeared broken because parts were removed from it and lying on top of it. The only washing machine running in the laundry area was the residential washing machine. <BR/>Interview on 02/06/2025 at 12:56 PM with the Laundry Aide revealed she had been the Laundry Aide about three months. The Laundry Aide stated for the past month there had only been one working residential washing machine. The Laundry Aide said that she works the first shift from 6:00 AM to 2:00 PM. The Laundry Aide revealed another Laundry Aide worked a second shift from 4:00 PM to 12:00 AM to assist with the laundry. The Laundry Aide stated sometimes the laundry was backed up because of how dirty the laundry became. The Laundry Aide revealed when the surveyors entered the facility laundry area on 02/04/2025 that the laundry was backed up due to excessive personals and blankets. The Laundry Aide did not know the facility policy regarding facility essential equipment. The Laundry Aide stated when laundry was behind, she notified the Laundry Supervisor. The Laundry Aide revealed it was important for residents to have clean linen and clothes to help prevent wounds and infections. The Laundry Aide also stated residents should feel like they were at home with clean laundry.<BR/>Interview on 02/06/2025 at 1:19 PM with the Laundry Supervisor revealed she had two shifts of full-time laundry aides. The Laundry Supervisor stated she was aware that there was only one functioning washing machine. She also said it was the Administrator's responsibility to ensure there was sufficient equipment for the facility including the washing machines. The Laundry Supervisor also revealed sometimes staff threw dirty linen in the trash because they did not think it could get cleaned.<BR/>Interview on 02/06/2025 at 2:22 PM with the Administrator revealed he was aware that the facility had one residential washing machine. The Administrator stated one residential washing machine was not sufficient to keep up with the population of the facility. The Administrator said it was his responsibility to ensure that the facility had sufficient equipment to meet the residents' needs. The Administrator stated he was unaware of the length of time that the facility had only had one washing machine. The Administrator also said that the facility had only had one washer since he started on 12/26/2024. The Administrator revealed he requested a new washing machine from corporate at a minimum of three times in the past 30 days. The Administrator stated the dryers worked properly. The Administrator also revealed he had the laundry sent out to the for cleaning once or twice since starting to work at the facility. The Administrator also said if residents did not have clean linen and clothes, it could affect their emotional well-being. The Administrator stated a new washing machine had just been delivered a few minutes prior to the interview.<BR/>Record review of the facility's current, undated Quality of Life-Homelike Environment policy reflected the following:<BR/>Policy Statement<BR/>Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .

Based on observation, interview, and record review, the facility failed to establish procedures to ensure that enough water was available in the facility in the event of a loss of normal water supply, for 1 of 1 facility.<BR/>The facility's emergency water supply consisted of 0 gallons of water on hand for a census of 68 residents.<BR/>This failure could place all residents in the facility at serious risk for complications from dehydration and sanitation.<BR/>Findings included:<BR/>Observation on 02/06/25 beginning at 12:50 PM of the facility revealed no emergency water in the facility. The kitchen was observed and the dietary manager was interviewed. No emergency was located. Two additional closets in the facility were observed and no emergency was located. <BR/>Interview on 02/06/25 at 1:10 PM with the Dietary Manager revealed that the Dietary Manager was unaware of any placement of emergency water. The Dietary Manager stated that she had never ordered emergency water for the facility and had no knowledge of emergency water stored in the facility. The Dietary Manager said that she was unaware of any policy of emergency water storage for the facility and had never been assigned the task of keeping emergency water for the facility on hand. The Dietary Manager also said that she had never been in-serviced on emergency water for the facility. <BR/>Interview on 02/06/25 at 2:22 PM with the Administrator revealed that he was unaware of any emergency water on site at the facility. The Administrator stated that he had asked the facility staff if they knew where emergency water was stored, and staff had told him they were not aware of any stored emergency water. The Administrator stated that the facility should have three days of water for each resident population of water on hand. The Administrator stated that there is a method of estimating the amount of emergency water required for a facility. But the Administrator stated he did not have the policy and would have corporate send it to him. The Administrator said that it was his responsibility to ensure that sufficient emergency water was on the premises for residents and staff. The Administrator also revealed that not having an adequate supply of water during an emergency could lead to dehydration for residents. <BR/>Interview on 02/06/25 at 2:41 PM with the Chief Nursing Officer revealed that the facility should have at least one gallon per resident for three days. The Chief Nursing Officer stated the facility should have 204 gallons of emergency water on hand at a minimum. The Chief Nursing Officer said that if residents do not get enough water, it could cause residents to need additional emergency medical interventions. The Chief Nursing Officer also stated that it was a combination of the Dietary Manager's responsibility and the Administrator's responsibility to ensure emergency water is kept at the facility. The Chief Nursing Officer placed an order for emergency water following this conversation. <BR/>Record review of the facility's current, undated Water/Dietary Considerations for Residents reflected:<BR/>:Policy Statement<BR/>This facility has planned for the dietary needs of its residents in the case of an emergency situation.<BR/> .4. A minimum of food and water to last for three days shall be maintained at the facility in a specific location. This minimal amount of food and water should be determined based on the number of residents, employees and visitors during a crisis or disaster situation.<BR/>Record review of the facillity's Emergency Preparedness; Loss of Water Supply revised October 2021, reflected: Under procedure; Preparation, 1. Each center maintains a supply of drinking water based on state-specific requirements (see OP6 1511.00, state emergency water requirements). It is recommended that, at minimum, the center have on hand two gallons of water per resident (2 gallons per resident x 68 residents = 136 gallons needed per day) and per employee (2 gallons x 105 employees = 210 gallons per day) per day for at least three days (136 gallons for residents + 210 gallons for employees = 346 gallons x 3 days = 1,038 gallons needed for residents and employees for 3 days), or more, for patients who are on medications or who are at risk for dehydration.<BR/>Record review of the facility's State emergency water requirements for Texas policy, revised June 2015, reflected: Keep at least a three-day supply of water per person; each person will need a gallon per day. (68 residents + 105 employees = 173 gallons x 3 days = 519 gallons)

Based on interview and record review, the facility failed to develop, implement, and maintain and effective training program for 8 of 11 staff (CNA A, CNA B, CNA, C, CNA D, CNA E, LVN G, LVN H,) reviewed for training.<BR/>The facility failed to ensure CNA A, CNA B, CNA, C, CNA D, CNA E, LVN G, and LVN H were provided with training on dementia and abuse, neglect and exploitation.<BR/>These failures could place residents at-risk for abuse and neglect due to lack of training.<BR/>Findings included:<BR/>1. Record review of the facility's current, undated Staff Roster reflected CNA A was hired on 06/07/23. <BR/>Record review of CNA A's training history revealed CNA A's training transcript did not indicate when last previous ANE training had been completed. <BR/>2. Record review of the facility's current, undated Staff Roster reflected CNA B was hired on 12/12/23. <BR/>Record review of CNA B's training history revealed CNA B's training transcript did not indicate when last previous ANE training had been completed. <BR/>3. Record review of the facility's current, undated Staff Roster reflected CNA C was hired on 10/17/23. <BR/>Record review of CNA C's training history revealed CNA C's training transcript did not indicate when last previous ANE training had been completed. <BR/>4. Record review of the facility's current, undated Staff Roster reflected CNA D was hired on 07/7/23. <BR/>Record review of CNA D's new hire history revealed CNA D's training transcript did not indicate when last previous Dementia and ANE trainings had been completed. <BR/>5. Record review of the facility's current, undated Staff Roster reflected CNA E was hired on 6/12/23. <BR/>Record review of CNA E's new hire history revealed CNA E's training transcript did not indicate when last previous Dementia and ANE trainings had been completed. <BR/>6. Record review of the facility's current, undated Staff Roster reflected LVN G was hired on 11/14/23. <BR/>Record review of LVN G's required annual training history revealed LVN G's training transcript did not indicate when last previous Dementia and ANE trainings had been completed. <BR/>7. Record review of the facility's current, undated Staff Roster reflected LVN H was hired on 10/10/23. <BR/>Record review of LVN H's required annual training history revealed LVN H's training transcript did not indicate when last previous Dementia training had been completed. <BR/>Interview on 02/06/25 at 12:12 PM with the HR Manager revealed the facility policy stated that all required trainings were to be completed every two years. HR Manager stated that the facility directed their staff to complete their required trainings online. The HR Manager said that she instructed staff to bring their completion certificates of each course completed to the DON. The HR Manager also revealed that it was the DON's responsibility to monitor all staff's trainings and ensure that they were completed. The HR Manager stated that trainings were imported because fall training led to decreased falls. The HR Manager said that dementia training was crucial because it can decrease abuse allegations as well as falls. <BR/>Interview on 02/06/25 at 12:30 PM with the DON revealed that annual trainings and on hire trainings were her responsibility. The DON said that she conducted some in-service trainings in person with staff like abuse and hand washing using quizzes to ensure staff understanding of the topic. The DON also stated that some trainings were on-line. The DON revealed that some in-services were completed for staff, but she could not locate them during the survey. The DON stated that there was no monitoring system in place to ensure that required trainings were completed and documented in the staff's employee file. The DON said that lack of education can lead to falls, fractures, and other dangerous situations for residents. <BR/>Interview on 02/06/25 at 1:12 PM with the Administrator revealed that he would have to review the facility policy to determine what the required trainings were for appropriate facility staff. The Administrator stated that it was the DON's responsibility to ensure annual and on hire trainings are completed for facility staff. The Administrator said that there was no monitoring system in place to ensure trainings were completed. The Administrator stated that there is potential for harm when staff are not properly trained. <BR/>Record review of facility undated policy titled Competency of Nursing Staff, revealed, <BR/> .Policy Interpretation and Implementation<BR/> 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements <BR/> defined by State law.<BR/> 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will:<BR/> a. participate in a facility-specific, competency-based staff development and training program; and <BR/> b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified <BR/> through resident assessments and described in the plans of care. <BR/> .4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to <BR/> competencies in areas such as: <BR/> a. <BR/>Preventing abuse, neglect and exploitation of resident property;<BR/> b. <BR/>Dementia manager;<BR/> c. <BR/>Resident rights;<BR/> d. <BR/>Percent centered care;<BR/> e. <BR/>Communication;<BR/> f. Basic nursing skills;<BR/> g. <BR/>Basic restorative skills;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #323's admission MDS dated [DATE] reflected the resident was an [AGE] year-old resident admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure). Resident #323 had a BIMS of 1 indicating his cognition was severely impaired. The MDS further reflected the resident did not have impairment to his upper and lower extremities and ambulated with no assistance. <BR/>Review of Resident #323's care plan initiated on 12/24/24 reflected the resident was at risk for elopement/wandering related to dementia and required placement on the secure unit to provide a secure environment due to risk of elopement. Interventions included to frequent monitor and identified a pattern of wandering and assess reason for wandering and provide redirection as needed . <BR/>Review of Resident #323's hospital records dated 12/01/24 reflected the following:<BR/> Patient is a [AGE] year-old male who presents to [Emergency Room] primarily for pneumonia and neurology was consulted for patient's recent history of elopement and getting lost concerning for newly diagnosed dementia. On chart review is noted that patient had eloped and gotten lost 5 times and family found him after he had fled <BR/>Observation on 02/04/25 at 11:19 PM, revealed there was wooden privacy fence around the outside of the building of the secure unit with three rails inside of the fence, one at the bottom, one in the middle and one towards the top of the fence. <BR/>Review of the facility's PIR dated 01/02/25 reflected that on 12/24/24 Resident #323 had left the facility without signing out and was found by the police department and was returned to his family. The resident was on enhanced supervision until the window of his room was repaired and installation of a fence on the side of the building with potential exiting windows was completed. <BR/>Review of Resident #323 progress notes dated 12/24/24 documented by LVN J reflected the following:<BR/>Resident was up from breakfast in the dining area. Resident ate 100% of meal. Resident showed no signs of pain or discomfort. At 1145, the patient was last observed entering his room. During routine rounds at approximately 12:45 PM, the patient was found to be absent from their room. A code white was initiated promptly, and the search for the patient is currently ongoing [Police] notified the facility that resident had be [sic] found by [Police] 2 hours ago and told resident to [family].<BR/>Interview on 02/05/25 at 10:45 AM, with CNA N revealed she was working the morning of 12/24/24 and sometime after breakfast they staff noticed Resident #323 was not in the secure unit. The CNA N said after breakfast the resident would normally go back to his room and only come out for meals. When they staff realized the resident could not be located, they all began to search the rooms and the bathrooms. After a while, they discovered the window to Resident #323's room was broken and that is how the resident had gotten out. CNA N described Resident #323 as being independent with his ADL's and very pleasant. There were times the resident was seen carrying his bag with his belongings and stand at the exit doors but he was usually easily redirected to go back to his room. <BR/>Interview on 02/05/25 at 11:29 AM, with LVN M revealed she was working during the elopement on 12/24/24 and during her morning rounds during breakfast all residents were accounted for in the secure unit and Resident #323 had gone to the dining room to eat. The LVN M said after breakfast she sat in the hall monitoring and around 11:30 AM she noticed the resident was not in his room so they began to look for him room by room and alerted the rest of the staff the resident was missing. They checked the secure unit doors and they remained locked and after that they noticed the window to his room was broke. They alerted management staff and 911 was also called and later found out he had been found by the police and taken to his family's home. LVN M said she normally did not work the secure unit and had been filling in for someone else. She said Resident #323 did not appear to be exit seeking that day and had not been carrying a packed bag stating he wanted to go home. <BR/>Interview on 02/05/25 at 12:40 PM, with MA O revealed he was working on 12/24/24 he was assisting other staff gather residents in the secure unit into the dining room for lunch. MA O said they realized Resident #323 was not in his room and they began to check every room and around the facility when they realized the window to his room was broken and appeared that is how he had eloped. Management was notified and 911 was also called. MA O said he was told the resident had been found by the police and take to his family's home. MA O further stated Resident #323 was very mobile, independent, with confusion and would only come out of his room for meals. The MA said he never recalled the resident to be exit seeking or saying he wanted to leave the facility. <BR/>Review of the facility's PIR dated 01/10/25 reflected on 01/06/25:<BR/>This resident had previously broken a window and left the facility. As the facility response, we built a wooden fence around the windows on this area of the secured unit. The resident broke a window on the same section and scaled the fence. Staff witnessed the resident scaling and because of the location of the exit had to respond by going around the building. Once they were on the other side of the fence the resident was gone. Staff initiated searchs [sic] for the resident and contacted the police and the police were able to find him two hours later <BR/>Interview on 02/06/25 at 10:25 PM, with LVN Q revealed she worked on 01/04/25 and Resident #323 had dinner in the dining room and had gone back to his new room he was placed in after he was brought back by his family after his first elopement. LVN Q said she was she was sitting in the hallway and during her rounds, sometime after dinner, did not recall the time, she went to Resident #323's room to check on him and did not find him. She happened to glance down the hall and noticed he was headed into his old room, the room he first eloped from, and as she went into that room she did not see Resident #323. LVN Q noticed the window had been forced open and as she went to look outside, she saw Resident #323 on top of the fence, that had been built after his first elopement, but she was not able to get to the resident fast enough even after calling after him. LVN Q alerted staff and by the time they went outside to look for the resident, he was nowhere to be found. LVN Q further stated she alerted management and 911 was called and she was later told the resident had been found by the police and again take to his family's home. <BR/>Interview on 02/05/25 at 3:50 PM, with CNA R revealed he was working on 01/04/25 outside of the secure unit when he was alerted that Resident #323 had eloped from the facility through a window. CNA R said all of the staff began to look for the resident but he was not found. CNA R further stated he did work on the secure unit but has assisted in looking for Resident #323. <BR/>Interview on 02/04/25 at 10:54 AM, with CNA L revealed she was not at the facility during incidents where Resident #323 eloped. CNA L said Resident #323 was independent and very nice. She said the resident was able to communicate his needs and at times he would pack his bag and stand next to the exit doors but was easily redirected back to his room. CNA L stated after his first elopement, the staff had put up a fence around the outside rooms. Resident #323 was taken back to the facility and was put in another room, facing the enclosed courtyard. <BR/>Interview on 02/05/25 at 1:08 PM, with LVN P revealed she worked with Resident #323 and he was usually anxious to be picked up by his family so they could take him home and had a cell phone he would use to call his family. Resident #323 was cooperative and very pleasant with everyone and would stay in room and only come out for meals. LVN P further stated one day she noticed Resident #323 has packed his bag and said he wanted to leave but he had never tried to open the doors or leave and was easily redirected to his room. <BR/>Interview on 02/05/25 at 1:26 PM, with the DON revealed on 12/24/24 staff alerted her that Resident #323 could not be located and they had noticed the window to the resident's room had been broken out. The DON said all the staff were searching for the resident and 911 had been called. The facility later got a call from the police about 4:30 PM stating Resident #323 has been found and take to his family's home. The DON said she was not told how far from the facility he had been found. After that elopement Resident #323's family kept the resident over the holidays and had been taken back the facility on 12/31/24 and placed in another room that did not face the outside of the facility. The DON said while the resident was gone they had fixed the window to his previous room, and they had put up a wooden fence around the perimeter of the secure unit. On 01/04/25 she again was alerted that while making rounds they noticed Resident #323 was not in his room and the window to his old room had been opened and the resident had been seen jumping over the wooden fence. The staff immediately ran outside to look for the resident but he was not found so they called 911. The DON further stated that the police had found Resident #323 and again had been taken back to his family's home. The DON did not know how far from the facility he had been located. Resident #323 did to return to the facility and the family decided to keep him at home. The DON said after each of Resident #323's elopement all the staff were re-in serviced on their elopement policy. Staff participated in an elopement drill to ensure they were competent during a resident elopement. All resident in the secure unit were put on 15-minute checks to make sure there were no other resident that were exit seeking. <BR/>Interview on 02/05/25 at 11:06 AM, with the Director of Maintenance revealed he had built the wooden fence around the outside of the secure unit and was not aware the fence rails should have faced the outside of the fence and not the inside due to the safety of someone being able to climb the fence. The Director of Maintenance further stated that would be a fast and easy fix and he would just have to turn the fence around by sections. <BR/>A Past Non-Compliance Immediate Jeopardy/Immediate Threat was identified on 02/05/25. The Administrator, the Regional Consultant were notified of the Past Non-Compliance Immediate Jeopardy on 02/05/25 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:10 PM. <BR/>Review of the facility's policy titled Elopements dated 2018 reflected the following:<BR/>Staff shall investigate and report all cases of missing residents. <BR/> .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing/designee <BR/> .c. if a resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative the Attending Physician, law enforcement officials <BR/>Observation on 02/04/25 at 10:27 AM revealed there was a staff member sitting in the hallway with a bedside table charting on a laptop. The staff member had visual of the hall where the resident rooms were located and the dining room where other resident were.<BR/>Observation of the secure unit at various times from 02/04/25 to 02/06/25 revealed there were no residents that appeared to have the physical and mental capabilities of climbing the fence. <BR/>Review of the Enhanced Supervision Monitoring Tool dated 12/24/24 and 12/25/24 revealed all the residents in the secure unit has been put on 15-minute checks by staff to ensure no other residents were exit seeking or showing signs of wanting to leave the secure unit. Further review of the Enhanced Supervision Monitoring Tool revealed there were no other residents identified as being exit seeking. <BR/>Review of the Elopement Drill/Actual Event Participation dated 12/27/24 and 12/28/24 revealed staff members actively participated in a drill on what to do when and if a resident went missing. <BR/>Review of the in-services dated 12/24/24 and 01/06/25 revealed staff were in-serviced on the facility's elopement and wandering policy. <BR/>Interview on from 02/04/25 to 02/06/25 at various times with LVN J, LVN P, LVN Q, LVN V, MA O, CNA S, CNA N, CNA T, CNA U, CNA I, and CNA R revealed residents were checked on at the beginning of their shift to ensure all resident were accounted for frequent round were made to monitor all resident for signs of exit seeking. They all said if they were to notice a resident was missing, they were to alert all staff working and begin to look for the resident. If the resident was not located in the building, they would notify management and call 911.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on two of four medication carts (back and front nurses' carts) and 3 of 3 staff (LVN R, RN NN, and LVN L) reviewed for pharmacy services.<BR/>The facility failed to ensure the back and front nurses medication cart contained accurate narcotic logs for Residents #184, #62, and #43.<BR/>LVN R, RN NN and LVN L failed to document the administration of narcotic medications in a correct and timely manner. <BR/>This failure could place residents at risk for drug diversion and delay in medication administration.<BR/>Findings included:<BR/>Observation on 01/08/24 at 02:48 PM, of the nurses' medication cart and the narcotic administration record, with LVN R, revealed the following information:<BR/>Resident #43's narcotic administration record sheet for Hydrocodone-Acetaminophen 5/325 mg was last signed off on 01/5/24 for a one-tablet dose given at 3:30 PM, for a total of 8 pills remaining while the blister pack count was 7 pills. The NAR sheet for Lorazepam 0.5 mg was last signed off on 01/07/24 for a one-tablet dose given at 3:20 PM, for a total of 8 pills remaining while the blister pack count was 7 pills.<BR/>Interview with LVN R on 01/08/24 at 3:02 PM, revealed she administered the Hydrocodone-Acetaminophen 5/325 mg 1 tablet and Lorazepam 0.5 mg 1 tablet to Resident #43 as needed for pain and anxiety and she had not signed off on the NAR. She stated she gave the resident the medication, but she forgot to document on the medication administration record and sign off on the narcotic administration log. She stated she knew she was to sign-out on the narcotic count sheet after administration and on the medication administration record, but she did not. She stated failure to do that would cause the narcotic count to show less on the next count and it could lead to a narcotics diversion. She stated she had done in-service on medication administration.<BR/>Observation on 01/08/24 at 3:33 PM, of the nurses' medication cart and narcotic administration record with LVN L, revealed the following information:<BR/>- Resident #184's sheet for Acetaminophen with codeine 300-30 mg revealed it was last signed off on 01/6/24 for a one-tablet dose given at 2:01 AM, for a total of 57 pills remaining while the blister pack count was 56 pills.<BR/>- Resident #62's sheet for Acetaminophen with codeine 300-30 mg revealed it was last signed off on 01/7/24 for a one-tablet dose given at 4:00 PM, for a total of 46 pills remaining while the blister pack count was 43 pills.<BR/>Interview with LVN L on 01/08/24 at 3:59 PM revealed the night shift nurse had administered Acetaminophen with codeine 300-30 mg 1 tablet to each Resident #184 and Resident #62 and she did not log off on the NAR. LVN L stated she had also administered Acetaminophen with codeine 300-30 mg 1 tablet to Resident #62 on 01/08/24 at 7:27 AM and 3:00 PM, and she had not logged off on NAR. She revealed she was supposed to log off after administration. LVN L stated she gave Resident #62 medication, but she documented on the medication administration record, and she did not sign it off on the narcotic administration log. She stated she knew she was to sign-out on the narcotic count sheet after administration and on the medication administration record, but she did not. She stated the night shift nurse had informed her she had not logged off and she did not notify the management. She stated she had done in-service on controlled substances.<BR/>Interview on 01/09/24 at 11:26 AM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. The DON stated after interviewing both nurses they admitted they did not count during shift change and they were taking action. She stated LVN L was not supposed to take the key without counting and making sure the narcotic count was correct. She stated it was her responsibility and the ADON's to audit the medication carts.<BR/>Interview on 01/09/24 at 1:29 PM, ADON G revealed she was responsible of checking the carts weekly. She stated she checks on counts on NAR to ensure they are correct to prevent diversion. She stated her expectation is when staff administer narcotics they should document on MAR and also log off on NAR. She could not tell the last day she had checked the carts .<BR/>Interview on 01/10/24 at 10:19 AM, RN NN revealed she was the night nurse on 1/7/23, and she forgot to sign off Acetaminophen with codeine 300-30 mg 1 tablet that she administered to Resident #62 on 1/7/24 at 09:00 PM. She stated she was aware she was supposed to sign off narcotics after administering. RN NN stated she was to count with the oncoming nurse, but they did not because the oncoming nurse took the cart to the hallway after report. RN NN stated she felt that was her fault and she regreted giving her the key before counting. She stated the risk of not counting was diversion of narcotics and no proof she had administered the medication to the resident. She stated she had done in-services on controlled substance and medication administration.<BR/>Interview with LVN L on 01/10/24 at 03:31 PM, she revealed she wanted to tell the truth she had not counted narcotics with the night nurse because the nurse dropped the key and walked away. She stated she did not report to management.<BR/>Review of the facility current Medication-Controlled Substances policy, dated November 2023, reflected the following: <BR/>Nursing staff must count controlled medications at the end of each shift. The nurses coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurate in accordance with accepted professional standards and practices for 1 of 7 residents (Resident #1) whose clinical records were reviewed. <BR/>The facility failed to ensure Resident #1's MAR was accurately and completely documented in their permanent clinical record on [DATE]. <BR/>This failure could place all the residents, who resided in the facility, at risk for inaccurate or incomplete clinical records. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses which included acute combines systolic and diastolic heart failure (congestive heart failure), Type 2 diabetes (body does not produce insulin to maintain normal glucose levels), Stage 4 chronic kidney disease (advanced kidney damage requiring dialysis), and morbid (severe) obesity. The resident discharged from the facility on [DATE] to the hospital. <BR/>Record review of Resident #1's last quarterly MDS dated [DATE] reflected the resident had severe cognitive impairment with a BIMS score of 3 (a score of 0-7 indicated severe cognitive impairment). She required substantial of one staff for dressing, toilet use, personal hygiene, and transfers. She required only supervision for her other activities of daily living. She was frequently incontinent of bladder and always incontinent of bowel. <BR/>Record review of Resident #1's SBAR Change of Condition Form dated [DATE] at 6:39 AM reflected Resident #1 was sent to hospital due to a fall. <BR/>Record review of Resident #1's Progress Note dated [DATE] at 3:49 PM and signed by the DON reflected: [Resident #1's] family member and family came to the facility to get [Resident #1's] belongings and stated [Resident #1] expired early this morning at the hospital. <BR/>Record review of the Resident #1's EHR reflected the following vitals recorded for Resident #1 on [DATE]: Blood pressure, 122/82 mmHg at 5:27 PM; and blood sugar, 100 mg/dL at 5:28 PM and pulse, 70 bpm at 5:27 PM signed by LVN A. Pulse, 78 bpm at 6:14 PM and O2 saturation, 97% at 6:14 PM signed by LVN B. <BR/>Record review of Resident #1's eMAR Medical Administration Notes dated [DATE] and signed by LVN A reflected at 5:26 PM the resident refused Apixaban and at 5:27 PM the resident refused Carvedilol. <BR/>Record review of Resident #1's eMAR Medical Administration Notes dated [DATE] and signed by LVN B reflected the resident refused Reglan at 6:15 PM, at 6:16 PM refused Apixaban, at 6:17 PM refused Caltrate, at 6:18 PM refused Carvedilol and at 6:19 PM refused insulin. <BR/>In an interview on [DATE] at 10:45 AM, LVN B said she did not work on [DATE]. She said she called in and LVN A was working. She said it was possible for another nurse to document under her name because she had her password saved in the computer. She said the documentation should reflect Resident #1 was in the hospital, and it would be impossible for anyone to take vitals since Resident #1 was not in the facility at the time the vitals were recorded. <BR/>In an interview on [DATE] at 11:02 AM, the DON and ADON said they thought the nurses had saved their passwords in the computer and did not pay attention when entering documentation. The DON said she entered in the nurse noted on [DATE] when Resident #1's family came to the facility to retrieve her things and informed her that Resident #1 had passed at the hospital that morning. She stated based on that information, it was impossible to take Resident #1's vitals or for her to refuse medications because Resident #1 was not in the facility and had already passed by the time the documentation was entered. She stated documenting incorrectly in the EMR placed residents at risk of not getting appropriate treatment or follow up. She said she had completed an in-service on securing passwords and documentation in the past but will start another one. She said she did not want anyone having access to another staff's password for documentation. <BR/>In a telephone interview on [DATE] at 11:21 AM, LVN A stated she did work on [DATE]. She said she did recall Resident #1 was sent to the hospital on [DATE]. LVN A said she did document that Resident #1 refused her medications on [DATE]. She said she was not sure if she documented under LVN B's password but said it could have been possible because when she got busy, she did not always check. LVN A said she did not recall that Resident #1 was not in the facility when she documented Resident #1's vitals and medication refusals. She said if the resident was not in the facility, they should be removed from the MAR so mistakes could not occur. When asked how she ensured residents were in the facility, she said she rounded at the beginning of the shift. She said when she administered medications, she checked to see that she had the right medication and the right resident before administration. LVN A did not have an explanation for documenting Resident #1's vitals or medication refusals on [DATE] when Resident #1 was not in the facility. She said doing that could place residents at risk of not getting appropriate care. <BR/>Record review of the facility's, Daily Position Sheet, reflected LVN B was scheduled to work; however. LVN B's name was crossed out and replaced with LVN A on [DATE]. <BR/>Record review of the facility's in-service record dated [DATE] and titled, POC Documentation, charting and documentation, reflected it was delivered by the ADON. The sign-in sheet included LVN A. <BR/>Record review of the facility's undated policy titled, Charting and documentation, reflected: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative and the Office of the State Long-Term Care Ombudsman representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one (Resident #1) of three residents reviewed for discharge rights.<BR/>The facility failed to provide a copy of the written notice of immediate discharge to Resident #1 and the Ombudsman when the facility decided that Resident #1 needed to be immediately discharged on 10/02/24, due to non-compliance with the smoking policy.<BR/>This failure placed residents at risk of not having access to available advocacy services, discharge options, and appeal processes.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 11/07/24, reflected the resident was admitted to the facility on [DATE] and discharged on 10/03/24 with diagnoses which included: fibroblastic disorder (tumors that affect connective tissue), Type II diabetes (body's inability to control blood glucose), muscle weakness, personality disorder, and acquired absence of right leg below the knee. <BR/>Record review of Resident #1's Quarterly MDS Assessment, dated 07/19/24, reflected the resident had a BIMS score of 15 which indicated the resident's cognition was intact. The MDS Assessment also reflected Resident #1 required set-up assistance and supervision with most ADLs. <BR/>Record review of Resident #1's care plan, dated 04/24/24, reflected the resident had impaired cognitive function/dementia or impaired thought processes related to dissociative and conversion disorder (personality disorder) with interventions that included administering meds as ordered, communicating with the resident/family/caregivers regarding resident's capabilities and needs, and monitoring/documenting/reporting any changes to cognition. The care plan also reflected the resident had a behavior problem related to resident's non-compliance with smoking policy. An update on 06/29/24 reflected Resident #1 signed the smoking policy; however, she violated the smoking policy on 09/27/24 by refusing to hand over smoking paraphernalia. Interventions included a 30-day discharge notice to be given, medications administered as ordered, caregivers to provide opportunity for positive interaction/attention, explain all procedures to the resident before starting and allowing the resident time to adjust, and explain/reinforce why behavior was inappropriate. <BR/>Record review of a letter titled 30-Day Discharge Collection Letter, dated 09/27/24, reflected it was a written notification that Resident #1 would be discharged from [nursing facility] 30 days from the date of the letter due to refusal to adhere to the smoking policy set by the facility Administrator. The notice included information on how to contact the Ombudsman and was signed by the former Administrator, ADON, and a notation that Resident #1 refused to collect and sign. <BR/>Record review of a letter titled Immediate and Effective Discharge Collection Letter, dated 10/02/24, reflected it was a written notification that Resident #1 would be immediately and effectively discharged from [nursing facility] due to refusal to adhere to the smoking policy set by the facility Administrator. The notice reflected the Social Worker would work with Resident #1 to make necessary preparations for a safe transition. The notice also included information on how to contact the Ombudsman. Further review reflected no handwritten signatures or notations regarding lack of signatures. <BR/>Record review of Resident #1's progress notes, 10/02/24-11/08/24, reflected there was no documentation to show that Resident #1 and the Ombudsman were provided with or attempted to be provided with a written copy of the immediate and effective discharge collection letter. <BR/>Record review of Resident #1's care plan conference note, dated 10/02/24, reflecte it could not initially be viewed by the investigator in the electronic record due to it not being completed and signed. The note reflected that it could only be edited, printed, or completed. The ADON later provided a hard copy of the care plan conference note that was locked and signed by the DON on 11/08/24 at 12:17 PM and reflected in part the following:<BR/>[Resident #1] requested to meet [Ombudsman], after she was found violating smoking policy, [Ombudsman] present in the meeting and [Resident #1] admitted that she violated the smoking policy and that she will not follow the facilities [sic] rule of supervised smoking and will not return paraphernalia. Facility issues her notice immediate/effective discharge. <BR/>In an interview on 11/07/24 at 09:25 AM, the DON stated Resident #1 had been discharged from the facility because she was non-compliant with the facility's smoking policy. The DON stated Resident #1 refused to turn in her lighter and cigarettes and would go outside and smoke whenever she wanted, outside of scheduled smoke times. The DON stated the behavior was dangerous to Resident #1 and other residents in the facility. The DON stated Resident #1 was issued an immediate discharge on [DATE] during a care plan meeting with the Ombudsman and the former Administrator. The DON stated Resident #1 also had labs drawn on 10/02/24 that came back critical for low sodium and the resident was sent to the local hospital. <BR/>In an interview on 11/07/24 at 03:56 PM, a representative at the local hospital stated Resident #1 arrived at the hospital on [DATE] and was diagnosed with low sodium which was a reason for her to be admitted . The representative stated Resident #1 was medically cleared and ready for discharge on [DATE]; however, the facility refused to allow the resident to return to the facility and Resident #1 had been at the hospital for 34 days with no place to go. The representative stated the facility informed them that Resident #1 had been issued a 30-day notice of discharge from their facility due to non-compliance with the smoking policy. The representative stated he understood the facility's reason for discharging Resident #1; however, if she was issued a 30-day discharge notice and was still within the 30 days, the facility should have been responsible for taking Resident #1 back to the facility and helping her find alternative placement. <BR/>In an interview on 11/07/24 at 04:53 PM, the Ombudsman stated she recalled having to visit with Resident #1 on multiple occasions to convince her to turn over smoking paraphernalia and follow the smoking policy; however, the resident always refused. The Ombudsman stated she last visited Resident #1 a day or two before she discharged to the hospital to again attempt to collect smoking paraphernalia and the resident refused. The Ombudsman stated she informed the former Administrator to follow the facility's policy and do what they needed to do as far as discharging Resident #1. The Ombudsman stated she was aware of the 30-day discharge notice that had been issued to Resident #1 at the end of September 2024; however, she was not aware of an immediate discharge notice issued on 10/02/24. The Ombudsman stated she was aware that the facility wanted to discharge Resident #1 because her behavior was a safety hazard; however, they had issued and rescinded discharge notices on multiple occasions to give the resident a chance to cooperate. The Ombudsman stated she could not recall receiving an official immediate discharge letter for Resident #1, but she needed to check her emails to confirm. <BR/>In an interview on 11/08/24 at 09:42 AM, Resident #1 stated she was currently at [local hospital] waiting for the Social Worker to find her a place to stay because [nursing facility] would not allow her to go back until they got a new administrator. Resident #1 stated she admitted to the hospital on [DATE] and was ready for discharge just a few days later. Resident #1 stated [nursing facility] refused to take her back because she did not follow their smoking policy. Resident #1 stated she was given a 30-day discharge notice a couple of weeks before being sent out to the hospital, so she still had time at the facility to work with them and the Ombudsman to find placement. Resident #1 stated she was not issued an immediate discharge notice prior to going to the hospital and was only aware of the 30-day notice. <BR/>In further interview on 11/08/24 at 9:48 AM, the Ombudsman stated according to her notes, she visited Resident #1 on 10/01/24 after the facility continuously called her about the resident's non-compliance with the smoking policy. The Ombudsman stated her note reflected that Resident #1 could be discharged ; however, there was not an official immediate discharge notice sent to her. <BR/>In an interview on 11/08/24 at 12:28 PM, the Corporate Nurse stated the facility was currently without an administrator and they had 30 days to find a replacement. She stated she was maintaining her position as the corporate nurse; therefore, all documentation left by the former Administration regarding the discharge of Resident #1 should be reviewed. The Corporate Nurse did not provide any further details. <BR/>In further interview on 11/08/24 at 01:26 PM, the DON stated she was not normally responsible for discharges and placement of residents. The DON stated she would only provide clinical information as needed. The DON stated the social worker and administrator handled the discharge process; however, the facility did not currently have a social worker or an administrator. The DON stated the former Administrator who dealt directly with the discharge of Resident #1 was no longer with the company and all they had were her notes. The DON stated Resident #1 was aware that she was receiving an immediate discharge because it was mentioned in the care plan meeting held on 10/02/24 and there was also an immediate discharge letter in the former Administrator's file. The DON stated the immediate discharge letter was not signed by Resident #1 because she always refused to sign anything that was given to her. The DON stated since she did not deal directly with the discharge, she could not confirm that an official immediate discharge letter had been provided to the Ombudsman. The DON stated the risk of not properly notifying a resident/RP and ombudsman of a discharge could be the resident not being assisted with finding placement and being safely discharged . <BR/>Record review of the facility's Transfer or Discharge, Emergency policy and procedure, revised December 2016, reflected in part the following:<BR/>Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s).