Every finding on record at Harbor Point Skilled Nursing

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. 1. The facility failed to ensure the stove area was cleaned and free of food particles. 2. The facility failed to ensure one deep fryer in the kitchen was kept clean. 3. The facility failed to ensure one of 2 refrigerators in the kitchen was free from expired food products. 4. The facility failed to ensure hot food products were at recommended food temperature These failures could place residents at risk of food-borne illnesses and compromised health conditionsFindings include:Kitchen observation and interviews on 04/14/26 at 8:15AM, revealed- the deep fryers in the kitchen had dark looking grease and brown substances around the deep fryer. Between the deep fryer and the stove were food particles and a dark looking substance. [NAME] A looked at the deep fryer and said the grease was supposed to be changed last week . She said she would change the grease on the deep fryer and clean the kitchen after meal services. She said she was off for the weekend. Observation of one of 2 free standing freezer in the kitchen (vegetables freezers) revealed 2-10-Ibs bag of ready to eat salad in a plastic bag, dated 04/2/26, yellowish looking and saggy. The Dietary Manager looked at the bags and took them out of the refrigerator. The Dietary Manager said he did not check the refrigerator, and the salad was oversight. He looked around the stove and the deep fryer. He said he would have the cooking area cleaned after meal service Observation of lunch meal on 04/15/26 at 12:30 PM revealed lunch was sweet and sour chicken, steamed rice, seasoned carrots and cinnamon apple. The alternate was fried chicken for those who could not eat sweet and sour chicken. The food temperatures were: The sweet and sour chicken was 164- F (degree Fahrenheit), streamed rice was 150 - F, seasoned carrots were 165 F, the Fried chicken was 130 F. when the chicken was cut through, it revealed the chicken had blood. The dietary manager said the chicken was undercooked and took it out of the steam table to reheat. The dietary manager said serving uncooked poultry could lead to food borne illness. During an interview with the Administrator on 04/15/26 at 3:00 PM, she looked at the chicken and closed her eyes. She said the chicken was undercooked. She said undercooked chicken may lead to food poisoning and should not be served. She said she would have in-service with all kitchen staff. During a phone interview with the Regional Dietitian, on 04/17/26 at 11:20 AM, she said all cooked meals should be at a proper temperature from the seam tables. She said cooked poultry should be at least 165 and above . Record review of a sent note from the Cooperate Dietitian revealed The Golden Rule:The USDA emphasizes that meat is safe to eat as long as it has reached the minimum internal temperature (e.g, 165 F for poultry or 145 F. for steaks and roasts). If you've hit those numbers with a food thermometer, that pink shade is just chemistry, not a safety risk.Record review of the facility's policy on kitchen sanitation, dated 10/15/2025, titled Nutrition policies and procedures: revealed Subject: Sanitation & Food Safety, Food and Nutrition ServicesThe DM monitors food safety and sanitation of the Food and Nutrition Department daily. The DM develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. Cleaning tasks are initiated as they are completed. (Refer to sample cleaning schedule).The Sanitation Review is completed monthly by the Dietitian and weekly by the Administrator. The DM completes as needed for educational purposes. The DM provides a cleaning schedule for each area and piece of equipment in the kitchen.

Based on interviews, and record review the facility failed to ensure residents had the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States for 12 of 12 anonymous residents reviewed for resident rights.The facility failed to provide residents the rights to update their personal information and the opportunity to exercise their rights as citizens of the United States.This failure could place residents at risk of isolation and low self-worth.Findings include:During a group meeting on an undisclosed date and undisclosed time, 12 of 12 anonymous residents complained of not being able to exercise their rights as citizens of the United States during the past primary elections and the next coming elections. The Anonymous residents said they always registered to vote but were not able to vote during the past primary election. All said no one had asked them about updating their voting records. eight Eight of the 12 residents said they had a valid voter's registration but had expired during their stay at the facility because the voter's registration was renewed every 12 months. three of 12 residents said the voting center was across the facility but there was no transportation to take them across the stree .During an interview with the Activity Director on [DATE] at 4:00 PM, she said she was not present at the facility during the last primary election, and she was not aware that residents would like to participate in the upcoming election. She said the discussion had not come up during the resident council meetingsDuring an interview with the Facility Social Worker on [DATE] at 2:00 PM, the Social Worker said the discussion came up with the former Activity Director, but nothing was done about the rights to vote. He said the Activity Director was responsible for following up with residents who were eligible to vote and had the proper documentation.During an interview with the Administrator and the DON on [DATE] at 4:30 PM, the Administrator said voting issues were brought up during the time of the Previous Activity Director. The Administrator said the current Activity Director was new and she would work with the current Activity Director to ensure residents were able to accomplish their interest. The Administrator said not allowing residents to exercise their rights may lead to isolation and low self-esteemRecord review of the facility's policy titled Leadership Policies and Procedures Revised 2017 completed [DATE] revealed-Policy:The Facility's staff will support the patient's/resident's right to participate or decline to participate in social, spiritual, or community activities and groups.Procedures:Facility staff:1. Encourages the patient/resident to choose for their abilities, needs and interest the types of activities and social events that they prefer.2. Develops the patient's/resident's activity and social care plans in order for the patient/resident to have an opportunity to choose when, where, and how he/she participates in activities and social events. Activities, social events, and schedules are developed in conjunction with thepatient's/resident's interests, assessment, and plan of care.3. Posts an activity calendar in a prominent place with specific information regarding the schedule for all activity/ recreation programs.4. Provides a private place for patient/resident meetings and groups.5. Individualizes activities available to patients/residents and provides activities for room boundpatients/residents.6. Encourages patients/residents who wish to meet with, organize, or participate in the activities of social, religious, and other community groups, at or away from the facility, to do so.7. Provides a designated staff person responsible for providing assistance and responding to written Procedures.9. Schedules religious services regularly as part of the activities calendar.

Based on interviews and record review the facility failed to provide, Comprehensive assessment, care plan and preferences of each resident, an ongoing program to support resident in their choice of activities both facility's sponsored group and individual activities design to meet the interest and support the physical, mental, and psychosocial well-being of each resident, encourage both independent and interaction in the community for 12 of 12 confidential residents reviewed for activities The facility failed to provide activities to meet the residents' needs and interests on Saturdays and Sundays. This failure could place residents at risk for a decline in quality of life, social and mental psychosocial well-being.Findings includeDuring a confidential group interview with 12 alert and oriented residents on undisclosed date and undisclosed time, it was revealed that there were no activities scheduled for Saturdays and Sundays. All agreed bingo was played almost daily, but there were no incentives that motivated going to the bingo games and there were no planned outing activities for the residents. The residents said the reason for not going out of the facility was due to lack of transportation. The group expressed the need to go out to neighborhood stores and community events from time to time and that had not happened. The group anonymously said, that was because they were told that the facility had no transportation to take them out'. Then group also expressed that there were no activities on weekends. All said they would like some types of event\activities that they could do to keep the day going by.During subsequent rounds and interviews, anonymous residents revealed they played bingo sometimes.During an interview with the Activities Director on 04/14/26 at 2:50 PM, the Activity Director said she worked Monday through Friday from 8:00 AM to 4:30 PM. She said she was off on Saturdays and Sundays. The Activity Director saidShe said she did put out things for the residents just in case they needed activities. She said the church groups did visit sometimes and she was new to the facility.During an interview with the facility Administrator on 04/14/26 at 4:30 PM, she said the Activity Director was new to the facility and the facility did not have an activity director for a while. She said her budget was tight for incentives, but the staff did go out of their way to do things for the residents and sometimes get donations from the community. The Administrator said she was working with the Activity Director to improve the activities for the residents. The Administrator said residents had not gone out as a group for a while due to transportation, because the county bus could only take 2 residents on wheelchair and the facility had no transportation. The Administrator said not providing meaningful activities of interest to residents may not stimulate residents and lead to diminished health conditions. She said she would work with the Activity Director and the residents to plan some activities of interest.

Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident (Resident #61) reviewed for pressure ulcer. LVN A failed to cleanse the peri-wound area of stage 4 pressure ulcers for Resident #61. This failure could place residents at risk for infections, delayed healing, and further decrease in quality of life. Findings include: Record review of Resident #61's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included: intracranial injury with loss of consciousness, cerebrovascular disease (a condition that affects the blood vessels that supplies the brain), Quadriplegia (Paralysis in all four limbs), gastrostomy (feeding tube inserted directly into the stomach allowing for nutrition), tracheostomy (a hole is made in the neck to create a new airway for breathing), muscle wasting, Pressure ulcer of sacrum and right hip. Record review of Resident #61's quarterly MDS, dated [DATE], reflected a BIMS score of zero, which indicated the resident cognition was severely impaired. Section M (Skin Conditions) reflected 2 stage 4 pressure ulcers (most severe pressure ulcer that is a deep wound that extends through all layers of skin and may involve the muscle, tendons, or bone) to right hip and sacrum. Record review of Resident #61's Physician Order, dated 4/6/2026, revealed the following orders description:Daily wound treatment: Clean stage 4 pressure wound to right hip with NS/WC, pat dry, apply collagen sheet pack with half strength Dakin's-soaked gauze and cover with dry dressing daily.Daily wound treatment: Clean stage 4 pressure wound to sacrum with NS/WC pat dry apply collagen sheet pack with a half strength Dakin's-soaked gauze and cover with dry dressings. Record review of Resident #61's Care Plan, dated 10/02/2025, reflected the resident was care planned for risk for pressure injury related to impaired mobility, incontinence, decreased cognition, current pressure injury, and fragile skin. Interventions included following the doctor'swound care orders as needed. Licensed Nurse to complete wound documentation weekly. Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage by cleaning with mild cleansing agents and using skin barrier cream for skin protection. During observation on 4/16/2026 at 10:00 a.m., the wound care nurse (LVN A) was observed performing wound care using aseptic technique. The nurse utilized moistened gauze with wound cleanser to clean the inner aspect of the wound in a circular motion and subsequently used dry gauze to dry the inner wound bed prior to applying Dakin's solution-moistened gauze and a covering dressing. The nurse did not cleanse the peri-wound (surrounding) area of the wound. This practice was observed during treatment of both the stage 4 sacral wound and the stage 4 wound to the right hip, where only the inner wound bed was cleansed and the surrounding peri-wound area was not cleaned prior to application of the dressing. During an interview with LVN A on 4/16/2026 at 12:23 p.m., When asked to describe proper wound care technique, the LVN stated wounds should be cleaned in a circular motion from clean to dirty, inside to outside, identifying the outer area as the peri-wound. She stated she was supposed to clean the inner area of the wound and then the peri wound area. She stated she was not sure if she had cleaned the peri wounds of the pressure ulcer on Resident #61's sacral area and right hip. She stated failure to clean the peri-wound area could result in infection, bacterial contamination, skin breakdown, and delayed wound healing. During an interview with the Facility infection preventionist (LVN C) on 4/16/2026 at 2:10 p.m., she stated while wound care monitoring was not her primary role, she conducted monthly audits in which she observed nursing staff perform wound care to ensure adherence to infection control practices. She stated wounds should be cleaned from the inner wound bed outward to the peri-wound area. She stated wound cleansing should include both the inner wound bed and the peri-wound (surrounding area). She stated failure to cleanse the peri-wound area which could result in infection, worsening of the wound, and delayed healing. She stated staff were expected to perform wound care in accordance with professional standards of practice to promote healing and prevent infection.During an interview with the DON on 4/16/2026 at 2:22 p.m., she stated wounds should be cleaned from clean to dirty, beginning at the inner wound bed and moving outward in a circular motion toward the peri-wound area, in accordance with physician orders. She stated the peri-wound (surrounding area) should be included in the cleansing process. The DON stated failure to cleanse the peri-wound area could result in bacterial contamination, infection, worsening of the wound, increased drainage, increased wound size or depth, and delayed healing. During an interview with the ADON on 4/16/2026 at 2:25 p.m., she stated the wound cleansing process may vary depending on the condition of the wound, which included the presence of drainage and severity, such as a stage 4 pressure ulcer. The ADON stated proper wound care included cleansing the inner wound bed and the peri-wound (surrounding area). She stated the risks associated with failing to cleanse the peri-wound area, could result in bacterial contamination, infection, and worsening of the wound. During an interview with the Administrator on 4/16/2026 at 2:45 p.m., she stated although she was not a nurse, the wound care should be performed using clean-to-dirty technique, the inner wound bed should be cleaned first, and then the surrounding area of the wound. She stated the risks associated with failing to cleanse the surrounding area of a wound, could allow germs to remain and spread into the wound, which could result in the wound worsening and delayed healing. Record review of the facility's policy and procedures on Dressing change wound evaluation, revision date 6/1/2015, reflected in part: Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers.

Based on interview and record review, the facility failed to coordinate the PASRR assessment for specialized services for 1 of 3 residents (Resident #1) reviewed for PASRR coordination and assessment. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #1's specialized services by a specific deadline. This failure could place residents with intellectual and developmental disabilities at risk for not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Finding included: Record review of Resident #1's electronic face sheet dated 07/30/25 reflected he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted of 12/29/23. His diagnoses included Cerebral palsy, dementia, unspecified severity, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder, bipolar disorder (A serious mental illness characterized by extreme mood swings). Essential hypertension (High Blood pressure), Muscle wasting and atrophy, Contracture, right knee, Contracture, left knee, and other lack of coordination., Record review of Resident #1's Annual MDS assessment dated [DATE] reflected Resident #1 was positive for serious mental illness, intellectual disability and other related condition. His cognitive patterns (BIMs) were coded as 9 out of possible 15, which reflected he was moderately impaired on cognition. Record review of Resident #1's care plan updated 05/18/23 with a start date of 05/03/25 reflected Resident #1 has been identified as PASRR Level II related to DX of: ID, Cerebral Palsy and Schizoaffective disorder, and Bipolar type. He will receive additional services through the State PASRR program at this time. Goal Resident will receive all specialized services related to positive PASRR through the next 92 days target date of 05/27/23.Record review of Resident #1's PASRR Comprehensive service plan dated 01/24/25 revealed there was a recommendation for a new custom wheelchair with positioning wedge. All specialized services were agreed on by the IDT team. Review of the Simple LTC-portal history spread sheet dated 04/11/25, reflected the NFSS form was not completed and submitted for customized wheelchair with wedge to PASRR office.During an interview with the MDS coordinator on 07/30/25 at 12:55PM, she said the therapy department usually completed the NFSS form. She said she does not do the NFSS forms.During an interview on 07/30/25 at 1:00PM, the Rehabilitation Director said she submitted the NFSS late because she had hard time getting Resident #1's Physician sign the necessary paperwork. She said the customized wheelchair was provided to Resident #1 about a month ago. She said the NFSS forms had been sent out as requested. She acknowledged that the NFSS was submitted late. During an interview on 07/30/25 at 2:00PM, the Administrator she said she remembered receiving an e-mail for PASRR office but might have overlooked it and would check again. Record review of the facility Provided policy did not address who was responsible for NFSS and time frame for submission.Record review of Facility provided policy titled Social Services, Policies and Procedure: subject: PASARR documentation policy indicated . PASARR CARE PLAN:3. Facility Nursing staff are trained in the roles and responsibilities to ensure the specializedservices are provided.4. Referrals/Notification of Significant Change:A. Facility staff will refer Level II residents and residents with newly evident or potentiallyserious mental disorder, intellectual disability, or a related condition for Level IIResident Review, upon a significant change in status assessment to the local MD or MI agency.5. The facility must notify the state-designated mental health or intellectual disability authoritypromptly when a resident with MD or ID experiences a significant change in mental or physical status.6. Any resident with newly evident or possible serious mental disorder, ID or a related conditionmust be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review.Examples of individuals who may not have previously been identified by PASARR to have MD, ID ora related condition include NOTE: this is not an exhaustive list. (RAI Manual) A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting thepresence of a mental disorder (where dementia is not the primary diagnosis). A resident whose intellectual disability or related condition was not previously identified andevaluated through PASARR. A resident transferred, admitted , or readmitted to a NF following an inpatient psychiatric stayor equally intensive treatment.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 15 of 44 residents ( CR # 1, CR # 2, Resident # 3, Resident # 4, Resident # 5, Resident # 6, Resident # 7, Resident# 8, Resident # 9, Resident # 10, Resident # 11, Resident # 12, Resident # 13, Resident # 14, and Resident # 15) reviewed for pharmacy services. The facility failed to ensure medications that were scheduled three and four times daily were administered at their scheduled times, resulting in medications being administered with only 2-4 hours between doses for Residents (CR # 1, CR# 2, Resident # 3, Resident # 4, Resident #5, Resident # 6, Resident # 7, Resident #8, Resident # 9, Resident # 10, Resident # 11, Resident # 12, Resident # 13, Resident # 14, and Resident # 15). The facility failed to ensure medications were administered timely between 7/22/2024 and 7/31/2024 which resulted in extremely late administration, up to 8 hours, of medications, such as insulin, diuretic, anticonvulsant, anticoagulant, anti-hypertensive, anti-depressive, and hypoglycemia. These failures placed residents at risk of experiencing exacerbation of pain and other health and psychiatric diagnoses, harmful drug to drug interactions, and other serious health related complications from taking prescribed medication after the scheduled times. Findings include: Observation and interview during medication pass with LVN A on 7/31/2024 at 1:00 pm, LVN A stated she passed morning and afternoon medications to 100 hall and 200 hall (approximately 40 residents). Other than the memory care unit. She said that on 7/31/2024 (approximately 6:00 am) she stated that the DON called her and informed her that she would pass medication on 7/31/2024 as MA A would not report to work. She said her shift was from 8:00 am-8:00 pm. She said she does not pass medication. She said she began passing medication on 100 hall at 8:15 am. She said being that she had not passed medication at this facility she was a little slow. She stated that she had given medication to residents on hallway one and she was giving medication to resident on hallway two. LVN A said she still had to pass medications to the residents on 200 hall (ten residents) and all the resident's medication were red on the EMAR at 1:15 pm, indicating they were all late at that time. Observation of the computer screen at that time revealed the medication on each resident's EMAR were highlighted red. LVN A said she was doing her best to administer medication to the residents. She stated that a contractor arrived at 11:00 am to assist with passing medication. CR # 1 Record review of CR # 1's face sheet, undated, revealed a [AGE] year-old male admitted to the facility on [DATE]. CR # 1 was discharged to the community on 7/31/2024 at 9:06 am. CR # 1's diagnoses included: Alcoholic cirrhosis of liver with ascites (a complication of alcoholic liver disease that occurs when fluid builds up in the peritoneal cavity), Other seizures (uncontrolled jerking, loss of unconsciousness), Hypokalemia (blood level low in potassium, anemia ( lack of blood),Hypothyroidism, unspecified ( a condition in which the thyroid gland doesn't produce enough thyroid hormone),hypotension (low blood pressure), Chronic kidney disease, stage 3 (when kidneys are moderately damaged and have difficulty filtering waste and fluid from the blood), Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria, abnormalities of gait and mobility, Cognitive communication deficit, Weakness, Muscle wasting and atrophy, not elsewhere classified, right lower leg, Muscle wasting and atrophy, not elsewhere classified, left lower leg, Dysphagia(difficulty swallowing), oropharyngeal phase, Gastro-esophageal reflux disease without esophagitis, Other recurrent depressive disorders. Record review of CR # 1's MDS, dated [DATE] revealed he rarely/never made himself understood and rarely/never understood others; he had a BIMS score of 13 (cognition is intact) he exhibited behaviors related to rejection of care within 4 to 6 days; he required extensive physical assistance from at least 2 staff for bed mobility and transfers; he required extensive physical assistance from at least one staff for eating and toilet use. Record review of CR #1's Care plan, last revised date 7/1/2024, revealed the following care areas: * CR # 1 was taking antibiotic therapy r/t Encephalopathy (medication Neomycin). Goal included he will receive therapeutic treatment from medication with no complications. Intervention included: a Licensed nurse would monitor for side effects including nausea, dizziness, muscle pain, respiratory distress, digestive upset, decreased cognition and report abnormal findings to physician. *CR # 1 had a diagnosis of GERD. Goal included CR # 1 would be free of gastric pain. Interventions included: medication administered as order, Monitor for side effects. *CR # 1 required the use of diuretic medication r/ t chronic kidney disease. Goal included CR # 1 would not exhibit signs of side effects of complications secondary to diuretic use. Interventions included: Administer medication as ordered by doctor. Monitor for side effects. *CR # 1 had diagnosis of Hypothyroidism. Goal included: CR # 1 will be free of edema, weight gain, and electrolyte imbalance. Interventions included: Administer medication as ordered by doctor. Monitor for side effects. Assess for fluid excess (weight gain, increased P; full/bounding pulse, jugular vein distention, OB, moist cough, rales, rhonchi, wheezing, edema, worsening of edema, increased urinary output, nausea/vomiting; liquid stools, confusion, seizures. *CR # 1 had a diagnosis of Alcoholic cirrhosis of the liver with ascites. Goal included: CR # 1 would not exhibit signs of fluid volume excess. Interventions included: Administer medication as ordered by doctor. Monitor for side effects. Assess for fluid excess (weight gain, increased P; full/bounding pulse, jugular vein distention, OB, moist cough, rales, rhonchi, wheezing, edema, worsening of edema, increased urinary output, nausea/vomiting; liquid stools, confusion, seizures. *CR # 1 had a diagnosis of seizures. Goal included: CR # 1 will not injure self-secondary to seizure disorder. Interventions included: Administer medication as ordered by doctor. If seizure occurs, remove all restrictive clothing and objects of potential harm. Turn head to side to maintain patent airway. *CR # 1 had a diagnosis of chronic kidney disease stage 3. Goal included: CR # 1 will maintain or improve current kidney function. Interventions included: Administer medications and obtain labs per provider order. Notify provider of any change in condition. *CR # 1 had a diagnosis of Hypotension. Goal included: Promote vascular perfusion as evidenced by: no development of blood clot, Blood Pressure is within resident's normal range, and, no occurrence of chest pain. Interventions included: Administer medication as ordered by doctors. Monitor medication/s' effectiveness and watch for severe adverse reaction as needed. Record review of CR # 1's physician's order for July 2024 revealed the following active orders: *Keppra tablet; 500 mg; Give 1 tablet by mouth twice a day ( 10:00 am and 7:00 pm) for seizures, *Lasix (furosemide) tablet; 40 mg give 1 tablet by mouth twice a day (10:00 am and 7:00 pm) for chronic kidney disease stage 3, Levothyroxine tablet; 125 mcg; Give 1 tablet by mouth once a day (6:00 am) for hypothyroidism, *Midrone tablet; 5 mg give 1 tablet by mouth three times a day (10:00 am, 4:00 pm and 10:00 pm) for hypotenson, *Potassium Chloride tablet; ER particles/crystals' 20 mEq; Give 1 tablet by mouth once a day (9:00 am) for hypokalemia, *Neonmycin tablet; 500 mg Give 1 tablet by mouth once a day (9:00 am) for alcoholic cirrhosis of liver with ascites *Spironolactone tablet; 1 tablet by mouth once a day (10:00 am) for alcoholic cirrhosis of liver with ascites. Record review of CR # 1's physician's order for July 31, 2024 at 1;50 pm he was not administered the following medication as scheduled due to POA refused. *Keppra tablet, *Lasix (furosemide), *Levothyroxine, *Midrone, *Potassium Chloride, *Neonmycin, and *Spironolactone. Observation and interview of LVN A on 7/31/2024 at 1:00 p.m., administering Lactulose solution to CR # 1. LVN A said CR #1's POA requested that she give the Lactulose and the remaining medication to include: Keppra, Lasix (furosemide),Levothyroxine, Midrone, Potassium Chloride, Neomycin, and Spironolactone. Observation and Interview with CR# 1 on 7/31/2024 at 1:00 pm revealed the discharge date on the face sheet was inaccurate. CR# 2 Record review of CR # 2's face sheet, undated, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. CR # 2 was discharged to the community on 7/31/2024 at 3:53 am. CR #2's diagnoses included: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side ( partial paralysis on one side of the body) Weakness, , edema(fluid retention), Familial hypercholesterolemia(high cholesterol level), Human immunodeficiency virus [HIV] disease( a virus that attack cells),Type 2 diabetes mellitus without complications ( high blood sugar) Hyperlipidemia(high level of fat in the blood), Hypokalemia (low potassium)Major depressive disorder( mental disorder that involves low mood), Guillain-Barre syndrome( immune system attacks the nerves), hypertension ( high blood pressure). Record review of CR # 2's discharged MDS dated [DATE] revealed he was discharged to home/community; he made decisions regarding task for daily life; he did not have altered level of consciousness; he did not have any indicators of psychosis; he did not exhibit rejection of care; supervision or touching assistance needed for eating; partial or moderate assistance needed for oral and personal hygiene; substantial/maximum assistance needed for toileting hygiene, showering, bathing, lower body dressing, and putting on and taking off footwear. Substantial/maximal assistance for chair/to bed chair transfer, toilet transfer, tub/shower transfer; frequent urine and bowel incontinent. Record review of CR #2's MAR dated 7/28/2024-7/31/2024 reflected the following: 7/28/2024 CR # 2's pulse rate was 73 and blood pressure 129/93 7/29/2024 CR #2's pulse rate was 72 and blood pressure 122/84 7/30/2024 CR # 2's pulse rate was 86 and blood pressure 125/92 Record review of CR # 2's care plan, revised 7/12/2024 revealed the following care areas: *CR # 2 is currently taking Eliquis for history of DVT. Goal included: CR # 2 will have no active bleeding. Intervention included: Administer anticoagulants as ordered; observe for signs of active bleeding (nosebleed, bleeding gums, petechiae, pain in joint and abnormal pain) *CR # 2 receives antidepressant medication R/T history of Depression. Goals included: CR # 2 will be prescribed the lowest effect dose. Interventions included: Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, hypotension, or anticholinergic symptoms. Monitor mood and response to medication. Monitor for effectiveness of medication. Provide medication as ordered. Record review of CR #2's physician's orders for July 2024 revealed the following active orders: *Amlodipine tablet; 10 mg; Give 1 tablet by mouth once a day (10:00 am) for hypertensive heart disease without heart failure *Biktarvy {bictegrav-emtricit-tenofov ala) tablet; 50-200-25 mg; Give 1 tablet by mouth once a day (10:00 am) for immunodefiency virus, *Eliqius tablet; 2.5 mg. Give 1 table twice a day (10:00 am and 5:00 pm) for hemiplegia and hemiparesis * Hydrochlorothiazide tablet; 25 mg, Give 1 tablet once a day (10:00 am) for hyperaldosteronism *Metoprolol tartrate tablet; 50 mg; Give 1 tablet by mouth once a day (10:00 am) for hypertensive heart disease without heart failure. *Pantoprazole tablet; 40 mg; Give 1 tablet by mouth once a day (10:00 am) for hyperaldosteronism *Potassium chloride capsule, extended release; 10 mEq; amt: Give 1 packet by mouth once a day (10:00 am) for hypertensive heart disease without heart failure. Record review of the facility's Medication Administration Compliance Report for 7/31/2024-8/2/2024 revealed the following for CR # 2: *Amlodipine tablet- scheduled daily for 10:00 am was administered at 2:15 pm on 7/31/2024 *Biktarvy tablet- scheduled daily for 10:00 am was administered at 2:16 p m on 7/31/2024 *Eliquis tablet- scheduled daily for 10:00 am was administered at 2:15 pm on 7/31/2024 *Hydrochlorothiazide tablet-scheduled daily for 10:00 am was administered on 2:15 pm on 7/31/2024 *Pantoprazole tablet- scheduled daily for 10:00 am was administered on 2:15 pm on 7/31/2024 *Potassium Chloride capsule-scheduled daily for 10:00 am was administered on 2:15 pm on 7/31/2024 Observation and interview with CR # 2 on 7/31/2024 at 1:20 pm reveals the discharge date on the face sheet was inaccurate. Resident # 3 Record review of Resident # 3's face sheet, undated, revealed a 68year-old male who was admitted to the facility on [DATE]. Resident # 3's diagnoses included: Cerebral palsy (a congenital disorder of movement, muscle, tone or posture), muscle weakness, muscle atrophy (a gradual process that involves loss of muscle tissue), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), schizoaffective disorder (a combination of two mental illnesses schizophrenia and mood disorder). Psychotic disorder (mental disorder characterized by a disconnection from reality), hypertension (high blood pressure) dementia (a group of thinking and social symptoms that interferes with daily functioning) and seizures (uncontrolled jerking and loss of consciousness). Review of Resident # 3's MDS dated [DATE] revealed he is usually understood; he had a BIMS score of 13 (cognition is intact); he did not exhibit behaviors related to rejection of care; he requires extensive assistance for bed mobility, transfer from at least two or more staff; supervision for eating help is required from staff; total dependence for toilet use from at least two or more staff. Review of Resident # 3's care plan, revised on 5/22/2024 revealed the following care area: *Resident # 3 receives antipsychotic medication R/T schizoaffective disorder, bipolar type. Goal included: Resident # 3 will not experience adverse side effects from medication thru the next review date. Interventions included: Administer medications as ordered per doctors and monitor side effects; Assess if the resident's behavioral symptoms present a danger to the resident and/or other, intervene as needed; Attempt gradual dose reductions as needed; monitor resident's behavior and response to medication *Resident # 3 has a diagnosis of Bipolar and Depression. Goals included Resident # 3 will have no unaddressed complication r/t Depression thru the next review date. Interventions included: Administer medication as ordered per doctor. Ensure that consent is obtained prior to administering medication. Monitor for side effects of Antidepressant. Monitor resident for side effects. *Resident # 3 is at risk for injury related to seizure disorder. Goals included Resident # 3 will not injure self-secondary to seizure disorder. Interventions included: Administer medications as ordered. Assess characteristics before, during and after seizure. Order labs as ordered. *Resident # 3 has a diagnosis of hypertension. Goals included: Resident# 3 blood pressure will stay within normal limits and will not have any signs and symptoms hyper/hypotension thru the next review dates. Interventions included: Administer all medications as ordered by doctor. Take and record blood pressure and heart rate before administering hypertensive medications. Record review of Resident # 3's physician's orders for July 2024 revealed the following active mediation orders: *Aricept (donepezil) tablet; 10 mg; Give 1 tablet by mouth at bedtime (8:00 pm) for Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety *Baclofen tablet; 10 mg; Give 1 tablet by mouth three times a day (8:30 am, 2:00 pm and 8:00 pm) for pain * Carbamazepine tablet; 200 mg; Give 1 tablet by mouth twice a day (8:30 am and 8:00 pm) for seizures *Depakote Sprinkles (divalproex capsule; 125 mg, Give 1 capsule by mouth three times a day (8:30 am, 2:00 pm and 8:00 pm) for major depressive disorder * Memantine tablet; 10 mg; Give 1 tablet twice a day (8:30 am and 8:00 pm) for unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety *Seroquel (quetiapine) tablet; 50 mg; Give 1 tablet twice daily (8:30 am and 8:00 pm) for schizoaffective disorder, bipolar. Record review of the facility's Medication Administration Compliance Report for 7/31/2024- 8/2/2024 revealed the following medications on 8/1/24 scheduled for 8:00 p.m., was administered at 10:17 p.m.: *Aricept (donepezil) tablet,- *Baclofen tablet,- * Carbamazepine tablet- *Depakote Sprinkles capsule * Memantine tablet- *Seroquel tablet- Resident # 4 Record review of Resident # 4's face sheet, undated revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 5's diagnoses included: Acute respiratory failure with d (results from inadequate gas exchange by the respiratory system), nontraumatic intracerebral hemorrhage, (bleeding in the brain that is not caused by trauma), Unspecified dementia (a condition where a person has dementia but doesn't have a specific diagnosis), muscle wasting and atrophy (wasting or thinning of muscle mass), weakness, bacterial pneumonia (a type of pneumonia caused by bacterial infection), diabetes mellitus (too much sugar in the blood) and hypertension (high blood pressure). Record review of Resident # 4's care plan revised 7/15/2024 revealed the following care areas: *Resident # 4 has a potential for complications related to pneumonia. Goals include: Resident # 4 will not exhibit signs of pneumonia or complications from pneumonia. Interventions included: Administer Levofloxacin x 5 days. Evaluate/record/report effectiveness and any adverse side effects. Monitor and report emergence of complications. *Resident # 4 has behavior episode AEB. Goals included: Resident # 4 will have a reduction in unwanted mood or behaviors for an increased quality of life. Interventions included: Give medication as ordered monitor for side effects and effectiveness. Notify family of changes. Ensure physical needs are met, Licensed Nurse to assess and treat the resident's description of pain. *Resident # 4 has a history of respiratory failure with trach placement. Goals included: Resident # 4 will not exhibit or develop respiratory distress as evidenced by no shortness of breath, o2 sat at or above 95%. Interventions included: Administer breathing treatments as ordered. Administer medications as ordered. *Resident # 4 has diagnosis of hyperlipidemia and hypertension. Goal included: Promote vascular perfusion as evident by blood pressure is within normal range and no occurrence of chest pain. Intervention included: Administer medications as ordered. Monitor medication effectiveness. *Resident # 4 has a history of CVA intracerebral hemorrhage with left side paralysis. Goal included: Resident # 4 will not develop CVA over the next 90 days. Intervention included: Give medication as ordered by doctor. Monitor for acute changes. *Resident # 4 has a history of diabetes. Goal included: Reduce the risk of complications as evidenced by managing blood sugar level documented under the MAR. Interventions included: Administer medication as ordered. Monitor for signs and symptoms of adverse reactions. Report to doctor as indicated. Monitor blood sugar as ordered. Record review of Resident # 4's physician's orders for July 2024 revealed the following active medication orders: *Lantus U-100 Insulin (insulin glargine) 100 unit/mL solution 15 units Subcutaneous at bedtime (8:00 pm) for type 2 diabetes mellitus with unspecified complications *Acidophilus-Pectin (lactobacillus acdioph-pectin) 75 million cell-100 mg capsule; give 1 capsule gastric tube three times a day every 8 hours (8:00 am, 12:00 pm and 4:00 pm) for gastrostomy status. *Cholestyramine Light (cholestyramine-aspartame) 4-gram powder; give 1 packet gastric tube three times a day, 1 packet in the morning, noon, and evening with meals for hyperlipidemia *Glucotrol XL (glipizide) 2.5 mg tablet extended release 24 hour; Give 1 tablet by mouth once a day (8:00 am) with breakfast for type 2 diabetes mellitus. *Lisinopril-hydrochlorothiazide 20-12.5 mg tablet; Give 1 tablet by mouth twice a day (8:00 am and 4:00 pm) for hypertension. *Metformin 1,000 mg tablet; Give 1 tablet by mouth twice a day with meal (8:00 am and 4:00 pm) for type 2 diabetes mellitus *Metoprolol Tartrate 25 mg tablet; Give 1 tablet gastric tube twice a day (8:00 am and 4:00 pm) for hypertension *Plavix (clopidogrel) 75 mg tablet; Give 1 tablet by mouth once a day (8:00 am) for nontraumatic intracerebral hemorrhage Record review of the facility's Medication Administration Compliance Report: for 7/21/2024-7/27/2024 revealed the following for Resident # 4: *Acidophilus-Pectin (lactobacillus acdioph-pectin) scheduled daily 8:00 am was administered at 9:21 am on 7/25/2024, *Cholestyramine Light (cholestyramine-aspartame) scheduled for 8:00 am was administered at 9:21 am on 7/25/2024, *Glucotrol XL (glipizide)- scheduled for 8:00 am was administered at 9:21 am on 7/25/2024, *Lisinopril-hydrochlorothiazide-scheduled for 8:00 am was administered at 9:21 am on 7/25/2024, *Metformin scheduled for 8:00 am was administered at 9:21 am on 7/25/2024, *Metoprolol Tartrate scheduled for 8:00 am was administered on 9:21 am on 7/25/2024, and *Plavix (clopidogrel) scheduled for 8:00 am was administered at 9:21 am on 7/25/2024. Resident # 5 Record review of Resident #5's face sheet, undated, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included: Dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #5's physician's orders for July 2024 revealed the following active medication order: *Ipratropium Bromide spray non-aerosol; 21 mcg (0.03%) spray; administer 2 sprays; nasal: Give 2 nasal sprays three times a day 10:00 am, 1:00 pm and 6:00 pm) for pulmonary obstructive disorder Record review of Resident # 5's Medication Administration Compliance Report for 7/31/2024-8/2/2024 revealed the following for Resident # 5: *Ipratropium bromide spray-scheduled for 1:00 pm was administered 2:19 pm on 7/31/2024. Resident # 6 Record review of Resident # 6's face sheet, undated revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 6's diagnoses included: Alzheimer's disease (a progressive disease that destroys memory), dementia (a group of thinking and social symptoms that interferes with daily functioning) and localized swelling mass and lump lower limb bilateral. Record review of Resident # 6's MDS dated [DATE] revealed she sometimes made himself understood; he had a BIMS 02 (severe cognitive impairment); he does not exhibit behaviors related to rejection of care; he does not use any mobility devices; he needs supervision for eating; he needs partial/moderate assistance for oral and physical hygiene, toileting, showering, bathing, upper and lower body dressing. Supervision with toilet transfer, tub/shower transfer, frequent urine, and bowel incontinent. Record review of Resident # 6's care plan revised 7/16/2024 revealed the following care areas: *Resident # 6 has cellulitis wound to left great toe. Goal included: Resident # 6 wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained. Interventions included: CNA to inspect skin, especially over bony prominences during bathing and personal care. Encourage fluids to maintain hydration. Wound care as ordered. Record review of Resident # 6's physicians orders for July 2024 revealed the following active medication orders: *Furosemide tablet; 20 mg; Give 1 tablet by mouth once a day (7:00 am-10:00 am) for localized swelling mass and lump limb bilateral. Record review of the facility's Medication Administration Compliance Report for 7/31/2024-8/2/2024 revealed for the following for Resident # 6: *Furosemide tablet- scheduled for 8:00 am and was administered at 11:53 am on 7/31/2024. Resident # 7 Record review of Resident # 7's face sheet, undated, revealed he was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 7's diagnoses included: Pneumonia (infection that inflames air sacs in one or both lungs), Down Syndrome ( a genetic chromosome 21 disorder causing developmental and intellectual delays), muscle weakness, muscle wasting and atrophy, dysphagia(difficulty swallowing), cognitive communication deficit, oropharyngeal phase( voluntary part of swallowing that moves food from the mouth to oropharynx, Generalized anxiety (intense, excessive, and persistent worry and fear), adjustment disorder (mental disorder) and developmental disorder( a group of conditions due to an impairment in physical learning, language or behavior areas). Record review of Resident # 7's MDS dated [DATE] revealed she sometimes made herself understood; there was no BIMS noted; never/rarely make decisions; needed some help self-care and indoor mobility; mobility device used wheelchair; supervision needed for eating; partial/moderate assistance needed for oral hygiene and upper dressing; substantial/maximal assistance needed for toileting, showering and bathing. Record review of Resident# 7's care plan revised 7/26/2024 revealed the following care areas: Resident # 7 has cognitive impairment r/t down syndrome and dementia. Goal included: Resident # 7 is at risk for adverse consequences R/T receiving antidepressant medication for treatment for Depression. Goal included: Resident # 7 will not exhibit signs of drug related side effects or adverse drug reaction thru the next review dates. Interventions included: Assess/record/effectiveness of drug treatment. Monitor and report signs sedation, hypotension, or anticholinergic symptoms. Ensure that consent is received prior to administering medication. Monitor resident's mood and response to medication. Administer medications as ordered per doctor. Record review of Resident # 7's physician orders for July 2024 revealed the following active medication: * Buspirone tablet; 7.5 mg- Give 1 tablet by mouth three times a day (7:00 am-9:00 am, 11:00 am-1:00 pm, and 4:00 pm-6:00 pm) for anxiety disorder, *Divalproex capsule, delayed release sprinkle; 125 mg- Give 2 capsules twice a day (7:00 am-10:00 am and 7:00 pm- 9:00 pm) for mood disorder, and *Escitalopram oxalate solution; 5 mg/5 ml; Give once a day (7:00 am-10:00 am) for anxiety. Review of the facility's Medication Administration Compliance Report for 7/21/2024-7/27/2024 revealed the following: * Buspirone tablet- scheduled daily at 8:00 am and was administered at 10:22 am on 7/26/2024, * Buspirone tablet- scheduled daily at 12:00 pm and was administered at 13:52 pm on 7/26/2024, * Buspirone tablet- scheduled daily at 4:00 pm and was administered at 5:43 pm on 7/26/2024, *Divalproex capsule-scheduled daily at 8:00 am and was administered at 10:22 am on 7/26/2024, and *Escitalopram oxalate solution scheduled daily at 8:00 am and was administered at 8:00 am on 7/26/2024. Resident # 8 Record review of Resident # 8's face sheet, undated, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 8's diagnoses included: Unspecified dementia(a group of thinking and social symptoms that interferes with daily functioning), Vitamin D deficiency ( lack of vitamin D from food and sunlight), Muscle spasm of back( a sudden, involuntary contraction of the back muscles), acute cough, muscle wasting and atrophy, generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), hypokalemia (low potassium), hypertension ( high blood pressure), Alzheimer disease( a progressive disease that destroys memory and other important mental functions). Record review of Resident # 8's physician's orders for July 2024 revealed the following active medication orders: *Neurontin (gabapentin) capsule; 100 mg; Give 2 capsules daily by mouth three times a day (10:00 am, 3:00 pm, and 8:00 pm) for pain, unspecified. This medication was administered at 11:18 am on 7/31/2024. *Amlodipine tablet; 5 mg; Give 1 tablet by mouth once a day (10:00 am) for hypertension. This medication was administered at 11:18 am on 7/31/2024. *Memantine tablet; 10 mg; Give 1 tablet by mouth twice a day (10:00 am and 6:00 pm) for Alzheimer's disease. Resident # 9 Record review of Resident # 9's face sheet, undated, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 9's diagnoses included Parkinsonism (a clinical syndrome characterized by tremors), Type 2 diabetes (high sugar level), swelling, mass and lump lower, bilateral, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident# 9's MDS dated [DATE] he made herself understood; he had a BIMS score of 4 (severe cognitive impairment); he did not exhibit behaviors related to rejection of care; set and clean up assistance needed for eating; partial/moderate assistance needed for oral, toileting and personal hygiene, upper and lower body dressing; supervision needed for toilet transfer, shower and tub transfer. Record review of Resident # 9's care plan, revised 6/19/2024 revealed the following care areas: *Resident # 9 has Parkinson's disease. Goal included: Resident # 9 will remain free of major injuries thru the next review dates. Interventions included: Assure the floor is free of glare, liquids, foreign objects; keep bed in lowest position with brakes locked. *Resident # 9 has diabetes mellitus. Goal included: Resident # 9 will have absence of signs of hypoglycemia and hyperglycemia thru the next review dates. Interventions included: Administer medications as ordered by doctor; monitor blood glucose as ordered per doctor, *Resident # 9 is at risk for adverse consequence R/T receiving antipsychotic medication for treatment of schizoaffective disorder. Goal included: Resident # 9 will not exhibit signs of drug related side effects or adverse drug reaction. Intervention included: Administer antipsychotic as ordered per doctor; monitor resident's behavior and response to medication. Resident # 9 has a diagnosis of bipolar/depression. Goal included: Resident # 9 will have no unaddressed complications r/t Depression thru the next review date. Interventions included: Administer medication as ordered per doctor and monitor for adverse effects; ensure that consent is obtained prior to administering medication; monitor for side effects of antidepressant. Record review of physician's orders for July 2024 revealed active medications: *Carbidopa-levodopa tablet; 25-100 mg; Give one tablet three times a day (8:00 am, 12:00 pm and 4:00 pm) for Parkinsonism, *Furosemide tablet; 20 mg oral; Give two tablets in the morning and one tablet in the afternoon (7:00 am-10:00 am) for

