Every finding on record at Frankfort Terrace

Based on observation, interview, and record review, the facility failed to identify areas in the facility that are at risk for Legionella and other waterborne pathogens according to the facility's water management program. This applies to all 113 residents residing in the facility. The findings include:The CMS-671 form titled, Long-Term Care Facility Application for Medicare and Medicaid dated June 8, 2026, showed the facility's census was 113. On June 8, 2026, at various times, multiple observations were made of residents' rooms having showerheads and sinks with faucets. On June 10, 2026, at 10:08 AM, V14 (Maintenance Director) stated the facility had two water tanks on each unit, and they had five total units. On June 10, 2026, starting at 10:16 AM, V14 showed each of the water tanks/water heaters on all the units and the water tank that supplies the kitchen. On June 10, 2026, at 9:41 AM, V13 (Chief Clinical Officer) stated they use the Centers for Disease Control (CDC) and Prevention Legionella Environmental Assessment Form as their assessment, and this assessment was done on April 8, 2026. V13 stated this was the only assessment they had. V13 also stated Based on our Legionella Environmental Assessment form from the CDC, our assessment shows that there are no areas within this building that have the potential to harbor Legionella. V13 continued to say the facility did not have a form or anything that showed these are the areas they are at high, moderate, or low risk, what they are doing to prevent those specific risks, the specific control measures associated with the risk areas, and what they are going to do if those specific control measures for their risk areas are not met. The facility's CDC Legionella Environmental Assessment Form dated April 8, 2026, completed by V2 (Director of Nursing, DON) showed, under question 18 the facility answered they have a water management program, and in the box below, showed, Addendum: As of 6-10-2026, Based on this Assessment there are no Identified Risk factors for Legionella. This assessment also showed that the facility has ice machines, water filters, and residents use respiratory therapy equipment. In the CDC Legionella Environmental Assessment Form, under the subtopic titled, How to use this form, showed findings from this environmental assessment can be used to develop a water management program by identifying areas at risk for Legionella growth and spread. In CDC's toolkit titled, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated September 30, 2025, showed Legionella grows and spreads in many parts of the building water systems such as hot and cold-water storage tanks, water heaters, water filters, showerheads, pipes, valves, and fittings, and ice machines. The same document showed one of the elements of a water management program is to identify areas where Legionella could grow and spread. The facility's undated Water Management Program, a two-page document, showed the program is designed to actively identify and manage hazardous conditions that support growth and spread of Legionella. The document also showed the water management program needs to assess how much risk the hazardous conditions in those water systems pose. Under the subcategory, background, it showed examples of where Legionella may grow; examples included hot and cold storage tanks, water heaters, faucets, showerheads, pipes, valves and fittings, and medical equipment such as CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure) machines.

Based on observation, interview and record review, the facility failed to maintain the kitchen in sanitary conditions, failed to follow labeling and storage procedures in dry storage, cooler and freezers and failed to follow sanitation guidance for dishes. This applies to all 113 residents that receive food prepared in the facility kitchen.The findings include: Facility Long Term Care facility application for Medicare and Medicaid dated June 8, 2026, showed that the facility census was 113 residents. The facility provided information that there are no residents on NPO (nothing by mouth) status.On June 08, 2026, starting at 9:31 AM, the initial tour of kitchen was conducted in presence of V7 (Dietary Manager) and the following concerns were observed: In the reach in cooler in the kitchen, there were multiple clear 4 oz bowls with cut up fruit that were placed on trays and covered with a clear wrapping. Some of the fruits bowls were partially opened and condensation from the inside the top of the cooler was seen dripping onto the trays. There was no date on the prepped fruit cups and manager stated that they were just made for the lunch meal. The temperature gauge on the outside of the larger reach in Freezer in the kitchen showed 15 degrees Fahrenheit. Multiple items were stacked up to the ceiling with many items toppling over. The frozen meat and other items were all randomly stacked one on top of the other with no air circulation. Some condensation was seen on various packaging's. There was a pool of congealed grayish liquid at the base of the outside door. A large free-standing reach in cooler in the kitchen that contained multiple individual 8 oz milk cartons, did not have an internal or external temperature gauge. Water was seen condensing inside the cooler and pooling into greyish color liquid at the edges of the lid that had was taped in areas. The temperature of one carton of fat free milk that was inside the cooler near the surface, was checked and it showed 46.8 degrees Fahrenheit. V7 remarked that the Freezer is old, and the temperature of the milk must have been elevated as some of the cartons were left over from breakfast that were re-stored in the cooler. During lunch meal observations on the same day, it was noted that the cartons of milk were placed in a large pan without ice near the steam table. In the dry storage area, cans containing food items were stored on racks and 3 cans of apple sauce, 1 can of whole kernel sweet corn and 1 can of refried beans (6 pounds, 10 oz/each can) were noted to be dented at the seams. V7 stated that whoever stocks these items on delivery oversees removing dented cans to a designated areas for return. A reach in cooler (that was near the cans) contained partially covered items dated 6/6 and were identified as chicken salad and peaches by V7. Another small container that was partially covered was not dated and contained a liquid substance which V7 identified as strawberry puree that was prepared last week. V7 remarked that all these items need to be tossed. In the same dry storage room, a 9.9 pounds box containing individual portions of whipped spread, had a label that showed refrigerate for best quality. V7 stated that the staff should have put back the box in the refrigerator after using it for breakfast meal. The dry storage room also had 3 tall, closed containers with food items that were not labeled. V7 identified these items as flour, sugar and breadcrumbs and stated that they may have been missed for labeling and dating. In the kitchen, near the steam table, there was a free-standing metal cart which had multiple bowls and stacks of small plates placed on shelving that had food debris and other unidentified substances. V8 (Dietary Aide) who was washing dishes in the vicinity at the low temperature dish machine, stated that these dishes were clean dishes. When V8 tested the sanitation well of the dish machine, the test strip turned a very dark shade of purple color that showed to be around 200 ppm (parts per million) on the color spectrum range of the test strip label. V7 stated that it should be 200-400 ppm. The top surface area of the dish machine had extensive brownish crumbly substances and other dirt and grime. Multiple rags that were very soiled were seen strewn on top of the dish machine and the conveyor belt that had stacked dirty dishes. V7 stated that they need to be sent to laundry. The sanitation buckets filled with Quaternary sanitizer were seen near the prep sink but had no rags in them. On the food prep area, there were food and other miscellaneous debris on the prep counters, on areas of a large mixer (that was covered in plastic), and inside a large pan that stored multiple cleaned utensils. A blender that was on the counter had food debris and greyish substance at the base. V7 stated that and that the blender has been cleaned and that the facility uses it to puree the food. Another smaller sized mixer was noted to be yellow color on the inside surface areas and V7 remarked that it also has been cleaned, and the yellow tinge is caused by food stains. V7 was notified of the above unsanitary food prep areas and importance of following guidance for sanitation of dishes.On June 9, 2026, at 2:30 PM, V6 (Dietitian) stated as follows: All items in the refrigerators should be properly covered in order to prevent cross contamination. There should be an internal thermometer gauge in the coolers and freezers. All food in coolers must be stored below 41 degrees Fahrenheit. Freezer food storage should allow enough air flow and circulation. All foods should be labeled and dated in the coolers and dry storage areas. The dented cans should be separated in a designated area. The low temperature dishwasher that is sanitized by Chlorine should test between 50-100 ppm. Too much solution has potential to coat the dishes washed and can be toxic. All food prep areas of the kitchen should be clean and free of debris. Facility undated policy titled Food Storage included:Policy: Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure:7. Food should be dated as it is placed on the shelves if required by state regulation. 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar .All containers or storage bags must be legible and accurately labeled and dated. 13. Refrigerated food storage:a) All refrigerator units should be kept clean and in good working conditional at all times. b) TCS (Time Temperature Control) foods must be maintained at or below 41 degrees Fahrenheit. Temperatures for refrigerators should be between 35 to 39 degrees Fahrenheit. c) Each refrigerator must be equipped with an internal thermometer. ciii) All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their dates or frozen (where applicable) or discarded. 14. Frozen Food: ci) All foods should be stored to allow adequate air circulation.f) Meat, fish, poultry should be stored on lower shelves, while fruits, vegetables, juices and breads should be stored on upper shelves. Facility policy titled Sanitation (effective date 5/2020) included:Guideline: The food service area shall be maintained in a clean and sanitary manner. Process: 2) All utensils, counters, shelves and equipment shall be kept clean, free from litter and rubbish .3) All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 4) Sanitizing of environmental surfaces must be performed with one of the following solutions: a) 50-100 ppm chlorine solution.6) Between uses, clothes and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solutions.17. The Dietary Manger will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Dietary staff will be trained to maintain cleanliness throughout their work areas during all tasks and to clean after each task before proceeding to the next assignment.

Based on observation, interview and record review, the facility failed to provide protein portions as shown on the menu spreadsheet for the lunch meal.This applies to 8 of 8 residents (R12, R37, R44, R50, R53, R65, R75, R96) observed for dining services in the sample of 24. The findings include:Daily spreadsheet for Spring Summer Menus, Week 3 Monday lunch meal showed that the main entree consists of 2 oz (ounce) protein portion of Italian Beef sandwich with one submarine roll. Other items listed for the lunch meal included Tater Tots (1/2 cup) and Fresh melon cup (1/2 cup).On June 8, 2026, at 12:31 PM, V9 (Cook) was cooking sliced Italian beef in a large pan with au jus and stated that each sandwich should have 3-4 slices in order to provide 2 oz serving of meat. On request, when V9 weighed 3 slices of cooked roast beef via a weighing scale, it showed 1 oz yield. On June 8, 2026, at 12:45 PM, during tray line service, V10 (Dietary Aide) was plating food and placed 3 slices of Italian beef on a 4-inch submarine roll for each resident who were on Regular diets, along with a side order of tater tots (4 oz) and fruit cup (4 oz) and R12, R37, R44, R50, R53, R65, R75 and R96 received the same. When asked how she knows how many slices to serve, V10 stated that she received directions from V7 (Dietary Manager) to provide the same. V7 was notified that only one ounce of meat was served to the above residents. On request, to validate how many slices should be used, V7 weighed 5 slices of Italian beef on a weighing scale to show a yield of 2 oz. On June 9, 2026, at 2:28 PM, V6 (Dietitian) stated that the facility should have served the required ounces of meat servings as shown on the menu spreadsheet to meet the protein needs for the day. Facility Diet Order listings showed that R12, R37, R44, R50, R53, R65, R75, R96 were on Regular consistency diets.

