**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, it was determined that the facility failed to monitor and maintain safe hot water temperatures, which were found to be up to 151 degrees Fahrenheit (F), on all residential wings/units of the facility, including the shower rooms. Further, staff failed to implement the system for reporting and acting upon ongoing concerns related to excessively hot water in resident care areas. Specifically, direct care staff with knowledge of excessively hot water temperatures did not record this information on the facility's Maintenance Log sheets as the concerns were identified. In addition, maintenance staff did not implement any additional checks of facility water temperatures to ensure they were within safe ranges after adjusting the mixing valve; and the facility failed to ensure an emergency call system was accessible to residents who used a common bathroom on the entry hall. This had the potential to affect all 48 residents in the facility; and the facility also failed to ensure a safe and secure environment by not having a monitoring system in place for residents who wandered and/or had exit seeking behaviors. This deficient practice affected one (Resident #49) of 18 sampled residents. The facility identified one current resident who was at risk for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, §483.25 (Quality of Care) at a scope and severity of L. The IJ began on 10/04/2024, when the Environmental Director adjusted the mixing valves to change the hot water temperature. The Administrator, Director of Nursing (DON), and Business Office Manager were notified of the IJ on 10/08/2024 at 10:23 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 10/09/2024 at 1:29 PM related to hot water temperatures. The IJ was removed, for the water temperatures, prior to the exit from the facility on 10/16/2024 at 6:00 PM, however the IJ an acceptable plan of removal was not received prior to exiting the facility related to elopement. In addition to the IJ above, the facility also failed to adequately assess, establish interventions, and provide supervision to prevent falls for 2 (Resident #21 and #25) of 18 sampled residents; failed to maintain safe and secure practices during medication preparation, which allowed Resident #49 to drink a medication left on the medication cart while the nurse was preparing medications. Findings include: Findings include: 1. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated resident was cognitively intact. Resident #18 used a manual wheelchair for ambulation, required substantial to maximal assistance with toileting, had active neurological diagnoses with deficit to left side. During an interview on 10/07/2024 at 11:27 AM, Resident #18 stated the facility had issues with the hot water temperature, and during a shower, the knob was set on cold and only hot water was coming of the faucet and burned the top of Resident #18's thigh. Resident #18 could not remember the staff member assisting with the shower. During an observation and interview on 10/07/2024 at 12:08 PM, the surveyor, with permission, entered Resident #21's bathroom and turned on the sink's hot water faucet, and placed their right hand under running water. The surveyor pulled their right hand out of the water stream due to the hot temperature, causing a red area on the back of the surveyor's hand. Resident #21 stated the water was hot and had received a burn while they were washing their hands, but did not report it to anyone. Resident #21 denied blistering and had only reddened hands. During an observation on 10/07/2024 at 1:24 PM revealed a white paper with all capital, black letters, hanging in the shower room, that indicated, Caution: do not turn on straight hot water. you must adjust the temperature with cold water to prevent burns. The quarterly MDS, with an ARD of 07/18/2024, revealed Resident #20 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #20 required partial to moderate assistance with toileting, bathing, and ambulation, and had a diagnosis of hand numbness and tingling caused by a pinched nerve. During an interview on 10/07/2024 at 3:20 PM, Resident #20 reported the water in the restroom sink had been scalding since Friday 10/4/2024 and had not washed their hands in their room since that time. Resident #20 stated the issue had been reported to the nurse and had not been fixed. During observations on 10/07/2024, a surveyor obtained hot water temperatures in shower rooms and resident rooms. Any common bathroom accessible to residents and staff. Temperatures were as follows: - At 2:30 PM Hot water coming from faucets in the bathroom in resident room # 310 was 139 F, Assistant Administrator used facility thermometer. The Assistant Administrator was unable to continue testing and Medical Records assisted the surveyor with the remaining water temperatures. Two rooms on each hall were checked. Hot water temperatures ranged from 139 F to 145 F. The Environmental Director was not at the facility. - At 2:33 PM Hot water coming from faucet in bathroom in resident room # 301 was 143 F, Medical Records used facility thermometer. - At 2:38 PM Hot water coming from faucet in bathroom in resident room # 201 was 145 F, Medical Records used facility thermometer. - At 2:40 PM Hot water coming from faucet in bathroom in resident room # 404 was 141 F, Medical Records used facility thermometer. - At 2:42 PM Hot water coming from the faucet in bathroom in resident room # 501 was 135 F, Medical Records used facility thermometer. - At 2:52 PM Hot water coming from faucet in bathroom in resident room [ROOM NUMBER] was 141 F, Medical Records used facility thermometer. - At 3:52 PM hot water coming out of shower head faucet in double shower room was 135 F, taken by surveyor. - At 4:00 PM hot water coming out of the faucet in Resident #20 - room [ROOM NUMBER] bathroom was 148 F, taken by surveyor. - At 5:04 PM hot water coming out of faucet in Resident #18 - room [ROOM NUMBER] bathroom was 145 F, Administrator used facility provided thermometer. - At 5:09 PM hot water coming out of the faucet in Resident #21 - room [ROOM NUMBER] bathroom was 148 F, Administrator used facility provided thermometer. - At 5:14 PM hot water coming out of the faucet in Resident #30 - room [ROOM NUMBER]A bathroom was 143 F, Administrator used facility provided thermometer. - At 5:23 PM hot water coming out of faucet in room [ROOM NUMBER] was 145 F, and Rooms #103, 105 and 107 were 151 F. No residents are housed on 100-hall, however, Resident #49 was observed wandering into rooms