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 23 (100- hall) of 59 residents reviewed for environmental concerns in that: The facility failed to provide a clean shower on 100-hall for the residents. This failure placed residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation on 12/21/2023 at 3:11p.m., revealed CNA B used a code to open the door to the shower room on hall 100. Observation on 12/21/2023 at 3:12p.m., revealed black substance that resembled mold, along the walls at the bottom of the shower. There was black substance at the bottom of the wall near the bathroom door. There was rust on the shower rails. The shower floors were filled with dirt. In an interview on 12/21/2023 at 3:15p.m. CNA D said housekeeping was responsible for cleaning the showers. She said there were no showers in the resident's rooms. She said the shower did not look clean. She said she never told anyone the shower was dirty because she did not think to tell anyone about it. She said the shower was the residents' hygiene and that was how they kept clean. She said she would not want to take a shower in a dirty bathroom so why would the residents. She said housekeeping was at the facility in the morning and the evening. She said having black substance at the bottom of the shower could cause the residents to get sick. In an interview on 12/21/2023 at 1:29p.m. Housekeeping A said she cleaned the restrooms every day. She said 12/20/2023 she noticed the black substance on the floor. She said she started 11/1/2023 and saw the mold on the floor when she started. She said she sprayed Clorox bleach on it. She said Clorox was not the right product to clean mold. She said she needed mold remover. She said she told the Housekeeping Supervisor about the mold, and she told her she would order mold cleaner. She said it was important to remove the mold because it can make the residents sick. She said she cleaned the showers after the CNAs have cleaned the showers. She said CNAs are responsible for cleaning the showers. She said a resident had not complained to her about the showers. She said they need rust remover, but she did not tell the supervisor. She said she did not know why she had not shared that with them. She said for now on they will clean the showers every day. She said when the residents get out of the showers, she will go behind them and clean. In an interview on 12/21/23 at 1:43p.m., the Housekeeping Supervisor said her job duties in housekeeping were to monitor the housekeepers. She said she also participated in cleaning as well. She said she sweeps, mop, clean bathrooms, and the toilets. She said she was recently informed about the black substance in the shower, and the dirtiness of the shower. She said maybe she could have used Tilex which is a bleach cleaner, to get what is possibly mold under control. She said she normally check on the cleanliness of the restrooms a couple of times a day. She said she mainly work on hall 300. She said she checked the restroom this morning, but it had been a day in half since she checked. She said she did not notice the mold the other day. She said infection control and residents being sick could happen because of the mold. She said she would not want to use a dirty restroom. In an interview on 12/21/23 at 1:50p.m., the Maintenance Director said he did maintenance supplies for housekeeping, he maintained the grounds, worked in laundry, completed temperature checks and more. He said there is a check list for the rooms that they have cleaned and will check over what they have completed to make sure staff is doing their job. He said he has not been in the shower room lately. He said there is no excuse, but he usually does not check the showers that often. He said no one has reported to him about the mold or the restroom being dirty. He said he did not notice the rusted shower rail. He said the employees in housekeeping, or the nurses are responsible for reporting to him about cleanliness and mold issues and they did not report the mold or the rusting rails in the restroom. He said sanitation and infection control is important so that it cannot spread bacteria or diseases. Record Review of the facility's policy titled Shower and Tub Room Cleaning revised on 03/2006 read in part . This procedure will remove soap scum, dirt and debris from these areas providing a safe and sanitary place for the patients/residents to bathe. This is a daily routine cleaning procedure. Clean, safe and odor free shower rooms and fixtures. Equipment: small bucket, mop bucket, wringers, brush (1X1 nylon w/handle), measuring cup, putty knife, cleaning cloths, broom, wet mop, and wet floor signs. Supplies: quaternary disinfectant cleaner, spray bottle of diluted disinfectant, glass cleaner, general purpose cleaner, tube/tile cleaner, trash can liners, soap, toilet tissue, and paper towels .

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired food products were discarded. The facility failed to ensure that the oven vent above the cooking stove was free of grease buildup. These failures could place residents at risk for food-borne illness. Findings Included: Observation and interview of the kitchen on [DATE] at 9:00AM, revealed the oven vent hood above one of one cooking stove had grease buildup on the vent hood. The Dietary Manager said she would call the servicing company for cleaning. She looked at the vent hood and said the last time it was clean was June of 2023. Observation [DATE] at 9:05 AM of the dry good s storage revealed 6 cartons of 48 oz of thicken sweetened tea with manufactured date of used by [DATE]. The Dietary Manager said she had just received the products from the food supply company. She took all 6 expired products out of the food pantry. In an interview with the Dietary Manager on [DATE] at 1:00 PM, the Dietary Manager said the grease buildup could be a fire hazard and the expired food products could lead to food poison and food borne illness. Review of the facility policy dated [DATE] titled Nutrition Policies and procedures reflected in part .Subject: Cleaning Vent hoods and filters .Monthly: clean vent hood to prevent accumulation of dirt and grease . And continued review of policy revealed no information on expired dry goods.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 (Resident #23) of 2 residents reviewed for respiratory care, in that: The facility failed to ensure Resident #23 had a physician's order for oxygen (O2). This deficient practice could place residents who used oxygen incorrect or inadequate respiratory support and could result in a decline in health. Findings Included: Record review of Resident #23's Face Sheet (undated) revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #23's diagnoses included moderate persistent asthma (airways became inflamed, narrow and swell produced extra mucus which made it difficult to breath) with acute exacerbation (person's respiratory symptoms significantly worsen), heart failure (chronic condition in which the heart does not pump as well as it should), chronic obstructive pulmonary disease (COPD) (lung disease causing restricted airflow and breathing problem). Record review of Resident #23's Annual Comprehensive MDS assessment dated [DATE] revealed she was assessed as having a BIMS of 12 out of 15 indicting Resident #23 was moderately cognitively impaired. Section B indicted Resident #23 was able to understand others and able to make herself understood. Section I Active Diagnoses indicted Resident #23 had medically complex conditions. Resident #23's active diagnoses included asthma and COPD. Section O did not reveal: Oxygen in use while in the facility. Record review of Resident #23's care plans dated 12/13/2023 revealed: Problem: Resident #23 had a history of COPD and asthma. Goal: Resident #23 will be free of signs and symptoms of respiratory infection thru next review date. Approach: Administer O2 as ordered by physician. Record review of Resident #23's Physician Progress Notes dated 12/15/2023 revealed Resident #23 remained dependent on supplemental O2 at 3 liters (the number the oxygen flow rate was set at) by nasal cannula (device to deliver supplemental oxygen into the nose). Record review of Resident #23's physician order report dated 12/01/2023-12/31/2023 revealed there was no oxygen order. During an observation on 12/19/2023 at 9:00 AM revealed Resident #23 was in bed with oxygen at 3 liters per minute by nasal cannula. During an observation and interview on 12/21/2023 at 11:30 AM revealed Resident # 23 was in bed with oxygen by nasal cannula. Resident #23 stated she used her oxygen and kept it on all the time. During an observation and interview on 12/21/2023 at 12:22 PM revealed LVN S observed Resident #23's oxygen. LVN S stated Resident #23 had oxygen on at 3 liters per minute continuous since she returned from the hospital on 12/05/2023. As the interview continued LVN S reviewed Resident #23's physician's orders. LVN S stated she did not see any physician's order for the oxygen or the oxygen flow rate. LVN S stated the nurse was responsible for monitoring the resident's physicians' orders and oxygen . During an interview and record review on 12/21/2023 at 12:38 PM the Facility Regulatory Specialist reviewed Resident #23's physician's orders. The regulatory specialist stated she did not see any physician's order for oxygen for the resident. She stated the risk for the resident was she could get too much oxygen and have elevated CO2 ) (end product of respirations caused headache, drowsiness, rapid breathing, mental confusion). During an interview and record review on 12/21/2023 at 12:51 PM the DON reviewed Resident #23's physician's orders. The DON stated she did not see any physician's order for oxygen administration. The DON stated the nurse who readmitted the resident from the hospital on 12/05/2023 was responsible for ensuring there was a physician's order for the oxygen. The DON stated each nurse who cared for the resident after her readmission was responsible for monitoring to ensure there was a physician's order for the O2 liter flow. The DON stated the risk of no physician's order for her oxygen was the resident could get too much oxygen. During an interview on 12/21/2023 at 1:36 PM the Administrator stated she expected residents on oxygen to have a physician's order for the oxygen and how many liters it was set to run. The Administrator stated the importance of a physician order was to ensure the oxygen was administered properly. The Administrator stated the nursing staff was responsible for monitoring resident's oxygen and physician's orders. The administrator stated the risk to the resident was respiratory illnesses such as COPD could be made worse. The Administrator state to prevent this in the future we will do chart audits. Interview on 12/21/2023 at approximately 3:00 PM The regulatory specialist provided the Lippincott Nursing Procedures 9th Editions dated 2023 titled oxygen administration. The regulatory specialist stated that was what the facility used for the oxygen policy and procedure. Record review of the Lippincott Nursing Procedures 9th Edition dated 2023 titled Oxygen Administration reflected in part . Implementation verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed .

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #1) of 5 residents reviewed for reporting of alleged violations. The facility failed to report to the state agency, incidents of neglect regarding a possible injury and fracture to the Resident #1's left elbow, after a fall in her room that occurred on 10/14/2023. The possible fracture to the left elbow was not reported to the state until 10/16/2023 which was two days after the incident occurred. This failure could place facility residents at risk of injury of unknown origin, abuse, and neglect. Findings included: Observation on 12/6/23 at 11:04 a.m. with Resident #1, revealed her sitting in a wheelchair near the nurse's station. A CNA pushed her wheelchair into her room. She looked well-groomed and there were no visible injuries on her body. In her room, there was a floor mat on both sides of the bed. The bed was in a low position. Resident #1 was not cable of being interviewed. During an interview on 12/6/2023 at 1:49 p.m. with Resident #1's family member who was also in the room with her, said Resident #1 fell twice in one day. She said one of the falls was due to an anxiety attack. She said the facility notified her of both falls. She said with one of the falls, Resident #1 had an x-ray completed at the hospital for a possible fracture. She said Resident #1 has been at the facility since October 2023. She said she had dementia. She said Resident #1 cannot stand on her own. She said when Resident #1 fell another time, she believes the partial in her mouth cut her gums which was why she was bleeding from the mouth. Record Review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis dementia, psychotic disturbance (a mental disorder characterized by a disconnection from reality), muscle weakness, gastro-esophageal reflux disease without esophagitis (a type of GERD that does not involve inflammation of the esophagus), and anxiety disorder. Record Review of Resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMS score of 02 indicating the resident was severely cognitively impaired. Resident #1 required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, substantial/maximal assistance with upper and lower body dressing, and she was dependent with showering and toileting hygiene. Record Review of the Provider Investigation Report dated 10/16/2023 revealed that the incident occurrent 10/14/2023 at 2:30 a.m. and it was not reported to the state until 10/16/2023 at 9:40 p.m. Record Review of the Provider Investigation Report dated 10/16/2023 revealed, On 10-14-2023 at 2:30 a.m., Resident #1 was found on the floor for the second time of the night shift. The nurse attempted to perform a head-to-toe assessment but Resident #1 was anxious and would not allow the nurse to perform the assessment. Record Review of the Provider Investigation Report revealed, On 10/16/2023 at 8:30 a.m., after seeing the x-ray results, the DON notified the Administrator, Resident #1 had a fall over the weekend and her x-ray results revealed possible left elbow fracture. Record Review of the Intake Investigative worksheet dated 10/16/2023 revealed, The fall was not reported to the Administrator until 9-16-23 at 8:30 a.m., that the x ray revealed a possible fracture of the left elbow. The Administrator said she meant 10-16-2023 and not 9-16-2023. During an interview on 12/6/2023 at 1:54p.m, with the DON, said the incident with Resident #1 was reported to her by LVN A. She said she did not notify the Administrator because she does not call the Administrator at night. She said one of the nurses should have called her. She said the nurse that does the reporting was responsible for reporting it to the Administrator. She said LVN A wrote the incident report, and she was the night nurse. During an interview with the Administrator on 12/6/2023 at 2:00 p.m., said she was told that a resident had fallen with no injury until it was confirmed that there was an injury. She said she talked to staff about reporting in a timely manner. She said the DON reports incidents and falls to the Administrator. She said the nurses might not have known to report it to her. She said the reporting was supposed to be done within 24 hours. She said it was called in late because she was notified about the incident late. She said the nurse was supposed to notify the RP, the Doctor, and the DON and she did. She said the DON will notify her. She said it is important to report any incident in a timely manner because the state requires it, and it was important to conduct the investigation in a timely manner. LVN A was not available to be interviewed because she was not at the facility during the time of the investigation, and she never answered the phone and nor did she return any phone calls to the surveyor. Record Review of the facility's policy titled Leadership Policies and Procedures, (revised 12/2009) read in part .The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. 2. The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident. The facility will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law.

44333 Based on observation, interview and record review, the facility failed to ensure that foods are store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen in that. The facility failed to ensure that foods were sealed, labeled, and dated. The facility failed to ensure that equipment was cleaned and in good operating condition. The facility failed to ensure that kitchen floors were cleaned. The facility failed to ensure that plates with dried food particles were not stored with clean plates. The facility failed to ensure that chipped plates were not stored with unchipped plates. The facility failed to ensure that menu items on the steam table was maintained at 135 degrees F and above. The facility failed to ensure the expired food was not stored with foods that are not expired. The facility failed to ensure that groceries received were not store directly on the floor. The facility failed to ensure that the dish machine had soap and was sanitizing at the proper PPM. An Immediate Jeopardy (IJ) situation was determined to have existed on 04/ ,d+[DATE] at 10:38am. While the IJ was removed on [DATE] at 5:26PM, the facility remained out of compliance at actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the facility's needs to evaluate the effectiveness of the corrective systems. These failures affected all residents who ate foods prepared by the kitchen and placed them at risk of foodborne disease and other illness. Findings included: Observations of the kitchen on [DATE] at 11:00am revealed the following: A bag of onions, and rice and a box of iced tea, were noted directly on the floor. There were undated, unlabeled cookies in a plain zip loc bag, rice, pasta, and frosted flakes. There were containers with rice, and flour opened that were not labeled or dated. Observation of the kitchen floor on [DATE] at 11:05am revealed debris, particles of food, utensils on the kitchen floor. Observation of the refrigerators and freezer in the kitchen on [DATE] at 11:08am revealed the following: A container of eggs, with a used by date of [DATE]. There were containers in the refrigerator that appears to be peaches, one appears to be macaroni and cheese, and sliced meat, that were open, unlabeled, and undated. There was an open sliced cheese not labeled or dated. There was a box with chicken with liquid residue spilling in the refrigerator not labeled or dated and contaminating other food items. There was an open carton of scrambled open carton and undated. There were missing shelfs from the freezers. Observations of the kitchen on [DATE] at 10:20am revealed the following: Debris was noted on the floor. The three-compartment sink was full of dirty dishes, steam table had an accumulation of burnt food particles in the wells and on the top. The sneeze guard had dried food particles on it. The grill has an accumulation of dried food particles on it and the stove had burnt food particles on it. Observation on [DATE] at 2:00pm of the refrigerator in the kitchen opposite the steam table revealed a box of molded rotten tomatoes, one bag of parsley and five bags of spinach with black liquid in the bags. Observation of the facility's kitchen on [DATE] between 10:45am and 12:00pm revealed the following: The hand washing sink beside the grill had brown stains all over it. The grill had an accumulation of burnt food particles on it. The stove top and had burnt food particles and grease on it, the inside of the oven had burnt food particles and grease. The sides of the deep fat fryer and the stove had dried food on them. The grill had an accumulation of burnt food particles on the surface and back splash. The wells of the steam table were black from burnt food particles and the water in the wells was brown. The sneeze guards had dried food particles on them. The shelf under the steam table had food stains and food particles on it. The floor of the kitchen had excess debris on it, food spillage and dirt. Observation on [DATE] at 12:05pm of the operation of the dish machine by Dietary Aide C revealed the litmus paper did not change color on testing to ensure that the dishes were sanitized. Further observation revealed there was no soap in the container that was attached to the dish machine. Dishes from breakfast was observed on the trolley in the dining room not washed. Pots and pans from breakfast were still in the three compartments sink not washed. In an interview with Dietary Aide C on [DATE] at 12:10 she said she was called in to assist the cook because the schedule aide had called in and that was why the dishes were not cleaned. She said they were short staffed. She stated she washed some dishes utilizing the dishwasher that morning. She stated she was not trained on using the dishwasher and she only knew how to turn it on. She stated that if dishes that were not washed properly it could cause residents to get sick due to cross contamination. Observation of the dishwasher on [DATE] at 12:10pm revealed there were two buckets one with liquid soap and liquid sanitizer. The bucket with the soap was crystallized. The tubing from the sanitizer to the dish machine was clogged. Surveyor determined it was clogged/ tubing was not working due to testing the dishwasher for sanitizer with litmus paper and it did not change color which would indicate sanitizer was not being used or getting through the tubing. Observation of the dry storage room on [DATE] at 1:00pm revealed the following: Macaroni, breadcrumbs, rice crispy, corn flakes in plain plastic open not labeled and dated. Grocery was stored directly on the floor not on pallets. Further observation on [DATE] at 1:05pm of the free-standing freezer revealed cookie dough and hash brown open not sealed. Observation of the kitchen's steam table on [DATE] at 1:55pm revealed the following menu items were not at the correct holding temperature: The menu items were green peas at 125 degrees F., chopped pork at 99 degrees F., Pureed peas at 123 degrees F., and Pureed pork meat at 120 degrees F. The surveyor observed Dietary Aide C about to plate items from the steam table. In an interview with Cook D on [DATE] at 1:57 pm he said the reheating was 120 degrees Fahrenheit. At that time, he was asked by the Surveyor if he was in-service on food temperature he said No. The surveyor at that time inform him the menu items needed to be reheated to the correct reheating temperature of 165 degrees Fahrenheit. Observation of meal service on [DATE] at 1:59pm revealed Dietary Aide C removed the food items and reheat them to 165 degrees Fahrenheit after being prompted by the surveyor. Observation on [DATE] at 2:00pm revealed chipped plates stored with unchipped plates. The divided plates had dried food particles in them. The plates were pointed out to Dietary Aide C, and she discarded the chipped plates and return the divided plates to the dish room to be rewashed. Interview on [DATE] at 2:00pm with Dietary Aide C she said that when dishes were washed, they should check them to ensure they were clean and not chipped before they were stored. This she said could prevent cross contamination. In an interview with the Dietician on [DATE] at 12:45pm she stated she comes to the facility on ce month typically on the 3rd week of the month. She stated at that time she reviews the menu, ask for a test tray, and audits the kitchen. She stated the last audit of the kitchen was [DATE]. She stated prior to exiting the facility she reviews the sanitation audit with the administrator in detail and discusses concerns. She stated she follows up the next time she was in the facility. She stated she met with the administrator on [DATE] and discussed the sanitation audit report with the administrator. She stated that the administrator should have addressed the concerns noted in the document. She stated if the dishes were not sanitized it could cause an increased risk of food borne illness. She stated that food that were not properly stored, labeled, and dated could pose a risk to residents as they can consume food that were expired or spoiled which can pose an increased risk of food borne illness. In interview with RVP on [DATE] at 12:00pm, she said that the administrator oversees the facility, and the kitchen as much as she can. She said she received the sanitation report via email, but she did review the sanitation report. She had not been in the kitchen, only to the door. She reported It's between the dietician and the administrator when they review the sanitation report, they discuss how they would solve the issue. She can't confirm what the issues were in March regarding the sanitation report. She stated Administrator oversees the overall operation of the facility. She said she did not expect to be told everything that goes on in the building as that was not her role, as she was the consultant. She said the administrator was the top of the chain at the facility, and she does not overstep her position. She stated she believed the facility was running well but based on this interview she would agree the system the administrator was using was not working. In an interview with Administrator on [DATE] at 2:00pm, she stated a Dietary manager was hired but has not yet started. She stated the facility has been without a dietary manager since the beginning of [DATE]. She stated on Thursday [DATE] she did rounds in the kitchen and observed the cleanliness, food storage but did not take an inventory. She stated on [DATE] the kitchen was clean, and all items were labeled and dated. She stated human resources did rounds on Friday [DATE] in the kitchen as well as ensuring it was clean and food items were stored correctly. She stated she would expect the kitchen to get dirty during service and cleaned daily. She stated that she did not keep a log of her kitchen audits because it was not a regulation. She stated that her audits are by pop ins and the area she audits varies. She stated she reviewed the sanitation report with the dietician and corrected all the issues. She stated she did go a little low on emergency food supply and she ordered more foods on [DATE]. She stated the kitchen currently has adequate shelving. She said the can opener was cleaned off because it was a little dirty and she did not purchase a new one. She stated if the kitchen is unsanitary, it can pose a risk to resident's health and safety due to cross contamination. She said if certain meats were not kept at the right temperature, that could cause residents to get sick. She stated that foods that are not dated or labeled can cause the kitchen staff not able to determine the correct best used by dates. She stated she could not answer to whether everything was dated, labeled and in accordance with professional standards of food service because she had not been back there that day. She stated if dishes were not being sanitized correctly it could cause cross contaminated. In an interview with Human Resource L on [DATE] at 10:00am, she stated she did not complete rounds in the kitchen and that would be the responsibility of the administrator. She stated she did not complete rounds in the kitchen on [DATE]. Observation on [DATE] between 4:45pm and 6:00pm revealed the following: Dirty dishes were noted in the dining room and on the hallway. Three compartment sinks were filled with dirty pans and baking sheets. The kitchen floors had debris, food particles and food spillage. Two dirty plates were observed on the dining table from lunch at 5:00pm. The sneeze guard had dried food particles on it. In an interview on [DATE] at 5:00pm with Dietary Aide G she said that Cook C was the only one working that morning as the aide who was schedule had called in. She said Cook D came in later that morning. She said everything was late and as a result the dishes were not cleaned, and she had to use disposables. She said she came in for her regular shift and was doing her duties. She stated that the three compartment sink was not used to wash or sanitize dishes from breakfast. In an interview on [DATE] Cook D at 6:15pm he stated that the Aide for the morning shift had called in and the cook had to work by himself until he got to work at about 10:30am that morning. He said because he had to help Cook A to set up and get lunch ready, he was behind and did not get a change to clean up. He said he was going to clean the kitchen up and wash the dishes before he leaves that day. In an interview with the RVP on [DATE] at 11:30 she said that there was some breakdown in communication and that was why it took longer than usual to get help that morning. She said the Aide said she send a text and the current management team was not on that text and did not receive the text as a result they were not notified. She said they were unable to get help in a timely manner. She said they were looking at another method of communicating that would include management staff. Observation of the steam table on [DATE] at 12:30pm revealed Cook E sharing lunch. He opens the cooler and without changing his gloves he started plating the food. He took up the breadstick and bend it in half and placed it on the resident's plate. He also used the same gloved hands to fix the food on the tray. An interview was attempted on [DATE] at 12:35pm with the Cook E but he did not respond when he was asked about changing his gloves. At that point he changed his gloves. The Dietary manager at that point discarded the food gave him tong to pick up the breadstick. The Dietary Manager told him at that time to use a tong to pick up ready to eat foods. Observation of the kitchen on [DATE] at 2:45pm revealed the stove was not cleaned it had an accumulation of dried food particles on the stove top. The Oven had an accumulation of grease and burnt food particles on the inside. Grill has an accumulation of grease and burnt to the back splash. Observation of the storage room on [DATE] at 2:55pm revealed foods in the Free-standing freezer were not labeled and dated: A plain plastic bag with steak fries not labeled or dated A box with Folded cheese omelets was opened and not sealed. A box with beef patties opened and not sealed. Fish patties and Pepperoni were in plain plastic bags, and they were not labeled or dated. Observation on [DATE] at 3:04pm of the refrigerator opposite the steam table revealed the following: Mushroom and green onion open not sealed, cheese sauce and apple sauce in plain plastic bag not labeled or dated. Can green peas, mashed potatoes and barbeque sauce, tomato paste, and peaches were not labeled and dated. Cornbread and garlic bread in plain plastic bags were not labeled and dated. In an interview with the Cooperate Dietitian on [DATE] at 3:45pm regarding the issues in the kitchen. She said that she was going to ensure that foods were sealed, dated, and labeled by in servicing the staff on labeling and dating of food items in the dry storage room, cooler and freezer. She also said she will have to do some cleaning. In an interview with the Dietary Manager on [DATE] at 4:00pm she said that she expected the staff to labeled, sealed, and dated all food items. She said she had in-serviced the staff on cleaning of the kitchen floor and the equipment. She said that she was going to ensure that the kitchen was cleaned by Wednesday. In an interview with the RVP on [DATE] at 4:15pm she said she was going to ensure the kitchen was cleaned starting [DATE]. She said that she was checking the kitchen and when she was not available the HR person would sit in for her. She said she was going to talk with the Dietitian so they can come up with a plan to maintain compliance in the kitchen. In an interview with the Dietary Manager on [DATE] at 4:15pm she said it was the expectation of the staff to label, seal, and date all food items when they are opened. She said they are expected to clean the equipment and clean the floor after each meal. She said they will have daily reminder until it becomes a normal routine, and not be reminded of what to do. Record review of the Nutrition Policies and Procedures dated [DATE]: Subject: safe Food Handling: Policy: Food acquisition, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. Procedures: 4. Handle food carefully to avoid contamination with potential harmful debris, such as broken glass or glass chips, sweeping and the like. 5. Dishes, flatware, and glassware are free from chips, cracks, or stain. Food/Beverages Prepared and Served by Facility Staff for Patients or residents. 4. All foods are stored, prepared, and served at temperatures that prevent bacterial growth. Hot foods are maintained at 135 degrees F or higher and cold foods are maintained at 40 or below at point of service. At point of delivery hot foods should be 120 F, cold foods ,d+[DATE] degrees F or per state regulations. 6. Food is served with clean, sanitized utensils. There is no bare hand contact. 7. The food preparation area and utensils used to prepare food are cleaned and sanitized prior to each use, using approved washing and sanitizing techniques. Subject: Sanitation & Food Safety in food and nutrition Services The Nutrition Services Director (NSD) will assume responsibility for food safety and sanitation of the Nutrition Culinary Department 4.The Sanitation Review is completed monthly by the Dietitian and copied to the Administrator. The NSD completes the form at least weekly. 6. The Audit and the action plan are submitted to the administrator and the facility quality improvement coordinator/infection control coordinator. Record review of the sanitation report dated [DATE] revealed a score of 0 (which means it is not up to standard) for the following items: All items covered, labeled, dated. Walls, floors, ceilings, vents, and doors clean. Daily cleaning schedule completed and followed. Can opener clean. Microwave clean. No cross contamination between clean and dirty side. All items air dried. Walls, racks, floors, clean. All carts and racks clean and in good repair. All painted surfaces clean with no chip. Emergency food and supplies available per facility policy and procedure. Comments: Missing shelving from coolers/freezers, order new can opener blade, replace cutting boards, post new cleaning schedule, paint all services with chipped paint, clean and paint ceiling vents. Steam table with food debris inside wells, steam table wells need repair. Dish machine logs, cooler/freezer logs not completed. Record review of facilities sanitation policy revealed that equipment and utensils will be sanitized after each use. A three-compartment sink is to be used for manual, washing, rinsing, and sanitizing utensils and equipment. If chemical sanitization is used it is recommended that the facility, follow the manufactures instructions. The Administrator was notified on [DATE] at 10:30AM an Immediate Jeopardy (IJ) situation was identified due to the above failures. The template was provided at this time. The Plan of Removal was submitted by the facility and was accepted on ,d+[DATE] /2023 at 2:20pm and included: Plan of Removal F812 IJ Ecolab was contacted [DATE] to inspect the dish machine. Ecolab was onsite [DATE] and confirmed the dish machine is working properly and tested . The dishes were washed and sanitized using dishwashing liquid and / or sanitizer on [DATE] Food in the refrigerators, freezers and dry pantry was discarded that was spoiled, undated and unlabeled and on the floor by [DATE] The floor was cleaned to remove the debris. The three compartment is no longer full of dirty dishes. The steam table was cleaned to remove the burnt food particles in the wells. The sneeze guard was cleaned to remove dried food particles. The grill was cleaned to remove dried food particles and the stove was cleaned to remove burnt food particles. This will be completed by [DATE]. The Dietary Departmental Leadership Policy, Sanitation and Food Safety in Food and Nutrition Services, Food service In a Disaster Policy, Food Preferences Diet History Policy, Meal Service for New Patients or Residents, Food Preparation, Menus Policies were reviewed by the Interim Certified Dietary Manager, Administrator, and New Certified Dietary Manager on ,d+[DATE]; ,d+[DATE]; ,d+[DATE]. No revisions were needed. Ecolab onsite [DATE] to confirm dish machine was set up with chemicals. The Interim Certified Dietary Manager was re-educated by the National Director of Nutrition Services as the trainer on [DATE]. The Interim Dietary Manager began working at the facility on [DATE] and was onsite ,d+[DATE]; ,d+[DATE]; ,d+[DATE]. New Certified Dietary Manager started [DATE]. Proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes Labeling, dating, and monitoring refrigerated or frozen food and pantry food items, including, but not limited to leftovers, so it is used by its use-by date, or frozen or discarded Temperatures are critical in preventing foodborne illness. Cooking food to the temperature and for the time specified below will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the resident if the food is eaten promptly after cooking. Low Temperature Dishwasher (chemical sanitization): o Wash -120 degrees - 140 degrees F; and o Final Rinse -50 ppm (parts per million) hypochlorite (chlorine) The dietary staff will be re-educated on the following by the Interim Certified Dietary Manager on [DATE] (date): Proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes Labeling, dating, and monitoring refrigerated or frozen food and food in pantry, including, but not limited to leftovers, so it is used by its use-by date, or frozen or discarded Temperatures are critical in preventing foodborne illness. Cooking food to the temperature and for the time specified below will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the resident if the food is eaten promptly after cooking. Low Temperature Dishwasher (chemical sanitization): o Wash -120 degrees - 140 degrees F; and o Final Rinse and checking of chlorine strips - 50 ppm with each cycle Cleaning schedules for the kitchen we established. Dietary competencies using the skills check protocol from the Food and Nutrition Services Policy Manual will be completed on the dietary staff by the Interim Certified Dietary Manager beginning on [DATE] and completed by [DATE]. This education and competencies will be completed by [DATE]. Any member of dietary staff not receiving this information by this date will receive prior to next scheduled shift The Interim Certified Dietary Manager/designee will make rounds in the kitchen 3 times daily for 5 days to validate kitchen sanitation and food storage using the Sanitation Rounds tool and validate proper dishwashing technique and appropriate food temperatures, the 3 X weekly for 4 weeks then weekly thereafter starting [DATE] New Certified Dietary Manager will receive training regarding cleaning schedules, Emergency supplies/food, and sanitation on [DATE] by Interim Certified Dietary Manager. The Regional [NAME] President of Operations will oversee compliance of this plan. Regional VP/designee will complete sanitation inspection of the kitchen weekly effective [DATE]. The Medical Director was notified of the Immediate Jeopardy and the contents of the plan of removal on [DATE]. An Ad Hoc (when necessary or needed) Quality Assurance Performance Improvement meeting was held on [DATE] to review contents of this plan. Surveyor Verification of Plan of Removal was as follows: Record review of in-service records dated [DATE] -[DATE] revealed that the Dietary Manager, Cooks and Dietary Aides were in-serviced on proper storage of leftovers, emergency supplies, food safety, food temperature, dish machine, sealed, labeling, and dating of food and appropriate liquids for pureed diet. Observation on [DATE] at 5:00pm of the dish machine located in the kitchen revealed, the dish machine was working and the litmus paper changed color indicating that the sanitizer was present. Observation on [DATE] at 11:00am of the Kitchen revealed food iwas dated, labeled, sealed and stored appropriately. Kitchen Observed clean. In an interview with Cook D on [DATE] at 11:00am she stated he was in-serviced on kitchen sanitization, food temperature, storage of left over and dating and labeling of foods. The staff was able to demonstrate understanding of training. Interview conducted with Cook C on [DATE] at 1:45pm, revealed he was in-serviced on sanitizing of dishes, pots and pans, food storage, food temperature, dating and labeling of foods. The staff was able to demonstrate understanding of the training. In an interview with Cook D on [DATE] at 2:00pm he stated he was in-serviced on kitchen sanitization, food temperature, storage of left over and dating and labeling of foods. The staff was able to demonstrate understanding of training. In an interview with Dietary Aide G on [DATE] at 1:55pm she stated she was in-serviced on kitchen sanitization, the dish machine, food temperature, storage of left over and dating and labeling of foods. The staff was able to demonstrate understanding of training. In an interview on [DATE] at 4:30pm with the RVP she said they were doing kitchen checks had three time a day for five days and then two time and then once a day until the facility complies and all staff are trained. She said they will be doing weekly and random audits to ensure continued compliance. In an interview with the Dietitian on [DATE] at 3:45PM she said that she was going to ensure that foods were dated and labeled. She said she will have to in-service the staff on labeling and dating of food items in the cooler and freezer. She also said she will have to do some cleaning. In an interview with the Dietary Manager on [DATE] at 4:00pm she said that expectation of the staff was to label, sealed and dated all food items. She said had in-serviced the staff on cleaning of the kitchen floor and the equipment. She said that she was going to ensure that the kitchen was kept clean all the time and will always be complying. The RVP was notified that the IJ was lowered on [DATE] at 5:26pm. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility needing more time to monitor the plan of correction's effectiveness.