Based on observation, interview and record review, the facility failed to provide food preferences to residents that had an order or requested for the same.This applies to 4 of 4 residents (R43, R55, R63, R86) reviewed for dining in the sample of 24. The findings include: 1. Facility daily menu spreadsheet for Week 3 Monday lunch meal showed the main entree was a 2 oz portion of Italian Beef sandwich on one submarine roll. On June 8, 2026, at 12:31 PM, V9 (Cook) was seen cooking sliced Italian beef in a large pan and stated that each sandwich should have 3-4 slices in order to provide 2 oz serving of meat. On request, when V9 weighed 3 slices of cooked roast beef via a weighing scale, it showed 1 oz yield. On 06/08/2026 at 12:45 PM, during tray line service, V10 (Dietary Aide) was plating food and placed 3 slices of Italian beef on a 4-inch submarine roll for each resident on a Regular diet. R63 and R86 diet card showed regular diet, double meat and they received 2 submarine rolls with 3 slices of meat on each roll showing that they received total of 2 oz meat for the meal instead of 4 oz (double meat). R63's care plan revised July 9, 2025, included that the resident is on a NCS (No concentrated Sweets) diet, double fruit and double meat at lunch and dinner. Interventions included to provide and serve diet as ordered. R86 care plan revised June 13, 2026, included that the resident is on a regular diet, double meat at lunch. Interventions included to provide and serve diet as ordered. 2. On June 8, 2026, at 11:05 AM, R43 stated Sometimes the trays are empty. I like scrambled eggs, but they don't give them every day. On June 10, 2026, at 8:50 PM, R43 was in the dining room and received 2 toasts, 2 milk cartons, 4 oz portion of yogurt and 4 oz bowl of oatmeal. R43's diet card showed NAS (No added Salt), Regular, 2 coffees, 2 milk, double cheese or meat, white toast, pink sugar. R43 was very upset and stated There is no meat or eggs. This is all I got. I have been waiting here for so long and this is all they gave me. V7 (Dietary Manager), who was at the serving station, stated that facility had Western Egg Bake for breakfast that morning and it has pork in it as an ingredient. V7 stated that R43's diet is no pork, therefore she did not receive the Western Egg Bake and was given yogurt instead. V7 stated that the kitchen does not prepare separate eggs for those that cannot have pork. R43's care plan revised May 18, 2026, showed that the resident is on General NAS diet, double cheese or meat at breakfast 2% milk with all meals. Interventions included to provide and serve diet as ordered. On June 9, 2026, at 2:16 PM, and on June 10, 2026, at 9:50 AM, V6 (Dietitian) stated that both R63 and R86 were complaining of being still hungry after their meal so she added double meat to provide satiety. V6 stated that she did not add double portions for these residents as they both were obese and further weight gain was not recommended. V6 stated that R43 is a picky eater and should also receive her diet preferences. V6 added that R43 is on double portions with breakfast and the facility should have prepared eggs without pork for R43, as an egg item is listed for breakfast. V6 added that these residents should have received the diet as ordered to meet their diet preferences and/or for weight maintenance. 3. R55's admission Record form showed R55 was admitted to the facility with the following diagnoses: schizophrenia, asthma, and pain. On June 8, 2026 at 11:07 AM, R55 stated she doesn't want the mechanical soft diet she is currently on. R55 stated she has told the staff and the dietary manager that she needed regular textured food and not the mechanical soft diet. R55 stated that when she told the staff about her preference to change her to a regular textured diet, they told her that they had to follow her diet order. R55 stated she can chew regular textured food. R55 stated she came from another facility and was on a regular diet not minced food. R55 stated she does not know why they put her on the mechanical soft diet. R55 stated her sister did not tell the facility to do that either. On June 8, 2026 at 1:19 PM, R55 was observed in the dining room eating a mechanical soft diet for lunch. R55 had minced steak on a bun with tater-tots, and a cup of fruit. R55 stated that no one had ever talked to her about what she can and cannot eat, and she has not had any test to determine her ability to eat a regular diet. R55 stated she does not have any pain or choking while eating or difficulty any swallowing. On June 9, 2026 at 11:48 AM, V7 (Dietary Manager) stated R55 has been telling him for the last couple of weeks that she doesn't want to be on a mechanical soft diet. V7 stated that R55 said she is able to chew regular food. V7 stated he told R55 that once she had a swallow evaluation then they can upgrade her diet. V7 stated R55 complained again yesterday that she didn't want chopped up meat. V7 stated that he cannot change the diet order that is up to the dietician and nursing staff. V7 stated he had not mentioned R55's preference for a different textured diet to the dietician or nursing. As of June 9, 2026 at 11:48 AM, R55 had the following diet order:Regular diet, Mechanical Soft texture, Regular- thin liquids consistency. Dated May 11, 2026. R55's care plan was absent of any care plan for difficulty in chewing or swallowing. On June 9, 2026 at 2:11 PM, V6 (Dietician) stated she does not upgrade or downgrade diets for textures. V6 stated R55 was on mechanical soft diet when she saw her on May 21, 2026 and did an assessment. V6 stated that at the time of R55's assessment, V6 did not have any concerns with R55's chewing or swallowing abilities. V6 stated was she not aware that R55 wanted a regular textured diet. V6 stated she did not know why R55 was on the mechanical soft diet. On June 10, 2026 at 9:33 AM, V2 (Director of Nursing) stated he was made aware of R55's preference for a regular textured diet when R55 came to him yesterday screaming that she did not want a mechanical soft diet and that she can eat regular textured food. V2 stated that if a resident complains to any staff about the texture of the food or if a resident wants the texture of their diet to be changed, then the staff should bring it to the attention of the dietary manager or himself. V2 stated they will then notify the dietician so the resident can get an assessment. V2 stated if the resident has informed the dietician of their preference for a different textured diet, then the dietician should be notified as soon as the different diet is requested by the resident.

Based on observation, interview and record review, the facility failed to provide nutrition supplemental foods to a resident that had ongoing significant weight loss.This applies to 1 of 9 residents (R6) reviewed for nutrition in the sample of 24.The findings include:R6's EMR (Electronic Medical Records) showed multiple diagnoses that included Parkinson's disease without dyskinesia, without mention of fluctuations, other dysphagia, gastro-esophageal reflux disease without esophagitis, slow transit constipation, neuroleptic. induced parkinsonism, paranoid schizophrenia. R6's MDS (Minimum Data Set) dated May 13, 2026, showed that R6 was cognitively intact. R6's diet order on POS (Physician Order Sheet) included NAS (No Added Salt) diet, Mechanical Soft texture, Regular- thin liquids consistency, milk with all meals, yogurt or ice cream with all meals, 2 hardboiled eggs with breakfast, sandwich HS (evening), Med pass 2.0 (nutrition supplement) 120 ml (milliliter) one time a day.R6's weight history in EMR showed as follows: 109.8 lbs/pounds (May 29, 2026), 111.6 lbs (April 30, 2026), 115.4 lbs (March 30, 2026), 123.2 lbs (February 16, 2026), 131.4 lbs (October 31, 2025). On June 8, 2026, at 12:18 PM, R6 was noted to have most dentition missing. R6's speech was unclear to most queries. V11 CNA (Certified Nursing Assistant) stated that R6 can feed self and gets mechanical soft diet and that R6 received mechanical soft diet with yogurt and milk for breakfast. V11 remarked She is picky about her food and sometimes she doesn't eat all her food. We give her shakes. Don't know how often she gets it. On June 9, 2026, at 1:20 PM, R6 had just finished her lunch meal and was in her room and stated that she did not receive yogurt or milk. R6 stated that she likes yogurt but does not care for milk. R6's diet card showed NAS, mechanical soft diet, hot cereal and yogurt at breakfast and did not show any supplemental food for lunch or dinner. On June 9, 2026, at 1:38 PM, V11 verified that R6 did not receive yogurt nor milk at lunch and gets coffee or water to drink. V11 added that R6 only received mechanical soft sausage at breakfast and hot cereal and did not receive any boiled eggs. V7 (Dietary Manager) also verified that boiled eggs were not prepared as sausage was on the menu for breakfast. On June 9, 2026, at 2:21 PM, and on June 10, 2026, at 9:55 AM, V6 (Dietitian) stated that R6's weight was trending down, and she is a picky eater and asked for milk and yogurt and two hard boiled eggs as preference and it was added to stabilize her weight. V6 stated that when she makes the recommendations, either she or V7 updates the diet order listings for the kitchen to follow. V6 added that V7 then updates the tray cards to reflect the diet orders with recommendations. V6 was informed that R6's diet card did not reflect current diet order that includes the hard-boiled eggs and yogurt and milk at lunch and dinner. V6 stated that she comes closer to the end of the month to address weight changes as the facility does their weights for residents at the end of the month. V6 stated that when she assessed R6 on May 21, 2026, she referenced April 30 (2026) weight and that R6 had lost 3.8 lbs in one month, lost 11.6 lbs (significant 9.6%) in 3 months and lost 19.8 lbs (significant 15.1%) in six months. V6 stated that R6 should receive all the foods listed in order to promote intake and maintain weight as she is a picky eater.Dietitian's most recent progress notes dated May 21, 2026, included as follows: Resident is on NAS, mechanical soft, thin liquids, milk with all meals, yogurt or ice cream with all meals, 2 hardboiled eggs with breakfast, sandwich HS. NKFA (No known food allergy). Height 55 inches, Current weight 111.6 lbs (April 30), BMI of 25.9- overweight, however appropriate due to advanced age. March weight 115.4lbs (March 30)- significant 9.6 lbs (7.7%) weight loss in 3 months. Weight history shows 3.8 lbs (3.3%) weight loss in 1 month, significant 11.6 lbs (9.4%) weight loss in 3 months and significant 19.8 lbs (15.1%) weight loss x 6 months. Weight loss is likely related to diagnoses, po [oral] intakes, advanced age and natural disease progression. Weight stability is desired. Adding Med Pass 120ml daily to support weight stability.R6's current care plan revised May 12, 2026, did not mention that residents had significant weight loss but showed to provide and serve diet as ordered and dietitian to evaluate and make diet change recommendations as needed.

Based on observation, interview and record review, the facility failed to puree Italian beef to pureed consistency for residents on pureed diets.This applies to 3 of 3 residents (R11, R13 and R66) reviewed for mechanically altered diets in the sample of 24.The findings include:Facility daily menu spreadsheet for Week 3 Monday showed pureed Italian beef sandwich as the main entree for pureed diets. On June 8, 2026, at 12:35 PM, during lunch tray line service, the meat that was prepared for the pureed meal appeared coarse texture and lumpy and was similar in appearance to the mechanical soft consistency meat. The total amount prepared was about two cups. V10 (Dietary Aide) who was on the tray line plating the food, stated that she is using a four-ounce scoop to serve the pureed meat. V7 (Dietary Manager) who was in the vicinity, stated that he has three residents on pureed diet consistency. On taste testing the pureed meat, there were small stringy pieces of meat that had to be chewed to be able to be swallowed. V7 stated that he prepared the same and V7 was notified that the pureed texture was not safe to serve. V7 took the mixture back to prep area to blend it again. On going to the area, it was noted that some of the contents of the earlier seen mixture were spilled on the outside of the blender. V7 stated that he tried to dump the contents into the blender straight from the pan and it spilled over. V7 was told that there was not enough content in the blender to serve three residents and that he would have to puree additional meat. V7 returned to the steam table area with a watered-down version of runny pureed mixture and placed it on the steam table. On request, the temperature of the pureed meat was taken and showed to be 127.4 degrees Fahrenheit. V7 was again notified of the watery consistency and unsafe temperature of the pureed meat. V7 also stated that he does not reheat the pureed foods after pureeing the same places it directly at the steam table. On June 9, 2026, at 2:48 PM, V6 (Dietitian) stated that pureed food should be smooth and lump free and require no chewing. V6 stated that the recipe should be followed to ensure that pureed consistency and nutrition is provided and food is reheated to 165 degrees Fahrenheit and serving temperature at minimum 135 degrees Fahrenheit at the steam table.Pureed recipe for Italian beef showed that for 2 oz portion of Italian beef to use 1 tablespoon of broth and blend to a smooth consistency. Reheat to minimum temperature of 165 degrees Fahrenheit and hold for service at 135 degrees Fahrenheit. Facility diet order listing showed that R11, R13, R66 are on pureed diets.