<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>Residents will not be transferred unless:<BR/>a. <BR/>The safety of individuals in the facility is endangered due to clinical or behavioral status of the resident. <BR/> .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution our facility will implement the following procedures:<BR/> .c. Prepare the resident for transfer; <BR/>d. Prepare a transfer form to send with the resident;<BR/>e. Notify the representative (sponsor) or other family member; <BR/> .g. Others as appropriate or as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (Residents #1 and #2) of four residents reviewed for dignity. <BR/>1. The Maintenance Director on 09/10/24 recorded Resident #1 with his personal cell phone while Resident #1 yelled and cursed at the facility staff.<BR/>2. CNA A took Resident #2's cell phone away when Resident #1 stated he was going to call 911 on 06/20/24. <BR/>This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.<BR/>Findings included: <BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included stroke, hemiplegia (paralysis to one side of the body), history of traumatic brain injury, muscle weakness, abnormal gait and mobility and depression. Resident #1 had a BIMS of 8, which indicated his cognition was moderately impaired. The MDS further indicated Resident #1 used a wheelchair for mobility.<BR/>Review of Resident #1's care plan initiated on 06/14/24 reflected he had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness and poor impulse control. Interventions included to analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. <BR/>On 09/10/24 at 12:02 PM revealed, while in the secure unit, there was a resident heard yelling and cursing. While in the secure unit's dining room the Maintenance Director was seen thru clear locked double doors, on the other hall. The Maintenance Director was holding a cell phone and appeared to be recording Resident #1 while he (Resident #1) yelled and cursed. <BR/>Observation and interview on 09/10/24 at 12:11 PM of Resident #1 revealed he was wheeling himself backwards in his wheelchair towards the front of the facility. Resident #1 was asked what happened, but the resident just kept repeating butthole repeatedly. Resident #1 was asked if the Maintenance Director was recording him, but the resident did not appear to comprehend what was being asked. <BR/>Interview on 09/10/24 at 1:19 PM with the Maintenance Director revealed Resident #1 had been calling him racial names and cursed at him and even threatened to burn the Maintenance Director's house down, from the time he hired at the facility two months prior. The Maintenance Director said, during the incident, he walked past Resident #1 in the hall and the Resident #1 hit him and began to yell and curse at him so the Maintenance Director said he began to record the resident with his cell phone to show management how the resident treated him. The Maintenance Director said after he recorded the resident's outburst, he went to the Administrator's office to show her, and he was told what he had done was not right and was told to immediately delete the video. The Maintenance Director further stated he did not know he was not supposed to record residents with his cell phone. <BR/>Review of the Maintenance Director's personnel file reflected he had been trained on how to manage residents with behaviors on 07/30/24. <BR/>Interview on 09/11/24 at 4:14 PM with the Administrator revealed after the incident, 09/10/24, the Maintenance Director went to her office and showed her a video of Resident #1 yelling and cursing at him. The Administrator said she told the Maintenance Director that recording the resident had not been right because he had violated the resident's right. The Administrator further stated a while back the Maintenance Director took a fan that belonged to the facility from Resident #1's room and the resident became upset therefore each time the resident saw the Maintenance Director he believed he would be taking his personal belongings. <BR/>Review of the facility's undated employee handbook reflected the following:<BR/> .Handheld Electronic Devices<BR/>The presence or use of camera, camera-enabled mobile phones, and other handheld electronic devices in the workplace may interfere with productivity, create privacy concerns, and lead to problems, including privacy violations and the unauthorized disclosure of confidential business and personal health information <BR/>2. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included multiple sclerosis, cognitive communication deficit, and muscle weakness. The resident had a BIMS of 13 which indicated his cognition was moderately impaired. <BR/>Review of Resident #2's care plan initiated on 06/20/24 reflected the resident refused care and could verbally and physically aggressive towards staff during care. Interventions included if the resident became combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed and notify the nurse of behaviors or refusal. <BR/>Review of the facility's Provider Investigation Report dated 06/30/24 reflected the following: Nurse in charge reported that This writer arrived at the nurse station [sic] find iPhone cellphone at the desk which was taken away by the CNA on duty so that the resident can not call 911, charge nurse [sic]take the phone immediately back to the [Resident #2] and put it back in his room by the bed side and reported immediately to administrator/DON.<BR/>Observation and interview on 09/10/24 at 10:22 AM with Resident #2 revealed he was in bed scrolling through his phone. He had a lot of food and food particles all over his bed and his draw sheet was soiled. The resident stated he did not staff change his linens and said he was fine. Resident #2 was asked about the incident when his phone was taken away and he said a staff, did not recall her name, had taken his phone when he tried to call the police and she had been fired. The resident did not go into details of incident and said he called the police often, but they would never press charges and would only talk to him. Resident #2 stated he felt safe at the facility and his phone had never been taken away again. <BR/>Interview on 09/09/24 at 4:45 PM with CNA Q revealed Resident #2 had called the police multiple times during the days around 06/30/24 for various of non-emergency reasons. The resident had called the police on Friday (06/28/24) and when they showed up the DON appeared as though she was frustrated and while the police were there she made the comment to take Resident #2's phone if he tried to call again 911 again. On Sunday (06/30/24) she assisted CNA A to try to change Resident #2 because he had BM all over himself and he had been refusing to be changed. When CNA Q entered the room they began to change the resident and halfway through the care, he began to get upset, yell and curse and knocked his bedside table over on the floor. CNA Q said she left the room and a while later she saw CNA A come out of Resident #1's room with his cell phone, put it at the nurse's station and said she had to take it away because he tried to call 911. The charge nurse for the next shift arrived to work at that time and asked about the cell phone and when she was told what happened, the charge nurse stated they needed to take the cell phone back to the resident. <BR/>Interview on 09/11/24 at 11:56 AM with CNA A revealed the days around the incident, 06/30/24, Resident #2 called the police many times and kept pressing his call light over and over from the time she arrived to work at 6:00 AM. On Friday, 06/28/24, Resident #2 called the police and while they were at the nurse's station, the DON said, if he tries to calls the police, take his phone away. On 06/30/24, she noticed Resident #2 had BM on himself and she explained to the resident that he needed to be changed and cleaned up. She and CNA B began to provide care to the resident and before they were done the resident began to resist and punched her in the stomach as she began to put his items on the bedside table. Resident #2 told her he was going to call the police, so she took his cell phone and put it at that nurse's station and explained to the charge nurse, did not recall which one, what had occurred and how she had been told to take the resident's phone away. CNA A was later told by the charge nurse to give the phone back to the resident. CNA A further stated she knew it was the resident's right to have his cell phone and call 911, but she said she had just followed the DON's orders and took the cell phone away. <BR/>Interview on 09/12/24 at 10:24 AM with LVN S revealed CNA A told her Resident #2 was combative during care on, 06/30/24, and the resident wanted to call 911 so the CNA had taken the resident's phone away. LVN S said she told CNA A she needed to take the phone back to the resident and at that time RN R arrived at the facility for her shift and took over the situation. <BR/>Interview on 09/12/24 at 9:28 AM with RN R revealed on 06/30/24 she arrived at her shift at the facility and noticed there was a cell phone at the nurse's station. LVN S told her it belonged to Resident #2 and told her CNA A had taken it away from the resident because he tried to call 911. CNA A stated she had been instructed by the DON to take his phone away if he tried to call 911. CNA A was instructed to take the phone back to Resident #2 and she then called the DON. The DON told RN R she had never instructed CNA A to take the resident's phone away. RN R said she went to Resident #2 to ask what had occurred and he kept repeating over and over that his phone had been taken away. The resident would not let her assess him, but she did not notice any injuries at the time. <BR/>Interview on 09/12/24 at 1:42 PM with the DON revealed Resident #2 had increased behaviors around the days of 06/30/24 where he was constantly calling 911 and the police showed up to the facility frequently. On Friday, 06/28/24, she told staff to monitor Resident #2 and redirect as needed but denied she told the staff to take his cell phone away. The day of the incident, 06/30/24, RN R called her to let her know CNA A had taken Resident #2's phone and RN C was instructed to return the cell phone to the resident immediately. The DON said it was a violation of the resident's right to have taken the phone away and it was his right to call 911 whenever he wanted. <BR/>Interview on 09/12/24 at 2:37 PM with the Administrator revealed she was called by RN S and told CNA A had taken Resident #2's phone so he would not call 911. RN C told her she had returned the cell phone back to Resident #2. The Administrator said staff were not allowed to take the resident's personal belongings because it was a violation of their rights.<BR/>Review of the Resident Rights provided by the facility on 09/10/24 reflected the following:<BR/>Resident Rights<BR/>Policy Statement<BR/>Employees shall treat all residents with kindness, respect, and dignity. <BR/>Policy Interpretation and Implementation<BR/>1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>a. a dignified existence; <BR/> .e. self-determination; <BR/>f. communication with and access to people and services, both inside and outside the facility;<BR/> .i. exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility; <BR/> .x communicate with outside agencies (e.g., local, state, or federal officials )regarding any matter <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #323's admission MDS dated [DATE] reflected the resident was an [AGE] year-old resident admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure). Resident #323 had a BIMS of 1 indicating his cognition was severely impaired. The MDS further reflected the resident did not have impairment to his upper and lower extremities and ambulated with no assistance. <BR/>Review of Resident #323's care plan initiated on 12/24/24 reflected the resident was at risk for elopement/wandering related to dementia and required placement on the secure unit to provide a secure environment due to risk of elopement. Interventions included to frequent monitor and identified a pattern of wandering and assess reason for wandering and provide redirection as needed . <BR/>Review of Resident #323's hospital records dated 12/01/24 reflected the following:<BR/> Patient is a [AGE] year-old male who presents to [Emergency Room] primarily for pneumonia and neurology was consulted for patient's recent history of elopement and getting lost concerning for newly diagnosed dementia. On chart review is noted that patient had eloped and gotten lost 5 times and family found him after he had fled <BR/>Observation on 02/04/25 at 11:19 PM, revealed there was wooden privacy fence around the outside of the building of the secure unit with three rails inside of the fence, one at the bottom, one in the middle and one towards the top of the fence. <BR/>Review of the facility's PIR dated 01/02/25 reflected that on 12/24/24 Resident #323 had left the facility without signing out and was found by the police department and was returned to his family. The resident was on enhanced supervision until the window of his room was repaired and installation of a fence on the side of the building with potential exiting windows was completed. <BR/>Review of Resident #323 progress notes dated 12/24/24 documented by LVN J reflected the following:<BR/>Resident was up from breakfast in the dining area. Resident ate 100% of meal. Resident showed no signs of pain or discomfort. At 1145, the patient was last observed entering his room. During routine rounds at approximately 12:45 PM, the patient was found to be absent from their room. A code white was initiated promptly, and the search for the patient is currently ongoing [Police] notified the facility that resident had be [sic] found by [Police] 2 hours ago and told resident to [family].<BR/>Interview on 02/05/25 at 10:45 AM, with CNA N revealed she was working the morning of 12/24/24 and sometime after breakfast they staff noticed Resident #323 was not in the secure unit. The CNA N said after breakfast the resident would normally go back to his room and only come out for meals. When they staff realized the resident could not be located, they all began to search the rooms and the bathrooms. After a while, they discovered the window to Resident #323's room was broken and that is how the resident had gotten out. CNA N described Resident #323 as being independent with his ADL's and very pleasant. There were times the resident was seen carrying his bag with his belongings and stand at the exit doors but he was usually easily redirected to go back to his room. <BR/>Interview on 02/05/25 at 11:29 AM, with LVN M revealed she was working during the elopement on 12/24/24 and during her morning rounds during breakfast all residents were accounted for in the secure unit and Resident #323 had gone to the dining room to eat. The LVN M said after breakfast she sat in the hall monitoring and around 11:30 AM she noticed the resident was not in his room so they began to look for him room by room and alerted the rest of the staff the resident was missing. They checked the secure unit doors and they remained locked and after that they noticed the window to his room was broke. They alerted management staff and 911 was also called and later found out he had been found by the police and taken to his family's home. LVN M said she normally did not work the secure unit and had been filling in for someone else. She said Resident #323 did not appear to be exit seeking that day and had not been carrying a packed bag stating he wanted to go home. <BR/>Interview on 02/05/25 at 12:40 PM, with MA O revealed he was working on 12/24/24 he was assisting other staff gather residents in the secure unit into the dining room for lunch. MA O said they realized Resident #323 was not in his room and they began to check every room and around the facility when they realized the window to his room was broken and appeared that is how he had eloped. Management was notified and 911 was also called. MA O said he was told the resident had been found by the police and take to his family's home. MA O further stated Resident #323 was very mobile, independent, with confusion and would only come out of his room for meals. The MA said he never recalled the resident to be exit seeking or saying he wanted to leave the facility. <BR/>Review of the facility's PIR dated 01/10/25 reflected on 01/06/25:<BR/>This resident had previously broken a window and left the facility. As the facility response, we built a wooden fence around the windows on this area of the secured unit. The resident broke a window on the same section and scaled the fence. Staff witnessed the resident scaling and because of the location of the exit had to respond by going around the building. Once they were on the other side of the fence the resident was gone. Staff initiated searchs [sic] for the resident and contacted the police and the police were able to find him two hours later <BR/>Interview on 02/06/25 at 10:25 PM, with LVN Q revealed she worked on 01/04/25 and Resident #323 had dinner in the dining room and had gone back to his new room he was placed in after he was brought back by his family after his first elopement. LVN Q said she was she was sitting in the hallway and during her rounds, sometime after dinner, did not recall the time, she went to Resident #323's room to check on him and did not find him. She happened to glance down the hall and noticed he was headed into his old room, the room he first eloped from, and as she went into that room she did not see Resident #323. LVN Q noticed the window had been forced open and as she went to look outside, she saw Resident #323 on top of the fence, that had been built after his first elopement, but she was not able to get to the resident fast enough even after calling after him. LVN Q alerted staff and by the time they went outside to look for the resident, he was nowhere to be found. LVN Q further stated she alerted management and 911 was called and she was later told the resident had been found by the police and again take to his family's home. <BR/>Interview on 02/05/25 at 3:50 PM, with CNA R revealed he was working on 01/04/25 outside of the secure unit when he was alerted that Resident #323 had eloped from the facility through a window. CNA R said all of the staff began to look for the resident but he was not found. CNA R further stated he did work on the secure unit but has assisted in looking for Resident #323. <BR/>Interview on 02/04/25 at 10:54 AM, with CNA L revealed she was not at the facility during incidents where Resident #323 eloped. CNA L said Resident #323 was independent and very nice. She said the resident was able to communicate his needs and at times he would pack his bag and stand next to the exit doors but was easily redirected back to his room. CNA L stated after his first elopement, the staff had put up a fence around the outside rooms. Resident #323 was taken back to the facility and was put in another room, facing the enclosed courtyard. <BR/>Interview on 02/05/25 at 1:08 PM, with LVN P revealed she worked with Resident #323 and he was usually anxious to be picked up by his family so they could take him home and had a cell phone he would use to call his family. Resident #323 was cooperative and very pleasant with everyone and would stay in room and only come out for meals. LVN P further stated one day she noticed Resident #323 has packed his bag and said he wanted to leave but he had never tried to open the doors or leave and was easily redirected to his room. <BR/>Interview on 02/05/25 at 1:26 PM, with the DON revealed on 12/24/24 staff alerted her that Resident #323 could not be located and they had noticed the window to the resident's room had been broken out. The DON said all the staff were searching for the resident and 911 had been called. The facility later got a call from the police about 4:30 PM stating Resident #323 has been found and take to his family's home. The DON said she was not told how far from the facility he had been found. After that elopement Resident #323's family kept the resident over the holidays and had been taken back the facility on 12/31/24 and placed in another room that did not face the outside of the facility. The DON said while the resident was gone they had fixed the window to his previous room, and they had put up a wooden fence around the perimeter of the secure unit. On 01/04/25 she again was alerted that while making rounds they noticed Resident #323 was not in his room and the window to his old room had been opened and the resident had been seen jumping over the wooden fence. The staff immediately ran outside to look for the resident but he was not found so they called 911. The DON further stated that the police had found Resident #323 and again had been taken back to his family's home. The DON did not know how far from the facility he had been located. Resident #323 did to return to the facility and the family decided to keep him at home. The DON said after each of Resident #323's elopement all the staff were re-in serviced on their elopement policy. Staff participated in an elopement drill to ensure they were competent during a resident elopement. All resident in the secure unit were put on 15-minute checks to make sure there were no other resident that were exit seeking. <BR/>Interview on 02/05/25 at 11:06 AM, with the Director of Maintenance revealed he had built the wooden fence around the outside of the secure unit and was not aware the fence rails should have faced the outside of the fence and not the inside due to the safety of someone being able to climb the fence. The Director of Maintenance further stated that would be a fast and easy fix and he would just have to turn the fence around by sections. <BR/>A Past Non-Compliance Immediate Jeopardy/Immediate Threat was identified on 02/05/25. The Administrator, the Regional Consultant were notified of the Past Non-Compliance Immediate Jeopardy on 02/05/25 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:10 PM. <BR/>Review of the facility's policy titled Elopements dated 2018 reflected the following:<BR/>Staff shall investigate and report all cases of missing residents. <BR/> .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing/designee <BR/> .c. if a resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative the Attending Physician, law enforcement officials <BR/>Observation on 02/04/25 at 10:27 AM revealed there was a staff member sitting in the hallway with a bedside table charting on a laptop. The staff member had visual of the hall where the resident rooms were located and the dining room where other resident were.<BR/>Observation of the secure unit at various times from 02/04/25 to 02/06/25 revealed there were no residents that appeared to have the physical and mental capabilities of climbing the fence. <BR/>Review of the Enhanced Supervision Monitoring Tool dated 12/24/24 and 12/25/24 revealed all the residents in the secure unit has been put on 15-minute checks by staff to ensure no other residents were exit seeking or showing signs of wanting to leave the secure unit. Further review of the Enhanced Supervision Monitoring Tool revealed there were no other residents identified as being exit seeking. <BR/>Review of the Elopement Drill/Actual Event Participation dated 12/27/24 and 12/28/24 revealed staff members actively participated in a drill on what to do when and if a resident went missing. <BR/>Review of the in-services dated 12/24/24 and 01/06/25 revealed staff were in-serviced on the facility's elopement and wandering policy. <BR/>Interview on from 02/04/25 to 02/06/25 at various times with LVN J, LVN P, LVN Q, LVN V, MA O, CNA S, CNA N, CNA T, CNA U, CNA I, and CNA R revealed residents were checked on at the beginning of their shift to ensure all resident were accounted for frequent round were made to monitor all resident for signs of exit seeking. They all said if they were to notice a resident was missing, they were to alert all staff working and begin to look for the resident. If the resident was not located in the building, they would notify management and call 911.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that menus were followed for 1 of 3 meals (lunch on 09/10/24) reviewed for meal accuracy.<BR/>The facility failed to serve pureed bread during the lunch meal on 09/10/24 to all eight residents (Residents #5, #8, #9, #10, #11, #12, #13, and #14) who required a pureed diet. <BR/>This failure could place residents at risk for poor intake and weight loss.<BR/>Findings included:<BR/>Review of Resident #5's admission record, dated 09/11/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Review of Resident #5's Quarterly MDS Assessment, dated 08/26/24, reflected he had a BIMS score of 99 indicating he was unable to complete the interview. His active diagnoses included non-alzheimer's dementia and malnutrition. Further review reflected Resident #5 received a therapeutic diet. <BR/>Review of Resident #5's physician's orders reflected an order for pureed diet with a start date of 08/21/24.<BR/>Observation on 09/10/24 at 12:07 PM of the facility's dining room revealed the steamtables with the lunch meal on it. <BR/>Interview on 09/10/24 at 12:09 PM with [NAME] C revealed he listed off the following items that were to be served to residents for the lunch meal: baked pork chops, mixed vegetables, rice, and a roll. [NAME] C said he had the same items for the mechanical soft and pureed diets.<BR/>Observation and interview on 09/10/24 at 12:10 PM with [NAME] C plating Resident #5's lunch meal revealed there were three scoops on the plate. [NAME] C said there was a scoop of meat, a scoop of potatoes, and a scoop of vegetables on the plate for Resident #5 who required a pureed diet.<BR/>Observation on 09/10/24 at 1:10 PM of a sample tray provided by the facility's kitchen revealed a plate of pureed food consisting of mashed potatoes, meat, and vegetables.<BR/>Interview on 09/10/24 at 1:23 PM with the DM revealed the pureed bread was not served during the lunch meal service earlier in the day because [NAME] C forgot to make it. The DM said [NAME] C was responsible for making the pureed bread and she normally followed up to make sure all components were made and ready to be served but she was busy with something else. The DM said she expected all residents to receive the same meal for each diet they required. The DM said the purpose of that was to make sure every resident got what they were supposed to on their plate. The DM said if a meal component was missing often from a resident's plate they would have nutrition values missing from their diet. <BR/>Interview on 09/10/24 at 1:37 PM with [NAME] C revealed he cooked all the food for the lunch meal earlier in the day. [NAME] C said he forgot to make the pureed bread, so it was not served to the residents. <BR/>Review of a list of residents who required a pureed diet reflected there were eight total residents, including Residents #5, #8, #9, #10, #11, #12, #13, and #14.<BR/>Review of the facility's Spring/Summer 24- Week 3 menu for Tuesday reflected: smother pork chop, confetti rice, braised red and green cabbage, and cornbread.<BR/>Review of the facility's undated policy, titled Menus, reflected: 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #39) of 18 reviewed for ADLs. <BR/>The facility failed to ensure Resident #39's contractured hands were kept clean and free of odor.<BR/>This failure had the potential to affectcould place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. <BR/>Findings included:<BR/>Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA, non-Alzheimer's dementia, malnutrition, bullous pemphigoid, and muscle wasting. The MDS further reflected the resident was not able to completed a BIMS due to her cognition being severely impaired.<BR/>Review of Resident #39's care plan, revised on 11/19/23, revealed the resident had an ADL self-care performance deficit. Interventions included the resident was totally dependent on one staff for personal hygiene. <BR/>Observation on 01/08/23 at 9:33 AM revealed Resident #39 was in bed with her eyes closed and she was not easily aroused when she was spoken to. Both her hands appeared to be contracted up to her face.<BR/>Observation and interview on 01/09/23 at 1:55 PM with CNA MM revealed she slowly opened Resident #39's right hand and her fingernails were observed to be about three-quarters of an inch long, they appeared to be digging into the palm of her hand, and there was an odor noted. The skin to the resident's palm was intact and there was no skin breakdown noted. CNA MM attempted to open the resident's left hand but the resident would not allow her to. CNA MM further stated it was the aides responsibility to cut the resident's fingernails and said she had cut Resident #39's fingernails the previous week and said hers just grow really fast. <BR/>Observation and interview on 01/09/24 at 2:47 PM with the PT revealed he pulled Resident #39's covers back and he attempted to slowly open the resident's right and left hand and once opened he stated there was an odor to the palms of the resident's palms from being closed and not cleaned. The PT further stated the fingernails needed to be cut because they were digging into her palms and could cause skin breakdown and the PT also did not think Resident's fingernails could grow that much in a week. <BR/>Interview on 01/10/23 at 12:30 PM with ADON X revealed aides should be cleaning the inside of Resident #39's hands and making sure her fingernails are were trimmed. ADON X stated she did not think the resident's nails would have grown three-quarters of an inch in a week. ADON X further stated it was important to keep the resident's palms clean/dry and fingernails trimmed to keep them from causing skin issues and odors. <BR/>Review of the facility's Fingernails/Toenails, Care of policy, dated 2018, reflected the following:<BR/>Purpose<BR/>The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections <BR/>Review of the facility's Activities of Daily Living (ADL's), Supporting policy, dated 2018, reflected the following:<BR/>Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). <BR/>Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit a resident to return to the facility after being hospitalized or placed on therapeutic leave for 1 of 3 residents (Resident #1) reviewed for bed hold. <BR/>The facility failed to re-admit Resident #1 after he was treated at a behavioral health hospital, when his discharge back to the facility was anticipated on 06/26/24. <BR/>This failure could place residents at risk of not getting the care and services required. <BR/>Findings included: <BR/>Review of Resident #1's Face Sheet reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] to the secure unit. Resident #1 had the following diagnosis: schizoaffective disorder (mental disorder with abnormal thought processes and unstable mood), heart failure, hyperlipidemia (high cholesterol), mild cognitive impairment (memory and thinking problems), and hypertension (high blood pressure). <BR/>Record review of Resident #1's nursing home discharge MDS, dated [DATE], revealed Resident #1's BIMS, to assess his cognition was blank. Section E of the MDS reflected - Behavior indicated no potential indicators of psychosis; other behavioral symptoms not directed towards others. The MDS reflected Resident #1 required setup or clean-up assistance with all activities of daily living skills. Also, the MDS Discharge Assessment reflected return anticipated. <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1's cognition was intact with a BIMS score of 14. Section E of the MDS reflected - Behavior indicated no potential indicators of psychosis; other behavioral symptoms not directed towards others. The MDS reflected Resident #1 required setup or clean-up assistance with all activities of daily living skills.<BR/>Record review of Resident #1's current care plan reflected Resident #1 had a behavioral problem related to banging on the door displaying aggressive behavior. The care plan reflected: Goal .resident will have no evidence of behavior problems or aggressive behaviors. Interventions included administer medications as ordered. Monitor for side effects and effectiveness, anticipate and meet resident needs, caregivers to provide opportunity for positive interaction, if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate, intervene as necessary, divert attention. <BR/>Record review of Resident #1's progress notes reflected the notes ended on 06/12/24, and the progress notes did not document Resident #1 was transferred to the hospital on [DATE]. There was also no documentation of a discharge summary. <BR/>Record review of the facility's current resident roster, dated 06/27/24, reflected Resident #1 was out on leave to the hospital. <BR/>Interview on 06/27/24 at 12:32 PM with RN A revealed he worked in the facility's memory care unit. He stated Resident #1 had unusual behaviors compared to other memory care residents, and he was younger and more alert. RN A stated Resident #1 walked and paced the floor a lot, write on the walls, try to intimidate other residents. RN A stated it was on Thursday June 14, 2024, Resident #1 kept pacing the floor and was passing a residents on the halls, entered his room and hit the sink, Resident #1 then came out saying he hit his head on the sink and wanted to kill himself. According to RN A, Resident #1 had small amount of blood in the middle of his forehead. RN A stated this was during shift change, so he and the oncoming nurse cleaned Resident #1's wound and administered pain medication. RN A stated he then tried to calm Resident #1 down, offered him snacks, and completed one on one monitoring while LVN B investigated the sink, room and contacted the doctor, DON and Administrator. RN A stated he stayed with Resident #1 until emergency services transferred Resident #1 to hospital for evaluation and further treatment. RN A stated Resident #1 had not returned. <BR/>Interview on 06/27/24 at 12:57 PM with LVN B revealed at the beginning of her shift on 06/14/24, Resident #1 came out of his room and reported that he hit his head on the restroom sink and wanted to kill himself. LVN B stated she assisted the resident with treatment and gave him pain medication. She stated she then conducted a full assessment for Resident #1. LVN B stated she contacted the doctor, DON, and Administrator which resulted in Resident #1 being transferred to the hospital for evaluation and treatment. LVN B stated Resident #1 had not returned to the facility. <BR/>Interview on 06/27/24 at 1:09 PM with the DON revealed on 06/26/24 she received a call from the behavioral health hospital, where Resident #1 had been sent, wanting to know if Resident #1 had transferred from the facility. The DON stated she confirmed he was a resident of the facility. She stated she was asked about the resident's return to the facility, and she responded that an assessment would need to be completed to see if he was able to return. The DON stated she informed the behavioral health hospital she was unsure when the assessment could take place. The DON stated she then referred the hospital to the Administrator. <BR/>Interview on 06/27/24 at 1:55 PM with the Administrator revealed she received a call from the behavioral health hospital and informed them that Resident #1 would not be able to return to the facility. The Administrator stated she expressed to the behavioral health hospital that the facility was possibly not the right place for Resident #1. The Administrator stated said she expressed that Resident #1 could only live on the memory care unit due to being an elopement risk; however, with his behaviors it was not safe for himself or other residents. The Administrator stated, The moment the facility sent a resident out to any hospital they are discharged from our system. She stated she told the hospital Resident #1 was not expected to return to the facility because his needs could not be met. The Administrator stated, discharge documents were not sent with Resident #1 when he transferred to the hospital. The Administrator stated, We wait until we get a call from the hospital to discuss discharge at that time. The Administrator stated the behavioral health hospital had been calling her throughout the day on 06/27/24, but she had not answered their call due to a surveyor being in the building. According to the Administrator, there was no risk to Resident #1 not being able to return to the facility at this time because he was currently at the behavioral health hospital. The Administrator stated she would follow-up with the hospital to give them referrals. <BR/>Interview on 06/28/24 at 12:07 PM with the Program Director at the behavioral health hospital revealed there was no paperwork that followed Resident #1 to the behavioral health hospital, so they had to work backwards to identify which facility he transferred from. The Program Director stated several failed attempts were made to contact the facility about Resident #1's return. The Program Director stated when they finally were able to speak with someone, they were told by the DON Resident #1 required an assessment to see if he was able to return to the facility. The Program Director stated she was then referred to the Administrator, who advised her that Resident #1 was not allowed to return due to property damage. The Program Director stated she asked if there was a formal discharge and requested discharge documents. The Administrator then stated there were no discharge documents sent with him, and he would not be able to return to the facility. The Program Director stated it was the responsibility of the facility to allow him to return since there was no discharge anticipated prior to exiting the facility. The Program Director stated Resident #1 was placed at risk of an unsafe discharge. <BR/>Review of the facility's current, undated Discharging the Resident policy reflected: <BR/> .5. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed, and telephone report is called to the receiving facility. Prepare transfer documents <BR/>Record review of the facility's current Bed Holds and Return Policy policy, dated March 2017, reflected:<BR/>Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.<BR/>1. <BR/>Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy.<BR/>2. <BR/>The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 5 residents (Resident #184, Resident #59, Resident# 38, and Resident #2) reviewed for infection control.<BR/>LVN B and MA D failed to perform hand hygiene between residents while administering medications to Residents #184, #59, #38 and #2. <BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Review of Resident# 184's entry MDS assessment, dated 01/05/24, revealed the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included elevated blood pressure, and atrial fibrillation (irregular heartbeat). Resident #184's BIMS score was not completed resident was newly admitted .<BR/>Review of Resident #59's quarterly MDS assessment, dated 11/15/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and thrombocytopenia (a condition in which the platelets are low in number, which can result in bleeding problems). Resident #59 had severe cognitive impairment with a BIMS score of 07. <BR/>Review of Resident #38's Quarterly MDS assessment, dated 11/01/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including encephalopathy (conditions that cause brain dysfunction), anxiety, and major depressive. Resident#38 had moderate cognitive impairment with a BIMS score of 10.