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, staff, and visitors for (59 of 61 residents) residing in the facility and having meals prepared from the only kitchen, and for the staff and residents in the building during gas leak. The Administrator failed to immediately take action when staff and residents reported a smell of gas in the facility for 3 days. The facility administration failed to ensure sufficient and replenished food supply for residents, proper storage, preparation, distribution and serving of food in accordance with professional standards of food safety in the absence of a Dietary Manager. The facility administration failed to ensure the kitchen was a sanitary work environment. The facility administration failed to have an effective system in place to ensure sufficient and routine replenishment of food for all residents. The facility administration failed to have a trained Dietary manager on staff to supervise staff, ensure sanitary work environment and ensure balanced meals were being provided to residents at assigned mealtimes. The facility administration failed to provide approved and adequate substitutions. The facility administration failed to have an effective system in place to ensure food was properly stored and that expired or spoiled food items were discarded. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:58 p.m. While the IJ was removed on [DATE] at 4:13 p.m., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. A second Immediate Jeopardy (IJ) situation was determined to have existed on [DATE] at 10:38am. While the IJ was removed on [DATE] at 5:26PM, the facility remained out of compliance at actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the facility's needs to evaluate the effectiveness of the corrective systems These failures placed all residents, staff, and visitors at risk of getting sick due to prolonged exposure to gas fumes and/or carbon monoxide and at risk of food borne illness. Findings include: Record review of public record request # PIR-,d+[DATE] on [DATE], revealed that Incident # 23002345 stated the FD was dispatched to the facility due to a 911 call concerning smell of gas inside. Fire Chief B was the reporter. It read in part on [DATE], E16 dispatched emergency traffic for smell of smoke or gas. upon arrival to scene to a single-story nursing home nothing was showing, and investigation commenced. once inside we were directed to the end of the 100 hall. Halfway down the hallway CO readings began to read 31 ppm. The reading continued to be reading between 18 and 30ppm in the end corridor. nursing staff was instructed to move residence out of Hall 100. All rooms and halls were investigated with 5 gas monitoring. Boiler room was noticed to have furnace that when turned on readings reached 700ppm of CO. (31ppm and 700 ppm indicates how many parts of carbon dioxide there is in one million parts of air). Maintenance was informed of this leak and gas supply was then turned off. maintenance informed us that plumbers would fix the leak tomorrow. the 100 hall was then ventilated until CO readings consistently maintained O ppm. End of call. Further review of the incident report revealed that there were four firemen on the scene. They were at the facility from 17:13:47(5:13 p.m.) to 18:39:01 (6:39 p.m.). Observation of the Fire Department Body camera dated [DATE] revealed: 17:25 (5:25 p.m.) Body cam #3: entered front door of facility, asked staff about kitchen, or any gas hook ups. Staff reported not knowing anything about the building. 17:25 (5:25 p.m.)- entered 100 hall. A staff stated to FD they had to raise a resident's window (this was near the end of hall, room [ROOM NUMBER] seen on video) 17:26 (5:26 p.m.) Resident on hall in wheelchair traveling down hall, heard FD stated reading of CO at 30 ppm. Then stated a big spike in the reading over there on the CO (the FD is at the back on 100 hall near therapy door) 17: 33 (5:33 p.m.) observed staff go into room [ROOM NUMBER] to assist resident 17:35 (5:35 p.m.) Observed resident in wheelchair on hall 100 near 106 17:46 (5:46 p.m.) heard a resident on 200 hall tell FD yesterday the gas smell was strong 17:49 (5:49 p.m.) staff ask FD if fire truck was in the front, he said yes, she was seen on her phone 17: 49 (5:49 p.m.) FD states maintenance said this happened about a week ago 17: 49 (5:49 p.m.) FD explained to staff they are getting readings of high CO levels but can't find where it is coming from. Staff heard on phone reporting to somewhere that there are high CO levels. 17:50 (5:50 p.m.) staff telling staff let's move residents 17:52 (5:52 p.m.)- 3 staff standing on 100 hall, not moving residents 17:53 (5:53 p.m.) staff comes to FD and states: I don't know what's going on, the administrator does not want to admit that there is high CO in the building do you want to talk to her? FD responded I don't care what she admits to. Staff dials a number and gives phone to FD- he said he was with FD, and he says one of your nurses said you might want to talk to me. He says to the person on the phone that they told staff to clear out the hall where they are getting CO reading and, clearing out the hallway was an immediate thing. 17:56 (5:56 p.m.) confirmed with staff that administrator was told to clear out that hallway, explains to staff that if they cannot find the leak and isolate the leak then they cannot let them stay operating and would have to shut the building down. Explained if fire started over here (100 hall) it could impact the other side of building. 18:06 (6:06 p.m.) FD says its strong reading going up and up 50 to 55, to 75. 18:07 (6:07 p.m.) shut off valve to gas line and started opening windows and doors. FD upset the maintenance saying that had a gas leak a week ago and didn't say anything. 18:09 (6:09 p.m.) FD stated every time that thing (referring to the furnace or hot water heater) would kick on they would have the CO emitted. Says probably been going on a while. Staff requested name and phone number in case she gets terminated. FD explained to her she was doing what they asked her to do. 18:12 (6:12 p.m.) FD moved outside stating it wasn't good to be standing around it. 18:19 (6:19 p.m.)- staff approached FD and asked about moving residents. FD stated it was recommended to move the patients. Staff Requested FD to call administrator, FD stated he already called her. Staff stated that she (person on the phone) told one of the nurses to not move the patients. FD said to tell her the other option is to have ambulances come and move all the patients. Explained they could get CO poisoning. 18:20 (6:20 p.m.) resident seen on 100 hall and FD told resident to go the other way. FD explained to nurses what carbon monoxide poisoning is. A Nurse told another nurse to call ADON- he said he got off phone with the assistant and he was told that the assistant said to keep the residents in the room. FD was saying it was very serious. And it wasn't up to the nurse, it was FD decision. Nurse called the administrator, administrator did not answer, and she left a message. FD told them to move residents again. FD said administrator texted and said she was driving; she didn't answer the phone. 18:23 (6:23 p.m.) staff started moving residents. FD stated that he already talked to the lady to move residents about 30 minutes ago. FD says it smells terrible almost like it had been leaking for a year. 18:35 (6:35 p.m.) FD explained to staff that they killed the gas. End of video An interview was conducted with Fire Chief A of the local fire department (FD) on [DATE] at 9:24 a.m., revealed him to state that A shift responded to an anonymous 911 call from Solidago Nursing and Rehab on [DATE]. He stated that they found the area near the lobby/nursing station had a carbon monoxide reading of 35 parts per million (PPM) on their 5-gas monitoring device which samples air and is used to detect oxygen (O2), carbon monoxide (CO), hydrogen sulfide (H2S ppm) and volatile organic compounds (VOC ppm) and low explosives level (LEL). He said that they must always do an air sample when there is complaint of a gas smell. As they moved further down Hall 100 and entered the boiler room located at the back of the building (where Halls 100 and 500 intersect), they found that the reading was 700 parts per million of carbon monoxide. Chief C informed RN V that they needed to evacuate the residents from Hall 100. He said that Chief C talked to the Administrator and maintenance director and when he noticed that staff were not moving residents off the hall, he announced that he would shut the whole building down. He stated that they decided to shut the main gas line down because natural gas not burning properly created the carbon monoxide. So, cutting the gas supply would eliminate any carbon monoxide because even a small amount of carbon monoxide can be harmful to the residents. He said they opened doors and allowed the carbon monoxide to dissipate before they left the facility. FD recommended that the facility contact a certified plumber. FD stated some symptoms of carbon monoxide poisoning included dizziness, headaches, shortness of breath, and loss of consciousness. An interview was conducted with LVN U on [DATE] at 3:25pm, she stated that she worked on [DATE]. She said that someone from Solidago called the fire department anonymously to report the gas smell. She said that she did smell gas in the building on or about [DATE] when she returned from being off on [DATE]. She said that she checked with the residents down Hall 100 and most said that they could not smell gas. She said that Resident #2 mentioned that he could smell gas and she heard from other staff (unwilling to provide names) that they had been smelling gas for about 1 week. She said that she did not report it to the Administrator. She said, they knew it smelled like gas. She said that (they) were the Administrator and ADON. She did not explain how they knew about the gas smell. An interview was conducted with the maintenance director on [DATE] at 3:45p.m., he said that staff reported that they could smell gas near 100 hall on or about [DATE]. He said that he put soap and water on all the valves (process called soaping the joint) near Halls 100 and 500. He said that he did not find a leak. He said if there was a leak the soap would bubble. He stated that this is a skill he was taught through previous work experience. He stated that it was reported to the Administrator during their morning meeting on or about [DATE]. He said that the Administrator as well as Therapy Director, BOM, SW, Wound Care nurse and ADON were present for the meeting. He stated that the therapy director was the first person to inform him of the gas smell. He said that the plumber came out on [DATE] but did not have the part to repair the gas valves on the furnace and hot water heater. He said that the FD turned the gas line off on [DATE]. The plumber returned on today ([DATE]) and replaced the valves on the furnace and the hot water heater. Observation rounds on [DATE] at 3:50 p.m., revealed a closet located at the back of the building near Halls 100 and 500 had a hot water heater and a furnace. The gas smell was strong. An interview was conducted with the Administrator on [DATE] at 4:12pm, she stated that RN V text her on [DATE] and said that there was a gas smell in the facility and the fire department had been called. She stated this is when she first learned that there was a gas leak and that they found carbon monoxide. She said that it was reported to her that the fire department had found a small gas leak. She said from what she understands, the alarm would have been triggered if there was over 50 parts per million of carbon monoxide in the building. She said that she did not believe that the small leak was harmful. She said the problem was resolved within an hour. She stated that carbon monoxide poisoning could cause headache, sleepiness, nausea and if super high could cause death. She confirmed that she was present for the morning meetings the week of ,d+[DATE]-[DATE] but denied anyone mentioning a gas leak. She informed me that she take the notes for their morning meetings.She stated she didn't smell any gas odors during the week of ,d+[DATE]-[DATE]. She stated the FD did not tell her to evacuate the residents. According to her, she informed her corporate RVP and VP of Clinical Services Director and was advised to follow directives of the fire department, keep them informed and take the residents vitals. She stated that the DON, ADON are charge in her absence and any emergencies are supposed to be handled by the maintenance director. An interview was conducted with Resident # 9 on [DATE] at 10:28am, revealed her to state that the Administrator was aware of the gas smell, and she did not do anything about it. She said that they had been smelling gas for about 1 week and nothing was done until the fire department was called on [DATE]. She said that she had all her faculties and that she told the Administrator that she could smell gas on or about [DATE]. She said that the Administrator is not telling the truth about the gas leak. She said the Administrator should have called the gas company. She said that the Administrator told her and others that the smell was coming from some flooring on Hall 500, but she did not believe her. She said that the Administrator was not trustworthy and did not care about the residents. Resident #9 resided on Hall 100. Record review of Resident #9 MDS dated [DATE] revealed C0500. BIMS summary score was 15. An interview was conducted with CNA N on [DATE] at 10:48 a.m., revealed that she was off a few days during the week of ,d+[DATE]-[DATE] but believe she returned to work on ,d+[DATE] or [DATE] and could smell gas. She said she called the ADON on ,d+[DATE] around 9:30 a.m. on the on-call phone to inform her that she could smell gas. She said the ADON told her she would call Administrator and let her know, but maintenance was aware of the problem. She said that she had a headache and was feeling sleepy on [DATE]. She said that someone called 911 and the fire department told RN V that they found high levels of carbon monoxide in the building. She said there is no freedom to voice concerns in the building, but she did report the gas smell to ADON. She said she made the ADON aware of it on Saturday [DATE], but ADON and Administrator allowed another day to go by without doing anything. An interview was conducted with CNA Q on [DATE]at10:50 a.m., stated that she was ill from the gas fumes. She said they wanted the fire department to come because they were worried about the residents. She said that the CNA's cares more about the residents than the Administrator does. She said that she works Hall 200 mostly but she also helps with Hall 100. She said that there was a gas smell in that area (Halls 100 and 500) for over a week. She said that she was having headaches and nausea from the gas smell. She said staff would talk amongst themselves, but they were afraid to call and get help. An interview was conducted with RN V on [DATE] at 2:49 p.m., she stated that the fire department came while on her 6a-6pm shift on [DATE]. She said that upon their arrival she immediately text the ADON (per chain of command). She said that there were approximately 4 or 5 on the fire team. She said that they began to walk throughout and around the outside of building checking for carbon monoxide. She said she was informed by a member of the FD that the carbon monoxide levels were high in the room where the puzzles were located (at the end of 100 and 500 halls) and boiler room. She said that the ADON said that she let both the Administrator and Maintenance Director know that the fire department was there due to the gas leak. At first, she said that the Administrator told her that the fire department was not there because she had checked the cameras. She said that she took a picture of the fire truck on her cell phone and text it to her. She said that she allowed Chief C to communicate with the Administrator from her cell phone. She said that she started soliciting help to evacuate the residents, getting them dressed and helping transfer them to their wheelchairs, because the FD told her that she needed to evacuate the residents from Hall 100. She said this is what Chief C told her to do. She said when she got back on the phone, the Administrator said that she was told that the levels were low and there was no need to evacuate the residents. She said that it was obvious that the FD felt they were not moving the residents fast enough, because Chief C announced that he would shut the whole building down if they did not start moving the residents. She said she text the Administrator again because she wanted to make sure she was okay with them moving the residents. She said that the Administrator responded, You were already moving them RN V. She said there was a lot of commotion because it was also time for change of shift. She said one fireman was observed coming from the outside and another from the back of the building. She said that only a few residents had been evacuated to the front lobby when she was informed that the fire department was going to shut down the gas line. The residents were taken back to their rooms. She was told that they were airing out the building and had propped open the back door for air to circulate. In an interview with Fire Chief A of the local fire department (FD) on [DATE] at 9:24a.m. revealed that A shift responded to an anonymous 911 call from the facility on [DATE]. He stated that they found the area near the lobby/nursing station had a carbon monoxide reading of 35 parts per million (PPM) on their gas monitoring device which samples air and is used to detect oxygen (O2), carbon monoxide (CO), hydrogen sulfide (H2S ppm) and volatile organic compounds (VOC ppm). He said that they must always do an air sample when there is complaint of a gas smell. As they moved further down Hall 100 and entered the boiler room located at the back of the building (where Halls 100 and 500 intersect), they found that the reading was 700 parts per million of carbon monoxide. Chief C informed RN V that they needed to evacuate the residents from Hall 100. He said that Chief C talked to the Administrator and maintenance director and when he noticed that staff were not moving residents off the hall, he announced that he would shut the whole building down. He stated that they decided to shut the main gas line down because natural gas not burning properly created the carbon monoxide. So, cutting the gas supply would eliminate any carbon monoxide because even a small amount of carbon monoxide can be harmful to the residents. He said they opened doors and allowed the carbon monoxide to dissipate before they left the facility. FD recommended that the facility contact a certified plumber. FD stated some symptoms of carbon monoxide poisoning included dizziness, headaches, shortness of breath, and loss of consciousness An interview was conducted with Therapy Director on [DATE] at 10:45 a.m., revealed that a gas odor was strong between [DATE]-[DATE] as the therapy room is in the corner of Hall 500 (where the highest concentration of carbon monoxide was found). She reported the gas odor to the Maintenance Director on or about [DATE]. He said that he would investigate it. She said that she kept the door to therapy closed. She said that the maintenance director talked about the gas leak multiple days in the morning meeting. She said that she mentioned it in the meeting too because the smell was strong. She said the maintenance director said he was working on it. She recalls the Administrator, ADON, SW, BOM, WCN and maintenance director being present for those meetings during the week of [DATE]-24, 2023. Record review of resident #1 face sheet revealed he was a [AGE] year-old male who was diagnosed with chronic obstructive pulmonary disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing) heart failure, cellulitis (a bacterial skin infection), muscle weakness, chronic pain, polyneuropathy (malfunction of many peripheral nerves through the body), chronic atrial fibrillation( an irregular and often rapid heart rhythm and mood disturbance and anxiety. He resided on Hall 100. Record review of Resident #1 MDS dated [DATE], section C0500. BIM summary score was 15. An interview was conducted with Resident # 1 on [DATE] at 11:15 a.m., he said that it was difficult for him to breath due to the strong gas odor on or about [DATE]. He described the smell as a heater furnace just being turned on for the first time in the winter. He said that a nurse (later known as RN V) came to open his window to allow a flow of air. He was later moved to the lobby. He utilizes an oxygen concentrator. He said he told the nurse that he was having difficulty breathing earlier in the day on [DATE]. He did not specify which nurse. He says multiple different staff came to his room. But, it was not the same nurse that opened his window. He said that the night nurse took his vitals. Record review of resident # 2 face sheet revealed that he was a [AGE] year-old male who is diagnosed with unspecified dementia, muscle weakness, abnormalities of gait and mobility, generalized arthritis, insomnia, post-traumatic stress disorder (PTSD). He resided on Hall 100. Record review of Resident # 2 MDS dated [DATE], revealed section C0500 BIM summary score was 8. An interview was conducted with Resident #2 on [DATE] at 11:26 a.m., he said that he experienced fast heartbeat and was light-headed on or about [DATE]. He said LVN U asked him if he could smell gas earlier in the week and he said that he did not smell anything at that time. But, on [DATE] he could smell gas and was light-headed. He said he does not usually feel that way. Resident # 2 resided on Hall 100. An interview was conducted with the ADON on [DATE] at 11:31am, she said that she was informed of the gas leak during morning meeting on [DATE], if she can recall correctly. She denied smelling gas. She said the maintenance director announced that he was trying to resolve the problem. She said she received a text from staff on [DATE] stating they could smell gas. She said she immediately informed the Administrator via text message. She said she was told that the maintenance director was working on fixing the problem. An interview was conducted on [DATE] at 10:42 a.m. with Texas master licensed plumber, with plumbing company. Stated he was completing another job for the facility related to draining and an employee said that they had an issue with gas. He stated he used a gauge test with air after shutting off the gas to check the pressure and the gauge was dropping slowly at 10psi. He stated it was letting air go through which would mean there is a leak. He replaced the valves on the meter on which had the central heating and water heater because it was where the leak was found. He called the gas natural gas. He did not check for carbon monoxide. He does not normally check for carbon monoxide. Record review of a letter from plumbing company, dated [DATE]th, 2023, revealed that they were working at facility on [DATE] doing some repairs to sewer line, same day that a facility staff personnel asked technicians to check on a smell of gas in the mechanical room. Technicians proceed to test the gas line with 10 PSI of air for 15 minutes and pressure dropped very slow, indicating that there was a leak in line. Technician turned gas off until parts were ordered, and service could be completed. The technicians ordered new valves for the water heater and furnace and returned to the facility the following day [DATE] to replace valve and perform another test at 10 PSI for another 15 minutes and pressure held indicating there was no more leaks at this unit. There is no mention of Carbon Monoxide check. A group interview ensued with Chief A, Chief C and attempted interview with Chief B on [DATE] at 10:30 a.m., Chief A stated that they found carbon monoxide at the facility. Chief B -was dispatched just before the interview started. Chief A stated that he arrived about 15 minutes after the team arrived to assist. Chief C stated that he spoke with the Administrator and Maintenance on [DATE]. He told the Administrator that the carbon monoxide was found in the building and numbers were highest in the back of the building near Halls 100 and 500. At that time, he stated that they needed to evacuate the residents down Hall 100. He said that the Administrator was pushing back. She said that maintenance told her that the levels were ,d+[DATE] ppms. He said he was the person that talked to maintenance, and he never told him that. He said the carbon monoxide numbers were not as high in the front of building or outside, but they were at 700ppms in the boiler room. He said that he handed the phone to RN V and when he did not observe them moving the residents, he announced at the front nursing station he would shut the whole building down. By that he said he would have called ambulances to transport the residents to a nearby hospital because any amount of carbon monoxide can be hazardous to people who are already ill. He said that he has never dealt with an administrator that would not follow his orders. He said the nurse handed her phone to him maybe twice, he felt like the Administrator was giving the nurse pushback too. A subsequent interview was conducted with ADON on [DATE] at 12:44pm, she stated that it was on Thursday in stand-up, maintenance director said that a plumber was coming. She said that she made a mistake on the date of the stand-up meeting because she worked on Thursday night (,d+[DATE]), so she was not in the morning meeting on ,d+[DATE]. It was on [DATE], if she recalls correctly. She said that the Maintenance director only said that he had a plumber coming. She said that they knew there was a boiler issue on Hall 500. The managers talk all day long, so she is not sure when the boiler issue first came up. She said that she first learned that it was gas leak when she received a text by RN V on Sunday ([DATE]th). RN V text her at 3:55pm, Hey the gas leak is a concern do we have a Co2 detector?. She said she asked her what is a co detector?. She notified the Administrator immediately via text. She said that the Administrator was driving but said she would call maintenance. She said RN V said she was concerned that it was carbon monoxide poisoning. She said that she told RN V, Maintenance and Administrator are aware and that they were in communication, if it was carbon monoxide the alarm would have gone off. She said she never talked to the fireman, she said that was something that Administrator needed to talk to them about. She said she talked to RN BB and he said fire department wanted them to evacuate the residents. Then, RN BB told her that the FD said don't move the residents because the carbon monoxide was so low that they did not have to move the residents. She said that she was going to head to the facility, but RR BB told her to hang tight, he didn't think he needed her to come because the fireman was coming back to him to report. She stated at 6:23p.m., RN BB text and said that fire chief wants everyone off Hall 100. Minutes later he said no need to evacuate because the fireman said the gas was being turned off. She denied that anyone reported or informed her that they smelled gas in the facility. She said the risk of carbon monoxide depends on the levels of gas exposure, headache, altered mental status the risk of gas or carbon monoxide exposure. She stated, If she was the Administrator, she would have immediately called the fire department or have maintenance shut the gas down. She stated that Resident # 13's family member reported the gas smell to her on [DATE]. A subsequent interview was conducted with maintenance director on [DATE] at 1:14pm, he said this is how he recalls the week of [DATE]-26, 2023: Thursday - (,d+[DATE])- report of gas smell from therapy director and an unnamed nurse. He stated that he went by the Administrator's office and reported it to her. He said both himself and his assistant worked on soaping the joints to try to find a leak on both Thursday and Friday. He said that they sprayed gas lines in 5 mechanical rooms. No leak found. Saturday (,d+[DATE])- came to the facility to soap more of the lines. No leak found. Sunday (,d+[DATE])- call from RN V said FD was there and wanted to speak with him. He said that he is not sure of the FD personnel that he spoke with, but he did say that they found carbon monoxide. He said he is not sure what amount. But high because he said that they were going to evacuate the residents. Then, he was told that the FD was just going to cut the gas line supply off and that he would need to get a plumber to fix the valves. An interview was conducted with BOM on [DATE] at 2:00 p.m., he stated that he recalls maintenance director informing them in morning meeting during the week of ,d+[DATE]-[DATE] about a gas leak. He stated that he attended morning meetings every day that week. He said that he recalls the Administration, Wound care nurse, Therapy Director, maintenance, and ADON in these meetings. An interview was conducted with Med Aide A on [DATE] at 2:32 p.m., she stated she had headaches and the stated that the gas smell started on or about [DATE], she was told it was not gas. That they were working on flooring down Hall 500. She said therapy was complaining about the smell too. She said her normal shift consisted of passing medication on Halls 100 and 200. She said that called in to work on [DATE] because she was not feeling well. She had a bad headache and nausea. A subsequent interview was conducted with the Administrator on [DATE] at 2:51 p.m., she stated that she was not informed by maintenance nor any other personnel that there was a gas smell in the building. She first learned about the gas leak/carbon monoxide on [DATE]. She denied the fire department staff told her to evacuate the residents. She said that it was RN V that wanted to move them, so she asked to speak to Chief C. She said that the risk of being exposed to carbon monoxide above 50ppms could cause headaches. She said that the carbon monoxide was low otherwise the alarm panel would have alarmed, according to her understanding of the fire panel at Solidago. She said that Occupational Safety and Health Administration (OSHA) standards says 50ppm of carbon monoxide is not hazardous. She did not provide any literature for OSHA Therefore, she did not see the harm. She did not call in an incident report to Health and Human Services for this reason. Review of the facility's activity report dated [DATE], revealed that Resident #13 family came to visit. They were concerned about the smell of gas. RN V said that she would report it to administration. Resident #13 was not interview able. He resided on Hall 100. Record review of the facility census dated [DATE], revealed that Resident #13 resided on Hall 100 close to the end of the hall where Hall 500 intersects. An interview was conducted on [DATE] at 12:57pm, the former Wound Care Nurse stated in morning meeting on approximately [DATE] or [DATE], therapy director reported that there was a strong smell of gas. She told the administrator that she had been smelling gas for a while. The Administrator stated that the 500 unit used to be on a separate gas line. That is why they could be smelling gas. He said multiple days it was bought up in the morning meeting. He said he felt like he was walking uphill for over a week. He said he would not return to work as