Based on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7. Based on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7.Findings include. On 7/9/25 at 12:37 PM, residents were interviewed during lunch service. R1 stated she is hot everywhere she goes, and her room is very warm. R1 stated she was provided with a fan, but it is not sufficiently cooling her room. R1 stated the lobby and staff offices are cool. R2 stated her room was too hot and she was not provided with a fan. R4 stated the dining room temperature was comfortable, but her room was too warm. R6 stated only the dining room was comfortable. On 7/9/25 at 2:42 PM, room temperatures were taken with V6 (Maintenance Director). R1's room temperature with a fan was 81.8 degrees F (Fahrenheit). R2's room temperature was 82.2 degrees F. R4's room temperature was 82.2 degrees F. R6's room temperature was 81.8 degrees F. On 7/9/25 at 3:05 PM, the weather app showed outside temperatures for the area at 85 degrees F. On 7/9/25 at 4:18 PM, V1 Administrator stated she had just been informed of the elevated resident room temperatures. V1 stated she does not follow a hot weather bulletin or receive hot weather alerts. On 7/9/25 at 4:36 PM, V6 (Maintenance Director) stated environmental temperatures are done three times per day in the front corridor, down each hallway and two or three random resident rooms down each hallway. V6 stated when temperatures are above 80 degrees F he is to report it to his supervisor. V6 that was the first time environmental temperatures were above 80 degrees F. Review of the environmental temperature logs provided show on 6/26 temperature logs were done three times in the resident halls and dining area. No environmental temperatures were measured in resident rooms. On 6/26 at 11:40 AM all environmental temperatures logged were over 80 degrees F (Fahrenheit) with the highest being 83.1 degrees F. On 6/26 at 3:30 PM the second environmental temperature done shows all temperatures above 80 degrees F with the highest reading of 85.5 degrees F. On 6/26 at 8:30 PM, three hallways measured over 80 degrees F with the highest reading of 80.6 degrees F. On 6/27 at 2:54 PM environmental temperatures were only conducted once and all temperatures measured over 80 degrees F with the highest reading at 83.2 degrees F. On 7/3 temperatures were logged twice. At 9PM environmental logged were over 80 degrees with the highest reading of 81.6 degrees F. On 7/4 temperatures were logged twice. At 9PM environmental logged were over 80 degrees with the highest reading of 81.6 degrees F. No hourly temperatures logs were provided for day with temperatures above 80 degrees F. The facility Hot Weather / Heat Emergencies policy date 11/1/2020 states the administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The Maintenance Director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of 71- 80 degrees F. If temperatures increase reading will be taken every hour.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This applies to 1 of 5 residents (R2) reviewed for abuse in the sample of 6. The findings include: R1's EMR (electronic medical records) showed that he was admitted on [DATE], and discharged on May 26, 2025, with diagnoses including schizoaffective disorder, depressive type, hypertensive heart disease without heart failure, cocaine abuse, unspecified with withdrawal, alcohol abuse, uncomplicated, peptic ulcer site unspecified, unspecified as acute or chronic, without hemorrhage or perforation, hypo-osmolality and hyponatremia, other poly osteoarthritis. R1's quarterly MDS (minimum data set) dated April 28, 2025, showed that R1 was moderately impaired in cognition. FRI (Facility Reported Incident) report included the following: Date/time of incident: May 26, 2025, 12:45 PM. Final Report sent to IDPH (Illinois Department of Public Health) on May 30, 2025. Brief description of incident: R2 alleges that co-peer [R1] hit him in the mouth with his hand. Body assessment completed and R2 was noted with swollen lip. First aide applied to his lip. On June 16, 2025, at 10:05 AM and 10:52 AM, V2 (Director of Nursing) stated that R1 was sent out to the hospital on May 26, 2025, and discharged to another nursing home from the hospital. Nursing incident progress note dated May 26, 2025, included that Resident (R1) was involved in initiating aggressive behavior towards peer (R2). R1 stated that peer (R2) cut him off. R1 was assessed for injuries, with none visible PRSC (Psychosocial Rehabilitation Service Coordinator) Behavior note dated May 26, 2025, included that R1 was physically aggressive towards co-peer (R2) in the dining area. R1 was escorted to social service office and an official statement was taken from him. He was counseled and was placed on one: one until the arrival of the ambulance to be transferred to the hospital for psychiatric evaluation. Progress notes dated April 29, 2025, included that R1 continues with aggressive behavior towards staff and peers. R1 throwing water and non-redirectable. Physician phoned and ordered received to send resident to hospital for psychiatric evaluation. Incident note dated April 28, 2025, included that peer (R3) was sitting and watching television and resident (R1) came up and swung at peer sticking peer's right arm. Resident was moved away from peer and counseled. Physician made aware and resident was given an as needed medication) and counseled. PRSC progress note dated April 13, 2025, included that R1 was physically aggressive towards co peer while in the dining room. R1 stated co peer was looking in his direction, so he hit him. Staff separated each party. R1 was counseled on his behavior. Physician made aware and orders were given for resident to be sent to hospital for psychiatric evaluation. R1 was placed on one to one until the arrival of the ambulance for transport. 2. R2's EMR included diagnoses of Schizophrenia, unspecified bipolar disorder, current episode manic severe with psychotic features other psychoactive substance abuse, uncomplicated. R2's Annual MDS dated [DATE], showed that R2 was cognitively intact. On June 16, 2025, at 10:35 AM, R2 stated It was Memorial Day. This guy [R1] was very aggressive and hit me. He hit me in the mouth and my whole lip got really big. I couldn't eat my food on Memorial Day as my mouth was all busted up and I wanted to enjoy my food. I did not want to go to the hospital and asked for an ice pack. I think he (R1) is dealing with some mental illness in the head, and he just likes to fight. I was not the first person he hit around here, and then he says he's sorry to the police officer and staff. I told the Administrator (V1) that I do not want to deal with him and don't want him to come back from the hospital. He was new and violent, and I told the Administrator that I want this [NAME] to leave here. A lot of people here is elders, and he does not need to be here. This is a safe and clean place, and I have been here for 5 years and it's my home. He (R1) has been sent out many times to the hospital after hitting people and all the residents don't want him to come back. I heard he wrestled with nursing and turned the medical cart over. He did all this in one month. On June 16, 2025, at 11:29 AM, V3, PRSD ((Psychosocial Rehabilitation Service Director) stated that the altercation on May 26, 2025, between R1 and R2 happened when R2 was at the water cooler assisting R6 to get some ice. V3 stated that R1 was standing there and reading the posted menu and R2 walked in front of him and crossed his path which set R1 off and caused him to strike out at R2. V3 stated this was reported to him by a witness staff member V4 (Certified Nursing Assistant) who was in the vicinity and currently on vacation. On June 16, 2025, at 1:44 PM, V5 (Licensed Practical Nurse) stated I was not in the vicinity when it happened. Everyone who was at the area said that [R2] went to open the container for ice for an older lady [R6]. [R1] thought that [R2] cut in front of him and punched him in the face. [R2] had the inside of his lip busted and it was swollen, and we put ice on it and let the doctor know. It was an abrasion inside the lip. [R1] had no injuries. R2's EMR included Nursing Incident progress note dated May 26, 2025, included that resident was in physical altercation with peer. Resident's separated and counseled. Body check revealed an abrasion to the inside of resident's upper lip. Lip slightly swollen and small amount of blood noted. Resident given ice pack and Physician make aware. Facility policy titled Abuse (effective December 2024) included as follows: Policy: This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, misappropriation of property, involuntary seclusion, or mistreatment of residents Definitions: The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS [Illinois Complied Statutes] 45/1-103) Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and requires medical attention (77 Illinois Administrative Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 482.12 Interpretive Guidelines).

Based on observation, interview, and record review, the facility failed to have a fully functioning call light system. This applies to all residents residing at the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/4/24 documents that the total census was 101 residents. On 06/04/24 at 11:13 AM, R92 was observed in her room and R92 said that she turned her call light on for staff to come down to put her brace on and nobody came down. At 11:24 AM R92 turned her call light on again. R92 said, I told my case manager that it is hard to get a CNA (Certified Nurse's Assistant) to come down to my room to help me. I feel I should get the same help as everyone else, and I don't. R92 was observed crying as she was speaking. At 11:31 AM the surveyor went to the nurses' station where the call light board was located and saw that R92's call light was on but not alarming. At that time V11 MDS (Minimum Data Set) Coordinator was observed in the nurse's station making the first announcement over the facility's overhead pager system that R92's call light was on. On 06/04/24 at 11:33 AM, V5 (Nurse) was in the nurse's station and said that sometimes the call light system will sound and sometimes it will not. On 06/04/24 at 11:35 AM, V6 (Nurse) was in the nurse's station and said that the call light system buzzer is to stay on the whole time the light is on. V6 said that sometimes no one is in the nurse's station to see or hear the call lights come on. On 06/04/24 at 11:44 AM, V4 (Maintenance Director) was in the nurse's station and said that the call light and buzzer is supposed to stay on until it is answered. On 06/04/24 at 11:47 AM the State Surveyor and V4 were in the nurse's station while the call light was being tested in a room and the call light showed the room, but it did not sound or buzz. At 11:48 AM the system was tested in another room and the system sounded/buzzed once but the board did not show what room was calling. At 11:48 AM, V4 said, I'm not going to make any excuses it's not working right. The last time I tested it was probably last month. I don't keep a log. V4 continued testing the system, at 11:54 AM the board lit up indicating a room, but it did not buzz/sound. At 11:55 AM the system buzzed once but the board did not light up indicating which room. On 06/04/24 at 12:54 PM V7 (Nurse) said that since she started in March 2024, she could not recall the call light system sounding a continuous buzzing while the call light was on. On 06/04/24 at 1:04 PM, V6 (Nurse) said that she has worked at the facility for [AGE] years and the last time she heard the call light system work properly was at least a month ago. V6 said that now the system will just chirp, or it will chirp and no light will come on. V6 said that she has told V4 about the call light system not working but she is not sure if she told V4 that the system doesn't continue to buzz until the light is turned off like it is supposed to. V6 said she should have reported it because if the call lights are not working someone could need help and they wouldn't know. On 06/04/24 at 1:11 PM, V5 (Nurse) said that she has worked at the facility for 2 years and she did not recall the system buzzing continuously when the call light is turned on until it is turned off. On 06/04/24 at 1:15 PM, V8 CNA (Certified Nurse's Assistant) said that they only know that the residents' call lights are on is when the nurses notify them. On 06/04/24 at 12:40 PM, V1 (Administrator) said that she did not know the last time the facility check the call light system and doesn't know how often it should be checked. Facility's call light policy dated 3/2021 showed that all defective call lights are to be reported to the nurse supervisor and or maintenance director.

