Every finding on record at Mary Free Bed Sub-Acute Rehabilitation

Based on interview and record review, the facility failed to ensure that they had Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 2 of 30 days (4/26/26 and 5/9/26) reviewed for RN coverage. Findings include:A review of the Daily Staffing Pattern sheets, dated 4/11/26 to 5/12/26, revealed that Registered Nurse/ Licensed Practical Nurse (RN/LPN) hours were not separated by licensure. The Daily Staffing Pattern Sheets had Total Hours (RN) listed. However, those hours were total nursing hours worked versus RN and/or LPN hours worked.A review of the facility's employee list revealed the facility employed both RN's and LPN's.During an interview on 5/13/26 at 8:45 AM, the Nursing Home Administrator (NHA) stated she thought the Total Hours (RN)on the Daily Staffing Pattern sheets were only RN hours. She stated she was not aware all of the total nursing hours were included in that line item. The NHA stated she would look into it and have the person who does the staffing sheets separate RN and LPN hours.On 5/13/26 at 10:50 AM, the facility provided a breakdown of the RN and LPN hours from 4/11/26 to 5/12/26. The breakdown revealed that the facility did not have any RN coverage on 4/26/26 and 5/9/26.During an interview on 5/13/26 at 12:37 PM, Unit Manager (UM) C stated when RN management works the floor they have an alternate code they use to punch in to include the hours that they worked. He stated he would look and see if an RN worked on 4/26/26 and 5/9/26. UM C stated the Director of Nursing (DON) was off for a little bit on leave, but they had an interim DON that filled in during the week. UM C stated he would look and see if they had any RN coverage on 4/26/26 and 5/9/26.During an interview on 5/13/26 at 12:43 PM, UM C stated he confirmed that there were not any RN's on 4/26/26 and 5/9/26. UM C stated on 4/26/26 the RN had PTO (paid time off) and they didn't catch it. He also stated on 5/9/26 they had an RN scheduled but the RN mixed up his schedule and did not show up to work.

Based on interview and record review, the facility failed to complete a Preadmission Screening (PAS)/Annual Resident Review (ARR) for a resident with a mental disorder for 1 (Resident #7) of one resident reviewed for PASARR.Findings include:Review of a Face Sheet for R7 revealed he admitted on [DATE] with pertinent diagnosis of Asperger's Syndrome, autistic disorder, post-traumatic stress disorder, and depression.Review of the PASARR Level I Screening dated 3/6/26 for R7 showed it classified R7 as a Hospital Exemption Discharge. Section II indicated that R7 had diagnoses of mental illness, had received treatment for mental illness, and had received one or more antipsychotic or antidepressant medications within the last 14 days. It also documented that R7 had a diagnosis of an intellectual disability or a related condition, such as epilepsy, autism, or cerebral palsy, which manifested before age [AGE].In an interview on 5/12/26 at 2:42 PM, Social Worker (SW) E confirmed that another PASARR should have been completed for R7 after the 30-day Hospital Exemption. SW E stated that this PASARR had been overlooked, completed an updated one on this date, and notified the appropriate entity. SW E added that most residents at the facility do not stay long and this one was inadvertently missed.

This citation pertains to intake 2607622. Based on interview and record review the facility failed to provide adequate supervision to ensure the safety of a severely cognitively impaired resident with a high fall risk for 1 (R86) of 2 resident reviewed for supervision, resulting in the potential for injury. Findings include:Review of a Facility Reported Incident (FRI) dated 8/9/25 for R86 revealed Patient briefly walked outside of the facility unattended. No previous elopement history and patient is used to going outside with his wife. Patient was outside for 15 minutes then returned to the facility, no injuries. The Investigation Summary/Actions Taken: [R86] goes outside nearly every day with wife. He went outside without her and stayed under the awning up front from 12:23 PM to 12:37 PM. [Certified Nursing Assistant (CNA) C] saw him from his room and notified [Registered Nurse (RN) D], while Security was called to bring him in. On admission, [R86] was assessed to not be a risk for elopement.Review of a Face Sheet revealed R86 admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis (one-sided weakness), seizures, and cognitive social or emotional deficit following a cerebral infarction. Review of the Minimum Data Set (MDS) dated [DATE] for R86 revealed he was severely cognitively impaired and had limited range of motion on one side.Review of a Physical Therapy Progress Note dated 8/8/25 for R86 revealed: Precautions: Fall risk, [right] hemiparesis, expressive aphasia (a disorder that affects how you communicate) . Conducted care conference with social work and pt's (patient's) wife, [Name] to discuss d/c (discharge) recommendations. Currently, recommending pt's wife to be home with pt as much as possible d/t (due to) pt's poor safety awareness.Review of a Physical Therapy Progress Note dated 8/9/25 for R86 revealed: W/C (wheelchair) mobility performed at distances of 240' (feet), encouraging him to find his way to his room and use the unaffected UE (upper extremity) for propulsion.Review of the Care plan for R86 revealed the following:-High to moderate risk for falls related to gait/balance problems, initiated 8/7/25.-Mobility: Partial/Moderate assist x1 person for transfers. Wheelchair for all mobility, initiated 8/8/25.-Risk for Wandering/Elopement identified, initiated 8/9/25.-The resident has impaired cognitive function or impaired thought process, initiated 8/11/25. Cue, reorient and supervise as needed.In an interview on 5/12/26 at 1:22 PM, CNA C reported R86 had a speech impairment, but she could understand him. CNA C reported she informed R86 that if he let someone know, he could go outside. R86 went down the hallway in his wheelchair, waved to her, got into the elevator and went outside. CNA C was not sure if he signed himself out. CNA C reported she didn't think anything else about it. A little while later, CNA C went to R86's room and saw him outside from the 5th floor through the window in his room sitting in the courtyard. CNA C did not think it was a big deal until the nurse overheard that R86 was outside and called security. CNA C did not recall staff reporting R86 could not go outside and felt if they are capable to go outside they can. CNA C felt he was not in danger or incompetent.Review of a Nursing Progress Note dated 8/9/25 for R86 revealed: This nurse received a message on [Phone] from downstairs that pt (patient) was outside in the front of the facility. Pt was observed being seen from his room window in [room number] on the front lawn. Floor staff immediately went to retrieve pt. Security was contacted. Security made contact with the pt and escorted him back to the unit. Pt routinely goes outside with his wife, however did not this time. Pt was reminded about not going off of unit without help. Pt's wife was reminded as well. Consent was given from pt to apply (wander device).In an interview on 5/12/26 at 2:47 PM, RN D stated that he was in another resident's room when he heard the Aides talking as they looked for a male resident (R86) who was outside. RN D explained that he remembered a similar previous incident, activated the elopement plan, and reported the incident to the Nursing Home Administrator (NHA). He then checked the sign out log and confirmed that R86 had not signed out. Security located R86, brought him back to the 5th floor, and placed a wandering device on him. RN D stated he could not remember how R86 got down to the courtyard and did not recall receiving any notification from the Receptionist or Guest Services on the first floor. He also reported that he did not remember R86 being fully cognizant and stated that R86 should not have been outside alone.During an interview on 5/13/26 at 8:24 AM, the Director of Nursing (DON) stated that staff transferred R86 to the 5th floor after he had been an inpatient on the 3rd floor. She explained that R86 was familiar with the facility because his wife visited him and they regularly went outside together. She acknowledged his cognitive impairment. She said the therapy department would assess any supervision needs, although nursing staff can also assess and implement measures. When asked if R86 was safe to go outside alone, she said the Therapy Staff would consider him unsafe to do so. She agreed that if the floor staff (CNA's) had known he needed supervision, they would have paid closer attention to prevent him from leaving the floor. She confirmed that R86's Care Plan did not include information telling CNA's that he needed supervision. She also stated that staff stationed near the elevators working are present only during the week. She clarified that when R86 left the floor on 8/9/25-a Saturday-staff were not monitoring the elevators. When questioned about staff education after the incident, she later confirmed that the Social Worker received education regarding the timeliness of resident cognition assessments following the incident.In an interview on 5/13/26 at 9:11 AM, Social Worker (SW) E stated that R86 had a low BIMS (Brief Interview for Mental Status) upon admission and that staff deemed him incompetent on 8/12/25. SW E reported that since this incident, the nurses and CNA's now join the 11:00 AM morning huddles to ensure staff are meeting all residents' needs. She acknowledged the concern of allowing a resident with severe cognitive impairment, high fall risk, limited mobility, and limited speech to leave the unit and go outside unsupervised. She stated that R86 could be impulsive, especially when he wanted to do something. She added that he could be stubborn and strongly wanted to go to the coffee shop, as he routinely did with his wife when he was on another floor prior to admission to the 5th floor. SW E acknowledged that the residents on their unit differ significantly due to their short term stays and the potential for post hospitalization delirium too. When asked how this type of incident would be prevented in the future unless staff can access the care plan addressing cognitive status and supervision needs, SW E stated that they are now addressing this in their morning stand up meetings. When questioned about the lack of staff stationed near the elevators on the weekends, SW E said that was a good point. In an interview on 5/13/26 at 9:11 AM, Social Worker (SW) E reported R86 did have a low BIMS (Brief Interview for Mental Status) upon admission and was deemed incompetent on 8/12/25. SW E reported that since this incident, they have the nurse and the CNA join the 11:00 AM morning huddles to ensure they are meeting all the residents needs. SW E understood the concern of a resident with severe cognitive impairment, a high fall risk with limited mobility and speech to leave the unit and go outside unsupervised and reported R86 could be impulsive especially when he wanted to do something. R86 could be stubborn and he really wanted to go to the coffee shop as he always did with his wife when he was on the other floor prior to admission to the 5th floor. SW E acknowledged the residents on their unit is much different due to their short term stays and even the potential for short term delirium post hospitalization. When asked how this would be prevented from happening again unless staff can access the care plan that would address their cognitive status and need for supervision, SW E reported she felt that is now being addressed in their stand-up meetings in the mornings.In an interview on 5/13/26 at 11:30 AM, Security Officer (SO) F reported he worked the day of 8/9/25 when he received a call for an elopement at 12:38 PM from the dispatch that the resident (R86) had been outside but no longer seen on the camera. Once he received a description of R86, he approached R86 who was in his wheelchair heading back to the [NAME] Entrance of building (the entrance near the elevators to get to the 5th floor).Review of the Security Incident Report dated 8/9/25 at 12:38 revealed the initial dispatch call was for an elopement. SAR (subacute rehab) alerted security to possible elopement of [room number for R86). Patient in surface lot area but not allowed to be outside.

Based on interview and record review, the facility failed to have 2025 Federal and State Agency survey results that are prominent and accessible to the public. Findings include:Review of the Survey binder near the elevator entrance of the facility revealed the last survey available for review was from an annual survey in 2024.In an interview on 5/12/26 at 3:13 PM, the Nursing Home Administrator (NHA) verified that the binder was missing surveys and stated that the surveys had been there, but someone may have removed them. The NHA stated she will add the missing surveys to the binder.Review of the survey history revealed there was a complaint survey conducted with citations and an exit date of 10/21/25 that was not located in the survey book and available for review.