Based on observation, interview, and record review the facility failed to provide a safe, functional, and sanitary environment for residents, staff, and the public for 3 of 4 days (March 23, 24, and 25) . The facility failed to contact the fire department to report a gas leak for 3 days after multiple reports of a gas smell. The facility failed to evacuate or move the residents which resulted in the residents being exposed to carbon monoxide for 3 days. An Immediate Jeopardy (IJ) was identified on 4/6/2023 at 5:58 p.m. While the IJ was removed on 4/11/2023 at 4:13 p.m., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. These failures placed all residents, staff, and visitors at risk of getting sick due to prolonged exposure to gas fumes and/or carbon monoxide, which could lead to death. Findings Include: Record review of public record request # PIR-2023-706 on 4/10/23, revealed that Incident # 23002345 stated the FD was dispatched to the facility due to a 911 call concerning smell of gas inside. Fire Chief B was the reporter. It read in part on March 26, 2023, E16 dispatched emergency traffic for smell of smoke or gas. upon arrival to scene to a single-story nursing home nothing was showing, and investigation commenced. once inside we were directed to the end of the 100 hall. Halfway down the hallway CO readings began to read 31 ppm. The reading continued to be reading between 18 and 30ppm in the end corridor. nursing staff was instructed to move residence out of Hall 100. All rooms and halls were investigated with 5 gas monitoring. Boiler room was noticed to have furnace that when turned on readings reached 700ppm of CO. (31ppm and 700 ppm indicates how many parts of carbon dioxide there is in one million parts of air). Maintenance was informed of this leak and gas supply was then turned off. maintenance informed us that plumbers would fix the leak tomorrow. the 100 hall was then ventilated until CO readings consistently maintained O ppm. End of call. Further review of the incident report revealed that there were four firemen on the scene. They were at the facility from 17:13:47(5:13 p.m.) to 18:39:01 (6:39 p.m.). Observation of the Fire Department Body camera dated 3/26/23 revealed: 17:25 (5:25 p.m.) Body cam #3: entered front door of facility, asked staff about kitchen, or any gas hook ups. Staff reported not knowing anything about the building. 17:25 (5:25 p.m.)- entered 100 hall. A staff stated to FD they had to raise a resident's window (this was near the end of hall, room [ROOM NUMBER] seen on video) 17:26 (5:26 p.m.) Resident on hall in wheelchair traveling down hall, heard FD stated reading of CO at 30 ppm. Then stated a big spike in the reading over there on the CO (the FD is at the back on 100 hall near therapy door) 17: 33 (5:33 p.m.) observed staff go into room [ROOM NUMBER] to assist resident 17:35 (5:35 p.m.) Observed resident in wheelchair on hall 100 near 106 17:46 (5:46 p.m.) heard a resident on 200 hall tell FD yesterday the gas smell was strong 17:49 (5:49 p.m.) staff ask FD if fire truck was in the front, he said yes, she was seen on her phone 17: 49 (5:49 p.m.) FD states maintenance said this happened about a week ago 17: 49 (5:49 p.m.) FD explained to staff they are getting readings of high CO levels but can't find where it is coming from. Staff heard on phone reporting to somewhere that there are high CO levels. 17:50 (5:50 p.m.) staff telling staff let's move residents 17:52 (5:52 p.m.)- 3 staff standing on 100 hall, not moving residents 17:53 (5:53 p.m.) staff comes to FD and states: I don't know what's going on, the administrator does not want to admit that there is high CO in the building do you want to talk to her? FD responded I don't care what she admits to. Staff dials a number and gives phone to FD- he said he was with the FD, and he says one of your nurses said you might want to talk to me. He says to the person on the phone that they told staff to clear out the hall where they are getting CO reading and, clearing out the hallway was an immediate thing. 17:56 (5:56 p.m.) confirmed with staff that administrator was told to clear out that hallway, explains to staff that if they cannot find the leak and isolate the leak then they cannot let them stay operating and would have to shut the building down. Explained if fire started over here (100 hall) it could impact the other side of building. 18:06 (6:06 p.m.) FD says its strong reading going up and up 50 to 55, to 75. 18:07 (6:07 p.m.) shut off valve to gas line and started opening windows and doors. FD upset the maintenance saying that had a gas leak a week ago and didn't say anything. 18:09 (6:09 p.m.) FD stated every time that thing (referring to the furnace or hot water heater) would kick on they would have the CO emitted. Says probably been going on a while. Staff requested name and phone number in case she gets terminated. FD explained to her she was doing what they asked her to do. 18:12 (6:12 p.m.) FD moved outside stating it wasn't good to be standing around it. 18:19 (6:19 p.m.)- staff approached FD and asked about moving residents. FD stated it was recommended to move the patients. Staff Requested FD to call administrator, FD stated he already called her. Staff stated that she (person on the phone) told one of the nurses to not move the patients. FD said to tell her the other option is to have ambulances come and move all the patients. Explained they could get CO poisoning. 18:20 (6:20 p.m.) resident seen on 100 hall and FD told resident to go the other way. FD explained to nurses what carbon monoxide poisoning is. A Nurse told another nurse to call ADON- he said he got off phone with the assistant and he was told that the assistant said to keep the residents in the room. FD was saying it was very serious. And it wasn't up to the nurse, it was FD decision. Nurse called the administrator, administrator did not answer, and she left a message. FD told them to move residents again. FD said administrator texted and said she was driving; she didn't answer the phone. 18:23 (6:23 p.m.) staff started moving residents. FD stated that he already talked to the lady to move residents about 30 minutes ago. FD says it smells terrible almost like it had been leaking for a year. 18:35 (6:35 p.m.) FD explained to staff that they killed the gas. End of video An interview was conducted with Fire Chief A of the local fire department (FD) on 4/4/2023 at 9:24 a.m., revealed him to state that A shift responded to an anonymous 911 call from Solidago Nursing and Rehab on 3/26/23. He stated that they found the area near the lobby/nursing station had a carbon monoxide reading of 35 parts per million (PPM) on their 5-gas monitoring device which samples air and is used to detect oxygen (O2), carbon monoxide (CO), hydrogen sulfide (H2S ppm) and volatile organic compounds (VOC ppm) and low explosives level (LEL). He said that they must always do an air sample when there is complaint of a gas smell. As they moved further down Hall 100 and entered the boiler room located at the back of the building (where Halls 100 and 500 intersect), they found that the reading was 700 parts per million of carbon monoxide. Chief C informed RN V that they needed to evacuate the residents from Hall 100. He said that Chief C talked to the Administrator and maintenance director and when he noticed that staff were not moving residents off the hall, he announced that he would shut the whole building down. He stated that they decided to shut the main gas line down because natural gas not burning properly created the carbon monoxide. So, cutting the gas supply would eliminate any carbon monoxide because even a small amount of carbon monoxide can be harmful to the residents. He said they opened doors and allowed the carbon monoxide to dissipate before they left the facility. FD recommended that the facility contact a certified plumber. FD stated some symptoms of carbon monoxide poisoning included dizziness, headaches, shortness of breath, and loss of consciousness. An interview was conducted with LVN U on 3/28/2023 at 3:25pm, she stated that she worked on 3/26/23. She said that someone from Solidago called the fire department anonymously to report the gas smell. She said that she did smell gas in the building on or about 3/24/23 when she returned from being off on 3/23/23. She said that she checked with the residents down Hall 100 and most said that they could not smell gas. She said that Resident #2 mentioned that he could smell gas and she heard from other staff (unwilling to provide names) that they had been smelling gas for about 1 week. She said that she did not report it to the Administrator. She said, they knew it smelled like gas. She said that (they) were the Administrator and ADON. She did not explain how they knew about the gas smell. An interview was conducted with the maintenance director on 3/28/23 at 3:45p.m., he said that staff reported that they could smell gas near 100 hall on or about 3/23/23. He said that he put soap and water on all the valves (process called soaping the joint) near Halls 100 and 500. He said that he did not find a leak. He said if there was a leak the soap would bubble. He stated that this is a skill he was taught through previous work experience. He stated that it was reported to the Administrator during their morning meeting on or about 3/24/23. He said that the Administrator as well as Therapy Director, BOM, SW, Wound Care nurse and ADON were present for the meeting. He stated that the therapy director was the first person to inform him of the gas smell. He said that the plumber came out on 3/27/23 but did not have the part to repair the gas valves on the furnace and hot water heater. He said that the FD turned the gas line off on 3/26/23. The plumber returned on today (3/28/23) and replaced the valves on the furnace and the hot water heater. Observation rounds on 3/28/23 at 3:50 p.m., revealed a closet located at the back of the building near Halls 100 and 500 had a hot water heater and a furnace. The gas smell was strong. An interview was conducted with the Administrator on 3/28/2023 at 4:12pm, she stated that RN V text her on 3/26/23 and said that there was a gas smell in the facility and the fire department had been called. She stated this is when she first learned that there was a gas leak and that they found carbon monoxide. She said that it was reported to her that the fire department had found a small gas leak. She said from what she understands, the alarm would have been triggered if there was over 50 parts per million of carbon monoxide in the building. She said that she did not believe that the small leak was harmful. She said the problem was resolved within an hour. She stated that carbon monoxide poisoning could cause headache, sleepiness, nausea and if super high could cause death. She confirmed that she was present for the morning meetings the week of 3/20-3/24/23 but denied anyone mentioning a gas leak. She informed me that she take the notes for their morning meetings.She stated she didn't smell any gas odors during the week of 3/20-3/24/23. She stated the FD did not tell her to evacuate the residents. According to her, she informed her corporate RVP and VP of Clinical Services Director and was advised to follow directives of the fire department, keep them informed and take the residents vitals. She stated that the DON, ADON are charge in her absence and any emergencies are supposed to be handled by the maintenance director. An interview was conducted with Resident # 9 on 3/29/23 at 10:28am, she stated that the Administrator was aware of the gas smell because on or about 3/21/23, she told her that she had been smelling gas for a few days. She said that the Administrator told her that the smell was coming from some flooring on Hall 500, but she did not believe her. She said the Administrator should have called the gas company. She said that the Administrator was not trustworthy and did not care about the residents. Record review of Resident #9 MDS dated [DATE] revealed C0500. BIMS summary score was 15. An interview was conducted with CNA N on 3/29/23 at 10:48 a.m., revealed that she was off a few days during the week of 3/20-3/24/23 but believe she returned to work on 3/24 or 3/25/23 and could smell gas. She said she called the ADON on Saturday (3/25/23) around 9:30 a.m. on the on-call phone to inform her that she could smell gas. She said the ADON told her she would call Administrator and let her know, but maintenance was aware of the problem. She said that she had a headache and was feeling sleepy on 3/25/23. She said that someone called 911 and the fire department told RN V that they found high levels of carbon monoxide in the building. She said there is no freedom to voice concerns in the building, but she did report the gas smell to ADON. She said although she made the ADON aware of it on Saturday 3/25/23, but ADON and Administrator allowed another day to go by without doing anything. An Interview was conducted with CNA Q on 3/29/23 at 10:50 a.m., states that she was ill from the gas fumes. She said they wanted the fire department to come to Solidago because they were worried about the residents. She said that the CNAs care more about the residents than the Administrator does. She said that she works Hall 200 mostly, but she also helps with Hall 100. She said that there was a gas smell in that area (Halls 100 and 500) for over a week. She said she was having headaches and nausea from the gas smell. She said staff would talk amongst themselves, but they were afraid to call and get help. An interview was conducted with RN V on 4/3/23 at 2:49 p.m., she stated that the fire department came while on her 6a-6pm shift on 3/26/23. She said that upon their arrival she immediately text the ADON (per chain of command). She said that there were approximately 4 or 5 on the fire team. She said that they began to walk throughout and around the outside of building checking for carbon monoxide. She said she was informed by a member of the FD that the carbon monoxide levels were high in the room where the puzzles were located (at the end of 100 and 500 halls) and boiler room. She said that the ADON said that she let both the Administrator and Maintenance Director know that the fire department was there due to the gas leak. At first, she said that the Administrator told her that the fire department was not there because she had checked the cameras. She said that she took a picture of the fire truck on her cell phone and text it to her. She said that she allowed Chief C to communicate with the Administrator from her cell phone. She said that she started soliciting help to evacuate the residents, getting them dressed and helping transfer them to their wheelchairs, because the FD told her that she needed to evacuate the residents from Hall 100. She said this is what Chief C told her to do. She said when she got back on the phone, the Administrator said that she was told that the levels were low and there was no need to evacuate the residents. She said that it was obvious that the FD felt they were not moving the residents fast enough, because Chief C announced that he would shut the whole building down if they did not start moving the residents. She said she text the Administrator again because she wanted to make sure she was okay with them moving the residents. She said that the Administrator responded, You were already moving them RN V. She said there was a lot of commotion because it was also time for change of shift. She said one fireman was observed coming from the outside and another from the back of the building. She said that only a few residents had been evacuated to the front lobby when she was informed that the fire department was going to shut down the gas line. The residents were taken back to their rooms. She was told that they were airing out the building and had propped open the back door for air to circulate. In an interview with Fire Chief A of the local fire department (FD) on 4/4/2023 at 9:24a.m. revealed that A shift responded to an anonymous 911 call from the facility on 3/26/23. He stated that they found the area near the lobby/nursing station had a carbon monoxide reading of 35 parts per million (PPM) on their gas monitoring device which samples air and is used to detect oxygen (O2), carbon monoxide (CO), hydrogen sulfide (H2S ppm) and volatile organic compounds (VOC ppm). He said that they must always do an air sample when there is complaint of a gas smell. As they moved further down Hall 100 and entered the boiler room located at the back of the building (where Halls 100 and 500 intersect), they found that the reading was 700 parts per million of carbon monoxide. Chief C informed RN V that they needed to evacuate the residents from Hall 100. He said that Chief C talked to the Administrator and maintenance director and when he noticed that staff were not moving residents off the hall, he announced that he would shut the whole building down. He stated that they decided to shut the main gas line down because natural gas not burning properly created the carbon monoxide. So, cutting the gas supply would eliminate any carbon monoxide because even a small amount of carbon monoxide can be harmful to the residents. He said they opened doors and allowed the carbon monoxide to dissipate before they left the facility. FD recommended that the facility contact a certified plumber. FD stated some symptoms of carbon monoxide poisoning included dizziness, headaches, shortness of breath, and loss of consciousness An interview was conducted with Therapy Director on 4/4/23 at 10:45 a.m., revealed that a gas odor was strong between 3/22/23-3/26/23 as the therapy room is in the corner of Hall 500 (where the highest concentration of carbon monoxide was found). She reported the gas odor to the Maintenance Director on or about 3/22/23. He said that he would investigate it. She said that she kept the door to therapy closed. She said that the maintenance director talked about the gas leak multiple days in the morning meeting. She said that she mentioned it in the meeting too because the smell was strong. She said the maintenance director said he was working on it. She recalls the Administrator, ADON, SW, BOM, WCN and maintenance director being present for those meetings during the week of March 20-24, 2023. Record review of resident #1 face sheet revealed he was a [AGE] year-old male who was diagnosed with chronic obstructive pulmonary disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing) heart failure, cellulitis (a bacterial skin infection), muscle weakness, chronic pain, polyneuropathy (malfunction of many peripheral nerves through the body), chronic atrial fibrillation( an irregular and often rapid heart rhythm and mood disturbance and anxiety. He resided on Hall 100. Record review of Resident #1 MDS dated [DATE], section C0500. BIM summary score was 15. An interview was conducted with Resident # 1 on 4/4/23 at 11:15 a.m., he said that it was difficult for him to breath due to the strong gas odor on or about 3/25/23. He described the smell as a heater furnace just being turned on for the first time in the winter. He said that a nurse (later known as RN V) came to open his window to allow a flow of air. He was later moved to the lobby. He utilizes an oxygen concentrator. He said he told the nurse that he was having difficulty breathing earlier in the day on 3/26/23. He did not specify which nurse. He says multiple different staff came to his room. But, it was not the same nurse that opened his window. He said that the night nurse took his vitals. Record review of resident # 2 face sheet revealed that he was a [AGE] year-old male who is diagnosed with unspecified dementia, muscle weakness, abnormalities of gait and mobility, generalized arthritis, insomnia, post-traumatic stress disorder (PTSD). He resided on Hall 100. Record review of Resident # 2 MDS dated [DATE], revealed section C0500 BIM summary score was 8. An interview was conducted with Resident #2 on 4/4/23 at 11:26 a.m., he said that he experienced fast heartbeat and was light-headed on or about 3/26/23. He said LVN U asked him if he could smell gas earlier in the week and he said that he did not smell anything at that time. But, on 3/26/23 he could smell gas and was light-headed. He said he does not usually feel that way. Resident # 2 resided on Hall 100. An interview was conducted with ADON on 4/4/23 at 11:31am, she said that she was informed of the gas leak during morning meeting on 3/24/23, if she can recall correctly. She said the maintenance director announced that he was trying to resolve the problem. She said she received a text from RN V on 3/26/23 stating they could smell gas. She said she informed the Administrator. She said she was told that the maintenance director was working on fixing the problem. She was informed by the night nurse that the fire department had shut off the gas line on 3/26/23 due to them finding CO in the building. An interview was conducted on 4/5/23 at 10:42a.m. with Texas master licensed plumber. He stated he was completing another job for this facility on 3/27/23 related to draining and an employee said that they had an issue with gas. He stated he used a gauge test with air after shutting off the gas to check the pressure and the gauge was dropping slowly at 10psi. He stated it was letting air go through which would mean there is a leak. He replaced the valves on the meter on which had the central heating and water heater because it was where the leak was found. He called the gas natural gas. He did not check for carbon monoxide. He said he does not normally check for carbon monoxide. A group interview ensued with Chief A, Chief C and attempted interview with Chief B on 4/6/2023 at 10:30 a.m., Chief A stated that they found carbon monoxide at the facility Chief B -was dispatched just before the interview started. Chief A stated that he arrived about 15 minutes after the team arrived to assist. Chief C stated that he spoke with the Administrator and Maintenance on 3/27/23. He told the Administrator that the carbon monoxide was found in the building and numbers were highest in the back of the building near Halls 100 and 500. At that time, he stated that they needed to evacuate the residents down Hall 100. He said that the Administrator was pushing back. She said that maintenance told her that the levels were 13/19 ppms. He said he was the person that talked to maintenance, and he never told him that. He said the carbon monoxide numbers were not as high in the front of building or outside, but they were at 700ppms in the boiler room. He said that he handed the phone to RN V and when he did not observe them moving the residents, he announced at the front nursing station he would shut the whole building down. By that he said he would have called ambulances to transport the residents to a nearby hospital because any amount of carbon monoxide can be hazardous to people who are already ill. He said that he has never dealt with an administrator that would not follow his orders. He said the nurse handed her phone to him maybe twice, he felt like the Administrator was giving the nurse pushback too. Record review of the morning meeting sign-ins revealed: 3/20/23- did not have a sign-in sheet provided 3/21/23- Administrator, DON, ADON, Wound Care Nurse, BOM, Therapy, SW, HR, Maintenance signed in for the meeting 3/22/23- Administrator, DON, ADON, Wound Care Nurse, BOM, Therapy, SW, HR, Late -Maintenance Assistant was here was written in on the line where maintenance signs. 3/23/23-Administrator, DON, ADON, Wound Care Nurse, BOM, Therapy, SW, HR, Late -Maintenance Assistant was here was written in on the line where maintenance signs. 3/24/23- Administrator, DON, BOM, Therapy, SW, Maintenance, HR There were no notes concerning a gas leak in the morning minutes. Record review of resident rights policy revised on 10/1/2020, stated in part 26. Homelike Atmosphere. Each resident has the right to a safe, clean, comfortable, and homelike environment. A subsequent interview was conducted with ADON on 4/6/2023 at 12:44pm, she stated that it was on Thursday in stand-up, maintenance director said that a plumber was coming. She said that she made a mistake on the date of the stand-up meeting because she worked on Thursday night (3/23), so she was not in the morning meeting on 3/24. It was on 3/23/2023, if she recalls correctly. She said that the Maintenance director only said that he had a plumber coming. She said that they knew there was a boiler issue on Hall 500. The managers talk all day long, so she is not sure when the boiler issue first came up. She said that she first learned that it was gas leak when she received a text by RN V on Sunday (March 26th). RN V text her at 3:55pm, Hey the gas leak is a concern do we have a Co2 detector?. She said she asked her what is a co detector?. She notified the Administrator immediately via text. She said that the Administrator was driving but said she would call maintenance. She said RN V said she was concerned that it was carbon monoxide poisoning. She said that she told RN V, Maintenance and Administrator are aware and that they were in communication, if it was carbon monoxide the alarm would have gone off. She said she never talked to the fireman, she said that was something that Administrator needed to talk to them about. She said she talked to RN BB and he said fire department wanted them to evacuate the residents. Then, RN BB told her that the FD said don't move the residents because the carbon monoxide was so low that they did not have to move the residents. She said that she was going to head to the facility, but RR BB told her to hang tight, he didn't think he needed her to come because the fireman was coming back to him to report. She stated at 6:23p.m., RN BB text and said that fire chief wants everyone off Hall 100. Minutes later he said no need to evacuate because the fireman said the gas was being turned off. She denied that anyone reported or informed her that they smelled gas in the facility. She said the risk of carbon monoxide depends on the levels of gas exposure, headache, altered mental status the risk of gas or carbon monoxide exposure. She stated, If she was the Administrator, she would have immediately called the fire department or have maintenance shut the gas down. She stated that Resident # 13's family member reported the gas smell to her on March 26, 2023. A subsequent interview was conducted with maintenance director on 4/6/23 at 1:14pm, he said this is how he recalls the week of March 20-26, 2023: Thursday - (3/23)- report of gas smell from therapy director and an unnamed nurse. He stated that he went by the Administrator's office and reported it to her. He said both himself and his assistant worked on soaping the joints to try to find a leak on both Thursday and Friday. He said that they sprayed gas lines in 5 mechanical rooms. No leak found. Saturday (3/25)- came to the facility to soap more of the lines. No leak found. Sunday (3/26)- call from RN V said FD was there and wanted to speak with him. He said that he is not sure of the FD personnel that he spoke with, but he did say that they found carbon monoxide. He said he is not sure what amount. But high because he said that they were going to evacuate the residents. Then, he was told that the FD was just going to cut the gas line supply off and that he would need to get a plumber to fix the valves. An interview was conducted with BOM on 4/6/23 at 2:00 p.m., he stated that he recalls maintenance director informing them in morning meeting during the week of 3/20-3/24/23 about a gas leak. He stated that he attended morning meetings every day that week. He said that he recalls the Administration, Wound care nurse, Therapy Director, maintenance, and ADON in these meetings. An interview was conducted with Med Aide A on 4/6/23 at 2:32 p.m., she stated she had headaches and the stated that the gas smell started on or about 3/21/23, she was told it was not gas. That they were working on flooring down Hall 500. She said therapy was complaining about the smell too. She said her normal shift consisted of passing medication on Halls 100 and 200. She said that called in to work on 3/24/23 because she was not feeling well. She had a bad headache and nausea. A subsequent interview was conducted with the Administrator on 4/6/2023 at 2:51 p.m., she stated that she was not informed by maintenance nor any other personnel that there was a gas smell in the building. She first learned about the gas leak/carbon monoxide on 3/26/23. She denied the fire department staff told her to evacuate the residents. She said that it was RN V that wanted to move them, so she asked to speak to Chief C. She said that the risk of being exposed to carbon monoxide above 50ppms could cause headaches. She said that the carbon monoxide was low otherwise the alarm panel would have alarmed, according to her understanding of the fire panel at Solidago. She said that Occupational Safety and Health Administration (OSHA) standards says 50ppm of carbon monoxide is not hazardous. She did not provide any literature for OSHA Therefore, she did not see the harm. She did not call in an incident report to Health and Human Services for this reason. Review of the facility's activity report dated 3/26/2023, revealed that Resident #13 family came to visit. They were concerned about the smell of gas. RN V said that she would report it to administration. Resident #13 was not interview able. He resided on Hall 100. Record review of the facility census dated March 29, 2023, revealed that Resident #13 resided on Hall 100 close to the end of the hall where Hall 500 intersects. An interview was conducted on 4/10/2023 at 12:57pm, the former Wound Care Nurse stated in morning meeting on approximately 3/20/23 or 3/21/23, therapy director reported that there was a strong smell of gas. She told the administrator that she had been smelling gas for a while. The Administrator stated that the 500 unit used to be on a separate gas line. That is why they could be smelling gas. He said multiple days it was bought up in the morning meeting. He said he felt like he was walking uphill for over a week. He said he would not return to work as he was not feeling well. He believes that the gas smell was making him sick because otherwise he had been healthy. He said that he would start to feel ill once he came in to work for almost a week or so. He said he had experienced headache and nausea. He said that it's scary because they have a lot of smokers in the facility and a lot of things that could have happened. His last day working at the facility was on 4/4/23 because he kept getting sick and other Administrative issues, which he did not want to discuss. An interview was conducted with the SW on 5/1/23 at 11:25 a.m. he stated that he attended morning meetings and stated that they were informed by maintenance that there was a gas leak sometime between 3/20-3/24/23, and he said that he informed the Administrator that he could smell gas directly as he his office was in the back of the building near Halls 100 and 500. He said that the Administrator told him that the smell was flooring down Hall 500. He said that he knew it was a smell of gas. He did not push the issue because he was a new employee. He said that his date of hire was on 2/20/23. Record review of a letter from plumbing company, dated April 10th, 2023, revealed that they were working at the facility on March 27 doing some repairs to sewer line, same day that facility staff asked technicians to check on a smell of gas in the mechanical room. Technicians proceed to test the gas line with 10 PSI of air for 15 minutes and pressure dropped very slow, indicating that there was a leak in line. Technician turned gas off until parts were ordered, and service could be completed. The technicians ordered new

44333 Based on interview, record review and observation, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 59 of 61 residents that receive food from the kitchen. 1.The facility failed to have an effective system in place to ensure sufficient and routine replenishment of food for all residents. 2.The facility failed to have a trained Dietary manager on staff to supervise staff, ensure sanitary work environment and ensure balanced meals were being provided to residents at assigned mealtimes. 3.The facility failed to provide approved and adequate substitutions. 4.The facility failed to have an effective system in place to ensure food was properly stored and that expired or spoiled food items were discarded. This failure had the potential to affect all facility residents who consumed food from the facility's kitchen. The findings included: Observation of the kitchen inventory of food supplies on [DATE] beginning at 11:08am revealed: The food supply on hand was only sufficient for one lunch or dinner meal to feed the entire census (59 residents eat food from the kitchen) based on the amount per serving of available food items: The facility has a 10 lbs. chuck roast which could serve 50 residents giving them 3 oz of protein. They also had 7 and ,d+[DATE] quarts of mix scrambled eggs, which would feed 50 residents. For produce, the facility had tomatoes that were rotten, spinach that was slimy and rotten. They had some parsley. Observation of the refrigerator in the main kitchen area on [DATE] beginning at 11:08am revealed the following: A container of eggs, with a used by date of [DATE]. Unlabeled, undated container of what appears to be peaches. Unlabeled, undated container of what appears to be macaroni and cheese. Unlabeled, undated, open container of what appears to be sliced meat. Unlabeled, undated open sliced cheese. Unlabeled, undated box of chicken with liquid residue spilling onto refrigerator. Undated open carton of scrambled eggs. Interview with Cook D on [DATE] at 11:15am, he stated he did not have the food available to cook that was on the menu for today. He stated that he would substitute spaghetti, but he does not have the ground meat. He stated he does not know what he will cook and was trying to figure it out. He stated the substitution items also were not available. He stated that he was not the one who orders food supply for the kitchen. He said the previous dietary manager who no longer works at the facility was responsible for ordering the food. He stated the administrator was now the person that orders the food. He stated that they do not have produce, as the produce they do have was molded. He stated the administrator was made aware they needed food on [DATE] and she told him she would work on it. He stated food should be labeled and dated so that they do not serve food that was not edible or within the use by date. Observation of lunch being served on [DATE] revealed lunch service began at 1:40pm and the last trays for lunch was served 2:24 pm. 6 to 7 residents received grilled cheese. Record review and observations for lunch and dinner on [DATE], revealed the items on the menu was not served. Lunch menu for [DATE] revealed teriyaki chicken, fluffy rice, seasoned mixed vegetables, fresh baked roll, frosted cake. Lunch menu served to residents on [DATE] was sliced pork, mashed potatoes, and cauliflower. Some residents observed eating grilled cheese sandwiches at lunch. Undated dinner menu revealed hot roast beef sandwich, baked potato, broccoli & cauliflower, gelatin cubes with whip topping. Dinner menu served to residents revealed chopped ham mixed with corn, beans, and cauliflower. Observation on [DATE] at 2:00pm of the refrigerator in the main kitchen area near the steam table revealed a box of molded rotten tomatoes, 1 bag of parsley, 5 bags of spinach with black liquid. Observation of lunch being served on [DATE] revealed lunch service began at 1:30pm and the last trays for lunch was served at 2:25pm. Record Review of Mealtimes posted in the dinning room of the facility revealed Breakfast is between ,d+[DATE]am, Lunch 12pm and dinner 5pm. Record review and observations for lunch and dinner on [DATE], revealed the menu item was not served. Lunch menu for [DATE] revealed red beans, rice & sausage, seasoned greens, fresh baked roll, cinnamon baked apples. Lunch menu served to residents revealed fries and sliced sausage. Dinner menu dated [DATE] revealed Turkey club sandwich macaroni salad, pickled beets, frosted chocolate cake. Dinner menu served to residents revealed chuck roast and beans. Observation of lunch being served on [DATE] revealed lunch service began at 2:30 p.m. Interview with Resident #2 on [DATE] at 1:48pm, he stated he has been waiting for 45 minutes for lunch. He stated he was very hungry and asked a dietary aide whose name he can't remember when food will be ready. He stated he was told it would be soon, but he has been waiting a long time. Interview with Resident #5 on [DATE] at 1:55pm, she stated she has been waiting for food and she was hungry. She stated the facility needs to hire more dietary aides and cooks because residents were hungry and have been waiting a long time. Interview with Resident #6 on [DATE] at 1:56pm, she stated she has been waiting 1hr and 30 mins for lunch. She stated breakfast was a long time ago and she was starving. Interview with Resident #7 on [DATE] at 2:02pm, she stated she came to the dining area around 11:30am. She stated the staff normally start serving lunch between 12pm and 12:30pm. She stated there was no snack other than the vending machine because when she goes to the kitchen, they are busy or shorthanded and no one comes to the door. She stated there was no snacks at the nursing station. Interview with Resident #10 on [DATE] at 2:08pm, she stated she had not been served lunch and that she was still waiting. She stated she was hungry. Observation on [DATE] at 2:09pm Resident #4, observed still awaiting lunch. Interview with Resident #8 on [DATE] at 2:15pm, she stated that she was hungry and waiting on lunch. Interview with Resident #9 on [DATE] at 2:25pm, she stated she had been waiting for 2 hours for lunch and was offered a grilled cheese sandwich. She stated she asked for ham and there wasn't any ham left. Observation and interview on [DATE] at 2:28pm with Resident #7 she stated the staff ran out of food and gave me a grilled cheese sandwich. Observation revealed a half-eaten grill cheese sandwich on the plate in front of Resident #7. Observation of the kitchen on [DATE] at 2:20pm during lunch revealed the food serving trays were empty and the administrator was preparing grilled cheese sandwiches. Interview at [DATE] at 2:21pm with Administrator she stated Cook D abandoned his shift and she was now the cook and the administrator. She stated she had her food handler's certificate. She stated she was making grilled cheese sandwiches because residents requested it. When asked if there were any other food options for residents, she stated the residents requested grill cheese. Interview on [DATE] at 11:45am with Cook C he stated he did not know what he was cooking that day and that he did not have the food supply to cook what was on the menu for that day. He states he contacted the Administrator, and she told him to find a substitute. He stated the person responsible for ordering food was the dietary manager who no longer works at the facility. He stated that the administrator was responsible for ordering food and that the last time he worked was [DATE] and he told the administrator on [DATE] that they needed food supplies. Interview on [DATE] at .with Dietary Aide A, she stated she last worked on [DATE] and she informed the administrator that the kitchen needed juice and snacks for the residents. She said the administrator told her she would handle it. She stated that she came back to work today [DATE] and there was not enough food supplies and still no juice or snacks ordered from her request that was made on [DATE]. Observation of the steam table on [DATE] at what time before lunch service revealed green peas at 25 degrees, chopped pork at 99 degrees, pureed peas at 125 degrees, pureed meat at 120 degrees. In interview with RVP on [DATE] at 12:00pm, she stated the administrator oversees the facility, and the kitchen as much as she can. She did not review the sanitation report but had received it via email. She has not been in the kitchen, only to the door. She reported it's between the dietician and the administrator when they review the sanitation report, they discuss how they would solve the issue. She can' not confirm what the issues were [DATE] regarding the sanitation report. She stated Administrator oversees the overall operation of the facility. Stated she does not expect to be told everything that was going on in the building as that was not her role, she was the consultant. She said the administrator was the top of the chain at the facility, and she does not overstep her position. She stated she believed the facility was running well but based in this interview she would agree the system the administrator was using was not working. In an interview with the Dietician on [DATE] at 12:45pm, she stated that the administrator contacted her on [DATE] about substituting menu for hotdog on a bun and peaches. She stated the administrator did not inform her of the menu that was supposed to be served. The Dietician stated she instructed her to substitute bread for bread, protein for protein, starch for starch and fruit and vegetable for fruit and vegetable. She stated residents consuming food that is expired and have no use by date, can have an increased risk of being sick. The Dietician stated there was a list for approved substitutions and was represented by replacing protein for protein, vegetable for vegetable, bread for bread, starch for starch and fruit for fruit. The Dietician stated the approval for [DATE] was not represented in the meal served. She stated without the appropriate substitution, residents can be at risk of not getting the appropriate amount of protein and caloric nutrition, which can lead to weight lost. In an interview with Administrator on [DATE] at 2:00pm, she stated a Dietary manager has been hired but has not started. Stated the facility has been without a dietary manager since the beginning of [DATE]. She stated on Thursday [DATE] she did rounds in the kitchen and observed the cleanliness, food storage and did not take inventory. She stated on [DATE] the kitchen was clean, and all items were labeled and dated. She stated human resources did rounds on Friday [DATE] in the kitchen as well ensuring it was clean and food items were stored correctly. She stated she would expect the kitchen to get dirty during service and cleaned daily. She stated that she did not keep a log of her kitchen audits because it was not a regulation. She stated that her audits are by pop ins and the area she audits varies. She stated she reviewed the sanitation report with the dietician and corrected all the issues. She stated she did go a little low on emergency food supply and she ordered more food on [DATE]. She stated the kitchen currently has adequate shelving. She stated she cleaned off the can opener because it was a little dirty and did not purchase a new one. She stated if the kitchen was unsanitary, it can pose a risk to residents due to cross contamination. She stated certain meat if not kept at the right temperature can cause residents to get sick. She stated that food not dated or labeled can cause the kitchen staff to not be able to tell how long it can be used. She stated she could not answer whether everything was dated, labeled and in accordance with professional standards of food service because she had not been back there today. She stated if dishes are not being sanitized correctly it could cause the dishes to be cross contaminated. In an interview with Medical Director on [DATE] at 3:00pm, he stated he was not informed of food issues and diet substitutions at the facility. Record review of the facility's undated nutritional policy revealed that resident's will be served liberalized diets that a resident would eat at home, unless otherwise indicated by Physician/registered dietician nutritionist assessment. The policy also revealed that meals will be served at consistent times daily with controlled portions. The key points of the policy revealed that the facility should: o Meet nutrition needs and enhance quality of life. o Identify the resident's nutrition care preferences/choices. o Optimize meal intake and increase satisfaction with meals. o Promote enjoyment and consumption of meals to prevent unintended weight loss and under nutrition. Record Review of the facility's undated nutrition policies related to purchasing reflected: - a system is in place to identify items needed, based on the menu, from the grocery, bread, dairy, and produce vendors. No salesperson is permitted to inventory and order food or supplies for the facility. - Check in each order as it is delivered, making certain that items are delivered as ordered and are not damaged. - Order and receive non-food supply according to need from supply inventory sheet in the same manner as food orders.