Based on interview and record review the facility failed to implement and document measure that prevent the waterborne pathogen Legionella and provide an up-to-date infection control policy. \This applies to all 101 residents that resided in the facility. Findings include: On 6/6/24 at 12:48 PM, V4 Maintenance Director stated corporate is responsible for testing for legionella and would have the reports. V4 stated he never heard of legionella. V4 stated each wing has hot water heater. V4 stated the last time he checked water temperatures was in March 2024. V4 stated he wasn't documenting because there were problems with the water heaters giving accurate temperatures. V4 Maintenance Director stated the resident and staff would tell him when the water temperatures dropped to make sure it was up to par. On 6/6/24 at 2:09 PM, V1 Administrator stated the facility uses well water and city tests the water for legionella. V1 stated water temperatures should be tested daily so if there is a problem, we know about it. On 6/6/24 at 3:00 PM V1 Administrator stated there is no infection control policy. V1 stated the facility has an infection control program. V1 stated she did not know when the program was last reviewed. V1 stated we don't have to test for legionnaires according to our corporate. V1 stated we do not have to do water flushing according to the water management program. On 6/6/24 at 3:17 PM, V4 Maintenance Director stated he does water flushing of the water heaters randomly monthly. V4 stated he does not log the flushing and did not know he was supposed to. V4 stated he called the city, and they test for legionella. The report goes on the bill and the bill goes to corporate. On 6/6/24 at 01:02 PM, V17 Infection Preventionist confirmed the undated document Infection Control and Surveillance Program was the facilities infection control policy. Documents provide as part of the infection control program includes Antimicrobial / Antibiotic Stewardship program dated 4/2020. Covid and Influenza dated 12/2020. Coronavirus dated 3/21. Care of residents with Covid 19 dated 5/13/20. Flu / Pneumovax Vaccine Dated 7/2022. The facilities undated Water Management Program for Legionella identifies control measures of temperatures at a variety of points. The program does not indicate the frequency or appropriate temperatures to control Legionella. Examples provided of what to do when controls are not met includes daily flushing of sink and showers, emptying of the ice machines and cleaning per manufactures instructions and testing of water. The last document water temperature check was done 3/21/24. The Village water report provided by the facility dated April / May 2024 does not list Legionella testing.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen and use proper sanitation while checking food temperatures. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 101 residents. On [DATE] at 10:49 AM, V9 (Dietary Manager) said there are no NPO (Nothing by Mouth) residents. All 101 residents eat from the facility kitchen. On [DATE] starting at 10:00 AM, the facility kitchen was toured in the presence of V9 (Dietary Manager) and the following was found: In the dry storage room refrigerators: 1. An opened bag of shredded lettuce, not labeled or dated with browning lettuce and yellow liquid in the bottom of the bag. 2. A bag of unlabeled and undated diced meat with yellow liquid in bottom of bag. V9 said it was diced turkey. 3. A partially sliced yellow onion in a resealable bag dated ,d+[DATE]. 4. A half empty gallon of 2% reduced fat milk with best by date of [DATE]th. 5. A full gallon of 2% reduced fat milk with best by date of [DATE]th. In the kitchen refrigerators: 6. A resealable bag of salami deli meat that is not labeled or dated. 7. An unlabeled medium sized bin of opened various deli meats dated [DATE] with yellow liquid in bottom of bin that meat is sitting in. V9 said the meats were turkey ham, turkey baloney, and turkey salami. 8. Half of a deli ham dated [DATE] sitting in pink liquid in a medium sized silver bin. 9. A pork roast dated [DATE]. V9 said it is defrosting for later in the week, but there is no defrost date on it to show when/if it was moved from freezer to refrigerator. In the dry storage: 10. The dry storage room is filled with boxes stacked on top of boxes of dry foods. Surveyor unable to reach or see the food on the shelves on one side of the room and unable to fully open the refrigerator doors on the opposite side of the room due to boxed food items that have not been appropriately stocked. V9 said the last delivery came on [DATE] in the evening. The boxes have multiple delivery dates, some of the boxes were delivered on [DATE], some on [DATE], and some on [DATE]. 11. A 14.5 ounce can of diced green sweet bell peppers with a large dent in can on the circulation rack. 12. A 1 gallon tub of grape jelly with lid not sealed and sticky red residue on the handle and the lid of the tub. When surveyor lifted tub off the shelf, a fly flew off the tub. 13. On [DATE] at 12:06 PM during a return to the kitchen tour, a 20-gallon flour bin was found with a Styrofoam cup inside used for scooping and a sticky brown substance under the lid of bin. 14. On [DATE] at 12:19 PM, while testing lunch food temperatures, V10 (Cook) wiped the thermometer with the same paper towel between each of the 7 food items, he did not clean/sanitize the thermometer probe. On [DATE] at 1:04 PM, V9 (Dietary Manager) stated all foods in the kitchen should be labeled and dated for food safety and for kitchen staff to be able to follow the first in, first out rule. V9 said all foods should be sealed to prevent pests or debris from contaminating the food. V9 said dented cans should be removed from circulation to prevent the food from being fed to residents and risking the residents getting sick or botulism. V9 said the food items should be stocked/put away after delivery and boxes should not be sitting on the floor because of the risk of contamination. V9 said if foods are not stocked/put away on shelves the FIFO (First In, First Out) rule is not being appropriately followed. V9 said expired foods should be discarded so the foods are not accidentally fed to residents with potential for foodborne illness. V9 said no Styrofoam cup or scooper should be stored in the flour bin because the cup could be contaminated and then contaminate the whole bin of flour. V9 said when V10 (Cook) checked food temperatures, he should have sanitized the thermometer with an alcohol wipe in between each food item to prevent the possibility of contamination and mixing foods. The facility's undated policy titled, Food Storage states, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 1. Label and date foods and put foods away promptly. 2. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of foods. a. old stock is always used first (first in- first out method). b. Supervise the person designated to put stock away to make sure it is rotated properly. c. Food should be dated as it is placed on the shelves if required by state regulation. d. Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food should be consumed, sold, or discarded will be visible on all high-risk food. e. Foods will be stored and handles to maintain the integrity of the packaging until ready for use . The facility's undated policy titled, Dry Storage Areas states, Policy: Dry storage areas will be kept in a condition which protects stored foods from infestation. Procedure: 1. Foods will be received, checked, and stored properly as soon as possible after delivery. 2. All items must be stored at least 6 inches off the floor .There must be adequate space on all sides of stored items to permit ventilation. 3. Floors, walls, shelves, and other storage areas will be kept clean .5. Dented cans without leaking or compromised seal will be stored separately in designated/labeled area . Care of the Storeroom [ROOM NUMBER]. Staff will maintain the care of the storeroom according to the following directions. a. All food will be arranged in the storeroom logically, with similar food stored together. b . New stock will be placed behind previously delivered items so that older stock will be used first . d. The storeroom will be cleaned on a regular basis. Floors will be swept and mopped at least weekly and more often as needed . The facility's provided undated document titled, Cold Storage Chart, USDA shows .Luncheon meats in opened package are good in the refrigerator for ,d+[DATE] days .

Based on observation, interview, & record review, the facility failed to provide ADL care (activities of daily living) to 4 0f 4 residents dependent of ADL care (R3, R42, R83 & R92) in a sample of 28. Findings include: 1. On 06/05/24 at 11:07 AM R3 was observed with facial hair on her chin. R3 stated that she did not know the last time she was shaved and that she wanted the staff to shave her. R3's electronic health record showed that she is an [AGE] year-old female admitted to the facility with diagnoses including paranoid schizophrenia, scoliosis, spinal stenosis, and polyosteoarthritis. R3's 5/1/24 MDS (Minimum Data Set) Section GG - personal hygiene showed that R3 is dependent on staff for care. A review of R3 electronic health records was conducted on 06/06/24 at 1:40 PM and it showed under Task GG- Personal Hygiene - no documentation for the last 6 months. R42's 30 day look back for Behavior Monitoring and Interventions from 5/8/24 - 6/6/24 showed no behaviors observed and the 30 days look back for ADL care for 5/8/24 - 6/6/24, did not show any refusal of ADL care. 2. On 06/04/24 at 10:36 AM R42 was observed with facial hair on her upper lip and chin. 06/05/24 at 12:54 PM R42 was again observed with facial hair on her upper lip and chin. R42 stated It has been over a week or so since anyone shaved me. It bothers me and I have asked them to shave me, and I am going to ask them again today. R42's electronic health record showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, type 2 diabetes and polyosteoarthritis. R42's 4/30/24 MDS section GG Personal hygiene showed that R42 needs partial to moderate assistance with personal hygiene. R42's Task GG showed no documentation no progress notes for last 6 months. R42's Progress notes were reviewed with no notes showing any refusal of ADL care. R42's 30 day look back for Behavior Monitoring and Interventions from 5/8/24 - 6/6/24 showed no behaviors observed and the 30 days look back for ADL care for 5/8/24 - 6/6/24, did not show any refusal of ADL care. 3. On 06/04/24 at 1:41 PM, R83 was observed with long jagged toenails, about a half an inch over her toes. R83 stated that it had been about a month since the podiatrist cut them, & that it bothers her that they are so long. R83 said, I told the staff and they said that they will get to it. R83 said that was the day before on 6/5/24. R83 electronic health record showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including bipolar disorder & type 2 diabetes. The facility Podiatry list for 5/7/24. R83 was on the list but the list did not indicate if she had been seen or refused as it did for all of the other residents. The facility was asked to produce the podiatrist progress notes for the resident and was unable to produce a note from the Podiatrist for services for R83 on 5/7/24. On 06/06/24 at 1:30 PM a record review for the last 60 days of R83's progress notes did not show any documentation of R83 refusing care including nail care and no progress notes for 5/7/24 podiatry care. R83's 3/21/24 MDS section C showed that R83's cognition is intact and section GG - Personal Hygiene showed that R83 needs supervision or touching assistance with personal hygiene. R83's Task - Behavior Monitoring & Interventions 30 day look back from 5/8/24 - 6/6/24 showed no behaviors observed and the 30 days look back for ADL care for 5/8/24 - 6/6/24 did not show any refusal of ADL care. R83's Task GG- Personal hygiene - showed no progress notes for the last 6 months. 4. On 06/04/24 at 11:13 AM R92 was observed with long jagged toenails. R92 said I can't remember the last time they were cut they reach/touch my shoes. They have a podiatrist here, but I have not seen him. On 06/04/24 at 1:22 PM R92 was observed with short, jagged fingernails. R92 said They need to be filed and I asked the staff, but they won't file them. R92 said that after the staff cut her nails, she asked them to file them, but they wouldn't do it. R92's electronic health record showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including schizophrenia, polyosteoarthritis, and type 2 diabetes. R92's 3/7/24 MDS section C showed that R92 cognition is intact & section GG Personal Hygiene showed that R92 needs substantial to maximal assistance. On 6/06/24 at 12:42 PM, R92's progress notes were reviewed for last 30 days and no notes were observed for refusing ADL nail care. R92's Task ADL care 30 day look back from 5/8/24 to 6/6/24 showed no documentation of refusal for ADL care. R92's 20 day look back for behavior monitoring and interventions from 5/8/24 through 6/6/24 showed no behaviors observed. On 06/04/24 at 2:17 PM, V2 DON (Director of Nursing) stated that as of this day no one is on the list to be seen by podiatry for this month. On 06/04/24 at 2:17 PM, V3 ADON (Assistant Director of Nursing) stated - the podiatrist comes every 6-8 weeks and as needed if we request them to come. V3 stated that the staff have the emery boards to file the nails when it is needed. On 06/06/24 at 2:33 PM V2 DON stated that the staff should be shaving the women and that nail care depends on if the resident is a diabetic or not. V2 stated that staff should notify the nurse so they can put the residents on the podiatry list, or the nurse can cut the nails. V2 state that he usually cuts the nails himself. V2 stated Last week I cut R92's nails and the nails could not be cut down anymore because of calluses on the nails. I told R92 that I would put her on the list to see the podiatrist. I did not put her on the list that was an oversite on me. I looked at her nails today and yes, they are long and jagged, but they are long because of the calluses, and they are jagged, but I did not file them, that is on me. V2 stated that if the residents refuse ADL care, they let the nurse know and we document that they refused. V2 said he had no knowledge of the residents refusing nail care or shaving and there is no documentation for R3, R42, R83 & R92 refusing nail care or shaving. On 06/06/24 at 10:41 AM, V1 (Administrator) said that if a resident asks for assistance with ADL care and requires assistance, staff should provide it. V1 said that staff should observe residents' nails when they give showers and notify the nurse if they need nail care. The facility's Nail Care policy date 3/2021 showed routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well-being for the residents. The policy showed under, Standard: nail care is a routine part of grooming each day. The policy showed under Procedure: clip one nail at a time and file the fingernails in an oval shape, file toenails straight and do not leave any edges. Determine the resident's preferred nail length.

