Every finding on record at Colfax General LTC

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food was stored appropriately and not left open to air in the kitchen freezer. These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 04/21/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 04/21/25 at 1:03 pm, observation of the kitchen revealed the following: - 3 pecan pies, 3 apple pies, 1 sheet cake, and 1 box of salmon fish fillets were not labeled or dated and stored in the kitchen freezer. - 1 package of pepperoni, 1 pack of chicken nuggets, and 1 box of salmon fish fillets were open to air and stored in the kitchen freezer. - 1 box of eggs was sealed but was not labeled or dated in the kitchen refrigerator. - 2, 12 pack soda cases were stored on the floor in the dry storage, and one case had been opened. B. On 04/21/25 at 1:34 pm during an interview with the Dietary Manager (DM), he confirmed all items listed on finding A and stated that all food items should be labeled, dated, stored appropriately.

Based on observation, record review, and interview, the facility failed to meet professional standards for 3 (R # 5, 6, and 7) of 9 (R #1, 5, 6, 7, 8, 9, 10, 11, and 12) residents when staff failed to: 1. Ensure R #5's, R #6's, and R #7's humidity (attachable bottle to moisten administered oxygen) is added to concentrator and that O2 concentrator is capable of having humidy added. 2. Label and date oxygen (O2) tubing per physician orders for R #5, R #6 and R #7. If the facility is not following physician orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's physician orders dated 02/28/25, revealed an order to change humidifiers (device used to moisten medical O2) and nasal cannulas (device used to administer medical O2) on the night shift every Friday. C. On 04/22/25 at 2:06 pm during an observation of R #5's room, R #5's concentrator (oxygen machine) did not have a humidifier as ordered by Physician and the O2 tubing was not labeled or dated . R #6: D. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. E. Record review of R #6's physician orders dated 02/28/25, revealed change humidifier/cannulas, date and initial every night shift every Fri (Friday). F. On 04/22/25 at 2:08 pm during an observation of R #6's room, R #6's concentrator did not have a humidifier as ordered. Label and dates were missing from the equipment. R #7: G. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE]. H. Record review of R #7's physician orders dated 02/28/25, revealed an order to change humidifiers and nasal cannulas on the night shift every Friday. I. On 04/22/25 at 2:10 pm during an observation of R #7's room, R #7's concentrator was found to be without a humidifier. Label and dates were missing from equipment. J. On 4/22/25 at 2:20 pm during an interview with Certified Nursing Assistant (CNA) #2, she stated the humidifier bottle and tubing should be changed weekly. CNA #2 confirmed staff are supposed to label and date the tubing and bottle. CNA #1 stated she is unaware of how humidity can be added to the affected resident concentrators. K. On 4/22/25 at 2:47 pm during an interview with Registered Nurse (RN) #1, she stated the CNAs and nurses are responsible for changing O2 tubing and the humidifiers as ordered by Physician. RN #1 confirmed the nasal cannulas and humidifier should be labeled and dated. RN #1 stated she doesn't know how to change or add humidity to the affected resident concentrators. RN #1 stated, I would expect these concentrators are to be replaced and be able to administer humidified air. L. On 4/22/25 at 3:11 pm during an interview with the Director of Nursing (DON), she stated, all the residents with concentrators should have a concentrator that is capable of adding humidity. The DON confirmed the affected resident concentrator was not capable of adding humidity.

Based on record review and interview, the facility failed to notify the resident's provider of a decline in condition for 1 (R #1) of 1(R #1) resident reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider when the resident experiences a change of condition, then the provider is unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: -Acute Kidney Failure (condition in which the kidneys can't filter waste from the blood). -Dementia (memory loss). -Chronic Obstructive Pulmonary Disease unspecified (shortness of breath). -Alcoholic Cirrhosis (damage of cells, swelling, and thickening of the liver). -Cerebral Vascular Accident (Stroke). -UTI (Urinary Tract Infection). B. Record review of R #1's daily care/progress notes revealed the following: - On 03/11/25, R #1 had refused to eat for a couple of days. - On 03/12/25, R #1's Medical Doctor (MD) progress notes stated that if R #1's condition did not improve in 24 hours, Staff will need to consider Emergency Department (ED) evaluation and hydration. The progress note further stated, nurses will contact providers with any concerns or changes. -On 03/16/25, R #1 was sent to the emergency room (ER) for a decline in condition. Due to sepsis (systemic infection) and UTI, R #1 was transported via air medical transport to [NAME], Texas for specialty evaluation and care. -The record did not contain any progress notes from 03/13/25 through 03/15/25 documenting R #1's health status, evaluations, or a decline in condition. -On 03/16/25 the progress note stated, R #1 presents with altered mental status, R #1 had 5 teeth removed on 02/25/25. The gums at removal sites are yellowish green. C. On 04/22/25 at 2:47 pm during an interview with Registered Nurse (RN) #1, she confirmed that staff should have called or texted the physician concerning any change in condition. D. On 04/22/25 at 3:11 pm during an interview with the Director of Nursing (DON), she confirmed the Medical Doctor (MD) should have been notified. E. On 04/22/25 at 3:56 pm during a phone interview with Provider #1, he stated that he was not notified of R #1's decline in condition. F. On 04/22/25 at 3:57 during a phone interview with Provider #2, she stated she was not notified of R #1's decline in condition.

Based on observation and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 1 (R #13) of 5 (R #2, #3, #4, #5, and #13) residents observed for call lights. If the facility does not have a functioning communication system, then residents are unlikely to get their immediate needs met by facility staff. The findings are: A. On 04/22/25 at 9:17 am during a call light observation, R #13's call light was activated, but it did not sound at the nurse's station or the unit to alert staff of call light activation. The call light did not activate the marquee (electronic signage displaying room numbers) notification, the nurse's station visual alert or nurse's station audible alert. B. On 04/22/25 at 9:20 am during interview with Registered Nurse (RN #1), RN #1 stated call lights should alert staff at the nurses station when activated and should display on marquee in the unit halls. RN #1 confirmed R #13's call light did not alert the nursing station when activated nor display on marquee of the call light and should have. C. On 04/22/25 at 9:25 am during interview with Certified Nursing Assistant (CNA) #1, she confirmed R #13's call light was not functioning. CNA #1 stated R #13's call light should be fully functioning when activated and it was not. D. On 04/22/25 at 9:36 am during a call light observation, R #13's call light was activated two more times and did not alert nurses station or display notification on marquee. E. On 04/22/25 at 9:36 am during an interview with CNA #1, she confirmed R #13's call light was still not functioning properly, and should have been. CNA #1 will notify maintenance. F. On 04/23/25 at 3:11 pm during an interview with Director of Nursing (DON), she stated, she was not notified of a call light issue. DON stated the facility policy is that the CNAs should report the malfunction to the charge nurse, then report the malfunction to maintenance. DON stated, while the call light is not working, staff should be rounding on the affected room every 30 minutes to ensure resident safety. DON confirmed the 30 minute room rounding was not occurring, and R #13's call light should have been fixed already.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Kitchen refrigerators were free from dietary staff personal food. 3. Food was stored appropriately and not left open to air in the kitchen. 4. Salad was stored on ice prior to meal service. These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 01/27/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 01/27/25 at 12:39 pm, observation of the kitchen revealed the following: - One Styrofoam To-Go container labeled [Name of [NAME] 1] dated 01/27/25 was stored in the kitchen refrigerator. - Three large plastic bags of crinkle cut fries were not labeled or dated and stored in freezer #1. - One large plastic bag of frozen meat was not labeled or dated and stored in freezer #1. - Seven large plastic bags of biscuits were dated 11/09 but not labeled and stored in freezer #1. - Two large plastic bags of cubed meat dated 12/01 but not labeled and stored in freezer #2. - Four large bags of chicken tenders dated 12/01 but not labeled and stored in freezer #2. B. On 01/27/25 at 12:53 pm during an interview with the Dietary Manager (DM), he stated that all food should be labeled, dated, and staff should not store their food in the resident refrigerator. C. On 01/30/25 at 11:45 am, observation of the kitchen revealed one box of 20 count [NAME] Spunkmeyer muffins were left open to air and stored on a kitchen table near freezer #2. D. On 01/30/25 at 11:47 am during an interview with the DM, he confirmed the muffins were left open to air and stated they should have been sealed for storage. E. On 01/30/25 at 12:04 pm, observation of the dining room revealed the following: - One plastic container of salad mix and one plastic container of chopped tomatoes were stored on the hot steam table, the salad mix and the tomatoes were not on ice while the DM served the residents their lunch plates. The salad was served to all residents in dining room. F. On 01/30/25 at 12:05 pm during an interview with the DM, he confirmed the salad mix and tomatoes were not cold and stated they should have been stored on ice during meal service.