<BR/>Review of Resident #2's Quarterly MDS assessment, dated 12/17/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including elevated blood pressure, anxiety, and muscle weakness. Resident # 2 had moderate cognitive impairment with a BIMS score of 03.<BR/>Review of Resident #2's January 2024 physician orders revealed orders for amlodipine tablet 10mg 1 tablet one time a day and losartan potassium tablet 100mgs 1 tablet by mouth one time a day.<BR/>Observation on 01/08/24 at 07:35 AM, revealed LVN A performing morning medication pass, during which she was observed popping the medication for Resident #184 before performing hand hygiene. LVN A was called in the room by Resident #184 before she finished preparing medication. She was observed getting to the room without performing hand hygiene Residnet#184 requested for his oxygen his to be connected. LVN A was observed connecting the nasal canula to Resident #184 and left the room. LVN A did not perform hand hygiene and proceeded to her cart, continued to prepare medication. She was then observed leaving her cart to another cart and got a bottle of senna 8.6mgs without performing hand hygiene. LVN A came back to her cart and finished preparing medication and was observed entering Resident #184's room and did not perform hand hygiene before administering the medications and after administering.<BR/>Observation on 01/08/24 at 07:48 AM, revealed MA D performed morning medication pass, during which he was observed preparing medication for Resident #59 without performing hand hygiene after he was observed in the dining room of the memory care unit helping residents get seated for breakfast. He later came to his cart, pulled blood pressure cuff disinfected and left to dry. He failed to perform hand hygiene before preparing medication for Resident #59. MA D did not perform hand hygiene before and after administering medications to Resident #59.<BR/>Observation on 01/08/24 at 07:53 AM, revealed MA D performing morning medication pass, during which time MA D checked Resident #38's blood pressure. MA D did disinfect the blood pressure cuff after using it on Resident #38 without gloves and he used the same wipe on his hands. MA D put the blood pressure cuff on top of the medication cart after use.MA D failed to perform hand hygiene before preparing medication for resident #38 and after administering medications to Resident#38.<BR/>Observation on 01/08/24 at 08:03 AM revealed MA D performing morning medication pass, during which time MA D checked Resident #2's blood pressure. MA D did disinfect the blood pressure cuff after using it on Resident #2 without gloves and he used the same wipe on his hands.MA D failed to perform hand hygiene before preparing medication for resident #2 and after administering medications to Resident#2.<BR/>Interview on 01/08/24 at 08:11 AM, MA D revealed he was supposed to perform hand hygiene before and after each resident or between the procedures to prevent contamination and spread of infection. MA D stated he forgot to perform hand hygiene and he did not have hand sanitizer on his cart, but he could have been washing his hands. MA D stated he was using the disinfectant wipe after using it on blood pressure cuff because he thought it would disinfect his hands too. MA D stated he was not performing hand hygiene until when the surveyor brought hand washing to his attention. He stated he knew he was supposed to don gloves while disinfecting the blood pressure gloves. MA D stated he was aware he was supposed to perform hand hygiene to prevent contamination and spread of infection. MA D stated he had done training on infection control.<BR/>Interview on 01/08/24 09:21 AM, LVN A revealed, she was supposed to perform hand hygiene before and after medication administration. She stated she forgot to perform hand hygiene because she got nervous. LVN A stated she had done training on infection control and handwashing.<BR/>Interview on 01/09/24 at 11:14 AM, the DON revealed her expectation was that staff would perform hand hygiene before and after medication administration. The DON stated she expected staffs perform hand hygiene wear gloves disinfect the blood pressure, cuff remove gloves and wash hands. The DON stated the facility had trained staff on hand washing on 1/1/24, and MA D was not in attendance, but he had done hand washing competency on 11/1/23. she stated failure to wash hands would lead to spread of infection.<BR/>Record review on 1/09/24 revealed training on hand washing and infection control dated 1/1/24, MA D did not attend.<BR/>Record review of facility's undated Hand Washing/Hand Hygiene policy, reflected: <BR/>This facility considers hand hygiene the primary means to prevent the spread of infections 6. wash hands with soap(antimicrobial or non-antimicrobial ) and water for the following situations:<BR/>a. <BR/>When hands are visibly soiled; and<BR/>7. Use an alcohol-based had rub containing at least 62% alcohol:or,alternatively,soap(antimicrobial or non -antimicrobial) and water for the following situations:<BR/>b. <BR/>Before and after direct contact with residents.<BR/>c. <BR/>Before preparing or handling medications.<BR/>f. <BR/>Before donning sterile gloves.<BR/>k. After handling used dressings, contaminated equipment,etc.<BR/>l. After contact with objects(e.g., medical equipment)in the immediate vicinity of the resident.<BR/>I. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and<BR/>m. After removing gloves.<BR/> .10.Single -use disposable gloves should be used:<BR/> .c. When in contact with a resident, or the equipment or .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 resident (Resident #1) of five residents reviewed for environment.<BR/>The facility failed to ensure Resident #1 had a functional call light. <BR/>This failure placed residents at risk of not being able to get staff assistance when they need it. <BR/>Findings included:<BR/>Review of Resident #1'S Face Sheet dated 06/03/2024 revealed she was a [AGE] year-old resident admitted to the facility on [DATE] from another skilled nursing home. Relevant diagnoses included fibroblastic disorder (connective tissue dysfunction,) diabetes type 2 (insulin resistance,) major depressive disorder (clinical depression where one feels sad, low, or worthless,) and insomnia (inability to sleep at night.) <BR/>Review of Resident #1's admission MDS dated [DATE] revealed she was cognitively intact with a BIMS score of 15. She was occasionally incontinent of bladder and always continent of bowel. She required a wheelchair for mobility and partial/moderate assistance for shower/baths.<BR/>Review of Resident #1's Comprehensive Care Plan dated 05/07/2024 revealed Resident #1 had acute pain related to fibroblastic disorder and intervention included for the resident to call for assistance when in pain. <BR/>In interview with Resident #1 on 06/03/2024 at 12:35 PM she stated her call light had not worked for a while. She could not specify how long her call light was not functioning; but she stated when she needed anything, she had to self-propel herself in her wheelchair to the nurse's station. She stated that was inconvenient for her. She stated that the facility staff was aware, but it had not been repaired yet. <BR/>In interview and observation with LVN A on 06/03/2024 at 12:36 PM, Resident #1's call light was activated, and the light located outside the door did not light up. LVN A was then interviewed at the nurse's station, and she confirmed that Resident #1's call light was not signaling at the nurse's station. She stated she was not aware that Resident #1's call light was not functioning . When LVN A was asked to provide a maintenance log for review, she was not able to provide it for review and stated that she thought the maintenance man was around the facility, but she did not know what his name was. She stated it was important for the facility's call light system to function so when resident's need the staff, they can let the staff know when they need something. <BR/>Facility maintenance staff was not available for interview at the time of the investigation.<BR/>In interview with the facility's Corporate Maintenance Director on 06/03/2024 at 1:21 PM he stated his expectations were for the facility's call lights to be functioning at all times. Stated he expected for staff to perform routine inspections and document any call light concerns on the facility's maintenance log. He stated he was not aware of Resident #1's call light not functioning but stated he was not the facility's on-site maintenance director and was not aware of all the specifics of this particular building. He stated it was important for the facility call lights to function properly so residents can get immediate service and if not, it would compromise care.<BR/>In interview with facility Administrator on 06/03/2024 at 1:41 PM, she stated that Resident #1 never complained to her about her call light; but stated staff should be rounding daily to check resident call light functionality. She stated it was not acceptable for Resident #1 to not have a working call light. She stated her expectations were for all residents have a call light that functioned as it was extremely important for resident care concerns.<BR/>Review of Facility Maintenance Log provide by the Corporate Maintenance Director on 06/03/2024 at 1:34 PM revealed no evidence of Resident #1's room call light not functioning. <BR/>Review of facility policy, ''Answering the Call Light, undated, provided by the Administrator on 06/03/2024 at 1:53 PM revealed The facility maintains a functional call light system . the staff shall complete routine rounds to maintain resident safety and well-being . General Guidelines . 4. Report all defective call lights to the nurse supervisor promptly. 5. Call light system that needs repair shall be reported to the maintenance staff promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #323's admission MDS dated [DATE] reflected the resident was an [AGE] year-old resident admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure). Resident #323 had a BIMS of 1 indicating his cognition was severely impaired. The MDS further reflected the resident did not have impairment to his upper and lower extremities and ambulated with no assistance. <BR/>Review of Resident #323's care plan initiated on 12/24/24 reflected the resident was at risk for elopement/wandering related to dementia and required placement on the secure unit to provide a secure environment due to risk of elopement. Interventions included to frequent monitor and identified a pattern of wandering and assess reason for wandering and provide redirection as needed . <BR/>Review of Resident #323's hospital records dated 12/01/24 reflected the following:<BR/> Patient is a [AGE] year-old male who presents to [Emergency Room] primarily for pneumonia and neurology was consulted for patient's recent history of elopement and getting lost concerning for newly diagnosed dementia. On chart review is noted that patient had eloped and gotten lost 5 times and family found him after he had fled <BR/>Observation on 02/04/25 at 11:19 PM, revealed there was wooden privacy fence around the outside of the building of the secure unit with three rails inside of the fence, one at the bottom, one in the middle and one towards the top of the fence. <BR/>Review of the facility's PIR dated 01/02/25 reflected that on 12/24/24 Resident #323 had left the facility without signing out and was found by the police department and was returned to his family. The resident was on enhanced supervision until the window of his room was repaired and installation of a fence on the side of the building with potential exiting windows was completed. <BR/>Review of Resident #323 progress notes dated 12/24/24 documented by LVN J reflected the following:<BR/>Resident was up from breakfast in the dining area. Resident ate 100% of meal. Resident showed no signs of pain or discomfort. At 1145, the patient was last observed entering his room. During routine rounds at approximately 12:45 PM, the patient was found to be absent from their room. A code white was initiated promptly, and the search for the patient is currently ongoing [Police] notified the facility that resident had be [sic] found by [Police] 2 hours ago and told resident to [family].<BR/>Interview on 02/05/25 at 10:45 AM, with CNA N revealed she was working the morning of 12/24/24 and sometime after breakfast they staff noticed Resident #323 was not in the secure unit. The CNA N said after breakfast the resident would normally go back to his room and only come out for meals. When they staff realized the resident could not be located, they all began to search the rooms and the bathrooms. After a while, they discovered the window to Resident #323's room was broken and that is how the resident had gotten out. CNA N described Resident #323 as being independent with his ADL's and very pleasant. There were times the resident was seen carrying his bag with his belongings and stand at the exit doors but he was usually easily redirected to go back to his room. <BR/>Interview on 02/05/25 at 11:29 AM, with LVN M revealed she was working during the elopement on 12/24/24 and during her morning rounds during breakfast all residents were accounted for in the secure unit and Resident #323 had gone to the dining room to eat. The LVN M said after breakfast she sat in the hall monitoring and around 11:30 AM she noticed the resident was not in his room so they began to look for him room by room and alerted the rest of the staff the resident was missing. They checked the secure unit doors and they remained locked and after that they noticed the window to his room was broke. They alerted management staff and 911 was also called and later found out he had been found by the police and taken to his family's home. LVN M said she normally did not work the secure unit and had been filling in for someone else. She said Resident #323 did not appear to be exit seeking that day and had not been carrying a packed bag stating he wanted to go home. <BR/>Interview on 02/05/25 at 12:40 PM, with MA O revealed he was working on 12/24/24 he was assisting other staff gather residents in the secure unit into the dining room for lunch. MA O said they realized Resident #323 was not in his room and they began to check every room and around the facility when they realized the window to his room was broken and appeared that is how he had eloped. Management was notified and 911 was also called. MA O said he was told the resident had been found by the police and take to his family's home. MA O further stated Resident #323 was very mobile, independent, with confusion and would only come out of his room for meals. The MA said he never recalled the resident to be exit seeking or saying he wanted to leave the facility. <BR/>Review of the facility's PIR dated 01/10/25 reflected on 01/06/25:<BR/>This resident had previously broken a window and left the facility. As the facility response, we built a wooden fence around the windows on this area of the secured unit. The resident broke a window on the same section and scaled the fence. Staff witnessed the resident scaling and because of the location of the exit had to respond by going around the building. Once they were on the other side of the fence the resident was gone. Staff initiated searchs [sic] for the resident and contacted the police and the police were able to find him two hours later <BR/>Interview on 02/06/25 at 10:25 PM, with LVN Q revealed she worked on 01/04/25 and Resident #323 had dinner in the dining room and had gone back to his new room he was placed in after he was brought back by his family after his first elopement. LVN Q said she was she was sitting in the hallway and during her rounds, sometime after dinner, did not recall the time, she went to Resident #323's room to check on him and did not find him. She happened to glance down the hall and noticed he was headed into his old room, the room he first eloped from, and as she went into that room she did not see Resident #323. LVN Q noticed the window had been forced open and as she went to look outside, she saw Resident #323 on top of the fence, that had been built after his first elopement, but she was not able to get to the resident fast enough even after calling after him. LVN Q alerted staff and by the time they went outside to look for the resident, he was nowhere to be found. LVN Q further stated she alerted management and 911 was called and she was later told the resident had been found by the police and again take to his family's home. <BR/>Interview on 02/05/25 at 3:50 PM, with CNA R revealed he was working on 01/04/25 outside of the secure unit when he was alerted that Resident #323 had eloped from the facility through a window. CNA R said all of the staff began to look for the resident but he was not found. CNA R further stated he did work on the secure unit but has assisted in looking for Resident #323. <BR/>Interview on 02/04/25 at 10:54 AM, with CNA L revealed she was not at the facility during incidents where Resident #323 eloped. CNA L said Resident #323 was independent and very nice. She said the resident was able to communicate his needs and at times he would pack his bag and stand next to the exit doors but was easily redirected back to his room. CNA L stated after his first elopement, the staff had put up a fence around the outside rooms. Resident #323 was taken back to the facility and was put in another room, facing the enclosed courtyard. <BR/>Interview on 02/05/25 at 1:08 PM, with LVN P revealed she worked with Resident #323 and he was usually anxious to be picked up by his family so they could take him home and had a cell phone he would use to call his family. Resident #323 was cooperative and very pleasant with everyone and would stay in room and only come out for meals. LVN P further stated one day she noticed Resident #323 has packed his bag and said he wanted to leave but he had never tried to open the doors or leave and was easily redirected to his room. <BR/>Interview on 02/05/25 at 1:26 PM, with the DON revealed on 12/24/24 staff alerted her that Resident #323 could not be located and they had noticed the window to the resident's room had been broken out. The DON said all the staff were searching for the resident and 911 had been called. The facility later got a call from the police about 4:30 PM stating Resident #323 has been found and take to his family's home. The DON said she was not told how far from the facility he had been found. After that elopement Resident #323's family kept the resident over the holidays and had been taken back the facility on 12/31/24 and placed in another room that did not face the outside of the facility. The DON said while the resident was gone they had fixed the window to his previous room, and they had put up a wooden fence around the perimeter of the secure unit. On 01/04/25 she again was alerted that while making rounds they noticed Resident #323 was not in his room and the window to his old room had been opened and the resident had been seen jumping over the wooden fence. The staff immediately ran outside to look for the resident but he was not found so they called 911. The DON further stated that the police had found Resident #323 and again had been taken back to his family's home. The DON did not know how far from the facility he had been located. Resident #323 did to return to the facility and the family decided to keep him at home. The DON said after each of Resident #323's elopement all the staff were re-in serviced on their elopement policy. Staff participated in an elopement drill to ensure they were competent during a resident elopement. All resident in the secure unit were put on 15-minute checks to make sure there were no other resident that were exit seeking. <BR/>Interview on 02/05/25 at 11:06 AM, with the Director of Maintenance revealed he had built the wooden fence around the outside of the secure unit and was not aware the fence rails should have faced the outside of the fence and not the inside due to the safety of someone being able to climb the fence. The Director of Maintenance further stated that would be a fast and easy fix and he would just have to turn the fence around by sections. <BR/>A Past Non-Compliance Immediate Jeopardy/Immediate Threat was identified on 02/05/25. The Administrator, the Regional Consultant were notified of the Past Non-Compliance Immediate Jeopardy on 02/05/25 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:10 PM. <BR/>Review of the facility's policy titled Elopements dated 2018 reflected the following:<BR/>Staff shall investigate and report all cases of missing residents. <BR/> .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing/designee <BR/> .c. if a resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative the Attending Physician, law enforcement officials <BR/>Observation on 02/04/25 at 10:27 AM revealed there was a staff member sitting in the hallway with a bedside table charting on a laptop. The staff member had visual of the hall where the resident rooms were located and the dining room where other resident were.<BR/>Observation of the secure unit at various times from 02/04/25 to 02/06/25 revealed there were no residents that appeared to have the physical and mental capabilities of climbing the fence. <BR/>Review of the Enhanced Supervision Monitoring Tool dated 12/24/24 and 12/25/24 revealed all the residents in the secure unit has been put on 15-minute checks by staff to ensure no other residents were exit seeking or showing signs of wanting to leave the secure unit. Further review of the Enhanced Supervision Monitoring Tool revealed there were no other residents identified as being exit seeking. <BR/>Review of the Elopement Drill/Actual Event Participation dated 12/27/24 and 12/28/24 revealed staff members actively participated in a drill on what to do when and if a resident went missing. <BR/>Review of the in-services dated 12/24/24 and 01/06/25 revealed staff were in-serviced on the facility's elopement and wandering policy. <BR/>Interview on from 02/04/25 to 02/06/25 at various times with LVN J, LVN P, LVN Q, LVN V, MA O, CNA S, CNA N, CNA T, CNA U, CNA I, and CNA R revealed residents were checked on at the beginning of their shift to ensure all resident were accounted for frequent round were made to monitor all resident for signs of exit seeking. They all said if they were to notice a resident was missing, they were to alert all staff working and begin to look for the resident. If the resident was not located in the building, they would notify management and call 911.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #39) of 18 residents reviewed for care plans. <BR/>The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #39's diagnosis of bullous pemphigoid (rare skin condition causing large, fluid-filled blisters). <BR/>This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. <BR/>Findings included:<BR/>Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA (stroke), non-Alzheimer's dementia, malnutrition, bullous pemphigoid, and muscle wasting. The MDS further reflected the resident was not able to complete a BIMS due to her cognition being severely impaired. The MDS also reflected the resident had impaired range of motion to the lower extremity. <BR/>Review of Resident #39's care plan, revised on 11/19/23, revealed the resident was at risk for pain due to bullous pemphigoid. Goals included the resident would be free of any discomfort or adverse side effects from pain medication. The care plan did not have further details of the autoimmune disease bullous pemphigoid. <BR/>Observation on 01/08/23 at 9:33 AM revealed Resident #39 was in bed with her eyes closed and she was not easily aroused when she was spoken to. Both her hands appeared to be contracted up to her face and there was no device in place in her hands for her possible contractures. <BR/>Observation and interview on 01/09/24 at 2:47 PM with the PT revealed he pulled Resident #39's covers back and he attempted to slowly open the resident's right hand and stated her wrist was very tight and contracted. The PT also assessed the resident's left wrist was currently not contracted but stated both hands could benefit from a hand carrot to prevent contractures/prevent contractures from worsening. <BR/>Interview on 01/10/24 at 12:30 PM with ADON X revealed she worked with Resident #39 as a charge nurse at their sister facility in March 2023 prior to the resident being admitted to the current facility in August 2023. ADON X stated that due to the resident's auto immune disease (bullous pemphigoid) they could not put anything in the resident's contractures because it would cause blisters. The ADON further stated, in the past they attempted to put a device in her contracture and they had caused large blisters in the palms of her hands so they decided the resident could not have anything in place. ADON X further stated she was responsible for resident care plans and said details of Resident #39's autoimmune disorder should have been documented. She said she thought she already addressed it and stated it was important so people would know how to care for the resident. <BR/>Review of Resident #39's clinical records from the previous sister facility, dated 05/2023, revealed the resident was being treated by a wound care doctor for multiple fluid filled blister suspicious for bullous pemphigoid which included the bilateral hands. <BR/>Review of the facility's policy titled Care Plan, Comprehensive Person-Centered reflected the following:<BR/>A comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #39) of 18 reviewed for ADLs. <BR/>The facility failed to ensure Resident #39's contractured hands were kept clean and free of odor.<BR/>This failure had the potential to affectcould place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. <BR/>Findings included:<BR/>Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA, non-Alzheimer's dementia, malnutrition, bullous pemphigoid, and muscle wasting. The MDS further reflected the resident was not able to completed a BIMS due to her cognition being severely impaired.<BR/>Review of Resident #39's care plan, revised on 11/19/23, revealed the resident had an ADL self-care performance deficit. Interventions included the resident was totally dependent on one staff for personal hygiene. <BR/>Observation on 01/08/23 at 9:33 AM revealed Resident #39 was in bed with her eyes closed and she was not easily aroused when she was spoken to. Both her hands appeared to be contracted up to her face.<BR/>Observation and interview on 01/09/23 at 1:55 PM with CNA MM revealed she slowly opened Resident #39's right hand and her fingernails were observed to be about three-quarters of an inch long, they appeared to be digging into the palm of her hand, and there was an odor noted. The skin to the resident's palm was intact and there was no skin breakdown noted. CNA MM attempted to open the resident's left hand but the resident would not allow her to. CNA MM further stated it was the aides responsibility to cut the resident's fingernails and said she had cut Resident #39's fingernails the previous week and said hers just grow really fast. <BR/>Observation and interview on 01/09/24 at 2:47 PM with the PT revealed he pulled Resident #39's covers back and he attempted to slowly open the resident's right and left hand and once opened he stated there was an odor to the palms of the resident's palms from being closed and not cleaned. The PT further stated the fingernails needed to be cut because they were digging into her palms and could cause skin breakdown and the PT also did not think Resident's fingernails could grow that much in a week. <BR/>Interview on 01/10/23 at 12:30 PM with ADON X revealed aides should be cleaning the inside of Resident #39's hands and making sure her fingernails are were trimmed. ADON X stated she did not think the resident's nails would have grown three-quarters of an inch in a week. ADON X further stated it was important to keep the resident's palms clean/dry and fingernails trimmed to keep them from causing skin issues and odors. <BR/>Review of the facility's Fingernails/Toenails, Care of policy, dated 2018, reflected the following:<BR/>Purpose<BR/>The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections <BR/>Review of the facility's Activities of Daily Living (ADL's), Supporting policy, dated 2018, reflected the following:<BR/>Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). <BR/>Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of four residents (Resident #73) reviewed for feeding tubes.<BR/>The facility failed to follow physician's orders of providing Resident #73 with his 20 hours of feeding intake. <BR/>This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of g-tube care.<BR/>Finding included: <BR/>Record review of Resident #73's face sheet, dated 01/10/24, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included aphasia (a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain) following cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood) and encephalopathy (a medical term used to describe a disease that affects brain structure or function; it causes altered mental state and confusion).<BR/>Record review of Resident #73's quarterly MDS assessment, dated 12/29/23, reflected the staff assessment for mental status was completed and indicated there was severe impairment cognitively.<BR/>Record review of Resident #73's physician's orders reflected: enteral feed order every shift 48 ml/hr, downtime from 0800-1200 with a start date of 09/07/23.<BR/>Record review of Resident #73's care plan, dated 12/05/23, reflected: Focus: [Resident #73] requires the use of a feeding tube and is at risk for aspirations, weight loss, and dehydration; Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable, no signs or symptoms of malnutrition, or dehydration through review date; Interventions: Administer tube feeding and water flushes as ordered.<BR/>Observation on 01/07/24 at 11:49 AM of Resident #73 revealed his tube feeding machine was not on and he was not able to answer any questions.<BR/>Observation on 01/07/24 at 1:03 PM of Resident #73 revealed his tube feeding machine was not on and he was not able to answer any questions.<BR/>Interview on 01/07/24 at 1:58 PM with LVN P revealed she was Resident #73's nurse and turned off his tube feeding machine this morning at 8:00 AM. LVN P said she knew Resident #73's tube feeding machine was supposed to be turned back on at 12:00 PM but she was late being able to do that earlier. LVN P said Resident #73's order stated he was supposed to receive 20 hours of nutrition and the machine should only be off for four hours. LVN P said she was busy during lunch service and forgot to turn the machine on when it was time at noon. LVN P said the purpose of ensuring Resident #73's machine was turned on was because she was expected to follow doctor's orders regarding his care. LVN P said not turning the machine on when it was time was caused Resident #73 to not get his full 20 hours of nutrition and it would put him at risk of losing weight if he had a minimal intake of the fluid or formula. <BR/>Interview on 01/09/24 at 12:49 PM with the Dietitian revealed she was not familiar with Resident #73's orders but said if his actual order was written with a specific hours for him to not have his tube feeding machine on, the order should be followed.<BR/>Interview on 01/09/24 at 1:02 PM with the DON revealed staff should adhere to any resident's down time for their tube feeding machine and nutrition. The DON said the order was in the system was so any nurse caring for that resident was responsible for following the order. The DON said the purpose of following the order was to make sure the resident got the proper amount of calories for sustainability and if not it put them at risk of losing weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #53) reviewed for dialysis.<BR/>The facility failed to ensure post-dialysis assessments were completed for Resident #53 after return from dialysis treatment. <BR/>This failure could place residents at risk of inadequate post dialysis care.<BR/>Findings included:<BR/>Record review of Resident #53's, undated, face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #53 had diagnoses which included acute kidney failure (when kidneys suddenly become unable to filter waste products from blood) and chronic kidney disease stage 3 (mild to moderate damage to kidneys, and they are less able to filter waste and fluid out of the blood).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 11/22/23, reflected a BIMS score of 6, which indicated her cognition was severely impaired. The MDS section O related to special treatments, procedures and programs reflected Resident #53 received dialysis.<BR/>Record review of Resident #53's care plan, dated 05/02/23, reflected Resident #53 needed hemodialysis rule out end stage renal failure. Resident #53 will have no signs of complication from dialysis through next review. The access site will function and be maintained without signs and symptoms of infection. Monitor/document for peripheral edema. Monitor/record/report to MD as needed any signs of infection to access site, redness, swelling, warmth or discharge. Obtain vital signs and weight per protocol. Report significant changes in pulse respiration and blood pressure immediately. Monitor/record/report to MD PRN sign and symptoms of renal insufficiency, changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. <BR/>Record review of Resident #53's physician's order, dated 01/10/23, reflected post dialysis monitoring; check site for clotting, bleeding, drainage and dressing intact. Monitor vital signs in the morning every Tuesday, Thursday, and Saturday for dialysis and in the afternoon every Tuesday, Thursday, and Saturday for dialysis.<BR/>Record review of Resident #53's EHR reflected no nursing documentation regarding Resident #53's dialysis monitoring of the resident's post-dialysis vital signs. <BR/>Record review of Resident #53's dialysis communication forms reflected dialysis communication forms with no information on the resident assessment and observation post-dialysis section on 12/02/23, 12/05/23, 12/07/23, 12/09/23, 12/12/23, 12/14/23 and 12/16/23.<BR/>Interview on 01/09/24 at 04:31 PM with the DON revealed it was the nurses' responsibility to send dialysis residents with a communication form to dialysis and get the form back when the resident returned to the facility so if there were orders from dialysis or changes, it was noted. Dialysis staff were not interviewed and no orders that were unattended to. She stated her expectation was for the nurses to perform post-dialysis assessments when residents returned from dialysis and document on dialysis communication forms on dialysis days. She stated failure to monitor the vital signs after dialysis staff would not note the change of condition, bleeding and whether the vitals were stable. She stated she had done training with staff and the last in-service was in December 2023. No change in condition noted.<BR/>Interview on 01/10/24 at 12:10 PM with RN E revealed he was aware he was supposed to send Resident #53 with the dialysis communication form when she left for dialysis and then collect the form when the resident returned from dialysis. RN E stated he knew he was supposed to monitor the dialysis access site for the bruit thrill (a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above incision line), dressing for bleeding and vital signs when Resident #53 was back from dialysis but he was not consistent because when Residnet#53 returned from dialysis in the afternoon, it would be during medication administration time. RN E stated failure to monitor and assess Residet#53 post dialysis put her at risk of low blood pressure and bleeding. He stated he had done trainings, but he could not tell whether dialysis was one of them.<BR/>Interview on 01/10/24 at 12:21 PM with ADON X revealed it was management's responsibility to ensure the staff completed post dialysis communication forms when Resident #53 returned to the facility. ADON X stated she went through the dialysis communication forms for December and noticed there was a big problem and staff were not completing the post-dialysis section when the surveyor brought the concern to her. ADON X stated the importance of assessments were to ensure the vital signs were stable and check for bleeding. She stated the risk for not assessing the vitals was Resident #53 could be unstable and the permcath (special catheter used for short-term dialysis treatment) could be bleeding. She stated the facility will do Inservice and monitor.<BR/>Interview on 01/10/24 at 03:41 PM with LVN A revealed she worked with Resident #53 on Thursday and Fridays, and she ensured Resident #53 went to dialysis on Thursday with the communication form filled. She stated she was responsible to fill out the dialysis communication form when the resident returned, after the assessment of the vials signs and checking the port site for bleeding, but she would forget. She stated failure to check vital signs and monitoring the port site could lead to low blood pressure and bleeding that could lead to Resident #53 experiencing dizziness and falls.<BR/>Record review of the facility's policy, dated 11/17/23, reflected the following, <BR/> .19. Facility will monitor departures and returns from dialysis center. The facility will document the resident's vital signs, general appearance, orientation, additional baseline data as needed. The resident clinical record will be documented wit this information. The date and time of the residents' return to the facility will be recorded by the nurse.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on two of four medication carts (back and front nurses' carts) and 3 of 3 staff (LVN R, RN NN, and LVN L) reviewed for pharmacy services.<BR/>The facility failed to ensure the back and front nurses medication cart contained accurate narcotic logs for Residents #184, #62, and #43.<BR/>LVN R, RN NN and LVN L failed to document the administration of narcotic medications in a correct and timely manner. <BR/>This failure could place residents at risk for drug diversion and delay in medication administration.<BR/>Findings included:<BR/>Observation on 01/08/24 at 02:48 PM, of the nurses' medication cart and the narcotic administration record, with LVN R, revealed the following information:<BR/>Resident #43's narcotic administration record sheet for Hydrocodone-Acetaminophen 5/325 mg was last signed off on 01/5/24 for a one-tablet dose given at 3:30 PM, for a total of 8 pills remaining while the blister pack count was 7 pills. The NAR sheet for Lorazepam 0.5 mg was last signed off on 01/07/24 for a one-tablet dose given at 3:20 PM, for a total of 8 pills remaining while the blister pack count was 7 pills.<BR/>Interview with LVN R on 01/08/24 at 3:02 PM, revealed she administered the Hydrocodone-Acetaminophen 5/325 mg 1 tablet and Lorazepam 0.5 mg 1 tablet to Resident #43 as needed for pain and anxiety and she had not signed off on the NAR. She stated she gave the resident the medication, but she forgot to document on the medication administration record and sign off on the narcotic administration log. She stated she knew she was to sign-out on the narcotic count sheet after administration and on the medication administration record, but she did not. She stated failure to do that would cause the narcotic count to show less on the next count and it could lead to a narcotics diversion. She stated she had done in-service on medication administration.<BR/>Observation on 01/08/24 at 3:33 PM, of the nurses' medication cart and narcotic administration record with LVN L, revealed the following information:<BR/>- Resident #184's sheet for Acetaminophen with codeine 300-30 mg revealed it was last signed off on 01/6/24 for a one-tablet dose given at 2:01 AM, for a total of 57 pills remaining while the blister pack count was 56 pills.<BR/>- Resident #62's sheet for Acetaminophen with codeine 300-30 mg revealed it was last signed off on 01/7/24 for a one-tablet dose given at 4:00 PM, for a total of 46 pills remaining while the blister pack count was 43 pills.<BR/>Interview with LVN L on 01/08/24 at 3:59 PM revealed the night shift nurse had administered Acetaminophen with codeine 300-30 mg 1 tablet to each Resident #184 and Resident #62 and she did not log off on the NAR. LVN L stated she had also administered Acetaminophen with codeine 300-30 mg 1 tablet to Resident #62 on 01/08/24 at 7:27 AM and 3:00 PM, and she had not logged off on NAR. She revealed she was supposed to log off after administration. LVN L stated she gave Resident #62 medication, but she documented on the medication administration record, and she did not sign it off on the narcotic administration log. She stated she knew she was to sign-out on the narcotic count sheet after administration and on the medication administration record, but she did not. She stated the night shift nurse had informed her she had not logged off and she did not notify the management. She stated she had done in-service on controlled substances.<BR/>Interview on 01/09/24 at 11:26 AM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. The DON stated after interviewing both nurses they admitted they did not count during shift change and they were taking action. She stated LVN L was not supposed to take the key without counting and making sure the narcotic count was correct. She stated it was her responsibility and the ADON's to audit the medication carts.<BR/>Interview on 01/09/24 at 1:29 PM, ADON G revealed she was responsible of checking the carts weekly. She stated she checks on counts on NAR to ensure they are correct to prevent diversion. She stated her expectation is when staff administer narcotics they should document on MAR and also log off on NAR. She could not tell the last day she had checked the carts .<BR/>Interview on 01/10/24 at 10:19 AM, RN NN revealed she was the night nurse on 1/7/23, and she forgot to sign off Acetaminophen with codeine 300-30 mg 1 tablet that she administered to Resident #62 on 1/7/24 at 09:00 PM. She stated she was aware she was supposed to sign off narcotics after administering. RN NN stated she was to count with the oncoming nurse, but they did not because the oncoming nurse took the cart to the hallway after report. RN NN stated she felt that was her fault and she regreted giving her the key before counting. She stated the risk of not counting was diversion of narcotics and no proof she had administered the medication to the resident. She stated she had done in-services on controlled substance and medication administration.<BR/>Interview with LVN L on 01/10/24 at 03:31 PM, she revealed she wanted to tell the truth she had not counted narcotics with the night nurse because the nurse dropped the key and walked away. She stated she did not report to management.<BR/>Review of the facility current Medication-Controlled Substances policy, dated November 2023, reflected the following: <BR/>Nursing staff must count controlled medications at the end of each shift. The nurses coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON.