This citation pertains to Intake # 2641086.Based on interview, and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 3 residents (Resident #101) reviewed for significant medication errors, resulting in a change in mental status and hospitalization for Resident #101 when an opioid pain medication was not charted as administered and not documented per physician orders and professional standards of practice.Findings include:Review of an Incident Summary revealed .(Licensed Practical Nurse (LPN) I) did not chart that she administered, but did sign out 20 mg (milligram) Butrans patch on 10/1/25, at 6:22am. Another nurse, (LPN J) signed out and applied another 20 mg Butrans patch on 10/7/25 at 10:14pm .(LPN J) saw that one patch had been signed out by (LPN I) previously 7 days earlier on 10/1/25. (LPN J) looked for the patch, but could not find it on the patient (Resident #101). On 10/8/25, (Resident #101) was lethargic, (LPN I) allegedly took 2 patches off in front of (the patient's) daughter and sent (Resident #101) to (Hospital Name) where she remains for inadvertent opiate overdose .Review of an Investigation Summary revealed .(LPN I) signed out the Butrans patch and placed on (Resident #101) on 10/1/25 (morning) and did not document in the electronic medical record that she did so. On the night of 10/7/25, (LPN J) saw that (LPN I) signed out the patch on 10/1/25, looked at shoulders for the patch, did not see it was placed below the incision, and (LPN J) applied another Butrans patch. (Resident #101) was lethargic the next day, (LPN I) removed 2 Butrans patches and sent (the) patient to (the) hospital after notifying (the) physician .Resident #101Review of an admission Record revealed Resident #101 was a female, admitted to the facility on [DATE], with pertinent diagnoses which included lumbar radiculopathy (a condition where the nerve roots in the lower back are compressed or irritated which can result in pain), intervertebral disc degeneration with back pain and lower extremity pain, spondylosis (a degenerative condition of the spine that affects the discs and joints between the vertebrae), major depression, chronic pain, high blood pressure, heart disease, osteoarthritis (a chronic joint disease that causes pain, stiffness, and loss of function), and orthopedic aftercare (indicating a recent orthopedic surgery).Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 9/30/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact.Review of a Care Plan for Resident #101 revealed the focus At risk for pain with a goal of (6/10) R/T (related to) (T10-L3 hardware removal) . with interventions which included Administer pain medications as ordered and evaluate for effectiveness and adverse effects. Notify provider if ineffective or if adverse effects are present . and .Offer non-pharmacological interventions to help reduce pain as needed . all initiated 9/24/25.Review of a Care Plan for Resident #101 revealed the focus The resident is on pain medication therapy .r/t surgery spinal fusion . with interventions which included Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift) .Ask physician to review medication if side effects persist .For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications .Monitor/document/report PRN (as needed) adverse reactions to analgesic therapy; altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinary retention . all initiated 10/5/25.Review of an Order Summary Report for Resident #101 revealed the physician order Butrans Transdermal Patch Weekly 20 MCG/HR (micrograms per hour) (Buprenorphine) Apply 1 patch transdermally (a method of administration where the medication is absorbed through the skin into the bloodstream) at bedtime every (Tuesday) . with a start date of 9/30/25.Review of the September 2025 Medication Administration Record (MAR) for Resident #101 revealed the physician order Butrans Transdermal Patch Weekly 20 MCG/HR (Buprenorphine) Apply 1 patch transdermally at bedtime every (Tuesday) . was documented on 9/30/25 as not given with a code 6 indicating the resident was hospitalized .Review of a Nurse's Note for Resident #101, dated 10/1/25 at 7:27 AM, revealed Patient receiving skilled care for T10-L3 Hardware removal with T12-L3 decompression and fusion. Patient is A&Ox2 (alert and oriented to person and place). (Medications) taken whole with water. Patient confused at baseline at the start of shift with agitation. Patient complained of 10/10 pain in lower back .Patient sent to ED (Emergency Department) per daughter request. Patient returned from ED with new order of antibiotic Cephalexin for UTI (Urinary Tract Infection). On call made aware of changes. Call light and hydration within reach . No documentation noted in the progress notes related to late administration of Resident #101's Butrans patch scheduled on 9/30/25.Review of Resident #101's Controlled Substance Proof-of-Use Record for Buprenorphine 20 MCG/HR .Apply 1 patch transdermally at bedtime every (Tuesday) revealed one patch was pulled from the narcotic storage box to be given on 10/1/25 at 6:22 AM.Review of the October 2025 MAR for Resident #101 revealed the physician order Butrans Transdermal Patch Weekly 20 MCG/HR (Buprenorphine) Apply 1 patch transdermally at bedtime every (Tuesday) . was documented on 10/7/25 as administered.Review of a Medication and Treatment Incident Report for Resident #101, dated 10/8/25, revealed .(LPN I) the evening of 10/8/25 discovered 2 Butrans patches on patient. She removed the patches prior to (patient's) transfer to (the) ED .Medication Error Type .Failure to Follow Procedure (explain): 10/1/25 Nurse did not document in (patient's) eMAR (electronic MAR) administration (and) location of Buprenorphine patch .Dispensing Error .10/1/25 transdermal patch not removed prior to 10/7/25 transdermal patch applied .Documentation Error .Charting error .In an interview on 10/20/25 at 2:35 PM, Certified Nursing Assistant (CNA) M reported she worked with Resident #101 on 10/8/25 during day shift. CNA M reported Resident #101 was usually very sensitive to touch and very painful. CNA M stated on 10/8/25 .I noticed I was able to roll and change her .She was talking with me, but she did seem more groggy than normal .In an interview on 10/20/25 at 3:00 PM, Family Member R reported Resident #101 appeared significantly drowsier than normal on the day she was sent to the hospital (10/8/25). Family Member R stated .(Resident #101) would kind of respond . but she was not fully oriented. Family Member R reported they voiced concerns regarding Resident #101's change in mental status and requested some interventions from the PA (Physician Assistant). Family Member R stated .I initially had asked if it was an opioid situation and maybe we should take the patch off. They didn't want to move too quickly . Family Member R reported they left around 4:00 PM and returned around 7:30 PM and stated .Her condition was even worse . Family Member R stated .They forgot to take one of the (Butrans) patches off, so (Resident #101) had two (Butrans patches) on. That was discovered as we were getting ready to transfer her (to the hospital) .as her blood pressure and oxygen were decreasing . Family Member R reported she observed LPN I remove two Butrans patches from Resident #101 prior to sending the resident to the ED, one from the right deltoid and the other from the upper/middle back.In an interview on 10/20/25 at 3:27 PM, LPN G reported she worked with Resident #101 on 10/8/25 during day shift. LPN G reported Resident #101 appeared alert and coherent earlier in the day. LPN G reported she administered Resident #101's PRN (as needed) Norco and a muscle relaxer prior to a scheduled therapy appointment. LPN G reported therapy staff came to her and reported Resident #101 was dizzy and clammy. LPN G reported Resident #101 had normal vital signs but did not end up participating in therapy. LPN G stated Resident #101 was .kind of out of it . LPN G reported while some drowsiness and sleepiness was not out of the ordinary for Resident #101, that day she was .more shaky and had some tremors .She wasn't able to hold onto things very well . LPN G reported she had the provider assess Resident #101 and they decided to keep the orders for her Butrans patch and make changes to a different pain medication.Review of a Provider Note for Resident #101, dated 10/8/25 at 1:48 PM, revealed Family concerned about oversedation this afternoon. On exam (patient) was Somnolent (sleepy/drowsy) but able to be aroused with voice alone .Staff noting (patient) was functioning normally this morning prior to taking PRN Norco (an opioid pain medication) dose prior to PT (Physical Therapy) .Plan is to D/C (discontinue) Norco effective immediately and monitor for improvement in mental status. If no improvement, consider reducing Robaxin dose or reduction in Buprenorphine patch .Review of a Nurse's Note for Resident #101, dated 10/8/25 at 8:00 PM, revealed Patient is very sleepy and hard to arouse. Patient is still able to follow verbal commands and answer questions. Fluids offered and patient took a few sips. Husband at bedside requested that patient be sent to (the) hospital. Contacted on call. Per on call send (patient) out if condition worsens and obtain vitals every hour. Vitals as follows: BP (Blood Pressure) 102/69, RR (Respiratory Rate) 16, O2 (Oxygen Saturation) 92%, T (Temperature) 97.4 (Fahrenheit) .Review of a Nurse's Note for Resident #101, dated 10/8/25 at 9:10 PM, revealed Change in condition. Vitals as follows: BP 68/49, P (Pulse) 72, (Oxygen Saturation) 83 (percent), T 97.4 (Fahrenheit), RR 16. Sent to (Hospital Name) ED due to worsening condition. Patient continues to be very lethargic and hard to arouse and (shows) symptoms of drug toxicity .In an interview on 10/21/25 at 11:19 AM, Interim Director of Nursing (DON) B reported Resident #101 had issues with pain management and had many changes to her pain medication orders throughout her stay. Interim DON B reported Resident #101 was assessed by palliative care, and orders were placed for a Butrans patch on 9/30/25. Interim DON B reported Resident #101's family wanted the patch initiated as soon as possible, so she (Interim DON B) stayed over to communicate to the night shift nurse (LPN I) the importance of applying the Butrans patch as soon as it was delivered from the pharmacy. Interim DON B reported the patient was sent out to the ED that day but later returned to the facility. Interim DON B reported Resident #101's family asked about the patch the next day, and she (Interim DON B) reported the resident received the patch because she trusted the nurse. Interim DON B reported on 10/8/25, she met with Resident #101, a family member, and the PA due to concerns expressed by the family. Interim DON B reported the PA made some changes to Resident #101's pain medication regimen and discontinued the PRN Norco. Interim DON B reported the next day (10/9/25) she discovered that the hospital records for Resident #101 indicated she had two Butrans patches on at the same time. Interim DON B reported she started to review Resident #101's electronic medical record and discovered the Butrans patch applied on 10/1/25 was not documented in Resident #101's MAR but was signed out on the Controlled Substance Proof-Of-Use Record. Interim DON B reported she interviewed LPN J who reported she looked for the Butrans patch on Resident #101 on 10/7/25, prior to the application of the new patch, but did not see anything. Interim DON B reported Resident #101 told LPN J someone else removed the first patch, so LPN J proceeded to apply the second Butrans patch. Interim DON B reported LPN I explained the two patches were removed when discovered, prior to Resident #101's transfer to the ED on 10/8/25.In an interview on 10/21/25 at 12:06 PM, Physical Therapist (PT) S reported she had a scheduled treatment with Resident #101 on 10/8/25. PT S reported Resident #101 was in bed when she arrived and complained of pain in her back. PT S reported she and Occupational Therapist (OT) T assisted Resident #101 into her wheelchair, and the resident complained of increased dizziness and appeared pale and confused. PT S reported they stopped treatment at that point and notified the nurse of Resident #101's condition.In an interview on 10/21/25 at 3:08 PM, LPN J reported she cared for Resident #101 on 10/7/25 (night shift). LPN J reported the order came up to apply a Butrans patch for Resident #101. LPN J reported she began to look for the old patch and Resident #101 reported staff had removed it. LPN J reported she then applied the new Butrans patch and documented the location in the MAR. LPN J reported there was no documentation in the MAR to indicate where the previous Butrans patch had been placed. LPN J stated .I did see that it had been applied, but I couldn't tell where it was applied .Attempted to contact LPN I via phone on 10/20/25 at 2:12 PM and 10/21/25 at 8:36 AM with no response received prior to survey exit.Review of a Critical Care Consultation note for Resident #101, dated 10/9/25 at 2:18 AM, revealed Chief Complaint: Altered mental status .She presented to the emergency department today from (Facility Name) because of mental status changes and inadvertent opiate overdose. Apparently, she inadvertently had 2 Butrans patches in place. They have been present for at least 24 hours. She was noted to be slowly becoming more lethargic and confused over the last few days. She has not had a whole lot to eat or drink over that period as well .In ED she was given a total of 6 doses of Narcan 0.4 mg (a medication used to reverse an opioid overdose). Each time her mental status would improve but decline once the Narcan dose wore off. ABG (arterial blood gas) demonstrated mild hypoxemia (a low level of oxygen in the blood). Creatinine 2.7 up from 0.9 10/6/2025 .Assessment/Plan .Inadvertent opiate overdose .In subacute rehab at (Facility Name) and had 2 Butrans patches 20 mg in place .Received 6 doses of Narcan 0.4 mg in the emergency department with adequate transient response .Narcan drip until opiate effects have worn off .Altered mental status .Related to opiate overdose as per above .Acute hypoxemic respiratory failure .Likely related to opiate overdose as well as underlying OSA (obstructive sleep apnea) .Review of the policy/procedure Controlled Substances, dated 6/2019, revealed Accurate accountability of the inventory of all controlled substances is maintained at all times. When a controlled substance is administered, the nurse administering the medication immediately enters the following information on the controlled substance count sheet and on the Medication Administration Record (MAR): 1) Date and time of administration (MAR, controlled substance count sheet) 2) Amount administered (controlled substance count sheet) 3) Remaining quantity (controlled substance count sheet) 4) Initials of the nurse administering the dose (MAR, controlled substance count sheet) .Review of the policy/procedure Transdermal Drug Delivery System (Patch) Application, dated 9/2023, revealed Purpose .To administer medication through the skin via proper placement of a transdermal patch and care of the application site(s) .Identify the location for the patch placement on the resident .Remove the old patch, and discard according to facility policy .Document placement site on the MAR .During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included a review/update of the policies/procedures for medication administration, education to licensed nursing staff on steps to take and process changes which included notification of the on-call manager when a narcotic patch is unable to be located on a resident, completion of a medication error report when a narcotic patch is missing, a process change where two licensed nurses are required to validate that a missing narcotic patch is not located with notification to the on-call manager prior to placing a new patch, and supplemental documentation added to narcotic patch orders to check placement and location of the patch every shift. The previous clinical resource nurse position was expanded and is now a Nurse Leader position to provide support, guidance and education for the evening shift. Audits were completed to review physician orders and administration records/narcotic logs for all residents. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. Compliance date of 10/17/25.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility, at 2:38 PM on 4/15/25, it was observed that the hopper in the walk-through Soiled Utility room, in the middle hall, was found with no handles on the faucet and minimal water in the basin of the bowl. This indicates the hopper had not been flushed in a while, once flushed, the basin water raised significantly. Further review of the hopper found that the basin spray hose handles were zip tied closed and not available for use or flushing. During a tour of the spa room, at 2:43 PM on 4/15/25, it was observed that the area that a spa tub was located was found to have two water lines coming into the room capped off and not available to be flushed. During a tour of the Soiled Utility room [ROOM NUMBER], at 2:56 PM on 4/15/25, it was observed that the basin of the hopper was found low in the bowl and raised significantly after flushing the hopper. The faucet handles were observed to have been removed, but with pliers, the surveyor was able to turn the faucet handle, and the right valve was found with discolored brown water coming from the fixture. The left valve did not dispense water when turned on. The hopper spray was found to be turned off at the source and would not flow when the pedals were pressed. An interview with Director of Facilities OO, at 3:13 PM on 4/15/25, found that staff in housekeeping flush water in vacant rooms weekly. When asked about minimal use or unused fixtures in the facility getting regular flushing's, DOF OO was unsure and stated they did not have a list of other fixtures being flushed. When asked if testing is being performed, DOF OO stated that they test quarterly for Legionella, and have started to do some free chlorine samples when those samples are taken, but no results were able to be provided. When asked if there was a control limit for free chlorine in the domestic hot water supply, DOF OO was unsure. A record review of the facility provided document entitled Legionella Control/Water Management Plan, last reviewed on 9/24/24, found that The procedure covers the following 4 steps: risk assessment, risk mitigation, operational management of risk and remediation of the following systems: .Domestic Cold water .Domestic Hot water. The policy goes on to state that Vacant or Unoccupied Rooms: all showers and faucets are flushed, for at least 1 minute, on a weekly basis by Environmental Services (EVS). Further review found that he Facility Director is Responsible for standard operating procedures (SOP's) for maintenance and operation of each applicable system above.