Based on observation and interview, the facility failed to ensure that all garbage and refuse containers have lids or are otherwise covered in the kitchen. This deficient practice could likely affect all 32 residents identified on the resident census list provided by the Administrator on 01/27/25. This deficient practice could likely result in shelter and feeding of pests. The findings are: A. On 01/30/25 at 11:45 am, observation of the kitchen revealed the following: - One small trash can filled with trash was not covered and stored under the dishwashing station next to an open box of muffins. - One large trash can was filled with trash and not covered next to the three compartment kitchen sinks and stove. B. On 01/30/25 at 11:48 am during an interview with the Dietary Manager (DM), he confirmed both trash cans were uncovered in the kitchen near food prep areas. The DM stated all trash cans should be stored with lids.

Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and life saving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #34) of 1 (R #34) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially life saving procedures. The findings are: A. Record review of R #34's physician orders dated [DATE] revealed R #34 was a Do Not Resuscitate (DNR- a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops) for her advanced directive code status. B. Record review of R #34's care plan dated [DATE] revealed R #34 was a DNR for her advanced directive code status. C. Record review of R #34's face sheet revealed R #34 was admitted into the facility on [DATE]. D. Record review of R #34's EHR revealed the record did not contain an advanced directive form. E. On [DATE] at 2:04 pm during an interview with the Social Services Director (SSD), she confirmed R #34's advanced directive code status was not uploaded into R #34's EHR nor was it available in physical form for nursing staff and should have been.

Based on record review and interview, the facility failed to report the results of an investigation regarding allegations of abuse for 2 (R #'s 8 and 22 ) of 2(R #'s 8 and 22) residents reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency (SA), then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Refer to F0610 for related findings. B. On 01/30/25 at 2:33 pm during an interview with the Administrator (ADM), she stated the incident involving R #8 and R #22 with an agency Certified Nurse Assistant (CNA) was not reported to the SA. The ADM stated that R #8 only reported experiencing issues with the agency CNAs bedside manner towards him and R #22, but the facility could not define what bedside manner meant in this case. When asked if this could be considered verbal abuse, the ADM was unsure and stated she could not rule out verbal abuse with the information that was provided to her. The ADM confirmed all allegations of abuse, including verbal abuse, should be reported to the SA.

Based on record review and interview, the facility failed to complete a thorough investigation and report the investigation findings within five working days, for an allegation of abuse for 2 (R #'s 8 and 22) of 2 (R #'s 8 and 22) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Record review of the facility's investigation report dated 12/23/24 revealed the following: - R #8 requested to speak to the Administrator (ADM) regarding concerns of bedside manner of an agency Certified Nursing Assistant (CNA) while assisting R #22. -R #8 stated that his back was turned when the agency CNA assisted R #22, he had concerns of poor bedside manner regarding that interaction. - Multiple residents were interviewed on 12/23/24 with the residents confirming poor attitude and bedside manner experienced by the agency CNA. - Due to the residents consistent highlighted concerns regarding the agency CNAs bedside manner, the agency CNAs contract was terminated. B. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE]. C. Record review of R # 8's Minimum Data Set (MDS- Resident Assessment and Care Screening) Section C: Cognitive Patterns- Brief Interview for Mental Status (BIMS: assessment used to monitor cognition; 0 to 7 points equals severely impaired cognition, 8 to 12 points equals moderately impaired cognition, and 13 to 15 points equals intact cognition) dated 11/14/24 revealed R #8 was scored as 15. D. Record review of R #8's nursing progress notes dated 12/20/24 through 01/01/25 revealed the notes did not contain any documentation of any allegations of abuse against an agency CNA (Certified Nursing Assistant) for R #8. E. Record review of R #22's face sheet revealed R #22 was admitted into the facility on [DATE]. F. Record review of R #22's MDS Section C: Cognitive Patterns- BIMS dated 11/27/24 revealed R #22 was scored as 11. G. Record review of R #22's nursing progress notes dated 12/20/24 through 01/01/25 revealed no notes were present that indicated any allegations of abuse against an agency CNA for R #22. H. On 01/27/25 at 4:42 pm during an interview with R #22, he stated that he could not remember any incidents involving staff. I. On 01/28/25 12:42 pm during an interview with R #8, he stated that several weeks ago an agency CNA did not talk to him nicely and had poor bedside manner. R #8 also stated that the agency CNA was rough with his roommate (R #22) on two different occasions which resulted in R #22 screaming out in pain. R #8 confirmed that he reported all incidents to the nursing staff and the ADM. J. On 01/29/25 at 4:01 pm during an interview with an anonymous employee (AE), they stated the incident involving R #8 and R #22 occurred sometime around 12/21/24 through 12/22/24. R #8 informed the AE that the agency CNA was rough with R #22, which caused R #22 to be in pain. The AE also stated this incident should have been reported to the SA, but it was not because R #22's arms did not have trauma to the skin. K. On 01/29/25 at 5:32 pm during an interview with Registered Nurse (RN) #1, she stated she heard about this incident (incident involving an agency CNA and R #'s 8 and R #22) as a rumor outside of the facility, but she was not involved with any part of the incident. L. On 01/30/25 at 9:43 am during an interview with CNA #1, she stated R #8 called her to his room after the incident with the agency CNA and reported that the agency CNA was rough with R #22 and rude to R #8. CNA #1 confirmed she informed the previous Assistant Director of Nursing (ADON) right away, and the previous ADON stated she would investigate the incident. The CNA #1 also stated that she did not remember the date when she informed the previous ADON. M. On 01/30/25 at 11:01 am during an interview with RN #2, she stated she was not there for the incident with R #8 and R #22, but the facility reporting process is for nursing staff to notify management so a complete investigation can be conducted. N. On 01/30/25 at 12:27 pm during an interview with RN #3, she stated she reported the incident regarding R #8 and R #22 to the ADM as soon as she was aware of what allegedly happened. RN #3 stated R #8 informed her that when the agency CNA was assisting and turning R #22, R #22 screamed very loudly and in a way R #8 had never heard before (sometime during the dates of 12/21/24 through 12/22/24). RN #3 confirmed R #8 was completely cognitive, so she reported the allegations of abuse involving R #8, R #22, and the agency CNA to the ADM. RN #3 also confirmed that she immediately assessed R #22 for injury (on 12/22/24), but due to R #22's cognitive decline, R #22 denied any concerns and R #22 did not have any injuries present. RN #3 also stated she believed the agency CNA pulled R #22's arm too roughly, which caused pain. RN #3 confirmed that she wrote a statement about R #8 and R #22's abuse allegations involving the agency CNA, and RN #3 delivered the statement to the ADM in the morning on 12/23/24. O. On 01/30/25 during an interview with the ADM, she stated that she talked to R #8 because of the concerns of R #8 had involving the agency CNA and how the agency CNA treated R #8 and R #22. The ADM stated R #8 informed her that the agency CNA was rude to R #8 and R #22, so she had an internal investigation completed. The ADM also stated that abuse was not reported to her after a facility team completed the investigation and staff did not provided her with any information about the agency CNA being rude to R #8 and R #22. The ADM confirmed that if she had been made aware of abuse allegations, then she would have reported the incident to the SA, but she did not. P. On 01/30/25 at 3:05 pm during an interview with the Social Services Director (SSD), she stated she was informed of this incident by the ADM on 12/23/24, so she was a part of the investigation team that reviewed the allegations of poor bedside manner and staff rudeness towards R #8 and R #22. The SSD stated that she interviewed R #8 and R #22 on 12/23/24. The SSD also stated that she was not made aware of staff roughness towards R #22 by the agency CNA during the investigation, so that was not investigated. The SSD confirmed that she was unaware of facility nursing staff having information related to this incident because she only interviewed residents during the investigation for the allegation of abuse involving R #8 and R #22, and facility staff was not interviewed during this investigation. The SSD also confirmed that if she had gotten more information from residents about the agency CNA being rough with R #22, then she would have interviewed facility nursing staff as well. Q. On 01/30/25 at 3:52 pm during an interview with the Interim Director of Nursing (DON) and new DON, they both confirmed that they would expect facility nursing staff to be interviewed during an investigation for allegations of abuse involving residents.