Based on observation, interview and record review, the facility failed to provide enough support personnel to carry out the functions of the food and nutrition service safely and effectively as evidenced by: The facility failed to have to sufficient staff who were trained in the kitchen to prepare meals and to have delivery of meals in the required time frame. The facility failed to ensure that the Cooks were trained to prepare modified diets in a form and consistency to meet resident's needs. This failure had the potential to place residents at the facility at risk of mealtime irregularity and loss of appetite resulting in weight loss and decreased psycho-social well-being. Findings Included: In an interview on 04/10/2023 at 11:00am with Dietary Aide G revealed that lunch was supposed to be served between 11:45 am and 1:00pm. She said that they were running late because the dietary aide had called in and Cook C was the only one working that morning. She said she came in to help Cook C. Observation on 04/10/2023 at 11:15am revealed Cook C preparing potatoes to put in the oven to bake for lunch. No other menu items were noted at that time. Interview on 4/10/2023 at 11:15am Cook C said he was behind and had not done preparing all the menu items for lunch because he was the only one working that morning. He said, he was going to prepare chopped pork and green peas with the bake potatoes for lunch. Observation of the facility's kitchen on 4/8, 4/9, 4/10 and 4/16/2023 between 11:00 am and 5:00 pm revealed the following: The hand washing sink beside the stove had brown stains all over it. The grill had an accumulation of burnt food particles on it. The stove top and had burnt food particles and grease on it, inside the oven were burnt food particles, food spillage and grease on the inside. The sides of the grill and stove had dried food on them. The wells of the steam table were black from burnt food particles and the water in the wells was brown. The sneeze guards had dried food particles on them. The shelf under the steam table had food stains and dried food particles on it. The floor of the kitchen had had debris, food spillage and dirt on it. The three-compartment sink was full of dirty dishes, dishes from breakfast was not washed they were still on the cart at the entrance door to the dish room from the dining room. Observation of the steam table on 4/10/23 at 1:40pm before lunch service revealed green peas at 125 degrees, chopped pork at 99 degrees, pureed peas at 125 degrees, pureed meat at 120 degrees. These menu items had to be reheated to 165 degrees F. Observation and interview on 04/10/2023 beginning at 1:45pm during the preparation of the pureed menu items revealed Cook C preparing the pureed diet for the lunch meal. Cook C took some pork and put it in the food processor and added water and blend it. For the peas he used 6 scoops using the #12 scoop which is equivalent to 2 and 3/4 ounces and put 6 scoops in the food processor and added some water and blend it, for the bake potatoes he put 8 potatoes in the food processor added water and blend it. Cook C did not peel the potatoes, he blended it with the skin. Observation revealed, and he did not measure any of the menu items, used plain water, and he did not use a recipe. At that point Dietary Aide, C said she was going to do another set of pureed baked potatoes, because the one on the steam table has skin and it was not smooth. She took the potatoes, peeled them and blended them. In an interview on 4/10/2023 at 2:00pm Dietary Aide C said that pureed meals needed to be smooth so that the resident could not choke on it and that was why he peel the potatoes. She said Cook C should peel the potatoes before he blends them to prevent residents from choking. Interviews with multiple residents between 4/8/2023 and 4/9/2023 during lunch revealed that they were waiting for lunch which was supposed to be served around 12 noon. Residents stated they have been waiting for two hours and they are hungry. Residents were told they ran out of food and was offered grilled cheese. Residents stated the kitchen was short staffed and they do not normally eat this late. Observation of lunch service on 4/8/23, and 4/09/2023 revealed the last trays for lunch was served 2:24 pm. On 04/10/2023 at 2:10pm revealed lunch was not served, and residents were observed waiting in the dining room. Further observation revealed residents asking for lunch. Lunch was served at 2:30pm. In an interview with Cook C on 4/10/2023 at 2:05pm he said he did not have a recipe for the pureed diet. He further stated he was not trained on preparing pureed diet. Asked why he did not peel the potatoes he did not answer. In an interview on 4/11/2023 at 12:55pm with Dietitian A she said that the staff were in-serviced on pureed diet when she was last in the facility. She said she was not sure if the current staff in the kitchen were trained and that she was going to in-service them again. She stated that the last time she was in the facility was 3/28/2023 and she did a sanitation audit. She said she had given a copy to the Administrator but was not sure if she had followed upon the concerns. Interview on 4/12/1023 between 12:30pm and 1:00pm with residents who eat in the dining room revealed lunch was always late. They said they need more staff in the kitchen to get lunch early. Observation on 4/12/2023 during the lunch services revealed that lunch was served at 1:45 pm. Observation of the kitchen on 4/16/2023 at 4:45pm revealed Cook D and Dietary Aide G in the kitchen preparing for the evening meal. Disposables were being used to serve the dinner meal. In an interview on 4/16/2023 at 4:50 pm with the Dietary Aide G she said the dietary aide who was supposed to work the morning shift called in and now that was why they are running late. She said that Cook D came in to help Cook C. She said she came in and did what she was supposed to do. She said the dirty dishes from lunch was still on the table in the dining room. The trays with dirty dishes from lunch was observed at the door of the dish room doorway. Observation on 4/16/2023 at 6:00pm revealed residents sitting in the dining room waiting for their meals. They stated it was 6:03pm and they had not gotten their dinner yet. Dinner tray was served at 6:05pm. In an interview on 4/16/2023 between 6:00pm and 6:10pm with residents who ate in the dining room revealed meals were late at times. They said lately meals were served very late. In an interview on 4/16/2023 at 6:10pm with Cook D he said Cook C was the only one who worked on the morning of 4/16/2023. He said he came in a little early to help Cook C, because they were short staff, but they try to ensure that residents got their meals. He said he was going to clean the dishes and pans before he left for the day because they were unable to clean the dishes after lunch because of they did not have the staff and that was why they had to use disposable for dinner. Further interviews conducted with Cook D and Dietary Aide G on 4/16/2023 at 6:15pm said they were not in-service on the issues in the kitchen. They said they have new dietary manager, and they will be in-servicing them starting 4/17/2023. In an interview with the Dietary Manager on 4/17/2023 at 10:30am she said they were short on staff. She said she heard about the staff issue Sunday morning after the fact. She said they were interviewing and hope they will be adequately staffed soon. Record review of the Leadership policies and procedures dated 11/1/2017 read in part . Subject: Staffing The facility leadership will provide enough staff to successfully implement patient/resident functions. Purpose: To provide sufficient staff with appropriate competencies and skills to provide nursing and related services to assure resident's safety and maintain the highest practical, physical, and mental wellbeing. Procedures: Provides qualified personnel based on organizational mission, scope of service provides the population served, and federal and state certification and licensure requirement. Nutritional Needs: Employs sufficient support personnel competent to carry out the functions of dietary services.'

Based on observations, interviews, and record reviews, the facility failed to ensure that the menus were followed and served on time for 4 of 4 observed meals in that: 1. Residents were served sliced pork, mashed potatoes, and cauliflower instead of teriyaki chicken, fluffy rice, seasoned mixed vegetables, fresh baked roll and frosted cake for lunch on 4/8/2023. 2. Residents were served chopped ham mixed with corn, beans, and cauliflower instead of hot roast beef sandwich, baked potato, broccoli & cauliflower, and gelatin cubes with whip topping for dinner on 4/8/2023. 3. Residents were served fries and sliced sausage instead of red beans, rice & sausage, seasoned greens, fresh baked roll, cinnamon baked apples for lunch on 4/09/2023. 4. Residents were served chuck roast and beans instead of Turkey club sandwich macaroni salad, pickled beets, frosted chocolate cake for dinner on 4/9/2023. This deficient practice could affect residents who received meals and snacks from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss. The findings included: Interview with Cook D on 4/8/2023 at 11:15am, he stated he did not have the food available to cook what was on the menu for today. He stated that he would substitute for spaghetti, but he does not have the ground meat. He stated he does not know what he will cook and is trying to figure it out. He stated the substitution items also were not available. He stated that he does not order the food supply for the kitchen, the previous dietary manager who no longer works at the facility was responsible for ordering the food. He stated the administrator is now the person that orders the food. He stated that they do not have produce, as they are molded. He stated the administrator was made aware they needed food on 4/7/2023. He stated she said she would work on it. He stated food should be labeled and dated so that they do not serve food that is not edible or within the use by date. Interview with Resident #2 on 4/8/2023 at 1:48pm, he stated he has been waiting for 45 minutes for lunch. He stated he was very hungry and asked a dietary aide whose name he can't remember when food will be ready. He stated he was told it would be soon, but he has been waiting a long time. Interview with Resident #5 on 4/8/2023 at 1:55pm, she stated she has been waiting for food and she was hungry. She stated the facility needs to hire more dietary aides and cooks because residents were hungry and have been waiting a long time. Interview with Resident #6 on 4/8/2023 at 1:56pm, she stated she has been waiting 1hr and 30 mins for lunch. She stated breakfast was a long time ago and she was starving. Record review of the menu for lunch on 4/8/2023 revealed the menu item posted was not served. The posted menu consisted of Teriyaki chicken, fluffy rice, seasoned mixed vegetables, fresh baked roll, and frosted cake. Observation of the lunch menu served on 4/8/23 at 2:34pm revealed sliced pork, mashed potatoes, and cauliflower. Some residents observed eating grilled cheese sandwiches. Record review of the undated dinner menu on 4/8/2023 revealed hot roast beef sandwich, baked potato, broccoli & cauliflower, and gelatin cubes with whip topping. Observation of dinner on 4/08/2023 at 6:00pm served to residents revealed chopped ham mixed with corn, beans, and cauliflower. Interview on 4/9/2023 at 11:45am with Cook C he stated he did not know what he was cooking that day and that he did not have the food supply to cook what was on the menu for that day. He states he contacted the Administrator, and she told him to find a substitute. He stated the person responsible for ordering food was the dietary manager who no longer works at the facility. He stated that the administrator was responsible for ordering food and that the last time he worked was 4/7/2023 and he told the administrator on that date that they needed food supplies. Interview on 4/9/2023 at 11:50am with Dietary Aide A, she stated she last worked on 4/7/2023 and she informed the administrator that the kitchen needed juice and snacks for the residents. She stated the administrator stated she would handle it. She stated that she came back to work today 4/9/2023 and there aren't enough food supplies and still no juice or snacks ordered from her request on 4/7/2023 Record review of the posted menu for lunch on 4/9/2023 revealed red beans, rice & sausage, seasoned greens, fresh baked roll, cinnamon baked apples the menu items posted were not served. Observation of the lunch Menu served on 4/9/23 between 1:30 and 2:24pm revealed the meal served to residents were fries and sliced sausage. Record review of the dinner menu on 4/9/2023 revealed Turkey club sandwich macaroni salad, pickled beets, and frosted chocolate cake. The menu was not served Observation of dinner service on 4/9/2023 at 6:00pm revealed that residents were not served what was on the menu, they were served chuck roast and beans. Record review of the Nutrition Policies and Procedures dated 8/1/2020 read in part . Subject: Menus Policy: Menu will be planned to meet the Nutritional Needs and preferences of the patients in accordance with the recommended dietary allowances of the food and nutrition board. Two four-weeks menu cycles per year are utilized. They are plans to include 5 servings of grains, 5 servings of fruits, and vegetables, 2 servings of milk, eggs or cheese (as protein source) per day. Procedures: 1.Utilize a facility menu to best fit the preferences of the patient or resident. The NSD is encouraged to hold a meeting for all residents prior to the start of the cycle menu. The NDS may modified the menu to meet the preference of residents, substituting foods of similar nutritive value for those items that were replaced. The facility's dietitian approves and signs all menus, diet modification, and menu changes. 5. The current menu is posted in the facility, so it's available to the residents and staff. 6. Plan menu in advance and keep file for 6 months. 7. Make appropriate substitutions when items on the menu are not available. 8. Substitutions offer similar nutritive value. 9. Provide an alternative entree, vegetables, and starch at lunch and dinner to allow choice and meet the needs of resident who refuse the original menu.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 9 days reviewed for sufficient staffing. The facility failed to ensure there was sufficient staffing for 04/22/2023 on the 6:00pm-6:00am shift with a facility census of 62 residents where 51 residents required one or two persons assist with transfers. The facility failed to ensure there was sufficient staffing to supervise and provide service for secure unit on 4/22/2023 on the 6:00pm- 6:00am shift for a secure unit census of 19. The facility filed to ensure there was adequate staffing to evacuate 62 residents in the event of an emergency. These failures could place residents at risk of not receiving care and services to meet their needs and could pose a risk in the event of an emergency with evacuation. Findings include: Record review of facility census on 4/21/23 revealed 61 residents. Record review of the facility's CMS 672 form dated 4/21/23 revealed the following: 51 residents required one or two staff assist with transfer 10 residents are dependent in transferring 16 residents have behavioral healthcare needs 56 residents frequently incontinent of bladder 42 residents frequently incontinent of bowel Review of the facility time sheets for 04/22/2023 revealed two staff (LVN U and RN BB) were assigned to 6:00pm -6:00am shift. CNA S was assigned to 2pm-10pm shift. CNA T was assigned to 2pm-10pm and 10pm - 6am shift. Record review of the memory care census revealed 19 residents with diagnosis of Alzheimer's /Dementia, 18 residents that were a fall risk, and 6 residents had behaviors. An observation on 4/22/23 at 7:23pm of the secure unit revealed residents were left unattended in secure unit for 15minutes or more (7;23pm -7:40pm). Observation of each room of the secure unit revealed no staff was present. Four residents were observed in their rooms. Fifteen residents were observed in the main area of the secure unit siting and some walking. A foul urine odor was present. In an Interview on 4/22/2023 at 7:45pm with CNA T (assigned to the secure unit on 4/22/2023), she stated she was asked by LVN U to give other residents on a different hall a smoke break due not having sufficient staff. She stated she thought that the nurse would come and supervise the residents. She said it was difficult to manage the resident's behaviors and monitor residents that were a high fall risk with only one staff. She stated the nurse comes in time to time. She stated that she was responsible for incontinent care, showers, dressing, getting the residents to bed, passing trays, and assisting residents. She reported that it was difficult with one staff to appropriately cater to all the resident's needs. She stated eight residents had behavioral needs. She stated she redirects residents by distracting them with snacks, tv or activities. She stated she tries to keep the residents in one area so she can supervise them all. She stated she does resident incontinent care one by one until she was finished with all residents. She stated she was asked by management to work 10pm - 6pm because there was no staff available. She stated some residents were combative, some had behaviors to include spitting, falling, and physical altercations. She stated she thinks that there should be more staff on the unit. She stated in the event of an emergency she would try her best to evacuate the residents, but she does not think it would be an easy task due to residents on the unit having cognitive communication concerns, memory concerns and not being mentally able to follow directions. In an interview on 4/22/23 at 6:55pm with RN BB, he stated he has worked for the facility for two months. He reported that 2 nurses are assigned to 6pm- 6am shift. He reported staffing is an issue due to people calling in. He stated on the weekends there are many times that CNA's and nurses do not show up for their assigned shift. He stated on 4/22/23 the facility was staffed with 2 nurses and 2 CNA's. He reported that this can cause medications to be administered late as well as call lights being unanswered for a significant time due to no staff being available to help. He reported he normally works on the 100 hall and many of his residents require assistance in the event of an emergency. He stated he would not know how to manage an emergency with the current staffing issues. He reported that he informed the ADON upon commencement of his shift on 4/22/23 when he realized there was not sufficient staff present for the shift. Her response was she was going to speak to the scheduling person and ask her to come to the facility to help. In an interview on 4/22/23 at 7:20pm with LVN U, she stated that CNAs called in and that the facility is short staffed. She stated she doesn't know all the residents that are two persons assist but its many of them. She stated that in the event of an emergency she would try her best to remove residents that are in immediate danger perhaps moving them to another area. She stated it would be difficult with the amount of staff present. She stated that the RN and LVN assigned to the 6pm-6am shift split the medication pass and that they do run a little behind because it's so many residents and short of staff. She stated she would notify ADON about the staffing to see what could be done. She reported that the facility is starting to use agency staff. In an interview on 4/27/23 at 6:10pm with RN BB, he stated the Staffing Coordinator arrived at the facility a little after 8pm and left before 11pm on 4/22/23. He stated she worked on 100 hall completing the duties of a CNA. He stated the secure unit needs more assistance because the CNA is left alone with 19 residents if the nurse must respond to other residents needs within the facility. In an Interview on 4/27/2023 at 2:58pm, the staff coordinator stated that she makes the schedule for the entire month, she puts it in a binder for staff to sign up for days and utilize agency when staffing is not adequate. She stated that she does staffing biweekly based on the needs of the facility. She stated that she is also considered on call. She stated that there is an on-call rotation to include ADON, CNA N and LVN O and Staffing coordinator. The rotation is changed weekly. The person that is on call will have to come in and cover the shift if a nursing staff calls in. She stated that LVN U texted her on 4/22/23 and told her that there was only one CNA in the building. She stated that the staffing should be 4 CNAs on 2pm-10pm shift to accommodate the needs of the facility. She stated that weekends and holidays staff call in, and that she comes in to assist when situations like this occur. She stated that the secure unit has 19 residents and 1 staff is always present. She stated it is not ideal. She stated that 2 CNA's and 1 nurse would be the ideal staffing to meet the needs of the residents on the secure unit on the 2pm-10pm shift. She stated that she has communicated this to the management and administration staff to include the ADON, DON and administrator. She stated that she does not believe she would be able to evacuate the residents with the staffing on 4/22/23. She stated at no point in time is the secure unit supposed to be left without staff to supervise the residents due to their cognitive needs. She stated she came in on 4/22/23 at 8:28pm and clocked out at 11:17pm. She stated she came to assist with coverage and the needs of the facility. She stated she assigned herself to hall 100 for the time she was at the facility on 4/22/23. She stated that CNA NN was assigned to 10pm-6am shift. She stated CNA NN came in for her assigned shift at 10:58pm- 6:52am. She stated that ideally there would be three CNAs for the 10pm- 6am shift to cater to the needs of the census of the facility. She stated that the RVP, Human resources, ADON and DON are aware of the staffing concerns. She stated they facility is combating the issue by utilizing agency staff and on call rotation. She stated they started utilizing agency staff around 4/13/23. In an Interview on 4/27/23 at 3:35pm with ADON, she stated the facility is adequately staffed on the 2pm- 10pm shift with 4 CNAs and 2 nursed from 6am-6pm. She stated that the goal for the secure unit to be adequately staffed would consist of 2 CNAs from 2pm-10pm and 1 nurse at 6pm-6am. She stated that she does not have a dedicated nurse for the 6pm-6am shift on the secure unit at this time. She stated that she was not aware of residents being left unsupervised on the secure unit on 4/22/23. She stated that it is her expectation that she would be notified of staffing needs and incidents where residents are left unsupervised. She stated that residents on the memory care unit being left unsupervised could result in injury to residents, elopement, ingestion of things such as sanitizer, and falls. She stated that in the event of an emergency if staff are not present that could pose an imminent risk to the residents on the secure unit. She stated she was made aware at about 7:30pm on 4/22/23 by RN BB that only one CNA was present from 2pm-10pm shift and that CNA was assigned to the secure unit. She stated she contacted the staffing coordinator and was told there is another CNA present at the facility. She stated CNA S was in the break room. She stated that the staffing coordinator was asked to go into the facility to fill in. The ADON stated there is no policy for staffing on the secure unit. In an Interview on 4/27/23 at 4:27pm with LVN U, she stated she saw CNA T leave the memory care unit on 4/22/23 and she was aware that no staff was supervising the residents on that hall. She stated she did not tell her to go give residents a smoke break and she is not sure where she went. She stated she was gone for about 15minutes. She reported not going to the secure unit to supervise the residents once she noticed CNA T leave the unit due to being busy doing other task and the facility being short staffed. She stated that it could be fatal if a resident fell or needed immediate care, and no one was there to supervise. She stated some residents have behaviors and that would also be a concern, as the residents are vulnerable. She stated in case of an emergency if no one was on the secure unit to supervise the resident it could mean that residents will not know what to do. She stated she knows that there is a lot to be fixed regarding staffing at the facility and meeting the needs of the residents. She stated the residents are not normally left alone. In an Interview with the RVP on 4/27/23 at 4:49pm, she stated that she is now functioning as the Administrator overseeing the facility as of 4/12/23. She stated that she was not aware of any staffing issues on 4/22/23. She stated that she is not aware of any incidents regarding residents being left unsupervised in the secure units. She stated that staff would let her know when there is a staffing issue. Then she would respond by posting a shift online. She stated that both ADON and Staffing coordinator work on call in the event there is a staffing issue. The RVP reported that she believes that the facility has the daily staffing necessary to meet the needs of the facility. She stated that she is actively trying to hire new staff. She stated that in the event of an emergency she thinks the residents on the memory care unit would be alert enough to try to push the emergency door open. She stated that in the event of an emergency the nurses would be alerted by an alarm, and they would respond to the memory care unit. She reported that some of the residents would be able to exit the facility without assistance. She stated she does not know the diagnosis of the residents on the secure unit but believes many of them are there due to wandering. She stated if left unsupervised the residents could fall or if there was a medical emergency needing immediate response it could be detrimental. She stated that some on the residents could have behaviors if triggered. She stated residents are put on the secured unit due to wandering, typically. She stated that there is a dedicated nurse for memory care unit. She does not know who the nurse is. She stated that the staffing system that she has in place is sufficient. She stated there is no policy on the number of staff needed to supervise residents on the secure unit.

Based on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance to 8 residents who received a pureed diet in that. The facility failed to follow the recipe for pureed menu items. The facility failed that foods were prepared by methods that conserved nutritive value and flavor. These failures could affect all residents who received pureed meals by placing them at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: Observation on 04/10/2023 at 1:45pm during lunch preparation of pureed menu items revealed Cook C preparing the pureed diet for the lunch meal. Cook C took some chopped pork put it in the food processor and added water and blend it. For the peas he used the #12 scoop which is equivalent to 2 and 3/4 ounces and put it in the food processor and add some water and blend it, for the potatoes he put the potatoes in the food processor and blend it. Cook C did not peel the potatoes he blended it with skin, and he did not measure any of the menu items. Cook C did not use a recipe. Record review of the of the undated recipe for Pureed Potatoes revealed 1 portion of potato place in food processor and add juice from meat until desired pudding like consistency was reached. Puree should be smooth texture, no lumps, liquid must separate from solid, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a spoonful. In an interview on 4/10/2023 at 1:55 p.m. with Cook C he said he did not have a recipe to follow for the pureed food. He said he was preparing pureed meals for 8 residents. He said he used water as liquid. It was explained that she did not measure the portion size of the menu items or the liquid. At that point he did not say anything. He said he was not trained to prepare pureed menu items. Observation on 4/12/2023 at 12:30pm revealed Cook C preparing pureed meat. He put the meat in the food processor went to the juice machine and got some juice and was about to pore the juice on the chicken. At that point the Surveyor intervened and asked what kind of juice he had, and he said it was lemonade. At that point he made some broth and blend the chicken. Interview with Cook C on 4/12/2023 at 12:45pm regarding the use of lemonade to puree the chicken he said he eats everything. Asked what should be used to puree the meat he did not answer. Record review of the undated pureed recipe for baked potato for 10 residents Potatoes, Baker 10 each Ground Pork 1 3/8 lbs. Cheese Cheddar grated 5/8 lbs. Sour Cream 5/8 cups. Puree: Smooth texture, no lumps, liquid must separate from solid, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a spoonful. Record review of undated Seasoned Green Peas for 10 Peas, green frozen 1 3/4 lbs. Pepper black 1/4 Tsp Salt 5/8 Tsp Margarine 0.05lbs. 1. Place peas in pot. Cover with minimum amount of boiling water. Simmer about 5 minutes until tender. Do not overcook. 2. Pureed Instructions: (Portion size=#8 dipper) Measure 1/2 cup cooked peas and 1 TBSP water for each serving needed into food processor. Blend until smooth. Pour into baking pan, cover, and reheat to 165 degrees before serving. Discard any leftover product at the end of meal service. Notes: 1. 4Pureed: Smooth texture. No lumps, liquid must not separate from solid, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a single spoonful. In an interview on 4/11/2023 at 12:55pm with Dietitian she said that the staff were in-serviced on pureed diet when she was last in the facility. She said some of the kitchen staff were new and she was not sure if they were in serviced. She said she said that she was going to in-service them again. Observation of Test Tray done on 4/14/2022 at 1:50pm revealed the following: Pureed carrots had no flavor it was bland, Pureed Lasagna was very spicey (hot from black pepper). Chicken had no flavor (bland). The meal did not look appetizing it had all the same color. In an interview with the Dietary Manager on 4/14/2023 at 1:55pm she said the lasagna was very spicy/peppery, the carrots and chicken had no flavor. She said she was going to have the staff in-service on the use of black pepper and ensure the menu items had flavor and the colors were not the same. Regarding the color she said she told one of the tray aides, the colors were the same when the tray line was set up. Observation and interview on 4/21/2023 beginning at 12:20pm of lunch revealed Cook E serving lunch, Cook E took a plate put some pureed vegetables, pureed meat, and pureed bread on the plate. He then put regular Twice Baked Potato Casserole on the plate. At that point the Surveyor asked what modified diet he was serving, and he said it was a pureed diet. Asked at that point if that was pureed Twice Baked Potato Casserole and he did not answer. Further observation revealed no pureed starch on the steam table. Cook E then took some Twice Baked Potato Casserole and put it in a pan pour some water from the faucet and pour it on the Twice Baked Potato Casserole, put it in the food processor and blend it. He did not measure the ingredients. In an interview on 4/21/2023 at 12:40pm Cook E was asked if he was trained on pureed diet he said No. The Surveyor at that point asked if he had tasted the pureed potato for flavor, he said it had flavor because the regular Baked Potato Casserole had flavor. At that point he was asked to take the temperature of the pureed baked potato casserole and it was 96.7 degrees F. He then took the pureed potato off the steam table and reheat it to 165 degrees F. Record review of Ingredients for baked potato casserole Bacon 1/10 pounds bacon Potato pearls dry 1/2 pounds Cold water 3 5/8 cups Dry Mince onion 1 1/4 Tsp Sour Cream 3/8 cups Shredded Cheddar Cheese 1/8 pound 5. Puree & Mechanical Soft Instructions: Portion size is 1/2 cup. Measure 1/2 cup prepared casserole for each serving needed into food processor. Blend until smooth. Pour into greased pan, cover, and reheat to 165 degrees F or higher. Discard any product left at the end of meal service, do not reheat. Notes: 1. For Pureed: Measure desired # of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener if needs thinning. Add commercial thickener if product needs thickening. 2. For Pureed: Smooth texture. No lumps, Liquid must not separate from, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a single spoonful. Record review of the monthly audit dated 3/28/2023 revealed that the kitchen staff was in-service on food storage/dry food storage, storage in refrigerator and freezer, dish machine, kitchen sanitization. Record review of the Nutritional Policies and Procedures date 8/1/2020 read in part . Subject: Food Preparation: Policy: Food will be prepared and attractively served using methods that conserve nutritive value, flavor, and appearance. 5. Batch cook vegetables to conserve nutrient value and maintain flavor and color. 6. Prepare altered consistency foods such as ground, chopped and puree foods to meet the patient's/resident's individual needs and satisfaction. The facility will use the international Dysphagia Diet Standardization Initiative (IDDS) as the foundation for texture modified foods and thickened drinks provided to residents.

Based on record review and interview, the facility failed to consult with resident physician and notify, consistent with his or her authority, the resident representative when there is a need to alter treatment significantly for 1 out of 8 residents (Resident #3) reviewed for notification of changes. -The facility failed to notify the physician when resident was refusing insulin Lantus on dialysis days Tuesday, Thursday, and Saturdays. This failure could place residents at risk for hyperglycemia (increase blood sugar levels) and hospitalization . Findings included: Record review of Resident #3 face sheet revealed an 63year old admitted to the NF on 01/21/2022 with the following diagnoses that included Type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage from pain and numbness in feet to issues with the functions of internal organs such as the heart and bladder), end stage renal disease (kidney disease), dependence on renal dialysis, absence of left leg below knee, hypertension (elevated blood pressure), and heart failure. Record review of Resident #3's MDS dated [DATE] revealed that resident had a BIMS score of 14 indicating that resident cognition was intact. Record review of Resident #3's Care Plan dated 02/15/2023 revealed that resident was being care planned for risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diagnosis of diabetes mellitus. Resident interventions included administer medications as ordered per MD, evaluate/record/report effectiveness/adverse side effects. Further review did not reveal that resident was being care planned for refusing his insulin. Record review of Resident #3's Physician Orders revealed the following orders: -dated 12/06/2022 dialysis Tuesday, Thursday, and Saturday -dated 02/08/2023 Lantus 20 units subcutaneous (beneath the skin) for diabetes mellitus once a day at 7:00am -dated 02/07/2023 Blood glucose checks twice a day at 7:00am and 8:00pm Record review of Resident #3's Nursing Progress Notes dated 04/10/2023 documented by LPN T revealed in part: .Resident refused scheduled long actin insulin. PA notified. Blood sugar was 130 at breakfast time. Checked resident's blood sugar at lunch 179. Resident is in stable condition resting in bed eyes closed call light in reach. Will continue to monitor . Further review of Resident #3's Nursing Progress Notes dated 04/11/2023 documented by LPN T revealed in part: .Resident refused insulin due to no appetite and his scheduled dialysis day. Blood sugar 137 resident is resting eyes closed stable condition shows no s/s (signs or symptoms) of pain or discomfort will continue to monitor. Family and PA (Physician Assistant) notified . Record review of Resident #3's MAR for January 2023 revealed on dialysis days the insulin Lantus was not administered on 8 dialysis days. Resident blood sugars were being done at 7:00am and 8:00pm with blood sugars ranging from 97-230. Record review of Resident #3's MAR revealed for the month of February 2023 the insulin Lantus was held 4 times on dialysis days with blood sugar ranging from 93-238. Record review of Resident #3's MAR for the month of March 2023 revealed that the insulin Lantus was held on 8 dialysis days with resident blood sugars ranging from 82-289. Record review of Resident #3's MAR for the month of April 2023 revealed that resident did not receive insulin on 6 dialysis days with blood sugars ranging from 120-254. Interview on 04/10/2023 at 12:50pm, LPN T said she was Resident #3's nurse. LPN T said Resident #3's blood sugar was 130 at 7:00am and anytime it was below 150 she would hold resident morning insulin Lantus because she was familiar with resident food consumption. LPN T said there was not an order to hold resident insulin Lantus she just done it that way. LPN T said she did not notify the physician about holding Resident #3's insulin and that Resident #3 and herself agreed to hold the insulin when resident blood sugar was below 130. Interview on 04/11/2023 at 1:49pm LPN T said on the days that Resident #3 did not receive his insulin for the month of April was because resident had refused and that she had documented. Interview on 04/11/2023 at 2:13pm the mobile DON said that if a resident was refusing their insulin as ordered by the physician, the physician should be notified so that interventions could be put in place to better care for the resident. Interview on 04/11/2023 at 3:05pm via phone the NP for Resident #3 said no one from the NF had called him regarding Resident #3 refusing his insulin on 04/10/2023 or any other day. The NP said if Resident #3 had been refusing his insulin, he would first talk to the resident educating resident on the benefits of taking his insulin before making any changes to his medications. Further interview with the NP said Resident #3 did not have PA (Physician Assistance) just himself and the doctor. Interview on 04/12/2023 at 9:00am the mobile DON and the ADON stated that Resident #3 had a NP that came to see him and not a Physician Assistant. Interview on 04/12/2023 at 9:20am RP for Resident #3 stated that they had never received a call from the NF on 04/10/23 or any other day that resident was refusing his insulin, or that resident insulin was being held or certain days. Observation on 04/12/2023 at 9:46am Resident #3 sitting in wheelchair at the front entrance of the NF wearing street clothing. Resident #3 had a left below the knee amputation (removal of a limb). Interview on 04/12/2023 at 9:46am Resident #3 said he went to dialysis on Tuesday, Thursday, and Saturday. Resident #3 said he sometime refused his insulin on these days because he sometimes did not feel good but did not refuse his insulin on Monday 04/10/2023. Interview on 04/12/2023 at 10:05am LVN X said if a resident refused their insulin, she would notify the doctor/NP and document the happenings. Interview on 04/12/2023 at 10:42 via phone RN U said the reason she did not administer Resident #3 morning insulin Lantus on 04/04/2023 was because resident was scheduled to go to dialysis. RN U said she was afraid resident might become hypoglycemic (low blood sugar) and therefore held resident insulin. RN U said she did not inform the doctor/NP of her holding the insulin and that it was nursing judgement. Interview on 04/12/2023 at 11:30am the mobile DON said she had reviewed Resident #3's MAR for 04/09/2023 and saw where resident insulin Lantus was not being administered as order by the physician. The mobile DON said she had begun to in-service the nurses on administration of insulin. The mobile DON said when insulin is not administered as order by the physician, resident blood sugar readings would not be consistent but up and down. The mobile DON said nurse LPN T could not come back to the NF to work and that the NF had suspended LPN T pending further investigation. The mobile DON said LPN T could not be trusted to work at the NF. Further interview on 04/12/2023 at 11:48am the NP said he learned from the surveyor and speaking with Resident #3 on 04/12/2023 that the insulin Lantus was not being administered as ordered. The NP said by not administering resident insulin as ordered placed resident at risk for becoming hyperglycemic (increase in blood sugar) or go into diabetic ketoacidosis (when the body does not have enough sugar to meet its energy needs, it will break down fat instead) which was not good. The NP said he would look at possibly making changes to resident insulin on dialysis days but first had to draw labs to see what resident Hemoglobin A-1 C level was. Further interview on 04/12/2023 at 12:38pm the mobile DON said it was herself and the ADON that monitored the resident MARs to ensure that the physician orders were being followed. The mobile DON said she had been working at the NF for 4 weeks. The mobile DON said how herself and the ADON was checking the MARS by reviewing the facility report that showed if all medications had been administered or not given. The mobile DON said she discovered that Resident #3 insulin was not being administered as ordered by the physician on 04/09/2023. The mobile DON said she began to in-service the staff regarding following physician orders and notifying the doctor when a resident (s) insulin is held or if the resident refuse a medication. Record review on 04/12/2023 of in-service done with the NF staff on insulin medication administration documentation, 5 rights of medication administration, and when a resident refuses to take insulin the doctor and RP must always be notified, dated 04/10/2023. Record review of physician orders for residents on dialysis revealed that Resident #3 was the only resident that received insulin. Interview on 04/19/2023 at 10:48am Doctor for Resident #3 said he and his NP were the only medical health care providers that gave orders on Resident #3 at the NF. The doctor said he learned from his NP that the Nursing staff at the NF was not administering resident insulin Lantus as order. The doctor said a conversation needed to be had with him and the NF regarding resident refusing medication Lantus so that he could look at other alternatives involving resident medication. Record review of the NF policy regarding Physician and Other Communication/Change in Condition revised 2017 revealed in part: .To improve communication between physician and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsibility regarding changes in condition .Notify the physician of change in medical condition .The nurse will document all assessments and changes in the patient's/resident's condition in the medical record .The patient's/resident family member/legal representative will be notified of any change in medical condition or treatment plan .