Based on observation, interview, and record review, the facility failed to contain respiratory equipment for 2 residents (R38 & R42) in a sample of 27. 1. On 06/04/24 at 11:00 AM R38's BIPAP (bilevel positive airway pressure) mask and O2 nasal cannula was observed not covered. R38 said I use my BIPAP ever night and the oxygen as needed. R38's electronic medical record showed that she has diagnoses including chronic obstructive pulmonary disease with acute exacerbation, asthma & sleep apnea. R38's 2/19/23 physician order showed, oxygen as needed for COPD (chronic obstructive pulmonary disease), & 12/19/23 Physician order showed, BIPAP at night at bedtime for COPD. 2. On 06/04/24 10:36 AM R42's CPAP mask (continuous positive airway pressure) and O2 nasal cannula was observed not covered. R42 stated, I use my CPAP every night at 10pm. R42's electronic health record showed that R42 has diagnoses including chronic respiratory failure and obstructive sleep apnea. R42's 6/11/23 physician's order showed oxygen as needed via nasal cannula at 2 liters per minute. R42's 6/11/23 physicians order showed O2 while on CPAP every night related to obstructive sleep apnea. On 06/06/24 at 10:35 AM, V1 (Administrator) stated that the machines should be stored and covered for infection control when not in use. On 06/06/24 at 2:33 PM, V2 DON (Director of Nursing) stated respiratory equipment including masks and nasal cannula should be contained or covered when not in use. V2 stated that the staff are to ensure that they are contained when they do rounds. The facility's CPAP - BIPAP guideline dated 3/2021 does not show how the equipment should be contained when it is not in use.

Based on observation, interview, and record review the facility failed to provide mental health rehabilitation services to a resident identified with a serious mental health condition. This applies to 1 of 1 resident (R74) reviewed for mental health rehabilitative services in the sample of 28. The findings include: On 06/04/24 at 10:31 AM R74 was lying in bed. R74 stated she does not attend group meetings. R74 stated she doesn't do much since she does not attend group. R74 stated the staff does not try to encourage her to go to group. On 06/05/24 at 4:15 PM R74 was lying in bed. R74 stated she did not attend any group sessions today. R74 said no one invites her to groups, and she does not know the dates or times they are held. R74 said if she was invited to groups, she would attend. On 06/06/24 at 9:14 AM R74 continued to be lying in the bed. R74 said since the facility does not offer her anything to do, she lays in the bed and sleeps all day. R74 said she seldom attends activities, and no staff members comes to talk to her. R74 said she does not talk to social services or counselors. On 06/06/24 at 9:32 AM V14 (Psychiatric Rehabilitative Services Director) said he just started at the facility two weeks ago. V14 said R74 does not attend any groups. V14 said the last time R74 attended a group session was in February 2024. V14 said he does not have documentation showing R74 refused any programming. V14 said R74 has not been invited to groups or have been seen by the psychologist. V14 said R74 does not receive any outside services. V14 said residents with psychiatric diagnoses should not lay in bed all day and should receive services from the psychologist. All residents should be involved in counseling, programs, or group. V14 said residents in the facility should attend groups or 1:1 counseling. The social services department should invite residents to group and provide 1:1 counseling to residents. V14 said the facility did not have a policy for groups and therapy. R74 was [AGE] years old. R74 was admitted to the facility on [DATE] with multiple diagnoses which included schizophrenia, generalized anxiety disorder, Alzheimer's Disease with early onset per the face sheet. R74's MDS (Minimum Data Set) dated 05/03/24 showed R74 was cognitively intact. The same MDS showed R74 required supervision or touching assistance with all ADL's (Activities of Daily Living). R74's PASRR (Preadmission Screening and Resident Review) II dated 08/29/23 showed R74 was eligible for nursing facility placement. The same screening showed R74 required the following rehabilitative services: 1) Consistent implementation during the resident's daily routine and across settings, of systemic plans which are designed to change inappropriate behaviors. 2) Provision of a structured environment for those individuals who are determined to need such structure (e.g., structured socialization activities to diminish tendencies toward isolation and withdrawal). 3) Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. 4) Individual, group, and family psychotherapy. R74's social services progress notes from 01/29/24-06/06/24 were reviewed. On 02/07/24 and 02/12/24 R74 had 1:1 anger management session provided by the counselor. No other documentation regarding group or 1:1 found in R74's EMR (Electronic Medical Record). R74's psychosocial care plans initiated 05/02/23 showed interventions: to encourage participation in activities and psychosocial group, re-educate and counsel resident on the benefits of attending/being compliant with psychosocial programming, remind resident of time/dates of programs and provide with a schedule as applicable.

Based on interview and record review the facility failed to respect residents' right to make choices about their diet. This applies to 3 of 3 residents (R47, R57 and R101) in a sample of 28 residents. Findings include: On 6/4/24 at 12:43 PM during lunch resident were observed eating a plain turkey burger with cheese, a few tater tots, and a cup of shredded pineapple. 1. R47 admitted to the facility on [DATE]. R47 has diagnoses that includes schizophrenia, prediabetes, iron deficiency anemia, obesity, hypertensive heart disease and bipolar disorder. R47's current Physician order is no added salt diet regular thin liquids, milk with all meals per resident's request. R47's physician orders do not include a caloric limit or order limiting food intake. R47's MDS (Minimum Data Set) dated 5/21/24 shows he is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. On 6/4/24 at12:43 PM, R47 stated he is not given extra food when he asks for it. R47 stated residents aren't allowed extra food unless they have double portions ordered. 2. R57 admitted to the facility on [DATE]. R57 has diagnoses that includes major depressive disorder, hyperlipidemia, type 2 diabetes, obesity, hypokalemia, alcohol abuse, anxiety, migraines, and hypertensive heart disease. R57's physician diet order is no added salt no concentrated sweets regular texture, thin liquids. R57's physician orders do not include a caloric limit or order limiting food intake. R57's MDS (Minimum Data Set) dated 4/1/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. On 6/4/24 at12:43 PM, R57 stated she can't get second helpings of food if she is still hungry. R57 stated the meals are not filling. R57 stated when you're in a place like this there is usually nothing to look forward to except a good meal. 3. R101 admitted to the facility on [DATE] with diagnoses that includes major depressive disorder, gastro-esophageal reflux disease, basal cell carcinoma, hypertensive heart disease, chronic rhinitis, and suicidal ideations. R101 physician diet order is no added salt regular texture, regular thin liquids. R101's physician orders do not include a caloric limit or an order limiting food intake. R101's MDS (Minimum Data Set) dated 5/7/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. On 6/4/24 at12:43 PM, R101 stated this isn't enough food for a child. R101 stated residents are not allowed to get second helpings of food. R101 stated she would get food from the vending machine when she gets hungry, but she did not have money for the vending machine, On 6/04/24 at 1:28 PM, V12 Dietary Aide stated there are no second helpings served to residents even if there is extra. Only resident that are on double portions are given extra food. On 6/04/24 at 1:28 PM, V9 Dietary Manager stated there are no second helpings for anyone that does not have double portions ordered. On 6/4/24 at 1:57 PM, V13 CNA (Certified Nursing Assistant) stated only residents that get double portions receive extra food. All other residents receive a single serving of their meal and are not given second helpings. On 6/6/24 at 2:09 PM, V1 Administrator stated If residents are still hungry, they will be provided a second helping. If there isn't enough for seconds, we can give them something else to eat. The facility did not provide a policy regarding resident meal choices and restrictions.

Based on observation, interview, and record review the facility failed to store and label medications properly. This applies to 1 of 1 resident (R48) reviewed for medication storage in the sample of 28. The findings include: On 06/05/24 at 9:00 AM The medication storage cabinet located inside of the nursing office contained a clear storage bag. R48 had three medications stored in the bag. The medications included: 1) Terconazole Cream 0.4% with directions to insert one applicator vaginally at bedtime until 06/01/24. The cream did not have a cap on it, and there was one applicator left in the box. 2) Ketoconazole shampoo 2% and 3) Albuterol Sulfate 0.083%. The medications were not stored in separate bags. The clear storage bag was not labeled. On 06/05/24 at 9:15 AM V2 (Director of Nursing) stated R48's vaginal medication was completed on 06/01/24 but the shampoo and nebulizer solution were still an active order. V2 stated the vaginal medication should not be stored with any other medications. V2 stated medications that residents take by mouth or inhalation should be separate from vaginal medications. V2 stated medications stored in bags should be labeled. R48 was [AGE] years old. R48 was admitted to the facility on [DATE] with multiple diagnoses which included schizophrenia, chronic obstructive pulmonary disease, and candidiasis of skin and nail. R48's order summary showed R48 was ordered Terconazole Vaginal Cream 0.4% on 05/24/24 and completed on 06/01/24. R48's current physician orders showed Albuterol Sulfate Inhalation Nebulization Solution and Ketoconazole External Shampoo 2%. The facility's Medication Storage Policy dated 03/2021 showed: Guideline- the facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines. Procedure- 4) Medications that have a different route from oral are kept separated and when appropriate in labeled and dated bags in the cabinets. 8) Discontinued medications are disposed of per facility policy.

Based on interview and record review the facility failed to invite residents to their interdisciplinary care plan meeting. This applies to 2 of 2 residents (R21 and R76) reviewed for care planning in a sample of 28 residents. Findings include: 1. R21 admitted to the facility on [DATE]. R21 has diagnoses that includes schizophrenia, venous insufficiency, gastro-esophageal reflux disease, hypertensive heart disease, hyperlipidemia, peripheral vascular disease, osteoarthritis, scoliosis, osteoporosis, and bipolar disorder. R21 MDS (Minimum Data Set) dated 5/1/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. R21's care plan dated 5/13/24 states the residents demonstrate strong activity participation as evidence by joining a variety of group programs, actively participating in, and supporting resident council. On 6/6/24 at 10:45 AM, R21 stated she did not remember the last time she was invited to a care plan meeting. 2. R76 readmitted to the facility on [DATE]. R76 has diagnoses that includes paranoid schizophrenia, obesity, type 2 diabetes, dorsalgia, gastro-esophageal reflux disease and vitamin d deficiency. R76's MDS (Minimum Data Set) dated 4/26/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. On 6/4/24 at 11:01 AM, R76 stated she did not know anything about care plan meetings and had not been invited to any. R76 stated it would be a good idea to participate in her care plan meetings. On 6/6/24 at 1:48 PM, V11 MDS Coordinator stated R21 and R76 have not been present during their interdisciplinary care plan meetings. V11 stated there is no documentation of R21 or R76 being invited to their care plan meetings. V11 stated there is no documentation of R21 or R76 declining to participate in their care plan meetings. On 6/6/24 at 2:09 PM, V1 Administrator stated residents should be invited to their care plan meetings, so they know what is going on with them and their plan of care. V1 stated there should be documentation they were invited to their care plan. The facility policy Care Plan Development dated 3/2021 states the facility's Interdisciplinary team, in consultation with the resident and his/her representative, develops and implements a person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to follow a physician's order for 1 resident (R92) in a sample of 27. Findings include: R92 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including schizophrenia, type 2 diabetes & osteoarthritis. On 06/04/24 at 11:13 AM, R92 was observed in her room with no braces on her wrist. There were 2 braces observed on her chair in her room at that time. R92 stated she wears braces on her wrists, but no one will come to help her to put it on. R92 stated, I can't put it on myself. The CNAs (Certified Nurse's Assistants) don't come to help put it on. I feel I should get the same help as everyone else, and I don't. R92 was observed crying as she was speaking. R92 said They know I have to wear the braces every day and that they are to put them on me, and they don't come. R92's 3/7/24 MDS section C showed that R92 cognition is intact & section GG Personal Hygiene showed that R92 needs substantial to maximal assistance. On 6/06/24 at 12:42 PM, R92's progress notes were reviewed for last 30 days and no notes were observed for refusing care. R92's Task ADL care 30 day look back from 5/8/24 to 6/6/24 showed no documentation of refusal for ADL care. R92's 20 day look back for behavior monitoring and interventions from 5/8/24 through 6/6/24 showed no behaviors observed. R92's 5/31/24 physician order showed, Bilateral volar wrist braces for wrist osteoarthritis. May take the brace off for bathing, eating and for breaks as needed. Avoid axial loading and heavy lifting with wrist every shift for Wrist Osteoarthritis. On 06/06/24 at 02:33 PM, V2 DON (Director of Nursing) stated that if a resident has an order for braces on their wrist and they ask staff to put them on staff should put them on. V2 said that staff should ensure that residents braces are on them. On 06/06/24 at 10:54 AM, V1 (Administrator) said that if a resident has an order for braces on their wrist, they should have them on. V1 stated that if a resident asks staff to put the braces on, the staff should put them on. The facility's Physician Orders-verbal and Fax (3/2021) showed under Procedure: Follow through with the orders as required.

Based on observation, interview, and record review the facility failed to provide adaptive eating utensils to a resident with upper extremity impairments. This applies to 1 of 1 resident (R5) reviewed for adaptive utensils. The findings include: R5 a [AGE] year-old admitted to the facility on [DATE] with multiple diagnoses which included dementia with behavioral disturbance, pressure ulcer of right buttock, diabetes, hypertensive heart disease, epilepsy, peripheral vascular disease, intellectual disabilities, schizophrenia, chronic obstructive pulmonary disease, and polyosteoarthritis per the face sheet. R5's MDS (Minimum Data Set) dated 03/22/24 showed R5 was cognitively impaired. The same MDS showed R5 had impairments to both upper and lower extremities. On 06/04/24 at 1:05 PM R5 was sitting in the dining room, at the table. R5 was being fed a mechanical soft diet by V16 (Certified Nursing Assistant). R5's meal card provided by the dietary department showed R5 was supposed to have a special spoon with meals. R5 did not have a special spoon during lunch. On 06/06/24 at 9:01 AM R5 was sitting at dining room table eating breakfast. R5 was being fed by V15 (Certified Nursing Assistant). Resident continues to not have the special spoon per the meal card for breakfast. On 06/04/24 at 1:05 PM V16 said R5 feeds himself at times. V6 stated R5 fed himself this morning for breakfast. On 06/06/24 at 1:30 PM V9 (Dietary Manager) stated R5 is fed at times but he can feed himself if he is not wound up. V9 stated R5 has a blue divider plate but does not have special utensils. V9 said when R5 feeds himself, he eats with the regular utensils. V9 stated she has no knowledge of R5 using special utensils and there are none in the kitchen for him. V9 stated R5 may have difficulties feeding himself without the proper eating utensils. On 06/06/24 at 3:22 PM V2 (Director of Nursing) stated he was not aware R5 required the use of an adaptive spoon for meals. V2 said R5 can feed himself. V2 said if the proper utensils are not given to R5, he may not get the proper nutrition and can lose weight. V2 said the kitchen should make sure R5 has the proper eating utensils. V2 said the facility does not have a policy for adaptive utensils, we follow the recommendations of the therapy department. R5's meal card showed a blue plate and a special spoon. R5's dietary care plan initiated 06/03/24 showed adaptive equipment: blue plate and special spoon as an intervention dated 03/22/24.

Based on observation, interview, and record review, the facility failed to ensure that their environmental temperature was comfortable and within acceptable range. This applies to 5 of the 5 residents (R1, R2, R3, R4, R5) reviewed for environmental temperature in the sample of 5. The findings include: On 7/27/23 from 12:32 PM through 3:21 PM, intermittent observation of the facility's environmental temperature was conducted with V4 (Maintenance Director) and V5 (Housekeeping Manager). The facility was warm all over the residents' area such as the dining/day room, A, B, C, D, and E hallways. During the observation on 7/27/23, the following were noted: At 12:32 PM, majority of the residents were in the day/dining room during lunch time. V4 (Maintenance Director) checked the temperature in the different spots of the dining room. The results came out between 82.7 to 84 degrees Fahrenheit (F) despite having a portable air-conditioning fan in one of the corners of the dining area. At 12:59 PM, V4 stated that the humidity is high. The air conditioner is overworking because it's very hot. It was not pumping adequately. V4 also stated that some residents open their windows which affects the flow of cold air. From 12:47 through 1:30 PM, the A, B, C, D, E hallways and random bedrooms were checked for the temperature which showed readings within acceptable ranges, however at 1:15 PM, R1 was in her bedroom. The room was warm and humid. The window was closed. R1 stated that her room was very warm, sometimes it really bothers her. R2 (R1's roommate) came in and stated that their room was very warm and uncomfortable. Additional temperatures were taken at 2:25 PM through 3:30 PM with V5 (Housekeeping Manager). V5 and state representative, checked the air vents as well. Multiple bedrooms were observed with faint warm air coming out from the vents which included bedrooms of R1, R2, R3, R4, and R5. R1's and R2's bedroom had 86.4F, R3's bedroom has 83F, R4's bedroom had 89.2F, and R5's bedroom was 85F. These residents all verbalized that their bedrooms were warm and uncomfortable. At 2:25 PM, R3 was noted coming out of her bedroom. R3 said that there's no air coming out of air conditioning vent. The warm air inside the facility has been going on for the past few days and she was having difficulty sleeping. At 3:45 PM, V3 (Corporate Maintenance) was at the back patio by the exit door, fixing the facility's air conditioning unit. There were some balls of wet dirt on the ground which was removed from the air-conditioning unit. V3 stated that basically it's hot in the day and cool at night because it was running non-stop, the air-conditioner froze up. The staff should have ensured that all windows were closed. There was ice build-up in the air-conditioning unit which blocks the air from getting inside the building. V4 should have checked it this morning for ice formation or ice build-up. Had V4 seen it this morning, he could have defrosted it, allowing the cold air to flow inside the building before the weather became too hot. V3 also said the last time he cleaned it was spring this year. On 7/27/23 at 3:27 PM, V5 (Activity) stated that every resident has different feeling about the environmental temperature and added that some resident's complaint that it was too warm, and some has no complaint. On 7/27/23 at 3:30 PM, V1 (Administrator) stated that there were residents who constantly open their bedroom windows which affects the air temperature circulating inside the building. V3 came to fix the air-conditioner because it was frozen. R1's, R2's, R3's, R4's, and R5's most recent minimum data set (MDS) indicates that they are alert and oriented. The facility was not able to present manufacturer's guidelines on how often they should clean the air-conditioning unit. However, there were balls of wet built-up dirt that was removed when V3 cleaned the air-conditioner. Facility's Daily Air Temperature Policy and Procedure dated 2/2014 indicates: Purpose: To Assure that air temperatures in the facility must maintain comfortable temperature of 71F to 81F.

Based on observation, interview and record review the facility failed to secure hazardous chemicals in a locked storage area in accordance with the facility policy. There were 96 ambulatory residents, all with psychiatric illness with access to the hallway where the chemicals were stored. This failure presented a serious health risk to all 96 residents residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on June 14, 2023, when hazardous chemicals were observed in an unsecured hallway during the environmental tour. On June 14, 2023, at 12:48 PM with V16 (housekeeping supervisor) hazardous chemicals were observed in an unsecured hallway that leads to the kitchen and laundry room. The hallway has an unsecured door with direct access to the main dining room where ambulatory residents gather for meals and activities. The ambulatory residents can easily access the unlocked door and enter the hallway where the chemicals are being stored. V16 staed that t there was no room in the locked storage area to secure the hazardous chemicals. V1 (Administrator) was notified of the Immediate Jeopardy on June 15, 2023, at 12:32 PM. The survey team confirmed by observation, interview, and record review the immediate jeopardy was removed on June 15, 2023, at 5:36PM. Noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: The facility's CMS form 672 (Resident Census and Condition) dated June 12, 2023, showed there are 96 residents who ambulate independently with or without an assistive device and 101 residents with diagnoses of psychiatric illness. The facility identified 34 residents with suicidal ideation. In the sample of 34 residents, 8 reviewed during the survey (R11, R42, R49, R57, R59, R74, R75, R76) identified with suicidal ideation, and were ambulatory. On June 14, 2023, at 12:48 PM with V16 (housekeeping supervisor) hazardous chemicals were observed in an unsecured hallway that leads to the kitchen and laundry room. The hallway has an unsecured door with direct access to the main dining room where ambulatory residents gather for meals and activities. The ambulatory residents can easily access the unlocked door and enter the hallway where the chemicals are being stored. In the unsecured hallway, there were twelve, five -gallon containers of cleaning chemicals sitting on the floor and four housekeeping carts with cleaning chemicals unsecured on top of the carts. Three of the four housekeeping carts did not have locks for the closed compartment. V16 was asked why the hazardous chemicals were being stored in the unsecured hallway. V16 stated there was no more room in the locked storage area for the chemical containers in the hallway. V16 acknowledged the door to the hall was a swing away door, had no lock on the door and the door is accessed from the main dining room. The residents use the main dining room for meals and activities. The door is not monitored, and staff are not present in the area when the kitchen is closed. V16 acknowledged three out of four housekeeping carts parked in the same hallway had missing locks to secure chemicals on the carts. An inventory of the chemical containers on June 14, 2023, at 12:55 PM included: 1. Eight, five-gallon containers of a yellow cleaning solution labeled chlorine additive for laundry and dishwashing. The label had the caution harmful if swallowed. The MSDS (Material Safety Data Sheet) showed the chemical to be corrosive and can cause skin burns and serious eye irritation requires the use of PPE (Personal Protective Equipment) during handling. The chemical is classified as a hazardous chemical as defined by the OSHA (Occupational Safety and Health Administration) hazard communication. 2. Three, five-gallon containers of a dark red cleaning solution labeled as a dish machine cleaning solution. The label had a caution that the chemical was corrosive, can cause skin burns and eye irritation. The MSDS stated keep locked up and harmful if swallowed. The MSDS also showed if direct contact with skin or if ingested could result in severe burns to the skin, mouth and throat, or severe eye irritation. 3. One, five- gallon container of floor cleaner. The label warns of serious eye damage or eye irritation. The MSDS shows keep out of reach of children regarding storage of the chemical. Also cautions the need for using PPE and hand washing when handling. 4. On the top of the housekeeping cart number one, there were two cans of foaming disinfectant spray, a can of glass cleaner and an open, unlabeled container of blue liquid with a brush in the container. V16 (housekeeping supervisor) identified the blue liquid as toilet bowl cleaner. 5. On the top of cart number two, there were two bottles of bleach cleaner and one container of toilet bowl cleaner. 6. On the top of cart number three, there were two cans of foaming disinfectant spray, a container of toilet bowl cleaner and an open, unlabeled container of purple liquid. V17 (housekeeping aide) identified the purple liquid as a cleaner and stated it makes things smell better. According to the MSDS, the foaming disinfectant spray is flammable and could cause serious eye irritation and cautioned to seek medical attention in case of ingestion. The OSHA hazard communication classified the disinfectant spray as a hazardous chemical. The toilet bowl cleaner contains hydrochloric acid and is corrosive to skin, eyes, and ingestion causes irritation or burns to the mouth and throat. The MSDS for the glass cleaner, shows it can be absorbed through the skin, is flammable and requires the use of PPE when handling. The MSDS for the purple cleaner shows it is to be stored in the original container, use PPE when handling, and it can cause skin and eye irritation if comes in direct contact with the skin or the eyes. Residents were observed gathering in small groups and walking throughout the dining room area without staff supervision during the entire survey from June 12 through June 14, 2023. The groups of residents were socializing independently and had to walk near the unsecured door (where the hazardous chemicals were stored) to access the A hallway where residents reside. The water cooler and ice container were also placed a few steps away from the unsecured hallway door and multiple residents were observed getting ice and water from the container. On June 14, 2023, at 2:15 PM, V1 (Administrator) was made aware of the chemicals being stored in the hallway. On June 14, 2023, at 4:04 PM, the same hallway door remained unlocked and the storage room door was propped open using a five- gallon container of blue chemical used for the dish machine. The label contained a caution statement that the chemical was corrosive and an irritant to skin and may cause eye irritation. There was no staff present in the hallway. The facility provided a Housekeeping Policy and Procedure, undated and titled, Housekeeping Carts. The Policy stated, All chemicals and other hazardous items will be kept inside the cart with the cart door locked unless attended or stored in a locked utility room, janitor's closet or storage room. The policy stated, Carts and all equipment will be maintained in a clean condition and good repair at all times. Locks will be maintained in functioning order. The facility presented a plan on June 15, 2023, at 3:49 PM, to remove the immediacy. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan on June 15, 2023, at 5:36 PM and the survey team reviewed and accepted the removal plan. The Immediacy was removed on June 15, 2023, at 5:36PM when the facility took the following actions to remove the immediacy: - Housekeeping carts fitted with locks on June 14, 2023. - The chemicals were removed from the hallway and placed in the locked storage room on June 14, 2023. All chemicals/cleaning/toxic agents will be stored in a locked and secure area when not in use. - The hallway door was locked and a keypad was installed on June 15, 2023. - The chemical storage room was fitted with a new lock on June 15, 2023 - An Emergency QAPI (Quality Assurance Performance Improvement) meeting with Medical Director and all department heads was held on June 15, 2023, regarding survey findings and plan of correction for Immediate Jeopardy component. - Re-assessments of all 32 residents currently in house, were identified for suicidal identification risk (including sampled residents R11, R42, R49, R57, R59, R74, R75, R76) were completed on June 15,2023. The 2 other residents will be reassessed upon their return to the facility. - In-service education and training for the housekeeping supervisor and housekeeping staff was initiated on June 15, 2023. The training included appropriate storage of housekeeping chemicals, locking chemicals in housekeeping carts, keeping unused carts in a locked storage room, and safely storing chemicals. Any staff on vacation will receive their training prior to returning to work. - In-service education for all staff (including nursing, dietary, activities, social services, medical records) was initiated on June 15, 2023. The in-service training included the appropriate storage of housekeeping chemicals, locking of housekeeping carts, storage of housekeeping carts in locked storeroom and keeping any chemicals away from residents. Any staff on vacation will receive their training prior to their return to work. - The Administrator/designee will perform the Quality Assurance monitoring activities including daily audits for 3 months to ensure all housekeeping carts are locked while on unit, stored in locked storeroom when not in use and all chemical/cleaning/toxic agents are stored in a locked and secure area when not in use. - The completed audits will be reviewed by the QA/QI (Quality Assurance /Quality Improvement) committee review and follow up as needed.

Based on observation, interviews and record review the facility failed to ensure that a resident who has a [DIAGNOSES REDACTED]. The facility also failed to consistently monitor and document the activities for a resident who was identified to be needing every 15 minutes monitoring due to inappropriate behavior. This applies to 1 of 3 residents (R1) reviewed for aspiration precaution and 1 of 3 residents (R5) reviewed for behavior. This failure resulted in R1 being found unresponsive with a meat lodged in the airway by the emergency medical personnel on [DATE]. R1 expired at the hospital with the cause of death of anoxic [DIAGNOSES REDACTED] due to aspiration of food bolus. The findings include: 1. R1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R1's speech therapy plan of care dated [DATE] showed that the resident has a [DIAGNOSES REDACTED]. The facility's initial incident report dated [DATE] (7:38 PM, time of incident) showed that R1 was found unresponsive, CPR (cardio pulmonary resuscitation) was initiated, 911 was called and R1 was transferred to the hospital emergency room . R1's physician and family were notified. R1's progress notes dated [DATE] (7:40 PM) showed an incidental note, Notified by CNA (certified nursing assistant) that res. (resident) was not responsive. Found res. in room in w/c (wheelchair)- not responsive- no pulse, resp. (respiration), or b/p (blood pressure). Did finger sweep-nothing felt in mouth. Began CPR. Called 911. 911 arrived & with light & forceps found food lodged deep in res. throat. Removed food. Ambulance left with res. for hospital. Still doing mechanical ventilation. The fire department report dated [DATE] showed that the dispatch was notified at 7:36 PM and that the fire department emergency personnel arrived at the resident at 7:42 PM. The fire department report showed that when the crew arrived at the scene, R1 was unconscious. CPR initiated, staff members of facility stated it was maybe a 5 minute downtime. IV (intravenous) established in the jugular. Pt. (patient) had a golf ball size hunk of meat lodged in her airway, after removal Pt. was intubated and Epi (epinephrine) was pushed. R1 was transferred to the hospital emergency room . R1's quarterly MDS (minimum data set) dated [DATE] showed a BIMS (Brief Interview for Mental Status) score of 11 showing that the resident is moderately impaired with cognition. The same MDS showed that R1 required limited assistance x 1 person physical assist with most of ADL's (activities of daily living) including eating. R1's physician signed POS (physician order [REDACTED]. R1's diet care plan initiated on [DATE] does not address the resident's swallowing problem (dysphagia). R1 ' s diet care plan also does not address the physician's orders [REDACTED]. The facility's dinner menu for [DATE] was Bratwurst sausage, hot dog bun, buttered green peas and fruited gelatin. R1's dietary flow sheet for the month of [DATE] showed that on [DATE], the resident ate 100% of the food served at dinner. In an interview held on [DATE] at 1:20 PM, E12 (dietary supervisor) stated that on [DATE], R1's meal tray ticket indicated a diet of regular, no added salt. E12 showed R1's meal tray ticket that was in place on [DATE]. The meal tray ticket showed that R1 was served regular, no added salt diet, double meat at supper. The same meal tray ticket showed on the bottom, To tuck chin at all meals, small bites/sips, slow rate of intake, upright 90 degrees. Aspiration precautions. In a phone interview held on [DATE] at 3:15 PM, E8 (CNA) stated that she worked on [DATE] during the 3PM - 11PM shift. Per E8, she was not the assigned CNA for R1. E8 stated that she saw R1 sitting at the dining table waiting for dinner to be served, but did not actually see R1 eat or what food the resident had for dinner on [DATE]. In a phone interview held on [DATE] at 2:00 PM, E9 (CNA) stated that she worked on [DATE] during the 3PM - 11PM shift, but was not the assigned CNA for R1. E9 stated that she was near the table where R1 and 6 other residents were eating, during dinner on [DATE]. Per E9, R1 was served two Bratwurst sausage sandwiches for dinner on [DATE] but, E9 does not know how the Bratwurst sandwiches were served to R1. E9 stated that she does not know if R1's Bratwurst sandwiches were cut into small bites or not. Per E9, she saw R1 holding the Bratwurst sandwich and biting into it. R1 finished the 2 Bratwurst sausage sandwiches. In a phone interview held on [DATE] at 10:30 AM, E7 (CNA) stated that she was the assigned staff for R1 on [DATE]. Per E7 she was the meal monitor assigned to R1's table. R1 was served two whole Bratwurst sandwiches and she saw R1 biting into it. R1 ate all the two Bratwurst sandwiches and all the rest of the food that were served for dinner on [DATE]. Per E7, on [DATE] she saw R1 ate the dinner meal but she was not at the same table with R1 to make sure that R1 eat in small bites. E7 stated that after dinner, R1 asked her for an incontinent brief, before R1 wheeled self from the dining room to the room. Per E7, while R1 was leaving the dining area, she did not see R1 pick up any food from any meal tray in the dining room. E7 added that, when the paramedics came to respond on [DATE], she saw the paramedics pulled out a meat from R1's throat. E7 described the meat to be approximately half to an inch long, round in shape like a sausage. In a phone interview held on [DATE] at 1:10 PM, Z1 (primary physician) stated that R1 has [DIAGNOSES REDACTED]. However, since there was an order for [REDACTED]. Z1 stated that he saw R1 at the hospital intensive care unit on [DATE] (day after the incident). R1 did not recover from being unresponsive and was declared brain dead. Z1 stated that because of no activity to R1's brain, the family decided to let go. The Coroner's death investigation report showed that R1 died on [DATE] at the hospital. R1's cause of death was, anoxic [DIAGNOSES REDACTED], due to or as a consequence of aspiration of food bolus. 2) On [DATE] at 10:25 AM R4 stated the following: About 2 weeks ago (R4 was unable to recall exact date of the incident) R5 exposed himself to her (R4). R5 touched R4 in her right thigh and her hair. R5 always say something sexual to her like saying R5 is gonna stick to me. R4 also sneaks in other wings and/or other bedrooms of female peers. R4 reported it to the staff and it seems like nothing is being followed up. Interviews of other residents were on [DATE] from 11:20 AM to 12:20 PM. R8, R9, R10, R11 and R12. At 11:20 AM R8 stated: R5 goes to other people's (residents') room. R5 follows female residents including her (R8) and say inappropriate things to them. R8 added Yes, I'm uncomfortable with R5. He (R5) is intimidating. At 11:25 AM R9 stated, Yes, R5 does follow women around. When I came here the first time, R5 introduced himself and held his hand out then R5 pulled me. R5 did it twice to me. At 11:30 AM R10 stated: R5 follows me around, R5 touches me in the arm and elbow. One time he (R5) grabbed my breast. Yes he goes to other people's room. At 11:40 AM R11 stated: R5 follows me (R11) around, whispering inappropriate words like Let's get together R5 already touched me twice today. I didn't tell anyone because I feel that it's too petty. R5 makes me uncomfortable. At 12:20 PM R12 stated: R5 had touched me in my breast and my butt. R5 touched me twice. R5 makes me uncomfortable. R5 follows me around sometimes. On [DATE] at 12:10 PM, E18 PRSC stated the following: E18 received complaints about R5 with regards to his sexual inappropriateness. Sometimes R5 has delusions that some of the women in the facility has had relationship with R5 in the past. E18 witnessed R5 staring at women and attempting to sneak in their wing. All staff watched R5 and when E18 is in the day area E18 also watched R5. R5 is on a 1:1 close monitoring every 15 minutes as part of the facility's interventions due to his behavior. R5 has been on 1:1 monitoring since April, 2015. After the interview, E18 left his office, came back at around 12:25 PM and presented a copy of 1:1 monitoring every 15 minutes for the month of August. When asked about the monitoring sheets from April to present, E18 later said (which is one and a half hour later around 2PM) he made a mistake with his statement, the 1:1 monitoring started in [DATE] not April. E18 then presented copies of monitoring sheets, which E18 said was from June to [DATE]. However, the monitoring sheets which E18 claimed were for month of [DATE] and [DATE] has no resident's name, no date, no staff signature and no reasons for monitoring. R5 has been observed in the day area/dining room on [DATE] from 11:15 AM to 12:10 PM roaming around without a staff supervision or monitoring him on a 1:1 basis. At 12:30 PM after interviewing E18 in his office, R5 was noted being monitored 1:1 by E20 (CNA/Certified Nursing Assistant). E20 does not have a monitoring sheet with her and at 1:10 PM E20 stated she just took over the monitoring from E21 (CNA), she will log all activities and whereabouts of R5 at the end of the shift. When E20 was asked if she would be able to tell surveyor the exact time, whereabouts and activities of R5's every 15 minutes since she started monitoring him (R5), E20 responded she's not sure. E20 added yes, she should have the monitoring log with her. On [DATE] at 1:15 PM E21 (CNA) stated, E21 monitored R5 on a 1:1 basis from 10:30 AM to 11 AM, then she turned it over to E20. Since the E20 has been monitoring R5 as far as she (E21) knows. When asked to present the copy of her monitoring log for R5, E21 stated she had not log it in yet.

A. Based on observation, interview, and record review, the facility failed to use appropriate methods to prepare and serve potentially hazardous food. This deficient practice resulted in an Immediate Jeopardy (IJ) for three residents (R1, R3, R10) from the sample, and two residents (R24 and R25) outside of the sample who were served unpasteurized fried shell eggs that were not cooked to a safe temperature that would congeal the yolks. R1, R3, R10, R24, and R25 who were served and then consumed the fried eggs, are considered to be in a highly susceptible population; immuno compromised, and at risk for the development of food borne illness (Salmonella). An IJ was identified on 5/16/13 at 8:42am when R1 was observed in the dining room ingesting a fried over easy egg with runny yolk. The box the eggs were packed in were labeled as fresh. The word pasteurized was not on the box. The steam table was observed at 8:47am with 15 fried eggs with runny yolks running all over each other only measured 100 degrees Fahrenheit and an additional serving plate with six fried eggs with runny yolks was sitting on top of the steam table. E1 (Administrator) was notified of the IJ on 5/16/13 at 1:25pm. While the immediacy was removed on 5/16/13 at 3:30pm, the facility remains out of compliance at a Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the education of all dietary staff (Food service manager, cook and dietary aides), regarding egg food preparation. All unpasteurized eggs were discarded by the dietary staff and fried eggs were removed from the menu. E1 (Administrator) stated only pasteurized raw eggs will be purchased starting 5/16/2013. The Findings include: 1. On 5/16/13 at 8:42am residents were observed eating eggs for breakfast. The yolk of the eggs were runny and pooling on the plates. At 8:44am E6 (Dietary manager), was asked what kind of eggs (pasteurized or unpasteurized) were used for breakfast. E6 stated, "I do not know what kind of eggs they are." E7 (Cook) gave the box that the eggs were in to the surveyor. The box was labeled fresh eggs. The word pasteurized was not on the box. At 8:46am E7 was asked to cook an egg like he would for a resident. E7 cracked the egg and poured it on the grill. With the corner of the spatula E7 poked several holes in the yoke and did a little circular motion in the center of the egg. E7 then flipped the egg making the total cooking time three minutes. The egg was immediately placed on a serving plate. E7 inserted a thermometer. The temperature reading reached 110 degrees Fahrenheit. During this time the steam table had a steel tray holding 15 eggs with broken runny yokes running all over the other eggs in the pan. This tray was in the steam table. Right on top of the steam table was a serving plate with six eggs with runny yokes. The temperature obtained at that time was 100 degrees Fahrenheit. E7 stated, "I turned off the steam table 15 minutes ago, approximately 8:25am." It was noted that residents continued to be served breakfast including fried eggs from the steam table. On 5/16/13 at 10:15am, E6 stated, "I took fried eggs off the menu for a few weeks. I just put them back on the menu. We only use pasteurized eggs. When asked how to fry an egg, E6 stated that once the egg is cracked, the egg would be put on the grill. When the white gets hard I would flip it." E6 did not know what temperature to cook the egg to. On 5/16/13 at 12:15pm during a phone interview Z1 (Order Technician from the Food Service Company) stated "Item number 6 that was ordered on [DATE] are unpasteurized eggs." On 5/16/13 at 10:02 am E16 (Registered Dietitian) that consults with the facility stated, that eggs should be cooked to 145 degrees Fahrenheit if given directly to the resident, and 155 degrees Fahrenheit if it is going to the steam table. The facility should only use pasteurized eggs. E16 was not aware that the facility uses unpasteurized eggs. On 5/16/13 at 10:35am, E7 (Cook) stated, "I cook 20 to 30 eggs at a time. I do not check the temperature of the eggs while they are on the grill. I will check a few once they are in the steam table." E7 was unable to state the difference between pasteurized and unpasteurized eggs. E7 states he fried about 90 eggs and scrambled 15 eggs for breakfast that morning. On 5/16/13 at 10:50am, E8 (Dietary Aide) stated, "I was trained to check the temperature of food on the steam table. I usually check when it is first put in and 30 minutes later. I forgot to check the temperatures today. I have never seen the cook recheck the eggs temperature ever." Instructions from the box containing the eggs instruct the user to, "Raw eggs must be heated to 140 degrees Fahrenheit for at least three and one half minutes." The recipe provided by the facility regarding preparation of scrambled eggs documents "Unpasteurized eggs when cooked to order in response to resident request and to be eaten promptly after cooking shall be cooked to an internal temperature of 145 degrees for 15 seconds; until the white is completely set and the yolk is congealed". The facility policy titled "Egg handling", documented under number seven "Eggs are to be cooked to 145 degrees Fahrenheit if served immediately. Eggs that are to be held prior to food service must be cooked to a minimum of 155 degrees Fahrenheit for 50 seconds." Under number eight it is documented, "Fried or soft cooked eggs may only be served if the egg is pasteurized." R10's medical record includes a [DIAGNOSES REDACTED]. The yolks were runny. I get them a couple of times a week." R3's [DIAGNOSES REDACTED]. On 5/16/13 at 3:30pm in the conference room R3 stated, " I had two eggs for breakfast today. The yolks were runny, that's how I like them. I have fried eggs two to three times a week." R24's [DIAGNOSES REDACTED]. R1's [DIAGNOSES REDACTED]." R25's [DIAGNOSES REDACTED]. I didn't ask for it, I prefer scrambled eggs." Documents provided by the facility document that 75 residents received fried unpasteurized egg on 5/16/13 at 8:42am The 2008 Food Service Sanitation Code state the following: Section 750.180 Cooking Potentially Hazardous Foods a) Raw animal foods, such as eggs, fish, poultry, meat, and food containing these raw animal foods, shall be cooked to heat all parts of the food to the following temperatures and times, except as specified in subsections (b) and (c) of this Section: 1) 145 degrees Fahrenheit (163 degrees Celsius) or above for 15 seconds for: A) Shell eggs that are broken and prepared in response to a consumers's order and for immediate service. 2) For pork and game animals, comminuted fish and meats, injected meats, and shell eggs that are not prepared for immediate service, 155 degrees Fahrenheit (68 degrees Celsius) for 15 seconds. On 5/16/13 the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the immediacy of the situation: 1. All unpasteurized eggs were discarded from facility on 5/16/2013 at 10:00am. Only pasteurized raw eggs will be purchased starting 5/16/2013. 2. Spring/Summer menu's include scrambled eggs and other variations of eggs excluding fried eggs due to the difficulty in maintaining fried egg's internal temperature. Fried eggs will no longer be served at the facility as of May 16, at 10:00am. 3. All dietary staff including dietary manager, cooks and dietary aides were inserviced on 5/16/2013 at 11 am by facility dietitian regarding egg preparation. All remaining dietary staff have been inserviced by consultant dietitian on 5/16/13 at 4 PM. 4. All residents who consumed fried eggs at breakfast on 5/16/13 will be monitored by nursing staff for 72 hrs. This monitoring began at 10:30am on May 16, 2013 until 7-3 shift on May 19, 2013. Vital signs and any changes in condition will be monitored by nursing staff and attending physician will be notified as needed. 5. A Quality Assurance audit form will be started to ensure egg products are served at the proper temperature. Administrator/Designee will conduct audit and any findings will be addressed immediately. This Quality Assurance audit began on May 16, 2013 at 12:00pm. 6. The results of the monitoring completed under this POC are submitted to the QA/QI Committee for review and follow-up. 7. All facility residents will be notified that the facility will no longer be serving fried eggs through resident council meeting on 5/17/2013 at 8:15 A.M.. B. Based on observation, interview, and record review the facility failed to ensure that storage shelves were clean and free from debris, failed to ensure that the freezers, ice machine and dry storage were clean, and failed to defrost food in a safe sanitary manner. This applies to all 112 residents who received meals from the facility's kitchen. The Findings Include: On 5/13/13 at 9:45am upon entering the kitchen by the handwashing sink a steel table with three shelves were observed with debris and spots of white substance that were stuck to the surface. The kitchen floor in general had many areas of debris and dark brown spots that did not move when scraped by the foot. Next to the dishwasher there were two steel carts with debris and black thick substance in the corners. E6, Dietary Manager stated, "This is where we keep the clean dishes. They will have to rewashed these dishes." The steel stand for the mixer had debris on the shelves and the wheels were covered with thick black debris. Another grey cart that was storing clean stainless steel pans per E3 (Maintenance Staff) had debris on all of the three shelves. The steel pans that were being stored also had build up of debris and grease. Freezer #1 had multiple white drips from top to bottom of the outside of the unit. Several small areas of thick brown markings. The shelves inside the unit were dirty. Freezer#2 had dirty shelves and walls. The milk cooler had pooled white substance at the bottom on the floor. The black crates holding the milk cartons have white thick buildup in the grooves of the crates. Inside the cooler were two open boxes of butter patties that were not covered. The oven was heavily soiled with thick build up of black grease. There were areas of thin brown liquid on the bottom of the oven. E6, Dietary Manager stated, "They know better than this. This needs to be cleaned." In the dry storage there are four white plastic bins that store cereal and rice. Two of the four bins were dirty with dark markings on the lids and partially inside the container. On 5/14/13 at 11:45 am on top of the oven were two steel pans with food product in them. There were no labels. E6 stated, "Oh that's supercereal from breakfast. They need to throw this out." The three compartment sink had two red cleaning buckets in sink #1. One bucket had clear water with two dirty cloths inside of the bucket. The other red bucket had dark grey liquid in it. The #2 or middle sink was full one third the way up with a orange liquid with floating debris. #3 sink was full of 5 pound bags of egg product that were frozen. E6, Dietary Manager stated, "We are thawing them out." The sink was full of a clear liquid. There was no running water going into the sink. E6 stated, "I don't know what time they were put in the sink." E6 then turned the faucet on to run water onto the frozen egg product. When asked when the sink was last sanitized E6 stated, "I usually just clean it with steel wool. We do not use the sink for sanitizing anymore." Documentation from the local County Health Department dated 5/11/13 stated that the facility has a history of Thawing meats in stagnant water. An Ice machine was located next to the dietary serving window. There were 2 trays of coffee cups on top of the ice machine for residents to use when getting liquids. These cups were dirty and stained. The scoop for ice was located inside the machine. The handle of the scoop was lying directly on the ice. The interior walls had brown debris on the surface. On the white plastic cube dispenser inside the ice machine there was a white and pink substance caked on the lip of the ice machine. This substance was flaking off onto the ice. A dirty black cart was also by the dietary window serving area. The sleeves on the cart had debris and build up of a black substance in the corner of the shelves. The CMS 672 form titled "Resident Census and Conditions of Residents" dated 5/13/13 documented that 112 residents resided at the facility.