Based on observation, record review, and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (front hall and back hall ) of four medication carts and one of one refrigerator reviewed for pharmacy services.<BR/>1. The facility failed to ensure expired medications in nurse medication carts for front hall and refrigerator were removed and destroyed.<BR/>2. The facility failed to ensure insulin were dated with opening dates.<BR/>3. The facility failed to ensure vaccines were stored at the right temperatures and refrigerator temperatures were being maintained within normal ranges. <BR/>These failures placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart, in the refrigerator, not putting opening date on insulin pens/vials and maintaining the refrigerator temperatures within ranges.<BR/>Findings included:<BR/>1. Observation on 01/08/24 at 03:11 PM of the facility refrigerator used for the sunflower Hall with LVN R revealed 2 packets of influenza vaccine 0.5 mL vials that were frozen. The temperature in the fridge was 42 degrees.<BR/>The temperature log was documented as follows:<BR/>01/01/24 - 30 degrees Fahrenheit.<BR/>01/02/24 - 31 degrees Fahrenheit.<BR/>01/03/24 - 31 degrees Fahrenheit.<BR/>01/04/24 - 31 degrees Fahrenheit.<BR/>01/05/24 - 31 degrees Fahrenheit.<BR/>01/06/24 - 40 degrees Fahrenheit.<BR/>01/07/24 - 48 degrees Fahrenheit.<BR/>01/08/24 - 40 degrees Fahrenheit.<BR/>There were also 2 acetaminophen suppositories with expiry date 03/23, 3 acetaminophen suppositories with expiry date 09/06/23 and 4 acetaminophen suppositories with expiry date 10/19/23.<BR/>Interview on 01/08/24 at 3:32 PM, LVN R revealed it was all nurses' responsibility to check the carts for expired medications and monitor the refrigerator temperatures. She stated the last time she checked the refrigerator was 01/05/24. and she only checked on the insulin for expiry and she did not check other medications and that is how she missed to see the flu vaccines were frozen. She stated the nurses are supposed to get all expired medications from the fridge and put them in the destruction boxes. LVN R stated she did not know the correct temperatures for the refrigerator, and she had been documenting every morning whatever reading was showing on the thermometer .She stated she had done in-service on labelling and checking of expired medications.<BR/>2. Observation on 01/08/24 at 03:33 PM, of the nurse's medication cart used for the Sunflower Hall back with LVN L revealed, three insulin pens of Levemir Subcutaneous Solution 100 unit/ml (Insulin Detemir), Lantus Solostar Solution Pen-injector 100 unit/ml (Insulin Glargine) and insulin glargine subcutaneous solution 100 unit/ml (Insulin Glargine) were open and partially used, and without an opening date. There were also two bottles of atropine open one with opening date of 4/10/23 and with use by date 9/6/23 and another with open date 11/9/22 and use by date 04/7/23.<BR/>Interview on 01/08/24 at 03:59 PM, with LVN L revealed it was all nurses' responsibility to put an opening date on insulin vial/pen after removing from the refrigerator. She stated she was supposed to check her cart every shift, for the opening dates and expiry dates. She stated short acting insulins are good for 28 days after being opened. She stated the effects of not putting opening date on insulin vials/pen they would not be sure when it expires and might not be effective in controlling blood sugars if administered. She stated she had completed training on labeling and storage of insulin.<BR/>Interview on 01/09/24 at 11:37AM, the DON revealed, her expectation was for all nurses to put opening dates on insulin once they remove from the refrigerator, and those not being used should be stored in the refrigerator. She stated the risk of not putting the opening dates nurses will not be able to tell when they expire. She stated if insulin expires it will not be effective and residents blood sugars will not be controlled. The DON stated the flu vaccines were not supposed to be frozen because it is well indicated on the box at what temperature they need to be stored. She stated the risk of vaccines being frozen they will not be effective if administered. She stated night shift staff are responsible of checking the refrigerator temperatures, documenting and removal of expired medications . She stated it is her responsibility and the ADONs to check the carts and medication rooms weekly and she does the monthly audit. She stated the refrigerator was supposed to be maintained between 36- and 46-degrees Fahrenheit. She stated she had done training on refrigerator monitoring with staff no in-service record was presented.<BR/>Interview on 01/09/24 at 01:29 PM, ADON X revealed night shift nurses are responsible of checking the refrigerators in medication rooms and for expired and monitoring the temperatures .ADON X revealed she would check the temperatures charting but not every day. She stated the last time she performed a weekly check was 1/5/24 and she did not notice the documented temperatures were not within the expected ranges. She stated she noted the flu vaccines were frozen after the surveyor mentioned they were frozen. She stated if staff were not checking the refrigerator for expired medications and medications were administered to residents, they would not be effective. She stated she had done in-service on refrigerator temperatures and opening dates. No record for in-service provided.<BR/>Interview on 01/10/24 at 10:19 AM, RN NN said she works night shift, and they are supposed to check the temperatures of the refrigerators, but no nurse is allocated. She stated the refrigerator temperatures should be between 36-46 degrees Fahrenheit.<BR/>Record review of the facility's current administering medication policy, revised 2018, reflected the following:<BR/>9.The expiration/beyond use date on the medication label must be checked prior to administering: When opening a multi-dose container, the date opened shall be record on the container .<BR/>Record review of the facility's current storage of medication policy, revised 2018, reflected the following:<BR/>9.Medication requiring refrigeration must be stored in a refrigerator (acceptable temperatures of 36-46 degrees Fahrenheit) located in the drug room (accepted temperature 68-77 degrees Fahrenheit) at the nurses' station or other secured location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide special eating equipment and utensils for one (Resident #5) of two residents reviewed for meal service. <BR/>The facility failed to provide Resident #5 a divided plate at lunch on 01/08/24 to assist her with eating independently. <BR/>This failure could place residents at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. <BR/>Findings included:<BR/>Review of Resident #5's face sheet, dated 01/10/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), dysphagia (a condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink), and cognitive communication deficit.<BR/>Review of Resident #5's quarterly MDS assessment, dated 12/28/23, reflected she had a BIMS score of 01 indicating severe cognitive impairment. <BR/>Review of Resident #5's physician's orders reflected an order for: Divided plate to be used for all meals. With meals related to cerebral pasly [sic] with a start date of 10/29/18.<BR/>Review of Resident #5's care plan, dated 11/30/22, reflected the following:<BR/>Focus: [Resident #5] is on a therapeutic, mechanically altered diet- Puree/nectar thick liquids. Resident meals are serve in a divided plate for all meals [sic].<BR/>Observation on 01/08/24 at 12:45 PM of [NAME] W plating Resident #5's lunch meal revealed it was plated on a flat plate and not on a divided plate. <BR/>Observation on 01/08/24 at 12:55 PM, Resident #5 in her room with her lunch plate revealed she was having trouble scooping up her food from the plate in front of her. Resident #5 was not able to answer any questions.<BR/>Interview on 01/08/24 at 12:56 PM with Resident #9, who was Resident #5's roommate, revealed Resident #5 was having trouble eating her food off the plate she was receiving. Resident #9 said she looked out for Resident #5 and said she was supposed to get a different plate that would help her scoop her food up easier to be able to eat. <BR/>Interview on 01/08/24 at 12:57 PM, the Staffing Coordinator revealed she was just helping out during the lunch service and took Resident #5 her lunch meal. The Staffing Coordinator said she did not know Resident #5 was supposed to have a divided plate with her meal but said that the kitchen was responsible for providing that.<BR/>Interview on 01/08/24 at 1:30 PM, the Dietary Manager revealed she thought the divided plate order was discontinued for Resident #5 and would have to pull one out of storage if it was still an active order. The Dietary Manager said she was told the divided plate order was taken off a few months ago and thought someone must have added it recently and not told her about it. The Dietary Manager said the kitchen was responsible for providing divided plates to residents that it was ordered for. The Dietary Manager said they normally checked resident's meal tickets while preparing their plates and did not notice the divided plate was listed on the meal ticket. The Dietary Manager said the purpose was to have the resident's food separated.<BR/>Review of the facility's policy dated 2018, and titled Assistance with Meals, reflected: Residents Who May Benefit from Assistive Devices .1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them.

Based on observation, interview and record review the facility failed to provide a comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 9 of 9 residents (Residents #48, #3, #43, #6, #76, #45, #135, #7, and #23) and 3 of 3 zones (Zones #1, #2, and #3) reviewed for environment. <BR/>The facility failed to ensure temperatures were above 71 degrees Fahrenheit after the heater went out on the night of 01/08/24 to the morning of 01/09/24. <BR/>An Immediate Jeopardy (IJ) situation was identified on 01/09/24. While the IJ was removed on 01/10/24, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems .<BR/>This failure could place residents at risk of hypothermia and extreme cold.<BR/>Findings included:<BR/>Observation on 01/09/24 at 8:30 AM when entering the facility, revealed it was noticeably cold and staff were still wearing their coats while in the building. <BR/>Observation on 01/09/24 at 8:39 AM of Zone #1's thermostat on the wall showed it was 60 degrees F.<BR/>Observation on 01/09/24 at 8:41 AM of the activity room's thermostat on the wall showed it was 63 degrees F.<BR/>Observation on 01/09/24 at 9:31 AM of Zone #1's thermostat showed it was 59 degrees F.<BR/>Observation on 01/09/24 at 9:34 AM of Zone #3's thermostat showed it was 65 degrees F.<BR/>Observation on 01/09/24 at 9:35 AM of Zone #2's thermostat showed it was 67 degrees F.<BR/>Interview on 01/09/24 at 8:35 AM with the Administrator revealed something happened to the heater and there was not heat in the facility.<BR/>Interview on 01/09/24 at 8:37 AM with Resident #48 revealed he was in his room laying in bed under blankets. Resident #48 said he was freezing cold and noticed it getting colder through the night. Resident #48 said he was not offered any extra blankets or anything after it started getting colder and had to get his coat to put underneath his blankets to keep him warm. <BR/>Interview on 01/09/24 at 9:02 AM with Resident #3 revealed she was in her room laying in her bed under blankets and was visibly shivering. Resident #3 said she had two blankets but needed a third one. Resident #3 said she noticed it started getting very cold last night. <BR/>Interview on 01/09/24 at 9:05 AM with CNA O revealed she noticed it was unusually cold this morning when she came in for her shift. CNA O said she reported this to her nurse because two residents (Residents #43 and #33) were in the Activity Room earlier and wanted to leave because it was too cold so they wanted to go back to their rooms. CNA O said she did not call the Administrator when she came in for her shift because she did not see a reason to do so. CNA O said everyone in the facility was already aware it was cold in the building because everyone could feel it.<BR/>Interview on 01/09/24 at 9:08 AM with Resident #43 revealed she was in her room sitting in a geri-chair with a blanket over her. Resident #43 said she was very cold and was waiting for more blankets. Resident #43 said she noticed last night that it got very cold, and she had to leave the activity room earlier because it was so cold.<BR/>Interview on 01/09/24 at 9:10 AM with Resident #6 revealed she was sitting at a table in the dining room with a coat and blanket covering her, eating her breakfast. Resident #6 said she was very cold last night and had to ask for two additional blankets from staff. Resident #6 said it was still cold this morning and she was not sure what happened with the heat in the building.<BR/>Interview on 01/09/24 at 9:11 AM with Resident #76 revealed he was in the dining room standing up drinking hot coffee. Resident #76 said he noticed it got very cold last night and the coffee was helping to warm him up.<BR/>Interview on 01/09/24 at 9:14 AM with Resident #135 revealed she woke up at 4:00 AM because she was so cold and had to get a thick blanket. Resident #135 said she had not been able to get warm since and last night when she went to bed she was okay.<BR/>Interview on 01/09/24 at 9:30 AM with Resident #7 revealed she was cold last night and was given a blanket a few minutes ago and was now getting warmer. <BR/>Observation and interview on 01/09/24 at 9:38 AM with Resident #23 revealed she was cold around midnight when she was woken up for her medication. Resident #23 said she felt cold and asked for an extra blanket.<BR/>Interview on 01/09/24 at 9:41 AM with Resident #45 revealed she was in her room and had all of her clothes piled on top of her in her bed. Resident #45 said it was very cold in the facility and she woke up about 2:00 AM last night and had to pile her clothes on top of her to keep warm. Resident #45 said she asked for blankets from staff but never got any from them. Resident #45 said she had not been able to warm up yet.<BR/>Interview on 01/09/24 at 9:46 AM with CNA B revealed she came to the facility at 6:00 AM this morning and noticed it was cold. CNA B said she did not notify anyone that the facility felt cold. <BR/>Interview on 01/09/24 at 9:59 AM, RN OO said he came to the facility around 5:45 AM and noticed it was cold. RN OO said the night shift also told him it was cold in the facility. RN OO said he tried to adjust the temperature and he could not tell what the temperature was, but he tried to get it up to 80 degrees F. RN OO said he started walking around giving blankets to residents.<BR/>Interview on 01/09/24 at 10:01 AM with LVN JJ revealed she worked the night shift, and it was cold in the facility. LVN JJ said she tried to increase the temperature and the temperature was going up and down and then went off. LVN JJ said she realized the hall started getting cold and she adjusted the thermostat on the wall. LVN JJ said she gave extra blankets to some residents but could not remember who they were.<BR/>Attempted interview via phone on 01/09/24 at 10:32 AM with LVN N was unsuccessful.<BR/>Attempted interview via phone on 01/09/24 at 10:37 AM with LVN Q was unsuccessful.<BR/>Interview via phone on 01/09/24 at 10:39 AM with CNA K revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility around 11:00 PM/Midnight/1:00 AM. CNA K said she did not check the thermostats in the facility but stated it was cold. CNA K said several residents started asking for blankets and she provided those for them. CNA K said the facility did not normally feel that cold inside. CNA K said everyone could feel the cold in the facility but she was not sure why it was so cold and did not report it to the Administrator. CNA K said she was not aware the heat was out in the facility. <BR/>Interview via phone on 01/09/24 at 10:50 AM with LVN J revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility early this morning. LVN J said she did not report it to the Administrator because she was not aware the heat was out. <BR/>In an interview on 01/09/24 at 12:00 PM with the Administrator revealed he was told by the alarm company that a wire was dislodged in one of the panels that the heater was connected to and that was what caused it to go out. The Administrator said he was notified on his way to work this morning around 7:00 AM or 7:15 AM by ADON X that the heat was out at the facility . The Administrator said he was not contacted by any staff who worked the overnight shift regarding the heat being out in the facility. The Administrator said he contacted the Maintenance Director immediately who was at the facility within minutes to assess where in the building the heat was out. The Administrator said when he got to the building, he did see that the thermostats in the building were reading in the 60s. The Administrator said he knew the weather outside was very cold and the wind made it even colder. The Administrator said he knew the temperature inside the facility was supposed to be between 71 to 81 degrees F per federal and state requirements. The Administrator said he expected staff to contact him anytime they noticed the heat was out at the facility and as soon as they noticed it. The Administrator said the risk of not having heat in the building put residents at risk of hypothermia or becoming sick from being too cold. The Administrator said while checking on residents this morning, a few of them had complained about the cold.<BR/>Interview on 01/09/24 at 12:25 PM with ADON X revealed she got to the building after 6:00 AM and noticed it was extra cold in the facility. ADON X said she checked each thermostat to make sure the heat was on and noticed a few were off so she turned them on and gave them a few minutes to kick on. ADON X said after 7:00 AM she called the Administrator to let him know it was very cold in the building and the heat was not working. ADON X said she saw the thermostats on the walls were in the 60s. ADON X said she was not contacted by anyone from the overnight shift about there not being heat in the building. ADON X said when she got to the building the overnight shift had already left but the day shift staff did tell her it was a lot colder than normal. ADON X said she told staff to start offering blankets to residents and passed warm liquids to them. ADON X said if the overnight shift started to notice it getting cooler in the facility, they should have contacted the Administrator or any manager to let them know what was going on, immediately.<BR/>Interview on 01/09/24 at 1:02 PM with the DON revealed she was on her way to the facility this morning when ADON X called her to say it was cold in the facility. The DON said she was not contacted by anyone on the overnight shift regarding the lack of heat in the building. The DON said she saw one thermostat on the wall in the facility and it was in the 60s. The DON said if the overnight staff noticed it getting cold in the facility during their shift, they should have immediately contacted the Administrator. <BR/>Interview on 01/09/24 at 2:58 PM with the Maintenance Director revealed he got to the facility early this morning around 6:35 AM and was outside the building for a while and when he came into the building, he noticed it was cold. The Maintenance Director said he noticed the A/C units outside were not running and then the Administrator called him to say that there was not any heat in the building. The Maintenance Director said he contacted the HVAC company to come out and help turn the heat on. The Maintenance Director said he noticed the thermostats read in the 60s. The Maintenance Director said he was not contacted by any overnight staff about the lack of heat in the building. The Maintenance Director said if he had been called by the overnight staff he would have come to the facility to try and fix everything immediately. <BR/>Record review of the local temperatures for the area (accessed at: National Weather Service: Observed Weather for past 3 Days: reflected the temperature at midnight on 01/09/24 was 49 degrees F with a wind chill temperature of 44 degrees F; the temperature at 5:00 AM was 35 degrees F with a wind chill temperature of 25 degrees F; and the temperature at 9:00 AM was 37 degrees F with a wind chill temperature of 28 degrees F.<BR/>Record review of the facility's policy, dated 2018, and titled Resident Rights reflected: 1. Federal and state laws guarantee certain basic rights to all residents of this facility.<BR/>This was determined to be an Immediate Jeopardy on 01/09/24 at 4:55 PM. The Administrator was notified. The Administrator was provided the Immediate Jeopardy template on 01/09/24 at 4:59 PM.<BR/>The following Plan of Removal submitted by the facility was accepted on 01/10/24 at 9:35 AM:<BR/>Plan of Removal<BR/>Immediate Jeopardy <BR/>On 01/09/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: F584 - The facility failed to establish and maintain a comfortable environment for residents when the heat went out in the facility and the temperature in the facility was as low as 59 degrees F. There is likely a serious adverse outcome that will occur due to the facility not taking immediate action when the facility's temperature was at 59 degrees F. Staff overnight did not immediately contact the Administrator when they noticed the building becoming unusually cold. The facility puts the residents at risk of not having a comfortable environment putting them at risk of being exposed to the cold.<BR/>All facility residents have the potential to be affected by deficient practice. <BR/>This is an isolated event; no residents, staff, or visitors suffered a serious adverse outcome due to the facility staff not immediately contacting the facility administrator when the facility's temperature in the building became unusually cold. <BR/>The facility needs to take immediate action to ensure all staff are aware of who/when to contact the Administrator in times of extreme cold/heat and know what actions to take to keep the residents safe and comfortable.<BR/>1). Action: The facility administrator upon becoming aware at 7 am (01/09/2024), immediately called the facility Maintenance Director, who was at the facility to troubleshoot the heating system; upon becoming aware that the heating system would not turn on, the facility administrator called HVAC and Electronic Engineer vendor to report to the facility to assist in repairing the heating system and ordered spot heaters to be delivered to the facility; spot heaters arrived at 9:30 am and installed portable heaters . The Electronic Engineer discovered a loose wire and repaired the loose connection at 11 am. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/09/2024<BR/>Responsible: Facility Maintenance Director and Facility administrator<BR/>2). Action: The facility administrator assigned wellness checks (assessing for signs of hypothermia) on 01/09/2024 at 7 am to the facility Assistant Director of Nursing hourly until the facility temperature came into acceptable range ; residents needing extra blankets and warm fluids were provided promptly. All resident complaints about uncomfortable temperatures were resolved at noon. On 01/09/2024. No resident suffered a serious adverse outcome.<BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/09/2024<BR/>Responsible: Facility administrator and Facility Assistant Director<BR/>3). Action: The Chief Nursing Officer updated and re-educated the facility Administrator and Director of Nursing on the Policy and Procedure for a). Reporting Unusual Occurrences/Events; which included the importance of prompt reporting of unacceptable temperatures and the importance of the facility always maintaining a temperature range of 71&deg;F to 81&deg;F. If/when unacceptable temperatures are observed such occurrence must be reported to the facility administrator immediately. The mode of education was a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024. Comprehension was assessed by the Chief Nursing Officer via the teach-back method on 01/09/2024. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Chief Nursing Officer<BR/>4). Action: The facility administrator educated Department managers on policy and procedure for reporting unusual occurrences and events , who then educated the facility staff in their departments which included the Director of Nursing educating Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs), the Environmental Services Supervisor educating both Housekeeping and laundry persons), Dietary Manager educating the Dietary Personnel (Cooks, Tray Aides), the Rehab Director educating therapy staff (Physical Therapist, Occupational Therapist, Speech Therapists) on duty of the facility Policy and Procedure for reporting unusual occurrences/events that could affect the health, safety, or welfare of the facility residents, employees, or visitors which include and is not limited to: <BR/>a. Interruptions of essential services (e.g. heating, air conditioning, food, water, linens, sewage, or needed medical supplies;<BR/>b. earthquakes, floods, gas explosions, fires, power outages;<BR/>c. Communicable disease;<BR/>d. Poisonings;<BR/>e. Death of a resident;<BR/>f. Inoperable emergency systems, equipment, or resident call systems; and<BR/>g. Allegations of abuse, neglect, and misappropriation of resident property.<BR/>Staff not on duty during the training period will receive 1:1 training before starting their next shift from the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the facility Administrator (LNFA) and will not be allowed to work until education has been completed. The mode of education was /will be a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024 and ongoing until all facility staff have been re-educated. Education is to be added as part of the orientation for ongoing training of new hires, agency, and PRN staff through a combination of employee training, employee monitoring, and reporting processes. The teach-back method will be used to assess comprehension on 01/09/2024, in addition to a signed affidavit; education will be ongoing until all facility staff have been re-educated.<BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Director of Nursing, Administrator, Director of Rehab, SVE Supervisor, Dietary Manager<BR/>5). Action: The Director of Nursing educated Licensed Nurses (RNs/LVNs), Certified Medication Aides, and Certified Nursing Assistants (CNAs) specifically on the need to keep residents and staff inside; ensure all windows and doors are closed and provide extra blankets and hot drinks/warm soups during extremely cold temperatures . Additionally, specific education was provided to Licensed Nurses (RNs/LVNs) on the need to assess and report signs of hypothermia to medical providers by the facility Staff Development Coordinator. The Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Comprehension checks will be completed weekly x 4 weeks by the Administrator; Comprehension will be gauged by score on a random quiz given to two staff persons on each shift; a score of ninety percent or greater will equate to comprehension; those scoring less than 90% will received immediate reeducation before being allowed to continue working. Issues and re-education identified by the Director of Nursing and/or Administrator will be tracked weekly x 4 in Standards of Care (SOC) meetings and compliance will be reviewed as part of monthly QAPI x 3 months. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: The Director of Nursing, Staff Development Coordinator, and Administrator<BR/>6). Action: An ad-hoc QAPI meeting was held, and the facility Medical Director was notified of the deficient practice and the plan of removal. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Administrator<BR/>The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by:<BR/>Observations on 01/10/24 and 01/11/24 of each zone's thermostats read above 71 degrees F and it was noticeably a comfortable temperature in the facility. <BR/>Interviews with LVN A, CNA B, LVN C, CNA S, MA D, RN E, LVN F, LVN L, CNA I, CNA AA, CNA BB, the Staffing Coordinator, ADON G, LVN T, CNA CC, CNA DD, RN EE, LVN FF, CNA GG, CNA HH, LA II, LVN N, LVN JJ, LVN Q, LVN KK, [NAME] W, the Dietary Manager, Dietary Aide LL, the Maintenance Director, ADON X, the DON, and the Administrator started on 01/10/24 thru 01/11/24 revealed they worked multiple shifts (6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM) on multiple days, including weekends. Staff knew to immediately notify the Administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain that they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. <BR/>Record review of in-service sheet, dated 01/10/24, and titled Unusual Occurrences revealed multiple staff had completed the training which included ensuring the Administrator was immediately notified, staff began to provide warm liquids and additional blankets to residents, and ensured all doors/windows were closed in the facility. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 01/10/24. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of widespread due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 5 residents (Resident #184, Resident #59, Resident# 38, and Resident #2) reviewed for infection control.<BR/>LVN B and MA D failed to perform hand hygiene between residents while administering medications to Residents #184, #59, #38 and #2. <BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Review of Resident# 184's entry MDS assessment, dated 01/05/24, revealed the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included elevated blood pressure, and atrial fibrillation (irregular heartbeat). Resident #184's BIMS score was not completed resident was newly admitted .<BR/>Review of Resident #59's quarterly MDS assessment, dated 11/15/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and thrombocytopenia (a condition in which the platelets are low in number, which can result in bleeding problems). Resident #59 had severe cognitive impairment with a BIMS score of 07. <BR/>Review of Resident #38's Quarterly MDS assessment, dated 11/01/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including encephalopathy (conditions that cause brain dysfunction), anxiety, and major depressive. Resident#38 had moderate cognitive impairment with a BIMS score of 10.<BR/>Review of Resident #2's Quarterly MDS assessment, dated 12/17/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including elevated blood pressure, anxiety, and muscle weakness. Resident # 2 had moderate cognitive impairment with a BIMS score of 03.<BR/>Review of Resident #2's January 2024 physician orders revealed orders for amlodipine tablet 10mg 1 tablet one time a day and losartan potassium tablet 100mgs 1 tablet by mouth one time a day.<BR/>Observation on 01/08/24 at 07:35 AM, revealed LVN A performing morning medication pass, during which she was observed popping the medication for Resident #184 before performing hand hygiene. LVN A was called in the room by Resident #184 before she finished preparing medication. She was observed getting to the room without performing hand hygiene Residnet#184 requested for his oxygen his to be connected. LVN A was observed connecting the nasal canula to Resident #184 and left the room. LVN A did not perform hand hygiene and proceeded to her cart, continued to prepare medication. She was then observed leaving her cart to another cart and got a bottle of senna 8.6mgs without performing hand hygiene. LVN A came back to her cart and finished preparing medication and was observed entering Resident #184's room and did not perform hand hygiene before administering the medications and after administering.<BR/>Observation on 01/08/24 at 07:48 AM, revealed MA D performed morning medication pass, during which he was observed preparing medication for Resident #59 without performing hand hygiene after he was observed in the dining room of the memory care unit helping residents get seated for breakfast. He later came to his cart, pulled blood pressure cuff disinfected and left to dry. He failed to perform hand hygiene before preparing medication for Resident #59. MA D did not perform hand hygiene before and after administering medications to Resident #59.<BR/>Observation on 01/08/24 at 07:53 AM, revealed MA D performing morning medication pass, during which time MA D checked Resident #38's blood pressure. MA D did disinfect the blood pressure cuff after using it on Resident #38 without gloves and he used the same wipe on his hands. MA D put the blood pressure cuff on top of the medication cart after use.MA D failed to perform hand hygiene before preparing medication for resident #38 and after administering medications to Resident#38.<BR/>Observation on 01/08/24 at 08:03 AM revealed MA D performing morning medication pass, during which time MA D checked Resident #2's blood pressure. MA D did disinfect the blood pressure cuff after using it on Resident #2 without gloves and he used the same wipe on his hands.MA D failed to perform hand hygiene before preparing medication for resident #2 and after administering medications to Resident#2.<BR/>Interview on 01/08/24 at 08:11 AM, MA D revealed he was supposed to perform hand hygiene before and after each resident or between the procedures to prevent contamination and spread of infection. MA D stated he forgot to perform hand hygiene and he did not have hand sanitizer on his cart, but he could have been washing his hands. MA D stated he was using the disinfectant wipe after using it on blood pressure cuff because he thought it would disinfect his hands too. MA D stated he was not performing hand hygiene until when the surveyor brought hand washing to his attention. He stated he knew he was supposed to don gloves while disinfecting the blood pressure gloves. MA D stated he was aware he was supposed to perform hand hygiene to prevent contamination and spread of infection. MA D stated he had done training on infection control.<BR/>Interview on 01/08/24 09:21 AM, LVN A revealed, she was supposed to perform hand hygiene before and after medication administration. She stated she forgot to perform hand hygiene because she got nervous. LVN A stated she had done training on infection control and handwashing.<BR/>Interview on 01/09/24 at 11:14 AM, the DON revealed her expectation was that staff would perform hand hygiene before and after medication administration. The DON stated she expected staffs perform hand hygiene wear gloves disinfect the blood pressure, cuff remove gloves and wash hands. The DON stated the facility had trained staff on hand washing on 1/1/24, and MA D was not in attendance, but he had done hand washing competency on 11/1/23. she stated failure to wash hands would lead to spread of infection.<BR/>Record review on 1/09/24 revealed training on hand washing and infection control dated 1/1/24, MA D did not attend.<BR/>Record review of facility's undated Hand Washing/Hand Hygiene policy, reflected: <BR/>This facility considers hand hygiene the primary means to prevent the spread of infections 6. wash hands with soap(antimicrobial or non-antimicrobial ) and water for the following situations:<BR/>a. <BR/>When hands are visibly soiled; and<BR/>7. Use an alcohol-based had rub containing at least 62% alcohol:or,alternatively,soap(antimicrobial or non -antimicrobial) and water for the following situations:<BR/>b. <BR/>Before and after direct contact with residents.<BR/>c. <BR/>Before preparing or handling medications.<BR/>f. <BR/>Before donning sterile gloves.<BR/>k. After handling used dressings, contaminated equipment,etc.<BR/>l. After contact with objects(e.g., medical equipment)in the immediate vicinity of the resident.<BR/>I. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and<BR/>m. After removing gloves.<BR/> .10.Single -use disposable gloves should be used:<BR/> .c. When in contact with a resident, or the equipment or .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for 1 of 4 residents (Resident #1) reviewed for neglect. <BR/>Resident #1 was left lying in a brief of feces and urine for over two hours. <BR/>This failure could place residents at risk of being neglected. <BR/>Findings included: <BR/>Record review of Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old woman with an admission date of 06/10/23. Her cognition was moderately impaired. Her diagnoses included stroke and pain. She was always incontinent of urine and bowel. She was totally dependent on 2 staff for toileting. <BR/>Record review of Resident #1's care plan, not dated, reflected the resident was totally dependent on staff for toilet use. <BR/>An observation and interview on 08/23/23 at 1:05 PM with Resident #1 revealed she was awake, alert, oriented, and upset. She said her brief had not been changed for the 6:00 AM - 2:00 PM shift. She said her brief was last changed by the 10:00 PM - 6:00 AM shift. She said she had asked staff, unknown names, to change her several times but no one wanted to do anything to help her. She said she was upset because no one wanted to help her. She said she was supposed to also be out of bed for therapy, but staff had not gotten her up. At 1:10 PM the Surveyor asked the Wound Care Nurse to help the resident because she said her brief needed to be changed. The Wound Care Nurse said she would ask the CNA to assist the resident. The Surveyor waited outside the resident's room. <BR/>An observation and interview on 08/23/23 at 1:30 pm revealed CNA A showed up to Resident #1's room. CNA A said she had not changed the brief of the resident on her shift because she was the only aide for 40 people, and she had been too busy to change her. CNA A said residents were supposed to be changed every 2 hours. CNA A said she asked for help, from unknown person, and no one would listen to her or help her. She said Resident #1 required assistance of two people to change her brief and CNA A had to go to another hall to get CNA B to help her. At 1:45 PM, CNA A and CNA B changed the brief of Resident #1. She was incontinent of bowel movement and urine that had soaked through the brief, through the drawsheet, and through the bed sheet onto the mattress. The urine/bowel movement-soaked sheets were tan colored. The resident had a reddened area of excoriation on the back of her left thigh that was approx. 5.0 centimeters by 2.0 centimeters. Resident #1 already had a treatment ordered for the excoriation that had been present. CNA A said the excoriation was caused by the brief. <BR/>An interview on 08/23/23 at 1:50 PM with Therapist C revealed he was assigned to Resident #1. He said he spoke to all the CNAs, including CNA A, at 8:15 AM and told them that they needed to get Resident #1 out of bed for therapy. He said he went back just before lunch and Resident #1 was still in bed. Therapist C said he asked the CNAs again to get her out of bed, but they never did. <BR/>An interview on 08/23/23 at 1:55 PM with LVN D revealed she was assigned to Resident #1 for the 6:00 AM - 2:00 PM shift. She said she was not aware the resident's brief had not been changed on her shift. She said they had plenty of staff until 2 agency staff CNAs were sent home at 10:15 AM. LVN D said that left 2 CNAs for 46 residents which was not enough staff to get the care done. <BR/>An interview on 08/23/23 at 2:15 PM with the DON revealed she was not aware Resident #1 did not receive a brief change until 1:45 PM on the 6:00 AM - 2:00 PM shift. She said she had extra staff and even had to send two staff home because of the extra staff. She said if Resident #1 would have requested to get her brief changed, then it would have been changed. The DON said the CNAs knew to ask her for help or the two ADONs that were working as well could assist them. She said if a resident did not receive incontinence care they could develop skin breakdown. The DON said she did not think Resident #1 had skin breakdown. The DON said it was her expectation that if a CNA needed assistance to provide care, then they needed to ask for the assistance. The DON said she would be completing a self-report of the allegation because CNA A neglected Resident #1 when she did not change her brief for the whole shift when she needed it. <BR/>Record review of facility Abuse/Neglect policy, dated 09/06/22, reflected:<BR/>It is the policy of the facility to administer care and services in an environment free of .neglect .<BR/>Neglect is the failure to provide necessary and adequate .care .<BR/>Staff may be aware or should have been aware of the service the resident requires but fails to provide that service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse and neglect, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #1 ) of 5 residents reviewed for abuse and neglect. <BR/>RN A failed to report to the Administrator when Residents #1 and #2 got into a physical altercation on 08/29/23. <BR/>This failure could place residents at risk of incidents of abuse, neglect, and/or exploitation not being reported timely and thoroughly investigated. <BR/>Findings included:<BR/>Review of Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 4. The resident's diagnoses included stroke, non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. <BR/>Review of Resident #1's care plan revised on 10/02/23 revealed Resident #1 was on psychotropic medications related to depressive disorders, delusional disorders, anxiety disorders. Interventions included monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. <BR/>Review of Resident #1's progress notes dated 08/29/23 completed by RN A revealed: Resident displaying behavior issues: attacking other residents and staffs. He was pushed to the floor by [Resident #2] after attacking him This usually happened when he perceived a man's response to a female as aggressive <BR/>Observation revealed Residents #1 and #2 both resided on the secure unit. Resident #1 was currently out of the facility and Resident #2 could not be interviewed due to his impaired cognition status. <BR/>Interview on 10/11/23 at 2:35 PM with RN A revealed Resident #1 had good and bad days. When the resident was having a bad day, RN A stated the resident would fight anyone and become aggressive if he saw males close to females. RN A said that day of the incident, 08/29/23, he was very aggressive and attacked Resident #2, and Resident #2 pushed Resident #1 back causing him to fall on the floor. RN A further stated there were no injuries to either resident. RN A further stated he did not recall if he contacted management staff about the incident stating there was always so much going on, on the secure unit. <BR/>Interview on 10/11/23 at 4:32 PM with the DON revealed she had not been made aware of the incident on 08/29/23 between Residents #1 and #2. The DON further stated staff were expected to let management staff know as soon as possible if incidents in the secure unit including resident to resident abuse. <BR/>Interview on 10/11/23 at 5:37 PM with the Administrator revealed he had not been made aware of the incident involving Residents #1 and #2 until today. The Administrator said that incident should have been reported to management staff immediately so he could have reported it to State Office because it was considered a resident to resident abuse incident. <BR/>Review of the facility's policy titled Abuse and Neglect, review date 09/06/22, reflected the following:<BR/>Policy Statement <BR/>It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. <BR/> .All allegations and/or suspicions of abuse must be reported to the Administrator immediately All allegations of abuse will be reported to [State Office] immediately after the initial allegation is received