44333 Based on observation, interview and record review the facility failed to have evidence that all alleged violations are thoroughly investigated and measures are taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate, corrective action must have been taken for 1 of 2 residents (Resident #12 ) reviewed for abuse and neglect - The facility failed to thoroughly investigate alleged incident of abuse and neglect by waiting 10 days after the incident to interview residents with memory concerns, not interviewing other resident that had contact with the alleged perpetrator and not completing the investigation within 5 days as required by the state for allegations of abuse and neglect. - The facility failed to take action to protect Resident #12. These failures could place residents at risk of further abuse and neglect. Findings included: Record review of Resident #12 face sheet, revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, muscle wasting and atrophy, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, unspecified osteoarthritis, and major depressive disorder. Record review of Resident #12's Brief Interview for Mental Status dated 3/28/23 revealed a score of 3 out of 15. Recall section revealed scores of 0. Temporal Orientation revealed a score of 0. Repetition of three words revealed a score of 3. Summary score revealed a score of 3. Record review of Resident #12's Care plan dated 4/5/2023 revealed Resident #12 has impaired communication evidenced by: reduced ability to be understood by others, reduced ability to understand others, impaired daily decision-making ability, speaks a foreign language (English was her 2nd language). Observation on 4/8/23 at 1:24pm revealed CNA Q was in a room for Resident #11 and Resident #12 when a surveyor overheard CNA Q speaking loudly stating Shut up using obscenities for example You will end up on the floor, I am not your friend anymore. Resident #12 was heard speaking loudly in Spanish. Laundry aid B entered the room and said something to CNA Q, and both exited the room. In an interview on 4/8/23 at 1:28pm with CNA Q she stated she was just playing with Resident #12 and that she always joked with her in that way. She stated she did not mean anything by her words and that she respects the residents. She stated she plays with many of them in that way. CNA Q stated she understands what abuse and neglect was and reported that she had received in service training on abuse and neglect. In an interview with administrator on 4/8/23 at 1:35pm she stated that CNA Q was in-service on abuse and neglect and that she would investigate the allegation of abuse. In an interview with Resident #12 on 4/8/23 at 2:43pm utilizing a Spanish phone translator service the resident was determined to be not interview able. Resident #12 was unable to answer questions or stay on subject. Record review of Resident #11 undated face sheet, revealed, an [AGE] year-old female admitted to the facility on [DATE] with the latest return of 3/14/23. Diagnosis includes cerebral infraction, muscle weakness, cognitive communication deficit. Major depressive disorder, and vascular dementia. Interview with MDS nurse on 4/27/2023 at 10:08am, she stated that the BIMS goes through the resident's cognition. She stated that Resident's #11 BIMS revealed she could not be interviewed. She is severely impaired no temporal orientation (orientation to year, month, and day), long term and short-term memory problem, classified as unscorable. Record review of Brief Interview for Mental Status for Resident #11 revealed a score of 0 which stated interview was not conducted (resident was rarely/ never understood). Record review of Resident #11 care plan dated 2/15/2023 revealed Resident #11 has an impaired ability to be understood by others, reduced ability to understand others, impaired daily decision-making ability. Record review of the Incident Intake Investigation Worksheet dated 04/17/23 revealed, on 04/08/23 the facility reported an allegation of abuse made by Surveyor at 2:00pm. The Description of the allegation stated, Surveyor was making rounds in the building when she overheard someone in a resident's room calling a resident ugly, and saying shut up using obscenities, don't fall or you'll end up on the floor and we are not going to be best friends. Provider response stated, Residents were assessed with no injuries noted. Administrator talked with residents to ensure they felt safe. Investigation summary revealed CNA Q was suspended pending investigation upon administrator notification of the verbal abuse. Reeducation was initiated including verbal abuse. Investigation findings revealed a status of confirmed. Provider investigation taken post investigation revealed reeducation completed on abuse and neglect. CNA Q remained suspended and then was terminated on 4/17/23. Record review of email dated 4/17/23 from Human resources to RVP revealed CNA Q was interviewed. The email stated, I was doing my rounds and when I entered the room, the patient's legs were kind of hanging out of the bed, so I repositioned her. I also tried to explain to her that if she fell , she was going to hurt herself. When I was done repositioning the patient [NAME] me Callete. When I asked the patient what that meant she told me it meant shut up. I will admit to laughing and repeating but I was not talking to the resident directly. The email also revealed that laundry aide B was in the room delivering clothes and she denied witnessing any type of abuse or neglect. Record review of resident questionnaire dated 4/18/23 given by Social worker revealed Resident #12 responded Yes to the question do you feel safe at this facility, responded no to the question has any staff member ever abused you verbally or physically, responded yes to the question do you feel that you can talk to your guardian angel about any concerns/grievances and responded by thanking the Social worker for asking or checking if there was anything else she would like to report. Record review of resident questionnaire dated 4/18/23 given by Social worker revealed Resident #11 responded Yes to the question do you feel safe at this facility, responded no to the question has any staff member ever abused you verbally or physically, responded yes to the question do you feel that you can talk to your guardian angel about any concerns/grievances and responded by thanking the Social worker for being her friend when she was asked if there was anything else she would like to report. Record review of document titled Record of in service dated 4/8/23 revealed in service on abuse, neglect, abuse coordinator and when abuse should have been reported. In service was signed by employees from all departments. Interview on 4/26/2023 at 1:36pm with social worker, stated that he was named the abuse and neglect coordinator on 4/24/2023. He stated he has been working at the facility for approaching 2 months. He stated he was told to inform the administrator and director of nursing of allegations of abuse and neglect. He stated he was informed by the administrator of the incident and instructed to complete the questionnaire for Resident #12 and Resident #11 on 4/18/23. He stated he did not interview any other residents that CNA Q may have interacted with. He stated he did not interview any other residents on the hall where the incident occurred or within the facility. He stated he believes the investigation was not thoroughly investigated because of this. He stated the administrator made it seem like it was not a big deal and like stuff like this happen. He stated that he is familiar with Resident #12 and her diagnosis. He stated that Resident #12 has a diagnosis that prohibits long term memory. He stated he was able to interview the resident but not sure about the validity of the interview due to her diagnosis and the interview being conducted on 4/18/23 10 days after the incident which occurred on 4/8/23. He stated he was still reviewing the packet that discusses his role as the abuse coordinator. He stated that as the abuse coordinator residents, staff and visitors would report allegations or incidents of abuse and neglect to him. He stated his protocol when investigating would be to go to each room, talk to all the residents in the immediate vicinity as well as the alleged perpetrator. He stated he is still learning the position of the abuse coordinator. In an interview on 4/26/2023 at 2:23pm with Laundry Aide B she stated that she has worked at the facility for two months. She stated that she has been trained on abuse and neglect upon hire. She stated that abuse can be how you talk to and treat a resident. She stated that she heard the resident from the first bed as you walk into the room closest to the door taking loud and it surprised her. She stated she overheard the resident saying, I'm going to call the police and CNA Q saying, I am going to give you the phone. She stated she didn't hear or witness any abuse or neglect. She stated that Human resources interviewed her on 4/17/23 and she stated she did not witness abuse or neglect. In an interview with RVP on 4/27/23 at 5:13pm she stated that it normally takes 5 days to do an investigation of abuse or neglect. She stated that she forgot and lost track of time. She stated that she reviewed the investigation and asked the social worker to go back and ask Resident #11 and Resident #12 about the incident. She stated that she knows that it was a little late after the incident. She stated that when there is an allegation of abuse or neglect and an employee was named as the perpetrator, the protocol would be to suspend the employee until the investigation was completed. She stated that she considers the Brief Mental Status of the residents when investigating abuse or neglect. She stated that the normal procedure would be to interview other residents that the employee would have had contact with. She stated that there was no documentation of any other residents being interviewed other than Resident #11 and Resident #12. She stated that she instructed the social worker to interview the two residents. Record review of Termination form dated 4/18/23 revealed CNA Q was terminated effective 4/18/23. Termination was involuntary. Record review of Policy titled Organizational ethics subject: abuse, neglect, exploitation, or mistreatment dated 11/1/2017 revealed: The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/ or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). Verbal abuse includes any use of Oral language, Written language, Gestured language including, but not limited to, disparaging or derogatory terms directed to or within the patient's/resident's hearing distance. The facility maintains that all allegations of abuse, neglect, misappropriation of property etc. are thoroughly investigated and appropriate actions are taken. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (CR #1) of 12 residents reviewed for abuse and neglect. 1. The facility failed to ensure CR #1, who was cognitively impaired and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility failed to ensure staff were consistently and sufficiently trained and competent in abuse/neglect prevention and providing care to residents with dementia and aggressive behaviors. 3. CNA A and CNA E failed to follow appropriate procedure and notify a nurse for guidance and assistance when CR #1 exhibited combative/aggressive behaviors. These failures resulted in two Immediate Jeopardy (IJ) situations identified on 10/06/2022 at 4:00 p.m. and 10/08/22 at 12:31 p.m. While the IJs were removed on 10/17/2022, the facility remained out of compliance at the severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed cognitively impaired residents with aggressive behaviors at risk of serious harm and death from possible abuse and neglect. Findings include: Record review of CR#1's face sheet revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) ,anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), protein-calorie malnutrition (inadequate intake of food), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity) of left lower leg, [CONDITION(S)] (persistent problems falling asleep), polyosteoarthritis (damage to cartilage, resulting in joint pain and swelling), [CONDITION(S)] (a persistently depressed mood or loss of interest in activities), pain, dementia (a chronic disorder marked by memory disorders, personality changes, and impaired reasoning), psychotic disturbance (disorder in which one loses contact with reality and experience hallucinations, and delusions), muscle wasting and atrophy, and right leg above knee amputation. Record review of CR #1's MDS dated [DATE] revealed he was usually understood when expressing ideas and wants and he was usually able to understand others; he had a BIMS score of 3 (severe cognitive impairment); he did not have hallucinations or delusions; he rejected care and wandered; he required extensive physical assistance from at least one staff for bed mobility, locomotion, and dressing; he required extensive physical assistance from at least two staff for transfers; he was totally dependent on at least one staff for personal hygiene and bathing; he was wheelchair bound; he was always incontinent of bowel and bladder; and he was prescribed antidepressant medication. Record review of CR #1's care plan, updated on 09/26/2022 revealed the following care areas: *Alzheimer's Disease (Goal: Resident will have positive experiences in the daily routine without having overly demanding tasks and without becoming overly stressed; Approach: Allow adequate time for resident to respond; Maintain a calm environment and approach to the resident; Use non-verbal communication techniques to encourage resident to respond); *he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *he was at risk for falls due to impaired cognition, impaired mobility, incontinence and use of [CONDITION(S)] medications. The resident has a camera in his room where is responsible party has witnessed him crawl on the floor when he wants to get up (Goal: Resident will not experience major injuries due to falls. Approach: Ensure fall mats are at bedside. Continue all interventions, Patient is not falling but scooting out of bed. Low bed and fall mats in place; Anticipate all needs; Encourage resident to ask staff for assistance. Staff to check frequently, if resident hollering out either put to bed or get up; Encourage socialization; Ensure call light is in reach and use call light; Monitor for incontinence per routine rounds and as needed. Ensure resident has shorts or pants on at all times); *he has impaired communication as evidenced by reduced ability to be understood by other, reduced ability to understand others, impaired daily decision-making ability and speaks Spanish (Goal: Staff will anticipate and meet all needs that resident is not able to communicate effectively. Approach: Allow time for resident to digest information - do not rush; Approach in a calm manner, call by name; Attempt to find an interpreter as needed; Praise resident for communication efforts; Reduce or remove all interfering environmental stimuli; Use terms, gestures that resident can understand and repeat as needed); and *he has dementia as evidenced by short term and long term memory problems and impaired ability to make daily decisions at times (Goal: Resident's needs will be met and dignity maintained. Approach: Allow time for tasks and responses; Explain all procedures using terms/gestures resident can understand; Involve in care as to maintain or increase level of independence; Reorient resident as needed; Repeat information as needed). Record review of CR #1's medical records revealed he arrived at the ER of a local acute care hospital via EMS on 10/02/2022 at 6:02 p.m. CR #1 was admitted to the hospital on 10/02/2022. CT scans of his cervical spine, head/brain, and maxillofacial area (face, jaw, and mouth) were completed. [CONDITION(S)] changes were found, but there were no acute intracranial abnormalities. X-rays were taken of CR #1's right knee, right hip/pelvis, and chest. No fractures or acute changes were found. CR #1's injuries were not described in the medical records (the complete medical record could not be provided because CR #1 was still a admitted in the hospital at that time). Record review of CR#1's Progress Note dated 10/02/2022 written by LVN V indicated, At 5:10 p.m. resident was found on floor by CNA. I was down hall 400 giving a resident his medications when CNA A came to me to let me know that CR #1 was found on the floor. Upon arriving, CR #1 had already been lifted off the ground and placed in his bed. I took his vitals: BP 120/77, P: 66, Resp: 17, O2: 95, Temp: 97.3, A&O x2. Resident was conscious upon arrival to his room and was very combative towards the CNAs. After taking his vitals I assisted CNA J in changing the resident because he had already kicked CNA A in the abdomen area and was also trying to kick the CNA E. After changing resident, we placed him in his wheelchair and took him to the nurse's station. I notified emergency contact on file and notified his physician. 911 was called and resident was sent to ER. Record review of CR #1's SBAR Communication Form, dated 10/02/2022 written by LVN K. The document read in part . Situation, The change in condition, symptoms, or signs observed and evaluated is/are: Fall with head injury, This started on 10/02/2022 . Other relevant information: Resident observed on floor by staff . Resident/Patient Evaluation . 3. Behavioral Evaluation: Physical Aggression . 8. Skin Evaluation: Laceration . 9. Pain Evaluation . Does this resident have pain: Yes, New Pain, Description/location of pain: head/bilateral eyes . Does the resident show non-verbal signs of pain (for residents with dementia)? Yes, Complains of pain . Review and Notify: Primary Care Clinician Notified: CR #1's Physician, Date: 10/02/2022, Time: 5:25 p.m. Recommendations of Primary Clinicians: send to ER for evaluation and treatment . Observation and interview on 10/06/2022 at 9:45 a.m., with CR #1 at a local acute care hospital, revealed he had a laceration to the corner of his left eye that was healing. He had dark purple bruising to his bilateral eyelids and underneath both eyelids. Both eyes were slightly red (white parts of eyes). CR #1's left wrist was covered with a dressing (CR #1 pulled out his IV and the new IV was protected by the dressing) and there was some light purple bruising to his left forearm. CR #1 had a right above the knee amputation. Interview with CR #1 via Spanish-speaking RN revealed CR #1 was cognitively impaired. Through the interpreter, CR #1 stated his injuries were caused by five women at his home who were very upset with him. CR #1 said he lived at home with his mother before he was admitted to the hospital (he did not recall living at the facility). CR #1 said nobody ever mistreated him. In a telephone interview on 10/06/2022 at 9:40 a.m., CR #1's RP said he observed CR #1 kicking and yelling, Help me! in his sleep since he was admitted to the hospital (he could not give the date of this observation). The RP said CR #1 told his other family members some girls hit him. He said in the video from the incident on 10/02/2022, CR #1 was in a low bed, and he got himself out of the bed. He said CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He said CR #1 wanted to be in pants and sometimes, his wheelchair was placed too far away from his bed. He said the facility's staff would get frustrated because they would put CR #1 in the bed, and he would get out over and over. He said CR #1's family put the camera in his room three years ago when he (CR #1) was on a different hallway. He said CR #1's former roommate (who was no longer at the facility) told him the facility's staff were mistreating CR #1. He said when he brought the mistreatment to the Administrator and DON at that time (neither were still employed at the facility) the staff involved was terminated. Observation of a video provided by CR #1's RP on 10/06/2022 a 10:30 a.m. (the video was not dated, or time stamped. The video did not have audio. CR #1's RP stated the video was recorded on 10/02/2022 and he identified CR #1 as the resident in the video) revealed it was recorded in CR #1's room. The video revealed a male (the faces of the individuals in the video were not completely clear) with an amputated right leg, slowly lowered himself off the side of a bed which was in a low position. The resident's face did not come in contact with any structure while he was alone in the video. The male scooted himself towards the door of the room. CNA E (CNA E identified herself as the CNA who had on a pink shirt and the other CNA as CNA A in a telephone interview on 10/05/2022 at 3:47 p.m.) entered the room and closed the door. CNA E was seen talking to CR #1 and she pointed towards the bed twice during the conversation. CNA E took a pair of blue pants out of a closet and threw them on the arm of a wheelchair which was near CR #1. When CNA E left the room and closed the door, CR#1 grabbed the blue pants and put them on while he was still on the floor. CNA E returned to the room with CNA A. CNA E walked inside the room, moved a bedside table that was near CR #1, moved back the sheet and blanket on the bed, and handed CNA A some gloves. Both staff approached CR #1. CNA E attempted to grab CR #1's left leg, but he started kicking. CNA A grabbed CR #1's left leg and right arm but let his left leg go because he was kicking. CNA A then grabbed CR #1's right stump with one hand and his right arm with her other hand but let him go because his left leg kicked the wheelchair and pulled it towards him. CNA E grabbed CR #1's left arm. CNA A pulled the wheelchair back and forcefully threw CR #1's left leg from the wheelchair but when he kicked her, she kicked him around his left side buttocks area. CNA E was still holding CR #1's left wrist and she dragged him across the floor several feet towards the bed. CNA A approached CR #1 and grabbed the right side of his pants and right side of his shirt while CNA E grabbed his left arm. The staff lifted CR #1's body. CR #1's head was on the bed, then both staff flipped his bottom half in the air and onto the bed while he was kicking. CNA A was standing in front of CR #1's head and top half and appeared to be struggling with him while he flailed his arms and his left leg and right stump appeared to be kicking in the air. CNA E pulled the privacy curtain but CR #1's left foot (He only had a foot on the left side. When the staff threw CR #1 into the bed, his left side was against the wall) could be seen moving around on the floor underneath the privacy curtain. In an interview with LVN K on 10/05/2022 at 11:30 a.m., she stated she was the weekend supervisor on 10/02/2022. She said CR #1 had dementia, was usually alert and oriented to person, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CR #1 was mostly Spanish speaking, but he could speak and understand some English. She said she interacted with CR #1 on 10/02/2022 when she passed morning medication and he was ok. She said CR #1 went back to bed after lunch. She said that evening, LVN V approached her and said CR #1 fell out of bed and hit his head, so she started to assist with getting CR #1's paperwork ready to transfer him to the hospital. She said at that time, she did not know anything other than CR #1 had a fall. She said she called the Administrator to inform her of the fall. She said LVN V was fluent in Spanish and when CR #1 was on the stretcher to leave with EMS, he told LVN V one of the aides hit him. She said she stopped and called the Administrator to notify her. She said CR #1's fall was not a surprise because he frequently crawled out of bed, but the head injury was a surprise (because he had never hit his head before). She said when she saw CR #1 at the nurse's station before he left with EMS, he had a laceration at the corner of one of his eyes the other eye was red. LVN K said CR #1 pointed at one of the aides (CNA A or CNA E) and told LVN V she was the one who hit him. She said CR #1's family member arrived at the facility on 10/02/2022 at 6:45p.m. and showed her the video of CR #1's assault before she posted it on social media. She said CNA A and CNA E were both out of the facility when the family member arrived. In a telephone interview with LVN V on 10/05/2022 at 4:00 p.m., she stated she worked PRN on weekends but 10/02/2022 was not the first day she worked with CR #1. She said CR #1 had dementia and tended to go in and out with memory. She said CR #1 could be combative when he was upset, but she never had issues with him trying to hit or kick her. She said redirecting CR #1 with coffee helped to calm him down. She stated she spoke Spanish. She said CR #1 had one leg, but he could self-propel in his wheelchair. She said staff put CR #1 in bed and he tried to get himself out. She said whenever there was a fall, CNAs were supposed to call a nurse to assess each resident for injuries. She said if the resident hit their head, neuro checks would be initiated. She said on 10/02/2022, she was down 400 hall passing medication when CNA A came and said CR #1 fell out of bed. She said she was confused because she thought CR #1 was already out of bed and in the dining room. She said earlier on 10/02/2022, she was doing medication rounds and CNA E came and said CR #1 was trying to get out of his bed. She said typically, staff put CR #1 in his wheelchair and take him to the nurse's station if he was trying to get up out of bed. She said she asked CNA E to put CR #1's pants on and put him in his wheelchair and take him to the dining room. She said she grabbed the medication cart and went down to CR #1's hall. She said she thought it was strange when she walked into CR #1's room and saw the privacy curtain was closed. She said she pulled open the curtain and saw CR #1 on the bed. She said CR #1's face shocked her. She said CR #1's injuries did not look they were caused by a fall. She said the area under CR #1's left eye was already puffy, liked he got socked (hit) in the face. She said the area above CR #1's eye was swollen and red. She said the blood vessels in both of CR #1's eyes had burst. She said CR #1 had a laceration in the corner of one eye. She said it looked like CR #1's whole eye burst. She said CR #1 kept cursing and yelling at CNA A and CNA E like he did not want them by him. CR #1 was angry. She said she told the CNAs CR #1's injuries were not consistent with a fall. She said one of the CNAs (she could not recall which one) said the laceration was from when CR #1 hit himself on the side rail. She said CR #1 was already in bed, so there was no way for her to tell how he fell or where. She said CNA J was in CR #1's room with her, so she (CNA J) assisted with incontinent care, and they changed his clothes. She said they put CR #1 in his wheelchair and took him to the nurse's station to get ready for transport. She said when LVN K saw CR #1 at the nurse's station, she said, Oh God! She said she told LVN K this (CR #1's injuries) did not look like a fall. LVN V said once EMS arrived, CR #1 was looking at CNA A while he cursed and said that was the [OBSCENITY] ing black [OBSCENITY] that hit him. She said she told LVN K, CR #1 said he was hit. She said CNA E went down the hall, but CNA A stayed close to the nurse's station watching the nurses and EMS prepare CR #1 for transport. She said when CR #1 saw CNA E walk down the hall, he said that's the [OBSCENITY] ing black lady that hit him. LVN V said she asked CR #1 who hit him, but he would not initially repeat what he said. She said CR #1 again said that is the other black [OBSCENITY] that hit him. She said after CR #1 left for the hospital, she called his responsible party and told him CR #1 fell but she did not know how he landed on the floor. She said she explained CR #1's injuries and told the responsible party they sent the resident to ER. She said the responsible party was very short and quickly said goodbye. She said within maybe 20-30 minutes, another one of CR #1's family members called and said they reviewed the video from the camera inside CR #1's room. She said the family member said both of the women (CNA A and CNA E) were fighting CR #1. LVN V said as soon as they got the information from CR #1's family member, LVN K walked towards the CNAs (CNA A and CNA E) and she saw one of them clock out. She said both CNAs were out of the building, but CNA A had to wait outside waiting for her ride. She said CNA A asked her who was going around saying CR #1 was assaulted. In an interview with the Administrator on 10/05/2022 at 10:30 a.m., she stated one of CR #1's family members posted a video of CR #1 being assaulted by CNA A and CNA E to social media. The Administrator said on Sunday, 10/02/2022, she was called by LVN K, who was the weekend supervisor at that time. She said LVN K initially told her CR #1 fell out of bed and was being sent out to a local hospital because he hit his head as a result of the fall. She said when she was in the process of reporting the unwitnessed fall with injury to HHSC, she received a text message (on 10/02/2022 at 6:03 p.m.) from CR #1's RP. She said the RP sent her the video of CR #1's assault by text. The Administrator said she had LVN K bring CNA A and CNA E to the conference room to question them about the video while she was on speaker phone. She said when she asked the CNAs about abuse and an unusual occurrence, without mentioning the specific resident's name, the CNA's said nothing happened. The Administrator said she told both CNAs to leave the building immediately and she notified the police. The Administrator said the next morning, 10/03/2022, she called both CNAs and asked about the abuse and video. She said both CNAs said nothing happened. She said both CNAs were terminated by phone on 10/03/2022. She said CNA E was calm and said okay, but CNA A reacted and said she wanted to press charges against CR #1 for kicking her. The Administrator said she asked CNA A if she used proper protocol during the incident with CR #1 and she said no. The Administrator said proper protocol would have been for the staff to get a nurse for assistance or walk away from the resident when he got aggressive. The Administrator said CNA A said she did not kick CR #1, but she tripped. The Administrator said an electronic monitoring sign was posted on CR #1's door and the camera had been placed in his room by his family for a while (she could not say how long the camera was in CR #1's room). The Administrator said CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CR #1's bed was in the lowest position at the time of the incident on 10/02/2022. She said CR #1 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CNA A and CNA E stayed (worked) on CR #1's hall a while (she could not say how long CNA and CNA E worked on CR #1's hall). She said according to the video she received from CR #1's RP, the incident occurred on 10/02/2022 at 5:00 p.m. In a telephone interview with CNA E on 10/05/2022 at 3:47 p.m., she stated CR #1 was combative and fought staff every day. She said when CR #1 was combative, she usually left him alone for a period of time, but when she came back, he was always still combative. She said on the day of the incident (10/02/2022), she heard CR #1 screaming and yelling from the hall. She said she went to CR #1's room and saw him on floor around 5:00 p.m. She said she went to get CNA A for assistance. She said when they picked CR #1 up off the floor, he had a laceration on his eye. She said the laceration probably happened when he fell out of the bed, but she did not know because she was not in the room when he fell . She said she did not see the laceration until they put CR #1 in the bed. She said CR #1 must have hit his eye when he fell but the laceration did not appear until they put him in the bed. She said when they proceeded to get CR #1 off the floor, he fought them like normal. She said after they got CR #1 up and back in his bed, they went to get a nurse. She said the nurse assessed CR #1 and told them put him in his wheelchair to send him out to the hospital. She said normal procedure would have been to get a nurse before they picked CR #1 up off the floor, but because he did that (placed himself on the floor) all the time, they just usually picked him up and put him in bed. She said CR #1 only spoke Spanish but the nurse who assessed him (LVN V) spoke Spanish to him. She said normally, she would call for a nurse to assess a resident before she put them in bed, but did not call for that this time. She said this (CR #1 being aggressive with staff) happened all the time with CR #1. She said in reference to the video of the incident from 10/02/2022, she was the woman in the pink shirt. She said she never had to drag CR #1 before as she did in the video, but he always wanted to fight. CNA E said she did not usually work on CR #1's hall and she did not work with CR #1 often. She said she had recently received abuse/neglect training, but she still did not feel she had been sufficiently trained to care for CR #1 and other aggressive residents like him. In a telephone interview with CNA E on 10/06/2022 at 11:06 a.m., she stated she was worried about losing her certification as a result of the incident with CR #1 on 10/02/2022. She said she did not hit CR#1 and his injuries were caused by CNA A hitting him. CNA E said she only held CR #1's arm when she tried to get him off the floor. Unsuccessful attempts were made to contact CNA E by phone for additional information on 10/17/2022 at 11:00 a.m., and 10/19/2022 at 3:42 p.m. Voicemail messages and texts were left. Unsuccessful attempts were made to contact CNA A by phone on 10/04/2022 at 11:09 a.m., 10/06/2022 at 11:37, 10/10/2022 at 3:15 p.m., and 10/19/2022 at 3:45 p.m. Voicemail messages and texts were left. In an interview with the Administrator on 10/06/2022 at 12:13 p.m., she provided CNA A and CNA E's training records and stated the records indicated neither of the CNAs completed two computer-generated trainings on dementia/aggressive behaviors, Alzheimer's Disease and Related Disorders, Behavior and ADL Management and, Caring for the Person with Dementia Behaviors and Communication. Record review of CNA A's employee record revealed she was hired on 06/30/2020 and was terminated on 10/03/2022. All background checks were completed upon hire. Record review of CNA A's training records revealed: Caring for a Guest with Dementia - Completed 06/30/2020. Alzheimer's Disease and Related Disorders, Behavior and ADL Management - dated 04/14/2022: Not completed (the Administrator said the training was not completed because there was no grade). Caring for the Person with Dementia Behaviors and Communication - dated 04/14/2022: Not completed (the Administrator said the training was not completed because there was no grade). About Caregiver Conduct, and Preventing, Recognizing, and Reporting Abuse - Completed on 09/16/22. Further review of the records revealed no other trainings/in-services related to residents with aggressive behaviors or Alzheimer's Disease/dementia. Record review of CNA E's employee record revealed she was hired on 01/19/2018 and was terminated on 10/03/2022. All background checks were completed upon hire. Record review of CNA E's training records revealed: Caring for a Guest with Dementia - Completed 01/19/2018. Alzheimer's Disease and Related Disorders, Behavior and ADL Management - dated 06/21/2022: Not completed (the Administrator said the training was not completed because there was no grade). Caring for the Person with Dementia Behaviors and Communication - dated 06/21/2022: Not completed (the Administrator said the training was not completed because there was no grade). About Caregiver Conduct, and Preventing, Recognizing, and Reporting Abuse - Completed on 09/16/22. Further review of the records revealed no other trainings/in-services related to residents with aggressive behaviors or Alzheimer's Disease/dementia In a follow-up interview with the Administrator on 10/18/2022 at 11:53 a.m., she stated the two trainings CNA A and CNA E failed to complete (Alzheimer's Disease and Related Disorders, Behavior and ADL Management and, Caring for the Person with Dementia Behaviors and Communication) were not mandatory trainings and she could not force staff to complete trainings that were not mandatory. She said those subjects (aggressive behaviors and residents with dementia) were mentioned in other mandatory trainings each staff member would have had upon hire. She said she did not think CNA A's and CNA E's competencies had anything to do with them abusing the residents. In an interview with CNA L on 10/09/2022 at 9:43 a.m., she stated she had not received any training at the facility regarding aggressive resident behaviors or caring for residents with Alzheimer's Disease and dementia. In an interview with CNA O on 10/09/2022 at 10:00 a.m., she stated she had not been trained regarding aggressive residents or providing care to residents with Alzheimer's Disease or dementia. In an interview with CNA T on 10/10/2022 at 2:02 p.m., she stated she had not received any training from the facility on how to care for residents with aggressive behaviors or residents with Alzheimer's Disease and dementia. In an interview with CNA N on 10/10/2022 at 2:12 p.m., she stated she had not received any training from the facility regarding providing care to residents with aggressive behaviors or residents Alzheimer's Disease and dementia. In an interview with CNA B on 10/10/2022 at 2:40 p.m., she stated she received training on how to care for residents with Alzheimer's Disease, dementia, and aggressive behaviors at a different facility she worked at previously. She said she had not received those trainings at her current facility. In an interview with the HR Director on 10/11/2022 at 12:21 p.m., she said she and the Administrator were responsible for ensuring staff were current with all training/in-services. She said they ran a report from their electronic training system every two weeks which listed each employee's training to be completed. She said the report was distributed to each department head to ensure their staff were trained. In an interview with the Administrator on 10/11/2022 at 12:42 p.m., she stated she and each department head were responsible for ensuring each staff were trained. She said she and the HR Director run and review a report from their electronic training system which indicated which trainings needed to be completed by each staff. She said the reports were distributed to each department head to make sure their staff complete training. The Administrator said she also frequently spoke to staff about their training needs. The Administrator said she did not know why CNA A and CNA E had not completed trainings listed on their training records. Record review of the facility's document Statement of Resident Rights undated revealed, You, the resident do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint . You have the righ [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure staff who provide direct services to residents had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure CNA A and CNA E, who were observed on video dragging, kicking, and throwing CR #1 into bed, had adequate, updated, and effective training specifically related to providing care to residents with dementia and aggressive/combative behaviors. An Immediate Jeopardy (IJ) situation was identified on 10/08/2022 at 12:32 p.m. While the IJ was removed on 10/17/2022, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed cognitively impaired residents with aggressive behaviors at risk of being physical abuse, neglect, hospitalization , or death. Findings include: Record review of CR#1's face sheet revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) , anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), protein-calorie malnutrition (inadequate intake of food), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity) of left lower leg, [CONDITION(S)] (persistent problems falling asleep), polyosteoarthritis ( damage to cartilage, resulting in joint pain and swelling), [CONDITION(S)] (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), pain, dementia (a chronic disorder marked by memory disorders, personality changes, and impaired reasoning), psychotic disturbance (disorder in which one loses contact with reality and experience hallucinations, and delusions), muscle wasting and atrophy, and right leg above knee amputation. Record review of CR #1's MDS dated [DATE] revealed he was usually understood when expressing ideas and wants and he was usually able to understand others; he had a BIMS score of 3 (severe cognitive impairment); he did not have hallucinations or delusions; he rejected care and wandered; he required extensive physical assistance from at least one staff for bed mobility, locomotion, and dressing; he required extensive physical assistance from at least two staff for transfers; he was totally dependent on at least one staff for personal hygiene and bathing; he was wheelchair bound; he was always incontinent of bowel and bladder; and he was prescribed antidepressant medication. Record review of CR #1's care plan, updated on 09/26/2022 revealed the following care areas: *Alzheimer's Disease (Goal: Resident will have positive experiences in the daily routine without having overly demanding tasks and without becoming overly stressed; Approach: Allow adequate time for resident to respond; Maintain a calm environment and approach to the resident; Use non-verbal communication techniques to encourage resident to respond); *he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *he was at risk for falls due to impaired cognition, impaired mobility, incontinence and use of [CONDITION(S)] medications. The resident has a camera in his room where is responsible party has witnessed him crawl on the floor when he wants to get up (Goal: Resident will not experience major injuries due to falls. Approach: Ensure fall mats are at bedside. Continue all interventions, Patient is not falling but scooting out of bed. Low bed and fall mats in place; Anticipate all needs; Encourage resident to ask staff for assistance. Staff to check frequently, if resident hollering out either put to bed or get up; Encourage socialization; Ensure call light is in reach and use call light; Monitor for incontinence per routine rounds and as needed. Ensure resident has shorts or pants on at all times); *he has impaired communication as evidenced by reduced ability to be understood by other, reduced ability to understand others, impaired daily decision-making ability and speaks Spanish (Goal: Staff will anticipate and meet all needs that resident is not able to communicate effectively. Approach: Allow time for resident to digest information - do not rush; Approach in a calm manner, call by name; Attempt to find an interpreter as needed; Praise resident for communication efforts; Reduce or remove all interfering environmental stimuli; Use terms, gestures that resident can understand and repeat as needed); and *he has dementia as evidenced by short term and long term memory problems and impaired ability to make daily decisions at times (Goal: Resident's needs will be met and dignity maintained. Approach: Allow time for tasks and responses; Explain all procedures using terms/gestures resident can understand; Involve in care as to maintain or increase level of independence; Reorient resident as needed; Repeat information as needed). Record review of CR #1's medical records revealed he arrived at the ER of a local acute care hospital via EMS on 10/02/2022 at 6:02 p.m. CR #1 was admitted to the hospital on 10/02/2022. CT scans of his cervical spine, head/brain, and maxillofacial area (face, jaw, and mouth) were completed. [CONDITION(S)] changes were found, but there were no acute intracranial abnormalities. X-rays were taken of CR #1's right knee, right hip/pelvis, and chest. No fractures or acute changes were found. CR #1's injuries were not described in the medical records (the complete medical record could not be provided because CR #1 was still a admitted in the hospital at that time). Record review of Resident Progress Note dated 10/02/2022 revealed LVN V wrote, At 5:10 p.m. resident was found on floor by CNA. I was down hall 400 giving a resident his medications when CNA A came to me to let me know that CR #1 was found on the floor. Upon arriving, CR #1 had already been lifted off the ground and placed in his bed. I took his vitals: BP 120/77, P: 66, Resp: 17, O2: 95, Temp: 97.3, A&O x2. Resident was conscious upon arrival to his room and was very combative towards the CNAs. After taking his vitals I assisted CNA J in changing the resident because he had already kicked CNA A in the abdomen area and was also trying to kick the CNA E. After changing resident, we placed him in his wheelchair and took him to the nurse's station. I notified emergency contact on file and notified his physician. 911 was called and resident was sent to ER. Record review of, SBAR Communication Form, dated 10/02/2022 revealed it was completed by LVN K. The document read in part . Situation, The change in condition, symptoms, or signs observed and evaluated is/are: Fall with head injury, This started on 10/02/2022 . Other relevant information: Resident observed on floor by staff . Resident/Patient Evaluation . 3. Behavioral Evaluation: Physical Aggression . 8. Skin Evaluation: Laceration . 