on 100-hall by surveyor. - At 5:34 PM hot water coming out of faucet in room [ROOM NUMBER] was 148 F, taken by Environmental Director, using a meat thermometer and confirmed by surveyor using non touch infrared thermometer. The Environmental Director stated hot water heaters were installed by (Company Name), a local plumbing company and the mixing valve could not be bypassed. During an observation on 10/07/2024 at 3:38 PM Administrator escorted surveyor to boiler room where three on-demand hot water heaters installed. The temperature on all three hot water heaters was set to 170° F. During interviews on 10/07/2024 at 3:55 PM, Certified Nursing Assistant (CNA) #4 stated they were unaware of any maintenance to the hot water being done recently, had noticed very hot water in all rooms, and was only aware of one resident who complained of hot water being especially hot and that was Resident #20, on 200-hall. CNA #4 stated to ensure water temperatures are comfortable for residents, staff test the water on their own arm without gloves. CNA #4 stated no residents have been burned yet. CNA #4 stated room [ROOM NUMBER] is too hot, and Resident #20 will not use the sink, and staff will not wash their hands in resident rooms, they use hand sanitizer after leaving rooms due to the temperature of the hot water. During interviews on 10/07/2024 at 3:57 PM, CNA #5 stated they were unaware of any maintenance on the hot water being done recently, had not noticed the water temperature being too hot and has not had a resident complain about the water temperature, and was not aware of anyone being burned by hot water. To ensure resident comfort when bathing, CNA #5 tested the temperature of the water on their wrist. The quarterly MDS, with an ARD of 08/15/2024, revealed Resident #30 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #30 required partial to moderate assistance with toileting and ambulation, used a manual wheelchair, required substantial to maximal assistance bathing, and had a neurological brain disorder. During an interview on 10/07/2024 at 3:57 PM, Resident #30 stated the water, in a shared restroom, was really hot since admission to the facility in February and was scared to use the water in the room. Resident #30 stated an aide was notified but could not recall the name of the aide. During an interview on 10/07/2024 at 3:57 PM, CNA #17 described the process used when providing resident showers by turning the water faucet half-way between hot and cold, and spraying it on the residents' leg and adjusting it per resident preference. During interviews on 10/07/2024 at 4:00 PM, Licensed Practical Nurse (LPN) #6 stated she had been employed at the facility for one week, was not aware of any service done on hot water heaters, and had noticed the water got hot and had to turn on a lot of cold water to try to adjust the temperature. LPN #6 stated no one had complained about the water temperature or of being burned by the hot water. During an interview on 10/07/2024 at 5:15 PM , the Environmental Director (ED) stated water temperatures were checked weekly. The ED stated water coming out of a resident's bathroom faucet was 148 degrees F, it would be a concern. The Environmental Director further stated anything over 120 degrees was of concern as it was a scald issue for residents and would expect staff to remove residents from the water. The Environmental Director stated the facility installed on-demand hot water heaters (HWH) that were set at 170 F, and there was a brass 2.5-inch mixing valve, a 1.5-inch pipe that sent water to the kitchen and laundry, and 2.5- inch pipe that carried water to other areas. The Environmental Director explained the mixing valve mixed in the cold water to keep the temperature at a goal, When I can get the mixing valve to work, the goal of the resident rooms was 115 degrees F to 120 degrees F. The Environmental Director stated the last time the mixing valve was adjusted was on Tuesday (10/01/2024) due to a CNA reporting there was no hot water to provide a shower, so the mixing valve was adjusted. The Environmental Director stated changes were not documented and was not aware changes needed to be documented. A review of a facility logs titled, Weekly Water Temperatures, dated 10/09/2023 to 10/01/2024, revealed water temperature readings were 115 degrees in all tested areas. Logs were not provided for the first week in October 2023, the fourth week in September 2024. The last documented entry was on 10/01/2024. A review of an untitled document identified as Maint. Log, revealed an entry on 10/05/2024 that indicated the bathroom water in room [ROOM NUMBER] gets too hot. During a phone interview on 10/07/2024, at 5:56 PM the plumbing company representative stated three on-demand hot water heaters were installed by the company and the hot water temperature can be adjusted all the way down to 120 degrees F at the hot water heaters and could be set up to bypass the mixing valve completely. The company representative stated the 2.5-inch mixing value was hard to come by and the last one was ordered from New Jersey. The representative further stated that at the time of installation the temperature was turned up to 170 F for the dishwasher in the kitchen. On 10/07/2024 at 6:01 PM, surveyors notified the Administrator and DON of unsafe water temperatures in resident bathrooms, common areas, and bath/shower rooms and no further showers/baths for residents should be done in the shower rooms until water temperatures are in the safe zone. During an interview on 10/07/2024, at 6:14 PM the Dietary Manager stated the dishwasher was a low temperature dishwasher and reaches a temperature of 125 degrees Fahrenheit and nothing in the kitchen required water temperatures to reach 170 degrees Fahrenheit. When the sink water was turned on it was very hot and steamy. The dietary manager stated it is very hot, be careful. The water temperature in the sink was 145 F. During an interview on 10/07/2024 at 6:20 PM, the Administrator stated signs were posted on shower doors that instructed that residents were not to receive showers or baths. During an interview on 10/07/2024 at 6:20 PM, the Administrator stated signs were [NAME] d 10/07/2024 after 6:01 PM on shower room doors that residents are not to receive showers/baths. Photos taken by surveyor. Signs were posted at 6:23PM. DON stated signs were posted because the facility was told they could not give showers until further notice. DON is unsure of why but thinks the temps were too high. No in-services were conducted. During an observation on 