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #323's admission MDS dated [DATE] reflected the resident was an [AGE] year-old resident admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure). Resident #323 had a BIMS of 1 indicating his cognition was severely impaired. The MDS further reflected the resident did not have impairment to his upper and lower extremities and ambulated with no assistance. <BR/>Review of Resident #323's care plan initiated on 12/24/24 reflected the resident was at risk for elopement/wandering related to dementia and required placement on the secure unit to provide a secure environment due to risk of elopement. Interventions included to frequent monitor and identified a pattern of wandering and assess reason for wandering and provide redirection as needed . <BR/>Review of Resident #323's hospital records dated 12/01/24 reflected the following:<BR/> Patient is a [AGE] year-old male who presents to [Emergency Room] primarily for pneumonia and neurology was consulted for patient's recent history of elopement and getting lost concerning for newly diagnosed dementia. On chart review is noted that patient had eloped and gotten lost 5 times and family found him after he had fled <BR/>Observation on 02/04/25 at 11:19 PM, revealed there was wooden privacy fence around the outside of the building of the secure unit with three rails inside of the fence, one at the bottom, one in the middle and one towards the top of the fence. <BR/>Review of the facility's PIR dated 01/02/25 reflected that on 12/24/24 Resident #323 had left the facility without signing out and was found by the police department and was returned to his family. The resident was on enhanced supervision until the window of his room was repaired and installation of a fence on the side of the building with potential exiting windows was completed. <BR/>Review of Resident #323 progress notes dated 12/24/24 documented by LVN J reflected the following:<BR/>Resident was up from breakfast in the dining area. Resident ate 100% of meal. Resident showed no signs of pain or discomfort. At 1145, the patient was last observed entering his room. During routine rounds at approximately 12:45 PM, the patient was found to be absent from their room. A code white was initiated promptly, and the search for the patient is currently ongoing [Police] notified the facility that resident had be [sic] found by [Police] 2 hours ago and told resident to [family].<BR/>Interview on 02/05/25 at 10:45 AM, with CNA N revealed she was working the morning of 12/24/24 and sometime after breakfast they staff noticed Resident #323 was not in the secure unit. The CNA N said after breakfast the resident would normally go back to his room and only come out for meals. When they staff realized the resident could not be located, they all began to search the rooms and the bathrooms. After a while, they discovered the window to Resident #323's room was broken and that is how the resident had gotten out. CNA N described Resident #323 as being independent with his ADL's and very pleasant. There were times the resident was seen carrying his bag with his belongings and stand at the exit doors but he was usually easily redirected to go back to his room. <BR/>Interview on 02/05/25 at 11:29 AM, with LVN M revealed she was working during the elopement on 12/24/24 and during her morning rounds during breakfast all residents were accounted for in the secure unit and Resident #323 had gone to the dining room to eat. The LVN M said after breakfast she sat in the hall monitoring and around 11:30 AM she noticed the resident was not in his room so they began to look for him room by room and alerted the rest of the staff the resident was missing. They checked the secure unit doors and they remained locked and after that they noticed the window to his room was broke. They alerted management staff and 911 was also called and later found out he had been found by the police and taken to his family's home. LVN M said she normally did not work the secure unit and had been filling in for someone else. She said Resident #323 did not appear to be exit seeking that day and had not been carrying a packed bag stating he wanted to go home. <BR/>Interview on 02/05/25 at 12:40 PM, with MA O revealed he was working on 12/24/24 he was assisting other staff gather residents in the secure unit into the dining room for lunch. MA O said they realized Resident #323 was not in his room and they began to check every room and around the facility when they realized the window to his room was broken and appeared that is how he had eloped. Management was notified and 911 was also called. MA O said he was told the resident had been found by the police and take to his family's home. MA O further stated Resident #323 was very mobile, independent, with confusion and would only come out of his room for meals. The MA said he never recalled the resident to be exit seeking or saying he wanted to leave the facility. <BR/>Review of the facility's PIR dated 01/10/25 reflected on 01/06/25:<BR/>This resident had previously broken a window and left the facility. As the facility response, we built a wooden fence around the windows on this area of the secured unit. The resident broke a window on the same section and scaled the fence. Staff witnessed the resident scaling and because of the location of the exit had to respond by going around the building. Once they were on the other side of the fence the resident was gone. Staff initiated searchs [sic] for the resident and contacted the police and the police were able to find him two hours later <BR/>Interview on 02/06/25 at 10:25 PM, with LVN Q revealed she worked on 01/04/25 and Resident #323 had dinner in the dining room and had gone back to his new room he was placed in after he was brought back by his family after his first elopement. LVN Q said she was she was sitting in the hallway and during her rounds, sometime after dinner, did not recall the time, she went to Resident #323's room to check on him and did not find him. She happened to glance down the hall and noticed he was headed into his old room, the room he first eloped from, and as she went into that room she did not see Resident #323. LVN Q noticed the window had been forced open and as she went to look outside, she saw Resident #323 on top of the fence, that had been built after his first elopement, but she was not able to get to the resident fast enough even after calling after him. LVN Q alerted staff and by the time they went outside to look for the resident, he was nowhere to be found. LVN Q further stated she alerted management and 911 was called and she was later told the resident had been found by the police and again take to his family's home. <BR/>Interview on 02/05/25 at 3:50 PM, with CNA R revealed he was working on 01/04/25 outside of the secure unit when he was alerted that Resident #323 had eloped from the facility through a window. CNA R said all of the staff began to look for the resident but he was not found. CNA R further stated he did work on the secure unit but has assisted in looking for Resident #323. <BR/>Interview on 02/04/25 at 10:54 AM, with CNA L revealed she was not at the facility during incidents where Resident #323 eloped. CNA L said Resident #323 was independent and very nice. She said the resident was able to communicate his needs and at times he would pack his bag and stand next to the exit doors but was easily redirected back to his room. CNA L stated after his first elopement, the staff had put up a fence around the outside rooms. Resident #323 was taken back to the facility and was put in another room, facing the enclosed courtyard. <BR/>Interview on 02/05/25 at 1:08 PM, with LVN P revealed she worked with Resident #323 and he was usually anxious to be picked up by his family so they could take him home and had a cell phone he would use to call his family. Resident #323 was cooperative and very pleasant with everyone and would stay in room and only come out for meals. LVN P further stated one day she noticed Resident #323 has packed his bag and said he wanted to leave but he had never tried to open the doors or leave and was easily redirected to his room. <BR/>Interview on 02/05/25 at 1:26 PM, with the DON revealed on 12/24/24 staff alerted her that Resident #323 could not be located and they had noticed the window to the resident's room had been broken out. The DON said all the staff were searching for the resident and 911 had been called. The facility later got a call from the police about 4:30 PM stating Resident #323 has been found and take to his family's home. The DON said she was not told how far from the facility he had been found. After that elopement Resident #323's family kept the resident over the holidays and had been taken back the facility on 12/31/24 and placed in another room that did not face the outside of the facility. The DON said while the resident was gone they had fixed the window to his previous room, and they had put up a wooden fence around the perimeter of the secure unit. On 01/04/25 she again was alerted that while making rounds they noticed Resident #323 was not in his room and the window to his old room had been opened and the resident had been seen jumping over the wooden fence. The staff immediately ran outside to look for the resident but he was not found so they called 911. The DON further stated that the police had found Resident #323 and again had been taken back to his family's home. The DON did not know how far from the facility he had been located. Resident #323 did to return to the facility and the family decided to keep him at home. The DON said after each of Resident #323's elopement all the staff were re-in serviced on their elopement policy. Staff participated in an elopement drill to ensure they were competent during a resident elopement. All resident in the secure unit were put on 15-minute checks to make sure there were no other resident that were exit seeking. <BR/>Interview on 02/05/25 at 11:06 AM, with the Director of Maintenance revealed he had built the wooden fence around the outside of the secure unit and was not aware the fence rails should have faced the outside of the fence and not the inside due to the safety of someone being able to climb the fence. The Director of Maintenance further stated that would be a fast and easy fix and he would just have to turn the fence around by sections. <BR/>A Past Non-Compliance Immediate Jeopardy/Immediate Threat was identified on 02/05/25. The Administrator, the Regional Consultant were notified of the Past Non-Compliance Immediate Jeopardy on 02/05/25 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:10 PM. <BR/>Review of the facility's policy titled Elopements dated 2018 reflected the following:<BR/>Staff shall investigate and report all cases of missing residents. <BR/> .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing/designee <BR/> .c. if a resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative the Attending Physician, law enforcement officials <BR/>Observation on 02/04/25 at 10:27 AM revealed there was a staff member sitting in the hallway with a bedside table charting on a laptop. The staff member had visual of the hall where the resident rooms were located and the dining room where other resident were.<BR/>Observation of the secure unit at various times from 02/04/25 to 02/06/25 revealed there were no residents that appeared to have the physical and mental capabilities of climbing the fence. <BR/>Review of the Enhanced Supervision Monitoring Tool dated 12/24/24 and 12/25/24 revealed all the residents in the secure unit has been put on 15-minute checks by staff to ensure no other residents were exit seeking or showing signs of wanting to leave the secure unit. Further review of the Enhanced Supervision Monitoring Tool revealed there were no other residents identified as being exit seeking. <BR/>Review of the Elopement Drill/Actual Event Participation dated 12/27/24 and 12/28/24 revealed staff members actively participated in a drill on what to do when and if a resident went missing. <BR/>Review of the in-services dated 12/24/24 and 01/06/25 revealed staff were in-serviced on the facility's elopement and wandering policy. <BR/>Interview on from 02/04/25 to 02/06/25 at various times with LVN J, LVN P, LVN Q, LVN V, MA O, CNA S, CNA N, CNA T, CNA U, CNA I, and CNA R revealed residents were checked on at the beginning of their shift to ensure all resident were accounted for frequent round were made to monitor all resident for signs of exit seeking. They all said if they were to notice a resident was missing, they were to alert all staff working and begin to look for the resident. If the resident was not located in the building, they would notify management and call 911.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #39) of 18 reviewed for ADLs. <BR/>The facility failed to ensure Resident #39's contractured hands were kept clean and free of odor.<BR/>This failure had the potential to affectcould place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. <BR/>Findings included:<BR/>Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA, non-Alzheimer's dementia, malnutrition, bullous pemphigoid, and muscle wasting. The MDS further reflected the resident was not able to completed a BIMS due to her cognition being severely impaired.<BR/>Review of Resident #39's care plan, revised on 11/19/23, revealed the resident had an ADL self-care performance deficit. Interventions included the resident was totally dependent on one staff for personal hygiene. <BR/>Observation on 01/08/23 at 9:33 AM revealed Resident #39 was in bed with her eyes closed and she was not easily aroused when she was spoken to. Both her hands appeared to be contracted up to her face.<BR/>Observation and interview on 01/09/23 at 1:55 PM with CNA MM revealed she slowly opened Resident #39's right hand and her fingernails were observed to be about three-quarters of an inch long, they appeared to be digging into the palm of her hand, and there was an odor noted. The skin to the resident's palm was intact and there was no skin breakdown noted. CNA MM attempted to open the resident's left hand but the resident would not allow her to. CNA MM further stated it was the aides responsibility to cut the resident's fingernails and said she had cut Resident #39's fingernails the previous week and said hers just grow really fast. <BR/>Observation and interview on 01/09/24 at 2:47 PM with the PT revealed he pulled Resident #39's covers back and he attempted to slowly open the resident's right and left hand and once opened he stated there was an odor to the palms of the resident's palms from being closed and not cleaned. The PT further stated the fingernails needed to be cut because they were digging into her palms and could cause skin breakdown and the PT also did not think Resident's fingernails could grow that much in a week. <BR/>Interview on 01/10/23 at 12:30 PM with ADON X revealed aides should be cleaning the inside of Resident #39's hands and making sure her fingernails are were trimmed. ADON X stated she did not think the resident's nails would have grown three-quarters of an inch in a week. ADON X further stated it was important to keep the resident's palms clean/dry and fingernails trimmed to keep them from causing skin issues and odors. <BR/>Review of the facility's Fingernails/Toenails, Care of policy, dated 2018, reflected the following:<BR/>Purpose<BR/>The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections <BR/>Review of the facility's Activities of Daily Living (ADL's), Supporting policy, dated 2018, reflected the following:<BR/>Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). <BR/>Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for two (Residents #11 and #12) of three residents reviewed for PASRR services.<BR/>1. The facility failed to submit Resident #11's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #11 by the specific deadline.<BR/>2. The facility failed to submit Resident #12's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #12 by the specific deadline.<BR/>These failures could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. <BR/>Findings included: <BR/>1. Review of Resident #11's face sheet, dated 09/07/23, reflected she originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included schizoaffective disorder, schizophrenia, and major depressive disorder. <BR/>Review of Resident #11's quarterly MDS Assessment, dated 06/18/23, reflected she had a BIMS score of 03, indicating severe cognitive impairment. <BR/>Review of Resident #11's care plan, dated 07/22/23, reflected she was considered PASRR positive and received habilitative services.<BR/>Review of Resident #11's PASRR Level One Screening, dated 12/07/22, reflected she had both an intellectual disability and developmental disability. <BR/>Review of an undated list of PASRR positive residents reflected Resident #11 was listed.<BR/>Review of Resident #11's Service Planning Team Signature Sheet Habilitation Coordination reflected a date of 08/02/23 when the PCSP was discussed. <BR/>Review of Resident #11's progress notes reflected the following: Pt, [Resident #11], pt's guardian, [Resident #11's RP], pt's MHMR PASRR HC's, [Resident #11's HC], and IDT members attended Care Plan meeting in person at nursing facility . as noted by the SW on 08/02/23.<BR/>Observation and interview on 09/07/23 at 9:20 AM of Resident #11 revealed she was lying in her bed but was not responding to any of the surveyor's questions.<BR/>2. Review of Resident #12's face sheet, dated 09/07/23, reflected the resident was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, insomnia, anxiety, and depression.<BR/>Review of Resident #12's quarterly MDS Assessment, dated 07/28/23, reflected she had a BIMS score of 08, indicating moderate cognitive impairment. <BR/>Review of Resident #12's care plan, dated 06/21/23, reflected she had moderate intellectual disabilities and was considered PASRR positive and was receiving habilitative services.<BR/>Review of Resident #12's PASRR Level One Screening, dated 06/23/17, reflected she had an intellectual disability. <BR/>Review of an undated list of PASRR positive residents reflected Resident #12 was listed.<BR/>Review of Resident #12's Service Planning Team Signature Sheet Habilitation Coordination reflected a date of 08/03/23 when the PCSP was discussed. <BR/>Review of Resident #12's progress notes reflected the following: Pt, [Resident #12], .PASRR HC's, [Resident #12's HC], and IDT members attended Care Plan Meeting in person at nursing facility . as noted by the SW on 08/04/23.<BR/>Observation and interview on 09/07/23 at 9:25 AM of Resident #12 revealed she was sleeping in her bed and would not respond to any of the surveyor's questions.<BR/>In an interview via phone on 09/07/23 at 10:03 AM with the MDS Coordinator revealed the RN at the IDT meeting was supposed to be responsible for ensuring the PCSP was submitted into the LTC online portal. The MDS Coordinator said the previous Administrator was the one who put that initiative in place, but she was not sure if the new Administrator was aware of that process. The MDS Coordinator said the PCSP needed to be added to the LTC online portal 24-48 hours after the IDT meeting occurred. The MDS Coordinator confirmed the PCSP's for Residents #11 and #12 were not submitted into the LTC online portal after their IDT meetings on 08/03/23 and 08/02/23.<BR/>In an interview on 09/07/23 at 1:40 PM with the Administrator revealed the MDS Coordinator was responsible for entering information into the LTC online portal after the IDT meetings occur. The Administrator said he did not have any specifics because he was not very familiar with the PASRR process, but he expected all information to be entered in a timely manner.<BR/>In an interview via phone on 09/08/23 at 3:52 PM with Resident #12's Habilitation Coordinator revealed the PCSP had not yet been submitted to the LTC online portal after the IDT meeting on 08/03/23.<BR/>Review of the facility's Coordination- Pre-admission Screening and Resident Review (PASRR) Program policy, revised 09/06/22, revealed it did not address submitting a resident's PCSP in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to inform the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for one (Resident #10) of one resident reviewed. <BR/>The facility failed to notify Resident #10's state mental health agency or intellectual disability agency of a significant change for Resident #10 when he expired on [DATE].<BR/>This failure could affect residents in the facility that are PASRR positive for their mental health agency or state intellectual disability agency not being notified of a significant change for residents. <BR/>Findings included:<BR/>Review of Residents #10's face sheet, dated [DATE], reflected the resident admitted to the facility on [DATE] and discharged from the facility on [DATE]. His diagnoses included cerebral palsy, seizures, and cognitive communication deficit. <BR/>Review of Resident #10's discharge MDS Assessment, dated [DATE], reflected the resident discharged on [DATE], and the resident was deceased . <BR/>Review of Resident #10's care plan, cancelled [DATE], did not reflect a positive PASRR status.<BR/>Review of Resident #10's PASRR Level One Screening, dated [DATE] reflected he had both an intellectual disability and developmental disability.<BR/>Review of Resident #10's progress notes reflected the following: Resident observed at approx. 11:27am with no pulse or respiration. Resident is not responding/nonreactive to verbal or painful stimuli. Resident is a DNR and on [hospice provider]. Family and hospice nurse at bedside. [Funeral Home Name] came and removed body from facility at approx. 1:45pm [sic]. as written by the DON.<BR/>Interview on [DATE] at 9:50 AM with the SW revealed she was not sure who would be responsible for notifying the Habilitation Coordinator of a resident's change in condition or expiration. The SW said she had never been made aware she was responsible for making those notifications but would assume it was either her or the MDS Coordinator who should make the notification. The SW said she was aware Resident #10 had expired sometime in [DATE].<BR/>Interview via phone on [DATE] at 10:03 AM with the MDS Coordinator revealed Resident #10 had expired sometime in [DATE] and was PASRR positive. The MDS Coordinator said she remembered speaking with someone associated with PASRR but did not have any proof of the call or notification made to the Habilitation Coordinator regarding Resident #10 expiring. The MDS Coordinator said she was responsible for ensuring the Habilitation Coordinator was informed of any significant change in a PASRR positive resident , including when they expired. The MDS Coordinator said the Habilitation Coordinator should be informed of any significant change with a PASRR positive resident, so they could follow-up on any changes in the resident's care.<BR/>Interview via phone on [DATE] at 11:00 AM with Resident #10's Habilitation Coordinator revealed he was informed about Resident #10's expiration a few weeks after it occurred through a family member. He stated the facility should have contacted him after the significant change occurred, so he could terminate services. He confirmed Resident #10 was PASRR positive.<BR/>Interview on [DATE] at 1:40 PM with the Administrator revealed he was not sure who was responsible for notifying the Habilitation Coordinator that a resident had a significant change. The Administrator said he would assume it would be the SW, but he had never told her that she was responsible for that.<BR/>Review of the facility's Coordination- Pre-admission Screening and Resident Review (PASRR) Program policy, revised [DATE], revealed it did not address significant changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for 1 of 4 residents (Resident #1) reviewed for neglect. <BR/>Resident #1 was left lying in a brief of feces and urine for over two hours. <BR/>This failure could place residents at risk of being neglected. <BR/>Findings included: <BR/>Record review of Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old woman with an admission date of 06/10/23. Her cognition was moderately impaired. Her diagnoses included stroke and pain. She was always incontinent of urine and bowel. She was totally dependent on 2 staff for toileting. <BR/>Record review of Resident #1's care plan, not dated, reflected the resident was totally dependent on staff for toilet use. <BR/>An observation and interview on 08/23/23 at 1:05 PM with Resident #1 revealed she was awake, alert, oriented, and upset. She said her brief had not been changed for the 6:00 AM - 2:00 PM shift. She said her brief was last changed by the 10:00 PM - 6:00 AM shift. She said she had asked staff, unknown names, to change her several times but no one wanted to do anything to help her. She said she was upset because no one wanted to help her. She said she was supposed to also be out of bed for therapy, but staff had not gotten her up. At 1:10 PM the Surveyor asked the Wound Care Nurse to help the resident because she said her brief needed to be changed. The Wound Care Nurse said she would ask the CNA to assist the resident. The Surveyor waited outside the resident's room. <BR/>An observation and interview on 08/23/23 at 1:30 pm revealed CNA A showed up to Resident #1's room. CNA A said she had not changed the brief of the resident on her shift because she was the only aide for 40 people, and she had been too busy to change her. CNA A said residents were supposed to be changed every 2 hours. CNA A said she asked for help, from unknown person, and no one would listen to her or help her. She said Resident #1 required assistance of two people to change her brief and CNA A had to go to another hall to get CNA B to help her. At 1:45 PM, CNA A and CNA B changed the brief of Resident #1. She was incontinent of bowel movement and urine that had soaked through the brief, through the drawsheet, and through the bed sheet onto the mattress. The urine/bowel movement-soaked sheets were tan colored. The resident had a reddened area of excoriation on the back of her left thigh that was approx. 5.0 centimeters by 2.0 centimeters. Resident #1 already had a treatment ordered for the excoriation that had been present. CNA A said the excoriation was caused by the brief. <BR/>An interview on 08/23/23 at 1:50 PM with Therapist C revealed he was assigned to Resident #1. He said he spoke to all the CNAs, including CNA A, at 8:15 AM and told them that they needed to get Resident #1 out of bed for therapy. He said he went back just before lunch and Resident #1 was still in bed. Therapist C said he asked the CNAs again to get her out of bed, but they never did. <BR/>An interview on 08/23/23 at 1:55 PM with LVN D revealed she was assigned to Resident #1 for the 6:00 AM - 2:00 PM shift. She said she was not aware the resident's brief had not been changed on her shift. She said they had plenty of staff until 2 agency staff CNAs were sent home at 10:15 AM. LVN D said that left 2 CNAs for 46 residents which was not enough staff to get the care done. <BR/>An interview on 08/23/23 at 2:15 PM with the DON revealed she was not aware Resident #1 did not receive a brief change until 1:45 PM on the 6:00 AM - 2:00 PM shift. She said she had extra staff and even had to send two staff home because of the extra staff. She said if Resident #1 would have requested to get her brief changed, then it would have been changed. The DON said the CNAs knew to ask her for help or the two ADONs that were working as well could assist them. She said if a resident did not receive incontinence care they could develop skin breakdown. The DON said she did not think Resident #1 had skin breakdown. The DON said it was her expectation that if a CNA needed assistance to provide care, then they needed to ask for the assistance. The DON said she would be completing a self-report of the allegation because CNA A neglected Resident #1 when she did not change her brief for the whole shift when she needed it. <BR/>Record review of facility Abuse/Neglect policy, dated 09/06/22, reflected:<BR/>It is the policy of the facility to administer care and services in an environment free of .neglect .<BR/>Neglect is the failure to provide necessary and adequate .care .<BR/>Staff may be aware or should have been aware of the service the resident requires but fails to provide that service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 13 of 14 (bedrooms #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, and #159) resident bedrooms, one of one shower rooms, and one of one hall in the facility's Secured Unit. <BR/>The facility failed to ensure the floors in bedrooms #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, and #159 were free of dustbuilt up dirt, dust and crumbs. <BR/>The facility failed to ensure the windowsill in bedroom [ROOM NUMBER] was maintanined with a cleanable, sanitary surface. <BR/>The facility failed to ensure ceiling tiles, in the Secured Unit corridor were free of water stains and sagging. <BR/>The facility failed to ensure the vaneer on a dresser in bedroom [ROOM NUMBER] was maintained to ensure a cleanable, sanitary surface. <BR/>The facility failed to ensure a matress in bedroom [ROOM NUMBER] was free of tares to ensure a cleanable, sanitary surface. <BR/>The facility failed to ensure floor tile in bedroom [ROOM NUMBER] was maintianed to ensure safety and sanitation. <BR/>The facility failed to ensure a footboard hanging from a bed in bedroom [ROOM NUMBER] was safely attached to the bed. <BR/>The facility failed to ensure the toilet, in the Secured Unit's only shower room was secured to the floor. <BR/>This deficient practice could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment.<BR/>Findings included:<BR/>Observations on 06/28/2023 between 11:30AM and 12:30PM in the facility's Secured Unit revealed, a buildup of dirt, dust and crumbs behind the doors of bedrooms #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, and #159; an unpainted windowsill in room [ROOM NUMBER] exposing metal and glue; the veneer from the front of a 3-drawer dresser in room [ROOM NUMBER] on the floor; a torn mattress in room [ROOM NUMBER]; floor tile missing in the threshold of the closet in room [ROOM NUMBER]; and a broken footboard on a bed in room [ROOM NUMBER]. Two ceiling tiles in the hall of the Secured Unit were observed to be water stained and sagging. The toilet in the Secured Unit shower room was not secured to the floor and tile around the base was broken allowing the toilet to move when touched. <BR/>An interview on 06/28/2023 at 11:37AM with Housekeeper A revealed she recently started working in the facility. She stated every room in the Secured Unit was cleaned for the day. She said she was awre the floors in the floors in the Secured Unit needed to be thouroughly cleaned but had not reported it to mamangement. She said she was not made aware of the broken furniture, headboard or toilet. <BR/>An interview on 06/28/2023 at 11:58AM with CNA B revealed the floors in the secured unit were very dirty. She said housekeeping did not always come to the Secured Unit to clean. She said she did see the ceiling tiles looked like they were going to fall down but did not report it to management. She said there was a maintenance logbook at the nurses' station outside the Secured Unit to record maintenance issues but did use it because she was focued on providing care to residents. <BR/>An interview on 06/28/2023 at 12:11PM with Resident #1 revealed she had not noticed the veneer from her dresser on the floor. She said housekeeping staff cleaned her room daily. <BR/>In an interview and observation on 06/28/2023 beginning at 12:18PM, LVN C said she had not noticed the loose toilet in the shower room, missing floor tiles, ripped mattress, discolored and sagging ceiling tiles, unmaintained windowsill, dirty floors, or broken footboard. She said had they been brought to her attention she would have informed management. She said housekeeping had cleaned the Secured Unit that morning, but the floors seemed very dirty. She said there were 20 residents in the Secured Unit, and none complained about the loose toilet in the shower room, missing floor tiles, ripped mattress, discolored and sagging ceiling tiles, unmaintained windowsill, dirty floors, or broken footboard. <BR/>An attempted interview on 06/28/2023 at 12:30PM with Resident #2, did not respond to questions about the unmaintined windowsill. <BR/>In an interview on 06/28/2023 at 12:33PM Resident #3 revealed she did not have a roommate. When the torn matress on the bed near the window was pointed out to [NAME] she said she did not see the mattress on the other bed in her room was torn because she did not use that bed. <BR/>In an interview on 06/28/2023 at 12:37PM, Resident #4 said she did not know there were floor tiles missing in her bedroom. <BR/>In an interview on 06/28/2023 at 12:40PM, Resident #5 said she did not know the footboard on her bed was broken. <BR/>In an interview on 06/28/2023 at 1:10PM, Resident #6 revealed he lived in the facility and his wife Resident #5 resident in the facility's Secured Unit. He said he was not aware of the broken footboard on his wife's bed but was concerned about the cleanliness of the Secured Unit. He said he was not sure if housekeeping ever went in there. He said he had not told the administrator or anyone else about it. He said his room was cleaned daily and felt his room was keep clean. <BR/>In an interview on 06/28/2023 at 2:15PM, the Housekeeping Supervisor stated she recently took over housekeeping at the facility. She said her staff cleaned the Secured Unit in the morning. She said the issue with the dirty floors was years of accumulated dirt. She said she will have to scrape the dirt off the floors to remove it. She said she could not speak for the previous staff but was working on getting the facility back into a clean condition. She said she started in the main facility but knows the Secured Unit had some cleaning issues. She said her staff know to report maintenance concerns to her and should do so as they were discovered. <BR/>In an interview and observation on 06/28/2023 at 3:00PM, the administrator revealed he was not aware of the loose toilet in the shower room, missing floor tiles, ripped mattress, discolored and sagging ceiling tiles, unmaintained windowsill, dirty floors, or broken footboard. He said he was been having issues with maintenance staff but had hired a new maintenance man who started on 06/30/2023. He said there was a maintenance log at the nurses' station where staff should report any maintenance issues. He stated this should be checked daily and signed off by the maintenance man when the task was completed. He said his regular maintenance man was on vacation until 07/03/2023. He said maintenance issues were discussed in morning meetings and he should have been following up with the log and checking the facility for maintenance issues. He stated the last entry in the maintenance log was 05/24/2023 so he was not sure if staff were reporting issues as they came up. He said he felt like the system was fractured due to the maintenance personnel issues and staff turnover. He said the issues would be addressed immediately as they could impact the resident's quality of life. He said the facility needed to ensure they provide a safe, comfortable environment for residents who lived in the Secured Unit. <BR/>An interview on 06/28/2023 at 4:21PM with the Corporate RN revealed the facility had been having issues with maintaining competent maintenance staff. She said the current one was on vacation, and they have another one starting on 06/30/2023. She said although they were not made aware of the specific maintenance and cleaning issues, they want to ensure they address them quickly because the residents deserve a safe and clean environment. She said they had a system in place where staff log maintenance issue in the logs at the nurses' station and the maintenance staff would address issues daily and document the completion date. She said the administrator should follow up with this to ensure issues were addressed timely and appropriately. <BR/>Record review of the facility's Maintenance Log between 03/03/2023 and 05/24/2023 reflected no documentation of maintnenace issues in the Secured Unit that involved the loose toilet in the shower room, missing floor tiles, ripped mattress, discolored and sagging ceiling tiles, unmaintained windowsill, dirty floors, or broken footboard. The last documented entry on the log was 05/24/2023. <BR/>Record review of in-service record dated 06/28/2023 and titled, Physical Environment, Maintenance issues reported to the Maintenance Director reflected the DON educated 17 staff. <BR/>A review of the facility's policy titled, Safe Environment, dated 09/22/2022 reflected, It is the policy of the facility to provide a safe environment in accordance with State and Federal regulations. The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public .the facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner .the facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #323's admission MDS dated [DATE] reflected the resident was an [AGE] year-old resident admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure). Resident #323 had a BIMS of 1 indicating his cognition was severely impaired. The MDS further reflected the resident did not have impairment to his upper and lower extremities and ambulated with no assistance. <BR/>Review of Resident #323's care plan initiated on 12/24/24 reflected the resident was at risk for elopement/wandering related to dementia and required placement on the secure unit to provide a secure environment due to risk of elopement. Interventions included to frequent monitor and identified a pattern of wandering and assess reason for wandering and provide redirection as needed . <BR/>Review of Resident #323's hospital records dated 12/01/24 reflected the following:<BR/> Patient is a [AGE] year-old male who presents to [Emergency Room] primarily for pneumonia and neurology was consulted for patient's recent history of elopement and getting lost concerning for newly diagnosed dementia. On chart review is noted that patient had eloped and gotten lost 5 times and family found him after he had fled <BR/>Observation on 02/04/25 at 11:19 PM, revealed there was wooden privacy fence around the outside of the building of the secure unit with three rails inside of the fence, one at the bottom, one in the middle and one towards the top of the fence. <BR/>Review of the facility's PIR dated 01/02/25 reflected that on 12/24/24 Resident #323 had left the facility without signing out and was found by the police department and was returned to his family. The resident was on enhanced supervision until the window of his room was repaired and installation of a fence on the side of the building with potential exiting windows was completed. <BR/>Review of Resident #323 progress notes dated 12/24/24 documented by LVN J reflected the following:<BR/>Resident was up from breakfast in the dining area. Resident ate 100% of meal. Resident showed no signs of pain or discomfort. At 1145, the patient was last observed entering his room. During routine rounds at approximately 12:45 PM, the patient was found to be absent from their room. A code white was initiated promptly, and the search for the patient is currently ongoing [Police] notified the facility that resident had be [sic] found by [Police] 2 hours ago and told resident to [family].