Based on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: An initial kitchen/food service tour was conducted on 4/14/25 beginning at 9:26 AM with Director of Dining Services (DDS) X and Clinical Nutrition Manager (CNM) W. The following observations/interviews/record reviews were completed: Food Labeling/Dating/Discarding On 4/14/25 at 9:38 AM in the cooler underneath the juice machine, there was a half-gallon container of 2% milk and a half-gallon container of organic soy milk that were opened but not labeled with an opened date or discard date. DDS X reported the items should have been labeled with opened and discard dates and immediately discarded the items. On 4/14/25 at 9:47 AM in a cooler on the cold service side of the cook's preparation area, there was a jar of grape jelly that was opened but not labeled with an opened date or discard date. There was a container of vinaigrette dressing labeled with a prepared date of 4/6/25 and a discard date of 4/13/25. DDS X reported the grape jelly should have been labeled with an opened and discard date and removed the item from the cooler. DDS X reported the vinaigrette dressing was from a weekly special that ended the day before and discarded the item. On 4/14/25 at 10:01 AM in the main walk-in cooler, there was an opened jar of artichoke hearts that was not labeled with an opened date or a discard date. DDS X reported the item should have been labeled with opened and discard dates and removed the item from the cooler. On 4/14/25 at 10:07 AM in the prep-cooler in the prep room, there was a decanter filled with ranch dressing that was not labeled with a prepared or discard date. DDS X reported the container of ranch dressing that the decanter was filled from was labeled with an opened and a discard date but not the decanter itself. On 4/14/25 at 10:19 AM in the Southview Pantry, there was a bag that had two containers of resident food that was dated 4/10/25. CNM W reported the facility followed the 72-hour rule for resident food items and the food items should have already been discarded because it was past the 72 hours. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . Food Cooling Review of the policy Food Handling Guidelines last revised 1/2025 revealed, .COOLING .* Cooling of potentially hazardous cooked foods: * Food shall be cooled from 135 F (degrees Fahrenheit) to 70 F as measured at its center within two hours and from 70 F to 41 F within an additional four hours for a total cooling time of six hours or less. * Use the Cooling Log .to document the temperature of the food at the following times: when placed in cooling equipment, and then at 2 hours and 6 hours after placing in cooling equipment. * Foods that have not cooled to 70 F within 2 hours of being placed in the cooling equipment: reheat once to 165 F and re-cool. If food was not below 70 F at 2 hours, and it was reheated, discard if not below 70 F at 2 hours when cooled for the second time. Food that is not below 41 F at 6 hours must be discarded . On 4/14/25 beginning at 9:55 AM, the Food Cooking and Cooling Logs were reviewed with DDS X. The following concerns were noted: A review of the Food Cooking and Cooling Log dated 4/1 revealed final cook time and temperature entries for Beef - 189 degrees at 10:00; Flank - 171 degrees at 11:45; Turkey - 180 degrees at 1:00; and Mar (unknown item) 166 degrees at 1:45. There were no recorded time and temperature entries for these food items after 2 hours. A review of the Food Cooking and Cooling Log dated 4/2 revealed final cook time and temperature entries and time and temperature after two hours entries for [NAME] - 190 degrees at 1:00 and 86 degrees at 3:00; Sweets - 201 degrees at 1:45 and 76 degrees at 4:00; Strokinoff (sic) - 187 degrees at 3:00 and 81 degrees at 5:00. There was no documentation that the food items had been reheated to 165 degrees and re-cooled as required per policy given the food items had not reached an internal temperature of 70 degrees or below at 2 hours. There was also an entry for Turkey - 189 degrees at 2:00. There was no recorded time and temperature entry for this item after 2 hours. A review of the Food Cooking and Cooling Log dated 4/7 revealed final cook time and temperature entries and time and temperature after two hours entries for Tomato Sauce - 187 degrees at 12:30 and 81 degrees at 3:00; Pot (potatoes) - 181 degrees at 1:30 and 79 degrees at 4:00; S. Pot (sweet potatoes) - 200 degrees at 2:30 and 87 degrees at 5:00. There was no documentation that the food items had been reheated to 165 degrees and re-cooled as required per policy given the food items had not reached an internal temperature of 70 degrees or below after 2 hours. A review of the Food Cooking and Cooling Log dated 4/8 revealed final cook time and temperature entries and time and temperature after two hours entries for Cheese Sauce - 201 degrees at 12:30 and 89 degrees at 3:00; Turkey - 169 degrees at 12:40 and 92 degrees at 3:00. There was no documentation that the food items had been reheated to 165 degrees and re-cooled as required per policy given the food items had not reached an internal temperature of 70 degrees or below after 2 hours. A review of the Food Cooking and Cooling Log dated 4/9 revealed final cook time and temperature entries for Mash (mashed potatoes) - 176 degrees at 11:30; Tomato Sauce - 201 degrees at 12:00. There were no recorded time and temperature entries for these food items after 2 hours. A review of the Food Cooking and Cooling Log dated 4/13 revealed final cook time and temperature entries and time and temperature after two hours entries for Turkey - 170 degrees at 11:00 and 80 degrees at 1:30; Beef - 175 degrees at 12:00 and 81 degrees at 2:00; Carrot 177 degrees at 12:00 and 76 degrees at 2:00; Sweets - 198 degrees at 1:00 and 101 degrees at 4:00; Pot Roast 187 degrees at 1:00 and 96 degrees at 4:00. There was no documentation that the food items had been reheated to 165 degrees and re-cooled as required per policy given the food items had not reached an internal temperature of 70 degrees or below after 2 hours. In an interview on 4/14/25 at 9:58 AM, DDS X reported, based on review of the food cooking and cooling logs, that staff were not checking the food temperatures after 2 hours consistently and when the food items after 2 hours had not reached 70 degrees or less, they were not reheating to 165 degrees and re-cooling the food. DDS X confirmed staff were not cooling the foods properly. 38905 During a tour of the kitchen, at 9:19 AM on 4/15/25, it was observed that two full sheet pans, one half sheet pan, and two eighth pans, were found stacked and stored with visible water accumulation stuck in between the equipment. According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD . During a tour of the drink station area of the main kitchen, at 9:10 AM on 4/15/25, it was observed that the underside of the portions of the drink spouts for the juice machines were found with an accumulation of sticky debris. During an observation of the large floor mixer, at 9:25 AM on 4/15/25, and interview with Director of Dining Services X found that the mixers get used daily. Observation of the mixer found an accumulation of dried mashed potatoes on the front grate. According to the 2022 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. (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 a tour of the dish machine area, at 9:30 AM on 4/15/25, it was observed that the machines data plate was found to state the pressure of the rinse needed to be 15 PSI. Observation of the next four cycles of the dish machine found that the flow pressure on the digital read out stated 30-37 psi for each rinse cycle that was run. When asked if staff look at the flow pressure, Clinical Nutrition Manager W and Executive Chef Z was unsure. According to the 2022 FDA Food Code section 4-501.113 Mechanical Warewashing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch).