10/07/2024, the main hall bathroom was accessible to residents, staff, and visitors. The bathroom door opened to the left, pushing inward. An emergency pull cord was located on the back of the door, over 5 feet from the floor, centered from left to right, would not be accessible to a resident, staff or visitor who was on the floor, or on the toilet, requiring assistance. The emergency pull device was just above surveyor's head, while standing, surveyor's height is 5' 4. The lock on the bathroom door was a slide lock and located above and to the right of the emergency light, requiring the surveyor to fully extend their arm to activate lock. During an interview on 10/08/2024 at 09:52 AM, CNA #2 stated Resident #18 did not notify the CNA of any burn. Showers did have to be stopped on 10/07/2024 due to cold water being too hot and the issues with the hot water were going on for about 2 weeks. CNA #2 stated Resident #18 received a shower on 10/107/2024 before lunch and was not documented until later in the afternoon. Resident #18 did complain about the temperature, the water was tested on CNA #2's arm and Resident #20 told CNA #2 it was still too warm, and CNA #2 turned the water down again. CNA #2 did not notify the nurse to assess Resident #20 for burns because the water was adjusted. During an interview on 10/11/2024 at 11:48 AM, CNA #8 stated staff were made aware of hot water temperatures on Monday and were told to stop doing showers and whirlpool baths and began doing bed baths, after checking water temperatures with a thermometer. CNA #8 stated reporting of repairs was done by writing on a clipboard in the charting room and needed to include the problem, room or location and the Environmental Director would take it from there, and the Environmental Director or a nurse would notify staff of any issues, problems or needed repairs that would affect the residents. During an interview on 10/11/2024 at12:03 PM, LPN #11 stated staff were made aware of hot water temperatures on Monday or Tuesday, and bed baths were begun with temperatures being checked with a thermometer. LPN #11 stated anything that involved residents, or the facility would be on the nurse's 24-hour report sheet and the nurse would call or text the information to the Administrator, DON and the Medical Director, and LPN #11 stated the CNAs do not receive the 24-hour report and are notified verbally by the nurse. LPN #11 stated residents are notified if they can understand, if not, families are notified. During an interview on 10/11/2024 at 2:13 PM, the DON stated she was not notified of the hot water temperatures until Monday, she contacted the Environmental Director and educated staff to begin checking water temperatures before providing bed baths. The DON stated residents were notified of the hot water temperatures, families were not notified and could not provide a reason. During an interview on 10/14/2024 at 11:51 AM, RN #12 stated the bathroom is used by residents, staff, and visitors and an ambulatory resident may be able to engage the lock. RN #12 stated if a resident fell in the bathroom, hopefully someone would hear them fall and check on them because there is no call light in the bathroom. RN #12 clarified there is no call light next to the toilet in the bathroom and the one on the door would be out of reach if a resident was on the floor near the door. During an interview on 10/16/2024 at 12:45 PM, CNA #1 stated the problem of hot water was identified when providing a shower to a resident and the water was not turning colder. CNA #1 stated the nurse was notified. CNA #1 could not recall a specific date but was prior to surveyors' arrival. During an interview on 10/16/2024 at 2:51 PM, the Administrator did not recall being notified of the hot water issues, had a phone tree to notify staff of hazards and risks, but the document was not up to date and was not used for notification of hot water issues. The Administrator then stated on Saturday evening something was said about adjusting water temperatures and was notified on Monday of a maintenance log entry made on Saturday about hot water. During an observation on 10/16/2024 at 12:34 PM, the surveyor obtained follow-up hot water temperatures in room [ROOM NUMBER] bathroom sink 77 degrees F; room [ROOM NUMBER] bathroom sink 75 degrees F. During an observation on 10/16/2024 at 12:28 PM, hot water heaters number 1 and 2 were set to 110 F, and number 3 was at 140 F. During an interview on 10/16/2024 at 3:00 PM, the Administrator stated residents did not normally use the bathroom on the main hall and if they did fall someone would either hear them or would find them if they were missing by calling an elopement. The Administrator stated there was a cord on the back of the main door, up high and it is not low enough for someone to reach if they were on the floor and there was not an emergency call light in the toilet area. 2. A review of the facility's undated new hire paperwork, facility policy titled, Elopement Policy and Procedure, indicated, if the resident is not found after an organized search of the facility the Administrator and Director of Nursing (DON) should be notified and the staff would be directed to notify the authorities/law enforcement to assist. A review of the admission Record, indicated the facility admitted Resident #49 on 07/25/2024 with diagnoses that included dementia, generalized anxiety disorder, and delusional disorders. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had severe cognitive impairment. A review of Resident #49's care plan initiated on 07/30/2024 and revised on 08/31/2024, revealed the resident was disoriented to place, had impaired safety awareness, wandering behaviors, a history of elopement from home, and an elopement from the facility on 08/30/2024. Interventions included distraction with structured activities, food, conversation, television, and books. Encourage placement of air tag watch per family. Identify patterns of wandering; purposeful, aimless, or escapist and intervene as appropriate. A review of Progress Note dated 07/25/2024 at 8:15 PM revealed, Medical Director was contacted when Resident #49 became agitated with exit seeking behaviors and stated they were getting out of here one way or another and that somebody better let them out so they could go home. A review of Elopement Risk Evaluation dated 07/25/2024 at 8:04 PM revealed, Resident #49 was At Risk of elopement with a score of 4. A review of Progress Note dated 07/28/2024 at 9:18 PM revealed, Resident #49 opened the emergency door at the 500-Hall, Resident #49 was taken back to her room and administered as needed order of an antipsychotic medication. A review of Elopement Risk Evaluation dated 08/04/2024 at 9:23 PM revealed Resident #49 was At Risk of elopement with a score of 4. The resident had a history of attempting to leave the facility, verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, wandered aimlessly or non-goal-directed, and the wandering behavior was like to affect the safety or well-being of the resident or others. A review of Progress Note dated 08/07/2024 at 7:35 PM revealed Resident #49 was agitated and exhibiting exit seeking behaviors. Resident #49 stated they had to get out, Resident was pushing on exit doors and setting off the alarms as they opened. A review of Progress Note dated 08/14/2024 at 5:24 PM revealed, Resident #49 was exhibiting exit seeking behaviors. It was stated Resident #49 wouldn't stop pushing on the doors and trying to get outside, the door alarms kept going off. During an interview on 10/11/2024 at 11:00 AM Licensed Practical Nurse (LPN) # 11 was asked about Resident #49's elopement. LPN # 11 responded which one? LPN # 11 stated there was an elopement on 08/30/2024 where the resident was found in the parking lot, again on 09/19/2024 when Resident #49 went through the first set of doors and was going out the second set on 500-Hall when LPN #11 reached the resident, and an unknown Sunday when Resident #49 walked out the front doors with visitors. During an interview on 10/11/2024 at 2:10 PM, the Administrator stated he was only aware of one elopement Resident #49 had on 500-Hall and was not aware of Resident #49 walking out the front door with visitors. The Administrator stated the resident was never out of sight of staff. The Administrator stated it was possible the facility staff had failed to report other occurrences. The Administrator stated the cameras were not regularly monitored and the front hallway was unoccupied on the weekends and was not in the line of sight of staff, making a more difficult area to monitor for elopement. The Administrator stated this was not an appropriate facility for Resident #49 and family had been approached about it in care plan meetings. The Administrator stated Resident #49's family was made aware the facility's interventions may not work and Resident #49 may have to be relocated to a facility with a memory care/dementia unit which was more secure. During an interview on 10/11/2024 at 2:54 PM Certified Nursing Assistant (CNA) #20 stated they had seen Resident #49 go out the 500-Hall doors twice. CNA #20 stated she yelled Resident #49's name, the resident turned and looked, then kept going. CNA #20 stated Resident #49 walked out the front doors on a Sunday and stated it was harder on the weekends to monitor the resident. The front doors were out of sight. During an interview on 10/15/2024 at 1:30 PM, a facility visitor stated about two months ago when entering the facility, Resident #49 walked out the front doors. In a follow-up interview on 10/16/2024 at 12:58 PM, the visitor stated the resident went to the left when exiting the facility. During an interview on 10/16/2024 at 12:41 PM, CNA # 1 stated Resident #49 exited the front door of the facility when no one was at the front. CNA #1 exited the facility through the front doors, when the shift ended at approximately 2:30 PM. CNA #1 stated the Administrator was at the door when CNA #1 opened the door and asked if the person outside was Resident #49. CNA #1 stated yes, and the Administrator, and an unknown staff member exited the doors and ran after Resident #49. The unknown staff member reached Resident #49 who was in front of the building, in the grass up by the road. CNA #1 stated the elopement was before public school started, either at the end of July or the beginning of August. During an interview on 10/15/2024 at 2:17 PM, Resident #49's family member stated they did not want to move Resident #49, but wanted to know why the facility accepted the resident if they could not handle the situation. 3. Review of an untitled, confidential document, located in the risk management history (Incident and Accident [I&A]) of the electronic health record revealed Resident #21 experienced 63 falls from 10/2023 to 10/2024. A review of the admission Record, indicated the facility admitted Resident #21 with diagnoses that included a decreased blood flow to the brain, convulsions, mental illness, and nerve damage of the extremities. A review of a revised care plan, dated 01/09/2024, revealed Resident # 21 had unavoidable falls r/t [related to] noncompliance with interventions. Interventions with an initiation date of 01/09/2024 were to continue fall precautions, educate resident on fall precautions, and follow facility protocol for fall precautions. 10/17/2023 non-skid strips were placed in front of toilet; 10/19/2023 signs placed; 10/19/23 non slip pad to w/c; 11/13/23 non-skid strips to bedside 11/21/23 toilet riser removed; 6/21/23 verbal education to staff; 6/5/24 encourage activities in common areas in evenings; 9/11/23 refer to FMP program; 9/11/24 Part B reveal; 9/11/2023 continue interventions on the at-risk plan, 06/21/2023 follow facility PP pertaining to falls; 10/01/24 staff will encourage resident to change into bed clothes after evening meal. A review of the quarterly MDS with ARD 08/09/2024 revealed Resident #21 had a BIMS of 12, which indicated the resident was moderately cognitively impaired, was independent standing from a seated position, required supervision with toilet transfer and was independent walking 10 feet; and had two or more falls since prior assessment with no injury, and two or more falls with injury. During an interview on10/07/2024 at 12:09 PM, Resident #21 stated they fell in the bathroom while toileting. Review of progress note dated 08/28/2024 at 11:47 AM, revealed Resident #21 was found on floor again, with no injury. Review of progress note dated 09/02/2024 at 2:19 PM, revealed Resident #21 was found on floor in room at 1:45 PM. Review of progress note dated 09/10/2024 at 1:18 PM, revealed Resident #21 was found on floor at 1:00 PM in front of their recliner, stood up to go to bathroom and fell, there was no injury. A review of skin evaluation dated 09/10/2024 at 1:32 PM, revealed Resident #21 did not have any skin issues. A review of progress note dated 09/11/2024 at 2:31 PM, revealed Resident #21 had a bruise to right buttocks related to fall. A review of Fall Risk Evaluation, dated 09/11/2024 at 7:37 AM, revealed Resident #21 was alert and oriented times 3, ambulatory, incontinent, had