<BR/>Interview on 02/05/25 at 10:45 AM, with CNA N revealed she was working the morning of 12/24/24 and sometime after breakfast they staff noticed Resident #323 was not in the secure unit. The CNA N said after breakfast the resident would normally go back to his room and only come out for meals. When they staff realized the resident could not be located, they all began to search the rooms and the bathrooms. After a while, they discovered the window to Resident #323's room was broken and that is how the resident had gotten out. CNA N described Resident #323 as being independent with his ADL's and very pleasant. There were times the resident was seen carrying his bag with his belongings and stand at the exit doors but he was usually easily redirected to go back to his room. <BR/>Interview on 02/05/25 at 11:29 AM, with LVN M revealed she was working during the elopement on 12/24/24 and during her morning rounds during breakfast all residents were accounted for in the secure unit and Resident #323 had gone to the dining room to eat. The LVN M said after breakfast she sat in the hall monitoring and around 11:30 AM she noticed the resident was not in his room so they began to look for him room by room and alerted the rest of the staff the resident was missing. They checked the secure unit doors and they remained locked and after that they noticed the window to his room was broke. They alerted management staff and 911 was also called and later found out he had been found by the police and taken to his family's home. LVN M said she normally did not work the secure unit and had been filling in for someone else. She said Resident #323 did not appear to be exit seeking that day and had not been carrying a packed bag stating he wanted to go home. <BR/>Interview on 02/05/25 at 12:40 PM, with MA O revealed he was working on 12/24/24 he was assisting other staff gather residents in the secure unit into the dining room for lunch. MA O said they realized Resident #323 was not in his room and they began to check every room and around the facility when they realized the window to his room was broken and appeared that is how he had eloped. Management was notified and 911 was also called. MA O said he was told the resident had been found by the police and take to his family's home. MA O further stated Resident #323 was very mobile, independent, with confusion and would only come out of his room for meals. The MA said he never recalled the resident to be exit seeking or saying he wanted to leave the facility. <BR/>Review of the facility's PIR dated 01/10/25 reflected on 01/06/25:<BR/>This resident had previously broken a window and left the facility. As the facility response, we built a wooden fence around the windows on this area of the secured unit. The resident broke a window on the same section and scaled the fence. Staff witnessed the resident scaling and because of the location of the exit had to respond by going around the building. Once they were on the other side of the fence the resident was gone. Staff initiated searchs [sic] for the resident and contacted the police and the police were able to find him two hours later <BR/>Interview on 02/06/25 at 10:25 PM, with LVN Q revealed she worked on 01/04/25 and Resident #323 had dinner in the dining room and had gone back to his new room he was placed in after he was brought back by his family after his first elopement. LVN Q said she was she was sitting in the hallway and during her rounds, sometime after dinner, did not recall the time, she went to Resident #323's room to check on him and did not find him. She happened to glance down the hall and noticed he was headed into his old room, the room he first eloped from, and as she went into that room she did not see Resident #323. LVN Q noticed the window had been forced open and as she went to look outside, she saw Resident #323 on top of the fence, that had been built after his first elopement, but she was not able to get to the resident fast enough even after calling after him. LVN Q alerted staff and by the time they went outside to look for the resident, he was nowhere to be found. LVN Q further stated she alerted management and 911 was called and she was later told the resident had been found by the police and again take to his family's home. <BR/>Interview on 02/05/25 at 3:50 PM, with CNA R revealed he was working on 01/04/25 outside of the secure unit when he was alerted that Resident #323 had eloped from the facility through a window. CNA R said all of the staff began to look for the resident but he was not found. CNA R further stated he did work on the secure unit but has assisted in looking for Resident #323. <BR/>Interview on 02/04/25 at 10:54 AM, with CNA L revealed she was not at the facility during incidents where Resident #323 eloped. CNA L said Resident #323 was independent and very nice. She said the resident was able to communicate his needs and at times he would pack his bag and stand next to the exit doors but was easily redirected back to his room. CNA L stated after his first elopement, the staff had put up a fence around the outside rooms. Resident #323 was taken back to the facility and was put in another room, facing the enclosed courtyard. <BR/>Interview on 02/05/25 at 1:08 PM, with LVN P revealed she worked with Resident #323 and he was usually anxious to be picked up by his family so they could take him home and had a cell phone he would use to call his family. Resident #323 was cooperative and very pleasant with everyone and would stay in room and only come out for meals. LVN P further stated one day she noticed Resident #323 has packed his bag and said he wanted to leave but he had never tried to open the doors or leave and was easily redirected to his room. <BR/>Interview on 02/05/25 at 1:26 PM, with the DON revealed on 12/24/24 staff alerted her that Resident #323 could not be located and they had noticed the window to the resident's room had been broken out. The DON said all the staff were searching for the resident and 911 had been called. The facility later got a call from the police about 4:30 PM stating Resident #323 has been found and take to his family's home. The DON said she was not told how far from the facility he had been found. After that elopement Resident #323's family kept the resident over the holidays and had been taken back the facility on 12/31/24 and placed in another room that did not face the outside of the facility. The DON said while the resident was gone they had fixed the window to his previous room, and they had put up a wooden fence around the perimeter of the secure unit. On 01/04/25 she again was alerted that while making rounds they noticed Resident #323 was not in his room and the window to his old room had been opened and the resident had been seen jumping over the wooden fence. The staff immediately ran outside to look for the resident but he was not found so they called 911. The DON further stated that the police had found Resident #323 and again had been taken back to his family's home. The DON did not know how far from the facility he had been located. Resident #323 did to return to the facility and the family decided to keep him at home. The DON said after each of Resident #323's elopement all the staff were re-in serviced on their elopement policy. Staff participated in an elopement drill to ensure they were competent during a resident elopement. All resident in the secure unit were put on 15-minute checks to make sure there were no other resident that were exit seeking. <BR/>Interview on 02/05/25 at 11:06 AM, with the Director of Maintenance revealed he had built the wooden fence around the outside of the secure unit and was not aware the fence rails should have faced the outside of the fence and not the inside due to the safety of someone being able to climb the fence. The Director of Maintenance further stated that would be a fast and easy fix and he would just have to turn the fence around by sections. <BR/>A Past Non-Compliance Immediate Jeopardy/Immediate Threat was identified on 02/05/25. The Administrator, the Regional Consultant were notified of the Past Non-Compliance Immediate Jeopardy on 02/05/25 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:10 PM. <BR/>Review of the facility's policy titled Elopements dated 2018 reflected the following:<BR/>Staff shall investigate and report all cases of missing residents. <BR/> .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing/designee <BR/> .c. if a resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative the Attending Physician, law enforcement officials <BR/>Observation on 02/04/25 at 10:27 AM revealed there was a staff member sitting in the hallway with a bedside table charting on a laptop. The staff member had visual of the hall where the resident rooms were located and the dining room where other resident were.<BR/>Observation of the secure unit at various times from 02/04/25 to 02/06/25 revealed there were no residents that appeared to have the physical and mental capabilities of climbing the fence. <BR/>Review of the Enhanced Supervision Monitoring Tool dated 12/24/24 and 12/25/24 revealed all the residents in the secure unit has been put on 15-minute checks by staff to ensure no other residents were exit seeking or showing signs of wanting to leave the secure unit. Further review of the Enhanced Supervision Monitoring Tool revealed there were no other residents identified as being exit seeking. <BR/>Review of the Elopement Drill/Actual Event Participation dated 12/27/24 and 12/28/24 revealed staff members actively participated in a drill on what to do when and if a resident went missing. <BR/>Review of the in-services dated 12/24/24 and 01/06/25 revealed staff were in-serviced on the facility's elopement and wandering policy. <BR/>Interview on from 02/04/25 to 02/06/25 at various times with LVN J, LVN P, LVN Q, LVN V, MA O, CNA S, CNA N, CNA T, CNA U, CNA I, and CNA R revealed residents were checked on at the beginning of their shift to ensure all resident were accounted for frequent round were made to monitor all resident for signs of exit seeking. They all said if they were to notice a resident was missing, they were to alert all staff working and begin to look for the resident. If the resident was not located in the building, they would notify management and call 911.

Based on observation, record review, and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (front hall and back hall ) of four medication carts and one of one refrigerator reviewed for pharmacy services.<BR/>1. The facility failed to ensure expired medications in nurse medication carts for front hall and refrigerator were removed and destroyed.<BR/>2. The facility failed to ensure insulin were dated with opening dates.<BR/>3. The facility failed to ensure vaccines were stored at the right temperatures and refrigerator temperatures were being maintained within normal ranges. <BR/>These failures placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart, in the refrigerator, not putting opening date on insulin pens/vials and maintaining the refrigerator temperatures within ranges.<BR/>Findings included:<BR/>1. Observation on 01/08/24 at 03:11 PM of the facility refrigerator used for the sunflower Hall with LVN R revealed 2 packets of influenza vaccine 0.5 mL vials that were frozen. The temperature in the fridge was 42 degrees.<BR/>The temperature log was documented as follows:<BR/>01/01/24 - 30 degrees Fahrenheit.<BR/>01/02/24 - 31 degrees Fahrenheit.<BR/>01/03/24 - 31 degrees Fahrenheit.<BR/>01/04/24 - 31 degrees Fahrenheit.<BR/>01/05/24 - 31 degrees Fahrenheit.<BR/>01/06/24 - 40 degrees Fahrenheit.<BR/>01/07/24 - 48 degrees Fahrenheit.<BR/>01/08/24 - 40 degrees Fahrenheit.<BR/>There were also 2 acetaminophen suppositories with expiry date 03/23, 3 acetaminophen suppositories with expiry date 09/06/23 and 4 acetaminophen suppositories with expiry date 10/19/23.<BR/>Interview on 01/08/24 at 3:32 PM, LVN R revealed it was all nurses' responsibility to check the carts for expired medications and monitor the refrigerator temperatures. She stated the last time she checked the refrigerator was 01/05/24. and she only checked on the insulin for expiry and she did not check other medications and that is how she missed to see the flu vaccines were frozen. She stated the nurses are supposed to get all expired medications from the fridge and put them in the destruction boxes. LVN R stated she did not know the correct temperatures for the refrigerator, and she had been documenting every morning whatever reading was showing on the thermometer .She stated she had done in-service on labelling and checking of expired medications.<BR/>2. Observation on 01/08/24 at 03:33 PM, of the nurse's medication cart used for the Sunflower Hall back with LVN L revealed, three insulin pens of Levemir Subcutaneous Solution 100 unit/ml (Insulin Detemir), Lantus Solostar Solution Pen-injector 100 unit/ml (Insulin Glargine) and insulin glargine subcutaneous solution 100 unit/ml (Insulin Glargine) were open and partially used, and without an opening date. There were also two bottles of atropine open one with opening date of 4/10/23 and with use by date 9/6/23 and another with open date 11/9/22 and use by date 04/7/23.<BR/>Interview on 01/08/24 at 03:59 PM, with LVN L revealed it was all nurses' responsibility to put an opening date on insulin vial/pen after removing from the refrigerator. She stated she was supposed to check her cart every shift, for the opening dates and expiry dates. She stated short acting insulins are good for 28 days after being opened. She stated the effects of not putting opening date on insulin vials/pen they would not be sure when it expires and might not be effective in controlling blood sugars if administered. She stated she had completed training on labeling and storage of insulin.<BR/>Interview on 01/09/24 at 11:37AM, the DON revealed, her expectation was for all nurses to put opening dates on insulin once they remove from the refrigerator, and those not being used should be stored in the refrigerator. She stated the risk of not putting the opening dates nurses will not be able to tell when they expire. She stated if insulin expires it will not be effective and residents blood sugars will not be controlled. The DON stated the flu vaccines were not supposed to be frozen because it is well indicated on the box at what temperature they need to be stored. She stated the risk of vaccines being frozen they will not be effective if administered. She stated night shift staff are responsible of checking the refrigerator temperatures, documenting and removal of expired medications . She stated it is her responsibility and the ADONs to check the carts and medication rooms weekly and she does the monthly audit. She stated the refrigerator was supposed to be maintained between 36- and 46-degrees Fahrenheit. She stated she had done training on refrigerator monitoring with staff no in-service record was presented.<BR/>Interview on 01/09/24 at 01:29 PM, ADON X revealed night shift nurses are responsible of checking the refrigerators in medication rooms and for expired and monitoring the temperatures .ADON X revealed she would check the temperatures charting but not every day. She stated the last time she performed a weekly check was 1/5/24 and she did not notice the documented temperatures were not within the expected ranges. She stated she noted the flu vaccines were frozen after the surveyor mentioned they were frozen. She stated if staff were not checking the refrigerator for expired medications and medications were administered to residents, they would not be effective. She stated she had done in-service on refrigerator temperatures and opening dates. No record for in-service provided.<BR/>Interview on 01/10/24 at 10:19 AM, RN NN said she works night shift, and they are supposed to check the temperatures of the refrigerators, but no nurse is allocated. She stated the refrigerator temperatures should be between 36-46 degrees Fahrenheit.<BR/>Record review of the facility's current administering medication policy, revised 2018, reflected the following:<BR/>9.The expiration/beyond use date on the medication label must be checked prior to administering: When opening a multi-dose container, the date opened shall be record on the container .<BR/>Record review of the facility's current storage of medication policy, revised 2018, reflected the following:<BR/>9.Medication requiring refrigeration must be stored in a refrigerator (acceptable temperatures of 36-46 degrees Fahrenheit) located in the drug room (accepted temperature 68-77 degrees Fahrenheit) at the nurses' station or other secured location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 5 residents (Resident #184, Resident #59, Resident# 38, and Resident #2) reviewed for infection control.<BR/>LVN B and MA D failed to perform hand hygiene between residents while administering medications to Residents #184, #59, #38 and #2. <BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Review of Resident# 184's entry MDS assessment, dated 01/05/24, revealed the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included elevated blood pressure, and atrial fibrillation (irregular heartbeat). Resident #184's BIMS score was not completed resident was newly admitted .<BR/>Review of Resident #59's quarterly MDS assessment, dated 11/15/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and thrombocytopenia (a condition in which the platelets are low in number, which can result in bleeding problems). Resident #59 had severe cognitive impairment with a BIMS score of 07. <BR/>Review of Resident #38's Quarterly MDS assessment, dated 11/01/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including encephalopathy (conditions that cause brain dysfunction), anxiety, and major depressive. Resident#38 had moderate cognitive impairment with a BIMS score of 10.<BR/>Review of Resident #2's Quarterly MDS assessment, dated 12/17/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including elevated blood pressure, anxiety, and muscle weakness. Resident # 2 had moderate cognitive impairment with a BIMS score of 03.<BR/>Review of Resident #2's January 2024 physician orders revealed orders for amlodipine tablet 10mg 1 tablet one time a day and losartan potassium tablet 100mgs 1 tablet by mouth one time a day.<BR/>Observation on 01/08/24 at 07:35 AM, revealed LVN A performing morning medication pass, during which she was observed popping the medication for Resident #184 before performing hand hygiene. LVN A was called in the room by Resident #184 before she finished preparing medication. She was observed getting to the room without performing hand hygiene Residnet#184 requested for his oxygen his to be connected. LVN A was observed connecting the nasal canula to Resident #184 and left the room. LVN A did not perform hand hygiene and proceeded to her cart, continued to prepare medication. She was then observed leaving her cart to another cart and got a bottle of senna 8.6mgs without performing hand hygiene. LVN A came back to her cart and finished preparing medication and was observed entering Resident #184's room and did not perform hand hygiene before administering the medications and after administering.<BR/>Observation on 01/08/24 at 07:48 AM, revealed MA D performed morning medication pass, during which he was observed preparing medication for Resident #59 without performing hand hygiene after he was observed in the dining room of the memory care unit helping residents get seated for breakfast. He later came to his cart, pulled blood pressure cuff disinfected and left to dry. He failed to perform hand hygiene before preparing medication for Resident #59. MA D did not perform hand hygiene before and after administering medications to Resident #59.<BR/>Observation on 01/08/24 at 07:53 AM, revealed MA D performing morning medication pass, during which time MA D checked Resident #38's blood pressure. MA D did disinfect the blood pressure cuff after using it on Resident #38 without gloves and he used the same wipe on his hands. MA D put the blood pressure cuff on top of the medication cart after use.MA D failed to perform hand hygiene before preparing medication for resident #38 and after administering medications to Resident#38.<BR/>Observation on 01/08/24 at 08:03 AM revealed MA D performing morning medication pass, during which time MA D checked Resident #2's blood pressure. MA D did disinfect the blood pressure cuff after using it on Resident #2 without gloves and he used the same wipe on his hands.MA D failed to perform hand hygiene before preparing medication for resident #2 and after administering medications to Resident#2.<BR/>Interview on 01/08/24 at 08:11 AM, MA D revealed he was supposed to perform hand hygiene before and after each resident or between the procedures to prevent contamination and spread of infection. MA D stated he forgot to perform hand hygiene and he did not have hand sanitizer on his cart, but he could have been washing his hands. MA D stated he was using the disinfectant wipe after using it on blood pressure cuff because he thought it would disinfect his hands too. MA D stated he was not performing hand hygiene until when the surveyor brought hand washing to his attention. He stated he knew he was supposed to don gloves while disinfecting the blood pressure gloves. MA D stated he was aware he was supposed to perform hand hygiene to prevent contamination and spread of infection. MA D stated he had done training on infection control.<BR/>Interview on 01/08/24 09:21 AM, LVN A revealed, she was supposed to perform hand hygiene before and after medication administration. She stated she forgot to perform hand hygiene because she got nervous. LVN A stated she had done training on infection control and handwashing.<BR/>Interview on 01/09/24 at 11:14 AM, the DON revealed her expectation was that staff would perform hand hygiene before and after medication administration. The DON stated she expected staffs perform hand hygiene wear gloves disinfect the blood pressure, cuff remove gloves and wash hands. The DON stated the facility had trained staff on hand washing on 1/1/24, and MA D was not in attendance, but he had done hand washing competency on 11/1/23. she stated failure to wash hands would lead to spread of infection.<BR/>Record review on 1/09/24 revealed training on hand washing and infection control dated 1/1/24, MA D did not attend.<BR/>Record review of facility's undated Hand Washing/Hand Hygiene policy, reflected: <BR/>This facility considers hand hygiene the primary means to prevent the spread of infections 6. wash hands with soap(antimicrobial or non-antimicrobial ) and water for the following situations:<BR/>a. <BR/>When hands are visibly soiled; and<BR/>7. Use an alcohol-based had rub containing at least 62% alcohol:or,alternatively,soap(antimicrobial or non -antimicrobial) and water for the following situations:<BR/>b. <BR/>Before and after direct contact with residents.<BR/>c. <BR/>Before preparing or handling medications.<BR/>f. <BR/>Before donning sterile gloves.<BR/>k. After handling used dressings, contaminated equipment,etc.<BR/>l. After contact with objects(e.g., medical equipment)in the immediate vicinity of the resident.<BR/>I. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and<BR/>m. After removing gloves.<BR/> .10.Single -use disposable gloves should be used:<BR/> .c. When in contact with a resident, or the equipment or .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately notify the resident representative regarding a significant change in the resident's medical status, for one (Resident #22) of 12 residents reviewed for changes in condition. <BR/>The facility did not notify Resident #22's responsible party of her change in condition on 11/01/22. The resident passed away on 11/01/22. <BR/>This failure could place all the residents residing in the facility at risk of their responsible parties not being aware of incidents involving a change in medical condition and not being able to participate in and make decisions regarding their care. <BR/>Findings included:<BR/>Review of Resident #22's MDS assessment, dated 10/20/22, reflected the resident was a [AGE] year-old-female with an admit date to the facility of 04/13/20. Her diagnoses included dementia and anorexia. Her cognitive status was severely impaired. <BR/>Review of Resident #22's current Care Plan reflected:<BR/>Resident has altered respiratory status, difficulty breathing related to hypoxia (low levels of oxygen in your body tissues), dependent on oxygen. <BR/>Review of Resident #22's progress notes reflected:<BR/>10/31/22 2:20 PM Resident obeys commands. Denies weakness, tremors, numbness or tingling. Resident is disoriented. Resident is lethargic. Mood is pleasant, no unwanted behaviors witnessed. Lungs clear throughout bilaterally. No difficulty breathing. No cough noted. Oxygen via nasal cannula. - LPN A<BR/>10/31/22 2:32 PM Resident admitted to hospice today, the RP was notified. The resident in bed at the moment resting. Respirations even and unlabored, fluids offered and encouraged. Bed remains to low position, safety measures in place, incoming nurse given report and will continue with plan of care. - LVN B<BR/>11/01/22 11:45 AM The CNA called this nurse to the resident's room. Upon arrival the resident was assessed. The resident was noted with a lot of secretions, and this nurse with the help of the CNA re-positioned the resident and suctioning was provided. The resident was on continuous oxygen at 2 liters per minute. The DON was notified and came to the room to see the resident. Hospice was called around 8:43 AM and stated they would send a nurse to come and see the resident. A voice message was left for the on-call doctor at 8:50 AM. The hospice nurse arrived around 11:00 AM and took over. The family was called at this moment but could not be reached. A voice message was left for the family. At this time received comfort kit and Atropine was administered as ordered. Close monitoring for any changes. - LVN B<BR/>11/01/22 3:36 PM The resident's RP was called around 2:30 PM again to be notified about the status of the resident. The RP answered the call and was notified by this nurse that the resident was not doing that well. Resident was in the room on continuous oxygen at 2 liters per minute. Incoming nurse was given report and will continue with plan of care. - LVN B<BR/>11/01/22 10:42 PM Resident had labored breathing at 2:40 PM, vital signs: BP 93/67, P 124 bpm, Resp 40. Hospice was notified. The Chaplain, Social worker, and a Hospice nurse present. Care handed over to the Hospice nurse. At 5:27 PM Hospice nurse reported to this nurse that the resident has expired. DON and Administrator aware; family and doctor notified. Resident's body picked up at 7:35 PM by funeral home personnel. - LPN A<BR/>An observation on 11/01/22 at 10:40 AM of Resident #22 revealed she was in respiratory distress. The resident had gurgling, rapid respirations, and was wearing oxygen via nasal cannula. The resident was breathing 55 times per minute per the Surveyor's count and did not respond when spoken to except she would move her arm. The Surveyor went and found LVN B. <BR/>An interview with LVN B on 11/01/22 at 10:44 AM revealed she said Resident #22, was going down and admitted to hospice 10/31/22. LVN B said the resident was not able to control her secretions during breakfast, and her oxygen saturation was low. LVN B said the resident had a change of condition at 8:14 AM. LVN B said her hospice diagnosis was senile degeneration of the brain (dementia). LVN B said she had contacted Hospice and the physician and was waiting for the hospice nurse to arrive . LVN B was observed going into Resident #22's room where she assessed Resident #22. LVN B said the resident's oxygen saturation improved from 69% to 72%. (Normal oxygen saturation is 97-100%)<BR/>An observation and interview on 11/01/22 at 10:56 AM revealed the Hospice Nurse arrived. She said the hospice comfort kit (kit containing medications to keep the resident comfortable) was on the way. LVN B told the Hospice Nurse that Resident #22 ate 100% of food with some coughing. LVN B said the resident was fine when she got to work, and she took her morning meds with no problems. LVN B said the change in condition started after eating breakfast. The Hospice Nurse asked LVN B if the resident's family had been notified, and LVN B said no. The Hospice Nurse said she was going to call the resident's family member. The Hospice Nurse said she was going to ask the family member if she wanted Resident #22 sent to the hospital for the change in condition or if she wanted the resident to remain at the facility. The Hospice Nurse spoke to a person (not the family or RP) and said upon admit to hospice the resident was alert and she received the call this AM about her change of condition. The Hospice Nurse told the person that based on what LVN B said and her assessment, Resident #22 choked on her food and appeared to have aspirated. The Hospice Nurse asked the person if they wanted the resident sent to the hospital for evaluation, or if she wanted the resident kept at the facility. The Hospice Nurse said the person wanted to keep the resident at the facility and keep her comfortable. <BR/>An interview on 11/01/22 at 11:30 AM with LVN B revealed the physician, Hospice and family were supposed to be notified regarding a change in condition. She said she did not call Resident #22's family or RP because she just wanted to get hospice to the facility. She said because the resident had just been placed on hospice, she wanted hospice to assess her before the family or RP was contacted. She said CNA C fed the resident breakfast. <BR/>An interview on 11/01/22 at 11:43 AM with CNA C revealed she said nothing happened when she fed Resident #22 breakfast and that she drank all of her liquids and ate all of her food. She said Resident #22 started having respiratory distress while she was eating, and she had to call the nurse. CNA C said she had fed the resident before. <BR/>An observation on 11/01/22 at 12:18 PM of Resident #22 revealed the resident had gurgling, rapid respirations, and was wearing oxygen via nasal cannula. <BR/>An observation on 11/01/22 at 2:09 PM of Resident #22 revealed the resident had gurgling respirations and was wearing oxygen via nasal cannula. Her breathing rate had slowed down. The resident appeared to be more comfortable. <BR/>An interview on 11/01/22 at 2:20 PM with the RP/Family Member of Resident #22 revealed she was never notified about the resident's change in condition, was out of state and did not know the resident was in respiratory distress. She asked if the resident had died, and the Surveyor told her no. She asked that the resident not be sent to the hospital for emergency treatment. She said she would have not requested emergency treatment if she had known earlier, because it would have just bought her a little more time. She said she spoke to the facility the day before and signed the Hospice paperwork for the resident. She requested Hospice keep her comfortable at the facility. <BR/>An interview on 11/01/22 at 3:33 PM with the Hospice Nurse revealed she accidently called the wrong family and did not contact Resident #22's RP or family. <BR/>An interview on 11/01/22 at 3:40 PM with the Administrator revealed she did not know Resident #22's RP or family was never called and thought the Hospice nurse spoke with the family member. The Surveyor informed the Administrator regarding the conversation with the family member at 2:20 PM on 11/01/22. <BR/>An interview on 11/02/22 at 9:55 AM with the Administrator revealed Resident #22 passed away at 5:24 PM on 11/01/22. <BR/>An interview on 11/02/22 at 1:52 PM with the DON revealed LVN B went to her office at approximately 8:30 AM on 11/01/22 and said Resident #22's oxygen saturation dropped. The DON said she had only been at the facility for a few days and was not at the facility on 10/31/22. She said on 11/01/22 when she went in to assess Resident #22, she assisted LVN B to reposition the resident and her oxygen saturation was at 45-52% at that time. (She was wearing her oxygen) The DON said her oxygen saturation improved to 77%. T he DON said she had found out on 11/01/22 from the Surveyor that the Hospice Nurse had called the wrong family for the resident and Resident #22's family/RP was not notified until the Surveyor had called the family/RP. The DON said she did not know why the correct family was not called when the resident had a change in condition on 11/01/22. She said if a resident had a change of condition the nurse should notify all parties, DON, RP, and doctor immediately. <BR/>Record Review of the facility's Policy and Procedure for, Change in Condition, dated August 2022, reflected: <BR/>It is the policy of this facility, that changes in a resident's condition, or treatment, are shared with the resident and/or a resident representative

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #39) of 18 residents reviewed for care plans. <BR/>The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #39's diagnosis of bullous pemphigoid (rare skin condition causing large, fluid-filled blisters). <BR/>This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. <BR/>Findings included:<BR/>Review of Resident #39's MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA (stroke), non-Alzheimer's dementia, malnutrition, bullous pemphigoid, and muscle wasting. The MDS further reflected the resident was not able to complete a BIMS due to her cognition being severely impaired. The MDS also reflected the resident had impaired range of motion to the lower extremity. <BR/>Review of Resident #39's care plan, revised on 11/19/23, revealed the resident was at risk for pain due to bullous pemphigoid. Goals included the resident would be free of any discomfort or adverse side effects from pain medication. The care plan did not have further details of the autoimmune disease bullous pemphigoid. <BR/>Observation on 01/08/23 at 9:33 AM revealed Resident #39 was in bed with her eyes closed and she was not easily aroused when she was spoken to. Both her hands appeared to be contracted up to her face and there was no device in place in her hands for her possible contractures. <BR/>Observation and interview on 01/09/24 at 2:47 PM with the PT revealed he pulled Resident #39's covers back and he attempted to slowly open the resident's right hand and stated her wrist was very tight and contracted. The PT also assessed the resident's left wrist was currently not contracted but stated both hands could benefit from a hand carrot to prevent contractures/prevent contractures from worsening. <BR/>Interview on 01/10/24 at 12:30 PM with ADON X revealed she worked with Resident #39 as a charge nurse at their sister facility in March 2023 prior to the resident being admitted to the current facility in August 2023. ADON X stated that due to the resident's auto immune disease (bullous pemphigoid) they could not put anything in the resident's contractures because it would cause blisters. The ADON further stated, in the past they attempted to put a device in her contracture and they had caused large blisters in the palms of her hands so they decided the resident could not have anything in place. ADON X further stated she was responsible for resident care plans and said details of Resident #39's autoimmune disorder should have been documented. She said she thought she already addressed it and stated it was important so people would know how to care for the resident. <BR/>Review of Resident #39's clinical records from the previous sister facility, dated 05/2023, revealed the resident was being treated by a wound care doctor for multiple fluid filled blister suspicious for bullous pemphigoid which included the bilateral hands. <BR/>Review of the facility's policy titled Care Plan, Comprehensive Person-Centered reflected the following:<BR/>A comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 7 rooms (room [ROOM NUMBER], #117, #118, #120, #122, # 127, and #144) of 30 rooms reviewed for privacy. <BR/>The facility failed to provide full privacy for residents of rooms #110, #117, #118, #120, #122, # 127, and #144<BR/>This failure could place residents at risk of no privacy.<BR/>Findings included:<BR/>Observations on 2/04/25 from 11:10 AM to 12:34 PM revealed room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed, curtain clips were present; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed and had several missing slats in the window blinds; rooms # 122-2 and #127-2 had no privacy curtains at all; and room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed. <BR/>Interview on 02/06/25 at 4:15 PM the HR Manager stated each resident needed privacy curtains to protect their privacy and to give them their own space. She stated her floor tech was responsible for changing out curtains but he had quit one week ago and had not been replaced. She stated she was ultimately responsible for the privacy curtains. <BR/>Interview on 2/06/25 at 3:45 PM with the Administrator revealed there was no policy addressing privacy curtains specifically but they fell under Resident Dignity and provided the facility's undated policy Quality of Life-Dignity, which reflected:<BR/>6. Residents ' private space and property shall be respected at all times.<BR/> a. Staff will knock and request permission before entering residents ' rooms.<BR/> b. Staff will not handle or move a resident ' s personal belongings (including radios and televisions) without the resident ' s permission.