This citation pertains to Intake: MI00151227 Based on interview and record review, the facility failed to provide adequate supervision, monitoring, and ensure safety precautions were in place and accurate in 1 of 1 residents (Resident #236) reviewed for elopement resulting in Resident #236 eloping from the facility which could negatively affect the resident's highest practicable physical, mental, and psychosocial well-being. Findings include: Review of Securitas HUGS Infant System revealed, .Real-Time Monitoring: Patient tags are monitored for connectivity to Hugs system .Tag communication verified every 60 seconds .Should the tag not be able to communicate with Hugs systems (tamper, battery, local network outage), the system will lock down the unit . Review of an Admission Record revealed Resident #236 was a male with pertinent diagnoses which included dementia with behavioral disturbance, anxiety, cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language), muscle weakness, and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #236, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated Resident #236 was severely cognitively impaired. Review of current Care Plan for Resident #236, initiated on [DATE], revealed the focus, .Elopement Risk: Resident is at risk for elopement due to (elopement score of 5), confusion and poor safety awareness with statements of wanting to go home . with the intervention .Assess elopement risk upon admission, quarterly, or with significant change in condition Apply wander alert bracelet - check placement and functioning daily .If actively seeking exit doors or attempting to leave the unit provide me redirection, distraction and or assistance from other associates . Review of Order dated [DATE] at 2:56 AM, revealed, .First scheduled time is [DATE] on the 7A-7P - MED PASS time period .Notes: Monitor and document placement of wander guard (HUGS tag/band) placement to right wrist. Document 1 if red light is blinking, 2 if no light is blinking. Document left or right wrist, if it had been moved for any reason . Review of [NAME] Healthcare System HUGS education revealed, .The HUGS tag is a reusable tag attached around the patient's ankle using a disposable strap. Is fully supervised -the tag send out a regular Heartbeat to the system .Will generate an alarm when it is removed from the safe area, when attaching strap has been tampered with or cut, when the tag stops communicating with the system, when the tag is loose or off the patient, and when the battery power is low .Waterproof and latex free .The back of the tag, together with the strap, detects the patient's skin .Applying the Hugs Tag .Insert the strap in the tag .Align the band with tag slot .Make sure this side up is on the outside .Insert band into tag slot starting from bottom of tag .Pull through until the brown material extends beyond the slot about ,d+[DATE] inch .Wrap tag around patient's ankle, and insert loose end of band into second tag slot .Pull band through, and listen for the battery status chime (two short beeps) .Check to make sure the tag is snug: The tag may wiggle some but it shouldn't rotate .Trim both ends of band .Leave enough of the strap to use to tighten at a later time .Assigning a New Tag .Once the tag is applied, click on the text New Baby to fill out the patient's name, gender, and room .If this step is not completed, the system will alarm every 20 minutes because the admission is incomplete .Discharging the HUGS Tag .The Hugs Tag must be discharged from the system before you can physically remove it .This is called discharging the patient .The patient should be brought to the Nurse Station/I room with the client computer to perform this step .Doing this will help prevent the loss of tags and will keep the patients safe until they actually leave .If the strap is cut before the tag is discharged from the A system, a Tamper Alert will occur .Removing the Hugs Tag: The tag is cut off .Remove the tag pieces immediately (If the two pieces touch, the tag can auto admit .Discard pieces and return tag for cleaning . Review of Nursing Progress note dated [DATE] at 3:39 AM, revealed, .ADL (activities of daily living) Performance 1 assist with ADLS, Cognitive Function: A&O (alert and oriented) x1 .Patient is confused, observed patient wandering outside of his room, Patient stated, I need to go patient was by the elevator. This nurse had to reorientation patient to room. Hugs tag put on right wrist. Patient was up all night trying to self-transfer to restroom, patient is unable to make needs known educated patient on the use of call light . Review of Clinical Note Entry dated on [DATE] at 1:30 PM, .Pt (Patient) was moved to 5129 to be closer to the nurses station . Review of Clinical Note Entry dated [DATE] revealed, .High fall risk related to dementia/possible Parkinson's disease or Lewy Body Dementia with vascular dementia .During his stay, he had dementia related agitation for which he was seen by Psychiatry and started on Zyprexa 5 mg at HS (hour of sleep). This was increased to 10 mg due to ongoing agitation with need to use a posey bed (hospital bed, canopy, and mattress system designed to help provide a safe, controlled environment for patients at extreme risk of injury from a fall or unassisted bed exit) . Note: Information from the resident's hospital stay. Review of Clinical Entry Note dated [DATE] at 1:12 PM, .Patient has been extremely anxious since after breakfast this morning. Patient observed self-propelling through the hallways with his wheelchair attempting to enter other patient's room. Pt. has been yelling at staff multiple times and state to this RN (Registered Nurse) that his wife took the money and the car and is gone and he is demanding to leave. Staff have attempted to redirect patient and are successful but within ,d+[DATE] minutes patient is back into the hallway yelling at staff and other visitors. Pt wife called with pt in the room three times this shift so far to attempt to deescalate patient, and it is briefly successful. Pt wife is unable to be here at this time. Pt is requiring constant supervision from staff and cueing/redirection to keep him safe .Pt is now refusing to eat any lunch and continues to yell out to anyone he sees. He refuses to participate in any activity or redirection attempt. Pt door left open, staff checking in every ,d+[DATE] minutes. Will continue to monitor. Fall precautions in place. Wander guard in place to patient's right wrist and observed to be functioning . Review of Elopement assessment dated [DATE] at 7:00 PM, revealed, .Wandering - Presence and Frequency: 3. Behavior of this type occurred daily .Wandering-Impact: Wandering: Risk of getting to dangerous place: Yes .Wandering: Intrude on privacy of others: Yes .Change in Behavior, wandering or other symptoms: Worse .The resident has previously attempted to leave a residence or other place unescorted: No .This resident is cognitively impaired and independently ambulatory .Yes .The resident has a history of elopement .No .Resident is on medication to manage elopement behavior: Yes .There has been a recent change in this medication: Yes .Resident has verbalized intent to leave facility .Yes .Resident is wandering to find family pet .Yes .Resident is wandering aimlessly .Yes .Resident is actively exhibiting exit-seeking behavior .Yes .Total Elopement Risk Assessment Score: 6 .Interventions .Comments on elopement behavior .H/O (history of) Dementia associated with Parkinson's. Pt (Patient) is AO (alert/oriented) to self and unable to determine safety .Elopement Deterrent device implemented .Elopement prevention care plan initiated or updated .Therapy referral for issues with activity and mobility requested . Note: Indicated Resident #236 was an elopement risk. Review of Unplanned Occurrence Report dated [DATE] at 12:38 PM, revealed, .Location of Incident: Outside main entrance .Not witnessed .Around 12:38 PM on ,d+[DATE] this writer was walking by patient's room and noted he was not in there as he previously was around 12:30 PM. RN (Registered Nurse)and other staff immediately began searching around the unit and could not find pt. 311 was called to page a code pink and security notified writer that patient was found outside of main entrance and was brought in by them. Staff quickly recovered patient and brought back to (Resident #236's room). When pt. was back, RN assessed his skin and there were no new findings or concerns. Patient's Hugs tag was also observed off of his wrist and nowhere to be found. When asking patient he reports Oh I cut that thing off system did not alert staff at any point .Preventions measures and/or corrective actions taken: New Hugs tag was applied and tested to ensure working, security staff and front desk noted pt. being high wander risk .Physician's statement: Will look into adjusting patient's Zyprexa as was recently decreased . In an interview on [DATE] at 3:19 PM, Registered Nurse (RN) I reported Resident #236 was very anxious, high wander risk and he had a Hugs tag on. RN I reported during shift change on [DATE], he had peeked in his room, he was lying in his bed, observed the hugs band on his right hand. RN I reported he had sent a message to the team the staff needed to check on him very often as he was ambulatory and anxious the previous day. RN I reported Resident #236 would get something in his mind and start walking and he was not using an ambulatory device, he could walk perfectly fine and walk quick, the main reason he was still here was a placement issue. RN I reported the facility was trying to keep him safe, as the day progressed he was fine most of the day but in the afternoon he was wandering around the floor, RN I reported he would do ,d+[DATE] minute checks and had the whole staff sent a message via the secured system and prompted staff if they see him to say Hi and redirect him, we needed an all team effort. In the afternoon, Resident #236 followed a visitor to the elevator and his Hugs tag alarmed, which indicated a staff assist was needed, it is a general alarm. RN I reported he was by the I room (nurse's station) and looked on the computer monitor to locate the resident. RN I reported the Hugs system program showed where his tag was going off at. RN I reported he was looking down the hallway and a family member was walking him back to the staff. RN I reported the staff were trying to redirect him as well as the family member, but he was anxious and ready to leave. RN I reported since he had gotten close to the elevator, he set off the alarm, and locked the elevator before he could get on it. RN I reported he remembered it happened twice on that shift. RN I reported once Resident #236 was redirected away, guided back to his room, within 5 minutes he was walking around the floor. During the rest of the shift, Resident #236 continued to wander, staff continued to supervise him, redirected him from other resident's rooms. RN I reported then when he came for his shift on Sunday, [DATE] at 07:00 AM the alarm was going off and he was wondering if Resident #236 was having behaviors already, but the night shift reported his alarm was dying and when the battery was dying or died it would set off the alarm. The alarm was alerting every few minutes. RN I reported Licensed Practical Nurse (LPN) JJ had changed the Hugs tag out. RN I reported he had visibly seen the Hugs on Resident #236 on the same arm. RN I reported RN II verified he was in the system on the screen. Late morning/early afternoon, RN I reported he was out doing a medication pass and peeked in Resident #236's room, he was not there, and he texted out on the secure chat to see if the staff had seen him. RN I reported he immediately gathered the staff as no one had indicated they had seen him and they searched the floor, we unable to locate the resident, called 311 for security to report a resident may have left the floor and security asked if he was a short, balding man and when confirmed, security reported they had Resident #236 and staff went and recovered him. RN I reported the Hugs tag was not on Resident #236. RN I reported if you cut or loosen the Hugs tag, the whole alarm will go off, and he was not sure where it ended up at. RN I reported Resident #236 reported he cut the Hugs tag off. RN I reported Resident #236 was assessed, and he was alright. RN I reported the staff immediately put a new Hugs tag on Resident #236. RN I reported he realized the other one placed in the morning had not been activated. RN I reported we were sure to test it this time and it alarmed; the rest of the day did not set it off. RN I reported when a Hugs tag was placed it would show new baby in the system, then the staff have to enter the name and room in the system. RN I reported he maybe used the Hugs tag once every 6 months. RN I reported he had received education during orientation. In an interview on [DATE] 01:08 PM, Guest Services (GS) KK reported when a resident leaves the floor, try to get in the elevator with a HUGS band, the alarm is activated. GS KK pointed at a yellow light on the ceiling at the entry way, reported this would illuminate, security would be alerted and would be able to see the resident on the camera and intervene. Guest Services is also contacted by security as well to be alert to the resident coming down. If they make it down there, the GS staff would stop the residents and question them. In an interview on [DATE] at 09:57 AM, Licensed Practical Nurse (LPN) JJ reported before shift change, the Hugs tag was alarming for a low battery, it was silenced and alarmed again. First shift went with me to Resident #236's room to change the bracelet. LPN JJ reported the process was to take the Hugs tag off the charger, test it, add it to the system, see New baby enter patient name and room, and walk in the room with RN I placed it on Resident #236's right wrist and cut off the old one, and then placed the used one on the charger. LPN JJ reported when queried if he had tested it, replied think we did. LPN JJ reported he did not enter Resident #236 into the computer system, LPN II had done that portion of the task. LPN JJ reported when the battery was charged, would pull off the charging dock and see a light indicated it was charged. LPN JJ reported when the Hugs tag was placed on a resident it would alert by beeping/chirping to show it was working. The nurse would make sure it was snug on the wrist, but ensure it would not rotate around the arm, or slip off. LPN JJ reported he had placed a Hugs tag on a previous resident and felt he knew the process. LPN JJ reported the monitoring system could show where a resident was on a map of the floor. LPN JJ reported there was an order to assess the bracelet/check the bracelet so many times each shift and that would be documented on the treatment administration record (TAR). In an interview on [DATE] at 11:15 AM, RN II reported the nurse texted Resident #236 had not been seen. RN II reported the Hugs tag he had on didn't do what it was supposed to do. RN II reported she was not sure if the battery was dead or something was malfunctioning but a new one was placed on him after he was brought back to the floor. RN 'II reported you would check it to see if it is working, assigned to a patient, when connect the band was connected on the disc it would make a chirp sound. RN II demonstrated to this writer on how to enter a resident into the monitoring system. RN II reported would go to the computer, bottom left corner Notifications it would show a New Baby it gives the number of the band and time, click on it and would enter the resident's information in the box, it would go to the top of the screen and show the name, room, unit, tag ID, location, and admitted . Then when discharging you would select the resident and box comes up and tells you if you discharge the resident (it shows the resident's name and the Hugs tag number), they would no longer be protected by the system, select OK to discharge. RN II reported the staff could also look at the map in the system and it would show the staff where the patient was on the map. RN II reported if the Hugs tag was working or charged it would send a red alert if a patient was close to the elevator door or actively on the elevator. It would ring over the overhead alert system. It would also alert to staff via the phones as well. RN II reported if the system was activated it would lock the doors and the elevators. It a resident attempted to cut off the band, it would set off an alarm in the system. Review of Staff Interview Summary dated [DATE], Guest Services MM interview revealed, .On Sunday [DATE], a patient from the 5th floor walked out of the [NAME] Entrance. Patient was wearing a t-shirt and said Goodbye to me as he was leaving. Patient had no designation on him that showed he was a patient (wristband, alarm, gown etc.:) .About ,d+[DATE] minutes later, a staff member on the 5th floor messaged the group chat on (Secure message system) asking if anyone had seen the patient walking around. I messaged back and asked if the patient was an old, white, bald man wearing a t-shirt. After confirming, I let the 5th floor know that the patient had walked outside. Staff on the 5th floor asked me to go get him, but I am not trained in patient retrieval, nor can I leave the desk during my shift. At the same time the patient was now in the main lobby with a security officer while they were trying to figure out who he was and where he was supposed to be. A few staff members from the 5th floor came down and I directed them to the main lobby where they retrieved the patient . Review of Staff Interview Summary dated [DATE], Security Officer LL interview revealed, .(Security Officer LL) states he was contacted by a visitor stating a man in slippers was by the hospital main entrance. (Security Officer LL) went to see what was going on and walked the man inside the main entrance .When he got inside three female staff members were there and brought him up to his room . In an interview on [DATE] at 11:27 AM, Director of Social Services (DSS) DD reported when a resident was admitted they were monitored for hospital delirium, and we would base if a competency assessment would need to be completed after about a week as typically it would take the average resident to settle in and recover. Social Worker (SW) EE reported the hospital notes were reviewed and there was good communication with admissions staff. SW EE reported the brief mental status ( BIMS) was completed by the Occupational Therapists (OT)s as they were here 7 days per week. DSS DD reported Resident #236 was his own person at the time this event occurred even though he had been displaying exit seeking behaviors prior to this incident which happened on a weekend. DSS DD reported they would have received an e-mail from staff, but the situation would be discussed during morning meeting where we would discuss interventions for the safety of the resident. DSS DD reported we have changed the process for mental status to start that sooner, if it was determined the resident needed to be assessed, the psychologist would assess and share their findings with the provider. In an interview on [DATE] at 10:46 AM, Director of Nursing (DON) B reported when she was contacted for the elopement, she was not informed the resident had made it outside the building. This was discovered when investigating the incident that the resident had left the building, was outside, and brought back into the building by security. At this point, was when the incident was reported to the State Agency. DON B reported Resident #236 did have a Hugs tag on him the day of the incident, [DATE]. It was changed right at shift change that morning, programmed correctly in the system, the previous one was dying, and the system was set up to alarm when a battery was dying, changed the physical tag and then cleared the alarm the new tag was accidentally disarmed. DON B reported IT director was contacted to ensure the system was working correctly and he did a deep dive and discovered the tag number assigned to Resident #236 was removed and disarmed. DON B reported when the alarm was alerting for the dying battery on the previous Hugs tag, and another nurse, RN II, was trying to be helpful and accidentally cleared the new Hugs tag that was assigned to Resident #236 on that morning. During an observation on [DATE] at 01:16 PM, This writer observed upon entering the 5th floor, there was a sign and book for residents who were going LOA (leave of absence) to sign out in the book. Received documentation of resident signing out of book. Review of HUGS History dated XXX[DATE] at 6:56:06 AM .Event Triggered .Location: [NAME] Addition/Floor 5/Zone 3 5th floor .Alert Name: Supervision 5th Floor .Corrective Action: (LPN JJ) .([DATE] 6:57:41 AM) Action Taken: Other Description: battery dead XXX[DATE] at 6:57:41 AM . Review of HUGS History dated [DATE] at 7:01:11 AM .Event Triggered .Location: [NAME] Addition/Floor 5/Zone 3 5th floor .Alert Name: Supervision 5th Floor .Corrective Action: (LPN JJ) .([DATE] 7:01:39 AM) Action Taken: Replaced tag with new one XXX[DATE] at 7:01:39 AM . Review of HUGS History dated [DATE] at 7:05:10 AM .Event Triggered .Location: [NAME] Addition/Floor 5/Zone 3 5th floor .Alert Name: Supervision 5th Floor .Corrective Action: (LPN JJ) .([DATE] 7:01:39 AM) Action Taken: Other .Description: Error XXX[DATE] at 7:05:49 AM . Review of HUGS History dated Review of HUGS History dated [DATE] at 7:07:43 AM .Protection Status Change .West Addition/Floor 5/Zone 3 5th floor .Alert Name: Supervision 5th Floor .Additional Details: Protection Status-Auto discharged . Review of HUGS History dated [DATE] at 07:07:43 AM .Tag Removed from Infant .Additional Details: Protection Status-Auto discharged assetID=11685 Tag Classification=Infant tagNetworkId=No tag assigned asset Name=(Resident #236) .Reason=TAG_IN_CHARGER . Review of HUGS History dated [DATE] at 07:07:44 AM .Event Triggered .Location: [NAME] Addition/Floor 5/Zone 3 5th floor .Alert Name: Auto Discharge Acknowledge .Corrective Action: (RN II) .([DATE] 07:08:18 AM) .Action Taken: Gave Tag to manager, re-tagged patient. Description: New . Review of HUGS History dated [DATE] at 07:18:18 AM .Event Triggered .Location: [NAME] Addition/Floor 5/Zone 3 5th floor .Alert Name: Auto Discharge Acknowledge .Corrective Action: (RN II) .([DATE] 12:55:26 PM) .Action Taken: autoDismiss Description: corrective_action_patient_discharge_auto_dismiss_description . Review of HUGS History dated [DATE] at 12:46:55 PM .Activity: Infant Admission .Additional Details: infantId=8675 .Tag Expiration Date=[DATE] 09:14:17.307 .HugsTagID-5966 .AdmitDate=Sun [DATE]:46:55 EST 2025 . Review of Video from Security Camera completed by Lead Security Officer - Days NN and received on [DATE], revealed, .Here is the timeline I have recovered from camera review: 12:20PM Patient walks from room to west elevator and takes it to the 1 st floor 12:24PM Patient gets off on 1st floor west and exits the building. He then walks around the surface lot and heads back towards main building. 12:28PM patient approaches the security vehicle in front of the main entrance and appears to be talking to it 12:29PM patient walks towards the main entrance doors, realizes he can't get in, and continues to walk the sidewalk toward the Therapath 12:31PM (Security Officer LL) exits building by main employee entrance and makes contact with patient in the therapy garden 12:36PM (Security Officer LL) and patient walk into main entrance where (Hospital) security is also present- security from both sides get patient into wheelchair. 12:42PM SAR (Sub-Acute Rehab) nursing is on scene in main lobby 12:45PM patient is back on SAR floor . Review of the policy Elopement - Missing Resident dated [DATE], revealed, .Upon return of the resident/elder to the community, the Director of Nursing Services or Charge Nurse should: Examine the elder for injuries .Contact the Attending Physician and report what happened .Contact the resident's/elders legal representative or sponsor and inform him/her of the occurrence .Complete an occurrence report .Make appropriate notations in the medical record .Seek any medical/psychosocial attention as necessary for the elder and as directed by the physician should an employee become aware that a resident is missing from the community he/she should determine if the resident in on an authorized leave or pass. If not; The wandering resident's charge nurse assigns direct care staff to look for the resident by dividing teams assigned to look inside and outside the community by area. Refer to internal facility search plan (Also look in areas that are locked) .Notify the Director of Nursing and Administrator .If the resident is not located in the buildings or on the grounds within 15 minutes the following process is initiated: Mandatory Follow Up .Review the list of elders who wander and wear wander bracelets .Complete checks of all elders who wear wander bracelets and assure adequate function and note these findings .Complete a check of all doors or working keypads and alarms and note this check and findings Report all these findings to Administrator . The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the elopement policy was reviewed and deemed appropriate, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

Based on observation, interview, and record review, the facility failed to discard expired food products, monitor cooling potentially hazardous foods, and properly sanitize dishware, resulting in the potential for increased risk of food borne illness, affecting all residents in the facility that consume food. Findings include: On [DATE] at 11:10 AM, staff were observed to be washing dishes in the dish machine. A plate simulating thermometer was ran through the dish machine to determine the sanitizing final rinse temperature and was found to be 145 degrees F. A second cycle was ran with the thermometer and the internal rinse temperature was 147 degrees F. At this time, Food Service Director (FSD) D was queried on what steps they need to take next and stated that they will stop using the dish machine and utilize the three-compartment sink. FSD D proceeded to contact maintenance to repair the dish machine. According to the 2017 FDA Food Code Section ,d+[DATE].11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S ,d+[DATE].111; P (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS ,d+[DATE].15, ,d+[DATE].112, and ,d+[DATE].113 and achieving a UTENSIL surface temperature of 71oC (160oF) as measured by an irreversible registering temperature indicator; P or (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 ,d+[DATE].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 ,d+[DATE].114(A), P (2) A contact time of at least 7 seconds for a chlorine solution of 50 MG/L 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), P (3) A contact time of at least 30 seconds for other chemical SANITIZING solutions, P or (4) A contact time used in relationship with a combination of temperature, concentration, and PH that, when evaluated for efficacy, yields SANITIZATION as defined in ,d+[DATE].10(B). On [DATE] at 11:11 AM, Dishwasher Y was observed to be rinsing off dishware as it was being taken out of the sanitizing compartment of the three-compartment sink. At this time, FSD D was queried on what the three compartment sink procedure is and stated that they rinse off silverware after the sanitizing step, but typically don't rinse off dishware. According to the sanitizer Manufacturer's Directions For Use, it notes, To Sanitize Hard, Non-Porous Food Contact Surfaces and Equipment: 1. Prior to sanitization, remove gross particulate matter with a warm water flush, then wash equipment with detergent or cleaning solution and follow with a potable water rinse. 2. Prepare the sanitizing use solution by adding 1 - 2 mL per 500 mL of water (,d+[DATE] ppm active quat) (or equivalent dilution). 3. Apply sanitizing solution by immersion, coarse spray, mop, wipe, flood techniques or circulation techniques as appropriate to the equipment or surface to be treated. Allow a contact time of at least 1 minute. 4. Allow surfaces to drain thoroughly and air dry before resuming operation. Do not rinse. According to the 2017 FDA Food Code Section ,d+[DATE].14 Rinsing Equipment and Utensils after Cleaning and Sanitizing. After being cleaned and SANITIZED, EQUIPMENT and UTENSILS shall not be rinsed before air drying or use unless: (A) The rinse is applied directly from a potable water supply by a warewashing machine that is maintained and operated as specified under Subparts ,d+[DATE] and ,d+[DATE]; and (B) The rinse is applied only after the EQUIPMENT and UTENSILS have been SANITIZED by the application of hot water or by the application of a chemical SANITIZER solution whose EPA registered label use instructions call for rinsing off the SANITIZER after it is applied in a commercial WAREWASHING machine. On [DATE] at 11:30 AM a container of [NAME] was observed to be cooling in the blast chiller unit. At this item FSD D was queried if the cooling process was being tracked and stated that it is on the cooling log. A review of the facilities, TCS* Food Cooking and Coolin Log, dated ,d+[DATE], notes that the cooling process started for the [NAME] at 8:45 AM. The log shows no entry or tracking entered at the two hour temperature check time for proper cooling. FSD D proceeded to instruct staff to re-heat the [NAME] to re-start the cooling process. According to the 2017 FDA Food Code Section ,d+[DATE].14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. P (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. P (C) Except as specified under (D) of this section, a TIME/TEMPERATURE CONTROL FOR SAFETY FOOD received in compliance with LAWS allowing a temperature above 5oC (41oF) during shipment from the supplier as specified in ,d+[DATE].11(B), shall be cooled within 4 hours to 5oC (41oF) or less. P (D) Raw EGGS shall be received as specified under ,d+[DATE].11(C) and immediately placed in refrigerated EQUIPMENT that maintains an ambient air temperature of 7oC (45oF) or less. 41982 On [DATE] beginning at 9:50 AM, an initial tour of the kitchen/food service area was conducted with Food Service Director (FSD) D and Clinical Nutrition Manager (CNM) C. The following observations/interviews occurred during this initial tour: At 10:00 AM in the walk-in freezer, noted a partial case of whipped topping with a use by date of [DATE]; a bag of ciabatta bread labeled with a discard date of [DATE]; and a box of popsicles with a received date of ,d+[DATE]. FSD D reported all the items should have already been discarded. At 10:05 AM, the Food Cooking and Cooling Logs dated [DATE] - [DATE] and [DATE] were reviewed with FSD D. The logs included rows of boxes for entries of: PRODUCT (referring to name of the food product to be cooled); FINAL COOK TIME & TEMP (temperature) .TIME COOLING STARTED (per log - cooling starts when temp reaches 135 degrees F [Fahrenheit]), TIME & TEMP AFTER 2 HOURS (per log - at 2 hours, temp must read at or below 70 degrees F) .TIME & TEMP AFTER TOTAL OF 6 HOURS (per log - At 6 total hours, temp must read at or below 41 degrees F) . There were 18 food products documented on the logs that included entries for the names of the food products to be cooled, along with the final cook times and temperatures. Of those 18 food products documented, 1 included an entry for TIME & TEMP AFTER 2 HOURS and 6 included entries for TIME & TEMP AFTER TOTAL OF 6 HOURS. None of the 18 food products documented contained the complete cooling information. FSD D confirmed that the cooling logs had not been completed appropriately and reported the staff needed further education on how to properly complete the cooling log. At 10:12 AM at the cook's station, noted a powdered sugar shaker that had a moderate amount of dried food on the handle and dried/caked powdered sugar and debris on the lid. FSD D removed the container and confirmed it should be cleaned. At 10:14 AM in the trayline cooler, noted an opened container of soy milk labeled with an opened date of [DATE] and a discard date of [DATE]. FSD D removed the item from the cooler and discarded. At 10:15 AM in cooler 9, noted a white jelly-like, unidentified substance on the bottom shelf of the cooler next to a 2-liter bottle of soda. FSD D reported he did not know what the substance was and that it should not be there and asked a staff member to clean and sanitize the area. At 10:23 AM in cooler 7, noted 5 containers of yogurt that had varied expiration dates in [DATE]. At 10:30 AM in cooler 13, noted a speed rack (a multi-shelf wheeled storage rack) that contained pre-cut desserts (cakes, Jell-O, etc.). The speed rack had dried food and debris on the racks. FSD D confirmed that the equipment needed to be cleaned.

Based on observation, interview, and record review, the facility failed to post required nurse staffing information on a daily basis, for all 39 residents in the facility, resulting in a lack of available staffing information for residents and visitors. Findings include: In multiple observations of the facility hallways and common areas, from 5/14/24 to 5/16/24, no posted nurse staffing information was identified. In an interview on 5/16/24 at 9:07 AM, Interim Administrator A reported the daily nurse staffing information was not posted. Interim Administrator A reported that the facility had experienced a transition with management staff, and the responsibility to post the nurse staffing information was not passed onto the appropriate staff member. Review of the policy/procedure Posting of Direct Care Daily Staffing Numbers, dated 11/1/19, revealed .At the beginning of each shift, the community shall post in a prominent location accessible to residents and visitors and in a clear readable format, the following information: a) Community name b) Current date c) Total number and actual hours worked (including call-ins and absences) by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift .Registered nurses .Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) as defined under state law .Certified Nurse Aides d) Resident census .

Based on interview and record review, the facility failed to annually review and update the required Facility Assessment, resulting in the potential for unidentified resources necessary to provide care and services to the resident population. Findings include: Review of the Facility Assessment document provided by the facility revealed the Facility Assessment was last completed, updated, or reviewed on 10/12/22. In an interview on 5/16/24 at 11:05 AM, Interim Nursing Home Administrator (NHA) A reported he had only been at the facility since April 2024. Interim NHA A reported he had contacted the former NHA who confirmed the Facility Assessment had not been completed, updated, or reviewed since 10/12/22. Interim NHA A reported he had since started working on an updated Facility Assessment and will review it with the quality team upon completion.

Based on observation, interview, and record review the facility failed to clean food and non-food contact surfaces to sight and touch, and discard food items by their use by date. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 42 residents who consume food from the kitchen. Findings Include: During the initial tour of the kitchen, on 3/20/23 at 10:20 AM., It was noted that clean coffee cups and bowels were stored on a metal wire rack to be stacked and stored. Many of the coffee cups and bowls were etched and scored on the inside, as well as stained, and had dried stuck on food debris inside of them. It was noted eating utensils (silverware) were stored in a plastic utensil holder, the holder had food crumbs inside on the bottom and many spoons, forks and butter knives were visibly soiled with stuck on food debris, and a build up of a dried white substance. Dietary Manager (DM) E reported the dishware and utensils should be clean on the inside and out, and there should not be any dried stuck on debris of any kind. At 10:35 AM., it was noted clean pots and pans are stored on a large wire rack. Numerous pots and pans were noted to have grease and grime buildup on the food contact surfaces, as well as the outside of the cookware. It was noted that the rack found pans stacked on top of one another with trapped moisture inside. At 2:50 PM., on 3/22/23 it was noted in the stand-up freezer that 2 pans of frozen calzones (folded pizza) were noted to have a use by date of 1/27/22. Noted in a reach in cooler near the food prep table a pan of shredded turkey was noted to be covered with loosely (open to air) saran wrap, and a use by date of 3/21/23. DM E reported the calzones and turkey should no longer be in the freezer and cooler for use and consumption and should have been discarded. 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. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Review of a facility Culinary & Supply Chain Policies with a revision date of December 7, 2020 revealed: Description: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Cover, label and date unused portions and open packages. Complete all sections on a universal date label or use an approved labeling system. Products are good through the close of business on the date noted on the label

Based on interview and record review the facility failed to revise an individualized care plan for 1 resident (Resident #219) of 13 residents reviewed for care plan revision, resulting in the potential for impaired physical, mental, and psychosocial well-being. Findings include: Resident #219 Review of a Face Sheet revealed Resident #219 admitted to the facility on [DATE] with pertinent diagnoses which included nontraumatic subdural hemorrhage and heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #219, with a reference date of 3/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #219 was cognitively intact. In an interview on 3/22/23 at 8:58 AM, Resident #219 reported that she is currently taking anti-biotics for treatment of a urinary tract infection after having urinary frequency and burning with urination. Review of a Progress Note for Resident #219, dated 3/18/2023 at 11:00 PM, revealed nursing staff obtained a urinalysis after Resident #219 complained of urinary frequency and burning with urination. Review of a physician Progress Note for Resident #219, dated 3/19/2023 at 9:53 AM, revealed the physician ordered Macrobid(anti-biotic) for Resident #219's symptoms of urinary frequency and burning with urination. Review of a current Care Plan Report for Resident #219 dated 3/22/2023, revealed no information regarding the diagnosis or treatment of a urinary tract infection. In an interview on 3/22/2023 at 10:33 AM, Director of Nursing (DON) B reported that weekend updates are normally discussed on Monday during the morning meeting and then care plans are updated by the unit manager. DON B reported that Resident #219's care plan was not updated to reflect her urinary tract infection diagnosis and treatment as it should have been. In an interview on 3/22/2023 at 14:14 PM, Nursing Unit Manager H reported that she typically reviews weekend happenings on Monday morning and updates the care plan appropriately. Resident #219's care plan was not updated to reflect her urinary tract infection.

This citation pertains to intake #MI00128486 Based on interview and record review, the facility failed to properly supervise 1 Resident (Resident #259) of a total of 13 Resident reviewed for accidents, resulting in Resident # 259 suffering a first degree burn during a therapeutic treatment. Findings include: A review of a Face Sheet revealed Resident #259 was admitted to the facility with pertinent diagnoses that included: generalized muscle weakness and multiple rib fractures. A review of an Incident Report dated 5/5/22, revealed that on 5/4/22 at 2:01pm, Resident #259 received a heat pack therapy on his lower back as a part of an Occupational Therapy treatment. Resident #259's skin was not monitored during the heat application and the Occupational Therapist left the Resident unattended. At 5:40pm on 5/4/22, a Certified Nursing Assistant (CENA) responded to Resident #259's call light and found a reddened area with skin peeling on Resident #259's back. On 5/5/22, a Nurse Practitioner determined the reddened area was a first-degree burn. It was determined Resident #259 suffered the burn while unattended during the heat pack therapy. A review of a policy created on 5/12/22 titled Heat Therapy and Patient Safety, revealed section IV stated heat therapy is only provided during a therapy session, with frequent skin checks .patients are not left unattended Therapists are to complete the Heat Therapy Application Checklist prior to application . A review of an education record revealed all therapy staff completed training regarding Heat application and burn prevention and implementation of the Heat Therapy and Patient Safety policy by 5/12/22. In an interview with Nursing Home Administrator (NHA) A on 3/22/23 at 1:05pm, NHA A reported the facility had not provided the necessary supervision to ensure Resident #259 remained safe during the heat therapy treatment and systemic changes were implemented as a result. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, a heat therapy policy was created and implemented, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

Based on interview and record review the facility failed to prevent the use of unnecessary medications (antibiotic) without clinical justification for 1 of 1 residents (Resident #219) reviewed for urinary tract infections, resulting in the inappropriate use of antibiotics and the potential for worsening of infections and antibiotic resistance. Findings include: Resident #219 Review of a Face Sheet revealed Resident #219 admitted to the facility on [DATE] with pertinent diagnoses which included nontraumatic subdural hemorrhage and heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #219, with a reference date of 3/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #219 was cognitively intact. In an interview on 3/22/23 at 8:58 AM, Resident #219 reported that she is currently taking antibiotics for treatment of a urinary tract infection after having urinary frequency and burning with urination. Resident #219 denied having any other symptoms at the time the antibiotics were ordered. Review of a Progress Note for Resident #219, dated 3/18/2023 at 11:00 PM, revealed nursing staff obtained a urinalysis after Resident #219 complained of urinary frequency and burning with urination. Review of a Progress Note for Resident #219, dated 3/19/2023 at 1:50 AM, revealed nursing staff notified the physician of urinalysis results positive for a urinary tract infection, with culture and sensitivity results pending. Resident #219 was noted as being stable and resting in bed. Review of a physician Progress Note for Resident #219, dated 3/19/2023 at 9:53 AM, revealed the physician ordered Macrobid(anti-biotic) for Resident #219's symptoms of urinary frequency and burning with urination prior to the return of the results of the urine culture and sensitivity. Resident #219 denied fever, chills, or flank discomfort. Physical exam revealed Resident #219 was comfortable, in no acute distress, alert and oriented. In an interview on 3/21/2023 at 1:19 PM, Director of Nursing (DON) B reported facility procedure was for medical providers to use McGreer criteria to determine appropriate use of antibiotics. DON B reported that Resident #219 did not meet McGreer criteria for initiation of antibiotic use prior to results of the urine culture and sensitivity when Macrobid was ordered on 3/19/2023. DON B reported that medical providers usually document a risk versus benefit analysis if beginning antibiotics prior to the return of a culture and sensitivity. DON B reported that a risk versus benefit analysis was not documented in this case. Review of facility policy/procedure Surveillance, dated 2/2022, revealed .Antibiotic stewardship programs are initiatives aimed at improving antimicrobial/antibiotic use in healthcare settings. Recommendations and interventions of an effective antibiotic stewardship program are designed to ensure that residents who meet the criteria for infection receive the right antibiotic, at the right dose, at the right time, and for the right duration . UTI should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine culture .

Based on interview and record review, the facility failed to ensure that 4 of 43 Certified Nursing Assistants (CENA's) received annual competency training, resulting in the potential for the delivery of nursing and related services that does not support the attain or maintenance of the Resident's highest practicable physical, mental, and psychosocial well-being. Findings include: In an interview on 3/22/23 at 11:15am, Nursing Home Administrator (NHA) A was asked to provide documentation of annual nursing staff training. A review of the annual nursing staff training documentation provided by Nursing Home Administrator (NHA) revealed a list of staff labeled as noncompliant for annual training. Further review revealed 4 Certified Nursing Assistants (CENA's) had not received the required annual training in the last 12 calendar months. 2 of the 4 CENA's were overdue for training by more than 24 months. In an interview on 3/22/23 at 1:05pm, Nursing Home Administrator (NHA) A confirmed that 4 Certified Nursing Assistants (CENA's) had not completed the required annual competency training within the last 12 months. NHA A reported the staff that had not received the required training only worked on an as needed basis and had not been available for training. NHA A also reported that although the staff had not completed the training, they were eligible to continue to provide care.

Based on observation, interview, and record review the facility failed to: 1. Properly store food product to minimize contamination and maintain quality; 2. Follow manufactures directions for cold holding; 3. Ensure proper working order of the dish machine; and 4. Ensure proper cleaning and drying before stacking and storing pots and pans. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 37 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 10:05 AM on 11/30/21, it was observed that boxes of White Bread Dough, Wheat Bread Dough, and Pizza Crust Dough were found opened and not securely sealed in the freezer. During a follow up tour of the kitchen, at 9:10 AM on 12/1/21, it was observed that two 5 gallon containers of chicken noodle soup were found on the bottom shelf in the produce walk in cooler, uncovered. When asked if the items were cooling, Chef O stated, No, they should be covered, and proceeded to grab lids for the containers. During a follow up tour of the kitchen, at 2:50 PM on 12/1/21, it was observed that a sheet pan of meatballs were found sitting out uncovered in the produce walk in cooler. According to the 2013 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 -3-306. 2. During the initial tour of the kitchen, at 10:15 AM on 11/30/21, observation of the spice shelf area found an open container of Soy Sauce. The manufactures label states Refrigerate After Opening. After reading the label, Chef O states, it says refrigerate after opening, I will throw it away. According to the 2013 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 §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: .(2) At 5ºC (41ºF) or less . 3. During the initial tour of the kitchen, at 10:22 AM on 11/30/21, a review of the Dishmachine Temperature Log, dated November 2021, found that some logged high rinse temperatures are lower than the180°F minimum requirement. At this time, an interview with Food Service Director H found the issue might have more to do with the employees pushing the dishes through the dish machine faster to get them done and not recording the proper temperature. During a follow up tour of the dish machine area, at 9:45 AM on 12/1/21, it was observed that the dish machines' minimum requirements (which are posted on the right side of the machine under the tray rack), state that the minimum temperatures for the wash cycle is 160°F and for the rinse cycle 180°F. A review of the facilities Dishmachine Temperature Log, dated November 2021, found that it stated the machine only needed 150°F for the wash cycle. When asked if he knew that the dish machines' minimum wash requirement was 160°F and not 150°F, Chef O was unaware of the temperature difference. Further review of the November 2021 logged temperatures for the dish machine found 15 logged wash temperatures less than the required 160°F, and 22 logged rinse temperatures less than the required 180°F. It was also noted that a column on the log stating Action Taken if Out of Range was left blank on all days. According to the 2013 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: .(3) For a single tank, conveyor, dual temperature machine, 71C (160F) . According to the 2013 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: (1) For a stationary rack, single temperature machine, 74C (165F); or (2) For all other machines, 82C (180F) . 4. During a follow up tour of the kitchen, at 9:35 AM on 12/1/21, a review of the clean pots and pans storage rack found two stacked 1/4 pans with large spots of stuck on food debris on the outside and inside of the pans. When the pans were pointed out to Chef O, they were taken to the dish room. Further observation of the storage rack found four sheet pans stacked and stored wet. When asked if the expectation is that pots and pans are stacked and stored after they are fully dry, Chef O stated, Yup, Correct. A revisit to the main kitchen, at 3:00 PM on 12/1/21, found four 1/4 pans stacked wet on the clean pots and pan storage rack. According to the 2013 FDA Food Code section Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD . According to the 2013 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. (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.