Based on observation and interview, the facility failed to assure medications and other medical supplies were properly stored and not expired. This deficient practice had the potential to affect all 28 residents identified on the facility census list provided by the Director of Nursing (DON) on 01/16/24. Improperly stored medications and medical supplies could likely lead to confusion and possibly result in residents being administered expired medications and supplies. The findings are: Medication Storage Room A. Observation on 01/16/24 at 2:01 pm, during a routine check of the facility medication storage room, revealed the following: 1. One container of Clorox Bleach Germicidal wipes expired on 04/14/22, 2. One, 30 gram (g) bottle of Nystop (Nystatin) powder (an antifungal, antibiotic powder used to treat skin infections caused by yeast) expired on 05/23/22, 3. One open bag of Goodsense cough drops, menthol flavor, 30 drops, expired on 07/01/22, 4. One jar of Vicks VapoRub (an ointment to help relieve cough, congestion, sore muscles, and toenail fungus), 3.52 ounce (oz) expired 04/01/22, 5. Two boxes On-call Express Lancet Strips (used to test blood sugar levels), 50 strips each, expired on 08/26/23 and 11/04/22, 6. Three boxes of On-Call Express Glucose Control Solution (used to calibrate glucometer machine which tests blood sugar levels) Lot #RT80238, Lot #RT80127,Lot #RT 80283 which expired on 10/16/21,01/08/20, 05/22/22, 7. One box Medline Safety needles, 25 gauge (G) by 5/8 inch (), 100 count, Lot #15030212 expired on 03/01/2020, 8. One box [NAME] Point syringe, 3 milliliter (mL), 25 G by 1, Lot #A170706 expired on 06/28/22, 9. One box [NAME] Point syringe, 3 mL, 25 G by 1 with needle, 100 count, Lot #A170706 expired on 06/28/22, 10. One Box Insulin syringe, 100 units (U), 31 gauge, 60 count, Lot #NP20188 expired on 06/21/23, 11. One Box [NAME] Point syringe with needles, 3 mL, 27 G by 1 1/2, 100 count, Lot #A160606 expired on 05/01/21, 12. One Box [NAME] Point syringe, 3 mL, 25 G by 1, 100 count, Lot #A180604 expired on 05/28/23, 13. One Box [NAME] Point syringe with needle, 3 mL, 25 G by 5/8, 100 count, Lot #G171106 expired on 10/28/22, 14. One Box [NAME] Point syringe with needle, 3 mL, 27G by 1 1/2, 100 count, Lot #A160606 expired on 05/01/21, 15. One Box [NAME] Point syringe with needle, 25 G by 5/8, 100 count, Lot #G181104 expired on 10/28/23, 16. Safety Needle, 25 G by 5/8, 24 count, Lot #15030212 expired on 03/2020, 17. Two [NAME] (BD) safety needles, 25 G by 1, Lot #6117885 expired on 0 4/01/21. B. On 01/16/24 at 2:35 pm during interview with RN #1, she confirmed the medical supplies were expired and should not be stored in the medication storage room. C. On 01/16/24 at 2:40 pm during interview with Director of Nursing (DON), she confirmed the medical supplies were expired and were not stored properly. Medication Storage Cart D. On 01/16/24 at 3:50 pm, during a routine check of the facility medication storage cart, two pills lay in the bottom of the second drawer. One small, oval, white pill had 17/11 stamped on it, and one, small, round orange pill had L15 stamped on it. Further observation revealed two loose pills lay in the bottom of the third drawer. One small, round, white pill did not have a stamp or identifying marks, numbers or letters; and one small, round, yellow pill had sg on one side and 458 on the other side. E. On 01/16/24 at 4:00 pm during interview with RN #1, she confirmed the pills in bottom of drawer were outside of their original, labeled packaging and were not stored properly inside the medication storage cart.

Based on an interview the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality, if the c ourse study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. This deficient practice is likely to affect all 28 residents living at the facility. Residents are likely not to receive the dietary nutritional services needed to thrive and their needs will not be met. The findings are: A. On 1/18/24 at 2:20 PM, during an interview with the Cook, he stated he was not certified as a Dietary Manager (DM). He also stated the company offered him the position of DM, but he has not decided if he was going to accept the position. B. On 1/18/24 at 2:30 PM, during an interview with the facility Administrator (ADM), she stated she was aware the cook was not certified and the facility offered him the DM position. The ADM stated the DM was an interim currently. ADM stated that they should have a CDM and she is working on getting Certified as a Dietary Manager.

Based on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety. This deficient practice is likely to affect all 28 residents identified on the resident census list provided by the Director of Nursing (DON) on 01/16/24. These deficient practices are likely to expose residents to food borne illnesses. The findings are: A. Observation on 01/16/24 at 11:53 am, during initial observation of the facilities food storage area, revealed the following: Please note the following items listed below were opened. 1. One box of 20 pounds of frozen stuffed bell peppers opened and not dated. 2. One box of 20 pound (lb) beef stroganoff opened and not dated. 3. One box of sausage patties opened and not dated. B. Observation on 01/16/24 at 12:00 pm, during observation of the facilities food storage area, revealed the following: 1. One box of 24 ounce (oz), citrus gelatin opened and not dated. 2. One box of 24 oz, red assorted gelatin opened and not dated. 3. One box containing Spanish rice opened and not dated. 4. One box containing long grain rice opened and not dated. 5. One 60 count box of variety potato chips opened and not dated. C. On 01/16/24 at 12:12 pm during interview with facility cook, he confirmed all items listed above were not dated. The cook further stated that staff was told to place items on the shelves and only label them when they are opened. This practice is not in accordance with professional standards of food service safety.