adequate vision, balance problems with standing and walking, required assistive device for ambulation, and had 3 or more falls in 3 months. During an interview on 10/11/2024 at 12:29 PM, LPN #11 stated Resident #21 was a fall risk and had 8 falls in the last year. LPN #11 stated the care plan should reflect the interventions for falls and the Assistant Director of Nursing (ADON) was responsible for updating the care plan and changes were made based on what was triggered in risk management and fall risk assessments. Current interventions included reminding the resident to use the call light, assist every 2 hours to toilet, observe when up and about, encourage participation in activities, monitor for mood, notify of activities, follow facility protocol - which was will have decreased falls, encourage participation in activities, and do frequent checks on the resident. LPN #11 stated it was important to have an accurate care plan and reflect a resident's needs in order to give them the best care and giving them what they need. LPN #11 stated specific interventions implemented included ensuring resident was coming out of their room and sitting and visiting or doing activities. During an interview on 10/14/2024 at 10:50 AM, the DON stated Resident #21 had greater than 25 falls since November 2023. Care plans were established by the MDS coordinator (ADON) and interventions were added when the facility reviewed falls in the morning meetings. Risk evaluations were completed after each fall on how likely the resident was to fall, medications currently being taken and what interventions the facility could change. The DON stated, We have done everything we can with Resident #21. The DON stated there was no root cause analysis done for why the resident had so many falls and that Resident #21 would get up, made their bed, and went to the bathroom without calling for assistance. The DON revealed that Resident #21 liked attention and would get on the floor and most of the incidents did not result in any injury and she was unaware if the Medical Director had evaluated Resident #21 regarding the falls. The DON stated interventions currently in place were non-skid strips in front of the toilet, non-slip pad in the wheelchair, non-skid strips at bedside, remove the toilet riser, verbal education, encouraged activities in evening, therapy and restorative therapy, and to have staff to assist with bedtime routine after the evening meal. The DON stated it was important for the care plan to be accurate and reflect the residents' needs So that everyone can take the best care of that resident and know to take care of them. During an interview on 10/14/2024 at 12:14 PM, the ADON stated Resident #21 had 59 falls since November of 2023 and fall risk assessments were done after each one and one was done quarterly and should be accurate to ensure interventions were in place on the care plan, which gives us a chance to better help our residents and staff knows what to do. The ADON stated Resident # 21 was non-compliant with interventions and the Medical Director had said to encourage activities and place resident in common areas to help prevent falls. Interventions that have been effective was a karaoke machine and resident coming out of the room into the common area during shift change. 4. A review of the admission Record, indicated the facility admitted Resident #25 with diagnoses that included a brain disorder causing forgetfulness, limited social skills, impaired thinking abilities; low blood pressure that causes lightheadedness, dizziness, fainting; anxiety disorder; weakness and cataracts. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #25 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #25 required partial to moderate assistance with oral hygiene, shower/bathing, dressing, personal hygiene, sitting to standing, transfer from bed to chair and walking; substantial to maximal assistance with toileting; and supervision or touch assistance with eating. A review of Resident #25's care plan, with an initiated date of 08/15/2023, revealed Resident #25 had an actual/potential risk for falls related to decreased mobility, impaired vision and decreased safety awareness. Resident #25 experienced falls on 07/08/2023, 06/19/2024, and 09/02/2024 with no injuries reported. Interventions included, educated staff, anticipate and meet needs, follow facility fall protocol and PT (physical therapy) to evaluate and treat as ordered or PRN (as needed) on 08/07/2023, educated staff to assist resident with changing positions and toileting every 2 hours, on 06[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, document review, and interviews, the administration failed to provide training and oversight to ensure the facility was free from the potential for injury related to identified concerns regarding elevated hot water temperatures. During the survey, the survey team identified hot water temperatures throughout all residential units / wings of the facility. Temperatures were found to be as high as 151 degrees Fahrenheit (F) in resident bathroom sinks, as well as resident shower rooms. Furthermore, the facility failed to ensure call light system was effectively working for 200 and 300 halls; and failed to implement an emergency backup system. The facility also failed to ensure a resident was free from physical abuse for 1 resident, Resident #21, who was heard yelling out at the contract lab technician to not draw the resident's blood. CNA #1 physically restrained Resident #21 while the resident's blood was drawn. These failures all resulted in Immediate Jeopardy for F600, F689, and F919. This failed practice resulted in Resident #18 and #20 complaining of being burned by the hot water on 10/07/2024 and 10/04/2024. Resident #30 indicated they were scared to use the water in their bathroom since February 2024 due to the hot water temperature. Resident #21 complained of water in their bathroom being too hot to use. Lack of an effective call light system has resulted in residents having to call out for assistance and or have a delay in assistance resulting in care not being received. Resident #21 reported a fear of needles, feeling terrible after the incident, and due to psychosocial harm, refused to take a shower today. Resident #21 was visibly upset as evidence by writhing hands, rubbing legs, and wiping tears from his/her cheek. The Administrator was notified of the IJ on 10/11/2024 at 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/13/2024 at 1:07 PM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM The findings include: A review of Administrator's job description revealed that they were responsible for managing and directing day to day operations for the facility in an effective and efficient manner. On 10/06/2024 at 6:00 AM shift change, when night shift staff notified day shift staff that the call lights were not working. Administrator and was notified and Administrator reported that he did not have a backup plan and attempted to call other nursing homes and was unable to borrow any bells. A review of an online shopping platform invoice, dated 10/06/2024, indicated the facility ordered 3 Jingle Bells, 24 wrist band jingle bells, 12 musical instruments, and 50 hand bells. A review of an invoice from (Business Name), dated 10/08/2024 indicated an order for a Central Unit NC 110/150/200. A hand notation at the bottom of the invoice indicated Call light part. On 10/9/2024 hand and wrist bells came in and were distributed to the residents. On 10/15/2024 (Business Name) arrived at facility and call light system was repaired. On 10/6/2024 it was observed by surveyors that the water temperatures coming from residents' bathrooms and common areas were extremely hot. Temperatures were observed with a staff member obtaining temperatures as high as 151 F in resident bathroom faucet. Report of Resident #18 and Resident #20 sustaining burns from hot water. A review of maintenance log dated 10/5/2024 had revealed an entry that indicated the bathroom water in room [ROOM NUMBER] gets too hot. During an observation on 10/07/2024 at 1:24 PM, revealed a white paper with all capital, black letters, hanging in the shower room, that indicated, Caution: do not turn on straight hot water. you must adjust the temperature with cold water to prevent burns. On 10/07/2024 at 5:15 PM , the Environmental Director stated the last time the mixing valve was adjusted was on Tuesday (10/01/2024) due to a CNA reporting there was no hot water to provide a shower, so the mixing valve was adjusted. The Environmental Director stated changes were not documented and was not aware changes needed to be documented. Also reported that mixing valve for hot water heater has problems getting it to work. 10/07/2024 after 6:01 PM on shower room doors that residents are not to receive showers/baths. Photos taken by surveyor. Signs were posted at 6:23PM. DON stated signs were posted because the facility was told they could not give showers until further notice. DON is unsure of why but thinks the temps were too high. No in-services were conducted. On 10/07/2024 at 1:52 PM, when Resident #21 was heard by yelling, crying, and begging, from room [ROOM NUMBER], by surveyor and facility staff. A surveyor and a facility staff member entered room [ROOM NUMBER] and observed a contracted laboratory technician standing next to Resident #21 drawing blood despite Resident #21 stating no. DON/Administrator was notified. On 10/08/2024 the contracted laboratory technician returned and had contact with seven residents. During an interview with a surveyor on 10/14/2024 at 10:10 AM, the Administrator stated the first incident of abuse was reported to the State Agency on 10/08/2024 at 10:54 AM but should have been reported 2 hours after the notification to them was made. The Administrator stated a pre-investigation was being done to see if there was a miscommunication to do a soft file, but there was no miscommunication. On 10/14/2024 at 2:51 PM, an interview with Administrator was completed and it revealed that there was no sitting administrator upon hire of the current Administrator. So, the Administrator felt like they were self-trained. The Administrator revealed that they educate themselves by googling it, phoning a friend, consult with the Interdisciplinary team, and looking at regulations. The Administrator stated the facility did not have any consultants and felt like the administrator needed more training. The Administrator stated the facility had a person that comes in on weekends and assists the administrator in areas that they are lacking in knowledge about. The Administrator stated the person was not a consultant but was just a friend from the industry. The Administrator reported that he just found out about the State Operations Manual Appendix PP within the last week. The Administrator stated he reviewed PP over the weekend to update himself on the regulations and felt it would increase their knowledge. Removal Plan: On 10/11/2024, upon notification of deficient practice of administration failing to perform education and training to ensure the facility was free from the potential for injury the facility completed the following: On 10/11/2024 at approximately 2:00 PM, the Board President and Medical Director met with DON and administrator to complete the following: Full review of job descriptions and expectations Full review of expectations of administration as held by the board of directors Education on regulations regarding reporting abuse and neglect allegations Education on ensuring emergency backup planning in the event of system failures such as call light systems. Education on follow up regarding tasks performed by interdisciplinary teams. This review and education will be placed on and reviewed at next board meeting currently scheduled for 10/16/2024 at 7:00 AM. Administrator/Designee will monitor resident areas for potential for injury through rounding twice daily and documentation five times per week for 8 weeks or until compliance is confirmed and verified with OLTC. Any negative findings will be reported to Admin, DON and Board President. Onsite Verification: The IJ was removed on 11/07/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 when the Board of Directors President and the Medical Director met with the Director of Nursing and Administrator to review their job descriptions and expectations. The Board of Directors reviewed the DON and Administrators job descriptions and expectations, federal regulations were reviewed for reporting abuse and neglect allegations, education on the need for emergency backup systems in the event of failures, education on the follow-up regarding task assigned to the interdisciplinary team. A total of five staff interviews were conducted with staff to verify training had been completed. The staff interviewed included Head of Hospitality, Environmental Service Director, Assistant Director of Nursing, Director of Nurse and the Administrator. The staff interviewed verified they had been trained on follow-up of interdisciplinary task, emergency backup plans, reporting of abuse and neglect, job expectations. A review of in-service sheets provided indicated the Director of Nursing and the Administrator had received education on job duties and Board of Directors expectations.