9. Pain Evaluation . Does this resident have pain: Yes, New Pain, Description/location of pain: head/bilateral eyes . Does the resident show non-verbal signs of pain (for residents with dementia)? Yes, Complains of pain . Review and Notify: Primary Care Clinician Notified: CR #1's Physician, Date: 10/02/2022, Time: 5:25 p.m. Recommendations of Primary Clinicians: send to ER for evaluation and treatment . Observation of a video provided by CR #1's RP on 10/06/2022 at 10:30 a.m. (the video was not dated, or time stamped. The video did not have audio. CR #1's RP stated the video was recorded on 10/02/2022 and he identified CR #1 as the resident in the video) revealed it was recorded in CR #1's room. The video revealed a male (the faces of the individuals in the video were not completely clear) with an amputated right leg, slowly lowered himself off the side of a bed which was in a low position. The resident's face did not come in contact with any structure while he was alone in the video. The male scooted himself towards the door of the room. CNA E (CNA E identified herself as the CNA who had on a pick shirt and the other CNA as CNA A in a telephone interview on 10/05/2022 at 3:47 p.m.) entered the room and closed the door. CNA E could be seen talking to CR #1 and she pointed towards the bed twice during the conversation. CNA E took a pair of blue pants out of a closet and threw them on the arm of a wheelchair which was near CR #1. When CNA E left the room and closed the door, CR#1 grabbed the blue pants and put them on while he was still on the floor. CNA E returned to the room with CNA A. CNA E walked inside the room, moved a bedside table that was near CR #1, moved back the sheet and blanket on the bed, and handed CNA A some gloves. Both staff approached CR #1. CNA E attempted to grab CR #1's left leg, but he started kicking. CNA A grabbed CR #1's left leg and right arm but let his left leg go because he was kicking. CNA A then grabbed CR #1's right stump with one hand and his right arm with her other hand but let him go because his left leg kicked the wheelchair and pulled it towards him. CNA E grabbed CR #1's left arm. CNA A pulled the wheelchair back and forcefully threw CR #1's left leg from the wheelchair but when he kicked her, she kicked him around his left side buttocks area. CNA E was still holding CR #1's left wrist and she dragged him across the floor several feet towards the bed. CNA A approached CR #1 and grabbed the right side of his pants and right side of his shirt while CNA E grabbed his left arm. The staff lifted CR #1's body. CR #1's head was on the bed, then both staff flipped his bottom half in the air and onto the bed while he was kicking. CNA A was standing in front of CR #1's head and top half and appeared to be struggling with him while he flailed his arms and his left leg and right stump appeared to be kicking in the air. CNA E pulled the privacy curtain but CR #1's left foot (He only had a foot on the left side. When the staff threw CR #1 into the bed, his left side was against the wall) could be seen moving around on the floor underneath the privacy curtain. Observation and interview with CR #1 at a local acute care hospital on 10/06/2022 at 9:45 a.m. revealed he had a laceration to the left corner of his left eye that was healing. He had dark purple bruising to bilateral eyelids and underneath both eyelids. Both eyes were slightly red (white parts of eyes). CR #1's left wrist was covered with a dressing (CR #1 pulled out his IV and the new IV was protected by the dressing) and there was some light purple bruising to his left forearm. CR #1 had a right above the knee amputation. Interview with CR #1 at that via Spanish-speaking RN revealed CR #1 was cognitively impaired. Through the interpreter, CR #1 stated his injuries were caused by five women at his home who were very upset with him. CR #1 said he lived at home with his mother before he was admitted to the hospital (he did not recall living at the facility). CR #1 said nobody ever mistreated him. In a telephone interview with CR #1's RP on 10/06/2022 at 9:40 a.m., he said he observed CR #1 kicking and yelling, Help me! in his sleep since he was admitted to the hospital (he could not give the date of this observation). The RP said CR #1 told his other family members some girls hit him. He said in the video from the incident on 10/02/2022, CR #1 was in a low bed, and he got himself out of the bed. He said CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He said CR #1 wanted to be in pants and sometimes, his wheelchair was placed too far away from his bed. He said the facility's staff would get frustrated because they would put CR #1 in the bed, and he would get out over and over. He said CR #1's family put the camera in his room three years ago when he (CR #1) was on a different hallway. He said CR #1's former roommate (who was no longer at the facility) told him the facility's staff were mistreating CR #1. He said when he brought the mistreatment to the Administrator and DON at that time (neither the Administrator nor DON were still employed at the facility) the staff involved was terminated. In an interview with the Administrator on 10/05/2022 at 10:30 a.m., she stated one of CR #1's family members posted a video of CR #1 being assaulted by CNA A and CNA E to social media. The Administrator said on Sunday, 10/02/2022, she was called by LVN K, who was the weekend supervisor at that time. She said LVN K initially told her CR #1 fell out of bed and was being sent out to a local hospital because he hit his head as a result of the fall. She said when she was in the process of reporting the unwitnessed fall with injury to HHSC, she received a text message (on 10/02/2022 at 6:03 p.m.) from CR #1's RP. She said the RP sent her the video of CR #1's assault by text. The Administrator said she had LVN K bring CNA A and CNA E to the conference room to question them about the video while she was on speaker phone. She said when she asked the CNAs about abuse and an unusual occurrence, without mentioning the specific resident's name, the CNAs said nothing happened. The Administrator said she told both CNAs to leave the building immediately and she notified the police. The Administrator said the next morning, 10/03/2022, she called both CNAs and asked about the abuse and video. She said both CNAs said nothing happened. She said both CNAs were terminated by phone on 10/03/2022. She said CNA E was calm and said ok but CNA A reacted and said she wanted to press charges against CR #1 for kicking her. The Administrator said she asked CNA A if she used proper protocol during the incident with CR #1 and she said no. The Administrator said proper protocol would have been for the staff to get a nurse for assistance or walk away from the resident when he got aggressive. The Administrator said CNA A said she did not kick CR #1, but she tripped. The Administrator said an electronic monitoring sign was posted on CR #1's door and the camera had been placed in his room by his family for a while (she could not say how long the camera was in CR #1's room). The Administrator said CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CR #1's bed was in the lowest position at the time of the incident on 10/02/2022. She said CR #1 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CNA A and CNA E stayed (worked) on CR #1's hall a while (she could not say how long CNA and CNA E worked on CR #1's hall). She said according to the video she received from CR #1's RP, the incident occurred on 10/02/2022 at 5:00 p.m. In an interview with LVN K on 10/05/2022 at 11:30 a.m., she stated she was the weekend supervisor on 10/02/2022. She said CR #1 had dementia, was usually alert and oriented to person, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CR #1 was mostly Spanish speaking, but he could speak and understand some English. She said she interacted with CR #1 on 10/02/2022 when she passed morning medication and he was ok. She said CR #1 went back to bed after lunch. She said that evening, LVN V approached her and said CR #1 fell out of bed and hit his head, so she started to assist with getting CR #1's paperwork ready to transfer him to the hospital. She said at that time, she did not know anything other than CR #1 had a fall. She said she called the Administrator to inform her of the fall. She said LVN V was fluent in Spanish and when CR #1 was on the stretcher to leave with EMS, he told LVN V one of the aides hit him. She said she stopped and called the Administrator to notify her. She said CR #1's fall was not a surprise because he frequently crawled out of bed, but the head injury was a surprise (because he had never hit his head before). She said when she saw CR #1 at the nurse's station before he left with EMS, he had a laceration at the corner of one of his eyes the other eye was red. LVN K said CR #1 pointed at one of the aides (CNA A or CNA E) and told LVN V she was the one who hit him. She said CR #1's family member arrived at the facility on 10/02/2022 at 6:45 and showed her the video of CR #1's assault before she posted it on social media. She said CNA A and CNA E were both out of facility when the family member arrived. In a telephone interview with CNA E on 10/05/2022 at 3:47 p.m., she stated CR #1 was combative and fought staff every day. She said when CR #1 was combative, she usually left him alone for a period of time, but when she came back, he was always still combative. She said on the day of the incident (10/02/2022), she heard CR #1 screaming and yelling from the hall. She said she went to CR #1's room and saw him on floor around 5:00 p.m. She said she went to get CNA A for assistance. She said when they picked CR #1 up off the floor, he had a laceration on his eye. She said the laceration probably happened when he fell out of the bed, but she did not know because she was not in the room when he fell . She said she did not see the laceration until they put CR #1 in the bed. She said CR #1 must have hit his eye when he fell but the laceration did not appear until they put him in the bed. She said when they proceeded to get CR #1 off the floor, he fought them like normal. She said after they got CR #1 up and back in his bed, they went to get a nurse. She said the nurse assessed CR #1 and told them put him in his wheelchair to send him out to the hospital. She said normal procedure would have been to get a nurse before they picked CR #1 up off the floor, but because he did that (placed himself on the floor) all the time, they just usually picked him up and put him in bed. She said CR #1 only spoke Spanish but the nurse who assessed him (LVN V) spoke Spanish to him. She said normally, she would call for a nurse to assess a resident before she put them in bed, but it did not call for that this time. She said this (CR #1 being aggressive with staff) happened all the time with CR #1. She said in reference to the video of the incident from 10/02/2022, she was the woman in the pick shirt. She said she never had to drag CR #1 before as she did in the video, but he always wanted to fight. CNA E said she did not usually work on CR #1's hall and she did not work with CR #1 often. She said she had recently received abuse/neglect training, but she still did not feel she had been sufficiently trained to care for CR #1 and other aggressive residents like him. Unsuccessful attempts were made to contact CNA E by phone for additional information on 10/04/2022 at 11:06 a.m., 10/17/2022 at 11:00 a.m., and 10/19/2022 at 3:42 p.m. Voicemail messages and texts were left. Unsuccessful attempts were made to contact CNA A by phone on 10/04/2022 at 11:09 a.m., 10/06/2022 at 11:37, 10/10/2022 at 3:15 p.m., and 10/19/2022 at 3:45 p.m. Voicemail messages and texts were left. In a telephone interview with LVN V on 10/05/2022 at 4:00 p.m., she stated she worked PRN on weekends but 10/02/2022 was not the first day she worked with CR #1. She said CR #1 had dementia and tended to go in and out with memory. She said CR #1 could be combative when he was upset, but she never had issues with him trying to hit or kick her. She said redirecting CR #1 with coffee helped to calm him down. She stated she spoke Spanish. She said CR #1 had one leg, but he could self-propel in his wheelchair. She said staff put CR #1 in bed and he tried to get himself out. She said whenever there was a fall, CNAs were supposed to call a nurse to assess each resident for injuries. She said if the resident hit their head, neuro checks would be initiated. She said on 10/02/2022, she was down 400 hall passing medication when CNA A came and said CR #1 fell out of bed. She said she was confused because she thought CR #1 was already out of bed and in the dining room. She said earlier on 10/02/2022, she was doing medication rounds and LVN E came and said CR #1 was trying to get out of his bed. She said typically, staff put CR #1 in his wheelchair and take him to the nurse's station if he was trying to get up out of bed. She said she asked CNA E to put CR #1's pants on and put him in his wheelchair and take him to the dining room. She said she grabbed the medication cart and went down to CR #1's hall. She said she thought it was strange when she walked into CR #1's room and saw the privacy curtain was closed. She said she pulled open the curtain and saw CR #1 on the bed. She said CR #1's face shocked her. She said CR #1's injuries did not look they were caused by a fall. She said the area under CR #1's left eye was already puffy, liked he got socked (hit) in the face. She said the area above CR #1's eye was swollen and red. She said the blood vessels in both of CR #1's eyes had burst. She said CR #1 had a laceration in the corner of one eye. She said it looked like CR #1's whole eye burst. She said CR #1 kept cursing and yelling at CNA A and CNA E like he did not want them by him. CR #1 was angry. She said she told the CNAs CR #1's injuries were not consistent with a fall. She said one of the CNAs (she could not recall which one) said the laceration was from when CR #1 hit himself on the side rail. She said CR #1 was already in bed, so there was no way for her to tell how he fell or where. She said CNA J was in CR #1's room with her, so she (CNA J) assisted with incontinent care, and they changed his clothes. She said they put CR #1 in his wheelchair and took him to the nurse's station to get ready for transport. She said when LVN K saw CR #1 at the nurse's station, she said, Oh God! She said she told LVN K this (CR #1's injuries) did not look like a fall. LVN A said once EMS arrived, CR #1 was looking at CNA A while he cursed and said that was the [OBSCENITY] ing black [OBSCENITY] that hit him. She said she told LVN K CR #1 said he was hit. She said CNA E went down the hall, but CNA A stayed close to the nurse's station watching the nurses and EMS prepare CR #1 for transport. She said when CR #1 saw CNA E walk down the hall, he said that's the [OBSCENITY] ing black lady that hit him. LVN V said she asked CR #1 who hit him, but he would not initially repeat what he said. She said CR #1 again said that is the other black [OBSCENITY] that hit him. She said after CR #1 left for the hospital, she called his responsible party and told him CR #1 fell but she did not know how he landed on the floor. She said she explained CR #1's injuries and told the responsible party they sent the resident to ER. She said the responsible party was very short and quickly said goodbye. She said within maybe 20-30 minutes, another one of CR #1's family members called and said they reviewed the video from the camera inside CR #1's room. She said the family member said both of the women (CNA A and CNA E) were fighting CR #1. LVN V said as soon as they got the information from CR #1's family member, LVN K walked towards the CNAs (CNA A and CNA E) and she saw one of them clock out. She said both CNAs were out o the building, but CNA A had to wait outside waiting for her ride. She said CNA asked her who was going around saying CR #1 was assaulted. In an interview with the Administrator on 10/06/2022 at 12:13 p.m., she provided CNA A and CNA E's training records and stated the records indicated neither of the CNAs completed two computer-generated trainings on dementia/aggressive behaviors, Alzheimer's Disease and Related Disorders, Behavior and ADL Management and, Caring for the Person with Dementia Behaviors and Communication. Record review of CNA A's employee record revealed she was hired on 06/30/2020 and was terminated on 10/03/2022. All background checks were completed upon hire. Record review of CNA A's training records revealed: Caring for a Guest with Dementia - Completed 06/30/2020. Alzheimer's Disease and Related Disorders, Behavior and ADL Management - dated 04/14/2022: Not completed (the Administrator said the training was not completed because there was no grade). Caring for the Person with Dementia Behaviors and Communication - dated 04/14/2022: Not completed (the Administrator said the training was not completed because there was no grade). About Caregiver Conduct, and Preventing, Recognizing, and Reporting Abuse - Completed on 09/16/22. Further review of the records revealed no other trainings/in-services related to residents with aggressive behaviors or Alzheimer's Disease/dementia. Record review of CNA E's employee record revealed she was hired on 01/19/2018 and was terminated on 10/03/2022. All background checks were completed upon hire. Record review of CNA E's training records revealed: Caring for a Guest with Dementia - Completed 01/19/2018. Alzheimer's Disease and Related Disorders, Behavior and ADL Management - dated 06/21/2022: Not completed (the Administrator said the training was not completed because there was no grade). Caring for the Person with Dementia Behaviors and Communication - dated 06/21/2022: Not completed (the Administrator said the training was not completed because there was no grade). About Caregiver Conduct, and Preventing, Recognizing, and Reporting Abuse - Completed on 09/16/22. Further review of the records revealed no other trainings/in-services related to residents with aggressive behaviors or Alzheimer's Disease/dementia. In a follow-up interview with the Administrator on 10/18/2022 at 11:53 a.m., she stated the two trainings CNA A and CNA E failed to complete (Alzheimer's Disease and Related Disorders, Behavior and ADL Management and, Caring for the Person with Dementia Behaviors and Communication) were not mandatory trainings and she could not force staff to complete trainings that were not mandatory. She said those subjects (aggressive behaviors and residents with dementia) were mentioned in other mandatory trainings each staff member would have had upon hire. She said she did not think CNA A's and CNA E's competencies had anything to do with them abusing the residents. In a telephone interview with CNA E on 10/06/2022 at 11:06 a.m., she stated she was worried about losing her certification as a result of the incident with CR #1 on 10/02/2022. She said she did not hit CR#1 and his injuries were caused by CNA A hitting him. CNA E said she only held CR #1's arm when she tried to get him off the floor. In an interview with CNA L on 10/09/2022 at 9:43 a.m., she stated she had not received any training at the facility regarding aggressive resident behaviors or caring for residents with Alzheimer's Disease and dementia. In an interview with CNA O on 10/09/2022 at 10:00 a.m., she stated she had not been trained regarding aggressive residents or providing care to residents with Alzheimer's Disease or dementia. In an interview with CNA T on 10/10/2022 at 2:02 p.m., she stated she had not received any training from the facility on how to care for residents with aggressive behaviors or residents with Alzheimer's Disease and dementia. In an interview with CNA N on 10/10/2022 at 2:12 p.m., she stated she had not received any training from the facility regarding providing care to residents with aggressive behaviors or residents Alzheimer's Disease and dementia. In an interview with CNA B on 10/10/2022 at 2:40 p.m., she stated she received training on how to care for residents with Alzheimer's Disease, dementia, and aggressive behaviors at a different facility she worked at previously. She said she had not received those trainings at her current facility. In an interview with the HR Director on 10/11/2022 at 12:21 p.m., she said she and the Administrator were responsible for ensuring staff were current with all training/in-services. She said they ran a report from their electronic training system every two weeks which listed each employee's training to be completed. She said the report was distributed to each department head to ensure their staff were trained. In an interview with the Administrator on 10/11/2022 at 12:42 p.m., she stated she and each department head were responsible for ensuring each staff were trained. She said she and the HR Director run and review a report from their electronic training system which indicated which trainings needed to be completed by each staff. She said the reports were distributed to each department head to make sure their staff complete training. The Administrator said she also frequently spoke to staff about their training needs. The Administrator said she did not know why CNA A and CNA E had not completed trainings listed on their training records. Record review of Abuse, Neglect, Exploitation, Or Mistreatment, revised 10/23/2019 revealed, Policy: 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappro [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 12 residents (CR #1) reviewed for quality of care. The facility failed to ensure CNA A and CNA E followed facility protocol and called for a nurse to assist and assess CR #1 before attempting to pick him up off the floor after an assumed fall. CNA A and CNA E failed to seek assistance from a nurse when CR #1 became combative/aggressive and resulted in CR #1 sustaining facial injuries. These failures placed residents at risk of injury and pain. Findings include: Record review of CR#1's face sheet revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) , anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), , contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity) of left lower leg, [CONDITION(S)] (persistent problems falling asleep), polyosteoarthritis (repetitive use of joints causes damage to cartilage, resulting in joint pain and swelling - with at least five joints), [CONDITION(S)] (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), pain, dementia (a chronic disorder marked by memory disorders, personality changes, and impaired reasoning), psychotic disturbance (disorder in which one loses contact with reality and experience hallucinations, and delusions), muscle wasting and atrophy, and right leg above knee amputation. Record review of CR #1's MDS dated [DATE] revealed he was usually understood when expressing ideas and wants and he was usually able to understand other; he had a BIMS score of 3 (severe cognitive impairment); he did not have hallucinations or delusions; he rejected care and wandered; he required extensive physical assistance from at least one staff for bed mobility, locomotion, and dressing; he required extensive physical assistance from at least two staff for transfers; he was totally dependent on at least one staff for personal hygiene and bathing; he was wheelchair bound; he was always incontinent of bowel and bladder; and he was prescribed antidepressant medication. Record review of CR #1's care plan, updated on 09/26/2022 revealed the following care areas: *Alzheimer's Disease (Goal: Resident will have positive experiences in the daily routine without having overly demanding tasks and without becoming overly stressed; Approach: Allow adequate time for resident to respond; Maintain a calm environment and approach to the resident; Use non-verbal communication techniques to encourage resident to respond); *he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *he was at risk for falls due to impaired cognition, impaired mobility, incontinence and use of [CONDITION(S)] medications. The resident has a camera in his room where is responsible party has witnessed him crawl on the floor when he wants to get up (Goal: Resident will not experience major injuries due to falls. Approach: Ensure fall mats are at bedside. Continue all interventions, Patient is not falling but scooting out of bed. Low bed and fall mats in place; Anticipate all needs; Encourage resident to ask staff for assistance. Staff to check frequently, if resident hollering out either put to bed or get up; Encourage socialization; Ensure call light is in reach and use call light; Monitor for incontinence per routine rounds and as needed. Ensure resident has shorts or pants on at all times); *he has impaired communication as evidenced by reduced ability to be understood by other, reduced ability to understand others, impaired daily decision-making ability and speaks Spanish (Goal: Staff will anticipate and meet all needs that resident is not able to communicate effectively. Approach: Allow time for resident to digest information - do not rush; Approach in a calm manner, call by name; Attempt to find an interpreter as needed; Praise resident for communication efforts; Reduce or remove all interfering environmental stimuli; Use terms, gestures that resident can understand and repeat as needed); and *he has dementia as evidenced by short term and long term memory problems and impaired ability to make daily decisions at times (Goal: Resident's needs will be met and dignity maintained. Approach: Allow time for tasks and responses; Explain all procedures using terms/gestures resident can understand; Involve in care as to maintain or increase level of independence; Reorient resident as needed; Repeat information as needed). Observation and interview with CR #1 at a local acute care hospital on 10/06/2022 at 9:45 a.m. revealed he had a laceration to the left corner of his left eye that was healing. He had dark purple bruising to bilateral eyelids and underneath both eyelids. Both eyes were slightly red (white parts of eyes). CR #1's left wrist was covered with a dressing (CR #1 pulled out his IV and the new IV was protected by the dressing) and there was some light purple bruising to his left forearm. CR #1 had a right above the knee amputation. Interview with CR #1 at that via Spanish-speaking RN revealed CR #1 was cognitively impaired. Through the interpreter, CR #1 stated his injuries were caused by five women at his home who were very upset with him. CR #1 said he lived at home with his mother before he was admitted to the hospital (he did not recall living at the facility). CR #1 said nobody ever mistreated him. In a telephone interview with CR #1's RP on 10/06/2022 at 9:40 a.m., he said he observed CR #1 kicking and yelling, Help me! in his sleep since he was admitted to the hospital (he could not give the date of this observation). The RP said CR #1 told his other family members some girls hit him. Observation of a video provided by CR #1's RP on 10/06/2022 at 10:30 a.m. (the video was not dated, or time stamped. The video did not have audio. CR #1's RP stated the video was recorded on 10/02/2022 and he identified CR #1 as the resident in the video) revealed it was recorded in CR #1's room. The video revealed a male (the faces of the individuals in the video were not completely clear) with an amputated right leg, slowly lowered himself off the side of a bed which was in a low position. The resident's face did not come in contact with any structure while he was alone in the video. The male scooted himself towards the door of the room. CNA E (CNA E identified herself as the CNA who had on a pick shirt and the other CNA as CNA A in a telephone interview on 10/05/2022 at 3:47 p.m.) entered the room and closed the door (CNA E did not see CR #1 lower himself to the floor). CNA E could be seen talking to CR #1 and she pointed towards the bed twice during the conversation. CNA E took a pair of blue pants out of a closet and threw them on the arm of a wheelchair which was near CR #1. When CNA E left the room and closed the door, CR#1 grabbed the blue pants and put them on while he was still on the floor. CNA E returned to the room with CNA A. CNA E walked inside the room, moved a bedside table that was near CR #1, moved back the sheet and blanket on the bed, and handed CNA A some gloves. Both staff approached CR #1. CNA E attempted to grab CR #1's left leg, but he started kicking. CNA A grabbed CR #1's left leg and right arm but let his left leg go because he was kicking. CNA A then grabbed CR #1's right stump with one hand and his right arm with her other hand but let him go because his left leg kicked the wheelchair and pulled it towards him. CNA E grabbed CR #1's left arm. CNA A pulled the wheelchair back and forcefully threw CR #1's left leg from the wheelchair but when he kicked her, she kicked him around his left side buttocks area. CNA E was still holding CR #1's left wrist and she dragged him across the floor several feet towards the bed. CNA A approached CR #1 and grabbed the right side of his pants and right side of his shirt while CNA E grabbed his left arm. The staff lifted CR #1's body. CR #1's head was on the bed, then both staff flipped his bottom half in the air and onto the bed while he was kicking. CNA A was standing in front of CR #1's head and top half and appeared to be struggling with him while he flailed his arms and his left leg and right stump appeared to be kicking in the air. CNA E pulled the privacy curtain but CR #1's left foot (He only had a foot on the left side. When the staff threw CR #1 into the bed, his left side was against the wall) could be seen moving around on the floor underneath the privacy curtain. Record review of Resident Progress Note dated 10/02/2022 revealed LVN V wrote, At 5:10 p.m. resident was found on floor by CNA. I was down hall 400 giving a resident his medications when CNA A came to me to let me know that CR #1 was found on the floor. Upon arriving, CR #1 had already been lifted off the ground and placed in his bed. I took his vitals: BP 120/77, P: 66, Resp: 17, O2: 95, Temp: 97.3, A&O x2. Resident was conscious upon arrival to his room and was very combative towards the CNAs. After taking his vitals I assisted CNA J in changing the resident because he had already kicked CNA A in the abdomen area and was also trying to kick the CNA E. After changing resident, we placed him in his wheelchair and took him to the nurse's station. I notified emergency contact on file and notified his physician. 911 was called and resident was sent to ER. Record review of, SBAR Communication Form, dated 10/02/2022 revealed it was completed by LVN K. The document read in part . Situation, The change in condition, symptoms, or signs observed and evaluated is/are: Fall with head injury, This started on 10/02/2022 . Other relevant information: Resident observed on floor by staff . Resident/Patient Evaluation . 3. Behavioral Evaluation: Physical Aggression . 8. Skin Evaluation: Laceration . 9. Pain Evaluation . Does this resident have pain: Yes, New Pain, Description/location of pain: head/bilateral eyes . Does the resident show non-verbal signs of pain (for residents with dementia)? Yes, Complains of pain . Review and Notify: Primary Care Clinician Notified: CR #1's Physician, Date: 10/02/2022, Time: 5:25 p.m. Recommendations of Primary Clinicians: send to ER for evaluation and treatment . Record review of CNA A's employee record revealed she was hired on 06/30/2020 and was terminated on 10/03/2022. All background checks were completed upon hire. Record review of CNA E's employee record revealed she was hired on 01/19/2018 and was terminated on 10/03/2022. All background checks were completed upon hire. In an interview with the Administrator on 10/05/2022 at 10:30 a.m., she stated one of CR #1's family members posted a video of CR #1 being assaulted by CNA A and CNA E to social media. The Administrator said on Sunday, 10/02/2022, she was called by LVN K, who was the weekend supervisor at that time. She said LVN K initially told her CR #1 fell out of bed and was being sent out to a local hospital because he hit his head as a result of the fall. She said when she was in the process of reporting the unwitnessed fall with injury to HHSC, she received a text message (on 10/02/2022 at 6:03 p.m.) from CR #1's RP. She said the RP sent her the video of CR #1's assault by text. The Administrator said she had LVN K bring CNA A and CNA E to the conference room to question them about the video while she was on speaker phone. She said when she asked the CNAs about abuse and an unusual occurrence, without mentioning the specific resident's name, the CNA's said nothing happened. The Administrator said she told both CNAs to leave the building immediately and she notified the police. The Administrator said the next morning, 10/03/2022, she called both CNAs and asked about the abuse and video. She said both CNAs said nothing happened. She said both CNAs were terminated by phone on 10/03/2022. She said CNA E was calm and said OK, but CNA A reacted and said she wanted to press charges against CR #1 for kicking her. The Administrator said she asked CNA A if she used proper protocol during the incident with CR #1 and she said no. The Administrator said proper protocol would have been for the staff to get a nurse for assistance or walk away from the resident when he got aggressive. The Administrator said CNA A said she did not kick CR #1, but she tripped. The Administrator said an electronic monitoring sign was posted on CR #1's door and the camera had been placed in his room by his family for a while (she could not say how long the camera was in CR #1's room). The Administrator said CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CR #1's bed was in the lowest position at the time of the incident on 10/02/2022. She said CR #1 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CNA A and CNA E stayed (worked) on CR #1's hall a while (she could not say how long CNA and CNA E worked on CR #1's hall). She said according to the video she received from CR #1's RP, the incident occurred on 10/02/2022 at 5:00 p.m. In an interview with LVN K on 10/05/2022 at 11:30 a.m., she stated she was the weekend supervisor on 10/02/2022. She said CR #1 had dementia, was usually alert and oriented to person, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CR #1 was mostly Spanish speaking, but he could speak and understand some English. She said she interacted with CR #1 on 10/02/2022 when she passed morning medication and he was ok. She said CR #1 went back to bed after lunch. She said that evening, LVN V approached her and said CR #1 fell out of bed and hit his head, so she started to assist with getting CR #1's paperwork ready to transfer him to the hospital. She said at that time, she did not know anything other than CR #1 had a fall. She said she called the Administrator to inform her of the fall. She said LVN V was fluent in Spanish and when CR #1 was on the stretcher to leave with EMS, he told LVN V one of the aides hit him. She said she stopped and called the Administrator to notify her. She said CR #1's fall was not a surprise because he frequently crawled out of bed, but the head injury was a surprise (because he had never hit his head before). She said when she saw CR #1 at the nurse's station before he left with EMS, he had a laceration at the corner of one of his eyes the other eye was red. LVN K said CR #1 pointed at one of the aides (CNA A or CNA E) and told LVN V she was the one who hit him. She said CR #1's family member arrived at the facility on 10/02/2022 at 6:45 and showed her the video of CR #1's assault before she posted it on social media. She said CNA A and CNA E were both out of facility when the family member arrived. She said the facility's protocol for falls depended on who found the resident. She said if a CNA found a resident on the floor or witnessed a fall, they had to get a nurse to assist and assess for the resident for injuries. She said if a resident was found on the floor, they should be left on the floor until they are assessed by a nurse. She said based LVN V's progress note, CR #1 was already in bed when she came entered the room and that was not proper protocol. In a telephone interview with CNA E on 10/05/2022 at 3:47 p.m., she stated CR #1 was combative and fought staff every day. She said when CR #1 was combative, she usually left him alone for a period of time, but when she came back, he was always still combative. She said on the day of the incident (10/02/2022), she heard CR #1 screaming and yelling from the hall. She said she went to CR #1's room and saw him on floor around 5:00 p.m. She said she went to get CNA A for assistance. She said when they picked CR #1 up off the floor, he had a laceration on his eye. She said the laceration probably happened when he fell out of the bed, but she did not know because she was not in the room when he fell . She said she did not see the laceration until they put CR #1 in the bed. She said CR #1 must have hit his eye when he fell but the laceration did not appear until they put him in the bed. She said when they proceeded to get CR #1 off the floor, he fought them like normal. She said after they got CR #1 up and back in his bed, they went to get a nurse. She said the nurse assessed CR #1 and told them put him in his wheelchair to send him out to the hospital. She said normal procedure would have been to get a nurse before they picked CR #1 up off the floor, but because he did that (placed himself on the floor) all the time, they just usually picked him up and put him in bed. She said CR #1 only spoke Spanish but the nurse who assessed him (LVN V) spoke Spanish to him. She said normally, she would call for a nurse to assess a resident before she put them in bed, but it did not call for that this time. She said this (CR #1 being aggressive with staff) happened all the time with CR #1. She said in reference to the video of the incident from 10/02/2022, she was the woman in the pink shirt. She said she never had to drag CR #1 before as she did in the video, but he always wanted to fight. CNA E said she did not usually work on CR #1's hall and she did not work with CR #1 often. She said she had recently received abuse/neglect training, but she still did not feel she had been sufficiently trained to care for CR #1 and other aggressive residents like him. Unsuccessful attempts were made to contact CNA E by phone for additional information on 10/04/2022 at 11:06 a.m., 10/17/2022 at 11:00 a.m., and 10/19/2022 at 3:42 p.m. Voicemail messages and texts were left. Unsuccessful attempts were made to contact CNA A by phone on 10/04/2022 at 11:09 a.m., 10/06/2022 at 11:37, 10/10/2022 at 3:15 p.m., and 10/19/2022 at 3:45 p.m. Voicemail messages and texts were left. In a telephone interview with LVN V on 10/05/2022 at 4:00 p.m., she stated she worked PRN on weekends but 10/02/2022 was not the first day she worked with CR #1. She said CR #1 had dementia and tended to go in and out with memory. She said CR #1 could be combative when he was upset, but she never had issues with him trying to hit or kick her. She said redirecting CR #1 with coffee helped to calm him down. She stated she spoke Spanish. She said CR #1 had one leg, but he could self-propel in his wheelchair. She said staff put CR #1 in bed and he tried to get himself out. She said whenever there was a fall, CNAs were supposed to call a nurse to assess each resident for injuries. She said if the resident hit their head, neuro checks would be initiated. She said on 10/02/2022, she was down 400 hall passing medication when CNA A came and said CR #1 fell out of bed. She said she was confused because she thought CR #1 was already out of bed and in the dining room. She said earlier on 10/02/2022, she was doing medication rounds and LVN E came and said CR #1 was trying to get out of his bed. She said typically, staff put CR #1 in his wheelchair and take him to the nurse's station if he was trying to get up out of bed. She said she asked CNA E to put CR #1's pants on and put him in his wheelchair and take him to the dining room. She said she grabbed the medication cart and went down to CR #1's hall. She said she thought it was strange when she walked into CR #1's room and saw the privacy curtain was closed. She said she pulled open the curtain and saw CR #1 on the bed. She said CR #1's face shocked her. She said CR #1's injuries did not look they were caused by a fall. She said the area under CR #1's left eye was already puffy, liked he got socked (hit) in the face. She said the area above CR #1's eye was swollen and red. She said the blood vessels in both of CR #1's eyes had burst. She said CR #1 had a laceration in the corner of one eye. She said it looked like CR #1's whole eye burst. She said CR #1 kept cursing and yelling at CNA A and CNA E like he did not want them by him. CR #1 was angry. She said she told the CNAs CR #1's injuries were not consistent with a fall. She said one of the CNAs (she could not recall which one) said the laceration was from when CR #1 hit himself on the side rail. She said CR #1 was already in bed, so there was no way for her to tell how he fell or where. She said CNA J was in CR #1's room with her, so she (CNA J) assisted with incontinent care, and they changed his clothes. She said they put CR #1 in his wheelchair and took him to the nurse's station to get ready for transport. She said when LVN K saw CR #1 at the nurse's station, she said, Oh God! She said she told LVN K this (CR #1's injuries) did not look like a fall. LVN A said once EMS arrived, CR #1 was looking at CNA A while he cursed and said that was the [OBSCENITY] ing black [OBSCENITY] that hit him. She said she told LVN K CR #1 said he was hit. She said CNA E went down the hall, but CNA A stayed close to the nurse's station watching the nurses and EMS prepare CR #1 for transport. She said when CR #1 saw CNA E walk down the hall, he said that's the [OBSCENITY] ing black lady that hit him. LVN V said she asked CR #1 who hit him, but he would not initially repeat what he said. She said CR #1 again said that is the other black [OBSCENITY] that hit him. She said after CR #1 left for the hospital, she called his responsible party and told him CR #1 fell but she did not know how he landed on the floor. She said she explained CR #1's injuries and told the responsible party they sent the resident to ER. She said the responsible party was very short and quickly said goodbye. She said within maybe 20-30 minutes, another one of CR #1's family members called and said they reviewed the video from the camera inside CR #1's room. She said the family member said both of the women (CNA A and CNA E) were fighting CR #1. LVN V said as soon as they got the information from CR #1's family member, LVN K walked towards the CNAs (CNA A and CNA E) and she saw one of them clock out. She said both CNAs were out o the building, but CNA A had to wait outside waiting for her ride. She said CNA asked her who was going around saying CR #1 was assaulted. Record review of undated facility document Statement of Resident Rights revealed, You, the resident do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint . You have the right to: . 3. Be free from abuse and exploitation; 4. Be treated with courtesy, consideration, and respect . Record review of Abuse, Neglect, Exploitation, Or Mistreatment, revised 10/23/2019 revealed, Policy: 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately . 1. Abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Willful, as used in this individual must have intended to inflict injury or harm . 6. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Procedures: . Component II: Training. 1. All new and current employees including volunteers receive continuous education, training and reinforcement that identify all aspects of abuse prohibition . 2. Education/training materials include: . B. Education on the rights of the resident and the responsibilities of a facility to properly care for its residents . D. Dementia management and resident abuse prevention . III: Prevention . 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: A. The use of derogatory/harassing language; B. Rough handling; and C. Ignoring the patient's/resident's needs, requests. 5. Ongoing assessments, care planning, and monitoring of those patients/residents with special needs that may lead to neglect, for example: A. History of aggressive behavior; B. History of entering other patient/resident rooms; C. History of self-injury; D. Communication disorder; and/or, E. Patients/residents requiring excessive nursing care or staff attention. F. Residents with history of resident-to-resident altercation . Record review of Combative Resident, Care And Safety revised on 03/02/2018 revealed, Policy: The Facility has procedures in place to protect the health and safety of residents, staff, visitors and other in the care or proximity of a combative resident. Procedures: 1. Any person who identifies a resident with a change in behavior or an escalation of behavior which may lead to physical combativeness, reports observation to a licensed nurse. 2. A licensed professional, e.g., nurse, social worker, licensed independent practitioner evaluates the resident and may intervene with behavior de-escalation techniques, if appropriate. 3. Individuals deemed to be combative or otherwise dangerous to self or other may be placed on close observation, which may include but is not limited to: A. Relocating individual to a less stimulating environment. B. Conducting frequent checks on the individual. C. Providing a one-on-one staff member for continuous observation and intervention. D. Redirecting attention or use of other therapeutic techniques for de-escalation. 4. Notification of change in condition and escalation of behaviors is made to: A. Physician or licensed independent practitioner. B. Family or responsible party. C. Law enforcement, emergency medical services or others as may be necessary or appropriate to ensure the safety and wellbeing of the combative person or persons in proximity to the situation . Record review of Fall Management revised 03/29/2019 revealed, Policy: 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls . 3. A patient/resident fall management program will be implemented that educates staff in creative, functional strategies while recognizing patients/resident's rights and their need to maintain the highest practical level of function. Definitions: fall refers to the unintentional coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force . A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . Procedures: . 5. If a fall occurs, qualified staff evaluates patient/resident for injury from the fall and determines what may have caused or contributed to the fall, including ascertaining what the resident was trying to do before he or she fell , addresses the risk factors for the fall such as the resident's medical condition, facility environmental issues, or staffing issue; and determines appropriate interventions to prevent future falls and completes a Fall Investigation Worksheet .