Based on record review and interview, the facility failed to prevent neglect for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents by: 1. Delay in sending R #1 to emergency room for evaluation and treatment after sustaining an injury 2. Not closely monitoring the injured site for changes in condition 3. Provider not completing a thorough physical assessment of the injury These deficient practices likely resulted in R #1's delayed transfer to the Emergency Department (ED) and receiving critical care required for an arm fracture. If the facility is not monitoring for residents' change in condition, properly assessing residents with significant injuries, or communicating with providers effectively, then residents are likely at risk of inadequate or delayed treatment. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms like progressive breathlessness and cough) 2. Hypertension (high blood pressure) 3. Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) 4. Pleural Effusion (fluid-filled space that surrounds the lungs) 5. Cyst of Kidney (fluid-filled pocket that can form inside your kidneys) 6. Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) 7. Chronic Kidney Disease 8. Pulmonary Embolism (one of the pulmonary arteries in the lungs gets blocked by a blood clot) 9. Heart Failure B. Record review of R #1's care plan dated [DATE] revealed, Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t [related to] Fatigue. Interventions: BED MOBILITY: The resident is totally dependent on 1 staff for repositioning and turning in bed as necessary, and TRANSFER: The resident requires extensive assist by 1 staff to move between surfaces as necessary. C. Record review of R #1's progress notes dated [DATE] at 4:05 pm revealed, Was made aware by CNA (Certified Nursing Assistant) that resident (R #1) was having R [right] elbow pain with visible swelling. Assessed residents R [right] elbow, swelling evident, with 1x1 [1 inch by 1 inch] skin tear and hematoma (bad bruise). [ .] Notified POA (Power Of Attorney) and PCP (Primary Care Physician) of incident. D. Record review of R #1's MD (Medical Doctor) progress notes completed by Nurse Practitioner (NP) dated [DATE] at 1:33 pm revealed, No concerns noted by staff admitted to LTC [Long Term Care] because she cannot safely care for herself at home. Musculoskeletal [relating to or denoting the musculature and skeleton together]: no gross bony deformities. E. Record review of R #1's physician orders dated [DATE] at 7:04 am revealed, Send to ER (emergency room ) for treatment and evaluation per doctor order. R #1 was sent to the ER via ambulance on [DATE]. F. Record review of R #1's ER History and Physical (HPI) dated [DATE] at 8:40 am revealed, This is a [AGE] year-old female with a history of dementia, hypertension, chronic atrial fibrillation not anticoagulated, COPD on 2 liters/minute of oxygen via nasal cannula, chronic kidney disease, pulmonary embolism, peripheral arterial disease with chronic right lower extremity wound and congestive heart failure brought in by ambulance for evaluation of an injury to the right elbow. History provided by nursing home staff and EMS (Emergency Medical Services) is that there was no reported fall. However, when the patient's [R #1's] daughter arrived, she [R #1's daughter] states that she received a call from the nursing facility 2 days ago stating that the patient had hit her elbow on the left. This morning, she [R #1's daughter] received another call from the facility stating that her mother's elbow was dislocated and had an open wound. No additional history provided. Patient [R #1] is unable to provide any history. Patient [R #1] denies any acute complaints, although has pain with any movement of her right upper extremity. Nursing staff reported to the ED (Emergency Department) staff that the patient has been hallucinating (a perception of having seen, heard, touched, tasted or smelled something that wasn't actually there) and trying to get out of bed. Right upper extremity Ace wrap reportedly applied by nursing home staff. Right upper extremity splint applied by EMS. G. Record review of R #1's ER Hospital Note dated [DATE] at 8:40 am revealed, R #1 was diagnosed with Open fracture of right humerus, Sternal fracture, and laceration (cut) on back amongst other chronic illnesses. H. On [DATE] at 4:18 pm during an interview with R #1's daughter, she stated, The facility called me on a Tuesday [[DATE]] and told me my mother had bumped her elbow on the wheelchair and they were letting me know she was getting pain medication. The next day [[DATE]], I called down there and asked how she [R #1] was doing. They said she was doing ok and her elbow hurt and they were giving her medicine. It [R #1's injury] happened on Tuesday [[DATE]] and on Thursday [[DATE]], when they called me, they [facility] said she [R #1] was on her way up here to [name of ER] and they said they think she dislocated her elbow. Her [R #1] arm was broken. They [local ER] sent her [R #1] to [Name of trauma center] and they were filing for elder abuse. They [local ER] told me her skin had split. My mother's skin was really dry. I don't know if they [facility staff] scraped her arm on something but I have no idea. They [trauma center] put her [R #1] on hospice because she could not survive the surgery. They suggested she be put on hospice, I put my mom [R #1] on hospice and she only lasted two days. She had two breaks in her arm. I. On [DATE] at 10:00 am during an interview with Registered Nurse (RN) #1, she stated, I assessed her [R #1 on [DATE] at 4:01 pm]. The Nurse Practitioner (NP) was coming in on Wednesday [[DATE]], but I let her (NP) know what I saw [via the phone on [DATE]]. I felt both [of R #1's] elbows. I didn't feel a dislocation in her [R #1] elbow. I gave her [R #1] the tramadol (pain medication) and let the NP know. The next day [[DATE]], the NP came in and we followed up on her [R #1]. When I talked to [R #1] that day [[DATE]], and she [R #1] said she wasn't having as much pain [in R #1's right arm], but she was just sore. The swelling was consistent [on R #1's right arm]. At the end of the day [[DATE]], [Name of NP] left and I didn't get to follow up [with NP regarding R #1]. I called her [NP on [DATE]] and she [NP] said to continue monitoring her [R #1 on Wednesday [DATE] after the NP assessed R #1]. [Name of Certified Nursing Assistant (CNA) #6] said she [R #1] was having a complaint of elbow pain after the transfer with the sit to stand transfer on [DATE]. She [R #1] didn't fall and the CNA's said she [R #1] didn't have a fall. [Name of CNA #1] was the one lifting her [R #1] up [by herself] and, she [R #1] screamed and scared [CNA #6] and she put her back down. It was unclear what happened to her [R #1] elbow. She [R #1] had a clavicle fracture, a spinal fracture, and a humeral fracture that was identified when she was taken to the ER. I couldn't wrap my arm around what happened [to R #1 to cause those injuries]. J. Record review of the facility Report on Investigation (undated) revealed, Findings- After reviewing camera footage, the incident with the lift on Tuesday [[DATE]] may have caused [R #1's] injury. Following the incident [on [DATE]], it appears [Name of R #1] no longer uses her arm throughout the day. Nurses recognized slight swelling after the injury and looked at it again next day [[DATE]] where there was more bruising and more swelling but only slightly. On [DATE] around 3:52 pm cameras show swelling is very apparent. K. On [DATE] at 11:24 am, during an interview with the NP, she stated, We were doing watchful waiting (closely watching a patient's condition but not giving treatment unless symptoms appear or change) [for R #1 after her right arm injury] and it [R #1's arm] got worse and we sent her to the hospital. She [R #1] was sent out [to the ER] and I didn't know she expired. I think it [R #1's injury] escalated and I think they [facility nursing staff] said it [R #1's arm injury] opened and was bleeding. I thought a little watchful waiting without laying eyes on it [R #1's right arm injury] would be fine. In hindsight, she [R #1] should have been sent out [to the ER] sooner. An expectation would be they [facility nursing staff] would hopefully see that [R #1's injury becoming worse and notify the NP]. I don't think I pulled her [R #1's] shirt up [to see her arm during an assessment on [DATE]], that was my thing that I didn't do. NP confirmed R #1 should have been sent to the ER sooner than she was sent out. NP confirmed she did not perform a complete assessment of R #1's injured right arm on [DATE] and she should have. L. On [DATE] at 5:50 pm, during an interview with an anonymous staff member, they stated, From the reports, I was told she [R #1] had an open fracture and they sent her to the ER. From what I understand, she [R #1] was in the sit to stand [chair] and she was pretty weak as it is. She [R #1] let go of her weight, this is what I understand because I was not there, she [R #1] let go of her weight and the sling caught her arm. She [R #1] said 'ouch' and they [nursing staff] set her [R #1] down and her arm started to swell. Unless she [R #1] really dropped her weight and wasn't set down right away, that would have to be a traumatic event. Even with her being so frail, her back being broken and the clavicle, unless she just dropped. M. On [DATE] at 10:21 am, during an interview with Nursing Aide (NA) #1, she stated, I was in the solarium (a room with extensive areas of glass to admit sunlight) and she [R #1] was getting on the lift with [Name of CNA #1] and she was secured. Her [R #1's] arm came off the bar and [Name of CNA #1] sat her [R #1] down. She [R #1] complained of elbow pain, so we told [Name of RN #1]. N. On [DATE] at 11:54 am, during an interview with the Social Services Director (SSD), she stated, Initially, when we reviewed cameras, we were looking at angles in the solarium. The other view showed that when she [R #1] was being lifted, you can see a jolt and her [R #1] arm falls and that's what we could see resulting in the fracture. [Name of RN #1] said she told [Name of NP] the next day she [R #1] had elbow pain [on [DATE]], but she [NP] didn't really assess it [R #1's injured right arm]. I would have expected her [NP] to do a full assessment [of R #1 after R #1's arm injury] and it [NP's assessment of R #1] was a look and go. She [NP] did not assess it [R #1's injured right arm]. [Name of previous Director of Nursing (DON)] knew about the lift incident [resulting in R #1's right arm injury] and she [previous DON] didn't think it was a big deal. She [previous DON] wasn't made aware of anything [involving R #1] until we were sending her [R #1] to the hospital.