Based on interviews, record review, and facility policy review, it was determined the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility. The Governing Body failed to ensure compliance with Freedom from Abuse, Neglect, and Exploitation during Survey. Immediate Jeopardy and Substandard Quality of Care (SQC) was cited at F600 at a S/S of a J. Additionally, Administration, F835 was cited at a S/S of a J; Quality Assurance and Quality Improvement, F867 was cited at a S/S of a J. Resident Call Systems, F919 was cited at a S/S of K. Supervision to Prevent Accidents, F689 was cited at a S/S of K. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.70 - Administration at a scope and severity of L. The Administrator was notified of the IJ on 10/11/2024 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/14/2024 at 7:51 AM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM The findings include: On 10/11/2024 at 10:45 AM, the Administrator stated the facility did not have a governing body policy. A review of a document titled, Meadowview Healthcare and Rehab Board Members documented members as the Board President, Governing Body Member (GBM) #13, GBM #18 and GMB #19. On 10/12/2024 at 2:51 PM, an interview with the Administrator revealed that the facility was a non-profit facility and did not have a governing body, but they had a Board of Directors that met once a month. The Administrator and the Board of Directors go over the current census, bank account balances, and from May to August 2024 their Medicaid funds were cut off due to not receiving non-profit paperwork. The Administrator reported to Surveyor that they request from the Board of Directors things such as trainings, to have consultants come in and assist the Administrator, update policies/procedures and the requests are always denied. The Administrator reports that the Board of Directors reply with that there is no reason to change or update anything due to the way things are handled have been the same way for a long time. The Administrator reported that anytime he asks the Board of Directors for anything, the Administrator does not get it. The Board of Directors will be identified as the Governing Body. On 10/15/2024 at 3:07 PM, a telephone interview with survey team with Governing Body Member (GBM) #13 revealed that the governing board met monthly. But GBM #13 did not attend the meeting in September and then revealed that they have not been to a meeting in a couple of months. It was revealed that there were four board members. GMB #13 reported that there had been some financial problems, but they were addressed and fixed. No further financial problems that GBM #13 was aware of. GBM #13 revealed that resident funds had not been addressed with the governing body. GBM #13 was not aware of the call lights being out or that the hot water burnt a resident. GBM #13 reported that GBM #13 had not had a recent meeting with the governing board since state surveyors had been in the building. The GBM #13 disclosed that they had worked on roof damage and few other building issues. GBM #13 reported that they were not aware of a pest problem or trash problem. Also, as far as GBM #13 knowledge, the Administrator had not asked for any trainings, or any other items related to training assistance. During an interview on 10/15/2024 at 3:28 PM, he Board President stated the board met monthly at the nursing facility. There are four board members, and the administrator was present during the meetings, and sometimes the Director of Nursing (DON) is present. The Board President revealed that they are short a member at this time. They have tried finding another member but have not been successful. The Board President revealed that they did not receive Medicaid funds from March to August due being frozen because they had to get all the paperwork submitted proving they were non-profit. They were unable to do so themselves, so they hired some Certified Payroll Accountants to assist them with the process. Also, the Board President revealed that the facility had to terminate a staff member that worked for the facility for using the facility credit cards and checks. The staff member was let go in February. It was reported that the board was aware of the pest problem and the administrator was told to fix it and the board members were under the assumption that it was taken care of. They were not aware that there continued to be a problem. The Board President revealed that the board was aware of the trash problem, revealed that the company that they were using was not picking up the trash routinely and the Administrator had changed companies to resolve the problem. They were not aware that there was an ongoing problem. The Board President reported that the Administrator had not asked for any more training. The board had provided a consultant to help the Administrator, but unsure of when or what the consultant helped with. The board was not aware of the federal rules and regulations for the nursing home. The board also did not review the bank statements or any financial papers of the nursing facility. On 10/16/2024 at 2:38 PM, an interview with the Administrator revealed that the governing body met that morning at 7:00 AM. The Administrator revealed that the governing body and himself realized there was a systemic failure and criteria for the nursing facility had not changed in thirty years. The Administrator stated federal rules and regulations were reviewed at the meeting. Removal Plan: On 10/11/2024, upon notification of deficient practice of ensuring a governing bodies implementation of policy and procedure regarding management and operations of facility the facility completed the following: On 10/11/2024 at approximately 2:00 PM, immediate board members- Board President and Physician- met with Administrator and Director of Nursing (DON). Review of current facility bylaws- such as Interdisciplinary team job descriptions and general day to day policy and operations- occurred. Board president and Physician reviewed job descriptions and expectations with Administrator and DON at this time. Board of directors to review and implement policy and procedures regarding management, operations and implementation of further policies. Additional policies- such as assignment and allocation to additional over viewers, appointment of additional board members, and expectations of the sitting board- to be reviewed and further discussed at scheduled board meeting currently scheduled for 10/16/2024 at 7:00 AM. Review and further implementation to be documented in board meeting minutes. Administrator/Designee will monitor implementation of board policy and procedures 2 times weekly through review and documentation with report to be provided to board president weekly on Fridays before end of business day for 8 weeks or until compliance is confirmed and verified with OLTC. All corrections were completed on 10/11/2024. Onsite Verification: The IJ was removed on 11/07/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 at 2:00 PM when the Board of Directors President, Medical Director, Director of Nursing, and Administrator met to review the facility ' s current by-laws for interdisciplinary team job descriptions, and the facility ' s general day to day policy and operations. The Board of Directors President, Medical Director, Director of Nursing, and Administrator met to review the facility ' s current by-laws for interdisciplinary team job descriptions, and the facility ' s general day to day policy and operations, Director of Nursing and Administrator job descriptions and expectations were reviewed, new board members were appointed and assignments were allocated, by-laws were updated, and the Administrator monitored new implementations and reported to the Board of Directors President every Friday. A total of 2 staff interviews were conducted to verify training had been completed. The staff interviewed included the Director of Nursing and the Administrator. The staff interviewed verified they had been trained on new bylaws, job descriptions, and expectations of the board. A review of in-service sheets provided indicated both had been provided training.

The facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain a program that developed and implemented effective improvement plans to correct identified areas of concern. After identifying Immediate Jeopardy at F600, F689, F835, F837, and F919, the facility's QAPI plan was requested. The Administrator was unable to locate the facility QAPI plan. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.75 - Quality Assurance and Performance Improvement at a scope and severity of L. The Administrator was notified of the IJ on 10/11/2024 at 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/14/2024 at 7:51 AM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM. Findings include: A review of an undated policy titled Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Policy & Procedure revealed that the facility would develop a QAPI plan in accordance with federal guidelines. The facility would address clinical care, resident quality of life and residents' choice. During an interview on 10/11/2024 at 2:30 PM, the Administrator stated that the QAPI binder was unable to be located. The Administrator stated that the QAPI binder was not up to par and he would no longer look for the binder. The Administrator stated the QAPI team was going to meet the second Tuesday of the month. The Administrator also stated the facility would like to add a resident to the QAA/QAPI team because he felt it would help identify systemic issues. The Administrator stated the QAPI program would help with better documentation and current policies. The Administrator stated that some of the facilities' current policies were from 1991 and need to be updated to current standards. The Administrator reported that a new QAPI binder had been started. The Administrator reported that it was important to have a QAPI program to help find issues within the facility and be able to fix them quickly. The Administrator stated he felt like his employees came to him a lot with problems. He did not think the QAPI program would bring any more problems up that his staff did not already bring to him, however, the Administrator stated he realized during the survey, he had a lot more problems than he knew about. Removal Plan: On 10/11/2024, upon notification of deficient practice to ensure an effective QAPI is in place, the facility completed the following: On 10/11/2024, the Director of Nursing (DON) and Administrator reviewed current regulations revolving around a Quality Assurance Performance Initiative (QAPI) program ensuring further comprehension of program needs, placement, reasoning and requirements. Interdisciplinary team (IDT) met with DON & Administrator to review and increase knowledge and education on QAPI. On 10/11/2024, DON and Administrator reviewed, adjusted and updated facility QAPI Policy & Procedure to include the following: - Scheduled time of the month for QAPI to be held - Reassignment of information to be provided from different members of IDT. - Requesting for resident president to be a part of QAPI meetings and information gathering Requesting that a floor staff member be a part of QAPI meetings and information gathering - Review on providing in-service education to all staff pertaining to QAPI, it's reasoning and methodology. Administrator/designee will oversee the implementation of comprehensive QAPI program through documentation 1 time per week for 8 weeks or until compliance is verified by OLTC. All corrections were completed on 10/11/2024. Onsite Verification: The IJ was removed on 11/06/2024 at 2:49 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 when the Director of Nursing (DON) and Administrator reviewed current regulations for Quality Assurance Performance Initiative (QAPI) program. The Interdisciplinary Team (IDT) met with the DON and Administrator reviewed and increased their knowledge on QAPI, monthly QAPI meetings were scheduled for the 2nd Tuesday of every month at 2:00 PM, QAPI responsibilities were assigned to each IDT member, the resident council present was asked to take part in the monthly meetings, the Activities Director met with residents from resident council for input on needed improvements, a Licensed Practical Nurse (LPN) who works the floor was asked and accepted to join QAPI committee, all staff were educated on QAPI, and the administrator provided his weekly documentation of QAPI oversite. A total of 9 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurse. The staff interviewed verified they had been trained on QAPI. A review of in-service sheets provided indicated 54 of 69 had been provided training. Those staff who were not physically present to receive the in-services were provided the power point on paper by the night shift charge nurse and signed the acknowledgement sheet which was returned to Human Resources.