Based on observation, interview and record review the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases in one of four resident halls (300 Hall) reviewed for COVID-19 infection control. 1. The facility failed to ensure residents who tested positive for COVID-19 did not cohort on the same hall as residents who tested negative for COVID-19 2. The facility failed to ensure staff were trained to properly doff PPE after providing care to a resident positive for COVID-19 and before leaving the COVID-19 positive unit 3. The facility failed to ensure staff intervened and tried to separate residents who had tested positive and negative for COVID-19 when they were comingling on the same hall 4. The facility failed to ensure staff encouraged positive residents to stay in their rooms or wear a face mask while outside of their rooms in the hallway of the COVID-19 positive unit 5. The facility failed to ensure residents who tested positive for COVID-19 had meals in their rooms instead of in the communal dining room on the COVID-19 unit An immediate jeopardy (IJ) was identified on 12/21/21. While the IJ was removed on 12/24/21, the facility remained out of compliance at a scope of widespread with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents, staff and visitors at risk of contracting the COVID-19 infection which could cause illness, hospitalization and /or death. Findings include: Record review of the CDC.gov website read, in part .the location of the COVID-19 care unit should ideally be physically separated from other rooms or units .facilities could consider having dedicated HCP to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift .HCP caring for residents with suspected or confirmed [CONDITION(S)]-Cov-2 infection should use full PPE (gowns, gloves, eye protection, and N95 or equivalent respirator) .HCP should remove and discard PPE in a dedicated container for waste or linen before leaving the resident room or care area .in general, it is recommended that the door to rooms remain closed to reduce transmission of COVID-19, however, in some circumstances (memory care units) keeping the door closed may pose resident safety risk and the door might need to remain open .if numerous residents are simultaneously identified to have known COVID-19 residents should remain in their current location . 1. Record review of the face sheet for Resident # 1 revealed an [AGE] year-old female with admitted [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission MDS dated [DATE] revealed a BIMS score of 99 indicating severely impaired cognitive skills for daily decision making and assistance required for bathing, hygiene, and dressing. Record review of the care plan revealed approaches for problems that included activity intolerance, cognitive loss/dementia, self-care deficit. Record review Vitals Report revealed Resident # 1's vital signs were evaluated and documented every shift. Record review of progress note dated 12/21/21 revealed Resident #1 remained COVID-19 positive without signs or symptoms. 2. Record review of the face sheet for Resident # 2 revealed a [AGE] year-old female with an admitted [DATE]. Resident # 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS dated [DATE] revealed a BIMS score of 99 indicating severely impaired cognitive skills for daily decision making and assistance required for hygiene, dressing and bathing. Record review of the care plan revealed approaches to identified problems of cognitive loss/dementia, wandering behaviors, activity intolerance, self-care deficit and risk for falls. Record review of Vitals Report revealed Resident # 2's vital signs were evaluated and documented every shift. Record review of progress notes dated 12/21/21 revealed Resident#2 remained COVID-19 positive without signs or symptoms. 3. Record review of the face sheet for Resident # 3 revealed an [AGE] year-old female with an admitted [DATE]. Resident # 3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS dated [DATE] revealed a BIMS score of 99 indicating severely impaired cognitive skills for daily decision making and assistance required for dressing, hygiene and bathing. Record review of the care plan revealed approaches to identified problems of limited physical mobility, risk for falls, mood problem, bladder incontinence, and self-care deficit. Record review of Vitals Report revealed Resident # 3's vital signs were checked every shift. Record review of progress notes dated 12/21/21 revealed Resident # 3 remained COVID-19 positive without signs or symptoms. Observation on the COVID-19 hall (secure unit) on 12/20/21 at 1:40 p. m. revealed there were 15 rooms on the hall and 20 residents. Four rooms at the end of the hall were designated for residents who were COVID-19 negative. Residents were observed wandering up and down the hall or standing in groups in the hall, without face masks. Three residents were standing less than 6 feet apart at the end of the hall, in front of a room that was designated for negative residents. Two of the residents in the group (Resident # 4 and # 5) were COVID-19 positive, and one was COVID-19 negative (Resident # 18), according to LVN B. A negative resident (Resident # 19) was sitting in a wheelchair in a doorway to a room designated as negative, less than 6 feet from the group of three, and another negative resident (Resident # 20) was standing behind her wheelchair. Resident # 1 was observed in the hall standing less than 6 feet from Resident # 2. Staff did not intervene or try to separate the group or re-direct the residents to their rooms. Housekeeper J was observed carrying trash out of a resident's room and down the hall wearing the same PPE as in the resident's room. CNA C was observed at 4:15 pm outside the rear exit door of the COVID-19 unit still wearing PPE. CNA C said she should have taken off her PPE before she went out the exit door. Observation in the COVID unit on 12/20/21 at 2:20 p.m. revealed resident #3 was in her wheelchair in the hall outside the dining room, with a mask on. Staff did not intervene or re-direct her to her room. Observation on the 300 Hall (secure unit) on 12/20/21 at 3:30 p.m. revealed 11 residents were in the dining room sitting at tables less than 6 feet apart and facing each other. In an interview on 12/20/21 at 9:50 a.m., the Administrator said the 300 Hall was the isolation hall, which had 17 residents who tested positive for COVID-19. The census on the 300 Hall was 20 residents. She stated there were no COVID-19 positive residents on the 100 or 200 halls, and the 400 hall was the warm unit for residents on quarantine with unknown COVID-19 status. The Administrator stated the 300 Hall was the facility secure unit, for residents with dementia or who were at risk for wandering. She said 2 rooms at the end of the 300 Hall were designated for COVID-19 negative residents, but there was no physical barrier to separate the positive rooms from the negative rooms. She stated it was difficult to move the negative residents out of the 300 Hall because they needed to be on a secured unit due to risk of wandering. In an interview on 12/20/21 at 11:00 a.m., the Dietary Manager stated they had training in infection control, including handwashing, PPE, standard precautions, and the COVID plan and the most recent training was a month ago. In an interview on 12/20/21 at 12:50 p.m., the Administrator stated if a staff member tested positive for COVID-19, they were sent home immediately to quarantine for 10 days according to CDC guidelines. She stated all residents and staff were tested using Rapid testing for COVID-19 infection, and if positive, the results were confirmed with a PCR test which is sent to the lab for results in 1 to 2 days. She stated there were 17 current staff who have volunteered to work in case of a staffing shortage, and the facility had contracts with 2 staffing agencies to help in case of staffing needs. She stated all residents who had tested positive for COVID-19 were already on the 300 hall but 2 residents were moved to the 300 hall immediately after they tested positive for COVID-19. In an interview on 12/20/21 at 1:10 p.m., the Infection Preventionist stated if a resident tested positive for COVID-19 and was not on the COVID-19 hall, they were immediately moved to that hall. She said the COVID-19 positive residents were already on that hall. She said it would be difficult to move them because they needed a secure unit due to their wandering and behaviors and it would be hard to keep them in their rooms on another hall. She further stated that COVID-19 infection was contained on the secure unit (300 hall). In an interview on 12/20/21 at 1:20 p.m., Med Aide G stated she did not work on the COVID-19 hall, but she had infection control training, including hand washing, PPE, contact and droplet precautions and COVID-19 protocol a few weeks ago. In an interview on 12/20/21 at 1:28 p.m., Housekeeper K said she did not work on the COVID-19 hall and she had training on infection control, including handwashing, PPE, standard precautions about 2 weeks ago. She said she cleaned rooms and hallways and wiped down surfaces with disinfectant daily. She said the 300 Hall had their own housekeeper who only worked on that hall. In an interview on 12/20/21 at 1:30 p.m., LVN L stated she did not work on the COVID-19 hall and she had in-services on infection control, including handwashing, PPE, contact and droplet precautions, COVID protocol, and the last training was in the last few weeks. In an interview on the COVID-19 unit on 12/20/21 at 2:20 p.m., Housekeeper J stated she only worked on the 300 Hall for her shift and stayed on that hall the entire time. She said she cleaned the rooms and halls, took out trash, disinfected all surfaces including handrails and high touch surfaces. She said she kept her PPE on the entire time she was on that hall. In an interview on the COVID-19 unit on 12/20/21 at 2:30 p.m., LVN B stated staff told the residents to stay in their rooms and to wear masks, but most residents did not understand because of not being able to understand due to dementia, and they just took the masks off and came out of their rooms and were up and walking around again. LVN B stated she only worked on the COVID-19 Hall (300 Hall) and did not go to any other hall while she worked. She said when she arrived for work, she was screened at the main entrance and went directly to the 300 Hall for her entire shift. In an interview on 12/20/21 at 3:15 p.m., CNA C stated she worked only on the COVID-19 Hall for her entire shift and was screened at the main entrance and went directly to the 300 Hall. She said they were supposed to take their PPE off and put it in the biohazard bin before they left the unit. Observation and attempted interview on the COVID-19 hall on 12/20/21 at 3:20 p.m. revealed Resident # 1 sat in a chair outside the door of her room on the 300 Hall. The resident was not wearing a face mask. CNA C reminded her she should be wearing a face mask, she touched her face and said yes and smiled. Staff did not intervene or try to re-direct her to her room. In an interview with CNA C on 12/20/21 at 3:35 p.m., she stated the staff tried to tell residents to eat in their rooms and some did, and staff tried to get the residents to stay in their rooms and wear masks, but the residents did not understand the restrictions due to their dementia, so they didn't do it. Record review of the facility Covid Tracker dated 12/20/21 revealed the following positive results for COVID-19: 12/10/21- 1 staff; 12/13/21- 1 staff; 12/14 21- 1 staff and 5 residents (Resident's #2, #4, #5, #6, #7: all vaccinated except Residents # 5 and #7) 12/16/21- 1 staff and 2 residents (Residents #8, #9- both residents vaccinated); 12/18/21- 10 residents (Residents #3, #10, #11, #12, #13, #14, #15, #16, #17, #18-all vaccinated except Residents #13 and #18)) TOTAL: 7 staff positive, 17 residents positive. This was determined to be an Immediate Jeopardy (IJ) On 12/21/21, at 2:40 p.m. the Administrator was notified of the IJ. The Administrator was given the IJ template on 12/21/21 at 2:40 p.m. Record review of the facility policy on Infection Prevention and Control-Coronavirus disease (COVID-19), revised 6/29/21, revealed in part .facility will designate a screener to complete the Prevent COVID-19 Screening Checklist on all individual's entry into the facility. Staff will be screened prior to each shift. The designated screener will not allow any individual that does not pass the screening to enter the facility .during periods of increased respiratory infection in facility, staff and residents will follow current CDC guidelines for PPE .it is imperative that staff always practice basic infection control measures including Standard Precautions, using meticulous hand hygiene and when indicated, appropriate use of personal protective equipment .environmental cleaning and disinfection, including management of laundry, food service utensils and medical waste, with appropriate PPE to be worn during cleanings . Record review of the facility policy Infection Prevention and Control - Infection Prevention and Control program and Plan, new policy dated 2/17/21, revealed in part .the ICPC .a facility wide program that incorporates a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases. The program covers all residents, staff, volunteers, visitors, and other individuals providing services .ICPC provides direction regarding outcome monitoring, patient and resident welfare, employee-based monitoring and care .Infection Preventionist is the coordinator of the ICPC including Antibiotic Stewardship, staff education and training, resident and family education, and resident health including immunizations and TB testing . ICPC goals are based on identified. Record review of the facility policy Personal Protective Equipment: Infection Prevention and Control, revised 4/17/20, revealed: facility staff follow clinical practice standards in selection, use, donning and doffing of personal protective equipment: procedures: 1. perform hand hygiene, 2. prepare all equipment, 3. apply gown, apply surgical or respirator mask, apply eyewear or goggle, apply clean gloves, 4. enter room and perform care and services according to resident need, 5. remove personal protective equipment prior to leaving the resident room 6. remove gloves and 7. remove eyewear 8. remove gown. The following Plan of Removal submitted by the facility was accepted on 12/21/21 at 10:14 p.m. Plan of Removal December 21, 2021 Residents with negative COVID status residing on the unit are being re-tested [DATE] and will be placed on appropriate unit and cared for based on results. Residents who recover from COVID-19 and those who test negative will transition out of the secured unit and will be placed 12/21/21 in the same area to allow for increased supervision including 1:1 supervision if necessary. The secured unit will be classified as the COVID positive unit effective 12/21/21 Residents will be tested based on facility outbreak testing criteria and for signs and symptoms of COVID-19. Residents will be screened Q-shift to be evaluated for signs and symptoms of COVID 19. If any resident outside the unit tests positive that resident will be moved to the designated COVID positive unit. Residents will dine in their rooms and activities will be provided 1:1 on the COVID positive unit 12/21/21 Staffing meeting will be held daily to discuss staffing to validate that staffing is scheduled to meeting the needs of the residents on the COVID positive unit 12/21/21 The Assistant Director of Nursing, Administrator and Director of Nursing (upon return) will be re-educated by the Clinical Consultant regarding the CDC guidelines to prevent the spread of COVID 19. The Assistant Director of Nursing received training from the Clinical Consultant the afternoon of 12/21/2021 prior to re-educating other staff. Clinical staff, therapy and housekeeping, and dietary staff will be re-educated by the Assistant Director of Nursing / designee on the following: Transmission based precautions criteria COVID positive and COVID negative residents cannot co-[NAME] or co-mingle on same unit and must be separated. If residents wander outside their rooms they must be encouraged to wear a mask or encouraged to remain in their rooms Donning appropriate PPE for a COVID positive unit per CDC guidelines whenever entering residents' rooms and doffing PPE prior to exiting Training will be provided to all staff on the updated Pandemic Response Plan Donning/Doffing competencies will be completed by Assistant Director of Nursing / designee with staff assigned to COVID unit, The charge nurses will be re-educated by the Assistant Director of Nursing / designee regarding the monitoring of appropriate PPE and appropriate measures to prevent the spread of COVID 19 and report any concern to the Administrator or Director of Nursing for addressing as indicated. This re-education and competencies will begin on December 21, 2021 and will be completed by 12/22/21. Any staff not receiving this education by this date will be educated prior to next scheduled shift. We will use an employee roster and schedule to track and document education compliance. Agency personal and or facility New Hires will receive this re-education prior to reporting for duty. The Medical Director was notified of the Immediate Jeopardy (IJ) on December 21, 2021 with the Administrator, Assistant Director of Nursing and the Regional Vice President of Operations and the Clinical Consultant and the Medical Director to review the facility's Pandemic response plan, the infection control policies and the contents of this plan of removal. The administrator is responsible for validation of the implementation of this plan. The pandemic response plan was updated by the Administrator. The state surveyor monitored the POR and included the following: Observation on 12/22/21 at 11:50 a.m. revealed screening including temperature check, questions about signs and symptoms of COVID-19 and masks and hand sanitizer available. Signs posted at the entrance regarding COVID-19 restrictions and signs with instructions to ring the doorbell for admittance. Observation of the 500 Hall on 12/22/21 at 1:30 p.m. revealed it was a vacant secure hall, and at the end of the 100 hall. There were 15 rooms, fire doors were closed at the entrance to the 500 Hall, with signs on the fire doors which indicated contact and droplet precautions and PPE was required to enter the hall Observation on the COVID-19 Hall (300 Hall) on 12/22/21 at 4:30 p.m. revealed the dinner cart was delivered to the entrance of the hall by dietary staff. Dietary staff left the cart at the closed door to the hall and knocked on the door to alert the staff that the meals were there. CNA C retrieved the meal cart from the doorway and rolled the cart to the dining room. There were 13 residents in the dining room sitting at tables with 1 or 2 persons at each table, spaced 6 feet apart. . Observation and interview on the COVID hall on 12/22/21 at 4:45 and 4:50 p.m., CNA C doffed her PPE and donned new PPE before entering a room to serve a meal, and doffed PPE before she left the room. She then donned new PPE outside the room. She stated she doffed and donned PPE before entering the room to serve the meal for infection control because she didn't want to spread the virus. Observation in the COVID-19 hall on 12/22/21 at 5:00 p.m. revealed CNA C rolled the empty meal cart to the end of the hall, doffed PPE at the doffing station before she exited, took the cart outside the exit door at the end of the hall, sprayed the cart with disinfectant spray and rolled the cart outside the locked fence to the secure unit for dietary staff to pick up. She donned new PPE and entered the COVID hall through the back door. Record review of the facility COVID Tracker dated 12/22/21 revealed: 12/21/21 - 4 staff, 3 residents positive (Residents # 19, #20, #21-all vaccinated); TOTAL: 11 staff positive, 20 residents positive. Continue testing using Rapid test and confirm positives with PCR test. Observation on 12/23/21 at 10:10 a.m. revealed screening at the front entrance to the facility which included temperature checks, questions about signs and symptoms of COVID-19 and face mask and hand sanitizer was available Observation on the COVID unit (300 Hall) on 12/23/21 at 1:40 p.m. revealed there was a nurse, 2 CNA's and a housekeeper on the hall. Staff were observed re-directing residents back to their rooms when residents were wandering in the halls. CNA C was observed taking Resident # 2 to her room to the bathroom, wearing the same PPE she was wearing in the hall. She doffed the PPE before she left the resident's room and donned new PPE outside the room. Observation on 12/24/21 at 8:40 a.m. revealed screening at the front entrance which included temperature checks, questions about signs and symptoms of COVID-19 and face mask and hand sanitizer was available Observation on the COVID-19 hall on 12/24/21 at 11:00 a.m. revealed there was a nurse, 2 CNA's and a housekeeper on the hall. Residents were observed either in their rooms and a few on the hall. Staff re-directed residents back to their rooms if they walked in the halls and encouraged residents to wear a face mask. In an interview on 12/22/21 at 12:00 p.m., the Administrator stated the COVID-19 Hall census was now 20, and all residents tested positive for COVID-19 as of 12/21/21, and there were no longer any negative residents on that hall . She stated there were dedicated staff who worked on the COVID-19 positive that hall only, and they were screened before their shift at the main entrance and went directly to the 300 Hall. She stated there were no positive staff working on that hall, and in-services were provided on handwashing, PPE, COVID protocol and infection control, which included a post-test and competency checklist. She stated staff were tested daily by Rapid test for COVID-19, and if the results were positive, it was confirmed by PCR test for COVID-19 and sent to the lab for verification. She said they had the PCR test kits in the facility. In an interview on 12/22/21 at 12:10 p.m., Housekeeper K stated she had infection control training about a week ago, and it covered handwashing, PPE, contact precautions, and had a test after the training. She said she did not work on the COVID hall, but they have their own staff on the hall. In an interview on 12/22/21 at 12:12 p.m., LVN L said she was from an agency. She said she had infection control training at her agency, and she had additional in-service and post-test on infection control, hand washing, PPE useage and COVID plan when she came to this facility. In an interview on 12/22/21 at 1:45 p.m., the Administrator stated if there were more residents who tested positive for COVID-19, they would be moved to the 500 Hall, which was not in use now, but it was a secure hall, with a separate entrance that could be closed off from the rest of the facility and had an exit door at the end of the hall. She stated after the first residents recover on the 300 Hall (designated COVID-19 hall), they would be moved to the end of the 300 Hall if they had symptoms, or to the 500 Hall. In an interview on 12/22/21 at 2:00 p.m., the Dietary Manager stated the cart with the meal trays for dinner for the COVID-19 hall were delivered at the door to the hall at 4:30 pm. She said the meals were all in disposable containers, and the dietary staff knocked on the door to the hall to alert the staff inside the food was there but did not enter the hall. She said someone in the hall would retrieve the cart, and after all the meals were delivered, staff in the hall would move the cart outside the door, disinfect the cart, and place it outside the locked fence since this is the secure unit and the fence must stay locked. In an interview on 12/22/21 at 2:10 p.m., the Central Supply revealed she had training on infection control about 2 weeks ago, which included handwashing, PPE, contact and droplet precautions, and COVID protocol. She said she did not work on the 300 hall, but they had staff who worked on that hall only. She said she made sure there were enough supplies available, which included PPE, and she ordered more if needed. She said there was a good supply of PPE in the facility, and it was stored in supply closets and in the Administrator's office. In an interview on 12/22/21 at 2:30 p.m., CNA M stated she had infection control training about 2 weeks ago, which included handwashing, PPE, contact and droplet precautions and COVID protocol. She stated she did not work on the 300 Hall, but they had staff who only worked on that hall. In an interview on 12/22/21 at 2:25 p.m., the Administrator stated if residents on the 300 Hall recovered, they would be moved to the 500 Hall, and depending on the number recovered and the number positive for COVID-19, the larger number would be on the 500 Hall. In an interview on 12/22/21 at 3:30 p.m., RN M on the 400 Hall, stated she had infection control training on 12/21/21, which included handwashing, PPE, contact and droplet precautions, and there was a post- test and skills check off. In an interview on the COVID-19 hall on 12/22/21 at 4:40 p.m., LVN N stated since all of the residents on the 300 hall were now COVID-19 positive, there was no need to separate them from residents who were negative. She said staff reminded residents to stay in their rooms to eat, and some did, but because of their cognitive status, they did not understand and were used to going to the dining room to eat so some residents were served meals in their rooms and some were served in the dining room, sitting at tables spaced 6 feet apart. She stated 6 residents ate their meals in their rooms, and there was one resident on G-tube feeding in his room. In an interview on the COVID-19 hall on 12/22/21 at 4:48 p.m., CNA C stated some of the residents just come to the dining room when it is time to eat because it is a routine, and they do not understand why they should stay in their rooms. She said there were some some residents who did eat in their rooms. She stated she would take the cart to the end of the hall after all the meals were delivered and doff her PPE at the doffing station before she went out the door and take the cart outside, spray it down with disinfectant, and place it outside the locked gate for the dietary staff to pick up. In an interview on 12/23/21 at 10:10 a.m., the Administrator stated the managers monitor the COVID-19 hall several times a day and documented what they observed but they look in the windows on the doors at the end of the unit and do not enter the unit for infection control precautions. She said if any issues, were found, it would be discussed with the staff working on that hall. In an interview on 12/23/21 at 10:45 a.m., CNA D stated she worked on the 200 Hall only, and had in-service on infection control on 12/22/21, and it included handwashing, PPE, screening, isolation precautions, and had a skills test after the training. In an interview on 12/23/21 at 10:50 a.m., Med Aide F said she does not work on the 300 hall, and she just had infection control training yesterday, including handwashing, PPE, contact and droplet precautions and a test afterwards. .In an interview on the COVID-19 hall on 12/23/21 at 1:45 pm, Med Aide E stated she had infection control training last week, and it included handwashing, PPE, isolation precautions and a skills check. She said all the staff wore PPE (gown, mask, face shield) while on the hall, and if they provided care to a resident in the room, they would doff the PPE in the room and don new PPE outside the room. In an interview on the COVID-19 hall on 12/23/21 at 2:00 p.m., CNA C said she only worked on the COVID-19 hall and she had infection control training this week which included handwashing, donning and doffing PPE, contact and droplet precautions, COVID protocol, and a test after the training. In an interview on 12/24 21 at 9:00 a.m., the Administrator stated there were no new positive COVID-19 cases in the facility, and all residents and staff were still being tested by Rapid test for COVID-19 and confirmed positives with PCR tests. She said the census on the COVID-19 hall remained at 20. Staff on the COVID-19 hall wore gowns in the hall and if they provided care to a resident, they doffed their PPE in the room and donned a new one outside the room and doffed PPE when they left the hall out the back exit door for the day. Record review of the facility Covid Tracker dated 12/23/21 revealed no new staff or residents tested positive for COVID-19, and continued testing using Rapid testing and confirmed positives with PCR tests. Record review of the facility IJ - Infection Control Plan of Action dated 12/21/21 revealed the following: all negative residents were tested on the 300 hall and all tested positive on 12/21/21 so they were not moved to another hall; the secure unit was classified as the COVID-19 unit on 12/21/21; residents were screened every shift and documented; any new residents who tested positive would be moved to the new COVID-19 unit-500 hall; staffing meetings held daily to ensure adequate staffing on the COVID-19 positive unit; ADON, DON, Administrator trained by Clinical Consultant regarding CDC guidelines to prevent the spread of COVID-19; clinical staff, therapy, housekeeping, dietary to be re-educated by the ADON on transmission based precautions; the Medical Director was notified of the IJ on 12/21/21. QAPI meeting on 12/21/21 regarding IJ to review the facility pandemic plan, infection control plan and plan of removal, and monitoring of staff regarding infection control practices. Record review of facility In-Services revealed documentation of in-services to all staff on 12/21/21 and 12/22/21 on infection control, handwashing, PPE which included donning and doffing, contact and droplet precautions, COVID-19 signs and symptoms and COVID-19 Response with a post-test and competencies which followed the training. Additional in-services were provided on Health Screening and Education - Screener Role along with competencies in screening all staff and visitors who went to the facility. Record review of screening documentation for 2 months revealed daily screening was done with no concerns. Record review of facility Daily Staffing Meetings for COVID unit revealed documentation of daily staffing meetings for the COVID-19 unit, dated 12/21/21 through 12/24/21, with agency assistance on the unit on 12/22/21, 12/23/21 and 12/24/21 to ensure adequate staffing for the unit. Record review of fa [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent injuries for 1 of 9 residents (CR #1) reviewed for accidents/supervision in that; -CNA B failed to adequately supervise CR #1 while completing incontinent care resulting in the resident falling out of bed and sustaining a left femur fracture. This failure affected 1 former resident causing injury, and placed her at risk of further injury, pain, and psychological harm. Findings include: Record Review of CR #1's face sheet revealed a [AGE] year-old-female initially admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's active physician orders [REDACTED]. Record review of CR #1's Quarterly MDS dated [DATE] revealed the resident's cognitive skills for daily decision making was severely impaired. Further record review of the resident's quarterly MDS revealed the resident required extensive one-person assist for toilet use and personal hygiene. She required extensive assistance of 2 staff for bed mobility. The MDS further revealed she had functional limitation related to upper extremity impairment on one side. Record review and interview on 1/3/2020 at 2:12pm with the ADON revealed CR #1's Care Plan Conference Summary dated 02/13/19 showed falls were documented in the comment section for care plan element Risks/Needs/Preferences/Strengths. The ADON said the Comprehensive Care Plan was not available for surveyor to review. The ADON stated it was locked because the resident was no longer at the facility and could no longer be printed. Record review of nursing progress note dated 11/25/2019 at 7:54pm read in part, Incident Note Text: Called to room by CN[NAME] Noted resident lying on floor on her left side. CNA stated, I was changing her, and I turned around to pull out some wipes from the bedside table. When I turned back, the resident was falling from the bed before I could catch her. Head to toe assessment done. Resident noted to have raised area on back of her head. C/O left arm and left lower extremity pain. Resident assisted back to bed. Notified MD/RP/NM and called 911. Resident transferred to ER by ambulance for evaluation and treatment. Record review of the Internal Facility Incident Investigating report summary dated 11/25/19 for CR #1 read in part, Resident had a witnessed fall from bed while receiving incontinent care from CN[NAME] CNA stated that during incontinent care, she turned around to grab some wipes from bedside table. As she turned back to face the resident, resident noted falling from bed. She stated that she was unable to catch resident as she was falling. Resident was assessed and placed back in the bed. Noted to have a raised area on back of head. Resident also c/o discomfort to left hip and left shoulder. Notified MD/RP/NM of incident. Call 911 and resident transferred to the ER for evaluation and treatment. Received report that resident sustained [REDACTED]. IDT discussed fall. Resident has hx of falls. Resident has been known to wiggle from chair/bed at times. Resident had a recent fall with injury on 07/31/19. Record review of CR #1's Discharge hospital notes dated 12/03/19 read in part, . is a 95 y/o resident who was transferred from NH to ER after suffering a fall. How pt fell is unclear as (family member) reports she is basically bedbound unless being transferred from bed to wheelchair .Multiple images obtained and only acute abn was found was the left femur fx. She has been admitted and is going to OR at this time ORIF this (morning) . Pt bedridden and likely will not benefit from rehab or SNF. Record review of CR #1's nurse progress notes dated 12/3/19 at 7:47pm revealed she was readmitted to the facility with old bruising and reddened areas to upper and lower extremities and incision site to left hip area. Record review of CR #1's nurse progress notes dated 12/6/19 revealed she was admitted to hospice care. Phone interview on 01/03/2020 at 9:42 AM with the CR #1's family member, she stated she was told by the facility that CR #1 was lying in bed and CNA B was preparing the resident for night time. She said the aide turned around to get a wipe and the resident fell out of bed. She stated the room was pretty small and there was another roommate in the room with her and the way the bedside table was positioned at the head of the bed, there was no way the resident could have fallen without the aide being aware. She stated she thought the resident fell elsewhere. She said she was told CNA B was the only aide in the room with the resident at that time of the incident. She stated prior to this fall, when she would visit CR #1, the resident knew who she was and that she was nowhere near dying. She said she was concerned with her fast decline and death shortly after the fall. She stated the resident had one other fall in the facility's shower room which also resulted in a fractured clavicle. Phone Interview on 01/03/2020 at 12:10 PM with CNA B, she stated she was in CR #1's room providing incontinent care, she said the resident had a large BM and she ran out of wipes, so she had to turn around to grab a pack of wipes that were on the bedside table. She stated when she turned she heard the resident say, oh oh and before she could grab the resident, the resident was on the floor lying on her foot. She stated she did not move from the bed but turned just to grab the wipes. When asked if the resident was able to turn herself in bed, she stated the resident could turn and roll over. When asked if there was a fall mat by the residents' bed, she stated not at the time of incontinent care because it was in the way of the bedside table. She said she moved it during incontinent care and it was put back after incontinent care was completed. Phone interview on 01/03/2020 at 12:18 PM with LVN A, when asked if she could explain the incident that occurred with CR #1, she stated she was at the nurses' station the night of the incident and CNA B came to the nurse station and said the resident had fallen out of bed. She stated the CNA said she was changing the resident and reached for some wipes and when she turned around, the resident fell out of bed. She said the CNA told her she tried to catch the resident but couldn't catch her in time. When asked if the CNA had left the room or if she was standing at the bed at the time of the fall, she stated the CNA demonstrated in the room where she was positioned and what happened. She said she was in front of the bed with the bedside table to the left of her, and CNA B told her she turned her head to reach for the wipes, then the resident said something and then fell on the floor. Further interview on 01/03/2020 at 12:18 PM with LVN A, when asked if there was a fall mat on the floor when the resident fell , she stated the floor mat was in the room, but it was pushed to the side because the CNA was standing in front of the bed. When asked if the mat was supposed to be moved during incontinent care, she stated the CNAs would move the mats because they end up standing on it and can trip when providing incontinent care. When asked if the resident was able to turn or move herself, she stated yes, the resident was mobile and able to turn. LVN A said she was fairly new when this incident occurred, stating this was the first time the resident had a fall when she was working with her. She further stated she thought the resident may have had one fall prior to this but it had been a while. Interview on 01/03/2020 at 12:39 PM with CNA C, when asked where the fall mat should be positioned during incontinent care she stated, when she was doing incontinent care, 9 times out of 10, she would be standing right on top of the mat further stating if the resident moves or if the railing is down, the resident could fall. She said, So why would I move the mat. When asked if there was a policy for the placement of the fall mats during incontinent care, she stated she never heard of any specific policy. Interview on 01/03/2020 at 12:54 PM with CNA D, when asked where the fall mat should be positioned during incontinent care, she stated in front of the bed. When asked if it should ever be moved during incontinent care, she stated she would move it then put it back after care was completed. When asked where she would move it to, she stated she would usually place it under the bed or would fold it up and put it in the corner. When asked what the policy was regarding the fall mat placement during incontinent care, she stated the policy was to fold the mat and put it in the corner. Interview on 01/03/2020 at 12:56 PM with CNA E, when asked where the fall mat should be positioned during incontinent care, she stated on the floor when asked where on the floor, she stated in front of or on the sides of the bed. When asked if the mat should ever be moved while providing incontinent care, she stated it should not be moved during care, further stating, I leave the mat right there because even during incontinent care, they can fall, so I leave it there. Interview on 01/03/2020 at 2:12 PM with the ADON, when asked where the fall mat should be positioned during incontinent care, she stated most CNAs move it because it could be a fall hazard for the CNA and they don't want to get hurt. She said they have to put the mat back once incontinent care is completed. When asked if there was a specific policy addressing placement of the mat during incontinent care, she stated no. She said if the CNA steps away from the bed or has to leave the room the mat would need to be put back in place. She stated in CR #1's case, the CNA stated she turned to get a wipe because the resident kept going and she had used the wipes she had on the bed. She said the CNA stated when she turned to get more wipes, the resident had already started to fall and the CNA said she could not catch her in time. Interview on 01/03/2020 at 3:04 PM with the DON, she stated there was no specific policy for fall mat placement during incontinent care. When asked if a CNA has to turn or move to get more supplies because they are not within reach, should the fall mat be put back in place, she stated the fall mat was moved by nurses because it was a trip hazard for the nurse, she then stated the CNA only turned her head to get more wipes. When told the facility's policy stated that supplies should be arranged where they can be easily reached, she stated the resident was able to turn herself and move her legs around the quarter rail and by the time the CNA turned her head, the resident was already falling. When asked if there should have been two CNAs in the room during incontinent care if the resident had already had a previous fall with injury and was able to reposition herself during incontinent care, she stated after the incident/fall, the residents' incontinent care was changed to a two person assist. Record review of the facility's policy on Perineal Care revised (MONTH) 2010 read in part, .Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies needed .Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached .