Every finding on record at Jamieson Nursing Home

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week potentially affecting all 21 residents residing in the facility. Findings include:A review of the Centers for Medicare & Medicaid Services (CMS) PBJ (Payroll Based Journal) Staffing Data Report for the 4th quarter of 2025 (July 1 to September 30) revealed the facility triggered for no RN staffing.A review of requested Daily Staffing Sheets from the 4th quarter of 2025 revealed the following dates without RN staffed: 7/4/2025, 7/12/2025, 8/10/2025, 9/1/2025On 1/7/26 at 11:00 AM, Nursing Home Administrator (NHA) was interviewed regarding RN coverage and explained on 7/4/2025 and 7/12/2025, the Director of Nursing (DON) was working the morning shift, however, is salary and does not punch in. The NHA went on to explain that on 8/10/2025 and 9/1/2025 the DON scheduled two Licensed Practical Nurses (LPNs) to work both the morning and night shift and confirmed there was no RN coverage those days.Review of the facilities' 'punch cards' confirmed on 7/4/2025, 7/12/2025, 8/10/2025, and 9/1/2025 there was no RN coverage documented.

Based on observation, interview and record review, the facility failed to provide appropriate assessments and documentation warranting the use of a physical restraint for four Resident (R #5, R #11, R #18, R #20) of twelve residents reviewed for restraints, resulting in the potential for feelings of helplessness, agitation, decreased physical functioning and injury. Findings include: R #5 (R5) Review of R5's face sheet, dated 7/24/25, revealed admission to the facility on 6/4/25 with diagnoses including weakness and dementia. Review of R5's minimum data set (MDS) assessment, dated 10/2/25, Section GG revealed R5 required partial/moderate assist for toileting hygiene, shower/bathing, upper body dressing, lower body dressing, and putting on/taking off footwear. R5's Brief Interview for Mental Status (BIMS) score was 3/15 indicating severe cognitive impairment. On 1/5/26 at 2:11 p.m., R5's bed was observed against the wall in their room, limiting access in or out on one side, and a bed alarm place. On 1/7/26 at 9:18 a.m., R5 was observed sitting in their recliner chair in their room with a padded alarm underneath them, on and functioning. R5's bed was against the wall. An attempted interview was conducted with R5 who was unable to answer questions appropriately. Review of R5's medical record revealed no consents or physician orders for the use of alarms or to have R5's bed against the wall. R #11 (R11) Review of R11's face sheet, dated 10/21/25, revealed admission to the facility on [DATE] with diagnoses including hemiplegia. Review of R11's MDS assessment dated , 10/29/25, Section GG revealed R11 required substantial/maximal assistance for toileting hygiene, shower/bathing, upper body dressing, and lower body dressing, and putting on/taking off footwear. R11's BIMS score was 1/15 indicating severe cognitive impairment. On 1/5/26 at 2:36 p.m., R11 was observed with a lap buddy in place while sitting in their wheelchair. The room of R11 was observed with the bed was against the wall and a bed alarm was in place and functioning. On 1/7/26 at 10:06 a.m., R11 was observed sleeping in their bed. The bed was against the wall, with a bed alarm was in place and functioning. R11 had a bed bolster restricting movement from the side of the bed not pushed against the wall and a fall mat was noted on the floor. Review of R11's medical record revealed no consents or physician orders for the use of alarms, bolsters, fall mats, or to have R11's bed against the wall. R #20 (R20) Review of R20's face sheet, dated 10/15/25, revealed admission to the facility on 9/23/24 with diagnoses including dementia and anxiety. Review of R20's MDS assessment, dated 10/15/25, Section GG revealed R20 required substantial/maximal assistance for toileting hygiene, shower/bathing, upper body dressing, and lower body dressing, and putting on/taking off footwear. R20's BIMS score was 3/15 indicating severe cognitive impairment. On 1/7/26 at 9:17 a.m., R20 was observed sitting in her wheelchair in her room. There was a padded alarm located on the back of her wheelchair. An interview was attempted with R20, who was unable to answer questions appropriately. R20's bed was observed against the wall. Review of R20's medical record revealed no consent or physician orders for the use of alarms or to have R20's bed against the wall. Resident #18 (R18) Review of R18's face sheet, dated 9/18/25, revealed admission to the facility on 8/6/25 with diagnoses including multiple myeloma (blood cancer), anemia, hyperlipidemia, and hyperlipidemia. Review of R18's quarterly (MDS) assessment, dated 12/28/25, revealed Section GG of the MDS assessment revealed R18 was partial/moderate assistance on staff for activities of daily living cares including toileting, shower/bathing, upper/lower body dressing, and putting on/taking off footwear. R18's (BIMS) revealed moderate cognitive impairment. On 1/5/26 at 11:41 AM, an observation was made of R18 in their room and lying in bed. R18 was observed to have the right side of their bed pushed up against the wall and a soft wedge on the left side of their bed. R18 also had a bed alarm underneath them. R18 was asked about the bed alarm and wedge and replied, So I don't get up and fall out of bed. On 1/5/26 at 11:45 AM, an interview was conducted with Registered Nurse (RN) C, who was asked if R18 had a consent on file for the bed alarm and replied, I would have to look. On 1/6/26 at 12:40 PM, an observation was made of R18 in the main dining room sitting at a table in their wheelchair with a bed alarm clipped on the back of their shirt. Review of R18's medical records unveiled the lack of a consent for the bed/positioning alarm. On 1/7/26 at 11:35 AM, an observation was made of R18 sitting in a recliner in their room with the bed alarm on them. Review of R18's care plan, dated 8/6/25, read in part, .Focus: (R18's name) is a risk for falls r/t (related to) deconditioning, gait/balance problems.Interventions: Anticipate and meet (R18's name) needs. (R18's name) has bed alarm at night. On 1/7/26 at 9:44 AM, the Director of Nursing (DON) was asked about consents for bed alarms and replied, We don't do consents for the alarms. The DON confirmed that there is no consent on file for bed alarms and beds against the wall have no care plan or reassessed during quarterly assessments. Review of policy, titled Restraint, dated 10/20/17, read in part, .is a restraint free facility. If a restraint is needed for safety of a resident a doctors written order is required with justification for the restraint. Review of policy, titled Bed Rail Restraint, dated 2016, read in part, .is a restraint free facility. If a bed rail is needed for safety, a doctors written order is required with justification for the restraint. And must be approved by family before restraint is applied.

Based on observation, interview, and record review the facility failed to implement interventions, assess accurately, and prevent the development of a stage II pressure ulcer for one Resident (Resident #2) of two residents reviewed for pressure ulcer development. Findings include:Resident #2 (R2) R2's face sheet revealed admission to the facility on 7/1/25, with diagnoses including dementia, insomnia, hyperlipidemia, and hypertension.Review of R2's comprehensive minimum data set (MDS) assessment, dated 7/23/25, Section GG revealed R2 required substantial/maximal assistance on staff for activities of daily living cares including toileting, shower/bathing, upper/lower body dressing, personal hygiene, and putting on/taking off footwear. R2's brief interview of mental status (BIMS) revealed severe cognitive impairment. Section M revealed R2 had no pressure ulcers, was at risk for developing pressure ulcers, and lacked any skin treatments or interventions. Review of R2's quarterly MDS assessment, dated 10/15/25, Section M revealed R2 had developed a stage II pressure ulcer.On 1/5/26 at 12:00 PM, an observation was made of R2 resting in their room in a reclining chair with feet elevated, wearing heel protector boots, and their left foot drawn up adding pressure to the heel. R2's room was observed with a regular mattress and not an air mattress and no heels up pad was observed. R2's pressure ulcer risk assessment, dated 9/13/25 (completed 74 days after admission) revealed a score of 14. According to the assessment, a score of eight and above is considered to be HIGH risk for developing pressure ulcers. R2's care plan, dated 10/15/25, read in part .Focus: (R2's name) has an ulcer of the L (left) heel r/t (related to) limited joint mobility.Interventions: Inspect the feet daily. Report changes to the nurse, dressing change done twice daily. R2's physician orders, unveiled the following:On 9/15/25 - wound wash to left heel, cover with bandage, and complete twice daily.On 10/1/25 - wound wash to left heel, cover with bandage, and complete twice daily.On 10/21/25 - cadexomer iodine gel (treatment used for infected or exudating wounds to heal or debride) apply topically to dc (discontinue) skin wound bed and complete twice daily. Reposition every two hours in bed and use pillows.On 10/28/25 - doxycycline (antibiotic) 100 milligrams (mg) twice daily for ten days.On 11/25/25 - wound wash to left heel, apply bandage, and complete twice daily.On 12/1/25 - wound wash to left heel, apply iodine, apply bandage, and complete twice daily. R2's treatment administration record (TAR), unfolded the following:September 2025 TAR- 12 opportunities out of 30 where treatment was not signed out by nursing.October 2025 TAR- 23 out of 62 where treatment was not signed out by nursing.November 2025 TAR- 14 out of 60 where treatment was not signed out by nursing. R2's skin audit tools, dated 8/30/25 through 1/3/26, revealed the following:On 8/30/25 - development of a blister on the left heel.On 9/20/25 - left heel necrosis (tissue death) / ulcer.On 11/11/25 and 11/18/25 - left heel drainage. R2's skin audit tools, dated 8/30/25 through 1/3/26, lacked any pressure ulcer assessments for size, drainage, color, pain, odor, or wound staging. On 1/7/26 at 11:45 AM, an observation was made of R2's wound dressing change with Registered Nurse (RN) C, who was asked when R2 developed the pressure ulcer and replied, A couple months ago. RN C was asked how R2 developed the pressure ulcer and replied, I think they got it from the wheelchair foot pedal or rubbing their heel on the bed. RN C was asked about interventions prior to the development of R2's pressure ulcer was and replied, Float heels. RN C stated that the boots came after the blister developed. The pressure ulcer opened had to be debrided and then R2 was put on antibiotics related to poor healing and developing cellulitis. During R2's pressure ulcer dressing change no measurements were taken. R2's pressure ulcer had some mild serous (clear, thin, and watery) drainage and was in an oblong moon shape (lateral to medial of the heel) on the back of their left heel. R2 had another open area on the lateral side of their left foot that appeared pink. RN C was asked how R2 developed the open area and replied, It looks like a skin tear from tape. R2 also had a q-tip size dark purple area on the ball of their left pinky to pad. On 1/7/26 at 12:15 PM, an interview was conducted with the Director of Nursing (DON), who was asked how R2 developed the pressure ulcer on their left heel and replied, They are constantly moving their feet around, rubbing on the bed, and pounding them on the floor. The DON was asked why pressure ulcer interventions were not placed sooner for R2 and declined to answer. Review of policy titled, Prevention of Pressure Ulcers, dated 3/2005, read in part, Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors.General Guidelines.6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed.General Preventative Measures.3. For a person in a chair. a. Change position at least every hour.Interventions and Preventative Measures: Residents with Risk Factors.Use a special mattress that contains foam, air, gel, or water.Consider off-loading pressure hourly. Review of policy titled, Pressure Ulcer Treatment, dated 12/2007, read in part, Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers.Documentation: The following information should be recorded in the resident's medical record.6. All assessment data (i.e., color, size, pain, drainage, ect.) when inspecting the wound. 7. Resident tolerance of the procedure.9. Resident refusal of the treatment.

Based on observation, interview, and record review, the facility failed to monitor operation of the dish machine to assure dishes, utensils, and other food preparation equipment were properly sanitized. This deficient practice had the potential to promote food borne illness amongst any or all of the facility population of 18 Residents. Findings include: On 1/22/25 at 1:00 PM, the kitchen staff were observed operating the chlorine based cold temperature dish machine. (This was a chemical sanitizing dish machine which used chlorine rather than hot water plus chemicals in the ware washing process.) Certified Dietary Manager (CDM) A was asked to measure the chemical sanitizer dispensing in the machine. A quaternary strip was used (which cannot measure chlorine present to sanitize the dishes or food preparation equipment being washed in the dish machine). When the strips were examined and determined to be unable to measure the sanitizer, the kitchen staff found one roll of chlorine strips in a bag labeled expires 2/14/24. The dish machine was retested and while the strip turned dark, there was not a comparison color chart to accurately compare and determine the level of chlorine the dish machine had dispensed. The amount of sanitizer could not be accurately determined. CDM A noted the kitchen staff had been recording the sanitizer level on the dish machine logs, but stated they had been using the wrong strips since the interim CDM had left last April. The FDA Food Code 2017 states: 4-703.11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: . (C) Chemical manual or mechanical operations, including the application of SANITIZING chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under S 4-501.114. Contact times shall be consistent with those on EPA-registered label use instructions by providing: (1) Except as specified under Subparagraph (C)(2) of this section, a contact time of at least 10 seconds for a chlorine solution specified under 4-501.114(A), P (2) A contact time of at least 7 seconds for a chlorine solution of 50 MG/L (liter) that has a PH of 10 or less and a temperature of at least 38oC (100oF) or a PH of 8 or less and a temperature of at least 24oC (75oF) .

Based on observation, interview, and record review, the facility failed to implement and develop an enhanced barrier precautions (EBP) policy, and update infection control policies annually based on standards of practice. This deficient practice has the potential to affect all residents regarding infection control practices. Findings include: On 1/21/25 at 11:00 AM, during the entrance conference, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were asked to provide the infection control program policies for the facility. Resident 14 (R14) Review of R14's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment of 15, indicative of intact cognition. Review of R14's care plan, date revised 12/28/24, read in part, .Focus: [R14] has a catheter: Neurogenic bladder. Goal: [R14] will remain free from catheter-related trauma .Interventions: Check tubing for kinks 1 x and prn (as needed) each shift. Monitor and document intake and output as per facility policy. Cath (catheter) will be changed monthly . R14's care plan lacked any initiation for EBP as indicated by the Centers for Disease Control (CDC) while performing catheter care, which is listed as a high contact care activity involving a medical device. On 1/21/25 at 12:30 PM, an observation was made of R14's room which lacked any Personal Protective Equipment (PPE) cart or EBP sign on the door indicating precautions were necessary to perform high contact direct care activities, such as catheter care. During an interview on 1/22/25 at 2:10 PM, R14 declined the opportunity for this Surveyor to observe catheter care. R14 was asked if facility staff wear any kinds of PPE and replied, They wear gloves. R14 was asked if facility staff wear a gown when performing catheter care and replied, No, just gloves. On 1/22/25 at 2:20 PM, an interview was conducted with Certified Nurse Aide (CNA) F, who was asked what PPE was used to perform catheter care for R14 and replied, I wear gloves and put a barrier down on the floor. I use alcohol swabs and a hat to collect the urine. CNA F confirmed no other PPE was used when providing catheter care. On 1/22/25 at 3:00 PM, a review of all the infection control policies was completed. The following infection control policies had not been updated annually per standards of practice: a. Covid-19 Vaccination policy last updated on 12/1/20; b. Influenza Vaccination policy undated and no revision; c. Pneumococcal Vaccination policy undated and no revision; d. Isolation - Initiating Transmission-Based Precautions last updated on 12/2007; and e. Surveillance/Antibiotic Stewardship policy undated and no revision. On 1/23/25 at 10:35 AM, an interview was conducted with the NHA, who was asked if she knew how often infection control policies were reviewed and updated and replied, I don't know, you would have to go ask the DON. On 1/23/25 at 10:45 AM, an interview was conducted with the DON, who was asked if she knew how often infection control policies were reviewed and updated and replied, Well yearly. We look at them in quality assurance (QA) and I have a sign off sheet in the infection control book that they were reviewed. The DON was asked to provide the sign off sheet that all the infection control policies were reviewed annually. The DON was also asked if the facility had a policy for EBP and if they had implemented EBP per CDC guidance. The DON replied, No, we do not have a policy for EBP. I did not know that a new implementation with infection control was out for EBP. The DON was unable to provide the sign off sheet by the time of exiting the survey. Review of the Quality Assurance policy, undated, read in part, Policy Statement: It is the policy of this facility to develop, implement, and maintain an ongoing program designated to monitoring and evaluate the quality of resident care, pursue methods to improve quality care, and to resolve identified problems .2. To establish and provide a system whereby a specific process, and the documentation relative to it, is maintained to support evidence of an ongoing Quality Assessment and Assurance Program, encompassing all aspects of resident care including safety, infection control .

Based on observation, interview, and record review the facility failed to serve the correct portions as planned on the menu. This deficient practice had the potential to negatively affect the nutritional status of all 18 residents residing in the facility. Findings include: During an observation in the dietary department on 1/21/25 at 12:48 PM, Certified Dietary Manager (CDM) A was serving lunch of split pea soup, ham salad sandwich, mixed fruited jello and beverage of choice. The following portion sizes were served: - Regular diet: 4 oz (ounces) split pea soup, 1/2 ham salad sandwich, - Puree diet: 2 oz split pea soup, 2 oz pureed ham salad bread mixture The planned menu was reviewed and revealed: - Regular diet: 8 oz split pea soup, 1/2 ham salad sandwich, - Puree diet: 4 oz (#8 scoop) split pea soup, 2 oz (#16 scoop) pureed ham salad bread mixture During an observation of lunch service on 1/22/25 at 12:30 PM in the dietary department, the following portion sizes of hot pork sandwich (pork over a slice of bread with gravy) mashed potatoes, mixed vegetables, and pears were served: - Regular diet: 2 oz pork on one slice of bread, 4 oz (1/2 cup) mashed potatoes/gravy, 4 oz (1/2 c) mixed vegetables - Puree diet: 2 oz. pork (pureed with bread), 2 oz mixed vegetables, 2.67 oz (#12 scoop) mashed potatoes The planned menu was reviewed and revealed: - Regular diet: 2 oz pork on slice of bread, 4 oz mashed potatoes/gravy, 4 oz mixed veg. (vegetables) - Puree diet: 4 oz (#8 scoop) pureed pork blended with bread, 4 oz pureed mixed vegetables, 4 oz mashed potatoes. The puree consistency diet received only half of the food that was planned on the menu. The menus were discussed at 2:05 PM on 1/22/25. CDM A stated a #8 scoop (or 4 oz) portions for each item on the puree diet would be too much. The evening meal was reviewed for 1/22/25, it planned the regular diet receive 8 oz of goulash, while the puree diets receive a #16 scoop (2 oz). The diet plan was not the same portion for each consistency. During a telephone interview on 1/22/25 at 1:46 PM, the Registered Dietitian (RD) H stated those residents receiving a pureed diet should receive the same portions as those with a regular consistency. The recipes were requested for the ham salad sandwich and the split pea soup. Neither recipe gave portion sizes or nutritional break downs. The ham salad sandwich recipe did not indicate the steps, ingredients, or amounts needed to produce a puree portion.

Based on observation, interview and record review the facility failed to train non-licensed employees with the State-approved training course for feeding assistance to residents. This deficient practice put vulnerable residents at risk of complications associated with being fed for all residents needing feeding assistance (approximately six residents). Findings include: During the breakfast observation in the dining room on 1/22/25 at 8:34 AM, Certified Dietary Manager (CDM) A was observed feeding Resident #4 (R4) a pureed diet. When asked why she was feeding R4, CDM A said assistance was needed as other staff were not available. When asked about the risk involved, CDM replied that all residents on a pureed diet were at risk for choking. CDM A stated, Occasionally they ask me to help out and feed . When asked if she had taken the State-approved training program for feeding assistants, CDM A said the DON (Director of Nursing) gave me a refresher when I started 3 maybe 4 years ago. During an interview on 1/22/25 at 10:35 AM, the DON stated, I taught (CDM A), not a class - just common-sense stuff . (CDM A) used to be a CNA (Certified Nurse Aide) and is a CDM now. I don't know if she has kept up her license . We were short staffed this morning. The DON did not have record of CDM A taking the State-approved training course for paid feeding assistants including, at a minimum, 8 hours of training in: feeding techniques, assistance with feeding and hydration, communication and interpersonal skills, appropriate responses to resident behavior, safety and emergency procedures, including the Heimlich maneuver, infection control, resident rights, and recognizing changes in residents that are inconsistent with their normal behavior and the importance of reporting those changes to the supervisory nurse. The DON stated she was not familiar with the State-approved training course. The facility provided a paper that read in its entirety: Procedure for feeding resident a pureed diet: Sit the resident up straight, give them time to swallow between bites, and offer liquids between every few bites. The page was signed by the Nursing Home Administrator (NHA) and was undated as to initiation date or review date. The facility also provided a paper that read in its entirety: Kitchen Staff Feeding Policy: DON can train kitchen staff to feed puree residents. If Kitchen staff is needed to help feed residents the DON should instruct them on the proper procedures in feeding Residents both puree and regular diets. The page was signed by the NHA and was undated as to initiation date or review date.

Based on observation, interview and record review, the facility failed to regularly assess the nutritional needs and follow the physician's diet order for two Residents (#11 & #18) of three residents reviewed for nutritional needs. This deficient practice resulted in the potential for nutritional compromise, undetected physical decline, and weight loss. Findings include: Resident #11 (R11) The medical record for R11 revealed an admitted [DATE]. Current diagnoses for R11 included: dementia, anxiety, depression, history of stroke, and history of traumatic brain injury. During meal rounds on 1/21/25 at 1:35 PM, R11 was observed in the dining room eating a pureed consistency lunch. She consumed 100% of her meal. The tray card read Regular Diet, Regular Texture although she was served a puree consistency diet. The tray card also included: Dislikes: .Split Pea Soup . R11 received pureed split pea soup. The medical chart for R11 revealed an active care plan which included, (R11) is at risk for nutritional deficits r/t (related to) many diagnoses that may affect nutrition unspecified dementia without behavioral disturbances, HTN (hypertension), major depressive disorder, GERD (gastroesophageal reflux disease) .traumatic brain injury . anxiety disorder, weakness . Date initiated: 01/31/2023. Interventions for this care plan focus included: .Provide and serve diet as ordered. (R11) has pureed diet, regular fluids, uses covered cup. Revision on 1/7/2025. While the care plan revealed a puree diet was planned, the physician diet order read: REGULAR CONSISTENCY, REGULAR DIET, THIN LIQUIDS dated 12/01/2021. This order was reviewed and signed as approved by Medical Director (MD) G on 1/8/25. (Handwritten telephone orders were present in the medical record from 12/1/24 which read pureed diet and were signed by Medical Director (MD) G on 12/1/24 but had not been carried forward to the January 2025 orders.) The medical chart for R11 also included quarterly and annual nutritional assessments dated 12/13/23, 3/4/24, and 12/31/24. The 12/13/23 annual nutritional assessment concluded R11 had a normal nutritional status with a score of 13. The 3/4/24 quarterly nutritional assessment concluded R11 had a normal nutritional status with a score of 14. The 12/31/24 quarterly nutritional assessment had changed and concluded R11 was At risk of malnutrition with a score of 8.0. There were no quarterly nutritional assessments between the 3/4/24 and 12/31/24 assessments. The nutritional status had the potential to be identified earlier if the missing assessments were completed. During an interview on 1/23/25 at 2:15 PM, Certified Dietary Manager (CDM) A was asked what actions were taken with this decline in nutritional status. With the missing nutritional assessments, she was not certain when the decline occurred and said, I must have missed a few (assessments). CDM A said with a decline in condition she would contact the consulting Registered Dietitian (RD) H. There was no documentation of RD H being alerted following the 12/31/24 assessment which identified R11 was At risk of malnutrition. Resident #18 (R18) The medical record for R18 revealed an admitted [DATE]. Current diagnoses for R18 included: kidney disease, depression, diabetes, dementia, and anxiety. During meal rounds on 1/21/25 at 1:00 PM, R18 was observed being fed lunch by Certified Nurse Aide (CNA) F. CNA F reported R18 usually accepted most of her pureed food but did not always take the fluids as well. R18's tray card read Regular Diet, Regular Texture although she was served a puree consistency diet. The medical chart of R18 was reviewed. The care plan for R18 included, Care plan: (R18) is at risk for nutritional deficits r/t many diagnoses that may affect nutrition (elevated blood pressure . chronic kidney disease [CKD] with stage 1 through stage 4 CKD, major depressive disorder, palpitations, DMII w/o (Diabetes type 2 without) complications . Interventions for this care plan focus included: .Provide and serve diet as ordered. Regular diet, regular texture, regular fluids, thin consistency . While the meal served was a puree diet, the physician diet order read: REGULAR dated 1/4/2023. This order was reviewed and signed as approved by Medical Director (MD) G on 1/9/25. (Handwritten telephone orders were present in the medical record from 12/1/24 which read pureed diet carnation instant breakfast drink (CIB) 4 oz [ounces] and were signed by Medical Director (MD) G on 12/1/24 but had not been carried forward to the January 2025 orders and had not been included in the care plan.) The medical chart for R18 included quarterly and annual nutritional assessments dated 1/7/24, 4/8/24, and 7/7/24. The 1/7/24 nutritional assessment concluded R18 was At risk of malnutrition with a score of 11. The 4/8/24 nutritional assessment concluded R18 was At risk of malnutrition with a score of 11. The 7/7/24 nutritional assessment concluded was At risk of malnutrition with a score of 10. There were no further quarterly or annual nutrition assessments after 7/7/24. This 7/7/24 last nutritional assessment completed by the CDM recorded a weight of 90.2 pounds. R18's most current weight was 86.1 pounds recorded in January 2025. During an interview on 1/23/25 at 2:33 PM, CDM A was asked about the missing assessments for R18 and replied, I am behind on that. I guess I missed two assessments. She (R18) has always been nutrition at risk. The consultant RD H progress note dated 12/13/2024 read in part: Note Text: Resident currently receives a regular diet, regular texture, regular fluids, thin consistency. It should be noted the handwritten telephone order of 12/1/24 had changed the diet to puree consistency. The consultant RD H progress note dated 12/17/2024 read: Note Text: Per discussion with CDM at facility visit CIB was added TID (three times daily) and diet cahnged (sic) to pureed in attempt to increase intake and weight. Will review as needed.

Based on interview and record review, the facility failed to provide rationale on pharmacy medication regimen review (MRR) recommendations being declined by the physician for two Residents (#6 and #11) of five residents reviewed for MRR's. Findings include: Resident #11 (R11) Review of R11's medical record revealed an admitted [DATE] with diagnoses including dementia, depression, and anxiety. A review of the 12/31/24 Minimum Data Set (MDS) assessment revealed a score of 3 on the Brief Interview for Mental Status (BIMS) assessment indicative of severely impaired cognition. Review of R11's pharmacy recommendation, dated 11/26/24, read in part, Comment: [R11] has a PRN (as needed) order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam 0.5 mg (milligrams), give 1 tablet by mouth twice daily as needed. Recommendation: Please discontinue PRN Lorazepam .If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period . R11's MRR dated 11/26/24 was signed by Medical Director (MD) G on 12/4/24 and marked decline to discontinue the medication without providing a rationale for continuation of use. 40383 Resident #6 (R6) Review of R6's medical record revealed an admitted [DATE] with diagnoses including depression, anxiety and diabetes. The current physician's orders dated 1/8/25 read: BLOOD SUGAR VIA FINGERSTICK (a short needle used to draw blood) VIA METER THREE TIMES DAILY ., GLIMEPIRIDE 4 MG (milligram) tablet Give 1 tablet by mouth twice daily with food A review of R6's pharmacy consultant report recommendations dated 10/22/24, read in part, - Comment: (R6) receives a sulfonylurea Glimepiride. Recommendation: Please discontinue Glimepiride. If appropriate, adjust the diabetes regimen by increasing Levemir. - Rationale for Recommendation: Sulfonylurea's should be avoided in older adults due to the risk of cardiovascular events and prolonged hypoglycemia . - Physician Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The Medical Director (MD) G did not provide a rationale and signed the consultation report on 11/6/24. A review of R6's pharmacy consultant report recommendations dated 12/18/24, read in part, - Comment: (R6) receives insulin and a sulfonylurea, Glimepiride concomitantly, increasing the risk of hypoglycemia. - Recommendation: Please discontinue Glimepiride. - Physician Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The Medical Director (MD) G did not provide a rationale and signed the consultation report on 1/8/25. A review of R6's pharmacy consultant report recommendations dated 12/18/24, read in part, - Comment: (R6) frequently requires insulin per sliding scale . - Recommendation: Please decrease sliding scale insulin to BID (twice per day) with the end goal of discontinuing sliding scale while adjusting the diabetes regime by increasing Levemir to 67 u (units) BID. Close monitoring (e.g. glucose) should accompany any change in diabetic therapy and guide further adjustments. - Rationale for Recommendation: Prolonged use of sliding scale insulin is not recommended as it often results in wide variations in blood glucose, including prolonged periods of hyperglycemia or hypoglycemia. - Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The Medical Director (MD) G did not provide a rationale and signed the consultation report on 1/8/25. During an interview on 1/23/25 at 12:26 PM, the DON stated, I have addressed this issue with this physician in the past and will have to do it again. Review of the Quality Assurance (QA) Committee policy, undated, read in part, .The QA committee shall include the following components for quarterly review .Pharmaceutical Services: Safe and effective drug therapy. Medication records will be reviewed monthly by the Registered Pharmacist for safety and effectiveness of the prescribed regimen. Problems will be referred to the attending physician. The DON will also review PO (oral) and medication records for UN necessary (sic) drugs, appropriate diagnosis for drug use, appropriate administration and side effects . Review of policy titled Antipsychotic Medication Use, revised April 2007, read in part, Policy Statement: Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.

Based on interview and record review, the facility failed to indicate a specific duration (end date) for PRN (as needed) psychotropic (drug that affects brain activity) medication, provide gradual dose reductions for psychotropic medications and include non-pharmacological interventions when psychotropic medications were prescribed for three Residents (#6, #11, and #12) of five residents reviewed for unnecessary medications. Findings include: Resident #11 (R11) Review of R11's medical record revealed an admitted [DATE] with diagnoses including dementia, depression, and anxiety. A review of the 12/31/24 Minimum Data Set (MDS) assessment revealed a score of 3 on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. Review of R11's, physician orders, dated January 2025, revealed a signature from the physician on 1/8/25 and an order dated 11/4/24 for Lorazepam 0.5 mg tablet, give 1 tablet by mouth twice daily as needed. No indication for use or end date for PRN Lorazepam was present on the physician orders. Review of R11's care plan, date revised 1/7/25, read in part, .Focus: [R11] has a behavior problem anxiety r/t (related to) dementia. Goal: [R11] will have fewer episodes of anxiety by review date .Interventions: Administer medications as ordered. Monitor/document side effects and effectiveness . R11's care plan lacked any non-pharmacological interventions for their anxiety. Review of R11's pharmacy recommendation, dated 11/26/24, read in part, Comment: [R11] has a PRN (as needed) order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam 0.5 mg (milligrams), give 1 tablet by mouth twice daily as needed. Recommendation: Please discontinue PRN Lorazepam .If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period . R11's MRR dated 11/26/24 was signed by the Medical Director (MD) G on 12/4/24 and it was marked decline recommendation without providing a rationale for continuation of this as needed medication. On 1/23/25 at 12:15 PM, a review of R11's medical record and physician progress notes, dated September 2024 through January 2025, revealed the lack of monitoring for the effectiveness and continued use of the PRN Lorazepam. On 1/24/25 at 11:00 AM, an interview was conducted with the Director of Nursing (DON), who was asked why R11 was prescribed the as needed Lorazepam and replied, (R11) was going through an adjustment period. The DON was asked why there was not an end date to the medication and replied, I am not sure, but there should have been an end date. The DON was asked if there was any follow-up from the physician on the use of the Lorazepam. The DON then reviewed R11's medical record and replied, I do not see any follow-up. Resident #12 (R12) Review of R12's medical record revealed an admitted [DATE] with diagnoses including depression and Parkinson's disease (a disorder of the central nervous system that affects movement). A review of the 12/20/24 MDS assessment revealed they scored 11 on the BIMS assessment indicating moderately impaired cognition. Review of R12's, physician orders, dated January 2025, revealed an order for citalopram 10 mg, give one tab daily. Review of R12's, MRR's dated July through December 2024, revealed R12 last had a gradual dose reduction (GDR) attempt on 9/6/23 and was due for another GDR on 9/17/24, but was not attempted. Review of R12's physician progress notes, dated September 2024 through January 2025, lacked any documentation regarding R12's citalopram depression medication. There was no evidence of a GDR attempt or rationale for clinical contraindication for not performing a GDR. On 1/24/25 at 11:00 AM, an interview was conducted with the DON, who was asked if R12 had any documentation of an attempt or clinical rationale for not performing a GDR in September 2024. The DON replied, I am not sure about a GDR or an explanation. I do not have any documentation that a GDR was attempted in September. Review of R12's care plan, date revised 1/7/25, read in part, .Focus: [R12] uses antidepressant medication r/t (related to) depression. Goal: [R12] will be free from discomfort or adverse reactions related to antidepressant therapy through the review date .Interventions: Administer antidepressant medication as ordered by physician. Monitor/document side effect and effectiveness Q (every) shift . R12's care plan lacked any non-pharmacological interventions for their depression. 40383 Resident #6 (R6) Review of R6's medical record revealed an admitted [DATE] with diagnoses including depression, and anxiety. The current physician's orders dated as approved by the attending physician on 1/8/25 included: Duloxetine HCL (hydrochloride) 60 MG capsule Give on capsule by mouth once daily (a medication used to treat depression). The care plan for R6 included a focus of: (R6) uses antidepressant medication Cymbalta r/t (related to) Depression. Date Initiated: 07/01/2023 Revision on: 08/20/2023 The only intervention for this focus was listed as, Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 07/01/23. No behavioral interventions were included. The care plan for R6 included a focus of: (R6) has a mood problem r/t Use/side effects of medication. Date Initiated: 07/01/2023 Revision on: 08/20/2023. The only intervention for this focus was listed as, Administer medications as ordered. Monitor/document side effects and effectiveness. Date Initiated: 07/01/23. No behavioral interventions were included. During an interview on 1/23/25 at 2:00 PM, the DON reviewed the care plan for R6 and indicated she could not find non-pharmacological interventions. The medical chart also included a daily BEHAVIOR/MOOD SYMPTOM TRACKING TOOL. It was noted for the January 2025 tracking, the tool included a column to document interventions for behaviors. For all days in January no behavioral interventions were listed. Review of the Quality Assurance (QA) Committee policy, undated, read in part, .The QA committee shall include the following components for quarterly review .Pharmaceutical Services: Safe and effective drug therapy. Medication records will be reviewed monthly by the Registered Pharmacist for safety and effectiveness of the prescribed regimen. Problems will be referred to the attending physician. The DON will also review PO (oral) and medication records for UN necessary (sic) drugs, appropriate diagnosis for drug use, appropriate administration and side effects . Review of policy titled Antipsychotic Medication Use, revised April 2007, read in part, Policy Statement: Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition. Policy Interpretation and Implementation .9. For acute psychiatric situations, antipsychotic medication use shall meet the following criteria: a. The acute treatment period is limited to seven days or less; and b. A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days, to identify and address any contributing and underlying causes of the acute psychiatric condition and verify the continuing need for antipsychotic medication; and c. Pertinent non-pharmacological interventions must be attempted .15. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences Facility requirements for antipsychotic use: 1. All physicians review and make note on effectiveness at each rounds visit .6. Annual gradual dose reduction or risk vs benefit statement for continued use.

Based on observation, interview, and record review, the facility failed to properly store potentially hazardous food and maintain a kitchen environment free of harborage conditions for pests, resulting in an increased risk of foodborne illness and potential for pests on the premise, affecting all residents that consume food from the kitchen. Findings include: On 2/5/24 at 11:28 AM, during an inspection of the kitchen, Cook C stated that the 1st section of the walk-in cooler was currently not working and they are working on getting it repaired. A bottle of opened ranch dressing was observed to be stored in the warm 1st section and the manufacturer's label states Keep Refrigerated. Additionally, an opened jar of sweet pickle relish was observed to be stored in the warm 1st section and the manufacturer's label states Refrigerate after opening. According to the facility's policy, Cold Food Storage Protocol, dated 10/28/2008, it notes, Policy: All perishable food will be stored according to HACCP guidelines. These food items will be maintained at 41*F or colder. According to the 2017 FDA Food Code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less. P (B) EGGS that have not been treated to destroy all viable Salmonellae shall be stored in refrigerated EQUIPMENT that maintains an ambient air temperature of 7 C (45 F) or less. P (C) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD in a homogenous liquid form may be maintained outside of the temperature control requirements, as specified under (A) of this section, while contained within specially designed EQUIPMENT that complies with the design and construction requirements as specified under 4 204.13(E). On 2/5/24 at 11:35 AM, mouse droppings were observed among trays and pot lids in the cupboard next to the oven. At this time, Cook 'C' was queried on pest problems in the facility and stated that they have caught one or two mice, but they hardly ever go in the cupboard where the mice droppings were observed. The kitchen was observed to have multiple rodent traps that were empty. No other areas in the kitchen were observed to have mouse droppings. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During an interview on 2/5/24 at 4:05 PM, the Administrator stated that they do their own pest control program. The Administrator continued to state that they have caught a few mice but don't have an issue with pests currently.

Based on interview and record review, the facility failed to ensure requirements for Preadmission Screening/Annual Resident Review (PASARR) were reviewed and revised annually for five Residents (R1, R11, R13, R14, and R16) of seven residents reviewed for PASSAR requirements, resulting in the potential for unmet mental health and/or intellectual/developmental disability care needs. Findings include: Resident #1 (R1) Review of R1's medical records, revealed a PASARR form (Form DCH-3877 [State Agency] used to determine mental health needs) dated 8/5/22 and indicated a Level II evaluation. There was no Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification. The PASARR dated 8/5/22 revealed an original admission to the facility on [DATE]. No annual review documentation could be found. The 'medical diagnoses' indicated R1 had resided at the facility since 2019 with diagnoses that included dementia and major depressive disorder. According to the Minimum Data Set (MDS) dated [DATE], R1 had moderate cognition impairment with a Brief Interview for Mental Status (BIMS) score of 11/15. R1 received an antidepressant medication seven days a week. Resident #11 (R11) Review of R11's medical records, revealed a PASARR form dated 8/1/22 and lacked any further PASARR form as required. The PASARR dated 8/1/22 revealed an original admission to the facility on [DATE]. According to the MDS dated [DATE], R11 had medical diagnoses of dementia and depression. Resident #13 (R13) Review of R13's medical records, revealed a PASARR form dated 8/5/22 and a Level II evaluation dated 8/5/22. The PASARR dated 8/5/22 revealed an original admission to the facility on [DATE]. No annual updated PASARR could be located in the medical record. According to the MDS dated [DATE], R11 had a medical diagnosis of depression. Resident #14 (R14) Review of R14's medical records, revealed a PASARR form dated 12/14/21 and lacked any further PASARR as required. The PASARR dated 12/14/21 revealed an original admission to the facility on [DATE]. According to the MDS dated [DATE], R1 had moderate cognition impairment with a BIMS score of 8/15. R14 received an antidepressant medication seven days a week and had medical diagnoses of depression and dementia. Resident #16 (R16) Review of R13's medical records, revealed a PASARR form dated 8/5/22 and a Level II evaluation dated 8/5/22. No updated PASARR could be found in the medical record. The PASARR dated 8/5/22 revealed an original admission to the facility on [DATE]. According to the MDS dated [DATE], R16 had severe cognitive impairment with a BIMS score of 1/15. R16 received an antipsychotic and antianxiety medications seven days a week and had medical diagnoses of anxiety, depression, and dementia. On 2/5/24 at 4:00 PM, a request was made to the Director of Nursing (DON) for an updated PASARR for R1, R11, R13, R14, and R16. On 2/6/24 at 1:30 PM, an interview was conducted with the DON and a second requested was made for the missing PASARR forms as stated above. The DON replied, I looked for them in the charts and I noticed they were not completed. I called Community Mental Health (CMH), and they are overdue. I just did them and now they are in the charts. On 2/7/24 at 10:00 AM, an interview was conducted with the DON who confirmed that the PASARR forms were to be completed annually. Review of the facility document titled, Pre-admission Level II Evaluation and Annual Resident Review (PASARR), undated, read in part, .[name of nursing home] will review assessments annually. Review of the facility document provided agreement with the local CMH, dated 6/12/18, read in part, .Preadmission Level II Evaluation and Annual Resident Review (PASARR) .B. The Nursing Facility shall initiate the referral by annual completion and transmittal of (State Agency) Form 3877 to the Board or by forwarding admission 3877/3878 Hospital Exemption Discharge ([NAME]) forms prior to the expiration of the [NAME] .Documentation .B. The Nursing Facility will be responsible for the following documentation: .1. Admission (State Agency) 3877/3878 Hospital Exempted Discharge forms .2. Annual completion and transfer to the Board of (State Agency) Forms 3877 and 3878 (as appropriate) at least 30 days, but preferably 2 weeks, prior to the previous review date or (State Agency) Determination .

Based on observation and interview, the facility failed to maintain smooth floors, secure free-standing wardrobes, and secure riser lids for the septic system, resulting in the potential for falls and entrapment, affecting residents, staff, and the public. Findings include: On 2/5/24 at 11:50 AM, the adhesive tile floor at the end of the hall, near rooms 101/102, was observed to have multiple tile squares peeling up, creating a tripping hazard. The peeling tiles were easily catching the Surveyors foot, while walking over them. An emergency exit was observed at the end of the hall, next to the damaged tiles. On 2/5/24 at 2:50 PM, the free-standing wardrobes in resident room #'s 122- 128 and 163-170 were observed to not be fastened to the wall. Multiple wardrobes were observed to not be level on the floor. The wardrobes have the potential to tip over when the door was opened, and weight was applied to the door. On 2/6/24 at 9:10 AM the septic tank riser at the south west drain system was observed to be damaged and duct taped together. Additionally, all four septic tank risers were not observed to be fastened shut to prevent accidental entrapment. During an interview on 2/6/24 at 9:30 AM, Maintenance Director F stated that the riser at the southwest drain system was run over by a car and they haven't found a replacement to match. During an interview on 2/6/24 at 10:55, the NHA was queried on the damaged floor and stated it was as a result of a carpet being placed in front of the emergency exit that would get wet from snow melt. The consistent wet floor warped the adhesive tiles. The NHA was queried further regarding the free-standing wardrobes potential for tipping over and stated that they haven't thought of securing the wardrobes to the wall.

Based on observation, interview, and record review, the facility failed to ensure the medication storage room was free of expired medications and failed to securely store medications, for one of one medication rooms and one of one medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of medications with reduced intended effect. Findings include: On 2/5/24 at 2:40 PM, an observation was made of the medication storage room with the Director of Nursing (DON). In the medication room the following items were found to be expired: a.) name brand needle 22-gauge with lot number 365608 and expiration date of 1/31/23 count seven; b.) name brand needle 21-gauge with lot number 365607 and expiration date of 3/31/23 count six; c.) name brand syringe with attached needle size 3 milliliters and 21-gauge inch and one half with lot number 7031546 and expiration date of 1/31/22 count twelve; d.) hydrocortisone cream, 2 ounces, with lot number 0110387 and expiration date of 10/22; e.) diclofenac sodium cream 1 % gel 100 grams with lot number SBBH and expiration date of 01/24; f.) name brand needle 23-gauge with lot number 6238534 and expiration date of 7/31/21 count two; g.) name brand needle 23-gauge with lot number CKDH12-01 and expiration date of 11/1/23 count half box 50 of 100 and; h.) name brand over the counter pain relief patches (lidocaine) with lot number 30L43 and expiration date of 12/23 count half box 10 of 20. On 2/5/24 at 3:00 PM, an interview was conducted with the DON. The DON was asked if the facility provides their own blood draws to residents and replied, Yes. We draw blood on the residents. The DON was asked if expired medication supplies should be kept in the active medication supply room and replied, No. I will throw them out now. The DON was asked how often the medication supply room is reviewed for expired medications and biologicals and replied, The medication room is reviewed by nursing staff and me twice a month on the 1st and the 15th of the month. On 2/6/24 at 10:42 AM, an observation was made of medication pass with Registered Nurse (RN) D who was in room [ROOM NUMBER] passing medications with this Surveyor. This Surveyor was observing medication pass and looked down at the floor and observed a round small pink pill on the floor under the base of the bedside table. RN D was asked if she had seen the pill and replied, Yes. I see it. RN D picked up the pill and later it was identified as Resident #20's lisinopril 20 milligrams that is administered at 9:30 PM every evening. Review of the Resident residing in room [ROOM NUMBER]'s medication administration record revealed that she received this medication at 9:30 PM and RN D verified and confirmed that the room had been cleaned the prior day by housekeeping. RN D was asked if the medication should have been loose on the floor of room [ROOM NUMBER] and replied, No. It should have been thrown away and re-dispensed. On 2/6/24 at 11:10 AM, an interview was conducted with the DON, who confirmed that no loose pills should be found or left in any residents' room. Review of facility policy titled, Medication Storage, dated 2015, read in part, Medication is stored and kept under lock and key in medication cart, and med room only .

Based on observation and interview, the facility failed to maintain exhaust ventilation in resident bathrooms, resulting in the potential for odors, affecting room #'s 167, 168, 169, and 170. Findings include: On 2/5/24 at 2:50 PM, the exhaust ventilation for the bathroom of room [ROOM NUMBER] was tested using a paper towel to test the suction of the vent. The paper towel showed no pull from the exhaust ventilation. During an interview on 2/6/24 at 9:05 AM, Maintenance Director F was queried on the ventilation system and stated that the two roof top air units were iced over. Maintenance Director F continued to state that a staff member turned on the air conditioning (AC) unit two days ago, causing the roof top units to build up ice. Maintenance Director F confirmed that the residents bathroom exhaust vents are not working properly for this reason. On 2/6/24 at 10:45 AM, resident bathroom exhaust fans for room #'s 167, 169, and 170 were observed to not be functioning using the paper towel test.

Based on interview and record review, the facility failed to ensure appropriate monitoring and assessment for a change in condition for one Resident (#4) of one residents reviewed for hospitalization . This deficient practice resulted in the potential for worsening in condition and delay in treatment. Findings Include: Resident #4 (R4) Review of R4's medical record revealed initial admission to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hypertension (high blood pressure), and frontotemporal neurocognitive disorder (a type of dementia) . Review of R4's most recent Minimum Data Set (MDS) assessment, dated 10/19/23, revealed a Brief Interview for Mental Status (BIMS) score of 1, indicative of severe cognitive impairment. Review of Resident Transfer Form revealed R4 was transferred from the facility to the local hospital on 10/11/23. The reason for transfer was listed as a decrease in hemoglobin (the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues). Review of hospital admission records dated 10/12/23 read, in part: .CHIEF COMPLAINT: Dark and tarry stools and anemia. HISTORY OF PRESENT ILLNESS: This patient is a [AGE] year-old white female who was sent here [hospital] from [facility] nursing home. She had been having dark stools for the past 2 weeks. Laboratory studies were done that showed her hemoglobin was 4.3 [reference range 12.0-16.0 g(grams)/dL(deciliter)] when she arrived here [hospital] but her hemoglobin was actually 3.3 [g/dL] . .IMPRESSION: .GI (gastrointestinal) bleed with acute blood loss anemia .transfused 4 units of packed red blood cells in the emergency room . On 2/7/24 at approximately 9:50 AM, an interview was conducted with Registered Nurse (RN) D regarding the events leading up to R4's hospitalization . RN D stated R4 had a gradual decrease in appetite and reported abdominal pain which prompted the physician to order lab work. RN D denied reports of abnormal stools or abnormal vital signs. Review of a Nursing Note dated 10/10/23 at 1800 (6:00 PM) read, in part: .skin paleness + [and] hypotensive (low) B/P's (blood pressures) in the last few wks (weeks). Dark stools, poor appetite at times. Belching . Review of R4's Bowel Movement Record in the 14 days leading up to her hospitalization did not reveal documentation of color nor consistency of the stools. Review of the physician notes in the prior two weeks did not indicate dark stools or alteration of appetite. Review of the R4's Vital Sign and Weight Flow Sheet revealed the following blood pressure measurements in the two weeks which lead up to R4's transfer to the hospital: 9/28/23: 104/61 (millimeters of mercury [mmHg]) 9/29/23: 96/54 9/30/23: 96/53 10/1/23: 113/43 10/2/23: 109/56 10/3/23: 98/49 10/4/23: 124/70 10/7/23: 93/48 10/8/23: 121/90 10/9/23: 111/63 10/10/23: 97/49, 99/58 10/11/23: 109/54 Review of R4's blood pressure measurements from 9/1/23 to 9/27/23 (the month leading up to R4's hospitalization on [DATE]), revealed an average blood pressure of 126/72. On 2/7/24 at 10:04 AM, an interview with conducted with the Director of Nursing (DON). The DON was asked the protocol that is expected if a vital sign was determined to be out of normal parameters. The DON stated, It would be expected to retake it [the vital sign]. If it was still too low or too high, the physician would be notified. The DON reviewed R4's blood pressure readings leading up to her hospitalization and acknowledged an overall reduction in blood pressure readings and several measurements that were considered out of normal parameters. The DON stated that the physician was noted via text message or call on the instances R4's blood pressures fell outside the normal range. No physician documentation prior to the day of the hospital transfer was produced to support this statement. On 2/7/24, at approximately 11:39 AM, a follow-up interview was conducted with RN D. RN D acknowledged that R4's blood pressures were trending down and not within her normal range in the days leading up to her hospitalization . RN D verified that communication with the physician is expected in these circumstances. No physician documentation prior to the day of the hospital transfer was produced to support this statement. Review of an undated facility policy titled, Nursing Policy and Procedure: Vital Signs Notification read, in part: .if warranted, nurses will contact doctor of any abnormal vital signs. Review of an undated facility policy titled, Change in Condition Policy read, in part: Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety . .1. Summarize Baseline Condition: Nursing staff should summarize a resident's normal (baseline) condition 2. Identify Important Changes: It's essential to identify whether changes in a resident's condition are important or not . .Remember that timely reporting of changes can lead to better outcomes for residents, while unreported changes may result in serious complications or even hospitalization . Communication and vigilance play a crucial role in maintaining resident safe and well-being.

Based on observation, interview and record review, the facility failed to post required staffing information on a daily basis to identify the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice resulted in the potential for residents and their representatives being unaware of the nursing staff available to provide care each shift and the potential for unmet care needs. Findings include: During an interview on 12/19/2022 at 11:30 a.m., the Nursing Home Administrator (NHA) was asked where the required daily staff posting was located. The NHA stated the Director of Nursing (DON) used the whiteboard in the nurses' stations to post the nursing staff working each day. The NHA stated the DON filled out a staffing sheet at the end of each day to include the total hours worked by the schedule nursing staff for that given day. The NHA reported she filed the staffing information and did not post the information anywhere in the facility. The NHA presented a Daily Census Report, dated 12/18/2022, and reported the form as the daily staff posting. When asked to present the Daily Census Report, for the present day, 12/19/2022, the NHA stated the form would not be completed until the end of day. An observation on 12/19/2022 at 11:45 p.m., revealed a white board located on the wall in the nurses' stations. Further review revealed the following written on the board with erasable marker: (First name only) 7a-7p (First name only) 7p-7a (First name only) 6a-6p (First name only) 1-8:30 (First name only) 5a-1p (First name only) 10p-4a (First name only) 6p-10p Census 22, Hours (blank) The staffing information written on the white board only included first names of staff and did not include credentials to allow residents and resident representatives to determine whether the listed staff were licensed or unlicensed nursing personnel. The information did not break down the staffing per shift or list the required number of licensed and unlicensed staff needed to care for the resident population per shift. A review of the Daily Census Report, dated 12/18/2022, revealed the following: Nursing Assignments: Charge Nurse 7A - 7P: (DON) 12 (hours) 35 (minutes). Charge Nurse 7P- 7A: (LPN L), 12 (hours) 27 (minutes). CNA (Certified Nurse Aide): (CNA M), 12 (hours) 5 (minutes) (CNA N), 8 (hours) 39 (minutes) (CNA O), 7 (hours) 10 (minutes) (CNA P), 12 (hours) 8 (minutes) (CNA Q), 6 (hours) 13 (minutes. Actual Census: 22. It was noted the form did not include a breakdown of how many of each type of staff, licensed and unlicensed, were required each shift. Further review revealed the CNAs listed were not broken down by shifts therefore it could not be determined how many CNAs worked each shift. A review of the Daily Census Report(s), for April 2022, June 2022 and December 2022 revealed all reports did not include a list the daily staffing required by licensed and unlicensed nursing staff, but rather the acutal hours worked for each member of the nursing staff. Each report did not break down how many of each type of personnel were needed each day and per shift, to care for the resident population. During an interview on 12/20/2022 at 10:30 a.m., the DON confirmed the daily staff requirements were being completed by her at the end of each day for the previous day. The DON stated she filled out the Daily Census Report(s), based on who worked each day based on actual hours worked and did not use the reports to determine staffing needs. The DON reported after completion the Daily Census Report(s), were presented to the NHA for filing.

Based on observation, interview, and record review, the facility failed to employ a qualified staff with the appropriate competencies, skill sets, and credentials to supervise and carry out the functions of the food and nutrition service including Resident nutritional assessments, service of individual diets with proper consistency and therapeutic needs, and follow up on residents at nutritional risk. This deficient practice resulted in the lack of oversight and leadership in the operation of the dietary department with the potential to result in clinical dietary needs of all 22 residents being compromised and unmet. Findings include: During an interview on 12/20/22 at 8:02 AM, the Dietary Manager (DM) I stated she was a cook and had agreed to try out the manager position. She stated she had been in the Certified Dietary Manager (CDM) correspondence class for over a year and it's not going so well. She stated she had been working 12-hour shifts until a new cook was hired about a month ago. DM I said it was hard to work long hours and complete class work. During an interview on 12/20/22 at 9:00 AM, the Nursing Home Administrator (NHA) stated she was unsure when DM I began the CDM course and did not have records. The NHA said the consulting Registered Dietitian (RD) J would know about that. On 12/20/22 at 9:43 AM, DM I presented an email revealing she had been enrolled in the CDM class since 11/2021. During an interview on 12/20/22 at 12:58 PM, the NHA said DM I was training for the dietary manager job, but the Director of Nursing (DON) was doing the nutritional assessments. During an interview on 12/20/22 at 1:15 PM the DON was asked about the nutritional assessments and said, I've never done them. The DON said she put the weights in the chart and notified RD J. The charts were reviewed together, and it was determined: - Resident #8 had no nutritional assessment. - Resident #18's most recent nutritional assessment was completed on 7/20/21. - Resident #6's most recent nutritional assessment was completed on 7/6/21. - Resident #22's most recent nutritional assessment was completed on 6/29/22. - Resident #2's most recent nutritional assessment was completed on 6/8/22. During a telephone interview on 12/21/21 at 8:52 AM, RD J stated they consulted for the facility and worked part time, approximately 4 hours every two or three months and precepted DM I for the CDM course completing six or seven lessons out of 16 or 18 lessons in the course. RD J said DM I had been at it for more than a year. RD J said the facility monitored the weights in the chart and if there were nutritional problems the facility let them know. RD J stated, I do not do quarterly nutritional assessments and they thought the DON was doing all of that. On 12/19/22 at 12:45 PM, the posted menu was reviewed. This menu was signed by RD J, but the attached copies of the therapeutic extension plan written for specialized diets were not signed or dated by RD J. Upon review, the planned posted menu did not match the therapeutic diet menu. On 12/19/22 at 1:00 PM, lunch was being served in the dining room. The menu listed Grilled Turkey and Cheese, Potato Salad, Potato chips, Ice Cream. The therapeutic diet menu listed coleslaw and no potato salad. No coleslaw had been produced for the therapeutic diets. The therapeutic diet menu indicated the Con CHO (Consistent Carbohydrate) diet was to include sliced peaches in place of the ice cream. The therapeutic diet menu also listed the 1500 calories diet was also to include sliced peaches in place of the ice cream. - Resident #8 had a tray card with a diet of Carb Control and had the Special Request of 4 starch, 1 fruit, 1 vegetable, 3 oz meat/equivalent, 1 fat. These listed exchanges would indicate a calorie controlled diet such as 1500 calories. Resident #8 received a meal of one-half turkey and Swiss cheese sandwich, potato salad, potato chips, ice cream and chocolate syrup and did not include any fruit (which should have been substituted for the ice cream per the therapeutic menu) and did not include a vegetable (which should have been coleslaw). The ice cream and sweet chocolate syrup had not been planned for that diet. - Resident #6 also had a tray card which indicated a Carb Control diet was to be served with the same notations of 4 starch, 1 fruit, 1 vegetable, 3 oz meat/equivalent, 1 fat listed. Resident #6 was also observed to receive one-half turkey and Swiss sandwich, potato salad, potato chips, and ice cream with strawberry syrup. (The same substitutions should have been made fore Resident #6 as was listed above for Resident #8.) The ice cream and sweet strawberry syrup had not been planned for that diet. - Resident #18 had a tray card indicating a diet of Reg. Mechanical. The other areas of the tray card including Special Requests:, Dislikes:, Beverage, Allergies: and Notes: were all blank. The food Resident #18 received was not a mechanically altered consistency but was pureed. The cook (Staff) A was asked about the diets printed on the tray cards and said the tray cards were not followed. On 12/20/22 at 8:17 AM, breakfast was served. - Resident #8 had a tray card specifying Carb Control but the Special Request area indicated 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat. Resident #8 received 4 oz apple juice (1 fruit), 2 pieces of buttered toast (2 starch and 2 fats), hash browns (1 starch) and eggs (1 meat), ~ 1 tablespoon jelly, and tea. No milk was received. Resident #8 stated she would like milk but I can't get everything I want. I am diabetic and they watch what I get. Resident #8 asked Registered Nurse (RN) F for more toast. RN F brought 2 more pieces of buttered toast (2 more starches and 2 additional fats) and another scoop of jelly (~2 tablespoons). In total, Resident #8 was served 5 starches, 4 fats, 1 fruit, 1 meat, no milk and 3 tablespoons of regular jelly. - Resident #6 also had a tray card specifying Carb Control and also listed 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat. Resident #6 was served: 4 oz orange juice (1 fruit) 1 tablespoon of peanut butter (1 meat), eggs (1 meat), 1 tablespoon scoop of jelly, and 2 slices of buttered toast. (2 starches 2 fats). Resident #6 reported she was not a milk drinker. The tray card also read oatmeal, sugar and banana on side, toast. No cereal or bananas were served to Resident #6. Resident #6 received 2 starch, 1 fruit, no milk, 2 meat, 2 fat and 1 tablespoon of regular jelly. - Resident #18's tray card read: Reg. Mechanical. Resident #18 received a pureed meal including pureed bread/toast and not a mechanically altered consistency. At 8:35 AM, DM I stated, Those are old cards. (Resident #6) does not ask for oatmeal and we are out of bananas today. When asked if there was special diet jelly as the therapeutic diet menu indicated, DM I said, We have regular jelly for the whole house. We use this jar. At 8:40 AM, RN F was asked about special diets and she replied, If the residents request something extra we try to stay within the parameters of the diet. During a chart review 12/20/22 at 10:15 AM the following was revealed: - Resident #8 was admitted [DATE] with diagnoses which included dementia, diabetes, and long-term use of insulin. Resident #8's current physician's orders included two types of insulin, check the blood sugar with a fingerstick three times daily, and a diet of Regular - CC (Consistent Carbohydrate). (The tray card with exchanges such as 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat observed at the breakfast meal had not been ordered by a physician.) - Resident #6 was admitted [DATE] with diagnoses which included diabetes, and gastroesophageal reflux disease (GERD). Resident #6's current physician's diet order was Regular. The most recent Nutritional assessment dated over a year ago on 7/6/21 revealed a weight of 106 pounds, but the current weight was recorded on 12/4/22 as 129 pounds. (The tray card with exchanges such as 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat, which was observed at the breakfast meal had not been ordered by a physician.) - Resident #18's current physician's orders had no diet ordered. The most recent Nutritional assessment dated over a year ago on 7/20/21 revealed a weight of 107 pounds and a score of 11 indicating Resident #18 was At risk of malnutrition. (The tray card printed with mechanical soft had not been ordered by a physician, and the diet received of puree had also not been ordered by a physician.) On 12/20/22 at 10:36 AM, DM I stated she had been in the CDM class but I have been working on the managerial part. The clinical part comes next. DM I said the RD and the Director of Nursing (DON) did the nutritional assessments in the medical charts as she has not really learned that part. When asked about special diets, DM I said, We have one with 1500 controlled calorie and a couple of pureed diets. When asked about Resident #6 (whose tray card read Carb Control and whose physician ordered diet was regular), DM I said, She would get peaches or fruit in place of ice cream. Potato salad would be the vegetable . We limit mostly her sugar intake . on days we have pudding or anything super sweet we give her fruit. She is our only one. When asked about Resident #8 (whose tray card also read Carb Control), DM I said she might be on a diet with restricted sugar maybe limited sugars. The therapeutic diet plan was discussed. This part of the menu was to direct the dietary staff on what to produce for residents on special diets. DM I said the RD only signed the top copy (not the therapeutic part). The menus were reviewed, and differences pointed out such as on Week 4 Wednesday the signed menu indicated beef stroganoff with noodles peas and ice cream was to be served, but the same day the therapeutic menu listed hot dogs, potato salad baked beans and pears. DM I said the therapeutic menus were wrong. DM I suggested we look at a different week. Week 3 Monday had a planned evening meal of meatloaf, mashed potatoes/gravy, green and yellow beans, bread/margarine, and apple crisp, while the same day the therapeutic menu listed taco casserole topped with taco chips, corn, and strawberry shortcake. During an interview 12/20/22 at 3:04 PM, the only member of the dietary staff in the facility, Staff K was asked for a policy or a manual on serving correct diets. Staff K said, I am new and the only one in the kitchen. I don't know about a diet manual. Staff K reported there were no diabetic diets that needed to be made. She said, there were two puree diets and one I think we are trying to beef up . I just go by the cards. When asked about the one diet she was referring to, Staff K looked up the tray card and found Resident #6 and said, It must be her. Look at the tray card. (Resident #6 whose tray card read Carb Control and also listed 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat) . She needs starch and fruit. During an interview on 12/20/22 at 1:31 PM, the chart discrepancies were reviewed with the DON who confirmed Residents (#18 and #22) had no diet ordered from the facility physician. The DON stated, They are not there . Why they never got put on the orders, I do not know. For Resident #18 (without a diet order, but with a tray card directing the staff to serve a mechanical soft diet, with ground meat and then observed to receive all formed items pureed) the DON did not see a care plan for nutritional concerns. The DON stated she would expect the diet consistency in the physician's orders and on the care plan. During the interview with the DON on 12/20/22 at 1:31 PM, Resident #6 was noted to have large weight increases for the past four months: - 12/4/2022 = 129.0 pounds - 11/6/2022 = 119.0 pounds - 10/5/2022 = 114.0 pounds - 9/5/2022 = 108.2 pounds No reweights had been taken. The DON stated, We get a reweight if the doctor orders it. We have not with her. The facility policy titled Weights and dated 11/24/2008, read in part: Re-weight: 1. Will be obtained immediately upon identification of weight gain or loss of 3 pounds or more . Charge Nurse: 2. ii. If the weight has a 3 pound variance immediately re-weigh. iii. Notify dietary of variance. During the interview with the DON on 12/20/22 at 1:31 PM, Resident #8 was noted to have a physician order for a Regular -CC (consistent carbohydrate) diet and was on insulin. The DON stated her expectation was the diet should have been on the care plan, but it was not included in the care plan. The DON stated Resident #8 did not get a lot of sugar and labs were good. Resident #8's A1C lab values (the primary test used for diabetes management) were reviewed with the DON and noted to be as follows: 7/12/21 9.8% 1/11/22 8.7% 8/24/22 9.8% The lab normal values for A1C were listed as 4.3% - 6.0%. The facility Diet Manual included a section on Diabetes and read in part: In order to prevent the serious complication of diabetes mellitus, individuals with diabetes and their caregivers are encouraged to: 1. Control Blood Glucose: According to the CDC (Centers for Disease Control and Prevention), 'In general, every percentage point drop in A1C blood test results (e.g. from 8.0% to 7.0%), reduces the risk of microvascular complications (eye, kidney and nerve disease) by 40%. An A1C indicates the average control of blood glucose level over a period of the past three months.' During the telephone interview on 12/21/22 at 08:52 AM, RD J stated the residents who were diabetic should receive a liberalized diet. When the observation of tray cards printed with 1500 calorie diet with exchanges was discussed, RD J stated That was a possibility as she was not in the building often. RD J stated she had not reviewed or signed the therapeutic diets. When the observation of the regular planned menus not matching the therapeutic menus was discussed, RD J stated, she was not surprised as she had not reviewed the therapeutic menus. During an interview on 12/21/22 at 10:51 AM, the NHA stated there was another staff member (Staff B) who was on the organizational chart over the dietary department. Staff B had taken the CDM course and had a certificate dated 3/12/1986. However, the NHA said Staff B had never taken or passed the CDM test after the course and had never become a CDM.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions and confirm safe food handling practices in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 22 residents who receive meal services out of the facility's total census of 22. Findings include: On 12/19/2022 at 10:31 AM, the kitchen's air conditioning unit above the entry door to the walk-in cooler was observed with an accumulation of dust and debris on its filters. Upon observation the surveyor inquired with the Cook, staff A, on how often the filters are cleaned or replaced on this unit to which they stated, maintenance cleans the filters, but I'm not sure when it was done last. On 12/19/2022 at 11:43 AM, an accumulation of dust and debris was observed on the fan grates, the ceiling, the walls, and on refrigeration lines in the walk-in cooler. At this time the surveyor inquired with staff A on the frequency in which the fan grates are expected to be cleaned to which they stated, I have no idea, that would be a maintenance question. On 12/19/22 at 12:07 PM, upon interview with the Maintenance Director, staff B, on the frequency in which the fan grates and surrounding areas are cleaned they stated, we take them apart once a year to clean them inside and out and paint the fan grates before reinstalling. Maybe we could start doing it twice a year. Review of U.S. Public Health Service 2017 Food Code, Chapter 4-602.13 Nonfood-Contact Surfaces directs that: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. On 12/19/22 at 11:21 AM, upon interview with the Cook, staff A, on if the facility prepares food products in advance and then cools them down for later use, they replied, Sometimes. We have a log posted on our freezer. At this time the surveyor reviewed the posted log on the reach in freezer mentioned by staff A. This document was titled, cool down tracking sheet and dated, December 2022. Review of the log by the surveyor revealed only one item dated, 12/6 stating, Tuna from can to freezer. Upon observation the surveyor asked staff A if they were the Cook who documented this on the log to which they stated, no, they are not here today. I really don't save things for later. I try to just cook what we need or make new when we run out. On 12/19/22 at 11:25 AM, containers labeled as sloppy [NAME] dated, 17-21, macaroni and cheese dated, 16-20, potato salad dated, 18-19, cream of vegetables dated, 18-22 and scrambled eggs dated, 18-19 were observed in the walk-in cooler. On 12/19/22 at 11:27 AM, these items were confirmed by staff A via an interview as being prepared in advance and cooled for later use. At this time the surveyor asked staff A if they were responsible for cooling any of the food products identified as being prepared in advance in the walk-in cooler to which they replied, No. The surveyor then followed up by asking staff A how the facility would normally handle food items such as these if they could not verify the foods were properly cooled to ensure the foods safety to which they replied, I see your point, I guess we will need to start keeping better track on our cooling log and throw things out if we don't. Review of U.S. Public Health Service 2017 Food Code, Chapter 3-501.15 Cooling Methods, directs that: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; Pf (2) Separating the FOOD into smaller or thinner portions; Pf (3) Using rapid cooling EQUIPMENT; Pf (4) Stirring the FOOD in a container placed in an ice water bath; Pf (5) Using containers that facilitate heat transfer; Pf (6) Adding ice as an ingredient; Pf or (7) Other effective methods. 3. On 12/19/2022 at 11:33 PM, Cook, staff A, was observed taking food temperatures of thin cuts of turkey lunch meat and grilled cheese sandwiches with a bimetal thermometer. At this time the surveyor inquired with staff A if that was the only type of thermometer they had available to use to which they stated, yes, we have several like this. Review of the U.S. Public Health Service 2017 Food Code, Chapter 4-302.12 Food Temperature Measuring Devices directs that: (B) A TEMPERATURE MEASURING DEVICE with a suitable small-diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature in thin FOODS such as MEAT patties and FISH filets. Pf Further review of the 2013 Food Code Annex 3 states: The presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded. When determining the temperature of thin foods, those having a thickness less than 13 mm (1/2 inch), it is particularly important to use a temperature sensing probe designed for that purpose. Bimetal, bayonet style thermometers are not suitable for accurately measuring the temperature of thin foods such as hamburger patties because of the large diameter of the probe and the inability to accurately sense the temperature at the tip of the probe. However, temperature measurements in thin foods can be accurately determined using a small-diameter probe 1.5 mm (0.059 inch), or less, connected to a device such as thermocouple thermometer.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests potentially affecting 22 residents who receive meal services out of the facility's total census of 22 and its staff. Findings include: 1. On 12/19/22 at 11:08 AM, a live mouse was observed by both the Cook, staff A, and the surveyor inside the waste receptacle located at the kitchens designated handwashing sink. Upon observation staff A promptly closed the lid to the waste receptacle and took the waste receptacle outside. On 12/19/22 at 11:10 AM, upon interview with staff A, the surveyor inquired if the facility used the services of a pest control company to which they stated, I don't think so, but maintenance would know more about the specifics on it. On 12/19/22 at 11:16 AM, upon interview with the Maintenance Director, staff B, regarding pest control responsibilities in the facility they stated, we lay glue traps down and monitor, we mostly leave them out in the kitchen and on the north side of the building. The surveyor then inquired who is responsible for monitoring of pests throughout the facility to which staff B replied, we all are. At this time the surveyor requested the most recent pest control related records to review. On 12/19/22 at 1:10 PM, record review of the last two months of hardware store receipt records revealed that the targeted pests being treated at the facility were mice via glue traps purchased on, 10/10/22 and, 11/10/22. On 12/19/22 at 1:19 PM, upon interview with staff B regarding the effectiveness of the glue traps they stated, they usually work pretty good, but when it gets colder outside, they always want to come in where it's warm. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests directs that: The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B) Routinely inspecting the PREMISES for evidence of pests;

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ELOPEMENT FOR ONE (#1) OF FOUR RESIDENTS KNOWN AS ELOPEMENT RISKS REVIEWED FOR ADEQUATE SUPERVISION FROM A FACILITY CENSUS OF 28 RESIDENTS. THIS FAILURE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY FOR RESIDENT #1. THE IMMEDIATE JEOPARDY BEGAN ON 7/15/11 AT APPROXIMATELY 8:00 P.M. WHEN RESIDENT #1, WHO WAS KNOWN BY THE FACILITY TO BE AT HIGH RISK FOR ELOPEMENT AND SHOWING SIGNS OF CONFUSION, EFFECTIVELY LEFT THE FACILITY THROUGH AN ALARMED EXIT DOOR AND CROSSED A BUSY HIGHWAY, M-23. RESIDENT #1 WAS FOUND BY A MOTORIST, AMBULATING ALONG SIDE OF THE ROAD, AND ASSISTED BY THIS MOTORIST (IDENTITY UNKNOWN TO RESIDENT #1) INTO THEIR VEHICLE AND BROUGHT BACK TO THE FACILITY. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 7/21/11 AT 9:00 A.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 7/21/11 AT 3:45 P.M. BY FACILITY ACTIONS, AS FOLLOWS: 1. REINSTITUTED VISUAL CHECKS FOR RESIDENT #1'S WHEREABOUTS/SAFETY EVERY FIVE MINUTES. 2. DEVELOPED/IMPLEMENTED PROCEDURES REQUIRING FACILITY STAFF TO VERIFY THE LOCATION AND SAFETY OF EACH RESIDENT WHO WAS KNOWN AS AN ELOPEMENT RISK WHEN THE MAIN ALARM IS TRIGGERED. 3. PROVIDED ALL FACILITY STAFF WITH AN ADDITIONAL EDUCATIONAL INSERVICE ON THE ALARM SYSTEM. 4. DEVELOPED AN ALARM SYSTEM POLICY WITH THE PLAN OF EDUCATING ALL FACILITY STAFF BEFORE ALLOWING THEM TO BE ON DUTY FOR RESIDENT CARE. THE SURVEYOR CONFIRMED BY OBSERVATION ALL EXIT DOORS WITH ALARMS SOUNDED WHEN OPENED, OBSERVATION OF FACILITY'S STAFF TO RESPONSE OF MAIN ALARM SYSTEM WHEN EXIT DOORS WERE OPENED, AND VERIFICATION ON-DUTY FACILITY STAFF KNEW THE NEW ALARM SYSTEM POLICY THROUGH INTERVIEW OF THE FACILITY STAFF. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED, AND CONTINUES AT A PATTERN LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM PENDING THE FACILITY'S ABILITY TO: 1. DEMONSTRATE THEIR ABILITY TO PREVENT RESIDENTS WHO ARE AT RISK FOR ELOPEMENT FROM EXITING THE FACILITY WITHOUT ADEQUATE SUPERVISION. 2. DEMONSTRATE ALL FACILITY STAFF'S COMPETENCE REGARDING NEW ALARM SYSTEM POLICY. 3. VERIFICATION BY THE STATE AGENCY. FINDINGS INCLUDE: RESIDENT #1 IS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS PLACED ON THE ANTIPSYCHOTIC MEDICATION RISPERDAL .25 MILLIGRAMS (MG) TWICE A DAY FOR treatment of [REDACTED]. THE RISPERDAL WAS INCREASED ON 6/14/2011 TO .25MG THREE TIMES A DAY. AN ELOPEMENT RISK assessment dated [DATE], FOR RESIDENT #1 READS, "RESIDENT NOTED TO WALK OUT DOORS, RESIDENT NOW AN ELOPEMENT RISK. CARE PLAN INITIATED AND INTERVENTIONS IN PLACE." THE CARE PLAN DATED 5/11/2011, DOCUMENTS HER ELOPEMENT RISK WITH A GOAL FOR RESIDENT #1 TO NOT LEAVE THE FACILITY UNATTENDED. VISUAL SAFETY CHECKS EVERY FIVE MINUTES AND A WANDERGUARD BRACELET SYSTEM WAS PLACED ON RESIDENT #1 AFTER AN ELOPEMENT ATTEMPT OCCURRED ON 5/22/11. AN ELOPEMENT RISK RE-ASSESSMENT FORM DATED 7/13/2011, INDICATED RESIDENT #1 HAD INTERMITTENT CONFUSION AND WAS AT RISK FOR ELOPEMENT. AN INTERDISCIPLINARY TEAM (IDT) MEETING WAS HELD ON 7/15/2011 AND DOCUMENTED, "DISCUSSED THE NEED TO CONTINUE FIVE MINUTE VISUAL CHECKS. IDT HAS DETERMINED THAT THE WANDERGUARD TETHER ALARM AND FIFTEEN MINUTE VISUAL CHECKS ALONG WITH ALL OTHER CHANGES ARE SUFFICIENT IN MAINTAINING RESIDENT'S SAFETY. WILL DISCONTINUE FIVE MINUTE CHECKS. ALL OTHER INTERVENTIONS REMAIN IN PLACE. WILL CONTINUE TO MONITOR BEHAVIORS". ACCORDING TO A FACILITY REPORTED INCIDENT (FRI) DATED 7/16/2011, RESIDENT #1 EXITED THE BUILDING ON 7/15/11 BETWEEN 7:45 P.M. AND 7:50 P.M. BY POSSIBLY USING THE AMBULANCE EXIT. THE FACILITY ALARM SYSTEM WAS BEING SET OFF FREQUENTLY BY RESIDENT #2, WHO WAS AGITATED. RESIDENT #2 REQUIRED THE ASSISTANCE OF TWO PEOPLE TO BE REDIRECTED AWAY FROM THE DOORS. IT IS SUSPECTED RESIDENT #1 EXITED THE AMBULANCE DOOR AT THE SAME TIME THE ALARM WAS GOING OFF AT THE SOUTH END OF THE BUILDING WHILE STAFF WERE TENDING TO RESIDENT #2. STAFF "C" WAS EXITING THE BUILDING TO LEAVE HER SHIFT AND MOTORIST "H" HAD RESIDENT #1 IN HER CAR. RESIDENT #1 WAS ASSISTED INSIDE WITH A COMPLETE ASSESSMENT DONE, AND NO INJURIES WERE NOTED. THE FAMILY AND PHYSICIAN WERE NOTIFIED. UPON INTERVIEW WITH RESIDENT #1 ON 7/20/2011 AT APPROXIMATELY 12:00 P.M., SHE STATED THAT SHE WANTED TO GO TO A SMALL TOWN (NAMED) WHERE SHE HAD LIVED FOR [AGE] years. SHE REVEALED SOME CONFUSION AS TO THE DAY OF THE WEEK AND WHAT THE WEATHER WAS LIKE OUTSIDE. WHEN ASKED ABOUT THE ELOPEMENT INCIDENT OF 7/15/2011, SHE SHRUGGED HER SHOULDERS AND SAID "AN EXIT SIGN MEANS TO EXIT." ON 7/20/2011 AT APPROXIMATELY 1:30 P.M., MOTORIST "H" WAS INTERVIEWED BY TELEPHONE. MOTORIST "H" STATED SHE SAW RESIDENT #1 WALKING WITH HER WALKER ON THE EAST SIDE OF M-23 ACROSS FROM SPRINGPORT ROAD ON 7/15/2011 AT APPROXIMATELY 8:00 P.M. RESIDENT #1 WAS WALKING WITH THE FLOW OF TRAFFIC BETWEEN THE PAVEMENT AND GRASS. MOTORIST "H" PULLED OVER AND STARTED TALKING TO RESIDENT #1. MOTORIST "H" STATED THAT RESIDENT #1 INDICATED SHE WAS GOING TO HER SISTER'S FUNERAL. (UPON INTERVIEW WITH RESIDENT #1'S SON ON 7/21/2011 AT 4:30 P.M., HE STATED THERE WAS NO FUNERAL.) MOTORIST "H" FURTHER STATED AFTER TALKING TO RESIDENT #1 FOR A PERIOD OF TIME, SHE CONVINCED RESIDENT #1 TO GET IN THE CAR AND RETURNED HER TO THE FACILITY, WHERE SHE HAD GUESSED RESIDENT #1 CAME FROM. THE INTERVIEW WITH MOTORIST "H", FURTHER REVEALED SHE ESTIMATED SHE WAS WITH RESIDENT #1 FOR 10 TO 15 MINUTES BEFORE STAFF ASSISTED RESIDENT #1 OUT OF THE CAR AND BACK INTO THE FACILITY. ON 7/20/2011 AT APPROXIMATELY 4:00 P.M., THIS SURVEYOR (# ) WALKED FROM THE FACILITY PARKING LOT DOWN THE GRAVEL DRIVEWAY AND ALONG M-23 TO SPRINGPORT ROAD IN FIVE MINUTES. THE DISTANCE WAS MEASURED AT 0.20 MILES BY AN AUTOMOBILE ODOMETER READING. USING THE DISTANCE TRAVELED BY RESIDENT #1 AND HER RETURN WITH MOTORIST "H", RESIDENT #1 WAS ESTIMATED TO HAVE BEEN OUTSIDE THE FACILITY, UNSUPERVISED BY STAFF FOR A MINIMUM OF 15 MINUTES, WITHOUT THE KNOWLEDGE OF STAFF. ON 7/21/11 AT 8:50 A.M., A TELEPHONE INTERVIEW WITH THE FACILITY ADMINISTRATOR CONFIRMED THERE ARE FOUR RESIDENTS (#1, #2, #3 AND #4) CURRENTLY LIVING AT THE FACILITY WHO ARE AT RISK FOR ELOPEMENT. ON 7/21/2011 AT APPROXIMATELY 2:00 P.M., CHARGE NURSE "D" WAS INTERVIEWED BY TELEPHONE. SHE STATED ON THE EVENING OF 7/15/2011, THE SOUTH ENTRANCE DOOR ALARM HAD SOUNDED MULTIPLE TIMES, TRIGGERED BY RESIDENT #2. AS A RESULT, STAFF HAD TURNED OFF THE DOOR ALARM MULTIPLE TIMES, BUT NO OTHER DOOR ALARMS WERE NOTICED TO BE ACTIVATED. IT WAS FURTHER DISCUSSED THAT RESIDENT #1 HAD TO HAVE SET OFF A DIFFERENT DOOR ALARM WHILE THE SOUTH DOOR ALARM WAS ACTIVATED, WHICH WAS NOT IDENTIFIED BY STAFF BEFORE DE-ACTIVATING THE SOUNDING DOOR ALARMS. THEREFORE, RESIDENT #1 ELOPED FROM THE BUILDING UNSUPERVISED BY STAFF AND WAS NOT IDENTIFIED AS MISSING UNTIL SHE WAS RETURNED TO THE FACILITY BY A PASSING MOTORIST ("H") APPROXIMATELY 15 MINUTES LATER. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE OR HAVE A SYSTEM IN PLACE TO ALERT THE FACILITY WHEN ONE (#1) OF THREE COGNITIVELY IMPAIRED RESIDENTS, WHO WERE KNOWN TO BE AT RISK FOR ELOPEMENT, ELOPED FROM THE FACILITY FOR AN ESTIMATED 5 TO 10 MINUTE PERIOD OF TIME, IN WINTER WEATHER WITH THE TEMPERATURE RECORDED AT 17 DEGREES FAHRENHEIT. WHEN RESIDENT #1 WAS FOUND, FACILITY STAFF REPORTED THAT HE WAS "AMBULATING IN THE DRIVEWAY...SHIVERING, FACE WAS RED AND COLD". THESE SUPERVISION FAILURES RESULTED IN IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY WAS IDENTIFIED ON 01/25/11 AT 5:00 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 01/10/11 AT APPROXIMATELY 4:30 A.M., WHEN RESIDENT #1, A COGNITIVELY IMPAIRED RESIDENT WITH KNOWN ELOPEMENT ATTEMPTS, EFFECTIVELY LEFT THE BUILDING, UNSUPERVISED THROUGH THE KEY-LOCKED LAUNDRY ROOM DOOR. RESIDENT #1 THEN FOUND ANOTHER DOOR THAT OPENED TO THE OUTSIDE AND EXITED THE FACILITY. A CO-OWNER OF THE FACILITY/MEMBER OF THE ADMINISTRATIVE STAFF WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 01/25/11 AT 6:00 P.M. A TOUR OF THE FACILITY WAS DONE WITH THE MAINTENANCE DIRECTOR/CO-FACILITY OWNER ON 01/25/11 AT APPROXIMATELY 3:55 P.M. SIX EXIT DOORS WERE OBSERVED WITH A SYSTEM (KEY-PAD ALARM OR MAGNETIC ALARMS) WHICH WOULD ALERT FACILITY STAFF WHEN OPENED. HOWEVER, THREE EXIT DOORS WERE ALSO OBSERVED WITH NO SYSTEM TO ALERT FACILITY STAFF WHEN OPENED. THESE DOORS ARE LOCATED IN THE LAUNDRY ROOM (NORTH HALLWAY), THE SOILED LAUNDRY ROOM (NORTH HALLWAY), AND THE MECHANICAL ROOM (NORTH HALLWAY). THESE DOORS HAD KEYS ATTACHED TO MAGNETS, HANGING ON THE DOOR JAMS THAT COULD BE ACCESSED FROM A STANDING POSITION. ON 01/26/11 AT 2:30 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FACILITY OWNER STATED THEY WERE IMPLEMENTING A PLAN OF STAFF SUPERVISION OF THE THREE KEY LOCKED DOORS ON A 24 HOUR BASIS, UNTIL KEY PAD DOOR ALARMS COULD BE INSTALLED ON THESE DOORS. ON 01/26/11 AT 2:30 P.M., FACILITY STAFF WAS OBSERVED SEATED IN A STRATEGIC LOCATION THAT ALLOWED THEM TO VISUALIZE THE THREE DOORS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT AN ISOLATED LEVEL, WITH THE POTENTIAL FOR MINIMUM HARM UNTIL THE FACILITY HAS PUT THE FOLLOWING PRACTICES IN PLACE: ENSURE ALL EXIT DOORS ARE EQUIPPED WITH KEY PAD ALARMS, IMPLEMENT PREVENTATIVE MAINTENANCE CHECKS ON ALL EXIT DOOR ALARMS, PROVIDE INSERVICE TRAINING FOR STAFF ON RESIDENTS WITH EXIT SEEKING BEHAVIORS, REASSESS ALL VULNERABLE RESIDENTS IDENTIFIED FOR ELOPEMENT RISK, AND ENSURE APPROPRIATE INTERVENTIONS ARE IN PLACE TO PREVENT THIS TYPE OF ACCIDENT FROM RE-OCCURING. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S CLINICAL RECORD REVEALED HE IS AN [AGE] year OLD MALE WHO HAS RESIDED IN THE FACILITY SINCE 10/27/09. THE FACE SHEET SHOWS HIS [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #1'S ANNUAL MINIMUM DATA SET ((MDS) dated [DATE], REVEALED HIS COGNITION AS HIGHLY IMPAIRED, WITH SHORT TERM AND LONG TERM MEMORY PROBLEMS. THE MDS REFLECTS HE CAN USUALLY UNDERSTAND WHAT IS BEING SAID TO HIM, HE MAY MISS SOME PART OF THE MESSAGE, AND CAN GENERALLY MAKE HIS NEEDS KNOWN. FURTHER REVIEW OF HIS ANNUAL MDS AND CARE PLAN REVEALED RESIDENT #1 IS INDEPENDENT WITH AMBULATION AND TRANSFERS. THE CARE PLAN DATED 11/06/09, DOCUMENTS HIS EXIT SEEKING BEHAVIOR AS HIS NEED TO "GO HOME OR FIND HIS CAR". A REVIEW OF THIS CARE PLAN REGARDING EXIT SEEKING BEHAVIOR DIRECTS FACILITY STAFF TO DO "FIFTEEN MINUTE VISUAL CHECKS, ATTEMPT TO REDIRECT FROM DOORS, ENCOURAGE HIM TO REMOVE HIS HAT AND COAT-RELAX STAY AWHILE". ON 01/25/11 AT APPROXIMATELY 2:20 P.M., AN INCIDENT REPORT DOCUMENTING THE ELOPEMENT FROM THE FACILITY WAS REVIEWED. THE DATE OF THE INCIDENT WAS IDENTIFIED AS 01/10/11. A REVIEW OF THE INCIDENT IDENTIFIED RESIDENT #1 WAS DISCOVERED OUTSIDE THE FACILITY AT 4:30 A.M. HE HAD EXITED THE BUILDING THROUGH A LAUNDRY ROOM DOOR THAT WAS TO BE KEY LOCKED AT ALL TIMES. THE INCIDENT REPORT REFLECTS THE FOLLOWING: CERTIFIED NURSE AIDE (CNA) "D" HAD JUST COME OUT OF A RESIDENT'S ROOM AND THOUGHT HE SAW RESIDENT #1 OUTSIDE. CNA "D" ALERTED THE NURSE, AND THEN WENT OUTSIDE TO GET RESIDENT #1. RESIDENT #1 WAS RETURNED TO THE INTERIOR OF THE BUILDING. HIS TEMPERATURE WAS RECORDED AS 97.0 DEGREES, FEET AND TOES WERE WARM, FINGERS, HANDS AND CHEEKS WERE COLD TO TOUCH, BUT NOT ICE COLD. HE WAS WRAPPED IN WARM BLANKETS AND GIVEN COFFEE TO DRINK. A HISTORICAL WEATHER SEARCH WAS DONE ON 01/26/11, VIA THE INTERNET AT WWW.WUNDERGROUND.COM. THE WEATHER SEARCH WAS COMPLETED TO DETERMINE WHAT THE AIR TEMPERATURE WAS AT THAT LOCATION DURING THE DATE AND APPROXIMATE TIME RESIDENT #1 WAS FOUND OUTSIDE. THE RECORDED TEMPERATURE FOR 1/10/11 AT 4:36 A.M. WAS 17.6 DEGREES FAHRENHEIT IN OSCODA, MICHIGAN. OSCODA IS SEVENTEEN MILES SOUTH OF HARRISVILLE. PER THE SAME HISTORICAL WEATHER SEARCH DONE VIA THE INTERNET, THERE WAS NO RECORDED AIR TEMPERATURE FOR HARRISVILLE, MICHIGAN FOR THIS TIME PERIOD. ON 01/25/11 AT APPROXIMATELY 2:30 P.M., AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) REVEALED RESIDENT #1 APPEARED TO HAVE NO ADVERSE EFFECTS FROM THE INCIDENT RECORDED ON 01/10/11. SHE INDICATED RESIDENT #1 "MAKES SEVERAL ATTEMPTS TO EXIT THE BUILDING DAILY, HE FAVORS THE NORTH END OF THE BUILDING WHERE YOU CAN SEE THE PARKING LOT, HE'S LOOKING FOR HIS CAR. HE WILL SET THE ALARMS OFF FREQUENTLY." AN OBSERVATION OF THE LAUNDRY ROOM DOOR TOOK PLACE WITH THE DON ON 01/25/11 AT APPROXIMATELY 2:40 P.M. SHE WAS OBSERVED ACCESSING THE KEY TO OPEN THE LAUNDRY ROOM DOOR FROM A MAGNETIC CLIP PLACED APPROXIMATELY FIVE FOOT SIX INCHES FROM THE FLOOR. AT THAT TIME, SHE SLID THE MAGNETIC CLIP HIGHER UP TO THE TOP OF THE DOOR FRAME, MAKING THE KEY MORE DIFFICULT TO REACH. OBSERVATION OF THE EXIT DOORS LEADING TO THE OUTSIDE FROM THE LAUNDRY ROOM, SHOW THAT RESIDENT #1 HAD TO AMBULATE APPROXIMATELY 30 PACES, OR 54 FEET, UNSUPERVISED, PAST TWO WASHER/DRYERS TO A SET OF DOORS THAT LEAD TO THE OUTSIDE. ON 01/25/11 AT APPROXIMATELY 2:15 P.M., ANOTHER COGNITIVELY IMPAIRED RESIDENT (#2), ALSO IDENTIFIED BY THE FACILITY AS AN ELOPEMENT RISK, WAS OBSERVED OPENING THE NORTH END HALLWAY DOOR. THIS DOOR ALARM SOUNDED AND STAFF RESPONDED IMMEDIATELY. RESIDENT #2 THEN TURNED AROUND AND AMBULATED BACK TOWARDS THE NURSES STATION. A TELEPHONE INTERVIEW TOOK PLACE ON 01/25/11 AT 3:13 P.M. WITH REGISTERED NURSE (RN) "B". RN "B" VERIFIED SHE WAS ON DUTY THE MORNING OF 01/10/11, AND STATED RESIDENT #1 "HAD BEEN AWAKE AND WANDERING THE HALLWAYS FOR MOST OF THE NIGHT". IT HAD BEEN A BUSY NIGHT AND SHE WAS SITTING AT THE NURSES STATION WHEN CNA "D" CAME RUNNING TOWARDS THE NURSES STATION, AND ANNOUNCED THAT RESIDENT #1 WAS OUTDOORS. RN "B" WENT ON TO SAY, "(CNA "D") SAW HIM THROUGH THE GLASS DOORS AT THE NORTH END OF THE BUILDING. (CNA "D") THEN RAN DOWN THE HALLWAY, EXITED THE BUILDING THROUGH THE LAUNDRY ROOM DOOR, AND RETRIEVED (RESIDENT #1)." DURING THE TELEPHONE INTERVIEW WITH RN "B" ON 1/25/11 AT 3:13 P.M., RN "B" STATED SHE HAD ASSESSED RESIDENT #1 WHEN HE CAME BACK INTO THE FACILITY. SHE STATED, "HE (RESIDENT #1) WAS DRESSED IN A T-SHIRT, YELLOW SWEATER, PANTS, SHOES AND SOCKS... IT WAS COLD OUTSIDE... HIS CHEEKS WERE RED, HANDS AND FEET WERE COLD. WE GOT HIM (RESIDENT #1) TO THE NURSES STATION, WE WARMED UP BLANKETS AND WRAPPED HIM UP AND GAVE HIM A CUP OF COFFEE." RN "B" EXPLAINED, "I WAS AT THE DESK AND NONE OF THE ALARMED DOORS RANG, SO THE ONLY WAY HE COULD HAVE GOT OUTSIDE WAS THROUGH THE LAUNDRY ROOM DOOR." RN "B" STATED SHE INTERVIEWED THE STAFF SHE WAS WORKING WITH AND STATED THAT CNA "D" MADE THE STATEMENT THAT "WHEN HE WENT OUTSIDE TO GET (RESIDENT #1), THE KEY WAS IN THE DOOR." THIS WRITER ASKED RN "B" IF SHE HAD ANY KNOWLEDGE OF THE KEYS BEING LEFT IN THE LAUNDRY ROOM DOOR? RN "B" REPLIED, "IN THE TEN MONTHS I'VE BEEN WORKING HERE, I'VE FOUND THE KEYS IN THE DOOR FOUR OR FIVE TIMES." A TELEPHONE INTERVIEW TOOK PLACE WITH CNA "D" ON 01/25/11 AT APPROXIMATELY 5:45 P.M CNA "D" STATED "... I WAS COMING OUT OF A RESIDENT'S ROOM AND I THOUGHT I SAW A FLASH OF YELLOW OUT THE GLASS DOORS (NORTH END OF FACILITY). I RAN TO THE NURSE AND TOLD HER... (RESIDENT #1) WAS OUTDOORS. THEN I RAN OUTSIDE TO GET HIM. THE KEY WAS IN THE DOOR TO THE LAUNDRY ROOM. I HAD TO BLOCK OPEN THE OTHER DOOR (OUTSIDE DOOR) SO WE COULD GET BACK IN... HIS (RESIDENT #1'S) HANDS FELT VERY COLD. HE WAS HUGGING HIMSELF AND SHIVERING... I GOT HIM BACK INSIDE AND THE NURSE ASSESSED HIM." THIS WRITER ASKED CNA "D" IF HE HAD KNOWLEDGE OF THE KEYS BEING LEFT IN THE LAUNDRY ROOM DOOR? CNA "D" STATED THAT HE HAD "ON OCCASION" OBSERVED THE KEY IN THE LAUNDRY ROOM DOOR. THE FACILITY STAFF FAILED TO PROVIDE SUPERVISION TO PREVENT AN ELOPEMENT OF A CONFUSED RESIDENT WITH A HISTORY OF ELOPEMENT ATTEMPTS AND FAILED TO HAVE A SYSTEM IN PLACE TO ALERT FACILITY STAFF WHEN ANY RESIDENT HAS LEFT THEIR FACILITY UNSUPERVISED. THIS IS A REPEAT DEFICIENT PRACTICE INVOLVING THE LACK OF ADEQUATE SUPERVISION FROM AN ABBREVIATED SURVEY DATED 7/20/10. ( )