Based on record review and interview, the facility failed to effectively manage pain for 1 (R #1) of 2 (R #'s 1 and 2) residents reviewed for pain by not assessing for pain and providing pain treatment. This deficient practice likely resulted in R #1 experiencing significant (long) periods of pain without sufficient relief for a fractured arm. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms like progressive breathlessness and cough) 2. Hypertension (high blood pressure) 3. Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) 4. Pleural Effusion (fluid-filled space that surrounds the lungs) 5. Cyst of Kidney (fluid-filled pocket that can form inside your kidneys) 6. Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) 7. Chronic Kidney Disease 8. Pulmonary Embolism (one of the pulmonary arteries in the lungs gets blocked by a blood clot) 9. Heart Failure B. Record review of R #1's physician orders dated 02/17/23 revealed, Tylenol (Acetaminophen) Oral Tablet 325 MG (milligrams), Give 2 tablet by mouth every 6 hours as needed for mild pain/ elevated temp [temperature]. C. Record review of R #1's physician orders dated 04/22/23 revealed, traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain. D. Record review of R #1's progress notes dated 06/06/23 at 4:05 pm revealed, Was made aware by CNA (Certified Nursing Assistant) that resident [R #1] was having R [right] elbow pain with visible swelling. Assessed residents R [right] elbow, swelling evident, with 1x1 [1 inch by 1] skin tear and hematoma (bad bruise). [ .] Notified POA (Power Of Attorney) and PCP (Primary Care Physician) of incident. E. Record review of R #1's MD progress notes completed by Nurse Practitioner (NP) dated 06/07/23 at 1:33 pm revealed, No concerns noted by staff admitted to LTC [Long Term Care] because she cannot safely care for herself at home. Musculoskeletal [relating to or denoting the musculature and skeleton together]: no gross bony deformities. F. Record review of R #1's physician orders dated 06/08/23 at 7:04 am revealed, Send to ER [emergency room ] for treatment and evaluation per doctor order. R #1 was sent to the ER via ambulance on 06/08/23. G. Record review of R #1's Medical Doctor Progress Notes dated 06/08/23 at 3:46 pm revealed, Had injury to her [R #1's] right humerus (lower end of upper arm bone) during a transfer 2-3 days ago and had sudden pain in right upper arm, was able to use it albeit (although) painful, this morning 6/8/2023 elbow area was draining/bleeding bruised, and was sent to the ED [Emergency Department], was found to have a Humerus fracture and was sent to [Name of local trauma center] hospital for further care. H. Record review of R #1's Pain Level Summary (Pain Assessment: 0-10 with 0 meaning no pain and 10 meaning most pain): 1. 06/06/23 at 4:04 pm: 9/10 pain level 2. 06/06/23 at 5:15 pm- 6/10 pain level 3. 06/08/23 at 3:30 am- 5/10 pain level R #1 was not assessed for pain on 06/07/23. I. Record review R #1's Medication Administration Record dated June 2023 revealed the following: 1. 06/06/23 at 3:59 pm- R #1 was administered 50 mg of Tramadol for pain. 2. 06/07/23: No pain medication administered 3. 06/08/23 at 3:30 am- R #1 was administered 50 mg of Tramadol for pain. There is no evidence that any other pain medication was administered between 06/06/23 and 06/08/23. J. On 07/11/23 at 4:18 pm, during an interview with R #1's daughter, she stated, They [facility] said she was doing ok and her elbow hurt and they were giving her medicine. She [R #1] was in horrible pain for two days. She [R #1] had two breaks in her arm. K. On 07/12/23 at 10:00 am during an interview with Registered Nurse (RN) #1, she stated, When I talked to [R #1] that day [06/07/23], she [R #1] said she was still having pain and she was sore. I [RN #1] told her [R #1] that it didn't have to be in horrible pain for her to get medication. The swelling [to R #1's right arm] was consistent. I want to say I gave her [R #1] that [pain medication] on Wednesday [06/07/23]. Whatever the MAR said is what I gave. RN #1 confirmed that R #1's MAR for pain medication was blank on 06/07/23. RN #1 also confirmed she did not assess R #1 for pain, nor give R #1 pain medication on 06/07/23, and she should have. L. On 07/12/23 at 11:27 am, during an interview with the Nurse Practitioner (NP), she stated she would expect nursing staff to assess R #1 for pain and manage R #1's pain during watchful waiting [an approach in which time is allowed to pass before medical intervention or therapy is used] after R #1 injured her right arm. M. On 07/13/23 at 10:22 am during an interview with Nursing Aide (NA) #1, she stated, She [R #1] complained of elbow pain [on 06/07/23], so we told [Name of RN #1]. She [R #1] had cried the whole lunch because she didn't eat. The nurses tended to her [R #1] because she was complaining of elbow pain [on 06/07/23]. NA #1 confirmed she informed nursing staff that R #1 was experiencing pain on 06/07/23.