Based on interview and record review the facility failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for emergency transfer for 4 of 4 residents (Resident #138, #139, #83, and #19) reviewed for LTCO notification, resulting in the potential for residents being inappropriately discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-Term Care Ombudsman to be unaware of the facilities practices related to transfers and discharges. Findings include: Review of an email correspondence on 11/29/21 at 9:22 A.M., Long Term Care Ombudsman (LTCO) P reported that she had not received notification of facility initiated transfers or discharges of residents from the facility since July 2020 of last year. During an interview on 12/2/21 at 10:15 A.M., Director of Nursing (DON) B reported that the facility Social Workers had not completed the correspondence to the LTCO and education to the social workers would begin immediately. Resident #138: Review of the Face Sheet revealed Resident #138 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with a fracture of the lower end of right tibia. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #138 had a brief interview for mental status (BIMS) score of 11 out of 15 which indicated she had impaired cognition. Review of Resident #138's Nurses Notes dated 9/10/21 revealed, RN (Registered Nurse) was notified by aid that pt (patient) has a severe headache. Pt is sitting in her green chair in room with legs elevated .EMS (Emergency Medical Services) arrived, report and paperwork provided. Pt will open her eyes but is no longer answer questions . (Indicating Resident #138 had an emergency transfer to the hospital). Resident #139: Review of the Face Sheet revealed Resident #139 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with spinal fractures. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #139 had a brief interview for mental status (BIMS) score of 13 out of 15 which indicated Resident #139 was cognitively intact. Review of Resident #139's Nurses Note dated 9/5/21 revealed, .EMS arrive took over care and transported the PT to (Name Omitted) Hospital ER (emergency room ). (Indicating Resident #139 had an emergency transfer to the hospital). Resident #83: Review of the Face Sheet revealed Resident #83 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with chronic [CONDITION(S)] and acute pulmonary embolism (a blood clot in the lungs). Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #83 had a brief interview for mental status (BIMS) score of 5 out of 15 which indicated she had severely impaired cognition and was discharged to Acute hospital on 11/15/21. Review of the Nurses Notes dated 11/15/21 at 02:20 PM revealed Resident #83 .had rapid decline through out the morning. respiratory distress (sic) .pt unable to follow commands .order to send pt (Resident #83) out to the emergency department. Resident #19 Review of a Face Sheet revealed Resident #19 was a male, originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 11/11/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #19 was cognitively intact. Review of a Clinical Note for Resident #19 dated 11/17/21 at 1:11 P.M. revealed, Pt (patient) sent to (Hospital Name Omitted) r/t (related to) AKI (Acute Kidney Injury) and [CONDITION(S)] per PA (physician assistant) order . Review of the State Operations Manual revealed, Facility-Initiated Transfers and Discharges In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility must send a notice of discharge to the resident and resident representative, and must also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Notice to the Office of the State LTC Ombudsman must occur at the same time the notice of discharge is provided to the resident and resident representative, even though, at the time of initial emergency transfer, sending a copy of the transfer notice to the ombudsman only needed to occur as soon as practicable as described below. For any other types of facility-initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative. Emergency Transfers--When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable, according to 42 CFR §483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.

Based on interview and record review the facility failed to develop a baseline care plan for anti-coagulation for 1 of 12 residents (Resident #33) reviewed for care plans resulting in the potential for staff to not have healthcare information necessary to properly care for the resident. Findings include: Review of the Policy Baseline Care Plan dated 11/1/17 revealed the facility .must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident. The Policy further revealed, The baseline/admission care plan will include information for the provision of effective person-centered care and will include the minimum healthcare information necessary to properly care for each resident immediately upon admission. Review of the Face Sheet revealed Resident #33 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with personal history of pulmonary embolism (a blood clot in the lungs). Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Baseline Care Plans for Resident #33 revealed no documented care plan for anti-coagulation. During an interview on 12/02/21 at 09:07 AM, Director of Nursing (DON) B stated if a resident was ordered a blood thinning medication (anti-coagulant) then we (facility) would have an anticoagulant care plan or should have an anti-coagulant care plan so the staff would know to .physical([NAME]) monitor signs and symptoms of anti-coagulation medications. DON B reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B stated a care plan .was not developed for Resident #33 on admission.

Based on interview and record review the facility failed to properly surveil infections and failed to follow standard guidelines for quarantine, during a pandemic. This deficient practice was noted during a focused infection control COVID-19 (an aggressive new highly contagious [MEDICAL CONDITION] disease) survey, and resulted in the potential for transmission of COVID-19 among all 32 vulnerable residents. Findings include: During a phone interview on 5/21/20 at 1:52 p.m., the Director of Nursing (DON) confirmed she was the Infection Preventionist for the facility. A review of the requested surveillance documents was conducted. The documents did not include cluster mapping of facility infections. The DON confirmed she did not conduct mapping of facility infections and stated, I do not do mapping on a physical map of the unit. It creates a challenge because we have so much turnover of residents. The DON said infections were recorded on the line list and if clusters were noted, caregivers were looked at. A review of the line lists for March, April and May 2020 was conducted. The line lists were in spreadsheet format, which were not legible for all columns, including the symptom resolve date column. Some residents were highlighted in yellow, and the DON confirmed those residents were sent out to the hospital, but no dates of transfers were noted on the line lists. The line lists did not delineate when signs and symptoms worsened to show timely transfers. The comment column information overarched the cell so as to be unreadable. The line lists also did not show the dates of any quarantine or transmission based precautions (TBP) initiated or discontinued, only what type of TBP. Of the 8 residents in quarantine in April 2020, only two were listed as in droplet/contact precautions. The other 6 were in standard precautions. Only one of the twenty listed residents in quarantine in May 2020 was in contact/droplet precautions. All others were in only standard precautions. The DON confirmed that residents were quarantined on the dedicated unit (as evidenced by the room number on the line list), and released from quarantine after seven days and two negative COVID-19 tests, even with symptoms. Since the line lists did not date symptom resolve or worsening, it was unknowable whether testing was done during or after symptom worsening or resolve. The line list also did not delineate whether any antibiotic use met standard criteria compliant with stewardship. The employee line lists for March, April and May 2020 were also reviewed and found to be absent any information regarding duration of symptoms or whether the employee returned to work following standards of practice. A follow up phone interview attempt was made on 5/22/20 at 8:05 a.m., but was unsuccessful. During a phone interview on 5/22/20 at 8:37 a.m., the Administrator (NHA) confirmed the DON was on vacation beginning that same morning. When explained the concerns over the line lists, the NHA said she would try to help decipher the concerns, and confirmed that residents were quarantined for only seven days, then tested twice and released from quarantine if the tests were negative. When asked if a resident could test negative at day seven, then still be positive with COVID-19, the NHA stated, I understand. They (residents) might test positive 4 days later. The Centers for Disease Control and Prevention (CDC) website https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed 5/22/20, revealed, .Considerations for new admissions or readmissions to the facility . Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. o All recommended COVID-19 PPE (personal protective equipment) should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. o Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic (COVID-19) infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home . The policy Infection: Prevention & Control, not dated, revealed, .Surveillance is a systematic method of collecting, consolidating, and analyzing data concerning a disease or event, followed by dissemination of the information with the goal of improving outcomes. Healthcare associated infection surveillance incorporated several approaches to minimize risks and control spread of infections .Antimicrobial Stewardship .interventions .meet the criteria for infection .Surveillance tracking includes validation of meeting the definition of infection .Infection trends or clusters are identified and investigated. One method to identify clusters is to track the types of infections on a floor plan. Place a check mark or circle in the room of each resident identified to have an infection for the month. Designate a different color for each type of infection .for room with multiple admissions in a month designate different admissions with infections by adding a symbol .determine any clustering . During the entrance conference on 5/21/20 at 10:00 a.m., the NHA confirmed there were no patients who tested positive for COVID-19 or were presumed positive. The NHA was asked if were any patients on Transmission-Based Precautions, or with respiratory symptoms. The NHA directed this Surveyor to speak with the DON. This Surveyor requested the infection surveillance materials, including line listings (infection tracking), mapping (visual representation of patients with infections), and the infection control policies during this interview. During an interview after the entrance conference on 5/21/20 at 10:24 a.m., the DON confirmed there were no patients with COVID-19, or presumed positive, and there were at least 16 residents on the isolation unit, on droplet and contact precautions. The DON added the patients were typically in isolation 14 days, but after 6 to 7 days we (the facility) do COVID tests 24 hours apart, then (with two negative tests) they (patients) move onto the 'non-isolation unit into another cohort (a group of patients who have similar infections or conditions)'. This Surveyor asked the DON to forward the surveillance documentation including the infection line listings and mapping (of facility infections) for the last three months, as well as a list of residents on transmission-based precautions, on the isolation unit. At 12:45 p.m., this Surveyor noted the Infection Surveillance documentation and policies had not been received, and let the NHA know the Survey team needed this documentation as soon as possible. During a follow-up interview on 5/21/20 at 1:30 p.m., the DON asked for further clarification regarding the infection tracking documentation needed, including clarification of the terms line listing and mapping. This Surveyor explained the line listing would include monthly infection tracking for staff and residents, and the mapping would include a visual representation of the resident infections (specifically respiratory) by room number. The DON acknowledged they (the facility) tracked infections however did not have any mapping of infections. The DON stated, I don't necessarily map per se. I look and see trends going on .I don't have a mapping. I look weekly .I map in my head but I don't have a hard copy . The DON was about the earlier comment about testing residents for COVID-19 on Transmission-based precautions, on day 6 to 7 (from admission). The DON confirmed some patients are removed from Transmission-based precautions and off the isolation halls prior to 14 days (from admission), with two negative COVID-19 tests.

Based on observation, interview and record review, the facility failed to provide immediate cardio [MEDICAL CONDITION] resuscitation (CPR) per the standards of practice and facility policy and procedure for 1 of 1 sampled resident (Resident #47) reviewed for CPR, from a total sample of 14 residents, resulting in an Immediate Jeopary for Resident #47, whose advanced directive indicated she was a full code, was found by Registered Nurse (RN) F on [DATE] at 5:35 a.m. without pulse or respirations and RN F did not perform immediate CPR for at least 5 minutes then performed inadequate CPR for Resident #47. Resident #47 was pronounced dead at 6:08 a.m. Findings include: Review of a policy titled Cardiopulmonary Resuscitation CPR revised [DATE] revealed: 1. Upon discovering unresponsive patient with no breathing or no normal breathing call for assistance by voice and activate the Code Blue button in the patients room. 2. Palpate for pulse if no pulse felt within 10 seconds, place backboard or head of bed under upper body to provide a flat rigid surface. 3. Initiate compressions . Review of a document titled Exhibit A, Code Response Services revealed: The Code Team shall oversee documentation of Code medical treatment and intervention provided at MFB/SAR in the MFB/SAR medical record. MHSM shall provide instruction and training regarding Code initiiation and reporting of Codes to MHSM. Additionally, MHSM personnel will participate in weekly testing of MFB/SAR Code notification process/procedure when initiated by MFB/SAR personnel responsible for such activities and may as agreed upon by the parties assist in process improvement activity to improve MFB/SAR Code notification process. For purposes of this Agreement, Code Services specifically excludes rapid responses, as defined by MHSM. Additionally, MFB/SAR shall be responsible to: a. Complete an initial assessment of the individual and determine if the individual at MFB/SAR is in full cardiovascular or respiratory arrest and Code Services are required. c. Stock and maintain code cart and cardiovascular and respiratory resuscitation equipment at MFB/SAR in a manner identical to those in use at MHSM and MFB/SAR personnel shall be responsible to relocate code cart and equipment to the location of the code for use by MHSM personel. d. Initiate emergency treatment, including basic CPR, until the Code Team arrives, and ensure appropriate, qualified MFB/SAR personnel remain at code location to provide necessary history and assistance to the Code Team e. MFB/SAR is responsible to confirm code status of any MFB/SAR patient and will not call Code Team for any MFB/SAR patient with a Do Not Resuscitate (DNR) order/status. f. Maintain current policies and procedures regarding code and Code Team notification and MFB/SAR team responsibilites, completion of training for MFB/SAR personnel and regularly and appropriately document such activities. Per the American Red Cross First Aid and Safety Handbook (2015), A person in [MEDICAL CONDITION] is unconscious, not breathing, and has no heartbeat. The Handbook revealed that a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is: 1). Early access to the emergency medical services (EMS) system, 2). Early CPR, 3). Early defibrillation, and 4). Early advanced medical care. The Handbook also revealed that without early CPR and defibrillation, the chance for survival is greatly reduced. According to the Handbook, once you begin CPR, do not stop except in one of these situations .another trained responder or EMS personnel take over. Review of a Face Sheet for Resident #47 revealed she was a [AGE] year old female with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact and was total dependent with the assist of 2 staff for transfers. Review of CNA Care Guide modified on [DATE] revealed: .Reposition every 2 hours . Review of a document titled ADL (Activities of Daily Living) Verification Worksheet for Resident #47 with observations between [DATE] at 12:00 a.m. and [DATE] at 9:38 a.m. revealed that on [DATE] at 5:06 a.m. was the last time Resident #47 had assistance with ADL's. In an interview on [DATE] at 12:13 p.m., Clinical Care Coordinator (CCC) RN Y reported there was no documentation on [DATE] on the CNA's charting documentation showing there was any care given to Resident #47 after 3:56 p.m on [DATE]. During an observation on [DATE] at 11:09 a.m. in the Security Office, review of the security camera video footage was reviewed with Security Officer M. The video revealed on [DATE] at 5:37 a.m. RN F went to Resident #47 room with the computer on wheels (COW). At 5:38 a.m., Registered Nurse (RN) F came out of the room and walked to the end of the hall. At 5:40 a.m., RN F came back down the hall and Security officer M confirmed that RN F went into the Therapy gym. At 5:42 a.m., RN F was seen walking down to Resident #47's room with a red emergency supply cart and entered the room (5 minutes after she had first entered the room). At that time a Certified Nurse Aide (CNA) walked out of the room next door and went next door to Resident #47's room. Then another CNA walked out of a neighboring room and went to Resident #47's room. Another nurse was visualized on the video standing at the end of the hall for a few seconds and then disappeared. At 5:44 a.m. more staff arrived to Resident #47's room with a crash cart that had a yellow cover over the top, the person pushing the cart had stopped in the doorway of the room but did not go in to the room with the cart. Security Officer M reported the staff pushing the yellow covered crash cart were from the 3rd or 4th floor. The crash cart with the yellow cover was then parked outside of the room along the wall in the hallway. At 5:48 a.m., a male staff member came down the hall and entered Resident #47's room and Security Officer M identified that the male staff member was a Respiratory Therapist. There was a CNA in the hall who took the crash cart parked in the hallway and started to roll it down towards the end of the hall. At 5:49 a.m. a staff member came out of Resident #47's room looking for the cart and ran down the hall to catch up with the CNA pushing the cart, grabbed supplies out of the cart and took them back to Resident #47's room. At 5:50 a.m. the CNA who pushed the yellow covered crash cart took it back down the hallway and sat it outside the door of Resident #47's room. At 6:08 a.m. staff were observed leaving the room. At 6:12 a.m. a lady who was a possible family member was observed crying walking down the hallway and was greeted by staff while walking to a chair in the hallway. During an observation and interview on [DATE] at 11:29 a.m., Security Officer O tried to pull up the video footage again dated [DATE] and was unable to obtain the data from [DATE] from 12:00 a.m. to around 9:00 a.m. Security Officer O reported she would have IT work on it. The Health Services and Operation Coordinator LL was in the room as well to help identify the staff who went into Resident #47'son [DATE]. In a telephone interview on [DATE] at 1:33 p.m., RN F reported she was doing a medication pass the morning of [DATE] around 5:30 a.m. when she went to give Resident #47 medications. When RN F approached Resident #47 she was not responding and had no respirations. RN F reported using her stethoscope to listen for a heartbeat on Resident #47's chest and found none. RN F then stated she did not know the code status of Resident #47, so she left the room to get the paper chart which was in the I room. The I room was a room down another hall where the nurses chart. RN F reported that after looking at Resident #47's chart, she noticed she was a Full Code and started walking back towards Resdient #47's and grabbed the red crash cart with the AED (Automated external defibrillator - portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm) along the way. RN F reported she then applied the AED pads to Resident #47 and pushed the staff assist (not the code blue button directly beneath the staff assist button) button that alerted the security officers. RN F then reported that after she placed the AED pads on Resident #47, the AED was analyzing Resident #47. RN F reported she then called the security office using a portable phone to inform them of the Code Blue. RN F reported she saw RN I before the activating the Code Blue alarm and said to RN I, 'We have a code here, what do we do here?' RN F reported she did not push the staff assist alarm or the code blue alarm when she first noticed Resident #47 was unresponsive because she didn't want to interrupt other staff from working until she knew what the code status of Resident #47's was. RN F reported that the AED advised No shock so she started chest compressions. RN F reported she was doing chest compressions for about 5 minutes before staff from floors 3 and 4 arrived. RN F reported using both hands for compressions with Resident #47 in bed on a specialty mattress that was inflated with no backboard in place. RN F reported there was no backboard on the red crash cart that was on her floor, but reported the mattress was eventually deflated by another staff member. RN F did not report whether she placed oxygen on Resident #47. During an observation of the residents' rooms, the red staff assist button located on the wall directly above the blue code blue button next to the residents' bed. Both buttons were clearly identified and color coded. In a telephone interview on [DATE] at 3:20 p.m., RN I reported she was in another residents' room when RN F came to the room that RN I was in. RN F then told tell RN I that Resident #47 had no respirations and no pulse. RN I reported that she could not leave right away because her resident was in the bathroom. RN I reported she did call security on a work phone and told security that (Resident #47) had no respirations and no pulse. In a second interview on [DATE] at 2:37 p.m., RN F reported that Resident #47's body was warm to the touch when she first entered her room on [DATE] around 5:30 a.m. and found her unresponsive. In a telephone interview on [DATE] at 12:59 p.m., CNA LL reported that on [DATE] when she heard there was a Code Blue, she was at the facility in another residents' room with another CNA. CNA LL reported she was in an isolation room and when she had finished assisting that resident, both CNA's ran to Resident #47's room and saw RN F performing CPR (Cardio [MEDICAL CONDITION] Resucitation) on Resident #47. The crash cart was taken to the room and the code team was asking for supplies. CNA LL reported she did not know what they wanted so the then the code team took over. RN F was in the room by herself at first and pushed staff assist button. CNA LL reported she was the only other person in the room with her. RN F asked CNA LL to get a nasal cannula, but could not remember every event detail. In a telephone interview on [DATE] at 1:21 p.m., CNA S reported that she was in another room with another resident when she heard a staff assist alarm sounding and went next door to Resident #47's room immediately with CNA P. CNA S then reported she saw RN F doing CPR on Resident #47. CNA S reported that RN F lowered the bed and was pushing on Resident #47's chest with both hands up and down really hard and did not remember if there was a board behind Resident #47's back. During an observation and an interview on [DATE] at 1:00 p.m., RN FF reported that she could find the code status of a resident on the computer (COW) as well as the paper charts. Review of a document titled Security Offense/Incident Report dated [DATE] revealed: On [DATE] at approximately 5:44 a.m. (7 minutes after RN F first found Resident #47 without pulse or respirations) (security officer) was patrolling the 2nd level west addition parking ramp when I heard over a Code Blue paged. At 5:45 a.m. I responded .At 5:53 the last of the code team arrived at the elevators and I responded to the room where the code team was performing CPR on Resident #47. At 6:08 a.m. the code team declared the patient deceased . Review of a Care Plan for Resident #47 dated [DATE] revealed: Problems: At risk for skin breakdown Assist with turning and repositioning as directed on resident summary (CNA Care Guide). Problems: I choose code A: hospitalization /Resuscitation Goals: My goal is to have my wishes honored .Problems: At risk for skin breakdown Interventions: Assist with turning as reposition as directed on resident summary. Review of a Nursing Clinical Note dated [DATE] at 8:22 p.m. revealed: .Alert and oriented to person, place, and situation. Reoriented to time. Tearful with interactions. Provided emotional support and reassurance Turned every two hours APM (alternating pressure mattress) mattress in working condition . Review of a Nursing Clinical Note dated [DATE] at 8:54 a.m., RN F charted Patient (Resident #47) admitted with sacral fracture. Alert and oriented to person, place, time and situation. Able to make needs known. Incontinent of bowel and bladder. Transfers with 2 assist and Hoyer (a mechanical lift). Admits to bilateral hip and bilateral lower extremities, bilateral hip and buttock pain at a 7. No family at bedside tonight. Patient slept most of night. Blood sugar at hs (bedtime) was 227. Patient continues on 2 liter fluid restriction. Left forearm dressing clean, dry and intact. Patient very lethargic and falls asleep in mid-sentence this shift. Call light and belongings within reach. Participating with therapy towards discharge goals. The note then continued, At 5:35 a.m. upon entering patient room, patient's skin color pale and no respirations noted. No heart beat noted upon auscultation. CPR and AED initiated. CPR discontinued at 6:08 a.m. per physician. Pupils fixed and dilated, no heart beat and no respirations upon auscultation. Attending physician, family members, and CCC notified There was no indication in the note that any part of it was late charting Review of a document titled After Action Review for Code Blue, West Addition, 5th Floor, room [ROOM NUMBER] on [DATE] revealed: Event Description: [DATE] 05:38:07 - RN F exits room, locates patient DNR status, notifies RN [DATE] 05:42:21 - 5th floor crash cart on scene [DATE] 05:42:31 - Staff Duress for RN F @ room [ROOM NUMBER] [DATE] 05:42:32 - Control begins paging Staff Duress [DATE] 05:43:08 - RN I 311 to report Code Blue @ room [ROOM NUMBER], patient not alert, not breathing, 'cold and gone' [DATE] 05:43:32 - Second call for 311 to report Code Blue @ room [ROOM NUMBER] [DATE] 05:43:39 - Control pages Code Blue, West Addition, room [ROOM NUMBER] overhead X3 [DATE] 05:43:45 - Unit 17 reports in route to west elevators [DATE] 05:43:57 - Control contacts MHSM vis 333, MHSM initiates Code Blue [DATE] 05:44:00 - CODE BLUE Unlock Action Group executed in Lenel [DATE] 05:45:43 - Unit 17 reports en route to west elevators [DATE] 05:46:54 - 4th Floor crash cart on scene [DATE] 05:48:38 - Respiratory Therapy on scene [DATE] 05:48:33 - MHSM Code Team arrives [DATE] 05:50:22 - Last of MHSM RRCT on scene [DATE] 06:08:25 - TOD called [DATE] 06:13:30 - Family on scene Conlusion: Although emergency or disaster events are low probability, they have a high impact on the patients, visitors and staff of facility. This Code Blue report demonstrates that the policy is well designed and that the staff is equipped and committed, but also that revisiting training with select staff may be advisable. Review of a document titled Emergency Supply Cart Signature Log for the months of [DATE], [DATE], [DATE], and [DATE] revealed daily missed signatures. Entry for [DATE] revealed Supplies needed, sent. on [DATE] revealed awaiting supplies. Entry for [DATE] revealed awaiting supplies. Review of a policy titled Emergency Supply Cart with a reference date of ,[DATE] revealed: 4. Utilize an Emergency Supply Cart Signature Log, while referencing the checklist every shift to verify that the items listed on the checklist are present and ready for use . b. Emergency Supply Cart Signature Log (for un-locked carts); i. The oncoming nurse validates that all equipment and care items listed on the checklist are present on the cart, signs and dates the signature log. ii. Any missing items or those that are expired or not in working order will be replaced by the oncoming nurse at the time of identification and a full Emergency Supply Cart Checklist should be completed and turned in to the Director of Nursing upon completion. 5. In the event that the cart is used, the nurse in charge checks the contents of cart against the Emergency Supply Cart Checklist and re-stocks the items used; signs and dates other checklist and submits checklist to the Director of Nursing upon completion. 6. Checklists and Signature logs are submitted to the Director of Nursing upon completion, but no less than monthly and to the MDQI Committee for review and follow-up recommendations. On [DATE], NHA A was notified of the immediate jeopardy that began on [DATE] as a result of the facilities failure to immediately cardio [MEDICAL CONDITION] resuscitation (CPR) and follow the standards of practice and facility policy and procedure or CPR. On [DATE], the following was verified to remove the immediate jeopardy: 1. As of [DATE], Resident #47 no longer resides in the facility. 2. On [DATE], the Clinical Care Coordinator completed a blanket audit of current resident to assure the code status is accessible in Vision (the compute software used). 3. Beginning [DATE], licensed nurses began education on verifying code status in Vision, the facility CPR policy including how to perform a code, on how to activate 'code blue' at the time when a resident is found unresponsive per policy, and on accurate documentation of CPR event and time line. No licensed nurses will be allowed to work prior to receiving this education. 4. Beginning [DATE], the Clinical Care Coordinator will conduct random interviews to assure knowledge of the process for identifying the resident code status and inititating CPR. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance with a scope of widespread and severity of actual harm that is not immediate jeopardy due to all staff had not received the inservice education and sustained compliance had not been verified by the state agency.