Based on observation, interview and record review the facility failed to provide a comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 9 of 9 residents (Residents #48, #3, #43, #6, #76, #45, #135, #7, and #23) and 3 of 3 zones (Zones #1, #2, and #3) reviewed for environment. <BR/>The facility failed to ensure temperatures were above 71 degrees Fahrenheit after the heater went out on the night of 01/08/24 to the morning of 01/09/24. <BR/>An Immediate Jeopardy (IJ) situation was identified on 01/09/24. While the IJ was removed on 01/10/24, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems .<BR/>This failure could place residents at risk of hypothermia and extreme cold.<BR/>Findings included:<BR/>Observation on 01/09/24 at 8:30 AM when entering the facility, revealed it was noticeably cold and staff were still wearing their coats while in the building. <BR/>Observation on 01/09/24 at 8:39 AM of Zone #1's thermostat on the wall showed it was 60 degrees F.<BR/>Observation on 01/09/24 at 8:41 AM of the activity room's thermostat on the wall showed it was 63 degrees F.<BR/>Observation on 01/09/24 at 9:31 AM of Zone #1's thermostat showed it was 59 degrees F.<BR/>Observation on 01/09/24 at 9:34 AM of Zone #3's thermostat showed it was 65 degrees F.<BR/>Observation on 01/09/24 at 9:35 AM of Zone #2's thermostat showed it was 67 degrees F.<BR/>Interview on 01/09/24 at 8:35 AM with the Administrator revealed something happened to the heater and there was not heat in the facility.<BR/>Interview on 01/09/24 at 8:37 AM with Resident #48 revealed he was in his room laying in bed under blankets. Resident #48 said he was freezing cold and noticed it getting colder through the night. Resident #48 said he was not offered any extra blankets or anything after it started getting colder and had to get his coat to put underneath his blankets to keep him warm. <BR/>Interview on 01/09/24 at 9:02 AM with Resident #3 revealed she was in her room laying in her bed under blankets and was visibly shivering. Resident #3 said she had two blankets but needed a third one. Resident #3 said she noticed it started getting very cold last night. <BR/>Interview on 01/09/24 at 9:05 AM with CNA O revealed she noticed it was unusually cold this morning when she came in for her shift. CNA O said she reported this to her nurse because two residents (Residents #43 and #33) were in the Activity Room earlier and wanted to leave because it was too cold so they wanted to go back to their rooms. CNA O said she did not call the Administrator when she came in for her shift because she did not see a reason to do so. CNA O said everyone in the facility was already aware it was cold in the building because everyone could feel it.<BR/>Interview on 01/09/24 at 9:08 AM with Resident #43 revealed she was in her room sitting in a geri-chair with a blanket over her. Resident #43 said she was very cold and was waiting for more blankets. Resident #43 said she noticed last night that it got very cold, and she had to leave the activity room earlier because it was so cold.<BR/>Interview on 01/09/24 at 9:10 AM with Resident #6 revealed she was sitting at a table in the dining room with a coat and blanket covering her, eating her breakfast. Resident #6 said she was very cold last night and had to ask for two additional blankets from staff. Resident #6 said it was still cold this morning and she was not sure what happened with the heat in the building.<BR/>Interview on 01/09/24 at 9:11 AM with Resident #76 revealed he was in the dining room standing up drinking hot coffee. Resident #76 said he noticed it got very cold last night and the coffee was helping to warm him up.<BR/>Interview on 01/09/24 at 9:14 AM with Resident #135 revealed she woke up at 4:00 AM because she was so cold and had to get a thick blanket. Resident #135 said she had not been able to get warm since and last night when she went to bed she was okay.<BR/>Interview on 01/09/24 at 9:30 AM with Resident #7 revealed she was cold last night and was given a blanket a few minutes ago and was now getting warmer. <BR/>Observation and interview on 01/09/24 at 9:38 AM with Resident #23 revealed she was cold around midnight when she was woken up for her medication. Resident #23 said she felt cold and asked for an extra blanket.<BR/>Interview on 01/09/24 at 9:41 AM with Resident #45 revealed she was in her room and had all of her clothes piled on top of her in her bed. Resident #45 said it was very cold in the facility and she woke up about 2:00 AM last night and had to pile her clothes on top of her to keep warm. Resident #45 said she asked for blankets from staff but never got any from them. Resident #45 said she had not been able to warm up yet.<BR/>Interview on 01/09/24 at 9:46 AM with CNA B revealed she came to the facility at 6:00 AM this morning and noticed it was cold. CNA B said she did not notify anyone that the facility felt cold. <BR/>Interview on 01/09/24 at 9:59 AM, RN OO said he came to the facility around 5:45 AM and noticed it was cold. RN OO said the night shift also told him it was cold in the facility. RN OO said he tried to adjust the temperature and he could not tell what the temperature was, but he tried to get it up to 80 degrees F. RN OO said he started walking around giving blankets to residents.<BR/>Interview on 01/09/24 at 10:01 AM with LVN JJ revealed she worked the night shift, and it was cold in the facility. LVN JJ said she tried to increase the temperature and the temperature was going up and down and then went off. LVN JJ said she realized the hall started getting cold and she adjusted the thermostat on the wall. LVN JJ said she gave extra blankets to some residents but could not remember who they were.<BR/>Attempted interview via phone on 01/09/24 at 10:32 AM with LVN N was unsuccessful.<BR/>Attempted interview via phone on 01/09/24 at 10:37 AM with LVN Q was unsuccessful.<BR/>Interview via phone on 01/09/24 at 10:39 AM with CNA K revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility around 11:00 PM/Midnight/1:00 AM. CNA K said she did not check the thermostats in the facility but stated it was cold. CNA K said several residents started asking for blankets and she provided those for them. CNA K said the facility did not normally feel that cold inside. CNA K said everyone could feel the cold in the facility but she was not sure why it was so cold and did not report it to the Administrator. CNA K said she was not aware the heat was out in the facility. <BR/>Interview via phone on 01/09/24 at 10:50 AM with LVN J revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility early this morning. LVN J said she did not report it to the Administrator because she was not aware the heat was out. <BR/>In an interview on 01/09/24 at 12:00 PM with the Administrator revealed he was told by the alarm company that a wire was dislodged in one of the panels that the heater was connected to and that was what caused it to go out. The Administrator said he was notified on his way to work this morning around 7:00 AM or 7:15 AM by ADON X that the heat was out at the facility . The Administrator said he was not contacted by any staff who worked the overnight shift regarding the heat being out in the facility. The Administrator said he contacted the Maintenance Director immediately who was at the facility within minutes to assess where in the building the heat was out. The Administrator said when he got to the building, he did see that the thermostats in the building were reading in the 60s. The Administrator said he knew the weather outside was very cold and the wind made it even colder. The Administrator said he knew the temperature inside the facility was supposed to be between 71 to 81 degrees F per federal and state requirements. The Administrator said he expected staff to contact him anytime they noticed the heat was out at the facility and as soon as they noticed it. The Administrator said the risk of not having heat in the building put residents at risk of hypothermia or becoming sick from being too cold. The Administrator said while checking on residents this morning, a few of them had complained about the cold.<BR/>Interview on 01/09/24 at 12:25 PM with ADON X revealed she got to the building after 6:00 AM and noticed it was extra cold in the facility. ADON X said she checked each thermostat to make sure the heat was on and noticed a few were off so she turned them on and gave them a few minutes to kick on. ADON X said after 7:00 AM she called the Administrator to let him know it was very cold in the building and the heat was not working. ADON X said she saw the thermostats on the walls were in the 60s. ADON X said she was not contacted by anyone from the overnight shift about there not being heat in the building. ADON X said when she got to the building the overnight shift had already left but the day shift staff did tell her it was a lot colder than normal. ADON X said she told staff to start offering blankets to residents and passed warm liquids to them. ADON X said if the overnight shift started to notice it getting cooler in the facility, they should have contacted the Administrator or any manager to let them know what was going on, immediately.<BR/>Interview on 01/09/24 at 1:02 PM with the DON revealed she was on her way to the facility this morning when ADON X called her to say it was cold in the facility. The DON said she was not contacted by anyone on the overnight shift regarding the lack of heat in the building. The DON said she saw one thermostat on the wall in the facility and it was in the 60s. The DON said if the overnight staff noticed it getting cold in the facility during their shift, they should have immediately contacted the Administrator. <BR/>Interview on 01/09/24 at 2:58 PM with the Maintenance Director revealed he got to the facility early this morning around 6:35 AM and was outside the building for a while and when he came into the building, he noticed it was cold. The Maintenance Director said he noticed the A/C units outside were not running and then the Administrator called him to say that there was not any heat in the building. The Maintenance Director said he contacted the HVAC company to come out and help turn the heat on. The Maintenance Director said he noticed the thermostats read in the 60s. The Maintenance Director said he was not contacted by any overnight staff about the lack of heat in the building. The Maintenance Director said if he had been called by the overnight staff he would have come to the facility to try and fix everything immediately. <BR/>Record review of the local temperatures for the area (accessed at: National Weather Service: Observed Weather for past 3 Days: reflected the temperature at midnight on 01/09/24 was 49 degrees F with a wind chill temperature of 44 degrees F; the temperature at 5:00 AM was 35 degrees F with a wind chill temperature of 25 degrees F; and the temperature at 9:00 AM was 37 degrees F with a wind chill temperature of 28 degrees F.<BR/>Record review of the facility's policy, dated 2018, and titled Resident Rights reflected: 1. Federal and state laws guarantee certain basic rights to all residents of this facility.<BR/>This was determined to be an Immediate Jeopardy on 01/09/24 at 4:55 PM. The Administrator was notified. The Administrator was provided the Immediate Jeopardy template on 01/09/24 at 4:59 PM.<BR/>The following Plan of Removal submitted by the facility was accepted on 01/10/24 at 9:35 AM:<BR/>Plan of Removal<BR/>Immediate Jeopardy <BR/>On 01/09/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: F584 - The facility failed to establish and maintain a comfortable environment for residents when the heat went out in the facility and the temperature in the facility was as low as 59 degrees F. There is likely a serious adverse outcome that will occur due to the facility not taking immediate action when the facility's temperature was at 59 degrees F. Staff overnight did not immediately contact the Administrator when they noticed the building becoming unusually cold. The facility puts the residents at risk of not having a comfortable environment putting them at risk of being exposed to the cold.<BR/>All facility residents have the potential to be affected by deficient practice. <BR/>This is an isolated event; no residents, staff, or visitors suffered a serious adverse outcome due to the facility staff not immediately contacting the facility administrator when the facility's temperature in the building became unusually cold. <BR/>The facility needs to take immediate action to ensure all staff are aware of who/when to contact the Administrator in times of extreme cold/heat and know what actions to take to keep the residents safe and comfortable.<BR/>1). Action: The facility administrator upon becoming aware at 7 am (01/09/2024), immediately called the facility Maintenance Director, who was at the facility to troubleshoot the heating system; upon becoming aware that the heating system would not turn on, the facility administrator called HVAC and Electronic Engineer vendor to report to the facility to assist in repairing the heating system and ordered spot heaters to be delivered to the facility; spot heaters arrived at 9:30 am and installed portable heaters . The Electronic Engineer discovered a loose wire and repaired the loose connection at 11 am. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/09/2024<BR/>Responsible: Facility Maintenance Director and Facility administrator<BR/>2). Action: The facility administrator assigned wellness checks (assessing for signs of hypothermia) on 01/09/2024 at 7 am to the facility Assistant Director of Nursing hourly until the facility temperature came into acceptable range ; residents needing extra blankets and warm fluids were provided promptly. All resident complaints about uncomfortable temperatures were resolved at noon. On 01/09/2024. No resident suffered a serious adverse outcome.<BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/09/2024<BR/>Responsible: Facility administrator and Facility Assistant Director<BR/>3). Action: The Chief Nursing Officer updated and re-educated the facility Administrator and Director of Nursing on the Policy and Procedure for a). Reporting Unusual Occurrences/Events; which included the importance of prompt reporting of unacceptable temperatures and the importance of the facility always maintaining a temperature range of 71&deg;F to 81&deg;F. If/when unacceptable temperatures are observed such occurrence must be reported to the facility administrator immediately. The mode of education was a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024. Comprehension was assessed by the Chief Nursing Officer via the teach-back method on 01/09/2024. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Chief Nursing Officer<BR/>4). Action: The facility administrator educated Department managers on policy and procedure for reporting unusual occurrences and events , who then educated the facility staff in their departments which included the Director of Nursing educating Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs), the Environmental Services Supervisor educating both Housekeeping and laundry persons), Dietary Manager educating the Dietary Personnel (Cooks, Tray Aides), the Rehab Director educating therapy staff (Physical Therapist, Occupational Therapist, Speech Therapists) on duty of the facility Policy and Procedure for reporting unusual occurrences/events that could affect the health, safety, or welfare of the facility residents, employees, or visitors which include and is not limited to: <BR/>a. Interruptions of essential services (e.g. heating, air conditioning, food, water, linens, sewage, or needed medical supplies;<BR/>b. earthquakes, floods, gas explosions, fires, power outages;<BR/>c. Communicable disease;<BR/>d. Poisonings;<BR/>e. Death of a resident;<BR/>f. Inoperable emergency systems, equipment, or resident call systems; and<BR/>g. Allegations of abuse, neglect, and misappropriation of resident property.<BR/>Staff not on duty during the training period will receive 1:1 training before starting their next shift from the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the facility Administrator (LNFA) and will not be allowed to work until education has been completed. The mode of education was /will be a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024 and ongoing until all facility staff have been re-educated. Education is to be added as part of the orientation for ongoing training of new hires, agency, and PRN staff through a combination of employee training, employee monitoring, and reporting processes. The teach-back method will be used to assess comprehension on 01/09/2024, in addition to a signed affidavit; education will be ongoing until all facility staff have been re-educated.<BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Director of Nursing, Administrator, Director of Rehab, SVE Supervisor, Dietary Manager<BR/>5). Action: The Director of Nursing educated Licensed Nurses (RNs/LVNs), Certified Medication Aides, and Certified Nursing Assistants (CNAs) specifically on the need to keep residents and staff inside; ensure all windows and doors are closed and provide extra blankets and hot drinks/warm soups during extremely cold temperatures . Additionally, specific education was provided to Licensed Nurses (RNs/LVNs) on the need to assess and report signs of hypothermia to medical providers by the facility Staff Development Coordinator. The Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Comprehension checks will be completed weekly x 4 weeks by the Administrator; Comprehension will be gauged by score on a random quiz given to two staff persons on each shift; a score of ninety percent or greater will equate to comprehension; those scoring less than 90% will received immediate reeducation before being allowed to continue working. Issues and re-education identified by the Director of Nursing and/or Administrator will be tracked weekly x 4 in Standards of Care (SOC) meetings and compliance will be reviewed as part of monthly QAPI x 3 months. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: The Director of Nursing, Staff Development Coordinator, and Administrator<BR/>6). Action: An ad-hoc QAPI meeting was held, and the facility Medical Director was notified of the deficient practice and the plan of removal. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Administrator<BR/>The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by:<BR/>Observations on 01/10/24 and 01/11/24 of each zone's thermostats read above 71 degrees F and it was noticeably a comfortable temperature in the facility. <BR/>Interviews with LVN A, CNA B, LVN C, CNA S, MA D, RN E, LVN F, LVN L, CNA I, CNA AA, CNA BB, the Staffing Coordinator, ADON G, LVN T, CNA CC, CNA DD, RN EE, LVN FF, CNA GG, CNA HH, LA II, LVN N, LVN JJ, LVN Q, LVN KK, [NAME] W, the Dietary Manager, Dietary Aide LL, the Maintenance Director, ADON X, the DON, and the Administrator started on 01/10/24 thru 01/11/24 revealed they worked multiple shifts (6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM) on multiple days, including weekends. Staff knew to immediately notify the Administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain that they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. <BR/>Record review of in-service sheet, dated 01/10/24, and titled Unusual Occurrences revealed multiple staff had completed the training which included ensuring the Administrator was immediately notified, staff began to provide warm liquids and additional blankets to residents, and ensured all doors/windows were closed in the facility. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 01/10/24. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of widespread due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for four (01/04/24, 01/05/24, 01/06/24, and 01/07/24) of 4 days reviewed for nurse staffing information. <BR/>The facility failed to post the required staffing information for 01/04/24, 01/05/24, 01/06/24, and 01/07/24. <BR/>This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.<BR/>Finding included: <BR/>Observation on 01/07/24 at 9:00 AM of the facility's lobby revealed the daily nursing staff posting was dated 01/03/24.<BR/>Observation on 01/07/24 at 11:00 AM of the facility's lobby revealed the daily nursing staff posting was dated 01/03/24.<BR/>Interview on 01/09/24 at 1:02 PM, the DON revealed the staffing coordinator updates the daily nursing staff posting during the week. The DON said RN J updated the daily nursing staff posting on the weekends. The DON said she went out of town on 01/02/24 and did not return to the building until 01/07/24 and usually checks to make sure the daily nursing staff posting was being updated each day. The DON said the purpose of the posting was to let staff and residents know what staff were available for that day. The DON said the risk of the post not being updated was that people need to know how many staff were in the building to care for the residents in case of an emergency and can account for all of them.<BR/>Interview on 01/09/24 at 1:23 PM, the Staffing Coordinator revealed she forgot to update the staffing posting daily after 01/03/24. The Staffing Coordinator said she was responsible for updating the daily nursing staff posting during the week and RN J updated the posting during the weekends.<BR/>Review of the facility's Posting Direct Care Daily Staffing Numbers policy, revised July 2016, reflected: <BR/> .1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview and record review the facility failed to provide a comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 9 of 9 residents (Residents #48, #3, #43, #6, #76, #45, #135, #7, and #23) and 3 of 3 zones (Zones #1, #2, and #3) reviewed for environment. <BR/>The facility failed to ensure temperatures were above 71 degrees Fahrenheit after the heater went out on the night of 01/08/24 to the morning of 01/09/24. <BR/>An Immediate Jeopardy (IJ) situation was identified on 01/09/24. While the IJ was removed on 01/10/24, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems .<BR/>This failure could place residents at risk of hypothermia and extreme cold.<BR/>Findings included:<BR/>Observation on 01/09/24 at 8:30 AM when entering the facility, revealed it was noticeably cold and staff were still wearing their coats while in the building. <BR/>Observation on 01/09/24 at 8:39 AM of Zone #1's thermostat on the wall showed it was 60 degrees F.<BR/>Observation on 01/09/24 at 8:41 AM of the activity room's thermostat on the wall showed it was 63 degrees F.<BR/>Observation on 01/09/24 at 9:31 AM of Zone #1's thermostat showed it was 59 degrees F.<BR/>Observation on 01/09/24 at 9:34 AM of Zone #3's thermostat showed it was 65 degrees F.<BR/>Observation on 01/09/24 at 9:35 AM of Zone #2's thermostat showed it was 67 degrees F.<BR/>Interview on 01/09/24 at 8:35 AM with the Administrator revealed something happened to the heater and there was not heat in the facility.<BR/>Interview on 01/09/24 at 8:37 AM with Resident #48 revealed he was in his room laying in bed under blankets. Resident #48 said he was freezing cold and noticed it getting colder through the night. Resident #48 said he was not offered any extra blankets or anything after it started getting colder and had to get his coat to put underneath his blankets to keep him warm. <BR/>Interview on 01/09/24 at 9:02 AM with Resident #3 revealed she was in her room laying in her bed under blankets and was visibly shivering. Resident #3 said she had two blankets but needed a third one. Resident #3 said she noticed it started getting very cold last night. <BR/>Interview on 01/09/24 at 9:05 AM with CNA O revealed she noticed it was unusually cold this morning when she came in for her shift. CNA O said she reported this to her nurse because two residents (Residents #43 and #33) were in the Activity Room earlier and wanted to leave because it was too cold so they wanted to go back to their rooms. CNA O said she did not call the Administrator when she came in for her shift because she did not see a reason to do so. CNA O said everyone in the facility was already aware it was cold in the building because everyone could feel it.<BR/>Interview on 01/09/24 at 9:08 AM with Resident #43 revealed she was in her room sitting in a geri-chair with a blanket over her. Resident #43 said she was very cold and was waiting for more blankets. Resident #43 said she noticed last night that it got very cold, and she had to leave the activity room earlier because it was so cold.<BR/>Interview on 01/09/24 at 9:10 AM with Resident #6 revealed she was sitting at a table in the dining room with a coat and blanket covering her, eating her breakfast. Resident #6 said she was very cold last night and had to ask for two additional blankets from staff. Resident #6 said it was still cold this morning and she was not sure what happened with the heat in the building.<BR/>Interview on 01/09/24 at 9:11 AM with Resident #76 revealed he was in the dining room standing up drinking hot coffee. Resident #76 said he noticed it got very cold last night and the coffee was helping to warm him up.<BR/>Interview on 01/09/24 at 9:14 AM with Resident #135 revealed she woke up at 4:00 AM because she was so cold and had to get a thick blanket. Resident #135 said she had not been able to get warm since and last night when she went to bed she was okay.<BR/>Interview on 01/09/24 at 9:30 AM with Resident #7 revealed she was cold last night and was given a blanket a few minutes ago and was now getting warmer. <BR/>Observation and interview on 01/09/24 at 9:38 AM with Resident #23 revealed she was cold around midnight when she was woken up for her medication. Resident #23 said she felt cold and asked for an extra blanket.<BR/>Interview on 01/09/24 at 9:41 AM with Resident #45 revealed she was in her room and had all of her clothes piled on top of her in her bed. Resident #45 said it was very cold in the facility and she woke up about 2:00 AM last night and had to pile her clothes on top of her to keep warm. Resident #45 said she asked for blankets from staff but never got any from them. Resident #45 said she had not been able to warm up yet.<BR/>Interview on 01/09/24 at 9:46 AM with CNA B revealed she came to the facility at 6:00 AM this morning and noticed it was cold. CNA B said she did not notify anyone that the facility felt cold. <BR/>Interview on 01/09/24 at 9:59 AM, RN OO said he came to the facility around 5:45 AM and noticed it was cold. RN OO said the night shift also told him it was cold in the facility. RN OO said he tried to adjust the temperature and he could not tell what the temperature was, but he tried to get it up to 80 degrees F. RN OO said he started walking around giving blankets to residents.<BR/>Interview on 01/09/24 at 10:01 AM with LVN JJ revealed she worked the night shift, and it was cold in the facility. LVN JJ said she tried to increase the temperature and the temperature was going up and down and then went off. LVN JJ said she realized the hall started getting cold and she adjusted the thermostat on the wall. LVN JJ said she gave extra blankets to some residents but could not remember who they were.<BR/>Attempted interview via phone on 01/09/24 at 10:32 AM with LVN N was unsuccessful.<BR/>Attempted interview via phone on 01/09/24 at 10:37 AM with LVN Q was unsuccessful.<BR/>Interview via phone on 01/09/24 at 10:39 AM with CNA K revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility around 11:00 PM/Midnight/1:00 AM. CNA K said she did not check the thermostats in the facility but stated it was cold. CNA K said several residents started asking for blankets and she provided those for them. CNA K said the facility did not normally feel that cold inside. CNA K said everyone could feel the cold in the facility but she was not sure why it was so cold and did not report it to the Administrator. CNA K said she was not aware the heat was out in the facility. <BR/>Interview via phone on 01/09/24 at 10:50 AM with LVN J revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility early this morning. LVN J said she did not report it to the Administrator because she was not aware the heat was out. <BR/>In an interview on 01/09/24 at 12:00 PM with the Administrator revealed he was told by the alarm company that a wire was dislodged in one of the panels that the heater was connected to and that was what caused it to go out. The Administrator said he was notified on his way to work this morning around 7:00 AM or 7:15 AM by ADON X that the heat was out at the facility . The Administrator said he was not contacted by any staff who worked the overnight shift regarding the heat being out in the facility. The Administrator said he contacted the Maintenance Director immediately who was at the facility within minutes to assess where in the building the heat was out. The Administrator said when he got to the building, he did see that the thermostats in the building were reading in the 60s. The Administrator said he knew the weather outside was very cold and the wind made it even colder. The Administrator said he knew the temperature inside the facility was supposed to be between 71 to 81 degrees F per federal and state requirements. The Administrator said he expected staff to contact him anytime they noticed the heat was out at the facility and as soon as they noticed it. The Administrator said the risk of not having heat in the building put residents at risk of hypothermia or becoming sick from being too cold. The Administrator said while checking on residents this morning, a few of them had complained about the cold.<BR/>Interview on 01/09/24 at 12:25 PM with ADON X revealed she got to the building after 6:00 AM and noticed it was extra cold in the facility. ADON X said she checked each thermostat to make sure the heat was on and noticed a few were off so she turned them on and gave them a few minutes to kick on. ADON X said after 7:00 AM she called the Administrator to let him know it was very cold in the building and the heat was not working. ADON X said she saw the thermostats on the walls were in the 60s. ADON X said she was not contacted by anyone from the overnight shift about there not being heat in the building. ADON X said when she got to the building the overnight shift had already left but the day shift staff did tell her it was a lot colder than normal. ADON X said she told staff to start offering blankets to residents and passed warm liquids to them. ADON X said if the overnight shift started to notice it getting cooler in the facility, they should have contacted the Administrator or any manager to let them know what was going on, immediately.<BR/>Interview on 01/09/24 at 1:02 PM with the DON revealed she was on her way to the facility this morning when ADON X called her to say it was cold in the facility. The DON said she was not contacted by anyone on the overnight shift regarding the lack of heat in the building. The DON said she saw one thermostat on the wall in the facility and it was in the 60s. The DON said if the overnight staff noticed it getting cold in the facility during their shift, they should have immediately contacted the Administrator. <BR/>Interview on 01/09/24 at 2:58 PM with the Maintenance Director revealed he got to the facility early this morning around 6:35 AM and was outside the building for a while and when he came into the building, he noticed it was cold. The Maintenance Director said he noticed the A/C units outside were not running and then the Administrator called him to say that there was not any heat in the building. The Maintenance Director said he contacted the HVAC company to come out and help turn the heat on. The Maintenance Director said he noticed the thermostats read in the 60s. The Maintenance Director said he was not contacted by any overnight staff about the lack of heat in the building. The Maintenance Director said if he had been called by the overnight staff he would have come to the facility to try and fix everything immediately. <BR/>Record review of the local temperatures for the area (accessed at: National Weather Service: Observed Weather for past 3 Days: reflected the temperature at midnight on 01/09/24 was 49 degrees F with a wind chill temperature of 44 degrees F; the temperature at 5:00 AM was 35 degrees F with a wind chill temperature of 25 degrees F; and the temperature at 9:00 AM was 37 degrees F with a wind chill temperature of 28 degrees F.<BR/>Record review of the facility's policy, dated 2018, and titled Resident Rights reflected: 1. Federal and state laws guarantee certain basic rights to all residents of this facility.<BR/>This was determined to be an Immediate Jeopardy on 01/09/24 at 4:55 PM. The Administrator was notified. The Administrator was provided the Immediate Jeopardy template on 01/09/24 at 4:59 PM.<BR/>The following Plan of Removal submitted by the facility was accepted on 01/10/24 at 9:35 AM:<BR/>Plan of Removal<BR/>Immediate Jeopardy <BR/>On 01/09/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: F584 - The facility failed to establish and maintain a comfortable environment for residents when the heat went out in the facility and the temperature in the facility was as low as 59 degrees F. There is likely a serious adverse outcome that will occur due to the facility not taking immediate action when the facility's temperature was at 59 degrees F. Staff overnight did not immediately contact the Administrator when they noticed the building becoming unusually cold. The facility puts the residents at risk of not having a comfortable environment putting them at risk of being exposed to the cold.<BR/>All facility residents have the potential to be affected by deficient practice. <BR/>This is an isolated event; no residents, staff, or visitors suffered a serious adverse outcome due to the facility staff not immediately contacting the facility administrator when the facility's temperature in the building became unusually cold. <BR/>The facility needs to take immediate action to ensure all staff are aware of who/when to contact the Administrator in times of extreme cold/heat and know what actions to take to keep the residents safe and comfortable.<BR/>1). Action: The facility administrator upon becoming aware at 7 am (01/09/2024), immediately called the facility Maintenance Director, who was at the facility to troubleshoot the heating system; upon becoming aware that the heating system would not turn on, the facility administrator called HVAC and Electronic Engineer vendor to report to the facility to assist in repairing the heating system and ordered spot heaters to be delivered to the facility; spot heaters arrived at 9:30 am and installed portable heaters . The Electronic Engineer discovered a loose wire and repaired the loose connection at 11 am. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/09/2024<BR/>Responsible: Facility Maintenance Director and Facility administrator<BR/>2). Action: The facility administrator assigned wellness checks (assessing for signs of hypothermia) on 01/09/2024 at 7 am to the facility Assistant Director of Nursing hourly until the facility temperature came into acceptable range ; residents needing extra blankets and warm fluids were provided promptly. All resident complaints about uncomfortable temperatures were resolved at noon. On 01/09/2024. No resident suffered a serious adverse outcome.<BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/09/2024<BR/>Responsible: Facility administrator and Facility Assistant Director<BR/>3). Action: The Chief Nursing Officer updated and re-educated the facility Administrator and Director of Nursing on the Policy and Procedure for a). Reporting Unusual Occurrences/Events; which included the importance of prompt reporting of unacceptable temperatures and the importance of the facility always maintaining a temperature range of 71&deg;F to 81&deg;F. If/when unacceptable temperatures are observed such occurrence must be reported to the facility administrator immediately. The mode of education was a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024. Comprehension was assessed by the Chief Nursing Officer via the teach-back method on 01/09/2024. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Chief Nursing Officer<BR/>4). Action: The facility administrator educated Department managers on policy and procedure for reporting unusual occurrences and events , who then educated the facility staff in their departments which included the Director of Nursing educating Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs), the Environmental Services Supervisor educating both Housekeeping and laundry persons), Dietary Manager educating the Dietary Personnel (Cooks, Tray Aides), the Rehab Director educating therapy staff (Physical Therapist, Occupational Therapist, Speech Therapists) on duty of the facility Policy and Procedure for reporting unusual occurrences/events that could affect the health, safety, or welfare of the facility residents, employees, or visitors which include and is not limited to: <BR/>a. Interruptions of essential services (e.g. heating, air conditioning, food, water, linens, sewage, or needed medical supplies;<BR/>b. earthquakes, floods, gas explosions, fires, power outages;<BR/>c. Communicable disease;<BR/>d. Poisonings;<BR/>e. Death of a resident;<BR/>f. Inoperable emergency systems, equipment, or resident call systems; and<BR/>g. Allegations of abuse, neglect, and misappropriation of resident property.<BR/>Staff not on duty during the training period will receive 1:1 training before starting their next shift from the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the facility Administrator (LNFA) and will not be allowed to work until education has been completed. The mode of education was /will be a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024 and ongoing until all facility staff have been re-educated. Education is to be added as part of the orientation for ongoing training of new hires, agency, and PRN staff through a combination of employee training, employee monitoring, and reporting processes. The teach-back method will be used to assess comprehension on 01/09/2024, in addition to a signed affidavit; education will be ongoing until all facility staff have been re-educated.<BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Director of Nursing, Administrator, Director of Rehab, SVE Supervisor, Dietary Manager<BR/>5). Action: The Director of Nursing educated Licensed Nurses (RNs/LVNs), Certified Medication Aides, and Certified Nursing Assistants (CNAs) specifically on the need to keep residents and staff inside; ensure all windows and doors are closed and provide extra blankets and hot drinks/warm soups during extremely cold temperatures . Additionally, specific education was provided to Licensed Nurses (RNs/LVNs) on the need to assess and report signs of hypothermia to medical providers by the facility Staff Development Coordinator. The Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Comprehension checks will be completed weekly x 4 weeks by the Administrator; Comprehension will be gauged by score on a random quiz given to two staff persons on each shift; a score of ninety percent or greater will equate to comprehension; those scoring less than 90% will received immediate reeducation before being allowed to continue working. Issues and re-education identified by the Director of Nursing and/or Administrator will be tracked weekly x 4 in Standards of Care (SOC) meetings and compliance will be reviewed as part of monthly QAPI x 3 months. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: The Director of Nursing, Staff Development Coordinator, and Administrator<BR/>6). Action: An ad-hoc QAPI meeting was held, and the facility Medical Director was notified of the deficient practice and the plan of removal. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. <BR/>Start Date: 01/09/2024<BR/>Completion Date: 01/10/2024<BR/>Responsible: Administrator<BR/>The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by:<BR/>Observations on 01/10/24 and 01/11/24 of each zone's thermostats read above 71 degrees F and it was noticeably a comfortable temperature in the facility. <BR/>Interviews with LVN A, CNA B, LVN C, CNA S, MA D, RN E, LVN F, LVN L, CNA I, CNA AA, CNA BB, the Staffing Coordinator, ADON G, LVN T, CNA CC, CNA DD, RN EE, LVN FF, CNA GG, CNA HH, LA II, LVN N, LVN JJ, LVN Q, LVN KK, [NAME] W, the Dietary Manager, Dietary Aide LL, the Maintenance Director, ADON X, the DON, and the Administrator started on 01/10/24 thru 01/11/24 revealed they worked multiple shifts (6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM) on multiple days, including weekends. Staff knew to immediately notify the Administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain that they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. <BR/>Record review of in-service sheet, dated 01/10/24, and titled Unusual Occurrences revealed multiple staff had completed the training which included ensuring the Administrator was immediately notified, staff began to provide warm liquids and additional blankets to residents, and ensured all doors/windows were closed in the facility. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 01/10/24. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of widespread due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 3 of 4 FY quarters reviewed (FY Quarter 1 2023 ([DATE]-[DATE]), FY Quarter 3 2023 (April 1-June 30), and FY Quarter 4 2023 (July 1-[DATE]) reviewed for administration.<BR/>The facility failed to submit data to CMS for FY Quarter 1 2023 ([DATE]-[DATE]), FY Quarter 3 2023 (April 1-June 30), and FY Quarter 4 2023 (July 1-[DATE]).<BR/>The facility's failures could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Review of the CMS PBJ report for CMS for FY Quarter 1 2023 (October 1- December 31) indicated the facility had failed to submit data for the quarter triggered.<BR/>Review of the CMS PBJ report for CMS for FY Quarter 3 2023 (April 1- June 30) indicated the facility had failed to submit data for the quarter triggered.<BR/>Review of the CMS PBJ report for CMS for FY Quarter 4 2023 (July 1- September 30) indicated the facility had failed to submit data for the quarter triggered.<BR/>Interview via phone on 01/08/24 at 2:45 PM, Corporate HR revealed she was responsible for submitting all the PBJ Staffing Data information. Corporate HR said she did not have access to the information and has not been able to submit the information for each quarter since May 2023. Corporate HR said the purpose of submitting the data to CMS was that it was a requirement.<BR/>Interview on 01/09/24 at 12:00 PM with the Administrator revealed he did not know much about the PBJ Staffing Data Report.<BR/>Review of the facility's policy revised 01/08/24, and titled Payroll Based Journal reflected: 1. The facility will electronically submit timely to CMS complete and accurate direct care staffing information

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook H) of 3 staff reviewed for kitchen sanitation. <BR/>Cook H failed to properly wear a hair restraint while in the food preparation area.<BR/>This failure could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>Observation on 01/07/24 at 12:05 PM, [NAME] H walked in to the kitchen without wearing a hair restraint.<BR/>Observation on 01/07/24 at 12:08 PM, [NAME] H walked in the kitchen again without wearing a hair restraint.<BR/>Interview on 01/07/24 at 12:10 PM, [NAME] H revealed she knew she was supposed to be wearing a hair restraint while in the kitchen and should have put one on before entering. [NAME] H said she forgot about that requirement because today was her first day back from being on maternity leave. [NAME] H said the purpose of wearing a hair restraint was to keep hair out of the food.<BR/>Interview on 01/08/24 at 1:30 PM, the Dietary Manager revealed all staff were expected to wear hair restraints while in the kitchen. The Dietary Manager said staff had access to hair restraints at the door to the kitchen so they can put them on before entering. The Dietary Manager said the purpose of wearing one was so that hair would not fall in a resident's food, drinks, or anything they were preparing food for. The Dietary Manager said she monitored all staff to make sure they were always wearing a hair restraint. <BR/>Review of the facility's Food Preparation and Service policy, revised October 2017, reflected: 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.<BR/>Record review of the Federal Food Code 2022 reflected: <BR/>2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.(8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook H) of 3 staff reviewed for kitchen sanitation. <BR/>Cook H failed to properly wear a hair restraint while in the food preparation area.<BR/>This failure could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>Observation on 01/07/24 at 12:05 PM, [NAME] H walked in to the kitchen without wearing a hair restraint.<BR/>Observation on 01/07/24 at 12:08 PM, [NAME] H walked in the kitchen again without wearing a hair restraint.<BR/>Interview on 01/07/24 at 12:10 PM, [NAME] H revealed she knew she was supposed to be wearing a hair restraint while in the kitchen and should have put one on before entering. [NAME] H said she forgot about that requirement because today was her first day back from being on maternity leave. [NAME] H said the purpose of wearing a hair restraint was to keep hair out of the food.<BR/>Interview on 01/08/24 at 1:30 PM, the Dietary Manager revealed all staff were expected to wear hair restraints while in the kitchen. The Dietary Manager said staff had access to hair restraints at the door to the kitchen so they can put them on before entering. The Dietary Manager said the purpose of wearing one was so that hair would not fall in a resident's food, drinks, or anything they were preparing food for. The Dietary Manager said she monitored all staff to make sure they were always wearing a hair restraint. <BR/>Review of the facility's Food Preparation and Service policy, revised October 2017, reflected: 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.<BR/>Record review of the Federal Food Code 2022 reflected: <BR/>2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.(8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and of exploitation of residents and misappropriation of resident property for 1 of 8 employees (CNA D) reviewed for employment registry screenings.<BR/>The facility failed to ensure a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care.<BR/>This failure could place residents at risk for abuse, neglect, exploitation and misappropriation of property.<BR/>Record review of CNA D's personnel file reflected a hire date of 07/07/23 and no EMR/NAR check was completed prior to this date. <BR/>Interview on 02/06/22 at 12:12 PM with the HR Manager revealed she began working at the facility in March of 2024. The HR Manager stated that CNA D had no EMR/NAR checks completed prior to her employment and hire date of 07/07/2023 nor the annual EMR/NAR check. The HR Manager stated that she discovered this when she was asked by this surveyor for the documentation. The HR Manager said that it was her responsibility to complete the annual EMR/NAR background checks for staff as well as upon hire. The HR Manager revealed that the staff member was suspended immediately until the EMR/NAR check was completed. The HR Manager stated that EMR/NAR checks were important to prevent abuse and neglect to residents. <BR/>Interview on 02/06/25 at 1:12 PM with the Administrator revealed EMR/NAR checks were supposed to be completed upon hire and annually by the HR Manager. The Administrator stated it was his responsibility to monitor that EMR/NAR checks were completed annually and upon hire. The Administrator revealed the importance of EMR/NAR checks were to prevent potential harm to a resident. <BR/>Record review of the facility's current, undated Abuse Prevention Program reflected the following:<BR/> .2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has:<BR/>a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;<BR/>b. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or<BR/>c. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the facility's main dining room and one (Hall 2) out of 2 halls reviewed for pests.<BR/>The facility failed to ensure the dining room and Hall 2 were free of gnats.<BR/>This placed residents at risk for an unsanitary environment and reduced quality of life.<BR/>Findings included:<BR/>An observation on 07/01/23 at 9:45 a.m., in the main area of the dining room revealed 8 - 10 gnats were noted flying around the ice machine, water dispenser machine, and soda machine. There was a sheet in the corner on the floor near the ice machine and soda that spewed over at the dispensing area of the machine which the gnats were drawn to. There were approximately 30 residents located in the dining room at the time for breakfast. <BR/>An observation on 07/01/23 at 10:30 AM of Hall 2 revealed one gnat flying near the nurses' station.<BR/>An observation on 07/01/23 at 11:00 AM of the conference room, revealed one gnat flying consistently in the Surveyor's face.<BR/>An interview on 07/01/2023 at 1:00 PM with the Administrator revealed the pest control company serviced the facility once a month. He stated he would be changing pest control companies because they have not been meeting the pest control needs at the facility. The Administrator stated the facility currently does not have a Maintenance Director. He stated that the new Maintenance Director was to begin on 07/03/2023. The Administrator revealed that pest control should improve with new pest control services. <BR/>Review of the facility's Pest Control invoice, provided by the facility, dated 04/01/2023 revealed only a bill of service, not services provided on the visit or pest treatment provided. No other pest control invoices provided.<BR/>A facility Pest Control Policy was requested on 07/01/2023 and 07/10/2023. Policy was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for 1 secure unit reviewed for activities.<BR/>The facility failed to ensure there were organized activities provided to the residents in the secure unit . <BR/>The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation. <BR/>Findings included:<BR/>Review of the facility's current February 2025 Activities Calendar for the secure unit reflected the following:<BR/>02/04/24<BR/>10:30 AM - Pretty Nails<BR/>2:00 PM - National Homemade Soup Day<BR/>3:00 PM - Table Games<BR/>02/05/24<BR/>10:00 AM - Exercise/Movie<BR/>10:30 AM - Arts and Crafts<BR/>2:00 PM - Resident Birthday Party<BR/>3:00 PM - Cookie and Apple Cider Social<BR/>02/06/24<BR/>10:00 AM - Exercise/Movie<BR/>2:00 PM Bingo<BR/>3:00 PM Senior Trivia<BR/>Observation on 02/04/25 at 10:22 AM, of the secure unit revealed there were 7 residents in the dining room and the TV was on and there were no activities going on at the time. At 12:04 PM staff began to gather the residents for lunch and surveyor exited the secure unit and not activities were noted during the continuous observation. <BR/>Observation on 02/05/25 at 10:37 AM, revealed there were 6 residents in the dining area and the TV was on and the radio was playing music in the background. Residents were noted to be wandering to and from their rooms and no activities were observed. <BR/>Observation on 02/06/25 from 10:42 AM to 12:20 PM, revealed some residents were sitting in the dining room and others were wandering in and out of the dining room and there was a staff member in the dining room monitoring the residents. No activities were observed during that time. <BR/>Interview on 02/06/25 at 1:45 PM, LVN M revealed she had been working at the facility on the secure unit for about 2 weeks and during her 6AM to 6PM shift, she had never seen any activities in the secure unit. LVN M said one of those days she did see the Activity Director paint a resident's nails. <BR/>Interview on 02/06/25 at 1:45 PM, the Activity Director revealed none of the activities that were on the calendar during 02/04/25 to 02/06/25 had been done on the secure unit. The Activity Director said it was difficult to try and do activities both on and off the unit and at times she would try to do some room rounds and paint their nails or comb their hair. <BR/>Interview on 02/06/25 at 4:02 PM, the Administrator revealed he thought there was some discrepancy in the amount of activities that were being done in the secure unit but was not aware none of them had been done during the last few days. The Administrator said they would need to review the schedule and ensure activities were being done on the secure unit. The Administrator further stated activities were important because lack of could lead to resident boredom which could increase resident behaviors. <BR/>Review of the facility's undated policy titled Activity Programs reflected the following:<BR/>Activity programs designed to meet the needs of each resident are available daily. <BR/>.1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 7 rooms (room [ROOM NUMBER], #117, #118, #120, #122, # 127, and #144) of 30 rooms reviewed for privacy. <BR/>The facility failed to provide full privacy for residents of rooms #110, #117, #118, #120, #122, # 127, and #144<BR/>This failure could place residents at risk of no privacy.<BR/>Findings included:<BR/>Observations on 2/04/25 from 11:10 AM to 12:34 PM revealed room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed, curtain clips were present; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed; room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed and had several missing slats in the window blinds; rooms # 122-2 and #127-2 had no privacy curtains at all; and room [ROOM NUMBER]-2 had no privacy curtain for the end of the bed. <BR/>Interview on 02/06/25 at 4:15 PM the HR Manager stated each resident needed privacy curtains to protect their privacy and to give them their own space. She stated her floor tech was responsible for changing out curtains but he had quit one week ago and had not been replaced. She stated she was ultimately responsible for the privacy curtains. <BR/>Interview on 2/06/25 at 3:45 PM with the Administrator revealed there was no policy addressing privacy curtains specifically but they fell under Resident Dignity and provided the facility's undated policy Quality of Life-Dignity, which reflected:<BR/>6. Residents ' private space and property shall be respected at all times.<BR/> a. Staff will knock and request permission before entering residents ' rooms.<BR/> b. Staff will not handle or move a resident ' s personal belongings (including radios and televisions) without the resident ' s permission.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the facility's main dining room and one (Hall 2) out of 2 halls reviewed for pests.<BR/>The facility failed to ensure the dining room and Hall 2 were free of gnats.<BR/>This placed residents at risk for an unsanitary environment and reduced quality of life.<BR/>Findings included:<BR/>An observation on 07/01/23 at 9:45 a.m., in the main area of the dining room revealed 8 - 10 gnats were noted flying around the ice machine, water dispenser machine, and soda machine. There was a sheet in the corner on the floor near the ice machine and soda that spewed over at the dispensing area of the machine which the gnats were drawn to. There were approximately 30 residents located in the dining room at the time for breakfast. <BR/>An observation on 07/01/23 at 10:30 AM of Hall 2 revealed one gnat flying near the nurses' station.<BR/>An observation on 07/01/23 at 11:00 AM of the conference room, revealed one gnat flying consistently in the Surveyor's face.<BR/>An interview on 07/01/2023 at 1:00 PM with the Administrator revealed the pest control company serviced the facility once a month. He stated he would be changing pest control companies because they have not been meeting the pest control needs at the facility. The Administrator stated the facility currently does not have a Maintenance Director. He stated that the new Maintenance Director was to begin on 07/03/2023. The Administrator revealed that pest control should improve with new pest control services. <BR/>Review of the facility's Pest Control invoice, provided by the facility, dated 04/01/2023 revealed only a bill of service, not services provided on the visit or pest treatment provided. No other pest control invoices provided.<BR/>A facility Pest Control Policy was requested on 07/01/2023 and 07/10/2023. Policy was not provided prior to exit.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days reviewed for nursing services. <BR/>The facility failed to provide RN coverage for 8 consecutive hours daily for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days.<BR/>This deficient practice could place residents at risk of no receiving specific nursing services due to staff being left without supervisory coverage .<BR/>Findings included:<BR/>Record review of a timesheet for all nursing staff who worked on 01/01/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 01/28/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 01/29/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 02/04/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 02/05/23 reflected there was not an RN who worked that day.<BR/>In an interview on 01/10/24 at 9:30 AM with the DON revealed it was a state requirement to have a RN on duty each day, which included the weekends . The DON said the purpose of this was so someone was at the facility to make assessments, in an emergency situation, and could make judgements. The DON said to her knowledge there were not any incidents on the above dates. The DON said the facility did not have a policy regarding RN coverage.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook H) of 3 staff reviewed for kitchen sanitation. <BR/>Cook H failed to properly wear a hair restraint while in the food preparation area.<BR/>This failure could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>Observation on 01/07/24 at 12:05 PM, [NAME] H walked in to the kitchen without wearing a hair restraint.<BR/>Observation on 01/07/24 at 12:08 PM, [NAME] H walked in the kitchen again without wearing a hair restraint.<BR/>Interview on 01/07/24 at 12:10 PM, [NAME] H revealed she knew she was supposed to be wearing a hair restraint while in the kitchen and should have put one on before entering. [NAME] H said she forgot about that requirement because today was her first day back from being on maternity leave. [NAME] H said the purpose of wearing a hair restraint was to keep hair out of the food.<BR/>Interview on 01/08/24 at 1:30 PM, the Dietary Manager revealed all staff were expected to wear hair restraints while in the kitchen. The Dietary Manager said staff had access to hair restraints at the door to the kitchen so they can put them on before entering. The Dietary Manager said the purpose of wearing one was so that hair would not fall in a resident's food, drinks, or anything they were preparing food for. The Dietary Manager said she monitored all staff to make sure they were always wearing a hair restraint. <BR/>Review of the facility's Food Preparation and Service policy, revised October 2017, reflected: 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.<BR/>Record review of the Federal Food Code 2022 reflected: <BR/>2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.(8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for four (01/04/24, 01/05/24, 01/06/24, and 01/07/24) of 4 days reviewed for nurse staffing information. <BR/>The facility failed to post the required staffing information for 01/04/24, 01/05/24, 01/06/24, and 01/07/24. <BR/>This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.<BR/>Finding included: <BR/>Observation on 01/07/24 at 9:00 AM of the facility's lobby revealed the daily nursing staff posting was dated 01/03/24.<BR/>Observation on 01/07/24 at 11:00 AM of the facility's lobby revealed the daily nursing staff posting was dated 01/03/24.<BR/>Interview on 01/09/24 at 1:02 PM, the DON revealed the staffing coordinator updates the daily nursing staff posting during the week. The DON said RN J updated the daily nursing staff posting on the weekends. The DON said she went out of town on 01/02/24 and did not return to the building until 01/07/24 and usually checks to make sure the daily nursing staff posting was being updated each day. The DON said the purpose of the posting was to let staff and residents know what staff were available for that day. The DON said the risk of the post not being updated was that people need to know how many staff were in the building to care for the residents in case of an emergency and can account for all of them.<BR/>Interview on 01/09/24 at 1:23 PM, the Staffing Coordinator revealed she forgot to update the staffing posting daily after 01/03/24. The Staffing Coordinator said she was responsible for updating the daily nursing staff posting during the week and RN J updated the posting during the weekends.<BR/>Review of the facility's Posting Direct Care Daily Staffing Numbers policy, revised July 2016, reflected: <BR/> .1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook H) of 3 staff reviewed for kitchen sanitation. <BR/>Cook H failed to properly wear a hair restraint while in the food preparation area.<BR/>This failure could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>Observation on 01/07/24 at 12:05 PM, [NAME] H walked in to the kitchen without wearing a hair restraint.<BR/>Observation on 01/07/24 at 12:08 PM, [NAME] H walked in the kitchen again without wearing a hair restraint.<BR/>Interview on 01/07/24 at 12:10 PM, [NAME] H revealed she knew she was supposed to be wearing a hair restraint while in the kitchen and should have put one on before entering. [NAME] H said she forgot about that requirement because today was her first day back from being on maternity leave. [NAME] H said the purpose of wearing a hair restraint was to keep hair out of the food.<BR/>Interview on 01/08/24 at 1:30 PM, the Dietary Manager revealed all staff were expected to wear hair restraints while in the kitchen. The Dietary Manager said staff had access to hair restraints at the door to the kitchen so they can put them on before entering. The Dietary Manager said the purpose of wearing one was so that hair would not fall in a resident's food, drinks, or anything they were preparing food for. The Dietary Manager said she monitored all staff to make sure they were always wearing a hair restraint. <BR/>Review of the facility's Food Preparation and Service policy, revised October 2017, reflected: 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.<BR/>Record review of the Federal Food Code 2022 reflected: <BR/>2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.(8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain and implement policies that ensured the residents right to request, refuse, and/or discontinue treatment for one (Resident #28) of 12 residents reviewed for documentation of treatment wishes in their medical records.<BR/>Resident #28 had a DNR document but no DNR order in Resident #28's electronic health record. <BR/>This failure could put residents at risk of receiving services such as CPR that they did not want. <BR/>Findings included: <BR/>Review of Resident #28's MDS assessment dated [DATE], reflected she was a [AGE] year-old-female with an admit date of [DATE]. Her diagnoses included Huntington's disease (a rare, inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain) Her cognitive status was moderately impaired. <BR/>Review of Resident #28's current Physician Orders reflected:<BR/>[DATE] Admit to Hospice. Diagnosis Huntington's Disease<BR/>[DATE] Full code <BR/>Review of Resident #28's Nurse's Notes reflected:<BR/>[DATE] 9:57 PM Newly admitted to facility from hospital. Resident is admitted to Hospice also today. Resident's admitting diagnosis Huntington's Disease with frequent Falls and diabetes.<BR/>Record review of Resident #28's Out of hospital DNR Order dated [DATE] reflected it was signed by the physician on [DATE]. The section for declaration by a qualified relative was signed on [DATE]. <BR/>An interview on [DATE] at 4:24 PM with the DON revealed she did not know if code statuses were correct for hospice residents, but she would find out. She said she did not know who was responsible for monitoring code statuses.<BR/>An interview on [DATE] at 1:53 PM with the Administrator revealed the plan for residents, including Resident #28, who had incorrect code statuses was for them to be corrected on [DATE]. She said if code statuses were not correct then the resident could be at risk of staff not being compliant with their rights . <BR/>Review of the Facility's Policy titled: Resident Right - Advanced Directive Tracking Program, dated [DATE], reflected: It is the policy of the facility to honor the advance directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or to change existing directives. 1. During the admission process the Social Services Director or designee will discuss with each resident and/or the person accompanying the resident the following.2 .3. Upon receipt of the advanced directive forms, copies will be made for the resident's clinical record and will be scanned into the electronic medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot mobility and good foot health for 1 (Resident #72) of 18 residents reviewed for foot care.<BR/>The facility did not ensure Resident #72 received toenail care. <BR/>This failure could place residents at risk for not receiving foot care which is consistent with professional standards of practice. <BR/>Findings included:<BR/>Review of Resident #72's MDS dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #72 had diagnoses which included end stage renal disease, aphasia (loss of ability to understand or express speech), CVA (stoke), and nontraumatic intracerebral hemorrhage . The MDS further reflected Resident #72 had long and short- term memory impairment. <BR/>Review of Resident #72's care plan, revised on 10/09/23, revealed the resident had ADL self-care performance deficit related to nontraumatic intracerebral hemorrhage. Interventions included total assistance with personal hygiene. <BR/>Observation on 01/09/24 at 2:00 PM of Resident #72 revealed he was sitting in a geri-chair in his room watching television. The resident's toenails to both feet were about half an inch long. The resident was asked if he wanted his toenails cut, and the resident replied yes in a slow low tone. <BR/>Interview on 01/09/24 at 2:04 PM with CNA MM revealed she did not know who was responsible for cutting the resident's toenails. The CNA said she had recently seen the podiatrist at the facility and thought maybe he would be cutting them at some time. <BR/>Interview on 01/10/24 at 12:41 PM with ADON X revealed resident toenails should be cut but by the nursing staff unless the resident was a diabetic. ADON X stated she had not been made aware of Resident #72's long toenails but said the CNAs should have been keeping up with fingernail and toenail care. ADON X further stated it was important to keep the resident's toenails cut due to dignity and possible skin issues. <BR/>Interview on 01/10/24 at 2:33 PM with the DON revealed she was not aware of Resident #72's long toenails. The DON said she had reviewed Resident #72's skin assessments and they all showed there were no problems with the resident's nails. The DON further stated she was not sure if the resident was on the Podiatrist's list as their Social Worker had left, and she would have to look through the documentation the Social Worker left behind. She said it was important for residents to have their nails cut for dignity purposes. <BR/>Review of the facility's Fingernails/Toenails, Care of policy, dated 2018, reflected the following:<BR/>Purpose<BR/>The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of 3 residents (Resident #184) reviewed for oxygen therapy.<BR/>The facility failed to acquire oxygen orders for Resident #184.<BR/>This facility failure could place residents at risk of missing or receiving inadequate treatment.<BR/>Findings included:<BR/>Record review of Resident #184's face sheet, dated 01/10/24, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (an irregular heart rhythm that begins in your heart's upper chambers), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record review of Resident #184's unspecified MDS Assessment, dated 01/05/24, reflected it was incomplete. <BR/>Record review of Resident #184's physician's orders reflected he did not have an order for oxygen.<BR/>Observation and interview on 01/07/24 at 12:54 PM of Resident #184 revealed he was in his room and had an oxygen concentrator machine running with a nasal cannula providing oxygen to him through his nose. Resident #184 said he just got to the facility and they gave him oxygen because he had requested it. <BR/>Observation and interview on 01/07/24 at 2:03 PM of Resident #184 revealed he had an oxygen concentrator machine running with a nasal cannula which provided oxygen to him through his nose.<BR/>Interview on 01/08/24 at 3:11 PM with LVN L revealed this was her first day working with Resident #184. LVN L said Resident #184 used an oxygen concentrator and had his oxygen level set to 2 liters/minute. LVN L said she thought Resident #184 had orders for the oxygen and would check his chart. LVN L said she did not see the orders for the oxygen and was not sure who put him on oxygen.<BR/>In an interview on 01/09/24 at 1:02 PM with the DON revealed Resident #184 was on continuous oxygen and should have an order for the oxygen. The DON said the purpose of ensuring residents have orders for treatment was because nurses were not allowed to administer anything to a resident without an order from a doctor for safety purposes. The DON said she was unsure of any risk to Resident #184 and would have to check his chart first. The DON said the responsibility to have the order in place was the charge nurse's caring for him.<BR/>Record review of the facility's Oxygen Administration policy, dated 2020, reflected: .Preparation .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days reviewed for nursing services. <BR/>The facility failed to provide RN coverage for 8 consecutive hours daily for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days.<BR/>This deficient practice could place residents at risk of no receiving specific nursing services due to staff being left without supervisory coverage .<BR/>Findings included:<BR/>Record review of a timesheet for all nursing staff who worked on 01/01/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 01/28/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 01/29/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 02/04/23 reflected there was not an RN who worked that day.<BR/>Record review of a timesheet for all nursing staff who worked on 02/05/23 reflected there was not an RN who worked that day.<BR/>In an interview on 01/10/24 at 9:30 AM with the DON revealed it was a state requirement to have a RN on duty each day, which included the weekends . The DON said the purpose of this was so someone was at the facility to make assessments, in an emergency situation, and could make judgements. The DON said to her knowledge there were not any incidents on the above dates. The DON said the facility did not have a policy regarding RN coverage.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and of exploitation of residents and misappropriation of resident property for 1 of 8 employees (CNA D) reviewed for employment registry screenings.<BR/>The facility failed to ensure a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care.<BR/>This failure could place residents at risk for abuse, neglect, exploitation and misappropriation of property.<BR/>Record review of CNA D's personnel file reflected a hire date of 07/07/23 and no EMR/NAR check was completed prior to this date. <BR/>Interview on 02/06/22 at 12:12 PM with the HR Manager revealed she began working at the facility in March of 2024. The HR Manager stated that CNA D had no EMR/NAR checks completed prior to her employment and hire date of 07/07/2023 nor the annual EMR/NAR check. The HR Manager stated that she discovered this when she was asked by this surveyor for the documentation. The HR Manager said that it was her responsibility to complete the annual EMR/NAR background checks for staff as well as upon hire. The HR Manager revealed that the staff member was suspended immediately until the EMR/NAR check was completed. The HR Manager stated that EMR/NAR checks were important to prevent abuse and neglect to residents. <BR/>Interview on 02/06/25 at 1:12 PM with the Administrator revealed EMR/NAR checks were supposed to be completed upon hire and annually by the HR Manager. The Administrator stated it was his responsibility to monitor that EMR/NAR checks were completed annually and upon hire. The Administrator revealed the importance of EMR/NAR checks were to prevent potential harm to a resident. <BR/>Record review of the facility's current, undated Abuse Prevention Program reflected the following:<BR/> .2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has:<BR/>a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;<BR/>b. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or<BR/>c. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.