Based on observation and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #4 and R #5) of 2 (R #4 and R #5) residents reviewed by not providing residents who smoke an area to smoke prior to changing the facility to a non smoking facility. This deficient practice is likely to result in the resident's life style, personal choices, needs and preference not being met. The findings are: Findings for Resident #4: A. On 07/11/23 at 1:15 pm, during an observation a notice was posted in the facility hallway stating, facility will be a smoking free facility effective immediately due to non-compliance of policy and safety. B. On 07/12/23 at 1:09 pm, during an interview with R #4, he stated he was made aware of facility updating smoking policy that facility was going to be a Non smoking facility. After the smoking policy had taken affect he made a decision to discharge due to not being able to smoke any longer on facility property. R #4 further stated he was offered nicotine patches, gum and lozenges. R #4 wanted to be able to continue to smoke. Findings for Resident #5: C. On 07/11/23 at 4:26 pm, during an interview with R #5, she stated Facility let resident know one evening that smoking policy had changed, and smoking was no longer permitted at facility. She stated that facility did offer either lozenges, patches, and/or gum to help with smoking urges; as well as allow residents to leave premises to smoke if desired. D. On 07/11/23 at 3:23 pm, during an interview with Certified Nursing Assistant (CNA) #2, she stated that residents did complain of the changes made to the smoking policy. It was implemented immediately and administration did not offer any other smoking alternatives besides the option of signing themselves out to leave the premises to go smoke. E. On 07/12/23 at 9:45 am, during an interview with Registered Nurse (RN) #1, she stated she was made aware that facility is no longer a smoking facility which was made effective immediately, unknown to staff as to why the facility changed their policy. She stated that residents that smoked were offered no alternatives to help alleviate smoking cessations. RN #1 further stated that R #5 was annoyed by that policy. She is not aware of any smoking assessments being completed for residents who smoke, and staff were unable to determine if resident is a safe smoker because assessments are not completed. F. On 07/12/23 at 5:45 pm, during an interview with the Assistant Administrator (AA), she stated the non-smoking policy was implemented in June of 2023 due to residents and staff practicing unsafe smoking by throwing cigarette butts in the grass, trash cans, and next to a propane tank. Residents and staff are allowed to leave the premises if they wish to continue to smoke. AA confirmed smoking assessments were not completed.

Based on record review and interview, the facility failed to conduct a resident smoking assessment for 2 (R #s 4 and 5) of 2 (R #s 4 and 5) residents reviewed for assessments. This deficient practice is likely to result in residents being at risk for smoking related injuries. The findings are: Findings for Resident #4: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE]. B. Record review of R #4's care plan dated 11/08/21 revealed facility did identify resident as a smoker and implemented goals and interventions. C. Record review of R #4's assessments revealed facility did not complete a smoking assessment for R #4. D. On 07/12/23 at 9:45 am, during an interview with Registered Nurse (RN) #1, when asked how the facility determines if the resident is a safe smoker or needs supervision, RN #1 stated, You can't know if they're [residents] safe smokers if one [smoking assessment] is not done. I think we do need the [smoking] assessments [for residents]. RN #1 confirmed R #4 did not have a smoking assessment completed; and R #4 should have had a smoking assessment completed to determine if they were safe smoker or if R #4 needed facility assistance. E. On 07/12/23 at 11:02 am, during an interview with the Social Services Director (SSD), she stated that nursing staff or a physician should have completed smoking assessment for R #4 and a smoking assessment for R #4 was not completed. F. On 07/12/23 at 12:00 pm, during an interview with the Nurse Practitioner (NP), she stated a smoking assessment was not completed for R #4. G. On 07/12/23 at 5:45 pm during an interview with the Assistant Administrator (AADM), she stated a smoking assessment was not completed for R #4 and should have been. Findings for Resident #5: H. On 07/11/2023 at 4:26 pm, during interview with R #5, when asked, how she is doing now that facility has a nonsmoking facility. R #5 stated smoking cessation (quitting smoking) was not easy to adjust when it first occurred. I. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. J. Record review of R #5's assessments revealed that a smoking assessment was not completed for R #5. K. On 7/12/23 at 12:00 pm, during an interview with the NP, she confirmed a smoking assessment was not completed for R #5, and should have been. L. On 07/12/23 at 5:45 pm during an interview with the Assistant Administrator (AA), she confirmed Smoking assessments was not completed for R #5, but should have been. 41988

Based on record review and interview, the facility failed to assure that 3 (R #'s 2, 3, and 6) of 6 (R #'s 2, 3, 4, 5, 6, and 7) residents were seen by the attending physician in the facility at least once a year. This deficient practice is likely to result in residents not receiving the required medical assessment and review resulting in resident receiving less than optimal care. The findings are: For Resident #2: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. B. Record review of R #2's Miscellaneous Page located in the Electronic Health Record (EHR) revealed R #2's last History and Physical assessment was completed on 01/26/20. For Resident #3: C. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. D. Record review of R #3's Miscellaneous Page located in the Electronic Health Record (EHR) revealed R #3's last History and Physical assessment was completed on 01/26/20. For Resident #6: E. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. F. Record review of R #6's Miscellaneous Page located in the Electronic Health Record (EHR) revealed R #6's last History and Physical assessment was completed on 06/11/20. G. On 07/13/23 at 2:31 pm during an interview with the Nurse Practitioner (NP), she stated, I haven't done an official History and Physical [assessment for R #'s 2, 3, and 6]. NP confirmed a yearly History and Physical assessment was not completed for R #'s 2, 3, and 6 and should have been done. H. On 07/13/23 at 2:32 pm during an interview with the Assistant Administrator (AADM), she confirmed R #'s 2, 3, and 6 did not have a yearly History and Physical assessment completed and they should have been done.

Based on record review and interview, the facility failed to notify the provider, Director of Nursing (DON), and nurse management team for 1 (R #2) of 1 (R #2) resident experiencing a new onset of pain. If the facility is not notifying the provider when there is a change of condition (onset of new pain), then the provider is unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. B. Record review of R #2's progress notes dated 07/11/23 at 6:36 am revealed, Patient [R #2] started complaining of both pain in both legs from the hip going downwards this morning around 0530 [am]. Tylonol [sic] 500 mg [milligrams] given to the patient but she still complains of pain. Day nurse notified to close monitor. C. On 07/12/23 at 11:28 am during an interview with the Nurse Practitioner (NP), she confirmed that she was not notified of R #2's increased pain on 07/11/23 and she would expect to be notified of that. D. On 07/12/23 at 5:17 pm during an interview with the current DON, she stated, When the pain medication was given [to R #2] at 6 [am] then they [facility nursing staff] should have followed up [with R #2. If it [R #2's Tylenol] still wasn't working, then [Name of NP] should have been notified. DON confirmed communication between staff and the provider for R #2's new pain was not done correctly.

Based on record review, observation, and interview, the facility failed to ensure that 1 (R #30) of 1 (R #30) resident reviewed was receiving the necessary behavioral health care services to meet the residents needs. This deficient practice likely resulted in resident not getting the care and assistance he needed, resulting in R #30 assaulting a staff member and being transferred to jail. The findings are: A. Record review of R #30's face sheet revealed R #30 was admitted into the facility on [DATE] with the following psychiatric diagnoses: 1. MAJOR DEPRESSIVE DISORDER 2. BORDERLINE PERSONALITY DISORDER 3. MILD COGNITIVE IMPAIRMENT (the stage between the expected decline in memory and thinking that happens with age) B. Record review of care plan date (OVERDUE) revealed the following: 1. Focus: The resident uses antidepressant medication r/t (related to) Depression. Interventions: Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts,withdrawal . 2. Focus: The resident uses psychotropic medications r/t Disease process. Interventions:PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's,social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Monitor/record occurrence of for target behavior symptoms pacing,wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. Focus: The resident is/has potential to be verbally aggressive r/t Poor impulse control. Interventions: C. Record review of R #30's Progress Notes dated 07/20/22 revealed, [Name of R #30], DON [Director of Nursing], and myself met with [Name of R #30] to go over a letter he left on my desk,(His medication bill). He wrote a note on it 'Do not give this to me again'. I explained to him that it was his prescription bill that the pharmacy sent him, he was angry about the bill. I told him, I would contact the pharmacy for him. [ .] He [R #30] started to get very angry and began yelling at me. [Name of DON] asked him to calm down, he stated he just gets so frustrated. He requested to be seen by a professional because he feels himself being more frustrated than usual and he stated that his Asperger's [a developmental disorder affecting ability to effectively socialize and communicate] is really bothering him and would really like to see a professional that could help him with it. We let [Name of R #30] know we would work on getting him help. D. Record review of R #30's Progress Notes dated 07/22/22 revealed, Notified by activities that resident [R #30] requested to herself and DON, [Name of DON], that he wanted go to [Name of Psychiatric Services/Behavioral Health Provider] to get his medication evaluated. Spoke with PCP [Primary Care Physician] regarding request. New order received. E. Record review of R #30's physician orders dated 07/22/22 revealed, Referral for [Name of Psychiatric Services/Behavioral Health Provider] for medication evaluation per resident request/PCP approval. F. Record review of the facilities communication report with Psychiatric Services/Behavioral Health Provider for R #30 was dated 07/25/22 at 2:36 pm. This indicated the facilities first attempt to refer R #30 for psychiatric services per physician order did not occur until 3 days after order was provided. Report revealed, 07/27/22- 9:27 am: Needed updated notes- didn't accept referral. Would need to be suicidal, homicidal, hallucinations. [Name of Psychiatric Services/Behavioral Health Provider] won't consider in patient or crisis. [Name of R #30] needs to get him a therapist or psychiatrist to have them send referral, emergency room . G. On 02/28/23 at 12:21 pm during an interview with the DON, she stated, We [facility] were trying to get him [R #30] to [Name of Psychiatric Services/Behavioral Health Provider] and they [Psychiatric Services/Behavioral Health Provider] said he [R #30] didn't meet the criteria [to be admitted into the Psychiatric Services/Behavioral Health Provider]. We [facility] tried multiple different places. We tried [name of behavioral health provider and name of name of Psychiatric Serves/Behavioral Health Provider] on 07/25/22, and both places refused to admit R #30. H. Record review of R #30's Progress Notes dated 07/26/22 at 8:11 am revealed, At approximately 0710 [am], Resident [R #30] approached Housekeeping Personnel, [Name of Housekeeper (HK) #1]. and got real close to her and started yelling at her. 'I have something to say to you. I want you to when I'm in on the commode you came and Knock, Knock, Knock. [sic] What the hell is wrong with you. You can't rush a bowel movement.' House Keeper Attempted to say 'I'm' but the resident stated: 'its not something to laugh about, Bitch.' He [R #30] grabbed her [HK #1] duster and hit her twice on the forehead, left temple area and positioned the handle across her neck and pushed her against the wall twice. This nurse intervened and took the duster away from resident so Housekeeper could be safe. He [R #30] stayed and cont. [continued] to curse and yell at her, spitting on her. After he finally stopped yelling, the Housekeeper walked away, per this nurses instruction. Res [Resident] stayed in hall way and stated; 'I waited 2 days to do this.' and then he walked away. I. On 02/28/23 at 1:11 pm during an interview with the Interim Administrator (IA), he stated, When asked if he was aware of any issue prior to the 07/26/22, IA stated. He's [R #30] yelled at people before. I wasn't aware of anything [R #30's behaviors/psychiatric services request] until the investigation. If there are indications or signs of something that he [R #30] was agitated, then yes [expects R #30 to be sent to the emergency room (ER) so R #30 can be referred to Psychiatric Services/Behavioral Health Provider]. I'm not certain what steps [Name of DON] was making to move him [R #30 to the Psychiatric Services/Behavioral Health Provider]. There was evidence of escalation and we knew that was a problem. [R #30] did state he needed more [psychiatric] services. We never anticipated what did come out. IA confirmed he would expect the facility to provider services to R #30 as ordered by a physician. IA further confirmed that R #30 had been taken to jail by the police after the incident. J. On 02/28/23 at 2:12 pm during an interview with the Social Services Director (SSD), she confirmed R #30 wanted to be transferred to a Psychiatric Services/Behavioral Health Provider located outside of the facility but R #30 needed a provider referral or ER referral before R #30 could be admitted into the Psychiatric Services/Behavioral Health Provider. SSD also confirmed the facility made initial contact with the Psychiatric Services/Behavioral Health Provider on 07/25/22. K. On 02/28/23 at 3:14 pm during an interview with the Facility Nurse Practioner (FNP), she confirmed R #30 was having increased psychiatric behaviors and she wanted him to be sent to the Psychiatric Services/Behavioral Health Provider as soon as possible. FNP stated, Mostly, I wanted him [R #30] to have a behavioral health evaluation. He [R #30] seemed paranoid and had delusions and thoughts about things. I knew getting into a behavioral health facility is challenging. FNP stated she wrote an order when she found out R #30 was having an increase in behaviors (07/22/22) and she would expect the facility to follow physician orders [referring to finding F] in a timely manner. L. On 02/28/23 at 4:49 pm during an interview with the DON, she stated, When he [R #30] came and talked to me and [Name of SSD], he [R #30] was not having a melt down at that time. He [R #30] just wanted to be re-evaluated for his medication. We called [Name of FNP] and let her know what was needed. He [R #30] was coming to us like he needed additional medication and he said he wasn't going to hurt anyone. I didn't think it [R #30's psychiatric behaviors] were that bad. We should have gone the hospital route (sent him to the hospital when he started showing behaviors) but, by the time she got involved the police had been called and R #30 was taken to jail. DON confirmed R #30's physician orders for psychiatric service request should have been responded to in a more timely manner. DON further stated that R#30 would not be allowed to return to the facility.

Based on observation and interview, the facility failed to store foods under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer are properly covered. 3. Ensuring used oil was covered appropriately, labeled, and dated in the dry storage. These deficient practices are likely to affect all 26 residents listed on the resident census list provided by the Director of Nursing (DON) on 02/17/23, and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 02/27/23 at 9:52 am during the initial tour of facility kitchen, the following was observed in the kitchen freezers, kitchen refrigerators, and kitchen dry storage: 1. 3- plastic storage bags of rolls was not labeled or dated and stored in the refrigerator. 2. 1- baked potato wrapped in aluminum foil was not labeled or dated and stored in the refrigerator. 3. 1- 37.05 ounce (oz) Sysco Classic Golden Grill Hash brown potatoes carton was left open to air and stored in the kitchen refrigerator. 4. Several pieces of chicken wrapped together in plastic wrap was not labeled or dated and stored in the freezer #1. 5. 1- large plastic bag of meatballs was not labeled or dated and stored in freezer #2. 6. 1- large metal pan of oil with aluminum foil loosely covering it was not labeled or dated and stored in the dry storage. B. On 02/27/23 at 10:13 am during an interview with the Dietary Manager (DM), he confirmed all findings and stated, If [food/beverage items] it's out of the original packaging then it [food/beverage items] should be labeled and dated. DM also stated that all food/beverage items should be labeled, dated, and stored appropriately. C. On 02/28/23 at 11:31 am during an follow up kitchen observation, the following was observed: Freezer #1: 1. 1- 11 pound (lb) box of Beyond Sausage was left open to air and stored in freezer #1. D. On 02/28/23 at 11:35 am during an interview with the DM, he confirmed the additional finding and stated food should not be left open to air.

The facility failed to ensure that Residents #14 and #15 received the correct consistency of thickened liquids as ordered by the physician. This resulted in an Immediate Jeopardy (IJ) being identified on 10/24/11 at 4:20 pm. The Administrator was notified of the findings for the IJ on 10/24/11 at 4:20 pm. The facility took corrective action by providing an acceptable Plan of Removal on 10/24/11 at 7:35 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope D. The Plan of Removal included the Director of Nursing (DON) training the staff nurse on duty for each meal on how to mix the thickener and proper administration. The DON and/or the Assistant Director of Nursing (ADON) will observe each meal to assure compliance until all nursing staff have been adequately trained no later than 10/27/11 by 5:00 pm. Trained feeders and Certified Nursing Assistants (CNA) will receive training on the proper consistency of liquids for each resident and how to know that each liquid is appropriate and watch each resident to assure they do not choke or aspirate on the liquid. The DON will begin training staff at the dinner meal of 10/25/11 on how to thicken liquids and observe to make sure it is done correctly. No liquids will be served to any of the three residents without supervision of the staff nurse. Follow-up will be completed on a quarterly basis and documented for the next 12 months. Physicians orders are in place for the consistency and are on the care plan. Orders will be obtained for each resident to be evaluated by Speech Therapy and to provide training. As new staff are hired they will be trained by the ADON and dietary director. Based on observation, record review and interview the facility failed to ensure that the correct consistency of thickened liquids was given for 2 (#14 and #15) of 3 (#5, #14 and #15) residents. This deficient practice likely caused R #14 and R #15 to have difficulty swallowing while drinking and is likely to cause other residents on thickened liquids to have difficulty swallowing while drinking, which could result in aspiration. The findings are: A. On 10/24/11 during a dining room observation for the dinner meal between the hours of 4:45 pm to 6:30 pm the following was observed. Resident (R) #14's dietary card did not contain any indications that he was on nectar thickened liquids. This observation was confirmed at 5:02 pm by certified nurse assistants (CNA) #3, #4 and the cook who were all present in the dining room. B. On 10/24/11 at 5:36 pm, during an interview with CNA #2, she stated three residents were on thickened liquids and all the residents were to receive nectar consistency. CNA #3 and #4 both stated they were unsure of the proper consistency for R #14. The cook stated all three residents were on pudding thickened liquids. C. On 10/24/11 at 6:15 pm, during an interview with the Dietary Manager (DM), she confirmed that nursing was responsible for adding thickener to residents liquids. The DM also confirmed that none of the staff received any training on thickened liquids. D. On 10/25/11 at 8:45 am, during observation, R #14 was given a sippy cup with water and ice and another sippy cup with cranberry juice and a glass of ensure. None of the liquids had thickener added to them. R #14 picked up the cup of cranberry juice and started drinking. R #14 began coughing and had difficulty catching his breath. Observed R #14's difficulty breathing, face turned red and this surveyor called out for help to CNA #3 and the Registered Dietician (RD). Both CNA #3 and the RD witnessed and confirmed that R #14 was choking on liquids served without any thickener. E. On 10/25/11 at 8:45 am, Registered Nurse (RN) #1 came to assist R #14 and she confirmed the liquids did not have any thickener added to them. RN #1 then thickened all of R #14's liquids to nectar consistency. RN #1 confirmed that R #14's diet card did not contain any information about nectar thickened liquids. F. On 10/25/11 at 11:30 am, during an interview with the Assistant Director of Nursing (ADON), she confirmed that the facilities medical director had not sent any resident for a swallowing evaluation since she had been in her position which was June 2011. G. On 10/25/11 at 11:40 am, during an interview, CNA's #2, #3, and #4 all confirmed they were never trained on how to administer thickener to resident's liquids. H. On 10/25/11 at 12:20 pm, during an interview with the RD and CNA #3, they both confirmed that R #14 was not served nectar thickened liquids prescribed by his physician. I. On 10/25/11 at 3:22 pm, during an interview with the ADON, she confirmed that no speech therapist had conducted any training's for the staff on thickened liquids. J. On 10/25/11 at 3:25 pm, during an interview with the RD, she was asked how the staff were administering thickener without training and she stated, "I don't know." The RD was asked how the staff knew what they were doing and she stated, "They don't." K. On 10/25/11 at 3:31 pm, during an interview with the Director of Nursing (DON), she confirmed the lack of training and stated they were working on it. The DON stated that she had been meeting with the RD for the last couple of months because they were aware of the problem. The DON confirmed that nursing was responsible for thickening the resident's liquids. L. On 10/26/11 at 10:04 am, during an interview, the DON confirmed that R #14's care plan did not contain any information about thickened liquids or swallowing difficulty. The DON also confirmed that the care plan for R #14 did not contain any interventions to prevent aspiration. The DON confirmed that the care plan for R #14 was generic and needed to be updated with pertinent resident information to include aspiration risk and liquid consistency. M. 10/26/11 at 4:10 pm, during an interview with the DON and the ADON, they both confirmed that the kardex for R #14 was a working care plan for the certified nursing assistants to follow for care needed. The kardex did not contain any information about the need for thickener or specific dietary guidelines regarding the use of thickener for R #14. The DON and ADON confirmed the kardex only contained the diet order but nothing about thickened fluids. N. Record review for R #14 revealed the following: 1. A physician order [REDACTED]." 2. A physician's progress note dated 10/03/11 contained the following note: "Choking on most liquids but eating well. Will try straws or sippy cups to see if choking can be prevented." 3. A physician's orders [REDACTED]. 4. A nutrition risk assessment dated [DATE] contained the following note: "Maintain mechanical soft diet, honey thickened liquids since February 2011." 5. R #14's admission nutrition assessment dated [DATE] stated "Thicken liquids". O. On 10/24/11, during a dining room observation for dinner between the hours of 4:45 pm to 6:30 pm, the following was observed. Resident R #15's dietary card did not contain any indications that she was on nectar thickened liquids, only thickened liquids. This was confirmed by Certified Nurse Assistants (CNA) #3, and #4 along with the cook who were all present in the dining room. P. On 10/25/11 during observation of R #15 from the hours of 8:00 am to 9:30 am she was observed sitting in the dining room with regular consistency liquids. Review of her diet card located in front of her on her tray indicated "No Concentrated Sweets/Puree/Thickened liquids." Q. On 10/25/11 at 9:40 am, during an interview, CNA #2 was asked if R #15 needed her liquids thickened, CNA #2, stated that "R #15 needed her liquids to be in a honey nectar like consistency." R. On 10/25/11 at 11:38 am, during review of R #15 medical record it did not indicate that a swallow evaluation had been completed. S. On 10/25/11 at 11:40 am, during an interview with the DON she stated "(Name of MD #1) told us that he would not be sending anyone out for any swallowing evaluations." T. On 10/25/11 at 12:13 pm, during observation, R #15 was sitting at the assisted dining table. CNA #3 filled a plastic cup with 4 ounces of orange juice, a plastic cup with 8 ounces of ice water, and a protein shake was placed in front of R #15. The orange juice and the ice water were not thickened as of 12:35 pm. RN #1 came and thickened the ice water to a nectar consistency. She also thickened the orange juice with only 1 teaspoon of thickener. R #15 was observed having difficulty swallowing. U. On 10/25/11 at 12:15 pm, during an interview with RN #1, she confirmed that R #15 was having difficulty swallowing and stated that R #15 was having problems swallowing because the CNA's do not know to thicken liquids and they did not know the correct consistency. V. On 10/25/11 at 12:40 pm during an interview with all three CNA's, (#2, #3, and #4) were asked if they had received any training on how to thickened liquids and they all stated "No." W. On 10/25/11 at 3:30 pm, during an interview with the DON, she was asked if staff had training on thickened liquids and she stated "We have been meeting with the dietitian for the last couple of months because we knew we had a problem in that area. We have not had any training whatsoever." Surveyor: Sanchez, Harold